Nov 2012

November 2012, Issue 7 ISSN : 2200-9876

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

Contents

www.anzsnm.org.au

Welcome

4

President’s report

5

General Manager’s report

6

Branch News

New Zealand

Queensland 7

South Australia

7

Western Australia

7

Victoria/Tasmania

8

Nurses

8

7

SIG

Technologists 9

– CPD Sub-committee

9

– PDY Sub-committee

9

Farewell from Judi Anderson 10 Accreditation

11

What’s That?

11

In retirement: John Bellen 13 Motion Correction: When to use 14 PET MRI Brain Scan

17

Case Studies

Hot spots’ in the lungs on a PET scan with no structural abnormality 18

Metastases in Carcinoid Tumour 20

Submitted Paper

When is a high blood glucose level too high for DG-PET brain imaging for dementia?

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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

July – June 1

November – October 1

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Journal Staff

Editorial copy & Advertising copy

Robyn Smith General Manager ANZSNM Secretariat PO Box 202, Parkville VIC 3052 Tel: 1300 330402 Fax: (03) 93879627 Email: secretariat@anzsnm.org.au

The Australian and New Zealand Society of Nuclear Medicine Limited

Design & Production

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

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

Submissions

(e) the training of persons in all facets of nuclear medicine.

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.

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

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

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

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

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

(a)

(b) The Research Grant Committee administers the

annual ANZNM Research Grant.

(c)

The Technologists Special Interest Group.

With the introduction of National Registration for Nuclear Medicine Technologists / Scientists as of July 1, 2012, the future role of the Accreditation Board was reviewed and Federal Council made a decision to disband the current Accreditation Board and re-allocate ongoing responsibilities to the ANZSNM – Technology Special Interest Group (TSIG).

The PDY and mentor program, CPD program, department accreditation and the overseas qualification exam will now be managed by sub-committees of the TSIG, currently being formed.

(d)

In addition to TSIG, there are several other special interest groups that maintain standards of practice for their particular speciality and provide a forum for their development in Australia and New Zealand.

These include the Radiopharmacy, Physics and Nurses Groups.

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

2 Gamma Gazette November 2012

The Technical Standards Committee sets minimum standards and develops quality control procedures for nuclear medicine instrumentation 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 Secretary Treasurer Committee

General Manager & Secretariat

Ms Liz Bailey (TSIG) email: ebailey@nsccahs.health.nsw.gov.au Dr Graeme O’Keefe (Physics SIG) email: graeme.okeefe@petnm.unimelb.edu.au Dr Sze Ting Lee (Vic/Tas) email: szeting.lee@petnm.unimelb.edu.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 Jennifer Guille (Radiopharmacy SIG) email: jennifer.guille@sesiahs.health.nsw.gov.au Professor Dale Bailey (NSW) email: Dale.Bailey@sydney.edu.au Dr Sam Berlangieri (Physician rep, ANZAPNM) Ms Robyn Smith, Mrs Genevieve Butler

All correspondence ANZSNM Secretariat

PO Box 202, Parkville VIC 3052 Tel: 1300 330402 Fax: (03) 93879627 Email: secretariat@anzsnm.org.au Technical Standards Committee Chairperson:

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

Research Grant Committee Chairperson:

Dr Graeme O’Keefe, email: graeme.okeefe@petnm.unimelb.edu.au

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

Ms Maree Wright, email: maree.wright@act.gov.au Mr Peter McConachie, email: peter.mcconachie@sesiahs.health.nsw.gov.au Ms Nikki Weinert & Ms Kathy Roy, email: qldbranchsecretaryanzsnm@gmail.com Mr Adam Freeborn, email: adam.freeborn@hotmail.com Dr 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 Marcia Wood, email: marcia.wood@austin.org.au CPD Program Sub-committee: Dr Clayton Frater PDY Program Sub-committee: Ms Tale Liiv 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

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 7th edition of the Gamma Gazette. The Queensland Branch was responsible for the second edition in July 2011 and it is again our turn. Since the last issue we have held a very successful day symposium at the Sirromet Winery at Mount Cotton, 35km southeast of Brisbane. The dominant news last year was the excessive rain and the northern cyclones and resultant devastation and flooding through much of the State. This year South-east Queensland has had even more rain, but the effect has not been as great and we are now currently in a relatively dry spell.

I was able to attend the ANZSNM TSIG meeting in Hervey Bay recently and it was very pleasing to be able to welcome Technologists from throughout Australia and New Zealand. It was a great opportunity for our techs to get together and as well as the education program they were able to network and discuss many important and exciting issues. Unfortunately Hervey Bay is a lot harder to get to with reduced airflights as a result of the GFC which has had a serious negative impact on the Queensland tourist industry. Not only are overseas visitors down but many Australians now prefer to travel overseas and take advantage of the high Australian Dollar.

The advent of the National Registration for technologists finally brings hope for us in Queensland that many more PDYs will be able to be employed now that the supervision ratios in Queensland will come down, in line with those of the ANZSNM. This will mean that PDY Technologists will be able to gain employment in our large regional centres (Queensland is the most decentralised State in Australia).

Technologists in Queensland are facing another issue – injecting of Drugs eg Frusemide or CCK, which currently they are precluded from doing under the Queensland Drugs and Poisons Regulation 1992. In 2010 Queensland Health was advised that the Regulations needed changing but so far nothing has been done. The Branch had also made a thoughtful submission on the revision of the Radiation Safety Regulation 1999. Unfortunately the Regulation has been changed without taking into account any of the submissions!

I will be stepping down as Chair of the Queensland Branch at our AGM in November after four years. I would like to thank the Committee and our members for their enthusiastic support over the period. Sincere thanks go once again to Lindajane Michel for her effort in collating submissions for this edition.

Andrew Southee MBBS(Hons), FRACP. MRCP(UK), MRCP(London)

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.

November 17

Radpharm Awards

Hosted by VSNMT as part of a VSNMT

Day Seminar focussing on Radiation Dose and Dosimetry November 25-29

WARMTH IRCT 2012, Levi, Finland November 25-30

RSNA 2012 Chicago

4 Gamma Gazette November 2012

2013 February

Physics SIG Workshop Sydney April 11-15

ANZSNM Annual Scientific Meeting

Exploring New Horizons

Perth Convention & Exhibition Centre, Perth, WA June 8-12

SNMMI meeting

Vancouver, BC Canada

President’s Report Taking on the role as President has been both challenging and exciting especially as we move towards a new management structure and future direction for the society. During the first 3 months in this position, having the guidance of Dr Sze Ting Lee, the immediate past president and Geoff Roff was invaluable, and I thank them for their support.

As you are aware, the ANZSNM has employed a General Manager, Ms Robyn Smith who has a background in managing professional associations and employs an operations manager, Ms Genevieve Butler who will be responsible for the ‘day-to-day’ working of the Society including the website. Robyn will be the key person involved in enhancing the ANZSNM professional management, role and profile within the Australian and New Zealand healthcare systems Robyn reports directly to the Council of the ANZSNM via the ANZSNM President. Moving the Society from being a collegiate organisation to a professional body ensures that the needs of members are met and the society is able to respond to the needs of government and organisations with regards to Nuclear Medicine.

A short profile on Robyn and Genevieve is included in this edition.

