Gary L. Dillehay

SNM Practice Guideline for Parathyroid Scintigraphy 4.0

1St. Louis, Missouri; 2Northwestern University, Chicago, Illinois; 3Thomas Jefferson University, Philadelphia, Pennsylvania; 4Southern Molecular Imaging, Savannah, Georgia; 5St. Thomas’ Hospital, London, United Kingdom; 6North Shore–Long Island Jewish Health System, New Hyde Park, New York; 7Barnes–Jewish Hospital, St. Louis, Missouri; 8Vanderbilt University, Nashville, Tennessee; and 9Milton S. Hershey Medical Center, Hershey, Pennsylvania

The ultrasonographic characterization of tendons

Ultrasonography has not been utilized in the diagnosis of musculoskeletal disorders. However, the superficial location of tendons and ligaments lend themselves to evaluation by this modality. The ultrasonographic characteristics of the normal Achilles tendon are described in both the rabbit and man. The characteristic ultrasonographic findings after injury to the Achilles tendon are also determined. This imaging technique provides a sharp definition of the tendon and surrounding structures and easily demonstrates abnormalities. The superficially located quadriceps tendon is also well visualized by ultrasound and representative examples are shown. Ultrasound should be considered as another useful method for evaluation of these superficial musculoskeletal structures.

The SNM Practice Guideline for Somatostatin Receptor Scintigraphy 2.0

VOICE Credit: This activity has been approved for 1.0 VOICE (Category A) credit. For CE credit, participants can access this activity on page 325 or on the SNM Web site (http://www.snm.org/ce_online) through December 31, 2013. You must answer 80% or the questions correctly to receive 1.0 CEH (Continuing Education Hour) credit.

Radionuclide cerebral imaging for confirmation of brain death in children: The significance of dural sinus activity

Radionuclide cerebral imaging revealed no cortical flow, but recorded persistent dural sinus activity in 14 of 55 clinically brain dead children. Of these 14 children, 13 had isoelectric electroencephalograms. Postmortem liquefactive necrosis was present in 7 cases. Although studies that demonstrated the absence of flow were confirmatory of brain death, dural sinus radioactivity in the delayed static images persisted in the presence of brain death.

F-18 FDG-PET predicts outcomes for patients receiving total lymphoid irradiation and autologous blood stem-cell transplantation for relapsed and refractory Hodgkin lymphoma

Total lymphoid irradiation (TLI) followed by high‐dose chemotherapy and autologous haematopoietic stem cell transplant (aHSCT) is an effective strategy for patients with relapsed/refractory classical Hodgkin lymphoma (HL). We report outcomes for patients with relapsed/refractory HL who received TLI followed by high‐dose chemotherapy and aHSCT. Pre‐transplant fludeoxyglucose positron emission tomography (FDG‐PET) studies were scored on the 5‐point Deauville scale. Of 51 patients treated with TLI and aHSCT, 59% had primary refractory disease and 63% had active disease at aHSCT. The 10‐year progression‐free survival (PFS) and overall survival (OS) for all patients was 56% and 54%, respectively. Patients with complete response (CR) by PET prior to aHSCT had a 5‐year PFS and OS of 85% and 100% compared to 52% and 48% for those without CR (P = 0·09 and P = 0·007, respectively). TLI and aHSCT yields excellent disease control and long‐term survival rates for patients with relapsed/refractory HL, including those with high‐risk disease features. Achievement of CR with salvage therapy is a powerful predictor of outcome.

The effect of fine-needle aspiration biopsy on the thyroid scan

Fine-needle aspiration biopsy (FNAB) is the most sensitive and specific procedure in diagnosing benign from malignant thyroid nodular disease. The effects of a FNAB on the thyroid scan, however, have never been studied. This assumes importance because a hot nodule on scan has been advocated as useful to differentiate certain benign from malignant follicular neoplasms. Thyrold scans were performed before and after FNAB on 11 patients with nodular thyroid disease and an area of normal or increased uptake either in the nodule or in a contralateral enlarged lobe to determine if the blopsy changed the pattern of isotope uptake. For this study, biopsies were done in the area of normal or increased uptake. In two patients, there was a reduction in isotope concentration in three nodules after FNAB, whereas no change was demonstrable in nine other patients. Review of the literature revealed a number of prior reports of hemorrhage, necrosis, or infarction of thyroid nodules after FNAB. Based on these data and the demonstration of a change in scan pattern in a patient following FNAB, it is concluded that FNAB may decrease the isotope uptake in thyroid nodules; therefore, the concept of clinical judgments being based on the scan pattern after FNAB should be reevaluated.

ABNM Position Statement: Nuclear Medicine Professional Competency and Scope of Practice

The purpose of this position statement is to define the scope of nuclear medicine practice and the professional competencies required now and for the future. Medical practice will change dramatically over the coming decades in ways no one can predict. The methodologies, technology, and radiotracers will certainly change. However, the core concepts and knowledge that were first required for nuclear medicine board certification in 1971 still hold true and will guide and sustain us into the future. The American Board of Nuclear Medicine (ABNM) is one of the 24 primary boards of the American Board of Medical Specialties (ABMS). This organizational structure provides an infrastructure that promotes transparency and accountability for all the member boards.

