European Association of Nuclear Medicine, September 4-8, 2004, Helsinki Fair Centre, Finland – a Review
Author: Dr Akmal Bhatti, Director
Nuclear Medicine physicians and technicians descended upon Helsinki this year and vied for hotel room space with ice hockey fans attending the World Cup for this sport. For the first time, nuclear medicine technicians attended a range of symposia and workshops at EANM, and from talking to a number of these individuals at the conference it became clear that they found the opportunity to do so alongside physicians extremely satisfying and of considerable merit. The most notable addition to the EANM programme for nuclear medicine technicians was the organisation of the Therapy and Dosimetry Track of the meeting as the 1st International Symposium on Radionuclide Therapy and Radiopharmaceutical Dosimetry.
Alongside the obligatory industry exhibitions symposia were organised with a view to engage participants in discussion around the current hot topics in the field. Nuclear medicine maintains its position as a key component of the diagnostic process within the secondary and tertiary healthcare sectors. From the conference it is clear that the impact of nuclear medicine is to be increasingly felt within the oncology field complementing the greater foothold the discipline has carved in cardiology and neurology.
It is unfortunate that space restrictions mean it is not possible within the Quarterly to review in depth our assessment on the many trends and potential applications described in the technical, scientific and industry-sponsored symposia. We have greatly condensed the information gathered through attendance at symposia and through stand exhibits to highlight technological advances and corporate activity which we consider to have an impact in the short to medium term.
Oncology
It is not difficult to predict that PET imaging will continue to have its most predominant use in tumour imaging. The versatility of the procedure means that a scan can take between 15 to 25 minutes, up to 18 exams can be performed per day generating diagnostic information to assist in the management of therapy on the equivalent of around 3500 patients per year per machine. In spite of the recognised usefulness of the technique there remains a considerable shortage of PET machines in Europe. Irrespective of this researchers are looking into expanding the types of tracers used for PET scans. Dr Andre Syrota in a Schering-sponsored symposium described how 18F-FDG labelled tracers are not always the most appropriate tracers in oncology. 18F labelled unmetabolized amino acids are being investigated for imaging amino acid transport in tumour imaging, with L-18F DOPA being investigated for imaging malignant brain lesions as 18F-DOPA is recognised as a surrogate of methionine. Specific enzymatic activity within tumour sites are also being investigated. It is known that 11C choline uptake is high in tumour tissue and that 11C-labelled choline has negligible urinary pass rate. 18F fluorinated choline analogues show some advantage in imaging over 11C -labelled cholines and these advantages could be exploited in imaging and detecting a variety of tumours.
There is gathering momentum in the detection of sentinel lymph nodes using nuclear medicine techniques to assist in staging of early breast cancer and selection of patients for axillary lymph node dissection. G. Paganelli of the Nuclear Medicine Division at the European Institute of Oncology in Milan, Italy described a new approach to early breast cancer treatment which is known as I.A.R.T. (Intraoperative Avidination for RadionuclideTherapy). The procedure involves an avidin based pre-targeting technique and the application of 90Y-Biotin to deliver a radiation dose to the tumour site capable of controlling local recurrence. IART is considered as a simple, low cost and easy to perform method that may represent an alternative to conventional external beam radiotherapy and Intraoperative Radio-Therapy (IORT) in early breast cancer.
Cardiology
An interesting debate is currently raging in both the cardiology and neurology fields where either different modalities are considered “superior” in terms of predicting prognosis and outcome (MRI perfusion vs nuclear medicine in cardiology) or gold standard clinical assessment vs a combination of neurological assessment and brain SPECT studies to early signs of Parkinson’s disease. Albert de Roos, MD, (Professor of Radiology, Leiden University Medical Center, Leiden, Netherlands) presented the case for MRI perfusion studies versus nuclear medicine stating that nuclear medicine was an outdated procedure. Professor de Roos argued that “MRI offers larger versatility of techniques for the assessment of ischemic heart disease.” In addition he also made a point of stating that MRI was superior to nuclear medicine scintigraphy studies due to the finding that first-pass perfusion has similar sensitivity and specificity as scintigraphy for the detection of perfusion defects. significantly less uptake into asymptomatic lesions.
Global systolic and diastolic left ventricular function are routinely measured through nuclear medicine imaging but MRI is now considered the new gold standard for left ventricular (LV) function assessment. Limitations of echocardiography and nuclear medicine techniques for global function analysis become more and more evident in terms of reproducibility and precision according to Professor de Roos. A number of papers were presented at EANM which referred to studies assessing the use of nuclear medicine to measure LV function so the debate on which procedure is the better one is set to continue for some time.
Neurology
The demands placed on healthcare systems will continue unabated as the number of persons aged 65 and over increases. With this rise the number of people presenting with age-related diseases such as Alzheimer’s disease and Parkinson’s Disease is also forecast to increase rapidly. In the case of Parkinson’s disease where misdiagnosis at early stages of the disease becomes problematic new approaches to either replace or to be used in collaboration with neurological assessment are welcome. Brain imaging using the SPECT technique is a new diagnostic tool in Parkinson’s disease. Dr Reinhard Ehret presented data which suggested that brain imaging in the early stages of PD saves time and costs, increases the patient’s compliance, improves the patient’s chances of coping with disease, helps to realise evidence-based medicine and leads to a more accurate diagnosis. As was witnessed at a GE Healthcare sponsored symposium there are still many people who consider gold standard clinical inspection and assessment of motor function the diagnostic tool of choice. Regardless of this ongoing debate there is considerable activity in identifying tracers for clinical use in the neuroscience field. Professor C Halldin presented a paper on “Present Status and Future Trends of Tracers for Clinical Use – Neuroscience.” In which he argued that molecular imaging techniques such as PET, SPECT and MRI were increasingly considered as superior for n vivo receptor mapping of the brain. He highlighted that the main aims for PET in clinical neurobiology was to
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visualise and quantify brain receptors in vivo. Useful brain tracers for PET and SPECT are dopamine DA, Serotonin, and noradrenaline, NA. Ideal tracers should be selective, reach specific binding peak equilibrium, at high signal and at low noise level.
