Poster Abstracts P OSTER ABSTRACTS P02 PROSTHETIC VALVE INFECTION AND THE USE OF F - 18 F DG PET/CT Nicole Kearney 1 , Suresh Viswanathan 2 , Samuel Adera 2 1 H unter New England Imaging, NSW, Australia 2 H unter New England Health, NSW, Australia Cardiology/Respiratory Background: A 74 year old male with previous history of myocardial P 01 infarction, CABG, aortic valve and aortic root replacement presented C OMPARISON OF GATED HEART BLOOD POOL STUDIES USING with Salmonella sepsis with an unknown source. The patient commenced NOVEL CADMIUM-ZINC-TELLURIDE SPECT IMAGING TECHNOLOGY intravenous ceftriaxone on admission to hospital and due to his prosthetic WITH CONVENTIONAL ANGER CAMERA PLANAR IMAGING aortic valve infective endocarditis (IE) was strongly suspected. Both Emma Fleming , Barbara Bedford, Hugh Dixon , Chuong Bui, transthoracic (TTE) and transoesophageal (TOE) echocardiograms showed Quee Li Chiam, Kien Lee no evidence of vegetation or aortic root abscess. CT performed of the Bankstown-Lidcombe Hospital, NSW, Australia abdomen and thorax failed to demonstrate any source of infection. On the fi fth day of hospital admission he developed bradycardia due to intermittent Background: Novel dedicated cardiac cameras using cadmium-zinc-tellu- atrioventricular block resulting in the insertion of a dual chamber ride (CZT) technology, primarily used for myocardial perfusion imaging, pacemaker. have dramatically higher performance than conventional Anger cameras. Using this novel technology to perform gated heart pool scans (GHPS) has Method & Results: F-18 FDG PET/CT images demonstrated abnormal tracer the potential to improve effi ciency, patient experience and dosimetry. accumulation in the root of the aorta extending to the site of valve prosthesis and in the anterior portion of the root of the aorta, at the site of an aneurysm, Aim: To compare the assessment of left-ventricular ejection fraction (LVEF) increased lung uptake in the upper right lobe and bilateral effusions. and function using CZT-SPECT imaging (GE570c) to conventional planar imaging (GE670). Discussion: TOE has a sensitivity of between 90 and 100% when detecting vegetations associated with IE. This fi gure decreases to 50% in the presence M ethods: 44 patients attending for GHPS were studied using conventional of a prosthetic valve. FDG PET/CT, while nonspecifi c in nature, is highly planar imaging (GE670), immediately followed by a 5 minute CZT-SPECT sensitive for detecting foci of infection and has a high negative predictive acquisition (GE570c). Planar images were manually processed to calculate value, and hence may have a role in detecting endocarditis/prosthetic valve the planar-LVEF (pLVEF). CZT-SPECT images were processed with an infection. One week following the PET scan a repeat TOE was consistent automated algorithm to calculate SPECT-LVEF (sLVEF). Wall motion was with development of aortic root abscess. assessed visually in both studies. C onclusion: This case demonstrates the usefulness of F-18 FDG PET/CT Results: One patient was technically unsuccessful due large body habitus in diagnosing IE more accurately than TOE or TTE, which are usually con- (BMI = 55) causing image truncation on GE570c. In 4 patients the sLVEF sidered the gold standard, and thereby facilitating the management of this measurement was unsatisfactory due to poor edge detection by the auto- relatively rare condition that carries signifi cant mortality. mated algorithm where there was adjacent increased gut or liver activity. However the automated algorithm for sLVEF was highly reproducible with retest correlation of 0.997. For the remaining 39 patients, using the linear regression equation y = mx + b, where y = sLVEF; x = pLVEF; Slope, m = 0.95; Intercept, b = 2.35%; Correlation, r = 0.82. All 6 reporting physicians found CZT-SPECT useful to assess regional wall motion abnormalities in all dimensions and to quantify absolute end diastolic and end systolic volumes. P 03 ‘AIR TRAPPING’ AS A CAUSE FOR V Q SPECT PERFUSION C onclusion: Measurement of LVEF using CZT-SPECT imaging correlated MISMATCH well with conventional planar imaging. Technical limitations arose in very large patients and in patients with increased gut and liver activity. CZT-SPECT is Kenny Sek , Charles Werren, Teck Siew , Michael McCarthy a useful three-dimensional imaging technique which increases reporter confi - R oyal Perth Hospital, Perth, Australia dence in assessing wall motion abnormalities and in quantifying volumes. It Background: The more widespread adoption of VQ SPECT and SPECT-CT has a promising role in GHPS to signifi cantly reduce imaging time and dose. has led to the increased detection of VQ mismatches. In some cases, this can be Figure 1 Comparison o f LVEF measurement with CZT-SPECT (sLVEF) to planar (pLVEF) imaging. © 2013 Royal Australasian College of Physicians 21 Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 43rd Annual Scientifi c Meeting of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) attributed to apparent increased ventilation as seen with the physiologic ‘rind’ Molecular Imaging effect in VQ SPECT. A similar effect can be seen in the setting of some pulmo- nary parenchymal pathology which causes apparent ‘air-trapping’, leading to P05 areas of marked perfusion reduction but maintained ventilation. This appears to DEVELOPING NATIONAL CAPABILITY FOR THE PRODUCTION AND be most common in the setting of emphysematous change. While this can be USE OF RADIOMETAL BASED RADIOPHARMACEUTICALS easily recognised if it is part of a diffuse emphysematous process, regional or Nigel Lengk, P aul Pellegrini , Elisabeth Oehlke , Benjamin Fraser , more localised lung parenchymal change can be more diffi cult to recognise. Ivan Greguric Aim: We would like to highlight the potential of this ‘air-trapping’ phenom- A NSTO, Lucas Heights, NSW, Australia enon in causing perfusion mismatch, resulting in a false positive VQ scan, Radiometals remain key radioisotopes for radio-medicine; the mainstay diag- and to explore features of ventilation-perfusion abnormalities on VQ SPECT nostic medical imaging isotope, 99m Tc, and important radioisotopes for radio- that could be helpful in differentiating non-embolic versus embolic causes. therapy, 90 Y and 1 53S m. However, the worldwide growth in PET centres, 18 Method and Results: We present three cases where underlying lung disease driven by the wildly successful [ F]-FDG, has provided a yet to be seized leads to at least partial perfusion mismatch. Discussion regarding the under- opportunity to deliver radiometal-based radiopharmaceuticals with clinical lying pathophysiology will be presented. We will explore certain unique scin- relevance to researchers. An ever growing set of radiometals is becoming tigraphic features of this ‘air-trapping’ phenomenon and the role of the CT available in Australia covering a wide range of half-lives, nuclear and chemical 64 68 86 89 component of SPECT-CT or CT chest will be emphasised. properties, these include Cu, G a, Y, Zr, and looking into the near 44 45 90 C ase 1: Congenital sublobar emphysema future, Sc, Ti and Nb. Case 2: Bronchiolitis obliterans A NSTO ’ s Lifesciences division is working to provide the Australian academic C ase 3: Interstitial pulmonary fi brosis and clinical communities access to the following key areas. Conclusion: These cases illustrate the fact that a variety of pulmonary parenchymal pathology can lead to pulmonary vascular changes causing Radioisotope supply perfusion mismatch. An expansile or bulging border around a ventilation or Two in-house 68 Ge/6 8G a generators; one solely for research and a larger perfusion abnormality should raise the suspicion that apparent perfusion generator for pre-clinical trials, provide access to this key radioisotope. mismatch could be due to ‘air-trapping’ phenomenon. Correlative anatomic ANSTO has provided fi nancial and technical support to numerous cyclotron information from CT images is particularly useful in confi rming the presence centres around Australia for development of solid targetry facilities, ensuring of this phenomenon as a potential mimicker of pulmonary embolism. supply of 124I , 6 4 Cu, 86 Y and 89Z r in the short-term and 44S c, 45 Ti and 90 Nb later. In coming years the OPAL reactor will begin producing pharmaceutical P 04 grade 1 77L u as part of the Australian government’ s investment in nuclear UNRECOGNISED MYOCARDIAL ISCHAEMIA ON ONCOLOGICAL medicine. F DG -P ET Kelvin Yap , Ganesh Ramaseshan, Kylie O’ Halloran, Kim Taubman , Radiometal Labelling Research and Development Stephen Schlicht In addition to our programs developing new ligands, tracers and improved Medical Imaging Department, St. Vincent ’ s Hospital Melbourne, radiometal labelling procedures, Lifesciences is supporting the development Victoria, Australia of new biomolecule treatments by providing researchers access to laborato- Background: Cardiac FDG uptake can be highly variable and non-uniform ries, procedures and expertise tailored specifi cally for functionalising bio- uptake is often dismissed as normal in this location. We present a case, where molecules for radiometal labelling. failure to recognise an important pattern almost led to adverse patient outcome. Preclinical Radiometal Tracer Development M ethod: 67 y.o. man with head and neck malignancy, underwent preopera- We are working to deliver novel radiometal-based diagnostic tracers to the tive staging PET at another institution. He was planned for partial glossec- Australian research and clinical community by accessing the pre-clinical tomy and neck dissection. programs of our key international partnerships at Memorial Sloan Kettering Cancer Centre and Massachusetts General Hospital. Our initial objective is D uring the anaesthetic induction, signifi cant ischaemic ECGs changes to supply the antibodies, i.e. [8 9 Zr]-J591. As our supply radiometals is diversi- caused the operation to be aborted. Subsequent adenosine sestamibi dem- fi ed we will expand into proteins, peptides and other biomolecules. onstrated a small LAD infarct with signifi cant peri-infract ischaemia. Coro- nary angiogram demonstrated triple vessel disease requiring surgical management. Semi-urgent coronary artery bypass grafts, were performed with good recovery. Patient the subsequently underwent an uneventful left partial glossectomy and neck dissection with complete clearance. This case was identifi ed, when he was referred for urgent inpatient myocar- dial perfusion study. Review of his staging FDG-PET demonstrated unre- ported intense LAD territory uptake. Literature review and discussion with PET specialists, confi rmed the presence of ischaemic or hibernating myocardium. R esults: Cardiac uptake of FDG, during routine oncological studies can be highly variable. depending on the length of fasting. After suffi ciently long fasting period (typically > 12 hours) the myocardial metabolism shifts to fatty acids as a source of energy. It has been well recognised by Gropler et al (1999), the septum and anterior wall containing signifi cantly less activity than the lateral and posterior walls. Conclusion: Despite the limitation of variable regional cardiac uptake during routine oncological FDG-PET, it should be recognised that increased uptake in the anterior and septal walls, is abnormal, and hibernating/isch- aemic myocardium should be excluded with other investigations. The failure to recognise this abnormal pattern may lead to adverse outcomes. 22 © 2013 Royal Australasian College of Physicians Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 Poster Abstracts P 06 M ethod: NEMA NU-4 image quality phantom performance testing was P ERFORMANCE EVALUATION OF PRECLINICAL PET SCANNERS performed on the Siemens Inveon with 18 F, 124 I and 64 Cu, using default WITH THE NEMA N U -4 IMAGE QUALITY PHANTOM USING A acquisition parameters and each of the available reconstruction algorithms. COLLECTION OF RADIOISOTOPES Further testing will be performed using 11 C, 6 8 Ga and 89Z r. The Bioscan R ik Nezich 1 ,2 , Anthonin Reilhac 3 , David Zahra 3 , Roger Price 1 ,2 NanoPET scanner will be tested with all of the mentioned isotopes. 1 R adiopharmaceutical Production & Development (RAPID) R esults: The fi gure shows NU-4 phantom images obtained for 18F , 6 4 Cu and Laboratory, Medical Technology and Physics, Sir Charles Gairdner 124I ; using the Inveon preclinical scanner and FBP2D reconstruction. The Hospital, Nedlands, Western Australia, Australia relatively poor image quality obtained with 124 I is mainly caused by single 2 S chool of Physics, University of Western Australia, gamma-photon contamination. Due to a higher positron range, recovery Western Australia, Australia coeffi cients obtained with 124I are well below the values measured with 1 8 F. 3 ANSTO Life Sciences, ANSTO, Lucas Heights, NSW, Australia Conclusion: NEMA NU-4 performance testing provides valuable informa- Background: The radioisotopes 1 8F , 11 C, 124 I, 68G a, 89 Zr and 6 4C u have found tion about the image quality achievable for a given PET scanner and numerous applications in small animal PET imaging, and this entire subset radioisotope. of isotopes will soon be available to Australian preclinical researchers. The suitability of an isotope for a given imaging application is determined largely by its radioactive half-life. However, other characteristic physical properties of the isotope such as the branching fraction and positron energy can severely impact image quality and the ability to accurately quantify uptake of the radio-labelled molecule. Furthermore, the specifi c acquisition parameters and reconstruction algorithms employed to generate the image can signifi - cantly affect the image quality and quantifi cation accuracy. T he NEMA NU-4 2008 standards describe a method to evaluate the per- formance of small animal PET scanners. The information gathered through the NEMA Image Quality phantom scanning experiment is valuable for optimising the scanner usage, because it allows for the best selection of acquisition/reconstruction protocols and provides knowledge of the resolu- tion limits of the system. © 2013 Royal Australasian College of Physicians 23 Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 43rd Annual Scientifi c Meeting of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) P07 commissioning of three key platform technologies; Optical (Bio-Lumines- A TECHNIQUE TO REDUCE LUNG AND LIVER