With the introduction of National Registration for Nuclear Medicine Technologists/Scientists as of July 1, 2012, the future role of the Accreditation Board was reviewed. The MRPBA undertook a decision to form an independent Accreditation Council that would oversee course and training program accreditation from July 1, 2012. At this time, the Federal Council made the decision to disband the Accreditation Board and to re-allocate the remaining duties of the Accreditation Board to the ANZSNM-TSIG. Consequently, the ANZSNMT are now responsible for the PDY and mentor program, CPD program, department accreditation and the overseas qualification exam. The TSIG are currently working on forming sub-committees to undertake these roles.

The new website launched at the Melbourne conference has been live for 3 months with the revised CPD database now also fully operational. There have been a few ‘teething’ problems and we encourage members to notify the Secretariat of any errors and access issues. Thanks to Robbie Barnett for his time and hard work in finalising this project.

The Technical Standards Committee has released the second Edition of the Requirements for PET Accreditation document that has been endorsed by the Federal Council. The new document recognises the increased number of new PET installations, especially regional PET centres, has updated the performance standards in-line with contemporary devices and includes an annual test of accuracy of reconstructed SUV values using 18F. A copy of the second Edition of the Requirements for PET Accreditation document is available on the ANZSNM website.

The International Relations Committee, chaired by Professor Andrew Scott successfully submitted a bid to the World Federation of Nuclear Medicine and Biology to host the 2018 meeting in Melbourne. Voting to determine the wining bid will be in Milan as part of the EANM and we wish them the best of luck.

The membership of the Society of Nuclear Medicine (SNM), during its annual meeting in Miami, Florida successfully voted on a name change for their society, now being known as the Society of Nuclear Medicine and Molecular Imaging (SNMMI) and the Society of Nuclear Medicine and Molecular Imaging – Technologist Section (SNMMI-TS). During this meeting the ANZSNM were approached by the SNMMI to be involved in a Nuclear Medicine Global Initiative project, a joint undertaking of 10 organisations with an interest in promoting standards and quality in nuclear medicine. The purpose of the project is to (a) promote health by advancing the field of Nuclear Medicine and Molecular Imaging, (b) encourage global collaboration in education and harmonisation of procedural guidelines and (c) improve quality and safety. The first meeting of this group will be held in Milan and I have no doubt that this initiative will be successful.

A proposal to establish an MI SIG that would operate under the banner of the ANZSNM has been discussed by the Federal Council in consultation with interested researchers from universities and other research institutes. We would like to assess the level of interest from members before establishing such as group. The suggestion to include an MI abstract category at the ANZSNM ASM was supported by the council and will be incorporated for future meetings.

Remember the next ANZSNM ASM will be held in Perth at the Perth Convention Centre, April 11-15, 2013 with abstract submissions opened as of August 2012 and early bird registration from November 2012. Hope to see you there.

Liz Bailey President ANZSNM

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General Manager’s Report Having joined the ANZSNM in July, I am enjoying a steep and interesting learning curve, along with my colleague Genevieve Butler. In these first few months we have undertaken an induction process with President Liz Bailey and other Council Members and I have learnt much from the opportunity to attend branch meetings in New Zealand and New South Wales as well as visit a number of Nuclear Medicine Departments and the ANSTO facility.

Although new to the nuclear medicine community, as a team we share a background of some 20 years of association/society management. I have held the role of CEO and General Manager for a diverse range of national and international associations, with Genevieve managing the operations and information technology aspect of these member organisations.

I am very excited about the role ahead with ANZSNM and believe the Federal Council has been forward thinking in moving from a collegiate structure to Robyn Smith & Genevieve Butler the new secretariat arrangement. The new team will combine to provide the equivalent of a full-time business week and we’re committed to work with the current strong foundation of the Society to bring further development and growth in the fast paced and evolving Nuclear Medicine environment.

Initially we have been focusing on improvements that can be made in the short term to the way we operate as a Society, and achieving efficiencies in how benefits and services are delivered to members in the area of: communication, website and content management; continuing professional development facilitation and recording; financial systems and on line payment facilities; and also improving the support and information to branches and SIGS to alleviate some of the pressures on the volunteer committee members.

Importantly, I have been able to represent ANZSNM at a range of government and professional forums to ensure the Society represents the membership’s interests and is consulted by government and other major stakeholders. I can see great benefit in this advocacy role under the direction of the President.

In terms of the longer term, our key objectives include: • Membership growth through improved and extended benefits • Increased public and government awareness of our Society • Improved professional status for our members through credentialing of professional qualifications • Diversified income streams • Effective governance in the credentialing of professional qualifications, government funding and grants At present I am working on an initial strategic plan to incorporate these goals and a priority work plan for the next two years. I welcome your input, ideas and suggestions. Please feel free to contact us using the new toll free number.

Based in Melbourne, the new Secretariat details are below: ANZSNM Secretariat Ph: +61 1300 330 402 Fax: +61 (0) 3 9387 9627 Email: secretariat@anzsnm.org.au PO Box 202 Parkville, Vic 3052 Robyn Smith General Manager ANZSNM

6 Gamma Gazette November 2012

Branch News NEW ZEALAND The Annual Branch meeting for the ANZSNM took place in Dunedin on September 8-9, 2012. For the first time the meeting was held in Dunedin and was convened by Mrs Chrissie Roodt and Professor Terry Doyle.

As usual there was >90% attendance from the New Zealand Nuclear Medicine community and the conference was supported well by our Industry sponsors. There were a range of different presentations including those from our Nuclear Medicine Physicians, our Technologists and Scientists. The first day included the Doctors’ peer review chaired

by Professor Terry Doyle and at the same time the Technologists had a workshop.

There was a wider number of individuals presenting which is what we had wished to encourage.

The highlight as usual was the Saturday night entertainment and this included dinner at the Forsyth Barr stadium (the Dunedin site for the Rugby World Cup participants) while the main meeting was held in the Barnett Theatre and the Dunedin Hospital adjacent to the Otago Medical School.

It was very pleasing that Dunedin took the mantle of holding this meeting. It was decided that next year’s meeting is to be convened by the Palmerston North Nuclear Medicine community with a date yet to be set.

It was also pleasing that a number of members of the PET community in New Zealand participated in the meeting and we look forward to more collaboration.

Dr Sue O’Malley Nuclear Medicine Physician, Christchurch Public Hospital QUEENSLAND The Queensland Branch has seen a smooth transition to National Registration, especially as we were fortunate to already hold state registration. We will encourage all members to voice any concerns they do have at our upcoming branch meeting and AGM which will be held in early November. The Radpharm presentations will also be held on this night, and we look forward to seeing this year’s case studies – particularly after the success of former QLD member Andrew Dixon at the ANZSNM ASM this year.

The TSIG day seminar held in our state in August proved to be a great weekend for all that attended, with the Hervey Bay event providing many interesting presentations and enjoyable social events.

We hope you enjoy this, the QLD edition of the Gamma Gazette!

SOUTH AUSTRALIA The South Australian Branch has held four branch scientific meetings in 2012. In February Dr Dylan Bartholomeusz presented The Role of Sentinel Node Mapping in Oesophageal Cancer at the Royal Adelaide Hospital. The second meeting in April was hosted by Radiology SA at Calvary Hospital, where Saima Ahmad was awarded the SA Branch Student Prize as the most outstanding student graduating from the Bachelor of Medical Radiation Sciences at the University of South Australia. The Scientific Meeting saw Dr. Ghee Chew present on the VAMPIRE Study, and CTCA and Myocardial Perfusion SPECT. In July, Dr Jones & Partners hosted a meeting where Dr Barry Chatterton presented Thoughts on Molecular Imaging, and James Shephard presented interesting cases. The final branch meeting was held in October at The Queen Elizabeth Hospital, where Leighton Barnden, Paul Sotiropoulos and Dr Rey Casse presented on Advances in Cerebral Perfusion Imaging. Attendances at all branch meetings have been excellent this year, and the Branch Committee would like to thank all hosts and presenters for their efforts in 2012.

