Volume 3, Issue 3

SUMMER 2006 pet center of excellence newsletter

SNM Members Appointed to National Academy of Sciences PET Coding Review Committee to Review State of and Resources By Denise A. Merlino, MBA, CNMT, CPC, FSNMTS Peter S. Conti, immediate past president of ET is a technology that continues to evolve, and coding, coverage, and payment both SNM and the PET Center of Excellence, Psystems have been evolving along with it. In March of 2005, PET providers and a number of other SNM members were transitioned from using complicated “G” series Healthcare Common Procedure Cod- recently named to the National Academy of ing System (HCPCS) codes to the American Medical Association (AMA) Current Sciences (NAS) ad hoc committee of experts Procedural Terminology (CPT) codes for Medicare-covered indications. Last January, to review the “state of the science” for nuclear PET radiopharmaceutical HCPCS codes were changed for FDG and rubidium. Finally, medicine. in May, the National Oncologic PET Registry (NOPR) went into operation providing “The 13-month $700,000 study will pro- Medicare coverage of FDG PET studies for all cancer indications that did not fall under vide the opportunity to validate the importance the current national coverage determination (NCD) policy. of basic nuclear medicine research,” said Every change brings with it the need to train staff, update billing software, and make Conti, a professor of , pharmacy and certain that all billing procedures are in compliance with the new regulations. The list biomedical engineering at the University of below summarizes the top 10 things you need to know about coding PET today. On the Southern California, Los Angeles. “Nuclear following page you will find a list of PET coding resources and, on page 3, a table listing medicine research has a proven record of all of the current PET codes and descriptions. leading to improvements—from bench to bed- 1. The Medicare National Coverage Determination (NCD) Manual is your bible for side—in the diagnosis and treatment of life- indications on which CMS has already reached a coverage determination. (Such threatening cancer and debilitating and indications are not eligible for NOPR.) Every PET facility should have this CMS neurological diseases that affect millions each document on hand when coding PET procedures. year.” 2. The PET NCD policy is considered an exclusionary policy; therefore, if a PET The study, which will be funded by the radiopharmaceutical or indication is not mentioned in the national coverage Department of Energy (DOE) and National policy and is not eligible under the new NOPR program, that procedure is not Institutes of Health (NIH), was prompted by a covered by Medicare. An example of this is “sodium fluoride F-18 bone scan $23 million cut in funding from DOE’s 2006 imaging.” Medicare does not currently cover this procedure. (Other third party fiscal year budget, effectively eliminating all payers may; however, I am not currently aware of any.) money for basic nuclear medicine and molecu- 3. Your local coverage determination (LCD) policies or carrier bulletins and news- lar imaging research. Basic molecular imag- letters (published by the Medicare contractor) are key sources for ICD 9 CM ing/nuclear medicine research has been funded diagnosis codes and any frequency limits. Carriers have discretion so these can by the DOE since biomedical research was vary from state to state. (Notice the NCD for PET does not mention ICD 9 diag- initially included in the Atomic Energy Act nosis codes except for PET for Alzheimer’s and neurodegenerative diseases.) If of 1954. (The Atomic Energy Commission was your contractor does not publicly publish this information or furnish it upon DOE’s predecessor.) The study is expected to request, you can obtain it through the Freedom of Information Act. provide findings and recommendations on the 4. Use AMA CPT codes for Medicare covered indications; for noncovered indica- following issues: tions use G (HCPCS) level II codes. • Future needs for radiopharmaceutical 5. Know the difference between diagnosis, staging, restaging, and monitoring. (Medicare development for the diagnosis and treat- does not pay for surveillance.) Details can be found in the NCD for PET. ment of human disease; (Continued on page 2. See Coding.) • Future needs for computational and instrument development for more precise localization of radiotracers in normal and PET on the Net 4 aberrant cell physiologies ; Views You Can Use 5 • National impediments to the efficient PET in the Literature 6 entry of promising new radiopharmaceu- SNM Speaks Out on PET 7 (Continued on page 2. See NASC.) JNM Publishes NCI-Sponsored Guidelines for Using FDG PET 10 In this issue (Coding. Continued from page 1.)

6. Always bill separately for the PET radiopharmaceutical. With so many questions in the PET community’s mind about Historically, payers bundled payment for PET radiophar- how to correctly code PET procedures, the SNM Coding and maceuticals with the PET procedure when billing with G Reimbursement Workgroup set out to answer over 25 common codes. After the transition to CPT codes, most Medicare questions and answers. Logged-in SNM members and Coding contractors set payment rates for radiopharmaceuticals Corner members can access SNM’s newly updated PET and PET/ separate from the procedures. There are a few states such CT Q & A at www.snm.org—click PRACTICE MANAGEMENT, as Florida that continue to bundle payment for FDG; stay then CODING CORNER. tuned, as this is likely to change. So how does a PET facility get the details on the 10 impor- 7. Know your technology. What is the difference between a tant issues listed above and keep pace with all these and future PET scan and a CT scan versus a PET/CT on an integrated changes? PET facilities should obtain and keep current a library system? The codes will change based on the type of equip- of important resources for PET. Additionally, they should check ment used and how and when the scan was acquired. frequently with CMS and their professional societies for changes 8. Know the important modifiers for PET procedures. For and updates to any of these documents. The following list of ref- example, “59” identifies a diagnostic CT on the same day erences should be considered staples in any PET facility billing as a PET or PET/CT scan, and the “QR” modifier is for department. NOPR patients. 9. For cardiac PET imaging, providers cannot use the wall motion and ejection fraction codes used with SPECT procedures. Instead, consider using “CPT 78499, unlisted nuclear medicine cardiac procedures.” PET Coding Resources 10. For FDG tumor brain imaging use CPT 78608, not the more general PET tumor codes CPT 78811-78816. As with Medicare National Coverage Determinations Manual Section any nuclear medicine coding, always use organ-specific 220.6 coding if available. www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf

