ANZSNM Gamma Gazette Autumn 2019 PDF

2019 AUTUMN EDITION | ISSUE 26
CELEBRATING THE 50 ANNIVERSARY

OF THE AUSTRALIAN AND NEW ZEALAND
SOCIETY OF NUCLEAR MEDICINE
ANZSNM 2019
Looking back to the year ANZSNM was founded
EST
CE
A
LE I O
BR AT
2019 AUTUMN EDITION | ISSUE 26
CONTENTS
From the President 3
Featured Article 4
30 years on: The Cold War and Nuclear Medicine
in Australia – a small example
Branch News 8
Special Interest Group News 14
Special 50th Anniversary Liftout 17
Education and Continuing
Professional Development (CPD)
• Case Studies 29
• What’s that? 53
Articles 59
Calendar of Events 66
Office Bearers 70
Editorial Design & Production Events & Advertising Enquiries

Rajeev Chandra, General Manager Ester Gomez, Creative Director marketing@anzsnm.org.au
ANZSNM Secretariat Enovate Studio
PO Box 6178, Vermont South, VIC 3133 ester@enovatestudio.com
1300 330 402 www.enovatestudio.com Submissions
(03) 8677 2970 secretariat@anzsnm.org.au
secretariat@anzsnm.org.au
From the President
The Australian and New Zealand Society of Nuclear Medicine was founded in 1969, and in 2019 we
celebrate 50 years as a professional organisation. This is a time to reflect on the growth in Nuclear
Medicine and the increasingly valuable role of our specialty in patient care and treatment decision-
making. Technological advances have driven change in the world, and this impacts on every aspect
of our daily lives, both at work and at home. Connectivity through the internet gives us access to
information in seconds and also has allowed us to bridge vast distances seamlessly, to the great
benefit of collaboration, knowledge and education. The challenge that is emerging however is how
to use this connectivity responsibly and also how to manage the information overload that it brings.
Given the speed of change of the last 50 years, I wonder what the next 50 years will bring? Roslyn Francis
President
In Gamma Gazettes throughout 2019 we aim to give a snapshot of our history in Nuclear Medicine, and to
acknowledge those who have contributed to our specialty and organisation. If you have photographs or stories
that you would like to share then we welcome these contributions as we mark this time in our history. I hope you
enjoy the Gamma Gazette throughout the year, and thank you to those who have taken the time to compile these
reflective pieces.
The recent Federal Government announcement of a new Medicare rebate for FDG PET in breast cancer from 1st
November 2019 is very welcome news. This follows on from a successful MSAC application by AANMS, originally
submitted in 2013, and finally approved earlier this year following a resubmission. The wording of the rebate will
be released in the next few months. This marks an important step forward in access to PET for patients with breast
cancer, to guide appropriate treatment decisions. Congratulations to AANMS for their efforts and persistence for
this important rebate.
The 49th ANZSNM Annual Scientific Meeting ‘Precision Nuclear Medicine’ is rapidly approaching. I am very much
looking forward to a vibrant scientific program that holds wide interest and will stimulate discussion and future
ideas. The theme of the Conference Awards dinner is 1969, to reflect the founding year of ANZSNM.
I would like to extend my gratitude to the Conveners of Dr Gabby Cehic, Prab Takhar and Dominic Mensforth,
and to their organising committee, for their energy, enthusiasm and hard work, which is enormously appreciated.
Thank you also to the Professional Conference Organisers, Phil Plevin, to our National and International invited
speakers and to our sponsors, for ensuring the success of ANZSNM ASM 2019. A reminder that ANZSNM AGM for
2019 will be held on Sunday 28th April at 1230pm at Hall L of Adelaide Convention Centre and all members are
encouraged to attend.
As I conclude this report and I think of my own journey and experiences in Nuclear Medicine, I reflect particularly
on the people who have inspired me, with their dedication, commitment, vision and generosity. We all have such
busy lives, we rarely allow ourselves the time to reflect and remember. I leave you with this quote from Dr Seuss
(Suess-isms) as you reflect on your own memories and experiences in Nuclear Medicine.
“Sometimes you will never know the value of a moment until it becomes a memory”
I look forward to seeing you in Adelaide.
2019 Autumn Edition | gamma GAZETTE | 3

Featured Article
30 years on: The Cold War and Nuclear Medicine in

Australia – a small example
Author: Dale Bailey PhD, Royal North Shore Hospital
This year marks the 30 year anniversary of the official end to the 20th century’s “Cold War” between the Eastern and Western
hemispheres – predominantly the eastern European Soviet Union and the West’s US & NATO-aligned allies. For those born after
this time, the Cold War was a period from the 1950s until the end of the 1980s where East & West were on a permanent status of
high alert for a pre-emptive attack from one on the other, and the guaranteed retaliation to follow, most likely starting or at least
certainly ending with all-out nuclear warfare referred to as “Mutually Assured Destruction”, or MAD. The military expenditure on the
Mexican stand-off that was the Cold War was enormous and was probably what eventually contributed to the ultimate collapse of
the Communist-led regime in the Soviet bloc, dominated by Russia. Essentially, the US and NATO outspent the Soviets on military
preparedness. Much of the culture of this period is infused with the nihilism of this episode in human history (see Kubrick’s Dr
Strangelove or read Neville Shute’s On the Beach, for example).
What has this global mega-event got to do with Australian Nuclear Medicine?
Not a lot. We did learn some years ago that, in spite of being a signatory to the Nuclear Non-Proliferation Treaty
(NPT), we had a uranium enrichment programme at the AAEC (now ANSTO) based on centrifugation. The main
reason for having such a programme is to be able to produce weaponisable uranium.
But my story is simpler and has a better outcome.
The first overseas meeting that I attended related to nuclear medicine and was a small (120 people) “retreat”
style meeting in Zeist, on the outskirts of Utrecht, The Netherlands called IPMI (Information Processing in
Medical Imaging) in 1987. It was held outside of the city in the woods in a Protestant church conference/retreat
centre. The idea was for the senior researchers in the field to live for a week with the juniors just entering after
completing their studies and have discussions over shared meals as well as lectures and presentations and
other outside activities. The accommodation was fairly simple in keeping with a retreat for a religious order.
The Proceedings, hand-typed on actual typewriters or on new devices called “Word Processors”, which were
actual hardware machines from IBM at the time, can be readily found online today with their hand-drawn
graphs and figures.
I made many lasting friendships at that meeting – in particular, with David Townsend, then from Geneva,
with whom I worked over the next 20 years or so on 3D PET imaging and reconstruction. David went on
to develop the first combined PET/CT scanner. There was also a very quiet woman there who came from
Prague in Czechoslovakia – I’ll simply call her Helena. She was an expert in a mathematical procedure applied
to images known as Principal Component Analysis (PCA), or alternately, Factor Analysis. This process could
take a dynamic sequence, such as a renal scan, and split the pixels into a number of parametric images
representing the fractional components of intravascular vs extravascular or specifically-bound radiotracer
based on decomposing the time-activity curves. Very impressive stuff. But still being in the Cold War period
it was surprising and interesting to meet someone from the “Eastern Bloc” outside the barriers of the Soviet
Union. This was around the time when David Bowie was singing about the Heroes “by the (Berlin) wall”. There
was great fascination in the west with what went on behind the Iron Curtain, as it was known.
Helena and I spoke mostly about the science we were involved in and what our work involved and, at the end
of the meeting, returned to our separate worlds.
4 | gamma GAZETTE | 2019 Autumn Edition

Featured Article
30 years on: The Cold War and Nuclear Medicine in Australia

– a small example (Continued)
At this time, I was a junior member of the Physics group at Royal Prince Alfred Hospital in Sydney with colleagues
such as Roger Fulton, Steve Meikle and Brian Hutton. There was no internet, email nor mobile phones or anything
that could vaguely be described as social media, and the only way to communicate was by written note delivered
by surface mail or by Fax, although this would likely not have been possible to eastern Europe.
After over a year back in Sydney after the Utrecht meeting

I received a phone call at RPA one day from a male with a
thick eastern European accent. He explained that he was a
friend of Helena’s from Czechoslovakia who was in Australia
visiting and asked if we could meet up. We arranged to meet
at the local RPA watering hole in Newtown for lunch one day.
When we met, he told me that he was involved in the textile
industry in Czechoslovakia and had been sent to Australia as
a guest of the Australian Wool Board to learn how to grade the
merino wool we produced. His English was very presentable
and we discussed many issues over lunch, without touching
“We can be heroes...”. David Bowie and wife
on anything of any substance, though.
Angie at the Berlin Wall which separated
East and West Berlin, and was symbolic
Again, for those too young to recall, at this time citizens of of the Iron Curtain which separated the
the Soviet bloc were not able to freely choose where they Eastern Bloc from the West.
would live and were effectively trapped in the Soviet Union,
unable to escape. Many died trying to leave. Parents arranged to have their children smuggled out to the West
knowing that it was highly unlikely that they would ever see them again. One ex-colleague as a teenager left his
parents at the border, where they waved him goodbye, as he fled to the West over a high mountain pass. It was
a very different world.
At the end of the lunch, my visitor leaned over close to me and said “Helena wants to defect to Australia”. He
told me that she had sent him to meet with me to see if I could help arrange for her to come to Australia on the
pretext of a scientific exchange or collaboration, with the intention that she would never return.
I was a little taken aback by this – it was all very clandestine and “spook” like. Could he actually be a spy testing
me out? Was he checking up on her after her one visit to the West in 1987? I nevertheless agreed that I would
look into the possibilities.
I wrote to Helena with a letter that said that we were very interested in her techniques and inviting her to come
to spend a period of time with us at RPA in Sydney. It was all very slow progress corresponding by regular mail
and, as it happened, events overtook us. Revolutions by the people started to happen in eastern Europe – the
polish shipyard city of Gdansk where the Solidarity movement was born, the collapse of the Balkan multistate of
Yugoslavia after the death of the dictator, Tito, or the relaxing of controls on open debate about society known
as “glasnost” in Moscow.

Featured Article
30 years on: The Cold War and Nuclear Medicine in Australia

– a small example (Continued)
In early November 1989 the Berlin wall came down and the Cold War was effectively over. I had just moved to
London on a short-term secondment to work at the world-renowned MRC Cyclotron Unit at Hammersmith
Hospital in West London. I paid a visit to Sydney in the middle of 1990 and found Helena in the department at
RPA. My colleagues at RPA had continued to correspond with her and invited her to join them in Sydney. In the
end, she did not need to escape or defect from the Soviet Union as it splintered apart. Helena moved on to the
USA and continued to work in the field of medical imaging.
My small encounter with the Cold War did not amount to much in the end as history overtook us, but looking
back it was a fascinating time and a reminder of what our world was like only a short time ago.
Members of the physics team at RPA in 1990 (L to R): Roger Fulton, Dale Bailey, Brett Jackson (employed by Medical Applications at the time,
part-based at RPA) Helena and Steve Meikle.

1
WANT TO REDUCE INJECTED DOSE BY UP TO 25%?
It’s now possible with the new 800 Series
Introducing the 800 Series. The new family of five nuclear medicine systems puts into practice
everything we’ve learned over the course of 20 years by bringing the latest in SPECT/CT advancements
to a wider range of clinical environments.
The 800 Series includes a collection of SPECT enhancements like SwiftScan Planar and SwiftScan
SPECT that can increase sensitivity and enable reduction of scan times or injected dose by as much as
25 percent , without a loss in signal-to-noise ratio.1
gehealthcare.com.au
1 Compared to LEHR collimator, with Step & Shoot scan mode (for SPECT) / without Clarity 2D (for Planar).
As demonstrated in phantom testing using a bone scan protocol, Evolution processing (for SPECT), and a model observer. Because model observer results
may not always match those from a human reader, the actual time/dose reduction depends on the clinical task, patient size, anatomical location and clinical
practice. A radiologist should determine the appropriate scan time/dose for the particular clinical task.
Branch News
Western Australia Branch News

In November last year, the WA Branch held its AGM but we are working as a committee too to see how
at Sir Charles Gairdner Hospital with some great we can not only entice people to move but how to
speakers and a lovely casual dinner afterwards. best support technologists who are new to WA once
At the AGM Dr Liz Thomas and Simone Culleton they’re here and how to encourage them to stay.
announced their resignations from the WA Branch
committee. We would like to sincerely thank them The WA Branch has started the New Year with a
both for the time and dedication they have given social event having dinner and watching the sun
to our committee over the years. We had previously set over a working week. We held our first scientific
called for any new committee nominations and meeting for the year at PRC Subiaco on Tuesday
were delighted to have three people keen to join 5th March where we heard the second part of Dr
us. Following a unanimous vote by those present at Andrew Henderson’s presentation from last year’s
the AGM, all three are now our newest committee AGM. There are also a few other presentations and
members. We welcome Rosemary Dallen, Jacqui interesting cases on the agenda for the night too.
Watts and Vivian Xiao on board. We have had a
few other changes within the committee too, with This year WA has a number of meetings planned and
Tiffany Langton now our Chairperson and Emma will also be hosting the 2019 TSIG Symposium which
Brook our new Treasurer. will be held in late Spring. Further information will
follow throughout the year and we are quite excited
During our last few committee meetings, we have to have an opportunity for so many WA technologists
been discussing the difficulty often experienced by to attend this year.
WA workplaces with attracting new technologists to
move West and stay here. There is no degree offered Finally, we would like to take this opportunity to
over here for Nuclear Medicine so most of us are officially thank all our industry partners who continue
from SA, NSW or Victoria. We don’t usually have local to generously support us financially, professionally
graduates wanting to start work but did following and socially. We value our relationships with you
the successful Health Workforce Australia Nuclear and are glad that you like to be a part of the nuclear
Medicine Scholarship Program offered to WA high medicine community over here in WA.
school students a few years ago. This is an issue
that has been taken to the ANZSNM Federal level Georgina Santich - Secretary, WA Branch
South Australia Branch News

This year we welcome our newest Branch Secretary/ The 2018 AGM was once again held at the Belgium
Treasurer Tess Smith on board and farewell Dai Beer Bar café with a delicious spread of shared
Nguyen. Dai did an outstanding job organising mains and dessert followed by an entertaining quiz
society meetings, sponsorship and managing the created and hosted by the Flinders Medical Centre
accounts and she continues to serve the society as NM staff.
a committee member for the 2019 Annual Scientific
Meeting. We are looking forward to seeing everyone at the
49th Annual Scientific Meeting of the Australian
Dom Mensforth will be retiring from his role as and New Zealand Society of Nuclear Medicine in
Federal Representative which he has served in Adelaide.
since 2013. We thank Dom for his dedication in
representing us and welcome Vicky Sigalas as his Elyse Langeluddecke - Chairperson, SA Branch
replacement this year.

Branch News
New Zealand Branch News

On 15 March 2019, during Friday Prayer, a devastating terrorist attack took place at the Al Noor Mosque and the
Linwood Islamic Centre in Christchurch, New Zealand. Fifty men, women and children lost their lives, with many
more injured. There are no words to express the profound sadness we are feeling after this horrific and tragic event.
On behalf of the New Zealand Branch we wish to extend our deepest sympathies to the victims and their families.
Many of us are experiencing immense fear, confusion and sorrow. We wish to offer support to all our members directly
or indirectly affected by this incident.
Amidst this time of grief and mourning, it has been heartwarming to see how New Zealand, as a community, has
banded together. It is imperative that we continue to support one another and celebrate our diversity. We must
actively commit to the inclusion and acceptance of all people, both professionally and personally. We must strive to
show each other kindness, respect, and compassion not just in our words but also in our actions.
As Martin Luther King Jr once said: Darkness cannot drive out darkness; only light can do that. Hate cannot drive out
hate; only love can do that.
They are us. Kia Kaha Christchurch and New Zealand.
This past September, Kirsten Worthington and the

team from Invercargill hosted a successful branch
meeting with approximately 50 delegates from
around NZ and a few from Australia. The meeting was
well supported by both delegates and trades.
The highlight was guest speaker, Mark Marcenko from

Tasmania who spoke on 68Ga - PET PSMA imaging.
Berry Allan also gave a review of his use of 99mTc
labelled PSMA to image prostate cancer.
Unfortunately, there were no NZ entrants for the

Radpharm or Paul Orr Award this past year. However,
there were two fabulous posters entered for the Poster
Competition, with both parties sharing the award.
Congratulations to Trish Mead for her poster titled
“75SeHCAT (bile acid malabsorption) Scans and to
Alana Clark for her poster titled “Pilot Study Assessing
for Diagnostic Benefit of Fusion of 68Ga-PSMA.”
The Saturday evening gala dinner was held at

Transport World - a local Invercargill museum, which
displays the famous Texaco truck (only 2 remain in the
world). The function was held in a display street within
the museum amongst the old cars and paraphernalia.
The costumes were fantastic!

Branch News
New Zealand Branch News (Continued)
Especially Chrissie Roodt, who

took home the Kevin Award for
her Speakeasy costume. Loads
of laughs and dancing was had
by all. Delegates had a rocky
departure when the weather
turned stormy, but all managed
to make the return journey
home safe and sound.
The New Zealand Nuclear

Medicine community has seen
many changes over the past
Guest speaker, Mark Marcenko few months. Many sites around
the country have seen upgrades
to their imaging departments
in the form of new cameras,
we have welcomed new
technologists and we continue
to have students progressing
through the distance education
Nuclear Medicine program
offered through the University
of Auckland.
Excitingly, Lutetium-177 PSMA

peptide receptor radionuclide
therapy is now available to
patients in New Zealand. This
treatment is being offered to
patients in Auckland under the
Kirsten Worthington - Convenor
direction of Dr. Remy Lim and
his team at Mercy Radiology.
Finally, I have been asked to pass on a message from one of our local delegates, Jacqueline Metzler (nee Bague),
former Charge Technologist with Ascot Radiology, as well as TSIG NZ Branch Representative (2014-2016). Jackie
has recently departed NZ to take on a new role as Chief PET/CT Technologist in Victoria, Canada at a newly
established PET department with BC Cancer. Jackie has asked me to pass on her sincere gratitude and thanks
to the many colleagues she has had the opportunity to collaborate with throughout both New Zealand and
Australia. She has great memories of her career, relationships, and experiences in New Zealand, and hopes to
return to Australasia at some stage in the future.

