March 2014

ISSN : 2200-9876

The official publication of the Australian and New Zealand Society of Nuclear Medicine

March 2014, Issue 11

Contents

www.anzsnm.org.au

Welcome

4

President’s Report

6

Branch News

South Australia

8

Western Australia

8

New Zealand

8

New South Wales

8

SIG

Physics and Computing 10

Technologists

10

International Relations Committee

13

Technical Standards Committee

14

Accreditation

16

Vale: Kevin Thomas Murphy 17 ANSTO to help supply the world with nuclear medicine

18

ANZSNM Research Grant Recipient 2014 20 My first EANM Annual Congress 22 Australian Supply of Lutetium-177 26 Theranostics: Hot science, cold facts 28 Case Studies

Autonomous hyperfunctioning sublingual thyroid tissue in a patient with congenital hypothyroidism, resulting in hyperthyroidism suggestive of Graves’ disease 30

Interesting Cases

Update on the QUEST international clinical study for determining the dose-response relationship in 90Y SIR-Spheres treatments: Towards individualising radioembolisation therapy 32

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.au March – February 1

July – June 1

November – October 1

1

Journal Staff

Editorial copy & Advertising copy

The Australian and New Zealand Society of Nuclear Medicine Limited

Design & Production

Robyn Smith General Manager ANZSNM Secretariat PO Box 202, Parkville VIC 3052 Tel: 1300 330402 Fax: (03) 9387 9627 Email: secretariat@anzsnm.org.au Rachel Bullard Deep Blue Design Studio Email: deepbluedesign1@mac.com

This issue compiled by NSW branch

Tracey Trevaskis

Elizabeth Bailey

Dale Bailey

Aims and Objectives

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 on 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 through standing committees and special interest groups: a) The Technical Standards Committee sets minimum

standards and develops quality control procedures

for nuclear medicine instrumentation in Australia

and New Zealand.

The ANZSNM Gamma Gazette is published three times a year: March, July and November.

Deadlines for each issue of the journal are the first of each month prior to publishing. Š 2014 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

2 Gamma Gazette March 2014

b) The Technologists Special Interest Group. With the introduction of National Registration for Nuclear Medicine Technologists / Scientists as of 1st July 2012, the future role of the Accreditation Board was reviewed and federal council made a decision to disband the current Accreditation Board and reallocate ongoing responsibilities to the ANZSNM – Technology Special Interest Group (TSIG). The PDY and mentor program, CPD program, department accreditation and the overseas qualification exam are now managed by sub-committees of the TSIG. 2) The Radiopharmaceutical Science SIG and a Physics SIG that maintain standards of practice for their particular speciality and provide a forum for development in Australia and New Zealand.

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 Treasurer Committee

Ms Liz Bailey (TSIG) email: Elizabeth.Bailey2@health.nsw.gov.au vacant Dr Sze Ting Lee (Vic/Tas) email: szeting.lee@petnm.unimelb.edu.au Dr Sue O’Malley (NZ) email: sue@omalley.co.nz Prof Dale Bailey (NSW) email: Dale.Bailey@sydney.edu.au Ms Lyndajane Michel (Qld) email: michell@qdi.com.au Assoc Prof Roslyn Francis (WA) email: roslyn.francis@uwa.edu.au Mr Dominic Mensforth (SA) email: Dominic.Mensforth@i-med.com.au Dr Darin O’Keeffe (Phyics SIG) email: Darin.OKeeffe@cdhb.health.nz Ms Sharon Mosley (ACT) email: sharontripodi@me.com Ms Jennifer Guille (Radiopharmaceutical Science SIG) email: jennifer.guille@sesiahs.health.nsw.gov.au Dr Sam Berlangieri (Physician rep, ANZAPNM) email: berlangieri@petnm.unimelb.edu.au Prof Vijay Kumar (International Relations Committee) email: vijay.kumar@swahs.health.nsw.gov.au

General Manager & Secretariat

Ms Robyn Smith, Mrs Genevieve Butler

All correspondence ANZSNM Secretariat

PO Box 202, Parkville VIC 3052 Tel: 1300 330402 Fax: (03) 9387 9627

Email: secretariat@anzsnm.org.au Branch Secretaries Australian Capital Territory New South Wales Queensland South Australia Victoria/Tasmania Western Australia New Zealand

Ms Maree Wright, email: maree_wright@hotmail.com Ms Tracey Trevaskis and Ms Elizabeth Bailey, email: tracenucmed@hotmail.com Ms Nikki Weinert & Ms Kathy Roy, email: qldbranchsecretaryanzsnm@gmail.com Ms Nicole Ayars, email: nicole.ayars@health.sa.gov.au Dr Zlata Ivanov, email: zlata.ivanov@arpansa.gov.au Ms Georgina Santich, email: wabranchsecretary@hotmail.com Ms Dianne Wills, email: Dianne.Wills@cdhb.health.nz

Special Interest Groups Technologists

Radiopharmaceutical/Science Physics/Computer Science

Nicholas Farnham, email: Nicholas.Farnham@health.sa.gov.au CPD Program Sub-committee: Dr Clayton Frater, email: clayton.frater@sswahs.nsw.gov.au Ms Jennifer Guille, email: jennifer.guille@sesiahs.health.nsw.gov.au Dr Darin O’Keeffe, email: darin.okeeffe@cdhb.health.nz

Technical Standards Committee Scientific Advisory Panel International Relations Committee Nurse Member Liaison

Chairperson: Dr Darin O’Keeffe, email: darin.okeeffe@cdhb.health.nz Chairperson: Professor Dale Bailey, email: Dale.Bailey@sydney.edu.au Chairperson: Professor Andrew Scott, email: Andrew.Scott@ludwig.edu.au Mr Erwin Lupango, email: Erwin.lupango@sessiahs.health.nsw.gov.au

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

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

3

Welcome Welcome to the first edition of the Gamma Gazette for 2014. Looks like our members are in for some great meetings coming up in each state as well as the conference to look forward to in April. If you can’t attend the conference please look out for the international speaker presentations at branch meetings in your state.

Thank you to our contributors and the sponsors for their input to this edition. This edition would not have been possible without the efforts of Liz Bailey and Dale Bailey from the NSW branch.

I’d like to take this opportunity to thank Robyn Smith for her service to ANZNSM as General Manager and for her assistance with this edition of the gamma gazette. We wish her well for the future.

Tracey Trevaskis NSW Chair

4 Gamma Gazette March 2014

Annual Scientific Meeting of the Australian & New Zealand Society of

NUCLEAR MEDICINE 25-28 April 2014, Adelaide

A Fusion of Ideas, Modalities & Disciplines

Register now!

An exciting program is planned emphasising the place of Nuclear Medicine in the multidisciplinary practice of medicine. Renowned international speakers from Europe & USA will join local & interstate experts both in Nuclear Medicine & associated fields such as Oncology & Surgery.

The Pre-conference Symposium, focusing on the integral value of molecular imaging in breast cancer & lymphoma, will be held at The Farm, a brand new conference venue in the heart of the beautiful Barossa Valley adjacent to Maggie Beer’s Farm Shop. Finish the afternoon with wine tastings & an opportunity to pick your own collection of goodies from Maggie’s famous delectables.

Check the website for the latest program updates. At the Conference keep up-to-date with our smart phone app - access session details; view speaker bios; take notes on sessions; participate in feedback; receive news alerts & more…

EVENTS

Adelaide is synonymous with wineries, restaurants, cafes & great food producers & there will be plenty of opportunity to saviour the good life!

Welcome Reception Saturday 26 April 2014 5.30pm-7.00pm. Adelaide Convention Centre.

Enjoy substantial food & fine wine amongst the twenty-nine trade booths, before experiencing some of Adelaide’s best restaurants or joining Nuc’s party.

Nuc’s Party, Welcome to the Lion’s Den Saturday 26 April 2014 7.30pm until late.

The “Tunnels” Lion Hotel, North Adelaide.

Nuc’s Party is legendary - relieve the stresses of the week & let the good times roll.

Dress: Jungle Safari Theme Gala Dinner Sporting Legends - Night of Nights Sunday 27 April 2014 7.00pm - 11.00pm Adelaide Convention Centre A three course meal , premium South Australian wines & a night of nights with a distinctly sporting theme, will ensure the Gala Dinner is the social highlight of the Conference.