Medicare Claims Processing Manual, Chapter 13 Radiology and other Diagnostic Procedures (NASC. Continued from page 1 ) . www.cms.hhs.gov/manuals/downloads/clm104c13.pdf tical compounds into clinical feasibility studies and strate- gies to overcome them; and CMS Medical Learning Network MLN Matters Expanded • The impact of shortages in radioisotopes or highly trained Coverage for PET Scans MM 3741 radiochemists on nuclear medicine research, and short- and www.cms.hhs.gov/MLNMattersArticles/downloads/MM3741.pdf long-term strategies to alleviate such shortages. National Listing of all NCD’s, and LCD’s Other SNM members on the NAS committee include Joanna S. www.cms.hhs.gov/mcd/search.asp Fowler, a senior chemist at Brookhaven National Laboratory and director of the Brookhaven PET Program, Upton, NY; S. James CMS Radiopharmaceutical Transmittals Adelstein, Paul C. Cabot Distinguished Professor of Medical Bio- www.cms.hhs.gov/Transmittals/2006Trans/list.asp physics at Harvard Medical School, Boston, MA; Joel Karp, chief Hospitals Transmittal 822 CR 4270 of the physics and instrumentation research section in the Depart- Physician offices Transmittal 923 CR 5054 ment of Radiology and director of the Department of Radiology PET Center at the University of Pennsylvania, Philadelphia, PA; SNM, Practice Management, Coding Corner, PET Facilities Thomas Lewellen, professor of radiology, adjunct professor of http://interactive.snm.org/index.cfm?PageID=3416 electrical engineering, and director of physics and instrumentation development in nuclear medicine at the University of Washington, SNM PET Coding Educational Materials Seattle; C. Douglas Maynard, former chair of the radiology depart- http://interactive.snm.org/index.cfm?PageID=3399 ment and currently professor emeritus of radiology at Wake Forest University School of Medicine, Winston-Salem, NC; Marcus E. National Oncologic PET Registry Raichle, professor of radiology, neurology, neurobiology, biomed- www.cancerPETregistry.org ical engineering, and psychology and codirector of the Division of Medicare Transmittal 956 CR 5124 Radiological Sciences in the Mallinckrodt Institute of Radiology www.cms.hhs.gov/transmittals/downloads/R956CP.pdf at the Washington University School of Medicine, St. Louis, MO; Thomas J. Ruth, director of the PET Program at the University of MLM Matters MM5124 British Columbia, Vancouver; and Heinrich Schelbert, professor www.cms.hhs.gov/MLNMattersArticles/downloads/MM5124.pdf of molecular and medical pharmacology at the University of Cali- fornia at Los Angeles. Other committee members include: Hedwig Hricak, Memo-

(Continued on page 4. See NASC.)

 PET Center of Excellence Newsletter/Summer 2006 www.snm.org/PET  2006 PET Coding Table

CPT/HCPCS Code Code Description Comments 78459 Myocardial imaging, positron emission (PET), metabolic evaluation 18F FDG used for myocardial viabil- ity 78491 Myocardial imaging, positron emission tomography (PET), perfusion, single study at rest 82Rb or 13N single study or stress

(If applicable, bill separately for stress procedure CPT 93015-18 and stress agent, J0152, J1245, or J1250.) 78492 Myocardial imaging, positron emission tomography (PET), perfusion, multiple studies at 82Rb or 13N multiple studies, rest rest and/or stress & stress

