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EARLEANM Technologists’ Guide
The Technologists’ Guide is an annual publication led by the EANM and composed under the lead of the EANM Technologists Committee.
Aims and Scope
The EANM Technologists’ Guide contains timely nuclear medicine-related topics and aims to publish the highest quality clinical, scientific, and educational material. The booklet deems not only to assist Technologists in their clinical routine but also a wide range of professionals working in the field of Nuclear Medicine.
Background information
The EANM Technologists’ Guide is traditionally launched on the occasion of the EANM Annual Congress during the first CTE Session, organised by the EANM Technologists Committee. After the official launch, the Technologists’ Guide can be downloaded for free.
All chapters of the Technologists’ Guide are based on volunteer work and are subject to peer review. The purpose of the peer review is to ensure only material of the highest quality is published and that the material is conveyed in a suitable fashion, using good-quality illustrations and a good standard of British English. Further, all chapters undergo copy editing before publication.
Ever since its inception, Nuclear Medicine has been known as a constantly evolving field. Radiopharmaceutical research over the years has proven productive and has become increasingly recognised for its diagnostic and therapeutic value for a range of clinical indications and patient pathways.
Consequently, it is upon the workforce to keep abreast of the latest developments, actively studying and remaining knowledgeable, and ultimately contributing to a smooth translation of theoretical research concepts into real everyday practice. In this respect, we also recognise that the use of some radiopharmaceuticals may be established in certain countries for a number of years, and yet simultaneously still feel new to others.
It is fundamental that the technologist understands the radiopharmaceutical journey from production to imaging acquisition, at the same time cultivating an understanding of imaging interpretation. This guide focuses on each element of that journey, based on a consistent structure introducing and explaining the basics and practicalities of each radiopharmaceutical.
It embraces a wide spectrum of clinical applications, and while none is yet very commonly performed at the time of this first edition, all hold great promise for future patient care. Developments in more targeted PET radiopharmaceuticals, in particular, are taking on a pre-eminent role as staging and restaging tools, as well as in predicting and monitoring response.
The chapters are a useful mix of methodical literature review, input based on the authors’ vast experience and critical thinking, with the goal of providing a summary of well-designed protocols and available techniques whilst acknowledging the dynamic nature of these new radiopharmaceuticals and how their use is still being optimised.
We hope it will serve as a reference toolkit, and that it spurs interest within multidisciplinary teams and encourages them to embrace novel procedures.
The editorial team appreciate the authors’ efforts, commitment and their willingness to collaborate, and extend their thanks to the members of the Neuroimaging Committee who kindly reviewed the chapters relating to their respective spheres of expertise.
We sincerely hope that this booklet will be valuable, both as a guide for those learning how to perform these procedures and as a vehicle for dissemination of best practice in our ever more interesting specialty.
COMING SOON
Since the earliest days of the discipline, the study of digestive disorders has historically been a very relevant area of study from the nuclear medicine point of view. The ability to visualise and characterise the varied physiological processes of the gastrointestinal systems without resorting to invasive methods makes nuclear medicine an effective and comparatively easy-to-perform method for evaluating these types of diseases.
The evolution of radiopharmacy and the available molecules, further development of the labelling processes and the routine application of these radiopharmaceuticals has enabled the study of the annexes of the digestive tract, which has also given increased importance to these nuclear medicine procedures
Gastrointestinal molecular imaging studies have been performed for a long time now, and their applicability varies according to the different needs of different populations across the globe. To this end, a wide variety of protocols have been developed and harmonisation is a major challenge in this area. Meal composition, imaging protocols, standardisation of results and many other specific challenges arise when these procedures are applied in the clinical setting.
With this in mind, this book provides a summary of the most-performed procedures in molecular gastrointestinal imaging, starting with basic anatomy and physiology and an overview of the available molecules in the radiopharmacy toolkit before going on to discuss a number of the procedures available. The various chapters have been written by authors with a wealth of knowledge and practical expertise in each of the covered topics, who outline the individual procedures together with their applications, the suggested protocols and the expected outcomes.
Last but not least, this edition of the Technologists’ Guide provides an overview of gastrointestinal molecular imaging procedures which have seen growing relevance in recent years. The growth of theranostics has resulted in an increased need to assess the function of some of the digestive organs, such as the liver or the salivary glands.
The editorial team thanks all the authors for their willingness to collaborate and hopes that this book will be useful, both as a guide for those learning how to perform these procedures and as a vehicle for dissemination of best practice in our field.
The specific management of radionuclide therapies requires the nuclear medicine technologist to venture into new fields of expertise and deal with specific needs in daily practice.
Besides the daily routine of dealing with diagnostic procedures, some additional procedures are required and necessary when entering the field of radionuclide therapy.
