Nuclear Medicine in the 21st Century: Integration with Other Specialties Integration"—the watchword of the 1960s cine worked to set a name for itself as an inde "icivil rights movement, and now a catch pendent medical specialty. It had been left with a word of modern business management— few battle scars after making a break from radi "Now that we is also a concept becoming more and more fre ology. "During the 1970s, nuclear medicine quently used by nuclear medicine leaders, was trying to establish its own turf, and we were have established scientists and industry leaders. Just as academic always on the defensive," explained Wagner. "Now disciplines, telecommunications firms, hospitals, that we have established ourselves as a strong ourselves as a and other businesses have been merging and medical specialty, we need to integrate with other strong medical reconfiguring their organizations, many nuclear departments and develop relationships that can medicine physicians are contending that nuclear benefit the institution as well as the patient." At specialty, we medicine needs to integrate with other special Johns Hopkins, nuclear medicine has always been ties such as cardiology, oncology and surgery in part of the radiology department, but this part need to integrate, order to increase the demand for nuclear medi nership has grown stronger through the years as cine procedures in managed health care systems. the two specialties have developed a nearly and develop In essence, nuclear medicine can no longer be a symbiotic relationship. Recently, the department relationships separate-but-equal medical specialty. "Integra established a PET radiopharmaceutical net tion is the key to our future," asserted Henry N. work that will soon begin providing PET tracers that can benefit Wagner, Jr., MD, professor of medicine, radiol to local hospitals. "Nuclear medicine has quadru ogy and environmental sciences at the Johns Hop pled its space, and we are getting a new PET scan the institution as kins Medical Institutions in Baltimore, MD. ner and cyclotron," said Wagner. He emphasized Nuclear medicine departments at several lead that the project was the result of a close collabo well as the ing academic institutions throughout the country ration between the nuclear physicians and radi patient." have already begun to create stronger connections ologists within the department. to other medical specialties, as well as to the Although radiology has traditionally been paired biological sciences. with nuclear medicine, other specialties like car In the most dramatic example of integra diology and internal medicine have also crossed tion, the nuclear medicine division at the Uni over into nuclear medicine. The establishment of versity of California Los Angeles (UCLA) the American Society of Nuclear Cardiology sev School of Medicine has merged with the Depart eral years ago provided a merging ground for car ment of Pharmacology in 1993 to form a new diologists and nuclear physicians. Moreover, Department of Molecular and Medical Phar the ABNM recently submitted a proposal to the macology. Other institutions, like Memorial American Board of Internal Medicine to develop Sloan Kettering Cancer Center in New York, a dual residency program, just as it has with radi have integrated nuclear medicine with other spe ology. cialties through weekly conferences and grand Nuclear physicians with dual specialties have rounds. Perhaps the most symbolic intertwining traditionally been radiologists or cardiologists, of nuclear medicine with other medical spe but whether they can actually integrate nuclear cialties is the recent advent of a combined medicine with other specialties remains an unan PET/CT scanner. In a technique called "fusion swered question. "Physicians from other spe imaging," the scanner can perform back-to-back cialties such as oncology and psychiatry have CT and PET studies to provide both anatomic expressed some recent interest in receiving board and metabolic information in a single scan certification in nuclear medicine, but whether session. (See box on page 2IN.) there will be jobs for these people has yet to be determined," said R. Edward Coleman, MD, a Making Peace After the Turf Battles professor of radiology and director of nuclear Through the 1971 establishment of its own pri medicine at Duke University Medical School in mary certifying board—the American Board of Durham, NC. Nuclear Medicine (ABNM)—nuclear medi Teaching hospitals throughout the country have

Newsline 13N begun their own training programs to enable A Partnership with Molecular Medicine residents in various specialties to rotate through When Phelps first conceived of merging nuclear nuclear medicine departments as part of their medicine and pharmacology at UCLA six years training. "We've built joint training programs and ago, he recognized the contribution that nuclear joint clinical programs with internal medicine, medicine could make to the newly emerging field similar to those we have with radiology," said of molecular medicine, which itself grew from Michael Phelps, PhD, chair of the Department of the merger between modern biology and medi Molecular and Medical Pharmacology at UCLA. cine. "I wanted to establish an academic envi "In addition, we have faculty from medicine, pedi ronment where basic biological and physical sci atrics, neurology and psychiatry that participate entists could come together with clinical scientists in our general nuclear medicine readouts to to contribute to the revolutionary advances occur increase our knowledge and involvement in med ring in the field of molecular medicine," Phelps ical management and for them to increase their said. "The new department would bring together knowledge about the benefits of nuclear medi diagnostic and therapeutic concepts of nuclear cine, as well as to be our advocates within their medicine and pharmacology to be a part of the practices." new molecular medicine."