In May, the SA Branch hosted Prof Greg Thomas at a Post-Conference Dinner at the Adelaide Pavilion. Prof Thomas gave a wonderful talk on his experiences performing CT scans on Ancient Egyptian Mummies in his presentation How Old is CAD? Did the Ancient Egyptians Need Cardiac Rehab?

The SA Branch Technologist’s Group has held three meetings this year, including most recently the Radpharm Award Presentations, where Paul Sotiropoulos was selected as the SA winner.

The next meeting will be the AGM & Quiz Night in December, which is always a very enjoyable evening.

Adam Freeborn ANZSNM SA Branch Secretary/Treasurer WESTERN AUSTRALIA It has been another mild winter for most of WA with glorious sunny days for the most part but not enough rain – in contrast to the rest of the country again I think!

As a branch we organised our annual workshop for July, with Musculoskeletal the topic this year. We held it at the University Club of Western Australia and it was the perfect venue. Other than the fact it was at the start of the WA school holidays, it was well attended and enjoyed by all who were able to be there. We had some excellent presentations from Dr Ros Francis, Dr Tony Hayes, Dr Geoff Bower, Dr Liz Thomas, Dr Jerry Moschilla and Domenic Morgan inspired us u

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Branch News to be the best technologists we can be and reminded us of some basic positioning skills and tips. Dr Nelson Loh also entertained us with a quiz that got our brains working!

We enjoyed hearing from our guest speakers Dr Duncan Sullivan, Dr Scott Isbel, Dr Nick Wambeek and Dr Seng Khee Gan who informed and entertained us about pathologies and injuries and provided a multidisciplinary angle.

We were thankful to be given generous sponsorship from Siemens, ANSTO Health, GE Healthcare, GMS, Insight and Lantheus Medical Imaging. We would like to thank the committee who organised the day, as well as everyone who attended and was part of the day. Most of the presentations were recorded and will be available on DVD for members to borrow.

We are now looking forward to our last couple of branch meetings, including our WA Radpharm Case Study presentation night to be held at Oceanic Medical Imaging and then our final meeting for the year, our AGM at Royal Perth which will involve dinner and a quiz night.

Don’t forget the 43rd Annual Meeting of the ANZSNM is to be held in Perth next year April 11-15 and we would love to see as many of you over here as possible. Please see http://anzsnm2013.com.au/ for all the information.

Georgina Santich Secretary, ANZSNM WA Branch VICTORIA/TASMANIA The second half of the year has seen the Victoria/Tasmania Branch committee busy finalising the Program for the Branch’s Annual Day Seminar and AGM that took place in Hobart on October 20, 2012 with a broad range of topics being presented by Tasmanian and Victorian Experts. Speakers included Endocrinologist Prof. John Burgess from the Royal Hobart Hospital who spoke on Iodine Nutrition and Haematologist Assoc. Prof Alhossain Khalafallah who presented on 99mTc-Sestamibi imaging of Bone Marrow.

I would like to thank our Tasmanian members for their support of this event in particular those who volunteered their time and energy to present on the day and also those ANZSNM members from Victoria who made the journey South for the weekend.

The AGM held as part of the Annual Day Seminar saw a changing of the guard with three members of committee standing down. I would like to thank Gurinder Mudher, Grace Kong and Maria Triantafillou for their hard work and contribution to the committee during their tenure. I would particularly like to thank Maria for her efforts over 10 years of service to the ANZSNM Nuclear Medicine community in her many roles including Federal Representative and Treasurer at the local and Federal level. Her knowledge and expertise will be missed by all of us remaining on the committee. I would like to welcome the new committee members elected at the AGM. CPD and Educational events remain the main focus of the Branch with several events being organised in the next few months. The VSNMT will again host the Radpharm Awards which will be held on Saturday November 17, 2012 as part of a VSNMT Day Seminar focussing on Radiation Dose and Dosimetry. I encourage all members to support this event. The ANZSNM Vic/Tas Branch is also looking to hold a combined CPD/End of Year Breakup event in early December so watch this space for further details. We are also looking forward to welcoming back Prof Kim Williams in January for what will be another interesting update on Nuclear Cardiology.

In addition to the Annual Day Seminar and various meetings throughout the year the Victoria/Tasmania Branch will expand its CPD and educational opportunities for members with the commencement of a series of “Molecular Imaging Masterclasses” in 2013. These focussed events will have limited places with ANZSNM members having priority access and complimentary registration to the event. These masterclasses will entail a 3-4hr Topic Specific CPD program which will kick off in February with a PET Masterclass. The program and venue will be confirmed in the next few weeks.

As this is the last Gamma Gazette of the year I would like to wish all members a Safe and Happy Festive Season and look forward to seeing you all at these exciting Society events in 2013.

Bridget Chappell Vic/Tas Branch Chair

Special Interest Group News NURSING Currently the Nursing SIG is not viable due to the decrease in attendance and membership, as a result we are not able to elect a new Chair of the group, in hope that interest will be revitalised in the not too distant future.

At the meeting in Melbourne in April 2012, we had five attendees but no one interested in taking my position.

In order to maintain the Nursing SIG in the hope of future interest I will remain as the Chair. We are looking at the option in maintaining the viability of the group.

Thank you.

Erwin Lupango

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Special Interest Group News TECHNOLOGISTS There are busy times ahead for the TSIG. Continuing Professional Development (CPD) program and the Professional Development Year (PDY) program are now under the umbrella of the TSIG, as subcommittees. Clayton Frater (CPD) and Tale Liiv (PDY) will be chairing these subcommittees, continuing on with the roles they started on the Accreditation Board. There will also be a member of the TSIG on each, along with a general member, with expressions of interest currently being sought. The membership of these subcommittees should be finalised and announced shortly. Accordingly, changes will be made to the TSIG regulations to incorporate these new functions, and we hope these will be released early next year ahead of a vote at the next TSIG AGM. On a related note, the CPD database is up and running on the ANZSNM website, with instructions and guideline documents available as well. I would urge all Technologists to familiarise themselves with the recent changes to the CPD program. This includes the change to hours from points, and the classification of activities as either general or substantive.

National Registration has now commenced and has hopefully gone smoothly for most technologists. The TSIG continues to correspond with the MRPBA with regards to many issues such as accreditation standards, as many aspects of these items are still in a transition phase and are yet to be finalised. Two important changes have already occurred as a result of these discussions. Firstly, the supervision ratio for the PDY program is now 1:1, with evidence of leave contingency required for sole practitioner sites. Secondly, the fee for departmental accreditation renewal has been removed at the request of the MRPBA. The Annual TSIG Symposium was held on August 11 in Hervey Bay, and was very well attended. This year we had 57 registrants for the symposium, which had a focus on new technologies. Many thanks to all of our speakers for the day, and in particular our invited speakers: Dr Berry Allen, Prof Dale Bailey and Dr Andrew Southee. Thank you also to all of our industry sponsors who make these events possible. This years’ event also included the options of dinner and whale watching, and it was great to have 43 people attend the dinner, and 27 join in for the whale watching. A big thanks must also go to the TSIG committee for all their efforts in organising the day. We look forward to seeing as many people as possible again next year.

