November 2016

ISSN : 2200-9876

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

November 2016, Issue 19

Contents

www.anzsnm.org.au

Welcome

3

President’s Report

7

ANZSNM Membership Benefits

8

ANSTO / ANZSNM Research Grant 2017

9

Branch News

New Zealand

10

Queensland

10

South Australia

10

Victoria/Tasmania 11

Western Australia

11

Technical Standards

12

TSIG Day Seminar report 13

SIG

Diary Dates

16

What’s That? 17 In Memorium: Professor Ignac Fogelman 18 Crossword 20 AttendO – what is it? 22 PET/CT Survey, (reprinted from © IPEM Scope Magazine) 24 Case Studies

Neurogenic Heterotopic Ossification (NHO) in an adolescent male following spinal cord injury 30

The use of 99mTc-Sestamibi parathyroid scanning in detecting suspected ectopic parathyroid glands 32

Deadlines The deadlines for each issue of Gamma Gazette for this year are set out below. These deadlines must be strictly adhered to in order to get the journal out on time. Do not leave the submission of copy until the last minute. For advice on how to submit material please go to the website www.anzsnm.org.au March – February 1

July – June 1

November – October 1

Neurogenic Heterotopic Ossification (NHO) in an adolescent male following spinal cord injury 2

Welcome WELCOME to the final edition of the Gamma Gazette for this year. 2016 is rapidly coming to the end following another exciting and busy year for the Society.

Contributions for this edition have been made by members of the WA Branch of the ANZSNM. We hope you find the time to browse through the Gazette. Find out what’s been happening in your branch, take a look at the interesting images under the “What’s That?” section, test your skills with Amy Evans’ crossword and perhaps learn something new when you read the case study about Neurogenic Heterotopic Ossification (NHO).

Once again, thank you to our sponsors and to all members who have contributed their time to the production of this edition. I would like to encourage all members to get involved with the ANZSNM; it is like so many things in life, the more you put into it, the more you will get out.

On behalf of the WA Branch of the ANZSNM, we wish you all a safe and relaxing festive season and we look forward to another rewarding year in the world of Nuclear Medicine. We hope you enjoy this edition of the Gamma Gazette.

Dr Elizabeth Thomas Chairperson WA Branch ANZSNM

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Journal Staff Editorial copy & Advertising copy

Design & Production

Andrew St John General Manager ANZSNM Secretariat PO Box 2195 Wellington Point, QLD 4160 Tel: 1300 330 402 Fax: (03) 8677 2970 Email: secretariat@anzsnm.org.au

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

Aims and Objectives

The Australian and New Zealand Society of Nuclear Medicine Limited

The objectives of the Society are as follows: 1. Promote a) the advancement of clinical practice of nuclear

medicine in Australia and New Zealand;

b) research in nuclear medicine;

This issue compiled by the WA branch.

c) public education regarding the principles and

applications of nuclear medicine techniques in

medicine and biology at national and regional levels;

Submissions

d) co-operation between organisations and

individuals interested in nuclear medicine; and

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

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

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.

Deadlines for each issue of the journal are the first of each month prior to publishing. Š 2016 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

4 Gamma Gazette November 2016

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 re-allocate ongoing responsibilities to the ANZSNM – Technology Special Interest Group (TSIG). The PDY and mentor program, CPD program, department accreditation and the overseas qualification exam 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

Prof Dale Bailey (NSW), email: dale.bailey@sydney.edu.au A/Prof Roslyn Francis (WA), email: roslyn.francis@uwa.edu.au Prof Vijay Kumar (IRC), email: vijay.kumar@health.nsw.gov.au Mr Dominic Mensforth (SA), email: dominic.mensforth@i-med.com.au Dr Elizabeth Bailey (TSIG), email: Elizabeth.Bailey2@health.nsw.gov.a Dr Giancarlo Pascali (Radiopharmaceutical Science Rep), email: gianp@ansto.gov.au Dr Susan O’Malley (NZ), email: sue@omalley.co.nz Dr Paul Roach (AANMS Rep), email: paul.roach@sydney.edu.au Mr David Thomas (VIC/TAS), email: David.Thomas@austin.org.au Dr Daniel Badger (SA): daniel.badger@health.sa.gov.au Ms Clare Radley (NZ): c.e.radley@gmail.com Mr Nicholas Ingold (ACT), email: nick@garranmedicalimaging.com.au

General Manager & Secretariat

Dr Andrew St John and Drajon Management Pty Ltd

All correspondence ANZSNM Secretariat PO Box 2195 Wellington Point, QLD 4160 Tel: 1300 330 402 Fax: (03) 8677 2970 Email: secretariat@anzsnm.org.au Branch Secretaries Australian Capital Territory New South Wales Queensland South Australia Victoria/Tasmania Western Australia New Zealand

Mrs Rachel Prior, email: rachael1285@gmail.com Dr Liz Bailey, email: Elizabeth.Bailey2@health.nsw.gov.au Mr James Turner and Mr Louis Gray, email: qldbranchsecretaryanzsnm@gmail.com Ms Kimberley Nguyen, email: kimberly.nguyen@bensonradiology.com.au Ms Jessica Welch, email: jessica.welch@austin.org.au Ms Georgina Santich, email: wabranchsecretary@hotmail.com Ms Pru Burns, email: pru.burns@prg.co.nz

Special Interest Groups Technologists Radiopharmaceutical/Science Physics/Computer Science Technical Standards Committee Scientific Advisory Panel International Relations Committee Nurse Member Liaison

Chairperson: Ms Marcia Wood, email: Marcia.Wood@austin.org.au Chairperson: Dr Giancarlo Pascali, email: gianp@ansto.gov.au Chairperson: Dr Daniel Badger (SA), daniel.badger@health.sa.gov.au Chairperson: Dr Darin O’Keeffe, email: darin.okeeffe@cdhb.govt.nz Chairperson: Prof Dale Bailey, email: dale.bailey@sydney.edu.au Chairperson: Professor Andrew Scott, email: Andrew.Scott@ludwig.edu.au Mr Erwin Lupango, email: Erwin.lupango@sessiahs.health.nsw.gov.au

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

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

5

President’s Report The times they are a changin’ WHO would have thought it? Bob Dylan wins a Nobel Prize for literature. The population of the UK votes to leave the European Union in the so-called “Brexit” referendum. The climate is undergoing demonstrable evidence-based changes likely due to human activity. And a reality TV star and real estate mogul with questionable personality traits wins the US Presidency. We certainly find ourselves in changing times.

Any group or organisation that does not recognise the rapid rate of change in our day-to-day lives risks becoming irrelevant and assigned to the pages of history.

Nowhere is this perhaps more obviously seen at present than in the struggle of our print news media to find their place in this brave new world. In our own small way, the leadership of the Society is also aware of the many changes that are happening in our discipline which will have an effect on the way we work and interact now and into the future. We see the impact of genetic sequencing in choices of drugable targets, the chemical engineering of molecules designed to target highly specific receptors and reporters, the advances in radiotracers available through developments in nuclear science and radiochemistry, and the effects of globalisation in rapidly translating developments from other domains into our clinical practice – witness the rapid take-up of PSMA PET imaging locally, where reports assert that PSMA PET imaging in Australia has had the highest “penetration” rate in the world, as the most recent example. We should brace ourselves for this accelerating rate of change to continue.