The Value of a PET/CT Scanner

tem since a CT component cannot be added on to existing PET scanners already in use, according to Townsend. "The cost will vary depending on the system," he said. "A nuclear medicine department may want a high-performance PET with a moder ate performance CT,whereas a radiology department may want the opposite." Still, the combined system will be less expensive

than purchasing the two machines separately since many of the same components can be used for both. "We have had responses

from nuclear medicine physicians, radiologists and oncologists at the conferences where I have been lecturing," Townsend said. "So far, the interest has been overwhelming."

The dual scan takes an average of 30 minutes to perform, A new imaging system that combines PET and CT in a single though some scans may take more than one hour (depending on scanner is currently being tested in research trials. Primarily the size of the area being imaged]. The PET/CT scanner will be useful for oncologie imaging, the fusion imaging system will marketed by Siemens CTI PET Systems in Knoxville, TN, and will enable physicians to obtain a CT scan and PET scan in a sin probably not become available until the end of the year 2000, gle session, making it easier to align the anatomic features of according to Townsend. In addition, General Electric (GE] Med a CT scan with the biological information shown by PET. Cur ical Systems in Milwaukee, Wl, has developed a fusion imaging rently, radiologists must perform CT and PET scans in sepa system that combines a SPECT scanner with a coincidence detec rate sessions, during which a patient's position may have shifted. tor and a CT scanner for anatomic images. The G E "Hawkeye"

The shift in turn may cause a movement of organs that makes scanner is currently awaiting approval from the Food and Drug the alignment of images difficult to achieve. "Since PET gives Administration. limited anatomical information, it is often difficult to pinpoint the exact location of a tumor in a PET scan, especially in the abdomen and in the head and neck," explained David Townsend,

PhD, an associate professor of radiology and senior PET physi cist at the University of Pittsburgh. Townsend helped invent the PET/CT scanner. In an abstract presented at the Society of Nuclear Medicine Annual Meeting in Los Angeles, Townsend and his colleagues compared whole-body ¡magestaken with the PET/CT scanner with PET imaging alone. They found that the combined system offered "better localization of lesions for surgical planning, dif

ferentiation of normal variants versus juxtaposed neoplastic processes, and characterization of biopsy sites."

The PET/CT scanner would be purchased as a separate sys

14N THE JOURNALOF NUCLEARMEDICINE•Vol. 40 •No. 7 •July 1999 UCLA School of Medicine (

Dept of Molecularand MedicalPharmacology

Division of Nuclear Medicine

DOE Laboratory of Structural Crump Institute for Biology and Molecular Medicine Biological Imaging

UCLA, the DOE, and He recalled that his idea of merging these two therapy in living animals. Various current pro N IH have joined forces disciplines was met with some opposition at first. jects range from studying the molecular/genetic to develop new drugs "There were difficulties in transferring nuclear mechanisms of cancer to learning about the mech and study the way they alter biological medicine from radiology to pharmacology and anisms for DNA integration into host cells by processes. bringing such diverse faculty and students together viruses that cause disease or are used as vehi to implement this new concept," he said. "Some cles for gene therapy. Some researchers are also people at UCLA were concerned that I was going exploring the neurochemical basis of normal cere to build just an imaging department," Phelps said. bral function and its alterations in disease, the "They did not see the wonderful way we could identification of the antigen for diabetes and its merge the principles of modern pharmacology treatment, NO signal transduction, and COX-2 and biology with biological imaging to create a inhibitors for the treatment of inflammatory new school of thought where imaging could pro disease, cancer and Alzheimer's disease. The over vide a unique way to watch and measure the inte all aim of these basic science studies is to develop grated function of cells, viruses, organ systems new pharmaceuticals and radiopharmaceuticals, and organisms." What began as a somewhat risky some of which will then be tested in clinical tri experiment is now a fully integrated department als within the same department. Attracted to the with a singular vision (albeit a diverse approach fact that a single department, housed within a to achieving it). renowned medical school, can both develop new As members in a department with nuclear med drugs and study the way they alter the biologi icine, the basic biological science faculty in cal processes of disease, pharmaceutical compa Phelps's department have integrated imaging in nies, the Department of Energy and the National their research projects. Researchers have been Institutes of Health have provided research grants able to more readily employ nuclear imaging in to UCLA (see "Pharmaceutical Discovery and their protocols thanks to the recent invention of Development," p 22N). The Department of Mol microPET, a miniature PET scanner that can be ecular and Medical Pharmacology, the Labora used to image small animals. MicroPET is being tory of Structural Biology & Molecular Medi used to image genetically engineered mice to see cine, the Crump Institute and the Division of if they are expressing the correct gene or to mon Nuclear Medicine (all of which are headed by itor the location and degree of expression in gene (Continued on page 25N)

