Nov 2013

ISSN : 2200-9876

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

November 2013, Issue 10

Contents

www.anzsnm.org.au

Welcome

4

President’s Report

5

Branch News Queensland 6

Vic/Tas

6

New South Wales

6

Western Australia

7

New Zealand

7

SIG

Radiopharmaceutical Sciene 10

Technologists

10

Technical Standards Committee

11

International Relations Committee

12

Accreditation

12

Vale: Gapelu Siliva 13 What’s That?

15

SNMMI Annual Conference, Canada 2013 16 Nuclear Medicine global initiative Dose Optimisation Project 21 Thinking outside the box 22 Role of the Clinical Nurse 24 The classical presentation of Erdheim Chester Disease (ECD) 30 The role of positron emission tomography in the diagnosis and staging of oesophageal carcinoma 34 Interesting Cases

Hypertrophic Pulmonary Osteoarthropathy – A rare appearance on bone scans in lung cancer patients 38

Left ventricular laceration and the complications that followed

40

Case Studies

Phaeochromocytoma 42

The value of the 3–phase bone scan

48

The role of complementary Ultrasound and Nuclear Medicine techniques in the pre-operative management of breast cancer

50

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

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;

This issue compiled by SA and NZ branches

Rachael Dunlop (SA)

Nicole Ayars (SA)

Dianne Wills (NZ)

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.

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 2013 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

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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: ebailey@nsccahs.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 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

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 Special Interest Groups Technologists

Ms Maree Wright, email: maree_wright@hotmail.com Position vacant, interim contact is Acting President Ms Liz Bailey, email: Elizabeth.Bailey2@health.nsw.gov.au 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

Radiopharmaceutical/Science Physics/Computer Science

Nicholas Farnham, email: Nicholas.Farnham@health.sa.gov.au CPD Program Sub-committee: Dr Clayton Frater PDY/Mentor Program Sub-committee: TBC 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: Professor Richard Smart, email: r.smart@unsw.edu.au Chairperson: Professor Dale Bailey, email: Dale.Bailey@sydney.edu.au Chairperson: Professor Andrew Soctt, 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

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Welcome Welcome to the November edition of the Gamma Gazette. This issue has been a collaboration between the South Australian and New Zealand ANZSNM branches.

Meetings have been held throughout the year with high levels of attendance at both the ANZSNM and ANZSNMT meetings. The ANZSNMT AGM and Radpharm presentation selection will be held on the 20th November. The ANZSNM AGM is scheduled for the 4th December. These meetings are always a great way to finish off the year.

South Australia is looking forward to hosting the 44th ANZSNM – ASM, which will be held in Adelaide at the Adelaide Convention Centre from April 25-28, 2014. The theme of the meeting is “A Fusion of Ideas, Modalities, and Disciplines”, with an exciting program, emphasising the place of Nuclear Medicine in the multi-disciplinary practice of medicine. Renowned international speakers from Europe and USA will be in attendance as well as local and interstate experts in both Nuclear Medicine and associated fields such as Oncology and Surgery.

The pre-conference symposium covering ‘Lymphatics in Cancer: The Grapes of Wrath’ will be held at the Farm in the Barossa Valley, taking advantage of the famous wine region located on our doorstep. The focus of this meeting will be new developments and clinical applications in breast cancer imaging and the use of PET and Nuclear Medicine therapy in lymphoma.

Registration will open this month, please refer to the ANZSNM conference website for more information.

Thank you to everyone who contributed and supported this edition of the Gamma Gazette. We hope everyone has a safe and happy Christmas and New Year.

Rachael Dunlop & Nicole Ayars South Australian Branch

Welcome to the November edition of the Gamma Gazette from New Zealand.

Since the NZ Branch collaborated with SA on the March 2012 edition of the Gamma Gazette the number of Nuclear Medicine Departments in NZ has grown by the addition of a new department on the North Shore of Auckland.

Many of the other departments have purchased new SPECT/CT cameras and the PET community is now performing bone scans with NaF supplied by the cyclotron in Wellington.

We hold an Annual Branch Meeting in a different NZ centre each year. Visiting speakers, NZ members presentations, a poster competition, Radpharm and Paul Orr Awards, trade displays and the ever popular social event make it an educational and fun weekend we always look forward to.

Training future Nuclear Medicine Technologists has continued to be an issue for our branch so we are heartened by the recently announced commencement of an Auckland University post graduate programme for Nuclear Medicine Technologists in 2014.

Many thanks to the contributors to this edition of the Gamma Gazette.

Dianne Wills Secretary, New Zealand Branch

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President’s Report Welcome to another exciting issue of the Gamma Gazette, the last for 2013. Another year has gone by and there have been many fantastic projects started for the society and its members.

The history project is in its final stages of completion with the final draft currently under review. We anticipate an initial hardcopy print un of 500 copies and the book being made available as an e-book for a small fee as well as on wikibooks to allow members to provide input for the next edition. Any members wishing to purchase a hardcopy of the history book please contact the secretariat.

With the formation of ARTnet (Australasian Radiopharmaceuticals Trials network), the ANZSNM and AANMS have undertaken a decision to contract a project officer for 6 months on a part-time basis to establish the network including development of terms of reference, operational structure, polices, procedures and establishing contacts with other existing networks. This position commenced in mid October and it is anticipated that the organisational structure will be finalised in the first 2 months. This is a very exciting project for the society and we encourage members to become actively involved with research and professional development.

The society has been approached and accepted the opportunity to participate in the combined RANZCZR/AIR/ ACPSEM meeting to be held in September 2014 at the Melbourne Convention and Exhibition Centre. The ANZSNM will sponsor a one-day Nuclear Medicine stream with a theme of PET in Radiotherapy Planning. The program will be co-ordinated by the Scientific Advisory Panel. The workshop will be held on Saturday September 6, 2014 at a cost of approximately $250 to $300 for a one-day registration, with full access to all sessions including radiology and radiation oncology.

This is just a reminder that abstract submissions have now opened for the ANZSNM ASM 2014 to be held in Adelaide from April 26-28. When you are preparing your abstracts, don’t forget about the awards including the GMS Poster Award, Mallinkckrodt Award (for technologists), Gammasonics Award, the ANSTO Award and the AANMS Registrar Award All award rules can be found on the ANZSNM website.

Following the AGM in Perth, three long standing council members resigned from their positions – Geoff Roff, Dr Dylan Bartholomeusz and Dr Graeme O’Keefe. On behalf of the council, I would like to thank them for their hard work over the past 4 or more years and hope to see them at future meetings. The positions have been filled by Dr Ros Francis, Dominic Mensforth and Darin O’Keeffe.

It is with great sadness that we acknowledge and remember our good friend and colleague Dr Ajit Padhy who recently passed away in Singapore. Dr Padhy was a Senior Consultant in Nuclear Medicine and PET at Singapore general Hospital.

He was the President of the WARMTH organisation and a great advocate for nuclear medicine throughout the Asia-Oeania region. Our deepest condolences and thoughts are with his family, he will be greatly missed by all in the nuclear medicine community.

Liz Bailey President ANZSNM

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Branch News NEW SOUTH WALES Following the conference we hosted a meeting on April 16 at St George Hospital with international guest speakers Dr Robert Hendel and Ms Bernadette Cronin. This meeting was well attended and the members were happy with the topics of cardiology and New Horizons for Nuclear Medicine Technologists.

Our next meeting was at Concord Hospitalon July 31 with guest speaker Professor Vijay Kumar. Vijay gave an interesting talk about infection and inflammation imaging and how far we have progressed. The meeting was well attended with approximately 70 members. We would like to thank Clayton Frater for his assistance in organising this meeting.

In NSW both the Hunter Imaging group and RAINS will hold their meetings in September and November respectively. Our next meeting will be at Siemens medical on Wednesday December 4.

Tracey Larnach Secretary NSW Branch QUEENSLAND We held our branch day seminar on Saturday September 21 at Carlton United Brewery, Yatala. Pictured right.

We were fortunate enough to have a wide variety of speakers and we had over 50 attendees. Our speakers included local Nuclear Medicine professionals as well as Amanda Carter (who spoke about paediatric techniques, including the mock MRI at the Royal Children’s Hospital), Dr Steven Zedler (equine bone scintigraphy), Major Karla Strong (Australian Army Medical Imaging), and Cuong Nguyen (Social Media in the Medical Radiation professions). There were a few brewery related activities on the day, with special mention to Louis Gray for winning the beer pulling competition and Peter Gentle Beer tasting at Yatala. for getting all of the beers correct in the blind beer tasting! Many thanks to all who attended, we hope you had a great day!

Our AGM and Radpharm presentations will be held on Tuesday the 12th of November at the Pineapple Hotel, Kangaroo Point. We are looking forward to seeing some interesting case study presentations and wrapping up 2013.

Nikki Weinert and Kathy Roy Qld Branch Co-Secretaries 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 at the Crowne Plaza Hotel Melbourne on October 12, 2013 with a broad range of topics being presented. The meeting was well attended with over 90 registrants enjoying an educational day on the banks of the Yarra followed by a quiet drink at Cyclomedica’s social gathering at The Wharf Hotel. I would like to extend a big thank you to all of those who made the day a success.

The AGM held as part of the Annual Day Seminar saw three new committee members joining the Victorian/ Tasmanian branch committee. I would like to welcome Lauren Moon, David Thomas and Mary-Anne Keady aboard and look forward to their contribution over the next few years. I would also like to thank Sze Ting Lee for her tireless work and contribution to the committee during her tenure which include being both the Vic/Tas Federal Council representative and President of the ANZSNM and convenor of the Melbourne 2012 ASM. Her knowledge and expertise will be missed by all of us remaining on the committee.

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 23, 2013 as part of a VSNMT Day Seminar. I encourage all members to support this event. 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 through out the year the Victoria/Tasmania Branch will continue its expanded CPD and educational opportunities for members with two new “Molecular Imaging Masterclasses” in 2014. These focussed events will have limited places with ANZSNM members having priority access

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Branch news and complimentary registration to the event. The program and venue will be confirmed closer to the time with the first 2014 Masterclass to be held in February/March.

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 2014.

Bridget Chappell Branch Chair WESTERN AUSTRALIA Our third branch meeting of the year was held after the ASM, on Tuesday June 11th at Royal Perth Hospital. Dr Bill Macdonald spoke on “P.E imaging - too much of a good thing”, which was an interesting insight into the diagnostic pathways which lead to imaging for PE. Dr Russell Troedson gave a case presentation on “Funny turns in a patient with a carcinoid tumour”.

The Radpharm presentation night was on Tuesday 15th October at PRC. There were 2 applicants, Amy Evans who presented “Gallium-68-Citrate in Infection Imaging: A Case Study” and Rhonda Harrup who connected to the meeting from a little town in France via some electronic wizardry. She delivered her paper “Lymphoscintigraphy with SPECT/CT for localisation of chyle leak” and complied with the Award requirements and ultimately won the Award.

Congratulations to both applicants for excellent papers and especially to Rhonda for persisting against the odds of distance.

The AGM is scheduled for Tuesday 26th November at Sir Charles Gairdner Hospital.

Many thanks to Stephanie O’Donnell and Georgina Santich from the WA Branch Committee, and the other volunteers who worked hard to put together the July issue of the Gamma Gazette. This was a bumper issue with many submissions!

Our workshop this year was on Endocrinology and was held at the University Club, UWA on August 3rd. It was a great success, with approximately 70 attendees and speakers from Endocrinology, Endocrine Surgery and Nuclear Medicine. This event received generous sponsorship from GE, Siemens, Genzyme, GMS, Imaxeon, Lantheus and ANSTO. CPD certificates were issued on the day to all who pre-registered for the workshop.

The Radiological Council of WA recently notified us that a problem involving Provisional registrants with AHPRA has been resolved. NMT Provisional or Limited registrants and students enrolled in an approved NM course are now able to undertake diagnostic NM studies under “personal supervision” of a licensee rather than “immediate personal supervision” which was the previous requirement.

Diane Cheong WA Branch Chair NEW ZEALAND The NZ Branch sadly lost a long serving and much liked member of our community earlier this year. Gapelu Siliva’s obituary is printed on page 13 in this issue of the Gamma Gazette.

The branch members are all very proud of Pru Burns from Pacific Radiology for becoming the first NZ contestant to win the Radpharm Award at the Perth meeting in April 2013.

On September 21 and 22 our Annual Branch Meeting was held in Palmerston North. As always the NZ Nuclear Medicine ‘family’ enjoyed catching up with old and meeting new members of our small community. There was an interesting variety of presentations including an instructive and entertaining talk from Dr Geoff Schembri and Dale Bailey on V/Q lung scanning.

Congratulations to Chantel McCubbin for winning the poster competition.

The Saturday evening social event was held at the beautiful, historic Highden Manor built in 1896. It was the perfect setting for a ‘Kluedo’ murder mystery game which entertained us throughout the wining and dining. The request to dress in character was enthusiastically embraced as illustrated by the photos on the next page.

We have had good news regarding the training of NZ Nuclear Medicine Technologists from Dr Berry Allen, the Nuclear Medicine Representative for the University of Auckland Medical Imaging Advisory Board .

The Auckland University has commenced a post graduate programme for qualified Medical Radiation Technologists. The programme has two courses on offer, the Post Graduate Certificate (PGCert), a one year part time course offered for Mammography and Medical Imaging, and the Post Graduate Diploma in Health Sciences (PGDipHSc), a two year part time programme currently offered for MRI, Medical Imaging, and Ultrasound specialisations.

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Branch news Auckland University has also recently announced the introduction of a Nuclear Medicine pathway for the PGDipHSc programme. It is anticipated the first students will be able to commence the Nuclear Medicine modules Semester two in 2014. The Nuclear Medicine pathway will also be a part time programme over two years.

The New Zealand Nuclear Medicine community welcomes the introduction of this integrated programme approach and looks forward to the commencement of student enrolments in 2014.’ Dianne Wills Secretary NZ Branch New Zealand Branch Annual Meeting Dinner: A Kluedo Murdery Mystery.

8 Gamma Gazette November 2013

Meet the New Zealand Committee Dr Justin Williamson Chairperson At the recent ANZSNM branch meeting the members were kind enough to elect me Chairman of the NZ branch.

Originally I am from Rotorua but I grew up in Auckland. Before I went to medical school (in Australia!) I was a civil engineer and a scientist. So if you want to scan a reinforced concrete patient, you know who to ask. After medical school I did basic training as a physician in New Zealand, Australia and Ireland.

My Nuclear Medicine training was at Royal Perth Hospital, St Vincents in Sydney and Loyola University Medical Center in Chicago. I have a diploma from the European School of Medicine (part of the EANM) and am board certified in the USA. My job is in the beautiful Hawkes Bay at Hastings Hospital.

For the next year I would like to concentrate on boosting the health of Nuclear Medicine in New Zealand.

Karen Wiki Treasurer Hi my name is Karen Wiki and I recently took on the role of Treasurer for the New Zealand Branch of the ANZSNM, I trained as a radiographer and then gained a post graduate qualification in Nuclear Medicine. I have been practicing Nuclear Medicine for the past 18 years in both the private and public sector.

I have worked in several departments within New Zealand and spent two years working in departments in London. For the past 4 years I have been working for Pacific Radiology in Wellington practicing Nuclear Medicine and PET/CT. In the last 12 months I have regained a scope to practice Diagnostic CT as well. Life is busy as I’m also a mother to two beautiful girls aged 7 and 9 years. I’m looking forward to my new role.

Dianne Wills Secretary This is my 5th year as Secretary of the NZ Branch.

After training as a Diagnostic Radiographer in Auckland, then being a mum for a few years, I began my training as a Technologist in the Nuclear Medicine Department, Christchurch Hospital in 1987. Now, 26 years later, I am still in Christchurch Hospital.

I have enjoyed giving something back to the Nuclear Medicine profession during my time as Secretary.

Stuart Carter TSIG Representative

I am from the UK and have been living in New Zealand for three years.

Before coming to New Zealand I studied a BSC in Physics and then an MSc in Nuclear Medicine. I worked in NHS hospitals for seven years and then came to New Zealand for an adventure.

I now work at Mercy PET-CT in Auckland, and have completed the Victoria Society of Nuclear Medicine diagnostic CT course which has proved useful for performing contrast enhanced PET-CT. I like living in Auckland. I cycle to work everyday and enjoy Aucklands mild climate. Even after three years in NZ I am still suprised by how friendly New Zealanders are, they are always happy to have a cup of tea and a chat.