For this reason the Society is undertaking a number of initiatives, including: • developing stronger integration of industrial partners into our Society by encouraging corporate membership and increasing interaction; • introducing new software applications and resources for improving and expanding resources for Continuing Education activities; • closer ties and more frequent discussions with other related professional organisations in our field such as AANMS, RAINS and ACPSEM locally, and EANM, IAEA, AOFNMB and SNMMMI internationally; • modifying the role of various SIGs and committees as the responsibility for training and accreditation changes; • increasing our interactions with ANSTO in the area of radiopharmaceuticals, availability and supply.

We want to hear from you about other ways that we can provide the sort of Society that you want. If we do not adapt to the changing times we may find ourselves left “blowing in the wind”.

Dale Bailey President ANZSNM president@anzsnm.org.au

Note from the Production Editor Submitting material for publishing in Gamma Gazette IMAGES: Please send image files saved as JPG or PDF at minimum 200dpi, no smaller than 10cm wide and NOT embedded within the text file.

TEXT: All text to be submittd in a word file format not PDF. Any queries please contact the ANZSNM Production Editor at deepbluedesign1@me.com 7

ANZSNM Secretariat PO Box 2195, Wellington Point, QLD 4160 secretariat@anzsnm.org.au

President Prof Dale Bailey Past President A/Prof Roslyn Francis

2017 ANZSNM Membership Benefits The ANZSNM which is the oldest and pioneering Nuclear Medicine body in Australia. It is the one professional organization for all individuals involved in Nuclear Medicine in Australia and New Zealand including public and private health practitioners, academics and researchers, and industry members. The ANZSNM provides a number of regular and unique activities for its members which are either free or at discounted rates: • • •

Vice-President Prof Vijay Kumar

•

Treasurer Mr Dominic Mensforth

•

General Manager Dr Andrew St John

Local Branch Meetings in most States which keep members up to date with the latest developments in nuclear medicine & provides CPD opportunities; The Gamma Gazette which is published 3 times per year, provides a major educational resource in nuclear medicine as well as a means of publication for individual members’ research work; Specific education seminars which highlight developing aspects of nuclear medicine run by special interest groups; The Annual Scientific Meeting which is the major education event for nuclear medicine in Australia and New Zealand and includes international as well as national experts; Specialised interest groups (SIGs) for Technologists, Radiopharma-ceutical Scientists and Physicists which focus on promotion of new developments and standards in these specific areas.

All of the above are recognised as continuing professional development (CPD) and membership of the ANZSNM allows members to record and track all their CPD activities though the Society website. In addition, a unique App called AttendO is now available for members to easily register their attendance at CPD events, automatically record their points and provide a logbook of reflection and learnings.

Other member benefits include: • • • • •

8 Gamma Gazette November 2016

A number of Awards for the recognition of members who present new research and development activities at local or national meetings and can be found on the ANZSNM website; The ANSTO/AZNSNM Research Award of $20,000 every year to support a member or team of members research activities, with an emphasis on new researchers; The ANZSNM website provides information about jobs and vacancies that are often not advertised elsewhere; ANZSNM members now have access to discounted rates at Quest Apartments at Gordon Place and Lonsdale Street in Melbourne, and with Europcar and National Australia Bank Australia-wide; In 2018 the ANZSNM will be hosting the World Federation of Nuclear Medicine and Biology event in Melbourne which will allow members the opportunity to interact with 2,000 delegates worldwide.

Inviting applications for

ANSTO/ANZSNM Research Grant 2017 Closing date extended to: Friday December 9, 2016 to commence in 2017 For further information on Research Grant conditions & applications visit www.anzsnm.org.au/resources/awards-grants ANSTO and the ANZSNM (“the Society”) are pleased to offer a competitive grant aimed at encouraging research in nuclear medicine in Australia and New Zealand. The grant is up to the value of $20,000 and is expected to run for approximately one year. ANSTO is Australia’s government-funded nuclear science organisation. Its vision is to deliver excellence in innovation, insight, and discovery through its people, partnerships, nuclear expertise and landmark infrastructure. In assessing applications for the grant, preference will be given to early career researchers in order to provide seed funding for pilot investigations that could lead on to further grant applications. The grant will be offered yearly but the evaluating committee reserves the right to not award the grant if there is no suitable application.

l l l l l

l

All aspects of nuclear medicine will be considered for this grant including, but not restricted to: novel developments in radiopharmaceuticals; hardware and software innovation; epidemiology and audit activities; pilot clinical trials; retrospective studies on outcomes in diagnostic and therapeutic procedures in nuclear medicine; education, training and professional development activities.

The ANSTO/ANZSNM Research Grant is intended to achieve one or more of the following: 1. Approach a meaningful conclusion in one year; 2. Assist investigators striving to establish new programs or new directions; 3. Fund initial exploratory research for which external funding will be sought subsequently; 4. Address circumscribed clinical problems of a sort unlikely to attract industry funding; 5. Survey groups of patients to assess the success rate, sequelae, safety or any other aspect of diagnostic or radionuclide therapy protocols; 6. Bridge the gap of a year between completion of one external grant and the commencement of another.

The evaluating committee will consist of one representative from ANSTO, one member of the Society’s Scientific Advisory Panel and the ANZSNM President or their delegate.

The successful applicant/team is expected to acknowledge ANSTO’s and the Society’s support in any publications and provide a report to be published in the Gamma Gazette upon completion.

The applicant will ideally present the outcome(s) of the research at the next ANZSNM ASM.

Prof Vijay Kumar PhD Member, Scientific Advisory Pane AZNSNM

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Branch News NEW ZEALAND IT was agreed that there would be a NZ branch meeting even though New Zealand had hosted the Annual Scientific Meeting in Rotorua.

The Christchurch team volunteered to host this and provide some new initiatives. Christchurch proved to be a big draw card with high attendance. It was convened by Dr Sue O’Malley and supported by Mrs Diane Wills and Rachel Wilson. It was planned to be financially neutral with good management and generous sponsorship made a pleasant profit. The new directions for the meeting embraced the PET community with active participation at the podium and audience. We also wanted more basic sciences and research, which provide a new perspective for our meeting.

It was also time for change with leadership of the ANZSNM NZ Branch chair changing from Dr Sue O’Malley who completed eight years as NZ Branch Chair to Mrs Victoria Brooks who was successfully nominated as the incoming chair. Victoria has been active in both the 2004 and the 2016 ASM and has convened very successful NZ Branch meeting in new Plymouth. She is enthusiastic and very experienced. We look forward to our NZ nuclear medicine community working with Victoria to promote and extend our society.