SNMMI Comment on ASCO 2013 “Choosing Wisely” Recommendation on Use of PET/CT in Recurrent Cancer Surveillance

The Society of Nuclear Medicine and Molecular Imaging (SNMMI) would like to comment on the recent publication of the American Society of Clinical Oncology (ASCO) Top Five List in Oncology as part of the Choosing Wisely Campaign. Specifically, we wish to comment on recommendation 3, which states: “Avoid using PET or PET-CT scanning as part of routine followup care to monitor for cancer recurrence in asymptomatic patients who have finished initial treatment to eliminate the cancer unless there is high-level evidence that such imaging will change the outcome.” The recommendation further states that monitoring of recurrence with PET/CT does not improve outcomes and that falsepositive tests can lead to unnecessary and invasive procedures (1). The SNMMI feels that these statements are overly broad and are subject to misinterpretation by the oncologic community. First and foremost, it must be clarified that the subject of this recommendation by ASCO is PET/CT using 18F-FDG. There are other radiotracers for oncologic imaging with PET/CT, including Food and Drug Administration–approved radiotracers such as 18F-fluoride for bone imaging and 11C-choline for imaging of prostate cancer. With the emergence of new radiotracers, we encourage the medical community to communicate with a greater degree of accuracy, specifying the type of PET/CT scan under discussion (e.g., 18F-FDG PET/CT). With regard to false-positive results, this is an issue with any diagnostic procedure. The authors of the recommendation supply no references to support the implication that 18F-FDG PET/CT is particularly more prone to false-positive results than are other imaging tests such as CT or MR imaging. In the setting of disease detection and surveillance, it must also be recognized that the performance characteristics of a given diagnostic procedure must match the clinical use and that false-positive rates (i.e., high sensitivity) are sometimes desirable. In screening mammography, for example, it would be beneficial to have high sensitivity over high specificity and to rely on the postscreening workup to differentiate truefrom false-positive cases. Other factors obviously come into the discussion, including cost, comparative effectiveness, and accessibility, all missing from the ASCO recommendation. Another issue is the statement that “Until high-level evidence demonstrates that routine surveillance with PET or PET-CT scans helps prolong life or promote well-being after treatment for a specific type of cancer, this practice should not be performed.” There are existing definitions of levels of evidence—for example, those put forward by the National Comprehensive Cancer Network—but the authors of the recommendation supply neither a definition nor a reference. In the absence of such a definition, the term high-level evidence becomes a moving target, and difficult to achieve. In fact, there are studies in the literature promoting the use of “surveillance” 18F-FDG PET/CT for selected tumor types, showing good test performance characteristics and improvement of patient outcomes. For example, in patients with cancers of the head and neck, disease detection with 18F-FDG PET/CT leads to improved outcomes (2,3). Similarly, in patients with colorectal carcinoma with rising carcinoembryonic antigen levels and negative findings on conventional imaging, 18F-FDG PET/CT shows incremental benefit in the detection of the site of recurrence, which could lead to directed therapy such as stereotactic radiotherapy (4). It is also established in the literature that there are scenarios in which surveillance imaging with 18F-FDG PET/CT provides no incremental benefit to the patient, such as in patients with certain types of lymphoma (5,6). To the point of emphasis on outcomes, we highlight an article in which surveillance imaging with 18F-FDG PET/CT in patients with advanced melanoma was shown to detect disease earlier than any other imaging procedure, yet despite the early detection there was no impact on overall patient survival (7). The recommendation also refers to policy documents from the Centers for Medicare and Medicaid Services and Cancer Care Ontario. These governmental bodies are directly or indirectly concerned with the economic impact of coverage of 18F-FDG PET/CT scans and as a result could be perceived as having a disincentive to promote their use. The ASCO recommendation also refers to a practice guideline issued by the European Society of Medical Oncology that discusses all aspects of the care of the patient with colon cancer. In fact, close review of this article reveals that 18F-FDG PET/CT is not mentioned specifically in the section on surveillance. The authors merely state, “other laboratory and radiological examinations are of unproven benefit. . . .” The SNMMI invites ASCO to collaborate on a framework for the incorporation of imaging into clinical trials, such that all involved parties could consider the results “high-level evidence.” In such a way, the societies could lead the way in defining and promoting the use of high-quality and impactful imaging and appropriately and specifically discourage the use of imaging when not justified by data. Such collaboration will better serve our patients and the physicians who care for them, by providing data-driven recommendations for the use of imaging in the cancer patient.

Euro-American discussion document on entry-level and advanced practice in nuclear medicine

The European Association of Nuclear Medicine Technologist Committee (EANMTC) and the Society of Nuclear Medicine Technologist Section (SNMTS) meet biannually to consider matters of mutual importance. These meetings are held during the SNM and EANM annual conferences. For several years, within these meetings, EANMTC and SNMTS have considered the value of having a Euro-American initiative in defining entry-level and advanced practice competencies for nuclear medicine radiographers (NMRs) and nuclear medicine technologists (NMTs). In June 2009, during the SNM annual conference in Toronto, it was agreed that a Euro-American working party would be established to consider advanced practice. It was recognized that any consideration of a definition for advanced practice would be predicated on an understanding or definition of entry-level practice. As a result, both types of practice would have to be considered. This discussion document outlines some of the background issues associated with advanced practice generally and specifically within nuclear medicine. The primary purpose of this document is to stimulate debate, on a Euro-American level, about the perceived value of advanced practice for NMRs and NMTs within nuclear medicine and to develop an internationally accepted list of entry-level competencies and scope of practice for NMRs and NMTs within nuclear medicine.

Tin level requirements for multiple gated studies in humans: a new perspective.

Abstract Stannous pyrophosphate (Sn-PYP) has been used for over a decade for in vivo and in vitro labeling of red blood cells with 99m Tc. Literature references indicate minimum levels of stannous ion [Sn(II)] acceptable for successful labeling, based on in vitro experiments, to range from 140 to 400 ng/mL of whole blood. Our study was undertaken in 200 patients using two different commercially available formulations of Sn-PYP in order to quantitate the Sn(II) levels required on an in vivo basis to achieve consistently high quality labeling.