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Special Interest Group News RADIOPHARMACEUTICAL SCIENCE Subcommittees of the SIG have been meeting regularly to develop: 1. Certification Syllabus. This is developing really well now, and is nearly complete. We are intending to invite RPS from each state to attend a weekend workshop as soon as we can organise an appropriate date (unencumbered by other events), to finalise and commence beta testing of the syllabus.

2. Registration. We have completed guidelines for admission to a Register of Radiopharmaceutical Scientists.

These are currently being considered by the Professional Standards Committee of ACPSEM. The Register will provide an identity for the profession whilst the Certification process is being undertaken. It has been developed in response to the question ‘what is a radiopharmaceutical scientist/ radiochemist/ radiopharmacist’ who are referenced in a number of documents, but never truly defined.

3. QC Harmonisation project. This has commenced with a survey explaining the reason and what will be undertaken. A Committee has been formed, and initial data on Tc-99m sestaMIBI collected. GMS have undertaken to do the validation of the technique(s) the Committee selects as the most viable. It is intended that the recommendations from this project will be posted on the website as well as presented at the Scientific Meeting.

4. ANZSNM website. Updates to the website have been submitted.

5. Combined SIG workshop on Lutate therapy. The RPS and Physics SIG’s are combining to present a workshop on the ‘science behind the radiolabelling of octreotate with Lu-177. It is planned for February, but date and venue to be confirmed. The workshop is expected to raise any poorly understood issues surrounding the radiolabelling and use of this therapeutic agent. There will be educative speakers and panel discussions of ‘experts’.

Jennifer Guille Chair of the Radiopharmaceutical/Science SIG TECHNOLOGISTS The TSIG have been quite active since the last meeting held before the Perth ASM. The TSIG provided a response to two consultation papers for the Medical Radiation Practitioners Board of Australia (MRPBA). The consultation papers were on Proposed Supervised Practice Guidelines and Proposed Professional Capabilities of Medical Radiation Practitioners. While we made comment on the both papers we had more concern with the Guidelines for Supervised Practice. The responses to these can be found on the AHPRA website. We also have provided responses to two more consultation papers, the draft medical radiation practice accreditation standard and Draft medical radiation practice accreditation process which were put out for review by the MRPBA’s Accreditation Council. Once again these can be found on the AHPRA website. Please note that it is important for all Technologist members to read these consultation papers and provide response, whether that is personally or via your state representative as input to the Technologist SIG response.

The TSIG held it Annual Day Seminar in Coffs Harbour on July 27, 2013, which was in its 5th year. It was well attended with 43 delegates and had a great program which covered Working in Rural Nuclear Medicine and Research.

Clayton Frater and the CPD Subcommittee has continued to be very active in continuing to adapt the CPD database and range of activities to make it more user friendly and contain information that will make the process easier come time if you have your CPD points audited. Note: A survey will be sent out shortly. It is important that you spend time to fill this out to provide feedback to us.

The PDY/Mentor Subcommittee has continued to be a busy role. We currently have 56 PDY technologists enrolled in the program. (Including 21 Victorian Interns) As was announced via communique last month, the ANZSNM are in discussions with the MRPBA on continuing to provide the service of a PDY program for 2014.

Tale Liiv, the chair of the PDY/Mentor subcommittee has announced that she will be resigning from the position as of the TSIG’s November meeting. We would like to thank Tale for the countless hours and effort she has put into this position.

Nick Farnham Chair of TSIG

10 Gamma Gazette November 2013

Technical Standards Committee

(TSC)

The TSC has not met together since the Perth ASM however the individual Working Groups have progressed their allocated tasks working independently: a. Dose Calibrator Quality Assurance The necessary changes to the National Measurement Regulations were finally made in July this year, so the Dose Calibrator Proficiency Testing Program (DCPTP) can now start. A trial of the program was undertaken at three clinical sites in Sydney in May and ANSTO has provided a PowerPoint presentation on the status of this project. Hopefully all the hurdles have now been cleared and this project can be completed nationally early in 2014. b. Revision of Minimum Quality Control Requirements for Nuclear Medicine Equipment, version 5.7 Nov 1999 The working party has made significant progress since the previous report in April 2013.

• The current version of the document Minimum Quality Control Requirements for Nuclear Medicine Equipment (version 5.7, 1999) document has been reviewed by all working party members and extensive comments received.

• A decision was made to split the Minimum Quality Control document into two separate documents

o a QC schedule that details minimum and recommended frequencies for performing QC tests

o a guidance document that presents methods by which the tests presented in the schedule may be performed. This document will present recommended methodologies only and practices are free to perform tests differently providing the technique used adequately assessed the parameter(s) being tested • Drafts of the above two documents were prepared and circulated to the working party for comment • Refined drafts were then circulated in June to the whole TSC, the Physics SIG and the TSIG for feedback • Feedback was received from 10 people with numerous refinements suggested. One member was against the concept of a set of minimum tests, however the working party remains convinced of the usefulness of such a set of tests in the goal of achieving good quality clinical images • The schedule document has been refined based on the feedback received and circulated to the working party and incorporated into the guidelines document. The document is available on the website. c. Software phantoms and clinical software validation • Work continues on the online software audit tool and a beta version should be available within 8 weeks.

• Peter Collins, chair of this WG, presented this project at the EANM meeting in October. d. Requirements for PET Accreditation (Instrumentation & Radiation Safety), 2nd Edition Following discussions at the TSC meeting in Perth, the PET Working Group added the following sentences to the document “Requirements for PET Accreditation (Instrumentation & Radiation Safety) 2nd Edition (2012)” The performance specifications in this document are not intended to be applied retrospectively to PET scanners installed in any facility prior to January 1, 2013. For these systems the previous version of the standards will still apply. However, any scanner installed in a new geographical location after January 1, 2013 will be subject to the specifications in this document irrespective of the provenance of the scanner (e.g., second-hand, refurbished, moved to a different site address, etc).

Richard Smart Chair of TSC

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International Relations Committee

(IRC)

The IRC has been involved in a series of meetings with major overseas Societies, and new initiatives, over the last 6 months.

At the US 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 AsiaOceania, 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 October 2013, with A/Prof. Nathan Better and Prof. Barry Elison representing Australia in the Program.

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 engagement with the IAEA and WHO leading up to the WFNMB congress are being pursued.

Andrew Scott Chair of the IRC

Accreditation Congratulations to the following departments that were granted Accreditation or Re-Accreditation for the training of PDY Technologists: Hunter Imaging Group, Cardiff #109 Hunter Imaging Group, Maitland #33 Medscan, Merrylands #165 HNE Health Nuclear Medicine & PET (Waratah) #119 Royal Prince Alfred Hospital #27 Benson Radiology Nuclear Medicine #2 Dr Jones & Partners #44

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Congratulations to the following technologists who were granted Accreditation: Stirling Ha Caitlin Caballero Samuel Toohey Alexander McLuckie Luke Cahill Gabrielle Morrissey Katrina Helen Devitt Marko Krnic Liam Anthony Hanlon Laura Stewart Aleasha Amato Matthew David Rajca Tianna Joy Cotton Christine Dorothy Powell William Campbell Anderson Kirsten Alice Docherty Brittany Emmerson Shirley Tieu Cassandra Maree Mulcahy William Campbell Anderson Kirsten Alice Docherty Shirley Tieu

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Gapelu Siliva “Gentleman Technologist” 12/12/49 - 16/6/13 On June 20 the entire staff of the Auckland Hospital Nuclear Medicine department, supported by colleagues from other branches of radiology attended the funeral service for Gapelu Silvia.

It was described as a “Small Pacific Island” funeral and we were hugely outnumbered by other members of the community who had also come to pay their respects and demonstrate that Gapelu had also played a major part in his community outside the field of medicine.

In addition to the Gapelu that we knew as colleague and friend, we were to hear of the important part that he had also played in his family, his Church and his community. What did not surprise us was to learn that he had applied the same process of thoughtfully considering a situation and the individuals involved before offering his own insights Gapelu was born in Samoa and earned an educational scholarship to New Zealand. He undertook his tertiary education in Radiography, and then in Nuclear Medicine. Throughout his life he maintained an active interest in education, his own, his family’s and those around him at work and in his wider community. He was particularly proud of his children’s educational achievements.

The ultimate quiet achiever, when Gapelu had decided to do something he would work at it until it had been done well. He was a humble man who was surprised at his success and high standing in the profession and his community. Those who knew him were not.

Nuclear Medicine colleagues Auckland Hospital

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Answer on page 28

What’s that?

Submitted by Dr. Barry Chatterton Royal Adelaide Hospital FDG PET in 60-year-old woman with neck lumps.

Figure 1.

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Society of Nuclear Medicine & Molecular Imaging (SNMMI) 2013 Annual Conference, Vancouver, British Columbia, Canada Report by Professor Vijay Kumar Department of Nuclear Medicine & PET, Westmead Hospital & The Children’s Hospital at Westmead, Sydney, NSW 2145 Conference Venue More than 5000 physicians, scientists, technologists, and exhibitors gathered at The Society of Nuclear Medicine & Molecular Imaging (SNMMI) Annual Conference, held in June 8-12, 2013 at Vancouver Convention Centre, Vancouver, British Columbia in Canada. SNMMI Society celebrated its 60th Annual Meeting and show-cased new research and technology in more than 110 continuing education sessions, in about 2,000 scientific papers and posters at the meeting where 150 companies represented on the exhibit hall floor.

The location of the conference venue was one of the best with extensive water views of the Pacific Ocean and the mountains. It was a spectacular sight to see the water-planes taking off and landing in the water. The old convention centre was used for plenary lectures and the new modern convention centre was used for hosting all the scientific sessions and a huge Scientific Exhibit Hall displayed all the latest technology in nuclear medicine instrumentation. The new convention centre was gigantic, like any other thing you see in the US and the corridor connecting the old and new convention centres is rather very long but they made it interesting by decorating them with wall murals of native Indians, stretching the whole length. They hung a huge globe at the very entrance of the new convention centre which is spectacular when it was lit up in the night time.

The city of Vancouver is one of the greenest cities in Canada and in the world, with beautifully manicured gardens, mountains and water views. The ocean, its back water and rivers have provided extraordinary beauty to the city and water-views for a large population living there. Anybody lucky enough to see “Butchart Gardens” in Vancouver islands will agree with me that it is the best garden in the

16 Gamma Gazette November 2013

world and it is humongous. Originally the place was a stone quarry but later developed into a “paradise on earth” by careful landscaping, selecting the right trees, plants and flowers in the appropriate place and decorating with ponds, fountains etc. The University of British Columbia is situated within a campus which is known for beautiful gardens, tree-lined streets and its natural beauty. The campus is expanding rapidly, but the natural beauty has never been compromised.

Pre-congress/Categorical seminars One of the unique concepts of SNMMI/SNMMI-TS is the Categorical Seminars as Pre-congress session, which was held on Sat 8th Jun. They had 8 concurrent sessions with a focus on a particular topic for each session: translational molecular cardiovascular imaging, challenges of regulatory & reimbursement approval for molecular imaging, radiolabelled peptides for PET imaging, need for introducing PET-MR, molecular imaging of neurodegenerative diseases, hybrid imaging in paediatric nuclear medicine and dosimetry for NET tumours & update on tumour imaging and therapy. The choices are too many to choose from and the sessions go from 8:00 am to 4pm. It is rather exhausting at the end of the day, as many are just catching up with jet-lag etc. Nevertheless, it is informative and focussed on one theme so very beneficial for people to know the latest developments in a comprehensive way. It is a new initiative from SNMMI/TS to welcome the first-time attendees for a “new professional lunch” to make them feel at home. For others, they have the “welcome reception”, the only social occasion for catching up with their colleagues or to make new acquaintance. The exhibit and poster hall opening is usually a formal

occasion with the elected officials of the society and uniform wearing brass band adding character to the colourful procession around the trade exhibit.

Main Conference The Annual Meeting opened with the SNMMI plenary session on Sunday, June 9. David Staples from DOE (Department of Energy) was a guest speaker from the government. He gave an update on the acute shortage and availability of Mo-99 and accordingly there are only two countries, viz Australia and South Africa, produce 99Mo from LEU (low enriched Uranium). Both Belgium and Netherland will stop producing 99Mo by 2015. Canada is the only country producing 99mTc directly from 24 MeV cyclotron and Canada will cease producing 99Mo by 2016. USA has the means of producing HEU (high enriched Uranium) but LEU is a problem. Since the demand is always huge, USA may restart or refurbish existing facilities to cope with the demand for Mo-99. Val Lewington of Guy’s & St. Thomas’ National Health Service Foundation Trust in London, presented the Henry N. Wagner Jr, MD, Lecture, “Moving Molecular Radiotherapy into the Mainstream: Have We Reached the Tipping Point?” Later that day, Josh Mailman, a patient advocate, presented “Many the Miles – A Patient’s Journey for Better Outcomes” at the SNMMI Technologist Section plenary.

Honours & Awards SNMMI honoured several leaders in the field at its two plenary sessions. Ted Treves, professor of radiology (nuclear medicine) and director of the Joint Program in Nuclear Medicine (JPNM) at Harvard Medical School, was named as this year’s recipient of the “Georg Charles de Hevesy Nuclear Pioneer Award” for his contributions to the nuclear medicine profession. Dean F. Wong, professor and vice chair of Radiology, and professor of Psychiatry, Neuroscience, Environmental Health Sciences, and Carey School of Business at Johns Hopkins University (JHU) in Baltimore, Md., received the prestigious “Paul C. Aebersold Award” for achievement in basic nuclear medicine.

Monday’s special plenary session welcomed a new leadership team for SNMMI as Dillehay became president, while Peter Herscovitch assumed the position of president-elect and Hossein Jadvar, the vice president-elect position. The leadership for SNMMI’s Technologist Section also changed hands during the meeting, with Scott Holbrook, taking the helm as president and April Mann, as president-elect.

SNMMI announced “Image of the Year for 2013” and the honour was given to Patrick Flamen and his colleagues for their image on “18F-FDG positron emission tomography/ computed tomography (PET/CT) scan illustrating the effectiveness of radium-223 dichloride in treating bone metastases in breast cancer patients with bonedominant disease”. SNMMI also held a Patient Program at the Annual Meeting where more than 75 patients and caregivers attended sessions on advances in nuclear medicine and molecular imaging.

Topics featured included dementia, neuro-endocrine tumours and lymphoma.

Henry Wagner – tribute Henry Wagner Jr. has passed away recently and he is considered the “father of nuclear medicine” and a session was dedicated to pay tribute to this great man who contributed significantly over several decades on important global scientific advancements in nuclear medicine. He was instrumental that nuclear medicine became a clinical medical specialty and became an inspiration for building up colourful Academic Career for many nuclear medicine personnel

around the globe. H. William Strauss highlighted the lessons learnt from the “Father of Nuclear Medicine - The Early Years” and S. James Adelstein spoke on “Wagner’s Impact on International Nuclear Medicine”. Yashuhito Sasaki spoke on how “Wagner was instrumental in introducing nuclear medicine to Japan”. Robert F. Dannals then indicated how Basic Science Lessons were learnt from Wagner who assisted Building an Academic Career for many. Finally Richard L. Wahl, who succeeded him at Johns Hopkins paid tribute to The Legacy of Henry Wagner at Johns Hopkins University. Wagner was a trump card for attracting big audiences at the SNM “highlight lecture” for over three decades. He was sadly missed.

Conference Highlights As I mentioned earlier, there were 110 continuing education sessions, more than 2,000 scientific papers and posters were presented at the meeting and 150 companies were represented on the exhibit hall floor. There were some outstanding sessions in neurology, neuroendocrine tumour imaging, therapy/oncology, infection/inflammation, PET/MR and Ga-68 generator, which were interesting, informative and well attended. It is beyond the scope of this review to give an exhaustive account of all the sessions.

Infection/inflammation One of the well attended sessions was on “Radionuclide Imaging of Inflammation and Infection: State of the Art”, which was sponsored

by ISORBE (international society of radiolabelled blood elements).

Two well-known speakers gave wonderful talks: Ora Israel on Soft Tissue Infection and Christopher J. Palestro spoke on Musculoskeletal Infection. The session was very informative and very comprehensive.