Branch News
New Zealand Branch News (Continued)
Yasmine Rennie & Karen Roeske Mark Marcenko & Karen Roeske Diana Huckett & Trish Mead
Behnam Farvardin, Isla Tree, Dr Josie Parker (back) Kirsten Worthington (front) & Alex Fox
Diana Huckett, Lynda Murray & Jane Hassall Fraser Duncan, Alan Jones & Will Styles Jane Hassall, Darin O’Keeffe & Barb Ovenden
As we begin 2019, there is much to look forward to. The New Zealand Nuclear Medicine community continues
to push full steam ahead to bring the latest technologies and developments to our patients. I feel very
honoured to be a part of such a diverse and passionate community.
On behalf of the NZ Branch, we look forward to catching up with our colleagues at the upcoming 2019 ANZSNM
Annual Scientific Meeting in Adelaide as well as our local Branch Meeting in Rotorua in early September 2019.
Jessica Fagan - Secretary, New Zealand Brach

Branch News
Victoria and Tasmania Branch News
We hope all of our members had a relaxing break

over the Christmas and New Year period. January
has meant one thing for the Vic-Tas branch over
the last few years; a chance to catch up on the
world of Cardiology from our regular speaker, Dr
Kim Williams. This year’s talk, with thanks to our
sponsor GMS, was on the link between cardiac
conditions and plant-based diet and which imaging
modality should be better utilised. It showcased the
potential of Nuclear Medicine to provide not only
physiological information but that the advancement
Dr Kim Williams
of CT in Nuclear Medicine also opens wider doors for
anatomical correlation.
non-invasive approach to cannulation, such as oral

18
F-FDG administration, to yield diagnostic quality
images and provide positive experience for needle
phobic patient. After the judges’ deliberation, Lauren
was chosen to represent our branch at the ANZSNM
in South Australia and we wish her all the best.
In continuing our goal of providing regular and

quality CPD options for our members, the Vic-Tas
branch is looking to host several “Master Classes” this
year, rather than the traditional full day seminar. Our
Dr Kim Williams' presentation
first class will be focussing on the non-medical side
of Nuclear medicine, such as writing and updating
a CV and interview techniques, as well as preparing
We also held the State finals of the Radpharm awards a research article, poster, or case presentation. We
that evening and had three great presentations: Emma will also be looking at incidental findings on Nuclear
Harding (Austin Health) presented on the ‘Impact Medicine Imaging and the utility of the CTAC data.
of the bone scan in a complicated meningococcal We also hope to have either pre or post-conference
patient’, where the bone scan changed the patients speakers from the Annual Scientific meeting in
management by revealing the severity of ischemia South Australia come to Melbourne, but this will
to the distal limbs and confirming necrosis prior to be confirmed once the Scientific Program has been
the right thumb and lateral below knee imitations; finalised.
Nicholas Daw (Peter MacCallum Cancer Imaging)
presented an ‘I-124 Case study’, showing the use of Keep an eye on Attendo Plus for further information
quantitative I-124 imaging and dosimetric analysis on these upcoming events.
to enable personalized I-131 therapy doses to be
prescribed; and Lauren Hudswell (Monash Health) Kim Jasper - Secretary, VIC-TAS Branches
presented ‘No needle to fear - An approach to needle
phobic patients’ which discussed using alternative

In loving memory of
Rudolph Leopold Chmiel
b 24-7-1942 Poland d 30-12-2018 Baptcare, Doncaster.
Rudolph was a most talented doctor, much

respected by his staff and colleagues.
He was a graduate of the Melbourne University and

St. Vincent’s Hospital Medical Schools.
He completed post graduate training in Radiotherapy

at the Peter MacCallum Clinic then pursued Nuclear
Medicine, training at the Royal Melbourne Hospital
with Dr. John Andrews. Whilst there he developed
techniques using Technetium DTPA in the
assessment of brain tumours, brain haemorrhage
and CNS infections on the basis of diffusion across
tissue concentration gradients.
He became Director of Nuclear Medicine at St

Vincent’s Hospital,1973 where he was renowned for
his innovation and medical insights. He continued
his interest in the use of diffusion with Tc-99m DTPA
to assess intra-abdominal abscess. He developed
a technique using IV perchlorate and aliquots of
Iodine to assess organification defects within the
thyroid as observed in Hashimotos Thyroiditis.
He pioneered the use of Tc-99m labelled RBC in “ His intelligence and curiosities spanned
the assessment of leg DVT. He also refined the
technique of assessing the site of GIT bleeding by many fields. He was keenly interested in the
using labelled RBC’s and taking sequences of one
function and design of the gamma camera and the
minute images that better depicted the site of gut
bleeding. With the confidence of the neurosurgeons, evolution of digital imaging. His approach was an
particularly Mr. Keith Henderson, he pursued
interests in CSF dynamics. Firstly, in elevating the inspiration to his staff and registrars and overall
CSF pressure once the intracranial cisterns had been
outlined with a nuclear medicine tracer to detect a genuine breath of fresh air. ”
CSF leakage. Using a similar approach, he studied
rates of CSF absorption in patients suspected of
Normal Pressure Hydrocephalus at graded elevation In his final years he was troubled by disabling
infusion pressures. Parkinson’s Disease and his demise was a blessed
release.
He was fluent in several European languages
having been born into and coming from troubled He will be sadly missed by his friends and colleagues.
times in Europe. Conversations were lively, at times
unpredictable but always good fun. Colin Styles, Mack Jost.
Special Interest
Group News
TSIG Day Symposium, 24th August 2019

The ANZSNM Technologist Special Interest Group would like to invite you to our Annual Day Symposium, to
be held on August 24th at The Esplanade Hotel in Fremantle, WA.
We will have a great lineup of presenters showcasing some of the best that WA Nuclear Medicine has to offer,
as well as exciting innovations and some quality career development.
As well as providing valuable CPD hours, this event provides the perfect excuse for a winter getaway.
Fremantle has everything you could want for any foodie, music lover, beachgoer, and great for families too.
Join us for dinner and drinks at Little Creatures Brewery after the day is over.
Registration and Call for Abstracts for this event is now open!
Register via website anzsnm.org.au/2019TSIG
Send abstracts to secretariat@anzsnm.org.au
EARLY BIRD PRICE STARTING AT ONLY $115 AND $70 (STUDENTS)
Accommodation discounts are available at The Esplanade Hotel for registrants to this event.
Please visit bit.ly/TSIG2019 for more information.
Sponsorship opportunities still available, please contact the secretariat for more information.
Nicholas Daw
Chair of the TSIG CPD and Education Committee
Annual Day Symposium
24 AUGUST 2019
THE ESPLANADE HOTEL
FREMANTLE, WA
REGISTER anzsnm.org.au/2019TSIG
Special Interest
Group News
International Relations Committee of ANZSNM

In 2018, a Lancet Oncology Commission in Medical to establish similar programs in these regions,
Imaging and Nuclear Medicine was established with input from ARTnet. This reflects the impact of
to review the global status of imaging in the the ARTnet program in the international nuclear
management of cancer patients, and to provide medicine community.
guidance and recommendations for infrastructure,
equipment, workforce and clinical guidelines for ANZSNM was represented in a final IAEA Regional
cancer imaging in developed and developing Cooperative Agreement project RAS/6/083
countries. ANZSNM is a formal participant in this "Improving patient care and enhancing
project, which is being co-ordinated by all major government participation in Nuclear Medicine
Nuclear Medicine and Radiology societies, as well programs" meeting in Singapore in December
as IAEA and WHO. Prof Andrew Scott is on the 2018. This program has resulted in enhanced
Executive Committee of this project, and meetings teaching and training of nuclear medicine
at RSNA in December 2018 and ECR in February professionals, and increasing referrals for nuclear
2019 have been held to develop this project. Initial medicine studies, throughout the Asia-Oceania
reports are planned for late 2019, with submission region. ANZSNM participation included hosting a
to IAEA and WHO and publication in Lancet teaching program during the WFNMB conference
Oncology to follow. Updates will be provided to in April 2018, and provision of experts to training
ANZSNM members during the next 12 months. sessions run by IAEA in Thailand.
Following meetings with SNMMI and EANM during Prof Andrew Scott
2018 regarding the success of the ARTnet clinical Chair
trials program, further discussions are underway
We thank the following corporate sponsors for their continuing support in 2019. By sponsoring, they demonstrate their
commitment and instrumental role in the advancement of clinical practice and research in nuclear medicine.
Their sponsorship also helps strengthen the relationship between the members of the society and those from the
sponsoring organisations, which enables their profession with the latest technology and developments in the field of
Nuclear Medicine.
If you are a Company serving nuclear medicine professionals and interested in our Corporate Sponsorship package
please contact secretariat@anzsnm.org.au

Over the past 50 years, The Australian and
New Zealand Society of Nuclear Medicine
has been at the forefront of the
Nuclear Medicine profession.
To every single member and individual who

has been part of this journey,
thank you!
We are committed to continue to be leaders

in our industry and to work together to keep
the society moving to the future.
Special 50th Anniversary
A Nuclear Medicine Society

The Beginnings
During the late 1960s, interest in nuclear medicine and a nationwide society of nuclear medicine had
been growing strongly throughout the larger states of Australia. A Victorian group was established and
a New South Wales group was just commencing.
In November 1968, a meeting of users of radioisotopes in medicine and biology was convened jointly
by Dr Provan Murray (physician, Prince of Wales Hospital), Mr Alan Downes (chemist, CSIRO) and Mr B. W.
Scott (physicist, State Bureau of Physical Services) to discuss the desirability of the formation of a society
embracing personnel involved in the use of radioisotopes. It was resolved, after considerable discussion,
that a society be formed to bring together all those people interested in the use of radioisotopes in
medicine and biology. Forty-eight people agreed to join such a society.
A steering committee, chaired by B. W. Scott, was appointed to investigate the name, objects and
membership. Members of this committee included Drs J. N. Gregory, I. S. Jenkinson, J. G. Morris, C.
Hambly, G. Lowenthal, Mr A. M. Downes and Associate Professor J. M. McRae. This committee produced
a draft resolution, in due course, in which it was proposed that the society be called the Society of
Nuclear Medicine (NSW). Great care was taken to define nuclear medicine in the widest possible terms
and to ensure that the membership qualifications were free from discrimination between university
graduates and non-graduates, or between medical and scientific or technical personnel, and that the
society should remain a purely-scientific society.
The Royal Australian College of Radiologists was keen to promote nuclear medicine and the Royal
Australian College of Physicians was interested in progressing plans to develop a course of training
leading to a joint diploma. However, although in general agreement on this way forward, at a meeting
in Sydney, both bodies decided to refer the matter to the forthcoming meeting in Adelaide so that
the nuclear medicine specialists could take the matter over together. This decision was made through
reservations expressed at that meeting by Dr John Morris and Dr Jim McRae.
The meeting in Sydney was a very valuable one in the development and establishment of the
impending society. It at least made it more obvious that workers in nuclear medicine were interested in
their own affairs and that Adelaide would be a landmark meeting of specialists in the field from all over
Australia.
In April 1969, Dr Harry Lander wrote to Professor W. S. C. Hare, expressing his desire to establish a
college of nuclear medicine. He strongly felt that the interests of those working in the field of nuclear
medicine could not be adequately represented by physicians, radiologists or pathologists, as the
discipline was an entity in its own right. He realised that there would be difficulties in establishing such
a college, but felt that they were surmountable. He sent copies of this correspondence to colleagues:
Dr John Andrews and Dr Les Dugdale in Melbourne and Dr John Morris in Sydney.1

Australian Society of Nuclear First Asia and Oceania

Medicine was established in Congress of Nuclear
May 1969, Adelaide Medicine and Biology held
in Sept 1976, Sydney.
1969 1976
1970
The society changed its name
to Australian and New Zealand
Society of Nuclear Medicine
(ANZSNM) as it is currently know at
the 1st Annual Scientific meeting
in 1970, Sydney. Membership
started in New Zealand.

Australian
Radiopharmaceutical Trial
Network (ARTNET) launched
in April 2014.
2014
1994 2018
12th Congress of the World
6th Congress of the World Federation of Nuclear
Federation of Nuclear Medicine and Biology is held
Medicine and Biology in in Melbourne
1994, Sydney.
Brian Hutton, Brenda Walker and Richard Smart

promoting the Sixth World Congress
ARTNET Research

A Nuclear Medicine Society (Continued)

Professor Hare’s response expressed his views on the subject of a
national body of nuclear medicine:
Such a society will prove an excellent forum for all those, both medical
and non-medical, who are interested in the speciality. Secondly, as you
have pointed out, there is a need for a course of training for medical
graduates leading to a certificate. In addition I think there is a third
need, which you imply, but which has not been discussed in detail yet,
and that is for some sort of association of medical nuclear medicine Ref 1
specialists, through which they can promote their professional status
etc. and which can act as a second forum for scientific discussion.
We have thought about the possibility of a college of nuclear medicine

being set up from the outset. However, the number of medical
graduates involved at this stage, and for a good number of years to Ref 3
come, is so small that it would be out of context with other established
colleges. The College of Radiologists would be disappointed if such
a move was made at this stage, as there is a strong feeling, along
American lines, that the radiological sciences should stick together.
To this end, I am sure every effort would be made to promote and
accommodate the speciality within the structure of the college. As
time goes by, if my predictions are correct, we would look to nuclear
medicine as playing a major part in college affairs. In a relatively short
time, the number of nuclear medicine specialists should exceed the
number of radiotherapists.2
Hare concludes his letter by emphasising the success of the impending

Adelaide meeting, but adding:
However, as Professor of Radiology, I hope the decisions which are

made are such that those working in the radiological sciences will
group together and not develop in isolation one from another. 2
There was very strong support from all recipients of Landers letter, but
all had reservations with regard to the establishment of a college of
nuclear medicine. Dugdale replied:
I am in sympathy with the idea of formation of a college of nuclear

medicine, but I am rather afraid that the practical difficulties involved
may render it impossible at this stage.3
Dugdale elaborated on what he felt would be some of the difficulties

associated with the proposal. He considered that foundation members
Ref 6


should be medically-qualified and involved in large-scale clinical
applications of radioisotopes. He felt that with this vocation limitation,
there would be probably only 15 to 20 people in Australasia suitable for
full membership. He also felt that it would be difficult for non-medically-
qualified persons within such a college and that they, regardless of
qualification or seniority, would never obtain full membership. This, he
believed, would lead to bitterness within the departments of nuclear
medicine. To satisfy all workers he said:
I would think it desirable that an Australasian society of nuclear medicine

Ref 2 be inaugurated, rather along the lines of the Society of Nuclear Medicine
in the USA.3
Dugdale concluded in saying that he was looking forward

with great interest to the meeting in Adelaide. However,
John Andrews was a little more diplomatic in his reply:
As you know, there has been discussions going on for

at least about two years regarding the future of nuclear
medicine and its associations, and I have been in a
somewhat unique position, being in both the Royal
College of Physicians and the College of Radiologists. It
is, however, the latter college that has asked me to help
in the preparation of part 1 of a diploma. I felt, from the
Ref 4 outset, it would be better if we were not irrevocably tied to
any one college and, for this reason, it was my suggestion
that the diploma should be a conjoint effort, involving
both colleges; and this eventually became accepted by
them.4
Previously, Andrews had thought of the possibility of an

independent body of nuclear medicine, but rejected it
because there were so few people actively working and
interested in the field. Now, he felt that things may have
changed. He concluded with what we would regard today
as a very sound prediction:
I would be interested to hear other people’s opinions

Ref 5
when we meet in Adelaide, which for nuclear medicine
will be a very important meeting, I feel.4
Ref 7

Foundation Meeting
The Society was inaugurated in Adelaide, in New South Wales – 24 Members & 6 Associates,
May 1969, when the majority of specialists in
nuclear medicine in Australia were gathered for Western Australia – 13 Members & 3 Associates,
the ‘Seminar in Nuclear Medicine’, conducted by
the South Australian Branch of the (now Royal) Victoria – 10 Members & 1 Associate,
College of Pathologists of Australia. At this historic
meeting, at the Royal Adelaide Hospital on 21 May Tasmania – 7 Members & 1 Associate,
1969, the following office Bearers were elected:
South Australia – 6 Members, and
President: Dr H. Lander
Queensland – 4 Members.
Secretary: Mr P. Simmons
In addition to the above, three medical or science
Treasurer: Dr P. M. Ronai graduates from New Zealand also joined the
Society within its first six months. Foreseeing
Committee: Mr B. W. Scott (NSW) likely membership from New Zealand, the
possibility of calling the Society ‘The Australian
Dr I. P. C. Murray (NSW) and New Zealand (or Australasian) Society
of Nuclear Medicine’ had been raised at the
Dr L. Dugdale (Vic) inaugural meeting in Adelaide. But, unfortunately,
as no New Zealanders were present at the
Dr J. Andrews (Vic) foundation meeting, it was considered perhaps
presumptuous to include any reference to New
Dr M. Quinlan (WA) Zealand in the title of the Society at that time.
Dr R. Stanford (WA) However, in view of the interest being shown

in the Society by New Zealanders in the field of
Dr R. J. Connolly (Tas) nuclear medicine, the name of the Society was
to be reconsidered at the first Annual General
Dr R. Baker (SA) Meeting to be held in Sydney on 11 February
1970. By that meeting, the membership had
Dr I. Buttfield (Qld) grown to over one hundred. This rapid growth was
attributed to the encouragement of membership
Mr R. Boyd (ACT) from as wide a group and variety of interests
as possible. The only requirement being, that
The meeting lasted two days; and with its initial a member or potential member should have
23 members, ‘The Australian Society of Nuclear an interest in nuclear medicine in one or other
Medicine’ was born. of its many facets, which included graduates
in medicine, physics, chemistry and pharmacy.
By November that year, the ASNM membership, Membership was also open to technologists
including both full Members and Associate (non- and representation from commercial interests,
graduate) Members, totalled seventy-nine. State particularly in the fields of nuclear instrumentation
representation included: and radiopharmaceuticals. Even at this early stage
of development, many companies had taken out

