NEWSLINE SNM Annual Meeting Focuses on Molecular / Research

esearch covering the most recent advances in un- derstanding, diagnosing, and treating some of the Rmost troubling and intractable diseases of modern times will be shared in more than 1,600 scientific pre- sentations and posters during SNM’s 53rd Annual Meeting, June 3–7, at the San Diego Convention Center. More than 4,000 physicians, technologists, scientists, and pharmacists are expected at the meeting, the world’s largest event for molecular imaging and nuclear medicine professionals. The educational and scientific program at the 53rd Annual Meeting is tailored to provide attendees with the most current and important information available in the field. SNM and SNMTS will also present about 100 con- tinuing education courses focusing on PET/CT, cardiovas- cular imaging, brain imaging, pediatric nuclear medicine, oncology diagnosis and therapy, and radiation safety. ‘‘Medical practitioners, technologists, scientists, phys- icists, and pharmacists from around the world come to this premier scientific and educational event to discover just how far molecular imaging and nuclear medicine have pushed our understanding of human disease,’’ said SNM President Peter S. Conti, MD, PhD. ‘‘From Alzheimer’s to schizophrenia, from breast cancer to thyroid cancer, molecular imaging and nuclear medicine research have a proven record of leading to improvements in the diagnosis and treatment of life-threatening diseases that affect The buttresses lounge at the San Diego Convention Center millions each year.’’ provides a place for informal meetings and spectacular views of Among the featured speakers will be: the city. • Simon R. Cherry, PhD, professor of biomedical engi- neering and director of the Center for Molecular and Century’’ during the SNM Technologist Section’s June Genomic Imaging, University of California, Davis. 4 plenary session, 12:45–2:15 PM. Metcalf is the co- Cherry will present, ‘‘Of Mice and Men and Positrons: author of Lighten Up: Survival Skills for People Under Advances in PET Imaging Technology,’’ as the annual Pressure. Henry Wagner Lecture on Sunday, June 4, from 8:30 • Henry N. Wagner, Jr., MD, director of the division of to 10:00 AM. radiation health sciences at Johns Hopkins University, • Alexander Gottschalk, MD, a pioneer researcher and Baltimore, MD, will once again discuss what’s on the author who helped shape modern , horizon for the molecular imaging/nuclear medicine will address ‘‘How to Interpret and Report the V/Q profession during his annual Highlights Lecture on Scan in the Post PIOPED II Era’’ during the Cassen Wednesday, June 7, from 11:30 AM to 1:00 PM. In his Lectureship on Monday, June 5, 9:45–10:45 AM. 29th Highlights Lecture, Wagner will summarize the Gottschalk worked with the first clinically useful meeting’s significant findings and current trends in prototype Anger scintillation camera and performed molecular imaging/nuclear medicine. Wagner will also the first dynamic camera studies of the brain and heart announce his annual Image of the Year. using 99mTc. A full listing of all continuing education programs, sci- • C.W. Metcalf, expert in stress management and entific sessions, and other events is available at www.snm. adapting to change, reveals ‘‘Life Skills for the 21st org/am under EDUCATIONAL AND SCIENTIFIC PROGRAM.

Newsline 13N E A Memoir of Pediatric Nuclear Medicine: Part III: Finding a Place NEWSLIN for Nuclear Medicine

major impediment to the utilization of pediatric In 1968, when I arrived at CMH, nuclear medicine techniques occurred in the mid- efforts to introduce nuclear medi- A 1970s with the introduction of competitive imaging cine techniques in pediatrics were technologies such as CT and . Although the early already underway. Harvey White, versions of these technologies were somewhat primitive, MD, a pioneer in pediatric the use of these modalities increased with technological and chair of the department of advances, innovative upgrades, and newer devices. My radiology, had already initiated thy- personal experiences in practice, research, and teaching in roid uptake studies in 1955 with nuclearmedicinespanned31/2decades.Iwouldremindread- 131 I-sodium iodide, using a scintilla- James J. Conway, MD ers that any memoir is merely one individual’s viewpoint on tion detector that was custom de- complex and multifaceted events that might be recounted signed for small children. It had a 1-inch scintillation differently by others. I also want to express my gratitude to crystal and collimator aperture. White recognized the all the individuals whose collegial contributions are recog- potential for nuclear medicine in pediatrics. In 1967, he nized or inadvertently omitted in this account. persuaded the hospital administration to purchase a Pho Gamma III Nuclear–Chicago camera, the first commercial to be installed in a pediatric hospital. The Introducing New Technologies to Pediatrics camera cost $34,440, with a yearly service contract of I was fortunate to participate in a 4-year training $1,420. My introductory experience with the gamma program in radiology from 1964 to 1968 at the Hospital of camera as a resident trainee at HUP led White to assign the University of Pennsylvania (HUP) in Philadelphia, PA, me to the new apparatus. He said, ‘‘The camera is yours; where nuclear medicine was the focus of intense research see what you can do with it.’’ We were the only 2 attending and development. The radiology training program included physicians in radiology, so in addition to promoting the new an extraordinary 6-month nuclear medicine rotation under technology and developing protocols for various studies, I the guidance of pioneer nuclear medicine practitioner also routinely performed my share of pediatric radiology David Kuhl, MD. After completing residency training in (including the novel Seldinger catheter technique for July 1968, I accepted a position in pediatric radiology at the , for which we made our own catheters) and Children’s Memorial Hospital (CMH) in Chicago, IL. radiotherapy with a 200-MeV orthovoltage therapy unit. The gamma camera was in a small room 2 floors above the main radiology department, and I spent my days running up and down stairs. After 9 months, White went on a well From the Newsline Editor: earned 7-month sabbatical, leaving me in charge along with This is the last in a 3-part series from James J. an early pediatric radiology resident, Arnie Shkolnik, MD. Conway, MD, a distinguished pioneer in pediatric That first year was a very hectic but rewarding learning nuclear medicine and past president of the SNM. experience. In the first part of the series (J Nucl Med. 2006; Within a year, we were acquiring 663 studies annually, 47[4]:12N), he recalled the individuals and early a volume that promised to continue to increase. I also advances that contributed to the introduction of wanted to perform bone scintigrams with 18F for children pediatric applications into the mainstream of nu- with osteogenic sarcoma and other bone tumors and clear medicine practice. In the second (J Nucl metastases. The higher energy radiopharmaceuticals were Med. 2006;47[5]:22N), he looked at the estab- not ideal for the thinner crystal of the gamma camera, so lishment of the Pediatric Nuclear Medicine Club we purchased a Nuclear–Chicago Pho-Dot II rectilinear within the SNM and at the challenges faced by the scanner for $11,500. Children were not tolerant of the tap- subdiscipline in its formative years. In the final tap-tap of the scanner as it traversed the field of interest, so installment, he offers a personal memoir of his expe- we often silenced the tapper, giving up the print matrix riences as a researcher, clinician, and educator. despite its worth as a back-up for the photo matrix. Conrad Nagle, MD Rectilinear studies took a long time with the low radiopharmaceutical doses administered. It was difficult

14N THE JOURNAL OF NUCLEAR MEDICINE • Vol. 47 • No. 6 • June 2006 NEWSLINE for the child to remain motionless for long intervals, so we The rapid development of CT had a much more pro- became adept at using the so-called ‘‘scintillation cocktail’’ found effect on nuclear medicine practice than did com- adapted from the cardiac cocktail of demerol, phenergan, parative developments in ultrasound. Nuclear medicine studies and thorazine. Nurses assisted us in monitoring children, of the brain, which were primarily acquired for anatomic with the appropriate resuscitation equipment at hand. information, were rapidly replaced by CT. Renal scintig- Although we had no serious problems with the scintillation raphy and renogram studies, however, provided functional cocktail, it was abandoned several years later after an information that ultrasound could not offer. The result for adverse event in the CT suite. Our use of sedation decreased all imaging modalities, however, was a period in which we dramatically in later years as our technologists developed ‘‘competed’’ to provide evidence of the utility and benefits more sophisticated handling techniques. I once was accused of specific approaches. The numbers tell a part of the story. of using anesthesia on all our children because of the high In 1968 at CMH, we performed 444 nuclear medicine quality of images that we routinely obtained. studies: 275 brain, 35 liver, 24 renal, 35 lung, 10 cerebro- One of my objectives was to promote the use of ra- spinal fluid, and 2 thyroid studies. By 1970, this number dionuclide techniques in children, and the pediatric staff had risen to a total of 871 studies. Our peak load occurred also wanted to know more about the new gamma camera, in 1975, with 619 brain, 244 renal, 237 liver, 354 bone so in the late 1960s and early 1970s, I attended as many scintigram, and miscellaneous other studies for a total of case conferences and presented as many grand rounds 1,854 procedures. After the installation of CT in 1977, as possible. I frequently commented at these conferences nuclear medicine brain studies decreased to 131 in 1978 on ways in which a specific nuclear medicine study bene- and by 1983 numbered only 33 (for early viral encephalitis fited or might be of service in the management of a child’s and in symptomatic children with normal CT studies). problem. One of the first local barriers that I encountered During the same period, the numbers of nuclear medi- in introducing nuclear medicine to the staff was an older cine renal and bone studies continued to grow. In 1982, we pediatrician who had served on the War Department requested that the hospital purchase a SPECT unit, but we Hiroshima Damage Survey team at the end of World were informed that we could not justify the cost of such War II. He came to every presentation I gave and would a unit based on any projections that business would describe to his fellow pediatricians and trainees in lurid increase sufficiently. So we embarked upon a personal detail the effects of atomic bomb radiation on Japanese solicitation to local businesses, and, in 1984, we eventually children. raised sufficient donated funds to support a field upgrade of Despite this challenge, continuing beneficial advances an existing older single- head large-field-of-view (LFOV) were clear to many of my pediatrician colleagues. The re- gamma camera. That was a tactical mistake. The studies sults of early brain studies with 99mTc-pertechnetate were took forever to record (thank heavens for the invention of so clearly superior to the risks associated with invasive Velcro straps), and the quality of the images was marginal and/or direct carotid or vertebral at best. After prolonged negotiation, Siemens Corporation angiography that the use of ‘‘noninvasive’’ radioisotope retrieved the field-upgraded SPECT camera, and we studies in children rapidly increased. Brain imaging was purchased a dedicated ZLC SPECT camera that served us the predominant study in our field in the early years, but well for several years. As the requests for brain, bone, and radioiosotope-based renal studies soon were recognized as other SPECT studies increased, we eventually purchased having major advantages over radiographic techniques. a Picker triple-head SPECT camera and a dual-head total- body imaging camera. Our most versatile camera was the low-energy small- Competition from New Technologies FOV mobile camera (LEM) by Searle Radiographics White was a champion for other new technologies at (successor to Nuclear–Chicago), with converging–diverging CMH well before most other pediatric hospitals ventured and pinhole collimators. It had high resolution and was a into new imaging territory. In 1974 he persuaded the good size for babies. All of our Legg–Calve–Perthes studies administration to install a very early Rohe ultrasound were performed with this camera. We also obtained high- scanner and in 1977 an EMI 5050 CT unit. Although each resolution renal scintigrams with 99mTc-glucoheptonate of these devices produced images that left much to the using the pinhole or converging collimator for babies. The imagination, rapid advances over the next decade would camera was also important for portable brain death studies affect the numbers and types of studies referred for nuclear in intensive care and even on occasion in surgery to localize medicine imaging. hard-to-find osteoid osteomas (1). Shkolnik, the radiology colleague in charge of the Radionuclide spurred major growth in ultrasound unit, subsequently proved its immense value in nuclear medicine at our institution, with 92 studies per- pediatric imaging. We shared research studies and reported formed in 1971 and 595 studies performed in 1981. At the on the advantages of each modality. Shkolnik was honored same time, the numbers of x-ray cystography studies did several years ago by the Society for Pediatric Radiology as not decrease significantly. It is my belief that the pedia- a distinguished pioneer. tricians who ordered the majority of the initial urinary tract