In view of the increased use of radionuclide therapies, we are convinced that this guide will provide valuable support for technologists who are starting out in the specific area of radionuclide therapy. The use of radionuclide therapies is revolutionising nuclear medicine, and it is time to expand our knowledge and expertise in this area to meet the need for well-trained staff. To aid colleagues in facing the challenges ahead, we have opted to prioritise the management of radionuclide therapies over describing the specific use and applications of the relevant radiopharmaceuticals.
When initiating the Technologists’ Guide 2022 and assigning the individual chapters, we decided to devote more attention to managing radionuclide therapy and those specific tasks that do not feature so prominently in the diagnostic setting.
In therapeutic settings, we are more involved in the care of patients. For the patient, it is important to be well-informed about the procedure, the measures to be taken to protect the patient and the public environment, and the logistics and costs of the therapy. Depending on the local legislation, patients sometimes need to be hospitalised because of the high exposure to the immediate environment. During hospitalisation, patients have specific needs which require more attention on our part. There is a higher risk of unexpected incidents, and risk assessment is required to put adequate procedures in place. We also address some specific radiation protection measures relating to the different characteristics of the radionuclides used. Finally, when dealing with radioactive waste, handling radionuclides and managing the hospitalisation of patients, we need specific procedures to ensure that the waste can be released according to the local requirements.
The Technologists’ Guide 2022 brings together experts from the fields of dosimetry, imaging, radiation protection, patient care and waste management, including physicians, medical and health physicists, radiographers and nuclear medicine technologists. I would like to express my gratitude to all the authors who shared their knowledge and expertise with us. We very much appreciate their willingness to accept the invitation to volunteer and make time for writing alongside their existing daily workload.
We hope the Technologists’ Guide 2022 will provide you with new insights and supply useful information to facilitate the management of radionuclide therapies.
Every year, the Technologists Committee publishes a Technologists’ Guide to develop and improve the nuclear medicine specialists’ knowledge and personal skills in various aspects of nuclear medicine. This year, together with an interdisciplinary group of specialists, we decided to address the topic of “Advances in PET-CT Imaging”, outlining recent advancements in radioisotope imaging with a special emphasis on PET-CT techniques.
PET-CT study allows us to evaluate the aetiology of various diseases and has therefore become an essential element of diagnostic management. The rapidly evolving technology of medical imaging is permitting the constant improvement of existing solutions while simultaneously eliminating the method’s limitations. Advances in PET-CT Imaging aims to provide a technical and clinical overview of PET-CT principles and applications, highlighting recent innovations and the latest solutions that are improving technical and clinical study outcomes.
This extensive guide encompassing nine chapters provides the reader with a wide range of information: from hardware and software updates, PET-CT artefacts and pitfalls through radiopharmaceutical advancements to the latest solutions in oncology and the definition and applications of radiomics. The contents guide readers through the long list of specific PET-CT characteristics, advantages, utilities and applications, not forgetting the method’s limitations and ways of avoiding their impact on the eventual PET-CT dataset.
We believe that hybrid imaging is not only a set of techniques and properties but also an especially interdisciplinary and qualified medical team, which has a significant influence on diagnostic management. The complexity of the PET-CT study means that the technician’s extensive knowledge and experience are vital to the success of the process. We hope that this latest edition of the Technologists’ Guide will be of benefit in helping our readers update their personal skill sets.
After nearly two decades since its first edition, the Technologist’s Guide is an established tradition and a valuable product of the nuclear medicine technologists’ community. We are all facing unprecedented challenges, both in our profession and in our homes. Seeing this Guide published in these circumstances is a tribute to our great colleagues, friends and our sponsor, who have dedicated time and other resources to ensure the tradition is kept alive.
Every year the Tech Guide, as we all know it, aims to bring together experts from the field and present concise opinions and guidance on a specific topic to support the workforce of technologists working in nuclear medicine. This year the topic is hybrid imaging in conventional nuclear medicine. When choosing the theme for the Tech Guide, the Technologists’ Committee had in mind the impact of non-PET hybrid imaging on nuclear medicine practice. Moreover, SPECT-CT and the Tech Guide are of similar age, so we wanted to focus on collating conventional hybrid imaging practices in one concise and up-to-date guidance document.
The Tech Guide is a partnership between EANM committees, physicians, scientists and technologists, and this year’s edition is no different. We partnered with the Physics Committee to cover the technical aspects of the imaging modality, as well as with the Paediatric Committee for their chapter. We wanted to acknowledge the achievements of fellow technologists like Dr Sebastijan Rep, who is not only an ambassador for the technologist’s role in quality assurance and quality control but also a new PhD graduate. Other chapters were co-authored by technologists and physicians or scientists, such as those on myocardial perfusion imaging and the contribution of hybrid imaging to radionuclide therapy.
As ever, the Tech Guide has practical content, with a focus on hands-on advice for technologists, showing the artefacts and pitfalls when imaging and the role of the technologist in achieving high standards of quality. The Technologists’ Committee also plays an important role in defining our communication strategy with patients in nuclear medicine, and we have tried to include this new topic in this year’s Tech Guide.
