E PATIENT-V5N1-777777_Layout 1 21-07-23 12:39 Page 1

VOL 5 • NO 1

THE FREE NUCLEAR MEDICINE & MOLECULAR IMAGINGEDUCATIONAL MAGAZINE AVAILABLE WORLDWIDENUCLEAR MEDICINEMADE SIMPLEMÉDECINE
NUCLÉAIRESIMPLIFIÉE
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THE ROAD TO THE WFNMB 2022
CONGRESS IN KYOTO

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FUNCTIONAL LUNG IMAGING
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References
Hess S, et al. Semin Thromb Hemost 2016; 42:1.
833–845A,, et al. Nucl Med Commun
2.
Sánchez-Crespo A
2008; 29(2): 173-177
T,, et al. Clin Imaging 2014; 38(6):3.
Grüning T
831-8354.
Isidoro JJ,, et al. Phys Med 2017; 41: 93-96

5.
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8.

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sensitivity, negative
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A when comparing sensitivity,
tomography
predictive value and accuracy (table 2).
)1PE,, chronic PE
PE,, pregnancy
pregnancy,,
Therefore, in situations of acute PE
paediatrics and the COPD population, V/Q SPECT can be
first-line
considered as a first-line investigation due to its high sensitivity
specificity,, low radiation and no adverse reactions.8
and specificity

Miles S, et al. Chest 2009; 136: 1546-1553
A,, et al. EC P
PulmonNasr Aulmon and Respir Medicine
2017; 4(3): 85-91
Bajc M, et al. Eur J Nucl Med Mol Imaging 46,
2429–2451
Leblanc M , et al. CANM Guidelines 2018;
published Nov 2018

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E PATIENT-V5N1-777777_Layout 1 21-07-23 12:39 Page 3

Editors:
Drs. Jean-Luc Urbain & François Lamoureux

Content
4

EDITORIAL BOARD

5

INTRODUCTION

6MEDICAL AND PHARMACOLOGICAL ADVANCES

8

13TH CONGRESS OF THE WORLD FEDERATION OF NUCLEAR
MEDICINE AND BIOLOGY TO BE HELD IN 2022 (WFNMB 2022)

10 INTERVIEW WITH DR. SEIGO KINUYA
12 WORLD FEDERATION OF NUCLEAR MEDICINE & BIOLOGY 20222024 TREASURER CANDIDATE: DR. FRANCOIS LAMOUREUX
13 DR. JEAN-LUC URBAIN PRESIDENT WFNMB 2021-2022
14 INTERVIEW WITH JAMES MCBRAYER
17 INTERVIEW WITH DR. DANIEL BADGER
18 ENTREVUE AVEC CHANTAL ASSELIN
INTERVIEW WITH CHANTAL ASSELIN
22 INTERVIEW WITH DR. RAYMONDE CHARTRAND
24 ENTREVUE AVEC DR. RAYMONDE CHARTRAND
26 FACEBOOK DE L’AMSMNQAMSMNQ FACEBOOK
27 ASSOCIATION DES MÉDECINS SPÉCIALISTESEN MÉDECINE NUCLÉAIRE DU QUÉBEC
28 INTERVIEW WITH TOM FRANCKE
32 ENTREVUE AVEC KRISTY OWEN
34 THE CANADIAN ASSOCIATION OF NUCLEAR MEDICINEASSOCIATION CANADIENNE DE MÉDECINE NUCLÉAIRE
37 INTERVIEW WITH SERGIO CALVO
39 LA THÉRANOSTIQUE AU SERVICEDES TUMEURS NEUROENDOCRINES
42 不同TSH抑制治疗对分化型甲状腺癌术后TSH、
FT3、FT4的影响
44 LA TÉLÉMÉDECINE À L’HEURE DE LA PANDÉMIE À LA COVID-19
TELEMEDICINE IN THE AGE OF THE COVID-19 PANDEMIC
48 TERAPIA CON YODO – 131 (YODO RADIOACTIVO)
EN HIPERTIROIDISMO
52 NEUROENDOCRINE TUMOURS: FINDING ZEBRASWITH NUCLEAR MEDICINE
54 CANM GUIDELINES FOR BRAIN PERFUSIONSINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY (SPECT)

Editorial Board:
Dr. François Lamoureux - Dr. Jean-Luc Urbain
Dr. Akram Al-Ibraheem - Dr. Zvi Bar-Sever Dr. Paige Bennett - Dr. Salah-Eddine Bouyoucef Dr. Sanjay Gambhir - Dr. Bennett Greenspan Dr. Mohamad Haidar - Dr. Juan Hatazawa Dr. Wei He - Dr. Rodrigo Jaimovich Dr Jolanta Kunikowska - Dr. Fernando Mutt Dr. Andrew Ross - Dr. Raymond Russel Dr. Einat Sapir - Dr. Mike Sathekge Dr. Chritian Scheiber - Dr. Andrew Scott Dr. Jean-Philippe Vuillez - Dr. Nadia Whithofs
Featured in this issue:
Dr. Frédéric Arsenault - Dr. Juan Luis Londoño Blair
Dr. Grégoire Blais - Dr. Steven Burrell
Dr. François-Alexandre Buteau - Dr. Wei He
Dr. Francois Lamoureux - Dr. Jean Luc Urbain
Publication Director:
Nicolas Rondeau Lapierre
Publisher:
Les Éditions Multi-Concept inc.
Artistic direction and printing:
Le Groupe Communimédia inc.
communimedia.ca
Advertisement information:
Nicolas Rondeau Lapierre
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nlapierre@editionsmulticoncept.com
Disclaimer: Authors are selected according to theextent of their expertise in a given specialty. The
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be held liable for their statements. The texts
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SUBSCRIBE HERE ! INSCRIVEZ-VOUS ICI !
SUSCRÍBETE AQUÍ ! 在这里签名! in your own language !
Don’t miss our next issue on Quantification and thesecond part of Theranostics (neuroendocrine tumors).

3

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:39 Page 4

EDITORIAL BOARD
Dr. Lamoureux and I are thrilled to introduce our outstanding editorial board members.
Through our travel and NM lecturing around the globe, we have met terrific scientists andcolleagues. Most, if not all of them, are really passionate about and true advocates for the field of
nuclear medicine. They strongly believe in the power, usefulness and safe use of NM diagnostic andtherapeutic procedures for the betterment of public healthcare worldwide. We are delighted that thefollowing leaders have embraced the concept of the Pangea-ePatient magazine and accepted to share
their invaluable expertise and experience with patients, referring colleagues, health care administrators,
government agencies and insurance companies.
Dr. Jean-Luc Urbain

Dr. Akram Al-Ibraheem, M.D.
Dr. Zvi Bar-Sever, M.D.,
President, Arab Society of Nuclear Medicine (ARSNM) Chair Pediatric Nuclear Medicine Council,
Chairman, Department of Nuclear Medicine & PET/CT EANM; Director, InstituteKing Hussein Cancer Center, Amman, Jordan
Schneider Children’s Hospital, Israel

Dr. Paige Bennett, M.D.,
Nuclear Medicine/Medical Imaging
Specialist, Wake Forest University,
USA

Dr. Bennett Greenspan, M.D.,
Past President of the SNMMI, USA

Dr. Jun Hatazawa, M.D., Ph.D.,
Dr. Mohamad Haider, M.D.
Vice-President, Arab Society of Nuclear Medicine (ARSNM) Past President of the AOFNMB,
Director, Nuclear Medicine Division and Cyclotron Facility Japan
American University of Beirut Medical Center, Beirut, Lebanon

Dr. Fernando Mutt, M.D.,
Past President ALASBIMN, Uruguay

Dr. Andrew Ross
Past President, CANM

Dr. Raymond Russel, M.D., Ph.D.,
Past President, CANM, Canada
Associate Professor of Medicine Warren Alpert
Medical School of Brown University, Director,
Nuclear Cardiology, Rhode Island Hospital &Past President, American Society of Nuclear Cardiology

Dr. Christian Sheiber, M.D., Ph.D.
Professor and Chief of Nuclear
Medicine, Hospitals de Lyon, France

4

Dr. Andrew Scott, M.D.,
Past President WFNMB,
Australia

Dr. Jean-Philippe Vuillez,
M.D.,Ph.D., Prof.,
Ancien président SFMN
Vice-Doyen Formation Directeur desétudes PU-PH – Médecine Nucléaire,FranceDr. François Lamoureux,M.D.,M.Sc., FRCPSC,
President, CANM, Canada

Dr. Jean-Luc Urbain,
M.D., Ph.D., CPE, FASNC
President 2021-2022 WFNMB
Past President, CANM, Canada

Dr. Salah-Eddine Bouyoucef, M.D.,
Ph.D., Chief Nuclear Medicine,
CHU Bab El Oued, Alger, Algeria

Dr. Sanjay Gambhir, M.D., Ph.D.,
Chief/Chair, Nuclear Medicine,
University of Lucknow, India

Dr. Wei He, M.D., Ph. D.,
Director of Nuclear Medicine and
PET/CT, Center Fu Dan University,
China

Dr. Rodrigo Jaimovich, M.D
Past-President of ALASBIMN
Professor, Nuclear Medicine
at Clinica las Condes S.A
Chili University, Chili

Dr. Einat Sapir, M.D., Ph.D.,
Professor, Sackler School of Medicine,
Tel Aviv University & Head,
Department of Nuclear Medicine
Tel Aviv Sourasky Medical Center, Israel

Dr. Mike Sathekge, M.D., Prof.,
University of Pretoria, Head of
Nuclear Medicine Steve Biko Academic Hospital & President, Colleges ofMedicine of South Africa, South Africa

Dr. Nadia Whithofs,
M.D., Ph.D,
Division of Nuclear Medicine
and Oncological Imaging,
CHU of Liege, Belgium

Dr Jolanta Kunikowska MD,PhD
Associate professor of nuclear
medicine department, Medical
University Warsaw Poland
President EANM

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:39 Page 5

INTRODUCTION
François Lamoureux
M.D.,M.Sc., FRCPSC
President, CANM

DEAR FRIEND AND
COLLEAGUES.
Francois Lamoureux and I arethrilled to introduce to ourinternational readers the newissue of the internationallyacclaimed Nuclear Medicine
magazine ePatient.
The lack of concerted efforts in research anddevelopment of new radiopharmaceuticals in thelast part of the 20th century created a climate ofuncertainty about the field of nuclear medicine at
the beginning of the 21st century. In a very
interesting and remarkable turn of events, thedevelopment of diagnostic and therapeutic
radiopharma-ceuticals based on patients’ diseases
genotypes and phenotypes and so-called isotopes
pairs (Nuclear Theranostics) have triggered a true
renaissance of the field of Nuclear Medicine.
Through their exquisite sensitivity and specificity,
Nuclear Theranostics, in combination with hybrid
imagers (SPECT/CT, PET/CT and PET/MR) willundoubtfully play a major role in precision
medicine by significantly improving patient
disease management, particularly in oncology.
As exciting as the renaissance of Nuclear Medicine
can be, it is also full of challenges. The practice ofa fully integrated diagnostic and therapeutic
nuclear medicine specialty requires in depth
knowledge in many different fields of medicine(e.g. prostate cancer, breast cancer, complex
imaging equipment along with an in depth
understanding of patient’s diseases andmanagement, health care systems and health careeconomics. This type of complex knowledge,
experience and expertise represents both unique
opportunities and significant challenges for
medical school and nuclear medicine centers
across the globe.

Jean-Luc UrbainM.D., Ph.D., CPE, FASNC
Past President, CANM

In this new issue of the magazine you will findinterviews from various medical and industry
leaders in the field sharing their views on thepresent and future of nuclear medicine, articles ontelenuclear medicine, the treatment ofhyperthyroidism, neuroendocrine tumors and acomprehensive review of brain SPECT imaging.
Also and through a heartfelt welcome note and adetailed interview of Dr. Seigo Kinua, a friend of
Francois and me, you will find all the informationthat you need to prepare for the 13th Congress ofthe World Federation of Nuclear Medicine.
The main theme of the WFNMB Congress in Japan
will be on Theranostics. In collaboration with theRegional and National Societies of Nuclear
Medicine and Biology, the WFNMB is preparing aseries of events that will paved the way to Kyoto
2022. Please stay tune as more is to come on theroad to Kyoto in the fall and winter issues of themagazine.
We hope you will enjoy reading this new issue ofthe magazine that illustrate nicely the current andfuture of our beloved specialty.

François Lamoureux
Jean-Luc Urbain

5E PATIENT-V5N1-777777_Layout 1 21-07-23 12:39 Page 6

MEDICAL AND PHARMACOLOGICALADVANCES

François Lamoureux,M.D., M. Sc.
François Lamoureux
M.D.,M.Sc.,President,
FRCPSC
QuebecAssociationofPresident,
CANM
Nuclear Medicine Specialists“With a simple
intravenous
injection of F-18
FDG that is
painless andwithout identifiableside effects, weare pushing thediagnostic limits
ever further andtracking downcancer cells intheir very lastcellular bastions.”

6

ANTIMATTER AT THE SERVICEOF NUCLEAR MEDICINE

A cancer cell that has lost all control over its unbridledmultiplication must constantly consume large
quantities of energy in the form of glucose (sugar).

We can now measure and visualize the metabolic
activity of an organ in a human being and detect its
functioning and integrity. This is positron emission
tomography (PET) or, expressed another way, thefunctional imaging of cell metabolism.

In nuclear medicine, a glucose analog, deoxyglucose,is used as a decoy: it mimics glucose by entering
cells but in a form that cannot be used as an energy
source by the cancer cell.

Using PET, we can detect certain pathologies, suchas cancer, which initially alter the normal physiologyof cells.
In order to live, function and reproduce, theorganism’s normal cells need energy in the form of
glucose (a sugar that can be metabolized by theorganism.) This energy source is indispensable to all
the living cells of the organism, and this sugar isfound naturally in the blood. The more active a cellis, the more sugar it consumes.

To detect intracellular deoxyglucose, the molecule isradioactively labelled beforehand with a positron(antimatter) in the form of fluoride-18 (F-18).
As it accumulates in cancer cells, the positiveelectrons (e+) of F-18 come almost immediately incontact with the cell’s negative electrons (e-). This
produces a disappearance of the injected matterand antimatter, an annihilation reaction in which
two photons are emitted at 180 degrees in the formof external radiation.

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:39 Page 7

The cell becomes radioactive and the emitted rays
are captured by an external PET camera. Powerfulcomputers interfacing with the PET camera identify
abnormal areas of radiation emission, a sign of theabnormal accumulation of F-18 FDG in the cancerous
tissue.
The cancer tumour is detected and its activity ismeasured. Then a 3-D reconstruction is done, in
multiple slices and dynamically. The result is an
exploratory metabolic autopsy of the patient in vivo
that is non-invasive.
The external shape of the PET camera’s detector
resembles a tomodensitometer or magnetic
resonance imaging device, but its function iscompletely different. The other two devices produce
mainly anatomical images of the organs of thehuman body.
Moreover, today PET cameras are being teamed up
with tomodensitometry detectors and, in the near
future, will also be paired with magnetic resonanceimaging devices in order to better localize the site ofpathological processes.
With a simple intravenous injection of F-18 FDG
that is painless and without identifiable side effects,
we are pushing the diagnostic limits ever further
and tracking down cancer cells in their very lastcellular bastions.
While F-18 FDG is currently the most commonlyused radioactive tracer, it is not the only one.
Carbon-11, oxygen-15 and nitrogen-13, forexample, can also be used to conduct neurological,
cardiac or pulmonary exams.
In Quebec, PET technology is currently available insome nuclear medicine units. In mid-2008, thanks
to new facilities in such places as Montréal, Quebec
City, Chicoutimi, Gatineau, Rimouski and TroisRivières, this newly deployed technology enabled
patients in centres that were not equipped withthese cameras to have access to PET scans within areasonable timeframe.
There are no inter-hospital charges or costs for
either hospitalized patients or outpatients. The costof each PET scan performed in a hospital centre isindividually, directly and completely covered by theGovernment of Quebec. PET scans are prioritizedbased on a patient’s clinical condition, whatever andwherever that may be, and not on the patient’s
physical location or the physical location of the PET
camera.
Considering that PET technology has been applied
as a just and universal social measure for all patientsin Quebec, this is a success story and an example tofollow.

7

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E PATIENT-V5N1-777777_Layout 1 21-07-23 12:39 Page 9

WELCOME LETTER
from WFNMB202
WelcomeOn behalf of the Japanese Society of Nuclear
Medicine (JSNM), I would like to cordially invite
you to Kyoto, the host city of the 13th Congressof the World Federation of Nuclear Medicine
and Biology to be held in 2022 (WFNMB 2022).
The 1st WFNMB Congress was realized in Tokyoand Kyoto in 1974 and was a great success. We
firmly believe that WFNMB 2022 will be anequally good opportunity to gather once again
in Japan in order to summarize theaccomplishments of the WFNMB during thepast half century and discuss strategies for the
future of the WFNMB as well as of nuclear
medicine itself in the next half century. Kyoto
was the city where the closing ceremony of the
1st Congress was conducted, making it fittingthat it will become the opening door to a newera of WFNMB.
JSNM would like to enhance mutual
collaboration among colleagues of the nuclear
medicine community throughout the world. Inorder to promote nuclear medicine in dailyclinical practice as well as the research field, as
many countries as possible should discuss
together at a single table in the WFNMB
Congress. One of the major missions of WFNMB
is to provide opportunities for education, study
and research especially to young fellows. It isvery important for them to obtain informationof these activities in a timely manner. The
WFNMB Congress is one of the key resources forthese purposes. Therefore, we would sincerely
like to request your country to join it topromote the bright future of all of our young
fellows.
Kyoto is the cultural heart of Japan and boasts
over a millennium of history featuring astunning total of 17 UNESCO World Heritage
Sites all located less than 30 minutes apart. The
best way to discover the “real Japan” is toinclude Kyoto in your itinerary. Kyoto has been
voted the best travel destination in Japan byvarious travel magazines and web media. Thisfriendly city of 1.5 million people offers endless
opportunities to gain meaningful hands-on
experience of rich Japanese culture through tea
ceremony, sake brewing, kimono wearing,swordsmanship and many more activities.

Post-congress
culturalsocial activities will beplanned in Kanazawa
located just 2 hours rideby express train from
Kyoto. Kanazawa is an oldcity of Samurai Culture incontrast to the Court Culture
in Kyoto. It was a great castle
town ruled by influential lords fromthe late 16th century to second half of the 19th
century. The area surrounding Kanazawa isfamous for hot springs and its cuisine making
use of fresh fish and vegetables. The rice wine(sake) produced in this region is of high quality,smooth and sweet, derived from the rice
grown in Ishikawa Prefecture as well as theconsiderable precipitation of the Hokuriku
region.
The Department of Nuclear Medicine,
Kanazawa University, where I have been serving
as chairperson since 2006, was established in1973 as the very first department of nuclear
medicine at a Japanese university. Therefore,
the length of the history of my place closely
coincides with that of WFNMB. This coincidence
is another reason making Kanazawa a suitable
place, in addition to Kyoto, to talk about boththe past and future of nuclear medicine.
It is my heartfelt wish that you allow us towelcome you all to Japan. We will do our best
to be able to offer you a great time in both
Kyoto and Kanazawa.

Sincerely,
Seigo Kinuya
WFNMB2022 Congress Chair
Professor, Department of
Nuclear Medicine,
Kanazawa University,
Japan

9

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INTERVIEW WITH

DR. SEIGO KINUYA
You are the chair of the NEXT CONGRESS OF THE
WORLD FEDERATION OF NUCLEAR MEDICINE AND
BIOLOGY (WFNMB) IN KYOTO JAPAN 7-11
SEPTEMBER 2022.
Could you GIVE US AN OVERVIEW OF THE EVENT.
We are preparing to have on-site face-to-facecongress. I hope that the pandemic of COVID-19
with the progress made in vaccination throughout
the world.
We will focus on what’s going on in nuclear
medicine by inviting prenarry speakers on the topicsof theranostics, neurology, cardiology, molecularimaging, AI and so on. One of Japanese Nobel Prizewinners, Dr. Koichi Tanaka who invented mass
spectrometric analyses of biological macromolecules,
will be invited. Recently, his group published a key
article in Nature regarding liquid biopsy for
Alzheimer’s disease. As you know, therapeutic drug,
aducanumab, for Alzheimer’s disease was approvedby the US FDA very recently. Amyloid PET isconnected to these trend, and Dr. Tanaka’s lecture
will have great impact on nuclear medicine
community in this regard.
One of the major missions of WFNMB is to educate
young people in the field and promote thedevelopment of nuclear medicine in developing
countries. For this sake, we wil prepare travel grants
to join the congress. Our President Dr. Jean-Luc
Urbain gave me a very good idea to have a session
dedicated to the educational challenges.
One of highlights of the very first congress of
WFNMB held in 1974 in Tokyo was the attendanceof the then Crown Prince and Princess at the
opening ceremony. We are negotiating with theauthority to invite a member of the JapaneseImperial Family for the opening ceremony once
again. Our request form is now on the table of the
Cabinet office and I am sure that the nuclear
medicine community in the world will be celebrated
We are expecting 4000 participants domestically andinternationally. You will be one of them!
What have been the most important changes thatyou have seen in the field of Nuclear Medicine overthe last 5 years!
Development of theranostics in the world is thebiggest one. In my country Japan, not many people
paid attention to targeted radionuclide therapy for10many years although therapies such as radioiodine
therapy for thyroid disease and 89Sr bone pain
palliative therapy have been widely adapted in theclinic. It was a kind of niche field in medicine.
However, many people began to recognize thesuccessful achievement of PRRT for neuroendocrine
tumors and PSMA therapy prostate cancer.
Introduction of alpha therapy with 223Ra for prostatecancer patients further pushed them toward thisfield. Then, successful story of 225Ac-PSMA ignited
their hearts. I have been involved in targetedradionuclide therapy for 35 years. Frankly speaking,I have not expected to see the current situation. I
would sincerely appreciate the big efforts of ourcolleagues in the world.
How do you see the field of Nuclear Medicine
evolving during the next 5 years!
The role of theranostics will get bigger and bigger
in clinical practice. In Japan, Lutathera, 177LuDOTATATE, is going to be approved. 131I-MIBG for
pheochromocytoma will follow. Clinical trial of 177LuPSMA for prostate cancer is being prepared.
Physician-led clinical trial of 64Cu-ATSM for brain
tumors is on the way.
In addition, clinical trials of targeted alpha therapy
with 211At (NaAt) for 131I-refractory thyroid cancerand 211At-MABG for pheochromocytoma are almost
ready to be initiated.

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:39 Page 11

PET imagings will also surely grow. Currently, we aredoing clinical trial of 68Ga-PSMA aiming
governmental approval in my University hospital.
We are also expecting that amyloid PET will bereimbursed after the domestic approval of
Aducanumab.
How do you see the training of residents andtechnologists in our Nuclear Medicine training
programs!
In order to offer patients with proper medical
management, all professionals including physicians,
nurses, technologists and nuclear physicists shouldcollaborate at the high level. All of them should
acquire updated technique and information.
Furthermore, communication is quite important.
Task shifting in hospitals has been promoted by the
Ministry of Health, Labour and Welfare (MHLW) in
my country for more than 10 years. For this sake, weshould understand the roles of each occupation.
Mutual training program should be needed. For
instance, Japanese Society of Nuclear Medicine(JSNM) has been discussing about JSNM Technology
in this regard in response to the Governmental
order.
As the chair of the WFNMB congress, what is yourgreatest wish for the specialty of Nuclear Medicine!
For the future of nuclear medicine, newtechnologies in both instruments and drugs are ofcourse required. However, development of humanresources is the most important thing. In addition,
we need more young people than ever in order tokeep growing. In my country, we have notsucceeded to get a good number of young fellows
in nuclear medicine for many years primarily due
to the shrink of nuclear medicine examinations
because of the alteration of medical careinsurance system about 20 years ago. However, wehave now very attractive tools of theranostics and
PET imaging in our hands. WFNMB congress is avery good opportunity not only for theinternational development but also for theadvertisement of nuclear medicine to young
doctors in my country.
You are currently the president of JSNM. What are
you doing to promote nuclear medicine in Japanand your neighboring countries in Asia?
Perhaps, Japan is one of the most underdeveloped
countries in theranostics mean. Lutathera is justgoing to be approved 4 years after EU approval.
68Ga-DOTATATE/DOTATOC is not available due tocomplicated regulations, and we have to use oldfashioned 111In-octreotide instead. Patients go
abroad to undergo PRRT or PSMA therapy toEurope or Australia. This situation is a shame of theJapanese nuclear medicine community. Five years
ago, JSNM launched the National Conference for

Nuclear Medicine Theranostics in which I have been
serving as the president. Nuclear physicians,
clinicians, patients and industrial people gather inthis platform. Lobby activities or advocacy activities
to the officials of Ministries and members of
Parliament are going to bear fruit. Now, we have
many supporters among representatives. Officials
are getting to understand the necessity to develop
radionuclide therapy in this country. Consequently,
the word “targeted radionuclide therapy” wasinstalled in the official statements of MHLW such as“Cancer Control Act” and “Requirements for Core
Hospitals for cancer control “.
One of the biggest issues is a lack of domestic
production of therapeutic radionuclides. After yearsof lobby activities, 2 representatives required a planfor domestic production of radionuclides, especially
225Ac, at the occasion of parliament assembly on
May 31, 2021. Four Ministers related to this issue
responded affirmatively.
Public lectures are often provided to make people
know the role of nuclear medicine in clinic. Many ofordinary people even do not know what nuclear
medicine is. They cannot imagine what targetedradionuclide therapy is. We need to continue thisactivity at any occasion.
Mutual activities with other societies have been
going on. We have MOU with SNMMI, EANM andthe societies of Asian countries. JSNM proposes
symposium in annual congress of SNMMI and EANM
every year, and collaborative sessions are regularly
prepared which have a good reputation.
Many of Asian countries are not well developed innuclear medicine practice. So that, supporting
educational activities is essential in this region.
JSNM has been working together with Asia Oceania
Association of Nuclear Medicine and Biology(AOFNMB), Asian Regional Corporative Council of
Nuclear Medicine (ARCCNM) and so on.
The collaborative work with
the International Atomic
Energy Agency (IAEA) was
initiated in 2018 by theleadership of the pastpresident of JSNM,
Prof. Jun Hatazawa.
The Consortium of 11
Universities
andInstitutions in Japan
has MOU with IAEA.
This aims to provide
young people in Asia
witheducational
occasions. Workshops andhands-on meetings are set
up in Japan. Although thisactivity is suspended now due to
COVID-19, it will be resumed hopefully next year.