Amyloid PET imaging session was well attended. The session had the following take home messages: (1) clinical diagnosis of Alzheimer’s disease. (2) appropriate use of amyloid PET in dementia care. (3) future research needed for better care of patients with dementia using amyloid PET. The introductory remark was given by Satoshi Minoshima on the “Development of Appropriate Use Criteria for Amyloid PET” followed by Peter Herscovitch who spoke on Clinical Diagnosis of Alzheimer’s Disease and Approval for Amyloid PET. Christopher C. Rowe spoke on Appropriate Use Criteria for Amyloid Brain Imaging and Kevin J. Donohoe followed that talk with “Requirements for Imaging Performance and Interpretation”. The session was concluded with panel discussion which was very useful.

PET/CT and Molecular Imaging in the Management of Malignant Melanoma This particular session was given by Andrew Scott and Michael Hofmann on behalf of the ANZSNM society. Andrew M. Scott spoke on “Recent Advances in the Management of Patients with Malignant Melanoma; PET/CT Staging and Restaging Melanoma”, with a particular reference to treatment of melanoma with ipilimumab.

Michael S. Hofmann followed this talk with “Lymphoscintigraphy with SPECT/CT in Malignant Melanoma” and continued with another talk on “PET/CT in Monitoring Response to Treatment: New PET Tracers”.

The topic has attracted big attendance over the past two years.

Therapy/Oncology Was another well attended session with Part I & II. Part I: This session was beneficial to Physicians, Pharmacists, Physicists, Technologists, and Residents/Students. They discussed the use of radium 223 dichloride and elaborated the science behind u 17

the therapy. Neeta Pandit-Taskar gave a talk on Clinical Overview of Radium 223 Dichloride. Rashid E. Ghani & Heather Koehler spoke on Radiation safety concerns regarding the handling and administration of radium 223 dichloride. Michele A. Panichi-Egberts addressed Licensing and Radiation Safety of Radium 223 Dichloride and state licensing requirements for radium 223 dichloride therapy.

Part II: In this session Val J. Lowe spoke on Prostate Cancer Imaging with Choline and evaluated the use criteria for C-11 choline PET/ CT imaging. Paul E. Kinahan spoke on PET/CT Quality Improvement which described common variables in quality and quantifications of PET/CT scans and examined the improvements of PET reconstruction techniques.

Ra-223 therapy Radium Ra 223 dichloride (Xofigo®) injection is indicated for the treatment of patients with castration-resistant prostate cancer (CRPC), symptomatic bone metastases and no known visceral metastatic disease. Radium Ra 223 dichloride injection was recently approved by FDA and therefore attracted lots of attention. D. Scott Wilbur spoke on Alpha-Emitting Targeted Radiopharmaceuticals for Radiotherapy Spoke about radium therapy – historic events, lymphoma treatment with radium etc. Silvia J. Jurisson briefed on Beta-Emitting Trageted Radiopharmaceuticals for Radiotherapy followed by Jason S. Lewis who elaborated on Translation of Radiopharmaceuticals for Radiotherapy. The session was useful to assess the differences of various types of therapeutic radionuclides (alpha emitters and beta emitters), recognise the future potential of targeted molecular radiotherapy and current limitations and more importantly summarised the current status of novel therapeutic radiopharmaceuticals.

Emerging PET Radiotracers This session was designed with the focus to identify the biological characteristics and potential clinical utility of emerging PET radiotracers. They illustrated clinical case examples with these new tracers with emphasis on proliferation, lipogenesis, and hypoxia.

Hossein Jadvar gave an impressive lecture on tracers of lipogenesis

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(acetate Choline) followed by Michael M. Graham who spoke on Tracers of Hypoxia (nitroimidazole), and final lecture to this session was given by Lale Kostakoglu on Tracers of Proliferation (FLT).

Gallium-68 Generators and Radiopharmaceuticals One of the areas where USA is lagging well behind Europe, Australia and the rest of the world is on “Gallium-68 Generators and Radiopharmaceuticals”. They organised a session to give an update on this aspect, which was sponsored by the Radiopharmaceutical Sciences Council, mainly organised by Neil A. Petry and David Wayne Dick. I had the opportunity to speak at that session as one of the invited speakers to give an update on the Developments and New Insights on Germanium-68/Gallium-68 Generator Systems. It was followed by another talk by Clemens Decristoforo who spoke on “Gallium-68 – A New Opportunity for PET Available from a Long self-life Generator: Clinical Application Beyond Radiolabeled Peptides”. Neil A. Petry and David Wayne Dick elaborated on Current and Future Regulatory Challenges on Ga-68 Generators and Radiopharmaceuticals. The session was concluded with open discussion with the participants and speakers, which was interesting as the packed audience stayed well beyond the time to participate in active discussion. It appears that FDA may allow the nuclear medicine community in the US to use Ga-68 generator in 2015.

Neuroendocrine Tumors and Personalized Medicine This is currently one of the most sought after sessions due to current interest in this area. It explained the basic molecular mechanisms of neuroendocrine tumors and their biomarkers. There were good presentations to assist selecting the best clinical and molecular imaging tools for the diagnosis of these tumours. More importantly, it was highlighted to integrate the available peptide radionuclide radiation therapies (PRRT) into the management of these tumours and identify the current best medical and surgical therapeutic approaches for neuroendocrine tumours. Several speakers spoke on different aspects: [123I] iodometomidate imaging in adrencortical carcinoma: evaluation of 58 patients, (2) survival after somatostatin-based radiopeptide therapy with [90Y-DOTA]-TOC and [90Y/177Lu -DOTA-TOC]

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in Metastasized Gastrinoma, (3) Can molecular response after peptide receptor radionuclide therapy predict the overall and progression-free survival, (4) 18F-FDG PET, use in the management of adrenocortical carcinoma, utility of 18F-FDG PET/CT in pediatric neuroblastoma comparison with 131 I-MIBG scintigraphy and (5) tracer kinetic analysis of 68Ga-DOTA-TATE and 68Ga-DOTA-TOC in Neuroendocrine Tumors.

PET-MR Clinical application for PET-MR was highlighted and is gathering momentum as this session was well attended by physicists, scientists and clinicians. Sangtae Ahn gave an impressive talk on Improved Attenuation Correction in PET/MRI by Combining MR Image Segmentation and Joint Estimation Approaches. Kyeong Min Kim then spoke on Comparison of SUV Obtained from PET/CT and PET/MR in Patients with Esophageal Cancer. Finally Georges N. El Fakhri spoke on Simultaneous PET/MR Imaging.

Radiopharmaceutical Sciences/Molecular Imaging/CMIIT Basic Science Summary Session This session was beneficial for Physicians, Pharmacists, Physicists, Residents/Students, and Technologists. It would help identify biological applications of investigational radiopharmaceuticals, identify novel approaches to construct molecular targeting probes, recognize some of the uses of investigational molecular targeting probes for cancer, neurologic disease, and other diseases, evaluate the potential efficacy of promising imaging agents currently under investigation and evaluate the potential for translation of probes to the clinical arena.

Current Problems, Controversies, and Techniques in Nuclear Medicine 2013 This session was presented in six parts with the following take-home messages to participants (1) Assess current imaging and therapy protocols and procedures and bring up to date and standardize.

(2) Examine the current job market and have guidance for seeing opportunities in job classifications that are non-traditional yet now part of nuclear medicine technology. (3) Assess current imaging and therapy protocols and procedures for hyperthyroidism and bring up to date and standardize. (4) Compare new diagnostic radiopharmaceuticals and their contributions to understanding dementia. (5) Assess the future as the role of the technologist expands into more radionuclide therapies. (6) Explain how PET imaging is interpreted through quantitative analysis and visual observation.

Trade Exhibition & Poster sessions Trade exhibition is always a central attraction at the SNMMI conference. It is the focal point for all the major players in Nuclear medicine industry to display their state-of-the art equipment with the latest technology: Gamma cameras, PET-CT cameras, PET-MR etc.

High pitched sales men try their best to convince the potential buyers to make their decision for their products. There was a big display of micro-SPECT & micro-PET cameras for pre-clinical imaging. It is a great place to learn the finer aspects of the equipment and discuss with the colleagues who already use them in their departments. Some booths have hot-coffee and most of them supply small souvenirs which attracts lots of attention. It is also a central point to meet your old friends and make new friends. Large displays included the PET tracer synthesis systems, hot-cells, automatic dispensers, radiation safety equipment etc. It is also a good place for selecting your recently released books, journals and other publications that may be of interest to you. This venue has the lunch and coffee shops where you can relax

and have a lunch break or catch up with friends. Besides, the array of new equipment, Siemens booth had a display of a humanoid head which was really fascinating. The face was constructed which looked realistic and it winked or moved the eye brow periodically which was unreal.

ANZSNM Booth ANZSNM has been having a booth at the SNMMI to promote the activity of our society internationally. Consequently, it attracted more international participants to our annual conferences in the recent years. Michael Kitchener, the next ANZSNM host and Liz Bailey, the current president of ANZSNM and Vijay Kumar, Secretary of IRC (International relations committee) have been manning the booth and distributed the brochure for the next ANZSNM conference in Adelaide & Barossa Valley, which attracted lots of attendees throughout the conference. One of the attractions is the display of soft toys (kangaroos, koala bears etc) and Australian chocolates which certainly attracted many attendees. Andrew Scott was invited to attend the WFNMB general assembly as the incumbent President for the next World Federation conference in Melbourne in 2018.

ANSTO dinner ANSTO has been hosting a Dinner night for Australian delegates attending the overseas conference for the past few years. This is a tradition to bring the mates together in a great night out in a relaxed atmosphere. In the past GE & other industry have been hosting such dinners for many years and it is great to see ANSTO is continuing the tradition. They have selected fabulous venues in the past and this year was no exception as you see big smiles in the faces of those attendees. There were breakfast sessions and official dinners hosted by several commercial equipment suppliers– which are great for relaxing after a hard days attendance.

In conclusion, back by popular demand, SNMMI is offering its Virtual Meeting for those unable to attend certain sessions or make the trip to Vancouver. The Virtual Meeting captured 70 of the most popular sessions, featuring more than 100 hours of content from the opening plenary through the Highlights Session, plus the molecular imaging, radiopharmaceutical, and data and instrumentation basic science summary sessions. CME, ACPE and VOICE credits are available through the Virtual Meeting. It may be a good idea that each department buys one DVD to the benefit of the people who did not attend the meeting or equally for the ones who attended also, as it is impossible to attend all the sessions. The conference was fantastic from scientific, social and professional net -working point of view.

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Nuclear Medicine global initiative Dose Optimisation Project Report by Darin O’Keeffe ANZSNM Physics SIG Chair In 2012 the US Society of Nuclear Medicine and Molecular Imaging (SNMMI) expanded their global outreach programme by forming the Nuclear Medicine Global Initiative (NMGI). The initiative is a forum for nuclear medicine leaders from around the world to discuss important issues that affect them and work to a joint consensus or conclusion that will affect nuclear medicine worldwide.

The goals of the NMGI are to: 1. to promote health by advancing the field of nuclear medicine and molecular imaging; 2. to encourage global collaboration in education, and harmonisation of procedure guidelines and other policies; and 3. to improve quality and safety.

The SNMMI president, Dr Fred Fahey, sent out invitations to international organisations involved in nuclear medicine and molecular imaging to attend a NMGI session at the EANM 2012 conference in Milan. Ten organisations sent representatives to this meeting primed with initiatives to work on. From an extensive list of possible initiatives it was decided that the NMGI would start with the topic of “dose optimisation”. Each organisation was asked to submit a brief document describing aspects of dose optimisation most important to them, and it was at this point that I became involved as the ANZSNM representative for the NMGI dose optimisation project. The ANZSNM submitted five items for consideration, addressing aspects of adult and paediatric diagnostic reference levels, and radioactivity schedules; optimal imaging procedures; equipment performance; hybrid imaging; and increasing administered activity on compassionate grounds.

The first video conference was held in January using the Webex service and this was a very interesting exercise with persons from timezones around the world over participating.

Being a video conference for me at 2 am in the morning,

you couldn’t get away with wearing your PJs. From this first meeting the NMGI dose optimisation group, led by Dr Fahey, decided to work on the area of paediatric dose optimisation. This decision was based on the importance of dose optimisation in our paediatric population, and we thought it would be the easiest area to start on as a multiorganisational project team. The team broke into three sub-project groups looking at a background to paediatric dosimetry, a review of existing guidelines for administered activity, and ideas on how to deliver educational resources on paediatric dose optimisation. Each group reported on their respective sub-projects at a NMGI meeting in Vancouver in June, and Liz Bailey and I represented the ANZSNM at this meeting. There was some degree of overlap between the work of the three groups. Not a bad thing, but we learnt to me more careful about this in the future. From a review of administered activity guidelines, there are three main documents: the EANM guidelines (which the ARSAC regulations link with), the 2010 North American Consensus document, and a recent document internal to the Japanese Society of Nuclear Medicine (written in Japanese). The NMGI group decided to undertake a global survey of paediatric nuclear medicine practices with regards to administered activity. This survey will be similar to the one completed for development of the North American guidelines, except host societies of the NMGI will be expected to translate it to their language requirements. Details will hopefully be available in the near future, so please take the opportunity to contribute.

Participation in the Global Initiative is an important opportunity for the ANZSNM to make a contribution to nuclear medicine at an international level. The dose optimisation project is just the beginning. This is an exciting time for the progress of nuclear medicine and molecular imaging, so please make the most of any opportunity you have to contribute.

Representatives from 10 nuclear medicine related societies and organisations attending the NMGI meeting held at the SNMMI Annual Conference in Vancouver, June 2013.

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Thinking outside the box Report by Pru Burns Pacific Radiology, New Zealand It is said New Zealand is famous for it’s sheep ... these last couple of months, we have decided NZ loves all it’s animals equally!

The first was for a PET/CT on a green Iguana, a resident at Wellington Zoo. The Iguana had been unwell for a few months, with what was suspected as a rare neoplasia on her skin. This skin cancer had only been diagnosed in reptiles four previous times. The cancerous nodules had been surgically removed, however her blood results still indicated that she had cancer.

Plain radiographs had been performed to check for signs of metastases but none were identified. The managing Vet had initially asked for a CT scan, and we suggested a PET/CT scan.

They jumped at the chance. Iguana’s are very hard to cannulate, so they performed a cut down procedure and exposed a vein in her leg. Unfortunately the 18F-FDG dose extravasated and so no PET images were obtained. We did get excellent CT images, although without the functional images metastases could not be

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excluded. The was no sign of metastases on the CT images. The Iguana is doing well, cancer markers are still of concern and the Vet staff are keen to repeat the PET/CT scan again if necessary.

Our next patient referral came from the Veterinary School at Massey University in Palmerston North. They had a canine who had undergone an previous adrenalectomy and they were still suspicious there were distant metastases. It is fortunate that one of the vets at Massey University is married to a NMT – so over dinner (perhaps an exaggeration!) they discussed the case and a PET/CT scan was suggested. We performed a PET/CT scan and found no evidence of metastases. The PET scan did show increased uptake in the thyroid gland. After consultation with the Veterinary team at Massey it was thought this uptake was abnormal. To date, the dog is doing better on thyroid supplementation and apparently chasing rabbits.

Our final case is a big one! Cantik (pronounced Shahn-tik) a 21-year-old female Sumartran tiger at Wellington Zoo had been suffering from fluid retention and weight gain. The veterinary staff were concerned that either she had congestive heart failure or a malignant process causing ascities. An ultrasound was performed, suggesting a mass on an adrenal gland. A CT scan with IV contrast confirmed a mass involving the right adrenal gland. The reporting Radiologist, ever keen to try new things, suggested a 18F-FDG PET scan of her whole body to

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assess for distant metastases. I immediately googled tiger + 18 F-FDG images = zero response! We treated her like a 105kg adult, injected 450MBq (a slightly larger than normal dose, to allow us to scan faster at 2 minutes/bed), waited 60 minutes and scanned base of skull to the top of the femur’s. I would have loved to have included her head, but she was very long and it was more important to include the pelvis. We scanned her on her side in preparation for the planned biopsy of the mass if it

was FDG-avid. The lesion was avid, and we performed the biopsy.

Unfortunately there was also extensive ascites, and following the scan it was decided to euthanase Cantik. This was an amazing experience for all our staff. The staff from Wellington Zoo who accompanied Cantik to the department were very supportive of us being near her, touching her and taking lots of photos. Despite the outcome, the PET/CT scan directed the correct course of action, much like we do every day for our human patients.