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studies were accustomed to ordering the x-ray studies and aging modality has its special niche for specific questions found this anatomic information easier to understand. Some that need answers. For nuclear medicine, this niche con- urologists preferred the anatomical and functional com- tinues to be the elucidation of function. ponents offered by ordering both studies. The radiologic literature persisted in promoting the x-ray cystogram,

NEWSLIN favorably comparing its capabilities with those of ultra- Research and Education as Part of Pediatric sound (but not nuclear medicine!) as a better technique for Nuclear Medicine Practice anatomy and detection of vesicoureteral reflux. Many such Finding a niche for the specialty of pediatric nuclear reports came from adult institutions or from pediatric medicine meant promoting our successes and reporting on institutions that lacked onsite nuclear medicine facilities. challenges through research, presentation, and publication. Bone also grew from 1973 to 1983 after Many of the early nuclear medicine pioneers joined the introduction of 99mTc-polyphosphate and 99mTc- multiple subspecialty societies purposefully to disseminate diphosphonate radiopharmaceuticals, along with improved information about pediatric nuclear medicine. At times we gamma camera resolution, total-body imaging, and SPECT had to persuade their societies’ leadership and committees capabilities. to get our material on the programs at meetings. Although A major scientific and technologic regret and disap- my colleagues at CMH often grumbled and commented on pointment was that I could never convince the adminis- my frequent absences to attend such meetings, they tration to purchase a PET camera. Instead, the hospital graciously gave me permission to do so. administrators turned to MR imaging. Every breakthrough I felt that presenting our work as scientific papers only in PET imaging that I promoted was sidelined by money for at the SNM was somewhat like ‘‘bringing coals to New- a major upgrade in MR capacity. Interventional radiology castle.’’ I often would offer the first presentation of our and upgrades in ultrasound also demanded the hospital’s work at a pediatric, orthopedic, urologic, or subspecialty resources. After a second sophisticated CT device was radiology meeting rather than at the SNM to spread the purchased in the 1980s, the volume of nuclear medicine word outside our field about the value of nuclear medicine. studies declined steadily. It became obvious that each im- The policy of many scientific organizations and journals (Continued on page 19N)

Monkey Business In addition to memories of accomplishments and challenges, every medical career has odd or out-of- the-ordinary moments that stand out in reminiscence. CMH contracted with Chicago’s Lincoln Park Zoo to provide diagnostic and surgical services for small animals in distress. We were asked to perform a brain scintigram on an infant gorilla who had suffered a seizure. They suspected that the gorilla had been injured and wanted to rule out a subdural hematoma. We were not allowed to sedate the little ape, who was quite frightened and restless. Sue Alice Hamilton, one of our senior technologists, climbed onto the imaging table and cuddled the gorilla in her arms while Sue Weiss obtained the images (see figure). We did not find Technologist Sue Alice Hamilton sooths an unsedated baby gorilla undergoing a brain scintigram. a subdural hematoma or other abnormality. The little gorilla grew up at the zoo and became the proud mother of her own little gorillas. On another occasion, zoo vets brought over a some- radiopharmaceuticals from Jim Quinn’s radiopharmacy what larger gorilla with a fever of unknown origin. On at Northwestern Memorial Hospital. We were pre- a weekend day, Weiss performed a 67Ga scintigram and paring for a 131I-macroaggregated albumin lung scinti- discovered a focal lesion in the abdomen. Surgery gram on an 8-year-old boy. The radiopharmaceutical revealed a perforation of the small bowel by an ingested arrived in a shielded syringe and was placed on a tray foreign object. We saved that gorilla’s life with a nuclear next to the child and the camera. The technologist medicine study that localized the site of infection. turned to set the camera parameters, and the boy Not everyone was as well behaved as our animal grabbed the syringe and squirted the entire radioactive patients. In the early days, we contracted for prepared dose into the room.

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(Continued from page 16N) initial treatment. These studies frequently failed to detect restricting presentation and/or publication to only new pyelonephritis as the underlying disorder. After the confer- materials inhibited the dissemination of important infor- ence, I persuaded Edward S. Traisman, MD, a pediatrician on mation to the many types of specialist physicians who the CMH staff, to refer infants with UTIs for a research study ordered our studies. Over the years, I published scientific that began in 1981 and was finalized in 1983. We studied 55 abstracts or papers in 37 different subspecialty publications children with 99mTc-glucoheptonate scintigraphy and found and scientific journals in an attempt to promote pediatric the technique to be a major breakthrough in differentiating nuclear medicine as widely as possible. pyelonephritis from simple UTI. The ramifications of this In 1970, I prepared ‘‘ of finding were immense: it meant that those infants with pyelo- Chest Masses in Children’’ as a poster presentation for the nephritis could receive more intense intravenous therapy and annual meeting of the SNM, where it was awarded a silver that perhaps we could prevent the ravages of unrecognized medal. The same exhibit subsequently received a certifi- and/or undertreated pyelonephritis, including recurrent pyelo- cate of merit award at the Radiological Society of North nephritis and hypertension. America (RSNA) meeting, a silver medal at the American In 1983 I was invited to an international symposium on Academy of Pediatrics meeting, and an honorable mention pyelonephritis at the University of Munster, Germany. Eight award at the American Medical Association meeting. I of the cases we had collected in the previous 2 years were mention this to emphasize that the same scientific exhibit, presented there and subsequently published in the confer- unlike a scientific paper, was welcomed at different meet- ence proceedings (7). We submitted our final report on the ings and provided a useful way to spread the visual word 55 cases to the journal Radiology in the same year. After about our field. The scientific exhibit promoted pediatric nearly 8 months, the reviewers rejected it as ‘‘too clinical’’ nuclear medicine in a more visual and memorable form to for a radiology journal. We then submitted the report to the larger audiences than could be achieved through a single- Journal of Pediatrics, where, after almost 6 months, it was delivery scientific paper presented to a limited audience. rejected as ‘‘too radiological’’ for a pediatrics journal. In For the 1971 SNM meeting, Sue Weiss, CNMT (who was 1986, almost 3 years after initial submission for publica- my chief technologist), and I presented a scientific exhibit and tion, the research was published in Pediatric Radiology (3). handout booklet on ‘‘Sedation and Injection Techniques in The paper provoked controversy and turmoil. The Children,’’ and the exhibit was awarded a bronze medal. description of a nuclear medicine scintigraphic test that Nuclear medicine practitioners were anxious to introduce accurately differentiated pyelonephritis from simple UTI or radionuclide techniques for children in their hospitals, but cystitis made both the pediatric and urologic communities managing children was often disruptive to adult schedules. Our question which diagnostic tests were most appropriate. The techniques for handling children proved especially helpful for intravenous (IVP), x-ray cystogram, and ultra- technologists, and in 1972 we published ‘‘Considerations for sound were the conventional studies obtained in a child the Performance of Radionuclide Procedures in Children’’ (2). with urinary tract symptoms. Although radiologists re- Between 1970 and 1979, we presented 12 exhibits on ported that the IVP was as sensitive as ultrasound, they various aspects of pediatric nuclear medicine at professional ignored renal scintigraphy’s significantly greater accuracy society meetings. Of note, in 1972, our first submission of than either in recognizing renal involvement with infection. a scientific paper on radionuclide cystography was rejected for Even treatment management became controversial. Some oral presentation by the program committee of the SNM, but infectious disease gurus even proposed that all UTIs be our scientific exhibit on the topic was awarded medals by the treated with a short intravenous course of antibiotics to be SNM and RSNA the same year. I often said that if a scientific followed by oral antibiotics, eliminating diagnostic imaging paper is rejected by a program committee for oral presentation entirely. Because of the continuing controversy, Richard but is accepted as an exhibit and given an award, then the topic Cohn, MD, a pediatric nephrologist at CMH, and I pub- must represent an important advancement. lished an editorial on the role of cortical renal scintigraphy A good example of a rejection was our frustrating expe- for the diagnosis of pyelonephritis in the Journal of Pedi- rience in attempting to publish our paper on ‘‘The Locali- atrics (8). That article stimulated more positive and negative zation of Urinary Tract Infection with 99mTc-Glucoheptonate responses from pediatricians and urologists than any other Scintigraphy’’ (3). Previous developments had been reported article that I have written. by Hirsch Handmaker, MD, Joe Leonard, MD, and John Other scientific exhibits we presented covered the McAfee, MD (4–6). Around 1980, I presented a few pedi- topics of lymphosarcoma in children (9), renal transplants atric studies with 99mTc-glucoheptonate at a small think-tank in children, Polaroid film artifacts (10), oral 99mTc in conference in Santa Barbara, CA. Pyelonephritis, especially in the differentiation of epigastric lesions (11), soft tissue the neonate and infant, frequently does not reflect the severity localization of bone-imaging radiopharmaceuticals, neo- of infection, and, at the time, most initial urinary tract natal osteomyelitis (12), and Legg–Calve–Perthes disease infections (UTIs) were treated with oral antibiotics for a short (13,14). Our recognition of predictive scintigraphic patterns interval. Intravenous pyelography and x-ray cystography were for Legg–Calve–Perthes disease was derived over many years routine follow-up studies when infants did not respond to of observation working with orthopedic surgeons Mihran