11

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:39 Page 12

World Federation of Nuclear Medicine & Biology 2022-2024
Treasurer Candidate:Dr. Francois Lamoureux• MD: University of Sherbrooke- Board Certified in Nuclear Medicine• M.Sc: University of London, England• Fellow Royal College of Canada• Medalist of the city of Paris• Professor at the University of Montreal• Membership: EANM, SNMMI, SFNM, CANM
• Past President of the AMSMNQ, President of the CANM
• Several presentations/lectures in Europe, North & South America• Editor in chief of the magazines Le Patient and ePatient• Main interests: Precision Medicine, Theranostics, NM Education

As Treasurer of the WFNMB,
I will work with all of you from across the world:
1. To maintain the stability and integrity of the WFNMB accounting practices by working in close collaboration with theauditors and immediate past treasurer of the WFNMB.
2. To develop methods and processes generating additional revenue streams in order to achieve long term sustainability of
the WFNMB and to support the educational endeavors of the WFNMB
I am currently the president of the Canadian Association of Nuclear Medicine and our organization as for more than 30 years
worked hand in hand with the WFNMB. I sincerely believe that the WFNMB plays a major role worldwide and bring a better andcloser partnership between countries to ensure the plus value of Nuclear Medicine.
With the development of new detectors, new radiopharmaceuticals and the rapid deployment of theranostics more than ever the
WFNMB is needed as a major interlocutor.
I have close relationships with IAEA and I strongly believe that through the IAEA the WFNMB could bring an increase in availabilityof Nuclear Medicine for the patients in the emerging countries. Everything is possible for an organization but we need some financial
security and if I am elected as the treasurer, I will work to secure the financial viability of the WFNMB. It will be my first and main
objective.
WFNMB is viewed around the world as a well-respected organization and I will be more than happy to be able to work in close
relationship with the executive board to help to make more available and high-quality Nuclear Medicine around the world.
I am a university professor of Nuclear Medicine, I trained many residents, made many
publications and I really believe that Nuclear Medicine has a tremendous future.

12

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:39 Page 13

Dr. Jean-Luc C. Urbain
President
World Federation of Nuclear
Medicine & Biology

Born in Belgium in the mid 50’s, I earned
my Medical Degree at the University ofLouvain, Belgium, and then pursued
residency training in Internal Medicine andNuclear Medicine. I subsequently obtained
a Ph.D. in Genetics and Molecular Biology
at Temple University in Philadelphia.
Professor of Imaging, Medicine andBiology for more than two decades I have
had the opportunity and privilege to visit
hospitals and medical centers and givelecture on all continents. I consider myself
as a citizen of the world.

Through my career, I have held leadershipand executive positions in Medical Imagingand Medicine in Belgium at the Universityof Leuven, in Canada at the University ofWestern Ontario and in the US at Temple
University, Fox Chase Cancer Center, The
Cleveland Clinic, the VA Administration and now
Wake Forest University. I have extensive
experience and expertise in committees andboards leadership, in the management ofintegrated health care systems and patientadvocacy groups and at regional, national andinternational levels of government.
As Secretary of the Belgian Society of Nuclear
Medicine in the 90’s I introduced a multilingualand pluralist approach to the operational tasksof the Society. As President of the Canadian
Association of Nuclear Medicine, I have worked
closely with national and international medical
associations and government health authorities
to mitigate major the major health and medical
isotopes crises of 2007-2008, analyzed andhelped establish medical resources needs,
benchmarks and allocation for key medical
service areas. I have also served as consultant andJean-Luc UrbainM.D., Ph.D., CPE, FASNC

advisor for Pharmaceutical, Radiopharmaceutical and Medical Systems companies. My
current main interests are in Medical Isotopes
Production and Supply, Patients’ Education
and Advocacy, Personalized Medicine andTheranostics.
The WFNMB is working tirelessly with the World
Health Organization (WHO), the International
Atomic Energy Agency (IAEA), the Health andNuclear Medicine Authorities from across theglobe, all national and regional Nuclear
Medicine Societies and Associations and the
Nuclear Medicine Industry to 1. Secure thesupply of and access to Medical Isotopes
2. Develop NM educational tools accessible to
the Nuclear Medicine Communities, Patients andReferring Physicians from around the world
3. Make sure that the Nuclear Medicine
Association/Societies from the emerging
countries benefit from the work of the WFNMB
and the regional NM Associations/Societies
4. Promote the field of Diagnostic andTherapeutic Nuclear Medicine (Theranostics)
across the globe, particularly in the underservedcountries.

13

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:40 Page 14

INTERVIEW WITHJames McBrayer
You have been actively involved in the field of
nuclear medicine for quite a while. Looking back at
your career, what are the most significant changes
that you have witnessed in the field over the past
10 years?
I have witnessed a great deal of change since
starting in nuclear pharmacy as an intern in 1988.
Following graduation from pharmacy school, I
practiced nuclear pharmacy in the United States,
Australia and New Zealand. Since taking on the roleof CEO of Cyclopharm in 2008, given the numerous
markets we distribute our products to, I have had
the ability to view nuclear medicine from a global
perspective.
In my opinion the top two changes in the past 10
years in nuclear medicine have been related toadvancements in imaging technology and in
Positron Emission Tomography (PET).
An example for advancement in imaging
technology can be seen in diagnosing Pulmonary
Embolism (PE). Nuclear medicine functional
imaging with SPECT has reversed a previous trend
toward anatomical imaging with CTPA. By
replacing 2D Planar for 3D SPECT imaging andshifting from probabilistic outcomes, nuclear
medicine physicians are delivering higher levels of
sensitivity and accuracy in diagnosing PE at afraction of the radiation dose compared to that ofCTPA.
I believe the other area of major change in the past
10 years in nuclear medicine has been in molecularimaging with PET. In the past decade PET has grownfrom a few oncology studies primarily using FDG toa growing array of agents used diagnostically inoncology, neurology, cardiology and MSK.
PET continues to evolve rapidly by providing theplatform for the development of Theragnostics.
These diagnostic – therapeutic combinations acting
on targeted biological pathways, predominantly
used in oncology, are set to provide nuclear
medicine its next major leap forward.

James McBrayer
CEO, Cyclopharm Ltd
Email: jmcbrayer@cyclopharm.com.au
Website: www.cyclopharm.com

Given Technegas’ unique properties, there are nocontraindications for its use, it is ideally suited for
3D SPECT imaging and dramatically reduces thepotential for hotspots often seen with competitive
nuclear medicine products such as DTPA aerosols.
Our largest regional market is Europe where we arereferenced in the EANM Guidelines 2009 as thepreferred ventilation imaging agent in diagnosing
PE. Our largest single country market is Canada. We
are approved for use in China and will be looking
forward in the coming years to expand the use ofTechnegas throughout Asia.
We are currently involved in the final stages of our
New Drug Application review with the USFDA andhope to bring Technegas to the United States verysoon.
Lung Ventilation studies for the diagnosis of
pulmonary embolism have been successfully
performed across the world for many decades withTechnegas. Can Technegas play a role for thequantitative evaluation of the lungs function inother diseases?

What is Cyclomedica?
Cyclomedica is a wholly owned subsidiary of theAustralian listed company Cyclopharm (ASX:CYC).
Cyclomedica is best known for our proprietaryfunctional lung ventilation imaging product
Technegas. First used clinically in 1986, Technegas
is now available in 60 countries around the world.

14

4.4 million patients have been imaged withTechnegas. Whilst best known for diagnosing PE,
with the advancement of more sensitive imaging
technologies to include SPECT-CT combined with
newly developed analytical software, Technegas is
more relevant today than it was when it was first
introduced in 1986.

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:40 Page 15

Given that Technegas can show true functional
ventilation to the point of gas exchange at thealveoli, we are seeing strong global interest from
respiratory physicians to apply Technegas to bothquantify the extent of disease and measure
response to therapy. We are working with both
nuclear medicine and respiratory physicians aroundthe world in clinical trials targeting severe asthma,
chronic obstructive disease, lung volume reduction
and lung transplant to name a few. An example ofone of these initiatives can be found via thefollowinglink:
https://hmri.org.au/newsarticle/nuclear-imaging-clear-airway-diagnosis.
What do you anticipate the role of artificial
intelligence (AI) be in the field of lung imaging?
Nuclear
Medicine
has
alwaysembracedadvancements in technology. In lung imaging I
have seen, where Technegas is available, that SPECT
is replacing Planar imaging. Recent techniques
using SPECT co-registered with low dose CT
augmented with analytical software is providing
another layer of information to clinicians notpreviously available.
In the September 2017 Lancet commissioned
publication entitled “After Asthma: redefining
airways disease” global leaders in the field of
respiratory medicine call for tests that can
incorporate “traits that can be measured” as wellas measures “in the context of social andenvironmental factors and extrapulmonary
comorbidities”. Rather than focusing on a singularimage interpretation, I see that AI’s greatest

contribution in patient outcomes will be indelivering personalized respiratory medicine byanalyzing the numerous and complex inputs
required to deliver on diagnostic, prognostic andtherapeutic outcomes.
You have had the opportunity to read the first two
issues of the NM magazine Pangea-ePatient. Whatdo you think of the magazine and what would
your suggestions be to improve it?
This publication is an important educational tool.
Similar to AI, Pangea-ePatient is in its own way
disruptive. I am entering my third decade in nuclear
medicine and have never known of a publication
with such global support within the discipline of
nuclear medicine combined with such broad reader
potential.
I am enthusiastic to learn about the endorsementfrom so many of the global Societies of Nuclear
Medicine and trust that this level of support will
only expedite the messages being sharedthroughout the world to our referring physicians.
Thank you for the honour of contributing toPangea-ePatient and congratulations on theimportant work that you are doing.

WHAT ISTECHNEGAS
Technegas is a hydrophobic nanoparticle dispersion of carbon-labelled 99mTechnetium8.
The nanoparticle size and hydrophobic properties of Technegas provide ideal
characteristics for gaseous behaviour and alveoli deposition into the lungs8-9. This provides
for a represention on imaging of peripheral penetration of Technegas to the lungs9.
According to the Canadian Associaion of Nuclear Medicine (CANM) and the European
Association of Nuclear Medicine (EANM) guidelines, Technegas is the preferred ventilation
agent for ventilation-perfusion (V/Q) functional lung imaging studies10-12. In a few breaths
and following SPECT or SPECT/CT, the clinician can produced 3D images providing
information on lung function and pulmonary physiology2,12.
References
1.
2.
3.
4.

Elojeimy S, et al. AJR Am J Roentgenol 2016; 207(6): 1307-1315
Bajc M, et al. Semin Nucl Med 2010; 40: 415-425
Isidoro J,
J, et al. Phys Med 2017; 41: 93-96
Inmai T,T, et al. Ann Nucl Med 2000;
200 14(4): 263-269

5.
6.
7.
8.

Hsu K,
K, et al. J Bronchology Interv Pulmonol
Pulmonol 2018; 25(1): 48-53
Hess S, et al. Semin Thromb Hemost 2016; 42(8): 833-845
Gopalan D,
D, et al. Eur Respir Rev 2017; 26(143): pii: 160108
Lemb M, et al. Eur J Nucl Med 1993; 20: 576-579

9.
10.
11.
12.

Senden TJ,
TJ, et al. J Nucl Med 1997; 38: 1327-1333
Leblanc M, et al. Nov 2018; https://canm-acmn.ca/guidelines
Bajc M, et al. Eur J Nucl Med Mol Imaging 2009; 36: 1356-1370
Roach PJ,
PJ, et al. J Nucl Med 2013; 54: 1588-1596

FFor
or more information, please visit wwwwww.cyclomedica.com.cyclomedica.com

15

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:40 Page 16

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Références
Hess S, et al. Semin Thromb Hemost 2016; 42:1.
833–845
2.
Sánchez-Crespo AA,, et al. Nucl Med Commun
2008; 29(2): 173-177
3.
Grüning TT,, et al. Clin Imaging 2014; 38(6):831-8354.
Isidoro JJ,, et al. Phys Med 2017; 41: 93-96

5.
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ligne en raison de sa sensibilité et de sa spécificité élevées, de sa
faible radiation et de l’absence d’effets indésirables.8

Miles S, et al. Chest 2009; 136: 1546-1553
Nasr Aulmon and Respir Medicine
A,, et al. EC P
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Bajc M, et al. Eur J Nucl Med Mol Imaging 46,
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Leblanc M , et al. CANM Guidelines 2018;
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Technegas™
Teechnegas™ n’est pas
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Dernière révision (A4):A4): v.2.1
v.
v.2.1 (14/avr/2021)
Pour
Pour plus d’informations, veuillez visiter wwwwww.cyclomedica.ca.cyclomedica.ca ou envoyer un courriel àtechnegas.sales@cyclomedica.ca
Page
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E PATIENT-V5N1-777777_Layout 1 21-07-23 12:40 Page 17

INTERVIEW WITH:

DR. DANIEL BADGER
You are the president of the AUSTRALIAN AND
NEWZEALAND SOCIETY OF NUCLEAR MEDICINE(ANZSNM).Could you succinctly describe the role of
the ANZSNM inthe field of Nuclear Medicine?
The ANZSNM’s role is to support all professionals
working inthe field of Nuclear Medicine inAustralia and New Zealand.This involves providing
guidelines,
training,
education,professional
development,
professional
standards,
butmorethan that, we are also a community of mutual
support. Wealso liaise with Government agencies
on matters relating toNuclear Medicine: funding,training and infrastructure. Weorganise an annual
scientific meeting in April/May each year http://www.anzsnmconference.com/ANZSNM2021/
Join usonline this May!
What have been the three most important changes
thatyou have seen in the field of Nuclear Medicine
over thelast five years?
• The biggest change has been radionuclide
therapy agentsbecoming part of normal /first line
care for cancer treatment.
• PET is so useful and beneficial. We now candeclare that PETis no longer special, it should beavailable in every majorhospital.
• Theranostics – Seeing exactly what we aretargeting with ourtherapy, and being able to lookat treatment response makesa huge difference topatient outcomes.
How do you see the field of Nuclear Medicine
evolvingduring the next five years?
The introduction of new targeted therapeutic
agents that workon more cancers will mean a shift
from a majority of diagnosticimaging to a majorityof therapeutic procedures.

Dr. Daniel Badger
0H$
University of Adelaide, South Australia
diagnostic imaging. Therapy requires a muchhigherstandard of radiation safety and preparation,and this startswith training programs.
As president of the ANZSNM, what is your greatest
wishfor the speciality of Nuclear Medicine?
My greatest wish is that all thedifferent professions
andgeographically separatedgroups can work
together inharmony to do much morethan any
single group couldachieve alone.

How do you see the training of residents
andtechnologists in our Nuclear Medicine training
programs?
They will need to focus a lot more on therapy. As aphysicistworking a lot in radiation protection, I’maware thatradionuclides used therapeutically carries
higher risks forpatients and staff, and sometimes wecan become complacentdue to being used tohandling low risk radioactive materialsused for

www.anzsnm.org.au

17

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:40 Page 18

ENTREVUE AVEC

Chantal Asselin
Vous êtes la responsable du programme de formation
des technologues en médecine nucléaire du Québec,Canada. Pourriez-vous nous présenter un court
résumé de votre parcours et de votre situation
actuelle?
Enseignante au programme de Technologie demédecine nucléaire au Collège Ahuntsic depuis 1986
et Responsable de la coordination du département,
des stages et Responsable de la radioprotection
depuis 1997.
À titre de consultante en radioprotection, publicationde plusieurs articles scientifiques, prestation denombreuses formations et conférences dans plusieurs
régions du Québec et provinces canadiennes ;réalisation de plusieurs avis ou normes pour l’Ordredes technologues en imagerie médicale et en radiooncologie du Québec ; Technologue émérite en
imagerie médicale depuis 2006 ; Mention d’honneur
de l’Association québécoise de pédagogie collégiale(AQPC) en 2010.
Le centre de formation existe depuis quand et à cejour combien de technologues en médecine ont été
formés?
Depuis 1968 jusqu’à aujourd’hui, nous avons formé
plus de 700 technologues qui travaillent dans une
cinquantaine de services de médecine nucléaire aux
quatre coins de la province.
Combien de professeurs (e) travaillent à la formationdes étudiants ?
9 enseignant.e.s en Technologie de médecine
nucléaire sont à l’emploi du collège Ahuntsic
présentement et ils sont soutenus par 2 techniciennes
de laboratoire.
L’excellence de nos technologues est reconnue dansle monde entier. En quelques lignes pourriez-vousnous décrire le parcours type d’un étudiant?
Durant les deux premières années du programme, lesélèves apprennent à préparer les produits
radiopharmaceutiques et à en contrôler la qualité
grâce à la grande générosité de nos partenaires del'industrie radiopharmaceutique. De plus, nos élèves
s'entraînent à injecter des produits de façon
sécuritaire, à produire des images de fantômes à
l'aide de caméras et à analyser l'information recueillie
à l'aide des mêmes logiciels que ceux utilisés dans leshôpitaux. Tout ce qui leur manque au collège, ce sontles patients !

18

CHANTAL ASSELIN, t.i.m.(E)Et ce sont les valeureux maîtres de stage etenseignants cliniques qui prennent la relève en centre
hospitalier durant la troisième année du programme
pour aider nos élèves à s'occuper des patients et à
mettre en pratique ce qu'ils ont appris durant leursdeux premières années d'étude.
Nous sommes également très impliqués dans laplanification et le placement de la main-d’œuvre.
Sachez que nous avons augmenté le nombred'admissions dans notre programme de 40 à 65 places
ces dernières années. Toute l'équipe du collège
travaille avec ardeur pour promouvoir notre
profession et surtout pour favoriser la réussite desélèves.
Combien existe-il de technologues en médecine
nucléaire actuellement actifs au Québec et dans
combien de centres?
Environ 530 technologues en médecine nucléaire sontactuellement actifs au Québec et ils œuvrent dansune cinquantaine de services à travers la province.
Avec le développement accéléré de nouveauxradiotraceurs, de détecteurs hybrides et de lathéranostique quels sont les défis les plus pressants
auxquels vous êtes confrontée?
Le domaine de la médecine nucléaire est en constanteévolution comme dans tous les domaines del’imagerie médicale. De mon côté, je considère avoir
vécu six grandes révolutions dans mes 35 années decarrière. Après l’arrivée des caméras gamma dans lesannées 70, j’ai débuté ma carrière de technologues
avec l’arrivée des ordinateurs au début des années 80.
J’ai participé à la formation des technologues lors de

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:40 Page 19

l’arrivée des caméras tomographiques par émission
monophotonique (TEMP) dans les années 90, suivie
des caméras par émission de positrons (TEP) au débutdes années 2000 et par les caméras hybrides TEPMTDM ou TEP-TDM au milieu des années 2000. La
théranostiqueetlareconstitution
desradiopharmaceutiques en milieu stérile sous hotte
font partie des nouvelles formations que nous avonsintégrées dans notre programme actuel et dans laformation sur mesure offerte aux technologues déjà
gradués.
Aussi, depuis plus de 30 ans, le Collège Ahuntsic
prend en charge la formation continue destechnologues en offrant des formations théoriques etpratiques sur mesure portant sur les nouvelles
technologies introduites dans notre domaine. Nous
offrons également des formations à distance depuisdéjà une quinzaine d’années, permettant ainsi derejoindre les technologues de toutes les régions duQuébec. Nous étions donc déjà prêts pour affronter
le télétravail pandémique !

Quel serait votre plus grand souhait pour votre
programme de formation des technologues enmédecine nucléaire?
J’ai deux souhaits :Améliorer l’attraction envers notre beau programme
et cette magnifique profession afin d’obtenir plus decandidats en fonction des besoins des régions. À cetégard, nous allons entreprendre des démarches auprès
du MSSS et des CISSS ou CIUSSS pour obtenir desbourses dédiées aux futurs technologues en médecine
nucléaire pour pallier la pénurie de main d’œuvre qui
sévit dans les différentes régions du Québec.
Que le ministère de l’Enseignement supérieurreconnaisse la valeur des équipements à la fine pointe
de la technologie que nous possédons et que lesbudgets octroyés à la seule maison d’enseignement qui
offre le programme soit à la hauteur de la qualité dela formation que nous offrons pour graduer destechnologues compétents et autonomes prêts à
intégrer le marché du travail à leur sortie de l’école.

INTERVIEW WITH Chantal Asselin
You are responsible for the training program fornuclear medicine technologists in Quebec, Canada.
Could you give us a short summary of yourbackground and your current position?
Teacher in the Nuclear Medicine Technology Programat Ahuntsic College since 1986 and Head of
Department Coordination, Internships and Radiation
Protection Officer since 1997.
As a radiation protection consultant, publishingseveral scientific papers, providing numerous
trainings and conferences in several regions ofQuebec and Canadian provinces; conducting several
recommendations or guidelines for l’Ordre destechnologues en imagerie médicale et en radiooncologie du Québec (Quebec College of Medical
Imaging and Radiation Oncology Technologists);
Emeritus medical imaging technologist since 2006;
Honorable mention of l’Association québécoise depédagogie collégiale - AQPC (Quebec Association ofCollege Education) in 2010.
How long has the training centre been in operations
and to date, how many medical technologists havebeen trained?
From 1968 to today, we have trained more than 700
technologists who work in 50 nuclear medicine
departments across the province of Quebec.

