Nanoradiopharmaceuticals: is that the future for nuclear medicine?

New advances in nanotechnology has been responsible for the development of a new science called nanomedicine. In the recent years many discoveries as nanotubes and nanoparticles, especially for pharmaceuticals use, has increasing the application of nanotechnology for medical purposes. In this direction the development of nanoradiopharmaceuticals are also promising as novel radiopharmaceuticals. In this study we made an extensive overview of the most recent advantages in this field of nanotechnology and a fully application to radiopharmaceuticals. Despite, we gaive some nanoradiopharmaceuticals already developed and under investigation for clinical use. The results described that is possible to make nanoradiopharmaceuticals of two ways. The first one directly: nanoencapsulating an already radioactive radiopharmaceuticals. And the second way is nanoencapsulating a non-radioactive ligand for posterior labeling with a radioisotope alikes 99mTc. In both cases the nanoradiopharmaceuticals are acquired. We ended that nanoradiopharmaceuticals are feasible and may represent the future of the nuclear medicine.     

Is hybridic positron emission tomography/computerized tomography the only option? The future of nuclear medicine and molecular imaging

As we all know, Nuclear Medicine is the medical science using nuclear radiation for diagnosis, treatment and research. Nuclear Medicine, in contrast to Radiology, makes use of unsealed sources of radiation. Nuclear Medicine a few years ago has partly offered Nuclear Cardiology, the most lucrative of all Nuclear Medicine "children" at that time, to Cardiology. Radiology, has succeeded in being recognized by the European Union Authorities as Clinical Radiology. The word "clinical" offers greater independence to Clinical Radiology and makes it difficult for such a specialty to relinquish any of its equipment i.e. the diagnostic CT scan or the newly developed fast angiography CT, to other specialties. Contrary to Clinical Radiology, Nuclear Medicine being a laboratory specialty in most countries seems to have no right to deny offering, after some period of "proper certified education", its PET camera to Clinical Radiologists. Nuclear Medicine by virtue of its unique diagnostic techniques and treatments, is and should be recognized as a "Clinical Specialty" The interference of other specialties in the fields of Nuclear Medicine is also indicated by the fact that in vitro techniques of Nuclear Medicine are often used by Endocrinologists and Oncologists in their own laboratories. Also in some hospitals the Director of the Radiology Department acts as the Director of Nuclear Medicine Laboratory. Finally at present, Radiologists wish after "proper certified education", to be on equal terms in charge of the new hybridic equipment, the PET/CT scanner. If that is followed to happen, Nuclear Medicine will be in a difficult position losing at least part of PET and consequently should ask for help from its "Overlords and Protectors" i.e. the National and the European Societies of Nuclear Medicine and the Society of Nuclear Medicine of the United States of America. Radiology as a specialty participating om equal terms with the PET camera will then include the study of: a) "open sources of radiation" b) nuclear radiation and c) molecular nuclear medicine. The "European Journal of Nuclear Medicine and Molecular Imaging" shall have to erase the three last words of its title and be renamed. As Professor Abass Alavi et al (2007), have mentioned: "Is PET/CT the only option?" In favor of PET/CT are the following: Attenuation correction (AC) and better anatomical localization of lesions visualized with PET. Also PET/CT can be used as a diagnostic CT scanner (dCT). Against using the PET/CT scanners are the following arguments: a) This equipment is not necessary because we can always ask the Radiologists for a dCT scan. Many patients have already done a dCT scan at the time they are referred for a PET scan to the Nuclear Medicine Department. b) The absolute clinical indications for PET/CT with the use of a contrast agent, are under investigation. c) Although there is at present a list of indications suggested for the PET/CT scanner, there are studies disputing some of these indications, as for example in metastatic colon cancer where a high diagnostic accuracy for PET study alone, has been reported. d) The option of AC performed by the PET/CT scanner has also been questioned. Artifacts may be up to 84%. e) The PET/CT is expensive, time consuming, space occupying, and needs additional medical and technical personnel. f) Not to mention the extra radiation dose to the patients. g) Shall we inform those young medical students who wish to become nuclear medicine physicians, to hold their decision till the content of future Nuclear Medicine is clarified? We may suggest that: Our specialty could be renamed as: "Clinical Nuclear Medicine" and include additional "proper certified education" on the PET/CT equipment. The PET/CT scanner should remain in the Nuclear Medicine Department where Radiologists could act as advisors.     