It wouldn’t be complete without a special guest ... Greg Ritchie media commentator & a first class batsman who played in 30 Tests will host the evening.

Join us for thought-provoking discussion, information sharing, strategising & problem solving as well as some great social events & networking.

Register online now at www.anzsnm2014.com.au or email anzsnm2014@plevin.com.au or telephone (08) 8379 8222 for further information.

www. a n z s n m 2 01 4 .co m . a u

President’s Report Welcome to the first issue of the Gamma Gazette for 2014.

We are very pleased that the history book project is finally complete. The council would like to acknowledge and thank those members that made contributions to the book. The book along with all pictures will be available on wiki-books via the ANZSNM website to members by the end of the month.

The ARTnet (Australasian Radiopharmaceuticals Trials network) joint venture is progressing well with the guidelines and terms of reference soon to be endorsed by the steering committee. The next step is the formation of the scientific committee, with expressions of interest for membership to this committee to be distributed in the next month.

A pilot program is currently being undertaken for site accreditation and camera validation. The official launch of ARTnet will be during the ANZSNM ASM Adelaide, program yet to be confirmed.

The TSIG has worked with the CPD sub-committee to improve the functionality of the CPD database to allow member to attach evidence and include comments for reflective practice, a mandatory requirement for professional development. As part of the ongoing efforts to assist members with record keeping for CPD, barcode scanners will be available for all technologist sessions held as part of the Adelaide ASM. A unique membership code will be printed on your name badge that can be scanned on entry and exit to each session.

Just a reminder of the upcoming ANZSNM ASM 2014 to be held in Adelaide from April 25-28, early bird registration closes March 14, 2014.

Liz Bailey President ANZSNM

Book launch Isotopes, Imaging and Identity – A History of Nuclear Medicine in Australia and New Zealand ANZSNM has recently published Isotopes, Imaging and Identity – A History of Nuclear Medicine in Australia and New Zealand. This book is the culmination of the contributions of numerous society members and an extensive network of industry colleagues.

Isotopes, Imaging and Identity – The History of Nuclear Medicine in Australia and New Zealand outlines the discoveries and achievements of interrelated disciplines within nuclear medicine and the development of various technologies introduced over the years to make nuclear medicine an integral part of patient management today.

It details the formation and expansion of a professional collegiate which became the ANZSNM and of many lifelong friendships including interstate and international cooperative ventures that have underpinned the vital contributions that nuclear medicine has made to medicine, within and beyond Australia and New Zealand.

We hope this book will hold a place of importance in the libraries of ANZSNM members and will be valued by others with any interest in contemporary nuclear medicine, medical history, Australian and New Zealand social history, and other related fields.

Members have the opportunity to obtain a copy of the book paying only the cost of postage and handling AU$25.00. In addition, in the New Year we will be establishing a wiki-book facility where an online version of Isotopes, Isotopes, Imaging and Identity – The History of Nuclear Medicine in Australia and New Zealand will exist. This will allow interested persons to make live comments and provide additional information to enable the content to evolve for future editions.

6 Gamma Gazette March 2014

Australian and New Zealand Society of Nuclear Medicine Limited ABN: 35 133 630 029

Isotopes, Imaging and Identity – The History of Nuclear Medicine in Australia Book

Order and Payment Form ANZSNM Members:

AU $25 (inc.GST) Qty.

Name: Preferred mailing address please: Street: State: Postcode: Email: CREDIT CARD PAYMENT: Mastercard/Visa (Please circle) Expiry:

/

CSV:

Amount to be deducted $ Card Holder’s Name Card Holder’s Signature Email completed form to: secretariat@anzsnm.org.au CHEQUE MADE PAYABLE TO ANZSNM ANZSNM Secretariat PO Box 202 Parkville, Vic 3052 Phone: 1300 330 402 Fax: 03 9387 9627 This document will be a tax invoice for GST when you make a payment

Branch News WESTERN AUSTRALIA Our Annual General Meeting was held on November 26, 2013 at the social club at Sir Charles Gairdner Hospital. As has become custom, the formalities were combined with a social event, this year a quiz night. Dr Russell Troedson and Rhonda Harrup gave excellent presentations on their experiences at the EANM held in October in Lyon, France. Thanks go to quizmaster Shayne White, and to Gabrielle Morrissey, who did a fabulous job preparing the quiz questions.

I would like to welcome Amy Evans to the WA Branch committee and I look forward to her contribution over the next few years. I would also like to thank Rick Hampson for his service and contribution to the WA branch during his tenure on the committee. Stephanie O’Donnell has taken over as treasurer, and Diane Cheong and Georgina Santich have been re-elected to the committee.

CPD and educational events remain the main focus of the Branch with several events being organised for the year. The next branch meeting was held at SKG Subiaco on February 11. Our annual workshop is scheduled for Saturday August 2nd at the University Club, UWA. I encourage all members to support this event.

I would like to wish all members a successful new year. We have a very exciting program ahead this year and I look forward to seeing you all at these events.

Liz Thomas, WA Branch Committee Member SOUTH AUSTRALIA We hope everyone had a wonderful Christmas and New Year period. Here in SA we ended 2013 with a successful Radpharm/Technologist’s AGM held at The Tivoli Hotel on November 26, kindly sponsored by Global Medical Solutions and the main branch’s AGM was held at the Hackney Hotel on December 4 which was kindly sponsored by Cyclomedica.

Overall we had a fantastic 2013 with well attended meetings and we look forward to a great year ahead with the first meeting in 2014 to be held in March. We also look forward to seeing many of you at the upcoming Adelaide Conference being held in April, the program and events all look fantastic!

Nicole Ayars, SA Branch Secretary/Treasurer ACT The ACT branch has been very quiet of late, welcoming new babies (Maree and Tony Congratulations!) and (Chris Thomas Congratulations!) and seeing staff leave to pursue their study dreams (Ashlee Harrison Congratulations!). “Canberra Hospital is sad to see Ashlee Harrison leave the department to pursue further education and is thankful for all her hard work over the past five years. On the other hand we are happy to announce that Megan Stirrat has been appointed as our new PDY. Congratulations to both girls!”

The branch had its last meeting just before Christmas, we organised it as a breakfast meeting so that it didn’t clash with our member’s family and sporting commitments and was surprisingly well attended. Just about everyone was able to get themselves out of bed for an early morning start and was rewarded with not only a decent breakfast but also some stimulating and topical conversation too. We now have a forward plan for 2014 with speakers planned and have just recruited James Green as our ACT ANZSNMT representative. Our next meeting is due in March.

Sharon Mosley, Chair, ACT Branch NEW SOUTH WALES Happy New Year to all. I am pleased to report an enjoyable meeting was held at Siemens Medical on December 4, 2013 with some old and new faces. I would like to thank Clayton Frater and Liz Bailey for their presentations and a HUGE thank you to Andy Willmott for a fun trivia session. We could not hold this meeting without the support of Siemens and we thank them for sponsoring this annual event.

We have had a few changes to the NSW branch committee as of our December meeting. I have now resumed the role of Chair and Liz Bailey as Treasurer and we will be sharing the secretary role. Our remaining committee members are Dale Bailey who is our Federal Representative, Marko Trifunovic and Sue Lefmann as general committee.

Daphne James and Matt Ayers have tendered their resignations and I would like to thank them both for their contribution to our branch over the years. We are looking to enlist some new enthusiastic people to keep the branch going.

If you think you would like to be involved please contact me via email tracenucmed@hotmail.com. CPD points are available to active committee members. Our Next meeting will be on Tuesday March 25 at Liverpool Hospital.

Followed by international conference speaker Dr Jamshid Maddahi, MD, FACC, FASNC, Professor of Molecular and Medical Pharmacology (Nuclear Medicine) Professor of Medicine (Cardiology) David Geffen School of Medicine, UCLA, USA on Tuesday April 29. This meeting will be held at Prince of Wales Hospital.

Remember all future NSW branch meeting details are on the website and are regularly updated so don’t forget to check what’s coming up. Please contact me if your contact details change as we send lots of branch information via email. I can be contacted on tracenucmed@hotmail.com A big thank you to those who made contributions to this edition of the Gamma Gazette. It has been a little disappointing considering the size of membership to not have more contributions. u Tracey Trevaskis, Chair NSW Branch 8 Gamma Gazette March 2014

Special Interest Group News TECHNOLOGISTS With the new year here the TSIG have a working party that are in the final stages of preparing a Scope of Practice Document for Nuclear Medicine Technologist’s/Scientists. We aim to have this out for public consultation shortly with a view to present the final version at the ANZNSM Annual Scientific Meeting in Adelaide this year.