How many teachers work on student training?
9 teachers in Nuclear Medicine Technology are
currently employed at Ahuntsic College and aresupported by 2 laboratory technicians.
The excellence of our technologists is recognizedaround the world. In a few lines, could you describea student's typical journey?
During the first two years of the program, students
learn how to prepare and perform quality control ofradiopharmaceuticals thanks to the collaboration
with our partners from the radiopharmaceuticalindustry. In addition, our students practice injecting
products safely, producing phantom images using
cameras, and analyzing information collected using
the same software utilized on a daily basis in
hospitals. All they are missing at the college are thepatients!
And it is the essential onsite supervisors and clinicalteachers, who then take over in the medical centersettings, during the third year of the program, toempower our students to develop their patient careskillset and put into practice what they learned
during their first two years of the program.
We are also very involved in the planning andplacement of the future workforce. Please note that
we have increased the number of admissions to our

19E PATIENT-V5N1-777777_Layout 1 21-07-23 12:40 Page 20

program from 40 to 65 places in recent years. The
entire institution works hard to promote our
profession and above all, to promote the success ofour students.
How many nuclear medicine technologists are
currently active in Quebec and in how many centres?
Approximately 530 nuclear medicine technologists
are currently active in Quebec and work in about 50
departments across the province.

offering bespoke theoretical and practical training on
new technologies that are introduced in our field. We
have also been offering remote training for the past
15 years, allowing us to reach technologists from all
regions of the Province of Quebec (1.5M km2). We
were already prepared to face pandemic thanks to
our remote capabilities!
6. What would be your greatest wish for your nuclear
medicine technologist training program?
I have two wishes:With the accelerated development of new
radiotracers, hybrid detectors and theranostics, what
are the most pressing challenges you face?
The field of nuclear medicine is constantly evolving as
in all areas of medical imaging. For my part, I havewitnessed six great revolutions in my 35-year career.
After the arrival of gamma cameras in the 70s, I
started my career as a technologist with the arrival ofcomputers in the early 80s. I participated in the
training of technologists with the arrival of Single
Photon Emission Computed Tomography cameras(SPECT) in the 1990s, followed by Positron Emission
Tomography cameras (PET) in the early 2000s and by
the hybrid cameras SPECT-CT or PET-CT in the mid2000s. Theranostics and the sterile compounding ofradiopharmaceuticals in shielded isolators areamongst the new trainings we have integrated into
our current program, and for the tailored training
offered to post graduate technologists.
For more than 30 years, Ahuntsic College has been
supporting the ongoing training of technologists by

20

To improve the attraction to our exceptional program
and this wonderful profession in order to get morecandidates according to regional needs. In thisregard, we will take steps with the Ministry of Health(MSSS), and Integrated Health and Social Services
Centres (CISSS), and Integrated University Health andSocial Services Centres (CIUSSS), to obtain grants
dedicated to future nuclear medicine technologists tobetter address the labour shortage in the various
regions of the Province of Quebec.
For the Ministry of Higher Education to recognize thevalue of the state-of-the-art equipment we have, andthat the allocated budgets, to the only educational
institution that offers the Nuclear Medicine
Technology program in the Province, are aligned with
the quality of the training we provide to ensure ourstudents graduate as highly competent andautonomous technologists, ready to enter the nuclear
medicine field.

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E PATIENT-V5N1-777777_Layout 1 21-07-23 12:40 Page 22

INTERVIEW WITH
DR. RAYMONDE CHARTRAND
I have founded and opened the Hôpital St-Luc
Nuclear Medicine Service in 1970 in Montreal. It
required a lot of determination being a female
physician, in charge, during this era. Being the only
girl from a family of 5 siblings, I had quickly learned
to defend my turf.
In 1976, Dr. François Lamoureux freshly back from
London, after a Master of Science from university of
London England, joined our service. He worked parttime balancing his workload as he was also workingat Hôpital Notre-Dame.
The Nuclear Medicine beginnings were extremely
arduous due to the Quebec Government. Considereda quaternary specialty, the Ministry of Health hadfrozen all budgets to reduce spending. The freeze
ended in 1978-1979.

Until recently, few women held leadership positions
in Nuclear Medicine. As a pioneer and scientist in thisfield, how have you been able to distinguish yourself
so greatly as a nuclear physician?
In our Class of 1965, we were 15 women to graduateout of a total of 93 doctors. Times have greatlychanged since then. After my residency in internal
medicine, I completed one year at the Montreal
General Hospital with Dr. Leonard Rosenthal in“Radioisotopes” as it was called at the time. The
following year I embarked on a fellowship of the
National Institutes of Health in the United States at
Upstate Medical Center in Syracuse, NY with Dr. John
G. McAfee (Canadian Radiologist from Toronto whose
groundbreaking research led to major medical
advances especially in blood cell labelling).
When I came back to Montreal in 1969, the Nuclear
Medicine Specialty (distinct entity from Radiology)
had just been created in the Province of Quebec. A
first in Canada, and actually, in all of North America.
In 1972, I passed the American Board of Nuclear
Medicine exam. Four years later, in 1976, anotherboard exam, this time at the Royal College ofPhysicians & Surgeons of Canada.

22

I became President of the Pedagogic Committee andDirector of the Nuclear Medicine Program, a position
I held until 1990. From the small nucleus of colleagues
since the very early days, we joined forces to establish
a solid Nuclear Medicine program that would ensure
medical coverage across the province including
remote regions. We trained brilliant specialists. In
parallel, the Ahuntsic College in Montreal, developed
an excellent program for NM Technologists. These
highly competent professionals play an essential rolein a nuclear medicine service or department. This
pivotal program utility was never doubted
throughout the years.
I consistently evolved in a university environment
alongside highly qualified physicians from all medical
specialties. It was a stimulating environment where
excellence and knowledge transfer were at theforefront. We educated the residents from the NM
program but also to residents from all otherspecialties,
generalmedicalpractitioners,
technologists, nurses, and future pharmacists.
Through the years our hospital became part of theCHUM – Centre Hospitalier de l’Université deMontréal (merge of 3 major hospitals). The CHUM
became a flagship institution for thyroid studies,
especially cancers. I was extremely involved in theiodine therapies, the introduction of thyrotropin alfa,
training all future NM specialists and an advisor to mycolleagues throughout the province (NM physicians,
endocrinologists, surgeons, etc.).
My involvement continued to evolve beyond thehospital and university settings. I became a Faculty
Clinical Professor at Université de Montréal. I thenE PATIENT-V5N1-777777_Layout 1 21-07-23 12:40 Page 23

seated as chairman of the Royal College of Physicians& Surgeons of Canada, quickly followed by the
Presidency of the Canadian Association of Nuclear
Medicine. In 1987, I became an Ambassador
Appointed from Le Palais des Congrès de Montréal
after obtaining the 5th World Nuclear Medicine
Congress in 1990.
I was always told that nature was generous with me.
I continuously had tons of energy, enthusiasm,
organization, and time-management skills. I am
thankful for the support my family always provided:
my husband, my 3 children, a loyal nanny for 25 years
and last but not least, empathetic and devoted
colleagues. My weekends were entirely focused onfamily and friends except, of course, when I was oncall at the hospital. I still remember my kids at a
young age, with coloring books, with me, at thehospital while I was on duty…
Marie Curie is considered by many to be the motherof Nuclear Medicine. What human and professional
qualities do you think she possessed to havesucceeded in such a career and to lay the foundations
for a new field of medicine?
Marie Curie was always present throughout my lifeand career (50 years) as a female Nuclear Medicine
Specialist. I was never able to negate or forget the
micro, milli and Curies, even though Becquerel later
became the international metric unit for radioactive
activity. For me, Marie Curie remains a model ofdetermination and passion. She represents a strengthof nature, being able to overcome life, adversity,
confidence in her abilities and the willingness to excel
sometimes to her own personal detriment.
As a medical professional, professor, and mentor
what advice would you give to women interested inpursuing and succeeding in a medical career?
Any woman, nowadays, can become a doctor if thatis her wish. It requires hard work, dedication, andperseverance. Our societies have greatly evolved forboth men and women, now more than ever,individuals aim for a balance between professional,
personal, and family life. In our field, female
residents can start a family, extend their residency, ifneed be, without being penalized or impacted intheir program. It certainly needs the support fromthe spouse or partner and family. That being said, thisis no different than any profession or area ofexpertise.

different conditions: for example, Parkinson’s, cardiac
amyloidosis, certain cancers, and the development of
new therapies (theranostics).
The imaging devices also greatly improved from thedays of rectilinear cartographs, to scintillation
cameras to more advanced SPECT, SPECT-CT as well as
PET-CT and PET-MR.
Informatics was slowly deployed in Nuclear Medicine
in the 1980s and brought more possibilities. Speech
recognition for example, was a game changer forphysicians. Developments are happening every day,
what will the future hold? What will the Artificial
Intelligence bring?
Nuclear Medicine, even though, now combining
anatomical modalities (with hybrid scanners) will
always remain a separate field from Radiology due toits unique approach, focused on molecular markers
for both diagnosis and treatment of disease. It is alsoa support field where we consistently contribute to
all medical specialties, bringing valuable input with
our state-of-the-art diagnostic services.
The
therapeutic aspect of Molecular Imaging will be
revolutionary (not only from Iodine), but all the
Theranostics where empathy and patient care will beof the greatest importance.
Women can tremendously perform in Nuclear
Medicine: Applied sciences, physics, instrumentation,
radiobiology, radiopharmacy are amongst the
impressive list of areas that should not stop female
candidates.
Finally after such a career in Nuclear Medicine what
is your greatest wish for future nuclear physicians?
I have embraced my profession, my practice and more
importantly my patients, I wish that all future Nuclear
Medicine physicians bring dedication, enthusiasm,
and passion at work in this great field while
maintaining a good balance between theirprofessional and personal lives.
Yes, this is my wish for the future of our field. The
world pandemic, my age, and my children suggested
that it was time for me to retire at 81 years old.

How do you see the future of medical imaging andNuclear Medicine? What role will women play in youropinion?
Nuclear Medicine never ceased to progress for the
past 50 years considering the disappearing of certain
studies and radiotracers but also, with the apparitionof new compounds to allow for the detection of23

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:40 Page 24

ENTREVUE AVEC
DR. RAYMONDE CHARTRAND
J'ai fondé et ouvert le Service de médecine nucléaire
de l'Hôpital St-Luc en 1970 à Montréal. Il fallait
beaucoup de détermination pour être une femme
médecin responsable à cette époque. Étant la seulefille d'une famille de 5 frères et sœurs, j'avais
rapidement appris à défendre mon territoire.
En 1976, le Dr François Lamoureux fraîchement revenu
de Londres, après un Master of Science university of
London England, rejoint notre service. Il travaillait à
temps partiel pour équilibrer sa charge de travail
puisqu'il travaillait également à l'Hôpital Notre-Dame.
Les débuts de la médecine nucléaire ont été extrêmement ardus à cause du gouvernement du Québec.
Considéré comme une spécialité quaternaire, leministère de la Santé avait gelé tous les budgets pourréduire les dépenses. Le gel a pris fin en 1978-1979.

Jusqu'à récemment, peu de femmes occupaient despostes de direction en médecine nucléaire. En tant que
pionnier et scientifique dans ce domaine, commentavez-vous pu vous distinguer autant en tant que
médecin nucléaire ?
Dans notre classe de 1965, nous étions 15 femmes àobtenir leur diplôme sur un total de 93 médecins. Lestemps ont bien changé depuis. Après ma résidence en
médecine interne, j'ai complété une année à l'Hôpital
général de Montréal avec le Dr Leonard Rosenthal en« Radio-isotopes » comme on l'appelait à l'époque.
L'année suivante, je me suis lancé dans une bourse desNational Institutes of Health aux États-Unis au Upstate
Medical Center de Syracuse, NY avec le Dr John G.
McAfee (radiologue canadien de Toronto dont lesrecherches révolutionnaires ont conduit à des avancées
médicales majeures, en particulier dans l’étiquetage).
À mon retour à Montréal en 1969, la spécialité demédecine nucléaire (entité distincte de la radiologie)
venait d'être créée dans la province de Québec. Une
première au Canada, et en fait, dans toute l'Amériquedu Nord. En 1972, j'ai réussi l'examen de l'American
Board of Nuclear Medicine. Quatre ans plus tard, en
1976, un autre examen du jury, cette fois au Collège
royal des médecins et chirurgiens du Canada.

24

Je suis devenu président du comité pédagogique etdirecteur du programme de médecine nucléaire, posteque j'ai occupé jusqu'en 1990. Du petit noyau decollègues depuis les tout premiers jours, nous avons uni
nos forces pour établir un solide programme demédecine nucléaire qui assurerait une couverture
médicale à travers la province, y compris les régionséloignées. Nous avons formé de brillants spécialistes.
En parallèle, le Collège Ahuntsic à Montréal, adéveloppé un excellent programme pour les
Technologues NM. Ces professionnels hautement
compétents jouent un rôle essentiel dans un service ou
un département de médecine nucléaire. Cette utilité
centrale du programme n'a jamais été mise en doute
au fil des ans.
J'ai constamment évolué dans un environnement
universitaire aux côtés de médecins hautement
qualifiés de toutes les spécialités médicales. C'était unenvironnement stimulant où l'excellence et le transfert
de connaissances étaient au premier plan. Nous avons
formé les résidents du programme NM mais aussi lesrésidents de toutes les autres spécialités, les médecins
généralistes, les technologues, les infirmières et les
futurs pharmaciens.
Au fil des années, notre hôpital est devenu une partie
du CHUM – Centre Hospitalier de l'Université deMontréal (fusion de 3 grands hôpitaux). Le CHUM est
devenu une institution phare pour les études sur la
thyroïde, notamment les cancers. J'ai été extrêmement
impliqué dans les thérapies à l'iode, l'introduction dela thyrotropine alfa, la formation de tous les futurs
spécialistes en NM et un conseiller auprès de mescollègues à travers la province (médecins NM,
endocrinologues, chirurgiens, etc.).

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:40 Page 25

Mon implication a continué d'évoluer au-delà dumilieu hospitalier et universitaire. Je suis devenu
professeur clinicien à l'Université de Montréal. J'ai
ensuite occupé le poste de président du Collège royal
des médecins et chirurgiens du Canada, rapidement
suivi par la présidence de l'Association canadienne demédecine nucléaire. En 1987, je suis devenu
Ambassadeur Nommé du Palais des Congrès deMontréal après avoir obtenu le 5e Congrès mondial demédecine nucléaire en 1990.
On m'a toujours dit que la nature était généreuse avec
moi. J'ai continuellement eu des tonnes d'énergie,
d'enthousiasme, d'organisation et de compétences engestion du temps. Je suis reconnaissante pour lesoutien que ma famille m'a toujours apporté : monmari, mes 3 enfants, une nounou fidèle depuis 25 ans
et enfin des collègues empathiques et dévoués. Mes
week-ends étaient entièrement consacrés à la famille
et aux amis, sauf, bien sûr, lorsque j'étais de garde àl'hôpital. Je me souviens encore de mes enfants à unjeune âge, avec des livres de coloriage, avec moi, àl'hôpital pendant que j'étais de service…
Marie Curie est considérée par beaucoup comme lamère de la médecine nucléaire. Quelles qualités
humaines et professionnelles pensez-vous qu'elle
possédait pour avoir réussi une telle carrière et jeter
les bases d'un nouveau domaine de la médecine ?
Marie Curie a toujours été présente tout au long dema vie et de ma carrière (50 ans) en tant que femme
spécialiste en médecine nucléaire. Je n'ai jamais été
capable de nier ou d'oublier les micro, milli et Curies,même si Becquerel est devenu plus tard l'unité
métrique internationale pour l'activité radioactive.
Pour moi, Marie Curie reste un modèle dedétermination et de passion. Elle représente une force
de la nature, capable de surmonter la vie, l'adversité,
la confiance en ses capacités et la volonté d'exceller
parfois à son détriment personnel.
En tant que professionnel de la santé, professeur etmentor, quels conseils donneriez-vous aux femmes
intéressées à poursuivre et à réussir une carrière
médicale ?
Toute femme, de nos jours, peut devenir médecin sitel est son souhait. Cela demande un travail acharné,
du dévouement et de la persévérance. Nos sociétés
ont beaucoup évolué tant pour les hommes que
pour les femmes, aujourd'hui plus que jamais, lesindividus
visentunéquilibre
entre
vie
professionnelle, personnelle et familiale. Dans notre
domaine, les résidentes peuvent fonder une famille,
prolonger leur résidence, si besoin est, sans êtrepénalisées ou impactées dans leur programme. Il acertainement besoin du soutien du conjoint ou dupartenaire et de la famille. Cela étant dit, ce n'est
pas différent de n'importe quelle profession ou
domaine d'expertise.

Comment voyez-vous l'avenir de l'imagerie médicale
et de la médecine nucléaire ? Quel rôle les femmesjoueront-elles selon vous ?
La Médecine Nucléaire n'a cessé de progresser depuis
50 ans compte tenu de la disparition de certainesétudes et des radiotraceurs mais aussi, avec l'apparition
de nouveaux composés permettant de détecter
différentes pathologies : par exemple, la maladie deParkinson, l'amylose cardiaque, certains cancers, ladéveloppement de nouvelles thérapies (théranose).
Les dispositifs d'imagerie se sont également
considérablement améliorés depuis l'époque descartographies rectilignes, des caméras à scintillation
aux SPECT plus avancés, SPECT-CT ainsi que PET-CT et
PET-MR.
L'informatique s'est lentement déployée en médecine
nucléaire dans les années 1980 et a apporté plus depossibilités. La reconnaissance vocale, par exemple, achangé la donne pour les médecins. Des évolutions se
produisent chaque jour, que nous réserve l'avenir ?
Qu'apportera l'Intelligence Artificielle ?
La médecine nucléaire, même si, maintenant,combinant des modalités anatomiques (avec desscanners hybrides) restera toujours un domaine distinct
de la radiologie en raison de son approche unique,axée sur les marqueurs moléculaires pour le diagnostic
et le traitement de la maladie. C'est également undomaine de soutien où nous contribuons
constamment à toutes les spécialités médicales,
apportant une contribution précieuse avec nos services
de diagnostic de pointe. L'aspect thérapeutique del'imagerie moléculaire sera révolutionnaire (passeulement de l'iode), mais de tous les théranostiques
où l'empathie et les soins aux patients seront de la plus
grande importance.
Les femmes peuvent être extrêmement performantesen médecine nucléaire : les sciences appliquées, laphysique, l'instrumentation, la radiobiologie, laradiopharmacie font partie de la liste impressionnantedes domaines qui ne devraient pas arrêter lescandidatures féminines.
Enfin, après une telle carrière en Médecine Nucléaire,quel est votre plus grand souhait pour les futurs
médecins nucléaires ?
J'ai embrassé ma profession, ma pratique et surtout
mes patients, je souhaite que tous les futurs médecinsen médecine nucléaire apportent dévouement,
enthousiasme et passion au travail dans ce granddomaine tout en maintenant un bon équilibre entre
leur vie professionnelle et personnelle.
Oui, c'est mon souhait pour l'avenir de notre domaine.
La pandémie mondiale, mon âge et mes enfants ont
suggéré qu'il était temps pour moi de prendre ma
retraite à 81 ans.

25

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:40 Page 26

Grégoire Blais MD, FRCP
Médecin nucléiste / Nuclear Medicine Specialist
Centre de santé et de service sociaux de la Haute-Yamaska
GranbyFacebook de l’AMSMNQAMSMNQ Facebook
VENEZ CONSULTER
https://www.facebook.com/AMSMNQ/
Venez consultez la page Facebook de l’association des médecins spécialistes enmédecine nucléaire du Québec. Vous y trouverez de multiples informations concernant
principalement la médecine nucléaire québécoise.
Nous y partageons des événements à venir, des articles intéressants et toutes nouvelles
susceptibles d’intéresser la communauté de médecine nucléaire d’ici et d’ailleurs. Nous
sommes aussi très fier de présenter les réalisations exceptionnelles de certains de nos
membres.
N’hésitez pas à nous contacter si vous souhaitez nous partager une bonne nouvelle, une
information, ou un article d’intérêt.

Grégoire Blais
Responsable de la page Facebook de l’AMSMNQCOME TO CONSULT
https://www.facebook.com/AMSMNQ/
Visit the Facebook page of the Quebec Association of Nuclear Medicine Specialists. You
will find a wealth of information there concerning nuclear medicine in Quebec.
This is where we share upcoming events, interesting articles and useful information
with the nuclear medicine community at home and abroad. We are also very proud toshowcase the exceptional accomplishments of some of our members.
Please do not hesitate to contact us if you have any good news, information, or article
of interest.
Gregoire Blais
Manager of the AMSMNQ Facebook page26

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:40 Page 27

ASSOCIATION DES MÉDECINS SPÉCIALISTESEN MÉDECINE NUCLÉAIRE DU QUÉBEC
L'IMAGERIE PERSONNALISÉE PAR LA MÉDECINE NUCLÉAIRE« La mission du comité de développement professionnel continu (DPC) de l’Association
des médecins spécialistes en médecine nucléaire du Québec (AMSNMQ) est de soutenirles médecins nucléistes à acquérir et à préserver leur expertise médicale, ainsi qu’à
améliorer leurs compétences de collaboration et de communication dans le but
de prioriser la qualité des soins aux patients. »COMITÉ EXÉCUTIF

Dr. Norman Laurin
Président

Dr. Frédéric Arsenault
Secrétaire

Dr. Karine Provost
Conseillière

Dr. Anthony Ciarollo
TrésorierDr. Éric Turcotte
Conseillier

Dr. Francois Lamoureux Dr.Keu Khun Visith
Président sortant (invité) Conseillier

ORGANISATIONSACOMEN • American Society of Nuclear Cardiology • Association Canadienne de Médecine Nucléaire •Association Chinoise de Médecine Nucléaire • British Nuclear Medecine Society • Cancer de la Thyroïde Canada •Commission Canadienne de Sureté Nucléaire • Collège des Médecins du Québec • Collège Royal des Médecins et Chirurgiens du Canada •European Association of Nuclear Medecine • Fédération de Médecins Spécialistes du Québec • Fondation Canadienne de la Thyroïde •International Atomic Energy Agency • Pubmed • Société Française de Médecine Nucléaire et d’Imagerie Moléculaire • Society of Nuclear
Medecine • Société Canadienne du Cancer • Université McGill • Université de Montréal • Université de Sherbrooke •World Federation of Nuclear Medicine and Biology

PARTENAIRES
Hermes Medical Solutions • Lantheus • Siemens Santé Limitée • GE Molecular Healthcare • Curium • Jubilant-DraxImage • Isologic •Philips • Segami • Cyclomedica • Financières des Professionnels • Sogemec

NOUS JOINDRE
Téléphone : (514) 350-5133 ou 1-(800)-561-0703
Télécopieur : (514) 350 -5151
Courriel : amsmnq@fmsq.org
2, Complexe Desjardins, porte 3000
C.P. 216 , succursale Desjardins
Montréal (Québec) Canada H5B 1G8Madame Michèle Laviolette
Directrice administrative

medecinenucleaire.com
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INTERVIEW WITHTOM FRANCKE
Tom, you are the President and CEO of Hermes Medical
Solutions. Can you give us a short idea of the company?
Hermes Medical Solutions is one of the pioneering software
companies in nuclear medicine and molecular imaging, andhas supplied the medical community with image display,
analysis and reporting software for 45 years. We are proudof focusing on innovation, to be the leader of new
developments and bring the best applications to the market
based on the latest clinical research.
Having a long scientific background, I believe in the valueof science driven development and the value of a close
collaboration with the scientific community. Our skilled
personnel convert your experience into the applications of
the future.
The Hermes software supports all clinically used NM/MI
procedures. Hermes simplifies the workflow for theclinicians in diagnosis and therapy in nuclear medicine andmolecular imaging providing excellent viewers, analysis andreporting tools.
With an HMS Workstation you have one work environment
for all applications in a multivendor camera clinic, and canfreely chose to buy additional cameras from any supplier
without having to change workstation.
Our local and professional support staff is quickly responsive
and match the nuclear medicine expertise of our customers.
Hermes is unique in that all our clinical support staff aretrained technologist with long clinical experience. We haveinstallations in more than 40 countries and are present
globally.
Where is Hermes Medical Solutions going and what will be
the impact for the Hermes Medical Solutions users?
Hermes strives to always have the most accurate andadvanced solutions for all clinical applications used in the
nuclear medicine field. We ensure this by our wide andextensive collaboration with the scientific community, alarge inhouse clinical expertise and skilled developers froma broad background.
The user interfaces is modern, intuitive, fast, flexible andconfigurable for every personal taste. The images can bereconstructed by the most advanced reconstruction
algorithms on the market to give accurate and comparable
uptake values regardless of camera brand and when theimage was taken.
Artificial intelligence (AI) combined with experience andmedically based knowledge is an important tool ineverything we do. We are often driving the developmentof new clinical practices in nuclear medicine, especially inthe fields of neurology, dosimetry, theranostics andoncology.

28

Tom Francke, Assoc. Prof.
CEO of Hermes Medical Solutions

Don’t miss the many new and unique functionalities andapplications which will be released in the coming months.
Primarily in oncology and Theranostics.
Anyone considering using an HMS Workstations in the
future can be certain they will have the latest tools andworkflows at hand; today and in the future. Regardless ofwhich camera brands they chose to use.
How is Hermes Medical Solutions involved in theincontournable field of Theranostics? What will it mean toHermes Medical Solution’s partners?
Theranostics is growing rapidly and Hermes has for many
years been the leader in the dosimetry software field that isessential for safe and effective internal radiotherapy. Hermes’
dosimetry software is not only used in clinical practice, butalso by the research community developing new clinicalworkflows. Most important, the pharmaceutical companies
developing the new tracers to be used in Theranostics in the
future use the Hermes software in their development andclinical trials. The most widely used organ dosimetry software,
Olinda, is exclusively provided by Hermes.
Hermes positions itself as the flagship for safe personalized
nuclear radiotherapy.
Finally, what is your greatest wish for Hermes Medical
Solutions and its clients?
Our customers, and the whole medical community, is ourstrongest focus. We welcome all the feedback we can get todevelop and give back the best possible products thecommunity will need in the future. Let us continue anddeepen the fruitful and mutual cooperation we have today.
We look forward to meet our colleagues again in person assoon as the pandemic allows.