Newsline 2IN CHCPPNEVUS COMMISSION ON HEALTH CARE POLICY ANO PRACTICE

CHCPP Update: HCFA Policy on Ordering Diagnostic Tests SNMrecently contacted Terrence Kay at definitive response from HCFA on this the radiologist, nuclear medicine or other the Health Care Financing Administra issue. To the best of my knowledge, physician as long as the ordering physi tion (HCFA) to inquire about ordering HCFA has never addressed our specif cian is notified of the additional testing. diagnostic tests. In part, that letter read: ic comments regarding the October We feel that we did address your com HCFA published policy and comments 1997 rule. ment in the October 31,1997 final rule on "Ordering Diagnostic Tests" in itsJune by indicating that we did not fully under 18, 1997 and October 31, 1997 rules. Kay replied on April 20, 1999 as fol stand your concern. We would like more In response to SNM's June 1997 com lows: specific information about the State and ments, HCFA's October 31, 1997 rule I am responding to your letter... Federal regulations which preclude any stated that "in order to address these con regarding the requirement that diag one other than a nuclear medicine physi cerns more fully, we would need more nostic tests payable under the physician cian from ordering nuclear medicine pro specific information as to the state and fee schedule be ordered by a physician cedures. This would be helpful for us to federal regulations in question." SNM's or nonphysician practitioner who is determine whether further revision of October 1997 comments responded to furnishing a consultation or treating the our regulations for diagnostic testing is this request for regulatory information; beneficiary for a specific medical prob needed. however, this issue was never addressed lem. There is no requirement that the Otherwise, we believe that your sug or clarified in the 1998 proposed or final order be in writing (except in the case gestion would eventually have to be rules. of an independent diagnostic testing facil extended to everyone and would, in effect, Members of our organization have ity), and there is no requirement that make the ordering requirement mean contacted us recently to inquire about the carrier verify the existence of such ingless. Finally, it would be helpful to ordering additional diagnostic tests an order before making payment. Fur know of any instances in which your (e.g. chest x-rays) when indicated. We ther, neither the rule itself nor the pre members are being denied payment inap are unable to respond to these inquiries amble discussion precluded coverage of propriately for their services because because we have never received a the performance of additional testing by of this requirement.

schman, respectively," said Phelps. Integration specialists who are quite open to new (Continued from page 2IN) While conceding that most nuclear ideas," said Homer Macapinlac, MD, Phelps) will receive a combined total medicine programs are not headed for clinical director of the PET facility at of more than $20 million in research the dramatic change that his department Sloan Kettering. Every cancer patient funding this year compared to $7 million underwent, Phelps emphasized that inte- is treated via a team approach that in funding six years ago. gration will play an integral role in involves weekly meetings among the If awards are any measure of success, nuclear medicine. "The concept of bio nuclear physician, surgeon and medical Phelps's department is among the most logical imaging is growing, and I believe oncologist. "We also give nuclear med successful in nuclear medicine. Lou it will become a new discipline in bio icine seminars in areas such as lym- Ignarro, PhD, a faculty member in the logical sciences," said Phelps. "I also phoma, melanoma and breast cancer department, won the Nobel Prize this believe that biological imaging exami that are well attended by the oncolo year and was elected this year, along nations of patients that stem from this gists," Macapinlac said. Moreover, each with Phelps, to the National Academy research will continually be building the of the five nuclear physicians on staff future of nuclear medicine." of Sciences. Phelps also won the 1999 has a special interest area such as head Enrico Fermi Presidential Award, the and neck cancer, whole-body PET imag highest and oldest science and tech Reaching Out to Other Specialties ing or monoclonal antibody therapies. nology award given by the United States Other research institutions through "Our nuclear physicians have liaisons government, for his invention of the PET out the country have created integrated with the disease management group scanner. "Also, two of the largest sell nuclear medicine departments, albeit in in each of our specialized areas," ing drugs, Viagra and the COX-2 a less formalized way than the depart Macapinlac said. "We are getting con inhibitors, were developed based on dis ment at UCLA. "At Sloan Kettering, we stant feedback about our procedures that coveries made by two faculty of the take a team approach, and our nuclear allows us to keep the relationship going department, Drs. Ignarro and Her- physicians have close contact with other and to give them what they need to deter-