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Tachdjian, MD, and Lou Dias, MD, at CMH. Our ob- servations allowed the first reliable predictable outcome early in the disease using a diagnostic imaging test. The implication from our study was that when the scintigraphic pattern indicates a poor prognosis, an intervention can be

NEWSLIN initiated at an earlier interval before irreversible damage occurs in the epiphysis. In 1976 we presented an exhibit and paper on pul- monary perfusion distributions in congenital heart disease in the neonate with transposition of the great arteries. That exhibit and subsequent publication (15) demonstrated that the pulmonary blood flow is equally distributed between both lungs in the newborn with d-transposition of the great arteries but that within weeks the pulmonary perfusion distribution becomes permanently asymmetric. Thus, a very early correction of the transposition within the first weeks of life is necessary to maintain equal distribution of blood flow into both lungs. I believe that our study accelerated the pediatric cardiac surgeons’ approach to correction of the defect at an earlier age. The advantage of noninvasive diagnostic imaging sig- nificantly aided in the early development of renal trans- plantation in children. Among the pioneers in pediatric renal transplantation were Ovar Swenson, MD, a pediatric general surgeon and chair of surgery at CMH; Lowell King, FIGURE 1. A research study of a dog kidney being perfused MD, and Casimir ‘‘Casey’’ Firlit, MD, pediatric urology on a Belzer perfusion pump and imaged with the pinhole surgeons; and myself. We quickly learned how to collimator. differentiate the various severities of acute tubular ne- phropathy from acute and chronic rejection. We also performed research to determine how long dog kidneys variable results. He pointed out that the results on a given could remain viable on a Belzer pump oxygenation machine patient from one institution could not be reliably compared (Fig. 1). We found that creating an infarction of approx- with results on the same patient from another institution. imately one-sixth the mass of the kidney would result in Pediatric urologists in the SFU were reported to be so a rupture of the kidney with time. Whenever we detected in frustrated that they began to doubt the value of the diuretic vivo partial infarct in a kidney with the gamma camera, we renogram. We felt the need to standardize the technique, were alert to a potential rupture of the transplant. That and, in October 1989, Maizels, Weiss, and I organized a research also led surgeons to transplant even the smallest conjoint meeting of interested practitioners from the SNM accessory arteries whenever possible and to refuse donor Pediatric Nuclear Medicine club and the SFU to meet at kidneys with multiple small arteries into the kidney. CMH (Fig. 2). Approximately 30 physicians, with Weiss as In 1968, Ranos Rado, MD, had introduced diuretic the lone technologist, attended the meeting. Joining me as renography in nuclear medicine. (16). We began to use the nuclear medicine physicians were Massoud Majd, George technique with the gamma camera in the late 1970s but Sfakianakis, Douglas Eggli, Andrew ‘‘Tip’’ Taylor, Ben soon found that many factors profoundly influenced the Greenspan, Eugene Anandappa, and Rick Shore. We at- final results and interpretation of the study. We continually tempted to define a standardized technique by considering modified our technique to minimize those factors that we all of the variables, including bladder catheterization, hydra- could control, such as hydration. For example, many babies tion, diuretic dose, time of injection, radiopharmaceutical, presented for their studies with minimum liquid input as if and analysis of half-time response. The result of our delib- they were undergoing an intravenous pyelogram. Their erations was ‘‘The Well-Tempered Diuretic Renogram’’ urine output was so minimal even with the diuretic re- (18,19). Maizels suggested evoking Bach’s ‘‘tempering’’–– sponse that false-positive responses misled interpretation. tuning a variety of instruments in different keys to play We eventually published an article that discussed the many together and produce a pleasing sound. factors that affected the diuretic renogram (17). Max We subsequently established a central repository for Maizels, MD, a pediatric urologist and cofounder of the data collection at CMH and created a standardized re- Society for Fetal Urology (SFU) expressed his concerns to porting system for ultrasound studies of the hydronephrotic me that diuretic renography was being performed with kidney in the infant (20). We also standardized the use of a variety of differing techniques at other institutions with (Continued on page 22N)

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(Continued from page 20N) NEWSLIN

FIGURE 2. Members of the Pediatric Nuclear Medicine Club and the Society for Fetal Urology on October 20, 1989, during their conjoint meeting at Children’s Memorial Hospital in Chicago, IL.

surgical terminology to describe findings in obstruction our country and why many physicians cling to ‘‘outmoded’’ at the time of surgery and the pathological reporting of procedures and techniques. the tissues comprising the obstruction. However, although everyone was in a compromise mode of agreement at the meeting, only a few institutions actually adopted the ‘‘well- With the Help of Friends and Colleagues tempered’’ renogram as the standard for their institution. I was fortunate to have supportive referring pediatri- I must confess that outside of the regulatory impedi- cians and other specialty physicians on our CMH staff. ments, trying to standardize the diuretic renogram technique Without their willingness to explore new techniques, such for neonatal hydronephrosis has been the most frustrating as radionuclide cystography, renal scintigraphy for trans- and disappointing experience of my entire professional plantation and infection, and Legg–Perthes, our techniques career. The technique for performing diuretic renography would have taken much longer to develop. Shore and remains an issue even today, and the ‘‘most ideal’’ method Anandappa were my nuclear medicine colleagues for many of is still debated at almost every meeting of the SNM the years that I served patients at CMH, and they tolerated my Pediatric Council. It is my contention that nuclear medicine many absences to spread the good word about pediatric practitioners are artisans and will perform a technique on nuclear medicine. My technologists labored long and the basis of their training or their own developmental ex- arduously. Among the many that spent many years and tears periences in practice. with me were Weiss, Hamilton, James Everett, and Lolita To illustrate the point, Weiss and I conducted a survey Fong. The last one to turn out the lights every day was Weiss. in the 1980s. We wanted to prepare a handout booklet on It was my greatest pleasure to introduce and teach techniques for performing pediatric studies, featuring pediatric nuclear medicine to perhaps 2,000 trainees, pediatric nuclear medicine and unusual nuclear medicine including nuclear medicine residents, fellows, and radiol- studies, to present to attendees at an SNM Central Chapter ogy residents from Northwestern Memorial Medical meeting. We surveyed a dozen full-time pediatric nuclear Center, Loyola Medical Center, Hines Veterans Hospital, medicine practitioners on how they performed 10 common Cook County Hospital, the U.S. Army and Air Force procedures. We were surprised to find that only a single medical services, and other Chicago medical institutions. individual performed his studies in ways similar to ours–– Many of the residents and fellows joined with me in and he had received initial training in our department! The publishing our work. We hosted visiting physicians and rest of the practitioners had been trained at different technologists from all over the world, including many of institutions or learned on the job, and each performed these the very early pioneers. Weiss was primarily responsible for common procedures in different ways. It is my belief that the training of countless nuclear medicine technologists physicians are loath to change practices learned during from the Northwestern Memorial Hospital, Triton College, their training. When a modicum of success is achieved in the College of DuPage, and other programs. Each and every following old beliefs, change will not occur without extraor- student maintained a log of the studies that they encoun- dinary effort. Perhaps this is one explanation for regional tered and were quizzed by Weiss at the end of the rotation. variations in surgical procedures or medical treatments in (Continued on page 24N)

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(Continued from page 22N) 7. Conway JJ. Radionuclide imaging of acute bacterial nephritis. Contrib Nephrol. 1984;39:28–35. May all of you be as fortunate as I in associating with such 8. Conway JJ, Cohn RA. Evolving role of nuclear medicine for the diagnosis a colleague in your work. and management of urinary tract infection. J Pediatr. 1994;125:335– This memoir has been about the early years of pediatric 336. 9. Schey W,White H, Conway JJ, KiddJ.Lymphosarcoma inchildren: a roentgenologic nuclear medicine, its trials, tribulations, and wonderful clinical evaluation of 60 children. Am J Roentgenol. 1982;117:59–72.