MISREGISTRATION cence and Bio-Fluorescence), micro-PET/MR and micro-SPECT/CT. IN PET /C T M ethod: Performance characteristics for the PET/MR and SPECT/CT Anna Nowicki , Shakher Ramdave, Lisa Bowker, John McKay, systems are measured and reported. Image data are presented for qualitative Jason Bradley review. Research capabilities are discussed. Southern Health, Melbourne, Victoria, Australia C onclusion: The commissioning of state-of-the-art pre-clinical platform Background: A common problem when interpreting PET/CT results is the technologies at the ACRF Centre for Translational Cancer Research and misregistration that occurs from breathing artefact. Artefact occurs as a result Imaging is summarised and the discussed with respect to future pre-clinical of the tidal breathing patterns throughout the PET acquisition. New technol- imaging potential. ogy and techniques are constantly evolving to improve breathing artefact in order to allow better interpretation of scans. Aim: The respiratory gating system employed in our PET/CT is very time consuming and result in long scan times. In a busy department additional P 09 acquisitions create time management problems due to high patient through- APPEARANCE OF 99MT C -SESTAMIBI THYROID SCINTIGRAPHY put. Our aim was to fi nd an alternative simple protocol to reduce breathing WITH CALCULATION OF THYROID-TO-BACKGROUND RATIO IN artefact. PATIENTS WITH GRAVES’ DISEASE, TOXIC MULTINODULAR GOITRE AND HYPOTHYROIDISM Method: A one bed static acquisition was acquired following a whole body PET/CT scan with signifi cant misregistration in either a lung or liver lesion. D avid Pattison 1 ,2 , James Westcott 1 , Dinesh Sivaratnam 1,3 , The patient is placed on the bed supine, with a fi rm strap around their lower Meir Lichtenstein1 chest. Instructions are given to breathe using their upper chest wall in isola- 1 D epartment of Nuclear Medicine, Royal Melbourne Hospital, tion, limiting diaphragmatic motion. The patient is put on 2 litre of oxygen Victoria, Australia to allow for better oxygenation, and to reduce any distress to the patient. A1 2 D epartment of Diabetes & Endocrinology, Royal Melbourne bed PET/CT is acquired over the region of interest at 2/mins per bed to Hospital, Victoria, Australia allow for enough counts but reduced time for patient. 3 D epartment of Cardiology, Royal Melbourne Hospital, Victoria, Australia Results: Our new breathing acquisition has vastly improved PET to CT data registration and in a majority of patients providing a more accurate localisa- B ackground: 9 9m Tc-sestamibi thyroid scintigraphy (9 9m Tc-STS) was recently tion and SUVs of lung and liver lesions. described as an accurate tool for differentiating between subtypes of Amioda- rone-induced thyrotoxicosis (AIT), with important therapeutic implications. C onclusion: Dedicated acquisitions to reduce breathing artefact can be an Type I AIT is due to iodine induced hyperthyroidism (increased 9 9m Tc-sesta- effective way of reducing misregistration in departments that are time poor mibi uptake), while Type II AIT is a destructive process (absent 9 9m Tc-sesta- or respiratory gating is unavailable. mibi uptake). Limited information is available about the appearance and quantifi cation of 9 9m Tc-sestamibi uptake in other thyroid disease. This study aims to describe the appearance of the thyroid (including calculation of thy- roid-to-background ratio [TBR]) in patients with incidental thyroid disease P 08 following injection of 9 9m Tc-sestamibi for parathyroid scintigraphy to provide P RE-CLINICAL IMAGING DEVELOPMENTS AT THE A CRF CENTRE insight into the appearance of 9 9m Tc-STS for investigation of AIT. FOR TRANSLATIONAL CANCER RESEARCH AND IMAGING 1 1 M ethods: Four cases of abnormal thyroid function were identifi ed during a Graeme O ’ Keefe , Sylvia Gong , Kevin Hickson 1 , Angela Rigopoulos 2, 2 2 1 ,2 retrospective audit of 9 9m Tc-sestamibi parathyroid studies performed at Royal Diana Cao , Mark Frewin , Andrew Scott st st 1 Melbourne Hospital (Parkville, Vic) between 1 October 2011 and 31 A ustin Health, Melbourne, Victoria, Australia 2 December 2012. One patient had Graves Disease, two had toxic multinodu- Ludwig Institute for Cancer Research, Melbourne, Victoria, Australia lar goitres (MNG) and a fourth patient had hypothyroidism receiving thy- Background: Progress on the Pre-clinical imaging capability at ACRF roxine replacement. Regions of interest were drawn around the thyroid, and Centre for Translational Cancer Research and Imaging is reported following background inferior to the gland, with subsequent calculation of area-nor- the completion of a dedicated Animal house facility and more recently, the malised TBR. 24 © 2013 Royal Australasian College of Physicians Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 Poster Abstracts R esults: Table 1 T hyroid scintigraphy following injection of 9 9m Tc-sestamibi and 9 9m Tc-pertechnetate with incidental thyroid disease Case 1 Case 2 Case 3 Case 4 Graves ’ Disease Toxic MNG Toxic MNG Hypothyroidism 9 9m Tc-STS appearance Symmetrical, diffuse ↑ uptake A symmetrical enlarged gland, Asymmetrical, heterogeneous Absent uptake heterogeneous uptake ↑ uptake Adenoma Localisation R lower pole R lower pole R upper pole L lower pole TBR 1.79 2.08 1.44 ∼ 1 99m Tc-pertechnetate study D iffuse ↑ uptake (except R lower Heterogeneous uptake, ‘hot’ nodule H eterogeneous uptake (R> L) N/A appearance pole) in L upper pole U ptake = 1.9% U ptake N/A* U ptake = 2.1% L, left; R, right; *derived from parathyroid subtraction study following injection 82 MBq 99mTc-pertechnetate. Conclusion: 18F-FDG is used predominantly for oncology, but increased 18F-FDG 1 . Hyperthyroidism (increased synthesis & release of thyroxine) due to activity is also associated with infection. Using 18F-FDG to assess infection Graves ’ disease and toxic multinodular goitre demonstrates elevated TBR in diabetic feet could potentially reduce imaging time, remove the risks following 99mT c-sestamibi injection. This is consistent with the fi ndings of associated with handling blood products, reduce the likelihood of motion 9 9mT c-STS in Type I AIT. artefacts, and reduce inpatient stay by providing results on the same day. 2. Chronic hypothyroidism is associated with absent 9 9m Tc-sestamibi uptake. A ims: The aim of this study is to initially assess the feasibility and utility of 18F-FDG in infection of extremities. Method: Patients referred to our department query infection of extremities who clinically require a bone scan (99mTc HDP) and a WBC scan (111In Musculoskeletal/Infection/Infl ammation Oxine or 99mTc HMPAO) and fi t within certain inclusion criteria will be P 10 invited to participate in this study. Each patient will undergo an additional I MPACT OF S PECT / CT ON GALIUM-67 IMAGING 18F-FDG PET scan of the area in question and will be followed for 3 months for treatments and outcomes. Their scans will be assessed independently and Rosalie Babicheva , Hugh Dixson, Kien Lee, Quee Li Chiam the randomly assigned Physicians will be blinded to patient outcome. Bankstown-Lidcombe Hospital, NSW, Australia R esults: Sample initial images of 18F-FDG in infection of extremities and Background: Ga-67 is a useful tool for the diagnosis of infl ammation and experiences of staff and patients will be displayed. chronic infection. Our aim was to evaluate the diagnostic value of SPECT/ CT for Ga-67 studies. Conclusion: This study is incomplete and ongoing and results will be reviewed upon conclusion. Methods: Three anatomic locations were evaluated chest, abdomen and pelvis. 73 studies were performed on a 6-slice Philips Precedence camera with CT for attenuation correction and anatomic localisation. Cases were evaluated by the reporting doctor with respect to ‘change in diagnosis’, ‘more accurate diagnosis’ and ‘increase in diagnostic confi dence’. P 12 F DG PET/ CT AND LARGE VESSEL VASCULITIS: A CASE STUDY C T effective dose (E) in milliSievert (mSv) was calculated for each patient using the formula, E = EDLPxDLP, where EDLP is the region-specifi c, DLP L aura Renshaw is normalised effective dose and DLP is dose length product. H unter New England Imaging, NSW, Australia Result: SPECT/CT changed diagnosis in 6 patients, increased accuracy of Background: PET/CT FDG provides a non-invasive, accurate way for diagnosis in 45 patients, and increased diagnostic confi dence in 60 patients. diagnosis of disease, especially in cases of pyrexia of unknown origin. PET/ Effective CT dose ranged from 1.1 mSv to 3.01 mSv, with a mean of 2.11 mSv. CT is also cementing its place as a useful diagnostic tool for patients with suspected vasculitis. PET/CT can be used to diagnose cases of large vessel C onclusion: CT provided helpful diagnostic information which was benefi - vasculitis in patients who otherwise have had no successful diagnoses. cial in 70% of patients with little additional radiation. Aim/Method: Presented here is a case of a 60 year old woman with sus- pected vasculitis. She had undergone an extensive workup in the search for a diagnosis, including a left temporal biopsy, repeated pathology and a P11 gallium scan, all of which yielded negative results. The patient underwent a 1 8F - FDG PET IN THE EVALUATION OF INFECTION IN THE PET/CT scan which fi nally diagnosed large vessel vasculitis, allowing for the EXTREMITIES – INITIAL EXPERIENCE patients treatment to go ahead. R oslyn Francis 1 ,2,3 , Simone Culleton 1,2 , Tatiana Segard 1,2 , Conclusion: This case highlights that for diagnosis of vasculitis, PET/CT Peter Robins 1,2, Peter Swift 1,2 , Elaine Campbell 1 ,2 FDG provides a highly sensitive and specifi c diagnosis tool. PET/CT is also 1 W A PET Service, Sir Charles Gairdner Hospital, Nedlands, Western useful for follow up imaging in these cases. Australia, Australia 2 N uclear Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia 3 U niversity of Western Australia, Perth, Western Australia, Australia P 13 B ackground: Referrals for query infection of the extremities are common AN INTERESTING APPEARANCE OF OFUJI’ S DISEASE ON A and increasing in number. The Gold Standard method for evaluating osteo- F1 8 FDG PET/ CT SCAN myelitis in the extremities is a 99mTc-HDP Bone scan with either 99mTc- HMPAO or 111In labelled white blood cells. These procedures are both Laura Renshaw complex and time consuming for both staff and patients. Labelling white Hunter New England Imaging, NSW, Australia blood cells involves handling of blood products with all the associated risks Background: FDG PET imaging is a well-known and established imaging and takes 36 hours before obtaining results. Imaging time on SPECT/CT tool in the fi elds of oncology, neurology, cardiology and infection. Its other gamma cameras can take 40–60 minutes with even the smallest patient move- uses and applications are still being discovered in research and fi ndings ment resulting in artefacts which may compromise diagnosis. around the world. © 2013 Royal Australasian College of Physicians 25 Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 43rd Annual Scientifi c Meeting of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) A im/Method: A patient was referred for a routine staging PET scan for left Results: In this patient, no appreciably abnormal uptake is noted on planar upper lobe malignancy. The patient underwent the PET scan as per protocol imaging. On SPECT/CT, low-grade gallium uptake is seen within several cysts and the images were quite interesting. The report notes low to moderate in the upper and mid poles of the right kidney. They suggest the cyst infection. uptake throughout the skin of the trunk as well as the lower limbs. On further C onclusion: Historically, gallium scans have a low sensitivity and specifi city questioning of the patient and investigation of past histology, these lesions for localising renal cyst infections. Because gallium is normally distributed in were in fact eosinophillic pustular folliculitis, also known as Ofuji’ s disease. the liver, spleen and bone marrow, and is excreted through the kidneys and Conclusion: No other reported or published images could be found of a bowel, it is generally not preferred for abdominal infection. With the addition PET scan showing this chronic skin condition. of SPECT/CT, gallium scans may be used to accurately delineate infected renal cysts complicating PKD. Such scans have advantages over standard diagnostic modalities and are very helpful in planning appropriate therapy. P14 PHYSIOLOGIC APPEARANCE OF POROUS ORBITAL IMPLANTS AT F- 18 FDG PET -C T – PICTORIAL ESSAY P16 INCIDENTAL FINDING OF A SOFT TISSUE SARCOMA ON BONE Peter Robins, Andrew Law SCAN Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia K ristina Wainwright, Eva Wegner Background: The most common indications for orbital enucleation include N uclear Medicine Department Prince of Wales Hospital, the treatment of intraocular malignancy, severe traumatic injury and a blind, NSW, Australia painful eye. Modern porous orbital implants are used following enucleation to achieve a more cosmetically acceptable result. Physiological processes that Preamble: The incidental diagnosis of a soft tissue sarcoma from a Tc99m- occur during integration of these implants affect the imaging appearances on MDP bone scan in our department has reinforced to us the importance of F-18 FDG PET-CT. assessment of extra-osseous bone tracer uptake. Extra-osseous uptake of methylene diphosphonate (MDP) can occur in several physiological but also A im: To illustrate the appearance of porous orbital implants on FDG pathological processes hence its presence should always be accounted for. PET-CT imaging. C ase: A 75 year old male was referred for a bone scan by his GP for investiga- Method: From patients scanned in the Western Australian PET Service over tion of a 3 month history of weight loss and anorexia. Planar imaging was the past 5 years, 5 patients were identifi ed with porous orbital implants. These performed and an area of amorphous tracer uptake was noted in the proximal patient ’ s images were reviewed and clinical follow-up was performed to assess medial left thigh. A dedicated SPECT/CT revealed the tracer accumulation to any adverse outcomes in regard to the prostheses. be within a large rounded mass in the thigh musculature which contained both R esults: The porous orbital implants showed signifi cantly increased FDG soft tissue and fat components. These