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Role of the Clinical Nurse:

A Sir Charles Gardiner Hospital Nuclear Medicine Department and WA PET Service Perspective Tammy Hagan, Clinical Research Nurse Associate Professor Roslyn Francis, Nuclear Medicine Physician Elaine Campbell, Data Manager SCGH Department of Nuclear Medicine and WA PET Service

INTRODUCTION Over the past 5 years, an increase in the number of clinical trials has lead to the introduction and development of the Clinical Research Nurse (CRN) role. A number of trials within the Sir Charles Gairdner Hospital Nuclear Medicine Department and WA PET Service are the result of collaboration with other specialities, but many are investigator initiated research trials originating from within the Nuclear Medicine department itself.1,2 This article briefly describes four of the current studies within the department and the CRN responsibilities within these studies. Guidelines governing the role are outlined and the role described, with an emphasis on participant advocacy and consent.

STUDY 1 Currently the department is conducting a glioma study, “11C-Methionine and 18F-Fluorothymidine PET-CT imaging in suspected residual or recurrent glioma” (as seen in Figure 1).3,5 The CRN role within this trial involves following up patients, assisting in data collection, injecting isotopes as per protocol and confirming participants’ PET scan bookings.

Figure 1: The overall impression on both scans were “definite treatment related change.

STUDY 2 Participants to the “Apoptosis Imaging in Malignant Pleural Mesothelioma” study are recruited from the Medical Oncology department within the hospital. Patient support is a large part of the CRN role in this trial as these participants are newly diagnosed with mesothelioma and undergo their first chemotherapies during this time.

Cannulating and injecting radioisotopes are performed by the CRN operating under the licence of the investigator, after attaining a departmental competency and completing a ‘Sealed and Unsealed Isotopes course’. Other responsibilities for the CRN include observing and reporting any adverse affects to the principle investigator and the radiation safety officer.4 The CRN has also developed procedural guidelines for injecting Annexin V, which comply with radiation safety requirements.

STUDY 3 Participants for the ‘Evaluation of FDG PET-CT in the Infection of Extremities’ study are recruited within the Nuclear Medicine department. Often the participants are diabetics and the preparation for the PET scan involves fasting, therefore the CRN needs to be able to inform the participants about medications, diet and hydration. To decrease the number of hospital visits for the participants the PET scan is booked to immediately follow the Nuclear Medicine imaging, this increases the trial consent rate and reduces the number of withdrawals.3,7 STUDY 4 The ‘Comparison between Ga-68 citrate PET-CT and Ga-67 citrate SPECT/CT for Infection Imaging’ study is a multicentred trial recruiting participants from SCGH and RPH Nuclear Medicine departments. Figure 2 is an example of the images acquired. The CRN role involves liaising between both sites to promote and educate staff about the trial and to assist with screening, consenting and booking of participants.

The role involves ensuring all investigators on the trial are aware of any protocol changes and the status of the trial. Trial preparation required developing protocols and guidelines that met the requirements of both sites.

Coordinating all providers in the process assures the participant of a smooth process. The aim of the CRN is to ensure the participants are treated professionally with sensitivity and compassion, and given optimal care whilst in our department.3,6

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role in contributing to nursing research.1 In this role the nurse also undertakes critical analysis of research, maintenance of accurate documentation and identification of suitable research questions.4

Gallium 68 Citrate PET-CT

THE CLINICAL RESEARCH NURSE ROLE

Gallium 67 Citrate SPECT-CT

Figure 2.

GUIDELINES The CRN plays a pivotal role within the research team, and works under direct supervision of the principal investigator.

Responsibilities include delivery of direct and indirect participant care and associated data collection for concurrent research studies undertaken in the department. The role is performed in accordance with the Therapeutic Goods Administration (TGA) guidelines, Note for Guidance on Good Clinical Practice (CPMP/ICH/135/95) and the National Health and Medical Research Council (NHMRC) National Statement on Ethical Conduct in Research Involving Humans.4 The CRN role includes finding participants notes, calling them up at the appropriate time and double-checking this does not clash with any of the participants’ other appointments. These tasks involve tracking notes on hospital based programs such as MERITS, TOPAS etc. Notes are retrieved from the medical records department or the relevant area (eg. Oncology).

Included in this task is the return of the notes to the correct area in a timely manner. Confidentiality and privacy is safeguarded by de-identifying data and storing the notes in the research room, which is a locked area, a requirement of the ethics committees at SCGH and Good Clinical Practice Guidelines.

The CRN role requires analytical skills in accessing and evaluating health information and research evidence, as this is fundamental to the understanding of the registered nurse

The new and developing CRN role covers protocol development and evaluation, recruitment and consenting of patients, administering radiopharmaceuticals and coordinating multi-site departments and personnel. Knowledge of Nuclear Medicine, Positron Emission Tomography, good clinical practice, epidemiology and biostatics are all essentials in meeting the demands of the CRN role. The CRN role is multifaceted and varies between trials as each trial has its own requirements and demands. An open communication between sites and departments must be developed and maintained.

Prior to arranging a PET/CT scan the CRN checks the participant meets the inclusion/exclusion criteria, ensures all relevant scan request forms are completed correctly and confirms the study participant has signed the correct consent forms. In each study the CRN needs to coordinate the PET bookings to correspond with the RAPID (cyclotron) weekly schedule for non-FDG radiopharmaceuticals productions. Good communication and coordination results in more efficient use of camera time and eliminates wasted doses, reducing radiation exposure.3,8 As these studies involve several bookings with both Nuclear Medicine and PET, the CRN needs to be able to liaise effectively with all stakeholders – PET and Nuclear Medicine technologists for camera time, laboratory staff for production of doses, participants to ensure they can meet the appointment times and have transport and hospital ward staff for inpatient appointments.

ADVOCACY Participant advocacy is one of the most important of the research nurse’s responsibilities. The International Conference on Harmonisation Good Clinical Practice (ICH GCP) (2) guide emphases that the protection, safety and wellbeing of trial participants must be a priority – no-one participating in clinical trials should be harmed. Anyone working in clinical research must, therefore, have up-to-date training in GCP (European Medicines Agency, 2002)2 and act according to the tenets of The Declaration of Helsinki’s Ethical Principles for Medical Research Involving Human Subjects.2 This stipulates that participants’ health and wellbeing must take precedence over all other interests. GCP training must be maintained on a two-yearly basis either by attending a

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one-day course, or through an online e-learning course with assessment .2 ,4 CONSENT Ensuring participants give fully informed consent before being enrolled to trials is an essential role for the CRN. Another important task is screening potential participants (outpatients and inpatients), making sure participants are given the Patient Informed Consent (PIC) and that they comprehend the intention of the study and what will be required of them. It must be made clear to participants that they do not have to enrol and are free to withdraw at any time without it affecting their treatment or care in any way.4 CONCLUSION The National Competency Standards for Registered Nurses (2006) 1 stipulates a nurse use best available evidence, relevant literature and research findings to improve current practice. As stated within these standards, a nurse participates in review of policies, procedures and guidelines based on relevant research, and identify and disseminate relevant changes in practice or new information to colleagues.1 The role of the nurse within Nuclear Medicine is an expanding and evolving one, with limited literature and nursing research on which the Nuclear Medicine nurse can base their practice.

Conducting clinical trials has lead to evidence based gold standards of treatments and imaging within Nuclear Medicine.3 Encompassed within the CRN role is the development of evidence based practice in Nuclear Medicine and progression of the scope of practise for Nuclear Medicine nurses. This includes participating in quality improvement activities, review of practice in relation to practice outcomes, standards and guidelines and new developments.4 The CRN in Nuclear Medicine plays a vital role in the advancement of imaging modalities by assisting in the delivery of novel tracers that will contribute to a higher standard of patient care and produce improved diagnostic and therapeutic monitoring

26 Gamma Gazette November 2013

models. The CRN role will ensure the delivery of the highest standard of care to all participants involved in clinical trials and, where relevant, their families, in partnership with all members of the multidisciplinary and research teams. The CRN will maintain clinical and research governance.4 Finally, research nurses also act as educators, mentors and advisors to other health professionals.

References 1. National Competency Standards for the Registered Nurse.

Australian Nursing and Midwifery Council. 4th edition. Jan 2006.

2. Wilkes L, Jackson D, Miranda C & Watson R. The role of clinical trial nurses: An Australian perspective. 2012.

Collegian 19(4). Royal College of Nursing (Australia).

3. Francis R, Segard T, Maton P & Campbell E. A snapshot of research activities at the WA PET Service. 2011. Gamma Gazette (4). Australian and New Zealand Society of Nuclear Medicine.

4. Pick A, et al. Getting started in clinical research: the role of the research nurse. 2010. Nursing Times; 107: online edition, 26 April.

5. Heiss Wolf-Dieter, Raab Peter and Lanfermann Heinrich.

Mulitmodality assessement of brain tumours and tumour recurrence. 2011. Journal of Nuclear Medicine 52(10; 1585-1600).

6. Nowak A, et al. Imaging in pleural mesothelioma: A review of Imaging Research Presented at the 9th International Meeting of the International Mesothelioma Interest Group.

2010. Lung Cancer 70(1-6). www.elsevier.com/locate/ lungcan.

7. Dumarey N, et al. Imaging Infection with 18F-FDG– Labeled Leukocyte PET/CT: Initial Experience in 21 Patients. 2006. Journal of Nuclear Medicine 47 (4; 625632) 8. Ujula T, et al. Synthesis, 68Ga labeling and preliminary evaluation of DOTA peptide binding vascular adhesion protein-1: a potential PET imaging agent for diagnosing osteomyelitis. 2009. Nuclear Medicine and Biology 36 (6; 631-641).

Chantel McCubbin’s winning poster at the New Zealand Annual Branch Meeting 2013

From page 15

What’s that? ... answer Bilateral Carotid body tumours (R>L) with mediastinal metastasis.

The images (figure 1) shows FDG uptake in masses in the region of both carotid bifurcations and in the right side of the chest adjacent to the mediastinum.

The patient had presented with a right sided palpable neck mass, and was subsequently investigated with CT angiography, I123 MIBG scanning, FDG PET and MRI. The lesions were eventually treated by embolization.

Discussion Carotid body tumors1 present most commonly as an asymptomatic palpable neck mass in the anterior triangle of the neck. They are slow-growing tumors that can remain asymptomatic for many years As they increase in size, pressure on adjacent structures can result in pain, hoarseness, and paralysis of the tongue.

The normal carotid body is a vascular structure 3-5mm in diameter in the adventitia adjacent to the carotid bifurcation. It is responsible for detecting the oxygen saturation in arterial blood and monitoring blood pressure. The cells are derived from the neural crest (neuroendocrine) and may be secretory of catecholamines (related to phaeochromocytoma) with similar syndrome.

Most cases are sporadic and present usually in middle age, but hyperplasia of the carotid body can be induced by long-term hypoxia (lung disease or high altitude). There is a familial form which presents younger, is more likely bilateral and malignant and associated with paragangliomas in other sites. There is also an association with Multiple Endocrine Neoplasia type 1. Overall about 15% of these tumours are malignant.

They tend to be very vascular and are readily visualised on contrast enhanced CT and MR, and ultrasound.

Radionuclide imaging may show avid FDG uptake due to high metabolic rate2 (as in this case), Increased MIBG uptake if secretory of catecholamines (negative in this case). And frequently octreotide uptake (111In

Figure 2A. Transaxial contrast CT showing bilaterally enhancing tumours

Figure 2B. 3D reconstruction of contrast enhanced CT showing major neck vessels and cascualr “blush” in tumours.

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28 Gamma Gazette November 2013

What’s that? ... answer or 68Ga) (not performed in this case)3. MIBG or octreotide uptake may give an indication of potential therapeutic radionuclides4.

Treatment may be with surgery, radiation therapy (internal or external) or embolisation.

References 1. emedicine.medscape.com/article/1575155 2. Macfarlane DJ, Shulkin BL, Murphy K, Wolf GT FDG PET imaging of paragangliomas of the neck: comparison with MIBG SPET. Eur J Nucl Med. 1995 :1347-50.

3. Gayana S, Mittal BR, Bhattacharya A, Radotra BD, Gupta AK (68) Ga-DOTATATE PET/CT imaging in carotid body tumor. Clinical nuclear medicine : 2013 38 191-3 4. www.cancercare.on.ca/common/pages/ UserFile.aspx?fileId=101885 Submitted by Dr Barry Chatterton, Royal Adelaide Hospital.

Figure 3: 24 hr SPECT/CT of 123I MIBG demonstrating no uptake in tumours (“hot” spot in the left neck is salivary gland).

Figure 4: Coronal Gadolinium contrast enhanced MRI showing enhancing tumours.

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The classical presentation of Erdheim Chester Disease (ECD): 2 cases in Hawkes Bay, New Zealand Report by Prue Lamerton Hastings Memorial Soldiers Hospital, New Zealand The first case of ECD was reported by William Chester and Jakob Erdheim in 1930. In 1972 Dr Ronald Jaffe reported a third case and coined the name Erdheim Chester disease.

Jaffe described the disease as a rare histiocytic disorder of adults characterized by an infiltrate of lipid-laden macrophages, multinucleated giant cells, and inflammatory infiltrate of lymphocytes and histiocytes in the bone marrow and a generalized sclerosis of the long bones sparing the epiphysis In a recent article published June 2013 it stated that only 500 cases have been reported since 1930 with 15 being in children. ECD usually presents in adults aged 40-60 with a 3:1 male to female ratio.

The rate of occurrence is not known, although it is believed to be under-diagnosed and/or misdiagnosed. At the present time, it is not categorized as a cancer, immune disorder, or infection. It is not believed to be contagious or hereditary. The cause is not known.

Clinical course varies from asymptomatic to multisystemic, life-threatening forms. The hallmark histological finding is the xanthogranulomatous infiltration of tissues with spumous histiocytes.

The characteristic findings of ECD are osteosclerosis of the long bones manifesting as bone pain, mainly affecting the distal lower limbs (50% of cases).

Constitutional symptoms include fever, weakness and weight loss and bone pain appears to be the most common presenting symptom.

Approximately 50% of patients have extraskeletal manifestations, including involvement of the hypothalamus/posterior pituitary, orbit, retroperitoneum, skin, lung, and heart.

The most frequent CNS manifestation is central diabetes insipidus followed by cerebellar symptoms, usually ataxia of gait.

Pulmonary involvement is an uncommon but important manifestation of ECD, because it causes Figure 1 significant morbidity and mortality. A frequent cardiovascular involvement is the ‘’coated aorta’’. (Figure 1).

Renal arteries can also be involved, leading to renovascular hypertension.

Pericardial involvement may be complicated by a tamponade. PseudoFigure 2

tumoral infiltration of the right atrium is also seen. Dyspnea, due to lung infiltration, has been reported.

Pseudo retroperitoneal fibrosis is sometimes complicated by bilateral hydronephrosis.

Abdominal CT scan may show a ‘’hairy kidney’‘appearance (in 50%) which can be Figure 3 biopsied. (Figure 2) The classic radiologic finding is bilateral and symmetric mixed cortical sclerotic and lytic lesions in the metaphyseal and diaphyseal regions of the long tubular bones, with sparing of the epiphyses and axial skeleton, although exceptions have been described. (Figure 3) 99mTechnetium bone scan shows almost constantly evidence of symmetric and abnormally strong labelling of the distal ends of the long bones of the lower limbs and upper limbs. (Figure 4) (18F) FDG PET/CT may be important in Figure 4 demonstrating bone marrow and in identifying an area for CT-guided biopsy in the case of extraskeletal involvement. (Figure 5) A variety of treatments have been advocated for this disease. The first-line treatment of controlling symptoms is corticosteroids.

Treatment of bone involvement with bisphosphonate has been reported, and other treatment options for extraskeletal involvement include radiotherapy, chemotherapy, interferon alfa therapy, and combination therapy. None have been highly effective; efficacy of the treatment options is difficult to evaluate as a result of the rarity of the disease.

ECD has a variable prognosis but is overall poorer in those with CNS involvement. Before IFN-alpha, the mean survival after diagnosis

u 30 Gamma Gazette November 2013

Figure 6: Note the sparing of the epiphyseal ends.

Figure 5: Extraskeletal abnormal uptake seen in the basal field of the right lung and linguinal in the left lung. was 19.2 months. Now with IFN-alpha treatments, the mortality rate is only 26%, and 5-year survival is 68%.

Most patients die within 2 to 3 years after diagnosis as a result of congestive heart failure, respiratory failure from lung fibrosis, or renal insufficiency. Median survival is only 32 months, and the overall survival rate is only 41% at 5 years.