sustaining membership in the society. But, more Airlines of Australia, would have cost: first-class
importantly, their representatives had joined as - $56.80, economy - $47.00 and group-travel -
individuals, many of whom took an extremely $42.00.
active role in affairs of the society.
The Society saw an unprecedented growth. The
The following year, in his presidential address at constitution was ratified at that first and very
the Annual Scientific Meeting, in Melbourne in successful Annual Scientific Meeting in Sydney.
1971, Dr Harry Lander was to say: Following representation from New Zealand, the
name was changed to the Australian and New
Not only have many companies taken out Zealand Society of Nuclear Medicine (ANZSNM)
sustaining membership in our society but more and by the second Annual Scientific Meeting,
important, their representatives have joined held in Melbourne, the membership numbered
our ranks as individuals and in many instances almost two-hundred. One of the major reasons
have been extremely active in the affairs of the for this rapid growth was the selflessness of the
society. This has undoubtedly been to our mutual Victorian Radioisotope Study Group, which had
benefit and certainly, in at least one respect, we been formed several years earlier. This group, with
must be rather unique and perhaps hold some its already strong and active membership and
sort of record. For I know of no other scientific regular, well-attended meetings, after negotiation
society – at least in this dextrorotatory part of with ANZSNM and of its own initiative, became
the world – in which successive secretaries have the Victorian Branch of the ANZSNM. This meeting
been drawn from the allegedly-tainted ranks of minds and achievement of unity should be
of the world of commerce. I assure you that the credited to Messrs R. J. de Groot, E. H. Clarke, R. J.
society has gained much from this particularly L. Alsop and Drs B. Rush, J. T. Andrews and L. M.
close association and I would like to take this Dugdale.
opportunity to thank our present Secretary, Mr
R. J. L. Alsop of Consolidated Nucleonics Pty Ltd The following letter was received from Mr R.
for the very valuable work he has performed on de Groot, Honorary Secretary/Treasurer of the
behalf of the society over the last twelve months. Radioisotope Study Group of Victoria.
The first Scientific Meeting of the Australian A special general meeting of the Radioisotopes
Society of Nuclear Medicine was held in Study Group was held on 15 April 1970 at the
conjunction with the Endocrine Society of Cancer Institute, Melbourne. The Chairman, Dr B.
Australia (joint sessions), over 11–13 February Rush, presided and approximately 20 members
1970, at the Prince of Wales Hospital, Randwick, attended. Dr Rush outlined, briefly, the history
NSW. The theme, over the three days, was focused of the group which came into being in 1966,
on radioimmunoassy, thyroid disorders and invivo following the successful completion of an eight
and invitro studies. Speakers included Professor week course on ‘Radioactive Isotopes in Diagnosis
Basil Hetzel, Drs Creswell Eastman, Proven Murray, and Investigation’. Since then, a fairly vigorous
Les Dugdale, Harry Lander, John Morris, David programme of scientific meetings involving
Cook, Fred Lomas and Ian Hales, and Mr Laurie W. lectures, demonstrations and instructional
Steven and B. W. Scott. Full registration was $5.00 evenings has been followed. Dr Rush paid tribute
and for Associates it was $2.00. Return air-travel to Mr K. H. Clarke in the organization and running
to this meeting, from Melbourne through Ansett of this course and in the early work of the group.

With a financial membership of 56 in 1969 and with

regard to our previous years’ scientific programmes,
the group may be regarded as a successful
enterprise.
The first two years
Dr Rush then referred to the Australian and New
Zealand Society of Nuclear Medicine. This society
was formed last year to cater for the interests of all of the Society
people involved in the practice of nuclear medicine
throughout Australia and New Zealand. A scientific
meeting was held in Adelaide last year and another were pivotal in
in Sydney in February this year.
In view of the formation of this society to cover the awakening of

interests similar to our own, but on a much wider
regional scale, the committee of the Radioisotope
Study Group has considered the future of the group interest in nuclear
and has held discussions with executive members
of the society to explore the possibility of our group
becoming the Victorian branch of the society. medicine and its
It would appear that there is no good reason for
the group to continue to exist as a separate entity new techniques
and that we should all join the society instead.
However, as the society can hold only periodic or
Annual Scientific Meetings on a wide regional scale, in Australia and
our local needs can be covered if we form a state
branch and preserve our scientific programme and
machinery for running it. This costs a small amount New Zealand, not
of money – mainly for postage etc. – and, as we do
not want to pay two subscriptions, an agreement
has been reached with the executive of the society only for routine
to rebate a portion of each member’s subscription
to the state branch for running expenses, so that we
can continue to function as before. diagnosis and
After brief discussion, it was resolved unanimously
that the Radioisotope Group be disbanded and that management but
all interested parties should apply for membership in
the Australian and New Zealand Society of Nuclear
Medicine and that the members of the society also for research.
resident in Victoria form the Victorian branch of the
society. Lander

Members of that committee forming the Victorian Branch were: Chairman, Dr B. Rush; Honorary Secretary/
Treasurer, Mr R. de Groot; Mr R. Alsop; Miss J. Milne and Drs J. Andrews, J. Coghlan, L. Dugdale, E. Gilford and
M. Pain.
Lander went on to say:
Public interest has been aroused and become manifest by the considerable space and time which has been
devoted to nuclear medicine and its various techniques by all forms of the mass media, both nationally and
regionally, in the last year or two. There must be few branches of medicine, for example, which have gained
as much attention as nuclear medicine did recently in the pages of that august publication: ‘The Australian
Financial Review’. This publicity has been educational, not only to hospital administrators and to the holders
of governmental purse strings, but has also been reflected in the generosity of certain public and private
sectors of the community.
An example of this was evident in Adelaide, where a complete gamma camera was generously made
available by Searle Nucleonics, solely for clinical research purposes. Outstanding contributions were
provided by charitable foundations, community organisations and several altruistic individuals in support
of the development and establishment of new departments of nuclear medicine in every state of Australia
and both islands of New Zealand. Of note, in 1969, there were only two gamma cameras in Australia; two
years later fifteen were in routine use with three in one laboratory and four departments having Dual
5” rectilinear scanners. Prior to this, the majority of expanding departments had a single head 3” or 5”
rectilinear scanner for diagnostic imaging.
Lander also showed concern for inadequately trained physicians and the need for adequate standards of
service in this expanding and new arena of medicine:
It is possible that this expansion has occurred, and is occurring, too quickly. I’m sure that it will be obvious
to all of you that too great a demand could lead all too easily to a rather large ‘credibility gap’ in the
science. If poorly-trained physicians are placed in charge of departments in which the work is carried out by
inadequately-trained technicians, only chaos can result and there will be a ‘backlash’ against the techniques
we have to offer.
Historically, in the first two decades of the use of radioisotopes in Australia, the majority of laboratories in
Australia and New Zealand were run either by trained therapy radiographers, physicists or technologists
under somewhat minimal or even no supervision by medical officers. This had occurred as the radioisotope
laboratories were regarded merely the ‘Cinderella’ offshoots of existing departments of radiology,
radiotherapy, endocrinology or even pathology. Where then did this field of medicine belong and to whom
should the discipline be entrusted?
Although there was interest from the above mentioned departments, it soon became obvious that nuclear
medicine facilities must be autonomous and self contained.


Lander concluded on this note:
Otherwise, they are forever likely to be understaffed or administered by persons who have little interest in, or
cognisance of their full clinical potential. If a good service is provided, nuclear medicine ‘sells’ itself and there
is generally little difficulty in obtaining adequate equipment and staff, for such is demanded by clinicians as
a diagnostic service. If, however, inaccurate diagnoses are made, or misleading or erroneous results given at
frequent intervals, then a service will inevitably fall into disrepute or, at best, not be used to its full advantage.
There was concern within the society that the greatest danger lay in persons without medical training,
irrespective of their qualifications, pontificating upon medical matters about which they were inadequately
informed; and clinicians ignorant of the art and science of nuclear medicine accepting these views without
qualification. This very situation was largely responsible for the rather sorry plight of nuclear medicine in the
United Kingdom and several European countries in the 1960s.
The society’s view was expressed by Harry Lander:
… ultimate responsibility for, and control of the application of these techniques to clinical problems, must reside
with the physician adequately trained in nuclear medicine techniques. The physician, physicist, chemist and
technologist must all work together in harmony, each appreciating the value and limitations of him/herself as
well as the other, if the best interests of the patient and the discipline are to be served.
It behoves us all – and I believe it is an important function of the society to ensure that adequate standards and
safeguards with respect to both equipment and personnel are not only established but maintained in all units.
Every endeavour must be made to upgrade those units which do not provide a satisfactory service; and there are
still several in this country.
Text references
1. Lander, H., pers. corresp. to Hare, W. S. C., 22 April 1969.
2. Hare, W. S. C., pers. corresp. to Lander, H., April 1969.
3. Dugdale, L. M., pers. corresp. to Lander, H., 29 April 1969.
4. Andrews, J. T., pers. corresp. to Lander, H., 1 May 1969.
Image references
1. Professor Provan Murray with jockey Shane Dye at the launch of
National Nuclear Medicine Day
2 & 7. The first Large Field of View (LFOV) gamma cameras were single
detector analog systems
3. The first mobile gamma camera, an Ohio Nuclear Mobile was
All content has been extracted from the book purchased at Royal Prince Alfred Hospital, Sydney
'Isotopes, Imaging and Identity. The history of the 4. Miss Sue Welch and Dr Basil Beirman at Geiger Cottage, Launceston
General Hospital (mid 1950s)
Australian and New Zealand Society of Nuclear 5. A Thyroid probe installed at the Peter MacCallum Cancer Centre
6. First PET scanner installed in NSW at the Royal Prince Alfred Hospital
Medicine.' (RPAH) Sydney in 1992. IN those days, an FDG brain scan being
performed by Stefan Eberl would take about 20 to 25 minutes to
acquire. On a modern PET/CT scanner, it can be done in 5 minutes.
Download a digital copy of this book here
www.anzsnm.org.au/resources/publications

PHD STUDENT
VACANCIES
Professor Karen Jones is a clinical researcher with a background in nuclear medicine. She leads a clinical research group, within
the Centre of Research Excellence in Translating Nutritional Science to Good Health. Her research programme capitalises on her
background in imaging and focuses on the role of the stomach in blood glucose and blood pressure responses to meals in health
and diabetes.
In 2016, Radiology SA generously donated a gamma camera to her group which is now established adjacent a purpose-built
radiation hot lab, within the new Clinical Research Facility in the Adelaide Health and Medical Sciences Building of the University
of Adelaide – the only gamma camera that is 100% dedicated to clinical research in South Australia. Her group was also recently
awarded research funds (Ian Potter Foundation; University of Adelaide; The Hospital Research Foundation) to purchase a second
‘research-dedicated’, but portable, gamma camera, to be located within the Royal Adelaide Hospital which will allow ‘high-risk’
research e.g. studies in the critically ill.
Future clinical research studies, utilsing imaging techniques, will evaluate potential effective management strategies based on recent
insights into the mechanisms underlying glycaemia and blood pressure regulation after meals. Professor Jones seeks 1 – 2 PhD
students to join her team (scholarships available). If you are interested please contact her:
Professor Karen Jones (DipAppSc, PhD)

William T Southcott Research Fellow in Nuclear Medicine
Adelaide Medical School
Faculty of Health and Medical Sciences
The University of Adelaide
E: Karen.jones@adelaide.edu.au
P: 08 8313 7821
Professor Karen Jones (left) with some of the members of the Centre of Research
Excellence in Translating Nutritional Science to Good Health in the Gamma
Camera Suite of the Clinical Research Facility in the Adelaide Health and Medi-
cal Sciences Building of the University of Adelaide.
health.adelaide.edu.au
Founding Sponsor
EduTrace
The Society's
eLearning Portal
Exclusive to ANZSNM members, EduTrace provides access to a

wide range of courses on-demand to add to your CPD continuing
education.
The content includes proprietary programs and others shared by

international imaging and therapy organisations with which the
ANZSNM has developed excellent relationships over the past
50 years.
Visit anzsnm.org.au/edutrace to get started.

NOT A MEMBER? JOIN TODAY
anzsnm.org.au/membership
Education & CPD
Case Study
PSMA PET/CT vs Multi Parametric MRI in Staging of

Prostate Cancer
Author: Rachel Watherston - Benson Radiology, South Australia
INTRODUCTION
Prostate cancer is one of the most common cancer diagnosed in Australian men with one in seven diagnosed
with prostate cancer by the age of 85. Detection of prostate cancer was originally achieved with a combination
of blood tests (Prostate Specific Antigen-PSA), digital rectal examination and trans rectal biopsy. Now, with the
addition of PSMA PET/CT and multi-parametric (MP) MRI there are more diagnostic tools to further aid in the
detection of both new and recurrent disease.
I will examine four case studies of patients who underwent both 68Gallium-PSMA PET/CT and MP MR imaging
in which lesions were not seen concurrently with both modalities.
All case studies were performed on a Siemens MRI scanner following standard protocol for prostate MP MRI
including high resolution T2, post contrast, ADC/DWI (apparent diffusion coefficient/diffusion weighted
imaging) images and upper abdominal T2 axial screen. All patients underwent specific preparation including
treatment with Buscopan to inhibit motion artefact caused by nearby structures. The 68Ga-PSMA PET/CT scans
were all performed on the GE Discovery IQ 5 ring PET/CT system with a total scan time of 13 – 15minutes;
covering vertex to mid thigh. Reconstruction was performed using Q Clear reconstruction (Bayesian penalised
likelihood reconstruction algorithm).
CASE STUDY ONE
Patient A, a 67-year-old male presented for a prostate MRI for initial staging with a PSA level of 13.1ng/mL.
Whilst the MRI demonstrated benign prostatic hyperplasia (BPH) there was no evidence of intermediate-high
grade malignancy and it was scored 2 on the PI-RADS 2.0 scale. Five weeks later, patient A presented for a PSMA
PET/CT scan with his PSA level now increased to 15ng/mL. He was injected with 116MBq 68Ga-PSMA with a
60 minute uptake time. The PET/CT demonstrated uptake in the base of the prostate gland, involving the right
and left peripheral region (Image 1). Despite retrospective review of the previous MRI, the disease was still only
evident on the PSMA imaging.
Image 1 - Patient A

Education & CPD
Case Study
PSMA PET/CT vs Multi Parametric MRI in Staging of Prostate Cancer

(Continued)
CASE STUDY TWO
Patient B was a 60-year-old male who initially had

a prostate MRI (on a 1.5T scanner) which showed a
single lesion left mid-gland, giving PIRADS score of
4. Subsequent biopsy of this area came back with
a negative result. Six months later he was referred
for a PSMA PET/CT Scan with a PSA level of 17ng/
mL. He was injected with 137MBq 68Ga-PSMA with Image 2 - Patient B Prostate Base
a 51 minute uptake time. The PSMA scan detected
multifocal uptake within the prostate gland (Image
2 and 3) and equivocal uptake within an inguinal
lymph node. One week later he attended for a follow
up MP- MRI (on a 3T scanner) noting the multifocal
disease demonstrated on the PET/CT Scan. Again,
the MRI demonstrated an unchanged 7mm mid
gland lesion in the Transitional Zone – Peripheral
Zone (TZ-PZ) Interface (Image 4), but the bilateral
basal and right apical gland abnormality show on
PET was not evident.
CASE STUDY THREE Image 3 - Patient B Apex
Patient C, a 77-year-old male, initially presented

for a staging prostate MRI which demonstrated a
left side PZ lesion in the mid gland, with a PIRADS
Score of 4-5, with a suspicious lymph node posterior
to the left external iliac vein. The patient also went
on to have a Nuclear Medicine Bone Scan (images
unavailable) which demonstrated suspicious
uptake in T11. Six months after the initial MRI, the
patient presented for a 68Ga-PSMA PET/CT Scan
with injection of 127MBq 68Gallium-PSMA and a
56minute uptake period. The PSMA PET/CT showed
only mild PSMA avidity in the left mid gland lesion,
corresponding with disease detected on MRI (Image
5). The T11 lesion and suspicious lymph node did
not demonstrate any significant 68Ga-PSMA uptake
(Image 6).
Image 4 - Patient B MRI

Education & CPD
Case Study

(Continued)
Image 5 - Patient C Prostate Image 6 - Patient C non-avid node
CASE STUDY FOUR
Patient D, a 70-year-old male, presented for an

initial staging MP-MRI with an increasing PSA
and strong family history of prostate cancer. The
MRI detected two PZ lesions, one in central mid
gland (Image 7) and one in posteromedial left mid
gland, the latter of which showed extra-prostatic
extension and possible seminal vesicle involvement
and equivocal bilateral pelvic wall lymph nodes.
Following the MRI, the patient was sent for a PSMA

PET/CT Scan to evaluate the equivocal seminal
vesicle and lymph nodes. The PSMA PET/CT
demonstrated uptake within the left posteromedial
mid gland lesion however there was no uptake noted
within the central mid gland lesion, nor in any lymph
nodes. This could possibly be attributed to the size Image 7 - MRI
of the lesion (6mm) being below the resolution of
the PET/CT scanner.
DISCUSSION
Prostate Imaging and Reporting Data System (PIRADS) is the scoring method used in reporting prostate
specific MRI. PIRADS score each lesion from 1 (clinically significant cancer is highly unlikely to be present) to 5
(clinically significant cancer is highly likely to be present). PIRADS examines the different image sequence (T2,
DWI, Dynamic Contrast Enhancement) appearances which differs depending on where the lesion is located.
PIRADS v2 was published in 2012 and since then has been validated in numerous research scenarios, and in
2015 was published by European Urology and American College of Radiology.