radiological appearances were consistent uptake within the prostheses in all 5 patients. No signifi cant periorbital with a soft tissue sarcoma. On direct questioning, the patient recalled that he uptake was identifi ed apart from physiological orbital muscle activity. had recently noticed an enlarging mass in that location. Following diagnostic Increased glucose metabolism within the orbital implant was not associated imaging, a biopsy proved it to be a malignant spindle cell sarcoma. It was with evidence of infection, tumour recurrence, or implant extrusion on fol- thought that this represented dedifferentiation of liposarcoma. The liposarcoma low-up of all 5 patients. had presumably been present for many years before undergoing malignant transformation and thus causing the patient’ s symptoms. Discussion: Porous orbital implants are made from materials including hydroxyapatite, aluminium oxide and polyethylene. The crystalline structure Discussion: Soft tissue sarcomas are uncommon mesenchymal tumours of the porous prostheses allows ingrowth of healthy vascular connective tissue which demonstrate a spectrum of histologic differentiation. Their presenting within 4 weeks, a process referred to as “fi brovascularisation”. This process symptoms are often vague but they most often occur in the thigh or retro- has several theoretical advantages over biologically inert prostheses including peritoneum. Most sarcomas accumulate Tc-99m MDP due to hypervascular- (1) better prosthetic movement due to development of soft tissue attach- ity, dystrophic calcifi cation and/or direct tumour cell formation of osteoid ments; (2) lower risk of prosthetic infection due to higher blood fl ow; and matrix. The calcifi cation may range from microscopic to macroscopic and (3) less chance of extrusion or prosthetic migration. Direct comparison correlates with MDP uptake. studies however, have not demonstrated a signifi cant outcome difference for Conclusion: Several primary and secondary malignancies accumulate MDP. porous implants over inert acrylic implants. Assessment of the soft tissues on a bone scan is thus essential, and will not Conclusion: Physiological high-grade FDG activity within porous orbital only improve its diagnostic value but also reduce the risk of a missed diag- implants should not be misinterpreted as implant infection or recurrent/ nosis of a malignancy particularly in patients in whom there is a high clinical residual tumour. suspicion. P15 SPECT/CT: A VALUABLE TOOL IN THE DIAGNOSIS OF INFECTED CYSTS IN POLYCYSTIC KIDNEY DISEASE Katherine Roy Princess Alexandra Hospital, Queensland, Australia Background: The infection of a cyst (pyocyst) within a polycystic kidney is a well-known and serious complication of Autosomal Dominant Polycycstic Kidney Disease (ADPKD). Diagnosing a pyocyst can be diffi cult because such a cyst can produce signs and symptoms that are non-specifi c. Diagnostic imaging tests are not always reliable for distinguishing pyocysts. A 61 year old woman presented to ED with nausea, vomiting, and lower back pain. Past medical history included a renal transplant due to PKD. She had a history of recurrent UTI. The patient developed fevers and decreased oxygen saturation, and had a raised CRP. Renal ultrasound, chest and abdomen x-rays found no source of infection. The patient was referred for a 67-Gallium-Citrate scan. 26 © 2013 Royal Australasian College of Physicians Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 Poster Abstracts F igure 1 Tc99m-MDP Whole Body Bone Scan obtained 2 hours following intravenous administration of 937 MBq of Tc99m-MDP. Neurology Method: A Hoffman brain phantom was fi lled with 40 MBq of activity to generate the same count rate found in the brain following a standard 700 MBq P17 dose of 9 9m Tc ECD. Multiple acquisitions were then performed for differing OPTIMISING BRAIN IMAGING ACQUISITION: HOFFMAN PHANTOM times with both low energy high resolution (LEHR) and low energy ultra-high ANALYSIS resolution (UHR) collimators. Acquisition Step times were at fi ve second C ulann Farrell , Marcia Wood , Christopher Rowe increments from 15–30 seconds, resulting in four acquisitions for each collima- D epartment of Nuclear Medicine and Centre for PET, Austin Health, tor set. Visual assessment was then performed by a senior Nuclear Medicine Austin Hospital, Melbourne, Victoria, Australia Consultant for resolution, noise level and patient considerations. B ackground: For a number of years our department has been performing U sing the optimised acquisition parameters a number of reconstructions of as many as 20 brain SPECT studies per week. A gamma camera upgrade in the phantom studies were performed using Flash 3D. A variety of numbers late 2012 necessitated a new protocol for brain imaging and the optimisation of iterations and subsets, as well as a range of Gaussian fi lter values from of new acquisition and reconstruction parameters incorporating new recon- 6.0–10.0 mm FWHM were used. Reconstruction was performed using both struction algorithms and attenuation correction methods. CTAC and Chang attenuation correction. Assessment was performed by the © 2013 Royal Australasian College of Physicians 27 Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 43rd Annual Scientifi c Meeting of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) same senior consultant, and the settings producing the best image quality rithm in the phantom images. Clinical studies demonstrated the same effect, were implemented. Further refi nements were made once a number of clinical with an average increase of 17%. Subtraction analysis showed Hoffman studies had been performed. phantom images using Chang ’ s algorithm for attenuation correction demon- R esults: Initial assessment of the phantom studies led to the selection of a strated increased activity in frontal regions compared with the CTAC, most 20 sec/step protocol with UHR collimators. Gaussian fi lters of 10.0 mm prominently seen using OSEM reconstruction. Similar results were seen in FWHM were decided on for the CTAC and Chang reconstructions. Follow- the clinical studies, as shown in Figure 1. ing evaluation of some clinical studies, high levels of image noise required Conclusion: Flash 3D and CTAC in Brain SPECT imaging have an effect the fi lter values to be increased to 11.0 mm and 12.0 mm. on image quality in comparison to our previous methodology, with regional Conclusion: Through the use of a Hoffman phantom we have developed an changes in counts evident. Further investigation of this is required and will optimised brain acquisition and processing protocol which requires only be presented at the meeting. minimal alteration for individual patients. Oncology/Therapy P 18 IMPLEMENTATION OF 3-DIMENSIONAL RESOLUTION RECOVERY P19 AND CTAC RECONSTRUCTION ALGORITHMS IN BRAIN S PECT OUTCOME OF IODINE-131 THERAPY FOR HYPERTHYROIDISM IN IMAGING HOSPITAL KUALA LUMPUR MALAYSIA Marcia Wood , Culann Farrell , Kevin Hickson , Bridget Chappell , Christopher Rowe Abstract withdrawn Department of Nuclear Medicine & Centre for PET, Austin Health, Melbourne, Victoria, Australia B ackground: Implementation of new technologies such as 3-dimensional P20 resolution recovery algorithms (Flash 3D®, Siemens Medical Systems) and T HE ROLE OF THE CLINICAL RESEARCH NURSE: A SIR CHARLES measured CT attenuation correction (CTAC) can potentially improve image GARDINER HOSPITAL NUCLEAR MEDICINE DEPARTMENT AND WA quality in the clinical arena. Validation of these technologies against previous PET SERVICE PERSPECTIVE methodologies is required to ensure correct image interpretation. As a centre Tammy Hagan, Ros Francis, Elaine Campbell with a strong neurology focus, this study seeks to demonstrate changes in Sir Charles Gairdner Hospital Nuclear Medicine Department, Western Brain SPECT image quality that occur from these techniques. Australia, Australia Method: Hoffman phantom images and 10 sequential, clinical patient Conducting clinical trials has lead to evidence based gold standards of treat- studies were processed using both OSEM and Flash3D. Attenuation correc- ments and imaging within nuclear medicine. Trials are run in conjunction tion was performed using both Chang’ s Algorithm and CTAC. The Chang with other specialities or within the department. Over the past 5 years the Algorithm used manually set 4-point ellipses in phantom studies, and auto- number of internal departmental clinical trials has increased and this has matic threshold edge detection in clinical studies. Four datasets were gener- lead to the role of the Clinical Research Nurse (CRN). The poster will cover ated per patient and analysed using PMOD, a statistical analysis program. the CRN role in the clinical trials of: ROI analysis was performed. Scaled, rigid matching was performed prior to • 11 C-Methionine and 18 F-Fluorothymidine PET-CT imaging in suspected subtraction analysis to demonstrate regional changes in count intensity residual or recurrent glioma. between techniques. • Apoptosis Imaging in Malignant Pleural Mesothelioma. Results: No signifi cant difference in counts was demonstrated between the • Evaluation of FDG PET-CT in the Infection of Extremities. Flash 3D and OSEM datasets for both phantom and clinical studies. CTAC • Comparison between Ga-68 citrate PET-CT and Ga-67 citrate SPECT/ resulted in a 20% increase in average counts compared with Chang ’s Algo- CT for Infection Imaging. Figure 1 E ffect of reconstruction on image quality. (A) Hoffman Phantom images. (B) Patient data demonstrating similar effects. 28 © 2013 Royal Australasian College of Physicians Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 Poster Abstracts The CRN role is multifaceted and varies between trials. Each trial has its Conclusion: This patient had exhausted all standard treatment preferences own requirements and demands. in an attempt to control her severe complications from progressive metastatic In this new and developing role many areas covered are protocol development NET – rendering her hospitalised. Treatment with PRRT offered this patient and evaluation, recruitment and consenting of patients in trials, administer- a dramatic improvement in her quality of life; enabling discharge from hos- ing radiopharmaceuticals. Trials involve covering one or more sites, often pital; cessation of costly TPN + SSA; resumption of oral dietary intake and a multiple departments and personnel. Meeting the demands of the CRN role functional return to activities of daily living. a nurse requires knowledge of nuclear medicine, positron emission testing, Although PRRT is rarely given with curative intent, it is an invaluable means good clinical practise, epidemiology and biostatics. of improving QOL. Lutetium should not be underestimated as a worthwhile treatment benefi ting both the patient and the healthcare system. P21 P 24 I NCIDENTAL FINDING OF METASTATIC MEDULLARY THYROID EFFECTS OF ALTERED INJECTION TECHNIQUE ON BREAST CARCINOMA DEMONSTRATED ON PARATHYROID SCINTIGRAPHY LYMPHOSCINTIGRAPHY RESULTS WITH 18 F- F DG PET CORRELATION Stephanie O ’D onnell, Georgina Santich, Geoffrey Bower Abstract withdrawn M ount Nuclear Medicine, Western Australia, Australia Background: Mount Nuclear Medicine performs a large number of breast lymphoscintigraphy studies for Sentinel Lymph Node (SLN) localisation. We were asked to change our primary injection technique from peritumoural (PT) using 4 × 0.25 mL, total 40 MBq to periareolar (PA) with 1 × 0.5 mL, P22 total 30 MBq of antimony sulfi de colloid as part of a planned study substitut- M INIMISING BROWN FAT UPTAKE IN 18F - FDG PET SCANS ing radiolocalisation with an 125 Iodine seed instead of hookwires for locating Penelope Maton , Roslyn Francis impalpable tumours. Intradermal injections were used when time was limited WA PET Service, Sir Charles Gairdner Hospital, Nedlands, Western and no SLN had been visualised. Australia, Australia Method: We reviewed results from a previous six month period of PT injec- The uptake of 18F-FDG by brown adipose tissue (BAT) in adult humans tions and then for the following six months of subcutaneous PA injections. has been documented in the literature since about 2002. Initially thought to Our standard SLN imaging protocol was used for both groups of patients. be prevalent only in younger, slim females and dependent on ambient tem- Imaging was performed on a dual head GE Myosight gamma camera or a perature, more recent reports include a wider range of patient demographics single head DigiRAD Ergo gamma camera. We then resumed PT injections and dependence of uptake on ambient temperature has not been proven. and reviewed the most recent six months of results. Uptake of FDG in BAT may lead to false positive PET scans, especially in Results: The success rate of visualisation of a SLN remained reasonably high the regions of the neck and diaphragm. Although the use of a concurrent CT (87.5% of 96 PA versus 93% of the 167 PT injection groups) and the time scan for anatomical localisation is now the norm and can improve confi dence taken to identify the SLN was similar. Both groups showed 99% visualisation in reporting abnormal uptake in these regions, there are many cases where of the SLN following intradermal (ID) injection. The rate of drainage to reduction of BAT uptake of FDG is the best or only strategy for certainty. internal mammary lymph nodes was considerably reduced however as PA The administration of 20 to 80 mg of propanolol, 60 to 120 minutes prior showed only 6% of patients with IM nodes (PT showed 23%). In the recent to FDG administration is reported to be effective. We present recent cases six months SLN visualisation was 73.3% PA and 87.2% PT. With ID injec- where 20 mg of propanolol administered 60 minutes prior to FDG adminis- tion results were 87.5% and 98.3% respectively. tration with patient warming from the time of propanolol administration to the time of the PET/CT scan has greatly reduced or eliminated the BAT Conclusion: We found that the depth and / or site of injection makes a uptake of FDG, and has infl uenced scan interpretation. Our standard prac- signifi cant difference to SLN drainage patterns. PT injection or deeper PA tice is now to fl ag patients with signifi cant BAT uptake (and no contraindica- injection, at the same depth as the cancer, as well as delayed imaging should tions) for a propanolol protocol for follow-up scans. identify an appropriate rate of internal