(Bill separately for stress procedure CPT 93015-18 and stress agent, J0152, J1245, or J1250.) 78608 Brain imaging, positron emission tomography (PET); metabolic evaluation 18F FDG used for brain tumor, Alzheimer or dementia 78609 Brain imaging, positron emission tomography (PET); perfusion evaluation Medicare noncovered service 78811 Tumor imaging, positron emission tomography (PET); limited area (e.g., chest, head/neck) 18F FDG used for tumor imaging of a single area 78812 Tumor imaging, positron emission tomography (PET); skull base to mid thigh 18F FDG used for tumor imaging of skull base to mid thigh 78813 Tumor imaging, positron emission tomography (PET); whole body 18F FDG used for tumor imaging of whole body 78814 Tumor imaging, positron emission tomography (PET) with concurrently acquired com- 18F FDG used for tumor imaging of puted tomography (CT) for attenuation correction and anatomical localization; limited a single area area (e.g., chest, head/neck) 78815 Tumor imaging, positron emission tomography (PET) with concurrently acquired com- 18F FDG used for tumor imaging of puted tomography (CT) for attenuation correction and anatomical localization; skull base skull base to mid thigh to mid thigh 78816 Tumor imaging, positron emission tomography (PET) with concurrently acquired comput- 18F FDG used for tumor imaging of ed tomography (CT) for attenuation correction and anatomical localization; whole body whole body QR Item or service provided in a Medicare specified study Use for NOPR studies modifier V70.7 Examination of participant in clinical trial Used by hospitals only for NOPR ICD 9 CM (place in second diagnosis position on UB claim form) studies G0219 PET imaging, whole body; melanoma for non-covered indications Medicare noncovered service G0235 PET imaging, any site not otherwise specified Medicare noncovered service G0252 Initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial Medicare noncovered service staging of axillary lymph nodes), not covered (full- and partial-ring PET scanners only) A9526 Nitrogen (13N) ammonia, diagnostic, per study dose, up to 40 millicuries If two studies, rest and stress, bill two units A9552 Fluorodeoxyglucose (18F) FDG, diagnostic, per study dose, up to 45 millicuries 18F FDG used for a variety of PET procedures A9555 Rubidium (82Rb), diagnostic, per study dose, up to 60 millicuries If two studies, rest and stress, bill two units

 PET Center of Excellence Newsletter/Summer 2006 www.snm.org/PET  PET on the Net

Below we present a small sample of some interesting articles that were recently turned up by the PCOE Newsletter’s search engine as it mined the Internet for mentions of positron emis- sion tomography. Click the headline to read the full story.

Bayer Divests Diagnostics to Siemens; Eases Impact of Schering Acquisition domain-B, June 30, India Siemens AG will acquire Bayer HealthCare Diagnostics Divi- sion, a member of the Bayer Group, for around €4.2 billion. The acquisition will enable Siemens Medical Solutions to expand its position in the high-growth molecular diagnostics market. … AnaSpec Provides Vital Stains for Amyloid Imaging Newswire Today, August 8, London, UK GE Healthcare to Set Up India’s First Radiopharmacy Center in When used in combination with PET or SPECT, amyloid-imag- Delhi ing tracers can facilitate the evaluation of the efficacy of anti- Chemie.de, June 26, Germany amyloid therapies. … GE Healthcare announced that it is setting up India’s first radiopharmacy center in the national capital, Delhi. … Siemens Completes Acquisition of Diagnostic Products Corpora- tion; When Pending Acquisition of Bayer Diagnostics is Complete, CHOP-R Followed by Zevalin®/Rituxan® Promising for Previously Siemens Medical Solutions will be the First Full Service Diagnos- Untreated Follicular NHL tics Company Cancer Consultants, June 12, Memphis, TN, USA Business Wire, July 27, Erlangen, Germany and Los Angeles, Results from a phase II trial reported that CHOP-R followed by CA USA Zevalin (90Y ibritumomab tiuxetan) and Rituxan (rituximab) pro- Siemens announced today that it has completed its acquisition of vides high complete response rates and encouraging progres- Diagnostic Products Corporation (DPC) (NYSE:DP), marking a sig- sion-free survival as initial treatment of follicular non-Hodgkin’s nificant milestone for Siemens as it enters the in-vitro diagnostics lymphoma. … (IVD) market. … Students Raise Money to Fight Cancer Schering in Alzheimer’s Diagnosis Pact with Avid Wetaskiwin Times Advertiser, July 24, Alberta, Canada Reuters, July 14, Frankfort, Germany In just two weeks, more than $27,000 in pledges was raised German drugmaker Schering will work with U.S. firm Avid at Sacred Heart School to fight cancer. The money is destined Radiopharmaceuticals to develop new diagnostic imaging for the whole-body PET scanner housed at the Cross Cancer agents for Alzheimer’s disease. … Institute in Edmonton. …

(NASC. Continued from page 2.) rial Sloan-Kettering Cancer Center, New York, NY; Joe Gray, The review experts are expected to solicit briefings from associate laboratory director for life and environmental science several quarters: from DOE, NIH, the Office of Management at the Lawrence Berkeley National Laboratory: Lin-Wen Hu, and Budget, and congressional staff on the study charge and associate director for research development and utilization at the expectations for the final report; from subject matter experts on Massachusetts Institute of Technology’s Nuclear Reactor Labo- trends, needs, and opportunities in nuclear medicine research, ratory, Cambridge, MA; Roger Macklis, professor of medicine isotope production, and shortages in trained personnel; from DOE at the Cleveland Clinic Lerner College of Medicine, Cleveland, staff and selected investigators on the Medical Applications and OH; Gustav Von Schulthess, professor of nuclear medicine at the Measurement Science program; and from NIH staff and selected University Hospital of Zurich, Switzerland; and Jacquelyn Yanch, investigators on radiotracer and radiopharmaceutical needs for professor of nuclear engineering at Massachusetts Institute of research and clinical practice. Technology, Cambridge, MA.

Letters to the Editor of the PCOE Newsletter are welcome and may be published in future issues. Send your comments to [email protected].