Towards the end of last year a retired farmer aged 71 years presented to Radiology, Hastings Hospital, for a left knee X-ray following a twisting injury after a fall off his motorbike while lambing.

Anterior and lateral L knee x-rays were performed showing the

Figure 8

Figure 7 shaft of the distal left femur and upper end of the tibia and fibula unusually sclerotic but the sclerosis had not extended beyond the fused metaphyseal line of the bones.

The differential diagnosis at that stage included osteoblastic secondaries, Paget’s disease, Fluorosis and myelosclerosis in addition to other rare possibilities.

A skeletal survey was suggested for further evaluation. (Figure 6) The skeletal survey showed sclerosis of distal third of femur, almost the whole shaft of the tibia and the fibula and the ulna and radii of both right and left upper limbs.

Marrow cavities were obliterated in region of sclerosis and appearances resembled the rare disorder Erdheim Chester Disease.

(Figure 7) A bone scan was suggested (figure 8).

The bone scan showed an unusual pattern of symmetrical increased uptake in the distal long bones, with epiphyseal sparing.

The findings were consistent with the x-rays. And not the pattern of metastatic neoplastic disease, nor was it typical of Pagets disease or myelofibrosis. This appeared to be consistent with a rare sclerosing bony dysplasia such as Erdheim Chester Disease.

At the time of diagnosis the patient appeared to have no symptoms and refused to have any further investigations. He was warned of symptoms to look out for including weight loss, polyuria/polydipsia and increasing bone pain affecting his limbs.

5 months later the second case who was a 76-year-old male presented to the nuclear medicine department for a bone scan

u 31

Figure 9

Figure 10

following abnormal weight loss. He also suffered from long standing pneumonia. He had a previous bone scan in 2009 for left sided joint pain with no cause identified. (Figure 9) The latest bone scan showed intense increased uptake in the distal bones with sparing of the epiphyses in a very unusual pattern which once again pointed to a classical presentation of Erdheim Chester Disease. As previously stated this can give systemic symptoms including interstitial lung disease and weight loss. (Figure 10) The patient was then reviewed by a respiratory specialist. A CT was ordered showing mediastinal lymphnodes, axillary lymphnodes

and nasopharyngeal mass. In May after a pulmonary biopsy he was diagnosed with diffuse large B cell lymphoma and a PET/CT was ordered. (Figure 11) The fused coronal slices shown here by the arrows point to the increased uptake in the left nasopharyngeal, and small nodal disease throughout the neck as well as a lesion in the right apex of the lung consistent with lymphomatous involvement.

The PET/CT also showed extensive mediastinal and hilar lymphadenopathy. With marked activity in both lung bases peripherally and posteriorly may reflect lymphoma or infection. (Figure 12) The patient went on to have 3 cycles of R-CHOP chemotherapy.

And referred to the hospice after suffering from neutropenia with sepsis, abnormal clotting, difficulty swallowing, chest pain and shortness of breath.

Unfortunately the PET/CT only covered down to mid thigh.

In conclusion both cases presented had the classical signs for ECD albeit that the second case was a good deal more complicated and although bone biopsies were not performed the physicians felt there was enough evidence to make the patients aware of the strong possibility of having Erdheim Chester Disease.

There is no disease so rare that it does not deserve attention

Figure 11

u 32 Gamma Gazette November 2013

Figure 12 References Scintigraphic Diagnosis of Erdheim-Chester Disease Hans Balink et al, Netherlands Erdheim-Chester Disease: The Effect of Bisphosphonate Treatment—A Case Report Sibel EyigÜr, Mda et al Hystiocytosis Association Up-to-Date ECD: Eric Jacobson Assistant Prof of Medicine Harvard Medical School

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The role of positron emission tomography in the diagnosis and staging of oesophageal carcinoma Danica A. Roncal Bachelor of Medical Radiation Science (Nuclear Medicine), University of South Australia

Abstract A 68-year-old male presents with newly diagnosed oesophageal adenoma at the level of the gastro-oesophageal junction. Computed tomography (CT), and Positron Emission Tomography (PET) fused with CT (PET/CT), were utilised to stage the progression of disease. CT imaging highlighted the primary lesion and one enlarged lymph node. PET/CT imaging demonstrated these lesions, along with one other lymph node metastasis. This case study found that CT imaging used in conjunction with PET/CT imaging could accurately stage disease in a patient, significantly impacting on future treatment and prognosis.

Introduction A 68-year-old male presents with newly diagnosed oesophageal adenoma at the level of the gastro-oesophageal junction. The patient previously underwent a Computed Tomography (CT) scan as part of initial work up and a whole body Positron Emission Tomography (PET) scan, fused with CT (PET/CT), was subsequently requested to determine possible metastatic disease in the lymphatic system.

The patient also had a history of Hodgkin’s lymphoma, which was diagnosed 19 years prior.

Oesophageal Carcinoma Oesophageal carcinoma has been ranked ninth of the most common cancers in the world.1 Causes and precursors to the disease include smoking, excessive alcohol intake, gastro-oesophageal reflux, obesity and previous mediastinal radiotherapy, and the disease has a wide geographic, socioeconomic and racial prevalence.1,2,3 It is also thought that Barrett’s oesophagus (i.e. a metaplastic change of the lining of the oesophagus from normal squamous to columnar intestinal epithelium due to prolonged irritation)1 can initiate the disease.2There are two types: squamous cell and adenocarcinoma.2 Squamous cell cancers generally affect the upper two-thirds of the oesophagus, whereas adenocarcinomas are found in the lower-third and gastro-oesophageal junction.2 In its early stages the tumour is often asymptomatic and presents with generalised symptoms such as dysphagia and weight loss.3,4 As a result, 75% of patients are diagnosed in the advanced stages with distant metastatic spread.3,4 It has also been suggested that this is due to a lack of accuracy in clinical staging and differentiation between curable and incurable disease.4 Long-term survival is less than a year, even with the most aggressive treatment.4 Non-Nuclear Medicine Procedure A CT scan of the chest, abdomen and pelvis was performed for the purpose of investigating nodal involvement and metastatic spread.

The report noted that the lungs, liver, spleen, pancreas, adrenal glands and kidneys were clear. No bony metastatic disease was seen. The primary tumour was visualised at the distal aspect of the oesophagus. Also, an enlarged lymph node was seen below the superior mesenteric artery, between the abdominal aorta and the inferior vena cava, which could represent metastatic spread.

Nuclear Medicine Procedure A whole body PET/CT scan was ordered to identify any metastatic disease, given that an enlarged lymph node was seen on the CT scan. Fluorine-18 fluorodeoxyglucose (F-18 FDG) is a glucose based positron emitter. As a result it localises in cells with high glucose metabolism, highlighting normal areas of radiopharmaceutical uptake such as in the brain and myocardium, with low-grade radiopharmaceutical uptake noted in the salivary glands, liver and bowel.5 Urinary system radiopharmaceutical uptake is seen due to the renal excretion of F-18 FDG. Standardised uptake value The standardised uptake value (SUV) is defined as the measured activity normalised for the body weight/surface area of the patient and the injected dose.5 For example, if the dose is uniformly distributed over the entire body, SUV = approximately 1 g/ml, thus it is a relative uptake measure.6 SUV = Region of interest (ROI) activity (kBq/ml)6 (Injected dose (kBq) / Weight of the patient (g)) Blood glucose If a patient’s blood glucose level is £150mg/dL (~8.3mmol/L) imaging may proceed.5 Patients with a blood glucose level between 150mg/dL (~8.3mmol/L) and 200mg/dL (~11mmol/L) may be imaged, however, this is also dependent on diabetic status and prescribed medication.5 As per current recommendations, patients with a blood glucose level of 3200mg/dL (~11mmol/L) should not be imaged and appointments rebooked.5 However, in practice this is not always feasible due to the high demand for PET/CT scans and the urgency of results for staging or treatment planning.

Contrast Depending on departmental protocol, water can be given as a contrast agent to delineate the gastrointestinal tract (GIT).5 In patients who present with pathologies within or surrounding the GIT, a barium sulphate based oral contrast is preferred as it provides better delineation of the GIT than water.5 For both water and oral contrast, two cups (~200-250mL each), are ingested by the patient 30 minutes before, and just prior to, the commencement of scanning.5

u 34 Gamma Gazette November 2013

Image 1: Coronal PET images.

Image 2: Fused PET/CT images highlighting the primary lesion.

This patient presented to the Nuclear Medicine department on the day of PET/CT scan having fasted overnight, was well rested and wearing warm clothing to avoid shivering, which would cause brown fat uptake.5 The patient’s height and weight was measured (to determine scanning protocols and SUV). His blood glucose was recorded as 5.9mmol/L. The patient was then placed in a resting room and injected with 349MBq of F-18 FDG. He ingested oral contrast as previously described. The total uptake period was approximately 70 minutes. The patient underwent a standard whole body protocol, scanning from the patient’s eyes to thighs, with arms resting above his head. The PET scan was performed using 10 bed positions at three minutes each. This was co-registered with a low-dose CT scan for anatomical localisation and tissue attenuation correction. The patient tolerated the PET/CT scan well and no

variation to protocol was required.

The report noted normal physiological uptake of F-18 FDG in the brain, musculature of the neck, pulmonary hila, heart, liver, bowel, kidneys and bladder (Image 1). An incidental finding of uptake in the lower pole of the left lobe of the thyroid was documented to potentially represent carcinoma, as thyroid malignancies are F-18 FDG avid, however, ultrasound and/or biopsy would be required for confirmation.

The primary lesion was visualised at the gastro-oesophageal junction (Image 2). The aorto-caval node, which was noted on CT, also displayed F-18 FDG uptake (Image 3). Furthermore, a right common iliac node was also seen (Image 3). The reporting doctor noted that due to the patient’s previous history of Hodgkin’s lymphoma, these two nodes could represent a recurrence of

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Image 3: Fused PET/CT images highlight the metastases in the aorto-caval node and right common iliac node. lymphoproliferative disease or metastatic spread of the newly diagnosed oesophageal carcinoma. The PET/CT scan was unable to differentiate between these two possibilities.

Discussion As discussed, oesophageal carcinoma is generally diagnosed in its advanced stages, and as a result the best imaging modalities must be utilised to accurately stage the disease as this can significantly affect a patient’s course of treatment.Image 3: Fused PET/CT images highlight the metastases in the aorto-caval node and right common iliac node.3 Patients who have a primary tumour that is easy to resect have a better prognosis, with a 20-30% five-year survival rate.4 CT imaging is vital to determine the tumour’s location and relation to surrounding structures. Furthermore, contrast enhanced CT imaging is useful in detecting liver metastases and other obvious sites of pathology2, and for evaluating metastases in lymph nodes that are enlarged. However, PET/CT imaging is more sensitive for detecting metastases in lymph nodes which are of normal size.5 Patients with metastatic spread to the lymphatic system have a poorer outcome, which decreases dramatically with the greater number of lymph nodes involved.4 PET/CT imaging has the potential to become the most efficient staging tool by determining the extent of distant nodal involvement in a single examination.4 Studies conducted have highlighted that PET/CT imaging is useful in identifying lymph node metastases in 20% of patients who had undergone work up by other methods such as barium swallow, endoscopy, biopsy, CT imaging, magnetic resonance imaging, ultrasound, echo-endoscopy staging thoracoscopy, laparoscopy and bronchoscopy did not detect any involvement.4 Furthermore, sensitivity of PET/CT imaging for nodal involvement has been reported as 88%, with a specificity of 93% and accuracy of 91%.3,4 However, PET/CT imaging is not sensitive enough to evaluate local invasion of the primary tumour,3 and cannot be used to determine the T stage of the tumour, or differentiate between adenocarcinomas and squamous cell tumours due to similar degrees of F-18 FDG uptake.5 In most cases, lesions with a SUV >4 are suspected of malignancy.5

36 Gamma Gazette November 2013

Conclusion In the case of this patient, the CT scan was useful in defining the margins of the primary tumour located at the gastro-oesophageal junction and to determine whether surgical resection was a feasible option. The PET/CT scan highlighted lymph node involvement, which significantly decreased the patient’s prognosis. Furthermore, the results of the procedure would most likely change the patient’s treatment to possible surgical resection of the primary tumour and involved lymph nodes, along with intensive chemo- and radiotherapy.

PET/CT imaging is recommended as a tool to determine metastatic spread of oesophageal adenocarcinoma due to its ability to detect lymph nodal involvement in a single procedure, along with its high sensitivity, specificity and accuracy.

References 1 Schumacher, L, Baril, N, & Wren, S 2009, Esophageal Cancer: Initial Staging, Gastrointestinal Carcinoma (online), viewed 1st September 2013, <www.springerlink.com.ezlibproxy.unisa.edu. au/content/q67l22546n202671/fulltext.pdf>.

2 Cook, G & Love, M 2007, Esophageal and Gastric Cancer, Springer (online), viewed 30th August 2013, <www.springerlink. com.ezlibproxy.unisa.edu.au/content/r715315177xk5v61/ fulltext.pdf>.

3 Jadvar, H & Bouyadlou, S 2005, Esophageal Carcinoma, Springer (online), viewed 1st September 2013, <www.springerlink.com. ezlibproxy.unisa.edu.au/content/gl8631hn5k200568/fulltext. pdf>.

4 Lerut, T, Coosemans, W, Decker, G, De Leyn, P, Nafteux, PH & Van Raemdonck, D 2001, ‘Cancer of the esophagus and gastroesophageal junction: potentially curative therapies’, Surgical Oncology, vol. 10, pp 113-122.

5 Lin, E & Alavi, A 2005, ‘PET and PET/CT: A Clinical Guide’, 2nd edition, Thieme, New York.

6 Kinahan, PE & Fletcher JW 2010, ‘PET/CT Standardized Uptake Values (SUVs) in Clinical Practice and Assessing Response to Therapy’ Seminars in ultrasound, CT and MR, viewed 19 September 2013, <www.ncbi.nlm.nih.gov/pmc/articles/ PMC302629>

NEW in 2014 Nuclear Medicine Pathway The University of Auckland is pleased to announce that a nuclear medicine pathway suitable for registration purposes will be offered within the Medical Imaging postgraduate diploma programme with specific nuclear medicine courses commencing in Semester Two, 2014. You may start your postgraduate diploma (PGDipHSc) in Semester One, 2014 by enrolling in the Imaging Anatomy and Pathology course MEDIMAGE 701 and/or an approved research methods course.

Please note that a clinical training position in nuclear medicine is a requirement of this particular pathway in the PGDipHSc(Medical Imaging). However if you wish to commence study to show to a prospective employer your willingness and aptitude for nuclear medicine, or if you want to find out if that is a potential career pathway for you, you may enrol in the PGCertHSc(Medical Imaging) programme and complete the two nuclear medicine technology courses prior to obtaining a clinical position.

The Nuclear Medicine pathway within the Medical Imaging specialisation consists of the courses listed in the table below: PGDipHSc in Medical Imaging (Nuclear Medicine pathway) (120 points)

Suggested Timetable for students commencing in 2014

MEDIMAGE 701 Imaging Anatomy and Pathology

Semester One, 2014

Approved research methods course

Semester One, 2014

Elective

Semester Two, 2014

MEDIMAGE 708 Nuclear Medicine Imaging Technology I

Semester Two, 2014

MEDIMAGE 709 Nuclear Medicine Imaging Technology II

Semester One, 2015

CLINIMAG 705 Nuclear Medicine Clinical Practice I*

Semester One, 2015

CLINIMAG 706 Nuclear Medicine Clinical Practice II*

Semester Two, 2015

MEDIMAGE 702 Professional Issues in Medical Imaging

Semester Two, 2015

*Subject to appropriate clinical training position Image courtesy of Accuron Radiology

To find out more information: About the Medical Imaging programmes generally or to apply, visit The University of Auckland website: www.fmhs.auckland.ac.nz/medical-imaging About more specific information about the range of courses, visit The University of Auckland website: www.fmhs.auckland.ac.nz/faculty/postgrad/ courses/course_all.aspx?subject=MEDIMAGE

Image courtesy of Pacific Radiology

For further information contact: Email: MIClinical@auckland.ac.nz

Interesting Case

Hypertrophic Pulmonary Osteoarthropathy – A rare appearance on bone scans in lung cancer patients Paul Sotiropoulos The Queen Elizabeth Hospital, Adelaide

Introduction HPOA (Hypertrophic Pulmonary Osteoarthropathy) is a condition characterised by abnormal periosteal new bone formation (periostitis) in the distal end of the long bones (Wei-Jen Shih, p.159).