mammary node drainage. P23 P25 LIFE CHANGING LUTETIUM-177 6 8 GA - DOTA- OCTREOTATE P ET AND P ET PROBE-GUIDED SURGERY IN THE LOCALISATION AND TREATMENT OF GASTRINOMA Davina Nicholls The Queen Elizabeth Hospital, Adelaide, South Australia, Australia Brenton O ’ Mara, Nelson Loh, Shayne White , Mikael Johansson , Spiro Raftopolous Background: 59 year old woman with metastatic neuroendocrine tumour Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia (NET) complicated by; high volume diarrhoea ( ∼ 4 L/day); hypotensive epi- sodes; exacerbation of fl ushing; weight loss – 16 kg in 4 months; and hospi- B ackground: We report a case of gastrinoma that was successfully resected talised continuously for 3 months. She remained poorly responsive to very under radio-guidance following 68G a-DOTA-Octreotate PET imaging. The high doses of somatostatin antagonist (SSA) and failed Trans Arterial Chemo case highlights the early sensitivity of 68G a-DOTA-Octreotate PET in spite Embolisation (TACE). Total Parental Nutrition (TPN) with extra SSA was of normal anatomical imaging studies (MRI, CT, EUS), and the utility of prescribed. She was referred to The Queen Elizabeth Hospital, South Aus- Octreotate PET and PET probe-guided surgery in the localisation and treat- tralia, for Peptide Receptor Radionuclide Therapy (PRRT). ment of gastrinoma. Method: The patient received 4 cycles of 7000 Mbq 177 Lu (Lutetium Methods: The patient presented with Zollinger-Ellison syndrome diagnosed Octreotate) every 8 weeks. Pre-medications for nausea were given and on clinical and biochemical grounds with a diagnostic secretin stimulation intravenous amino acids were administered for renoprotection. Whole test. Initial anatomical imaging (CT, MRI and EUS) was unable to detect a Body SPECT/CT imaging was performed 24 hrs post 177 Lu administration. lesion. The treating team requested 6 8 Ga-DOTA-Octreotate PET imaging. Serial Quality Of Life (QOL) data was recorded over the 6 months of R esults: 6 8 Ga-DOTA-Octreotate PET demonstrated a persistent Octreotate- therapy. avid focus between the uncinate process of the pancreas and the inferior vena Results: There was dramatic clinical and biochemical response as early as cava with no further Octreotate-avid lesion identifi ed to suggest disseminated 3 weeks post fi rst dose of 177 Lu. This enabled cessation of TPN, with disease. The patient underwent surgical exploration following re-administra- reduction and eventual cessation of the high doses of SSA. She was able to tion of 6 8 Ga-DOTA-Octreotate. A 6.5 mm neuroendocrine tumour within a resume a normal diet, the diarrhoea was markedly reduced and she began to lymph node posterior to the uncinate process of the pancreas was successfully put on weight. Throughout her 4 cycles, imaging and QOL surveys docu- detected with a PET probe and removed. The patient reported signifi cant mented the improvement in both tumour burden and quality of life, clinical improvement in the early post-operative period. We are awaiting clinical respectively. follow-up to confi rm a complete biochemical and PET response. © 2013 Royal Australasian College of Physicians 29 Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 43rd Annual Scientifi c Meeting of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) Conclusion: 6 8 Ga-DOTA-Octreotate PET has high early sensitivity in the testes within the scrotum. The left inguinal mass was therefore correctly identi- localisation of gastrinoma and other types of neuroendocrine tumour and fi ed as a retractile (rather than undescended) testis, which is a physiological may facilitate surgical localisation. Early anatomical imaging modalities were fi nding at this age. In the absence of abnormal uptake elsewhere, the diagnosis negative despite early visualisation of the Octreotate-avid lesion with PET of a complete metabolic response was confi dently made and inappropriate imaging. The surgical team acknowledges that resection of the lesion would biopsy of the left inguinal mass was avoided, saving the young patient and his have been extremely diffi cult without assistance of a PET probe. family signifi cant distress and another general anaesthetic. Discussion: The differential diagnosis of an inguinal mass in male patients includes lymphadenopathy (malignant, infective or infl ammatory), hernia, aneurysm (false or true), varicocoele, spermatic cord lipoma/hydrocoele, as P26 well as a malpositioned testis. Assessing the metabolic activity increases INCIDENTAL FOCAL THYROIDAL 18F - FDG UPTAKE ON P ET- CT: specifi city in characterising the mass on PET-CT. HISTOPATHOLOGICAL CORRELATION 1 Conclusion: A retractile or undescended testis should always be considered Andrew Robertson , Dee Nandurkar 1 , Ian Jong 1 , Shakher Ramdave 1 , 1 1 2 in the differential diagnosis of a metabolically active soft tissue mass along Geoffrey Soo , Jason Bradley , Michal Schneider-Kolsky 1 the line of the inguinal canal in the appropriate clinical setting. D epartment of Medical Imaging, Monash Medical Centre, Victoria, Australia 2 Department of Medical Imaging & Radiation Sciences, Medicine, Faculty of Nursing and Health Sciences, Monash University, Victoria, Australia P28 B ackground: Increasing use of 18F-fl uorodeoxyglucose (FDG) positron M ANAGING PATIENT ANXIETY IN PAEDIATRIC NUCLEAR MEDICINE emission tomography-computed tomography (PET-CT) has resulted in Katherine Stanton1 , Tracy Benger 1 , Rapsodie Barbour 2 increased incidental fi ndings of focal thyroidal FDG uptake. Previous studies 1 N uclear Medicine, Women ’ s and Children’ s Hospital, performed overseas suggest a high risk of malignancy in these incidentally South Australia, Australia detected thyroid lesions. 2 C entre for Health Promotion, Women ’ s and Children’ s Health A ims: To determine (i) the proportion of patients undergoing PET-CT for Network, South Australia, Australia assessment of nonthyroid cancer in an Australian metropolitan hospital B ackground: Paediatric Nuclear Medicine requires patient cooperation to setting who have focal thyroidal FDG uptake; (ii) the proportion of these obtain an optimal scan. We have observed high levels of patient anxiety induc- patients who undergo fi ne needle aspiration biopsy (FNAB) of the thyroid ing lack of cooperation. This is caused by injection fear and the necessity to lesion, hemithyroidectomy or total thyroidectomy; and (iii) the proportion of remain still and can be exacerbated over multiple appointments. Environ- these patients with incidentally detected thyroid malignancy. ment, lack of availability of distraction devices and failure to explore alterna- Methods: A retrospective audit of all PET-CT studies performed at South- tives are contributing factors. We aimed to promote a healthy outcome ern Health between February 2011 and January 2013 was performed. psychologically for children attending our department. Patients undergoing PET-CT for assessment of nonthyroid cancer with an M ethod: In response to this identifi ed need, we applied for a Health Promo- incidental fi nding of focal thyroidal FDG uptake were identifi ed from our tion grant which funded the project and allowed us to work with a mentor database. Patient medical records, Radiology and Pathology databases were from Health Promotion. Evidence in the literature demonstrates the benefi ts reviewed to identify patients who had been further investigated with FNAB of employing distraction techniques for painful procedures including veni- of the thyroid lesion, hemithyroidectomy or total thyroidectomy. puncture on children. We purchased an IPad, bubble machine and “Buzzy Results: Of 4395 PET-CT studies performed at Southern Health, 2.5% Bee” injection distractor and documented the benefi ts of these devices in our (112/4395) demonstrated focal thyroidal FDG uptake. 42% (35/84) of department. patients undergoing PET-CT for assessment of nonthyroid cancer with focal R esults: Qualitative evaluation was conducted through surveying patients, thyroidal FDG uptake had been further investigated with FNAB, hemithy- parents and staff. Responses showed that the use of distraction devices in roidectomy or total thyroidectomy. 17% (6/35) had a malignant cause for Nuclear Medicine was helpful to reduce patient anxiety levels. Using interac- their focal thyroidal FDG uptake. Causes included follicular thyroid carci- tive applications on the IPad allowed for effective distraction of children to noma (n = 2), papillary thyroid carcinoma (n = 2), medullary thyroid carci- reduce their focus on the injection. Through working with the Health Promo- noma (n = 1), and metastatic lung carcinoma (n = 1). The remaining 83% tion unit, staff in our department improved research and project skills. We (29/35) were benign. Causes included hyperplastic nodules, colloid nodules were able to adjust our working practice to accommodation our patient’ s and follicular adenomas. The average SUV max of malignant lesions (8.9) needs through applying health promotion methodology. was not signifi cantly different from that of benign lesions (6.2). Conclusion: High patient anxiety levels may compromise the quality of a Conclusion: All patients undergoing PET-CT with an incidental fi nding of Nuclear Medicine study, particularly in the paediatric cohort. Through focal thyroidal FDG uptake should be recommended for further investigation research and stakeholder consultation, we have implemented effective tech- with ultrasound-guided FNAB of the thyroid lesion in the fi rst instance. niques to reduce patient anxiety. This collaborative project has encouraged our staff learn about health promotion and associated models of healthcare relevant to reducing anxiety in children having Nuclear Medicine scans. It has enabled us to employ a holistic approach to health within our department for the benefi t of our patients. Paediatric P27 I MAGING PITFALL – RETRACTILE TESTIS IN PAEDIATRIC LYMPHOMA: CASE REPORT P 29 P eter Robins , Andrew Law FLT IN PAEDIATRIC BRAIN TUMOURS S ir Charles Gairdner Hospital, Nedlands, Western Australia, Australia Russell Troedson 1,2 , Elizabeth Thomas 1,2, Nick Gottardo 2 1 A im: To highlight an imaging pitfall in characterising groin masses in male WA PET Service, Western Australia, Australia 2 paediatric patients on PET-CT and to discuss the differential diagnosis. P rincess Margaret Hospital for Children, Western Australia, Australia M ethod: A 5 year old male patient underwent PET-CT imaging with F-18 W e present 2 children with brain stem gliomas who were evaluated with F18 FDG under general anaesthetic for restaging of treated Hodgkin ’s disease of FLT PET imaging. the left inguinal region. Background: Patient 1. A 13 yo boy on holiday in Singapore presented to R esults: PET-CT demonstrated mildly increased FDG activity in a new hospital semi comatose. MRI showed a 3 × 2.6 cm mass in the posterior fossa 12 mm soft tissue mass in the left groin that was suspicious for recurrent with hydrocephalus. He underwent emergency EVD insertion and was trans- disease. The lesion had an elongated ovoid appearance and the low dose CT ferred to PMH. A Neurosurgical opinion advised against biopsy. localised the mass to the left inguinal canal. Further analysis revealed only one An F18 FLT study showed moderately intense uptake with Maximum SUV testis within the scrotum, although a previous PET-CT scan had shown both 1.56 supporting a high grade tumour. 30 © 2013 Royal Australasian College of Physicians Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 Poster Abstracts The patient was commenced on radiation therapy with a rapid and marked This research examines how the response of the dose calibrator varies with response supporting the presumption of a high grade tumour ( likely glioma). the volume and density of solution in the vial. Patient 2. A 2 yo girl with progressive stridor onset at 6 months of age. ENT Method: To determine the dependence of the dose calibrator’ s (Capintec review with fi breoptic exam following adenotonsillectomy noted vocal cord 55TW) response on the volume of the sample, a solution of ∼ 1100 MBq of paralysis. Urgent MRI showed a large cervicomedullary tumour. One year Yttrium-90 chloride was assayed in a standard microspheres shipping vial following initial treatment tumour progression was diagnosed. F18 FLT while increasing the volume in 0.2 mL intervals, but keeping the total activity imaging showed moderate uptake with SUV max 0.86 ( intermediate). constant. In addition the solution on top of an unused dose of Yttrium-90 D ebulking surgery was undertaken and pathology revealed ganglioglioma labelled microspheres was removed and the microspheres were shaken until with ki-67 positive in up to 5% of tumour cells. There was tumour progres- they reached a uniform suspension and then the activity in the vial was sion in keeping with high grade tumour. Patient commenced on focal radio- assayed as water was added in 0.2 mL increments, while the total activity therapy and oral temozolomide. remained constant. M ethods: F18 FLT PET-CT imaging was undertaken 1 hour post tracer Results: The dose calibrator overestimated activity as the volume of the injection. Uptake within the tumour was identifi ed and maximum SUV was solution was decreased. When the activity was in the microspheres suspended measured. in water an almost identical over-response was observed as the volume changed. No signifi cant effects of density of spheres in the dose calibrator Results: The tumours were clearly identifi ed in both patients. Maximum response were observed. SUV measurements were in the non low grade range. Conclusion: The dose calibrator has a signifi cant relative response variation Clinical progress for both patients was in keeping with high grade tumours. with volume of the measured sample, and measures of residual activity fol- C onclusion: PET assessment of brain tumours has the potential to be a lowing with withdrawal of Yttrium-90 treatment dose should be corrected for useful assessment tool. the change in volume. If the density of the microspheres in the suspension did have an effect on the response of the dose calibrator it was too small to Greater uptake on an FLT study may predict a high grade tumour and allow be observed in this experiment. commencement of therapy prior to tumour progression. Assessment of appropriate quantitation parameters and cut off values in further paediatric studies would be helpful. P31 THE AUTOMATED MONITORING TOOL FOR MANAGEMENT OF Physics/Instrumentation Q C/ QA RESULTS IN NUCLEAR MEDICINE/P ET SERVICE – S CGH P30 A ndrea Giacomet, Jan Boucek , Paul Brayshaw ACTIVITY MEASUREMENT OF YTTRIUM-90 MICROSPHERES IN Nuclear Medicine/PET Service – Sir Charles Gairdner Hospital, DOSE CALIBRATORS – THE INFLUENCE OF VOLUME AND DENSITY Nedlands, Western Australia, Australia Nicholas Forwood 1, Dale Bailey 1 ,2 , Kathy Willowson 3 B ackground: The Nuclear Medicine and PET service at Sir Charles Gairdner 1 N uclear Medicine Department, Royal North Shore Hospital, Sydney, Hospital is a large department with three SPECT/CT and two PET/CT scan- NSW, Australia ners, and has a QC program that includes daily and other, less frequent, tests. 