For us in the editorial team, publishing this Guide is a way of saying thank you to the nuclear medicine community for all your passion and dedication to patient care. We wanted to showcase the impact of our profession within the nuclear medicine community, as well as the high standard of quality delivered by technologists across Europe.
We trust that you will find the Tech Guide enjoyable reading, and we would like to thank you all for taking part in the success of this project.
In 2008, the EANM Technologist Committee published a Technologist’s Guide entitled The Radiopharmacy. It is available online through the EANM website and covers topics relevant to daily radiopharmacy practice, such as design, preparation, dispensing and documentation.
Since then, many radiopharmaceutical practices have changed, especially with the introduction of new radiotracers. This year’s Technologist’s Guide includes the basics, starting from the history of radiopharmaceuticals, and proceeds to the high-end radiopharmaceuticals used in translational medicine. Illustrations and tables have been included to facilitate the understanding of certain principles. The most widely used radiopharmaceuticals in SPECT and PET have been dealt with separately because of the breadth of development since the previous publication in 2008. This year’s Technologist’s Guide also covers radiopharmaceuticals used in therapy. Authors from different backgrounds have contributed to the Guide, ensuring that it will be an important addition to the knowledge base required to perform radiopharmacy. It is an unmissable collection of information that will prove an essential aid in the clinical setting and will keep the technologist up to date with the latest radiopharmacy principles and practices.
The EANM Technologist Committee would like to thank all the authors who have kindly offered their time and expertise, which have been fundamental to the creation of this book.
Prostate cancer is the second most common cancer in men worldwide. Due to increasing life expectancy and the introduction of more sensitive diagnostic screening techniques, prostate cancer is being diagnosed more frequently, with rapidly increasing incidence and prevalence. It has a wide spectrum of biological behaviour, ranging from indolent low-risk disease to highly aggressive castration-resistant prostate cancer.
Nuclear medicine imaging plays a key role in this heterogeneous disease as it can answer key clinical questions at various phases of the disease, the imaging being tailored to each phase. Nuclear medicine has demonstrated efficacy for cancer detection, with an increasing number of potential targets for imaging and treatment.
The first chapter of this book describes the prostate’s anatomy, physiology and pathology. The radiopharmaceuticals that allow the study or treatment of prostate cancer are discussed in the subsequent chapter. Conventional nuclear medicine represents a cost-effective resource in the management of prostatic disease, and the third chapter documents the specific imaging procedures for diagnostic planar imaging and hybrid SPECT/CT. The following two chapters provide an overview of protocols and the diagnostic value of PET/CT imaging using fluorine-18 and other non-fluorine-18 radioisotopes labelled with different molecules. PET/CT is a useful tool for guided radiotherapy planning; consequently, the sixth chapter describes the acquisition and reconstruction protocol for the purpose of radiotherapy. One of the most recent developments in nuclear medicine is theranostics: the seventh chapter reviews the state of the art, describing the use of theranostic pairs and quantitative analysis of tissue and tumour uptake in optimisation of patient treatment. The eighth chapter broadens the vision of the field of therapy, adding treatment based on alpha-emitting radionuclides. Nuclear medicine technologists play an important part in the multi-professional management of prostate cancer patients. In addition to being directly involved in therapy through the performance of various roles, they are responsible for other tasks such as patient preparation and imaging processing. The ninth chapter describes the clinical pathway of the patient in order to improve understanding of the technologist’s tasks.
The recent advances in prostate cancer-specific tracers were significantly supported by the advent of translational medicine. With this in mind, the final chapter explains how molecular and non-invasive preclinical imaging become rapidly emerging fields in preclinical cancer drug research and development.
We hope that this overview of the state of the art of nuclear medicine imaging and therapy in prostate cancer will provide a valuable resource for all technologists and clinical staff involved in this field.
The EANM Technologist Committee would like to thank all the authors who have kindly offered their time and expertise, which have been fundamental to the creation of this book.
Technologists are members of the team required to implement diagnostic imaging in nuclear medicine (NM). In many hospitals, technologists are responsible for quality assurance (QA) duties. The development of hybrid imaging has further increased the need for strict implementation of quality control (QC) and rendered QC more demanding. These new guidelines from the EANM Technologist Committee address the tasks necessary for the smooth implementation of QC in NM departments.
Quality control is required to ensure that NM equipment is functioning properly and constitutes an important part of quality management in an NM department. The described QC tests are designed to detect problems before they affect clinical patient studies. They are intended to provide a full evaluation of equipment performance and to ensure that equipment is performing properly after service or adjustment.
Quality control is important due to the need to optimise patient exposure and image quality during NM imaging examinations. The image quality is dependent upon the data acquisition parameters, which must be adapted to the detector system and also the reconstruction algorithm, based on which the acquisition time can be shortened or the administered activity of the radiopharmaceuticals can be decreased.