NEWSLIN successes. I leave the memoirs of current practice to my 10. Weiss S, Conway JJ. Polaroid film artifacts. JNuclMedTechnol.1976;4: colleagues who are still in the trenches. 183–188. 11. Weiss S, Conway JJ. Oral Tc99m-pertechnetate: an aid in the differentiation of Finally, nothing that I may have accomplished could epigastric lesions. J Nucl Med Technol. 1974;2:146–149. have happened without the behind-the-scenes support of 12. Bressler EL, Conway JJ, Weiss SC. Neonatal osteomyelitis examined by bone my wife, Dolores, who for 50 years has put up with my scintigraphy. Radiology. 1984;152:685–688. 13. Conway JJ. Radionuclide in pediatric orthopedics. Pediatr shenanigans, late hours, frequent travels, and bringing Clin North Am. 1986;33:1313–1334. home ‘‘strangers’’ from all over the world for dinner. 14. Conway JJ. A scintigraphic classification of Legg-Calve-Perthes disease. Semin Nucl Med. 1993;23:274–295. 15. Muster AJ, Paul MH, Van Grondelle A, Conway JJ. Asymmetric distribution of the pulmonary blood flow between the right and left lungs in d-transposition of REFERENCES the great arteries. Am J Cardiol. 1976;38:352–361. 16. Rado JP, Banos C, Tako J. during furosemide (Lasix) 1. Harcke HT, Conway JJ, Tachdjian MO, et al. Scintigraphic localization of bone diuresis. Nucl Med (Stuttgart). 1968;7:212–221. lesions during surgery. Skel Radiol. 1985;13:211–216. 17. Maizels M, Firlit CF, Conway JJ, King LR. Troubleshooting the diuretic renogram. 2. Conway JJ. Considerations for the performance of radionuclide procedures in Urology. 1986;28:355–363. children. Semin Nucl Med. 1972;2:305–315. 18. Society for Fetal Urology and Pediatric Nuclear Medicine Council, SNM. The 3. Traisman ES, Conway JJ, Traisman HS, et al. The localization of urinary tract ‘‘well tempered’’ diuretic renogram: a standard method to examine the asymp- infection with Tc99m glucoheptonate scintigraphy. Pediatr Radiol. 1986; tomatic neonate with hydronephrosis or hydroureteronephrosis. J Nucl Med. 16:403–406. 1992;33:2047–2051. 4. Handmaker H. Nuclear renal imaging in acute pyelonephritis. Semin Nucl Med. 19. Conway JJ. ‘‘Well-tempered’’ diuresis renography: Its historical development, 1982;12:246–253. physiological and technical pitfalls and standardized technique protocol. Semin 5. Leonard JC, Allen EW, Goin J, Smith CW. Renal cortical imaging and the Nucl Med. 1992;22:74–84. detection of renal mass lesions. J Nucl Med. 1979;20:1018–1022. 20. Fernbach SK, Maizels M, Conway JJ. Ultrasound grading of hydronephrosis: 6. McAfee, JG. Radionuclide imaging in the assessment of primary chronic introduction to the system used by the Society for Fetal Urology. Pediatr Radiol. pyelonephritis. Radiology. 1979;133:203–206. 1992;23:478–480.

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SNM LEADERSHIP UPDATE Connecting Our Past With the Future

s medical practitioners, we seek to provide the educational meetings—is reported highest quality patient care to improve the health of as advances in molecular imaging. Aindividuals and—ultimately—our society as a whole. The accreditation and certification/ Over the past few years, a biological and technological recertification processes we follow evolution in imaging has allowed us to examine the cellular require updated knowledge of mo- or molecular basis of diseases—and explore its potential in lecular imaging. It is undisputable managing and treating illnesses. that molecular imaging break- Molecular imaging, a new term to many, is quite familiar throughs have in large part grown to those of us practicing in nuclear medicine. It is, in fact, out of nuclear medicine tools and Peter S. Conti, MD, PhD a common thread that links our past with our future. techniques, and so we realize that President, SNM ‘‘Twinkling atoms,’’ as the late SNM historian William G. nuclear medicine has evolved into Myers frequently called radioisotopes, form the cornerstone something larger than what the profession’s pioneers en- of molecular imaging, but the term should perhaps refer to visioned. Our field has evolved into molecular imaging and any atom attached to a molecule that provides a detectable will have a significant impact on health care over the next signal, be it through fluorescence, bioluminescence, resonance 5, 10, and more years, and SNM is the foundation for its relaxation, or form of contrast. We already know that patients continued progress. SNM’s place is to coordinate, interact, with cancer, heart disease, , or debilitating neurological communicate, and integrate molecular imaging with the conditions benefit from earlier, more accurate diagnoses and entire health care system. safer, more effective treatments when their medical care in- What we do these next few years will have a tremendous cludes scanning technologies such as PET or SPECT with impact on the future of care for patients, as well as on our CT. The possibilities of molecular imaging in providing new profession as a whole. Since SNM’s members have the sci- insights, treatments, and diagnostic methods are limitless as entific and clinical backgrounds to advance the science, scientific discoveries and technology continually increase. technology, and application of molecular imaging for pa- Molecular imaging now includes a number of related imaging tients, the society over the past few years has initiated—and technologies such as MR spectroscopy, optical imaging, and is now accelerating—a transition of its programs and ser- contrast enhancement using biologically active or ‘‘smart’’ vices to focus on molecular imaging modalities such as agents. As these technologies enter the clinical arena, we will PET, PET/CT, SPECT/CT, MRI, and contrast ultrasound. witness a paradigm shift in medicine and an evolution in the More and more, you will see this emphasis in our educa- standards of patient care—and SNM is now positioned to tional programs, products, and services; our meeting ab- stand front and center as the essential society to harness its stracts; our expert speakers; our growing list of research power for the future of quality medical care. grants and fellowships; and, perhaps, even in the very More and more, molecular imaging will enable physi- ‘‘look’’ and name of the society. cians to define disease in individual patients by relating location, function, structure, and biochemistry. Molecular im- aging will be able to answer: What is the patient’s problem? ‘‘Bench to Bedside’’ Launches Where is that problem? Can anything be done about In a historic action, SNM’s board of directors approved it? What is the best chance of treatment? Is a patient re- the launch of ‘‘Bench to Bedside: A Molecular Imaging Cam- sponding to a drug treatment? Does the treatment help? The paign’’ to raise $5 million over the next 5 years to support effective drugs of the future will be designed for diseases outreach activities to referring physicians and patient groups; defined at the molecular level, and treatment will be based fund translational clinical studies and small innovative trials; on in vivo detection and monitoring of abnormal molecular support advocacy for molecular imaging; and train the cur- processes using biomarkers and imaging. rent imaging workforce and educate future generations of practitioners on the applications of molecular imaging. SNM Evolves With Molecular Imaging During its 52 years, the society has never sponsored The research we read—published in our renowned a fundraising effort of this magnitude, and the program has journal and released in scientific abstracts at our respected been jump-started with a generous $1 million pledge from

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GE Healthcare. This special, concentrated fundraising ters, and individual members—are valuable resources. I want initiative, which will be carried out in partnership with to applaud the work of the members who examined health the Education and Research Foundation and which debuts care policy and practice issues, who wrote the first procedure at our Annual Meeting, brings molecular and nuclear im- guideline for PET/CT imaging with cancer patients, and who aging professionals together to take molecular imaging into look to improve the profession as residents and interns.