2 Faculty of Health Sciences, University of Sydney, Sydney, NSW, Results are saved on separate acquisition computers, making monitoring and Australia analysis time-consuming and laborious. Moreover, results are kept only for a 3 S chool of Physics, University of Sydney, Sydney, NSW, Australia certain period, after which they are automatically deleted. We designed and Background: Yttrium-90 labelled microspheres, used in the treatment of implemented an automatic QC monitoring system that logs and analyses QC liver cancer, have historically been diffi cult to calibrate in nuclear medicine results to (i) ensure a permanent record of QC data, and (ii) check not only departments. A recommended method is to measure the activity of the the immediate conformance, but also the trend of QC results over time. microspheres in the glass shipping vial using a dose calibrator and then Method: Visual Basic and Windows Scripts were written to automatically measure residual activity after drawing out the required volume for treatment. back up QC results from the acquisition computers to a network drive. The F igure 1 Relative dose calibrator response for Yttrium-90 in solution and Yttrium-90 microspheres. © 2013 Royal Australasian College of Physicians 31 Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 43rd Annual Scientifi c Meeting of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) Scatter Ratio 34.8 33.8 32.8 31.8 30.8 29.8 28.8 20/03/12 29/04/12 8/06/12 18/07/12 27/08/12 6/10/12 15/11/12 25/12/12 3/02/13 F igure 1 S catter Ratio – Biograph mCT. back-up fi les were assessed using front-end tools developed in MS Access 1 . N EMA Standards Publication NU 2-2007. “P erformance Measurements and MS Excel to extract relevant QC information, insert it into the database of Positron Emission Tomographs” , Published by National Electrical and manage results. Manufacturers Association (NEMA), 2007. R esults: A permanent, backed-up record of all scanners QC data was created on a department shared drive. Tabulated data facilitated analysis and the scheduling of tests. The ability to view trends in QC results at a glance R adiation Safety assisted in the timely detection of problems, even if results were within the tolerance interval, e.g. a sudden variation on the trend of Scatter Ratio Values P 33 was detected on a PET/CT scanner: A PRELIMINARY REVIEW OF PET DOSE DISPENSING PRACTICES WITH EXTREMITY MEASUREMENTS C onclusion: The automated monitoring tool has become an integral part of our QC program. It facilitates the organisation and control of QC testing, Gordon Chan, Kenneth Young, Sylvia Gong , Kevin Hickson, and the monitoring of QC results warns of possible problems with the equip- Andrew Scott ment before they manifest, allowing timely intervention. Faster detection of A ustin Health, Melbourne, Victoria, Australia QC problems has improved communication and feedback of technical issues Background: Due to handling unsealed radioactive sources, extremity doses to vendors and technologists. are a major concern to nuclear medicine staff. The hand exposure to radio- pharmacists dispensing PET doses was reaching maximum allowable limits and a semi-automated syringe dispenser was instigated for dispensing FDG P 32 doses. A signifi cant twenty-fi ve times reduction in doses resulted. NEMA NU2 2007 PERFORMANCE MEASUREMENTS AND H owever it is not practicable to use the dispenser system for research com- COMPARISONS OF 2ND AND 3RD GENERATION GEMINI pounds and it is estimated that this was now contributing around 70% of TIME-OF-FLIGHT PET/ C T SCANNERS extremity doses. Thus a preliminary review of PET dose dispensing practices Kevin Hickson , Graeme O ’ Keefe , Sylvia Gong , Andrew Scott was undertaken. A ustin Health, Melbourne, Victoria, Australia M ethod: Two experienced operators manually dispensed 20 syringes of PET Background: In this study we present a comparison of the performance of radiopharmaceutical each, 10 syringes without a syringe shield and 10 with. two recently installed Philips GEMINI TF PET/CT scanners, one Gemini The activity to be dispensed was 10 mCi (370 MBq), a commonly used dose TF Generation 2 scanner (TF64) and one Gemini TF Generation 3 for research. The operators were timed and the dispensed activities recorded. scanner (TF128). The PET component in both of these scanners uses Exposure measurements were recorded using the instadose™ dosimeter lutetium-yttrium oxyorthosilicate (LYSO) crystals in a fully 3-dimensional worn around the wrist of the dominant hand. mode with good timing resolution to operate as a time of fl ight scanner. Results: The results show the same extremity exposure rate and time taken The TF128 also incorporates High Throughput Acquisition (HTA), which by both operators to dispense unshielded syringes. Operator A ’ s exposure increases the high-count rate capabilities of the TF128 compared to the rate was 30% less when dispensing using a syringe shield, however their TF64. The timing resolution of the TF64 and TF128 is reported to be 575 ps dispensing time increased threefold. Operator B ’ s exposure rate only and 495 ps respectively [1]. decreased by 10.5% when dispensing shielded syringes, probably due to the syringe being removed from the shield when removing the air bubble because M ethod: Performance measurements on the scanner were made using the of diffi culty with visualisation through the syringe shield lead glass. However National Electrical Manufacturers Association (NEMA) NU2-2007 proce- the easier air removing procedure resulted in only doubling the unshielded dures to benchmark the scanners conventional imaging capabilities. syringe dispensing time. Results: It was found that with the incorporation of HTA and faster elec- Conclusion: Dispensing PET radiopharmaceuticals with shielded syringes tronics a higher noise equivalent count rate was maintained for the TF128 can lead to a signifi cant reduction in hand exposure. However there is a compared to the TF64. The spatial resolution and image quality of both signifi cant increase in dispensing time due to the awkwardness of handling scanners was increased compared to the PET department’ s original Gemini a heavy shield and diffi culties with visualisation through the lead glass. PET/CT scanner. Decreasing exposure time is not as effective as shielding. Further investiga- C onclusion: The installation of these new PET/CT scanners is a valuable tion is warranted. addition to the departments imaging capabilities. The incorporation of HTA into the TF128 PET/CT is particularly valuable for clinical studies that require a high injected activity for example Rb-82 cardiac studies. 32 © 2013 Royal Australasian College of Physicians Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 % Poster Abstracts P34 Radiopharmacy/Radiochemistry AUDIT OF RADIOTRACER DOSING IN ‘DAY BEFORE SURGERY’ BREAST SENTINEL NODE LYMPHOSCINTIGRAPHY P 35 PRECISE MEASUREMENT OF THE PRIMARY PROTON BEAM Maria McGill , Russell Troedson , J oe Landman ENERGY OF AN ISOCHRONOUS 18 M E V CYCLOTRON USING A R oyal Perth Hospital, Western Australia, Australia STACKED FOILS TECHNIQUE: BEFORE AND FOLLOWING A MAJOR Background: A 60 yr old female with breast cancer underwent ‘day before ENGINEERING UPGRADE surgery’ breast lymphoscintigraphy at Royal Perth Hospital. As per the Ali Asad 1 , Ali Asad 2 , Sun Chan 1 , David Cryer 1 , Roger Price 3 , departmental protocol an intradermal peri-areolar injection of 100 MBq of Peter Gibbons 1 99 mTc colloid was administered. The next day the surgeon noted a tender 1 S ir Charles Gairdner Hospital, Nedlands, Western Australia, area of erythema around the injection site and raised his concerns regarding Australia possible radiation injury to the skin. 2 I maging & Applied Physics, Curtin University, Western Australia, A review of current protocol was undertaken and it was concluded that a Australia skin dose of > 20 Gy could cause radiation induced injury to the skin. The 3 S chool of Physics, University of Western Australia, Perth, Western hospital Radiation Safety Offi cer recommended that the administered dose Australia, Australia for intradermal injection in a single site be capped at a maximum of 40 MBq. Background: In 2003, an 18/9 MeV cyclotron was installed at SCGH Perth. A 40 MBq dose would give a skin dose of approximately 17 Gy. An audit was Since then, PET radiopharmaceutical doses have risen from 1000 to 9000/ undertaken to ensure the reduced dose did not impact upon the detection yr. In 2012 the cyclotron underwent a major upgrade to a dual-proton beam, of sentinel lymph node(s) intra-operatively. plus doubling of total beam-current (from ∼8 0 to ∼ 1 60 μ A). Beam-energy M ethod: A review of the medical notes of 10 patients who received 100 mBq before and after upgrade was measured using the stacked-copper (Cu) foils and 10 patients who received 40 mBq was undertaken. Data was collected technique, plus investigating the effects of foil thickness and beam-straggling relating to the dose of radiotracer administered and the subsequent detection on energy measurement accuracy & precision. of the sentinel node(s) both on nuclear imaging and intra-operatively. M ethod: Stacked n atC u foils ( 65 Cu & 63 Cu), purity > 99.99% and nominal Results: thicknesses 100, 75, 50 or 25 μ m were proton-bombarded in separate experi- 1) Of the patients receiving the new dose of 40 mBq, all of the sentinel nodes ments, each consisting of a particular foil-size and multiple runs. In separate identifi ed on nuclear imaging were also identifi ed intra-operatively with determinations, activities of 6 3Z n, 6 5 Zn and 6 2 Zn produced in each foil were the gamma probe. measured by γ -spectroscopy. Together with stopping-power and reaction- 2) During the audit period no negative feedback was received from the specifi c cross-sectional data these activities were used to calculate beam- breast surgeons at Royal Perth Hospital. energy. The method uses a simple model for predicting activity of the chosen 3) T here was no notable difference in the ex-vivo counts when comparing Zn-isotope in each foil of the stack, then compares this distribution with the two different doses of radiotracer (Figure 1). measured values, with beam-energy as a least-squares fi tting-parameter (1). Conclusion: The reduction in dose from 100 MBq to 40 MBq for intrader- Results: Figure shows combined data without energy-straggling correction mal peri-areolar ‘day before surgery’ breast lymphoscintigraphy did not nega- (negligible). The grand-mean primary-beam energy (combining both tively impact on the detection of sentinel node(s) intra-operatively. EXFOR and IAEA cross-section data sets, as well as all foil thicknesses plus 6 3,65 Zn data) was 18.08 MeV ± 0.09(SD)(0.5%CV) and 18.07MeV ± 0.12(SD) (0.6%CV) before and following upgrade, respectively (ns). 62Zn-derived results (not shown) were very similar. Figure 1 Ex-vivo counts with two different doses of radiotracer. © 2013 Royal Australasian College of Physicians 33 Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 43rd Annual Scientifi c Meeting of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) Cyclotron Energy before and after the upgrade on two-column separation; recently refi ned to one-column. When relevant, this included recycling enriched 64 Zn for re-use. 6 1C u is now available for 18.3 preclinical imaging studies. 18.2 18.1 nominal energy P37 18 DEVELOPMENT OF NOVEL LIGANDS FOR EMERGING RADIOMETAL ISOTOPES 17.9 Mean of IAEA & EXFOR Mark Ashford, Leena Burgess , Wai Cheng Cheah, 17.8 and 63 65 Anwen Krause-Heuer , Benjamin Fraser, Ivan Greguric , Zn & Zn. 17.7 Nigel Lengkeek A ustralian Nuclear Science and Technology Organisation (ANSTO), 17.6 Lucas Heights, NSW, Australia 0 25 50 75 100 125 B ackground: The use of radiometals (non-Tc, non-Re) in targeted diagno- Foil Thickness (micron) sis and radiotherapy of different disease states has increased signifi cantly over the last 15 years. ANSTO LifeSciences radiometals program seeks to provide F igure Beam energy v s. Cu-foils thickness ( μm ), before and following a suite of radiometal tools for use in PET imaging and therapeutic modalities cyclotron upgrade, After upgrade, only 50 μ m foil thickness used. Mean to improve upon the existing technologies which are currently dominated by data before upgrade shown as diamonds; that following, a triangle. 