Tag Archives: nuclear medicine

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Improving radiation protection

EANM join forces with scientific organisations to investigate the impact of medical radiation exposure on patients and medical staff

(Vienna, August 21, 2018) Nuclear medical techniques are essential in diagnosing a large number of diseases and in treating various kinds of cancer. Since nuclear medicine is based on the use of radioactively labelled substances patients are exposed to a certain amount of radiation. Although doses are low and have to be weighted against the high diagnostic and therapeutic benefit, the improvement of radiation protection is a main concern of the European Association of Nuclear Medicine (EANM). „Recently, EANM has joined forces with scientific organisations from related disciplines in order to specify risk estimations and promote cutting edge research which will serve as a basis for improving protective measures. Patients as well as staff are going to benefit considerably from these efforts“, says EANM expert Prof. Klaus Bacher.

Modern health care is hardly conceivable without nuclear medicine. Nuclear imaging comprises highly efficient diagnostic techniques that provide precise information on early stages of numerous conditions, ranging from narrowed arteries over the presence of tumours to the onset of dementia. This is most valuable information that doctors can draw upon to design individually tailored and timely therapies for their patients. Apart from these diagnostic aspects, nuclear medicine also provides targeted treatments for cancer patients where high local tumor doses can be achieved while minimizing the radiation burden affecting healthy tissue.
Joining forces for better data
For nuclear medical diagnosis as well as treatment the patient is injected with substances, for example glucose, that are radioactively labelled. Although the applied radiation doses are low there is an ongoing discussion among experts to which extent risks such as cancer induction can be excluded. Highly important as this matter is for both patients and staff clinically relevant studies based on sufficient and appropriate data are still rare. In order to fill this gap and thus provide the prerequisite for reliable risk estimations the European Alliance for Medical Radiation Protection Research (EURAMED) was founded ( www.eibir.org/scientific-activities/joint-initiatives/european-alliance-for-medical-radiation-protection-research-euramed/). The goal of the association is to promote and support research in order to clarify the various and complex medical radiation protection issues and to translate the results into clinical practice. Together with a number of other scientifically related organisations EANM is a founding member of EURAMED and will have a leading role in the oncoming years through presidential and vice-presidential positions. It is for the first time that different disciplines such as radiology, radiotherapy, medical physics and nuclear medicine join forces in such a manner. A common strategic research agenda (SRA) for medical radiation protection has already been published.
Recommendations are under way
Another important step forward towards an improvement of radiation protection is MEDIRAD (Implications of Medical Low Dose Radiation Exposure). This project has been established in order to investigate the impact of medical low-dose radiation exposure on patients and medical staff and to set up science-based policy recommendations for their effective protection. It was developed under the guidance and with significant input of EURAMED and EANM ( www.medirad-project.eu/). MEDIRAD“s research consortium, consisting of over 70 scientists from 33 organizations and 14 countries, received 10 million Euros in funding from the European Commission and started in June 2017. „The research will significantly improve our medical understanding and practice of radiation protection“, says Prof. Bacher. In the field of nuclear medicine research results are expected to optimize the radiation exposure during diagnostic PET/CT examinations and to improve the treatment of thyroid cancer patients using radioactive iodine therapy. Other fields of research concern radiation exposure in breast radiotherapy and the impact of nuclear medical procedures in cardiovascular diseases. „EANM has always taken radiation protection seriously and welcomes the close cooperation of clinicians and medical physicists. Discussing and investigating these issues in a number of interdisciplinary scientific committees will lead to appropriate recommendations for the justified use of nuclear medical procedures very soon“, says Prof. Bacher.
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Alzheimer’s disease: Patients benefit from nuclear imaging

(Vienna, 19 April 2018) With the help of Positron emission tomography (PET) Alzheimer“s disease (AD) can be detected long before the onset of the symptoms by making beta-amyloid in the brain visible. However, since there is still no cure for AD the question has been raised if such a diagnosis is really beneficial for the patient or rather more of a burden. First results of a large study, currently under way, show that PET diagnosis helped to improve medical management and counseling in over 65% of the patients. „AD patients clearly benefit from nuclear imaging,“ says Dr. Valentina Garibotto, expert of the European Association of Nuclear Medicine (EANM).