It causes clubbing of the digits of the hands and feet, enlargement of the extremities and painful and swollen joints (Cancer Research UK, 14th Dec 2012). There are primary and secondary conditions of HPOA, secondary being most common which usually occurs from an underlying cause such as primary lung cancer (Kroon HM, 1982p.53). Other causes can also be from cystic fibrosis, crohn’s disease, breast and oesophageal cancer and Hodgkin’s disease (Wei-Jen Shih, 2004- p.161).

Etiology underlying HPOA is not fully understood, with several mechanisms proposed (Medscape, 1994-2013). Treatment or reversal of HPOA is to eliminate the primary cause which is usually

tumour or infection (Wei-Jen Shih, 2004, p.160). Relief can be given with analgesics and bisphosponates (Cancer Research UK, 14th Dec 2012).

Patient Presentations and Procedure Two patients, recently diagnosed with lung cancer, underwent bone scans in the same week, to investigate metastases. Both were asymptomatic and pain free in the bones.

Patient 1, with adenocarcinoma, had a right upper lung mass, seen on x-ray and CT, as well as brain metastases seen on MRI. PET scanning showed no other sites of metastastic deposits.

Patient 2 had no extra-thoracic metastases detected and a bone scan was performed for routine staging and preoperative assessment.

900MBq of 99m-Tc MDP was intravenously injected in both patients and Whole Body Scanning was performed with a double head Phillips Gamma Camera, as well as additional static views of the extremities especially.

Scan Appearances/Results Both patients displayed increased diffuse uptake of tracer in the long bones especially both femora, tibiae and radii. There was minor degenerative disease also noted, with no sites of obvious bony metastases. This typical appearance was reported as HPOA which is non metastatic (paraneoplastic).

Discussion

Patient 1-WBBS

38 Gamma Gazette November 2013

In these two particular cases, both patients did not have any typical symptoms or clinical features of HPOA. Most patients will have bone pain or swollen joints with clubbing of the digits. The increased uptake seen on the bone scans is from bone remodelling which occurs as irregular periosteal deposition of cancellous bone with tuft hypertrophy (WeiJen Shih, 1982- p.159). HPOA is quite a rare condition and therefore it is seldom seen even on bone scans. HPOA occurs in only 4-12% of bronchogenic carcinoma patients (Kroon HM, 1982-p.53). It is usually seen in the lateral aspect of tubular bone as well as the epiphyses. No other complimentary imaging was performed on the patients to confirm HPOA

u

Myocardial uptake on a bone scan

Patient 1- STATIC VIEWS as nuclear medicine is most sensitive; however x-rays are commonly used as they are more specific.

Resolution of HPOA appearances on a bone scan can be seen if the underlying cause is removed, such as lobectomy in lung cancer. If surgery is not possible even chemo/radiotherapy will result in symptoms to subside as well (Wei-Jen Shih, p.160 & 161).

Symptoms will often improve or disappear, often within a few days of treatment, as well as scintigraphic findings which usually improve after 1-2 months after therapy. Radiological findings however, such as x-rays, will persist for up to several years after treatment due to the pronounced periosteal bone formation (Kroon HM, 1982-p.54) associated with HPOA. Patient 1 in this case study died within a matter of months after his bone scan. Patient two had surgery as well as chemo/radiotherapy but unfortunately died also within the year, therefore we did not rescan him either to see any scintigraphic improvement of HPOA. Signs of HPOA may be seen before or after any symptoms develop of the underlying cause or disease process, up to many years (Medscape, 1994-2013). Hence, early detection may be important to diagnose and treat the underlying condition, maybe even lung cancer in those rare cases (personal communication, G. Cehic, Jan 2005).

Patient 2-WBBS

References • Wei-Jen Shih, 2004, Pulmonary Hypertrophic Osteoarthropathy and its Resolution.

• Seminars in Nuclear Medicine, 34(2):159-163 • Kroon HM, Pauwels EKJ: Bone Scintigraphy for the detection and follow-up of hypertrophic osteoarthropathy. Diagn Imaging 1982; 51:47.

• Cancer Help/Research UK, 14th Dec 2012, accessed 1/10/2013, <www.cancerresearchuk.org/cancer-help/about-cancer/cancerquestions/hypertrophic-pulmonary-osteoarthropathy#how> • Medscape- Hypertrophic Pulmonary Osteoarthropathy, 19942013, author: Richa Dhawan, <emedicine.medscape.com/ article/333735-overview#> (accessed 1/10/2013)

Patient 2-STATIC VIEWS

39

Interesting Case

Left ventricular laceration and the complications that followed Nicole Ayars Nuclear Medicine Technologist, Royal Adelaide Hospital, South Australia

INTRODUCTION A 37-year-old man presented to the emergency room due to multiple self-inflicted stab wounds. Surgery was performed to repair the lacerations to the chest, four superficial and one penetrating the left ventricle, during which the patient underwent a thoracotomy and sternotomy to aid in the repair. Two days post trauma a CT scan (figure 1) was performed as the patient had suffered seizures and now had the inability to move his right side. This scan showed an acute left middle cerebral artery (MCA) infarction, thought to be cardio-embolic in nature. On day four post trauma (90 hours post stroke) the patient also underwent a decompressive craniotomy to help resolve the pressure build up, and prevent further damage occurring.

CASE REPORT He presented to the Nuclear Medicine department on day 26 post trauma to investigate the complications he had experienced and

because he was now subject to ongoing low grade fevers. A bone scan was requested. The patient was injected with 800MBq of 99mTc-MDP with initial blood pool images following injection, and delayed images were performed two hours later.

The delayed images performed (figure 2) showed an increase in activity in the left calvarium, sternum, and left sixth rib. The calvarium and sternum activity was due to the recent surgery and the rib activity was thought to be due to a fracture or post-surgical repair.

The same patient then presented again to the Nuclear Medicine department five days later (day 31 post trauma) for a cardiac perfusion test. The patient was experiencing chest pain with T-wave inversion and slightly elevated troponin query reversible ischemia.

The departmentâ&#x20AC;&#x2122;s protocol was followed performing a Dipyridamole stress test with 390MBq of 99mTc-Sestamibi injected.

A rest test was performed later that afternoon with 950MBq of TcSestamibi being injected.

Images (Figure 3) showed a defect in the distal lateral wall of the left ventricle adjacent to the apex which remained unchanged between the stress and rest images. The stab wound to the heart was noted to be 2cm lateral and parallel to the left anterior descending artery involving the distal diagonal branch. An ejection fraction of 48% was also noted. The findings were consistent with the myocardial scar in the area mentioned above from the self-inflicted stab wound. There was no convincing evidence of myocardial reperfusing ischemia.

Once the patient was stable he was discharged. The patient then went on to have intensive rehabilitation for neurological and cardiac reasons. During this time a history of

Figure 1: Patientâ&#x20AC;&#x2122;s CT scan images.

Figure 2: delayed bone scan images.

40 Gamma Gazette November 2013

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Left Ventricular Laceration and the complications that followed

Figure 3 (top left, right and right): Stress/Rest Cardiac Perfusion images. substance abuse, and psychiatric symptoms were obtained, as due to the patients MCA a prior formal psychiatric evaluation was not possible. A long term antidepressant was prescribed.

DISCUSSION In general, penetrating wounds to the heart have an increased risk of mortality due to a number of associated risk factors, most commonly the development of cardiac tamponade (when blood or fluid collects in the pericardium), blood loss or coronary artery injury.1 Typically, in a penetrating stab wound the right ventricle, due to its location in the chest, is often the most affected, followed by the left ventricle, then the left and right atria.1,4 In terms of cardiac arteries most commonly injured, it tends to be the left anterior descending artery and less commonly the right coronary artery, due to their position in the chest.4 However, gunshot wounds are still considered much more lethal than stab wounds, 77% vs 42%.2,3 Between 1%-6% of patients have some form of stroke post cardiac surgery being within those 24 hours or within the days that follow.5 Our patient suffered his MCA 2 days post trauma. Cardiac Perfusion tests using an array of nuclear medicine isotopes can help in the detection and localisation of defects within the myocardial tissue.6 Cardiac tissue that has experienced ischaemic infarction heals similarly to cardiac tissue that has experienced severe injury, it often develops necrosis and scar formation.6 This can often lead to chronic heart failure further down the track.6 REFERENCES 1. Kaljusto M, and Tonnessen T. (2012). How to mend a broken heart: a major stab wound of the left ventricle. Retrieved from World Journal of Emergency Surgery, www.ncbi.nlm.nih.gov/pmc/articles/PMC3467162/ 2. Tyburski JG, Astra L, Wilson RF, Dente C, and Steffes C. (2000).

Factors affecting prognosis with penetrating wounds of the heart.

Retrieved from Journal of Trauma 48 (4):pgs587-91, www.ncbi.nlm.nih.gov/pubmed 3. Praeger PI, Praeger J, Abdel-Razek AM, and Elmann EM, (2013).

Stab Wound of the Heart with Unusual Sequelae. Retrieve from Texas Heart Institute Journal, www.ncbi.nlm.nih.gov/pmc/articles/PMC3709238/ 4. Steven J. Co, Charlotte J. Yong-Hing, Sandro Galea-Soler, Balazs Ruzsics, U. Joseph Schoepf, Amr Ajlan, Paul Farand, and Savvas Nicolaou. (2011). Role of Imaging in Penetrating and Blunt Traumatic Injury to the Heart. Retrieved from Radiographics, The journal of continuing medical education in Radiology, radiographics.rsna.org/content/31/4/E101.full 5. Merino JG, Phil M, Latour LL, and Warach S, (2013). Blood Brain Barrier Disruption After Cardiac Surgery. Retrieved from American Journal of Neuroradiology 34(3):pgs518-523, www.ncbi.nlm.nih.gov/pmc/articles/PMC3509275/ 6. K C Sybrandy, M J M Cramer, and C Burgersdijk, (2003).

Diagnosing cardiac contusion: old wisdom and new insights.

Retrieved from Heart, BMJ Group, www.ncbi.nlm.nih.gov/pmc/articles/PMC1767619/

41

Case Study

Phaeochromocytoma â&#x20AC;&#x201C; 2 case reports Dr Leesa Equid Sir Charles Gairdner Hospital, Western Australia

INTRODUCTION Phaeochromocytomas and paragangliomas are rare neuroendocrine tumours found in 0.1-0.2% of patients with hypertension.1 Phaeochromocytoma refers to catecholamine-secreting tumours within the adrenal medullary chromaffin cells and paragangliomas to those outside the adrenal medulla.2-7 Of these paragangliomas the majority are found in the superior and inferior abdominal paraaortic areas (75%), urinary bladder (10%), thorax (10%) and the head, neck and pelvis (5%).3 These tumours are investigated in three patient subgroups 1) in a symptomatic patient, 2) found as an incidental adrenal mass on imaging or 3) following investigation based upon a familial genetic screening for tumours in Multiple Endocrine Neoplasia Type 2 (MEN2), von Hippel-Lindau (VHL) Syndrome, Neurofibromatosis I and those with Succinate Dehydrogenase Family disorders.2 We present two patients who came to the Nuclear Medicine Department at Sir Charles Gairdner Hospital on the same day for 123I-MIBG scans to assess for diagnosis and staging of their phaeochromocytoma. Both were identified incidentally as having adrenal masses on imaging for alternate pathology; one case was a sporadic phaeochromocytoma and the other associated with VHL. These two cases provided an opportunity to address the current medical literature available on phaeochromocytoma from the initial suspicion of disease to investigation, surgical management and genetic counselling of patients.

CASE REPORT 1 A 63-year-old man presented for an 123I-MIBG scan to evaluate an adrenal mass, thought to be phaeochromocytoma, for evidence of metastatic disease and sizing/localisation prior to surgical management the following week.

Initially he presented to his chiropractor with a 1-2 year history of worsening back pain upon movement. He had no significant medical problems. His father had hepatocellular carcinoma; however there were no other known cancers or genetic conditions of note in the family.

His GP arranged a CT of his spine in October 2012 which showed an incidental left adrenal mass 29x29x23mm in size. He was subsequently referred to a surgeon who arranged a tri-phasic CT with pre-contrast and post-contrast arterial scanning with delayed imaging in April 2013. The CT showed a 75x57x64mm lesion with central low attenuation areas measuring 18-22 Hounsfield units which did not enhance post-contrast.

He then underwent blood testing including: Full Blood Count, Urea and Electrolytes, Liver Function Tests, Calcium, Parathyroid Hormone, Vitamin D, DHEA-Sulphate, Aldosterone, Renin and Plasma Metadrenalines. High Plasma Metadrenalines were

42 Gamma Gazette November 2013

the only abnormality: Plasma Nor-Metadrenaline 4020 pmol/L (laboratory normal <660 pmol/L) and Metadrenaline 4620 pmol/L (laboratory normal<300 pmol/L) which increase the suspicion of a phaeochromocytoma.

As a result of these suggestive blood tests he underwent a PET scan looking for metastatic disease which failed to show any FDG avidity. An 123I-MIBG was arranged one week prior to his surgical date to investigate for non-FDG avid metastatic disease and to localise the tumour, most likely a phaeochromocytoma. He had been started on an alpha-blocker by the surgeon and was to commence use of a beta-blocker the day after his 123I-MIBG scan.

123 I-MIBG scanning demonstrated intense peripheral activity in the left retroperitoneal soft tissue mass. This is in keeping with a phaeochromocytoma with central necrosis. There was no MIBGavid regional lymph node involvement or distant metastatic disease identified.

CASE REPORT 2 A 78-year-old female underwent an 123I-MIBG scan to assess an incidental adrenal mass to confirm diagnosis of phaeochromocytoma.

She had a positive family history of VHL, with an affected son, sister and daughter-in-law.

In October 2012 she presented to a peripheral Perth hospital with 10/10 severity back pain which was restricting her movement.

A CT performed at the time demonstrated a prolapsed disc, renal calculi and an incidental adrenal mass which required further investigation.

She underwent a tri-phasic adrenal wash-out CT study which showed a 31x26x29mm left adrenal mass with attenuation measuring 24 Hounsfield units on enhancement phase and 56 units on delayed imaging.

She had blood tests: Full Blood Count, Urea and Electrolytes, Liver Function Tests, Thyroid Function Tests, Aldosterone, Renin,

Image 1: Patient 1 whole body images demonstrating intense peripheral activity in the left adrenal mass.

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Phaeochromocytoma

Image 2, 3 and 4 (left, top right, bottom right): SPECT/CT, coronal SPECT/CT, transaxial SPECT/CT.

detected at a younger age as a result of screening programs, with an average age of 25,9 however due to the varied phenotypic presentation they can arise in any decade of life.10 10% of cases are picked up incidentally on imaging for alternate pathology, 10% of phaeochromocytomas are found to be malignant and 10% are bilateral.9 Image 5: patient 2 whole body images demonstrating activity in the left adrenal mass Calcitonin, Plasma Metadrenalines, Serum Cortisol and urine tests: Urine Albumin-Creatinine Ratio, Urine Microscopy and Culture and 24hr Urine catecholamines over the period of March to April 2013.

Her abnormal results were 24hr Urine – Noradrenaline 573 pmol/L (laboratory normal<560 pmol/L) and plasma Nor-Metadrenaline 1280 pmol/L (laboratory normal <600 pmol/L).

An 123I-MIBG scan was done to confirm the diagnosis of phaeochromocytoma, as the initial step in planning surgical management for her tumour. On MIBG scintigraphy the left adrenal mass exhibited intense MIBG uptake in keeping with the diagnosis of phaeochromocytoma. There was no evidence of a MIBG-avid catecholamine-secreting extra-adrenal paragangliomas, regional lymph node involvement or evidence of metastatic disease.

DISCUSSION Phaeochromocytoma is a rare condition that can occur at any age, typically presenting in the 40-50s and has equal gender incidence of 0.8 per 100,000 population per year. It has been suggested that this is an underestimate as 50% of tumours have later been detected at autopsy.8 Familial phaeochromocytomas are often

PHYSIOLOGY Phaeochromocytomas have varied biochemical characteristics – most secrete noradrenaline, some both noradrenaline and adrenaline, few mostly adrenaline and rarely they will produce dopamine(2).