 PET Center of Excellence Newsletter/Summer 2006 www.snm.org/PET  Views You Can Use

Fig. 2

Fig. 3 Fig. 1

PET/CT Case: Breast Cancer stains indicated was of breast origin. The histology was identical to the prior bladder lesion, and immunostains This 77-year-old woman had a history of right radical were obtained from the bladder specimen showing it rep- mastectomy for ductal carcinoma 16 years earlier. Four resented a breast metastasis. years ago she presented with metastatic breast carcinoma in a right neck lymph node, for which she received hor- How Did PET/CT Imaging Help? monal therapy. An adenocarcinoma in the bladder was PET CT demonstrated abnormal right inguinal recently discovered and a cystectomy was suggested. A / nodes, when biopsied lead to the diagnosis of PET/CT was ordered for additional staging information that, , metastatic breast cancer , rather than an additional and restaging of the breast cancer. alone primary cancer in the bladder. Inappropriate treatment The PET/CT showed uptake in a subcarinal lymph was therefore avoided. node and a left lung nodule (Fig. 1, arrowheads). Tracer Recent studies have shown the utility of PET for uptake was also present in three right inguinal lymph staging and restaging women with breast carcinoma nodes (Figs. 1 and 2, gray arrows) and a left iliac lymph (1,2). node (Figs. 1 and 3, white arrows). The right inguinal adenopathy had not been detected clinically. An ultra- References sound-guided, right inguinal lymph node biopsy showed 1. Br J Surg. 2005;92:1363–1367. a poorly differentiated adenocarcinoma which immuno- 2. J Clin Oncol. 2004;22:1253–1259.

About Views You Can Use This case was provided by David Seldin, MD, Franklin Square Hospital Center, Baltimore, MD. It was also featured on the Web site of Gabriel Soudry, MD, at www.petcases.com. In addition to the Web site, Dr. Soudry also mails printed versions of his example cases to referring physicians in Franklin Square and the surrounding community. Working with Dr. Soudry and other PET specialists, the PCOE Web site (www.snm.org/PET) features “Views You Can Use,” single-sheet PDFs that include specific cases, images, and references. As a PCOE member, you can add your own contact information to these sheets and distribute them electronically or by printed hard copy to referring physicians for educational purposes.

 PET Center of Excellence Newsletter/Summer 2006 www.snm.org/PET  PET in the Literature The international literature on PET and PET/CT continues to grow at a pace that challenges both researchers and clinicians. In each issue, the PCOE Newsletter presents a tomographic slice of the breadth of PET literature Speaks Out that appears in publications around the world. Weekly lists of all published PET research are available to logged-in members in the PET Center of on PET Excellence Web area at www.snm.org/pet in the PET References Archive under Resources. Articles selected for relevance to clinical oncologists are

also featured weekly under PET News.

Cardiology Nitrate Administration Increases Blood Flow in Dysfunctional Stem cells: a regenerative pharmaceutical. (16868534) but Viable Myocardium, Leading to Improved Assessment of Shanthly N, Aruva MR, Zhang K, et al. Myocardial Viability: A PET Study. Q J Nucl Med Mol Imaging. 2006;50:205-216. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve& db=PubMed&dopt=Citation&list_uids=16883010 Neurology Slart RH, Agool A, van Veldhuisen DJ, et al. Net influx of plasma 6-[F]fluoro-l-DOPA (FDOPA) to the J Nucl Med. 2006;47:1307–1311. ventral striatum correlates with prefrontal processing of affective stimuli. (16882026) Abnormal accumulation of [18F]fluorodeoxyglucose in the Siessmeier T, Kienast T, Wrase J, et al. aortic wall related to inflammatory changes: three case reports. Eur J Neurosci. 2006;24:305–313. (16878709) Takahashi M, Momose T, Kameyama M, et al. Serotonin Transporter Binding in Bipolar Disorder Assessed Ann Nucl Med. 2006;20:361–364. using [11C]DASB and Positron Emission Tomography. (16875929) General Clinical Practice Cannon DM, Ichise M, Fromm SJ, et al. Chapter 3: The hypothalamus, hormones, and hunger: Biol Psychiatry. 2006;60:207–217. alterations in human and illness. (16876568) Goldstone AP. Oncology Prog Brain Res. 2006;153:57–73. F-fluorodeoxyglucose-positron emission tomography in evaluation of primary cutaneous lymphoma. (16882175) Contribution of monoamine oxidase (MAO) inhibition to Kumar R, Xiu Y, Zhuang HM, et al. tobacco and alcohol addiction. (16884739) Br J Dermatol. 2006;155:357–363. Amsterdam JV, Talhout R, Vleeming W, et al. Life Sci. 2006; Jun 15; [Epub ahead of print]. Increased 18F-FDG Uptake in Degenerative Disease of the Spine: Characterization with 18F-FDG PET/CT. (16883005) Instrumentation & Data Rosen RS, Fayad L, Wahl RL. Deformable and rigid registration of MRI and microPET images J Nucl Med. 2006;47:1274–1280. for photodynamic therapy of cancer in mice. (16878577) Fei B, Wang H, Muzic RF, Jr., et al. Radiopharmacology Med Phys. 2006;33:753–760. Tissue Distribution of 18F-FDG-Labeled Peripheral Hematopoietic Stem Cells After Intracoronary Administration [Evaluation of the performance of a gamma camera equipped in Patients with . (16883008) with a 5/8” versus 1” thick NaI detector]. (16875026) Kang WJ, Kang HJ, Kim HS, et al. Schaffarich P, Dobrozemsky G, Dudczak R, et al. J Nucl Med. 2006;47:1295–1301. Z Med Phys. 2006;16:134–139. Imaging Prostate Cancer with 11C-Choline PET/CT. (16883001) Reske SN, Blumstein NM, Neumaier B, et al. A new predictive and prognostic marker (ATP bioluminescence J Nucl Med. 2006;47:1249–1254. and positron emission tomography) in vivo and in vitro for delivering adjuvant treatment plan to invasive breast tumor patients. (16860527) Loo WT, Tong JM, Cheung MN, et al. Biomed Pharmacother. 2006; Jun 23; [Epub ahead of print].