NEWSLIN the future, continuing the exploration of biological and tech- The society is keeping its eye on what’s going on at the nological innovations to fight diseases. national level, especially when it comes to funding basic SNM leaders have been quietly working on this campaign science research through the Department of Energy and de- for several months, and the early pledge from GE Healthcare veloping guidance documents for investigational new drugs signals that the initiative will be an overwhelming success. and manufacturing practices for PET drugs. As SNM lead- For more information on the program, visit SNM’s Web site ers continue to express our members’ needs in talks with at www.snm.org/micampaign. government and regulatory agency representatives, we collaborate with related allied organizations on issues such SNM Clinical Trials as developing uniform protocols for PET, MR, and CT Since its founding in 1954, the society has played imaging. a significant role in achieving important milestones that have The society initiated a new industry partnership pro- greatly advanced our profession. Our pioneering thinkers gram aimed at encouraging collaborative efforts with the have been—and continue to be—the driving force behind commercial sector to promote rapid advance and innovation many biological and technological imaging advances. in medical care through molecular imaging. SNM and in- The society sees as part of its role the responsibility to dustry will partner on a wide range of projects, promoting facilitate the movement of molecular discoveries made by research grants and scholarships, advocating for reform on the hands of a scientist at the lab bench into the hands of Capitol Hill, and providing continuing education opportu- a physician treating sick patients with debilitating and nities. Industry and SNM leaders will discuss controversial incurable diseases. Health care innovations come from this topics involved in molecular imaging basic research, clin- ‘‘bench to bedside’’ approach, connecting or ‘‘translating’’ ical issues, instrumentation, and drug discovery during an basic biomedical research into clinical research and then Industry Molecular Imaging Summit this year, and we clinical practice. SNM hopes to help basic scientists see the continue to work with commercial representatives of the potential clinical applications of research while enabling Nuclear Medicine Industry Leaders Working Group. clinical researchers to glimpse what new findings are on the As my term as SNM president ends during this month’s horizon with its initiation and development of the multi- Annual Meeting in San Diego, I am optimistic about the center SNM Clinical Trials Group. This exciting initiative future of SNM and its members. I want especially to thank will create the opportunity for the society to contribute to several individuals for their support and guidance: my wife current and future nuclear medicine clinical practice in and family for their unending support and encouragement; a positive and unbiased way, allowing the continued suc- my colleagues at USC for their patience and understanding; cess of nuclear medicine in clinical practice, in drug devel- my predecessors, Mathew Thakur, PhD, and Henry Royal, opment, and in the evolving field of molecular imaging. MD, for their guidance and inspiration; my successors, Over time, these small trials are expected to encompass all Martin Sandler, MD, and Sandy McEwan, MD, with whom the interests and possible applications of molecular imaging I have had a wonderful working relationship; the board of and diagnostic and therapeutic nuclear medicine. directors for their wisdom and courage; and, of course, Virginia Pappas, SNM chief executive officer, and her staff Resources, Political Power, Allies for the countless hours of help, guidance, and advice over Physicians must be trained to become experts in all the last 3 years. hybrid imaging techniques, and referring physicians must be By connecting SNM’s past with the future, we will educated on the benefits of molecular imaging. Our Learning continue to see our membership grow and the number of Center—with its Web portal, workshops and symposia, and our clinical procedures increase. I am confident that SNM newly developed, self-paced online courses—and our Life- will continue its longstanding commitment to embracing long Learning and Self-Assessment Program modules are innovative ideas and seizing important opportunities, cre- valuable, comprehensive educational tools that cultivate ating a tremendous impact on patient care. medical imaging professionals with modern knowledge and concepts. The PET and Molecular Imaging centers of excel- Peter S. Conti, MD, PhD lence—along with our various councils, committees, chap- President, SNM

26N THE JOURNAL OF NUCLEAR MEDICINE • Vol. 47 • No. 6 • June 2006 NEWSLINE

SNM PUBLIC AFFAIRS UPDATE National Oncologic PET Registry Begins Accepting Patient Data

he National Oncologic PET Registry (NOPR) offi- essentially all types of cancers in- cially began accepting patient data May 8. The last cluding, but not limited to, brain, Tstep in the process for launching the NOPR occurred cervical, small cell lung, pancreatic, when the American College of Radiology (ACR) Insti- testicular, and ovarian cancers. (Cov- tutional Review Board (IRB) reviewed and approved a erage for breast cancer diagnosis and slightly modified project plan in late April. On February 10, initial staging of axillary nodes was the Centers for Medicare & Medicaid Services (CMS) previously excluded and remains so.) announced an agreement with the NOPR to collect data on PET scans as part of a project to evaluate the efficacy of NRC and NARM Hugh Cannon PET as an oncologic tool, thereby allowing for greatly ex- Last year Section 651(e) of the SNM Director of Public panded coverage of PET under Medicare’s new ‘‘coverage Energy Policy Act of 2005 granted Affairs with evidence development’’ protocol. However, following the Nuclear Regulatory Commission that announcement, it became apparent that some changes (NRC) regulatory authority over naturally occurring and were necessary related to IRB review and approval and accelerator-produced radioactive material (NARM). Legis- consent issues. lators gave the NRC just 18 months to promulgate new The new project design requires both the patient and the regulations covering NARM. Around April 7 the NRC referring physician to indicate their willingness to partic- released the proposed draft NARM rule package that was ipate in the research component of the NOPR, although being submitted to the commission for review in an effort to written informed consent is not required. Should either the give the public extended notification. The proposed draft patient or referring physician choose not to participate in rule package is available online at: http://ruleforum.llnl.gov/ the NOPR research, the information pertaining to that spe- cgi-bin/library?source5*&library5narm_lib&file5*&st5 cific patient’s PET scan will be excluded from the research ipcr. database. Refusal of either the patient or referring phy- The commission met on regulatory interests related to sician to participate in the NOPR research will not affect the Energy Policy Act of 2005 on May 15, and the NARM CMS reimbursement for the PET scan. As originally planned, package was expected to be among the discussion topics. CMS reimbursement for PET scans covered by the NOPR We expect that the final proposed draft rule for NARM will is based upon receipt of the required information from the be released for a 45-day public comment period sometime referring physician within the designated time frame. after the May 15 meeting, pending any major alterations Since CMS announced its intent to support a PET reg- requested by the commissioners. istry in January 2005, SNM representatives have assisted in The SNM Public Affairs staff encourages all members developing NOPR, a national, Internet-based, audited data with an interest in radioactive materials—particularly those repository designed to gather PET data from Medicare who own or work directly with cyclotrons—to contact us at beneficiaries and providers. In addition to SNM, represen- [email protected] or 703-708-9000 ext.1322 to share their tatives from the Academy of Molecular Imaging (AMI), impressions and/or concerns about the proposed draft rule ACR, the ACR Imaging Network, and the American Society package. Your insight would be much appreciated as the SNM of Clinical Oncology have also played key roles in guiding staff and leaders prepare to develop comments on the final the project’s development. The opening of NOPR means draft rule that is expected to be released within the next that Medicare coverage for PET will be available for couple of months.

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NEWSBRIEFS NEWSLIN National Oncologic PET sent is not needed. Should either the Brookhaven and Mt. Sinai Registry Opens patient or referring physician choose Join in Translational The National Oncologic PET Reg- not to participate in the NOPR re- Research search, the information pertaining to istry (NOPR), a landmark project in- The U.S. Department of Energy that specific patient’s PET scan will be tended to expand coverage for PET (DOE) Brookhaven National Labora- excluded from the research database. imaging in a broad range of cancer tory and the Mount Sinai School of Refusal of either the patient or refer- indications, began accepting patient Medicine (MSSM) announced on April ring physician to participate in the entries on May 8. The registry is a 5 an agreement to establish a Joint Cen- national, Internet-based, audited data NOPR research will not affect CMS reimbursement for the PET scan. As ter for Translational Biomedical Imag- repository designed to gather PET data ing. Building on earlier Brookhaven/ from beneficiaries and providers and to originally planned, CMS reimburse- ment for PET scans covered by the MSSM collaborations using radio- report on that data. More than 600 PET tracers and brain-imaging techniques, facilities nationwide have already reg- NOPR is based upon receipt of the required information from the referring including PET, to investigate the istered to take part in NOPR and can biological bases of attention-deficit/ now be reimbursed by CMS for PET physician within the designated time- frame. hyperactivity disorder (ADHD) and indications currently not covered for substance abuse, this formalized agree- payment. Data from NOPR and asso- NOPR is sponsored by the Acad- ment will foster more robust research ciated research projects will allow bet- emy of Molecular Imaging and man- collaborations investigating these and ter assessment of the impact of PET aged by ACR and the ACR Imaging other conditions, including Alzheimer’s on the management of patients with Network. Since the original announce- disease and depression. various forms of cancer or suspected ment of plans for the registry in January The Brookhaven Lab’s world-class cancer. 2005, SNM representatives have as- medical-imaging scientists will benefit The last step in the sometimes chal- sisted in developing the registry. ‘‘The from collaboration with the medical lenging preparations to launch the launching of this registry is a mile- school, where research professionals registry was American College of stone for cancer patients,’’ said SNM can help identify new molecular targets Radiology (ACR) Institutional Review President Peter S. Conti, professor of Board (IRB) approval of a modified radiology, clinical pharmacy, and bio- for radiotracer development and pro- project plan. Although the Centers for medical engineering at the University vide access to a broad base of patient Medicare and Medicaid Services (CMS) of Southern California, Los Angeles. populations. The agreement also estab- announced in February a final agree- ‘‘SNM continues to work collabora- lishes a mechanism for joint appoint- ment with the NOPR to collect data tively with our colleagues from dif- ments for Brookhaven scientists and for on oncologic PET scans in expanded ferent associations to advance patient mentoring of Mount Sinai graduate coverage areas as part of an effort to care. PET advances will continue to students. Mount Sinai researchers will support permanent coverage decisions, provide new dimensions in imaging gain access to Brookhaven’s sophisticated subsequent changes to the agreement cancer as the medical community in- imaging tools, expertise in radiotracer were needed. The major change to the tegrates advances made in molecular , and specialized facilities for original project design was clarification and cellular biology, chemistry, phys- the development of new tracer molecules. that the research in which the NOPR ics, pharmacology, engineering, and ‘‘This agreement draws on the com- entity will be engaged is not considered computer sciences.’’ plimentary strengths of our 2 institu- exempt from IRB approval. However, The launch of the registry was tions,’’ said Fritz Henn, Brookhaven PET centers and referring physicians accompanied by a Web cast at which Lab’s new Associate Laboratory Di- working through the registry are not NOPR staff and CMS representatives rector for Life Sciences. ‘‘Our hope is considered to be engaged in the NOPR answered questions from physicians that this center will foster innovations research and do not need separate IRB and others interested in participation. in radiotracer development and imag- approval. To learn more about the registry, view ing techniques that can be translated to The new project design requires an orientation slide set, download improvements in the understanding, both patients and referring physicians forms and other materials for registra- diagnosis, and treatment of disease, as to indicate their willingness to partic- tion, and follow the accrual of patients well as advances in drug research and ipate in the research component of the in different disease categories, visit development.’’ Dr. Dennis Charney, NOPR, although written informed con- www.cancerpetregistry.org. (Continued on page 33N)