Education & CPD
Case Study

(Continued)
Whilst there has been significant improvement in the in spatial resolution. With rapid advances in PET
PIRADS Scoring System from v1 to v2, the system, imaging technology, these factors are becoming
like all imaging, is not flawless and there will be a less of an issue; for example, the sensitivity of the
proportion of cases that are false negative. There is PET/CT scanner in all 4 of these cases has a recorded
varied figures amongst the literature in regards to sensitivity of 23.7cps/kBq and axial resolution of
negative predictive value for Prostate MP MRI. An 4.5mm – 5.11mm (at 1 -20cm radius). Combined
article in European Urology [1] gives a median NPV with the fact that some of the lesions in Case 3 and
of 82.4%, whereas Grey et. al. in BJU International [2] 4 were PSMA avid, this raises the possibility of false
puts the NPV as high as 97.7% (with PIRADS Score of positives on MP MRI, hence not being identified on
1-2 being classed as negative). However, the evidence PSMA PET/CT. Unfortunately, there was no follow up
supporting the use of MP MRI in the initial staging of on histopathology results from these cases to confirm
prostate cancer is overwhelming; supported further either imaging results.
by the inclusion of Prostate MRI in the Medicare
Benefits Schedule in July 2018 for both diagnosis and These cases confirm the value of both modalities in
surveillance. the diagnosis and staging of prostate cancer. Neither
PET or MRI could be defined as more superior, rather
The sensitivity of PSMA PET/CT scanning varies both procedures should be viewed as an essential
throughout the literature, with most suggesting tool in the staging process. It also demonstrates
around 80-90%. The specificity of PSMA PET/CT is also the importance of communication across a multi-
high (up to 100%), particularly with extra-prostatic modality team, with the ability to retrospectively
involvement. However, PET/CT does face its own review scans in conjunction with new results to
limitations, in particular with sensitivity of the scanner examine false negatives/positives and ensure
with low grade/equivocal uptake and limitations clinically important diagnoses are not being missed.
References
1. Moldovan, Paul C. et al. 2017, ‘What Is the Negative Predictive Value of Multiparametric Magnetic Resonance Imaging in Excluding Prostate Cancer at Biopsy?
A Systematic Review and Meta-analysis from the European Association of Urology Prostate Cancer Guidelines Panel’, European Urology, Volume 72 , Issue 2 ,
250 – 266
2. Grey, A. D., Chana, M. S., Popert, R. , Wolfe, K. , Liyanage, S. H. and Acher, P. L. 2014, ‘Diagnostic accuracy of PI‐RADS scoring’, BJU International, Volume 115, pp.
728-735
3. American College of Radiology 2015, PIRADS Prostate Imaging – Reporting and Data System, viewed 2nd March 2019, < https://www.acr.org/-/media/ACR/
Files/RADS/Pi-RADS/PIRADS-V2.pdf>
4. Richenberg, J.L 2016, ‘PIRADS: Past Present and Future’, Clinical Radiology, Volume 71, pp 23 – 24
5. Applied Radiology 2019, ‘68Ga PSMA PET CT improves initial staging of high risk prostate cancer patients, viewed 1 March 2019, <https://appliedradiology.
com/articles/68ga-psma-pet-ct-improves-initial-staging-of-high-risk-prostate-cancer-patients>

Education & CPD
Case Study
Impact of the bone scan in a complicated Meningococcal

patient
Authors: Emma Harding, Jessica Welch, Christian Testa, Kunthi Pathmaraj, Sze Ting Lee, Andrew Scott - Austin Health, Heidelberg, Australia
BACKGROUND
Neisseria meningitides is a Gram-negative bacterium1 that is naturally present in the nasopharynx in 5 – 15% of
the general population without progressing to meningococcal disease3. There are 13 serogroups, however only
organisms from A, B, C, X, Y, or W-135 are responsible for causing invasive meningococcal disease (IMD). Strains
B, C, Y and W-135 are the most common strains in Australia for which there are vaccines available.
There are two forms of meningococcal disease: meningitis and meningococcemia. Meningitis is found primarily
in the meninges while meningococcemia bacteria affect the systemic circulation1. Acute meningococcemia has
a severe and sudden onset1. Symptoms typically begin with fever and headache, and progress to a purpuric
rash, hemodynamic instability, shock, coma and often death1. The long term consequences of meningococcal
disease include cognitive deficit, visual impairment, hearing loss, motor deficit, seizures, hydrocephalus, and
loss of limbs due to tissue necrosis4. Worldwide, approximately 1.2 million cases of meningococcal disease are
diagnosed annually, with around 135,000 fatalities. In Australia, 383 cases of invasive meningococcal disease
were reported in 20174.
CASE HISTORY
A 34 year old male collapsed at home and was

transferred via ambulance to Austin Health. The
patient had experienced mottled appearance on his
skin and mild viral symptoms for three weeks prior,
but suddenly deteriorated.
The provisional diagnosis was severe septic shock

of unclear focus. Initial investigations performed Photograph 1: Patient’s extremities appeared black,
included a CT of the brain, chest, abdomen and pelvis, leathery and ulcerated.
and blood tests. These investigations failed to detect
an intracranial abnormality or a septic focus within the A bone scan was initially requested to assess perfusion
chest, abdomen or pelvis. The patient was admitted to to the right thumb and to query the presence of
ICU. He remained in ICU for 19 days where coma was osteomyelitis.
induced for the first 7 days, and the patient required
resuscitation twice. METHOD
Meningococcaemia was diagnosed as serogroup A three phase Bone Scan was performed using 99mTc-
MenW via blood cultures on the second day of MDP. A dynamic flow study of the hands was acquired
admission. following the intravenous administration of 686MBq
of 99mTc-MDP. Additional blood pool acquisitions
The patient’s right thumb, right distal 2nd, 4th and 5th of the hands and whole body were acquired.
digits and both feet appeared black and leathery. His Delayed imaging was performed three hours post
arms and legs were immobile due to pain and loss of administration and included a whole body scan,
sensation. delayed static of the hands and SPECT/CT of the feet.

Education & CPD
Case Study
Impact of the bone scan in a complicated Meningococcal patient (Continued)
A low dose CT was performed and co–registered with the SPECT for the purpose of anatomical localisation.
Acquisition Parameters Matrix

Flow 3 sec/frame 64 x 64
Blood pool - Hands 120 seconds 128 x 128
Whole Body Blood Pool 25 cm/min 256 x 1024
Whole Body Bone Scan 12 cm/min 256 x 1024

Static – Hands 240 seconds 256 x 256
SPECT/CT – Feet 20 sec/frame x 60 frames 128 x 128
Table 1: Acquisition parameters
Image 1: Whole body blood pool Image 2: Delayed whole body bone scan
RESULTS
The bone scan demonstrated absent perfusion or tracer uptake in the right 1st metacarpal and entire right
thumb, entire left foot, 1st and 5th proximal to distal phalanges of the right foot on the early and delayed
imaging. Additionally, apparent mild reduction in tracer uptake was evident in the left femoral head, which was
nonspecific and potentially artefactual.
The whole body bone scan identified little to no perfusion or bone uptake to the right thumb and, unexpectedly,
to the bilateral distal lower limbs, consistent with peripheral ischemic injury resulting in bone and soft tissue
necrosis.

Education & CPD
Case Study
DISCUSSION
The patient was treated with Ceftriaxone and Tazosin,

specific antibiotics for severe bacterial infection.
Compartmental syndrome was diagnosed resulting in
bilateral forearm fasciotomies to relieve the pressure
and tension caused by the loss of circulation. Intensive
physiotherapy was performed in an attempt to restore
circulation to the lower limbs.
A second bone scan was requested 11 weeks following

the initial bone scan, to assess viability of both feet,
prior to a planned bilateral Below Knee Amputation
(BKA).
This Bone Scan included dynamic flow of the feet

following an injection of 669MBq of 99mTc-MDP,
blood pool acquisitions of the feet and whole body,
delayed imaging at three hours post administration
of radiopharmaceutical, included a whole body scan,
delay static of the hands and SPECT/CT of the feet.
Image 3: Blood Pool (left) and delay (right)

static of handsbone scan
Image 5: Whole body bone scan November 2018

Image 4: Whole body bone scan September 2018
The bone scan findings were consistent with amputation at the carpometacarpal joint of the right thumb and
diffuse mildly increased blood pool and osteoblastic activity present throughout the right wrist and small
joints of the right hand. Blood flow, blood pool and osteoblastic activity in the distal right foot and mid to distal
left foot was absent and unchanged since the previous bone scan.
The patient proceeded to surgery for bilateral BKA.

Education & CPD
Case Study
CONCLUSION
A 3–phase bone scan is a valuable procedure to determine perfusion and viability of bone and soft tissues. In
this instance, both scans significantly changed the medical management of this patient, revealing the severity
of ischaemic injury to the distal limbs and confirming necrosis prior to amputation.
References
1. Kirsch E, Barton R, Kitchen L, Giroir B. Pathophysiology, Treatment and Outcome of Meningococcemia: A Review and Recent Experience. The Pediatric Infectious Disease
Journal. 1996;15(11):967-979.
2. Milonovich L. Meningococcemia: Epidemiology, Pathophysiology, and Management. Journal of Pediatric Health Care. 2007;21(2):75-80.
3. Jafri R, Ali A, Messonnier N, Tevi-Benissan C, Durrheim D, Eskola J et al. Global epidemiology of invasive meningococcal disease. Population Health Metrics. 2013;11(1).
4. Department of Health | Meningococcal Disease (Invasive) [Internet]. Health.gov.au. 2019 [cited 4 January 2019]. Available from: http://www.health.gov.au/internet/main/
publishing.nsf/Content/ohp-meningococcal-W.htm
ANZSNM NZ
SAVE
Branch Meeting THE
– DATE

For the first time, the NZ branch of the ANZSNM are joining with
our MI and RT colleagues, in a combined meeting with the NZIMRT.
This is a great opportunity to interact, learn and share what is

happening in our Nuclear Medicine, PET/CT, Radiology and
Radiation Therapy departments.
Social functions include Welcome drinks on Friday 30th August,

and Gala dinner Saturday 31st August.
Call for abstracts have open now and registration will be available shortly.
Attendance certificates will be issued via Attendo Plus.
We would like to encourage all ANZSNM members, both in

Australia and NZ, to consider coming to support this joint initiative.
Come and present in a collaborative environment!
Rotorua Energy Events Centre


@
Education & CPD
Case Study
F-FDG PET/CT Hits the Bullseye for Assessing Off Target

18
Inflammatory Response from Immunotherapy for Melanoma

Authors: Sean Baker1 & Loren Katchel - 1Princess Alexandra Hospital, Brisbane, Australia
INTRODUCTION A follow up brain MRI post treatment indicated disease

recurrence in the surgical bed. A monitoring 18F-FDG
Melanoma is a highly aggressive form of cancer that PET/CT indicated disease progression as it showed an
develops in the skin’s melanocytes, however, it can intensely FDG avid lesion in the patient’s left flank.
occur in the eye or in the mucous membranes of The persisting parietal lobe lesion was re-excised and
the oral cavity, anus and genitalia.1 In most cases it further treated with radiation therapy, the left flank
arises in the skin due to overexposure to UV radiation, lesion was excised, and the patient underwent an
risk factors such as fair skin, family history and the additional three cycles of chemotherapy.
BRAF gene mutation also increase the likelihood of
development. Melanomas only account for 2% of A three-month follow-up PET/CT scan again showed
all skin cancers, yet they attribute to 75% of all skin disease progression with residual FDG-avidity being
cancer related deaths in Australia.1 Treatment options seen in the previously excised left flank region
for melanoma are dictated by the stage of the disease. and an intensely avid left sided inguinal node was
The options can be a combination of surgical removal, noted (figure 1). Due to the inefficiency of previous
chemotherapy, targeted therapies, radiation therapy treatment, alternate options were discussed and
and immunotherapy.2 it was decided that a four-cycle immunotherapy
regiment would be the best option. The patient
With recent developments there has been a underwent a combination of immune checkpoint
greater use of immunomodulatory therapies blockade agents, Ipilimumab and Nivolumab, and
whereby monoclonal antibodies are used to target continued to be monitored.
T-lymphocyte activation regulators and thus inhibit b)
tumour cell related immune tolerance. For many INVESTIGATIONS
3
years now 18F-FDG PET/CT has been a pillar for the

staging, restaging and management of patients with After two cycles of immunotherapy, the patient had
melanoma. The aim of this case study is to examine the a three-month follow-up 18F-FDG scan where he was
utility of 18F-FDG PET/CT for the assessment of adverse intravenously injected with 359.22MBq of 18F-FDG
inflammatory responses in melanoma patients on the and a skull vertex to toes PET/CT was acquired at
afore mentioned immunotherapy.4 65 minutes post injection. Low dose non-diagnostic
CT was performed for attenuation correction and
CASE REPORT anatomical localisation purposes. The patient’s BSL
was 5.1 mmol/L prior to injection.
A 25-year old male with malignant melanoma of
unknown primary presented for staging. At the time of Imaging showed interval reduction in the size and
diagnosis, he had a large parietal lobe metastasis that FDG-avidity of both the left flank region and the
was treated with a craniotomy followed by stereotactic left inguinal lymph node, suggesting response to
radiosurgery to the cavity. He then completed three treatment. However, diffusely intense 18F-FDG uptake
cycles of the melanoma specific chemotherapy agents was noted in the thyroid (figure 2) and although
Dabrafenib & Trametinib. indicative of thyroiditis, further investigations were
recommended for correlation.

Education & CPD
Case Study
F-FDG PET/CT Hits the Bullseye for Assessing Off Target Inflammatory
18
Response from Immunotherapy for Melanoma (Continued)
Figure 1: 18 F-FDG WB PET MIP Figure 2: Mid-immunotheraphy 18F-FDG PET/

a) March 2018 - FDG-avid left flank lesion CT September 2018 displaying diffusely FDG-avid
b) June 2018 - Residual 18F-FDG uptake in left thyroid, a)WB MIP, b) coronal fusion, c) axial fusion
flank region and FDG-avid left inguinal node
The patient’s combination immunotherapy was temporarily stopped, his thyroiditis was brought under control
with Dexamethasone and Propranolol, and then standalone Nivolumab immunotherapy was recommence
after only a brief delay.
Thyroid function tests (TFT)s were performed showing a thyroid stimulating hormone reading of less than
0.05, coupled with a thyroxine reading of 77. A nuclear medicine thyroid uptake scan was also acquired which
yielded an uptake ratio of 0 and along with the TFT results, thyroiditis was confirmed.
Another 18F-FDG scan was acquired following the completion of the patient’s remaining immunotherapy with
similar acquisition parameters as previously noted. The imaging showed no significantly FDG-avid residual/
recurrent disease and no new FDG-avid disease was identified. 18F-FDG uptake was still present in the thyroid.
However, based on the patient’s TFTs, thyroiditis was completely resolved and the residual thyroid uptake could
be a response to treatment. Overall, the scan appearance was reflective of a complete metabolic response to
therapy, with no newly noted adverse responses to immunotherapy (figure 3).

Education & CPD
Case Study
F-FDG PET/CT Hits the Bullseye for Assessing Off Target Inflammatory
18
Response from Immunotherapy for Melanoma (Continued)
DISCUSSION
Immune-related adverse events resulting

from the combination Ipilimumab-Nivolumab
immunotherapy, which is evident in the discussed
patient, is proving very common, being reported as
high as 70% in studies with melanoma patients. It
has been widely reported that the risk of immune-
related adverse events such as colitis, hepatitis,
hypophysitis, thyroiditis, nephritis, pneumonitis,
Figure 3: Post
dermatitis and arthritis is greater with Ipilimumab
immunotherapy 18F-FDG
than what they are with Nivolumab.5,6,7 The onset of
WB MIP showing no new
these adverse events typically occurs within 6 to 8 or residual FDG-avid
weeks of commencing these immunotherapy agents. disease and persistent
Some of these adverse events can be severe or life thyroid uptake in line with
threatening and require immediate management, response to treatment
which can often include a combination of
corticosteroids, immunosuppressants and treatment CONCLUSION
discontinuation.4 By managing these adverse events
appropriately, you provide the best opportunity to With immunotherapy reportedly having higher
continue the immunotherapy regiment without progression-free survival and objective response
compromising the efficacy of the treatment.5 This rates, it is apparent that there will be increased future
is why the rapid detection of these adverse events application of immunotherapy for the treatment
is paramount as it allows for early and adequate of melanoma.6 In this case along with many other
intervention of the inflammatory processes. In this reported cases 18F-FDG PET/CT has proved to be a
case 18F-FDG PET/CT demonstrated thyroiditis in a very valuable tool for the detection and diagnosis
seemingly asymptomatic patient, which may have of immune-related adverse events in patients on
continued to go undetected without the scan. immunotherapy for melanoma.5
As the patient’s thyroiditis was detected at a relatively Therefore, early imaging with 18F-FDG PET/CT as an
early stage, the treating team were able to provide immune-related adverse event detection tool should
early intervention and resolve the process quickly. be considered as a routine procedure in the melanoma
As a result, the patient was able to recommence the immunotherapy treatment pathway. Imaging at 6-8
Nivolumab immunotherapy promptly, with minimal weeks after commencing immunotherapy could be
compromise to the efficacy of the treatment. vital for diagnosing and treating immune-related
adverse events as well as ensuring the overall
treatment continuity.7
References:
1. Melanoma Institute Australia 2018, Understanding Melanoma - What is melanoma?, viewed 5 Nov, 2018 https://www.melanoma.org.au/understanding-
melanoma/what-is-melanoma
2. SkinCancer.net 2017, Excision of Skin Cancer viewed 5 Nov, 2018 <https://skincancer.net/treatment/excision-surgery/>
3. Perng P, Marcus C, Subramaniam R. 2015, ‘18F-FDG PET/CT and Melanoma: Staging, Immune Modulation and Mutation-Targeted Therapy Assessment, and
Prognosis’, American Journal of Roentgenology. vol. 205(2), pp. 259-270.
4. Postow M. 2015, ‘Managing Immune Checkpoint-Blocking Antibody Side Effects’, American Society of Clinical Oncology Educational Book, vol. 35 pp. 76-83.
5. Wong A, McArthur G, Hofman M, Hicks R. 2017, ‘The Advantages and Challenges of Using FDG PET/CT for Response Assessment in Melanoma in the Era of Targeted
Agents and Immunotherapy’, European Journal of Nuclear Medicine and Molecular Imaging, vol. 44, pp. 67-77.
6. Larkin J, Chiarion-Sileni V, Gonzalez R, Grob J, Cowey C, Lao C et al. 2015, ‘Combined Nivolumab and Ipilimumab or Monotherapy in Untreated Melanoma’, New
England Journal of Medicine, vol. 373(13), pp. 1270-1271.
7. Perng P, Marcus C, Subramaniam R. 2015, ‘18F-FDG PET/CT and Melanoma: Staging, Immune Modulation and Mutation-Targeted Therapy Assessment, and
Prognosis’, American Journal of Roentgenology. vol. 205(2), pp. 259-270.ion of immunotherapy for the treatment of melanoma