Mrs Pru Burns generously offered to continue as Secretary for another two years. Pru provides solid service and her willingness to continue will be greatly appreciated.

Mrs Karen Wiki has completed her role as Treasurer for two years. Karen developed some novel budget templates which have been taken up by the Secretariat. Karen’s contribution was acknowledged at our branch meeting. She will be replaced by Ms Arminder Kaur.

Our next meeting will be in Hamilton in 2017 with Dr Berry Allan accepting this challenge.

PMSA has been flourishing in Auckland and is likely to start in Christchurch soon.

There is a new SPECT CT camera due to be installed in Dunedin very soon and Christchurch have approval but need a safe space after earthquake building damage.

There is an increasing number of trainees in NM departments. Most are MRTs who are continuing their education to include functional imaging. It’s good to see increased training as this represents growth.

Likewise many NM techs have started to upgrade their CT with a course provide by RAINS. This will be my last report in this capacity. It has been my privilege to work with many inspirational and dedicated individuals in different skilled areas, all of who show energy, direction and conviction. The Federal Council has changed a lot since I first joined nine years ago. This was a time of turmoil transitioning into a Limited Liability Company. It was clear, that the need to become a more professional body required a full time Secretariat service. This enabled the administration to run seamlessly leaving with governance and professional direction to the elected representatives. The website has markedly progressed and there is a vision to stream education to members. We want the ANZSNM website to be the Go-To place.

Dr Sue O’Malley Outgoing Chair

QUEENSLAND ON September 24 the Qld Branch held our Bi-Annual Seminar at the Sandstone Point Hotel. We had 10 speakers in total talking on a variety of topics. The day was a success with over 60 people registering for the event. The venue was very pleasant and the committee were very happy with how the day went. Many thanks to the committee members for their hard work putting the day together. Big thanks also to the sponsors and speakers of the event.

The next meeting is planned for November and will be presentations for the Radpharm Award for Queensland. This will also be the last meeting for outgoing committee members James Turner, Louis Gray and Emma Snow. It will also be my last meeting as Chairperson. I would like to personally thank all the committee members I have worked with over the past four years and wish the new committee all the best.

Ms Melinda Wilson Chairperson

SOUTH AUSTRALIA SINCE the last branch report, we have had two ANZSNM Branch meetings and also a Technologists Group meeting. These were well attended. The most recent branch meeting was held on October 26 at Dr Jones and Partners.

There hasn’t been much change within SA from the July issue of Gamma Gazette.

We heard, last issue that students are now being placed in rural towns to allow them to complete the AHPRA requirements. In addition to this, students are now being offered placement positions in the United 10 Gamma Gazette November 2016

u

Branch News

continued

Kingdom, which is an amazing opportunity for the students here in SA. The scientific aspect of our meeting focused on prostate carcinoma, PSMA and positive lymph nodes.

The technologists group meeting was focussed around thyroid imaging, including a thyroid protocol review and thyroid scanning in neonates. This meeting also reiterated the importance of keeping track of our CPD and what is required to maintain registration.

Lastly (and sadly) we are saying goodbye to our Secretary/Treasurer Kimberly Nguyen in mid november and are calling upon anyone interested in taking over her role to please email your nominations through to Kimberly or myself.

Brittany Martin ANZSNM SA Branch Chair Person

VICTORIA/TASMANIA WE have had a busy few months in the Vic/Tas branch, culminating in our Annual Day Seminar on Saturday September 17. Over 80 technologists from around the state (and the country) came to hear an interesting and varied program of speakers.

We started with cardiology, hearing from Dr Dinesh Sivaratnam that (thankfully) Nuclear Cardiology is NOT Dead and Buried, followed by a presentation from Mark Dobson on The Bankstown experience with combining CTCA and Nuclear Cardiology. Rheumatology was the focus of the second session with Dr Clair Owen presenting on Whole Body PET/CT and its uses in polymyalgia rheumatica, and then Dr Dickson presented an overview of Nuclear Medicine in Rheumatology.

We were lucky enough to have another “Pioneer Lecture”, with Helen Paterson giving the audience a trip down memory lane, as well as a reminder to the younger techs of how far we’ve come in 30 years.

The afternoon session was focused on PSMA production, with talks from Dr Douglas Smyth on the licensing and legalities of producing in-house, from David Krenus about F-18-PSMA and Nicholas Siebert explaining the “Lab-Eazy” synthesis module.

As with any good Day Seminar we ended with a social gathering at the nearby Wharf Hotel which gave everyone a good chance to chat and catch up.

We would like to welcome two new committee members, Christian Testa and My Linh Diep and the committee is looking forward to working with them to plan our 2017 Calendar.

Kim Jasper Victoria/Tasmania Branch Chair

WESTERN AUSTRALIA Hello from the WA Branch, we have had a very busy second half of the year. August is always our Annual Workshop and this year’s topic was “Head and Neck”.

We are very fortunate to have such fantastic speakers who reply “yes” when we ask if they would be available to present to us. We would like to send a sincere thank you to our local presenters; Professor Peter Panegyres, Dr Mike McCarthy, Simone Culleton, Dr Zeyad Al-Ogaili, Dr Annette Lim, Dr Melanie Jackson, Dr Susan Mincham, Dr Nick Gottardo and Associate Professor Ros Francis. We also had Professor Steven Meikle from NSW and Nick Ingold from the ACT. All presentations at our Annual Workshop were greatly appreciated and both educational and relevant to our practice. We have subsequently received a lot of positive feedback from attendees regarding the outstanding quality of presentations.

We would also like to officially thank our generous sponsors for their continued support of our events here in WA and we are delighted that many of them were able to join us on the day too. Our grateful thank you goes to; Ben Herring from GE Healthcare, Neil Foster and Tim Lagana from Siemens, Sally-Ann Cornelius from Imaxeon, Adrian Wroe and Simon Osborne from GMS, ANSTO Health and the ANZSNM. Finally to our attendees, we are always pleased that so many of you come along to our workshop each year. We hope you all found the day interesting and thought provoking. Our Annual Workshop is open to all members throughout Australia and New Zealand so if you feel like a Winter break in the West, please RSVP next year and come and join us for the day.

We have our Radpharm Award presentation evening as well as our Annual General Meeting and dinner to round out our year.

Thank you all once again and I hope you have a great finish to 2016 and we look forward to seeing you in the New Year.

Georgina Santich WA Branch Secretary 11

Special Interest Group News TECHNOLOGISTS THE ANZSNM Technologist Special Interest Group continues to have strong focus on continuing professional development and we are currently working on several projects to increase the range and type of CPD activities provided to nuclear medicine professionals. Work continues on the PET modules to be made on-line as a way for members’ to gain expertise in PET/CT theory and clinical practice. The TSIG have been working closely with the University of Queensland to develop an MRI course for nuclear medicine technologists and other allied health professionals with a PET/MRI focus. The course has now been endorsed by the University of Queensland and is available for enrolments in 2017. We would encourage any technologists with an interest in PET/MRI to consider undertaking the course. The TSIG are very proud to see this course come to fruition as a means to provide educational pathways for our technologist members.