Our focus will continue with Continuing Professional Development with the ongoing review and adjustment to the CPD Program and Database.

The TSIG is organising its yearly Day Seminar to be held in Queenstown NZ in July 2014, with flyer and program to come out shortly.

Nick Farnham Chair TSIG

PHYSICS AND COMPUTING

Column 8 Welcome to the first Physics and Computing Special Interest Group (SIG) column. At the last AGM in Perth the Physics SIG announced their intention to produce a regular column for the Gamma Gazette. The original idea was to produce a separate newsletter for the Physics SIG members only, but it was decided that other members may be interested as well so why not put it in the Gamma Gazette. So what you are reading is a combination of items that are both for the Physics SIG members and the ANZSNM membership in general. This is a rather brief, rather informal introductory article to hopefully stimluate members to make contributions. If there are particular topics you would like explored in future columns or you would like to contribute something, please email the Physics SIG Chairperson or Secretary.

Please note that this column has been authored by the Physics SIG Chair (darin.okeeffe@cdhb.health.nz) and with the exception of noted contributions, it does not necessarily reflect the views or educational qualities of the Physics SIG members (i.e. blame the author for the bad bits).

Thanks to Dale Bailey for the creative play on words for the title of this column.

SIGnal

Brief SIG news PET/MRI – Continuing education presentations The 2012 Annual Scientific Meeting presentations on PET/MRI by Professor Simon Cherry and the 2013 Physics SIG Symposium “PET/MRI for Beginners” presentations are now on the Physics SIG webpage under “Workshops”.

IAEA We are all aware of the International Atomic Energy Agency (IAEA) role in the nuclear industry and its standards for radiation protection (for example, the transport regulations for radioactive material), but are you aware that it also has health-related technical cooperation programmes and radiation protection programmes for healthcare.

One such programme is the Radiation Protection of Patients (RPOP), and this programme has produced a multitude of free material. Have a look at rpop.iaea.org.

If you want to know more about how the IAEA supports medical physics in nuclear medicine, have a look at the article IAEA Support to Medical Physics in Nuclear Medicine (Maghzifene and Sgouros) in the May 2013 issue of Seminars in Nuclear Medicine.

Radiation risks at low doses The May 2013 issue of the journal Radiology contains a commented reprint of the International Organization for Medical Physics (IOMP) policy statement on predictions of induced cancers and cancer deaths in a population of patients exposed to low doses (< 100 mSv) of ionising radiation during medical imaging procedures. Have a read

u

10 Gamma Gazette March 2014

Special Interest Group News

continued

if you want to know the concern about ignoring the large uncertainties in risks for low radiation dose, and why these uncertainties should be explained when expressing these risks in the popular media.

EJNMMI Physics Springer has called for submissions to a new journal called EJNMMI Physics. EJNMMI Physics is an open access, electronic-only journal, publishing about 40 articles per year. Editor-in-Chief is Professor Thomas Beyer. The intention of the journal is to provide an international platform for scientists, users and adopters of nuclear medicine with a particular focus on physics matters. The journal is calling for original contributions with a focus on applied physics and mathematics in nuclear medicine, as well as imaging system engineering and prototyping. This includes physics-driven approaches or algorithms supported by physics that foster early clinical adoption of nuclear medicine imaging and therapy regimens. Go to springer.com for more details.

IT Corner Handy information technology tips DOIs – Maybe you’ve noticed the slightly cryptic Digital Object Identifier (DOI) terms on the bottom of journal papers, websites, or presentations. They’ve been around since 2000 but didn’t become an international standard until 2012. DOIs are digital pointers to objects, with the objects being physical, digital, or abstract.

Doesn’t sound like a big deal really, except these links are meant to be persistent irrespective of changes to the destination website. If a website changes then the link between the DOI and website is updated - it is all done via a registry system. In the context of journals, using a DOI takes you to the article on the publisher’s website even if the website has completely changed. Of course this requires the publisher to update the connection, but you don’t have to worry about that. Some of the DOIs are reasonably obvious e.g. 10.1053/j. semnuclmed.2009.07.003 takes you to an article in a 2009 issue of Seminars in Nuclear Medicine, but others can be much more cryptic. Most of the handling of DOIs is automatic, but occasionally you have a paper copy of an article and you want to find the article online. If you go to dx.doi.org you can enter (paste) DOIs into a dialog box and it will redirect you to the official resource. Another application is pasting the DOI into a search engine such as PUBMED to take you straight to the abstract. Linking a DOI in an electronic article means it won’t go out-of-date if the website is restructured (see below). Recording the DOI allows you to refer to the journal article without having to write down the title, authors, journal, issue, and page numbers. Very handy on PowerPoint presentations. Finally, there are a range of DOI applications such as CrossRef and DataCite whose backbone for citation connectivity is based upon DOIs. If you want more information there is a detailed handbook available on the DOI system (doi: 10.1000/182).

Around the region A section with news from around the Australasian region. Only one contribution was received for this issue of the Gamma Gazette.

DOSIsoft for internal dosimetry Kathy Willowson and Dale Bailey Institute of Medical Physics, University of Sydney, and Department of Nuclear Medicine, Royal North Shore Hospital We have recently purchased the Linux based DOSIsoft internal dosimetry package, geared specifically towards Y dose map generation for treatment planning and evaluation of radioembolisation therapy for liver cancer.

DOSIsoft is a French company working in collaboration with well-respected dosimetry experts, such as Irene Buvat and Manuel Bardies, and have only recently produced the software on the back of an external beam radiation therapy package.

The package allows multi-modality and time point data to be incorporated into a single environment, where automatic/manual co-registration can be performed, followed by easy delineation of structures of interest (2D, 3D, interpolation, thresholding, filling techniques, etc.), dose map generation (from either the planning (99mTcMAA study or the 90Y PET itself), and dose volume histogram generation, as well as multiple statistical and clinical analysis options, including RECIST and PERCIST measures.

We are in the very early stages of trialling the software but are very impressed with the functionality and 90

u

11

Special Interest Group News

continued

Figure: Example of dose map (top left and lower right), segmented tumour volume (top right), and DVHs for tumour and healthy liver (lower left) for a recent radioembolisation patient. broad range of tools available. The developers are currently working on extending this package to 177Lu dosimetry.

Q&A In November 2013 we called for contributions to the nuclear medicine physics Questions & Answers section.

This section will be launched in the next Gamma Gazette, so keep the questions coming in.

Darin Oâ&#x20AC;&#x2122;Keefe Physics and Computer Science SIG

12 Gamma Gazette March 2014

International Relations Committee

(IRC)

The IRC has been involved in a series of meetings with major overseas societies, and new initiatives, over the last six months.

At the SNMMI Annual Scientific Meeting in Vancouver in June, Prof. Andrew Scott with President Elizabeth Bailey met with the SNMMI leadership to discuss a range of issues relevant to each Society, including teaching and training, credentialling, Mo-99 supply, workforce planning, and reimbursement issues.

The participation of the ANZSNM in the SNMMI Global Dose Optimization initiative, through the active involvement of Dr Darin O’Keeffe, was also gratefully acknowledged. Further meetings at the SNMMI conference were also held with the Asia-Oceania Federation of Nuclear Medicine and Biology (AOFNMB) Executive, and World Federation of Nuclear Medicine and Biology (WFNMB) Executive, with Prof. Andrew Scott, Prof. Vijay Kumar, and Dr Sam Berlangieri participating.

Important outcomes from the meetings included engagement of the ANZSNM in planning for major teaching and training programs within Asia-Oceania, and confirmation of plans for ANZSNM to participate in the WFNMB conference in 2014. There was also acknowledgement of our support for the creation of a new nuclear medicine journal in the Asia-Oceania region – the Asia-Oceania Journal of Nuclear Medicine and Biology – which has Prof.

Dale Bailey as an Associate Editor.

The IRC has also been involved in the organisation of an IAEA International Conference on Integrated Medical Imaging in Cardiovascular Diseases, held in Austria in September 2013, with A/Prof. Nathan Better and Prof.

Barry Elison representing Australia in the Program.