Marcia Wood Chair, ANZSNMT PDY SUB-COMMITTEE We currently have 61 PDY technologists enrolled in the Nuclear Medicine PDY program. This number includes 14 Victorian Interns. We have 63 mentors who are currently active in the program. This number includes 13 NMIC members, some of whom mentor for PDY as well as NMIC. We would love to see more technologists become mentors, application forms are available on the ANZSM website or by direct email to the secretariat. We are looking for mentors with lots of enthusiasm and who will also be available and flexible for their graduate. Technologists must have at least 3 years postgraduate experience and must currently be practising nuclear medicine.

The ANZSNM PDY program has also been approved by the MRPBA for 2013, but with a change in ratio of supervised practitioner to general registrant practitioner of 1:1. More information on this can be found on the MRPBA website.

Tale Liiv Chair, PDY Sub-committee CPD SUB-COMMITTEE Following the incorporation of the ANZSNM Accreditation Board into the TSIG, the essential role of the CPD subcommittee remains unchanged and the new sub-committee will now consist of a Chair, a member of the TSIG and a member of the Society. Ideally to meet once a year at the Annual Meeting, in between meetings, questions from both the ANZSNM membership and the MRPB will be discussed internally by the sub-committee with a formal report provided regularly to the TSIG and Federal Council. Important changes to reiterate to members is that from July 1, 2012, CPD for ANZSNM revalidation is no longer required but it is required for MPRB/AHPRA Registration and is now 60 hours in a triennium ending November 30, 2015. From the ANZSNM website members can now access the electronic CPD database, the revised CPD spreadsheet, CPD reporting templates and a FAQ sheet.

Clayton Frater Chair, CPD Sub-committee

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Goodbye and thankyou Dear Members, I wanted to take this opportunity to say goodbye to the many friends I have made over the 20+ years I worked as the Secretariat for the ANZSNM. I would also like to publicly thank those Society members who made contact with me when the official announcement of the new Secretariat was made to wish me all the best for the future – I was very touched by their concern.

When I first started working for the Society, I was employed by the Victorian Medical Postgraduate Foundation (VMPF). Gordon Chan approached them for assistance with administrative matters and I was allocated the project. Allan Scott first got me involved with the Accreditation Board to assist him as Secretary of the Board with taking Minutes of meetings and other routine matters. Over time, the Accreditation Board grew into the largest component of my work for the Society.

In 1999, the VMPF lost its Victorian Government funding and reduced staff from 12 to 1.5. As they were going to have to tell the three organisations (ANZSNM, the Australasian Radiation Protection Society and the Australasian Society for Immunology) for whom I was providing secretariat services by that stage that VMPF would no longer be able to provide the service, I decided that I would start up my own company and continue to do what I had been doing for about eight years at that time. So in March of 2000, I moved house to Ferntree Gully where I could afford a larger residence than where I was living in St Kilda and set up an office at home.

As the work for the Society grew, it became my largest client and it has been enjoyable to be involved with the society. I hope to continue working for my other clients and spend more time on my own personal projects, generally related to jazz and Morgan horses, my two passions.

Although I haven’t met a large percentage of members in person, there are many people I have dealt with over the years on an ongoing basis – I am even friends on facebook with one or two! – and have had a very good working relationship with and who I already miss communicating with and, of course, there were the Executive Committee/Council/AB members who I met with regularly and got to know quite well – I will miss talking to you all.

I would also like to thank Rachel Bullard, Production Editor of the old ANZ Nuclear Medicine journal and the new Gamma Gazette, and Debbie McKay who has acted as bookkeeper for the AB for many years – we worked together closely and I appreciated their assistance and guidance in their areas of expertise.

I wish all members the best for the future. For technologists there are many changes occurring since National Registration came in and I hope that everything goes smoothly with the changeover.

Have a great Christmas and New Year and stay safe from bushfires, floods, earthquakes and anything else Mother Nature can throw at us.

Judi Anderson

10 Gamma Gazette November 2012

Accreditation Congratulations to the following departments which were granted Accreditation or Re-Accreditation for the training of PDY Technologists: Northcoast Nuclear Medicine, Buderim – Cert # 9 Wollongong Hospital, Wollongong – Cert # 15 St George Hospital, Kogarah – Cert # 16

St Vincent’s Hospital, Sydney – Cert # 17 North Coast Radiology, Lismore – Cert # 20 The Prince of Wales & Sydney Children’s Hospital, Randwick – Cert # 22 South West Nuclear Medicine, Liverpool – Cert # 71 SKG Nuclear Medicine,

Murdoch – Cert # 82 The Canberra Hospital, Garran – Cert # 83 Regional Imaging Border, West Albury – Cert # 103 Congratulations to the following technologists who were granted Accreditation from September 2012: Kerry-Ann BARTER

Sathvik PRASAD Mushda RAHUFI Drew MANSFIELD Andrew MARKEWYCZ Hugh MORGAN My Linh DIEP Lucy HORD Vesna LAJIC Fiona LARSEN Rania KASSAB James GREEN

Answer on page 16

A: What’s that?

W. Phillip Law Radiology Department, Princess Alexandra Hospital, Brisbane, Queensland Clinical Notes A 70-year-old male with recurrent right pleural effusions – fluid cytology showing atypical cells – was referred for PET/CT. There is a remote history of melanoma in the right leg excised 20 years ago. Imaging was performed one hour after the injection of 363MBq F18-FDG. Selected MIP, coronal and axial PET/CT images are displayed.

11

See You in Perth!

We take great pleasure in inviting you to the 43rd Annual Scientific Meeting of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM 2013), to be held in Perth from 11 – 15 April, 2013.

Nestled on the banks of the Swan River estuary, Perth is the dynamic capital of Western Australia, and is home to 1.7 million people. The ANZSNM Annual Scientific Meeting will be held at the Perth Convention Centre, which is a purpose built, modern conference and exhibition facility centrally located between the Perth waterfront and city centre. There are numerous accommodation, dining and entertainment options within easy walking distance of the Perth Convention Centre.

The pre-conference symposium will be held on Friday 12th April at the University Club, located at the University of Western Australia. The Symposium will highlight advances in Molecular Imaging, and includes expert National and International speakers.

This promises to be a day of education and ideas for the future.

KEY DATES: Call for Abstracts

NOW OPEN

Registration Open

26 Nov 2012

Call for Abstracts Close

24 Jan 2013

Early Bird Registration Close 8 Mar 2013 Registrations Close

4 Apr 2013

Committee Meetings

11 Apr 2012

Pre Meeting Symposium

12 Apr 2013

Annual Scientific Meeting 13 – 15 Apr 2013

The annual scientific meeting will be held from Saturday 13th April to Monday 15th April, with a theme of ‘Exploring New Horizons’.

The scientific program will hold interest for all, with an exciting panel of international and national speakers discussing a range of clinical and technology issues across all aspects of Nuclear Medicine and Molecular Imaging. In addition to invited speakers, there will be oral and poster presentations, interactive sessions and award sessions. The large exhibition area at PCEC will provide an interactive space for our industry partners to display the latest in equipment and products.

April is one of the best times of the year in Western Australia and you might consider combining a holiday with your visit, either before or after the conference. Explore the state’s southwest, famous for its surfing beaches, forests, fine dining and wines.

Further afield are the Great Southern region, the Goldfields, and some spectacular scenery in WA’s north, including Ningaloo reef, Karijini National Park and Broome and the Kimberley.

Meeting Managed by arinex pty ltd GPO Box 128, Sydney NSW 2001 P: + 61 2 9265 0700 F: + 61 2 9267 5443 E: nm2013@arinex.com.au

We look forward to seeing you in ‘the West’ next year.