Education & CPD
Case Study
Return of Heat Denatured 99mTc RBC Spleen Studies

Author: Jessica Keen - NMT Monash Health, VIC
INTRODUCTION
Patients without functional splenic tissue have an
Heat Denatured 99mTc Red Blood Cell Spleen studies increased risk of contracting infections and often
are infrequently performed in most nuclear medicine require life-long treatment with antibiotics and up-to-
departments, despite their accuracy in determining the date immunizations particularly against pneumococcal,
presence of functional splenic tissue. A new study being meningococcal, Hemophilus influenzae and annual
conducted at Monash Health by medical student Sarah influenza vaccinations (4). These patients also maintain
Luu and Deputy Director of Infectious Diseases A/Prof Ian caution around others that may be unwell and around
Woolley in association with Spleen Australia and Alfred animals to avoid bites and scratches which could
Health has seen the demand for these studies grow. introduce infections (3).
Their research is still underway but required recruiting
patients who had undergone a splenectomy following Depending on the type and severity of the splenic trauma,
trauma and was designed to assess the long-term splenic tissue has been known to lodge anywhere in the
outcomes of these patients, with a facet of the study peritoneal cavity and can regenerate in a process known
focusing on identifying those with residual functional as autotransplantation (4). Due to this phenomenon,
splenic tissue. Following blood test screening for Howell- patients whom have undergone splenectomies as a result
Jolly bodies and immunoglobulin Memory B cells which of trauma have a reduced risk of contracting infections
are indicators for functional splenic tissue, patients were due to having residual or ectopic functioning splenic
referred to Nuclear Medicine to locate any functional tissue (3). The volume of functional splenic tissue is also
splenic tissue (1). hypothesized to correlate with improved immunity (3).
BACKGROUND CASE STUDY HISTORY
The spleen itself is a blood-rich organ which serves the A 34-year-old male presented to the Nuclear Medicine
purpose of proliferating lymphocytes which support the department after being recruited for this study, having
immune system (2). The spleen also filters out defective undergone a splenectomy following a motor cycle
and aged blood cells and platelets from the circulation accident 9 years ago. The patient had reported taking
whilst its macrophages remove foreign matter from the daily antibiotics since the surgery up until the past 6
blood. The spleen is also involved in storing platelets, months when he was recommended to withdraw from
monocytes and breakdown products in the blood such them by his medical specialist. The patient would instead
as iron that can be returned to the blood when needed only take antibiotics when he began feeling unwell.
(2).
Splenectomies are most commonly performed LABORATORY PROCEDURE

following trauma to the abdomen to prevent life-
threatening hemorrhaging occurring into the Invitro labelling of RBC’s with Tc-99m was performed
peritoneum. Splenic ruptures can occur from using a Eu-Tag® kit. For this process, 3ml of whole blood
motor vehicle accidents, assaults, sporting injuries, was taken from the patient in a syringe with ACD which
complications during abdominal surgery, infections, is then combined with the reaction syringe (containing
malignancy or from hematological conditions (3). stannous chloride, sodium citrate and dextrose) and

Education & CPD
Case Study
Return of Heat Denatured 99mTc RBC Spleen Studies (Continued)
incubated for 10 minutes at room temperature, this

allows the stannous ion to diffuse across the RBC
membrane (5).
The contents of syringe I (containing sodium

hypochlorite) is then added to the reaction syringe and
mixed to oxidize any extracellular stannous ion. This is
then followed by the addition of syringe II (containing
citric acid, sodium citrate and dextrose) which is
also mixed and further sequesters any extracellular
stannous ions (5).
An evacuated vial is then placed into a lead pot with

the RBC’s added, followed by the addition of 1GBq of
99mTcO4-, where the 99mTcO4- diffuses across the
RBC membrane and is reduced by the stannous ion.
The whole vial is then placed into a shielded hot water
bath at 49.5 degrees Celsius +/-0.5˚C for 15 minutes to Figure 1. Planar Images demonstrating splenic
denature the red blood cells (5). Care is taken not to tissue in the left posterior abdomen.
overheat or underheat the red blood cells as this can
lead to increased liver uptake or conversely increased
blood pool activity, both which reduce splenic uptake
(6).
Approximately 800MBq of Tc-99m Denatured RBC’s is

then drawn up and reinjected into the patient within
30 minutes after blood withdrawal.
IMAGE ACQUISITION
Imaging commences 30 minutes post injection with

anterior/posterior planar statics performed including
all the thorax down to liver, and another over the
abdomen including from the liver to the bottom of
pelvis (figure 1). A SPECT/CT (figure 2) is then performed Figure 2. Coronal Fused SPECT/CT demonstrating
to include any splenic tissue identified as per the posterior perinephric splenic tissue.
reporting Nuclear Medicine Physician’s instructions.
FINDINGS
In this case, the reporting physician noted on the SPECT/

CT, 2 foci of denatured red blood cell accumulation
in the left upper quadrant, one posterior to the

Education & CPD
Case Study
Return of Heat Denatured 99mTc RBC Spleen Studies (Continued)
gastric fundus measuring 1.8cm in diameter (figure 3) CONCLUSION

and another measuring 2.2cm in diameter in the left
perinephric space (figures 2 & 4) which is in keeping with Heat denatured 99mTc labelled red blood cell scintigraphy
residual splenic tissue. is highly sensitive and accurate in determining the
presence and volume of functional splenic tissue. As
this study is still in progress, it will be interesting to
follow up their findings as more patients are referred
to the department for imaging. More importantly for
the patients who have undergone a splenectomy, it is
exciting to determine if these patients do in fact have
residual functional splenic tissue, as this could greatly
impact on their treatment regiments including reduced
dependence on antibiotics and how they live their every-
day lives.
References:
1. Spleen Australia Annual Newsletter [Internet]. Spleen.org.au. 2018 [cited 27

February 2019]. Available from: https://spleen.org.au/vsr/files/2018_Spleen_
Australia_annual_newsletter.pdf
2. Marieb E, Hoehn K. Human anatomy & physiology. 9th ed. Essex: Pearson;
2014. 817-818 p.
Figure 3 Top: Axial CT and SPECT/CT,
3. Splenic rupture – Knowledge for medical students and physicians [Internet].
Bottom: MIP Images localizing splenic tissue Amboss.com. 2019 [cited 28 February 2019]. Available from: https://www.
posterior to gastric fundus. amboss.com/us/knowledge/Splenic_rupture
4. Return of normal functioning spleen after traumatic splenectomy. Journal
of the Royal Society of Medicine [Internet]. 2004 [cited 27 February
2019];97(8):391. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC1079560/
5. Kowalsky R, Falen S. Radiopharmaceuticals in Nuclear Pharmacy and Nuclear
Medicine. 3rd ed. Washington: American Pharmacists Association; 2011.196-
197 p.
6. Infrequently Performed Studies in Nuclear Medicine: Part 1. Journal
of Nuclear Medicine Technology [Internet]. 2008 [cited 27 February
2019];36(3):141,142. Available from: http://tech.snmjournals.org/con-
tent/36/3/132.full
Figure 4. Top: CT and SPECT/CT, Bottom: MIP

Images localizing perinephric splenic tissue.

Education & CPD
Case Study
Congenital Hypothyroidism (CH) and Lingual Thyroid in

Neonate on Thyroid Uptake Scan
Author: My Linh Diep - Monash Health, Victoria
CLINICAL HISTORY
• Female neonate born at term gestation.
• Routine Neonatal Screening Test (NST) at two days old found elevated TSH of 121.
• Mum denied health problems during pregnancy.
Referred for nuclear medicine thyroid uptake scan by paediatric endocrinologist.
IMAGING
Patient presented to nuclear medicine department at eight days old for thyroid uptake scan with peripheral
intravenous cannula inserted by paediatric endocrinologist. Patient intravenously administered 28MBq of
99m
TcO4-. Imaging commenced after uptake of 15 minutes. Simultaneous static acquisition of the neck in the
anterior and left lateral view for five minutes. No uptake found in the native thyroid bed. Small focal area of
pertechnetate uptake in the floor of the mouth yielding 1.3% uptake. Thyroid uptake scan concluded ectopic
thyroid tissue in lingual or thyroglossal duct tract region.
MANAGEMENT
Patient seen in Outpatient Clinic at Monash Children’s Hospital for congenital hypothyroidism (CH). Patient
commenced 50 µg thyroxine three days per week and 25 µg four days per week, equating to total of 250 µg per
week. Clinical follow-up two weeks later showed body weight and length tracking on the 90th centile and head
circumference on the 50th centile. Patient was breastfeeding on demand and gaining weight. Thyroid function
tests showed significantly improved TSH and T4. Mum reported patient being sleepier compared to siblings but
patient otherwise showed continued growth in length and weight.
Figure 1. Anterior and left lateral static acquisition of neck on Philips CardioMD
gamma camera.

Education & CPD
Case Study
Congenital Hypothyroidism (CH) and Lingual Thyroid in Neonate on Thyroid

Uptake Scan (Continued)
Figure 2. Anterior view of neck with ROI over focal area of uptake in lingual region. Background ROI over
supraclavicular area.
Repeat TFTs and clinic follow up at 14 weeks of age revealed slightly suppressed TSH and slightly elevated T4.
Hence, thyroxine dose was reduced to f 225 µg/week. Follow-up is planned for two months’ time.
UNITS REFERENCE
RANGE
Table 1. Serial TFTs in first 20 weeks of life. Reference range is age-specific.
DISCUSSION
The patient in this case study demonstrates pertechnetate uptake in an ectopic thyroid gland, a form of thyroid
dysgenesis3. Approximately 80% of primary CH is associated with thyroid dsygenesis3. Almost 90% of thyroid
ectopy occurs in the lingual region, owing to halted descent of the thyroid gland which usually moves from the

Education & CPD
Case Study
Congenital Hypothyroidism (CH) and Lingual Thyroid in Neonate on Thyroid

Uptake Scan (Continued)
foramen caecum (base of tongue) to its expected visual and psychomotor development in the first
position in the central midline neck during three years of life and appropriate intervention
embryologic development.2 It is typical for the are imperative3. Physiologic hormone demands
lingual thyroid to be singular and the only source of change through major stages of growth2. Hence,
thyroid hormone production2. An ectopic thyroid ongoing monitoring through school years,
can develop a goitre which can produce obstructive puberty and adulthood is also recommended3.
tongue base symptoms if not appropriately
treated2. Approximately 33% of children with This case report highlights the vital role a
thyroid ectopy also have hypothyroidism. thyroid uptake scan plays in early detection of
Thyroid ectopy and hypothyroidism in adults childhood primary CH and lingual thyroid. Prompt
is rare, as the condition usually manifests at progression to hormone therapy is correlated with
an early age1,2. Ultrasonography, useful to higher chances of normal cognitive and physical
confirm structural absence of the thyroid gland development into adulthood1,3.
in its expected position, and thyroid uptake
scan are key diagnostic tools to investigate References:
thyroid dysfunction3. The pertechnetate thyroid
uptake scan may also identify alternate causes 1. David S. Saleh, Sarah Lawrence, Michael T. Geraghty, Patricia H.
for the presenting hypothyroidism such as Gallego, Karen McAssey, Diane K. Wherrett and Pranesh Chakraborty.
thyroid agenesis, which is characterized by “Prediction of congenital hypothyroidism based on initial screening
absent pertechnetate uptake in the neck, or thyroidstimulating-hormone” BMC Pediatrics (2016) 16:24
dyshormonogenesis which is characterized by 2. Germano Guerra, Mariapia Cinelli, Massimo Mesolella, Domenico
pertechnetate uptake within a normally sited Tafuri, Aldo Rocca, Bruno Amato, Sandro Rengo, Domenico Testa.
thyroid gland. “Morphological, diagnostic and surgical features of ectopic thyroid
gland: A review of literature” International Journal of Surgery 12
CH is the most common preventable cause (2014) S3eS11
of intellectual disability1 and can be graded 3. Juliane Léger, Antonella Olivieri, Malcolm Donaldson, Toni Torresani,
biologically based on serum free T4 levels. Heiko Krude, Guy van Vliet, Michel Polak, Gary Butler on behalf
According to the European Society of Paediatric of ESPE-PES-SLEP-JSPE-APEG-APPES-ISPAE, and the Congenital
Endocrinology guidelines serum free T4 level <5 Hypothyroidism Consensus Conference Group. “European Society
pmol/L is classified as mild CH, 5 < 10 pmol/L for Paediatric Endocrinology consensus guidelines on screening,
is moderate CH, and 10 – 15 pmol/L is severe diagnosis, and management of congenital hypothyroidism” Hormone
CH3. Untreated CH in young children result in Research in Paediatrics 2014;81:80–103
neurological, psychiatric and somatic deficits1.
Over the last 30 years the TSH screen, a

component of the neonatal screening program,
plays a major role in early detection of CH in
neonates1. Early treatment with thyroxine within
the two weeks of birth optimises developmental
outcomes3. Fortnightly follow up of TSH values
is recommended until normalisation, then 2 – 4
month follow ups thereafter. Monitoring of speech,

Education & CPD
Case Study
Utilisation of Lymphoscintigraphy SPECT/CT imaging

in the localisation of lymphatic leakage site following
complicated femoral hernia repair.
Author: Kimberly Nguyen - Benson Radiology, Ashford Specialist Centre, Adelaide, South Australia.
CASE STUDY
A 44-year-old female presented with persistent intermittent right groin swelling following right femoral hernia
repair.
Initial CT imaging showed a 54mm enlarged right inguinal collection suggestive of infective post operative seroma/
lymphocele. The collection was also aspirated under ultrasound guidance and sent for microbiological testing,
which showed no culture growth after 14 days incubation.
Figure 1: Transaxial CT scan image demonstrating 54mm inguinal

collection on the right side.
Four weeks later the patient underwent a nuclear imaging.

medicine lymphoscintigraphy study for the localisation
of the lymphatic leakage site. The patient was injected SPECT/CT imaging was then performed to confirm
in the first web space of each foot with 20MBq of 99mTc uptake within a right external iliac/common femoral
Nanocis. node close to the anteromedial acetabular margin,
demonstrating activity extending to the medial aspect
Serial planar imaging demonstrated normal lymphatic of the inguinal collection.
drainage on the left, into inguinal, pelvic and para-aortic
nodes. On the right, uptake was visualised within right This node was marked on the skin surface anteriorly and
inguinal node with gradual accumulation of low grade, laterally and the patient was sent to theatre for operative
extranodal activity in the right anterolateral inguinal ligation of the leak site.
region, corresponding with the collection seen on CT

Education & CPD
Case Study
Utilisation of Lymphoscintigraphy SPECT/CT imaging in the localisation of

lymphatic leakage site following complicated femoral hernia repair. (Continued)
DISCUSSION
Lymphatic leakage is a rare postoperative

complication which can lead to further health
problems.
Early ligation or suture of the leakage site is

helpful to avoid metabolic complications and
shorten hospitalisation stay.
Nuclear medicine lymphoscintigraphy with

SPECT/CT imaging can play a pivotal role in
locating the site of lymphatic leak, resulting
in an improved patient outcome.
References:
Lv S et al. A review of the postoperative lymphatic leakage.

Figure 2 Planar lymphoscintgraphy images acquired 15 minutes Oncotarget. 2017 Sep 15; 8(40): 69062–69075.
post injection to 100 minutes post injection. Tyndall, S et al. Groin lymphatic complications after arterial
reconstruction. Journal of Vascular Surgery. 1994 vol.19 (5):
858 – 864.
Figure 3 Transaxial SPECT/CT image demonstrating

lymphatic nodal uptake adjacent to the medial aspect
of the right sided inguinal collection.

Biograph Vision
See a whole new world of precision
At Siemens Healthineers, we were inspired to make breakthrough improvements in PET/CT. Biograph VisionTM, featuring
Optiso Ultra Dynamic Range (UDR) detector introduces the first1 silicon photomultiplier (SiPM)based detector with 3.2
mm LSO crystals and 100% detector coverage, resulting in a cascade of clinical and workflow benefits.
Transcend digital with the Optiso UDR Detector 1. LSO, a fast and efficient scintillator, is grown
and cut in-house through a vertically-integrated
manufacturing process to ensure the highest
quality.
1 2. 3.2 mm crystal elements are individually
selected and deliver high isotropic spatial
2 resolution; higher spatial resolution may result
in improved lesion detectability.
4 3. 100% coverage of the crystal area with
SiPM sensors results in a timing resolution of
3 214 picoseconds and 3.9 times higher effective
sensitivity for faster scans and lower dose.
4. A small block size delivers >1870 kilo counts
5 per second effective peak NECR for improved
clinical performance.
5. High-flow direct-cooling of the detector
plate allows the detector to operate at room
temperature for outstanding performance,
serviceability and improved patient comfort.
Small crystals
big impact 54
540 ps 214 ps
• 3.2 mm crystals > 8 cm segment > 3.2 cm segment aph Vision)
• 214 ps time-of flight of response of response (Biograph
Vision)
Fast time-of-flight enables smaller segments of response. This improves the signal-to-noise ratio.
healthcare.siemens.com.au/molecular-imaging
1. Based on competitive literature available at time of publication. Data on file.
Printed in Australia | © Siemens Healthcare Pty Ltd, 2019

Education & CPD
Case Study
The Advantage of PET/MRI over MRI Alone: Multiple

Meningioma a Case Study
Authors: Remi Hillery1, James Turner1
1
Department of Nuclear Medicine and Molecular Imaging, Princess Alexandra Hospital, Brisbane, Australia
INTRODUCTION
A meningioma is a slow growing intracranial tumour The use of hybrid imaging in the form of PET/MRI
that originates from the meninges, accounting for plays an important role in investigating meningiomas
approximately 35% of all primary brain tumours in and therapy planning for lesions in complex locations
adults. Ninety percent of these tumours are benign. and in disease recurrence3. PET/MRI may provide
There is no known cause of meningiomas, but there additional critical information for treatment planning
is a 2:3 male to female prevalence, with approximately that MRI alone is not capable of, leading to better
2.3% going undiagnosed1. patient outcomes.
The occurrence of multiple meningiomas in a single CASE REPORT

person accounts for up to 10% of all meningiomas, and
while they may be more difficult to manage, surgery is A 52-year-old female presented to the PET department
still the preferred option for treatment of symptomatic for a 68Gallium-DOTATATE PET/MRI scan querying
lesions2. Meningiomas may appear sporadically, meningioma recurrence. The patient had a history of
through familial means (including Neurofibromatosis childhood leukaemia that was treated with radiation
Type 2 or familial meningiomatosis), from previous therapy to the brain.
head trauma or be radiation induced. There are
various symptoms of meningioma, which depend on In 2014, the patient underwent stand-alone brain MRI
the location of the lesion1. imaging that reported at least four old meningiomas
and one new lesion in the left frontal lobe, with a WHO
Meningiomas have a high level of expression of Grade I. She was diagnosed with multiple intracranial
Somatostatin Receptor subtype 2 (SSTR2), in which meningiomas and required a right parietal craniotomy
there is excellent tumour-to-background ratio. Thus to resect a large parasagittal meningioma that was
imaging with somatostatin receptor ligands has been causing leg weakness. The patient also underwent
established2. retinal detachment surgery to her left eye. Otherwise,
the patient was functioning well.
DOTATATE is a somatostatin analog that has shown a
high affinity for SSTR2, and once labelled to 68Gallium, In 2015, further MRI imaging showed the meningiomas
can be used for Positron Emission Tomography were increasing in size, growing to WHO Grade II. The
(PET) imaging for improved spatial resolution and patient’s treating team were planning Gamma Knife
quantification2. radiotherapy treatment, and requested her to have
a 68Gallium-DOTATATE PET/MRI scan for accurate
While Magnetic Resonance Imaging (MRI) alone is localisation of the recurring lesions. These images
the gold standard for imaging meningiomas, it may would accurately localise the sites of disease and be
have inadequate sensitivity and specificity in cases of used extensively in her treatment planning.
scar formation within patients’ post-surgery or post-
radiation therapy2.