At the European Association of Nuclear Medicine Annual Scientific Meeting in Lyon in October, Prof Andrew Scott and Dr Sze Ting Lee also met with current President of the World Association of Radionuclide Therapy (WARMTH) and WFNMB, and have agreed to foster closer relationships and collaborative efforts of both Societies and the World Journal of Nuclear Medicine.

President Elizabeth Bailey, Prof Andrew Scott, Dr Sze Ting Lee and Dr Peter Collins also met with the executive of various international societies. The ANZSNM will have two CME sessions at the upcoming SNMMI Annual Scientific Meeting in St Louis in 2014, and President Bailey has also secured a CME session at the EANM technologist group in Sweden in 2014. Following on from these closer relationships with our international counterparts, there will be senior executive representation from the SNMMI and EANM at the ANZSNM Annual Scientific Meeting in Adelaide, including the current President of the SNMMI, Dr Gary Dillehay.

Planning is also underway for the leadership of the WFNMB to be assumed by Prof Andrew Scott and his executive in 2014, at the WFNMB congress. Initiatives for the WFNMB to be more engaged in developing strategic policies and programs for teaching, training and quality engagement with the IAEA and WHO leading up to the WFNMB congress are being pursued.

Andrew Scott Chair of the IRC

13

Technical Standards Committee

(TSC)

ANZSNM Software Quality Assurance website An online software tool has been developed for evaluating clinical software. The software, which is currently a beta version, has 2 primary functions: (1) to enable audits of clinical software to be more easily performed and (2) to allow users to test their processing skills against previously audited data.

Audits Clinical software should be evaluated to ensure its accuracy and reproducibility and audits can be used as part of this process. Audits can be used for benchmarking against national/international standards or for internal validation of new software releases. The new website tool is designed to facilitate the audit process, which can be time-consuming using standard methods. It can be used for national ANZSNM audits, or for local/department audits.

Administration Several mechanisms are available to delegate administration of the site. A user can initiate a new software audit (using current datasets) by registering a request to the site administrator. The user can also be given privileges to administer existing audits. Once an audit is completed the administrator is able to download the results in a format suitable for statistical analysis.

Training This mode, which uses the results from a previous audit, will be particularly useful for new staff. Participants are provided with an immediate online report after data entry â&#x20AC;&#x201C; a statistical comparison of their data with the audit results.

Datasets A gated blood pool dataset will be used for initial beta testing of the site. Other datasets (Interfile and DICOM format) are planned â&#x20AC;&#x201C; eg. renal.

Beta testers have been selected to evaluate the site, but you can click on following link to try it out! http://apps.anzsnm.org.au/ss/ Peter Collins Chair Robert Barnett Site Developer/Member Software Quality Working Group Technical Standards Committee ANZSNM

14 Gamma Gazette March 2014

Accreditation Congratulations to the following departments which were granted Accreditation or Re-Accreditation for the training of PDY Technologists: Royal Melbourne Hospital 37 Sir Charles Gairdner Hospital 43 Illawarra Nuclear Imaging 92 Shoalhaven Nuclear Imaging 93 Central Gippsland Health Service 115 PRP Diagnostic Imaging, Cumberland 140 PRP Diagnostic Imaging - Dubbo 147 Benson Radiology, Nuclear Medicine 149 Christchurch Hospital Nuclear Medicine Dept 57 Kanwal Nuclear Medicine 112 Royal Brisbane & Women’s Hospital 29 Wangaratta Nuclear Medicine 3 Peter MacCallum Cancer Centre 38 Lyell McEwin Hospital 131 Northern Hospital Radiology 102 Campbelltown Nuclear Medicine 129 Qld X-Ray, St Andrews Toowoomba Nuclear Imaging 42 Royal Hobart Hospital 60 Queensland X-ray St Vincent’s Toowoomba 110 SKG Nuclear Medicine, Subiaco 128 MIA Werribee Radiology 156

16 Gamma Gazette March 2014

Congratulations to the following technologists who were granted Accreditation: Cassandra Maree Mulcahy Melanie Dela Cruz Todd Strickleton Christopher Travis Poonam Sherma Helen Pipilakis Nermina Hasanbergovic Thuy Le Sarah Jesudason Alesandra Corey Monique Adele Auciello Allen Sivarajah Felicity Cottrill Bianca Maree Greco Emily Kate O’Kearney Qing Ya Yao Jacqueline Liselle Walker Kimberley Jane Caslick Amy Ellen Blanch Christopher James Anderson Aishling Barrett Danielle Kate Lutze Kayla Rogerson Ilijana Milivojevic Sarah Daniel Christopher Sharpe Todd Strickleton Sean Cranney Christopher Travis Jessica Bryan Seyed Amir Aghaei Meybody Rhys Whitelock Georgia Lee Reid Emma Elizabeth Dodd

Vale

Kevin Thomas Murphy January 15 1962 â&#x20AC;&#x201C; January 21, 2014 Kevin was laid to rest at the Northern Suburbs Memorial Gardens January 28 2014. Kevin passed away peacefully at Royal North Shore Hospital leaving behind his parents, a brother and two sisters.

Kevin arrived in Sydney in 1987 with a two year work visa and dreams of fun and adventures. Kevin developed such a strong connection to Australiaâ&#x20AC;&#x2122;s people and places that he officially became a citizen of his new homeland in January of 1992.

Kevin worked as a Nuc Med. Tech at Royal North shore Hospital and worked for numerous companies over the past 26 years. He was well known and liked by many and will be sorrowfully missed.

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ANSTO to help supply the world with nuclear medicine 2013 was another amazing year for ANSTO marked by some important milestones, award winning research and cutting-edge science. We celebrated the 60th anniversary since the passing of legislation that led to the establishment of Australia’s home of expertise in all things nuclear, at Lucas Heights in Sutherland Shire. ANSTO also took the helm of the iconic Australian Synchrotron in Melbourne, bringing two of Australia’s most significant pieces of scientific infrastructure together advancing scientific outcomes for the nation in environmental, manufacturing mining, medical imaging and carbon dating research.

Importantly for the future of nuclear medicine, both in Australia and beyond, in 2013 ANSTO received approval from the independent regulator, the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) for its new Molybdenum-99 (99Mo) production facility. The $168 million plan will position ANSTO at the centre of the global fight against cancer and heart disease, and will be established at the Lucas Heights campus.

There are two main elements to the plan: • An export scale nuclear medicine manufacturing plant. This will secure Australia’s ability to produce 99Mo long into the future. The increased capacity will meet current and future domestic demand and still leave a significant proportion of product available for export which will support global demand. 99Mo is the parent isotope to Technetium (99mTc) and is primarily used for diagnosis of heart disease and cancers. Currently in Australia each year 550,000 people receive a diagnosis using 99Mo/99mTc, whereas the world demand is for 45 million doses a year. Australian 99Mo is produced using low enriched uranium which is part of the global push towards non-proliferation.

• A Synroc waste treatment plant. Synroc is an Australian innovation that can reduce the volume of nuclear byproducts by 99% (compared to other methods such as cementation) and which will deliver a permanent, safe and economical way of treating waste from past, current and future manufacture of nuclear medicines. The Synroctreated waste will be sent to the national radioactive waste management facility once it has been sited, constructed and licensed.

Why establish a new Mo-99 production facility @ ANSTO? Medical diagnostic imaging techniques using technetium-99m

18 Gamma Gazette March 2014

(99mTc) account for approximately 80% of all nuclear medicine procedures. Disruptions in the supply chain for this medical isotope – which has a half-life of 66 hours for 99Mo and 6 hours for 99mTc, and thus must be produced continually – can lead to cancellations or delays in important medical tests.

Unfortunately, supply reliability has declined over the past decade due to unexpected or extended shutdowns at the few ageing, 99Mo-producing research reactors and processing facilities. These shutdowns have created conditions for global supply shortages. World shortages of the radioisotope 99Mo, will continue to occur due to ongoing challenges to the operators of ageing nuclear reactors, and will increase significantly in 2016 with the closures of the National Research Universal reactor (Canada) and OSIRIS reactor (France), who currently supply approximately 45% of global demand. Current studies forecast that from 2016 the shortages will recur.

In reality there is not a “world market” for 99Mo but a series of geographical markets that are dominated by long established providers. The major market is US/Canada (47%) followed

by Europe and Japan. The Asia Pacific market is fragmented, however developing country markets, particularly China, India and Latin America are set to grow.