Images supplied by Tourism WA

Ros Francis and Bill Macdonald Conference Co-Convenors 14 Gamma Gazette July 2012

Perth Convention & Exhibition Centre www.anzsnm2013.com.au

For more information visit www.anzsnm2013.com.au

In Retirement

A fond Farewell to

John Bellen One of a kind and much-loved

John has recently retired after many (many) years of sterling service to nuclear medicine, in Adelaide and Brisbane.

He was an excellent radiochemist of the old-school, start-from-scratch variety. These days, many practices buy in the radiopharmaceutical in a syringe, pre-dispensed to a specific patient. Practices with more extensive hot labs, will milk a generator and reconstitute the radiopharmaceutical with a bought-in cold kit. But John was manufacturing in-house cold kits, at the Royal Adelaide, in the days before they were commercially available. And not only nuclear medicine pharmaceuticals: he was also involved in early work on gadolinium contrast agents for MRI. When he moved to the Royal Brisbane, John set up and managed a hot lab that supported a complex case load. This included supplying radiopharmaceuticals for diagnostic scanning at other hospitals, as well as the Royal; and also radionuclide therapy such as 131I for thyroids, 90Y for knees, 153Sm for bone marrow. As in Adelaide, he suffered and survived TGA audits and achieved TGA registration. And he was always one to embrace new challenges: he was running the cyclotron and manufacturing FDG, when PET came to the Royal Brisbane.

It was probably a combination of his get-it-done approach and his occasional klutziness, that made him such a source of great anecdotes.

“My favourite memory was during the imaging of a mouse carcass with a pinhole collimator. John was distracted during its downward travel and kept his finger on the button. The old cameras had no proximity protection, and John spent the afternoon removing bits of mouse from the aperture of the collimator.”

“Gastric emptying scans were done with labelled chicken livers. The radiopharmaceutical was fed to the chicken, which was then sacrificed and its liver extracted and cooked. One day, there was an urgent scan and no chickens. But John had a supply of lab rats ... It turns out that rat liver is indistinguishable from chicken liver, at least by the time John has finished cooking it.”

“Of course, then, as now, if he were caught out, the sheepish smile and the deep blush appeared immediately”.

But it was his friendliness and steadfastness that make him so widely liked. He was always kind, always thoughtful, always ready to do what needed to be done. It was never about him; always about the patient. He’s a gem.

Picture above: John Bellen, 1971 at the Royal Adelaide Hospital.

13

Motion Correction: When to use Elizabeth A Bailey Department of Nuclear Medicine, Royal North Shore Hospital

Motion in cardiac SPECT studies can create artefacts in reconstructed images if significant movement occurs. There are 3 types of body motion that can occur during a cardiac SPECT acquisition (Fitzgerald et al., 2001): 1. left-right displacement (transverse shifts) 2. translation of the body around its axis (whole body rotation) 3. cranial-caudal displacement (vertical shifts) Many studies investigating the effect of motion on image quality have been published, including phantom simulation studies using varying degrees and types of motion. Motion correction algorithms were developed to allow correction for motion in SPECT acquisitions and are available with commercially available software packages. The literature describes 5 different motion correction algorithms that have been developed for clinical use: 1. Cross-Correlation 2. Diverging Squares Algorithm 3. 2-dimensional fit method 4. Projection-Reprojection Technique 5. Manual Shift Cross Correlation Cross correlation method uses a frame-to-frame, discrete cross-correlation function between two 1D data sets to determine motion. A summed projection along the y-axis is created for each projection to create a 1D dataset. The profiles from successive projections are compared with each other, and the magnitude of shift in the profile count distribution is measured and used to motion correct the projection data. This method is sensitive to sudden movement between projections and less sensitive to gradual motion. It can also be affected by non-cardiac activity. The use of an external point source can help better quantify patient motion.

Diverging Squares Algorithm The diverging squares algorithm starts by locating the heart, which is assumed to be the region of projection data with highest counts. A rectangular ROI (3 x 3cm) is created around the centre point for each projection image and gradually expanded in all directions to cover most of LV, up to approximately 6 x 6cm. The algorithm then aligns all the projection images by shifting the centre of the heart in each projection to follow a predetermined trajectory and maintain a constant position throughout the entire study. The can be erroneous performance of this motion correction algorithm if there are high count densities from adjacent hepatic or

14 Gamma Gazette November 2012

subdiaphragmatic activity.

2-dimensional fit method The 2F fit method defines a circular region of interest that encloses the whole heart in a 45 degree LAO projection. The x-coordinate assigned to the centre of the circle at 0 degrees or the anterior projection and the y-coordinate assigned to the centre of the circle at 90 degree or the left lateral projection are determined. Because the calculated x and y positions can be determined for each projection from COR camera data, the actual patient projection data of x and y positions can be compared against the calculated data and adjusted for motion if required.

Projection-Reprojection Technique The projection-reprojection technique iteratively reconstructs the heart and reprojects the image. The displacement vector between serial projections is calculated by minimizing the differences between subsequent reprojections. The vector is then used for motion correction This motion correction techniques functions well with all motion patterns.

Manual Shift When using manual shift, the operator manually shifts individual projections to align the heart position in consecutive frames. This method is time consuming and may not be consistent or reproducible.

Shifts of 1 pixel or less are usually considered inconsequential, whereas shifts of 2 pixels or more frequently cause artefacts that may result in misinterpretation of myocardial perfusion images. Motion that occurs when the heart is close to the detector is more likely to introduce image artefacts, because corresponding projections have higher photon counts and contribute more information to the reconstructed SPECT images. Motion occurring early (on a single detector system) and in the middle (on a dual detector system) are more likely to introduce significant artefacts. Even considerable motion will have little effect when affecting 1 or 2 frames only, whereas lesser displacement that affects multiple frames causes apparent perfusion defects.

Motion artefacts have a characteristic appearance that includes: a. “hurricane sign” – caused by motion-induced smearing of photon counts in opposing directions around the LV, as seen in figure 1, b. distorted ventricular shape, where the heart may appear elongated or tilted (figure 2),

c. discontinuities of left ventricular walls, d. non-anatomic defects, e. hot spots (figure 3).

Image defects also have a characteristic appearance, dependent on the type of motion: a. Downward motion → Antero-septal

wall defect b. Upward motion → Antero-lateral

wall defect c. Multiple bounces → Inferior wall defects Prone SPECT imaging has been used to improve the spatial resolution of the heart and diaphragm, and to reduce inferior wall attenuation artefacts.

However, distance from the detector during prone SPECT is increased and may induce anterior wall artefacts. Therefore, it should only ever be used in conjunction with supine imaging (Lowenstein et al., 2003).

It should be noted that the EANM Guidelines state that: “Motion correction algorithms only correct for relatively minor and simple forms of motion, such as in the longitudinal axis. More complex patterns involving rotational motion cannot be corrected for. Movement by 1 pixel does not produce significant artefacts in the reconstructed images.

It is recommended that only motion by 2 pixels or greater justifies correction” (Hesse et al., 2005) References Fitzgerald J, & Danias PG. (2001). Effect of motion on cardiac SPECT imaging: recognition and motion correction. J Nucl Cardiol, 8(6), 701706.

Hesse B, Tagil K, Cuocolo A, Anagnostopoulos C, Bardies M, et al. (2005). EANM/ESC procedural guidelines for myocardial perfusion imaging in nuclear cardiology. Eur J Nucl Med Mol Imaging, 32(7), 855-897.