99m Tc. This will enable researchers and clinicians to study and diagnose diseases with a greater effi cacy and effi ciency. Method: Many of the ligands currently available for radiometals have numerous drawbacks , including unfavourable in vivo properties such as thermodynamic and kinetic stability and poor lipophilicity. We are developing C onclusion: The stacked-foils method is a simple and reliable measurement new ligand systems to have improved radiometal specifi city while including of beam-energy. Its application before and following a major engineering design fl exibility allowing us to manipulate properties such as biodistribution upgrade to the cyclotron showed very good agreement, whether the measure- patterns, excretion rates, pharmacokinetics, thermodynamics and i n vivo ment was based on 62 Zn, 6 3 Zn or 65 Zn production, for each foil thickness. stability. The synthesis should be straightforward and cost effective and have the potential for bioconjugation in the initial design. Complexation studies 1 . Burrage JB , A sad A H et al . Austr Phys Eng Sci Med (2 009) 3 2 :9 2– 97. are performed in vitro to assess the ligands suitability. R esults: We are developing ligand systems for 6 8 Ga, 8 9 Zr, 6 4C u, 9 0 Y and 1 77 Lu. We have prepared a novel analogue of the ubiquitous ligand NOTA (Figure 1, b); our system replaces the biologically labile carboxylic acid with a cor- P 36 responding, biologically inert isotere, a tetrazole. This manipulation should E FFICIENT CYCLOTRON-BASED PRODUCTION & PURIFICATION OF provide additional stability and increased complex lipophilicity. Our studies THE P ET ISOTOPE 61 CU USING NATURAL-ZN OR ELECTROPLATED have shown that a tetrazole analogue of NOTA (Figure 1, b) forms stable 64 ZN -ENRICHED TARGETS cold-metal complexes with potential PET metals of interest such as Ga3 +. Ali Asad 1 , Suzanne Smith 3 , Sun Chan 1 , Charmaine Jeffery 1 , 1 1 ,4 Conclusion: ANSTO LifeSciences provides a complete synthetic ligand and Laurence Morandeau , Roger I. Price 1 metal complex program, complementing its broader Radiometals Program. S ir Charles Gairdner Hospital, Nedlands, Western Australia, The aim of which is to provide an array of clinically relevant ligands that can Australia 2 be used in multiple applications for specifi c metal radiopharamceuticals for Imaging & Applied Physics, Curtin University, Western Australia, improved patient outcomes. Australia 3 B rookhaven National Laboratories 4 School of Physics- University of Western Australia, Perth, Western NH Australia, Australia 2 Background: The PET isotope copper-61 (6 1 Cu; T 1/2 = 3.4 h; β + m ean N N N N range = 0.242–0.527 MeV) is suitable for radiolabelling diacetyl-bis(N 4 - N N methylthiosemicarbazone) [ 61 Cu-ATSM], for imaging of hypoxic tissue. 6 1 Cu can be produced using several nuclear reactions, including 61 Ni(p,n)6 1C u, N N 62 H H Ni(p,2n)6 1 Cu and 64 Zn(p,α ) 6 1 Cu. Natural abundance of 64Z n (48.6%) N N makes it a cheaper target than Ni isotopes. A challenge is developing a rapid, effi cient separation to isolate the desired 6 1 Cu, including removing Zn target- N NH N NH material and co-produced Ga radioisotopes. N N N N N N Method: Natural-Zn ( natZ n) foils were purchased (d = 15 mm; thick- N N ness = 50 μ m; 99.99% purity; Goodfellow). Alternatively, enriched 6 4 Zn (99.8%; Isofl ex) was electroplated onto Al, Ag or Au backing discs. Collec- HN N HN N tively, these Zn-targets were irradiated for < 60 min using 11.7 MeV protons at 30 μA . At end-of-bombardment, target was transferred to a fume-hood and N N N N dissolved in 1 mL of 10 M HCl at room-temperature. Digest was quantita- a b tively transferred to a cation-exchange column AG 50 W. Cu & Zn isotopes were eluted with 25 mL of 10 M HCl; Ga isotopes were retained on the F igure 1 Structures of bioconjugation p-NH2 B n-NOTET (a), and column. Eluted fraction of Cu & Zn transferred onto an anion-exchange AG NOTET (b). 1X8 column and 6 1C u was fi nally eluted with 20 mL of 2 M HCl. Zn fraction was eluted using 0.05 M HCl, to yield enriched 6 4 Zn for re-use. R esults: All targets (n at Zn disc or 6 4Z n electroplated onto either of 3 sub- strates – Al, Ag or Au) showed excellent stability under irradiation. Separation of 6 1C u was complete within 120 min. Final product had > 98% radionuclidic P 38 purity. Recovery of enriched 6 4 Zn for recycling (for relevant targets) was S IMPLIFIED PROCEDURE FOR THE PREPARATION OF 68G A- MAA > 9 5%. In a recent improvement, we used a single-column method to separate Alireza Aslani , Graeme Snowdon, Paul Roach Zn & Ga from Cu fraction within 30 min (results not shown). Royal North Shore Hospital, Sydney, NSW, Australia C onclusion: A rapid, effi cient separation process for production of 61 Cu Background: Macroaggregated Albumin (MAA) labelled with [9 9mT c] from Zn targets with high radionuclidic purity has been demonstrated, based NaTcO4 - is well established. [6 8 Ga]-labelled MAA ( 68G a-MAA), a PET radio- 34 © 2013 Royal Australasian College of Physicians Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 Beam Energy (MeV) Poster Abstracts pharmaceutical, has many advantages. Although there are a number of P 40 methods of 68 Ga-MAA production and quality control (QC) in the literature, E STABLISHMENT OF ROUTINE PRODUCTION OF 68G A- they are often diffi cult to reproduce in the lab. We describe an easy-to-follow, OCTEOTRATE IN PERTH: ONE YEAR ON detailed method. L aurence Morandeau1 , Ali Asad 1,2, Charmaine Jeffery 1 ,3 , Methods: 6 8G aCl 3 was eluted from an Eckert & Ziegler® IGG100 1.5 GBq Peter Gibbons 1 , Christopher Jones 1 , Tatiana Segard 4 , Roslyn Francis4 , 68 Ge/6 8 Ga generator with 0.1 M HCl onto a Strata X® ion exchange car- Peter Robins 4 , Roger Price 1,5 tridge. The 6 8G aCl3 was then eluted from the cartridge with 0.4 mL of acidic 1 R adiopharmaceutical Production & Development (RAPID) acetone into a reaction vial. The acetone was evaporated from the reaction Laboratory, Medical Technology and Physics, Sir Charles Gairdner vial (110°C for 600 sec). Normal saline (1.0 mL) was then added to the reac- Hospital, Nedlands, Western Australia, Australia tion vial to reconstitute the 68 GaCl3 . 2 I maging & Applied Physics, Curtin University, Western Australia, 1M Ammonium acetate buffer was prepared: 3.85 g in 50 mL water and 1 mL Australia 3 of conc HCl. pH was adjusted to 4.5 using glacial acetic acid. 0.1 M sodium C entre for Forensic Science, University of Western Australia, Perth, phosphate buffer (pH 7.0) was prepared. Western Australia, Australia 4 D epartment of Nuclear Medicine, Sir Charles Gairdner Hospital, O ne vial of MAA (Drax Image®) was washed (twice) by suspending in saline Nedlands, Western Australia, Australia (10 mL), centrifuged for 5 mins at 190 g, and the supernatant removed. 5 S chool of Physics, University of Western Australia, Perth, Western Ammonium acetate buffer (0.4 mL) was then added to the washed MAA and Australia, Australia resuspended. The 6 8 GaCl3 was then manually added (500 MBq in 1.5 mL) 68 to the MAA vial via 0.22 μ M fi lter. The vial was boiled for 7 min and 2 mL Background: G a-Octreotate (PET/CT), commonly used for the visualisa- of phosphate buffer was added once completed. tion of somatostatin receptor (SSTR)-positive neuroendocrine tumours is more sensitive and offers higher spatial resolution compared to the conven- 6 8 Ga-MAA QC: ITLC-SG in 0.4 M Citric Acid. Particle sizes were verifi ed tional 111 In-DTPA-octreotide (SPECT/CT) SSTR imaging. The RAPID using a haemocytometer. Laboratories routinely produce 68G a-Octreotate using the ITG silica based 68 68 Results: The MAA was labelled with 350 MBq 6 8G aCl3 . Mean QC was G e/ G a generator coupled to the iQS Ga-68 Fluidic Labelling Module. 95.3%. Particle sizes were approximately 20 μ M–100 μ M. Accepted limits Method: The generator is eluted with 4 mL of HCl0.05M into a preheated > 90% of particles between 10 μ M and 90 μ M) and none > 150 μ M . Total reactor (95°C) containing 25 μg of Octreotate peptide in 1 mL of sodium synthesis time was approximately 35 mins from start to fi nish. acetate 0.1 M. After 10 min reaction, the reaction mixture is transferred to a Conclusion: The procedure successfully allows a convenient preparation of C-18 Sep-Pak cartridge pre-conditioned with Ethanol 70% and water. After 68 68 Ga-MAA which can readily be adapted for clinical use. washing with 5 mL of NaCl0.9%, Ga-Octreotate is eluted off the Sep-Pak with 2 mL of 30% Ethanol followed with 5 mL NaCl0.9%, through a sterile fi lter into the collection vial. Radiochemical purity (via HPLC analysis and P 39 TLC analysis), pH measurement and radionuclidic purity analysis are COMPARISON OF A G1 - X 8 RESIN AND C U RESIN FOR assessed before release for patient injection. RADIOCHEMICAL SEPARATION OF COPPER-64 FROM NICKEL AND Results: In the year 2012, the RAPID Laboratories performed 108 6 8 Ga- COBALT Octreotate syntheses for a total of 267 patients. The average synthesis yield Charmaine Jeffery 1,2 , Ali Asad 1,3 , Sun Chan 1 was 67% and the radiochemical purity >9 5%. The synthesis time is < 15 min. 1 S ir Charles Gairdner Hospital, Nedlands, Western Australia, from time of generator elution. Australia The cost for a 6 8 Ga-Octreotate dose was $287 per patient, compared to a cost 2 University of Western Australia, Perth, Western Australia, Australia of $3,300 for a dose of 1 11 In-DTPA-octreotide. Only two 1 11 In-DTPA-octreo- 3 C urtin University of Technology, Western Australia, Australia tide scans were performed in WA in 2012 while 65 were performed in 2009. B ackground: Copper-64 is a radioisotope that has satisfactory physical Conclusion: The development of the routine production of 6 8 Ga-Octreotate characteristics for PET imaging (t1 /2 = 12.7 hr, β + avg = 278 keV, β + m ax = 652.9 keV, to the WA PET Service not only improved the diagnostic performance of β + abundance = 17.87%). It can be coupled with a variety of specifi c cell patients with neuroendocrine tumours but also created cost saving benefi ts markers for diagnostic imaging. Copper-64 has been routinely produced at to the WA Health system. 68 Ga-Octreotate (PET/CT) has superseded the the Sir Charles Gairdner Hospital cyclotron facility since 2011, via the conventional 1 11 In-DTPA-octreotide (SPECT/CT) in Western Australia. 6 4 Ni(p,n)6 4 Cu production pathway1 . Radiochemical separation is required to isolate copper-64 from target nickel- 64 and co-produced cobalt isotopes (cobalt-55,-57,-61). This has been achieved using anion exchange chromatography, using BioRad AG1-X8 P41 anion exchange resin with low concentrations of hydrochloric acid in OPTIMISATION OF PRODUCTION & PURIFICATION OF THE LONG- aqueous/alcohol solution. A new resin, CU Resin, has been developed specifi - HALFLIFE RADIOMETAL PET ISOTOPE 89 Z R: TOWARDS PROVISION cally for radiochemical separation of copper isotopes produced via proton OF A NATIONAL RESOURCE FOR PRECLINICAL IMAGING bombardment. A trial was undertaken to compare i) the performance of the APPLICATIONS resins, and ii) the purity of the subsequent copper-64. Rainer Scharli 1,2, Sun Chan 1 , Charmaine Jeffery 1 ,3 , Ali Asad1 ,4, Method: 32 batches of copper-64 were produced utilising BioRad AG1-X8 Laurence Morandeau 1 , Roger Price 1,2 (Nov 2011 to Nov 2012). CU Resin was trialled from Jan 2013. Each product 1R adiopharmaceutical Production & Development (RAPID) PET was evaluated for radionuclidic purity (HPGe gamma spectrometry) and Laboratories, Medical Technology & Physics, Sir Charles Gairdner metallic purity (ICP-MS). Hospital, Nedlands, Western Australia, Australia 2 Results: The average processing time, from receipt of irradiated nickel-64 S chool of Physics, University of Western Australia, Perth, Western to packaging of copper-64 product, using AG1-X8 resin is 2 hours. Using Australia, Australia 3 CU Resin halves the processing time to 1 hour. The AG1-X8 resin copper-64 C entre for Forensic Science, University of Western Australia, Perth, is 99% isotopically pure, with metallic species in low parts per million con- Western Australia, Australia 4 centrations. Evaluation of the CU Resin product has not been completed. D epartment of Imaging & Applied Physics, Curtin University, Western Australia, Australia C onclusion: Radiochemical separation using CU Resin is straightforward 89 and faster than the process using AG1-X8 resin. Results are still being col- Background: The radiometal positron-emitter Z r, with its long half-life lated for the purity of copper-64 produced using CU Resin; therefore no (78 hr) is a candidate for PET imaging. Hitherto, challenges in its production comparison of purity has been made. and separation had restricted its use, but recent advances have enabled the 1 CM Jeffery , S V S mith, A H A sad , S C han and R I Price, ‘R outine Produc- capacity for transcontinental shipping of signifi cant (ie; ∼ GBq) activities of tion of Copper-64 Using 11.7 MeV Protons ’, A merican Institute of Physics purifi ed product, initially for preclinical research. This study reports optimi- Conference Proceedings. 1 509, pp. 8 4 –9 0 ; doi:h ttp://dx.doi.org/10.1063/1. sations that facilitate this objective in the Australasian context. 4773946 ( 2012) . Method: A semi-automated in-house external beamline was attached to a port of an IBA 18/9 cyclotron. A target comprised of two stacked pure (99.9%) yttrium foils, each (mean) 127 μ m thick and 15 mm diameter was © 2013 Royal Australasian College of Physicians 35 Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 43rd Annual Scientifi c Meeting of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) proton-bombarded at < 40 μ A at 11.7 MeV for 120 min to produce 8 9Z r via from the 45 Sc target disc; solvent-solvent extraction and hydroxamate-resin reaction 89 Y(p,n) 89 Zr. Yttrium foils are cradled in an aluminium backing plate (1,3), the latter very similar to methods of (2). Thus, our existing procedures and sealed with a front disc insert, as shown in Fig. Following target insertion, for 89 Zr are adapted for 45 Ti, based on hydroxamate-resin column separation the front face of the target assembly is pressed pneumatically against a Viton® using HCl & water washes and fi nally 1M oxalic-acid product elution. Since O-ring seal. Helium-gas cools on the beam side, and chilled water on the reaction cross-sections for 89 Zr and 4 5T i are similar in magnitude and energy- rear. dependence, produced activities are likely similar, at ∼ 2 GBq. Conclusion: 4 5T i as a PET-imaging isotope has not been widely studied, however it can be readily produced in a ‘conventional’ radiometal solid-tar- getry laboratory. Its ‘intermediate’ half-life, high positron-emitting effi ciency and interesting biological applications make it an attractive area of study. 