The Annual TSIG Symposium for 2016 was held in Canberra on Saturday July 23 at the National Press Club of Australia. We had a record number of registrants for this event, with over 80 people attending the program. The program this year presented a multi-modality focused view of head & neck imaging, along with a presentation on quantitative SPECT and a session on continuing professional development and advanced practice. Many of the delegates attended the dinner in the evening as well for the 3 course dinner also held at the National Press Club of Australia. Over the past few years, these events have grown and grown. Next years’ event will be held in July at Sovereign Hill, Ballarat, Victoria.

The Annual Scientific Meeting was held in Rotorua New Zealand at the Energy Events Centre from April 2225. The Technologist Symposium featured invited technologist speaker A/Prof David Gilmore from Regis College Boston among others. Mr Aaron Scott, President of the Society of Nuclear Medicine & Molecular Imaging – Technologists Section (SNMMI-TS) attended the meeting and this provided an opportunity for the TSIG to strengthen our working relationship with the SNMMI-TS. We also saw the first reciprocal Mallinkcrodt Award winner representing the SNMMI-TS present their paper at our local conference. Hopefully, this will be the first of many more to come. We would also like to congratulate Lisa MacFarlane as the winner of the Radpharm Award for her presentation “PSMA – Going for Gold” and Sarah Stephenson as the winner of the Mallinckrodt Award for her presentation “General Anaesthetic for Paediatric PET /CT – Evolution of procedures due to a changing clinical environment”. As part of the award, Sarah will present her paper again at the SNMMI meeting in Denver next year as part of the SNMMI-TS program.

At the 2016 SNMMI meeting in San Diego, the 2015 Mallinckrodt award winner, Ms Lauren Dorn from St Vincent’s Hospital Melbourne gave her award winning presentation as part of the Technologist Symposium. She was also recognised at the SNMMI-TS Awards ceremony, this is the first time the Australian Mallinckrodt Award winner has been formally recognised in this manner.

During the SNMMI-TS, members of the TSIG also met with members of the executives of the EANM Technologists’ group and the SNMMI –TS, and further meetings will be held at the upcoming EANM meeting.

Through Technologist representatives on the International Relations Committee and the TSIG, we hope to strengthen our ties with these groups and also to provide Australian input into global initiatives regarding technologists, and provide opportunities for international collaboration for our members.

During the AGM of the TSIG held at the Annual Scientific Meeting, a proposal was put forward to restructure the TSIG around key strategic areas in a drive to engage members and facilitate more activities and projects.

This was overwhelmingly supported by those present, and work has begun to form committees to take on these roles. The TSIG are working with the ANZSNM Federal Council to ensure that the restructure meets the strategic goals of the society and constitutional requirements. We hope to complete this within the forthcoming months.

Marcia wood ANZSNMT Chair

12 Gamma Gazette November 2016

TSIG DAY SEMINAR 2016 – A Capital Calibration The 8th Annual TSIG Day Seminar was held on July 23, 2016 in Canberra, ACT, Australia. This Annual Seminar is aimed at increasing accessibility of continuing education for rural technologists. It was held at The National Press Club of Australia, and allowed space for presentations and for the main sponsors of this to have display booths and representatives on hand to answer any questions the delegates may have had. This year our sponsors included Siemens, Bayer, Imaxeon, Genyzme, Cyclomedica, MIPS, ANSTO Health, Gamma Gurus, Global Medical Solutions, Landauer PETNET Solutions, and Lantheus Medical Imaging. We genuinely thank these sponsors for their support, as these meetings wouldn’t be possible without them. It is always appreciated to have their knowledgeable representatives available to keep delegates up to date with the newest technology.

The main focus of the morning sessions was on Nuclear Medicine’s role in the diagnosis and treatment of Head & Neck Cancer, including presentations on Sectional Anatomy, Radioiodine Therapy, Radiation Therapy and PET/CT from Dr Lois Comber, Dr Fred Lomas, Rebecca Van Gelder and Scott Evans. The afternoon session saw Jacqueline Toohey present a case study of papillary thyroid carcinoma, Chris McLaren taking an entertaining and poignant ‘Look Back’, before Dr Iain Duncan and Nick Ingold showed us the exciting present and future with xSPECT. The late session saw discussion on Advanced Practice, Technologist Training and CPD, including a presentation on the new Graduate Certificate in MR-PET at University of Queensland from Gail Durbridge, along with a look at some of the highlights from the SNMMI meeting in San Diego.

Dinner was also held at the National Press Club and we were treated to a gastronomic extravaganza. The dinner provided an opportunity for networking and socialising while enjoying a chef’s choice 3 course menu.

This was also well attended and plenty of new friendships were forged and old ones renewed.

The Canberra TSIG Seminar set a record for attendance with 80 attendees. A new app, Attend-O, was trialled for the day, with delegates scanning QR codes with their smartphones to record and confirm their attendance at each session.

This app is at a testing stage only and the TSIG Committee welcomes member feedback regarding the app - what was useful, what could be improved, what did or didn’t work. Please email any feedback to the Secretariat and it will be passed along to the TSIG Committee.

Jackie Bague, Adam Freeborn, James Green

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PROGRAM INFORMATION

Postgraduate Coursework Program in

MAGNETIC RESONANCE AND POSITRON EMISSION TOMOGRAPHY This program is primarily designed for nuclear medicine technologists and diagnostic radiographers seeking to

UPSKILL IN THIS EMERGING SPECIALISATION.

Commencing 2017: Semester 1 or Semester 2 Location: St Lucia Delivery Mode: External, internal

This program covers the fundamental operational and theoretical considerations relevant to MR-PET imaging technology. It’s designed for professionals such as nuclear medicine technologists and diagnostic radiographers.

Medical imaging is developing at a rapid pace and hybrid medical imaging systems are becoming more commonplace. With the blend of high-resolution Magnetic Resonance Imaging (MRI) and the physiological data of Positron Emission Tomography (PET), MR-PET is making quite an impression in medical diagnosis. The operation of this new hybrid system requires an understanding of both the MRI and PET standalone technologies.

The Graduate Certificate in MR-PET is designed for professionals such as nuclear medicine technologists and diagnostic radiographers who require a more in-depth knowledge of the theoretical fundamentals and operational considerations of a hybrid MRI scanner and PET scanner.

future-students.uq.edu.au

An exciting feature of this new course is the oneweek on-campus attendance, where students are able to operate MRI scanners, and practice scanning on human volunteers.

Career opportunities This program is primarily designed for nuclear medicine technologists and diagnostic radiographers, wanting to upskill in this emerging specialisation. It may also be of interest to researchers using this exciting technology.

Program structure Graduate Certificate in Magnetic Resonance and Positron Emission Tomography • 8 units (0.5 year full-time or part-time equivalent)

Courses

• MR-PET Hardware and Software Integration Covers MR-PET instruments used for clinical applications.

• Clinical Magnetic Resonance Imaging Covers patient screening, preparation and common clinical MRI protocols used when imaging various parts of the human body.

