Radiation Medicine T he “human side ” of nuclear applications
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International Atomic Energy Agency
Radiation MedicineRadiation MedicineTThe “human sidehe “human side”” of nuclear applications of nuclear applications
Pedro Andreo, DirectorDivision of Human Health (NAHU)
Department of Nuclear Sciences and Applications
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Radiation Medicine 2 International Atomic Energy Agency
BACKGROUNDBACKGROUND
• The utilization of radiation in medicine for diagnosis and treatment dates from the 19th century, almost from the time x-rays and radioactivity were discovered
• Now its use is deeply embedded in medical practice. For many purposes, it is indispensable – both for diagnosis and for treatment
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Radiation Medicine 3 International Atomic Energy Agency
THE DIVISION OF HUMAN HEALTH THE DIVISION OF HUMAN HEALTH
•Nuclear Medicine & Diagnostic imaging
•Radiation Oncology & Cancer Treatment
•Medical Physics & Dosimetry
•Nutrition
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Radiation Medicine 4 International Atomic Energy Agency
CONTENTSCONTENTS
•“Nuclear” techniques in medicine:Radiation Medicine
What is and what is not “Nuclear Medicine”
•The birth of PACT (Program of Action for Cancer Therapy)
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Radiation Medicine 5 International Atomic Energy Agency
THREE DISTINCT FIELDSTHREE DISTINCT FIELDS
• Diagnostic radiology100% diagnostic
• Radiotherapy100% treatment
• Nuclear medicine80% diagnostic
10% treatment
10% lab tests
Multidisciplinary team: physicians, physicists, radiographers,..
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Radiation Medicine 6 International Atomic Energy Agency
THREE DIFFERENT TYPES OFTHREE DIFFERENT TYPES OFRADIATION SOURCESRADIATION SOURCES
• Diagnostic radiologyX-rays
• RadiotherapyHigh-activity sealed sources
radioisotopes, solid, capsule
Medical accelerators
• Nuclear medicineLow-activity unsealed sources (*)
radioisotopes, mostly liquid radiopharmaceuticals(*) except for therapeutic uses
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Radiation Medicine 7 International Atomic Energy Agency
DIAGNOSTIC X-RAYSDIAGNOSTIC X-RAYS
The left hand of Mrs Roentgen, some 100 years ago(1895)
Modern pelvic and thorax X-ray examinations using digital techniques
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Radiation Medicine 8 International Atomic Energy Agency
Are X-rays atomic/nuclear?Are X-rays atomic/nuclear?
bremsstrahlunginteraction
N
x-ray
electron
characteristicx-rays added
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Radiation Medicine 9 International Atomic Energy Agency
…. delivering As Low radiation dose to the patient As Reasonably Achievable
To produce an anatomical or functional patient image (using x-rays) which is clinically useful ….
The goal of Diagnostic Radiology
A.L.A.R.AA.L.A.R.A..
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Radiation Medicine 10 International Atomic Energy Agency
microcalcifications
Mammography - the “ultimate” challenge with regard to X-ray image quality
typically 25-30 kV;special anode-filter
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Radiation Medicine 11 International Atomic Energy Agency
1895
High-resolution imaging in 3D usingmulti-slice Computed Tomography
techniquesand helical scanning
X Ray tube
Detector array
80-140 kV;typically 120 kV
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Radiation Medicine 12 International Atomic Energy Agency
Angiography and interventional proceduresare performed using image intensifiers orflat panel detectors
~ 70-100 kV
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Radiation Medicine 13 International Atomic Energy Agency
To deliver As High radiation dose As possible (Reasonably Achievable) to a “clinical target”…
… while keeping the dose to other regions and organs as low as possible.
The goal of Radiotherapy
A.H.A.R.AA.H.A.R.A..