Lowenstein BA, Pezzuti R, & Cohen MC. (2003).

The use of prone imaging on acute resting gated myocardial perfusion imaging with Tc99m sestamibi. J Nucl Cardiol, 10(2), 211-212.

Figure 1: The ‘hurricane sign’ (yellow arrow) is caused by smearing of the photons due to motion commonly as a result of a lateral shift of the patient during the acquisition.

Figure 2: In the short axis plan, the heart should be circular with welldefined endocardial and epicardial borders. The presence of motion can result in a distortion in the shape of the heart as indicated by the yellow arrow.

Figure 3: The sinogram shows a slight lateral shift during the acquisition which has resulted in a ‘hot spot’ artefact in the horizontal long axis slice as shown by the yellow arrow.

15

From page 11

A: What’s that? ... answer There is a focal area of intense FDG activity in the right groin. The prior history of melanoma in the right leg although remote does raise concern for inguinal nodal metastasis, however, the intense FDG activity localises to a fluid attenuation structure which arises from the right anterior bladder wall and appears to be herniating through the right inguinal canal. FDG activity within the lesion is equivalent to urine within the bladder.

The appearances are those of an anterior bladder diverticulum herniating into the right inguinal canal. There are small dependent calculi within the bladder diverticulum.

The right pleural effusion shows no significant FDG activity, and there is indeterminate low-grade uptake in small subcarinal and hilar nodes which are currently under imaging surveillance.

This case highlights the utility of CT correlation for areas of unusual or unexpected tracer accumulation.

16 Gamma Gazette November 2012

PET CT MRI Brain Scan Nathan Cassidy, Lili Yu and Myles Collins Queensland X-ray Townsville

Scanner Siemens Biograph mCT Clinical History Early onset dementia showing progressive memory loss.

Technique 228MBq of F18-FDG was injected via the right cubical fossa vein. BSL was 5.2mmol/L. PET images were acquired.

CT images were acquired spirally through the head following IV injection of iodinated contrast.

PET and a diagnostic CT images were fused and reviewed. The PET images were also fused to a recent MRI. Findings There is symmetrical decreased uptake of FDG in the parietal lobes. The remainder of the cerebral cortex shows normal activity.

The basal ganglia show normal activity. The CT images show only a subtle impression of atrophy in the parietal lobes. The recent MRI also shows atrophy of the parietal lobes.

Conclusion Marked decrease in a symmetrical pattern of the parietal lobes bilaterally with subtle atrophic changes noted on CT and MRI. The appearances are suggestive of Lewy Body Disease.

17

Case Study

‘Hot spots’ in the lungs on a PET scan with no structural abnormality Dr Suranga Weerasooriya

CASE REPORT The subject was a 50-year-old man with a history of B cell NHL about 10 years ago, recently presented with enlarged neck nodes. He underwent a staging CT scan on the 16/04/2012 which demonstrated enlarged right sided deep cervical nodes with soft tissue abnormality in the right submandibular gland region. No other disease was identified in the rest of the body.

The staging PET scan was performed on the 07/05/2012.

Patient was fasted for 6 hours prior to the procedure. His blood glucose level at the time of injection of FDG was 6.2 mmol/L. Intravenous access was obtained via the right antecubital fossa and patient was injected 338 MBq of FDG intravenously. No complications were encountered at the time of cannulation or during the time of intravenous injection of the tracer.

PET images were acquired at 62 minutes post injection. Images were acquired from the base of the skull to the upper thighs and co-registered Figure 1: Transaxial PET, CT and fused images showing the right sided central pulmonary with low –energy CT images for uptake. There is no evidence of structural abnormality on the CT. anatomical localisation and tissue attenuation correction purposes. The images were obtained on the Phillips Gemini scanner and viewed – albumin colloid, that radiotracer can bind to small clot formed in on the Hermes workstation. the vessel, subsequently embolising in the microvasculature of the PET images demonstrated increased uptake of tracer in the lungs.1,2 right deep cervical region consistent with lymphoma. However, A possible explanation for these foci in the lungs is deposition interestingly we found three foci of FDG accumulation in the right of microemboli which has been reported in literature previously. lung. There was no abnormality identified on the low-dose CT This is seen secondary to paravenous injection, which is a common images. Patient’s contrast CT images were again reviewed in the characteristic in many of the reported cases. The damage to the light of findings of the PET scan, to correlate for any structural venous endothelium during paravenous injection is postulated to abnormality on the CT. There were no abnormalities on the CT cause formation of blood clots at the site of injury, which in turn images to account for the findings on the PET. detach from the vein, lodge in the pulmonary vasculature and are It has been observed fairly frequently with 99mTc- MAA and 99mTc seen as hot spots in the lung.4,5 Because the blood clots are mixed with injected radiotracer, they may be very intense which is best illustrated in this study, particularly more centrally located focus.

Pulmonary micro-embolism provoked during 18F-FDG injection Dr Suranga Weerasooriya , MBBS, MSc can be considered the only reason ‘technically’ responsible for these Advanced Trainee in Nuclear Medicine, false-positive findings. It is postulated that the cellular activation Royal Adelaide Hospital, South Australia process at the site of pulmonary microemboli requires energy with 18 Gamma Gazette November 2012

‘Hot spots’ in the lungs on a PET scan with no structural abnormality

a consequent increased glucose uptake. The clues in this patient were the evidence of vascular injury as seen on the PET/CT images as a streak of increased uptake along the right brachial vein and the very high intensity of uptake.

REFERENCES 1. Hung JC, Pronto JA, Hammers RJ: Radiopharmaceutical-related pitfalls and artifacts. Semi. Nucl Med 26:208-255, 1996 2. Goldberg E, Lieberman C: “Hot spots” in lung scans. J Nucl Med 18:499, 1977 3.

Hany TF, Heuberger J, von Schulthess GK: Iatrogenic FDG foci in the lungs: a pitfall of PET image interpretation. Eur Radiol 2003 4. Farsad M, Ambrosini V, Nanni C, Castellucci P, Boschi S, Rubello D, Fabbri M, Franchi R, Fanti S: Focal lung uptake of 18 F-fluorodeoxyglucose ( 18 F-FDG) without computed tomography findings. Nucl Med Commun 2005, 26:827-830 5. Ha JM, Jeong SY, Seo YS, Kwon SY, Chong A, Oh JR, Song HC, Bom HS, Min JJ: Incidental focal F-18 FDG accumulation in lung parenchyma without abnormal CT findings. Ann Nucl Med 2009, 23:599-603.

Figure 2: A second focus of FDG uptake in the right lung parenchyma with CT images showing no abnormality. Also note the mild extravasation of tracer in the right upper arm.

Figure 3: Transaxial view of the neck showing the FDG avid lymph nodes in the right deep cervical chain consistent with the lymphoma.

19

Case Study

Cardiac Metastases in Carcinoid Tumour Melinda Wilson

Macquarie Medical Imaging, Macquarie University Hospital, Macquarie University NSW 2109

PATIENT HISTORY • 64-year-old man with recent discovery of extrinsic caecal compression on routine colonoscopy; • Subsequent CT scan showed ileocaecal mesenteric mass, multiple mesenteric nodules and probable hepatic metastases; • In retrospect, the patient describes facial flushing. Elevated platelet serotonin levels were shown; • Patient referred to our department for an In-111 pentetreotide scan.