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E PATIENT-V5N1-777777_Layout 1 21-07-23 12:41 Page 32

ENTREVUE AVEC

Kristy OwenÀla suite de ses études à la faculté des sciencesde University of British Columbia (UBC) de
Vancouver au Canada, Madame Owen aobtenu son diplôme du programme de Technologie
de médecine nucléaire du British Columbia Instituteof Technology (BCIT) en 2006. Enseignante etcoordonnatrice clinique à BCIT (faculté des sciencesde la santé – médecine nucléaire) depuis plus de 10
ans, elle occupe également divers autres postes. En
2020, elle fut élue à titre de Directrice, membre duconseil d’administration de l’Association Canadienne
des Technologues en Radiation Médicale (ACTRM)
ainsi que membre ex officio du conseil consultatif dela même association pour la Colombie-Britannique.
En juillet 2021, Mme Owen ajoutera le poste de coresponsable du programme de médecine nucléaire de
BCIT à son CV.
En plus de sa présence sur de nombreux comités deleadership, publication de plusieurs articles
scientifiques et implication dans la communauté dela médecine nucléaire, Kristy fut la récipiendaire denombreux prix de reconnaissance tel que le Bowers
Medical Suppliers Scholarship (BCIT), le BCIT Health
Sciences Dr. Joseph Cohen Award for Outstanding
Academic Performance, le UBC Entrance Scholarshipfor Outstanding Academic Performance et le Ministryof Education Provincial Scholarship.
POURQUOI MON TRAVAIL EN MÉDECINE NUCLÉAIREEST COMME CETTE DESTINATION VACANCESFAVORITE QUE VOUS VOULEZ GARDER SECRÈTE ?
Avez-vous déjà déniché la plus magnifique desdestinations vacances ? Parfaitement calme, météo
optimale, privée, peu fréquentée, bon prix, disponible
au moment idéal ? Si convoitée que vous hésitez à lapartager avec vos amis de peur qu’ils ne vous la volent? C’est ce que je ressens lorsque je pense à ma carrière
en médecine nucléaire. Une carrière que je meconsidère choyée d’avoir trouvée. Avec seulement
quelques recherches, je fus intriguée : un mélange desoins aux patients, une technologie de pointe, lascience du rayonnement, la physique et le travail delaboratoire. Ce que je n’avais pas réalisé, c’est à quelpoint une journée dans la vie d’un technologue en
médecine nucléaire est excitante, à quel point j’allais
acquérir des connaissances en imagerie, à quel point
l’avenir serait fascinant pour la détection et letraitement des maladies, comment cela aurait unimpact direct sur la santé des patients, combien
d’emplois diversifiés il y aurait et à quel point lacommunauté de la médecine nucléaire est
dynamique. Une communauté dont je ferai toujours
partie. Je n’avais jamais envisagé que bien des années

32

Kristy Owen, RTNM

plus tard, je me sentirais toujours comblée et fière dema croissance personnelle et professionnelle.
Permettez-moi donc de partager mon secret avec
vous ...
Les technologues en médecine nucléaire commencent
habituellement leur journée dans le « laboratoirechaud (radioactif) » où ils manipulent des produits
radiopharmaceutiques (produits pharmaceutiques
radioactifs), les testent pour en vérifier la qualité etles préparent à être administrés aux patients.
L’immense variété d’études réalisées dans undépartement de médecine nucléaire peut êtreattribuée au fait que l’aspect fonctionnel de chaquesystème de corps humain peut être imagé pourdétecter une série de maladies telles que l’infection,l’inflammation, ou le cancer. Au fur et à mesure queles patients arrivent tout au long de la journée, un ou
une technologue administrera un traceur radioactif
spécifique par voie intraveineuse, sous-cutanée, oraleou par inhalation. Chaque traceur est choisi et crééchimiquement pour mettre en évidence une fonction
spécifique du corps des patients et est ensuite
visualisé à l’aide d’une caméra hybride. Les caméras
hybrides, comme la tomographie par émission
monophotonique/tomodensitométrie (TEMP/TDM enfrançais ou SPECT/CT en anglais) et la tomographiepar émission de positons (TEP/TDM en français ou
PET/CT en anglais), créent des images hautement
sensibles et spécifiques qui sont évaluées et
examinées de façon approfondie et dans un souci dequalité, par l’œil méticuleux d’un ou d’une
technologue. Les technologues sont les experts de ce
métier et peuvent souvent reconnaître deschangements subtils sur une image avant qu’unmédecin ne valide les informations. Cela signifie quele technologue a un impact direct et crucial sur lesrésultats d’examen et de l’état de santé de chaquepatient. Des habiletés marquées de soins au patientE PATIENT-V5N1-777777_Layout 1 21-07-23 12:41 Page 33

et un niveau élevé d’attention aux détails sontessentiels car les patients peuvent potentiellementêtre dans un état critique. Afin d’optimiser davantage
les résultats pour les patients, les technologues enmédecine nucléaire font partie intégrante de l’équipede soins de santé et travaillent dans unenvironnement interprofessionnel avec d’autres
modalités d’imagerie, des médecins, des infirmièreset bien d’autres professionnels de la santé.
La physique des sciences de la radiation est une partie
importante de l’ensemble des compétences destechnologues
enmédecinenucléaire.
Lesrayonnements ionisants, historiquement associés à lapeur et à l’hésitation, sont explorés en profondeur
dans leur formation. La connaissance et l’éducation
dans ce domaine sont primordiaux et lestechnologues maîtrisent les procédures de sécurité
requises pour se protéger et protéger leurs patients.
Au cours de leur formation exhaustive, les craintes
sont démystifiées et la vérité sur les avantages et lesrisques associés aux différents types de rayonnement
sont clarifiés. Des appareils de mesure personnelle durayonnement sont portés pour vérifier leur diligencelors de la manipulation des rayonnements ionisants.
La sécurité des patients, sous tous les aspects, est leurresponsabilité et ils en sont perpétuellement
responsables. Le rayonnement en médecine nucléaire
est essentiel et sauve des vies tous les jours !
La médecine nucléaire va de l’avant à un rythme
incroyable grâce à l’avancement de l’équipement
technologique et le développement de nouveauxradiotraceurs. Les caméras hybrides ont apporté lacapacité de parfaitement localiser les changements
fonctionnels au niveau cellulaire dans le corps, ladétection précoces des maladies, et ce avec précisionet acuité. La technologie TEP/TDM, axée
principalement sur l’oncologie, a eu un impact majeur
sur les résultats de millions de patients atteints decancer. Les nouveaux radiotraceurs TEP peuventévaluer le cancer du sein et de la prostate ainsi quede nouveaux traceurs neurologiques de TEP qui
peuvent diagnostiquer la maladie de Parkinson, la
maladie d’Alzheimer et l’ENC (encéphalopathie
traumatique chronique). La théranostique, véritablerévolution en médecine nucléaire, ouvre de nouvelles
voies pour des diagnostics et des traitements ciblés ducancer. La recherche dans ces domaines est
continuelle et abondante. Les caméras TEP/TDM et
TEMP/TDM surgissent partout au Canada générant un
besoin criant de technologues pour les utiliser.
Après avoir obtenu votre diplôme d’une école
accréditée et réussi un examen de certification, vousdevenez technologue certifié en médecine nucléaire.
Alors que plusieurs prennent leur retraite dans cemême rôle, la possibilité d’une variété de carrières
vous attend. Au sein de mon réseau, des collègues
technologues ont reçu une formation croisée poureffectuer
d’autresprocéduresd’imagerie
diagnostique comme la TDM, l’IRM et l’échographie.

Certains sont passés à l’industrie et travaillent pourdes fournisseurs d’équipements et de logiciels, dessociétés d’accréditation ou des organismes deréglementation. D’autres sont devenus gestionnaires,
responsables de la pratique, enseignants, doyens,opérateursdecyclotronsou
agentsderadioprotection. Certains ont quitté le Canada pourtravailler à l’échelle internationale. Fait intéressant,les technologues formés au Canada sont reconnus ettrès recherchés à l’échelle mondiale pour leur niveau
de formation élevé. Trouver une niche dans cetteindustrie qui vous captive est non seulement
gratifiant, mais aussi tout à fait accessible.
Qu’est-ce qui fait que tant de gens restent dans ledomaine de la médecine nucléaire ? Eh bien, dans
mon cœur, je crois que c’est la communauté que nous
avons créée. À l’échelle provinciale, nationale etinternationale, il y a un sentiment d’inclusivité et delien entre les diplômés en médecine nucléaire de tous
les niveaux. J’ai été directement témoin de la passion,de la sensibilisation, de la promotion et de la fierté
de notre discipline lors d’événements partout dans lemonde. En tant qu’enseignante au Programme demédecine nucléaire du British Columbia Institute ofTechnology – BCIT (l’Institut de technologie de la
Colombie-Britannique) et Directrice, membre duconseil d’administration de l’Association Canadienne
des Technologues en Radiation Médicale (ACTRM),
mobiliser les nouveaux membres de ce domaine enpleine croissance et de cette communauté florissante
est quelque chose dont je suis extrêmement fière.
Attirer les futurs diplômés dès le début en lesprésentant aux principaux partenaires et intervenants
leur offre de belles occasions d’établir des liens. Qu’ils’agisse de bénévolat, de participation à desconférences ou tout simplement partager l’excitation
autour des innovations de la médecine nucléaire, ces
nouveaux diplômés sont déjà investis dans notre
communauté. Dans cette industrie, les gens se sentent
connectés, et quand ils se sentent connectés àquelque chose de plus grand, cela leur donne unsentiment d’appartenance. Je crois que c’est ce
sentiment d’appartenance qui crée une tellesatisfaction au travail.
Que vous débutiez en tant que nouveau diplômé ou
que vous soyez dans le domaine depuis des décennies,
la médecine nucléaire offre des possibilités illimitéesd’apprendre et d’explorer. Trouvez ce créneau parfait.
Connectez-vous à d’autres personnes. Faites cettedifférence. Bien qu’aucune carrière ne puisse
remplacer la destination vacances de vos rêves, si belle
et parfaite, je peux vous assurer que cette discipline
est précieuse et essentielle. La science fascinante, latechnologie impressionnante, l’optimisation des soins
aux patients et les résultats des traitements, le travail
dans un milieu multidisciplinaire en constanteévolution ne sont que quelques-unes des raisons pourlesquelles j’ai pu apprécier à quel point cette carrière
m’a apporté une telle satisfaction personnelle
jusqu’ici.

33

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:41 Page 34

BOARD OF DIRECTORS / CONSEIL D’ADMINISTRATION

President,
Dr. François Lamoureux,président

Past President,
Dr. Andrew Ross,président sortantVice-President and Secretary-Treasurer Member-at-Large,
Dr. Salem Yuoness,
Dr. Jean-Luc Urbain,
vice-président et secrétaire-trésorier membre à titre personnel

Member-at-Large,
Member-at-Large,
Dr. Christopher O’Brien, mem- Dr. Mark Bryanton,bre à titre personnel
membre à titre personnel

Member-at-Large,
Dr. Philip Cohen,
membre à titre personnel

Member-at-Large,
Dr. Norman Laurin,
membre à titre personnel

Member-at-Large,
Dr. Glenn Ollenberger,
membre à titre personnel

Member-at-Large,
Dr. Jonathan Abele,
membre à titre personnel

Member-at-Large,
Dr. Antoine Leblond,membre à titre personnel

Member-at-Large,
Dr. Cheryl Lynn Jefford
membre à titre personnel

THE CANM
3 Its dedication to promote the transfer ofscientific bench discoveries into molecular &personalized medical diagnostics and therapies.

Member-at-Large,
Dr. Jonathan Boekhoud
membre à titre personnel

Member-at-Large, (Resident)
Dr. Peter Maliha
membre à titre personnel

3 Its ability to promote, develop andsupport the use of medical isotopes inthe emerging countries.

THE PANGEA PROJECT

3 Its proven commitment to educate andprovide high level training to nuclear
medicine professionnals from acrossthe world, particul-arly from emerging
countries in collaboration with theRoyal College of Canada.
3 The Pangea project.

• Promoting nuclear medicine• Education / Teaching around the world• Continuous training
nmpangea.com

Nicolas Rondeau Lapierre

INFO CONTACT
General manager / Directeur général
Canadian Association of Nuclear Medicine /Association canadienne de médecine nucléaire

canm@canm-acmn.ca
www.canm-acmn.ca
1.514.963.3269

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:42 Page 35

CANM-ACMN ANNUEL SCIENTIFIC MEETING
Virtual 6 November 2021

CANM VIRTUAL CONFERENCENOVEMBER 6, 10 AM - 6:30 PM ET

SAVE IMPORTANT DATESAnnual General Meeting (AGM)__________________________• Response to Therapy -IMMUNOTHERAPY• Nuclear medicine response• The future in Nuclear Medicine
One-day virtual conference
Registration to come!
Deadline to Register:November 1, 2021
Offered to CANM Members
and open to any others.
COLLOQUE VIRTUEL
SFMN

2-4 septembre 2021

Beffroi de Montrouge

EANM

20-23 october 2021

Virtual

CANM

6 november 2021

Virtual

CANM

7-10 april 2022

Montreal

AMSMNQ

22-24 april 2022

Sherbrooke

SNMMI

11-14 june 2022

Vancouver

WFNMB

7-10 september 2022

Kyoto

EANM

15-19 october 2022

Barcelona

Wednesday, September 22, 2021 @ 7pm ET
Registration to come!
Deadline to Register: September 17, 2021
Offered to CANM only.
The Canadian Association of Nuclear Medicine strives for excellencein the practice of diagnostic and therapeutic nuclear medicine bypromoting the continued professional competence of nuclear
medicine specialists, establishing guidelines of clinical practice, andencouraging biomedical research. We work with all professionals
in nuclear medicine to ensure that Canadians have access to thehighest quality nuclear medicine services.

In the meantime, please mark your calendar!

SISTER ORGANIZATIONSCANM 2020-2021 SPONSORS
Scotiabank-CMA
Affinity Groupcanm@canm-acmn.ca
www.canm-acmn.ca
1.514.963.3269

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INTERVIEW WITHSERGIO CALVO

Sergio,youarethepresidentoftheRadiopharmaceuticals Division of Jubilant Pharma. Can
you give us a brief summary of your involvement in
Nuclear Medicine and Jubilant?
First, I would like to thank e-Patient for theopportunity. I have a background in engineering. I haveworked in nuclear medicine since 1999, at Siemens, GE
Healthcare, and joined Jubilant one and a half years
ago. I was fortunate to be a part of the development
and market introduction of breakthrough technologies
like digital PET/CT, and the inception of Artificial
Intelligence (AI) applications for medical imaging. I was
attracted to Jubilant for the opportunity to work forthe pharmaceuticals side of nuclear medicine, which isa fascinating field. It is a privilege to have both perspectives, and one of my goals is to increase the synergy
between radiopharmaceuticals and medical devices.
Jubilant Pharma has evolved into a global pharmaceuticalcompany offering a wide range of products and services
fromspecialty
pharmaceuticals
tocontract
manufacturing, generics, complex generics and active
pharmaceutical ingredients. The Radiopharmaceuticals
Division has a similar heritage, being formed with theacquisition of Draximage in 2008, which was founded 66
years ago----essentially at the birth of Nuclear Medicine.
We are based in Montreal, present in 22 countries, andmarket leaders in North America in lung imaging andiodine therapies. We have unique products like theCardiac PET technology leading product RUBY-FILL Rb-82
Generator and a large pipeline of breakthroughinnovations. Being part of this larger organization gives
us access to Jubilant peer companies rich in R&D andinnovation which has significant application potential toboth diagnostic and therapeutic Nuclear Medicine.
Jubilant Radiopharma is well established in the global
nuclear medicine market. What are the biggest
challenges of the nuclear medicine industry in the next
five years?
Challenges bring opportunities, and I am very positive
about the opportunities we see, which will help propel

the specialty to greater success and patient benefit; but
there is work to do in some areas. Isotope supply is aconcern as demands for new and existing isotopes
increase with the adoption of novel imaging tracers andradiopharmaceutical therapies (RPTs). We need to growcapacity and need to transfer this capacity to industry.
As you know, developing and approving
radiopharmaceutical therapies require multiple clinical
trials of increasing size, complexity, cost and risk of
success. Although big pharma is investing in RPTs, ourindustry consists of small and mid-sized companies withlimited resources and expertise to conduct large clinical
trials. We need to make the clinical development process
more efficient. Logistics will get more complicated withradiotherapy isotopes for broad distribution on a global
scale. Radioactive waste will also be a concern with longlived isotopes, especially alpha emitters. We will have totrain nuclear medicine workers to manage more
complex isotopes and handling procedures to assurehigh level of safety to workers and staff. At the sametime, there is a greater recognition of the value of RPTs
by other medicine disciplines and they will be keen to
get the training and capability to use these advances.
This will require Nuclear Medicine Physicians tocollaborate and keep their training relevant and robust.
This will be good for the patients and the field as thebest minds will be involved and identify further advancesin therapy---especially about RPTs and non-radioactive
therapies and/or RPT facilitators. Reimbursement will bea specific concern as more expensive therapies enter themarket, and the healthcare systems will need educationon the benefits of RPTs and may not be prepared for thisincrease in expense. Finally, with so many treatment
options, we need to educate consumers so that thepotential patients know that nuclear medicine
treatment options are available, and how they compare
to other methods, and what combination therapies
might be better than either alone---as often seen instandard medical oncology.
As you mentioned in the previous question, theapproval process of new radiopharmaceuticals is longand expensive worldwide. Is there a way forcompanies and medical community to ease the process
to the benefit of our patients?
It is true that the process is still long and expensive
though it has been improving over the years. One
example is the excellent work of the ICH (International
Council for Harmonization), which has significantly
improved interagency collaborations.
There is room for even more harmonization ofrequirements. With universal requirements, we will beable to collaborate more efficiently worldwide, andmake the process cheaper by using the same clinicaldata across markets. This would accelerate the approval
process and timelines, and coupled with timely
education of healthcare community and patients about

37

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the product will ensure that new products are adopted
faster into the practice of medicine and position it for
expansion of indications and life cycle management.
On the industry side, we need to invest in and improveutilization of digital technologies to store and shareclinical data safely and efficiently, which has the added
benefit of providing a platform for development of AI
applications.
The key words are collaboration, simplification, trust
and transparency. Jubilant believes that a key way tobenefit patients is to have a well-designed productdevelopment roadmap with robust data, relevant
medical indications and meticulous investigators.
Nuclear Medicine Theranostics is growing and already
impacting patients. How will Jubilant contribute to thisemerging field of Nuclear Medicine?
Theranostics is the opportunity of our lifetimes and is at
the core of Nuclear Medicine’s unique value andtechnology. Because of the complex biochemistry ofhumans, there are nearly unlimited possibilities inoncology and other specialties. The targeted nature ofradiopharmaceutical therapies in particular, and Nuclear
Medicine in general, means that each application will
require a different and specific targeted molecule. Theretypically is no ‘one-size’ fits all, no silver-bullet, which has
been the approach of big pharma until recently. They,
too, now see the need and value to provide more specificmolecules for specific targets. The outcome is a lot ofwork for small, medium and large companies in thedevelopment of theranostics.
Jubilant is all in. We are leaders in Iodine-131, the firsttheranostic application developed 75 years ago that set
the template for the long-awaited targeted therapies.
We also have a clinical-stage MIBG program forneuroblastoma, which, when approved, with improve
lives of hundreds of sick children every year.
Our core competencies in R&D, Medical Affairs, ClinicalDevelopment, Regulatory, Quality, Marketing and Sales
are fit for innovation and being shaped to develop
theranostic applications. We are also investing instrategic alliances and commercial partnerships toexpand our portfolio, and working closely with drug
discovery experts of our parent company, Jubilant
Pharmova, with vast resources that include
computational algorithms to discover and develop
precision therapeutics.
We will not only play in theranostics, we want a leadingrole in this field.
How do you see the future of Nuclear Medicine in thenext five years?
The future is already happening. We are seeing thestrongest momentum in nuclear medicine ever withradiopharmaceutical therapies coming into mainstream.
More specifically, I have no doubt that we will see wide38

adoption of therapies targeting PSMA, with several
recent approvals, and fibroblast-activated protein which
is highly expressed in many cancer-associated fibroblasts.
The data available on FAP inhibitors for imaging andtherapy has been significant and consistent, and is socompelling that clinical success is self-evident.
I also expect nuclear medicine imaging to grow into
whole new applications. Rheumatoid arthritis, forexample, is biochemically complex and can be treatedwith different types of expensive biologics. There is anunmet need to predict and monitor treatment
response; a clear opportunity for nuclear medicine.
Finally, and as mentioned at the beginning of thisinterview is the promise and now, developing, realityof AI applications which will undoubtedly be part ofdiagnostic imaging. This may be a concern for nuclear
medicine as we are late to the AI applications. By
harvesting more information from data, AI makes
medical images more clinically insightful. We usually
think about how AI will impact the work of imaging
physicians. Another aspect is how AI will impact
imaging modalities and how they compete against
each other. Anatomical modalities powered by AI will
be more capable of, for example, measuring function.
Likewise, nuclear and molecular imaging powered by
AI will be incredibly more insightful for diseaseevaluation and treatment strategy. However, ourcommunity must hurry to collaborate and develop AI
applications. As of today, there is much more activity in
AI developments for anatomical modalities; and given
the inherent strengths of what Nuclear Medicine canuniquely provide we have strong AI potential.
Finally, what is your greatest wish for Jubilant, nuclear
medicine and the patients you serve?
I have many wishes. One of them is that nuclear
medicine will impact even more broadly than today thefield of cardiology. Myocardial perfusion PET has provenitself to be the most powerful non-invasive test to assess
coronary artery disease. Referring physicians embrace
the Cardiac PET modality whenever available as it helps
them make better treatment decisions. I strongly believe
Cardiac PET can and should grow 10-fold or more in theUS, and 100-fold in the rest of the world.
In a broader perspective, my wish is that nuclear
medicine realizes its full potential to diagnose and treat
disease, becoming one of the pillars of personalized
medicine.
And for my company, I wish Jubilant Radiopharma to
be an innovation leader, constantly renewing themission statement set forth in 1955: to improve
patients’ lives through nuclear medicine. Benefiting thepatient is what we stand for along with the healthcare
providers who use our products.

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François-Alexandre Buteau, MD, FRCPC
Spécialiste en médecine nucléaire, CHU de Québec
Université Laval
Frédéric Arsenault, MD, MSc, FRCPC
Spécialiste en médecine nucléaire, CHU de Québec
Université Laval

LA THÉRANOSTIQUE
AU SERVICE DES TUMEURSNEUROENDOCRINES
des troubles respiratoires ainsi que la perte depoids. Ces signes et symptômes peuvent êtrefacilement confondus pour ceux de la ménopause,d’un côlon irritable, de la maladie cœliaque, del’asthme, etc.

LA CLASSIFICATION DES TUMEURSNEUROENDOCRINESLes TNE sont tout d’abord classifiées d’après quelorgane elles proviennent, puis selon si elles
sécrètent ou non des substances bioactives(hormones, protéines). Ces substances peuvent
causer des symptômes et diminuer la qualité de vie
des patients. Certaines substances sécrétées par les
TNE peuvent même potentiellement menacer lavie.
Les TNE sont classées selon 3 grades (G1 à G3), basés
sur leur taux de prolifération tumoral. En règle
générale, les tumeurs G1 sont les mieux
différenciées et les plus quiescentes, tandis que lestumeurs G3 sont plus dédifférenciées et plus
agressives. Les TNE bien différenciées ont uneévolution qui sera généralement lente : il n’est pas
rare de voir des patients atteints de TNE mener unevie active pendant 10, 15, et parfois même plus de
20 ans. Différents traitements ou combinaisons detraitements seront administrés au cours de cettepériode. Ces traitements visent essentiellement
deux objectifs : ralentir la progression de la maladie
et redonner une qualité de vie aux patients.

LES TUMEURS NEUROENDOCRINESLes tumeurs neuroendocrines (TNE) représentent
un groupe de cancers trouvant une origine
commune lors du développement de l’embryon
durant de la grossesse chez l’être humain. Ces
tumeurs peuvent se développer à partir deplusieurs organes, dont les intestins, le pancréas etles poumons. Initialement, les patients atteints
d’une TNE sont asymptomatiques. Puis, au fil dutemps, ils développeront des symptômes souvent
non spécifiques, compliquant le diagnostic. Ces
symptômes incluent notamment de la diarrhée, dela douleur abdominale, des bouffées de chaleur,À leur surface, la plupart des cellules tumorales desTNE surexpriment des récepteurs à la somatostatine
à des degrés divers. La somatostatine est une
hormone agissant sur la motilité de l’estomac et del’intestin, ainsi que sur les fonctions hépatiques etpancréatiques. Il existe 5 sous-types de récepteurs
à la somatostatine (SSTr1 - SSTr5), le plus
fréquemment rencontré dans les tumeurs étant le
SSTr2. Certains traitements, notamment lesanalogues de la somatostatine (octréotide,lanreotide) peuvent s’y fixer et ainsi limiter laprolifération cellulaire (donc, ralentir laprogression) et inhiber la sécrétion des substances
bioactives (améliorer la qualité de vie).