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Radiation Medicine 14 International Atomic Energy Agency
TeletherapyTeletherapy
Sealed Co-60 source or electron/photon accelerator
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Radiation Medicine 15 International Atomic Energy Agency
Modern accelerator teletherapyModern accelerator teletherapy
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Radiation Medicine 16 International Atomic Energy Agency
Brachytherapy sourcesBrachytherapy sources
Brachytherapy applicators
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Radiation Medicine 17 International Atomic Energy Agency
Nasopharynx applicator
Cervix applicator
Afterloader system (nasopharynx)
Afterloader system (cervix)
Brachytherapy treatmentsBrachytherapy treatments
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Radiation Medicine 18 International Atomic Energy Agency
Nuclear Medicine
Diagnosis Oncology
Cardiology Neurology
Therapy LaboratoryTumour markers
Molecular biologyGene
expression
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Radiation Medicine 19 International Atomic Energy Agency
NUCLEAR MEDICINENUCLEAR MEDICINEIN-VIVO APPLICATIONS (90%): Diagnosis and
TherapyThe fundamental principle is the use of “agents”, which localize in specific organs or tissues on the basis of their biochemical or physiological properties (radiopharmaceuticals)
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Radiation Medicine 20 International Atomic Energy Agency
PM-tubesDetectorCollimator
Position XPosition Y -> computerEnergy Z
Detector: gamma cameraDetector: gamma camera
Radioactive source is
inside the patient
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Radiation Medicine 21 International Atomic Energy Agency
Tomographic acquisition - anatomicalTomographic acquisition - anatomical
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Radiation Medicine 22 International Atomic Energy Agency
Dynamic acquisition - funcionalDynamic acquisition - funcional
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Radiation Medicine 23 International Atomic Energy Agency
Nuclear CardiologyNuclear Cardiology
Chronic Syndromes
Stable angina; previous myocardial infarction
• Diagnosis of Coronary Artery Disease (CAD)
• Assessment of specific risk conditions: diabetes
• Management of patients with known or suspected chronic CAD: Assessment of disease severity
Risk stratification
Prognosis
Evaluation effects medical therapy and/or surgery
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Radiation Medicine 24 International Atomic Energy Agency
Nuclear NeurologyNuclear Neurology
In several cerebral diseases:
• Integrated diagnosis
• Therapy assessment
• Early detection ofdegenerative diseases
MRI 18-FDG-PET 3D
E Tremor ParkinsonControl MSA
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Radiation Medicine 25 International Atomic Energy Agency
Radionuclide TherapyRadionuclide Therapy
Thyroid Cancer Metastatic cancers
Iodine-131: the silver bullet
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Radiation Medicine 26 International Atomic Energy Agency
• Differentiated thyroid carcinoma
• Diffuse non-Hodgkin lymphoma
• Metastatic neuro-endocrine tumours
• Painful bone metastases
131I
131I-MoAb
111In-Octr
153Sm
Radionuclide Therapy: Established RoleRadionuclide Therapy: Established Role
complementary tool to surgery, chemotherapy and radiotherapy
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Radiation Medicine 27 International Atomic Energy Agency
Radionuclide Therapy: Radionuclide Therapy: emerging applicationsemerging applications
Radio Immuno Therapy (RIT)Radio Immuno Therapy (RIT)
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Radiation Medicine 28 International Atomic Energy Agency
MMolecular olecular bbiologyiology n nuclear techniques uclear techniques are used in to detect drug resistanceare used in to detect drug resistance
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Radiation Medicine 29 International Atomic Energy Agency
Nuclear Medicine in-vitro Nuclear Medicine in-vitro techniquestechniques
• Detection of drug resistance: Tuberculosis, malaria, HIV
• Diagnosis of communicable diseases: Tuberculosis, Hepatitis, Chagas disease, Leishmaniasis, Dengue fever
• Diagnosis of genetic disorders: Fragile x-syndrome, thalassemia, sickle cell anemia
• Diagnosis of papilloma virus (associated with cervical cancer)
• Diagnosis of congenital hypothyroidism (associated with mental retardation)
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Radiation Medicine 30 International Atomic Energy Agency
PET imagingPET imaging
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Radiation Medicine 31 International Atomic Energy Agency
Multimodality imaging (image fusion)Multimodality imaging (image fusion)
CT: anatomy
PET: function
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Radiation Medicine 32 International Atomic Energy Agency
THREE DIFFERENT TYPES OFTHREE DIFFERENT TYPES OFRADIATION DOSE TO THE PATIENTRADIATION DOSE TO THE PATIENT
• Diagnostic radiology (over 2 billions exam)Low dose to patient (most exams)
Large population dose
Risk: stochastic effects
• Radiotherapy (5.5 millions treatments)High dose to patient (intended!)