In-111 Pentetreotide Scan • Patient injected with 213MBq of In-111 Pentetreotide. Delayed scanning was performed at 4 and 20 hours post injection; • Wholebody and SPECT/CT images were acquired at 4 hours and static images of chest and abdomen at 20 hours; • There was intense tracer accumulation in the ileocaecal mass.

Anterior to that, there was a focus of avid tracer accumulation in the right lower anterior abdominal wall; • There are multiple mesenteric foci of tracer uptake, particularly in the left paracolic gutter – this corresponds to the peritoneal nodules seen on CT scan. There are at least three peripheral intrahepatic foci of tracer accumulation that are consistent with metastases; • In addition, there is a large focus of intense tracer uptake in the thorax, SPECT/CT shows uptake to be intracardiac, most probably in the interventricular septum; • Patient was recommended to undergo an MRI of the heart to correlate the finding on the pentetreotide scan.

Figure 1: SPECT 4hr Transverse.

Figure 2: SPECT 4hr Sag/Coronal.

MRI Scan Report A 2.3 x 1.4 x 4.5 cm lobular mass arising from the anteroseptal left ventricular myocardium, displays a broad based attachment to the subendocardium, and protrudes into the left ventricular cavity.

BACKGROUND Carcinoid tumours are neuroendocrine tumours that arise from the enterochromaffin cells throughout the gut.1 More than twothirds of carcinoid tumours are found in the gastrointestinal tract.2 They can metastasize to regional lymph nodes, the liver and beyond. Carcinoid tumours are rare, arising in 1.2 to 2.1/100,000 persons in the general population. Hepatic metastases can lead to carcinoid syndrome. This is due to the over-production of many vasoactive substances, including serotonin, which is released into the systemic circulation and can lead to symptoms of flushing, diarrhoea and abdominal cramping.

Melinda Wilson The Prince Charles Hospital Chermside, Queensland 4032

20 Gamma Gazette November 2012

Figure 3: SPECT/CT image 4hours of pelvic metastasis.

Cardiac Metastases in Carcinoid Tumour

(Far left) Figure 4: SPECT/CT image 4hours of abdomen metastasis.

Figure 5: SPECT/CT image 4hours of liver metastasis.

Carcinoid tumours express somatostatin receptor subtypes 2 and 5 and therefore avidly take up In-111 Pentetreotide and other Octreotide analogues.

Myocardial metastases occur in around 2% to 22% of patients with metastatic cancer.3 The most common primary tumours that metastasize to the heart are breast, lung and malignant melanoma. Although carcinoid tumours have been described in almost every organ, there are few reported cases of confirmed carcinoid metastases to the heart. The incidence is reported as <1%.4 MANAGEMENT A laparotomy was performed to debulk the tumour and peritoneal deposits to relieve the patient’s obstructive symptoms. The cardiac metastasis was conservatively managed since it was asymptomatic, was not associated with ECG abnormalities and surgery was deemed hazardous with a high risk of local recurrence.

REFERENCES 1. Maroun J, Kocha W, Kvols L, et al. (April 2006). “Guidelines for the diagnosis and management of carcinoid tumors. Part 1: The gastrointestinal tract. A statement from a Canadian National Carcinoid Expert Group”. Curr Oncol 13 (2): 67–76.

2. Modlin IM, Lye KD, Kidd M (February 2003). “A 5-decade analysis of 13,715 carcinoid tumors”. Cancer 97 (4): 934–59.

Figure 6: SPECT/CT image 4hours of heart metastasis.

3. Tochi M, Wiliiams KA (2008). “Mass-ive” infarction: Case report and review of myocardial metastatic malignancies”. J Nucl Cardiol 2008;15:719-26.

4. Bangkim CK, Niraj N, et al (April 2012). “Isolated cardiac metastasis in a patient with neuroendocrine carcinoma of pancreas discovered on 68Ga-DOTANOC PET/CT”. J Nucl Cardiol 2012 27 Apr 2012.

Special thanks to Dr Fred Khafagi and Temeeka Parry.

Left: Figure 7: Pre contrast image – T2 weighted Black Blood with Fat Saturation image.

Right: Figure 8: Post contrast image – immediate post gadolinium injection.

21

Submitted Paper

When is a high blood glucose level too high for FDG-PET brain imaging for dementia?

Jessica Welch, Wesley Ng, Sherylene Desmond, Kevin Hickson, Kunthi Pathmaraj, Salvatore Berlangieri, Christopher Rowe Department of Nuclear Medicine and Centre for Positron Emission Tomography, Austin Health, Victoria, Australia

ABSTRACT The demand for F-18 Fluorodeoxyglucose (FDG) PET to investigate the presence and characterise the type of dementia has greatly increased over the past few years. Concurrent diabetes can result in a high blood glucose level (BGL) that can result in poor quality images and potentially interfere with accurate reporting of the study.

Aim: To determine the relationship between BGL and image quality in FDG PET brain studies and to establish a threshold BGL which will ensure diagnostic image quality.

Method: FDG-PET brain images from 266 patients (153 diabetic and 113 non-diabetic) who had presented for the investigation of dementia were retrospectively analysed. The images were analysed blinded to the patient’s BGL status. All scans were assessed qualitatively and rated as good, fair or poor quality.

Results: FDG-PET imaging when performed with a BGL <7 mmol/L, produced diagnostic quality images consistently. As the BGL increased above 7, the incidence of studies judged as fair or poor quality also increased. It was found that when the BGL was between 10.1 and 11 mmol/L, 14% of scans were of poor quality, whilst a BGL above 11.1 mmol/L increased the incidence of poor quality studies to about 44%.

Conclusion: Optimal quality brain FDG PET scans can be routinely obtained with BGL <7mmol/L, but a diagnostic quality FDG PET scan is also possible with a BGL between 7.1 and 11.0mmol/L. Patients with a BGL >11.1mmol/L should be rescheduled or administered insulin.

Key words: FDG, PET, brain imaging, Blood Glucose level, diabetic

BACKGROUND The demand for F-18 FDG PET to investigate the presence and characterise the type of dementia has greatly increased over the past few years. In patients presenting with cognitive symptoms of dementia, regional brain metabolism is a sensitive indicator of Alzheimer’s Disease (AD) and neurodegenerative disease in general. A recent literature review found that FDG PET had 93% accuracy for detection of Alzheimer’s disease in recent cross sectional studies.1 Among patients with neuropathologically based diagnoses, PET has identified patients with AD and patients with any neurodegenerative disease with a sensitivity of 94% and specificities of 73% and 78%, respectively.2 Another study has demonstrated the value of FDG-PET brain imaging were the distinction between controls and AD patients was 93% sensitive and 93% specific, and even in very mild dementia (at MMSE 24 or higher) sensitivity was still 84% at 93% specificity3.

Significantly abnormal metabolism in mild cognitive deficit (MCI) Corresponding Author Jessica Welch Centre for P.E.T – Austin Health Level 1, Harold Stokes Building Austin Campus Studley Road, Heidelberg, VIC, 3084 Tel: 03 9496 3718 Fax: 03 9457 6605 email: Jessica.welch@austin.org.au

22 Gamma Gazette November 2012

indicates a high risk to develop dementia within the next two years and reduced neocortical glucose metabolism can probably be detected with FDG PET in AD on average one year before onset of subjective cognitive impairment.3 Concurrent diabetes can result in a high BGL that can result in poor quality images and potentially interfere with accurate reporting of the study. It is not uncommon to encounter diabetes in patients with possible dementia due to the average age of the study cohort.