39

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LA THÉRANOSTIQUE
Le mot théranostique est une contraction destermes thérapeutique et diagnostique. La
théranostique consiste à élaborer un traitement
ciblé pour une maladie à partir de tests ou
d’examens spécifiques en médecine chez unpatient. Ces tests permettent de prédire uneréponse favorable significative de la maladie à untraitement ciblé avant même d’avoir tenté letraitement.
La théranostique n’est pas spécifique à la médecine
nucléaire : par exemple, en oncologie on va
rechercher une mutation génétique (exemple :BRAF) afin d’offrir un traitement ciblant cettemutation (exemple : anti-BRAF, comme ledabrafenib), et ce peu importe qu’il s’agisse d’uncancer de la thyroïde, d’un cancer colorectal ou
d’un mélanome. En médecine nucléaire, il nous serapossible d’imager précisément les cellules
tumorales surexprimant les SSTr, qui guidera
ensuite un traitement ciblé visant à déposer de laradiation localement à ces cellules, via les SSTr.

L’IMAGERIE DES TUMEURSNEUROENDOCRINES
En médecine nucléaire, il est possible d’administrer
un radiotraceur permettant d’imager les organes et
les tumeurs surexprimant les récepteurs à lasomatostatine. Ceci se fait à l’aide de peptides(analogues de la somatostatine, tels octréotate,octréotide) liés à un radioisotope propice à fairedes images (le gallium-68 a remplacé presqueentièrement l’utilisation de l’Indium-111).

40

Ces examens d’imagerie médicale permettent derépondre à quatre objectifs : le diagnostic d’une
tumeur neuroendocrine, la recherche demétastases à distance, déterminer le degré desurexpression des SSTr à la surface des tumeurs, etle suivi du traitement. Dans l’histoire naturelle dela maladie, les cellules tumorales vont finir par sedédifférencier, et perdre peu à peu leur capacité à
exprimer les SSTr à leur surface. Ces tumeursconsommeront alors une importante quantité deglucose et nécessiteront donc une imagerie au
Fluoro-deoxy-glucose (FDG). Comme la maladien’est pas parfaitement homogène chez un mêmepatient, il est fréquent de devoir réaliser les deuxétudes TEP (imagerie fonctionnelle des récepteurs
à la somatostatine et imagerie métabolique au
FDG), selon le jugement du médecin traitant lepatient.

LE TRAITEMENT DES TUMEURSNEUROENDOCRINES
Lorsque la maladie est diagnostiquée à temps, leseul traitement pouvant guérir la maladie est une
opération au cours de laquelle le cancer sera
complètement réséqué. Malheureusement, lamaladie est souvent trop avancée localement ouelle est métastatique au moment du diagnostic. Il
faut donc contrôler la progression de la maladie etses symptômes. Les traitements de chimiothérapie
et la radiothérapie n’auront qu’un effet limité surle contrôle de la croissance de la maladie et la survie
des patients, sauf en cas de maladie agressive (G3).
L’opération et les autres thérapies locales(embolisation, radiofréquence, hépatectomie
partielle, etc.) offrent un excellent contrôle local delamaladieetdesmétastases
cibléesE PATIENT-V5N1-777777_Layout 1 21-07-23 12:42 Page 41(cytoréduction). Pour certains sous-types detumeurs, de plus récentes biothérapies incluant les
inhibiteurs du mTOR (everolimus) et les inhibiteursde la tyrosine kinase (sunitinib) peuvent s’avérer
efficace surtout pour le contrôle des symptômes, etd’une efficacité limitée quant au contrôle de laprogression de la maladie et de la survie despatients.

LE TRAITEMENT À L’AIDE D’ISOTOPESRADIOACTIFS
En médecine nucléaire, il est possible de traiterquelques cancers en allant déposer de la radiation
locale précisément aux cellules néoplasiques. Cette
radiation est produite par certains radioisotopesémettant des particules chargées. Le Lutétium-177
qui émet des particules chargées de type bêta est
maintenant couramment utilisé dans le mondepour le traitement de certains cancers, comme les
TNE et les cancers de la prostate. Son utilisation aété démontrée efficace et sécuritaire.
D’autres atomes radioactifs sont actuellementétudiés pour une utilisation clinique. On revient au
principe de théranostique : il est possible desubstituer un atome émettant des particules
chargées au radiotraceur qui nous a permisd’imager les tumeurs surexprimant les SSTr, et on
sait ainsi que toutes les tumeurs qui ont été vues àl’imagerie fonctionnelle recevront une dose
significative de radiation déposée localement.
Donc, selon l’atome radioactif utilisé, le mêmeagent est utilisé pour faire des images médicales,ou pour traiter ensuite la maladie.
Pour les tumeurs neuroendocrines, il est possible desubstituer un atome de Lutétium-177 à l’atome de
Gallium-68 utilisé pour faire des images sur les
peptides se liant aux SSTr. Ce traitement est mieux
connu sous l’acronyme PRRT, pour « Peptide
Receptor Radionuclide Therapy ». L’octreotate agit
comme le messager qui permettra de livrer
localement de la radiation principalement aux
cellules cancéreuses surexprimant les récepteurs à
la somatostatine, identifiées lors de l’acquisition
des images diagnostiques.
L’effet de la radiation locale ciblée sera triple :direct, par des bris d’ADN, indirect par lamodification du milieu environnant des cellules
hostile pour le cancer (création de radicaux libres)et par l’effet abscopal, caractérisé par une
activation du système immunitaire du patient
contre les cellules cancéreuses.

s’assurera que le traitement sera sécuritaire etadéquat pour le patient. Notamment, il est
important de s’assurer que toutes les lésions
connues surexpriment suffisamment les récepteurs
à la somatostatine. Comme la substance radioactive
se distribue dans le corps et se concentre dans une
moindre mesure dans quelques organes dits
critiques (par exemple les reins et la moelle
osseuse), une évaluation de la fonction de cesorganes sera réalisée et répétée périodiquement
durant les cycles de traitement afin de s’assurerd’une bonne tolérance.

L’ADMINISTRATION DE LA PRRT
Il existe plusieurs protocoles d’administration de la
PRRT, certains centres administreront une plus
grande activité à chaque cycle du traitement, alorsque d’autres administreront une dose moindre,mais davantage de cycles tant que les patients lestolèrent. Le protocole le plus répandu consiste enune phase d’induction de 4 cycles où une activité
fixe de substance radioactive (7,4 GBq ± 10 %) est
administrée aux 8 ± 1 semaines.
Chaque injection est précédée d’administrationd’acides aminés, réduisant la dose de radiation aux
reins, ainsi que d’antinauséeux. De cette façon, letraitement est alors très bien toléré. Suite au
traitement, il est possible d’obtenir des images par
scintigraphie à partir des photons émis du lutétium177. On peut ainsi confirmer que le traitement sefixe là où initialement prévu lors de l’étude
diagnostique, et il est possible d’effectuer descalculs de dosimétrie pour les tumeurs et lesorganes critiques. On s’assure ainsi que la quantitéde radiation reçue par ces organes demeure dansles limites jugées sécuritaires, et que la radiation
reçue par les tumeurs soit significativement
supérieure à celle aux organes sains.
Une réponse à la PRRT est jugée favorable lorsqu’ily a 1) diminution des symptômes liés à la sécrétion
hormonale; 2) arrêt de la progression de la maladie,voir diminution de la charge tumorale. Une réponsecomplète est exceptionnelle dans 1-2% des cas.
Dans de rares cas, il peut y avoir un échec au
traitement, c’est-à-dire que le patient ne répond
pas à la PRRT, et la maladie continue sa progression.
D’autres options thérapeutiques seront alors à
considérer.

LES ÉTAPES PRÉALABLES
À L’ADMINISTRATION DE LA PRRTCe traitement s’adresse aux patients symptomatiques et/ou avec une maladie progressive. Un
médecin spécialiste en médecine nucléaire

41

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:42 Page 42

Wei He,M.D., PH. D.,
Director of nuclear medicine departement and PET/CT
Center Fu Dan University, affiliated with Shanghai
Hua Dong Hospital
China

不同TSH抑制治疗对分化型甲状腺癌术后
TSH、FT3、FT4的影响
【摘要】目的：探讨不同促甲状腺激素（TSH）抑制对分治疗化型甲状腺癌术后 TSH、游离三碘甲状腺原氨酸（FT3）、血清游离甲状腺素（FT4）的影响。方法：选取 2018 年 8月 -2019 年 2 月本院收治的分化型甲状腺癌患者 80 例为观察对象，按随机数字表法将其分为对照组（n=40）与试验组（n=40），两组均给予甲状腺癌根治术治疗。术后，对照组给予常规剂量左旋甲状腺素治疗，试验组给予抑制剂量左
旋甲状腺素治疗。比较两组治疗前后甲状腺功能、骨生化指标、心血管与骨骼系统不良事件发生及复发情况。结果：治疗后，试验组 TSH 低于对照组，FT3、FT4 均高于对照组（P<0.05）。治疗后，两组血钙、血磷及碱性磷酸酶（alkaline phosphatase，ALP）比较，差异无统计学意义（P>0.05）。对照组心血管与骨骼系统不良事件发生率为 17.50%，复
发率为 7.50%；试验组不良事件发生率为 12.50%，复发率为
5.00%，试验组心血管与骨骼系统不良事件与复发率稍低于对照组，但两组比较差异均无统计学意义（P>0.05）。结论：对分化型甲状腺癌术后患者实施抑制剂量左旋甲状腺素治疗
，可改善甲状腺功能，且不良事件发生风险较低，临床应用价值显著。
【关键词】 促甲状腺激素 抑制治疗 分化型甲状腺癌 游离三碘甲状腺原氨酸 血清游离甲状腺素

甲状腺癌根据组织学分类可分为分化型、非分化型，其中分化型甲状腺癌（differentiated thyroid carcminoma，DTC） 在 甲 状 腺 癌 中 占 比 可 达 95%，是一种常见的内分泌恶性肿瘤，具有恶性程度较低，手术效果较好的特征 [1]。术后多采用促甲状腺激素（Thyroid stimulating hormone，TSH） 抑制或替代治疗、
放射性 131I 治疗等辅助方式，以提高手术治疗效果，改善预后。尤其是 TSH 抑制治疗不仅能抑制垂体分泌 TSH，还能
维持甲状腺功能，以发挥其维持与抑制的双重作用 [2]。但有临床研究认为，甲状腺激素会促使骨量丢失与骨代谢，继而引发骨折或骨质疏松等不良事件 [3]。因此，在本次研究观察中，选取本院 2018 年 8 月 -2019 年 2 月收治的60 例
DTC 患者手术治疗后实施 TSH 抑制治疗，并对 TSH、FT3、FT4 水平及用药安全性展开讨论与分析，现报道如下。
1 资料与方法
1.1 一般资料 选取 2018 年 8 月 -2019
年 2 月本院收治的 DTC 患者 80 例为观察对象。纳入标准：均符合《甲状腺结节和分化型甲状腺癌诊治指南》[4]诊
断标准，且经甲状腺超声或甲状腺发射单光子计算机断层扫描（ECT）检查诊断为甲状腺实性、冷结节，术后病理诊断为 DTC；既往无甲状腺功能亢进或减低
病史；术后行放射性 131I 清除残余甲状腺组织。排除标准：既往行颈部放射治疗；术前口服甲状腺素制剂或口服碘制剂；合并下丘脑垂体轴方面疾病；合并术后并发症如感染、乳糜漏等；术前合并骨质疏松或影响骨代谢疾病者。按随机
数字表法将患者分为对照组与试验组，每组 40 例。所有患者及家属均知情同意并签署知情同意书，本研究已经医院伦理委员会批准。
1.2 方法 两组均行甲状腺癌根治术治疗
，所有患者均于全身麻醉下实施甲状腺42

癌根治术，对于术中快速病理提示淋巴结转移患者，给予颈
部淋巴结功能性清扫术。经颈部 CT 检查以及颈部彩色多普勒超声检查均未见残余甲状腺组织者视为清甲治疗成功。对
照组给予常规剂量左旋甲状腺素治疗。每天口服 2.0 μg/kg
左旋甲状腺素钠（生产企业：常州康普药业有限公司，批准
文号：国药准字 H20030502，规格：50 μg）。试验组给予抑制剂量左旋甲状腺素治疗。每天口服 2.5 μg/kg 左旋甲状腺素钠。治疗中密切监测患者甲状腺功能，其中对照组需要维持 TSH 水平在 2~10 mU/L、游离三碘甲 状 腺 原 氨 酸（free triiodothyronine-3，FT3）水平在 2.8~7.1 pmool/L、血清游离甲状腺素（serum free thyroxine，FT4） 水 平
在 10.3~31.0 pmol/L； 试 验 组FT3、FT4 维持水平同对照组，TSH 指标水平则低于0.3 mIU/L。两组术后均持续治疗 6
个月。
1.3 观察指标与判定标准 （1）比较两组治疗前后的甲状腺功能。于治疗前后清晨空腹状态下采集两组静脉血 5 mL，行
抗凝与离心处理，应用血清自动免疫分析仪（瑞士罗氏公司
Roche Cobas e411）检测患者 TSH、FT3、FT4 水平。（2）比较两组治疗前后骨生化指标。采用上海索莱宝生物科技有限公司生化试剂盒对血清钙、磷、碱性磷酸酶（alkaline
phosphatase，ALP）水平采用比色法检测。比较两组患者治
疗后心血管及骨骼系统不良事件发生与术后 1 年复发情况，包括心悸、心绞痛、心动过速、钙丢失、骨质疏松等。
1.4 统计学处理 采用 SPSS 21.0 软件对所得数据进行统计分析，计量资料用（x-±s）表示，比较采用 t 检验；计数资料以率（%）表示，比较采用 字2 检验。以 P<0.05 为差异有统计学意义。
2 结果
2.1 两组一般资料比较 对照组男 17 例，女 23 例；年龄46~73 岁，平均（59.50±13.50） 岁；平均术后 131I 用量（109.85±12.55）mCi。试验组男 15 例，女 25 例；年龄45~74 岁，平均（59.35±14.35）岁，平均术后 131I 用量（110.45±12.85）mCi。两组一般资料比较，差异均无统计
学意义（P>0.05），具有可比性。
2.2 两组治疗前后甲状腺功能比较 治疗前，两组各项甲状腺
功能指标比较，差异均无统计学意义（P>0.05）。治疗后，试验组 TSH 低于对照组，FT3 与 FT4 均 高 于 对 照 组，差 异 均 有 统 计 学 意 义（P<0.05）。见表 1。

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:42 Page 43

2.3 两组治疗前后骨生化指标比较 治疗前，两组 各 项 骨
生 化 指 标 比 较， 差 异 均 无 统 计 学 意 义（P>0.05）。治疗后，两组血钙、血磷及 ALP 指标比较，差异均无统计学意义（P>0.05）。见表 2。
2.4 两组心血管与骨骼系统不良事件发生与复发情况比较 试
验组心血管与骨骼系统不良事件发生率与复发率均稍低于对照组，两组比较差异均无统计学意义（P>0.05），见表 3。
3 讨论
DTC 作为甲状腺癌最为常见的类型，近年来，其发生率在
全球均呈现出增高趋势，但死亡率无明显变化 [5]。DTC 是起源于甲状腺滤泡上皮的恶性肿瘤，临床表现单一，为无痛
性甲状腺结节、颈部肿块，其质地坚硬 [6]。但随着病情发
展，肿瘤逐渐增大会对邻近器官、组织造成压迫和侵犯，继
而并发面容潮红、心动过速、吞咽困难、呼吸困难等症状[7]。目前临床中对甲状腺癌确切病因仍未完全明确，但认为
癌基因、电离辐射、性别、碘摄入及遗传等影响因素均与 DTC 发生、发展有着直接关系 [8]。甲状腺癌根治术作为治疗 DTC 的主要方式，TSH 抑制治疗则是术
后治疗首选方法，通过联合治疗可提高患者生存质量。因DTC 患者癌细胞表面存在可被 DTC 刺激受体，术后容易增生或复发，经抑制TSH，则能够控制术后肿瘤复发 [9]。TSH 是
一种由腺垂体分泌的激素，经由与 TSH 受体相互结合，经
cAMP 信号通路对 Tg、TPO、NIs 水平表达进行调节，从而对细胞增生分化调控，利用甲状腺反馈性抑制 TSH 水平，达到
抑制残留甲状腺癌组织生长的积极效果 [10]。
虽然 TSH 抑制治疗效果得到公认，但长时间TSH 抑制治疗会影响患者机体内环境变化，将成骨细胞与破骨细胞之间的
动态平衡打破，从而干扰骨代谢过程，致使患者术后并发骨质疏松症状 [11-12]。且邱海江等 [13] 研究认为，TSH 水
平与治疗时间存在交互作用，尤其是中、高危女性患者，TSH
治疗会引发骨质疏松，且绝经后女性影响更明显，分析原因得知，其一在于绝经后女性运动能力降低，自身骨骼重建速率下降；其二为绝经后性激素变化，雌激素分泌减少导致垂
体分泌的 FSH 呈代偿性增加，将原有骨代谢平衡打破，因此临床中对于 TSH 剂量选择一直存在争议 [14]。马超 [15]研究报道中显示，DTC 患者行甲状腺癌根治术后给予常规剂
量 TSH 对于甲状腺激素无明显抑制作用，可能诱发甲状腺特异性蛋白表达水平增高，促使残留甲状腺肿瘤组织增生。而
给予抑制剂量用药干预后则提示 TSH 水平降低，FT3、FT4
水平增高，表明 TSH 抑制治疗有助于帮助患者术后甲状腺功能维持在亚临床甲亢状态，降低癌灶增殖风险 [16]。
在本次研究中，通过对试验组实施 TSH 抑制治疗后甲状腺
功能得到明显改善，骨代谢情况则与治疗前差异不明显，表明抑制剂量的甲状腺激素对于患者骨生化在短期内无明显影
响，但 ALP 指标水平稍有上调，提示患者破骨与成骨细胞活
性提高，这可能与 TSH 信号传导改变相关，对于骨重建有一
定影响；同代瑞等 [17] 研究结果基本一致。本研究试验组
术后心血管及骨骼系统不良事件发生率及术后 1 年复发率较对照组降低，但两组差异不明显，这是因长期使用超生理剂
量甲状腺激素，可导致心脏负荷加重与心肌缺血，严重情况
下可致使心律失常；而 TSH 抑制治疗则能减轻对心脏与骨代
谢影响，再次证实，TSH 抑制治疗对于避免肿瘤复发，降低
病死率有着积极作用 [18-19]。但需注意，骨密度与骨代谢变化是一个缓慢过程，在短期内虽未发现其对于骨骼系统影
响，但还需延长观察时间，并在行
TSH 抑制治疗同时展开抗骨质疏松初级预防，确保钙离子摄入，加强对 DTC 患者术后辅助治疗过程中风险评估 [20]。
综上所述，对分化型甲状腺癌术后患者实施抑制剂量左旋
甲状腺素治疗，可改善甲状腺功能，且不良事件发生风险较低，临床应用价值显著。
参考文献[1] 霍艳雷，王丹阳，吴书其，等 .TSH 抑制治疗对绝经后
分化型甲状腺癌患者骨密度的影响 [J]. 中华核医学与分子影像杂志，2017，37（4）：212-215.
[2] 杨柳，靳水，吴彬彬，等 . 促甲状腺素抑制治疗对分化型甲状腺癌患者术后左室收缩同步性的影响 [J]. 中国实用医刊，2018，45（21）：16-18，22.
[3] 焦奋哲 .131I 联合重组人促甲状腺激素在分化型甲状腺癌中的应用 [J]. 中国实用医刊，2018，45（14）：59-61，
65.
[4] 中华医学会内分泌学分会，中华医学会外科学分会内分泌学组，中国抗癌协会头颈肿瘤专业委员会，等 . 甲状腺结
节和分化型甲状腺癌诊治指南 [J]. 中华内分泌代谢杂志，2012，28（10）：779-797.
[5] Hoermann R，Midgley J E M，Dietrich J W，et al.Dualcontrol of pituitary thyroid stimulating hormone secretion by thyroxine and triiodothyronine in athyreotic
patients[J].Ther Adv Endocrinol Metab，2017，8（6）：83-95.
[6] 邢颖，刘晓莉，孙辉，等 . 分化型甲状腺癌术后不同TSH 抑制水平对育龄女性患者血清抗米勒管激素的影响 [J].
重庆医科大学学报，2018，43（12）：1545-1550.
[7] 钱炜伟 . 促甲状腺激素抑制疗法在甲状腺癌治疗中的作
用及对患者不良反应发生情况的影响 [J]. 世界最新医学信息文摘，2019，19（34）：65-67.
[8] Thaís Gomes De Melo，Aglecio Luiz Souza，Elizabeth
Ficher，et al.Reduced insulin sensitivity in differentiated thyroid cancer patients with suppressed
TSH[J].Endocrine Research，2017，43（2）：73-79.
[9] 唐霞琳，张健，陶世冰 . 分化型甲状腺癌术后相关激素
水平及 TSH 抑制治疗合适介入时间的研究 [J]. 实用癌症杂
志，2018，33（11）：1873-1875，1884.
[10] 张志健，莫艳平，陈超，等 . 甲状腺癌根治术后不同剂量优甲乐抑制治疗对糖脂代谢、骨代谢的影响 [J]. 岭南现代临床外科，2019，19（2）：169-173.
[11] 杨林，赵建国 . 分化型甲状腺癌术后促甲状腺激素抑制 治 疗 分 析 [J]. 黑 龙 江 医 学 ， 2017， 41（ 12） ： 12041205.
[12] S Zhang，B Q Wang，H Huangfu.The clinical characteristics and treatment strategies of differentiatedthyroid carcinoma in adolescents and children[J].Revista Colombiana De Cirugía，2017，31（7）：515-519.
[13] 邱海江，方孙阳，罗钧刚，等 . 分化型甲状腺癌术后
TSH抑制治疗对骨密度的影响 [J]. 浙江医学，2018，40（12）：1320-1323，1327.
[14] 王燕，潘在用，林志刚 . 促甲状腺激素抑制疗法对老年甲状腺癌患者免疫功能及血清 CD44V6、FT3、FT4 水平的影响 [J].中国老年学杂志，2018，38（5）：1110-1113.
[15] 马超 . 分化型甲状腺癌术后 TSH 抑制治疗对腰椎、髋关节及膝关节骨密度的影响 [J]. 医学临床研究，2017，34（9）：1771-1773.
[16] 魏巧兰，李和玲，张斌 . 促甲状腺激素抑制疗法对甲状腺癌术后患者预后及癌周组织 TIPE2、STAT3 表达的影响[J]. 实用癌症杂志，2017，32（8）：1260-1263，1266.
[17] 代瑞，杨枋 . 不同剂量促甲状腺激素对分化型甲状腺癌病人术后相关指标的影响 [J]. 蚌埠医学院学报，2018，
43（4）：510-512.
[18] 何强 . 促甲状腺激素抑制治疗对分化型甲状腺癌术后
的疗效及安全性分析 [J]. 实用癌症杂志，2017，32（3）：511-513.
[19] 田克强，罗克勍，谢鋆晖，等 . 促甲状腺激素抑制疗
法在老年甲状腺癌患者中的应用效果 [J]. 中国医学创新，2018，15（36）：41-44.
[20] 黄飞，邱昌洪 . 甲状腺癌患者行甲状腺癌根治术后应
用口服钙剂和维生素 D 预防低钙血症的效果观察 [J]. 中国
医学创新，2018，15（3）：39-42.