Education & CPD
Case Study
The Advantage of PET/MRI over MRI Alone: Multiple Meningioma a

Case Study (Continued)
IMAGING
The patient was intravenously injected with 142 MBq 68Gallium-DOTATATE and had an uptake time of 45
minutes. Following this, a single station PET/MRI of the brain was performed using the Siemens Biograph
mMR 3T. The procedure involved simultaneous high resolution axial T2 weighted images and intravenous
Fig. 1 – Example of head coil and positioning used Fig. 2 - MIP of patient’s brain PET/MRI
during PET/MRI brain acquisitions showing multiple DOTATATE-avid lesions
Gadolinium enhanced T1 weighted sequences.

An ultrashort TE MRI sequence was also used for
attenuation correction. The entire image acquisition
took approximately 30 minutes.
Imaging showed multiple DOTATATE-avid small

durally based lesions, both supratentorial and
infratentorial, which appeared consistent with
meningiomas, with a total of 15 to 20 likely sites
(many more than originally suspected from MRI
alone) (Fig. 2 & 3).
There was a small area of cerebral gliosis underlying

the right parietal craniotomy that is consistent with
the patient’s prior surgical resection (Fig. 4). There
Fig. 3 - Fused axial slice demonstrating also appeared to be an altered signal in the left ocular
multiple Gallium-68-DOTATATE avid lesions globe, likely related to the patient’s recent retinal
detachment surgery.

Education & CPD
Case Study

DISCUSSION
Despite management of single meningiomas being extensively studied, there is only limited information on
the histology and suitable treatment pathways for multiple meningiomas. Often multiple meningiomas are
difficult to manage, as each lesion may have different aetiology’s and cause various symptoms depending
on location. It is difficult to determine which lesion may be responsible for particular symptoms, whether it
requires treatment and what the best treatment option is4.
The use of hybrid PET/MRI provides a more comprehensive investigation as it combines the anatomical
information of the MRI with the quantitative molecular biology of PET imaging4. 68Gallium-DOTATATE used in
conjunction with PET/MRI has been proven useful in the diagnosis, grading and monitoring of meningiomas,
particularly in treatment planning, as well as delineating tumour extent and determining therapy induced
changes versus recurrence5. It has a very high tumour-to-background ratio and is a reliable predictor of tumour
growth in WHO Grade I & II tumours, with higher sensitivity than stand alone MRI5. As 68Gallium- DOTATATE is
taken up areas of increased SSTR2 expression, it may also be used in the application of determining patient
suitability for DOTATATE-based therapy as an option of treatment4.
Fig. 4 - MRI, PET and Fused Slice of brain PET/MRI displaying area of cerebral gliosis following craniotomy

Education & CPD
Case Study

PET/MRI utilises a single radiopharmaceutical dose and acquires images simultaneously, taking the same
amount of time as stand-alone MRI, and has been found superior in the setting of differential diagnosis
between therapy-induced changes and recurrence5.
PET/MRI provides accurate multi-parametric imaging that is highly sensitive and has improved lesion
detection with the high-contrast anatomical MRI information and quantitative PET information, and can
incorporate DWI, perfusion MRI and MR spectroscopy.
This overall diagnostic advantage results in a better treatment outcome for the patient6.
CONCLUSION
Multiple meningiomas are challenging to accurately diagnose and even more difficult to determine best
treatment pathway1. PET/MRI imaging with 68Gallium-DOTATATE plays an important role in management and
therapy planning, as it provides more substantial information on recurrent meningiomas or meningiomas
in complex locations. In addition PET/MRI also provides necessary information for radiotherapy planning,
including delineating resection margins and target volumes of these lesions 5.
In this particular case the patient’s disease could have been significantly underestimated if only
standalone MRI imaging was performed. Given the 68Gallium-Dotatate PET/MRI scan identified many more
lesions (15-20) compared to the number of lesions (5) identified on the standard MRI scans. For Gamma
Knife treatment the PET/MRI provided an accurate reflection of disease extent, leading to more accurate
treatment planning and ultimately improved patient outcomes.
References:
1 Wong, R.H., Wong, A.K., Vick, N., & Farhat, H.I. (2013). Natural history of multiple meningiomas. Surgical Neorology International, 71(4). doi: 10.4103/2152-
7806.112617. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683641/ on 13/03/2019
2 Rachinger, W., et al. (2015). Increased 68Ga-DOTATATE uptake in PET imaging discriminates meningioma and tumor-free tissue. Journal of Nuclear
Medicine, 56(3), 347-353. doi: 10.2967/jnumed.114.149120. Retrieved from http://jnm.snmjournals.org/content/56/3/347.full.pdf+html on 13/03/2019
3 Sommerauer, M., et al. (2016). 68Gallium-DOTATATE PET in meningioma: A reliable predictor of tumor growth rate? Neuro-Oncology, 18(7). doi: 10.1093/
neuonc/now001. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26865086 on 13/03/2019
4 Miles, K.A., Voo, S.A., & Groves, A.M. (2018). Additional clinical value for PET/MRI in oncology: moving beyond simple diagnosis. Journal of Nuclear Medicine,
59(7), 1028-1032. doi: 10.2967/jnumed.117.203612. Retrieved from http://jnm.snmjournals.org/content/59/7/1028.full.pdf+html on 13/03/2019
5 Iagaru, A., Hope, T., & Veit-Haibach, P. (2018) PET/MRI in oncology. Springer International Publishing
(eBook). doi: 10.1007/978-3-319-68517-5. Retrieved from https://books.google.com.au/
lr=&id=g7ZIDwAAQBAJ&oi=fnd&pg=PA185&dq=advantages+of+pet.=saX34aHwt5&sig=la9AJbXo87Cmo8QX2X9Iikvpqws#v=onepage&q&f=false on
12/03/2019
6 Rosenkrantz, A.B., et al., (2016). Current status of hybrid PET/MRI in oncologic imaging. American Journal of Roentgeneology, 206(1), 162-172. doi: 10.2214/
AJR.15.14968. Retrieved from https://www.ajronline.org/doi/full/10.2214/AJR.15.14968 on 13/03/2019

Education & CPD
What’s that
What’s that? Case 1 - There is often more than meets the eye
Author: Lauren Hudswell - Monash Health. Victoria
CLINICAL NOTES
The patient is a 68-year-old male with elevated parathyroid hormone and calcium levels who presented for
investigation of a suspected parathyroid adenoma. Whilst a medical history was obtained for this patient,
they did not provide a complete history. A dual isotope parathyroid scan was performed with 39.9MBq of
99m
Tc-Pertechnetate for the thyroid image acquired at 15 minutes post administration and 819MBq of 99mTc-
Sestamibi for the parathyroid image acquired 30 minutes post administration. Delayed statics and SPECT/CT
were performed three hours post 99mTc-Sestamibi administration. What is the eye catching feature of this scan?
Image 1: Top Row: 99mTc04- images. Middle Row: Early 99mTc-Sestamibi

images . Bottom Row: Delayed 99mTc-Sestamibi images
DISCUSSION the right lobe of the thyroid in the lower pole, there
is also another feature that makes this an interesting
Localisation of 99mTc-Sestamibi occurs via passive image. Seen slightly in the thyroid images but
diffusion in the mitochondrial membranes where much clearer in the early and delayed parathyroid
increased number and activity of mitochondria images, the heart is located on the right hand side
results in increased localisation of tracer(1). As such, of the chest and the liver on the left as evident in
both parathyroid and cardiac tissue are evident on images 1-3 (above and following page). After further
a 99mTc-Sestamibi scan. Though this scan is positive questioning of the patient it was identified that the
for a parathyroid adenoma contiguous and behind patient had situs inversus totalis (SIT).

Education & CPD
What’s that
What’s that? Case 1 - There is often more than meets the eye (Continued)
SIT is a congenital condition with an incidence of

1:10,000 (2), where there is complete mirror image
reversal of major thoracic and abdominal organs. It
is also referred to as situs inversus with dextrocardia,
whereby the heart angles towards the right side of
the chest instead of the left (2,3). This transposition
of anatomy includes the lymphatic system, blood
vessels, intestines and nerves. The lungs are also
transposed with the right lung being bilobed and
the left being trilobed (2). SIT is also closely linked
with Kartageners syndrome (KS), a syndrome of
dysfunctional cilia, which this patient was also
Image 2: Fused coronal SPECT/CT Slice diagnosed with. KS occurs in 20-25% of all SIT cases
(3).
CONCLUSION
This is an interesting educational case for students,

interns and technologists who may not have
previously come across SIT in a clinical setting. It is
a helpful reminder that it is important to consider
all components of an acquired image, and not just
the anatomy or physiology being investigated,
for the detection of incidental findings. In many
patients with SIT there can be a delay in diagnosis
and treatment with symptoms often presenting
on the contralateral side to traditional diagnosis.
Image 3: Fused transaxial SPECT/CT Slice Surgical procedures in patients with SIT are complex,
requiring surgeons to recognise the mirror image
of anatomy prior to the operation. Further imaging
would be required for this patient prior to the
parathyroidectomy to identify the location of
surrounding vasculature.
References
1. Ponto J. Mechanisms of Radiopharmaceutical Localisation. The University of New Mexico Health Sciences Center, College of Pharmacy. 16. 2012:16(4)
2. Mujo T, Finnegan T, Joshi J, Wilcoxen K, Reed J. Situs ambiguous, levocardia, right sided stomach, obstructing duodenal web, and intestinal nonrotation: A case
report. J Radiol Case Rep 2015;9(2):16-23
3. Roongruanchai J, Narongsak W, Plakornkul V. Situs inversus totalis and ultrastructure of respiratory cilia: report of cadaveric case. J Med Assoc Thai
2012;95(1):132-13

Education & CPD
What’s that
What’s that? Case 2

Author: Barry Chatterton
BACKGROUND
A 23-year-old keen athlete (football, basketball) presents with four year history of right groin pain.
Radiopharmaceutical : 99m TC HDP 700MBq
FIG 1 - The blood pool images show increased

vascularity in the region of the pubic symphysis. The
delayed scan shows increased uptake, particularly
to the right of the midline in the right pubic bone
adjacent to the symphysis.
FIG 2 - The delayed SPECT/CT shows increased

activity in the right pubic bone adjacent to the
symphysis. This is associated with a small calcified
adjacent focus and secondary ossification centre.
Figure 1: Blood pool (1min after injection) and This junction of the pubis, apophysis and soft
delayed images (3 hr after injection) anterior planar tissue might be expected to represent an area of
images of pelvis. biomechanical weakness that endures considerable
forces during athletic single stance manoeuvres.1
ANSWER
The findings are those of “Pubic apophysitis”2. A

secondary ossification centre located along the
anteromedial corner of pubis beneath the insertions
of symphysial joint capsule and adductor longus
tendon. Chronic stress may cause distraction of this
ossification centre with chronic inflammation.
The condition usually presents in the mid teen years

and with rest is usually self-limiting. This patient had
Figure 2: Delayed (3hr) SPECT/CT images continued to exercise despite symptoms.
(radionuclide, low dose CT, fused) with transverse,
coronal and sagittal images centred on the pubic The abnormality may be seen on SPECT/CT, CT or
rami. MRI scans.
References:
1 Robinson P, Salehi F, Grainger A, et al. Cadaveric and MRI study of the musculotendinous contributions to the capsule of the symphysis pubis. AJR Am J
Roentgenol 2007;188:
2: Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes. Sailly M, Whiteley R, Read JW, et al.Br J Sports Med2015;49:828–834.

Articles
Production of metallic radionuclides on a medical

cyclotron
Author: Courtney Hollis - SAHMRI
Metallic radionuclides are widely used in nuclear

medicine as components of diagnostic and theranostic
radiopharmaceuticals. Generator production of 99mTc
and 68Ga has led to these being two of the most
commonly used metallic radionuclides, for SPECT
and PET imaging respectively. However, recent supply
chain issues and shortages have highlighted the
vulnerability and reliance on 99mTc and 68Ga generators.
Moreover, not all metallic radionuclides with desirable
physical properties for the development of new
radiopharmaceuticals are amenable to generator
production.
Image 1: Comecer EDS unit with
The Research and Development (R&D) team at PTS connected to irradiation unit
the Molecular Imaging and Therapy Research Unit
(MITRU), a part of the South Australian Health and
Medical Research Institute (SAHMRI), are focussed
on developing Good Manufacturing Practices (GMP)
production for metallic radionuclides using cyclotron
radiation. The radionuclides routinely produced are
64
Cu, 89Zr and 68Ga. MITRU has a dedicated external
beam line on a GE PETtrace 880 cyclotron for solid
target irradiation. This is combined with a Comecer
electrochemical/dissolution/storage (EDS) unit
with pneumatic transfer system (PTS) which allows
production of a solid target via electroplating, transfer
of the target to the irradiation unit on the external
Image 2: Irradiation unit on external beamline
beam line, and dissolution of the irradiated target.
of GE PETtrace 880 cyclotron
The dissolved irradiated target is then transferred to
the Comecer Taddeo-PRF purification module which
performs the remote and automated purification of
the product to give the metallic radionuclide in a form
suitable for use as an active pharmaceutical ingredient
(API).
64
Cu is a low energy positron and beta emitter with
a half life of 12.7 h, which makes it a promising
candidate for both diagnostic (PET imaging) and
theranostic applications. The extended half-life makes
it practical to ship the radionuclide or 64Cu labelled
radiopharmaceuticals across Australia. The R&D
team at MITRU routinely produce 64Cu in the form of
Image 3: Comecer Taddeo-PRF
purification module.

Articles
Production of metallic radionuclides on a medical cyclotron (Continued)
CuCl2 in 0.05 M HCl for use as an API at activities of

64
Research continues at MITRU to further refine the
up to 18 GBq. Due to its versatility there has been an cyclotron production of 64Cu, 89Zr and 68Ga to allow for
abundance of novel research using 64Cu, as evidenced the supply of these metallic radionuclides to research
by the recent ANZSNM conference. groups and companies located in Adelaide (68Ga) and
Australia wide (64Cu and 89Zr).
This has culminated with on-going clinical trials of
64
Cu radiopharmaceuticals such as neuro endocrine Further reading:
tumour imaging agent, 64Cu-SARTATE, and the hypoxia
imaging agent, 64Cu-ATSM.1-2 1. First-in-human trial of Cu-SARTATE PET imaging of patients with
64
neuroendocrine tumours demonstrates high tumour uptake and

89
Zr is a longer-lived positron emitter with a half- retention, potentially allowing prospective dosimetry for peptide receptor
life of 78.4 h, which matches the biological half-life radionuclide therapy. Hicks RJ, Jackson P, Kong G, Ware RE, Hofman MS,
of an intact monoclonal antibody, making it ideal Pattison DA, Akhurst T, Drummond E, Roselt P, Callahan J, Price R, Jeffery
for immuno-PET imaging. At MITRU the R&D team C, Hong E, Noonan W, Herschtal A, Hicks LJ, Harris M, Hedt A, Paterson BM,
produce 89Zr in the form of 89Zr-oxalate in 1 M oxalic Donnelly P. Journal of Nuclear Medicine, 2018, ahead of print. doi: 10.2967/
acid for use as an API at activities of up to 4 GBq. In jnumed.118.217745.
a recent study MITRU produced 89Zr was used to 2. Evaluation of Hypoxia with Cu-ATSM. Lapi SE, Lewis JS, and Dehdashti F.
label antibodies directed to innate immune markers Seminars in Nuclear Medicine, 2015, 45(2), 177–185.
CD11-B and IL-1β, which are indicators of colonic 3. Immuno-PET of Innate Immune Markers CD11b and IL-1β Detect
inflammation.3 Further development of this immuno- Inflammation in Murine Colitis, Dmochowska N, Tieu W, Keller MD, Wardill
PET technology could provide a less invasive approach HR, Mavrangelos C, Campaniello MA, Takhar P, and Hughes PA. Journal of
than endoscopy for the diagnosis and monitoring of Nuclear Medicine, 2018, ahead of print, doi: 10.2967/jnumed.118.219287
inflammatory bowel disease. 89Zr has also been used 4. Molecular Imaging and Quantitation of EphA2 Expression in Xenograft
to label anti-EphA2 antibody for the immuno-PET Models with 89Zr-DS-8895a. Burvenich IJG, Parakh S, Gan, HK, Lee F-T, Guo
imaging of epithelial cancers.4 N, Rigopoulos A, Lee S-T, Gong S, O’Keefe GJ, Tochon-Danguy H, Kotsuma
M, Hasegawa J, Senaldi G, and Scott AM. Journal of Nuclear Medicine, 2016,
68
Ga is a shorter-lived positron emitter, with a half-life 57(6), 974-980.
of 68 minutes, which is routinely used in clinical PET 5. 68Ga-DOTATATE Compared with 111In-DTPA-Octreotide and Conventional
facilities worldwide; generally in the form of [68Ga]Ga- Imaging for Pulmonary and Gastroenteropancreatic Neuroendocrine
DOTA-TATE for imaging neuroendocrine tumours and Tumors: A Systematic Review and Meta-Analysis. Deppen SA, Blume J,
[68Ga]Ga-PSMA for prostate cancer.5-6 Bobbey AJ, Shah C, Graham MM, Lee P, et al. Journal of Nuclear Medicine,
2016, 57, 872-878.
As previously mentioned, 68Ga is obtained from the 6. Sensitivity, Specificity, and Predictors of Positive Ga-Prostate-specific
68
decayed parent radionuclide 68Ge using commercial Membrane Antigen Positron Emission Tomography in Advanced Prostate
68
Ge/68Ga generators. However, these generators Cancer: A Systematic Review and Meta-analysis. Perera M, Papa N, Christidis
are not without drawbacks; only a limited and D, Wetherell D, Hofman MS, Murphy DG, et al. European Urology, 2016, 70,
finite quantity of 68Ga is able to be accessed (< 1.85 926-937.
GBq per elution) and the high demand for 68Ga 7. Rapid and automated production of Ga-68 chloride and Ga-68-DOTA-
radiopharmaceuticals means that supply chain issues, TATE on a medical cyclotron. Tieu W, Hollis CA, Kuan K, Takhar P, Stuckings
leading to availability shortages, are keenly felt. M, Spooner N, and Malinconico M. Nuclear Medicine and Biology, 2019,
The MITRU R&D team have developed a method of manuscript accepted.
producing 68Ga at activities of up to 6 GBq.7