These guidelines cover the principles of QC and QA, including QC and the improvement of imaging protocols for both imaging and non-imaging instrumentation. The first part describes separately the QC tests for conventional NM modalities such as planar gamma camera imaging, SPECT and PET and also for hybrid methods such as SPECT/CT and PET/CT. An individual chapter is devoted to CT system QC, as this constitutes an important element in the optimisation of acquisition protocols. The second part covers image optimisation protocols for SPECT/CT and PET/CT modalities and accreditation for clinical trials. The third part describes the QC of non-imaging instrumentation, such as radionuclide dose calibrators, intraoperative probes, body uptake probes and well counters.
This overview of QC and protocol optimisation will be a valuable tool for technologists and all clinical staff involved in this particular field.
In the name of the EANM Technologist Committee, I would like to thank all the authors who have taken the time to prepare and write the chapters and all the editors who have helped to create this book.
Since the beginning of the 20th century, ionising radiation has been employed in medicine for diagnostic and therapeutic purposes. The belief that radioactive sources could heal many different diseases led to a rapid increase in the usage of radioactive material; in conjunction with the lack of knowledge of the biological effects of radiation, this resulted in many accidents and numerous pathologies in both patients and operators.
Ionising radiation procedures for medical purposes have been invaluable in improving patient care. Accordingly, the use of radiation in medicine has continued to increase over the years, accompanied by improvements in safety standards. Nuclear medicine (NM) has been deeply involved in this process. Both applications – diagnostic and therapeutic – showed great initial potential, and important advances have repeatedly been achieved over the intervening decades.
The development of NM has been accompanied by great responsibility since the safety of both the professional and the patient depends on the correct use of radiation. The professional should not be harmed by the radiation needed to perform each procedure, and the patient should only be exposed to radiation after the benefit/risk ratio has been considered.
This year’s Technologist’s Guide aims to give an overview of the principles of radiation protection and to provide the professional with the knowledge required to act in accordance with these principles. A further intention is to set out the principles of dose optimisation. There is a consensus that all NM procedures must be justified; furthermore, the radiation used in each procedure must be carefully calculated and based on rigorous quality standards.
This book starts with overviews of the interaction of radiation with matter and the fundamentals of dosimetry. It continues by covering the international basic safety standards and radiobiology principles. The basic concepts of dose optimisation for diagnostic and therapeutic procedures involving the use of radionuclides are explained, and an individual chapter focuses specifically on dose optimisation in the paediatric population. After this, aspects of occupational radiation protection are covered, and finally, the design of an NM department is discussed, keeping in mind the particularities that need to be considered to ensure compliance with radiation protection standards. Each chapter includes a description of the specific role of NMTs as main actors in procedures who also bear responsibility for the application of radiation protection in daily practice.
Neurological disorders are already affecting hundreds of millions of people worldwide, of whom more than 50 million suffer from epilepsy, and around 35.6 million have Alzheimer’s disease or other dementias. Furthermore, greater life expectancy and the overall ageing of the general population in both developed and developing countries will contribute to continued increases in the prevalence of many chronic and progressive physical and mental conditions, including neurological disorders.
Diagnostic nuclear medicine investigations have evolved from being a research modality in evaluating the function and disease of the central nervous system to an established clinical tool in neurology. In recent years, new technologies and techniques have been developed to improve the quality of the images acquired, thereby enhancing the clinical impact of these techniques. Moreover, radiopharmaceutical development has allowed SPECT and PET imaging to become increasingly acute and to cover more pathologies. From metabolism to perfusion, brain function has been studied in various conditions, including dementia, epilepsy, movement disorders and brain tumours. These advances represent a challenge for technologists, given that each new technique and piece of equipment requires optimisation of protocol design. In the neuroimaging context, technologists also play a key role in patient care, which can be particularly challenging owing to the inability of patients suffering from neurological disorders to cooperate and the demanding nature of the examinations. In this book, we begin by describing the brain’s anatomy, physiology and pathology (Chapter 1). After this, tracers for brain imaging are discussed (Chapter 2). The following two chapters provide an overview of the imaging of oncological disease by means of SPECT or SPECT/CT and PET/CT techniques (Chapters 3 and 4). Imaging in neurological and vascular brain diseases is also analysed, focussing first on SPECT and SPECT/CT technology and then on PET/CT (Chapters 5 and 6). The use of PET/CT in brain tumour radiotherapy planning is discussed in Chapter 7. The application of the emerging technology of PET/MRI for brain imaging is approached in Chapter 8. Brain imaging in the case of suspicion of brain death is described in Chapter 9. The final chapter is devoted to the special health care and surveillance needs of patients affected by neurological disorders. This extended overview of neuroimaging techniques and the clinical state of the art will provide a valuable tool to all clinical staff, including not only technologists but also physicians, physicists and students interested in this particular field. The EANM Technologist Committee would like to thank all the authors who have kindly offered their time and expertise, which have been fundamental to the creation of this book.
Cardiovascular diseases are the leading cause of morbidity and mortality in the developed world, and their frequency is also increasing in less developed countries [1]. A reliable and rapid diagnosis is important to reduce the number of deaths and allow the introduction of appropriate therapy at a very early stage of the disease.