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(Continued from page 28N) awarded by the SNMTS Professional treating cancer were the focus of an Dean of Academic and Scientific Development and Education Fund April 5 briefing on Capitol Hill in Affairs for MSSM and Senior Vice (PDEF). The 2 12-month $20,000 Washington, DC, sponsored by the President for Health Sciences for Nuclear Medicine Practitioner Program National Electrical Manufacturers As- Mount Sinai Medical Center said, ‘‘In grants will be awarded by the PDEF, sociation (NEMA) and U.S. Oncology. addition to pursuing the research in- with support from members of the The event was moderated by Repre- terests we already share with our SNMTS Corporate Friends program, sentative Mike Rogers (R-MI), chair of Brookhaven colleagues, Mount Sinai including Biogen Idec, Bristol Myers– the House of Representatives Cancer scientists will likely identify new Squibb, Capintec Inc., GE Healthcare, Care Working Group. ‘‘A comprehen- medical problems where imaging can Mallinckrodt Inc., and MDS Nordion. sive approach to cancer diagnosis and play a role. Our medical expertise and ‘‘SNMTS is proud to announce the treatment has a tremendous impact on experience in clinical studies will also creation of these new grants, which patients across the entire nation,’’ said be a great asset when trying to trans- will help universities, colleges and Rogers. ‘‘With emerging research con- late and apply Brookhaven’s capabil- related institutions launch new master’s tinually pointing to imaging as a crucial ities and developments in imaging to degree–level programs for imaging part of that care continuum, ensuring that clinical studies of disease and behavior specialists,’’ said SNMTS President all Americans can access quality imaging disorders in patients.’’ Valerie R. Cronin. ‘‘Developing this services is absolutely essential.’’ Under the agreement, Brookhaven new level of health care provider will A white paper, Medical Imaging in Lab scientists will continue to initiate have a tremendous impact on the field of Cancer Care: Charting the Progress, and lead their own research pro- imaging specialists,’’ she said, adding was released at the event. It surveys grams, as well as operate, maintain, that programs could be available as recent innovations in imaging and and advance the core imaging facilities, early as the 2007 fall term. The SNMTS the direct results of those innovations associated technical staff, and compo- recently evaluated the need for an in cancer diagnosis and treatment. nents of the clinical infrastructure. This advanced degree for nuclear medicine Among the benefits discussed at the novel integration of physical and technologists in clinical practice. As the briefing were: less invasive diagnosis life sciences has led to a variety of profession has matured, technologists and treatment, more effective man- advances in radiopharmaceuticals and have taken on roles in the clinical setting agement approaches, increased effi- nuclear medicine instrumentation and that are considered beyond the standard ciencies and savings in cancer care, will continue to be funded by the Of- practice domain. and resulting increased worker pro- fice of Biological and Environmental ‘‘A nuclear medicine practitioner ductivity. Research within the DOE Office of would be able to provide a broad range Joe Hogan, president and CEO of Science and by the National Institutes of services under the supervision of GE Healthcare, spoke on behalf of of Health (NIH). In the start-up phase a physician in a variety of settings,’’ NEMA, calling imaging one of the of the collaboration, a core group explained Martha W. Pickett, chair of single most important technologies of scientists from the 2 institutions will the SNMTS Advanced Practice Task ever invented. ‘‘I’m proud to say that conduct pilot studies to demonstrate the Force. ‘‘This new clinical role offers an imaging devices have contributed dra- value of the program and to provide opportunity for significant career ad- matically to the improvement in cancer preliminary data. These data will then vancement for technologists.’’ be used to apply for joint MSSM/ The deadline for completion and care, advancements such as combined Brookhaven research grants from fund- filing of the electronic application is PET/CT imaging allow physicians to ing agencies such as NIH. All NIH June 15. Additional information and the see cancer earlier, localize and person- grants for joint research conducted by application can be found at www.snm. alize treatment, and carefully monitor the center would be awarded to and org/grants. Eligible applicants are rep- that treatment,’’ he said. administered by MSSM. resentatives from U.S. colleges or uni- Also released at the briefing were U.S. Department of Energy versities or consortia of institutions. a timeline highlighting advances in Recipients will be announced in August. medical imaging and cancer care since 1950 and a series of fact sheets, SNMTS Offers Grants for For more information about thesegrants, contact Kathy Bates, SNM director of including descriptions of imaging mo- NM Practitioner Program: development, at [email protected]. dalities, recent cancer statistics, a glos- June 15 Deadline for Society of Nuclear Medicine sary of cancer terms, and case studies. Applicants Technologist Section For copies of the white paper and The SNM Technologist Section these additional materials, visit www. (SNMTS) announced on April 17 that Charting the Progress of medicalimaging.org. 2 new competitive grants aimed at Medical Imaging National Electrical encouraging the launch of advanced The benefits and increasing utility Manufacturers Association practice degree programs are being of medical imaging in diagnosing and (Continued on page 42N)

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FROM THE LITERATURE NEWSLIN Each month the editor of Newsline changes in concentration of specific ated with multifocal tumors, central selects article on diagnostic, thera- cytokines interleukin, tumor necrosis compartment removal, and ipsilateral peutic, research, and practice issues factor-a, and interferon-g, suggesting dissection. Overall 5- and 10-year sur- from a range of international publica- that therapeutic effects from RIT may vival rates were higher than 98%. The tions. Many selections come from out- be tied to changes in inflammatory authors concluded that ‘‘total thyroid- side the standard canon of nuclear response. The authors concluded that ectomy followed by radioiodine ther- medicine and radiology journals. This their results suggest that the ‘‘antimi- apy is an optimal treatment strategy month the literature contained a re- crobial efficacy of RIT involves kill- that makes it possible to achieve a cure markable number of articles on the ing through promotion of fungal cell in a vast majority of pediatric patients utility of PET and other nuclear medi- apoptosis-like death, reduction in yeast with differentiated thyroid carcino- cine techniques in predicting response capsule size, cooperation with macro- mas.’’ to treatment in a variety of diseases. phages, and modulation of the inflam- Annals of Surgery Several of these are included in this matory response.’’ review. Note that although we have Journal of Infectious Diseases divided the articles into diagnostic and therapeutic categories, these lines Increasing Radioiodine are increasingly blurred as nuclear Surgically Treated Thyroid Uptake in Thyroid Cancer medicine capabilities rapidly expand. Cancer in Children Metastases Many diagnostic capabilities are now Demidchik and colleagues from Liu et al. from the Leiden Univer- enlisted in direct support of and, often, Belarus, Germany, and Japan reported sity Medical Center (The Nether- in real-time conjunction with thera- in the April issue of Annals of Surgery lands) reported in the April issue of pies. These briefs are offered as a (2006;243:525–532) on a retrospective the European Journal of Endocrinol- monthly window on the broad arena study to evaluate the results of surgical ogy (2006;154:525–531) on a study in of medical and scientific endeavor in treatment for thyroid cancer in pedi- which the retinoid X receptor activa- which nuclear medicine now plays an atric patients. The study included 740 tor bexarotene was assessed for its essential role. individuals who were younger than potential to increase 131I uptake in 15 years old at the time of surgeries, treatment for metastases of differenti- which included total thyroidectomy ated thyroid carcinoma (DTC). The in 426 (57.6%), lobectomy in 248 studyincluded11patientswithme- Therapy –––––––––––––––––––––––– (33.5%), subtotal thyroidectomy in 58 tastases from DTC and documented (7.8%), and partial lobectomy in 8 insufficient 131I uptake. Each patient RIT for Fungal Infection (1.1%) patients. Patients were fol- received injections of recombinant In an article published in the lowed for a mean of almost 10 years human thyroid-stimulating hormone May issue of the Journal of Infec- (although the range was quite broad and was imaged with whole-body tious Diseases (2006,193:142721436), at 1.5–236.4 months). Of the 204 scintigraphy and SPECT 3 days after Dadachova et al. from the Albert (27.6%) individuals in whom recur- administration of 185 MBq 131I . Each Einstein College of Medicine (Bronx, rences were noted, 73 (9.9%) ex- patient then received 6 weeks of NY) reported on a study designed to perienced local relapses, 90 (12.2%) treatment with 300 mg of bexarotene elucidate the mechanisms by which ra- distant metastases, and 41 (5.5%) a per day, and the imaging protocol was dioimmunotherapy (RIT) has been noted combination of local and distant re- repeated. The authors found that to be effective in treating fungal and/or currences. Factors found to be signif- bexarotene treatment induced 131I bacterial infections. Investigating the icantly associated with recurrent nodal uptake in metastases in 8 patients, actions of 213Bi-labeled monoclonal disease were young age at diagnosis, but uptake was evident only on antibodies in in vitro studies of Cryp- multifocal carcinomas, N1 status, and SPECT, with incomplete matching to tococcus neoformans, they found that no neck lymph node dissection per- metastases on CT. They concluded microbicidal effects resulted mainly formed. Significant risk factors for that bexarotene partially restores 131I from ‘‘direct-hit’’ killing, with contri- lung metastases were female gender, uptake in metastases of DTC, but that butions from crossfire effect. RIT also young age at diagnosis, and presence ‘‘the clinical relevance of this obser- promoted apoptosis-like death in fun- of symptoms. Postoperative hypopara- vation may be limited due to the gal cells and was associated with thyroidism was significantly associ- differential responses of the different