1 . Vavere AL & W elch MJ JNM ( 2005) 46: 6 83– 690 2. Scharli RK et al A IPConfProc ( 2012) 1 509: 101– 107. doi:1 0.1063/1.4773949 3. Gagnon K et al A IPConfProc ( 2012) 1509: 2 11– 214. doi:1 0.1063/1.4773949 P43 THE ESTABLISHMENT OF A PET RADIOPHARMACEUTICAL RESEARCH AND PRODUCTION FACILITY AT THE CENTRE FOR ADVANCED IMAGING F igure Assembly of y ttrium stacked-discs target. D amion Stimson 1 , Tim Fulcher2 , Larry Reed 3 , David Reutens 1 1 T he Centre for Advanced Imaging, Brisbane, Queensland, Australia 2A xiom Molecular, Sydney, NSW, Australia 3 R esults: I BA Increasing the beam energy from 11.7 MeV to 16 MeV increased the EOB activity by 40%. Doubling the beam current, doubled the end-of- Background: The Centre for Advanced Imaging (CAI) was created in 2009 bombardment (EOB) activity. Doubling irradiation time also doubled the and refl ects the growing role of multi-modality imaging in cutting-edge EOB activity (applies to ‘thin’-targets, ‘short’ irradiation-times). It was more biotechnology and biomedical research at the University of Queensland convenient to change beam current and irradiation time than to irradiate at (UQ). An initiative of the CAI is the establishment of a PET radiopharma- 16 MeV. EOB activity (by HPGe γ - spectroscopy) of 8 9 Zr in target discs was ceutical research and production facility which includes a state-of-the-art 1.36 GBq ( ± 0.53 GBq[SD], n = 3), 64% (± 25%, n = 3) of theory, with a cyclotron and radiopharmaceutical research and production laboratories. maximum of 1.84 GBq. Using published techniques based on hydroxamate The installation and commissioning of the cyclotron, hot-cells, and radio- column-extraction, with some original innovations, 89 Zr was recovered from chemistry synthesis equipment will be described and the results presented. the target with 93% (± 17%[SD], n = 3) effi ciency, with a radionuclidic purity Equipment and Method: A ‘Cyclone Twin’ 18 MeV dual ion source cyclo- of >9 9% and chemical purity 0.2 ppm Zr (± 0.3 ppm[SD], n = 3, ICP-MS), tron ( IBA, Belgium ) was procured along with 14 hot cells ( TEMA, Italy ), 6 comparable to published data. Effective specifi c activity via titration-by- automated radiochemistry modules for research and a further 2 modules for chelator method was 408 MBq/ μ g (± 26 MBq/ μg , n = 3). All results were com- GMP [ 18F ]FDG radiosynthesis (I BA) . The cyclotron has 8 target ports and parable to published data. is equipped with [ 18 F]fl uoride, [1 1 C]CO2 , [1 1 C]methane, and [1 3 N]nitrogen C onclusion: This study has demonstrated capability for production of radio- targetry along with a solid target station for [ 124I ]iodine and [6 4 Cu]copper nuclidically and chemically pure 89 Zr of acceptable specifi c activity. Zirco- production. The suite of hot-cells include laminar fl ow isolators for radio- nium-89 has been routinely produced in our laboratory since June 2012. This pharmaceutical dispensing to GMP standards, and a specialised hot-cell capability permits the transport of product across Australasia of suffi cient equipped with tele-manipulators for solid target processing. The research activity and reliability for preclinical applications, at least. radiochemistry modules include 3 ‘MeI-Plus-CO 2’ and a ‘MeI-Plus-CH4 ’ modules ( Synthra ) for [ 11 C]methyl iodide synthesis and subsequent radiola- belling and 2 nucleophillic [ 18F ]radio-fl uorination modules ( Synthra, Germany) . P42 THE RADIOMETAL ISOTOPE TITANIUM-45 AS A CANDIDATE FOR F ollowing the installation and commissioning of the equipment, site accep- PRECLINICAL PET IMAGING: PRODUCTION, PROCESSING & tance testing was performed including cyclotron target saturation yields and POSSIBLE APPLICATIONS the manufacture of a range of [11C] and [18F] based radiopharmaceuticals. R hys Sheil 1,2 , Rainer Scharli 1 ,3 , Roger Price 1,3 1 R APID PET Laboratories, Medical Technology & Physics, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia 2D epartment of Imaging & Applied Physics, Curtin University, Western Australia, Australia 3 S chool of Physics, University of Western Australia, Perth, Western Australia, Australia Outline: Platinum complexes are an industry standard against some refrac- tory cancers. However, their therapeutic range and persistence are limited; side effects are signifi cant. Titanium(IV) organo-complexes are promising alternatives. However, lack of understanding of their biological pathways prevents comprehensive clinical trials. Context: By substituting an atom of natural titanium (Ti) in an organo- complex with the PET- isotope 45 Ti (T1 /2 = 3.1 hr; β + ratio = 85%) it may be possible to study the radiopharmacokinetics of Ti-complexes in preclinical models. An interesting application would be labelling apotransferrin, because of its avid chelation with Ti(IV), and its apparent role in tumour develop- ment. 45 Ti can be produced by solid-targetry using a medical cyclotron, utilising reaction 45 Sc(p,n) 45 Ti with a proton energy of ∼ 14.5 MeV (1). Objective: To produce 4 5T i with high NCA specifi c activity, suitable for chelation to bifunctional ligands. Radiolabelled complex in turn to be used in microPET studies. Cyclotron production of 45 Ti follows the solid-targetry methods of Scharli e t al , developed partly in our laboratory (2). There are two Figure 1 ‘ Cyclone T win’ 18 MeV Cyclotron depicting open vacuum main methods for subsequent chemical separation and purifi cation of 4 5 Ti chamber and solid target beam-line. 36 © 2013 Royal Australasian College of Physicians Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 Poster Abstracts Results and Conclusion: To this end, the CAI has procured a cyclotron, P 45 hot-cells and radiochemistry synthesis modules. The commissioning data for R ECOIL AND CONVERSION ELECTRON IMPLICATIONS TO BE the former will be presented with a brief summary of the installation and TAKEN INTO ACCOUNT IN THE DESIGN OF THERAPEUTIC commissioning procedures of both the cyclotron and radiochemistry synthe- RADIOPHARMACEUTICALS UTILISING IN VIVO GENERATORS sis modules. Further, the challenges encountered during this work will be J an Rijn Zeevaart 1 , Zoltan Szucs 2 , Sandor Takacs 2 , Johann van Rooyen 3 , described. David Jansen 1 1 R adiochemistry, South African Nuclear Energy Corporation, South Africa P44 2 I nstitute of Nuclear Research of the Hungarian Academy of AUTOMATED PRODUCTION OF 124I AND 64 C U USING I BA TERIMO Sciences, Budapest, Hungary AND PINCTADA METAL ELECTROPLATING AND PROCESSING 3 R adiation and Reactor Theory, South African Nuclear Energy MODULES Corporation, South Africa Henri Tochon-Danguy1 ,2 , Stan Poniger 1, Harris Panopoulos 1, Background: The use of radionuclides as potential therapeutic radiophar- Graeme O ’ Keefe 1,2, John Sachinidis 1 , Andrew Scott 1,2,3 maceuticals is increasingly investigated. An important aspect is the delivery 1 A ustin Health, Centre for PET, Melbourne, Victoria, Australia of the radionuclide to the target whereby the radionuclide is not lost from 2U niversity of Melbourne, Victoria, Australia the chelating agent. For i n vivo generators it is important whether the daugh- 3 L ICR Melbourne Branch, Victoria, Australia ter radionuclide stays inside the chelator after decay of the parent B ackground: There is worldwide interest in long-lived positron emitters for radionuclide. molecular imaging and the development of novel immuno-PET techniques. Method: A fully relativistic equation has been derived for calculating the This has led to the recent installation of a new lab dedicated to automated kinetic energy of the recoiling nucleus assuming that the chemical bond solid target isotope production including 124 I and 6 4C u. between DOTA and a radionuclide is 4 eV. It indicates that the classical recoil M ethod: 1 24 I is produced by the 1 24T e(p,n)1 24I reaction using the IBA Nirta effect for β -decay only applies to decays with a Q value higher than 0.6 MeV. 166 166 90 90 target. Highly enriched 124 TeO 2 is mixed with 6% Al2 O 3 ( ∼ 300 mg) and The D y/ H o generator (Q = 0.486 MeV) and the Sr/ Y generator melted using the IBA Terimo module at a furnace temp of 780°C for 10 min (Q = 0.546 MeV) were prepared by the standard DOTATATE labelling pro- into the circular cavity of a platinum target disk. cedure and then loading on a C-18 cartridge. DOTATATE is adsorbed on the cartridge while free metal cations and metal DTPA complexes can be Following irradiation, thermochromatographic separation of radioiodine is eluted. Due to the high thermodynamic stability and kinetic inertness of performed using the same Terimo module. The target disk is heated to 780°C metal-DOTA type complexes, the release of the parent radionuclide is inhib- with a 75 mL/min sterile fi ltered air fl ow to release the 1 24 I, which is recovered ited. If recoil of the daughter nuclide (during the decay) took place it leads in 1 mL of 0.01 M NaOH. to the release of the daughter radionuclide which is eluated with DTPA. 6 4 Cu is produced with the IBA Nirta target by the 6 4N i(p,n) 64 Cu reaction. The Results: It was found that 72% of the daughter (1 66H o) was liberated from target is produced by electroplating highly enriched 6 4N i onto a silver disk. the DOTA chelator, in contrast to our recoil calculations but corresponding Following irradiation, the disk is loaded into the IBA Pinctada module and to the ratio of transition of holmium atoms via the Auger process. For the β the plating layer dissolved in recirculating 3 mL 12 M HCl at 70°C. The 90S r/9 0 Y (transition via the Auger process is absent) generator a 1% release solution is purifi ed on AG 1-X8 anion exchange cartridge, washed with 12 M from the DOTA chelator was recorded as compared to the estimated 10.2% HCl and EtOH, and 64C u eluted with ∼ 2 mL of water. from the β continuum spectrum of 9 0S r. R esults: Table 1 show the target irradiation parameters and production Conclusion: The discrepancy between the experimental and theoretically yields of 124 I and 6 4C u obtained to date. calculated release can be explained by a correction of the chemical bond energy to 4.4 eV. Conclusion: We have successfully implemented fully automated production of 1 24 I and 6 4 Cu at Austin P.E.T. Centre. Future work will focus on the QC methods. Acknowledgment: The Solid Target facility is an AUSTIN/ANSTO/LICR R enal/Gastroentology partnership. P46 RELATIVE RENAL FUNCTION MEASUREMENT FROM SUPINE DUAL 124 64 HEADED GEOMETRIC MEAN Table 1 Production of I and Cu R obert Barnett, Simon Gruenewald R adioisotope Irradiation P roduction @ EOS Westmead Hospital, Sydney, Australia M Bq (mCi) Background: Total and relative renal function measurement from a DTPA scan is an essential part of live kidney donor assessment because although 1 24 I 12 μA 3.5 hrs 455 (12.3) left nephrectomy is favoured for its longer vein, the donor should always be 15 μ A 18 hrs 2479 (67.0) left with a normal well functioning kidney. For many years at Westmead 10 μ A 8 hrs 400 (10.8) Hospital, a seated single head posterior view scan (SH) has been performed and if there was asymmetry of greater than 45:55% function, a subsequent 12 μ A 10 hrs 984 (26.3) DMSA scan with geometric mean analysis was used as the gold standard. 12 μA 8 hrs 828 (22.4) This revealed the limitations of the SH even with depth correction. 64C u 25 μ A 2.5 hrs 100 (2.7) A im: To compare DTPA relative renal function measurement from supine 20 μA 5.5 hrs 155 (4.2) dual headed geometric mean (GM) studies with those obtained from SH. 35 μA 4 hrs 636 (17.2) Method: We analysed the GM relative function results of 26 potential kidney transplant donors and compared them with an independent group of 31 35 μ A 6.2 hrs 1191 (32.2) donors who had SH studies. We calculated the standard deviation of the percentage right kidney relative function (100 * R/R + L). The standard devia- tion was 2.8% for the SH and 1.1% for the GM. Four normal SH studies (as confi rmed by DMSA) were incorrectly classifi ed as abnormal. Discussion: The signifi cant (p < 0.01) reduction in standard deviation from SH to GM was attributed to diffi culties in determining kidney depth from lateral images acquired from SH studies, a reduction in patient motion and variability of kidney position when supine and improved background correc- tion from the GM image. The small standard deviation in our results indicate that an incorrect abnormal classifi cation is very unlikely for a GM study (p < 0.01). © 2013 Royal Australasian College of Physicians 37 Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 43rd Annual Scientifi c Meeting of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) Conclusion: Measurement from supine dual headed geometric mean sig- R esults: There were 513 HBS scans reviewed of which, 508 met inclusion nifi cantly increases the reliability of a DTPA scan for live kidney donor criteria. Results per annum analysis by referral indication are summarised in assessment. Figure 1. There has been a 2-fold increase in HBS performed from 2008–2012. The most common referral type is investigation of gallbladder function(eg right P 47 upper quadrant pain and cholecystitis), accounting for >8 0% studies per C R-51 EDTA GLOMERULAR FILTRATION RATE ASSESSMENTS ON annum, which decreased slightly over time from 90.2% of total referrals in LIVE KIDNEY DONORS TO BUILD A REFERENCE DATA SET 2008 to 81.3% in 2012. There has been a signifi cant increase in Sphincter of Oddi Dysfunction(SOD) and residual liver volume referrals, with these O liver Luddington 2groups representing 3.3% of referrals in 2008 and 16.3% in 2012, demon- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia strating a trend for new uses of HBS. The use of HBS for investigation of B ackground and Aim: The assessment of glomerular fi ltration rate (GFR) bile leaks remained constant over this period. is clinically important for the staging of renal disease and for evaluating live Conclusion: HBS referrals have not decreased over time despite increasing kidney donors. use of competing modalities. The most common indications are still for inves- T he gold standard for GFR assessment uses renal clearance of inulin, tigating gallbladder function, but increases in SOD evaluation and residual however this method is considered too impractical for routine clinical use. liver volume referrals indicate an evolving use of this imaging technique. Therefore the GFR is frequently evaluated from the plasma clearance of Cr-51 ethylene-diaminetetraacetic acid (Cr-51 EDTA). When compared to the inulin infusion method, – the GFR calculated with Cr-51 EDTA is reported to be up to 15% lower, – so inulin normalised population data sets are not equivalent. Sir Charles Gairdner Hospital has routinely assessed GFR for live kidney donors using Cr-51 EDTA, – so used this population to obtain normalised data. Method: This was a retrospective study of 135 subjects (39 male, 96 females; aged 20–80 years) assessed as live kidney donors. The GFR was evaluated from Cr-51 EDTA plasma clearance using blood samples taken at 1.5, 2.5 and 3.5 hours. The slope-intercept GFR was corrected for body surface area using the Haycock formula and for the fast exponential using the Brochner- Mortensen equation. R esults: There was no signifi cant change in GFR for both males and females between the ages of 20 and 40. Males having a mean GFR of 103.4 mL/min 1.73 m 2 and females having a mean of 104.9 mL/min 1.73 m2 . After the age of 40, GFR reduced linearly using