Alzheimer“s disease is the most frequent cause of dementia and one of the most important causes of disability in the elderly. The condition induces a decline in mental ability that usually develops and progresses slowly. Memory and judgment are impaired, and personality may deteriorate. The target of the PET examination is beta-amyloid, which is the chief component of plaques that are one of the hallmarks of Alzheimer“s. Recently developed tracers (radioactively labelled substances the patient is injected with) make these plaques visible on the computer screen. By applying this method the likelihood of Alzheimer“s disease can be established in patients with a higher degree of certainty, as compared with other routine diagnostic tools.

PET exams improve health care management
While its accuracy is uncontroversial the benefit of nuclear imaging for AD patients has frequently been questioned: Since there is no cure for this disease the gained diagnostic knowledge might be considered not only useless but an unnecessary psychological burden for the patient while he is still fit. In order to clarify this matter and to examine the actual impact of PET procedures on AD patient care and health outcome two large studies are currently under way: The IDEAS study (Imaging Dementia-Evidence for Amyloid Scanning) in the USA (www.ideas-study.org) and the AMYPAD study (Amyloid Imaging to prevent AD) in Europe (amypad.eu).

IDEAS started in 2016 and includes 18.000 participants. First results show that the outcome of PET scans have concrete beneficial consequences: They led to a change in medical and general health care management in around 65% of the patients. These changes consisted among other things in different drug prescriptions, making use of the fact that amyloid imaging allows doctors to determine with high accuracy whether in patients with mild symptoms Alzheimer“s is the cause or whether it can be excluded, so that some other kind of dementia or another condition has to be taken into account. Thus, depending on the PET exam results doctors changed to drugs specific for Alzheimer (namely aceltycholinesterase inhibitors) or they reversely abandoned these drugs in favor of a better suited medication, for exampleantidepressants or antipsychotics. PET scan results in favor of AD also induced an appropriate counseling about safety and future planning, thus helping patients and their friends and family to avoid preventable risks. For example, a diabetic who is also diagnosed with AD would not be left alone any longer to manage his insuline doses. „These interim results already provide convincing evidence that AD patients benefit largely from a more accurate diagnosis and we expect further study outcomes to complete the picture,“ says Dr. Valentina Garibotto of the EANM Neuroimaging Committee.

Nuclear imaging pivotal in AD research
Further important insights are to be expected of the AMYPAD study which has just started. This is a collaborative research initiative and part of the European Innovative Medicines Initiative (IMI). The overall goal of the program is to determine the value of amyloid PET imaging to diagnose and guide treatment, namely clinical trials, in AD. „Despite the hitherto unsatisfying results of therapeutic trials, our knowledge and understanding of AD has dramatically evolved over the last decades and PET imaging has played and still plays an increasingly central role. Accordingly, the next EANM focus meeting will be fully dedicated to the field of neuroimaging in AD. Entitled „Molecular Imaging of Dementia – The future is here“ it will invite worldwide experts to update the community on the latest developments,“says Dr. Garibotto.