For tumours to become biochemically detectable metnoradrenaline secretion needs to increase four fold while noradrenaline 15 fold.2 Metadrenalines (metadrenaline and metnoradrenaline) are typically measured in favour of catecholamines (adrenaline and noradrenaline) for diagnosis as the catecholamine metabolism within phaeochromocytomas to metadrenalines shows positive correlation to tumour size.2 Metadrenalines are also less affected by stress, foods and medications than catecholamines.2 Figure 1 demonstrates the production of catecholamines and conversion to metadrenalines in the body, taken from Barron et al.2 SYMPTOM PRESENTATION The two patients presented in these case reports were found to have adrenal masses which identified as a result of imaging for alternate pathology. Patients also present following familial genetic screening or with symptoms requiring investigation.

A triad of clinical symptoms has been described in cases of phaeochromocytoma – headache, sweating and tachycardia.7 Most patients do not experience all three of these symptoms, however, headache is the most common in 90% of cases followed by sweating in 60-70%.7 Hypertension is the most common reason for

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Phaeochromocytoma

Image 6, 7 and 8 (left, top right, bottom right): SPECT/CT, coronal SPECT/CT, transaxial SPECT/CT.

Figure 1 (above): Origin of plasma catecholamines and metadrenalines expressed as a percentage of the total. The metabolism of the catecholamines, with metabolites derived from either adrenal medulla or sympathetic nervous system and converted by the liver to HVA (homovanillic acid) and VMA (vanillyl mandelic acid). Adapted from Barron et al 2010.

Figure 2 (below): The “triad” of symptoms seen most commonly in symptomatic phaeochromocytoma patients.

investigation for phaeochromocytoma, however 5-15% of patients have normal blood pressure at the time of diagnosis.11 Suspicion for phaeochromocytoma should be raised in a number of clinical situations, as outlined in figure 3.

BIOCHEMICAL TESTING There is no consensus as to the “best test” for diagnosis of phaeochromocytoma. A number of tests are considered first line including 24 hour urine fractionated catecholamine and metadrenalines as well as plasma metadrenalines. In the cases presented the first patient had plasma metadrenalines and catecholamines tested and the second patient underwent 24 hour urine testing prior to plasma metadrenalines and catecholamines.

These tests have a high sensitivity (96-99%) and low specificity (8589%, down to 77% if over age of 60),12 indicating the predictive value of a negative test is very high. There are a large number of

u 44 Gamma Gazette November 2013

Phaeochromocytoma

Suspicion for phaeochromocytoma Hypertension in young patients (<20y) Hypertension with rapidly manifesting complications • myocardial infarction • stroke • hypertensive retinopathy Hyperadrenergic spells – self-limiting episodes of non-exertional palpitations, diaphoresis, headache, tremor, pallor Hypertension with special features • recurrent crises • labile BP • orthostatic hypotension • cardiomyopathy • neurocutaneous fibromas • weight loss Resistant Hypertension Family history of • phaeochromocytoma or paraganglioma • VHL • MEN2 • medullary thyroid carcinoma • Neurofibromatosis type 1 Radiological detection of an adrenal mass ADAPTED FROM HARARI and UpToDate Figure 3: scenarios which raise suspicion of phaeochromocytoma. false positives, which leads to potentially unnecessary imaging and surgical procedures.12 Plasma fractionated metadrenalines are currently recommended in patients with a high risk for phaeochromocytoma (those with a high pre-test probability determined by: family history of phaeochromocytoma, genetic syndromes, past history of resected phaeochromocytoma and incidental adrenal masses on imaging).12,13 Patients who present with symptoms including headache, sweating and tachycardia are deemed low risk, therefore should undergo 24 hour urinary fractionated metadrenalines and if elevated, imaging is required.12,13 A 24 hour urinary fractionated metadrenalines is also recommended for those with paroxysmal hypertension as the pre-test probability remains low in these patients.12,13 IMAGING Further investigation is required following positive blood or 24 hour urine fractionated metadrenalines and catecholamines due to the high false positive rates as a result of the low sensitivity. Imaging is required to rule in or out phaeochromocytoma prior to surgical intervention. A number of imaging modalities are available, with CT and MRI the first tests of choice9– the choice is dependent upon availability of these imaging modalities. MRI lacks the resolution of CT, however it avoids the radiation and dye involved in a CT.14 CT and MRI show a 98-100% sensitivity for phaeochromocytoma and

70% specificity, when combined with initial biochemical tests these numbers increase.14 On CT phaeochromocytomas may present as solid (2/3 of cases), cystic or complex.9 Most have attenuation values greater than 10 HU however those containing a greater proportion of fat (similar to adenomas) may have values less than 10.9 Tri-phasic CT is used to demonstrate the presence of either homogenous or variable enhancement of the tumour.9 Phaeochromocytomas on MRI appear as bright lesions on T2 weighted images, with similar signal intensity of CSF in up to half of cases(9). Variable intensity can be attributed to increased water content in cystic or necrotic tumours.9 On T1 weighted images phaeochromocytomas are typically isointense to liver and muscle, however presentation varies with the presence of necrotic areas or haemorrhage within the tumour.9 FUNCTIONAL IMAGING There are a number of differential diagnoses for adrenal masses at the time of imaging, illustrated in figure 3. Functional imaging is often required following conventional imaging because of the variable presentation seen in phaeochromocytomas. It allows for further improvement in the specificity associated with both biochemical testing and imaging for these tumours. Functional imaging also has a role in localisation of metastatic disease, detection of extraadrenal tumours – paragangliomas, as well as assessing for tumour recurrence.

Metaiodobenzylguanidine (MIBG) is a noradrenaline analogue that was developed in the 1970s in order to image tumours from neuroendocrine origin. It localises to presynaptic adrenergic nerves by an amine transport system and moves into the cytoplasmic storage vesicles of the cells. It can be labelled with either 131I or 123 123 I. I is the favoured label for use with SPECT due to the lower gamma energy (159keV versus 360keV) permitting higher activities of 123I-MIBG to be injected. Images with 123I-MIBG are usually available within 24 hours as opposed to delayed imaging with 131 I-MIBG.15 It has also been shown to provide better image quality allowing more accurate localisation of the tumour using SPECT-CT.15 123 I-MIBG scintigraphy was used in both cases. Sensitivity related to MIBG is dependent on the affinity of MIBG to the transport system, variable amounts of cytoplasmic storage granules and in dedifferentiated tumours, the loss of the amine transport system.9 Meta-analysis has been conducted on the use of MIBG scintigraphy for phaeochromocytoma demonstrating a sensitivity of 94% and specificity of 92% when used alone.14 These values are higher when used in conjunction with biochemical testing and conventional imaging and can be affected by the concurrent use

Differential Diagnosis for Adrenal Masses Adrenal adenoma Adrenocortical carcinoma Adrenal neuroblastoma Adrenal metastases Adrenal lymphoma Figure 4: Differential diagnosis for an adrenal mass.

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Phaeochromocytoma

of a number of medications including calcium channel blockers, Tricyclic antidepressants, caffeine and mirtazapine which must be ceased prior to MIBG testing.15 FDG-PET was used in the case of the first patient. It has been shown to have a higher sensitivity than MIBG and CT/ MRI, however it is not used as a first line for imaging.14 Its main role is for investigating dedifferentiated tumours that lack the amine transport system which is required for MIBG imaging and biochemical testing.14 MALIGNANT VERSUS BENIGN TUMOURS Phaeochromocytomas have a 10% risk of metastatic disease.6 Metastases most commonly occur within two years of identification of the primary tumour however they can appear up to 40 years after first diagnosis.6 Harari et al reviewed current literature on malignant potential in phaeochromocytomas by searching the PubMed database for the period 1993-2010 and found no definitive way to predict malignant potential.6 There are no known histological features that determine if a phaeochromocytoma will become malignant10 and no standardised staging system – they are grouped into benign (localised), regional and metastatic. The most common sites for metastatic disease are bone, lung, liver and lymph nodes).9 In 2002 Thompson et al developed the Phaeochromocytoma of the Adrenal Gland Scaled Score (PASS) which can be used to distinguish between benign and malignant tumour potential on histopathology.16 A score of <4 indicates benign behaviour and >4 aggressive, likely malignant.16 They studied 100 patients of which 50 had benign tumours and 50 malignant. In their discussion they recommend trialling the scale on a larger sample of patients to demonstrate the scores validity.16 It has since been studied and shown to have variable accuracy in predicting malignancy, however is still used as there is no better scoring system available.9 MANAGEMENT It is important to identify and surgically remove phaeochromocytomas early as they may cause lethal hypertensive crises, malignant arrhythmias and multi-organ failure. These risks are also present intra-operatively at the time of endotracheal intubation and manipulation of the adrenal gland. Pre-operative measures are taken to reduce this risk by controlling hypertension and volume expansion.17 Patients are commenced on an alpha-blocker 1014 days pre-op, typically phenoxybenzamine or a selective alphablocker such as prazocin which has a more favourable side-effect profile. They are started at a low dose and incrementally increased with twice daily blood pressure measurements aiming for a blood pressure less than 120/80 standing and a systolic blood pressure greater than 90 standing. A high sodium diet (>5000mg daily) is commenced on day 2-3 of alpha-blockage to aid with volume expansion, however this is contraindicated in cases of heart failure and renal insufficiency. Beta-blockers are commenced 2-3 days pre-op at a low dose to aid in preventing an intra-operative hypertensive crisis.

Adrenalectomy is performed in cases of phaeochromocytoma and resection is done with intent to cure. Laparoscopic adrenalectomy can be done transabdominally or from the retroperitoneal

46 Gamma Gazette November 2013

approach, with retroperitoneal giving better surgical outcomes – reduced operation time, blood loss, shorter duration in hospital and decreased complication rates.18 Complications typically arise in cases with severe pre-operative hypertension, high secreting tumours or in cases of recurrence.18 Surgical management of phaeochromocytomas does not always lead to correction of hypertension or cure. These patients require lifelong monitoring for recurrence as there is currently no clear cut test to distinguish malignant from benign tumours.19 Most patients should go on to have annual biochemical testing to detect recurrence.19 Genetic counselling can be offered to patients, as it is at Sir Charles Gairdner Hospital in all cases of sporadic phaeochromocytoma. It is becoming increasingly recognised that genetic conditions have variable phenotypic expression in phaeochromocytoma and genetic testing is beneficial to the individual and their family as mutations are present in 12.7-24% of sporadic phaeochromocytomas.1,20 The first patient in this case will go on to have genetic testing and the second patient already has a diagnosis of VHL. CONCLUSION Phaeochromocytomas are rare endocrine tumours arising in 0.10.2% of hypertensive patients. There is a genetic component in a number of these tumours and they have a high risk of mortality associated with them. Many are picked up incidentally on imaging for other pathologies or are found in symptomatic patients where their doctor has a clinical suspicion leading to catecholamine and metadrenaline testing.

The most important message about phaeochromocytomas is to consider them as a differential diagnosis. If unrecognised and untreated they can be a life-threatening disease and therefore must be carefully considered as their presentation is variable and inconsistent. There is currently no “Gold Standard” test for the initial investigation for phaeochromocytoma or a good tool for distinguishing malignant or benign, therefore ongoing research is needed to find out more about these endocrine tumours – genetics, presentation, biochemical testing, conventional and functional imaging, management and prognosis. This case study gives insight into the diagnostic pathway, treatment and follow-up of phaeochromocytoma.

REFERENCES 1. Bryant J, Farmer J, Kessler L, et al. Pheochromocytoma: The Expanding Genetic Differential Diagnosis. Journal of the National Cancer Institute. 2003;95(16):1196-204.

2. Barron J. Phaeochromocytoma: diagnostic challenges for biochemical screening and diagnosis. J Clin Pathol.

2010;63:669-74.

3. Goldstein R, O’Neill J, Holcomb G, et al. Clinical experience over 48 years with pheochromocytoma. Ann Surg. 1999;229:755.

4. Grumbach M, Biller B, Braunsteing G, et al. Management of the clinically inapparent adrenal mass (“incidentaloma”). Ann Intern Med. 2003;138:424.

5. Guerrero M, Schreinemakers J, Vriens M, et al. Clinical spectrum of pheochromocytoma. J Am Coll Surg. 2009;209:727.

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6. Harari A, Inabnet W. Malignant pheochromocytoma: a review.

American Journal of Surgery. 2011;201:700-8.

7. Manger W, Gifford R. Pheochromocytoma. J Clin Hypertens (Greenwich). 2002;4:62.

8. Sutton M, Sheps S, Lie J. Prevanence of clinically unsuspected pheochromocytoma. Review of a 50-year autopsy series. Mayo Clin Proc. 1981;56:354.

9. Leung K, Stamm M, Raja A, et al. Pheochromocytoma: The Range of Appearances on Ultrasound, CT, MRI, and Functional Imaging. AJR. 2013;200:370-8.

10.

Kolackov K, Tupikowski K, Bednarek-Tupikowska G. Genetic Aspects of Pheochromocytoma. Adv Clin Exp Med. 2012;21(6):821-9.

11. Neumann H, Pawlu C, Peczkowska M, et al. Distinct clinical features of paraganglioma syndromes associated with SDHB and SDHD gene mutations. JAMA. 2004;292:943.

12. Lenders J, Pacak K, Walthers M, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA. 2002;287:1427.

13. Sawka A, Prebtani A, Thabane L, et al. A systematic review of the literature examining the diagnostic efficacy of measurement of fractionated plasma free metanephrines in the biochemical diagnosis of pheochromocytoma. BMC Endocr Disord. 2004;4:2.

14. Jacobson A, Deng H, Lombard J, et al. 123I-MetaIodobenzylguanidine Scintigraphy for the Detection of Neuroblastoma and Pheochromocytoma: Results of a MetaAnalysis. J Clin Endocrinol Metab. 2010;95(6):2596-606.

15. Bombardieri E, Giammareile F, Aktolun C, et al. 131I/123IMetaiodobenzylguanidine (MIBG) scintigraphy: procedure guidelines for tumour imaging. Eur J Nucl Med Mol Imaging.

2010;37:2436-46.

16. Thompson L. Pheochromocytoma of the adrenal gland scaled score (PASS) to separate benign from malignant neoplasms. A Clinicopathologic and immunophenotypic study of 100 cases.

Am J Surg Pathol. 2002;26:551-66.

17. Tauzin-Fin P, Sesay M, Gosse P, et al. Effects of perioperative alpha 1 block on haemodynamic control during laparoscopic surgery for phaeochromocytoma. Br J Anaesth. 2004;92:512.

18. Plouin P, Duclos J, Soppelsa F, et al. Factors associated with perioperative morbidity and mortality in patients with pheochromocytoma: analysis of 165 operations at a single centre. J Clin Endocrinol Metab. 2001;86:1480.

19. Amar L, Servais A, Gimenez-Roqueplo A, et al. Year of diagnosis, features at presentation, and risk of recurrence in patients with pheochromocytoma or secreting paraganglioma. J Clin Endocrinol Metab. 2005;90:2110.

20. Jimenez C, Cote G, Arnold A, et al. Review: Should patients with apparently sporadic pheochromocytomas or paragangliomas be screened for hereditary syndromes? J Clin Endocrinol Metab. 2006;91:2851.

47

Case Study

The value of the 3â&#x20AC;&#x201C;phase bone scan Rachel Wilson Nuclear Medicine Department, Christchurch Hospital, New Zealand

PATIENTS CLINICAL HISTORY A 66-year-old woman was seen in the Emergency department in June 2013 with a one month history of left side back pain radiating down to the knee.

She had xrays taken of her lumbar spine and left hip which showed significant spondysolithesis at the L5/S1 level and a possible lucent lesion within the proximal left femur posteriorly (image 1). She was discharged with referrals to orthopaedics for disc decompression. This surgery was postponed due to anaesthetic concerns about anaemia and dilated cardiomyopathy.

Five weeks later the patient returned to the Emergency department with generally declining health. Her pain from her back and leg was not controlled and she had significant weight loss in the last two months. The cause of her anaemia was unknown. She was referred to her GP for follow-up.

The patient had surgery for L4/L5 decompression and L5/S1 fusion in August 2013. She was well post op and was discharged four days later.

Six days after surgery she returned to the Emergency Department with back pain. She was struggling to mobilise at home due to severe pain in the back and left hip/buttock pain. Further xrays of her lumbar spine were taken and she was admitted to hospital for further investigation.

Two days into her admission a bone scan was requested querying the progression of the left femoral lesion.