 PET Center of Excellence Newsletter/Summer 2006 www.snm.org/PET  noid receptors by positron emission tomography (PET), opening a door to the development of new medications to treat drug depen- Speaks Out dence, obesity, depression, schizophrenia, Parkinson’s disease and Tourette syndrome. on PET Discovery of the [11C]JHU75528 radioligand, a radioactive biochemical substance that is used to study the receptor systems The PCOE Newsletter presents a round-up of press releases, letters, of the brain, “opens an avenue for noninvasive study of central and statements issued by SNM that relate to PET, PET/CT or PET cannabinoid (CB1) receptors in the human and animal brain,” explained Andrew Horti, assistant professor of radiology at Johns radiopharmaceuticals. We are reproducing truncated versions of these Hopkins Medicine, Baltimore, Md. He explained that there is evi- press releases here. Each headline links to the full version online. dence that CB1 receptors play an essential role in many disorders including schizophrenia, depression and motor function disorders. “Quantitative imaging of the central CB1 using PET could provide Coming Soon: 3-D Imaging That Flies “Through” a great opportunity for the development of cannabinergic medica- and “Around” Cancer tions and for studying the role of CB1 in these disorders,” added Released: July 12, 2006 the co-author of “PET Imaging of Cerebral Cannabinoid CB1 Receptors with [11C]JHU75528.”… Stanford University Pilot Study Demonstrates Feasibility of 3-D PET/CT Images’ “Omnipotent Perspective” to Is Being Overweight All in the Brain? Visualize, Diagnose Cancer and Heart Disease, Says Released: June 5, 2006 Article in July Journal of Nuclear Medicine PET Study Links Obesity to Serotonin Receptor, RESTON, VA—Stanford University researchers demonstrated for the first time the ability to create 3-D positron emission tomog- Suggesting Possibility of Curbing Appetite raphy (PET)/computed tomography (CT) images for “fly-through” with Future Drugs and “fly-around viewing” of cancer in the lungs and colon, SAN DIEGO, CA—By using positron emission tomography according to a study in the July issue of The Journal of Nuclear (PET) to study the brain’s neuroreceptors in relation to obesity, scientists may be getting closer to determining important informa- Medicine. … tion about the neurobiological mechanisms involved, according to “Three-dimensional fusion provides unique views of the body a group of Danish researchers. … that internal organs typically impede,” said Quon. “Our new imag- “From our molecular imaging research, we have discovered ing and processing protocol can peel away the organs, highlight that overweight people have more of a certain type of serotonin tumors and detect cancerous ‘hot spots’—providing an omnipo- receptor (the so-called 5-HT2A receptor) in their brains,” said tent perspective of the body,” he indicated. Stanford’s 3-D fusion David Erritzoe, research fellow with the Neurobiology Research imaging “appears to have potential for presurgical visualization, Unit and Center for Integrated Molecular Brain Imaging in Copen- particularly in guiding biopsies,” explained the coauthor of “‘Fly- hagen, Denmark. Serotonin is a chemical compound in the brain ing Through’ and ‘Flying Around’ a PET/CT Scan: Pilot Study 18 involved in the regulation of many functions, including appetite, and Development of 3-D Integrated F-FDG PET/CT for Virtual sleep and emotions, he added. “This relationship suggests that Bronchoscopy and Colonoscopy.” This imaging technique “may add important diagnostic information that may herald new applica- (Continued on page 8) tions for the use of PET/CT,” he noted. In addition, its diagnostic value was demonstrated in one case in which it revealed a cancer lesion that had not been detected by PET, CT or PET/CT imag- Annual Meeting Research ing. “This one case shows the potential synergistic enhancement of both PET and CT when rendered into three dimensions,” said Abstracts Available Online Quon. … All of the June press release excerpts below Researchers Use Brain’s Receptors Sensitive describe research presented at the 53rd SNM to Pot to ‘Open Door’ in Treating Drug Annual Meeting, held June 3-7 in San Diego, CA. Dependence, Neurological Disorders Each headline links to the full press release on Released: June 6, 2006 the SNM Web site or you may view all SNM press Johns Hopkins Scientists Develop New PET Radiotracer releases in the NEWS CENTER at www.snm.org. to Visualize Cannabinoid Receptors Abstracts of the research presentations may be SAN DIEGO, CA—A team of Johns Hopkins researchers viewed online at The Journal of Nuclear Medicine developed a new radiotracer—a radioactive substance that can be Web site at http://jnm.snmjournals.org. traced in the body—to visualize and quantify the brain’s cannabi-