Risk: deterministic and stochastic effects
• Nuclear medicine (32 millions procedures)Low doses (mostly)
Risk: stochastic effects
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Radiation Medicine 33 International Atomic Energy Agency
1895 1995
“… it is likely that CT examinations will become the
largest contribution to population dose from man-made exposures
in many countries.”
UNSCEAR, 2004
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Radiation Medicine 34 International Atomic Energy Agency
QUALITY ASSURANCE AND QUALITY CONTROL
MEDICAL PHYSICS: key player for the technical aspects of Radiation Medicine
To optimize the dose delivered to a patient in clinical procedures, both diagnostic and therapeutic, so that the desired outcome of the medical prescription is achieved.
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Radiation Medicine 36 International Atomic Energy Agency
CANCER AND THE UN SYSTEMCANCER AND THE UN SYSTEMThe IAEA is the only UN player in Nuclear The IAEA is the only UN player in Nuclear
Technology transfer for cancer prevention, Technology transfer for cancer prevention, diagnosis and treatmentdiagnosis and treatment
• International Agency for Research on Cancer (IARC)
• World Health Organization World Health Organization (WHO) Programme on (WHO) Programme on Cancer Cancer Control
• IAEA research and IAEA research and technical cooperation on technical cooperation on nutrition, nuclear medicine nutrition, nuclear medicine and radiation therapyand radiation therapy
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Radiation Medicine 37 International Atomic Energy Agency
Nuclear techniques: an appropriate Nuclear techniques: an appropriate solutionsolution
for cancer treatment and pain relieffor cancer treatment and pain relief
•Radiotherapy:Needed for at least 50% of cancer patients
•Nuclear Medicine: Less frequent but effective for some wide-spread and diffuse cancers
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Radiation Medicine 38 International Atomic Energy Agency
SOME FACTS
•In the more industrialized countries, one person in three gets a cancer
•For each one of us this means that, most likely, we will have one case of cancer among the closest members of our family
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Radiation Medicine 39 International Atomic Energy Agency
approx 150 million in developing countries
100 million will be 100 million will be suitable for suitable for radiation radiation treatmenttreatment
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1990 1995 2000 2005 2010 2015 2020
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case
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ear
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developingcountries
industrializedcountries
WHO-IARC (2003)
Of the 260 million new cancer cases in 20 years, Of the 260 million new cancer cases in 20 years, there will bethere will be
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Radiation Medicine 40 International Atomic Energy Agency
IAEA resources are inadequate to respond to the silent crisis
• In 10 years, approx In 10 years, approx 100 M$ for over 100 M$ for over 500 projects in 100 500 projects in 100 developing developing countriescountries
•At least $1-2 billion needed now
•Demand will increase more than 50% over the next 20 years
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Radiation Medicine 41 International Atomic Energy Agency
Programme of Action on Cancer Therapy(PACT)
One House: Meeting Global Needs
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Radiation Medicine 42 International Atomic Energy Agency
Programme of Action for Cancer Programme of Action for Cancer Therapy (PACT)Therapy (PACT)
•Work with partners on prevention and control (Agency: radiation medicine)
•Raise public awareness
•Mobilize resources
Patient set-up for treatment with a 60Co teletherapy machine
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Radiation Medicine 43 International Atomic Energy Agency
Programme of Action for Cancer Programme of Action for Cancer TherapyTherapy(PACT)(PACT)
Treatment using a High-Dose-Rate 192Ir brachytherapy machine
•Board of Governors approves June 2004 GOV/2004/39
•General Conference resolution Sept 2004 GC (48)13D
•PACT Programme Office (PPO) established Nov 2005SEC/NOT/2048
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Radiation Medicine 44 International Atomic Energy Agency