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Nuclear imaging targets the origins of back pain

World Spine Day 2017

(Vienna, October 16, 2017) Low back pain is an increasing and extremely widespread condition that becomes chronic in many patients, causing severe physical and emotional distress. Moreover, back pain is one of the leading causes of activity limitation and work absence all over the world and thus, has an enormous economic burden. Up to 80% of patients with back pain suffer from unspecific pain without identifiable cause. „But for those patients who are suspected to have a pain generator responsible for their complaints imaging techniques such as SPECT/CT can open up the path to efficient treatment,“ says Prof. Dr. Willm Uwe Kampen, expert from the Bone and Joint Committee of the European Association of Nuclear Medicine (EANM) on the occasion of the World Spine Day 2017.
Lately, molecular imaging using SPECT/CT (Single photon emission computed tomography / computed tomography) has become increasingly valuable in identifying pain generating lesions in patients suffering from back pain. This novel technique detects the raised metabolism that accompanies abnormal bone changes that cause back pain, and accurately localizes these to the anatomic sites that may be approached for treatment. „Identifying these physiological processes is essential since they precede anatomical changes by weeks, sometimes even months, and very often mark the actual targets for efficient treatment,“ says EANM expert Prof. Dr. Willm Uwe Kampen. This goal is achieved by tracers – weakly radioactively labelled substances the patient is injected with – and highly sensitive cameras which register the increased radioactive radiation emitted by the critical spots. The strength of hybrid SPECT/CT imaging lies in delivering such functional information on bone metabolism combined with the information from computed tomography (CT) which uses X-rays to assess the exact position and structure of the affected bones and joints. Thus, the combination of both methods (SPECT/CT) in a single examination has become state of the art in order to obtain a complete diagnostic picture whenever specific anatomical and physiological causes for back pain have to be assumed. „SPECT/CT offers the best of both worlds, as this novel hybrid imaging method combines the strengths of traditional CT with the proven benefits of nuclear medicine imaging, helping to establish a more accurate diagnosis in certain cases of severe back pain and opening up pathways for therapies with long-lasting effects. One of the fields where SPECT/CT has proven particularly helpful is the assessment of persisting or recurring back pain after spinal fusion surgery,“, says Prof. Kampen.
„This kind of treatment, which has become quite common in patients who suffer from constant back pain, sometimes causes follow-up complications. Persisting pain in these patients has multifarious reasons: Among them are postoperative infections, the improper placement of implants, broken screws, the loosening of hardware or the failure of bone fusion. Moreover, the rigid fixation of vertebrae can lead to increased stress on the adjacent spine segments. This might cause degeneration of the vertebrae above or below the fixed spine region or of facet and sacroiliac joints. While other imaging techniques such as Magnetic Resonance Imaging (MRI) provide precise and highly useful anatomical information this is often not sufficient since areas that are only anatomically suspicious are not necessarily the real origins of the back pain. In all these cases additional information on possible alterations in bone metabolic activity is crucial to establish what really induces the symptoms. SPECT/CT can provide all this information in a convenient single examination. Several studies show that SPECT/CT can track down pain causing conditions that are less easily – or not at all – captured by X-ray- and magnetic resonance images. „Ultimately, by improving the surgeon“s understanding of what is causing the patient“s symptoms, SPECT/CT has a profound role in selecting the right patient for the right treatment at the right time,“ according to Prof. Kampen.

Tracking down the culprits
The same advantages apply, of course, when it comes to examinations that are not connected to post-operative problems. CT and MRI provide reliable information on anatomical abnormalities such as disc herniation, degeneration of the vertebrae or potentially pathological changes of the bone marrow. But again, in an ageing European population it is becoming increasingly difficult to identify the culprit lesion on a background of multiple incidental degenerative findings. By localizing increased metabolic activities SPECT/CT helps filtering out the relevant pain generators. SPECT/CT has also proven valuable in patients with chronic low back pain who had undergone manual therapy without experiencing pain relief. SPECT/CT could identify facet joints that were metabolically active due to initial degeneration but without morphological changes seen in conventional radiography or even in CT. Subsequently, these patients received targeted treatment with facet joint injections which brought considerable alleviation, thus confirming the diagnostic value of SPECT/CT and the importance of functional in addition to anatomical imaging in order to select the right treatment. Thus, SPECT/CT opens up promising research paths that allow to assess and increase the efficiency of manual therapy.
„The relevance of SPECT/CT for identifying and staging cancer that has spread to bone has long been acknowledged. But recently it has become clear that SPECT/CT is an extremely useful problem-solving tool that can benefit a significant portion of patients with low back pain. In an increasingly cost-aware healthcare environment, being able to predict with SPECT/CT who will benefit from a particular treatment is an important prerequisite for an efficient treatment that in many cases can turn a life long burden into a curable condition,“ concludes Prof. Kampen.