 PET Center of Excellence Newsletter/Summer 2006 www.snm.org/PET  (Continued from page 7) the 5-HT2A receptor is crucially involved in regulation of body Wichana Chamroonrat, a research fellow at the Hospital of the weight and that the receptor should be exploited as a target for University of Pennsylvania in Philadelphia. “Recent studies have regulation of appetite,” said Erritzoe, co-author of “Overweight shown that FDG PET can be used in the evaluation of a variety of Associated With Increased Serotonin 2A Receptor Binding in inflammatory and infectious processes, and we extended the use Humans,” the first study to examine links between the 5-HT2A of this noninvasive scanning technique in our study,” noted the receptor and body weight. … co-author of “FDG-PET Is Highly Accurate for the Diagnosis of PET scans were performed on 76 healthy humans, of whom Chronic Osteomyelitis.” … 47 were normal weight (body mass index between 19.2 and 24.9) Researchers used FDG-PET imaging with 57 patients with sus- and 29 were overweight (BMI between 25.1 and 34.7). “The rela- pected osteomyelitis, comparing scanning images with their final tionship between the brain’s 5-HT2A receptors and body weight diagnosis based on surgical findings, microbiology and clinical will prompt further investigation to explore whether this is a trait follow-up, noted Chamroonrat. “FDG PET images allowed physi- or rather a state marker of obesity,” said Erritzoe. “Our study cians to correctly diagnose the presence or absence of osteomyeli- emphasizes the importance of conducting large-scale PET studies tis in 53 of 57 patients,” she said, as well as in 26 of 27 patients in healthy people to address complex questions with molecular with chronic osteomyelitis. FDG PET had a 93 percent accuracy brain imaging,” he indicated. … rate in the evaluation of osteomyelitis, she added. …

PET/CT Offers “Superior” View of Atherosclerosis FDG PET Takes Its Place as a Valuable Tool in Plaque, May Be Used to Identify Those High at Diagnosing Fevers of Unknown Origin Risk for Heart Attack, Released: June 5, 2006 Released: June 5, 2006 Study Widens Use of PET Scans, Say Researchers Massachusetts General Hospital Researchers Release in the Netherlands Findings About Plaque Inflammation SAN DIEGO, CA—By providing early diagnosis of fevers SAN DIEGO, CA—Positron emission tomography (PET) in of unknown origin in patients, positron emission tomography combination with computed tomography (CT) offers a “superior” (PET)—with the radiotracer fluorodeoxyglucose (FDG)—elimi- view of atherosclerosis plaque inflammation—so much so that it nates the need for additional exhaustive and invasive tests, say may eventually be used to identify individuals who are at high risk researchers from university and community hospitals in the Neth- for heart attack or stroke, according to researchers at Massachu- erlands. … setts General Hospital in Boston. … “PET has the potential to make an enormous impact in pro- “The future is using PET/CT—and other developing technolo- viding earlier diagnosis and risk stratification, in delivering the gies—to assess plaques that are biologically active with deadly right therapy early and in avoiding long in-patient hospital stays,” consequences when they misbehave,” said Ahmed Tawakol, said Wim J.G. Oyen, nuclear medicine physician and professor of cardiologist and co-director of the Cardiac MR/PET/CT Program nuclear medicine at Radboud University Nijmegen Medical Centre at Massachusetts General Hospital. “PET/CT in combination is in Nijmegen, the Netherlands. “For patients with fever of unknown more powerful than either PET or CT alone, providing us with origin, FDG PET offers the chance for earlier diagnosis with fewer an enriched data set,” added the coauthor of “Combined PET/CT diagnostic procedures and an earlier start of adequate treatment. Assessment of Carotid Plaques: A Human Histopathological For referring physicians, FDG PET offers the opportunity to short- Study.” … en the diagnostic process, which is now often performed during a long in-patient evaluation—in many cases over many weeks,” No Bones About It: FDG PET Successful in added the co-author of “A Prospective Multicenter Study of the Difficult-to-Detect Chronic Osteomyelitis Value of FDG PET as Part of a Structured Diagnostic Protocol in Released: June 5, 2006 Patients With Fever of Unknown Origin.”… Molecular Imaging Aids Diagnosis—and Developing “We were struck by the fact that PET indicated that half of the 70 patients studied had no abnormal findings as the cause of the Treatment—for Bone and Bone Marrow Infection, fever,” said Oyen. With a negative result from a PET scan, physi- Report Philadelphia Researchers cians “can cross out other diagnostic tests (such as chest X-rays SAN DIEGO, CA—Diagnosing chronic osteomyelitis—a and abdominal ultrasound) since those tests won’t reveal causes common, serious and often incapacitating infection of bone and for the fever,” he said. In addition, PET contributed to the diag- bone marrow—in children and adults is often difficult, posing nosis of one-third of the patients, “picking up diseases that would a challenge to physicians. Using positron emission tomography have required other diagnostic tests,” he noted. … (PET)—with the radiotracer fluorodeoxyglucose (FDG)—“is a highly effective imaging method for determining the presence or absence of chronic osteomyelitis,” detailed researchers from the ADHD Drug ‘Harmonizes’ With Body’s Dopamine Hospital of the University of Pennsylvania and Children’s Hospi- System, Gives Hint to Effect on Children, Adults tal of Philadelphia … Released: June 5, 2006 “Our findings show that FDG PET should be employed as Preliminary Basic Science Study Provides Direct Evidence a study of choice for diagnosing chronic osteomyelitis,” said of Beneficial Effect of Methylphenidate (Continued on page 9)