The last five years have shown that new entrants (including ANSTO), with commercial approaches can make significant inroads based on the need of suppliers to ensure diversity of supply.

The recent supply shortages have highlighted the fragility of the supply chain. This has led to changes in the price structure and the coordination of reactor schedules, to better serve the global nuclear medicine community. It has also shown that there is a considerable price upside as the cost of 99Mo is a very small fraction of the cost (and reimbursement) of imaging procedures.

It is useful to understand the global supply situation however irradiation capacity presents a partial picture and does not

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ANSTO to help supply the world with nuclear medicine

SUPPLY CHAIN OVERVIEW

1. Nuclear reactors irradiate highly enriched uranium (HEU) targets to create Mo-99.

Globally, there are 54 research reactors producing radioisotopes. Only 5 of these produce the majority of the world supply of Mo-99. NRU (Canada), HFR (Netherlands), BR2 (Belgium), OSIRIS (France) and Safari (South Africa).

2. The targets are shipped to specialised Mo-99 processing facilities across the globe.

95 - 98% of the worldâ&#x20AC;&#x2122;s supply of Mo-99 is produced by 4 companies based in Canada, Netherlands, Belgium and South Africa.

account for geographical limitations relating to the production of bulk 99Mo and generator manufacturers. Not all 99Mo-irradiating reactors have associated processing facilities, which results in regional constraints on processing production and loss of product through higher decay during transportation.

The Australian Scene Fortunately for the nuclear medicine community in Australia it has been largely insulated from the global supply issues. ANSTO owns and operates the newest 99Mo-irradiating reactor in the world, which is operating at an average of 300 days per year for the past three years. ANSTO also houses the associated 99Mo processing facilities; and a 99mTc generator production facility which enables timely and efficient utilisation of the isotope from production to patient. ANSTO also have established backup supply agreements which ensure that 99mTc generators can be produced when OPAL is undergoing routine maintenance work.

The new 99Mo processing facility will be established with a design life of 25 years, supporting ANSTOâ&#x20AC;&#x2122;s commitment to nuclear medicine in Australia and New Zealand for many years to come.

3. The targets are processed to extract either pure or raw Mo-99.

Waste is transferred to a waste treatment facility, and ultimately to a long term storage facility.

4. The processed Mo-99 is shipped to Tc-99m generators manufacturers.

Mo-99/Tc-99m generator manufacturers (Covidien, Lantheus Medical Imaging, GE Healthcare, IBAMolecular, NTP) then sell onto nuclear pharmacies and hospitals. ANSTO also manufacture and sell their trademarked Gentech generators.

5. Nuclear pharmacies and hospitals use the generators to compound and dispense technetiumbased products for administration to the patient.

19

ANZSNM Research Grant Recipient 2014 The ANZSNM Scientific Advisory Panel (SAP) received a number of quality applications for the 2014 ANZSNM Research Grant.

The Grant is funded with the aim of supporting investigation, clinical projects or experimentation aimed at the discovery and interpretation of facts or the development or application of theories in the field of Nuclear Medicine/ Molecular Biology.

Clinical projects are defined as projects that centre on groups of patients or other human subjects. It is recognised that clinical and collaborative arrangements may dictate that some aspects of work funded may be carried out at other sites.

Following an assessment process managed by Dr Vijay Kumar (SAP) the Research Grant was awarded to Dr Kenny Sek, Nuclear Medicine Physician and Associate Professor Ros Francis from the Nuclear Medicine Department of Sir Charles Gairdner Hospital Perth.

A pilot study of the utility of combination F18fluorodeoxyglucose and F18- fluorocholine positron emission tomography imaging in hepatocellular carcinoma An overview by Dr Kenny Sek Hepatocellular carcinoma (HCC) is the 5th most common cancer in men and 7th most common in women worldwide. The worldwide incidence of HCC is growing. Despite recent advances in therapeutic options, only a small proportion of patients have a realistic chance of cure at time of diagnosis. Patients who are incurable often succumb to the disease within 3 to 6 months. There is therefore a need for further research into new diagnostic, staging and prognostic techniques in order to optimise management options and improve patient outcome.

PET has been used in HCC imaging since the 1990s but is yet to have its role well defined. F18-fluorodeoxyglucose (FDG) has poor sensitivity in HCC diagnosis (50-70%). This is mainly because well differentiated HCC retains similar enzymatic activity to normal hepatocytes leading to low FDG accumulation and a false negative result. In poorly differentiated HCC, normal hepatocyte function is lost and therefore higher FDG uptake is often seen, i.e. higher SUV values. These tumours are also more likely to metastasise. F18-FDG PET therefore has a role in assessing tumour differentiation and evaluation of metastatic disease in select cases. F18-FDG PET is superior to CT in assessing residual or recurrent tumour after locoregional

Case example 52 year old man with hepatitis C related liver cirrhosis. Surveillance ultrasound detected a segment 7 lesion. MRI findings were consistent with HCC. He had RFA treatment and biopsy performed at the time showed well differentiated HCC.

20 Gamma Gazette March 2014

therapies and may guide further treatment. There is suggestion that F18-FDG PET can also predict microvascular invasion which is a poor prognostic feature in HCC. The low sensitivity of F18-FDG PET can be mitigated by the addition of a second tracer. PET tracers of lipid metabolism such as C11-choline and C11-acetate have been shown to accumulate in well differentiated HCC and may have a complementary role to F18-FDG. F18-fluorocholine (FCH) is a choline analog and is more readily available, has a more convenient half-life and has better imaging characteristics compared to C11-based tracers. There are only three published studies to date evaluating the role of F18-FCH combined with F18-FDG PET in HCC imaging, all performed by a French group.

F18-FCH was found to be significantly more sensitive in HCC detection, particularly in well differentiated HCC and proposed to be able to predict microvascular invasion and early recurrence following surgical resection.

Our pilot prospective study will assess the utility of F18-FDG and F18-FCH PET imaging in HCC with four main aims.

1. To define the sensitivity and specificity of combined F18-FDG and F18-FCH PET compared to conventional imaging (CT or MRI) 2. To define the accuracy of combined PET in predicting tumour differentiation and presence of microvascular invasion in HCC 3. To examine whether pre-treatment combined PET predicts time to progression and survival in HCC over a 2 year follow up period 4. To investigate the role of combined PET in predicting treatment response, disease progression and recurrence post RFA or TACE We aim to recruit 30 patients and have so far enrolled 8 patients. A case example is illustrated below. If initial results are encouraging, it is likely that these patients will be transferred into larger studies with broader aims and higher patient numbers. Funding for these larger studies will be sought from national bodies using the data generated from this pilot study.

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My first EANM Annual Congress Rhonda Harrup, Nuclear Medicine Technologist, Fremantle Hospital, WA

Last October I attended my first EANM Congress in Lyon.

Earlier last year, a few Techs from Freo decided we needed to escape the walls of the Nuclear Med Department (not to be confused with the prison which is just up the road). We decided to combine the EANM Congress with some extended travel. (In Jennifer’s case, it was much extended.) We did our research, although none of us were presenting (actually Antonio did all the research) and we decided to join the EANM. The European Association of Nuclear Medicine (EANM) is the umbrella organization of Nuclear Medicine in Europe.

The goal of the EANM is to provide a suitable medium for the dissemination and discussion of the latest results in the field of Nuclear Medicine and related subjects. It was founded on 6th September 1985 in London. It is incorporated in Vienna and its activities extend throughout Europe.

In 1999 EANM membership was opened to Nuclear Medicine Technologists. Since their inclusion in the association their activities have continuously widened and Technologist membership has now increased to over 300. In recent years the wider EANM membership has risen to over 3200 individual members who are Physicians, Scientists, Technologists or other persons working in Nuclear medicine or related fields.

At EANM ’13 the association launched its new logo to include ‘Biomedical Imaging and Therapy for Personalized Healthcare’ to reflect the current trends in Nuclear Medicine.

EANM membership fees for Technologists in 2013 were 130 EURO which included hard copy subscription to the European Journal of Nuclear Medicine and Molecular Imaging (EJNMMI). Membership with on-line access to the EJNMMI was 110 EURO and 40 EURO with no Journal access.

Membership to the EANM also provides access to various e-learning activities. The European School of Nuclear Medicine (ESNM) also holds courses at its Vienna headquarters (fees are charged).