Is tomotherapy the future of IMRT?

Intensity-modulated radiotherapy (IMRT) has become established in many clinics round the world and is, arguably, technically feasible in any facility. Serial tomotherapy contributed an extensive role in its introduction into the mainstream in the second half of the 1990s. In tomotherapy, literally "slice therapy", highly conformal treatments are possible because of the advantages available within the treatment planning of the IMRT process. Currently the majority of clinics implementing IMRT are doing so using conventional clinical linear accelerators (Linacs) fitted with an integrated multileaf collimator (MLC). At this point in time we may wonder if there is any scope for further dramatic changes in this new technology. As we venture from IMRT initial implementation into image guided therapy it is clear that major changes in approach are still valid and needed. If, at each treatment fraction, we can ensure that treatments are delivered accurately by integration of volumetric imaging into on-line validation, then we can attempt higher levels of conformality. A new treatment machine, the helical tomotherapy system, is available that combines the benefits of tomotherapy with on-line volumetric imaging. In this article we will review this approach and explore its features.     

Is imaging the future of axillary staging in breast cancer?

Axillary management in patients with breast cancer has become much less invasive with the introduction of sentinel lymph node biopsy (SLNB). However, over 70 % of SLNBs are negative, questioning the generic use of this invasive procedure. Emerging evidence indicates that breast cancer patients with a low axillary burden of disease do not benefit from axillary lymph node dissection (ALND). Non-invasive techniques such as paramagnetic iron oxide contrast-enhanced magnetic resonance imaging (MRI) may provide genuine alternatives to axillary staging and should be evaluated within clinical trials. Selective axillary surgery could then be offered based on imaging findings and for therapeutic intent. This non-operative approach would reduce morbidity further and facilitate interpretation of follow-up imaging. Key Points ? Modern imaging and biopsy greatly help the axillary staging of breast cancer. ? Superparamagnetic iron oxide (SPIO)-enhanced MRI offers a further advance. ? Sentinel lymph node biopsy may become redundant with SPIO-enhanced MRI. ? Selective therapeutic axillary surgery should be based upon preoperative imaging findings.     

The future of nuclear medicine technology: are we ready for advanced practice?

OBJECTIVE: The purpose of this study was to identify the clinical skills, commonly performed by nuclear medicine technologists (NMTs), that are beyond the entry-level practice guidelines and to determine NMTs' interest in the development of an advanced practice career pathway for nuclear medicine technology. METHODS: The Society of Nuclear Medicine Technologist Section (SNMTS) conducted a survey of 1000 technologists certified by the Nuclear Medicine Technology Certification Board (NMTCB) to determine which advanced clinical skills were being performed by NMTs and the level of training required to perform these skills. RESULTS: Those who responded to the survey were older and tended to have more years of experience and a higher level of responsibility as compared to the average technologist. Sixty-two percent of the respondents thought the SNMTS should develop an advanced practice career pathway, and 85% thought that advanced practice education should be delivered in nontraditional formats such as nights, weekends, and by distance education. CONCLUSION: NMTs reported a high level of interest in an advanced practice career pathway that could be completed while they remained employed.     

Is spirituality relevant to the practice of medicine?

The interrelationship between spirituality and medical science has been looked upon with suspicion for centuries. While in ancient societies medicine and religion were intertwined, in the West separation between these two since the Middle Ages has created a wall of mistrust which undermined the relationship. During the last two decades, however, there has been an upsurge of interest in the role of spirituality in medical practice in North American universities. There are a number of reasons for this development. They include an increasing number of patients particularly those with life threatening or chronic diseases who expect their spiritual concerns to be acknowledged and addressed. Furthermore, the unprecedented increase in medical technology has diminished the need for medical practitioners to provide compassionate care and has raised the awareness of physicians of the danger of dehumanization of medical institutions. Consequently, medical education programmes in a growing number of medical schools have begun to implement courses encouraging the integration of spirituality and medicine.     