• MR Safety and Monitoring Covers the principal hazards of MRI environment and its effects on the human body and equipment.

• Magnetic Resonance Imaging: Fundamentals Explores the principles and methods that underpin MRI.

Entry requirements

Further program information

Graduate Certificate in Magnetic Resonance and Positron Emission Tomography Program code: 5654 CRICOS Code: 092060D Bachelor degree in mathematics; physics; chemistry; biology; medical imaging; medical radiation; radiography; allied health; biomedical engineering; computer science or a relevant discipline (as deemed relevant by the Program Coordinator).

To find out more about this program, contact the Centre for Advanced Imaging at The University of Queensland.

Applications on the basis of post-secondary study and two years work experience in a related field will be individually assessed.

______________________________________

International students: English proficiency IELTS overall 6.5; writing 6, reading 6, speaking 6, and listening 6. For other English Language Proficiency Tests and Scores approved for UQ, view the English proficiency policy at futurestudents.uq.edu.au/english-requirements.

P: +61 7 3365 8263 E: education@cai.uq.edu.au W: cai.uq.edu.au/education Find us on Facebook at: www.facebook.com/centreforadvancedimaging

In the event of any conflict arising from information contained in this publication, the material approved

by The University of Queensland Senate shall prevail.

Banner images on this page: Left - Anaplastic thyroid carcinoma, image courtesy of Siemens Healthcare.

Right - Rodent model, image courtesy of Centre for Advanced Imaging.

CHOOSE UQ LEADING RESEARCH Ninety five percent of UQ’s broad fields are now above or well-above world standard, and none are below (2015 Excellence in Research for Australia (ERA) assessment

INTERNATIONAL REPUTATION UQ is one of only three Australian members of the global Universitas 21, a founding member of the Group of Eight (Go8) universities, and a member of Universities Australia

ESTEEMED TEACHERS More national teaching awards than any other Australian University

GLOBAL LEADER Ranked in the top 50 in the world overall (QS World University Rankings, 2015-2016)

SUCCESSFUL GRADUATES UQ graduates enjoy full-time employment rates and salaries higher than the national average

WORLD-CLASS FACILITIES Access state-of-the-art laboratories and research facilities

VIBRANT CAMPUSES Dynamic on campus environment, with over 190 sporting and cultural clubs and societies

CRICOS Provider Number 00025B

Enquiries – International applicants P: +61 3 8676 7004 E: study@uq.edu.au Enquiries – Australian applicants

future-students.uq.edu.au

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

All events are on the ANZSNM website: www.anzsnm.org.au/events

2017

23 November WA Branch AGM Fiona Stanley Hospital

10 February Physics SIG Symposium University of Sydney

27 November – 2 December RSNA 102nd Scientific Assembly & Annual Meeting Chicago, USA

21 – 23 April 2017 ANZSNM Annual Scientific Meeting Hobart, Tasmania, Australia

1 December ANZSNM Earlybird membership renewals close

2018

9 December ANSTO-ANZSNM Research Grant applications close

20 – 24 April 2018 WFNMB 2018 Congress Melbourne, Australia

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16 Gamma Gazette November 2016

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Scan this QR to visit our website:

Submitted by: Amy Evans, Sir Charles Gairdner Hospital

Answer on page 35

What’s that?

Clinical history A 76-year-old male presented to the Nuclear Medicine Department at Sir Charles Gairdner Hospital for a myocardial perfusion scan (MPS). The clinical question being asked was for the presence of significant ischaemic heart disease as part of a pre-operative assessment.

The patient had previously had heart surgery – the insertion of a stent 9 years prior and had a history of ischaemic heart disease. Current medications were listed as aspirin, Lipitor and Nexium.

The patient underwent a two day rest/stress study receiving 536MBq 99mTc-MIBI for the rest and 532MBq 99mTc-MIBI for the stress. On both days, imaging was performed approximately one hour post injection.

Upon review of the images the scan demonstrated relatively normal myocardial perfusion with no significant ischaemic heart disease and only a minor fixed inferoapical perfusion defect. However, during the scan extra cardiac uptake in the mediastinum was identified.

It demonstrated similar intensity to that of the myocardium and although round in shape it was also slightly smaller in appearance.

17

In Memoriam:

Professor Ignac Fogelman

IT IS with great sadness that I write this memorial to the passing of Professor Ignac Fogelman who was a close friend, colleague and mentor. He passed away on July 5, 2016 following a long battle with leukaemia.

Ignac was born in a refugee camp in Italy in the tumultuous period after World War II, moving with his parents to Glasgow, where he grew up. He completed his medical studies at Glasgow University and rapidly began to distinguish himself with several publications, including one of the first reported cases of toxic shock syndrome which was published in the Lancet. He initially trained in endocrinology but became intellectually interested in bone disease and did much of the early work on skeletal scintigraphy under the supervision of Iain Boyle. He moved to London to take up the post of consultant physician at Guys and St Thomas’s Hospital in 1983. Ignac was appointed director of the Department of Nuclear Medicine and served in this position between 1988 and 1997. He set up and served as the director of the Osteoporosis Screening and Research Unit in 1988 and helped establish positron emission tomography (PET) in both its oncological and skeletal applications. Ignac also had strong links with the National Osteoporosis Society, where he served as a board member and chaired the Densitometry Forum for many years. Appointment as Professor of Nuclear Medicine at King’s College followed in 1996.

Ignac was involved in the production of over 400 original articles in peer-reviewed journals and 15 textbooks of nuclear medicine. He is most recognised for the production of the Atlas of Nuclear Medicine, the third edition being released in 2014 and Radionuclide and Hybrid Bone Imaging which was released in 2013. During this rich academic period he mentored many great physicians such as Gary Cook, Gopinath Gnanasegaran, H. Mohan and Paul Ryan, to mention just a few. Amongst these were a number of Australians such as Ivan Hoshon, Sharon Hain and Eva Wegner. Ignac had the extraordinary capability of bringing the best out of everyone around him. He was never threatened by brilliance in others but encouraged them to be the best they could be. I rarely heard him say anything critical or bad of the people with whom he worked or socialised.

Ignac was one of the most intellectually rigorous, generous, gentle, kind and loyal men I ever met. I first encountered him when I was a junior registrar attending the SNM Meeting in St Louis in 1989. He became one of the closest friends I have ever had over the next few years. I tell this story to indicate how open he was and how little ones’ position in life meant to him. There was an extraordinary capacity for love and affection and this manifested in enduring friendships with people such as Lenny Freeman, Dave Collier, Henry Wagner, Ted Silberstein, Graham Russell, Rob Coleman, Helen Nadel and Ora Israel. He loved coming to Australia and did so on many occasions. Ignac had many close friends here, in particularly, Monica Rossleigh, Provan Murray and Dale Bailey to name a few.