Newsline 25N mine treatment for their patients." diologist sees cardiac patients and per form more than 2000 PET scans this While it is true that nuclear physicians forms perfusion imaging," he said. year, compared to 1600 scans last year who work at a cancer center may have Most nuclear medicine leaders and 1200 scans in 1997. Although an easier time integrating into a spe believe, however, that nuclear medicine nuclear physicians perform the scans cialty beyond nuclear medicine, nuclear will remain a separate entity unto itself and process all the data at Duke, physicians at broader-based hospitals with nuclear physicians maintaining researchers from various specialties can still apply the techniques used at broad-based practices in nuclear med have recently become more well-versed Sloan Kettering to their own practices, icine or radiology. Still, the growing in the intricacies of PET, according to according to Macapinlac. For instance, number of uses for nuclear medicine in Coleman. "However, I don't see inte a nuclear physician can focus on sports molecular imaging has ignited an excite gration of nuclear medicine with other medicine and set up a team with ortho ment among physicians outside the specialties at this point," he said. pedics, while another can focus on car nuclear medicine field. "The under Only time will tell whether integration diology and create links with the car standing and knowledge of PET among is indeed the wave of the future. For the diac care unit. In fact, Wagner takes this referring physicians has increased dra present, nuclear physicians can use one concept one step further: He said he matically over the last year or two," said simple assessment to determine whether believes that the disintegration of the Coleman. He has experienced a sig their own discipline has become more traditional nuclear medicine department nificant increase in referrals for PET integrated: Where is it located? "Our and the integration of nuclear medicine procedures, especially after Medicare department is located in a busy section into various specialties could be a very began to cover PET for certain indica of the hospital, not in the basement away real possibility in the next millennium, tions. "Our department experienced a from everyone," said Macapinlac. at least at some institutions. "A nuclear 30% increase in PET procedures from "Referring physicians want us in a con oncologist would have an oncology 1997 to 1998, and we expect the increase venient location, so they can drop in on practice and also perform lym- to continue this year," said Coleman. He a regular basis and see our scans." phoscintigraphy, just like a nuclear car said he expects his department to per —Deborah Kotz

SNIDD an opportunity to determine if these prob by building complete micro-PET sys (Continued from page 23N) lems exist before developing a compound tems within CT or MRI machines in order two of the first eight commercially pro further. Put another way,tremendous cost to combine precision functional and duced small-animal PET scanners, which savings can be realized by being able to anatomical imaging." are copies of the prototype scanner devel make early decisions about a lead com Lack of communication and the cur oped by Cherry's research group (see pound's suitability for further develop rent limitations of nuclear imaging Chatziioannou et al, "Performance Eval ment." modalities are not the only challenges uation of microPET: A High-Resolution Another anticipated benefit is that SNIDD faces in forging industry-acad LSO PET Scanner for Animal Imaging," micro-PET will provide more sophisti emic partnerships, said Frank. "The inter in this issue). cated ways to utilize the many transgenic national pharmaceutical industry has "We originally built the prototype as mouse models of disease that have recently concluded, very significantly, a physics challenge without really appre become central to the drug development that no drug company can singularly own ciating the wide range of applications. process, said Cherry. "With micro-PET, the new imaging modalities. Rather, these We now find we need a second system we can repeat the same study on a single technologies will remain in the public here at UCLA because the small-animal mouse, which allows us to do very use domain and drug companies will com scanner has become our most heavily ful things such as monitoring the bio pete on a drug-by-drug basis. Still, the used PET machine," said Cherry. An chemical response to drugs as a function proprietary nature of molecules and anticipated dividend of commercializ of time. In the future we also believe that imaging systems patented by a phar ing micro-PET that SNIDD emphasizes we will be able to monitor gene therapy maceutical company will have to be con is that the technology will provide a seam with PET, providing us with a tool to sidered by its academic partners who less transition from preclinical phar assess new molecular therapies. Con want access to these resources." Another macologie studies to phase I trials, said tinued improvements in PET spatial res challenge, added McCarthy, will be to McCarthy. "At the early stage in drug olution will in a year or so allow for more try to standardize the way in which val development, compounds are evalu precise measurements of the biologic idation studies of new radiopharma- ated in small animal models. In many effects of drugs on particular sets of cells ceuticals are carried out among the radio- cases, these compounds may behave dif in the mouse. Perhaps within five years pharmaceuticals research community. ferently in higher species. PET provides these capabilities will be further enhanced —JillKatz

26N THE JOURNALOF NUCLEARMEDICINE«Vol. 40 •No. 7 •July 1999