43

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:42 Page 44

Grégoire Blais MD, FRCP
Médecin nucléiste / Nuclear Medicine Specialist
Centre de santé et de service sociaux de la Haute-Yamaska
GranbyLA TÉLÉMÉDECINEÀ L’HEURE DE
LA PANDÉMIE À
LA COVID-19

D

epuis mars 2019 sévit l’importante pandémieà la « COVID-19 ». Depuis cette période il y a
eu un confinement important et c’est imposé
la distanciation sociale et le port du masque. Ces
mesures ont impacté sur le travail de tous et chacun
car on nous demandait de sortir que pour des raisons
essentielles. Heureusement les mesures ce sontadoucit au fil des mois. Toutefois selon l’évolution
récente de la pandémie les mesures sanitaires pourraient se resserrer.
Cette crise sanitaire a favorisé grandement letélétravail. Bien que déjà utilisé par beaucoup deprofessionnels et entreprises son usage alittéralement explosé et ce à la grandeur de laplanète. Et la médecine n’y a pas fait exception.
Beaucoup de médecins ont découvert une nouvelle
façon de travailler avec ses avantages etinconvénients. Bien que rien ne remplace une
consultation en présentiel, beaucoup de celles-ci se
faisaient par téléphone ou virtuellement. Évidement
les patients nécessitant un examen en personne avec
un médecin était possible mais l’affluence aux
hôpitaux et cliniques a diminuée de façon
impressionnante comme on le souhaitait.
En plus des téléconsultations de nombreusesréunions, webinaires, formations ou colloque ce sontfait presqu’exclusivement en mode virtuel.
En imagerie médicale certaines procédures exigent
la présence d’un médecin sur place. Par contre unetrès bonne partie du travail peut se faire à distanceavec le matériel approprié. Tant en radiologie qu’enmédecine nucléaire le télétravail ou télémédecine
est bien implanté depuis plus d’une dizaine d’annéeset ce pour les gardes de soir, de nuit ou de fin desemaine.
Certains médecins ont des stations de télémédecine
aussi efficaces à leur domicile qu’à l’hôpital ou à leurclinique. Avec l’avancement importante de latechnologie, ces stations de télétravail sontdisponibles à des prix non prohibitifs. La plupart dutemps ces consoles ont les mêmes fonctionnalités

44

TELEMEDICINE IN THE
AGE OF THE COVID-19
PANDEMIC

S

ince March 2020 the significant "COVID-19"
pandemic has raged. From this period, there
was significant confinement, social distancing
and the wearing of masks were imposed. These
measures have impacted on everyone's work because we were only asked to go out for essential reasons. Fortunately, the measures have softened overthe months. However, depending on recent developments of the pandemic, health measures could
tighten.

This health crisis has greatly favored teleworking.
Although already used by many professionals andcompanies, its use has literally exploded all over theplanet. Medicine was no exception; many doctors
discovered a new way of working with advantages
and disadvantages. Although nothing replaces aface-to-face consultation, many of these were doneby phone or virtually. Obviously, patients requiringin-person examination with a doctor was possible,
but the flow to hospitals and clinics declined
dramatically as expected.
In addition to the teleconsultations, many meetings,
webinars, trainings and seminars were held almost
exclusively in virtual mode.

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:42 Page 45

qu’en milieu clinique, c’est-à-dire logiciel de dicté,
PACS, etc,.
Ces stations de travail peuvent prendre la formed’une tour avec de multiples écrans ou encore êtreun portable ou tablette. Cette dernière option
permet donc de faire du télétravail n’importe où.
Lorsque la pandémie est arrivée il a été rapide etsimple de mettre les nucléistes et radiologiste en
télétravail. Il a fallu tout de même augmentersignificativement le nombre de station detélétravail. La principale difficulté fut d’obtenir lesautorisations informatiques et c’était bien
compréhensible vue les demandes tous azimuts detélétravail.
Lors de la pandémie, grâce à ces systèmes detélétravail bien établie, les médecins de l’imagerie
ont pu rapidement s’adapter aux mesures deconfinements. Cela fut utile aussi pour lesmédecins mis en quarantaine mais apte àtravailler.
Les systèmes de télémédecine permettent en plus
du télétravail à domicile, de brancher les systèmesd’imageries dédiés d’hôpitaux distants entre eux.
Pour se faire les protocoles d’échange de données
doivent être compatibles. L’utilité de ces échanges
de données est multiple. Par exemple si un milieu
temporairement sans médecin pour faireinterprétation ses examens à distance par un
autre médecin. On évite de cette façon dedéplacer un patient et d’avoir des ruptures deservices. Cela permet aussi à deux médecins se

In medical imaging, some procedures require thepresence of a physician on site. However, a very
good part of thework can be done remotely with the appropriate
equipment. In both radiology and nuclear
medicine, teleworking or telemedicine has been
well established for several years. Whether for
evening, night or weekends shifts.
Some doctors have telemedicine workstations thatare just as effective in their homes as they are in
hospitals or clinics. With the significant
advancement in technology, these telecommuting
workstations are available at reasonable prices.
Most of the time, these consoles have the samefunctionality as in a clinical setting, i.e. dictation
software, PACS, etc.
These workstations can be a tower with multiple
screens or even be a laptop or tablet. This last
option therefore makes it possible to telework
anywhere.
When the pandemic started, it was quick and easy
to telecommute the nuclear medicine physicians
and radiologists. However, the number ofteleworking workstations had to be significantly
increased. The main difficulty was getting thecomputerpermissions
and
that
was
understandable given the all-out demands forteleworking.
During the pandemic, thanks to these wellestablished teleworking systems, imaging doctors

45

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:43 Page 46

were able to quickly adapt to containment
measures. Very useful also for doctors quarantined,
but able to work.

situant à des kilomètres de distance de discuter d’uncas compliqué.
Depuis le début de la pandémie les hôpitaux
universitaires ont dû composer avec la proximité desrésidents et spécialistes dans les salles de lectures.
Pour respecter la distanciation sociale dans bien descas la supervision des résidents a dû se faire à
distance. Encore une fois grâce à une télémédecinebien établie en imagerie le déploiement de latechnologie a pu se faire rapidement.
Au milieu des années 2000 le gouvernement de laprovince du Québec a voulu implanter une interface
entre les différents système PACS de la province.
Cette liaison entre les différents système PACS devait
permettre d’échanger d’une façon fluide lesexamensd’imagerie
entre
les
différentsétablissementsdesoins
québécois.
Malheureusement quinze ans plus tard l’exercice n’apas été concluant, et principalement en médecine
nucléaire. Parallèlement à cela, un groupe
informatique dédié à l’informatique en médecine
nucléairelegroupeHERMESSOLUTIONSMEDICALES, a développé tranquillement un réseau
d’utilisateurs HERMES dans de nombreuse unité demédecine nucléaire québécoise. Ces différents
services ayant le système HERMES peuvent doncéchanger facilement des données, aussi complexes
qu’elles soient. Un des avantages des systèmes
HERMES est qu’ils peuvent recueillir des données
natives ou non des différentes compagnies œuvranten médecine nucléaire. Un tel réseau d’utilisateurscomme celui d’HERMES est précieux et surtout en
période de pandémie. Avoir de nombreux
utilisateurs reliés prévient la découverture, aident
aux consultations entre collègues et aide a réaliser
des projets de recherches multicentriques.
Cette période de pandémie a amené de nouveauxparadigmes dans le travail hospitalier ainsi que dansles autres sphères de travail. En médecine letélétravail est devenu une nouvelle norme qui nedisparaitra pas lorsque la pandémie sera finie. En
médecine la téléconsultation s’avère très utile maiselle ne remplace pas toute une visite en présentiel.
Certains réunions scientifiques ou formation se
feront virtuellement. En imagerie le télétravail était
bien implanté avant la pandémie mais ce fut unebelle opportunité pour le consolidé. Médicalement
nous seront mieux préparer s’il y a une nouvelle
vague de la COVID-19.

46

Telemedicine systems allow, in addition to
teleworking from home, to connect the dedicatedimaging systems of distant hospitals to each other.
To do this, exchange protocols must be compatible.
The usefulness of these exchanges is manifold. For
example, if a site is temporarily without a doctor,
exams can be interpreted by another doctor
remotely. In this way, we avoid moving a patient andhaving service disruptions. Also, two doctors
standing miles apart discussing a complicated case.
Since the beginning of the pandemic, university
hospitals have had to deal with the proximity ofresidents and specialists in the reading rooms. To
respect social distancing, in many cases thesupervision of residents had to be done remotely(room nearby or in another establishment). Onceagain, thanks to a well-established telemedicine inimaging, the deployment of the technology wasable to be done quickly to avoid a breakdown insupervision.
In the mid-2000s, the government of the province ofQuebec wanted to establish an interface between
the various PACS systems in the province. This link
between the different PACS systems was supposed
to make it possible to exchange imaging
examinations in a fluid way between the different
healthcare establishments in Quebec. Unfortunately,
fifteen years later the exercise was not successful,and mainly in nuclear medicine. At the same time,an IT group dedicated to computing in nuclear
medicine, the HERMES SOLUTIONS MEDICALES
group, has gradually developed a network of
HERMES users in numerous nuclear medicine units
in Quebec. These different departments with thiscomputer system can easily exchange data,
regardless of the data complexity. One of theadvantages of this computer platform is that it cancollect data from different companies working in
nuclear medicine. Such a network of users of thissystem is precious, especially during a pandemic.
Having a large number of connected users prevents
uncovering, helps consultation between colleagues
and helps to carry out multicentre research projects.
This period of pandemic brought new paradigms in
hospital work as well as in other spheres of work. In
medicine, telecommuting has become a new normthat will not go away when the pandemic is over. In
medicine, teleconsultation is very useful, but it does
not replace an entire face-to-face visit. Some scientificmeetings or training will take place virtually. In
imaging, teleworking was well established before thepandemic, but it was a great opportunity toconsolidate it. Medically, we will be better prepared
if there is a new wave of COVID-19.

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:43 Page 47

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Juan Luis Londoño Blair
Médico Nuclear
Jefe servicio Medicina Nuclear
San Vicente Fundación
Hospital Universitario
Columbia
South AméricaTERAPIA CON YODO – 131(YODO RADIOACTIVO) EN HIPERTIROIDISMO
tóxico. Existen algunas causas menos comunes dehipertiroidismo: tiroiditis destructiva (generalmente causada por medicamentos como la
Amiodarona) y el hipertiroidismo facticio(autoinducido por medicamentos).
La enfermedad de Graves está causada por
anticuerpos del propio organismo contra losreceptores de TSH en la célula tiroidea, mientras
que el bocio multinodular tóxico y el adenoma
tóxico están causados por una mutación que activa
ciertas células de la glándula tiroides.
Algunos de los síntomas del hipertiroidismo
incluyen: temblor fino simétrico, intolerancia al
calor, pérdida de peso (a pesar de un buen apetito),
nerviosismo, irritabilidad, pérdida de la concentración, taquicardia, arritmias, hiperdefecación,
debilidad muscular, trastornos de la menstruacióny, en la enfermedad de Graves, puede haberalteraciones oculares (orbitopatía) y en la piel. La
mayoría de los pacientes tienen aumento de
tamaño de la glándula tiroides (bocio) que puede
ser difuso, uni o multinodular.
Los hallazgos en los exámenes de laboratorio en
pacientes con hipertiroidismo generalmente
muestran el de TSH bajo, T4libre y T3libre altos y
autoanticuerpos contra el receptor de TSH (TRAb)
positivos, en pacientes con hipertiroidismo por
Enfermedad de Graves.

L

a tiroides es la glándula endocrina más grandede nuestro cuerpo y cumple funciones muy
importantes, como la producción de hormonas
tiroideas.
Se necesita que haya niveles dehormonas tiroideas normales para que exista unfuncionamiento de todos los tejidos y órganos en
el cuerpo. Se estima que existe cerca de un 11%
de la población con alteraciones en la glándula
tiroides y que ocurre hipertiroidismo en un 2-3%
de la población adulta, siendo más frecuente en
mujeres (6:1 con respecto a los hombres).
Las causas más comunes de hipertiroidismo son elhipertiroidismo autoinmune, o enfermedad de
Graves; el bocio multinodular tóxico y el adenoma

48

La ecografía se utiliza para determinar el tamaño
y la vascularización de la glándula tiroides;
también para localizar el número, tamaño ycaracterísticas de algún nódulo tiroideo. La
ecografía y los exámenes de laboratorio son elacercamiento diagnóstico de primera línea enpacientes en quienes se sospecha hipertiroidismo,para diferenciar sus varias formas.
La gamagrafía de tiroides con yodo radioactivo ocon Tecnecio-99m pertecnetato es muy útil para
caracterizar
lasdiferentes
formasdehipertiroidismo y provee información útil para
planificar la terapia con radioyodo. Existen varios
patrones gamagráficos, de acuerdo a la causa delhipertiroidismo. La gamagrafía de tiroides, cuando
se realiza con yodo – 123 o yodo – 131 permiteE PATIENT-V5N1-777777_Layout 1 21-07-23 12:43 Page 49

calcular el porcentaje de captación en la glándula
tiroides, lo cual aporta información importantepara planear la terapia con yodo.

TRATAMIENTO DEL HIPERTIROIDISMO
Existen tres opciones para el tratamiento delhipertiroidismo en los pacientes:
1. Medicamentos antitiroideos
2. Tiroidectomía o cirugía de remoción
de la glándula tiroides
3. Terapia metabólica con yodo radioactivo
Generalmente en tratamiento se realiza de forma
inicial con los antitiroideos (Metimazol, Carbimazolo Propiltuiracilo).
Estos medicamentos rápidamente producen una respuesta favorable condisminución de los síntomas y de las hormonas
tiroideas circulantes, pero presentan una alta tasa
de recurrencia si se suspenden, por lo cual deben
administrarse por un tiempo prolongado, lo cual
puede a su vez, producir efectos secundarios, quepueden variar desde efectos leves (como una
erupción
cutánea)hasta
complicaciones
importantes como agranulocitosis o hepatitis por
medicamentos) y por lo tanto, deben realizarse
controles periódicos de laboratorio y seguimiento
médico.
La cirugía generalmente se reserva para pacientes
con
enfermedaddeGravesrecurrente;enfermedad de Graves con oftalmopatía severa opacientes con un bocio multinodular que no secontrole con la terapia médica, especialmente enpacientes con un bocio muy grande que estécausando compresión a estructuras vecinas.

TRATAMIENTO CON YODO RADIOACTIVO
El yodo – 131 es un isótopo radioactivo del yodo,
que cuando se está desintegrando como parte delproceso de ser radioactivo, emite radiación
ionizante en forma de partículas β- que son
responsables del 94% de los efectos biológicos deeste radioisótopo.
Los efectos radiobiológicos del yodo en los tejidos
pueden ser indirectos, por interacción de laspartículas β- con el agua de nuestro cuerpo, que
producen radicales libres, que interactúan con
ciertas moléculas de la célula, o directos, porinteracción con el DNA del núcleo de la célula.
Estos efectos combinados producen daño de lacélula tiroidea, con destrucción de los folículos
tiroideos, que son reemplazados por tejido
fibrótico.
El efecto final de esta forma de terapia es
comparable a la remoción quirúrgica del tejido
tiroideo, pero de una forma no invasiva y sin las
posibles complicaciones quirúrgicas o anestésicas
en los pacientes. Si bien el objetivo final de esta
terapia es que el paciente recupere la función

normal de la glándula tiroides, en pacientes conenfermedad de Graves es el de producir
hipotiroidismo, una condición que causa menos
complicaciones en los pacientes y que puede
tratarse de forma fácil con hormonas tiroideas.
Indicaciones
La terapia con yodo radioactivo está indicada enpacientes con hipertiroidismo que no respondan (otengan intolerancia) a los medicamentos
antitiroideos y que tengan orbitopatía leve amoderada.
Contraindicaciones
La terapia con yodo radioactivo estácontraindicada en embarazo y lactancia. Algunas
contraindicaciones son relativas, como por
ejemplo: la incapacidad para seguir las medidas deradioprotección para el público luego de la terapia;
sospecha de cáncer tiroideo concomitante,
hipertiroidismo descontrolado.
En pacientes con enfermedad de Graves yoftalmopatía, la terapia debe ser cuidadosamente
vigilada por la posibilidad de aumentar esta
condición, especialmente en pacientes fumadores.
Preparación para la terapia
Debe confirmarse el hipertiroidismo con exámenesde laboratorio; realizar ecografía de tiroides para
calcular el volumen de la glándula y gamagrafía
tiroidea con test de porcentaje de captación parauna mejor caracterización de la enfermedad y laplaneación de la terapia con yodo. En mujeres enedad fértil se debe descartar el embarazo.

49

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:43 Page 50

Se le debe explicar al paciente y sus familiares deforma cuidadosa el procedimiento, sus posibles
efectos secundarios, las alternativas terapéuticas y las
medidas de radioprotección para los familiares y parael público en general.
En caso de lactancia, ésta debe suspenderse o laterapia con yodo radioactivo debe posponerse hasta
que se termine la lactancia, para disminuir la dosis deradiación en el bebé y en el tejido mamario.
Los medicamentos antitiroideos deben suspendersepreviamente a la terapia, entre 3 y 10 días, según eltipo de medicamento.
El paciente también debe suspender previamente ala terapia los medicamentos que contengan yodo,
como por ejemplo la Amiodarona.
Debe evitarse el uso de exámenes diagnósticos que
utilicen medio de contraste yodado al menos 60 – 90
días antes de la terapia, ya que el yodo noradioactivo que contiene el medio de contraste
podría afectar la efectividad del tratamiento.
Efectos secundarios
A corto plazo: aumento de los síntomas delhipertiroidismo: esto se debe a la liberación dehormonas tiroideas al torrente circulatorio por ladestrucción del tejido tiroideo por el radioyodo yocurren en los primeros 5 a 10 días luego de la
terapia. Generalmente es bien tolerado y se puedeevitar reiniciando los antitiroideos luego de 5 días dela administración del yodo.
También puede ocurrir tiroiditis por yodo, que está
dada por el efecto inflamatorio de la radiación

50

ionizante y que cursa con dolor e hinchazón en laregión anterior del cuello y que puede tratarse
fácilmente con medicamentos antiinflamatorios.
Efectos a largo plazo: puede ocurrir hipotiroidismo
hasta en un 80% de los pacientes (recordar que éstees uno de los objetivos de la terapia). En pacientes
en quienes falla la primera terapia y continúan con
hipertiroidismo, puede hacerse una segunda terapia,
con la cual se obtienen resultados en cerca de un
90% de los pacientes. Si falla la segunda terapia,
debe considerarse cirugía.
Puede ocurrir, como ya se mencionó, oftalmopatía
tiroidea o puede empeorarse si el paciente ya la
tenía, especialmente en pacientes fumadores. Lospacientes que sufren de esta condición y van a ser
tratados con yodo radioactivo, deben premedicarse
con corticosteroides orales para prevenir elempeoramiento de esta complicación.
Aunque no se ha demostrado que el radioyodo
produzca infertilidad, en hombres debe esperarse 4
meses después de la terapia para que puedan
concebir, tiempo en el cual ocurre un completorecambio de los espermatozoides y en mujeres, almenos 6 meses, para valorar la presencia dehipotiroidismo y poder iniciar el tratamiento
adecuado antes de un embarazo.
Aunque existe el riesgo potencial de padecer algúntipo de cáncer por el uso de radiación ionizante, ésteno ha sido demostrado, con lo cual se puede deducir
que esta terapia que se ha usado por al menos
70 años es completamente segura.

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:43 Page 51

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E PATIENT-V5N1-777777_Layout 1 21-07-23 12:43 Page 52

Steven Burrell, MD, FRCPCHead of Nuclear Medicine
QEII Health Sciences Centre
Halifax, Nova Scotia.

Neuroendocrine Tumours:
Finding Zebras with Nuclear Medicine
NEUROENDOCRINE TUMOURS
Neuroendocrine Tumours (NETs) are of muchclinical interest these days, due to their risingprevalence, unusual clinical manifestations, and
new impactful imaging tests and therapies. Unlike
most tumours which are associated with a specificorgan (such as lung cancer arising from the lungs),
NETs arise from specialized neuroendocrine
cells disseminated throughout the body.
Neuroendocrine cells are similar to nerve cells(neurons), but they also produce hormones likeendocrine cells. The small bowel is the mostcommon site of origin, with the pancreas and lungs
also being common. Other sites include theadrenal glands, other parts of the gastrointestinal
tract, and less frequently the thyroid, prostate,ovaries, and other organs.
A minority of NETs are considered poorlydifferentiated, and they behave as aggressive
cancers. The majority however are welldifferentiated, meaning they retain many of theproperties of the parent tissue and organ fromwhich they arise, and these are less aggressive.
They may spread throughout the body(metastasize), for example to lymph nodes, theliver, and bones, but they tend to do this slowly,
over years. Thus while the number of people
diagnosed with a NET in any given year may below, the number of people living with NETs andtheir symptoms is substantially higher due to thelonger survival. A hallmark of neuroendocrine
tumors is that many secrete hormones andpeptides which can cause significant clinical healthproblems.
The type of hormone produced reflects the organof origin of the NET. NETs originating in the small
bowel (most common site) often produce
serotonin which leads to the “carcinoid
syndrome”, causing excessive diarrhea, flushing,asthma-like symptoms, and potentially criticaldamage to heart valves. NETs arising from thepancreas can produce excessive amounts of insulin(leading to dangerously low blood sugars), gastrin(leading to overproduction of gastric acid anddamage to the lining of the stomach), and others.
NETs arising from the adrenal glands overproduce

52

hormones such as adrenalin, leading to bouts ofsevere hypertension which can have dangerous
complications. In addition to these hormonerelated syndromes, NET patients often present
with abdominal pain due to the local effects of thetumours, including bowel obstructions.
Although neuroendocrine tumours are relatively
uncommon, their documented prevalence is rising
significantly, in part due to better awareness andtesting. NETs are infamous for eluding initialdiagnosis. The symptoms are often non-specific,
potentially attributable to a wide variety of otherdisorders, many of which are much more common.
It is not rare for patients with symptoms of NETs togo many years before the diagnosis is correctlymade. This scenario has led organizations such as
the Canadian Neuroendocrine Tumour Society toadopt the zebra as their mascot. This is a reference
to the old medical school adage “when you hear
hoofbeats, think of horses, not zebras”, a plea totrainees to think first of the common conditions
and not to first think of rare ones. Clearly the call
now is to also think of the zebras! The ultimate
identification of a NET depends on clinicalassessment, lab work, and imaging. Many of thelab and imaging tests are specific to NETs, requiring
the physician to have first thought of a NET before
ordering.

NUCLEAR MEDICINE IMAGING OF NETS,
WITH EMPHASIS ON 68GA-DOTATATE PETManagement of many diseases is greatly aided bymodern medical imaging, and as with many
tumours imaging of NETs is facilitated by Nuclear
Medicine. 68Ga-DOTATATE PET scanning has
emerged as the premiere imaging modality in
NETs. DOTATATE (or similar molecules such as
DOTATOC or DOTANOC) binds to somatostatin
receptors which are present in very high numberson the surface of neuroendocrine tumours. The
attached radioisotope 68Gallium (68Ga) emitsenergy which is detected by a special nuclear
medicine camera, a Positron Emission Tomography(PET) scanner. Scanning a patient after injection of
68Ga-DOTATATE creates detailed images whichshow with great accuracy the presence ofneuroendocrine tumours in the body (see Figures).

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:43 Page 53

Ga-DOTATATE PET scans play important roles
throughout the NET patient’s journey:
Diagnosing a NET

68

Assessing for Recurrence
When recurrence of a treated NET is suspected,
Ga-DOTATATE PET scanning can confirm therecurrence and its extent.

68

As discussed NETs can be very difficult to diagnose.
If a NET is suspected a 68Ga-DOTATATE PET can be
instrumental in finding the primary NET.

Determining Appropriateness for Therapy with
Lu-DOTATATE

177

Staging
When a NET is diagnosed, 68Ga-DOTATATE PET
scanning is often the most accurate way to find out
how far the tumours have spread in the body,which is important for deciding on the best
therapy for a patient. In comparison with otherimaging tests this method often finds more sites of
disease, leading to important changes in treatment
approach in a significant number of patients.
Monitoring of Therapy
Ga-DOTATATE PET scanning is often the mostaccurate test for monitoring a NET patient’s
response to treatment, such as somatostatin
analogs, chemotherapy, biologically-targeted
therapies, or radioisotope therapies.

68

This exciting new therapy utilizes the same NETseeking molecule DOTATATE as used in scanning
discussed above. However, the attachedradioisotope, 177Lutetium, gives off radiation thattreats the tumours rather than creating images.
This concept is known as Theranostics, in which thesame tumour-seeking molecule is used for both
Therapy and Diagnostics by being combined withdifferent radiation-emitting isotopes. Neuroendocrine Tumour scanning with 68Ga-DOTATATEand therapy with 177Lu-DOTATATE is opening thedoor to important new Theranostic pairs, forexample in prostate cancer, bringing concepts
refined in the management of NETs to wider
cancer applications.

68

Gallium-DOTATATE PET Scans. Figure 1: Normal Scan. This overview (“MIP”) image demonstrates normal distributionof 68Gallium-DOTATATE in several organs. Figure 2: Metastatic Neuroendocrine Tumour. 2a: MIP image shows spread tomultiple areas in the liver ({) and to the central abdomen (arrow). 2b and 2c: Cross-sectional PET-CT images from thesame scan show details of the liver metastases and lymph node metastases in the central abdomen. This is a very common
pattern of spread of neuroendocrine tumours.