It is difficult to measure the effect that Professor Fogelman had on so many facets of what we

18 Gamma Gazette November 2016

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In Memoriam: Professor Ignac Fogelman

now call molecular imaging. He researched and wrote extensively on bone disease and PET to mention just a few of his intellectual interests. One must not forget his love for the good life. My brother Robert christened him “Six-star Fogelman� after one memorable visit to London. Ignac loved the theatre, opera, travel, good food and wine and celebrated this with his friends and family on numerous occasions. I first tasted Petrus, Salon and Mouton Rothschild at a dinner party at the Fogelman home and on numerous other occasions with good friends such as Ian and Sue Smith.

A great family was a crucial part of what made Ignac the man he was and remained so till the end. Coral, his wife made the home a refuge from the pressures of academic life. She supported Iganc through thick and thin, fire and storm and remained graceful, nurturing and loving even under the terrible stresses of the last few weeks of Ignac’ life. She was supported by their wonderful children Richard and Gayle, their spouses Samantha and Jason and four grand kids.

As Protagoras said, man is the measure of all things. Ignac enriched many lives with his kindness, humour and generosity and was the definition of the Renaissance man. He had a voracious appetite for literature and art. He managed to visit every obscure art gallery be it private or public on his many travels the world over. He was also an internationally recognised bridge player. Philip Larkin, his favourite poet captured the inner rascal and quirky sense of humour in Ignac. We spent many hours arguing about literature and poetry, particularly when I saw him in London a few weeks before his death. He found my favourite poet William Blake a little obscure. However I think that Blake captured the special qualities that Ignac possessed better than anything else we read and is a fitting epitaph to a truly great human being. May he rest in peace.

To see a World in a Grain of Sand And a Heaven in a Wild Flower Hold Infinity in the palm of your hand And Eternity in an Hour (Auguries of Innocence by William Blake) Hans Van der Wall November 2016

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Cardiac Nuclear Medicine Crossword by Amy Evans, Sir Charles Gairdner Hospital

Answers page 34

crossword clues ACROSS 1

99mTechnetium-sestamibi and 99mTechnetium-tetrofosmin both bind to ______ ______.

6

______ stress tests can be performed in patients who cannot tolerate exercise or where an exercise stress test is contraindicated.

10

Cardiac ______ is the amount of blood the heart pumps in 1 minute.

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In a blood pressure reading, the numerator represents ______ pressure.

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On ECG – the T wave represents the ______ of the ventricles.

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Normal ______ ventricular ejection fraction is >55%.

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The ______ ______ carry deoxygenated blood to the lungs.

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The ______ wall of the left ventricle is supplied by the right coronary artery.

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Normal ______ ______ is 120/80 or below.

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A ______ is the instrument used to measure blood pressure.

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In a blood pressure reading, the denominator represents ______ pressure.

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The ______ ______ is the quantity of blood pumped out of the ventricle in one heartbeat displayed as a %.

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The left ventricle pumps ______ blood to the entire body.

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______ can be used to reverse side effects caused by dypridamole.

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The right ventricle pumps ______ blood to the lungs.

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Myocardial perfusion scans can help differentiate between normal perfusion, ischaemic heart disease and myocardial ______.

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A gated blood pool scan or equivalent can be used to monitor patients undergoing ______ chemotherapy.

34

______ is a b1-agonist.

36

When imaging the heart with 201Thallium, the process of ______ enables rest and stress imaging from a single injection of tracer.

38

The ______ valve is located between the left atrium and left ventricle.

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Dypridamole and Adenosine are ______.

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Myocardial ______ imaging can be performed using 18F-FDG.

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On ECG – the P wave represents depolarization of the ______.

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The most common protocol used when performing an exercise stress test is the ______ protocol.

DOWN 2

When performing a gated heart pool scan a ______ ______ ______ view that demonstrates clear septal separation of the two

ventricles is required.

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The coronary circulation is right-dominant IF the posterior descending artery is supplied by the ______ ______ ______.

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The pulmonary valve is also known as the ______ valve.

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The ______ fibres conduct electrical impulses and trigger contraction of the ventricles.

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The mitral valve is also known as the ______ valve.

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The ______ wall of the left ventricle is supplied by the left anterior descending.

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The______ valve is located between the right atrium and right ventricle.

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The myocardium has two metabolic states; fatty acid and ______ metabolism.

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______ - ______ volume is the volume of blood in the ventricle at the end of contraction.

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On ECG – the QRS complex represents rapid ______ of the left and right ventricles.

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The coronary circulation is left-dominant IF the posterior descending artery is supplied by the ______ ______.

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______ is defined as a rapid heart rate.

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The ______ ______ carry oxygenated blood to the heart.

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Normal ______ ventricular ejection fraction is >45%.

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With ______ heart disease, defects seen on stress images should resolve on rest images.

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______ - ______ volume is the volume of blood in the ventricle at the end of the filling phase.

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The ______ valve prevents backflow of blood from the pulmonary trunk to the right ventricle and enables the reverse.

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The interventricular ______ separates the left and right ventricle.

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The volume of blood pumped from the left ventricle in one beat is referred to as the ______ volume.

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The ______ wall of the left ventricle is supplied by the circumflex artery.

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The ______ valve allows blood to flow from the left ventricle to the aorta when it contracts and prevents back flow when it relaxes.

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______ data is collected from R-wave to R-wave and distributed into 8-16 bins.

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www.attendo.com.au & www.attendo.co.nz Atten-doh – what is it - FAQ

Dear Member, As many of you will know the Society has been exploring the use of an App to simplify the process of tracking arrivals and recording CPD at events. The original intent was to assist the “organiser” (Branch Committees) of the meeting and to ensure one seamless process and experience for those attending irrespective of location. As the app was tested it become obvious that users (members) were suggesting additional features they would like for themselves when using the app. We have incorporated some of these in the present version and more work being will be done in development for roll-out in early 2017.

Introducing AttendO – and how it will benefit you AttendO is an app available on the Apple (iPhone only, Ipad coming) and Android store for free download by all ANZSNM members.

You first create a personal profile which enables you to receive notifications of upcoming events (essential that you select ANZSNM as your organisation when setting up your Profile), to indicate your attendance, find maps as to how to get to the event and, to scan-in on the day to any event that is organised using AttendO. The scan records your attendance.

In your profile screen the number of CPD points you have earned is cumulatively recorded each time you scan in.

There is also a CPD logbook feature which is now available for you to write your reflections and learning whilst at the event. The feature also allows you to email your records of attendance to your nominated email address. A direct interface with the central ANZSNM database is being developed but initially we will after 5 days of completion of the event be uploading to your personal CPD record and thereafter manually checking every 5 days.

AttendO also has an instant feedback form that is designed to appear five minutes before the end of the scheduled event for you to provide instant feedback to the meeting organisers.

What about recording non-AttendO events?

The way AttendO presently works is that it relies on QR codes being created and scanned to record your arrival. When there are no QR codes then it is unable to “track” CPD. Another paid version of this app is being developed to allow you to record Journal readings, in-house seminars etc. The current ‘workaround’ is for you to login as an organiser within the app – create an event-receive a QR code and scan that. We see that as too tedious and therefore a better solution is being developed. In the meantime, of course you can still can access and login to the ANZSNM CPD website or try the workaround.