Now Available in
Print & Digital
KEY CONTENT
• Case studies
• Papers & Abstracts
• Industry Specific Reports
• Industry News
• Events and Awards
• Community Members Profiles
Gamma Gazette is the official publication of the

Australian and New Zealand Society of Nuclear
Medicine.
Founded in 1969, the ANZSNM is the major
professional society for those practising
Nuclear Medicine in Australia and New
Zealand.
KEY MEMBERSHIP BENEFITS

• Free subscription to Gamma Gazette
• Free access to the society’s online portal
• Discounts to industry events
• Exclusive access to all state branch meetings
• Access to a community of industry professionals
• Free enewsletter direct to your inbox every month
Articles
Innovative cancer research

An ANSTO radiochemist has been awarded a scholarship to carry out research at the world-renowned Sloan
Kettering Cancer Center in New York.
To coincide with World Cancer Day, ANSTO is pleased to announce that radiochemist Leena Hogan (pictured
below) has been awarded the prestigious ‘Dr Joan R. Clark Research Scholarship’ from the University of Sydney.
Leena Hogan, Radiochemist
As the recipient of the scholarship Hogan will be As part of her PhD studies at ANSTO and The University
travelling in March 2019 to the world-renowned of Sydney, Hogan has been working on new ways to
Memorial Sloan Kettering Cancer Centre (MSKCC) in attach radionuclides, like gallium-68, to biological
New York. The seven week trip is supported by the vectors to produce new radiopharmaceuticals.
University of Sydney and ANSTO, and Hogan will
be working in the laboratories of eminent cancer “My work is aimed at improving the way we attach the
researcher Prof Jason S. Lewis, the Emily Tow Jackson radionuclide to the radiopharmaceutical. Our new
Chair in Oncology at MSKCC. method can potentially improve currently available
radiopharmaceuticals by increasing their sensitivity
Prof Lewis develops radiopharmaceuticals for targeted for detecting tumours, increasing their brain uptake
diagnosis and treatment of cancer. and decreasing radiation burden to patients”.
His laboratories specialise in using cutting-edge, During her time at MSCKK Hogan will have access
non-standard radionuclides including zirconium-89, to world-class radiochemistry and pre-clinical PET
lutetium-177 and gallium-68. These radionuclides are imaging facilities.
attached to biological vectors (often small molecules,
peptides or antibodies) and then evaluated in pre- These facilities will allow her to determine if the
clinical animal models to determine suitability for new ligand system – developed during her PhD –
advancement to human clinical trials. called ‘NOTET’ works better than ‘NOTA’ or ’DOTA’
which are the current gold standards for gallium-68
Using the best methods available to attach radiolabelling.
radionuclides to radiopharmaceuticals is critical to
their work.

Articles
Innovative cancer research (Continued)
The highly efficient radiopharmaceutical development models using gallium-68 DOTATATE. Hopefully we
pipeline at MSKCC will allow Hogan to evaluate her will demonstrate NOTET allows greater sensitivity
ligands in 7 weeks, a task that could take 6-12 months for detecting tumours, radiolabelling at lower
at ANSTO. temperatures, and a decreased radiation burden to
patients,” said Hogan.
“If NOTET proves better than NOTA or DOTA in a
number of ways, including how well it holds onto the Head of radiochemistry at ANSTO Dr Ivan Greguric has
gallium-68, it could become the new gold standard for developed an ongoing, strong relationship with Prof
radiolabelling with gallium-68,” said Hogan. Lewis and MSKCC.
Hogan explains that not only is NOTET designed to Previous collaborative projects include the evaluation
hold onto gallium-68 more strongly than NOTA or of a prototype ANSTO developed gallium-68 generator.
DOTA but it is predicted to be less ‘polar’ or form more Prof. Lewis has also participated in an ANSTO breakfast
lipophilic complexes with gallium-68. symposium on multi-modal imaging at the recent
WFNMB2018 conference in Melbourne.
This has tremendous potential applications as
increased lipophilicity may allow the development “This is great opportunity for Leena to work at a world-
“first in class” gallium-68 radiopharmaceuticals for leading cancer research facility and experience, first-
diagnosing brain diseases. hand, clinical translation of basic research into first in
human radiopharmaceutical trials,” said Greguric.
“Currently almost all PET radiotracers for diagnosing
brain diseases are based upon the radionuclide The results of the work undertaken at MSCKK will
fluorine-18, but our ligand NOTET may open up this be included in Hogan’s PhD thesis and forthcoming
entire field to gallium-68. scientific publications. Her PhD Is supervised by
Emeritus Professor Trevor Hambly at the University of
Gallium-68 has the advantage over fluorine-18 that Sydney and ANSTO’s Dr Nigel Lengkeek.
it can transported to hospitals in generators. This
alleviates the need for local cyclotron production of The award is named in honour of the American
the radioisotope and can save hospitals millions of chemist and former University of Sydney Fulbright
dollars,” said Hogan. scholar who pioneered early work in the field of
x-ray crystallography. The award allows outstanding
Hogan went on to explain that another challenge in the inorganic chemistry PhD students to study abroad at
design of ligands for gallium-68 radiopharmaceuticals world class research institutes.
is finding a temperature that efficiently allows
radiolabelling but does not decompose the sensitive
biological vector (small molecule, peptide or antibody).
This article has been reproduced with the permission of ANSTO. For more
“The potential great advantage of NOTET is that it details, visit ansto.gov.au/news
can be radiolabelled under mild, room temperature
conditions, and that these conditions are favourable
for many sensitive biological vectors. We will be
performing a side-by-side comparison of NOTET
with NOTA / DOTA in neuroendocrine tumour animal

Articles
Relevance of the blood glucose concentration, and

current management with GLP-1 receptor agonists, to
clinical gastric emptying measurement in diabetes
Authors: Karen L. Jones1,2,3, Kate Romeo3, Cristina Blefari3
1
Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide Medical School, The University of Adelaide, Adelaide, Australia
2
Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
3
School of Health Sciences, University of South Australia, Adelaide Australia
ABSTRACT
Despite being developed in the late 1970’s - 1980’s, ground in a highly regulated manner into particles
scintigraphy still represents the ‘gold standard’ <1mm in size (the lag phase) before it is emptied in
measurement of gastric emptying and, in the past an overall linear pattern, while high-nutrient liquids
decade, referral rates have increased substantially, empty after no, or little, lag phase in a linear, and
consequent to the recognition that disordered, low-nutrient liquids in a monoexponential, fashion.
particularly delayed, emptying occurs frequently. Inhibitory feedback arising from the interaction of
Guidelines for standardisation have been developed, nutrients with the small intestine plays a major role in
however, there is marked variation in the technique the regulation of gastric emptying. In health, gastric
between users. Gastroparesis occurs in ~40% emptying exhibits a low intra-, but, substantial inter-
of people with longstanding type 1 (insulin- individual, variation of 1-4kcal/min1. The latter is
dependent), or type 2, diabetes and gastric emptying even greater in patients with diabetes given that
measurements are, accordingly, performed frequently disordered gastric emptying, particularly, abnormally
in this group. Diabetes is associated with both elevated slow (gastroparesis), occurs frequently i.e. in ~30-
(hyperglycaemia) and abnormally low (hypoglycaemia) 50% of patients with longstanding diabetes, and
blood glucose concentrations – hyperglycaemia slows, some patients have more rapid emptying2, 3. Patients
while hypoglycaemia accelerates, gastric emptying. with diabetic gastroparesis frequently experience
Glucagon-like peptide-1 (GLP-1) receptor agonists bothersome upper gastrointestinal symptoms, such as
are increasingly used to treat hyperglycaemia in type nausea, fullness and vomiting4, 5 which affect quality of
2 diabetes and, particularly when “short-acting”, have life adversely6. The incidence of diabetic gastroparesis
profound effects to slow gastric emptying. is increasing, in part because both type 1 and type 2
diabetes are more common, and it represents a major
INTRODUCTION cause of health care costs7. In people with diabetes
who are taking insulin, gastroparesis may lead to
Clinical research is particularly rewarding when the increased fluctuations in glycaemia and a propensity
outcomes can be translated into significant changes to hypoglycaemia so that overall blood glucose
in clinical practice – this is the case for information control, usually assessed by measurement of glycated
relating to the effects of acute changes in blood haemoglobin, is poor, which increases the risk of
glucose and so-called GLP-1 receptor agonists on the diabetic complications such as eye, kidney and nerve
rate of gastric emptying. Gastric emptying is a complex damage8. Hence, measurement of gastric emptying in
process, dependent on the integration of contractions diabetes is important. In Australia, there has been an
in different regions of the stomach and proximal small approximate doubling in the number of scintigraphic
intestine, to deliver nutrients into the small intestine, gastric emptying referrals/annum in the last decade
to maximise digestion and absorption. Solid food is (~5400 in 2018; Medicare Australia).

o f exc e l l e n c e i n
Nuclear Medicine
al
rt of The Australian and New Zealand Society of Nuclear Medicine
o
ucation P
• Free subscription to Gamma Gazette, the society's official

Ed
magazine, which provides news, educational articles and a

e
in means of publication for individual members’ research work.

Onl
• Exclusive access to EduTrace, the society's platform of
s educational resources to support your CPD
i tie • Access and discounted prices to Local Branch Meetings, which
n
keep members up to date with the latest developments in
tu
Oppor
nuclear medicine.
• Exclusive invitations to education seminars which highlight
developing aspects of nuclear medicine run by special interest
ing
groups.
• Exclusive invitation and a discounted rate to attend the society's
rk
e t wo Annual Scientific Meeting which is the major education event

for nuclear medicine in Australia and New Zealand and
N
includes international and national experts.
rces • Advocacy and representation with suppliers and government
u bodies
o
• Specialised interest groups (SIGs) for Technologists,

able Res
Radiopharmaceutical Scientists and Physicists

• Access to industry Awards for the recognition of members
who present new research and development activities at local
lu
or national meetings.
Va
• Access to The ANSTO/AZNSNM Research Grant Award of

$20,000 every year.
• Exclusive access to members-only resources, including
G G historical publications and records of the Society’s activities
to since its establishment in 1969.
n
• Subscription to the society's monthly news update, delivering

criptio
the latest news, events, job vacancies and other matters

relevant to the profession.
• Access to a network of professionals through local and national
bs
events and conferences

Su
• Free Attendo Plus CPD & Compliance mobile app.
anzsnm.org.au/membership
Articles
Relevance of the blood glucose concentration, and current management

with GLP-1 receptor agonists, to clinical gastric emptying measurement in
diabetes (Continued)
MEASUREMENT OF GASTRIC EMPTYING solid and liquid meal components was greater during
hyperglycaemia when compared to euglycaemia (~4-
While there are a number of techniques that can be 5 mmol/L)15. Furthermore, Schvarcz et al have shown
used to measure gastric emptying, including SPECT, in health and type 1 diabetes that even changes
MRI, non-radioisotopic breath tests, absorption in blood glucose within the normal physiological
kinetics of oral drugs e.g. paracetamol, radiopaque postprandial range (~4-8 mmol/L) have a significant
markers, the Smart Pill and ultrasonography, impact on gastric emptying of solids and liquids.
scintigraphy, developed in the 1970s-80s, remains
the ‘gold standard’8. The US and Europe have Hypoglycaemia
developed guidelines for standardisation of the While a number of studies have evaluated the
technique9, 10, however, the suggested test meal, effect of hyperglycaemia (~15 mmol/L) on gastric
‘powdered Eggbeaters®’ with bread, jam and water, emptying, information relating to the effects of
has significant limitations and is not available hypoglycaemia (~2-3 mmol/L) on gastric emptying is
in Australia. A recent audit in South Australia much more limited16. In a series of studies by Schvarcz
demonstrated marked variations in the technique and colleagues, using a so-called glucose-insulin
used – test meals, radiopharmaceuticals (dual or clamp, hypoglycaemia (~2.0 mmol/L) was shown to
single isotope) and imaging times, between nuclear accelerate gastric emptying of solids and liquids in
medicine departments (unpublished), which is clearly healthy subjects and patients with uncomplicated
suboptimal. Two important issues overlooked in this type 1 diabetes substantially17, 18. In a subsequent
audit were the relevance of measurement of blood study by our group, using scintigraphy, the marked
glucose concentrations and the increasing use of acceleration of gastric emptying by hypoglycaemia
glucagon-like peptide-1 (GLP-1) receptor agonists in (~2.6 mmol/L) was shown to occur in people with
patients with diabetes, which represents the focus of longstanding type 1 diabetes19. This study also
this article. demonstrated that the magnitude of the acceleration
was greater when baseline gastric emptying was
EFFECTS OF BLOOD GLUCOSE ON GASTRIC EMPTYING relatively slower. Further studies by our group have
also shown in healthy subjects that hypoglycaemia
It is now well established that acute changes in the (~2.6mmol/L), induced via a glucose-insulin clamp,
blood glucose concentration have major reversible accelerates glucose absorption markedly, as assessed
effects on the rate of gastric emptying in both healthy by the glucose analogue, 3-O-methylglucose (3-
subjects and patients with diabetes8. OMG)20.
Hyperglycaemia Accordingly, at a minimum, fasting blood glucose

Studies by our group11, 12 and others13, 14 have concentrations should be assessed in all patients with
established that acute hyperglycaemia (~15 mmol/L) diabetes, and ideally measured at 30-minute intervals
has a profound effect to slow gastric emptying in during the gastric emptying study. In the event that
both health and diabetes. In a study by Fraser and fasting levels are high, any delay in gastric emptying
colleagues, the number of patients with type 1 should be viewed circumspectly due to the potential
diabetes with abnormally delayed gastric emptying of effects of hyperglycaemia.

Articles

EFFECTS OF GASTRIC EMPTYING ON BLOOD GLUCOSE

on slowing of gastric emptying (Figure)23 and are
While the blood glucose concentration markedly frequently associated with gastrointestinal symptoms
influences the rate of gastric emptying, the relationship such as nausea and vomiting, particularly soon after
is bi-directional such that, in both healthy subjects21 commencement of treatment24. In contrast, long-
and patients with type 2 diabetes22, approximately acting GLP-1 receptor agonists are thought to have
35% of the variance in the postprandial blood glucose more profound effects on lowering fasting, as opposed
response is dependent on the rate of gastric emptying to postprandial, blood glucose concentrations via
i.e. more rapid gastric emptying leads to a greater rise their insulinotropic actions25. We have recently shown,
in blood glucose. however, that long-acting GLP-1 agonists have an
effect to slow gastric emptying (unpublished). During
GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONISTS clinical measurement it is, therefore, important to
recognise the potential effects of GLP-1 receptor
GLP-1 receptor agonists are now used widely, and agonists on gastric emptying. If ceasing medication
increasingly, in the management of type 2 diabetes, to prior to measurement, the drug should be withdrawn
lower elevated fasting and postprandial blood glucose for at least 4 half-lives.
concentrations. The hormone, GLP-1, released from
the intestine stimulates insulin, suppresses glucagon SUMMARY
and slows gastric emptying – all contributing to a
reduction in blood glucose. GLP-1 receptor agonists In patients with diabetes, technologists are
were developed because GLP-1 is broken down recommended to:
rapidly (2-4 min) in the circulation and can be “short-
acting” (e.g. lixisenatide, exenatide BD) or “long- • measure fasting blood glucose concentrations.
acting” (e.g. dulaglutide, liraglutide, exenatide QW) • ask all type 2 patients whether they are
based on their plasma half-life8. The first available GLP- taking a GLP-1 receptor agonist as part of their
1 receptor agonist, exenatide BD, available since 2005, management and, if so, which one.
is a synthetic version of Exendin-4, first identified • allow adequate time for the drug to be ‘washed
in the venom of the Gila Monster lizard – but that is out’ effectively, if ceasing medication prior to
another story! Short-acting GLP-1 receptor agonists the gastric emptying study.
lower postprandial blood glucose concentrations • provide all relevant information to the reporting
substantially, predominantly via their marked effect physician.