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New: Funny cartoons assist nuclear medicine physicians

Help for children during nuclear medical examinations

New: Funny cartoons assist nuclear medicine physicians

Sunny & Tim and their team help children through nuclear medical examinations (Source: Dr Ronald van Rheenen, Floris de Jonge)

Nuclear medical examinations can be stressful for patients – particularly for children. But Sunny the Isotope, Tim the Tracer and Rob the Receptor help reduce the strain. These cartoon characters, which have been developed by Ronald van Rheenen, expert of the European Association of Nuclear Medicine (EANM)., The Visual Education Project that gave birth to these characters provides child patients with age-appropriate information on the imaging examination. They make preparation rules easy to understand and lend a touch of fun and adventure to the procedure.
Undergoing a nuclear medical imaging examination can be quite a challenge. Some of these procedures last over an hour. During this time the patient is required to lie still on the imaging bed and avoid any motions as these might render the images being created useless for diagnostic purposes. For the same reason eating is sometimes not allowed prior to the imaging. All this is particularly demanding for children whose examinations make up an estimated 10 % of all nuclear medical examinations. They are also intimidated by the unfamiliar environment with its large nuclear medicine cameras whose detectors are placed very close to the body and somtetimes directly over the patient“s head. Concerns that the examination might be painful add to young patients“ anxiety. The accompanying parents are not always able to cheer up their child as they themselves might be distressed not knowing what to expect and which results the examination will provide.
In order to alleviate such fears and improve diagnostic accuracy through better cooperation of doctors and their young patients Dr Ronald van Rheenen, Nuclear Medicine Physician at the University Medical Hospital in Groningen (Netherlands) initiated the nonprofit Visual Education Project. Its „heoresheroes“ are Sunny the Isotope and Tim the Tracer, cartoon characters who appear in three different stories where they stand for the radioactive and the tracer substance that together form the radiopharmaceutical the patient is injected with. Tim takes Sunny on a journey through the body and guides him to Rob the Receptor who represents the target organ where the radiopharmaceutical accumulates. There Sunny shines his „special lights“ which reperesent the emitted radiation. This enables the „Photo Doctor“ to take pictures of the diseased areas. While this refers to diagnostic procedures one of the story lines also addresses nuclear medical therapy: This time Sunny & Tim are joined by Sam the Demolisherwho destroys the sick-spot. The stories are freely available as animations on YouTube and can be purchased as picture books (for links see below). Dr. van Rheenen, who pursues these educational activities in his free time, cooperates closely with the graphic designer Floris de Jonge. He brought the characters and storylines to life that Dr. van Rheenen had in mind. Meanwhile both have created three other storylines dealing with radiological imaging examinations.
The adventurous stories, straightforwardly told and catchily illustrated, not only help dissolve anxieties but also guide the childrens“ preparation before and their behaviour during examination. But the education material not only aims at very young readers. It might even help adults with low-health-literacy to understand the procedures and purposes of nuclear medicine. „Our decision to convey information in the form of visualized stories is motivated by the fact that most of the textual or verbal information which is provided prior to our examinations or therapy, is not correctly remembered – if at all,“ says Dr. van Rheenen. The project that started off three years ago as a local initiative based in Groningen has already spread its material considerably. The EANM and several European hospitals as well as patient platforms have the animations running on their websites or refer to it. With the support of the EANM the project is now on the verge of developing into a global initiative. Currently, versions in German, Spanish, French and Cantonese are under way and Dr. van Rheenen is dicussing possibilities of further dissemination with different National Nuclear Medicine Societies.
„It is essential to tailor explanations to the childrens“ grasping ability. Introducing the Visual patient education project to pediatric nuclear medicine and explaining the procedure with cartoon characters is a very promising tool to alleviate fears and apprehension and to transform the nuclear medicine study into a fun experience. This improved patient experience leads to improved cooperation resulting in studies of higher technical quality, ultimately leading to improved diagnostic accuracy“, says Dr. Zvi Bar-Sever, Chairman of the EANM pediatric committee.