53

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:43 Page 54

CANM GUIDELINES FOR BRAIN PERFUSIONSINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY (SPECT)ABSTRACTAUTHORS:

These guidelines are submitted to the Canadian Association of Nuclear Medicine(CANM). Except for Procedure Guidelines issued in 2018 by the European Societyof Nuclear Medicine (ESNM), there have been no updates on the use of brain
perfusion single photon emission computed tomography (SPECT) since 2009 [1].
These guidelines are meant to compliment and extend the use of Brain Perfusion
SPECT primarily based on the existing guidelines issued in 2009 by the European
Association of Nuclear Medicine Neuroimaging Committee (EANM) (ENC). The
purpose of the guidelines, similar to those in 2009, is to assist nuclear medicine
practitioners and clinicians when making recommendations, performing,
interpreting, and reporting the results of brain perfusion single photon emission
computed tomography (SPECT) studies using 99mTc- labelledradiopharmaceuticals. It is the intent of the authors to focus on new extensive
studies expanding the use of brain perfusion scintigraphy in brain trauma, neuropsychiatry, and inflammation. In addition, new instrumentation is now available
using solid state detectors and multiple pinhole detectors. Like the EANM
guidelines, the aim of this review is to assist Canadian nuclear medicine specialists
in conducting standard examinations for brain perfusion SPECT imaging, which
will increase the diagnostic impact of this technique in clinical practice. Like the2009 EANM guidelines which replaced a former version of the guideline publishedin 2001 [2] and the individual experience of experts in European countries, theCANM guidelines are intended to present information specifically adapted to
Canadian practice.

NUCLEAR MEDICINEAUTHOR KEYWORDS
Brain Dementia Ethyl Cysteine Dimer Epilepsy HMPAO Perfusion SPECT Traumatic
Brain Injury, Neuro-Psychiatry

54

PF COHEN MD FRCP(C) ABNM
Clinical Professor, Radiology
University of British Columbia
Department of Nuclear Medicine
Lions Gate HospitalNorth Vancouver, BC Canada
Email: philip.cohen@vch.ca
Robert Tarzwell, MD, FRCPCClinical Assistant Professor - Department of Psychiatry
Cross Appointment - Department of Radiology
Faculty of Medicine
University of British Columbia, Vancouver, BC
Leonard Numerow MD FRCP(C)Radiology and Nuclear Medicine
Clinical Assistant Professor - Department of Radiology
Cumming School of Medicine
University of Calgary, Calgary, Alberta
Yin-Hui Siow, MD, FRCPC
Director – Nuclear Medicine
Southlake Regional Health Centre,
Newmarket, Ontario
John M Uszler, MD, MS
Assistant Clinical Professor of Molecular
and Medical Pharmacology, UCLAE PATIENT-V5N1-777777_Layout 1 21-07-23 12:43 Page 55

Dan G. Pavel, MD (Deceased)
Past Director of Nuclear Medicine
Professor of Radiology/ Nuclear Medicine
University of Illinois Medical Center, Chicago, Ill
Sonia Neubauer, MD
Nuclear Medicine specialist
Adjunct Professor University of Chile
Director Nuclear Medicine Dept. at Clínica Las Condes
Joe Cardacci MBBS, FAANMS, FRACP
University of Notre Dame, Fremantle –School of Medicine
Director, Diagnostic Nuclear Medicine –Hollywood Private Hospital
Consultant Physician,
Perth, West Australia, Australia
NEUROLOGY
Manu Mehdiratta MD FRCP(C)
Trillium Health Partners
University of Toronto,
Toronto Canada
Behzad Mansouri MD PhD FRCP(C)
University of Manitoba
Winnipeg, Manitoba
PSYCHIATRY/PSYCHOTHERAPY
Theodore A Henderson MD PhD
The International Society ofApplied Neuroimaging (ISAN)
The Synaptic Space, Inc. Denver, CO
Neuro-Luminance, Inc. Denver COJohn F. Rossiter-Thornton, MB, FRCPC
Rossiter-Thornton Associates.
Toronto, Ontario
Muriel J. van Lierop, MBBS, MD PAC(M)Private PracticeToronto, Ontario
Mary McLean MBChB, FRCP(C)
Private practiceToronto Ontario
Zohar Waisman MD, FRCP (C)University of Toronto,
Consultant neuropsychiatrist
Homewood Health organization
COMPUTER SCIENCE
Simon W. DeBruin, MSEEGood Lion Imaging
Columbia, Maryland
SPECIAL THANKS TO:
Dr. John W. Baird
369 Main St.
Markham, ON
James McLean, MS, P.Eng.
Toronto Ontario
Mina Bechai
CEO
Initio Medical
Toronto, Ontario
Hayley Wagman, BSc
Medical student
University of Toronto
Alexi T GOSSET
Medical Student
University of Toronto

Introduction
As described in the 2009 EANM guidelines [1], SPECT is a nuclear medicine
procedure producing tomographic and three-dimensional images of the
distribution of a radiopharmaceutical as Maximum Intensity Projection (MIP) or
as Normal Database Comparison 3D images..
Using well established radiotracers, hexamethyl propylene amine oxime (HMPAO,
Ceretec) and ethyl cysteine dimer (ECD, Neurolite), both radiolabeled with
99mTechnetium (99mTc), this technique can be used to measure regional cerebral
perfusion. Three physiological properties were noted by the EANM whichradiopharmaceuticals must exhibit to be useful for the measurement of brain
perfusion by SPECT. First, they are required to cross the tight junctions of the bloodbrain barrier. Second, their extraction should approximate unity and the extraction
itself should be independent of blood flow so that initial distribution is proportional
to regional cerebral blood flow (rCBF). Finally, tracers must be retained within thebrain in their initial distribution long enough for diagnostic tomographic images
to be obtained [3]. Ideally, tracers should show no redistribution, so that initialtracer uptake remains unchanged for several hours. This produces a “frozen
image” which reflects rCBF at the time of injection.
There are differences between the two commercially available
radiopharmaceuticals ECD and HMPAO, including in vitro stability, uptake
mechanism, cerebral distribution, [4] and dosimetry. In normal brain tissue, thekinetic properties of the two agents are very similar. Both agents enter the brain
cells passing through the blood-brain barrier due to their lipophilic nature andremain there due to conversion into hydrophilic compounds. For ECD retention,de-esterification is the crucial reaction leading to hydrophilic conversion, while for
HMPAO, instability of the lipophilic form and glutathione interaction have been
proposed. Differences in the retention mechanisms may account for some differentof the tracers in specific disorders such as subacute stroke, where ECD distribution
seems to reflect metabolic activity more closely, whereas HMPAO is better
correlated with cerebral perfusion [5]. As a consequence, both tracers can be used,
but they are not interchangeable.
In the 2009 EANM guidelines, it was stated that neither ECD nor HMPAO SPECT
provide absolute quantitative flow values. As an alternative, quantitative SPECT
with SUV uptake values can be used with the brain perfusion agents. In clinicalpractice, SPECT is usually used to estimate relative regional flow differences basedon the comparison of count density ratios between various regions such as
right/left asymmetries, or ratio in relation to reference regions, such as the
cerebellum or visual cortex.. Increasingly, quantitation has been used to assess
uptake values relative to normal data bases.
As with the EANM guideline, the CANM guideline deals with the indications,assessment, processing, interpretation and reporting of brain perfusion SPECT
using the commercially available 99mTc-labelled radiopharmaceuticals ECD and
HMPAO.
A. Indications
A.1 Evaluation of suspected dementia [6-53].
SPECT perfusion now allows differentiation of Alzheimer’s Disease (AD) fromcontrols, AD from Fronto-Temporal Dementia (FTD), AD from vascular dementia,
AD from Lewy body dementia (LBD), and studies indicate that SPECT has predictive
value in Mild Cognitive Impairment (MCI)
Taken together, studies of perfusion SPECT in the diagnosis of AD with comparison
to a longitudinal clinical course or histopathology demonstrate sensitivity in therange of 82–96% and specificity in the range of 83–89% [17]. Neuroimaging data
supports that different types of Vascular Dementia can be distinguished by SPECT[31]. Differentiating AD from FTD with quantitative analysis of multi-headed
gamma camera data compared to autopsy findings had a 96% sensitivity and an
80-84% specificity [14] [17][33]. The sensitivity for differentiating AD from LBD
was 89%, while the specificity was 84% [17] [34-38]. A total of 495 patients with
MCI have been followed over 2–5 years [17][39][41-50] in 10 longitudinal studies
that included a baseline SPECT scan. All studies used multi-headed gamma
cameras and quantitative analysis [17][39-50], and yielded an overall sensitivityof 89% and specificity of 89% [17] compared to clinical assessment alone [47].
PET/CT, PET/MR and amyloid tracers are also available to diagnose dementia. The
use of other technologies complement brain perfusions SPECT, but the optimal
diagnostic test is determined by availability, costs, and government or insurance
reimbursements.

55

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:43 Page 56

A.2 Presurgical lateralization and localization of epileptogenic foci [54-62].

reasons, it is highly unlikely that a pathognomonic finding or a “neuroimaging
fingerprint” will be found for any pure psychiatric disorder [125].

Ictal SPECT studies (preferably complemented by inter-ictal investigations) areindicated in temporal and extra-temporal focal epilepsies for localization of fociprior to epileptic surgery.

Despite its limitations, a substantial body of research literature exists for brain
perfusion SPECT in the evaluation of psychiatric disorders

A.3 Evaluation of traumatic brain injury [63-72]

ADHD

SPECT has shown perfusion abnormalities in traumatic brain injury despite normal
morphology, and results are considered to have a prognostic value for persistenceof neuropsychological sequelae.
A 2014 systematic review by Raji and colleagues [64] showed Level IIA evidence
for the utility of brain SPECT in the evaluation of TBI. The review identified 52 crosssectional studies and 19 longitudinal studies with a total of 2,634 individuals over
30 years of literature supporting this conclusion. Perfusion SPECT proved moresensitive than CT or MRI [65-70]. Jacobs and colleagues followed a group ofpatients with TBI who had SPECT scans within three weeks of injury. They found
an abnormal baseline SPECT had a sensitivity of 100% and specificity of 85% forpredicting persistent neuropsychological deficits at 12 months, while a negative
baseline SPECT had a negative predictive value of 100% for neuropsychologicaldeficits at 6 and 12 months after injury. In total, 18 cross sectional studies showedcorrelation between abnormal SPECT findings and neuropsychological deficits [64].
This suggests that abnormalities found with brain SPECT can correlate with and,
therefore, be predictive of functional outcomes.
A retrospective study of over 20,000 subjects showed that SPECT can distinguish
TBI from PTSD with 80-100% sensitivity and an average of 70% specificity [71].
Replication of this study in a smaller sample of 196 military veterans with TBI,PTSD, or both showed accuracy of between 83% and 94% in distinguishing
between these conditions [72].
A.4. Evaluation of inflammation, toxin exposure, substance abuse [73-112]
Perfusion SPECT may be indicated and provide helpful information in progressive
inflammatory disorders (e.g. Rasmussen’s syndrome) [73], viral encephalitis (e.g.
herpes simplex encephalitis) [69], vasculitis (e.g. systemic lupus erythematosus,
Behçet’s disease) [75,76], and HIV-encephalopathy [77].
Solvent-induced encephalopathy has been demonstrated with perfusion SPECT[78-81]. Perfusion SPECT revealed diffuse hypo-perfusion in 94% of cases in one
study [79].
Perfusion SPECT reveals diffuse hypoperfusion in metal toxicity [82], mold toxicity[83], and other toxin exposure [81,84,85], including recreational toxins [85-91].
SPECT is also beneficial in the identification and grading of severity of hepatic
encephalopathy due to ammonia toxicity [92-96], even in mild cases [97], as well
as for tracking progress [96].
Carbon monoxide poisoning is characterized by decreased perfusion of the bilateralfrontal cortex, bilateral temporal cortex, and the globus pallidus [75] [98-103].
Specifically concerning recreational drugs, perfusion SPECT imaging reveals diffuse
hypoperfusion throughout the cerebral cortices, but predominately in the frontal
and temporal cortices [104-108].
A.5 Assessment of Neuropsychiatric Disorders [113-172]
The use of perfusion SPECT neuroimaging for psychiatric indications has increased
significantly over the past two decades. Unlike neurological diagnoses, which canbe verified by biopsy, there are no recognized histopathological markers forpsychiatric diagnoses. Psychiatric disorders are defined by the DSM-5 (Diagnostic
and Statistical Manual of Mental Disorders Version 5), based not on pathology but
upon a constellation of symptoms.
Comorbidity is the rule rather than the exception in psychiatric conditions. In
bipolar disorder, for example, the comorbidity of attention-deficit-hyperactivitydisorder (ADHD) occurs in approximately 57% of adult bipolar patients [119] andup to 98% of pediatric bipolar cases [117]. With depression many depressed
patients also are comorbid for anxiety in up to 60% of cases [115, 116, 121]
Patients with ADHD frequently have coexisting mood disorders (59%), anxiety,oppositional disorders, or learning disorders [115, 118, 122-124]. For all these56

Decreased frontal lobe perfusion is a consistent finding in ADHD across multiple
SPECT studies [81, 126-133] and confirmed by multiple functional MRI studies[134, 135] and infrared spectroscopy [136]. For example, SPECT scans of
medication-naïve children with ADHD (N=40) were compared to normal controls
using statistical parametric analysis [126]. Decreased perfusion was found in theprefrontal cortex, orbitofrontal cortex, and middle temporal gyri, while increased
perfusion was found in the somatosensory cortex and anterior cingulate gyri [126].
With stimulant treatment, perfusion increased in the prefrontal cortex [126, 131].
Clinical experience has heavily supported these findings [81, 137].
Perfusion SPECT neuroimaging also is beneficial in the differential diagnosis of ADHD.
Since inattention, impulsivity, and hyperactivity are non-specific signs of frontal lobe
dysfunction, it is not surprising that toxicity, concussive brain injury, incipient bipolar
disorder, infection, and inflammation can produce similar symptoms complexes as
ADHD. SPECT can reveal these alternative causes [81, 114, 138].
Bipolar Disorder
In contrast, bipolar mania, which can present symptomatically like ADHD, often
demonstrates increased perfusion in the frontal cortex, particularly the dorsolateralprefrontal cortex and possibly greater on the left [139, 140]. Patients with bipolar
mania also typically do not show the decrease in prefrontal perfusion unless they
have comorbid ADHD as described above [81]. While the total number of subjects
studied in ADHD and bipolar disorder number less than 200, the clinical experienceamong experts worldwide across hundreds of thousands of scans supports thecorrelation of these disease processes with these perfusion patterns.
Increased and asymmetric perfusion of the thalamus may serve as a possible
endophenotypic pattern of Bipolar Disorder in the manic or euthymic states [141,142]. Bipolar depression may be similar to unipolar depression in terms ofdecreased frontal cortex perfusion [143], but it is possible the two can be
distinguished by differences in the perfusion of the thalamus and basal ganglia
in the depressed state. Perfusion, whether measured by SPECT or fMRI, isincreased in the thalamus in bipolar disorder [139,140,143,144]. It must beemphasized that these types of endophenotypic patterns may not be evident
upon visual inspection of tomographic data for an individual SPECT scan. Rather,
these findings may only be manifest in the statistical comparison of perfusion
data to normative databases.
Depression
Over 150 studies of perfusion SPECT imaging of depression containing more than
12,100 subjects have been completed. A consistent finding in early SPECT (Xenon
or HMPAO) studies of depression was decreased perfusion in the frontal, and often
temporal, cortices, as well as the superior anterior cingulate gyri [145-148]. Later,
two distinct patterns of perfusion were recognized – decreased perfusion in typicaland melancholic depression and increased frontal lobe perfusion in atypicaldepression [149-152]. Increased perfusion in the subgenual anterior cingulate
gyrus in treatment-resistant depression was first described by Goodwin andcolleagues [153], but has been recognized as a hallmark sign of treatment resistantdepression, subsequently [152, 156, 157]. Remission or response to treatment ischaracteristically followed by increased perfusion in the affected areas [153-155].
Response to antidepressant therapy could be predicted by the degree of frontal
hypoperfusion and of subgenual hyperperfusion. Notably, response to serotonin
reuptake inhibitors was predicted by higher frontal and cingulate perfusion [156,158-159], while response to electroconvulsive therapy (ECT) or transcranial
magnetic stimulation (TMS) was predicted by lower frontal and cingulate
perfusion. Increased metabolic activity and perfusion in the thalamus [160, 161]
is also a frequently reported finding in unipolar depression. Increased symmetricalperfusion of the thalamus has been consistently seen by expert clinicians
worldwide on tens of thousands of perfusion SPECT scans.
OCD
Obsessive-compulsive disorder (OCD) is considered to result from an abnormal
overactivity of a circuit involving the frontal cortices, anterior cingulate gyri,caudate nuclei and the thalami [162]. Increased perfusion of the caudate nuclei

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:43 Page 57

and the anterior cingulate gyri have been reliable perfusion SPECT findings across
12 studies involving 229 subjects with OCD vs. 139 controls. Similar increased
metabolism in these same areas has been found in studies utilizing FDG-PET andfunctional MRI. These findings were recently reviewed [163].

Check to insure the patient can cooperate during the procedure. Confirm there
are no contraindications.

PTSD

1. Patient should be positioned in a quiet, dimly-lit room

The symptom overlap between post-traumatic stress disorder (PTSD) and traumaticbrain injury has complicated the correct diagnosis, particularly among military
personnel [164, 165]. Perfusion SPECT studies and fluorodeoxyglucose (FDG)-PET
studies have made similar findings in PTSD. Increased perfusion of the caudate
nuclei is often found in PTSD [72, 166, 167]. Another SPECT study showed thatcompared to controls, PTSD patients had increased cerebral blood flow in thelimbic regions along with decreased perfusion in the superior frontal, parietal, andtemporal regions [168]. A systematic analysis of multiple regions of the default
mode network revealed that PTSD resulted in increased perfusion in the basal
ganglia, cingulate gyri, thalamus, prefrontal cortices, and medial temporal cortices
in both military [72] and civilian [167] populations. Provocation studies using
perfusion SPECT, perfusion PET and fMRI have shown increased perfusion in the
amygdala, hippocampus, insula, but decreased perfusion in the medial prefrontal
cortex [169-172].

A.6 Assessment of brain death [173-195].
Scintigraphic assessment of arrest of cerebral perfusion is an accurate techniqueto confirm brain death [173]. Brain death scintigraphy is indicated for theassessment of brain blood flow in patients suspected of brain death. This study
may be helpful when clinical assessment and electroencephalography are lessreliable in diagnosing brain death because of conditions such as severe
hypothermia, coma caused by barbiturates, electrolyte or acid–base imbalance,endocrine disturbances, drug intoxication, poisoning, and neuromuscular blockade.
Brain death scintigraphy may also be helpful in patients who are being considered
as possible organ donors or when family members require documentation of lackof blood flow.
A.7 Cerebrovascular Disease [196-208]
Brain SPECT has been shown to be efficacious in the understanding of cellular viability,
hemodynamic reserve and cellular ischemia in the context of severe cerebrovasculardiseases [196]. In particular, SPECT can be useful to evaluate cerebrovascular reserveusing a vasodilatory challenge.
Cerebrovascular reserve assessment using brain perfusion SPECT is mostcommonly completed using acetazolamide, which inhibits carbonic anhydrase
causing carbonic acidosis and results in cerebrovascular vasodilatation. This results
in an increase in cerebral blood flow by decreasing vascular resistance. An initial
SPECT baseline scan is completed and compared with the second scan after
acetezolamide challenge. Areas of hypoperfusion are identified.
This can be useful in patients with TIA, completed stroke, carotid artery stenosis
or occlusion, vascular anomalies, post carotid surgery, before and after
cerebrovascular surgery or stent placement. Vasodilatory challenge can also be
used to differentiate neuronal causes of dementia versus vascular dementia.
The acetazolamalide challenge should not be completed within 3 days of a recent
ischemic stroke or intracranial hemorrhage. Acetazolamide is known to provoke
migraine in a patient with a history of migraine and the challenge is contraindicatedin patients with known sulfa allergy.
B. Contraindications
1. Pregnancy

C.2 Injection

2. An intravenous cannula should be started 10-15 minutes prior to injection.
3. Patient should be positioned in a comfortable (preferably supine position).
4. Patient may keep eyes open, or be offered an eye mask. Ears can be unplugged.
5. No interaction should take place with the patient for at least 5 minutes before
and up to 5 minutes after the injection
6. Note any alterations that might affect the rCBF during injection of theradiopharmaceutical (e.g. Patient motion or talking.)
7. Allow 30-40 minute washout period during which the patient is encouraged
8. to drink water and to urinate.
9. Patients should be informed they will be required to lie still for 30-60 minutes
during the scan..
If patients are assessed as being unable to lie still for the examination, becauseof neurocognitive disorders or dementia, it may be a consideration to use conscious
sedation such as a short acting benzodiazepine. The sedative can be administeredapproximately 5 minutes after tracer injection, when it is unlikely to affectbiodistribution. If a sedative is used, it is important to have EKG monitor or pulse
oximetry available.
D. Information pertinent to performing rCBF SPECT studies
1. Patient history should include neurological and psychiatric disorders, as well as
indicated reason for the SPECT scan, history of previous surgery, allergies,
radiation or trauma to the brain.
2. Results of recent anatomic imaging studies (CT or MRI)
3. Results of recent functional studies – such as EEG, fMRI, PET scans
E. Precautions
There should be continuous supervision of the patient by the technologist or nurse
during the course of the study. Patients with epilepsy or suspected dementia or
psychiatric concerns should be especially closely monitored.
F. Radiopharmaceutical
F.1 Radionuclide 99mTechnetium
F.2 Pharmaceutical
1. ECD
2. HMPAO stabilized preferentially, or unstabilized
F.3 Preparation
1. Use pertechnetate from generators that have been eluted within 24 hours
2. Use fresh generator pertechnetate not older than 2 hours, especially for
HMPAO.
3. For HMPAO, the manufacturers recommendation regarding incubation time
before injection should be respected. Non-stabilized HMPAO (injection assoon as possible), blue-dye stabilized and Cobalt stabilized HMPAO(30 minutes incubation).
F.4 Quality Control
Radiochemical purity should be determined on each vial prior to injection
according to manufacturers recommendations in the package inserts. It should be>90% for ECD and >80% for HMPAO

2. Sulfa allergy
3. Breast Feeding unless able to stop for 24 hours after scan

F.5 Timing the Injection

4. Inability to remain stationery or supine for duration of the scan

Injection may proceed once quality control is passed., but not later than 30 minutes
after drug vial is reconstituted for unstabilized 99mTc HMPAO, 4 hours for stabilized
99mTc HMPAO, and 6 hours for 99mTc ECD

C. Patient preparation
C.1 Prior to Injection

F.6 Administered Activity
Patients should be told to avoid stimulants (such as coffee, cola and energy drinks),
alcohol, smoking, and any drugs known to affect cerebral blood flow.

1. Adults: 555-1110 MBq (typically 740 MBq of either radiopharmaceutical57

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2. Children:a. Administered activity = “baseline activity”
x multiple (from dosage card – see EANM
Paediatric dosage card table v. 1.5.2008)
b. For ECD: “baseline activity” = 32 MBq(minimum recommended activity = 110 MBq)c. For HMPAO” “baseline activity = 51.8 MBq(minimum recommended=110 MBq)
Doses of radiation following administration of radiopharmaceutical is shown below:

detectors are becoming available, and are likely to compete with PET in terms ofresolution and count-rates. Clinical studies however with these detectors are
currently limited, but it is likely these types of detectors will become more common
in the next decade.
Low Energy High resolution (LEHR) or LEUHR parallel-hole collimators remain themost readily available collimators for brain imaging. They are acceptable if
sufficient count rates are obtained. LEAP or Low Energy All Purpose collimators
are not suitable. Generally, the highest resolution collimator is best. Newerdetectors using multiple pinholes are preferred, or fan-beam collimators, comparedto the parallel-hole collimators. There is always generally a trade-off between
resolution and sensitivity. In the case of fan beam collimators, or newer multiple
pinhole detectors, it is important to make certain the entire head is in the field ofview, particularly the cerebellum.
Of all nuclear medicine imaging procedures, a brain SPECT scan is one of thehardest to do correctly. The overall quality of the scan depends on getting many
details right, and the procedure is not very forgiving when all aspects of theimaging technique are not flawlessly executed. Because of the enormous variability
in brain scan images, it is especially important to have great consistency inperforming these scans such that interpretation and comparisons of these studies
can be done more reliably.
Brain SPECT procedure volumes are small and account for less than one percent
of all NM procedures. One of the reasons why brain SPECT imaging is notprescribed more often is that poor execution, combined with a lack of experience,
produces sub-optimal images causing unhelpful findings, resulting in fewer
referrals.
H.2 Instrumentation

G. Data acquisition
G.1 Time from injection to start of data acquisition
1. Try always to keep the same time delay from injection to the startof data acquisition.
2. 99mTc-ECD: For best image quality allow a delay of 30-60 minutes since wash-out
due to non-specific uptake improves the signal to noise ratio in this period.