Benign thyroid disease: what is the role of nuclear medicine?

Nuclear medicine is directly involved in both the diagnosis and treatment of benign thyroid disease, which requires an understanding of the pathophysiology and management of thyroid disorders in addition to expertise in nuclear methodology. Thyroid uptake and imaging, the principal nuclear tests in thyroid disease, may be used as follows: (1) Differential diagnosis of hyperthyroidism: A very low thyroid uptake suggests destructive ("subacute") thyroiditis, a self-limited disorder, whereas a normal or elevated uptake is consistent with toxic nodular goiter and Graves' disease. Scintigraphic characteristics also help differentiate between nodular and Graves' disease. (2) Function of thyroid nodules: Fine-needle aspiration biopsy with cytological examination (FNAB) is used routinely to assess for malignancy in thyroid nodules. Scintigraphy may be of assistance before FNAB. "Hot" nodules are generally benign and do not require FNAB, while "cold" nodules may be malignant. (3) Differential diagnosis of congenital hypothyroidism: Scintigraphy combined with ultrasound examination may be used to identify such conditions as thyroid agenesis, dyshormonogenesis, and incomplete thyroid descent. Treatment of Graves' disease and toxic nodular disease with (131)I may require greater clinical involvement and decision analysis compared with thyroid uptake and imaging. The following aspects of treatment are particularly important: (1) Risk: Radioiodine treatment may occasionally aggravate hyperthyroidism, Graves' ophthalmopathy, and airway obstruction caused by large, nodular goiters. Alternative treatments, including the temporary use of antithyroid drugs, and surgery for nodular goiters, may be considered. (2) Radioiodine dose: Cure of hyperthyroidism with a single (131)I treatment is desirable, though not always possible. Such factors as a large goiter, severe hyperthyroidism, and prior propylthiouracil therapy, may contribute to treatment failure. (3) Informed consent: A detailed discussion with the patient regarding the clinical risks, outcomes, and side effects of (131)I is a critical component of successful management.     

How will we teach and practice nuclear medicine in the next decade in Europe?

In the next decade, nuclear medicine physicians in Europe will try to guarantee a more homogeneous level of training and education of their specialty throughout the continent. In routine nuclear medicine, they will focus more on the possibilities and availability of positron-emission tomography (PET) and on nuclear medicine therapy. Nuclear medicine physicians will be more active and interactive with students at the universities and will offer more lectures and more active training in the specialty. Nuclear medicine specialists will try to be even more interactive with clinicians and make their specialty open and better understandable for other disciplines. Nuclear medicine physicians will initiate more cost-benefit studies and more multicenter studies to prove that their procedures are evidence-based. They will communicate more intensively with industry for a better understanding of clinical problems and for development of new useful radiopharmaceuticals. They will promote their specialty in the public more intensively and will reasonably explain the risks and benefits of radionuclide examinations.     

Should nuclear medicine physicians give the results of radioisotope examinations directly to patients?

Patients often ask for the results after a radioisotope procedure, which can make nuclear medicine physicians feel uncomfortable. In Belgium, nuclear medicine physicians are not supposed to disclose results directly to patients, but to send them to the referring physician. We undertook this work to determine the official rules and practical attitudes in other countries. An introductory letter and a questionnaire were sent to 103 eminent nuclear medicine specialists from 37 countries. Seventy responses (32 countries) were received. Official rules seemed to exist in only seven countries. Most of the respondents indicated that their attitude depended on the clinical situation and the results of the test. Many respondents emphasized that, while in some situations the results should be communicated directly to patients in order to initiate treatment rapidly, in other situations, such as cancer, the referring physician was better suited to disclose the results. The advantages and drawbacks of different attitudes are discussed. Practically and universally applicable rules are difficult to establish, but choosing one solution remains preferable to no standardized attitude at all. An official body, including the medical community, representatives of the population and legal experts, should define an official rule which should be widely communicated, stressing its advantages and drawbacks. In practice, all nuclear medicine physicians would have to do would be to stick to the rule.