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Prostate cancer: Identifying and destroying the tumour through nuclear medicine therapy

(Vienna, December 13, 2016) Prostate cancer patients who are resistant to hormone treatment used to have a poor prognosis. Until recently, the diagnostic and therapeutic possibilities had been limited, but now innovative developments in nuclear medicine imaging and therapy open up promising pathways. Novel substances used with PET/CT (positron-emission tomography combined with computed tomography) not only allow for better diagnosis but also offer treatment options where other therapies have failed. „This offers a glimpse of hope to patients who suffer from this particularly severe form of prostate cancer,“ says EANM expert Prof. Markus Luster.
Prostate cancer is the second most frequently diagnosed cancer in men and causes around 90.000 deaths per year in Europe. Up to every second patient who has his prostate surgically removed or has undergone radiation therapy suffers from relapse. In severe cases the level of testosterone upon which the tumour is dependent to a large extent has to be reduced drastically in order to fight the disease. This is usually done by hormone therapy. However, a considerable number of patients are or will become resistant to this kind of treatment (so called castration-resistant prostate cancer / CRPC). This means that in spite of therapy the tumour has not been destroyed definitively and in many cases is now affecting the lymph nodes or has even extended to the stage of often painful bone metastases. Prognosis of patients who progress to this stage is poor.

A common means to detect prostate cancer and assess the stage of the disease is the measurement of the level of prostate-specific antigen (PSA), which serves as a biomarker for the presence of cancer cells. However, in patients whose testosterone production has been suppressed medically PSA levels are often too low to be measured. This includes CRPC patients in whom this therapy has failed to eradicate or halt the tumour. Moreover, PSA measurement provides no information about the sites and the extent of the recurrent cancer. However, newly developed nuclear medicine methods have opened up promising diagnostic avenues that might more sensitively and accurately enlighten both patient and physician about the location and extent of disease. At the same time, this new approach also provides new therapeutic modalities which can improve the still poor prognosis of CRPC-patients in the future. The leading part is played by a protein called Prostate-Specific Membrane Antigen (PSMA). It is found abundantly on the surface of prostate cancer cells and its number appears to be increasing with the aggressiveness of the disease. This makes PSMA an ideal target for detecting cancer cells by nuclear imaging. The essential means to achieve this is the Ga-68-PSMA-ligand, a substrate that binds to PSMA – comparable to a key that fits into its lock – which is labelled with the radionuclide Gallium 68. This tracer has already been used successfully in a large number of PET/CT examinations: After the patient has been injected with Ga-68-PSMA-ligand the tracer is taken up by the cancer cells which are made visible for the examining physicians by the radiation. „The substance has proven to be highly sensitive and reliable in detecting carcinoma in lymph nodes as well as metastases in other body regions. Over the past decade or so other substances such as choline have been evaluated and applied but in terms of accuracy and diagnostic outcome Ga-68-PSMA is now state of the art,“ says Prof. Markus Luster.