Joining the EANM meant my registration fee for EANM ’13 was only 80 EURO. This represented great value as it included entry to the welcome reception as well as day passes throughout the congress for public transport to and from the venue.

My EANM ’13 experience began in Paris after persuading Deanie’s hubby to let her join me as my conference buddy.

We arrived a few days prior to the start of the Congress, and managed to squeeze in a few compulsory Parisian sites (and food).

We travelled south to Macon via TGV and drove to Tournus spending a few nights sampling the areas gastronomic delights. Tournus, in the Burgundy region is famous for its Abbey, as well as the number of Michelin star restaurants in town. Escargot was on the surprise degustation menu. It was surprisingly nice. We also visited some local wineries and Chateaus.

We arrived in Lyon via Gare de Lyon Part-Dieu where our hotel was located just a few minutes’ walk from the station.

We were very impressed to see the EANM signage throughout the station directing delegates to the appropriate bus stop outside. There was also an EANM information/help desk situated inside the station.

We had drinks in Jennifers (party) room and eventually

u 22 Gamma Gazette March 2014

made it to dinner after I managed to get everyone lost. (David is always right) Deanie was annoyed that everyone kept popping out to the casino without her. We didn’t tell her that Antonio actually did sneak out to the real one.

We chose not attend the pre-Congress Symposia, preferring to spend our money at the nearby shopping centre.

That evening we made our way by bus to the Congress Centre and picked up our ‘dag bags’.

The EANM ‘13 venue, Cité Internationale or Centre de Congrès, Lyon was very impressive, situated between the Rhone River and the Parc de la Tete d’Or. EANM ‘13 was opened by the Congress president Dominique Le Guludec, Professor of Biophysics and Nuclear Medicine at University Paris 7. She is head of the Department of Nuclear Medicine at Hôpital Bichat.

The opening ceremony was held in the Amphitheatre where the plenary sessions were held. We were entertained by orchestral movie themes celebrating the Lumière brothers from Lyon who are credited with capturing the world’s first motion pictures. The welcome reception followed, where we were presented with a magnificent array of culinary delights throughout the amphitheater.

Over 5000 delegates attended the EANM ’13, primarily from Italy, France and Spain. The rejection rate for abstracts was around 16 percent. There were many parallel sessions making it difficult to choose which ones to attend.

If anyone is feeling intimidated at the thought of presenting at a conference, then the EANM Congress provides a good opportunity. Presentations are in English and while most struggled through admirably, the phrase “Sorry, I don’t understand the question” became a common catch cry, rescuing many potentially doomed presenters.

The WA attendees agreed that the quality of presentations at our local ANZSNM Scientific meetings were of a higher standard than those of the EANM in comparison. (With the exception of Tatiana’s, of course who was our only WA presenter.)

The second day we attended the Technologists’ session after bumping into a familiar face on the bus (actually it was his voice we recognised) Both Deanie and I worked with Dr Ralph McCready at the Royal Marsden Hospital in Sutton, Surrey. (Deanie, many years before me). He was presenting at the Tech’s session and asked us to come along to support him. We were glad of this afterwards, as we discovered that free lun ches were provided in the Tech’s sessions.

Dr McCready has produced a website that may be of interest to some of you. Nucmed-memories.com The EANM produces a book each year in the form of a “Technologist’s Guide’. The 2013 edition, titled Radionuclide Metabolic Therapy Clinical Aspects, Dosimetry and Imaging was launched and handed out at the Tech’s session. On-line copies of the books are available to EANM Members on their website. Eanm.org The industry exhibitions were a highlight.. My favourite display (without prejudice…Thanks for dinner BTW Tim) was from Siemens, complimenting their latest cameras with two extremely realistic half bodies. Many, myself included, could not resist the temptation to touch them, needing to make certain they were not real. They also had a giant head, frightening onlookers, moving his eyes and raising his eyebrows as they walked past. There were many other displays, but too numerous to mention.

The exhibition was also a great place to grab a coffee (and a Chocolate

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Koala from the ANZSNM stand).

There was of course the corporate dinners. ANSTO kindly invited us to attend their annual dinner. For 2013 it was held at the Paul Bocuse Brasserie where we got to chat with fellow Aussie delegates in a relaxed atmosphere, enjoying some wonderful food and wine. (Thanks ANSTO). Jennifer wanted to ensure there was no Andouillette on the menu.

Unfortunately the ANSTO dinner clashed with the Siemens Dinner which was held at a Chateau just outside of Lyon. I heard from reports that it was a fantastic night.

The Congress was held over a 3 and half days, from Saturday to Tuesday with the Pre-Congress symposia on Friday. I mostly attended sessions pertaining to my current interests, which were breast and sentinel node imaging, neuroendocrine tumours, radionuclide therapy and dosimetry and cardiac MIBG imaging. It was exciting to see emerging technologies such as Pet Mammography (PEM). Apologies for the lack of technical content as I decided for the first time at a conference not to take notes. Abstracts can be found on the EANM website. eanm.org

24 Gamma Gazette March 2014

It was interesting to note that doses in Australia tend to be lower than that of our European counterparts, in particular for sentinel node scintigraphy. I was also made aware of the fact that Nuclear Medicine Technologists in Australia are given more responsibility, with respect to undertaking tasks, such as intravenous injections and quantitative analysis, which in some European departments are performed by Nuclear Physicians. (BTW Bill works in none of these) I first learned of this on a visit to the European Institute of Oncology in Milan in June last year. This is reflected in the remuneration for Technologists (in Italy, at least) compared to those in Australia.

The closing ceremony was held around Midday on the 4th day, where they presented the Congress Awards and introduced EANM â&#x20AC;&#x2122;14 Congress president Wim Oyen. (left) EANM â&#x20AC;&#x2122;14 will be held in Gothenburg, Sweden The rest of our stay in Lyon was spent sightseeing before travelling to Aix-en-Provence for a few days prior to returning to Perth. I now look forward to my next EANM Congress and wonder why I waited so long to attend my first.

Australian Supply of Lutetium-177 From the middle of 2014, ANSTO Health will be producing the radiochemical Lutetium-177 Chloride at the Lucas Heights campus. ANSTO personnel are currently finalising GMP validation and working closely with regulators to receive final approval.

Clinical trials show that Lutetium-177-dotatate (Lu-177) therapy has been very successful in treating some people with neuroendocrine tumours. A number of Australian hospitals, including Fremantle Hospital and the Peter MacCallum Cancer Centre, have been global pioneers with this investigational therapy.

Neuroendocrine Tumours (NETs)

Neuroendocrine tumours: a Guide for Nurses, National Centre for Neuroendocrine Tumours, NET Nurse Task Force, 2012 Though considered to be a rare tumour type, neuroendocrine tumours affect around 8000 Australians, with approximately 750 new cases diagnosed each year. Onset is insidious with non-specific symptoms, meaning that many people are not diagnosed until they have reached a metastatic phase of their disease.

Imaging neuroendocrine tumours with Gallium-68dotatate has greatly assisted with the diagnosis and staging of these cancers.

Therapy can then take several forms, with peptide receptor radionuclide therapy (PRRT) being one of them. Here, Lu-177 is used to radiolabel a peptide (usually dotatate) and this combination is administered to patients. The combination 26 Gamma Gazette March 2014

is attracted to receptors on the tumour where it attaches and releases radioactivity, making it a very focused and specific therapy for tumours.

Recent data published by Prof Harvey Turnerâ&#x20AC;&#x2122;s team at Fremantle Hospital have shown progression-free survival of 31 months following Lu-177-dotatate therapy (Claringbold et al, 2012).

Lu-177 in Australia will be non-carrier-added The ANSTO production facility will focus on making the noncarrier-added (n.c.a.) form of 177LuCl3. This is chemically more complex, however provides a superior product with higher specific activity.

High specific activity leads to higher labelling efficiency, allowing the use of less peptide; longer shelf-life; and greater time flexibility for labelling and treating patients The n.c.a. method also limits the amount of the metastable long-lived isotope Lu-177m (half-life 160 days) that is present.

Producing Lu-177 n.c.a. requires irradiation of Ytterbium-176, followed by chemical separation processes using resin columns. The required activities are dispensed into vials and terminally autoclaved, providing a sterile GMP product. The half-life of 6.6 days greatly assists the logistics of production, transportation and use at the clinic.