Organiser logins – and how it will benefit you and the branch committees For the majority of members, you will only ever need to login as a guest (see previous section). There is a separate profile that you can create for being an organiser to create AttendO events. As an ANZSNM member and for a limited time you can create your own organiser profiles and organisations (think your hospital section) to create your own events and meetings. This could be of use in your other meetings where you need to keep a record of attendance and strict record compliance with time of attendance.

Branch committees, having decided on the relevant meeting details advise the Secretariat to post these on the ANZSNM website.

These same details will be entered within the app by the Secretariat. All those who have downloaded AttendO and chosen ANZSNM in their profile will receive instant notification when the event is created and all the relevant details.

22 Gamma Gazette November 2016

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Leading up to and on the day itself, there is the “Onsite Register” function which allows the committee representative at the door to generate reports of who has arrived and who is yet to arrive including the ability to ‘mark’ those who may not have downloaded the app.

This means there is no more need for sign in sheets at the door or the work involved in generating these sheets The other advantages that AttendO provides is that it creates files for generating certificates of attendance and can facilitate follow up by the Secretariat to sign up nonmembers who have attended ANZSNM events.

A visual overview of the AttendO Process: 1. Prior to event:

2. At the event

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Š IPEM Scope Magazine, Volume 25, Issue 3, pp 10-15, September 2016. Kindly supplied by Usman Lula, Editor-in-Chief of IPEM Scope magazine with permission from IPEM for reproduction in Gamma Gazette, November 2016, Issue 19, the official publication of the Australian and New Zealand Society of Nuclear Medicine.

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Case Study

Neurogenic Heterotopic Ossification (NHO) in an adolescent male following spinal cord injury Dr Elizabeth Thomas Princess Margaret Hospital, Perth, Western Australia

Clinical history • 15-year-old boy suffered T4 spinal cord injury following a motorbike accident (Figure 1) • Near complete paralysis • Following initial surgical stabilisation of the fracture, he began an inpatient neuro-rehabilitation program.

• 4 weeks post injury he developed increased spasticity at the hips.

• Clinical question – is there evidence of heterotrophic bone formation?

Left: Figure 1. Note Fracture of T4 vertebral body with Above: Figure 2. Normal radiograph of hips. No evidence of heterotopic ossification

Investigations X-ray of pelvis (Figure 2). Hips enlocated. No evidence of heterotopic bone formation.

Bone scan (Figure 3). Heterotopic bone evident on planar and SPECT images lateral to the right greater trochanter and superior to the right femoral neck (arrows). NFO confirmed diagnosis.

Key discussion points NFO common following spinal cord injury, less common in children than adults. Pathophysiology not completely understood.

Presentation: Clinical spectrum varies from asymptomatic incidental finding to severe loss of range of movement, increased spasticity, pain (if sensory spared), and eventually, joint ankylosis.

Affects joints below the level of the spinal cord injury. Most common is hips.

Signs often present from 3 weeks post injury, but usually diagnosed between 1-6months post injury.

Figure3: Bone scan.

30 Gamma Gazette November 2016

Symptoms: Decreased joint movement, periarticular swelling and erythema, increased spasticity, low grade fever Long term sequelae: reduced movement

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Neurogenic Heterotopic Ossification (NHO) in an adolescent male following spinal cord injury

Bone spect. can result in loss of adequate seated position and lead to pressure sores, impair transfers, mobility and other activities of daily living.

Diagnosis: Early diagnosis essential. 3 phase bone scintigraphy is the gold standard. Increased uptake on all 3 phases initially. As the NFO matures, the bone scan returns to normal by 6-18 months.

Bone scan the gold standard for monitoring NFO maturation ? quantitative SPECT. Management: Bisphosphonates such as etidronate and pamidronate. Work by binding with hydroxyapatite thereby blocking the transformation

of amorphous calcium phosphate into hydroxyapatite crystals, without inhibiting the formation of bone matrix. Continued for 6 months. May get “rebound ossification” – bone matrix already formed may undergo mineralisation. Surgical resection of heterotopic bone is sometimes required, but only after the NHO has matured on bone scan.

References 1. Van Kuijk AA, Geurts ACH, van Kuppevelt HJM. Neurogenic heterotopic ossification in spinal cord injury. Spinal Cord.

2002; 40: 313-326 2. Vanden Bossche L, Vanderstraeten G. Heterotopic ossification: a review. J Rehabil Med. 2005;37:129-136

31

Case Study

The use of 99mTc-Sestamibi parathyroid scanning in detecting suspected ectopic parathyroid glands Chrystal Connie Douflias University of South Australia, Adelaide, Australia

Abstract Primary hyperparathyroidism is the third most common endocrine disease.1 The most common symptoms relate to biochemical abnormalities of elevated calcium serum and/or parathyroid hormone (PTH) levels found via blood test.1 Once diagnosed, primary hyperparathyroidism can be treated by partial or complete parathyroidectomy; this is the surgical excision of the overactive parathyroid glands.1 This case report provides an overview of the use of Computed Tomographic (CT) imaging and Nuclear Medicine (NM) parathyroid imaging and its role in the diagnosis of hyperparathyroidism, specifically in this case ectopic parathyroid. A general overview of the protocols undertaken in both imaging modalities will also be detailed.

Key Words: Parathyroid, 99mTc Sestamibi, Hyperparathyroid, Adenoma, Ectopic, CT, SPECT/CT, Nuclear Medicine, Imaging

Introduction A 56-year-old female patient presented to NM for a parathyroid scan. The patient was diagnosed with hyperparathyroidism four years ago from a previous NM parathyroid scan and has since undergone removal of all four parathyroid glands. From such time, the patient displayed persistent hyperparathyroidism with severe hypercalcaemia. The patient was referred for an ultrasound neck exploration which was unsuccessful; she was then referred for a CT scan. The CT scan showed a small nodule adjacent to the upper aspect of the right atrium which was nonspecific. The patient was then referred for a NM parathyroid scan querying ectopic parathyroid gland. To evaluate whether the nodule was an ectopic adenoma, the protocol utilised the single radiopharmaceutical 99mTc Sestamibi (MIBI). This protocol is known to localise and confirm abnormal parathyroid for future management and treatment planning, i.e. surgical removal of the gland(s).

Nuclear Medicine Procedure A single isotope/dual phase protocol was applied in this case which utilised 770MBq of 99mTc MIBI in 1.0ml and 99mTc MIBI was administered intravenously. The patient was asked to remove their necklace as it may have caused an obstruction to the visualisation of anatomy in the area of interest. Five minutes post injection, the patient was positioned on the gamma camera bed, supine, feet first with their head on a low cushion to adequately extend the neck. The patient was given a very small head holder under their head and a small cushion under their knees and an arm strap for comfort. The examination room had been prepared prior to patient arrival and a pinhole collimator was positioned over the neck. Images were then acquired at 5 minutes post injection which included anterior, 30 degree right anterior oblique (RAO) and 30 degree left anterior oblique (LAO) of the thyroid. At 20 minutes an anterior mediastinum image was acquired using the low energy high-resolution (LEHR) collimator.