Glucose metabolism is tightly connected to neuronal activity. Any changes in neuronal activity induced by disease are reflected in an alteration of glucose metabolism4. However, when hyperglycemia is present, there is increased competition of elevated plasma glucose with FDG at the carrier enzyme. This often is usually associated with high intracellular glucose and circulating insulin levels driving FDG into muscle, resulting in reduced uptake in the brain.4 Currently, when a patient scheduled for a FDG-PET brain scan presents with an elevated BGL, there is uncertainty in deciding whether to proceed or reschedule the study to another day when there is a chance that the BGL may be better controlled.

AIM The aim of this study is to establish a threshold BGL for patients presenting for FDG-PET brain imaging to ensure diagnostic image quality.

When is a high blood glucose level too high for FDG-PET brain imaging for dementia?

METHODS Table 1 demonstrates the distribution of patients in each FDG-PET brain images from 266 patients (diabetic and category of image quality for a range of BGL values. non-diabetic) who had presented for the investigation of dementia were retrospectively analysed. All brain Image Quality imaging appointments at Austin Health are scheduled

Good Fair Poor in the morning. FDG PET imaging was performed under BGL n % n % n % Total standardised conditions (>4 hours fasting) on a Philips <7 51 91.1 5 8.9 0 0.0 56 Allegro PET camera in 3D mode and the scans were reconstructed using 137Cs attenuation correction and 7.1 - 8.0 80 83.3 14 14.6 2 2.1 96 a RAMLA 3D algorithm. A 10-15 minute acquisition 8.1 - 9.0 33 67.3 14 28.6 2 4.1 49 was commenced 30 minutes post injection of 220 9.1 - 10.0 13 46.4 13 46.4 2 7.1 28 280 MBq of FDG.

10.1 11.0 6 42.9 6 42.9 2 14.3 14 Reconstructed images were qualitatively reviewed > 11.1 8 34.8 5 21.7 10 43.5 23 and rated as good, fair or poor quality by a senior Nuclear Medicine Technologist and an experienced Table1: Distribution of patients in each category.

Nuclear Medicine Physician. The analysts were blinded to the patientâ&#x20AC;&#x2122;s BGL when reviewing the images.

Images were classified according to the following criteria: groups (p<0.001). The difference between the Fair (8.9,1.8) and Poor (11.1, 2.4) groups is also statistically significant (p <0.001).

Good = image demonstrated good target (grey matter) to 83 of the 113 non-diabetic patients demonstrated a BGL greater background (white matter, scalp and facial structures) ratio than 7.1mmol/L, which was interpreted as impaired fasting glucose. and clear definition of internal brain structures; In this group we found that the majority (n=69) demonstrated good image quality with a small number demonstrating fair (n=13) and Fair = image contained noise but preservation of definition poor (n=1) image quality. of internal brain structures; FDG-PET imaging when performed with a BGL <7 mmol/L in both the diabetic and non-diabetic patients produced diagnostic quality Poor = poor target to background ratio, noisy image with images consistently. As the BGL increased above 7, the incidence little definition of internal brain structures; non-diagnostic of studies judged as fair or poor quality also increased. Despite image quality. this finding, it is not possible to predict the quality of the FDG brain The BGL for each scan quality group was compared by students study with certainty in the presence of an elevated BGL, since there t-test. Statistical analysis was performed using GraphPad software,5 is inconsistency when correlating imaging quality to an elevated which is an online calculator.

BGL. For example, in some instances a BGL of 11.3 mmol/L yielded a good quality scan whilst a BGL as low as 7.1 mmol/L resulted in a poor quality scan.

RESULTS It was found that when the BGL was between 10.1 and 11 mmol/L, 14% of scans were of poor quality, whilst a BGL above From the 266 patients, 153 patients were diabetic and 113 were 11.1 mmol/L increased the incidence of poor quality studies to non-diabetic. It was noted that in the non-diabetic group 83 patients about 44%. It would therefore be reasonable to recommend that were classed as having impaired fasting glucose. when a patient presents with a BGL >11.1 mmol/L, they should be either rescheduled or administered insulin to lower the BGL to an acceptable level before proceeding with the PET scan in an attempt DISCUSSION to optimise the quality of the study. A study performed by Berchert et al. proposes a management protocol for the acute correction of The results show that there is a statistically significant difference in hyperglycaemia with insulin which has the potential to significantly the mean value of the Good (mean: 7.7, SD: 1.6) and Fair (8.9, 1.8) improve the statistical quality of brain FDG PET images. This study demonstrated with computer simulations that acute correction of hyperglycaemia according to the proposed bolus insulin protocol should increase the FDG uptake of the brain by up to 80%.6 The demographics of the population requiring an FDGPET brain scan for dementia are commonly elderly, over weight and diabetic (often poorly controlled). Hence it is not uncommon that the BGL of these patients is often elevated.

Rescheduling the PET scan for patients with an elevated BGL is not always possible since these elderly patients are often reliant on family or friends to transport them for the PET study. Additionally if their diabetes is always poorly controlled, there may be little benefit in rescheduling the PET study to Figure 1: Image quality classifications. another day. Rescheduling should only be considered if the u 23

When is a high blood glucose level too high for FDG-PET brain imaging for dementia?

Figure 2: The number of patients in each BGL range for the diabetic and non-diabetic groups.

BGL is unusually high for a normally well-controlled diabetic patient.

The results of this study leads us to believe that it is reasonable to proceed with the FDG PET scan if the patientâ&#x20AC;&#x2122;s BGL is elevated, but still under 11.1 mmol/L, as the likelihood of a diagnostic study is far more likely than a non-diagnostic study.

A sub-group of eight patients taking Metformin, a hypoglycaemic drug for diabetes control, were identified. Interestingly, it was noted that patients on Metformin showed a trend for poorer quality brain scans regardless of the BGL and this observation warrants further study.

CONCLUSION Factors such as inconvenience to the patient and history of poorly controlled diabetes influence our decision to proceed with FDG-PET brain studies in patients with dementia when the BGL is greater than 8 mmol/L. In most instances we now proceed with imaging when the BGL is elevated but under 9.0 mmol/L. The decision to proceed with imaging when the BGL is 9.1 â&#x20AC;&#x201C; 11.0mmol/L is made on a case-by-case basis and patients with a BGL >11.1mmol/L are rescheduled or administered insulin.

24 Gamma Gazette November 2012

REFERENCES 1. Bohnen, Nicolaas I. Djang, David S W. Herholz, Karl. Anzai, Yoshimi. Minoshima, Satoshi. Effectiveness and safety of 18F-FDG PET in the evaluation of dementia: a review of the recent literature. [Review] J Nucl Med. 53(1): 59-71, 2012.

2. Silverman DH, Small GW, Chang CY, et al. Positron emission tomography in evaluation of dementia: Regional brain metabolism and long-term outcome, JAMA. 2001; 286(17): 2120-7.

3. Herholz K, PET studies in dementia. Ann Nucl Med. 2003 Apr;17(2):79-89.

4. Alan D. Waxman, MD; Karl Herholz, MD; David H. Lewis, MD et al, Society of Nuclear Medicine Procedure Guideline for FDG PET Brain Imaging, Version 1.0, February 8, 2009.

5.

Graphpad Software http://www.graphpad.com/quickcalcs/ index.cfm 6. Buchert R, Santer R, Brenner W, et al, Computer simulations suggest that acute correction of hyperglycaemia with an insulin bolus protocol might be useful in brain FDG PET, Nuklearmedizin.

2009;48(1):44-54.

Australian and New Zealand Society of Nuclear Medicine