Given that the last EANM Technologist’s Guide, entitled Myocardial Perfusion Imaging, was released way back in 2004, it is certainly time for this new book. During the intervening period, Nuclear Medicine Cardiology has made great progress, with the development of new radiopharmaceuticals for myocardial perfusion imaging and the introduction of new imaging equipment with new postprocessing programmes. This book provides the reader with information on the current state of the art in myocardial imaging in Nuclear Medicine. It opens by introducing all the myocardial imaging methods, including those beyond Nuclear Medicine. The common clinical indications for myocardial perfusion scintigraphy are then discussed, followed by guidance on patient preparation and the different types of stress protocol and a presentation of the main advantages and disadvantages of the multidisciplinary approach and advanced practice. Advances in radiopharmaceuticals for myocardial perfusion imaging are then introduced. The following three chapters are more technically oriented, enabling the reader to learn about the different SPECT, SPECT/CT, D-SPECT and PET/CT protocols and the imaging equipment, with image processing and software. The final chapter elucidates the causes and effects of potential artefacts and pitfalls in myocardial perfusion imaging. I would like to thank all the authors who have taken the time to write the chapters and all of my fellow editors who have helped to create this book. I hope all professionals who work in the area of Nuclear Medicine Cardiology or are interested in this topic will enjoy reading and using the book.
This year we have focussed on radionuclide therapy for our book. For decades, radionuclide therapy has been used to help manage a range of malignant and benign diseases, and for many pathologies, its utility is well-known and well-documented. In the early years, the radionuclide range and the pathologies which could be managed (treatment and/or palliation) were limited. However, significant progress continues to be made, and there has been considerable expansion in the available therapeutic radionuclides and the pathologies they can manage.
On this basis, we feel it is time for this book to be published. The book brings together experts in the field of radionuclide therapy from Europe and America so that they can share their theoretical knowledge and clinical/practical experience. These experts emanate from various professional backgrounds and include medical physicists, nuclear medicine physicians, radiographers, nuclear medicine technologists and others. The book commences with background information about radionuclide therapy (Section I). If you are new to radionuclide therapy, then we suggest that special attention is paid to the first four chapters as the information covered will give you a good theoretical grounding; with this in mind, you can progress to read about the clinical and technical aspects of radionuclide therapy in Section II. Here, attention is paid to how to conduct radiotherapy procedures and the pathologies it can treat and/or where it can be used for palliation. This section contains significant input from those who practice radionuclide therapy, especially nuclear medicine physicians and others with various relevant clinical skills. In Section III, we consider the future, and particular emphasis is placed on molecular therapy. The final chapter considers new radionuclides, which may become valuable in the future. We should like to thank the authors who have taken the time to write the chapters and also the reviewers who have provided constructive feedback to the authors. We acknowledge that writing and reviewing involve a considerable effort, and we hope that the readers will find this book useful for training and practical purposes.
In 2008 approximately 13 million new cases of cancer were diagnosed worldwide, and nearly 8 million deaths were attributed to it. The most common causes of cancer death were lung, stomach and liver cancer [1]. Worldwide, the incidence of cancer is a fifth higher in men than in women. As the population grows, cancer will inevitably increase, too – even if incidence rates remain the same. Over half of all cancers are diagnosed in developing countries, and this proportion is expected to increase over time. Based on current rates, projections indicate that by 2030 there will be around 21 million new cases diagnosed annually and approximately 13 million deaths from cancer [2].
Whilst cancer rates have increased, the ability to treat cancer effectively has improved substantially owing in major part to better diagnostic procedures that permit more timely detection of cancer. The enhanced prognostic ability of diagnostic tests allows for the streaming of patients into more appropriate treatment or palliation (individualised) schemes. And, of course, the methods by which cancer can be treated or managed have improved considerably. Alongside these developments, new approaches to treatment/management continue to be tested and introduced. Thirty years ago, many patients who developed cancer saw it as a death sentence; today, this is no longer the case, as many cancers are curable. Improvements in radiotherapy treatment regimens have created the need for more accurate planning. Various factors have brought about this change. For instance, there have been moves towards less radical surgical techniques, sparing healthy tissue but placing demands on the radiotherapy service to ensure that residual cancerous tissue is treated. Radiotherapy has evolved, too, with more targeted treatment fields being applied, again, to spare healthy tissue and thereby help minimise unwanted effects of radiation therapy. To meet this goal, it is necessary to ensure that the radiotherapy field is planned as accurately as possible. Until recently, CT has played a major role in radiotherapy planning, but now PET/CT has started to evolve to help define radiation treatment fields. In 2008 [3], the IAEA released helpful information which proposed that PET/CT would likely prove valuable in radiotherapy planning. More recently, the EANM selected a collection of journal papers that may also prove useful in understanding the value of PET/CT in radiotherapy planning; these can be accessed via the EANM website [4]. The philosophy which underpins the use of PET/CT is related to the fact that the combination of PET and CT data allows structural and functional information to be demonstrated and evaluated together. The combination of anatomical (CT) and functional (PET) information can give the healthcare team better insight into not only cancer distribution and physical tumour size but also metabolic activity levels.