The anterior mediastinum image included salivary glands at the

32 Gamma Gazette November 2016

top of the field-of-view (FOV) and the myocardium at the bottom; these images where all acquired for 5 minutes each.

The acting NM physician assessed all the acquired images and took into consideration the patient’s history and requested a SPECT/CT over the neck, including the mediastinum to assess the increased radiopharmaceutical focal uptake noted in the 20min anterior mediastinum image at Figure 2.

The patient was able to leave the NM department and return for their 2 hour delayed parathyroid images. When the patient returned, the method used to acquire the images for the anterior, RAO and LAO of the neck was repeated. For all static images, the camera parameters were automatically set to 128 x 128 matrix size with 1.23 zoom. The SPECT image was acquired in a non-circular orbit and in step and shoot mode for 32 views at 15 seconds per view.

Figure 1: Thyroid early and delayed images.

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The use of 99mTc-Sestamibi parathyroid scanning in detecting suspected ectopic parathyroid glands

Low dose CT scan was then acquired immediately after the SPECT without moving the patient and in the same position.

The CT topogram was then acquired first allowing the correct anatomical coverage of the thyroid and mediastinum to asses for ectopic parathyroid glands. CT topogram was acquired at 20 mA and 120 kV. The FOV window was slightly adjusted to allow appropriate coverage of the neck and chest and the CT was then obtained at 50 mA and 120kV. Results Figure 1, which shows early and delayed images, demonstrates the uniform tracer uptake within the thyroid gland in the early phase images, most of which washes out by the 2 hour scan.

However, Figure 2, which is an image of the 20 minute anterior chest, shows a small focus 20 Min ANT CHEST of tracer uptake in the thorax and again Figure 2: Anterior Chest Planar Image in the SPECT/CT shows focal increased MIBI uptake. correlative imaging in Figure 3. Figure 3, which shows the SPECT images (A), CT images (B) and fused SPECT/CT images reveals the focus to be within a

soft tissue lesion in the epicardium which is located adjacent to the right atrium. These avid findings and clinical context suggest an ectopic parathyroid adenoma in the epicardium.

The images obtained by this NM parathyroid scan were assistive in the successful diagnosis of the ectopic parathyroid adenoma in the epicardium. No variations were made to the protocol for this patient.

Ultrasound The ultrasound was the initial point of investigation to assess this patient for any parathyroid adenomas. The scan was made through both sides of the neck, however did not show evidence of any parathyroid adenoma. This was due to the adenoma lying within the mediastinum, which is located outside the imaging parameter of ultrasound. The patient was consequently referred for a CT scan.

CT CT was performed on this patient a few hours prior to presenting for a parathyroid NM scan.

CT is a modality that is inexpensive and readily available. This procedure provided the subsequent investigation for this patient.

The technique used for this study was consistent of three phases from the upper neck to the middle of the mediastinum. CT findings showed a small nodule adjacent to the upper aspect of the right atrium and this measured approximately 11 x 7mm. The small nodule was anatomically located through CT, however the finding was non-specific and a small pericardial/epicardial lymph node was an alternative possibility to an ectopic parathyroid. The patient was then referred for her parathyroid NM scan querying ectopic parathyroid.

Discussion Initial Investigation for hyperparathyroidism usually begins when the patient clinically displays elevated calcium serum levels in the blood. The patient may present with weakness, fatigue and bone pain.3 In primary hyperparathyroidism patients, using MIBI in a NM parathyroid exam has superior sensitivity of 90% due to the energy characteristics and avid localisation in the mitochondria of the parathyroid tissue.3 NM provides functional information and significantly increases success

Figure 3: SPECT images (A), CT images (B), Fused SPECT/CT (C) all images are in transverse, coronal and sagittal planes localising abnormal increased 99m Tc MIBI uptake in epicardium adjacent to the right atrium.

33 u

The use of 99mTc-Sestamibi parathyroid scanning in detecting suspected ectopic parathyroid glands

Figure 4: Transverse arterial phase CT image anatomically locates small nodule adjacent to the upper aspect of the right atrium.

in preoperative adenoma localisation.3 CT provides anatomical information of the nodule and in combination with NM yields greater information for diagnosis and surgical information prior to parathyroidectomy.2

Conclusion The patient showed persistent symptoms of hyperparathyroidism post parathyroidectomy. CT was able to anatomically locate the small nodule however could not determine the specifics of the node. NM was able to provide functional information and was confirmatory for an ectopic parathyroid in the epicardium. CT and NM parathyroid imaging in conjunction were able to provide a successful diagnosis for this patient. The patient is now able to manage their symptoms from this diagnosis by surgical removal of the gland.

34 Gamma Gazette November 2016

References 1 Gasparri, G, Camandona, M, Palestini, N, 2015, Primary, Secondary and Tertiary Hyperparathyroidism Diagnostic and Therapeutic Update, Springer Milan, Milano.

2 Levine, D, Wiseman, S, 2010, ‘Fusion imaging for parathyroid localization in primary hyperparathyroidism’, Expert Review of Anticancer Therapy, Vol.10(3), pp.353-63.

3 Mettler, FA & Guiberteau, MJ 2012, Essentials of Nuclear Medicine Imaging, 6th edn, Saunders Elsevier, Philadelphia.

From page 17

What’s that? ... answer The patient’s pre-operative assessment was for a known thymoma resection.

The mediastinal mass was discovered as a round opacity one month prior on a plain film chest x-ray. The patient had a chest CT with contrast which confirmed the left anterior mediastinal mass with a favoured diagnosis towards a thymic neoplasm. A PET scan was performed for further staging; the lesion demonstrated diffuse increased uptake with an SUVmax of 4.6.

A biopsy performed the day after the PET scan identified the mass as a thymoma.

Solitary anterior mediastinal masses are most frequently due to thymic neoplasms (Erdogan, et al., 2006). Uptake of 99mTc-MIBI in thymoma is well described in the literature (Aydın, et al., 2011).

This study highlights the importance to always check the raw data of your scans. Not only does this promote the opportunity to check scan quality, it opens up the door to incidental findings such as this.

References 1. Aydın, F., Sürer Budak, E., Dertsiz, L., Belgi, A., Arslan, G., & Güngör, F. (2011). Incidental detection of a benign Thymoma on Tc-99m MIBI myocardial perfusion study. Malecular Imaging and Radionuclide Therapy, 20(2), 73–74. doi:10.4274/mirt.019513 2. Erdogan S, Sen S, Senturk E, Afsin H. Unexpected extramyocardial Tc-99m MIBI uptake: detection of non-myastenic thymoma. Turk J Nucl Med. 2006;15:116–119.

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crossword

36 Gamma Gazette November 2016

answers

Australian and New Zealand Society of Nuclear Medicine