34N THE JOURNAL OF NUCLEAR MEDICINE • Vol. 47 • No. 6 • June 2006 NEWSLINE metastases within each patient and the of 1.9 radioactive nodes were biopsied Value of Lymphadenectomy low intensity of 131I uptake.’’ in 686 of 1,177 breasts. Sixty-four of in Melanoma European Journal of Endocrinology 142 breasts showed metastasis to the In an article e-published ahead of most radioactive node only, 39 showed print on April 12 in the Annals of metastasis to nodes other than the Surgical Oncology, Wong et al. from Diagnosis ––––––––––––––––––––––– most radioactive node, and 39 showed the Memorial Sloan–Kettering Cancer metastasis to both the most radioactive Center (New York, NY) reported on SPECT in Pediatric Back node and other radioactive nodes. The a multi-institutional outcomes study of Pain authors concluded that, ‘‘it is neces- patients with melanoma who were sary to harvest radioactive lymph Takemitsu and an international found to have positive sentinel nodes nodes other than the most radioactive’’ group of researchers from Japan, but did not undergo complete lympha- and advised that efforts to remove Thailand, and the United States re- denectomy. The study included data every radioactive lymph node will ported in the April 15 issue of Spine on 134 patients (median age, 59 years) minimize false-negative results. (2006;15:9092914) on a retrospective from 16 institutions who did not European Journal of undergo complete lymph node dissec- study of pediatric athletes with low Surgical Oncology back pain and unilateral tracer uptake tion (CLND) after positive sentinel at the pars interarticularis on SPECT lymph node procedures. The primary but no defect on radiographs. The PET and Axillary Lymph melanoma was located on the extrem- study included 22 children (average Node Assessment ities, trunk, and head or neck in 45%, age, 12.3 6 2.5 years) with these 43%, and 12% of patients, respec- Gil-Rendo et al. from the Clinica histories and with pain presumed to tively. Median follow-up was 20 Universitaria of Navarra (Pamplona, months, and median time to recur- have resulted from athletic activities. Spain) reported in an article e-pub- The average duration of pain was rence was 11 months. Nodal recur- lished ahead of print on April 18 in the 21 6 23 weeks. Investigation of the rence was a component of the first site British Journal of Surgery on the clinical record indicated that 19 of recurrence in 20 patients (15%), value of 18F-FDG PET in detecting (86%) children had been found to and nodal recurrence-free survival was axillary lymph node involvement in have increased uptake at L5, 6 (27%) not statistically different from that breast cancer. The study included 275 to have spina bifida occulta, and 8 seen in a comparative group of pa- women with breast cancer. All under- tients who underwent CLND. Nor was (36%) to have scoliosis. Despite the 18 went F-FDG PET imaging. Axillary disease-specific survival for positive- fact that the majority of patients (18, lymph node dissection was performed 82%) had good outcomes, the authors SLN patients who did not undergo in a subgroup of 150 women, regard- cautioned that those with longer his- CLND (80% at 36 months) signifi- less of imaging results. In the second tories of symptoms were more likely cantly different from the group that group of 125 women, sentinel lymph to be at risk for persistent pain with underwent CLND. The authors con- node biopsy was performed only in athletic activity. They recommended cluded that this study emphasizes the those women in whom pathologic ax- that these patients and those with spina ‘‘the importance of ongoing prospec- illary uptake was not demonstrated on bifida occulta be followed carefully tive randomized trials in determining PET. In the entire group of 275 pa- for increased risk of low back pain. the therapeutic value of CLND after tients, the sensitivity and specificity of positive sentinel lymph node biopsy in Spine 18 F-FDG PET for detecting axillary melanoma patients.’’ involvement were 84.5% and 98.5%, Annals of Surgical Oncology Selection of Sentinel respectively (2 false-positives and 22 Nodes for Biopsy false-negatives). PET showed patho- In an article e-published ahead of logic uptake in 21 women, indicating print in the April 18 edition of the involvement of the internal mammary PET as Predictor in European Journal of Surgical Oncol- lymph node chain. Whole-body PET Esophageal Cancer ogy, Morota et al. from the Cancer also identified second synchronous tu- Treatment Institute Hospital (Tokyo, Japan) re- mors in 5 asymptomatic patients and Levine et al. from Wake Forest ported on a study of radioactivity hematogenous metastases in 2 pa- University (Winston-Salem, NC) re- thresholds for sentinel node biopsy in tients. The authors concluded that the ported in the April issue of Annals of breast cancer. The study included high positive predictive value of PET Surgery (2006;243:472–478) on a 1,179 procedures for primary breast suggests that tracer uptake in the axilla study designed to assess the value of cancer, in which the level of radioac- could be an indication for full axillary 18F-FDG PET in predicting response tivity and order of removal of each lymph node detection without pre- among patients undergoing con- lymph node were compared with vious sentinel lymph node biopsy. comitant chemoradiation for locally results from pathology. An average British Journal of Surgery advanced esophageal cancer. Although

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approximately 25% of such patients cancers. Two neuroradiologists and 2 standard clinical staging with CT and undergo a pathologic complete re- radiation oncologists were asked to physical examination.’’ sponse to the treatment, most proceed contour GTVs first with the informa- International Journal of Radiation to scheduled resection because other tion provided by CT alone and then Oncology, Biology, Physics diagnostic methods (CT, endoscopy, with PET/CT data. The authors found

NEWSLIN ultrasound) are unable to verify re- near-significant variation across physi- PET for Outcomes sponse. At the time of publication, cians’ CT volumes and significant var- Evaluation in Malignant the ongoing study had included 64 iation across PET/CT volumes. They Lymphoma patients with T3–T4N0M0 or T1– noted that whereas 1 radiation oncol- In an article published in the April T4N1M0 esophageal cancer who un- ogist’s PET/CT volumes were signif- issue of Haematologica (2006;91: derwent PET imaging before and 4–6 icantly larger than his CT volumes, the 522–529), Zijlstra et al. from the weeks after chemoradiation (cisplatin, other radiation oncologist’s CT vol- VU University Medical Center (Am- 5-fluorouracil, and 50.4 Gy radiation). umes were larger than his PET/CT sterdam, The Netherlands) reported All patients underwent esophagec- volumes. Although no significant in- on a study designed to systematically tomy, and response was determined terdisciplinary variation was found, review the literature on the diagnos- from pathology results. As expected, the significant differences in GTVs tic performance of 18F-FDG PET in a pathologic complete response was across these observers led the authors evaluation of first-line therapy of found in 27% of patients, with path- to conclude that the need for a de- Hodgkin’s disease and non-Hodgkin’s ologic residual microscopic disease in lineation protocol had been confirmed. lymphoma (NHL). The authors 14.5%, partial response in 19%, and International Journal of Radiation searched major European and U.S. stable or progressive disease in 39.5%. Oncology, Biology, Physics publication databases for relevant stud- A pretreatment standardized uptake ies up to January 2004. After reviewers value (SUV) $15 was associated with assessed the methodologic quality of an observed 77.8% significant re- PET/CT in Anal Carcinoma studies reporting adequate statistical sponse (both complete response and In another article e-published results and follow-up periods, 15 stud- residual microscopic disease) com- ahead of print in the April 18 issue ies with a total of 705 patients met the pared with only 24.2% significant of the International Journal of Radi- inclusion criteria. The authors noted response for patients with a pretreat- ation Oncology, Biology, Physics, that most studies were deficient in that ment SUV ,15. Significant response Cotter et al. from the Washington Uni- they did not indicate whether the gold was observed in 71.4% of patients with versity School of Medicine (St. Louis, standard or reference test was inter- a posttreatment decrease in SUV $10 MO) reported on a study comparing preted with or without knowledge of compared with 33.3% when the the relative efficacies of CT and PET/ PET findings. Pooled sensitivity and SUV decreased ,10. The authors CT in staging of carcinoma of the anal specificity for detection of residual concluded that pre- and posttreatment canal, with special attention to abili- disease in Hodgkin’s disease were 18 F-FDG PET assessment can be ties in identifying spread to inguinal 84% and 90%, respectively, and for ‘‘useful for predicting significant re- lymph nodes. The study included 41 NHL were 72% and 100%, respec- sponse to chemoradiation in esopha- patients with biopsy-proven anal car- tively. The authors concluded that geal cancer’’ and that ‘‘these data cinoma who underwent a complete although PET showed reasonable sen- should be considered in evaluation of staging procedure, including physical sitivity and high specificity for evalua- 18 patients for esophagectomy after che- examination, CT, and F-FDG PET. tion of first-line therapy in Hodgkin’s moradiation.’’ PET/CT detected 91% of nonexcised and NHL, ‘‘standardization of proce- Annals of Surgery primary tumors (compared with 59% dures is required before implementa- for CT) and identified abnormal up- tion in clinical practice.’’ take in the pelvic nodes of 5 patients Haematologica Protocols for PET/CT with normal pelvic CT scans. PET/CT Treatment Volumes detected abnormal nodes in 20% of Riegel et al. from St. Vincent’s groins that were normal on CT and in PET for Initial Diagnosis in Comprehensive Cancer Center (New 23% that were unremarkable on phys- NSCLC York, NY) reported ahead of print on ical examination. PET/CT also showed Herder et al. from the VU Uni- April 18 in the International Journal abnormal uptake in 17% of groins neg- versity Medical Center (Amsterdam, of Radiation Oncology, Biology, Phys- ative on both CT and physical exam- The Netherlands) reported in the April ics on the need for gross tumor volume ination. The authors concluded that issue of the Journal of Clinical On- (GTV) delineation protocols for PET/ PET/CT ‘‘detects the primary tumor cology (2006;12:1800–1806) on a co- CT use in treatment planning in head more often than CT’’ and ‘‘detects operative study investigating the utility of and neck cancers. The study included substantially more abnormal inguinal PET for initial diagnostic management 16 patients with head and neck lymph nodes than are identified by (Continued on page 41N)