Articles

References
1. Brener W, Hendrix TR, McHugh PR. Regulation of the gastric emptying of 13. Samsom M, Akkermans LMA, Jebbink RJA, Van Isselt H, VanBerge-
glucose. Gastroenterology 1983;85:76-82. Henegouwen GP, Smout AJPM. Gastrointestinal motor mechanisms in
2. Jones KL, Horowitz M, Wishart JM, Maddox AF, Harding PE, Chatterton BE. hyperglycaemia induced delayed gastric emptying in type I diabetes mellitus.
Relationships between gastric emptying, intragastric meal distribution and Gut 1997;40:641-6.
blood glucose concentrations in diabetes mellitus. J Nucl Med 1995;36:2220-8. 14. MacGregor IL, Gueller R, Watts HD, Meyer JH. The effect of acute hyperglycemia
3. Horowitz M, Harding PE, Maddox AF, Wishart JM, Akkermans LM, Chatterton on gastric emptying in man. Gastroenterol 1976;70:190-6.
BE, et al. Gastric and oesophageal emptying in patients with type 2 (non- 15. Fraser RJ, Horowitz M, Maddox AF, Harding PE, Chatterton BE, Dent J.
insulin-dependent) diabetes mellitus. Diabetologia 1989;32:151-9. Hyperglycaemia slows gastric emptying in type 1 (insulin-dependent)
4. Schvarcz E, Palmer M, Ingberg CM, Aman J, Berne C. Increased prevalence diabetes mellitus. Diabetologia 1990;33:675-80.
of upper gastrointestinal symptoms in long-term type 1 diabetes mellitus. 16. Marathe CS, Marathe JA, Rayner CK, Kar P, Jones KL, Horowitz M.
Diabetic Medicine 1996;13:478-81. Hypoglycaemia and gastric emptying. Diabetes Obes Metab 2019;21:491-8.
5. Du YT, Rayner CK, Jones KL, Talley NJ, Horowitz M. Gastrointestinal Symptoms 17. Schvarcz E, Palmer M, Aman J, Berne C. Hypoglycemia increases the gastric
in Diabetes: Prevalence, Assessment, Pathogenesis, and Management. emptying rate in healthy subjects. Diabetes Care 1995;18:674-6.
Diabetes Care 2018;41:627-37. 18. Schvarcz E, Palmer M, Aman J, Lindkvist B, Beckman KW. Hypoglycaemia
6. Talley NJ, Holtmann G, Agreus L, Jones M. Gastrointestinal symptoms and increases the gastric emptying rate in patients with type 1 diabetes mellitus.
subjects cluster into distinct upper and lower groupings in the community: a Diabetic Medicine 1993;10:660-3.
four nations study. Am J Gastroenterol 2000;95:1439-47. 19. Russo A, Stevens JE, Chen R, Gentilcore D, Burnet R, Horowitz M, et al. Insulin-
7. Wang YR, Fisher RS, Parkman HP. Gastroparesis-related hospitalizations in induced hypoglycemia accelerates gastric emptying of solids and liquids in
the United States: trends, characteristics, and outcomes, 1995-2004. Am J long-standing type 1 diabetes. J Clin Endocrinol Metab 2005;90:4489-95.
Gastroenterol 2008;103:313-22. 20. Plummer MP, Jones KL, Annink CE, Cousins CE, Meier JJ, Chapman MJ, et
8. Phillips LK, Deane AM, Jones KL, Rayner CK, Horowitz M. Gastric emptying and al. Glucagon-like peptide 1 attenuates the acceleration of gastric emptying
glycaemia in health and diabetes mellitus. Nat Rev Endocrinol 2015;11:112-28. induced by hypoglycemia in healthy subjects. Diabetes Care 2014;37:1509-15.
9. Abell TL, Camilleri M, Donohoe K, Hasler WL, Lin HC, Maurer AH, et al. 21. Horowitz M, Edelbroek MA, Wishart JM, Straathof JW. Relationship between
Consensus recommendations for gastric emptying scintigraphy: a joint report oral glucose tolerance and gastric emptying in normal healthy subjects.
of the American Neurogastroenterology and Motility Society and the Society Diabetologia 1993;36:857-62.
of Nuclear Medicine. J Nucl Med Technol 2008;36:44-54. 22. Jones KL, Horowitz M, Carney BI, Wishart JM, Guha S, Green L. Gastric
10. Rao SS, Camilleri M, Hasler WL, Maurer AH, Parkman HP, Saad R, et al. emptying in “early” noninsulin-dependent diabetes mellitus relationship to
Evaluation of gastrointestinal transit in clinical practice: position paper of oral glucose tolerance and appetite. J Nucl Med 1996;37:1643-8.
the American and European Neurogastroenterology and Motility Societies. 23. Jones KL, Rigda RS, Buttfield MDM, Hatzinikolas S, Pham HT, Marathe CS, et
Neurogastroenterol Motil 2011;23:8-23. al. Effects of lixisenatide on postprandial blood pressure, gastric emptying and
11. Jones KL, Berry M, Kong MF, Kwiatek MA, Samsom M, Horowitz M. glycaemia in healthy people and people with type 2 diabetes. Diabetes Obes
Hyperglycemia attenuates the gastrokinetic effect of erythromycin and affects Metab 2019 [ePub ahead of print].
the perception of postprandial hunger in normal subjects. Diabetes Care 24. Marathe CS, Rayner CK, Jones KL, Horowitz M. Glucagon-like peptides 1 and 2
1999;22:339-44. in health and disease: a review. Peptides 2013;44:75-86.
12. Plummer MP, Jones KL, Cousins CE, Trahair LG, Meier JJ, Chapman MJ, et 25. Drucker DJ, Buse JB, Taylor K, Kendall DM, Trautmann M, Zhuang D, et al.
al. Hyperglycemia potentiates the slowing of gastric emptying induced by Exenatide once weekly versus twice daily for the treatment of type 2 diabetes:
exogenous GLP-1. Diabetes Care 2015;38:1123-9. a andomised, open-label, non-inferiority study. Lancet 2008;372:1240-50.
Corresponding author: Professor Karen Jones, William T Southcott Research Fellow in Nuclear Medicine, Centre
of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Level 5
Adelaide Health and Medical Sciences Building, Cnr North Tce and George St, Adelaide, SA 5005, Australia.
Email: karen.jones@adelaide.edu.au | Telephone: +61 8 8313 7821

EVENTS CALENDAR
26 - 28 April 2019 1 May 2019

49th Annual Scientific Meeting of QLD Branch Meeting
the Australian and New Zealand
Society of Nuclear Medicine Visit website for venue
details
Adelaide Convention Centre,
1 CPD Points
Sth Australia
6 CPD Points
9 - 12 May 2019 11 June 2019

13th Asia Oceania Congress of WA Branch Meeting
Nuclear Medicine and Biology (Post Conference)
QUBE/Qbox hotel Shanghai, SKG Radiology, St John of God
Pudong New Area, Shanghai, Hospital, 12 Salvado Road,
China Subiaco, WA, 6008
1 CPD Points
22 - 25 June 2019 3 July 2019

SNMMI Annual Meeting SA Branch Meeting
Anaheim, California, Women's and Children's

USA Hospital
1 CPD Points
6 July 2019 24 July 2019

VIC/TAS Branch Scientific SA Branch ANZSNMT
Meeting (The A to Z of Meeting (Biliary Imaging)
Thoracic Imaging)
RSA Calvary, North Adelaide
Austin Health, 145 Studley
Road, Heidelberg VIC 3084 1 CPD Points
1 CPD Points
anzsnm.org.au
Attendo Plus mobile App
50th Annual Scientific
Meeting of the Australian
and New Zealand Society
of Nuclear Medicine
24th – 26th April 2020
Sydney, Australia
www.anzsnmconference.com/ANZSNM2020
@anzsnm2020
ANZSNM 2020 on Facebook:

http://bit.ly/anzsnm2020
On behalf of the Australian and New Zealand Society of Nuclear

Medicine (ANZSNM)
and New Zealand Society of Nuclear Medicine, which will be held in

Sydney, from the 24th – 26th April 2020. The theme of the
past (2020 hindsight) and a strategic look forward (2020

vision).
The main program will be supported by pre-conference
learning, big data and their role in precision medicine

(Intelligent Imaging Summit 2020) on
24 April.
Mark ANZSNM 2020 in your diary.
Please refer to the Conference website for more
ANZSNM 2020 Conference Manager

Plevin and Associates Pty Ltd
See you in Sydney in April 2020! Tel +61 8 8379 8222 | anzsnm2020@plevin.com.au
Back to Basics
CROSSWORD CLUES
Down
1. Telmisartan (Micardis) is a type of … II

receptor blocker.
2. A syndrome with symptoms including
nausea, vomiting, early satiety,
postprandial fullness, bloating and
upper abdominal pain.
4. … shunt, also known as LeVeen
Shunt.
5. A process of blood formation
occurring primarily in the bone marrow.
6. A condition of excess circulating
bilirubin.
7. Hormone with molecular formula
C15H10I4NNaO4. Also known as
levothyroxine.
8. Avascular … commonly affects the
ends of long bones.
10. A peptide hormone that regulates
the endocrine system, also known as
growth hormone-inhibiting hormone.
16. … effects occur by chance and is
thought to follow the linear-quadratic
no threshold hypothesis.
18. The amount of blood pumped out
of the ventricle divided by the total
amount of blood in the ventricle equal
the … fraction.
19. Abnormally reduced cardiac muscle
mobility.
22. Syndrome is characterized by
hypercortisolism.
24. Pharmaceutical labelled with
Carbon-11. Metabolized into acetyl-CoA.
27. A common indication for CSF leak
investigation.
Across
3. …. tumour, the second most common benign parotid tumour, 20. Method of radiopharmaceutical localization in the RES
representing up to 10 – 15% of all parotid epithelial tumours. following intravenous colloid injection.
9. A type of upper urinary tract infection. 21. ... acid is utilized in assessing renal cortical defect.
11. … cells are specialized stellate macrophages located in the 23. German for ‘braking radiation’.
liver sinusoids. 25. … cell is the most abundant cell in the adrenal medulla.
12. ... disease is characterized by structural and functional Columnar in shape.
neurodegeneration. 26. An outpouching of the small intestine.
13. … cancer, is the third most common thyroid cancer. 28. Secreted by the alpha cells of the pancreatic islets to increase
14. A condition comprising cholesterol stones, black pigment blood sugar.
stones or brown pigment stones. 29. …. -90 is a pure beta emitter with half-life of 2.6days & average
15. Method in which phosphate groups bind to the hydroxyapatite tissue penetration of 2.5mm in liver.
crystal in bone. 30. ... famously said ‘Fish are friends not food’. Also name of
17. A breakdown product of creatinine phosphate in muscle. exercise test protocol with four 3-minute stages.
FIND THE ANSWERS ON PAGE 71

Download it from
the iTunes Store
• Register and get notified for upcoming events

Download it from
• Check in using the QR scanner Google Play
• Receive instant certificates of attendance
• Record your CPD points
• Keep a logbook
• Provide instant feedback
COMING SOON
All from one single app and

all synchronised with your
membership file
OFFICE BEARERS
President A/Prof Roslyn Francis (WA)

Vice President Dr Daniel Badger (SA)
Past President Prof Dale Bailey (NSW)
Treasurer Mr Dominic Mensforth (SA)
Committee Ms Marcia Wood (TSIG)
Dr Rajiv Bhalla (RPS)
Mr Nicholas Ingold (ACT)
Ms Judy Duong (QLD)
Ms Victoria Brooks (NZ)
Mr Christian Testa (VIC/TAS)
Dr Geoff Schembri (AANMS Representative)
General Manager & Secretariat Rajeev Chandra and Drajon Management Pty Ltd
All Correspondence ANZSNM Secretariat, PO Box 6178, Vermont South, Victoria 3133
Tel: 1300 330 402 | Fax: (03) 8677 2970
Email: secretariat@anzsnm.org.au
Branch Secretaries
Australian Capital Territory Mrs Rachel Prior
New South Wales Vacant
Queensland Miss Remi Hillery and Ms Loren Katchel
South Australia Mrs Tess Smith
Victoria/Tasmania Ms My Linh Diep
Western Australia Ms Georgina Santich
New Zealand Ms Jessica Fagan
Special Interest Groups/

Committees
Technologists Chairperson: Dr Elizabeth Bailey
Radiopharmaceutical Science Chairperson: Dr Rajiv Bhalla
Physics Chairperson: Dr Daniel Badger
Technical Standards Committee Chairperson: Dr Darin O’Keeffe
Scientific Advisory Panel Chairperson: Prof Dale Bailey
International Relations Committee Chairperson: Prof Andrew Scott
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:
ARPANSA Heidelberg VIC 3084

619 Lower Plenty Road Tel: (03) 9496 3336
Yallambie VIC 3085 Fax: (03) 9457 6605
Tel: (03) 9433 2211 email: gordon.chan@petnm.unimelb.edu.au
Fax: (03) 9432 1835
Mr J. Gordon Chan
Department of Nuclear Medicine,
Austin & Repatriation Medical Centre,
AIMS AND OBJECTIVES OF THE
AUSTRALIAN AND NEW ZEALAND
SOCIETY OF NUCLEAR MEDICINE
1. Promote:
• The advancement of clinical practice of nuclear
medicine in Australia and New Zealand;
• Research in nuclear medicine;
• Public education regarding the principles and
applications of nuclear medicine techniques in
medicine and biology at national and regional
levels;
• Co-operation between organisations and
individuals interested in nuclear medicine; and
• The training of persons in all facets of nuclear
medicine.
2. Provide opportunities for collective discussion
CONTENT SUBMISSIONS
on all or any aspect of nuclear medicine through
standing committees and special groups:
• The Technical Standards Committee sets Scientific submissions on all aspects of nuclear
minimum standards and develops quality control medicine are encouraged and should be
procedures for nuclear medicine instrumentation forwarded to the Secretariat (instructions for
in Australia and New Zealand.
authors published at www.anzsnm.org.au).
• The TSIG Committee is the group overseeing
the Technologist Special Interest Group (TSIG) Letters to the Editor or points of view for
and ensures that all projects, committees and discussion are also welcome.
activities of the TSIG align with the values and
strategic plan of the ANZSNM. It reports directly
to the ANZSNM Federal Council and oversees If original or public domain articles are found
the two TSIG working groups: CPD & Education and considered to be of general interest to the
Working Group and Technologist Workforce membership, then they should be recommended
Advocacy Working Group. The committee is
to the Editor who may seek permission to
able to form working groups to perform specific
tasks as required to provide opportunities for the reprint.
benefit of Technologist members of the ANZSNM
after consultation with the ANZSNM Federal The ANZSNM Gamma Gazette is published
Council.
three times a year. Deadlines for each issue of
• The Radiopharmaceutical Science SIG and a
Physics SIG that maintain standards of practice the journal can be found on our website
for their particular speciality and provide a forum anzsnm.org.au
for development in Australia and New Zealand.
DISCLAIMER
ANSWERS CROSSWORDS
The views expressed in any signed article in the
1. Angiotensin 16. Stochastic journal do not necessarily represent those of
2. Gastroparesis 17. Creatinine the Society.
3. Warthin’s 18. Ejection
4. Peritoneovenous 19. Hypokinesis The individual rights of all authors
5. Haematopoiesis 20. Phagocytosis are acknowledged.
6. Hyperbilirubinemia 21. Dimercaptosuccini
7. Thyroxine 22. Cushing’s © 2019 The Australian and New Zealand
8. Necrosis 23. Bremsstrahlung
9. Pyelonephritis 24. Acetate Society of Nuclear Medicine.
10. Somatostatin 25. Chromatin
11. Kupffer 26. Meckel’s Copyright is transferred to the Australian and New Zealand
12. Alzheimer’s 27. Otorrhea Society of Nuclear Medicine once an article/paper has been
13. Medullary 28. Glucagon published in the ANZSNM Gamma Gazette (except where
14. Cholelithiasis 29. Yttrium it is reprinted from another publication).
15. Chemisorption 30. Bruce

ANZSNM Gamma Gazette Autumn 2019 PDF

Загружено:

Сведения о документе

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

ANZSNM Gamma Gazette Autumn 2019 PDF

Загружено:

Авторское право:

Доступные форматы

2019 AUTUMN EDITION | ISSUE 26

CELEBRATING THE 50 ANNIVERSARY

in Australia – a small example

Editorial Design & Production Events & Advertising Enquiries

I look forward to seeing you in Adelaide.

2019 Autumn Edition | gamma GAZETTE | 3

30 years on: The Cold War and Nuclear Medicine in

But my story is simpler and has a better outcome.

4 | gamma GAZETTE | 2019 Autumn Edition

30 years on: The Cold War and Nuclear Medicine in Australia

After over a year back in Sydney after the Utrecht meeting

2019 Autumn Edition | gamma GAZETTE | 5

30 years on: The Cold War and Nuclear Medicine in Australia

6 | gamma GAZETTE | 2019 Autumn Edition

Western Australia Branch News

South Australia Branch News

8 | gamma GAZETTE | 2019 Autumn Edition

New Zealand Branch News

They are us. Kia Kaha Christchurch and New Zealand.

This past September, Kirsten Worthington and the

The highlight was guest speaker, Mark Marcenko from

Unfortunately, there were no NZ entrants for the

The Saturday evening gala dinner was held at

2019 Autumn Edition | gamma GAZETTE | 9

New Zealand Branch News (Continued)

Especially Chrissie Roodt, who

The New Zealand Nuclear

Excitingly, Lutetium-177 PSMA

10 | gamma GAZETTE | 2019 Autumn Edition

New Zealand Branch News (Continued)

Jessica Fagan - Secretary, New Zealand Brach

2019 Autumn Edition | gamma GAZETTE | 11

Victoria and Tasmania Branch News

We hope all of our members had a relaxing break

non-invasive approach to cannulation, such as oral

In continuing our goal of providing regular and

12 | gamma GAZETTE | 2019 Autumn Edition

Rudolph was a most talented doctor, much

He was a graduate of the Melbourne University and

He completed post graduate training in Radiotherapy

He became Director of Nuclear Medicine at St

TSIG Day Symposium, 24th August 2019

Register via website anzsnm.org.au/2019TSIG

Send abstracts to secretariat@anzsnm.org.au

EARLY BIRD PRICE STARTING AT ONLY $115 AND $70 (STUDENTS)

Please visit bit.ly/TSIG2019 for more information.

Annual Day Symposium

International Relations Committee of ANZSNM

2019 Autumn Edition | gamma GAZETTE | 15

To every single member and individual who

We are committed to continue to be leaders

A Nuclear Medicine Society

2019 Autumn Edition | gamma GAZETTE | 17

Australian Society of Nuclear First Asia and Oceania

18 | gamma GAZETTE | 2019 Autumn Edition

Brian Hutton, Brenda Walker and Richard Smart

2019 Autumn Edition | gamma GAZETTE | 19

A Nuclear Medicine Society (Continued)

We have thought about the possibility of a college of nuclear medicine

Hare concludes his letter by emphasising the success of the impending

However, as Professor of Radiology, I hope the decisions which are

I am in sympathy with the idea of formation of a college of nuclear

Dugdale elaborated on what he felt would be some of the difficulties

Rotorua Energy Events Centre