This book, the third and final in the PET/CT series, gives an introduction and overview of PET/CT for radiotherapy planning. Knowing that the readership could include those with limited familiarity with radiotherapy, we have included background information about this. Consequently, the early chapters introduce cell biology, radiobiology, side-effects of radiation therapy and radiation tolerance doses; these are followed by an overview of external beam radiotherapy (conventional, IMRT/Rapid Arc and stereotactic). Treatment planning is then introduced. At this stage, those new to radiotherapy planning will have gained a level of understanding to help contextualise the remaining chapters, which concentrate on PET/CT for radiotherapy planning. Whole-body FDG PET/CT scanning for radiotherapy planning is becoming the “state of the art”, done on a multidisciplinary basis by qualified staff from the Radiotherapy Department and the Nuclear Medicine and PET Department [5]. Therefore we took a strategic decision to invite authors from our collaborators, ESTRO and SNMT, to contribute their expertise in this field for this Tech Guide Book. ESTRO authors, as experts in radiotherapy planning, have contributed with the chapters ”Introduction to Radiotherapy”, “Method and Treatment Planning”, and “4D CT and 4D PET”. SNMT, our American counter partner, has written about future prospects for PET/ CT in radiotherapy based on the introduction of novel tracers in the chapter “New tracers”. We would like to thank all chapter authors and peer reviewers who have helped us to create this book, in close collaboration with ESTRO and SNMT, for radiation therapy technologists, radiographers and nuclear medicine technologists and guests in your departments. We hope the reader will enjoy reading and using the book.
Owing primarily to the wide availability of 18F-FDG, PET/CT has established its place in the diagnosis and management of several prominent diseases, especially in the field of oncology. In recent years, an increasing number of alternative new PET radiopharmaceuticals have become commercially available, opening the way to new applications of PET/CT imaging. Since a greater variety of biological functions can be visualised by PET/ CT with these new positron radiopharmaceuticals, the number of PET/CT applications will increase in cardiology and neurology as well as in oncology.
This second PET/CT Technologist’s Guide will be of value not only for nuclear medicine technologists but also for other professionals working with PET/CT. As the first book covered instrumentation, protocol optimisation, radiation protection and patient care issues, this book provides the reader with information on the principles of PET radiochemistry and the current state of clinical applications of PET/CT in the fields of oncology, cardiology, infection and inflammation and neurology. The first chapter covers the principles of PET radiochemistry. In addition to presenting the basic knowledge of PET chemistry, it also discusses the regulatory rules which require increasing awareness of the challenges involved in the production and quality assurance of PET radiopharmaceuticals. This chapter offers the reader an excellent overview of all the issues and aspects related to the preparation of PET tracers. Chapter 2 presents the clinical applications of PET/CT in oncology, with a review of the strengths, weaknesses, current evidence and future directions of this imaging technique over a wide range of tumours. PET/CT applications in the detection and follow-up of infection and inflammatory disease are rather new and still unrecognised by some. Chapter 3 reviews the main indications for 18F-FDG PET/CT in this field and discusses the advantages and pitfalls compared with imaging using labelled white blood cells. The introduction of new PET tracers such as 82Rb and the increasing availability of PET devices in combination with high-end CT scanners is opening the way for increasing the use of PET/CT in cardiology. Chapter 4 discusses the clinical applications in the field and covers patient preparation and PET/CT protocols. Imaging the brain with PET/CT is still an open field with many possibilities. Thanks to the large number of PET tracers for brain imaging that are either already available or expected to become available. This final chapter offers an overview of the current applications of PET/CT imaging in different brain diseases.
After the broad view offered by the first two volumes on technology, radiation protection, patient care and clinical applications of PET/CT, the third book in this series, to be published in 2012, will address the great challenge posed by multimodality approaches involving PET/CT. In particular, it will consider the radiotherapy applications of PET/CT imaging. The ultimate quality of PET/CT imaging depends on the expert input of a number of professionals, including physicians, physicists, chemists, pharmacists and technologists. Only good teamwork between the professionals working in the area of PET/CT imaging will ultimately ensure a high-quality diagnosis of disease. The importance of such collaboration also applies to this booklet, in which the good quality reflects the excellent teamwork between the EANM Radiopharmacy, Oncology, Cardiovascular and Neurology Committees and Task Group on Infection and Inflammation and the EANM Technologist Committee. We hope that you enjoy reading this book and that it will prove a valuable resource for all professionals who work in the area of PET/CT or are interested in this topic.