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(Continued from page 36N) respectively. PET significantly and Los Angeles, reported in the April issue in patients with non-small–cell lung positively changed management ap- of the Archives of General Psychiatry cancer (NSCLC). The study included proaches in 24 patients. The authors (2006;63:442–448) on a study com- 465 patients enrolled at 22 hospitals. concluded that PET is a ‘‘sensitive paring perceived loss of memory Patients referred for imaging with posttherapy surveillance modality for ability with cerebral metabolic de- a provisional diagnosis of NSCLC detection of recurrent cervical cancer cline in individuals at genetic risk for were randomly assigned to a tradi- even in asymptomatic patients and Alzheimer’s disease. The study in- tional work-up according to interna- aids in deciding treatment plans and, cluded 30 cognitively intact adults tional guidelines (233 patients) or to eventually, may have favorable impact (age range, 50–82 years) with age- 18F-FDG PET imaging with either on prognosis and survival.’’ associated memory complaints. Four- histologic/cytologic verification or Gynecologic Oncology teen of these individuals were carriers follow-up (232 patients). Patients in the of the apolipoprotein E-IV (APOE4) second group whose images indicated Dopamine Release Differs allele associated with risk for Alz- noncentral tumors with no mediastinal in Men and Women heimer’s disease. Each participant or distant metastases proceeded di- In an article e-published ahead of underwent standardized neuropsycho- rectly to thoracotomy. The authors print on April 7 in Biological Psychi- logical testing and a self-appraisal of found that the number of procedures atry, Munro et al. from the Johns memory functioning measuring fre- to finalize staging was equal in the 2 Hopkins University School of Medi- quency of forgetting, seriousness of groups, although the early PET ap- cine reported on the results of a study forgetting, retrospective functioning, proach significantly reduced the num- using 11C-raclopride PET to explore and mnemonics use. Each individual ber of mediastinoscopies. Agreement sex differences in striatal dopamine also underwent 18F-FDG PET imaging between initial diagnoses and final release in healthy adults. The study at baseline and after 2 years. At initial staging was good in both groups, and was widely covered in the popular and evaluation, APOE4 carriers and non- costs did not differ significantly. The scientific press. The authors compared carriers did not differ significantly on authors concluded that initial diagnos- baseline striatal dopamine binding po- objective memory measures or on mem- tic use of 18F-FDG PET in patients with tential and dopamine release in men ory functioning questionnaire scores. suspected lung cancer ‘‘does not reduce and women after either an amphet- However, the factor score for fre- the overall number of diagnostic tests, amine or placebo challenge. No differ- quency of forgetting correlated signif- but maintains quality of TNM staging ences were identified in baseline icantly with global cerebral metabolic with the use of less invasive surgery.’’ binding potential, but, after amphet- decline after 2 years in all subjects, Journal of Clinical Oncology amine challenge, men had significantly regardless of genetic risk. The factor greater dopamine release than women score for mnemonics use also cor- in the ventral striatum and in 3 of 4 related significantly with metabolic PET After Cervical Cancer additional striatal regions. Men also decline in the temporal regions in Therapy rated the positive effects of amphet- APOE4 carriers alone. These results In an article e-published on March amines higher than did women. The indicated that memory complaints 27 ahead of print in Gynecologic researchers suggested that the robust among middle-aged and older individ- Oncology, Chung et al. from the dopamine release in men might account uals may point to underlying and National Cancer Center (Goyang, Re- for increased vulnerability to stimulant otherwise nonsymptomatic cerebral public of Korea) reported on the use of use addictions and methamphetamine metabolic changes. Moreover, com- 18F-FDG PET in monitoring recur- toxicity. They concluded that ‘‘future pensatory strategies, such as mnemon- rence in women after treatment for studies should control for sex and may ics use by APOE4 carriers, may reflect cervical cancer. The retrospective have implications for the interpretation underlying metabolic changes in specific study included 120 women who had of sex differences in other illnesses brain regions associated with prodromal undergone whole-body PET imaging involving the striatum.’’ Alzheimer’s disease. The authors con- after achieving complete response to Biological Psychiatry cluded that, ‘‘self-reported mnemonics therapy for cervical cancer. Associated use may be helpful in identifying persons records indicated that 76 patients for clinical monitoring.’’ would have recurrent disease, 20 of PET Correlation with Archives of General Psychiatry whom were asymptomatic at the time Reported Memory Loss of imaging. PET detected 73 (96.1%) In another article that was carried of these patients and correctly identi- widely in the press (with accompany- Serial PET in Relapsed fied 38 (84.4%) of 45 patients with no ing admonitions to diagnosticians to Lymphoma recurrence. The specificity and accu- listen more carefully to patients’ self- Schot et al. from the University racy of PET in assessment of re- reports of memory loss), Ercoli et al. Medical Center (Groningen, The currence were 84.4% and 91.7%, from the University of California, Netherlands) reported in the April

Newsline 41N E

issue of Haematologica (2006;91: survival rates of 71% and 58%. Those recently in Ann Oncol. 2004;15: 490–495) on a study to determine the who showed no response relapsed 8022807) on the effects of such stim- optimal time for pre-autologous stem soon after transplantation. The authors ulation on regional blood flow and cell transplantation PET imaging in concluded that 2 serial PET scans oxygenation in head and neck tumors. patients with relapsed lymphoma. The predict outcomes after autologous The study included 11 patients with

NEWSLIN study included 39 patients (28 with stem cell transplantation more pre- high-grade gliomas (6 recurrent), who aggressive non-Hodgkin’s lymphoma cisely than the more standard single underwent initial PET imaging to [NHL] and 11 with Hodgkin’s disease) interim PET in patients with relapsed verify status, followed by cervical spi- who were eligible for second-line che- lymphoma. nal cord stimulation. A second PET motherapy and stem cell transplanta- Haematologica study was acquired during stimula- tion. Each patient underwent PET tion. Basal glucose metabolism was imaging at 2 or 3 time points: before found to be higher in tumor than treatment; after 2 cycles of induction Cervical Spinal Cord in peritumoral areas, with significant chemotherapy; and, in individuals Stimulation increases in glucose uptake during with an abnormal second PET, after Clavo et al. from the Dr. Negrin stimulation of 43% and 38%, respec- a third cycle of chemotherapy, just University Hospital (Las Palmas, tively. The authors concluded that before transplantation. Patients were Spain) reported in the April issue this study confirms a modification of followed for at least 6 months (me- of the Journal of Neurosurgery (2006; locoregional blood flow and oxygena- dian, 22 months) after therapy, and 104:5372541) on a study using 18F- tion by cervical spinal cord stimulation 54% relapsed after stem cell trans- FDG PET to evaluate changes in and suggest that these results ‘‘open up plantation. Those patients who showed glucose metabolism in brain tumors new approaches to modifying the effect a complete response on PET after the before and during cervical spinal cord of radiochemotherapy in the treatment second and third cycles of chemo- stimulation. The authors have previ- of malignant brain tumors.’’ therapy had 2-year progression-free ously reported in 3 articles (most Journal of Neurosurgery

(Continued from page 33N) bilitating apathy, which in severe sofa is now working as an investment cases can lead to a potentially fatal adviser in Sydney.’’ BMJ carried the PET as Focus of Annual complication: a lack of motivation to satire a step further with counter- BMJ Spoof breathe.’’ PET was featured as the comments from a clinical pharmacol- The medical world waits with optimal diagnostic approach for the ogist who accused his colleagues of bated breath for the annual British condition. The article noted that 1 ‘‘medicalizing’’ normal slacker ten- Medical Journal (BMJ) contribution study estimated that 1 in 5 Australians dencies. ‘‘Indolebant may bring some to straight-faced farce on April 1. may have the condition, costing the relief to those with a debilitating form This year, the fictitious but soberly economy $1.7 billion per year in lost of MoDeD,’’ he said, ‘‘But common reported offering focused on a neuro- productivity. But, the article contin- laziness is not a disease. People have logic application of PET in ‘‘a new ued, help may be on the way in the an absolute right to just sit there.’’ and potentially life-threatening condi- form of Indolebant, a cannabinoid Fans of the annual BMJ tradition tion called motivational deficiency CB1 receptor to be marketed by are hard pressed to know which is disorder (MoDeD).’’ Citing the Healthtec, an Australian biotechnol- more entertaining: the satire itself or groundbreaking work of Dr. Leth ogy company concluding phase II the astonishing number of newspapers Argos, a neurologist at the University trials of the MoDeD treatment. Argos and other media outlets that pick up of Newcastle in Australia, the article was quoted as noting, ‘‘Indolebant is the story each year and unquestion- described the primary symptoms of effective and well tolerated. One ingly run it as serious news. MoDeD as ‘‘overwhelming and de- young man who could not leave his British Journal of Medicine

Erratum

A typographical error on the second page of the article ‘‘SNMTS Announces 2006 Scholarship and Grant Recipients’’ in the April 2006 Newsline (J Nucl Med. 2006:47[4]:25N–26N) incorrectly associated the Mayo Clinic with Maryland (MD) rather than Minnesota (MN). A corrected version of the page has been placed in the online archives. Newsline regrets the error.

42N THE JOURNAL OF NUCLEAR MEDICINE • Vol. 47 • No. 6 • June 2006