the following equations: Male GFR = −0.458 × (Age)+121.5 (4.35 mL/min 1.73 m 2 per decade) Female GFR = −0.936 × (Age) +141.5 (7.7 mL/min 1.73 m 2 per decade) Conclusion: Cr-51 EDTA is cleared by the kidneys up to 15% slower than inulin, – and also shows good agreement with Gurmandeep et al, (similar study in 2005). This normalised data set can aid in determining renal disease and identifying eligible donors. Figure 1 HBS r eferrals indication per annum. P48 P50 PROTEIN LOSING ENEROPATHY A CCURACY OF RAPID S PECT-CT IN PATIENTS WITH ACTIVE GASTROINTESTINAL BLEEDING Abstract withdrawn Peter Robins, Teck Siew , Divya Nair, S hayne White Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia P 49 Background: Labelled red blood cell imaging with rapid SPECT-CT has been EVOLVING TREND OF THE UTILITY OF HEPATOBILIARY shown to be a valuable diagnostic tool in patients presenting with active gastro- SCINTIGRAPHY IN A TERTIARY INSTITUTION intestinal bleeding at Sir Charles Gairdner Hospital, particularly in increasing the accuracy of localisation of bleeding sites and reporter confi dence. K era Pethybridge , Marcia Wood , Bridget Chapple , David Thomas , Sze Ting Lee , Christopher Rowe M ethod: With iterative reconstruction algorithms, 6-slice CT, LEAP collima- Austin Health, Melbourne, Victoria, Australia tors and resolution recovery, diagnostically acceptable SPECT-CT scans can be performed in less than 8 minutes, minimising artefacts and registration Background: Hepatobiliary scintigraphy (HBS) continues to provide valu- errors from mobile gut activity and allowing accurate localisation of bleeding able physiological and functional information in evaluation of hepatocellular sites. An audit has been undertaken on all gastrointestinal bleeding studies function and biliary system patency for over 40 years. During this time performed at SCGH in 2012 to compare reported bleeding sites with fi ndings concurrent advances in ultrasound and cross-sectional imaging have contin- on CT angiography and/or repeat colonoscopy, endoscopy, capsule endoscopy ued to compete with HBS for diagnostic utility. or surgery. A im: To explore the vicissitudes in HBS referrals over fi ve years to determine R esults: The audit revealed 22 studies performed on 20 patients and 7 of its evolving role in clinical practice. these studies showed active bleeding. All reported sites of bleeding on Method: A retrospective review of HBS patients at our institution in 2008– Nuclear Medicine studies closely correlated with actual sites of bleeding on 2012. Inclusion criteria comprised of patients having undergone HBS with subsequent investigations or surgery. 99m Tc-DISIDA, + /-CCK (Cholycystokinin), with appropriate patient prepa- Conclusion: Labelled red blood cell imaging with rapid SPECT-CT allows ration and imaging. Scans were excluded if study results were suboptimal fast and accurate localisation of the bleeding site in patients presenting with due to patient noncompliance or inappropriate physiology. active GI bleeding. Current Diagnostic Imaging Pathway guidelines recom- Patient details were categorised into scan year, sex, age, CCK use, referral mend labelled red blood cell imaging in this clinical setting and a rapid indication and report fi ndings. Statistical analysis was performed to quanti- SPECT-CT protocol should be considered by Nuclear Medicine depart- tatively review referral tendencies. ments providing this service. 38 © 2013 Royal Australasian College of Physicians Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 Poster Abstracts T echnologist Symposium reduction in staff radiation exposure, of up to 25%. We compared the use of a combination of unit doses and manual dispensing with a fully automated P51 dispensing and delivery system to determine the impact on radiation expo- THE WAY TO THE CHEST IS BETWEEN THE TOES sure to nuclear medicine technologists. M y Linh Diep , Lisa Bowker , William John McKay Method: Nuclear Medicine Technologists working in the PET suite were Monash Medical Centre – Southern Health, Victoria, Australia asked to wear personal dosimeters (Panasonic, Japan) at chest level to Background: There are few successful reported cases of lymphoscintigraphy monitor their whole body radiation exposure. Staff recorded the date and used to localise a chylothorax. Common causes of chylothorax are surgical time of the reading, dose in mSv, length of the reading and the number of and trauma, but idiopathic cases also occur. Early detection of chylothorax patients injected. These results were tabulated using an Excel spreadsheet. is imperative to prevent complications such as malnutrition, anaemia and The average number of patients injected and the average dose received by hypoproteinaemia. The aim of this case study was to localise the source of the technologist per day were calculated for each method of injection. The chylothorax in a 68 year old male with a past history of severe Barrett’ s technologist dose rate was divided by the number of patients injected to oesophagus and poorly differentiated oesophageal cancer. determine the dose received per patient, allowing direct quantitative com- parison between the two delivery methods. Other factors such as changes in M ethod: 62 MBq of 99mTc-antimony colloid was injected into the left foot workfl ow, ease of use, staff acceptance, average patient dose and specifi c webbing between the fi rst and second toes. Planar images were acquired for concentration were reviewed through the use of a technologist survey and 10 minutes through the thorax and abdomen, demonstrating abnormal accu- database search. mulation of radiotracer in the superior mediastinum. The presence of a gastric hernia prevented accurate localisation of the chyle leak. To assist with R esults: Following a review of 484 patients using the combination method, localisation delayed SPECT/CT imaging was performed immediately follow- the mean administered dose was 304 MBq (196–565 MBq) as compared to ing injection of 50 mL iodine contrast through a central venous catheter. A the automated system giving 246.5 MBq (246.6–295.9 MBq). The total tech- chyle leak was visualised originating from the thoracic duct in the superior nologist dose per day for an average of 10 patients injected decreased from mediastinum, tracking to the left costophrenic gutter. The patient subse- 0.03 to 0.016 following implementation of the automated system. The quently underwent thoracic duct ligation and surveillance of chylothorax average dose received by the technologist per patient using the combination resolution. method was 0.003 mSv compared with the automated system being 0.0015 mSv. This showed an overall dose reduction to Technologists working Conclusion: This case study successfully demonstrated the role of nuclear in the PET suite of 48%. medicine in localising post-surgical chylothorax. The combined use of 99mTc-antimony colloid, SPECT/CT and iodine contrast is unprecedented, C onclusion: A signifi cant reduction in staff radiation exposure was seen demonstrating a novel approach to iodine contrast use in nuclear medicine. following the implementation of an automated dispensing and delivery system. Administered activity decreased by approximately 18%, which may contribute to dose reduction. This system improved the overall accuracy of P52 the dispensed dose with a resultant increase in workfl ow and effi ciency. THE IMPORTANCE AND BENEFIT OF PERFORMING A T C- MAA BREAKTHOUGH SCAN PRIOR TO SIRT: A CASE STUDY A my Evans Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia P 54 B ackground: Selective internal radiation therapy, or SIR-Spheres, is an “THREE CLICK” SEMI-AUTOMATIC CREATION OF PATIENT NOTES effective treatment for primary and secondary tumours localised to the liver. IN G .E . CENTRICITY R. I . S. INFORMING USERS OF RADIONUCLIDE A hepatic artery perfusion scan, or 99mTc-MAA-breakthrough study, is ADMINISTRATION WITH PRECAUTIONS APPROPRIATE TO RISK. performed prior to administration of the spheres and is an effective way to NOTE EXPIRY IS SET AUTOMATICALLY manage therapy dose and predict tracer distribution. The primary aim of this D ouglas Mackey 1 , Clayton Frater 2 , Stephanie Chen 1 poster is to highlight both the importance and benefi ts of performing the 1C oncord Hospital, Sydney, NSW, Australia breakthrough study. The secondary aim of this poster is to increase knowl- 2 S chool of Medicine, Sydney University, NSW, Australia edge of scan appearance and causes for unexpected tracer distribution. A im: To inform RIS users about patient radionuclide administrations M ethod: 24 99mTc-MAA hepatic artery perfusion scans were performed at Method: A free windows macro tool, Auto Hot Key (AHK) was programmed our site in 2012. Several of these cases exhibited unexpected tracer distribu- so that on pressing the F9 key it checks for the presence of CENTRICITY tion and will be presented as interesting cases to discuss the reasons behind RIS. If present, AHK displays radio button choices for these radionuclide altered biodistribution and how this affects therapy planning and reporter administrations. confi dence. R esults: It was found that altered biodistribution in the hepatic artery perfu- 99mT c < = 200 MBq delay 2 hrs sion scan was caused by liver/lung shunting, inadvertent delivery of 99mTc- 99mT c 200 – 500 MBq delay 3 hrs MAA to other organs, free pertechnetate in the 99mTc-MAA dose, refl ux of 99m hepatic arterial blood to abdominal organs as well as delay in imaging (greater Tc 500 – 1500 MBq delay 6 hrs than 1 hour) following administration of 99mTc-MAA. 99m Tc > > 1500 MBq (CALARA) delay 10 hrs Conclusion: The 99mTc-MAA-breakthrough study is an essential part of 131I <= 600 MBq delay 4 days – slow clearance the SIRT patient’ s management. The study enables quantifi cation of liver/ 131 I 600 – 2000 MBq delay 8 days – slow clearance lung shunting for SIRT dose calculation. In addition to this, the scan can 131 highlight problems that have occurred during 99mTc-MAA administration I 2000 – 4000 MBq delay 14 days that will need to be rectifi ed prior to the therapy administration. Finally, the 131 I > 6000 MBq delay 14 days scan can identify patients that have refl ux of hepatic arterial blood to the 131 I Lipiodol delay 20 days – slow clearance stomach and other abdominal organs which facilitates the knowledge of potential side effects. 67 Ga ∼ 200 MBq 90 Y On choosing one and pressing the O.K. button, AHK calculates a precaution P53 period and simulates a mouse click which opens the RIS note fi eld of the IMPACT OF USING AN [18F ]- FDG AUTO-DISPENSER ON STAFF selected patient. AHK copies both advice text and precaution period appro- RADIATION EXPOSURE – COMPARISON TO A MANUAL METHOD priate for the radionuclide administration into the note and sets the note D ave Francia , Meaghan Johnson , Nicholas Forwood, Elizabeth Bailey expiry in days. The operator may then cancel, save, or modify and save the Nuclear Medicine Department, Royal North Shore Hospital, Sydney, note. NSW, Australia Variation in note mouse click co-ordinates may be required on workstations B ackground: Previous studies have shown that the use of an automated with different screens. These are easily determined with the AHK utility dispensing and delivery system for [ 18 F]-FDG has resulted in a signifi cant “Au3_spy.exe”. © 2013 Royal Australasian College of Physicians 39 Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40 43rd Annual Scientifi c Meeting of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) Results: The note insertion tool proved easy to use and confi gure. Consen- Nuclear Medicine (SNM) are playing an active role in aiding implementation sus was needed between RSO, Physicians and Technologists on the texts to of successful QA programs in nuclear medicine practices. be inserted for the radionuclide choices. RIS users within our institution and P urpose: The purpose of QA programs is to continually evaluate the quality at other district hospitals appreciated the notifi cations. of all components in nuclear medicine departments including professional C onclusion: AHK is a fl exible tool, free under the GPL which may be used competence, with a view for quality improvement. QA programs will ensure to easily provide tailored department specifi c RIS advice on patients who all examinations are justifi ed, ALARA principles are adhered to, written have undergone radionuclide administration. The method works with G.E. protocols are followed for procedures, self-evaluation is conducted regularly CENTRICITY RIS and the notes expire after a settable period. Keystrokes and continued education is encouraged. are few. Method: The fi rst step in QA is documentation of procedures, which can take the form of Standard Operating Procedures, Work Instructions or Pro- tocols. Proper documentation ensures that staff follow an accepted protocol for performing procedures so that consistency is always maintained. Review of contemporary work practices, Radiation safety practices, Occupational P 55 Health and Safety Practices, Staff training and development program and QUALITY ASSURANCE IN NUCLEAR MEDICINE AND PET Staff accreditation status must be documented and reviewed regularly. If Kunthi Pathmaraj, Andrew Scott defi ciencies or nonconformities are found, follow-up actions and a remedial Department of Nuclear Medicine and Centre For PET, Austin Health, schedule must be established and a time frame should be formulated to Melbourne, Victoria, Australia enforce remedial action and conformance. Background: Quality Assurance (QA) in Nuclear Medicine is rapidly C onclusion: Quality Assurance if undertaken in a methodical and consistent becoming an integral aspect of providing a professional and high quality manner will greatly assist the department in ensuring the highest standards diagnostic imaging service to patients. International regulatory bodies such of patient care and staff well-being are met. Since Nuclear Medicine is a as the Human Health Division of the International Atomic Energy Agency practice that involves the use of radiation, it is imperative that transparent (IAEA) as well as national and international societies such as the Australian and traceable documentation is maintained to ensure best practice standards New Zealand Society of Nuclear Medicine (ANZSNM) and Society of are being met. 40 © 2013 Royal Australasian College of Physicians Internal Medicine Journal 2013; 43 (Suppl. 1): 21–40