PET-CT is expanding rapidly in many countries and has quickly established its place in the diagnosis and management of several prominent diseases. This has come about through a growing and convincing evidence base in regard to its efficacy, combined with sound financial reasons. Taken together, these provide a firm argument for the routine use of PET-CT in certain disease processes. With this in mind, this book, the first in a series of three about PET-CT, comes at a timely moment. The next two books in this series will be published in 2011 and 2012. Each chapter has a reference list, though we have tried to keep these lists to essential references only. Finally, most chapters also have a short reading list, which seeks either to develop fundamental background knowledge that should be present prior to reading the chapter or to give direction on how to extend your knowledge after reading the chapter.
This book covers some fundamental aspects of PET-CT in preparation for the two subsequent books. It commences with a chapter on a radionuclide radiologist’s perspective on the use of PET-CT in his medical practice. This is an important starting point because it makes a clear statement about how PET-CT is evolving in a particular country with a view to providing a routine service. Having introduced this perspective, the book progresses to a number of equipment-related chapters. These outline how PET-CT imaging and radionuclide production equipment work and also they explain what quality checks might be conducted to ensure optimal performance. Given that PET-CT radiation protection requirements are complex, we have included a substantial chapter on this. This comprises three elements – ‘sta(’, ‘patient’ and ‘department design’. There is also a chapter on patient care, and, as with radiation protection, we have anticipated an existing level of general knowledge about these particular issues. The final chapter presents arguments on how competence to practice could be achieved and what considerations should be borne in mind when designing educational curricula. Building on this book, the second in the series will explore some more fundamental issues (such as radiochemistry QC) before progressing to the detail of how PET-CT procedures are conducted. We hope that you enjoy reading this book and the two related ones. More importantly, we hope that this book will serve as a valuable resource when conducting PET-CT procedures and also designing educational processes that seek to ensure staff are competent in their roles. Finally, as part of this preface, we have included below a concise glossary of terms and abbreviations that aim to give a simple insight before you begin reading this book.
Radionuclide evaluation of the genitourinary system includes quantitative estimates of renal perfusion and function. With the widespread use of ultrasound and computed tomography, the evaluation of renal anatomy by radionuclide imaging has diminished, and the role of nuclear renal imaging has become more confined to functional analysis. Indications for renal scanning include sensitivity to radiographic contrast material, assessment of renal blood flow, and differential or quantitative functional assessment of native and transplanted kidneys. Nuclear techniques have also proved of value in examining ureteral and renal pelvic obstruction, vesicoureteral reflux, and suspected renovascular hypertension.
The diagnoses of urinary tract obstructions and assessment of their functional significance are common indications for radionuclide imaging in adults and children. Obstruction may be suspected based on clinical findings or as an incidental finding of a dilated renal collecting system on IVP, CT, ultrasound or radionuclide renal imaging. Standard imaging techniques, such as IVP and ultrasound, evaluate structure but do not depict urodynamics. This technologist guide focuses on dynamic imaging techniques in obstructive renal pathology. Chapter 1 will bring a clear overview of renal anatomy and function. Chapter 2 is all about the radiopharmaceuticals we can use for dynamic renal imaging. Chapter 3 describes the patient preparation and the imaging protocol. Image and curve interpretation is included in chapter 4. The last chapter (5) is dedicated to special considerations for pediatric patients. I hope that this guide will provide a clearer understanding of dynamic renal imaging in obstructive renal pathology and can be a useful tool in your daily practice.
This booklet contains chapters on all relevant topics of the daily radiopharmacy practice of technologists, such as radiopharmacy design, preparation and dispensing as well as documentation written by European experts in the field, both radiopharmacists and technologists.
Improvements in radionuclide imaging technologies and therapy contribute to Europe’s increased demand for nuclear medicine services. This rising demand has further reinforced the critical role of nuclear medicine technologists, and best-practice guidelines have become crucial to offering the best service to the public. It is also important that best-practice guidelines are developed and implemented at the European level to harmonise patient care across European countries.
The Technologist Committee of the EANM has been very active and successful in promoting high standards for the daily work of nuclear medicine technologists in the different countries of Europe and has assisted in the development of high-quality national systems of education and training of nuclear medicine technologists. The Committee has also contributed to several EANM initiatives on education, and the Education Sub-Committee has published a series of “Technologist’s Guides”. The present booklet “Best Practice in Nuclear Medicine – Part 2” covers important items, such as European regulatory issues, best practices in radiation protection, quality assurance of equipment and best practice in procurement. This booklet may serve not only as a reference for improving the quality of practice but also as a resource providing a quick and efficient method to find references for additional readings.
Nuclear Medicine departments offer a large diversity of diagnostic and therapeutic procedures, which often play a central role in patient management. At the same time, the field is constantly evolving, with new procedures being continuously introduced. In such a rich and developing scenario, adherence to best practice guidelines becomes crucial to offering the best patient care.