 PET Center of Excellence Newsletter/Summer 2006 www.snm.org/PET  (Continued from page 8)

SAN DIEGO, CA—The brain’s dopamine system, which has and size with use of a fully 3-D, time-of-flight positron emission long been associated with reward learning and reward-related tomography (PET) with computed tomography (CT) scanner. … behavior, works differently in treated and untreated attention “This new time-of-flight scanner—used with LYSO detec- deficit hyperactivity disorder (ADHD) individuals, according to a tor crystals—will improve the diagnostic accuracy of images, study presented by German researchers … potentially leading to improved sensitivity and specificity in “The significant difference we found between treated and cancer lesion detection tasks in heavy patients, who have tradi- untreated ADHD patients provides an important hint on the effect tionally been difficult to image,” said Suleman Surti, a research of the most commonly prescribed drug for this disease, which has assistant professor at the University of Pennsylvania. “The current long baffled and frustrated parents and physicians,” noted Felix M generation of PET scanners is limited in the quality of images Mottaghy, research fellow at University Ulm in Germany. Until produced for those patients who are overweight,” he said. “This this study, there has been no direct evidence pointing to the ben- new technology can also reduce scan times for small- and aver- eficial effect of methylphenidate (drugs like Ritalin) on the body’s age-size patients without losing diagnostic accuracy,” added the dopamine system, added the co-author of “Midbrain, Striatal co-author of “Imaging Performance of an LYSO-Based TOF PET and Amygdalar Dopaminergic Dysfunction in Attention Deficit Scanner.” … Hyperactivity Disorder (ADHD).” … Philips Gemini TF is the world’s first commercially available The researchers used positron emission tomography (PET), a time-of-flight PET/CT system that allows this more accurate track- noninvasive brain scan, with 18F-DOPA, an imaging drug that is a ing of photons using time measurements without compromising precursor of dopamine. The University Ulm researchers also used good characteristics of traditional PET scanners. Image acquisition statistic parametric mapping to obtain the statistical comparison of could be shortened to 10–20 minutes for a whole-body PET scan, normalized and reoriented brain images, said Mottaghy. “It gives depending on patient size. … an impression of the distribution of differences within the brain comparing groups of patients or different conditions within one Japanese Researchers Get to the Heart of subject,” he explained. … Atherosclerosis A Step Toward Halting Alzheimer’s: Using Released: June 4, 2006 FDDNP PET To Detect Disease Progression, PET Reveals High-Risk Heart Patients Before Mild Cognitive Impairment Disease Becomes Clinically Evident Released: June 5, 2006 SAN DIEGO, CA—Using positron emission tomography (PET), the medical isotope 15O-water and cold pressor tests, Japa- UCLA Researchers Use PET Radiotracer to Demonstrate nese researchers were able to detect the beginnings of atheroscle- Progression of Alzheimer’s Pathology for Diagnosis and rosis—before the disease became clinically evident. … Monitoring of Therapeutic Interventions This revelation will allow physicians to advise high-risk SAN DIEGO, CA—By using positron emission tomography patients—who show no cardiovascular symptoms—to make life- (PET) with the radiotracer 18F-FDDNP, UCLA scientists were able style changes modifications or to undergo medical treatment, said to detect increases in the brain pathology (of beta-amyloid plaques Masanao Naya, a physician at Hokkaido University Graduate and neurofibrillary tangles) associated with the progression of School of Medicine in Sapporo, Japan. In addition, research- Alzheimer’s disease. … ers determined that elevated levels of interleukin-6—one of the “We have demonstrated that the worsening of memory and inflammatory chemicals produced by endothelial cells and that other cognitive functions is correlated with the increase of 18F- has been associated with an increased risk of heart disease—is DDNP brain binding in a progressive pattern closely matching “a major determinant” of coronary endothelial dysfunction, espe- the known pattern of pathology progression,” explained Vladimir cially in individuals with high blood pressure.… Kepe, assistant researcher at the David Geffen School of Medicine “We can assess the endothelial dysfunction in the human heart at the University of California, Los Angeles. “Our method is sensi- noninvasively using PET and evaluate factors that can determine tive to detect the regional increases in pathology (or the nature of endothelial dysfunction,” said the co-author of “Determinants of the disease) as well as spreading of pathology within the brain of Coronary Endothelial Dysfunction in Hypertensive Patients.”… the same person as the disease worsens over time,” added the co- In their study, researchers examined 27 untreated patients with author of “Detection of MCI-AD and Control-MCI Conversions in high blood pressure. Myocardial blood flow was measured both at Alzheimer’s Disease Patients With 18F-FDDNP PET.”… rest and during stimulation induced by a cold pressor test by using PET with 15O-water. … Just-Right PET/CT Imaging for Patients of All Sizes Released: June 4, 2006 Time-of-Flight PET Scanner With Detector Crystals Improves Diagnostic Accuracy for Whole-Body Imaging SAN DIEGO, CA—Researchers discovered that diagnostic accuracy of images can be improved for people of varying weight