Importantly, ANSTO will be able to make around 1 TBq of Lu-177 n.c.a. per production run. This is sufficient to provide therapy for around 100 patients. Having a local supply will eliminate the need to import this radioisotope from Europe.

Global security of supply The ANSTO facility will use proven technology developed by the German company, Isotope Technologies Garching (ITG).

In fact by the end of 2014, there will be three production

u

facilities making identical forms of Lu-177 n.c.a. These are ITG (Germany, using the FRMII reactor), ANSTO (Australia, using the OPAL reactor) and NTP (South Africa, using the SAFARI reactor). Having three independent facilities producing an identical radiochemical forms an important part of a global commitment to an uninterrupted supply of Lu-177 n.c.a.

Reactor schedules have been designed to be complementary and ongoing communication between the three sites ensures confidence around back-up supply.

References 1. Claringbold P et al. Cancer Biotherapy and Radiopharmaceuticals 2012, 27(9):561-9.

2. Forrer F et al. Journal Nuclear Medicine 2013, 54:1045â&#x20AC;&#x201C; 52.

3. Neuroendocrine tumours: a Guide for Nurses, National Centre for Neuroendocrine Tumours, NET Nurse Task Force, 2012. http://www.carcinoid.org/content/ neuroendocrine-tumors-guide-nurses

Future The local production of a new therapeutic agent represents a landmark for ANSTO, and an important milestone for cancer therapy.

In the first instance, Lu-177 n.c.a will be combined with dotatate and used to treat neuroendocrine tumours. Because of its ability to label a number of antibodies and peptides that target tumours in the body, Lu-177 n.c.a will also be a valuable tool for clinical research into a range of other cancer therapies. For example, several publications have already reported early phase clinical trials of Lu-177-dota-rituximab in the treatment of lymphomas. (Forrer et al 2013).

As well as becoming an important global provider of Mo-99 through our nuclear medicine project, ANSTO is very excited to be driving this project that is anticipated to will provide a treatment option for numerous cancer sufferers in the years to come.

It should be noted that Lu-177 is an unregistered, investigational radiochemical. Therapy for patients requires additional radiochemistry in the clinic.

For any enquiries around this, please contact Jane Langford at ANSTO on 02 97179550 or jane.langford@ansto.gov.au

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Theranostics: Hot science, cold facts A joint symposium, Theranostics: Hot Science, Cold Facts was held by the ANZSNM Physics SIG and Radiopharmaceutical Science SIG at the Austin Hospital in Melbourne on February 14, 2014.

The use of complementary molecular targeting vectors for radionuclide imaging and therapy defines the field ofnuclear medicine Theranostics. Chair of the Physics SIG, Darin O’Keefe and Chair of the Radiopharmaceutical SIG Jennier Guille believe this growth area of Nuclear Medicine has great potential, but as simple as Theranostics may first appear, this field is complex and full of knowledge traps. They designed the Symposium to bring together a national collection of internationally recognised scientists and clinicians to introduce and detail this important area of clinical practice.

Over 100 members attended the symposium from all over Australia and with several delegates from NZ. The intensive full day program consisted of a range of presentations within four sessions themed: • The Elegance of therapeutic Pairs; • 68GA and 177 Lu: The New Kids on the Block; • Theranostic Physics: Imaging, Dosimetry and Safety; and • Delivering Theranostics – Experience Across Australia.

Session Chairs included Andrew Scott and Harvey Turner, Jennifer Guille and Peter Roselt, Dale Bailey and Darin O’Keeffe, Rodney Hicks and GraemeO’ Keefe.

The Organising Ccommittee would like to thank the Sponsors who provided valuable support to the Symposium.

Their support enabled the SIGs to provide an excellent professional development opportunity for a small registration fee. Delegates in attendance were entitled to 6.5 CPD hours.

ANZSNM Theranostics Symposium 2014 Sponsors: • Global Medical Solutions Australia • IDB Holland bv • Siemens Ltd Australia & New Zealand • ANSTO • IMAXION Pty Ltd • GE HealthCare Australia Pty Ltd

28 Gamma Gazette March 2014

Diary dates Email the Production Editor at the Secretariat on secretariat@anzsnm.org.au to list your upcoming conference and meeting dates on the diary page.

2014 25-28 April ANZSNM 44th Annual Scientific Meeting Adelaide, South Australia 12-14 May Molecular Imaging Meeting Odense, Denmark 22-25 May 8th European Symposium on Paediatric Nuclear Medicine Girona, Spain 7-11 June SNMMI Annual Meeting St Louis, Missouri, USA 26 July TSIG Symposium Queenstown, New Zealand

PET/CT in Radiotherapy Planning Melbourne, Australia 18-22 October EANM Annual Congress of the European Association of Nuclear Medicine Goteborg ,Sweden

2015 17 – 20 April 2015 ANZSNM 45th Annual Scientific Meeting Brisbane, Queensland 31 Oct – 4 Nov 2015 AOFNMB 2015 Asia Oceanic Congress of Nuclear Medicine and Biology Jeju, Korea

2 August WA Annual Workshop University Club, UWA 22-31 August 11th Congress of the World Federation of Nuclear Medicine and Biology. Cancun Mexico 4-7 September 2014 Combined Scientific Meeting incorporating ANZSNM workshop:

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Case Study

Autonomous hyperfunctioning sublingual thyroid tissue in a patient with congenital hypothyroidism, resulting in hyperthyroidism suggestive of Graves’ disease Colin Mercer Canberra Imaging Group BACKGROUND Congenital hypothyroidism presents in approximately 1 in 3,500 new births, or 70 babies annually in Australia (Coakley & Connelly, 2006). The most common cause is thyroid dysgenesis where the thyroid gland fails to develop properly. In these cases the thyroid gland may be absent or ectopic. Routine screening of newborns with congenital hypothyroidism present with low recorded thyroxine (T4) and triiodothyronine (T3) hormones. Treatment of congenital hypothyroidism consists of thyroxine replacement shortly after birth for life.

Ectopic thyroid tissue is a rare presentation, resulting from anomalies in the embryological development of the thyroid gland. It occurs in 1 per 100,000-300,000 people, however it rises to 1 per 4,000-8,000 patients where thyroid disease is present (Noussios, G. et al, 2011).

The location in these cases can be anywhere along the embryologic development pathway, including the tongue, lateral neck, mediastinum, and the sub-diaphragmatic organs (Noussios, G. et al, 2011).

Unlike congenital hypothyroidism where there is low levels of T3 and T4, Graves’ disease causes the thyroid gland to overfunction. It is an autoimmune disease that is characterised by antibodies that behave similarly to thyroid stimulating hormone (TSH). These antibodies stimulate the TSH receptors, and result in the thyroid gland producing high levels of thyroxine, often producing symptoms of hyperthyroidsim.

INTRODUCTION The following case report presents a patient with congenital hypothroidism, who developed thyrotoxicosis, and following 99mTc thyroid imaging demonstrated functional sublingual thyroid tissue, with uptake and blood tests consistent with Graves’ disease.

CASE REPORT A 31-year-old female with a history of congenital hypothyroidism, developed symptoms consistent with hyperthyroidism over a number of months. Symptoms included tremors, tachycardia, palpitations, sleeping difficulty, and fatigue. Her blood test results revealed high levels of T3 and T4, with very low readings of TSH. The patient had been taking thyroxine since birth, which had been

very stable and well controlled during her life, up until her onset of recent symptoms.

It was deemed necessary to conduct a 99mTc thyroid scan to evaluate possible causes for the sudden change in hormone levels.

The patient was not required to cease thyroxine for the normal 4-6 weeks, as any functioning thyroid tissue identified, would be deemed to be functioning outside the normal negative feedback control mechanisms.

Twenty minutes following the injection of 99mTc, planar neck, whole body, and SPECT/CT images were acquired. Anterior and left lateral planar images in Figure 1, demonstrates a focal area of abnormal tracer accumulation in the area just below the base of the tongue, with normal salivary gland uptake. There is absent uptake in the thyroid bed consistent with congenital hypothyroidism. Whole body imaging in Figure 2 demonstrated normal physiological uptake throughout the remainder of the body. SPECT/CT in Figure 3 demonstrates a focal area of abnormal tracer accumulation, and localises the uptake to the base of the tongue.

Figure 1: Focal uptake seen in the area just below the base of the tongue.