Nuclear Medicine technology is a demanding and sophisticated profession. The continuous technological developments, radiopharmaceuticals, procedures and patient care make it one of the most rapidly evolving healthcare professions. For example, novel targets for imaging have emerged, such as labelled glucose for the imaging of cancer, labelled somatostatin tracers for the imaging of neuroendocrine disease and beta CIT homing onto the dopamine transporter for the investigation of patients with movement disorders. Progress is coming in the imaging of Alzheimer’s disease, imaging of atherosclerotic plaque and the imaging of angiogenesis and hypoxia. Sentinel lymph node detection has changed the surgical management of patients presenting with early breast cancer.
At the same time, all diagnostic procedures have benefited from major progress in instrumentation; and in the last five years, the emergence of multimodality imaging has become routine. Conventional gamma cameras have been linked to advanced CT scanners (SPECT/CT), and modern PET scanners have been linked to multi-slice CT devices (PET/CT). Nuclear Medicine therapy has also been growing far beyond the established treatment of benign and malignant thyroid diseases. I-131, when linked to metaiodobenzylguanidine is used in treating neuroendocrine malignancies, such as pheochromocytomas and neuroblastomas. Newer ligands targeting the SS2 receptor subtypes are emerging, labelled with Yttrium 90, Lutetium 177 and other radionuclides. Pain palliation in advanced metastatic and skeletal prostate and breast disease has become available, with one-third of patients showing excellent response to a variety of radionuclides, including strontium 89-chloride, rhenium-186 as etidronate, samarium-153 as ethylene-diaminetetramethylene phosphonate.
Several labelled antibodies have been entered in clinical trials, and some have now been approved as specific treatment options, such as Zevalin or Yttrium- 90 labelled ibritumomab tiuxetan and Bexxar – I-131 labelled tositumomab. With such continuing developments and innovation, the best practices may become a moving target. Clearly, best-practice guidelines must be developed and implemented at the European level that helps Nuclear Medicine departments to provide the best patient care. Updated procedural and clinical guidelines are available from the EANM website for many well-established diagnostic and therapeutic procedures. Adherence to such guidelines is highly desirable to harmonize patient care across the diversity of European countries. European Nuclear Medicine technologists practice Nuclear Medicine in departments where most of these procedures are performed in a patient’s diagnosis or follow-up. As members of their institutional healthcare team, they also function as patient advocates, educators, healthcare researchers, technical and therapy specialists, and interdisciplinary consultants and play a key role in offering the best clinical practice. Nuclear Medicine must embrace the principles of best practice as the basis for clinical judgement within the context of working as part of a multi-disciplinary team in medical diagnosis and therapy. Within such multi-disciplinary teams, Nuclear Medicine technologists must play a leading role in establishing clinical standards and clinical protocols.
To offer best practices, continuing education is essential. The education process in Nuclear Medicine includes graduating from an accredited programme, completing a summary of clinical competence and completing a professional certification examination when available. The education process assures that Nuclear Medicine technologists have the knowledge, skills and judgement to be competent healthcare providers in their highly specialized discipline. In addition, lifelong learning is a core value for all healthcare professions. Therefore, entry-level education in Nuclear Medicine must be supported by formal and self-directed professional development programmes. All these programmes, including cognitive, affective and clinical competence, must be part of best-practice codes in any Nuclear Medicine department. Like all healthcare professions, Nuclear Medicine must move with the times, changing and adapting its principles and relationships, acknowledging the expectations of patients and the developing practice of other healthcare disciplines. Like all healthcare professions, only by understanding, accepting and adapting to these changes can Nuclear Medicine offer best-practice and retain its relevance within medicine and society.
The first publication of the EANM Technologist Committee, sponsored by Bristol Myers Squibb in 2004, was a book on myocardial perfusion imaging for technologists. We are very grateful that they have sponsored us again this year to produce this book on parathyroid imaging, the second book in what we hope will be a series.
We hope that we have combined the theory and rationale of imaging with the practicalities of patient care and equipment use. I think that certain things I wrote for the last book bear repeating, so I will do so here to benefit those for whom this is their first book. Knowledge of imaging theory provides a deeper understanding of the techniques satisfying for the technologist and can form the basis for wise decision-making. It also allows the technologist to communicate accurate information to patients, their carers and other staff. Patient care is always paramount, and being able to explain why certain foods must be avoided or why it is necessary to lie in awkward positions improves compliance as well as satisfaction. Awareness of the rationales for using certain strategies is needed to know when and how various protocol variations should be applied in acquisition or analysis, e.g. for the patient who cannot lie flat for long enough for subtraction and may need to be imaged with another protocol or when we may need a different filter if the total counts are low. Protocols will vary between departments, even within the broader terms of the EANM Guidelines. This booklet is not meant to supplant these protocols but will hopefully supplement and explain the rationales behind them, thereby leading to more thoughtful working practices. The authors are indebted to several sources for information, not least local protocols, and references have been given where original authors are identifiable. We apologise if we have inadvertently used material for which credit should have been, but was not, given. We hope that this booklet will provide helpful information as and when it is needed so that the integration of theory and practice is enabled and encouraged.