As he points out PSMA is not only useful for diagnostic but also for treatment purposes: The PSMA-ligand can be labelled with another radionuclide called Lutetium-177 that is able to destroy the cancer cell from inside through radiation. „Several tests have demonstrated that Lu-177-PSMA-therapy can reduce tumour mass and alleviate pain. Patients who have no other treatment options left and whose cancer cells have been shown to take up PSMA-ligands are very likely to benefit from the diagnostic and therapeutic potential of PSMA imaging and therapy,“ says Prof. Markus Luster.
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Alzheimer’s disease: Early diagnosis through novel imaging technique

New nuclear imaging techniques make tau tangles in the brain visible

New nuclear imaging techniques help to detect a key factor involved in Alzheimer“s disease (AD) much earlier and more precisely than before. Recently developed tracers, used with positron emission tomography (PET) make tau tangles in the brain visible. For the first time these deposits which cause severe neuronal malfunctions can be identified and investigated „live“ in the brains of AD patients long before the onset of noticeable mental impairment. „This is an important step towards our goal to develop efficient drugs to fight and eventually cure AD“, says Dr Silvia Morbelli, expert of the European Association of Nuclear Medicine (EANM).
Many important details of the causes and the progress of AD remain to be elucidated. However, recent research results in the field of nuclear imaging have now brought about a major breakthrough in the diagnosis of the disease, raising hopes for early detection and targeted therapeutic approaches. Over the last few years, PET imaging has already enabled the visualization of -amyloid plaques (one of the hallmarks of AD) in the spaces between nerve cells. Now several recently developed PET tracers make it possible to track down tau deposits in the brains of AD patients too. Tau protein is an important building block of the so-called cytoskeleton, which is essential for the proper working of the nerve cells of the brain. In AD patients this protein undergoes changes that trigger the breakdown of the cytoskeleton. At the same time, unbound tau proteins clump together forming neurofibrillary tangles. The harmful impact of tau tangles on brain function is even more clearly established than that of beta-amyloid, making tau deposits a key suspect as a mediator of neurodegeneration. Before this recent breakthrough, these tau tangles could only be analyzed in post mortem brains.

Illuminating tau“s destructive potential
Based on these findings a neuroimaging research group of the University Hospital of Cologne (Germany) has now managed to precisely localize and measure tau tangles in AD patients and attribute them to corresponding neuronal malfunctions. The new tracers were used to measure tau tangles while also studying neuronal dysfunction with radioactively labelled glucose and amyloid tracers to measure amyloid plaques in the same subjects. A link between brain deposits and neuronal dysfunction could only be found for the tau tangles but not for amyloid plaques, thus highlighting the role of tau for the understanding of the development of AD. „The fact that the existing amyloid imaging technique is now able to be used in conjunction with tau imaging will allow us to study these events in patients in a much more comprehensive fashion“, says Dr Silvia Morbelli.

Opening up new treatment avenues
While imaging technologies are advancing rapidly, the development of effective treatments is still lagging behind. Against this backdrop amyloid imaging has already proven its value as it can identify plaques 10 to 15 years before the onset of cognitive symptoms. The same opportunity now exists for the detection of tau tangles. Even though there is no cure so far, certain medications can reduce the symptoms and thus preserve the patients“ mental abilities to a certain degree for a limited time span. „With the emergence of tau PET ligands, drug companies developing new therapeutics designed to halt or reverse AD now have the opportunity to test and monitor their drugs at an early stage of the disease process. The earlier a treatment is started, the greater are the chances of it being effective.“ says Prof Antony Gee, Chairman of the EANM Drug Development committee.
At present, many clinical trials evaluating potentially disease-modifying drugs only enroll AD patients who have been shown to have amyloid plaques using PET. However, with the discovery of tau PET tracers, alternative inclusion criteria can be considered expanded to tau tangles for the evaluation of new AD therapeutics. „Distinguishing more accurately between the clinical consequences of anti-tau and anti-amyloid effects will help to facilitate more effective and faster clinical trials. These are prerequisite for the identification of new AD therapies“, says Dr Silvia Morbelli.
Furthermore: The novel tau tracers are anticipated to help major breakthroughs for the investigation and diagnosis of non-AD related neurodegenerative diseases in which tau deposits play a similarly crucial role. This includes other types of dementia and parkinsonian syndrome.
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