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visualise functional significance in patients, for example in PD assessing the function of D1, D2, D3, D4 and D5 subtype receptors.
Professor Halldin stated that the future trend would be for tracers to be tailor-made to investigate different density of receptors in subtypes of interest, different binding equilibria and different half lives.
The wealth of information on new tracers being developed for PD and AD and investigation of PET and SPECT imaging in other neurological disorders are far outside the scope of this article but we alert readers to the fact that if they wish for further elaboration on any other trends within this area that we are happy to entertain enquiries with particular reference to EANM.
Redressing the shortfall in PET growth in Europe
A bottleneck in the expansion of nuclear medicine capabilities continues to be the low number of PET scanners in Europe and a fragmented manufacturing and distribution structure for PET products. These topics were discussed in a lunchtime symposium organised by Schering AG where delegates of the conference were told of the developments within the PET scanner market and the official indications of PET in diagnosis within a number of European countries. Information on reimbursement remains vague due to the heterogeneity of criteria and scenarios within which PET scanning is recommended for use. It was interesting to hear that in Germany where there is 1 PET scanner installed per 1.1m of the population that PET scans are only reimbursed for hospitalised patients at around €1100 per scan. For outpatients there is no reimbursement in place.
According to information gathered from National Associations in May 2004, eleven European countries have PET scanners for which no strict guidelines for use are enforced. These countries are Austria, Czech Republic, Denmark, Germany, Greece, Italy, Netherlands, Poland, Portugal, Slovenia and Sweden. Only eight EU countries have been identified as “employing” PET scanners for strict indications. These countries are Belgium, France, Hungary, Luxembourg, Republic of Ireland, Spain and the UK. The guideline indications are as shown in the table opposite.
The number of dedicated PET scanners installed worldwide between 1992 and 2002 was around 1600 units - 1020 in the U.S., 470 in Europe, and 110 in Japan. In addition to the above data, in Europe around 100 PET scanners are in use in Germany compared with 84 in Italy. From the commercial viewpoint companies supplying scanners and radiopharmaceuticals to the sector will have noted that the number of planned installations for Europe over the next five years is in the region of 116 units. A total of 30 scanners are due to be installed in Italy, 24 in France, 21 in Spain, 8 in the U.K., six in Sweden, five in Finland, and four in Belgium. The number of cyclotrons in Europe in 2001 was 62, with a further 22 planned for the next five years.
Supplying the radiopharmaceutical demand
As the growth of PET scanner installations increases the main radiopharmaceutical suppliers are creating initiatives which will aim to secure the timely manufacture and despatch of Fluo-based radiopharmaceuticals (e.g. FDG) to PET customers. Schering and IBA have created a joint venture which will reinforce the Schering market leading position as a supplier of FDG to its target customer base in Europe.
Source: EANM conference & HBS Consulting research
Mr Mossakowski (Business Development Director for IBA) explained that IBA was an engineering company which acquired Eastern Isotopes in 2000 when it became the number 2-3 player in the supply of FDG isotopes. Through its distribution of this product it manages to turn over $40m in revenues. The company has three sites in Europe in Lyon, Milan and Brussels. The company was approached by Schering which through CIS bio international had acquired the number 1 position in Europe within this sector. Schering has 7 centres in France, 2 in Paris, 1 each in Nancy, Bordeaux, Remes and Nimes and is planning another centre in France. It has an established network of distributors which ensures that it can supply fluo-based radiopharmaceuticals to any customer in Europe each morning. Two centres are also planned for the UK to be operational by November 2004. IBA has an association as a supplier of radiopharmaceuticals to MAP Medical Technologies which is a 2002 acquisition of Schering’s and as part of this new collaboration with Schering AG the company’s lay down a significant added challenge to other corporate players such as MDS Nordion in the European radiopharmaceutical supply chain.
Philips Medical Systems/BMS join forces
Another corporate collaboration which was unofficially unveiled at the EANM was the joint marketing agreement between Philips Medical Systems and Bristol Myers Squibb Medical Imaging. These companies described the outlines of an agreement which would see Philips Medical Systems offering new customers of imaging modalities, such as nuclear cardiology cameras, with financing assistance relating to the purchase of the modality while promoting at the same time the BMS line of cardiology imaging agents such as Cardiolite. The involvement of Philips Medical Capital is crucial to the attractiveness of this initiative because it provides prospective customers with a range of payment options when they consider modality purchase. Through our consulting work HBS Consulting has been well aware for some time that purchasers of a range of medical device equipment were keen to look at new ways in which they might be able to finance their purchases. As budgets continually tighten and the pace of innovative change seemingly increases, purchasers are faced with the need to capture the benefits of product improvement while maintaining financial control within their institutions. Purchasers are therefore looking to suppliers to offer them options in the way they conduct sales transactions.
The nuclear medical imaging field is, as the Philips Medical/BMS agreement shows no stranger to this predicament. Developments in this sector need to be closely watched and lessons need to be learnt by those companies which market high cost medical devices to private clinics and public hospitals.
We hope to make reviews of meetings we have attended a much more regular feature of the HBSQuarterly and to present in the areas which fit with the main business units across the medical device sector. Our upcoming presence at Medica and particularly RSNA 2004 should allow us to present similar reviews in the next Quarterly.