Dedicated brain SPECT imaging systems, such as a triple detector gamma camera
with fan beam collimation, are no longer produced due to a declining interest inthese scans. This means that most brain SPECT studies today must be acquiredwith a general-purpose SPECT camera, typically a dual detector camera with large
field of view detectors.
Unfortunately, a general-purpose camera system can make it more difficult toexecute a high-quality brain SPECT scan, e.g., clearing the patient’s shoulders
without clipping the lower part of the brain. However, with proper technique, goodresults can be obtained.

3. 99mTcHMPAO: For best image quality allow a delay of 30-90 minutes
4. Imaging should be completed within 4 hours after injection. Excessive delay
should be avoided because of radioactive decay.
G.2 Set-up for data acquisition
1. Positioning of the patient• The patient should be encouraged to void prior to beginning the study for
maximum comfort and to avoid movement. Following completion of the study thepatient should be asked to void again to decrease radiation exposure.

Note: Certain specialized cameras may deviate and not be equipped withtraditional detector heads, such as ring detector systems. For these systems, someof the requirements provided in this document may not be applicable. In thesecases, the operator should follow the recommendations of the equipment vendor.
Best
Camera typededicated brain scanner
Collimator typededicated
Counts in study
10M+
Radius of rotation <160mm

Bettertriple detector
Fan beam
8-10M
160-180mm

Good
dual detector
LEHR parallel hole
6-8M
180-200mm• The patient should be told about how much time the study will take to complete,and positioned for maximum cooperation with the study. Since post-processing
can correct for minor movements of the head, the patient’s comfort is more
important to a successful scan than perfect alignment of the head.

H.3 Count statistics• The patient should be cautioned not to move during the study. If the patient isunable or unwilling to avoid movement, sedation may be considered. A head
immobiliser is not necessary but some light restraint such as pillows or tape might
be used.

Like in all nuclear medicine studies a trade-off must be made between counts(statistics) and scan time. For patient comfort, shorter scan times are preferred,and it is recommended to keep acquisition time within the clinical tolerable limit(30 min). For good image quality, more counts are better, and it is recommended
to acquire 10M counts minimum.

H. Imaging Devices
H.1 BackgroundThe study is most commonly performed with dual head detectors. A SPECT-CT
hybrid scanner has advantages of x-ray attenuation correction, but dual headdetectors face limitations of being able to get collimators close to the patient
because of patient shoulder obstruction. A dedicated Brain SPECT system, withtriple detectors is preferable, if available, particularly with fan-beam collimation.

There are several factors that have an impact on the acquired number of counts
in a scan. The following factors increase the number of counts, and they arereviewed below
1. Utilizing a camera with multiple detectors
2. Using a collimator with higher sensitivity
3. An increase in acquisition time
4. A higher injected dose

New detectors, using Cadmium Zinc Telluride (CZT) solid state ring systems or
Sodium Iodide scintillation (NaI) scanners with multiple scanning or pinhole

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H.4 Number of detectors

H.9 Filtered back projection (FBP)

Brain SPECT scans require a full 3600 rotation around the subject’s head. The total
number of acquired counts increases proportionally with the number of detectors.
A minimum of two detectors is recommended because the acquisition time for asingle detector camera will be outside of the clinical tolerable range. Note: Certain
specialized cameras may deviate and not be equipped with traditional detector
heads, such as ring detector systems. For these systems, some of the requirements
provided in this document may not be applicable, and in these cases the operator
should follow the recommendations of the equipment vendor.

The traditional reconstruction method used in tomography is back projection (BP)because it is simple and fast and can be implemented easily on off-the-shelfcomputer systems without any need for specialized hardware.

H.5 Collimators
The reconstructed resolution of a gamma camera system is determined largely by
the collimator resolution. Brain SPECT perfusion studies are acquired with 99mTc andrequire a ‘low energy’ (LE) collimator. Collimator design is a trade-off between
resolution, sensitivity, and septal penetration (rejection of unwanted photons).
Because collimator terminology is not standardized between vendors, it is importantto review the collimator specifications rather than relying on terms like highresolution (LEHR), general purpose (LEAP).
H.6 Acquisition time

However, using BP for the reconstruction of SPECT data has its limitations and is infact not the best suited method. The prerequisites for BP to work correctly are that
it is expected that the data has unlimited statistics and has perfect resolution (pencil
beam reconstruction). For SPECT data these two requirements are not valid and an
approximation at best. SPECT data is count poor (low statistics) and of low resolution
which also is not constant but changes with distance from the detector surface.
To deal with these limitations a filtering function is introduced to reduce the noiselevel in the reconstructed images to make them interpretable. The filter makes outof back projection, filtered back projection (FBP). The filter is commonly implemented
as a pre-filter, i.e., the raw projection images are filtered prior to back projection.
The typical type of filter used in SPECT imaging is the Butterworth filter which iscontrolled by two parameters: cut-off and order. The order is usually fixed at 3 or 5,
and the cut- off determined the final resolution and noise level (image texture).
Please note that the cut-off is related to the sampling, i.e., the pixel size of theimages. Higher sampling, i.e., smaller pixels, require a lower cut-off to achieve asimilar smoothness compared to images acquired with larger pixels.

The total number of counts in a SPECT scan is proportional to the acquisition time.
Longer acquisition times will increase the susceptibility of patient motion which
has a detrimental effect on image quality. Therefore, every effort should be madeto maximize patient comfort during the scan. However, there is a limit to how far
the acquisition time can be extended without risking patient motion. A practicallimit is 30 min. Occasionally, other measures may be necessary such as headrestraints or sedation.

Since FBP is a well-defined reconstruction method, the differences in
implementation between vendors are small which allows for a standardization inreconstruction parameters based on the type of study and the acquisition
parameters. This is an advantage because it makes it easier to establish imaging
guidelines that, when followed, produce consistent and good quality data.

H.6 Injected dose

There are other reconstruction methods that are better suited to SPECT data, butthey do require a much higher computational effort and only recently became
feasible for general-purpose computer hardware.

The total number of counts is proportional to the injected dose. However, there isa limit to how much activity can be administered to the patient without exceeding
the maximum radiation exposure limits. It is recommended to maximize theallowable dosage for best results.
Note: The operator must always follow all local rules and regulations pertaining
to the allowable administered dosage.
H.7 Energy window
Because a gamma camera has a limited energy resolution, an energy acceptancewindow must be set based on the energy level of the radioisotope in use (140keV
for 99mTc). Opening the energy window will increase the number of counts in a scan
but will also increase the fraction of scattered events (bad counts). The measured
location of a scattered event does not represent its original source location.
Thus, scattered events deteriorate image quality by increasing the noise level.
Reducing the energy window will decrease the number of scatter events but also
reject some of the non-scattered (good counts) events due to the limited energy
resolution of the imaging system. Most used energy window settings are 15% or
20% for 99mTc. For most situations, the operator is advised to follow therecommendations provided by the equipment vendor. Note: Some camera systems
may include an option for scatter correction. H.8 Image reconstruction
A series of raw images (i.e., projection data) as acquired by a SPECT camera cannot
be interpreted directly but must first be digitally reconstructed. Reconstruction isa part of the image generation process and should therefore be considered an
extension of the gamma camera. In other modalities, such as CT, the user is often
removed from the reconstruction process but in SPECT imaging the choice ofreconstruction parameters is paramount to the attainable image quality anddepends strongly on the imaging equipment, the local acquisition parameters, andquite often the patient itself.
In terms of image reconstruction, a general distinction is made between filtered
back projection and iterative reconstructions. They differ considerably and are
discussed in some detail below.
There are some other image processing functions that can be considered part ofimage reconstruction, most notably: attenuation correction, which is an essential
element of brain SPECT imaging. Other optional functions include scattercorrection and resolution recovery which are discussed below.

H.10 Iterative reconstruction (IR)
Unlike FBP, iterative reconstruction is more of an umbrella term, which does not
say much about the method or its performance.
Two of the most common generic iterative reconstruction schemes are known as
MLEM (maximum likelihood estimation method) and OSEM (ordered subset
expectation maximization). The latter is more frequently used in SPECT imaging
because it is a faster algorithm. For performance reasons, most OSEM
implementations were initially in 2D (i.e., slice by slice) but nowadays most vendors
have switched to a full 3D implementation. OSEM-3D is the preferred method in
SPECT because the limited resolution of the data results in considerable crosstalk
between slices which is ignored in 2D implementations.
An iterative reconstruction engine goes through several iterations whereby theforward projection of the reconstructed slices is compared to the raw projection
images. An error signal is added, or multiplied, to the synthetic projections andback projected again. This process repeats itself until the differences between theoriginal projections and the computed projections are below a certain error
threshold or until a set number of iterations is reached.
The most important advantage of iterative reconstruction in SPECT imaging is thefact that the imaging system (i.e., gamma camera and collimator) can be modelledin the algorithm, resulting in more accurate images. For example, the intrinsic
resolution, the energy resolution, and other physical parameters of the camera
can be considered when computing the reconstructed slices from the raw data.
Also modelling of the collimator geometry is of significant benefit because theoverall SPECT image resolution is primarily determined by the collimator design.
Iterative reconstruction methods tend to provide greater image contrast, i.e., thedifferences between areas of high and low up take are enhanced and the overall
dynamic range of useful information is extended. However, it also causes structuresthat appear singular and smooth in FBP to be visualized as clusters of hotspots.
The images have the appearance of being sharper and of higher resolution,
however the additional detail can also be perceived as noisy, especially without
correlation to detailed anatomy such as an MRI scan on the same subject. Thiscan make the SPECT images more difficult to read because the interpreter thinks
in larger structures and must use his/her imagination to lump several hotspots
together to come to an interpretation. This poses a considerable mental effort on
the readers and they often prefer some filtering to ease interpretation. The

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smoothing can simply be achieved by applying a post-reconstruction filter, or canbe implemented as a control to the reconstruction engine which specifies thedesired/expected resolution of the final images.
H.11 Attenuation correction (AC)All SPECT imaging is affected by attenuation which in most procedures can be
tolerated but must be corrected for in brain imaging. The effect of attenuation
depends on the energy of the emitted gamma quants, the density of the medium,and the distance traveled by the quant through the patient’s body. The loss oftransmission due to attenuation is an exponential function of distance. For 99mTc(140keV) the attenuation coefficient is 0.15cm-1, which translates to a transmission
loss of 50% when photons travel 4.58cm through water (density = 1.0). As a result,photons originating from the center of the brain (basal ganglia) are detected with
an apparent lower count rate than photons originating from the surface of thebrain (cortex). Since the objective of brain SPECT perfusion imaging is to measure
and compare regional blood flow in different functional areas of the brain; thiscannot be done without attenuation correction.
Note: the theoretical attenuation coefficient of 0.15cm-1 for 99mTc in water must
typically be reduced to 0.12cm-1 to compensate for the presence of scatter. The
exact value can be determined through a phantom measurement acquired under
the same conditions as a brain SPECT scan.
The most common implementation of attenuation correction in brain SPECT
imaging is a post- reconstruction technique based on the method developed by
Chang [209 210] This method assumes that the attenuation within the patient’s
brain is uniform which is a first order approximation because it does not consider
the bony structures surrounding the brain which are of a higher density than thebrain tissue itself. However, given the overall resolution of SPECT imaging thissimplification is thought to be acceptable because the differences compared to amore accurate representation of attenuation are considered insignificant comparedto other limitations in SPECT imaging such as scatter.
Chang’s method of attenuation is computed and applied on a slice-by-slice basis.
The traditional implementation is manual and requires the operator to draw
elliptical shaped contours around the patient’s head (including bone and scalp).
From these contours, and the attenuation coefficient, a correction matrix is
calculated for each slice that produces the AC corrected slice by multiplication
with the original uncorrected slice.
Note: Chang attenuation correction must be performed in the original orientationof the scan, i.e., prior to any reorientation.
Manual attenuation correction is a time intensive process and is rather subjective,i.e., the process is operator dependent and not reproducible. Some
implementations automate the process by analyzing the background noise in theimages (scatter) which falls off outside of the patient’s head. This typically produces
an irregular contour which however can be constrained programmatically to
produce a shape consistent with the expected outline of a human head. This canwork quite well most of the time, however in both cases it is recommended tosave the outlines overlayed on the slices as a QC image for review.

H.12 Resolution recovery
The resolution of a gamma camera equipped with a collimator changes with
distance. A parallel hole collimator basically is a slab of lead of a certain thickness,with lots of small (circular) holes in it. The intent is to only pass gamma photons
that enter a hole perpendicular to the surface of the collimator. Photons arrivingfrom different angles are attenuated by the lead walls between the holes and do
not reach the detector. Due to the final length of the holes, they have an
acceptance angle, i.e., photons arriving from angles that are slightly off
perpendicular still make it to the detector. Looking back from the detector throughthe collimator holes, the circular area that is seen increases with distance whichmeans the resolution of the imaging system decrease with distance. This is thereason why in nuclear medicine the imaging distance is so important to obtaining
data of high quality (resolution).
The loss of resolution with distance is a pure geometrical effect and it is constantfor a given collimator design. The collimator can be modelled in the iterative
reconstruction engine with just a few parameters. During each forward andbackward projection cycle the change in resolution is accounted for, and thereby
resolves a higher resolution image. This method is also known as collimatordeblurring which more accurately describes its function.
Today most iterative reconstruction implementations for SPECT imaging include
this function. It is a good reason to switch from FBP to iterative as it brings a realadvantage to the imaging chain.
H.13 Scatter correction
All gamma camera systems can acquire multiple energy windows simultaneously.
This feature was originally developed for dual-isotope imaging to capture photon
events at multiple energy levels. However, it can also be used to capture scattered
events which can information that can be used to our advantage.
Scatter correction typically requires the acquisition of two additional energy
windows, surrounding the photopeak window, in separate image channels (triple
energy window technique). Because the scatter windows contain scattered events
only, and their energy is in close proximation of the photopeak events, their noise
spectrum is considered like the noise spectrum of the scattered events recordedin the photopeak window. By means of a weighted subtraction technique, thenoise content of the photopeak images may be reduced, however it can never becompletely removed.
In theory, scatter correction will increase signal to noise ratio of the acquired images.
Phantom measurements are typically used to show its effectiveness; however, its
performance on clinical data is highly dependent on the correct adjustment ofweighting and care must be taken not to overcorrect the images. We want toseparate the good counts (wanted signal) from the bad counts (noise), by subtractingout an estimation of the noise. Because the noise estimation can never be exact, it
can unfortunately subtract too much background and degrade our signal.
H.14 Comparing methods

Modern iterative reconstruction methods may include a reconstruction of thepatient’s head shape from a separately acquired scatter window, typically
positioned just below the photopeak window. This reconstructed shape, associatedwith an attenuation coefficient, can then be used to simulate the attenuation in
the forward and backward projection paths as part of the reconstruction engine.
This can be considered an improvement but because it is no longer a postreconstruction method it cannot be called Chang anymore.
Hybrid SPECT/CT cameras have a CT scanner on board which can be used to obtaina real density map of the patient’s head from which an attenuation map, a socalled -map, can be derived. This -map is then used within the iterative
reconstruction engine to correct for attenuation during the forward and backward
projections (CTAC). Although the CT scan itself is of limited diagnostic use in brain
SPECT perfusion imaging, and the CT scan adds to the total radiation exposure, it
is still considered the most accurate implementation of attenuation correction.
Note: some SPECT/CT camera systems may not be compatible with fan beamcollimators. In those situations, one must decide if the value of CTAC outweighs
the sensitivity improvement of a fan beam collimator.

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Fig. 1a - Histogram comparison

Fig. 1b – Cumulative distribution function

Images produced by FBP and iterative reconstruction from the same projection
data will be different. Most of the differences will be due to image texture, e.g.,
signal to noise, resolution, etc. However, it can not be excluded that different
images can lead to a different interpretation. This can be a complication, especiallyin a mixed environment. Because each brain is unique, it can take years of

E PATIENT-V5N1-777777_Layout 1 21-07-23 12:43 Page 61

experience to become a fully rounded reader. Therefore, it is important to produce
images in a consistent way. Despite their assumed superiority over FBP, thechallenge for using iterative reconstruction is the lack of standardization.

epilepsy monitoring unit to ensure the quickest possible injection time. Patientsshould have continuous video-EEG monitoring in order to relate the injection time
exactly to the time point of the behavioural and electrical seizure onset and end.

These figures illustrate the difference in behaviour of FBP vs IR on the same clinicalprojection data. The area under the histogram curves is the same but the peak isshifted downwards for IR. This is consistent with our expectation that IR will increase
image contrast, i.e., the noise is pushed down and a higher max is resolved.

J.2 Interictal SPECT studies

I. Interventions

The conditions for tracer injection are the same as for the Ictal SPECT scan, but
additionally continuous EEG monitoring should be performed from at least 2 hours
before until 15 minutes after injection to exclude the possibility that seizures
occurred shortly before and during the uptake period of the radiopharmaceutical.
Interictal studies may add useful information to ictal studies.

I.1 Vasodilatory challenge
K. Interpretation criteria
The following recommendations focus on acetazolamide (Diamox TM). Somestudies have been performed with dipyridamole (Persantine) SPECT stress.
Dipyridamole (0.57 mg/kg) is given intravenously 3 minutes before infusion of99m
Tc-HMPAO, with patients studied 30 minutes after Injection. Acetazolamide isa carboanhydrase inhibitor and leads to an increase in rCBF in normal cerebral
vessels via dilatation of the cerebral arteries.
I.2 Indications
The evaluation of cerebrovascular reserve in TIA, completed stroke, carotid arterystenosis or occlusion, vascular anomalies, and evaluation of the results of carotid
surgery, preoperative evaluation of the need for selective carotid shunting during
carotid endarterectomy, evaluation of cerebrovascular reserve before and after
cerebrovascular surgery or stent placement. It may also be useful to help
distinguish vascular from other causes of dementia.
I.3 Contraindications
1) Known sulfa allergy.
2) Use of acetazolamide is not recommended within 3 days of an acute stroke or
recent intracranial hemorrhage.
3) Use of acetazolamide may provoke migraine in patients with a migraine history

K.1 Visual interpretation
Images should be read on computer screen with a similar colour table used for all
patients.
Ideally interpretation will be correlated with CT or MRI anatomic studies, or if
possible, with the use of a hybrid imaging system such as SPECT-CT. If there areanatomic abnormalities, the SPECT study should be interpreted relative to theobserved morphological changes, including atrophy and partial volume changes.
If available, image fusion software may be useful to help clarify the rCBF changes
against the anatomic changes.
L. Reporting
L.1 General Reports should include all pertinent information, including the name ofthe patient and other identifiers, such as birthdate, name of the referring physician,type and date of examination, type of equipment, radiopharmaceutical including theadministered activity, and patient history, including the reason for requesting the study
and any potentially interfering medications.
L.2 Body of the report

4) Caution should be used in patients with renal or hepatic insufficiency.

L.3 Procedures and materials:

I.4 Acetazolamide dosage and properties

Include in the report a brief description of the imaging procedure (including thetype of attenuation/scatter correction used) and assessment of scan quality (ifcompromised, give the reason, e.g., motion artifacts, interstitial injection, poor
radiopharmaceutical preparation.

1) Dosage:a) Adults: 1000 mg by slow intravenous pushb) Children: 14 mg/kg body weight2) Acetazolamide is a diuretic (patients should void prior to positioning under thecamera)If sedation is performed, briefly describe the procedure, including the type andtime of medication given in relation to the time of radiotracer injections.

3) Adverse effects: mild vertigo, tinnitus (perioral) paresthesia, and rarely nausea.
In general these effects are self-limited and do not require specific treatment.
Postural hypotension may also occur.

If interventions are performed, briefly describe the protocol applied.

I.5 Study protocols
Since the vasodilatory effect is most pronounced around 15 to 20 minutes after
injection of acetazolamide, the radiopharmaceutical should be injected within thistime frame.

Describe whether or not the SPECT pattern is normal or not. If findings areabnormal, describe the location and intensity of abnormal tracer uptake.
Description of the anatomic location of the abnormalities (i.e., based on Brodmannareas) can be useful.

Various protocols have been used to study rCBF under baseline condition, andacetazolamide provocation. The 2-day repeat study technique is simplest and therefore
preferable (allow sufficient time between the investigations for residual activity toclear, e.g. 24-48 hours). Either test, whether baseline or challenge, may be performed
first. A “challenge first” test might be favoured, since if it is normal, then the baseline
study can be omitted. On the other hand, performing the baseline study in advanceof the challenge study can be helpful if large perfusion defects are present, suggesting
the need for caution during the challenge infusion of acetazolamide.

The vascular anatomy might also be useful if relating the lesions to vascular origins.
The criteria used (visual assessment, quantitative or semi-quantitative
measurements, or comparison with normal database) should also be reported.

One-day protocols using split-dose techniques (second dose at least twice the firstdose) require more sophisticated evaluation and data processing, and therefore
are less favoured.
J. Epilepsy focalization
J.1 Ictal SPECT studies
The tracer should be injected as soon as the patient begins seizing (via intravenous
line placed previously). It is recommended that prepared syringes be stored in the

L.4 Findings

L.5 Limitations
Where appropriate, identify factors that could have limited the sensitivity andspecificity of the exam, such as patient motion or lesions below the resolution of
the detector.
L.6 Clinical issues
The report should answer any clinical issues raised in the examination history or
imaging request.
If the patient is traveling on the day of injection, they should be informed thatthey may set off radiation detection devices at international airports.
L.7 Comparative data

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Comparisons to previous examinations and reports, if available, should be enteredinto the report. Results of anatomic imaging studies (CT, MRI) if available, image
fusion results, should also be discussed where relevant.
L.8 Interpretation and conclusions:
To the extent possible, provide a differential diagnosis based on generally accepted
disease- specific patterns. If no such pathognomonic patterns exist, theinterpretation should be considered as requiring confirmation with other tests,
follow-up or additional studies, or referred to as “consistent with” or “notconsistent with” the reasons for ordering the studies.
M. Quality Control
See procedure guidelines of the EANM
N. Sources of error
1. Unintended cerebral activation
2. Artifacts (patient movement, camera problems, computer software malfunction)
3. Interference with drugs

10. Woodford H.J., George J. Cognitive assessment in the elderly: a review of clinical methods
DOI: 10.1093/qjmed/hcm051 469-484. First published online: 12 June 2007.
11. Kubota T, Ushijima Y, Yamada K, Okuyama C, Kizu O, Nishimura T. Diagnosis of Alzheimer’s
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diagnostic accuracy? Eur J Nucl Med Mol Imaging. 2005; 32: 414-421.
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13. Miwa K, Inubushi M, Takeuchi Y, Katafuchi T, Koizumi M, Saga T, Sasaki M Performance
characteristics of a novel clustered multi-pinhole technology for simultaneous high-resolution
SPECT / PET Annals of Nuclear Medicine. June 2015; Volume 29, Issue 5: 460-466.
14. Bonte FJ, Harris TS, Roney CA, Hynan LS. Differential diagnosis between Alzheimer’s andfrontotemporal disease by the posterior cingulate sign. J Nucl Med. 2004; 45: 771-4.
15. Song IU, Yoo I, Chung YA, Jeong. The value of brain perfusion SPECT for differentiation
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16. HashimotoH, Nakanishi R, Mizumura A, Hashimoto Y, Okamura Y, Yamanaka K, Ikeda T.
Prognostic value of 99mTc-ECD brain perfusion SPECT in patients with atrial fibrillation anddementia. EJNMMI Research. 2020; 10:3

4. Normal variation
5. Level of contrast or background subtraction
6. Inappropriate thresholding can result in artifact. Thresholding should only be
used based upon knowledge of a normal database
7. Colour table: Use of non-continuous colour tables may overestimate changes
due to abrupt colour changes.
O. Technological developments
New SPECT cameras are being developed with improved detector efficiency andspatial resolution, such as those using solid state detectors, such as CZT (Cadmium
Zinc Telluride) or dedicated multi-pinhole detectors, continuous or discontinuous
rings, or SPECT-CT for attenuation correction. MRI-SPECT fusion is available byseveral software vendors. Certain novel cameras allow for dynamic 4-D SPECT
acquisitions, as well as PET-resolutions.
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