 PET Center of Excellence Newsletter/Summer 2006 www.snm.org/PET  Nuclear Medicine, Department of Radiology, University of Penn- Journal of Nuclear Medicine sylvania, Philadelphia, PA; Adriaan A. Lammertsma, Department Publishes NCI-Sponsored of Nuclear Medicine and PET Research, VU University Medical Centre, Amsterdam, the Netherlands; Steven Larson, Department Guidelines for Using FDG PET of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY; David A. Mankoff, Division of Nuclear Medicine, ublication of consensus recommendations for the use of University of Washington, Seattle; Barry A. Siegel, Mallinck- PFDG-PET in National Cancer Institute (NCI) trials will go rodt Institute of Radiology, St. Louis, MO; and Annick Van den a long way in helping physicians and scientists determine ways Abbeele and Jeffrey Yap, Department of Radiology, Dana-Farber to manage cancer and promote drug development in the future. Cancer Institute, Harvard Medical School, Boston, MA. The recommendations, published in the June issue of The Journal of Nuclear Medicine, focus on the practical aspects of FDG PET (patient preparation; image acquisition, reconstruction and analy- pet center of excellence newsletter sis; and quality assurance) and provide a valuable reference for incorporating PET into clinical trials. “There should be less variability in the performance of FDG The PET Center of Excellence Newsletter is a quarterly PET in clinical trials by enacting these recommendations,” member information service published under the direction explained principal author Lalitha K. Shankar, NCI medical of the PCOE leadership and the Society of Nuclear officer at the Cancer Imaging Program. “This would help speed Medicine. the evaluation of FDG PET as a biomarker. If FDG PET, as is hoped, proves to be a useful biomarker in certain cancers—such PCOE Newsletter Editorial Board as lymphoma, lung and breast cancer among others—this could Paul E. Christian, BS, CNMT, PET potentially result in be shorter clinical trials in these malignancies [email protected] and improved therapy for patients with these cancers,” she said. Summer Issue Editor: These guidelines, drafted by PET experts at various universities Gabriel Soudry, MD and institutes in the United States and abroad, represent a step [email protected] toward qualifying FDG PET as a biomarker or biologic indicator David L. Lilien, MD to assess cancer treatment response. [email protected] “To date, there has been no significant agreement on the best methodology for obtaining or analyzing 18F-FDG PET. Standard protocols needed to be developed so that data about the effective- PCOE Board of Directors ness of FDG PET as an indicator of treatment response in patients James W. Fletcher, MD could be collected and compared,” Shankar added. Publication of President the consensus recommendations is the culmination of attempts to Homer A. Macapinlac, MD reach agreement between physician and scientist members of the Vice President imaging community on certain basic issues regarding the acquisi- Nancy M. Swanston, CNMT, RT(N) tion and analysis of these scans, she said. Secretary/Treasurer The recommendations are the result of a workshop sponsored Carolyn J. Anderson, PhD by NCI’s Cancer Imaging Program in Washington, DC, in 2005. Jacqueline C. Brunetti, MD Participants reviewed the status of FDG PET technology and Paul E. Christian, CNMT, BS clinical experience in both diagnosis and in monitoring therapeutic Dominique Delbeke, MD, PhD response. More recently, NCI, the U.S. Food and Drug Adminis- Marcelo F. Di Carli, MD tration and the Centers for Medicare & Medicaid Services entered Michael J. Gelfand, MD into a memo of understanding to improve “the clinical utility of D. Scott Holbrook, BS, CNMT, FSNMTS biomarker technologies as diagnostic and assessment tools that Lale Kostakoglu, MD facilitate the development of safer and more effective cancer Alan H. Maurer, MD therapies.” Henry D. Royal, MD 18 “Consensus Recommendations for the Use of F-FDG PET George M. Segall, MD as an Indicator of Therapeutic Response in Patients in National George Zubal, PhD Cancer Institute Trials,” was authored by Shankar, Daniel Sulli- van, Cancer Imaging Program, National Cancer Institute, National SNM Chief Executive Officer Institutes of Health, Bethesda, MD; John M. Hoffman, Division of Virginia Pappas, CAE Nuclear Medicine, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City; Steve Bacharach, Depart- Managing Editor ment of Radiology, University of California, San Francisco, CA; Ann Coleman, MA Michael M. Graham, Division of Nuclear Medicine, Department of Radiology, University of Iowa, Iowa City; Joel Karp, Division of

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