DISCUSSION Following the 99mTc thyroid scan, the hyperfunctioning ectopic thyroid tissue was localised to the base of the tongue. As the patient was on thyroxine, and the lesion did not demonstrate any suppresion from the current thyroxine treatment, it was suggestive of functional thyroid tissue operating outside the normal negative feedback system. With consultation with the referring endocrinologist, the clinical diagnosis

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Autonomous hyperfunctioning sublingual thyroid tissue in a patient with congenital hypothyroidism, resulting in hyperthyroidism suggestive of Graves’ disease

Figure 2: Normal physiological uptake throughout the remainder of the body.

Tranverse

Coronal

Sagittal of Graves’ disease was made.

Follow up antibody testing was arranged to confirm the diagnosis, and the patient ceased thyroxine from the date of the scan. The treatment of Graves’ disease was withheld until accurate T3 and T4 levels could be established following the cessation of thyroxine. It was hoped that the small amount of functional thyroid tissue at the base of the tongue, coupled with the addition of Graves’ disease, would be sufficient to supply enough thyroid hormones for the patient. Depending on follow up T3 and T4 blood test results, either thyroxine replacement or treatment for Graves’ disease may need to be administered.

Figure 3: SPECT/CT demonstrates focal uptake at the base of the tongue.

REFERENCES Coakely, J., & Connelly, J. (2006). Congenital Hypothyroidism.

Retrieved from www.apeg.org.au/portals/0/resources/ congenitalhypothyroidism.pdf Noussios, G., Anagnostics, P., Goulis, D. G., Lappas, D, & Natsis, K. (2011). Ectopic thyroid tissue: anatomical, clinical, and surgical implications of a rare entity. European Journal of Endocrinology, 165, 375-382. doi:10.1530/EJE-11-0461

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Interesting Case

Update on the QUEST international clinical study for determining the dose-response relationship in 90Y SIR-Spheres treatments: Towards individualising radioembolisation therapy Kathy Willowson1, Dale L Bailey2, Michael Tapner3 and Steve Jones3

QUEST (Quantitative Uptake Evaluation in Sir-spheres Therapy) is an investigator driven initiative to work towards a standard approach to imaging and dosimetry in 90Y SIR-Spheres internal radionuclide therapy (SIRT). The study is a direct collaboration between investigators at Sydney University, Royal North Shore Hospital (RNSH) and Sirtex Medical, the North Sydney based manufacturer of SIRSpheres, and is currently funded through an ARC Linkage Project.

The primary aim of the study is to investigate the dose-response relationship associated with SIRSpheres treatment for liver cancer. Dose distribution maps will Figure 1: Baseline FDG PET scan demonstrating extensive liver disease (upper); Follow-up FDG PET be determined from quantitative 90Y scan demonstrating significant response in the liver at 8 weeks post-therapy with SIR-Spheres (middle); PET imaging, whilst response will be 90 Y PET scan of the liver 24 hours after implantation of SIR-Spheres showing dose distribution (lower). assessed on both functional FDG PET data (PERCIST approach) and from around the world participating in data contribution for the early anatomical contrast-enhanced CT data (RECIST approach). In the phase of the study â&#x20AC;&#x201C; site assessment. The site assessment is set to broader sense, the study is part of a complimentary investigation into establish which sites can produce quantitative and comparable 90Y the possibility of a new treatment planning approach for optimisation PET data on their current systems, and so which sites will participate of radioembolisation. An example of the type of data that will be in the clinical phase of the study. The site assessment phase acquired in the QUEST study is shown in figure 1, with baseline and is a large scale standardisation study, with the goal of producing follow-up FDG PET/CT scans acquired guidelines for optimised acquisition and reconstruction parameters on the same system as has been used to map the distribution of the for 90Y PET on different vendor and generation scanners in order to 90Y SIR-Spheres after implantation. In the example shown, at followachieve comparable quantitative accuracy. up 8 weeks after SIRT there has been virtually complete resolution of The site assessment has consisted of a strict experimental the FDG-avid lesions seen prior to treatment. protocol followed by all centres, imaging 90Y solution in the NEMA While QUEST began as a small study intended for RNSH, the need IEC body phantom over a one week period during activity decay. for statistically significant numbers saw QUEST extended to other All reconstructed data have been submitted to the core laboratory sites. As of today, the QUEST study currently has more than 40 centres at RNSH for analysis by a single researcher (KW), using identical software and techniques, to provide as much consistency as possible. To date, 207 data sets have been submitted, each 1. Institute of Medical Physics, University of Sydney, consisting of four images acquired over a one week period, from a Camperdown, 2006 NSW total of 41 different sites, acquired on 55 different scanners. Data 2. Department of Nuclear Medicine, Royal North Shore Hospital, have been submitted from all three of the major vendor scanners St Leonards, 2065 NSW 3. Research and Development, Sirtex Medical, North Sydney, 2060 NSW (GE, Philips and Siemens), on a variety of systems (both time of flight and non-time of flight capabilities).

Contact: kathy.willowson@sydney.edu.au There are still several sites to contribute as the preliminary

u 32 Gamma Gazette March 2014

Update on the QUEST international clinical study for determining the dose-response relationship in 90Y SIR-Spheres treatments: Towards individualising radioembolisation therapy

Figure 2: Example of recovered concentrations in CT-defined volumes of interest for the different diameter hot-spheres in the IEC Body Phantom. Comparable results from TOF scanners from all three vendors can be seen, as well as the positive impact of 3D vs 2D iterative reconstruction on a non-TOF scanner. phase of the study draws to a close. The numbers involved in the site assessment reflect the high level of interest internationally that the study has generated, largely due to the generous support from Sirtex, and the intense academic and clinical interest in the study and the possible outcomes that may follow. The majority of sites are from Europe and USA, including Harvard Medical School, Johns Hopkins University, Memorial Sloan Kettering Cancer Center, MD Anderson Cancer Center, Oxford University Hospital, and many more prestigious sites. There have also been contributions from Hong Kong and Singapore, and several Australian sites. Preliminary findings suggest consistency between all current generation scanners from the main vendors (figure 2), with varying degrees of diminished performance for Y-90 imaging seen in older models without resolution recovery and time of flight. In particular, previous software employing 2Donly OSEM reconstruction results in large deterioration of quantitative ability. Recall that the positron fraction from the decay of 90Y yields only 32 positrons per MBq (or 32 ppm) which means that scanner sensitivity is a crucial factor in determining the overall performance. There are also suggestions that consistent under- estimates of concentration recovered in spheres containing higher concentration of 90Y than in the background are a result of the large random coincidence fraction arising from the Bremstrahlung radiation seen when imaging the less

than ideal 90Y, and the inability of the reconstruction algorithm to deal with these without introducing image bias.

Work has begun at RNSH to establish the most appropriate clinical protocol for participating sites to follow. This involves baseline imaging with both contrast-enhanced CT and FDG PET, followed within a 3 week period by therapy work-up (in the form of a [99mTc]-MAA shunt study) and SIR-Spheres treatment itself. Followup imaging is performed at approximately eight weeks with FDG PET and three months with CT. All clinical image analysis is performed on the dedicated (FDA approved) 90Y dosimetry platform, DosiSOFT (Cachun, France) at RNSH (figure 3). The software allows for image co-registration and fusion, segmentation of hepatic lesions and healthy liver on both anatomical and functional data as well as dose map generation through dose kernel convolution with the associated dose volume histograms.

The final clinical protocol is expected to be shaped by a panel of international investigators who have been involved in the trial development. The study will not involve any changes to the patient treatment, but is rather a post hoc data collection exercise, which may involve additional imaging (the follow-up FDG PET). Site assessment is expected to be closed by March 2014, and results presented at the coming nuclear medicine meetings (SNMMI and EANM).

The clinical data collection phase of QUEST is scheduled to begin late 2014 following finalisation of the required protocol to fit with both European and American regulations, as well as ethics approval from each site.

Sirtex Medical have been an avid contributor to the study in many ways, and the interest that has been gained in the study at the global level through a number of invited workshops and discussion meetings aimed at both clinical and scientific experts in radioembolisation is a promising indication of things to come.

Figure 3: Example of DosiSOFT output showing the 90Y PET generated dose map in units of Gy (upper left and lower right), the CT-defined segmented tumour (upper right), the corresponding dose volume histogram for both the CTdefined lesion and the FDGdefined lesion (lower left).

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Australian and New Zealand Society of Nuclear Medicine