BONE SCAN The patient was administered 700 Mbq of TC 99m hydroxymethane diphosphonate (HDP) and a three phase bone scan performed.

A Siemens Symbia T2 camera was used for dynamic, static and SPECT/CT images.

Blood flow and blood pool images showed a marked increase in activity in the left hip with appearance consistent with extensive

Image 1: Xray left Femur.

48 Gamma Gazette November 2013

Image 2: Blood pool pelvis. haematoma (Image 2).

Delayed whole-body imaging at three hours showed increased activity in the left femoral head. Increased uptake was also present at the sites of recent spinal fusion L4/L5 and L5/S1 within normal limits post surgery (Image 3).

SPECT/CT showed a left intertrochanteric fracture with soft tissue swelling (Image 4). CT appearances of the proximal left femur were very different to the right suggesting an infiltrated process.

The bone scan was not hot in the left intertrochanteric fracture region which could be due to an underlying pathological process.

DISCUSSION Pathological fractures occur from low energy injuries which occur through an area of bone weakness with a pre-existing abnormality.1 This woman was delivering meals on wheels when she was gently nudged by a car in May 2013. This was one month prior to her initial presentation to the Emergency Department. The exact date of the fracture is not known but appears to be shortly after her lumbar spine surgery. When talking to this lady she did wonder if this had something to do with the cause of her pain. Her initial xrays taken in June 2013 did show a lucent lesion in the left femur but the spinal problems were taken as precedence. Her main complaint was the pain in her back. An MRI was suggested at the time of this xray but this may not have been done due to the patient having a pace maker.

A cause of her anaemia was not found but was normocytic u anaemia. Anaemia can be a feature associated with cancer.4

The value of the 3–phase bone scan

FURTHER IMAGING The patient had a CT Spine/Lumbar Spine on the day before the Nuclear Medicine Study. For unknown reasons this was not reported until 10 days later. This was reported as a probable pathological fracture of the subtrochanteric region.

The patient had three further CT studies performed. Multiple nodular pulmonary opacities were seen on a CT Chest, giving a high suspicion of metastatic malignancy. Multiple non-acute thoracic vertebral compression fractures were noted, with no definite destructive thoracic bony lesion. A large multilobulated soft tissue mass surrounded the fracture site. This mass most likely reflected a primary mass. There was involvement of the hamstring, gluteal, adductor compartment muscles and the proximal quadriceps muscles as well as the distal iliopsoas muscle.

OUTCOME After her bone scan she was put on bed rest with traction. Ultrasound guided Fine Needle Aspirate of Femur interim report of high grade Sarcoma.

She went on to have an intramedullary fixation of Femur. This dislocated the following day and was repositioned.

This patient is currently still in hospital recuperating after surgery and is being seen by orthopaedics and haematology departments.

The final histology reports came through from samples taken at the time surgery 2 ½ weeks later. This showed appearances favouring a pleomorphic undifferentiated sarcoma, grade 3.

CONCLUSION The bone scan was pivotal in this case. The patient’s care and plan strategy changed after the nuclear medicine bone scan to concentrate on the left femur neoplasm.

REFERENCES 1. Dwyer, Tim. Maligant Bone Tumours, The Bone School 2009 www.boneschool.com/ 2. Weatherall, D J. Normocytic Anaemi June 2011, oxfordmedicine.com/view/10.1093/med/ 9780199204854.001.1/med-9780199204854chapter-220505 3. Wheeless, CR, Wheeless Textbook of Orthpaedics, June 20 2012, www.wheelessonline.com/ortho/pathologic_fracture 4. Anemia: A Manageable Side Effect Sarcoma, news.cancerconnect.com/anemia-a-manageable-side-effectsarcoma/

Image 3: Whole Body Bone Scan.

Image 4: Spect/CT images.

49

Case Study

The role of complementary Ultrasound and Nuclear Medicine techniques in the pre-operative management of breast cancer Stephanie L. Bracci Bachelor of Medical Radiation Science (Nuclear Medicine), University of South Australia ABSTRACT One in eight Australian women will develop breast cancer before the age of 85 years.1 However, while the incidence is on the rise, so is the five-year survival rate, which can be as high as 98% depending on tumour size and negative nodal status.1 This can be mainly attributed to technological advancements in the medical imaging field which have lead to swift diagnosis and treatment.2 This report focuses on a 62-year-old female with recurrent cancer of the left breast which was diagnosed using ultrasound imaging with a core biopsy, the use of Positron Emission Tomography/Computed Tomography (PET/CT) to further stage the disease and lymphoscintigraphy to identify sentinel nodes for surgical excision along with the tumour mass.

The period between diagnosis and surgery was within one week, allowing for the chance of an excellent prognosis due to the use of these highly specialised imaging modalities.

INTRODUCTION This case study focuses on a 62-year-old female patient with recurrent Invasive Lobular Carcinoma (ILC) of the left breast. Her first incident of ILC was detected eight years prior. On feeling a lump during self-examination, the general practitioner referred her for a series of tests suspecting relapse of the primary tumour.

ILC is the second most common type of breast cancer affecting women worldwide.3 This subtype is characterised by sizeable tumours, invasion of surrounding breast parenchyma and a slow metastatic rate with the most common site being the gastrointestinal tract (GIT).3 The initial procedure conducted on the patient was an ultrasound guided core biopsy which located a tumour at ‘10 o’clock’ relative to the nipple location and was confirmed pathologically to be ILC. The patient subsequently underwent surgical ‘work-up’ procedures including a Nuclear Medicine PET/CT scan; the extent of disease, in terms of primary tumour mass, local and distant and metastases was assessed. Following PET/CT imaging, lymphoscintigraphy was performed to map out sentinel nodes for surgical excision along with the primary tumour.

Ultrasound Imaging Ultrasound is particularly useful in characterising breast lesions.4 Additionally, it allows for further testing such as guiding biopsies, instilling confidence in physicians that an accurate diagnosis can be made.5 The protocol for breast ultrasound involves a number of steps including: not applying deodorant, lotions or powder under the armpit; removal of clothing from the waist up; wearing a gown open at the front, and a numbing agent as well as ultrasound gel is applied to the area of interest in preparation for imaging.5 Three passes of 14 gauge core biopsies traversing the tumour site were conducted. The collected samples were sent for pathological analysis.

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Figure 1. Ultrasound image of the left breast lesion.

The patient’s breast ultrasound images demonstrated an abnormal lobulated mass in the left breast with irregular margins (Figure 1) located at ‘10 o’clock’ relative to the nipple location and measuring 23.4mm along its axis. All other breast and axillary tissue was unremarkable and an immediate PET/CT scan was recommended to complement ultrasound in the restaging of the disease.

u

The role of complementary Ultrasound and Nuclear Medicine techniques in the pre-operative management of breast cancer

A

B

PET/CT Imaging After the patient’s initial diagnosis was made, she underwent a Nuclear Medicine PET/CT scan to demonstrate the extent of the disease. The appropriate preparation was followed including: a six hour fasting period; height and weight were recorded to determine body mass index and scan mode; blood glucose levels were measured to be within normal limits (i.e. <8.3mmol/L); a 60 minute resting period ensued; metal items were removed; two cups of plain water were ingested to outline the GIT, and the patient voided immediately pre-imaging to avoid obscuring pelvic structures.6,7 The patient was then injected with 330MBq of 18Fluorine (18F)Fluorodeoxyglucose (FDG) intravenously and scanned from the level of the eyes to thighs (whole body) with arms resting above the head for 30 minutes at eight bed positions.

The resultant PET/CT fusion images demonstrated the primary tumour (in the left breast medially; Figure 2A) as well as a focal area of increased 18F-FDG activity in the left upper sacral vertebra (Figure 2B). The low dose CT component of the scan demonstrated an area of lucency in this region, suspicious of a lytic bony metastasis. An incidental finding included a focus of increased 18F-FDG uptake in the right lobe of the thyroid (Figure 2C). The CT component of the scan demonstrated this area as ‘hypodense’ and further testing (ultrasound and fine needle aspiration biopsy) was recommended as it was uncertain if the lesion was malignant or benign. No significant nodal activity was found. Degenerative change in the shoulders was also noted.

Lymphoscintigraphy Nuclear Medicine lymphoscintigraphy of the left breast was performed prior to the surgical excision of the lesion. The patient was injected with 40MBq of 99mTechnetium Antimony Colloid peri-tumourally while her arm was raised above her head in the surgical position.8 The theory behind this procedure is that the

C

Figure 2: PET/CT fusion images of the (A) primary tumour, (B) sacral lesion and (C) thyroid lesion.

radiopharmaceutical will follow the physiological drainage patterns of the breast tissue into the lymphatic system, allowing for much greater accuracy as the closet node is not always the sentinel node.8 Once injected, the patient was encouraged to massage the area, keep warm and move her arm around to encourage lymphatic uptake of the tracer.8 Images were then acquired until the sentinel node appeared at 60 minutes post radiopharmaceutical injection.

The patient’s images demonstrated a sentinel node in the left axilla (Figure 3) which was marked on the skin in two planes (anterior and lateral) in permanent marker in preparation for surgery.

Figure 3: Lymphoscintigraphy of the left breast.

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The role of complementary Ultrasound and Nuclear Medicine techniques in the pre-operative management of breast cancer

DISCUSSION After breast cancer is confirmed, ultrasound is often the initial imaging modality performed as it is associated with no radiation burden.4 It can also effectively characterise the primary tumour mass, assess nodal status and guide biopsies which are the gold standard in diagnosing a range of different cancers, including ILC.4,5 While highly operator dependent, ultrasound is recognised as a particularly sensitive breast imaging modality as variations in glandular tissue do not affect image interpretation.9 Furthermore, ultrasound has the ability to distinguish between cystic (benign) lesions, which tend to be hypoechoic and homogeneous, and solid lesions which appear heterogeneous with irregular margins and are suspicious of malignancy.9 Once ILC relapse was confirmed in this patient, the main role of PET/CT imaging was the restaging of the cancer. It is an extremely valuable examination as it is minimally invasive and provides unique functional information superimposed on anatomical structures.10 Furthermore, 18F-FDG characterises lesions as active or necrosed, a task which is difficult with anatomical imaging alone (where scarring can confuse image interpretation) and is extremely important when determining treatment strategy.10 While the CT component of the PET/CT scan is not considered ‘diagnostic’, it is often sufficient to visualise abnormalities.2 For this patient, the CT appearances were reported as being suspicious of a bony sacral deposit and thyroid lesion, and the recommendation was made that the findings be closely monitored to determine if future treatment is required.

For this patient, the PET/CT and the ultrasound images provided similar information about the size, shape and location of the primary tumour as well as suggesting negative nodal status, instilling confidence in staging and surgical success. The staging information obtained from the ultrasound images and in particular, the PET/CT scan, influenced the treatment strategy for the patient which included surgical excision of the tumour and sentinel node/s. To aid in this process, lymphoscintigraphy was performed.

The application of lymphoscintigraphy has been extremely valuable in the post-therapy survival of breast cancer patients in terms of morbidity.11 Due to this refined technique, the past method of wide local excision has been abandoned and patients no longer have to try to manage the massive oedema caused by this drastic procedure)11.

While there are other methods available to map out the sentinel node, including the use of intra-operative blue dye, lymphoscintigraphy is arguably the most accurate; the blue dye technique has the disadvantage that it may demonstrate the entire chain of lymph nodes and those closest to the lesion don’t always include the sentinel node that will drain the tumour.2 CONCLUSION Breast cancer rates are on the rise due to increasingly effective screening tools. Therefore, it is important for patients to be able to access the best diagnostic techniques available with a short time period between diagnosis and treatment.

Ultrasound and PET/CT imaging provided unique findings and together with lymphoscintigraphy played an important role in the successful treatment of this patient.

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This is just one example of a very common clinical scenario whereby the use of specialised, complementary imaging procedures, have potentially provided the patient with the best possible outcome.

REFERENCES 1 Cancer Australia 2013, Breast Cancer Statistics, viewed 19 September 2013, <canceraustralia.nbocc.org.au/breastcancer/about-breast-cancer/breast-cancer-statistics>.

2 Buscombe, J, Holloway, B, Roche, N, & Bombardieri, E 2004, ‘Position of Nuclear Medicine Modalities in the Diagnostic Work-up of Breast Cancer’, The Quarterly Journal of Nuclear Medicine and Molecular Imaging, vol. 48, no. 2, pp. 109-118.

3 The Mayo Clinic 2013, Invasive Lobular Carcinoma (ILC), viewed 19 September 2013, www.mayoclinic.com/health/ invasive-lobular-carcinoma/DS01063 4 Ly, A & Pitman, M 2013, ‘Breast Ultrasound-Guided FineNeedle Aspiration: A Case Report Stressing the Sonographic Features of Benign Versus Malignant Breast Masses and the Pitfalls of Lobular Carcinoma’, Pathology Case Reviews, vol.

18, no. 1, pp. 40-42.

5 Medline Plus 2012, Breast Biopsy – Ultrasound, viewed 19 September 2013, www.nlm.nih.gov/medlineplus/ency/article/007432.htm/>.

6 Royal Adelaide Hospital 2010, Philips and Gemini PET/CT Acquisition Protocols and General Duties Manual, Section CL-6015: PET/CT Wholebody – Set up & Acquisition, Royal Adelaide Hospital, South Australia, viewed 19 September 2013.

7 Delbeke, D, Coleman, R, Guiberteau, M, Brown, M, Royal, H, Siegel, B, Townsend, D, Berland, L, Parker, A, Hubner, K, Stabin, M, Zubal, G, Kachelriess, M, Cronin, V & Holbrook, V 2006, ‘Procedure Guideline for Tumor Imaging with 18F-FDG PET/ CT 1.0’, Society of Nuclear Medicine and Molecular Imaging Practice Guidelines, Oncology, viewed 19 September 2013, <interactive.snm.org/docs/jnm30551_online.pdf>.

8 Royal Adelaide Hospital 2010, Siemens Symbia SPECT/CT Acquisition Protocols and General Duties Manual, Section CL1004: Lymphoscinigraphy – Breast, Royal Adelaide Hospital, South Australia, viewed 19 September 2013.

9 Kuhl, C, Schrading, S, Leuttner, C, Morakkabati–Spitz, N, Wardelmann, E, Fimmers, R, Kuhn, W & Schild, H 2005, ‘Mammography, Breast Ultrasound, and Magnetic Resonance Imaging for Surveillance of Women at High Familial Risk for Breast Cancer’, Journal of Clinical Oncology, vol. 23 no. 33, pp.

8469-8476.

10 Radan, L, Ben-Haim, S, Bar-Shalom, R, Guralnik, L & Israel, O 2006, ‘The Role of FDG-PET/CT in Suspected Recurrence of Breast Cancer’, American Cancer Society, vol. 107, no. 11, pp.

2545-2551.

11 Sun, X, Liu, J, Wang, Y, Wang, G, Zhoul, Z, Lil, Y, Liu, Y, Lil, T, 2010, ‘Role of Preoperative Lymphoscintigraphy for Sentinel Lymph Node Biopsy in Breast Cancer Patients’, Japanese Journal of Clinical Oncology, vol. 40, no. 8, pp. 722-725.

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.

2–3 November 10th Annual CPD/CME Conference Sydney, Australia 11–22 November Foundation of PET-CT Training Course Sydney, Australia 11 November PET/CT Symposium Melbourne, Australia 14 November Tasmania Allied Health Symposium Hobart, Australia 17-21 November WARMTH’s 8th International Conference on Radiopharmaceutical Therapy Manila, Philippines 22-23 November EANM/ESTRO Educational Seminar in PET in Radiation Oncology Vienna, Austria 23 November VSNMT Day Seminar Details TBA 26 November WA Branch AGM Perth, Australia

2014 17–21 February 3rd Pet/MR Workshop Tuebingen, Germany 25-28 April 44th Annual Meeting of ANZSNM Adelaide, Australia 7-11 June SNMMI Annual Meeting St Louis, Missouri, USA 22-31 August 11th Congress of the World Federation of Nuclear Medicine and Biology. Cancun Mexico 18-22 October EANM Annual Congress of the European Association of Nuclear Medicine Goteborg ,Sweden

2015 17 – 20 April 2015 45th Annual meeting of ANZSNM Brisbane, Australia 31 Oct – 4 Nov 2015 AOFNMB 2015 Asia oceanic Congress of Nuclear Medicine and Biology Korea

Australian and New Zealand Society of Nuclear Medicine