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THE ACNM REPORT
January 1999
FROM THE PRESIDENT
Have you made your reservations to Fort Lauderdale yet so you can participate in our 26th Annual Meeting? The opportunities for advancing your knowledge and skills are great as are those for enjoyable fellowship with colleagues. Since we will be meeting at the same time and in the hotel as the Society of Nuclear Medicine, we can take advantage of this proximity to share information and further cooperation between our organizations. As the year draws to an end, so does my term as your President. Whatever progress was made by the College during this year was the result of the dedicated effort of our off, members, and the central office. The members of the College are fortunate to have as part of our professional community persons willing to take on and carry out the tasks that make things run smoothly. They deserve your personal thanks and congratulations. On the other hand, I take responsibility for not having achieved all that we set out to do. One has to leave something for the next President to do. On the whole this has been a good year for the College. We have made our presence increasingly felt at meetings of professional associations in and out of the Nuclear Medicine community. For example, I represented the College at a special meeting on isotope production held in Dallas under the auspices of the DOE and the Medical College of South Carolina. Dr. Haynie represented the College at the ACR Intersociety Commission meeting in Colorado this past summer. The College has also applied for membership in this commission. Dr. Ahluwalia represented our interests at a recent meeting of the United States Nuclear Regulatory Commission in Kansas City, MO. This participation and representation is vital to our continued health as a professional society. As we increase our external activities we also take on new responsibilities that impact on the College. We must in the very near term examine how the College will relate to and work with other organizations. In this regard, it is interesting to note that a recent analysis of crossmemberships show that of our 340 active members, 209 are also members of the American College of Radiology; 219 are members of the Society of Nuclear Medicine; 279 are members of the RSNA; data on cross membership with the ACNP was not available. This survey shows that our members have multiple nuclear medicine and radiological affiliations. We must, therefore, examine what is unique to the College and how to take advantage of these features to increase our membership and the involvement of the members in the activities of the College. This is a task that goes beyond the term of the President. Because of this conviction, I have recommended to Dr. Hance, Chairperson of the Board of Representatives, that a special task force be appointed to take on this task. ACNM will soon enter cyberspace. We are in the process of establishing an ACNM web page. As we move forward in this new venture your input will be vital. Please let us know what you would like to see on the page and what information, chat rooms, and interactive discussion groups we should include. It is our goal to create a vehicle that will enhance your practice and knowledge base. Make it your page. Let me take this opportunity to extend to the ACNM community my best wishes to you and your families for a new year filled with health, happiness, and peace. Rita and I look forward to greeting you at the President's Reception and the Fellowship Convocation in Fort Lauderdale. Come join us for an exciting and pleasurable weekend.
FROM THE CHAIRMAN's CORNER
One of the joyous occasions each year at our Annual Meeting is the awarding of the Distinguished Fellowships to members of the American College of Nuclear Medicine. This year we have an outstanding Fellowship class and Fellowships will be awarded to the following five members:
I would like to invite all colleagues, friends, former mentors, former students and acquaintances of these five fine nuclear medicine physicians to attend our meeting from February 5-7, 1999 in Fort Lauderdale, Florida, and to come to the Fellowship Convocation to join in honoring these fine physicians.
EDITORIAL COLUMN
The last item on the scientific program is the Annual Nuclear Medicine Quiz. This will be the fourth time for a quiz presentation and will be supervised by Eduard V. Kotlyarov, M.D. In previous sessions, we have presented about a dozen very interesting cases. This has been one of the highlights of the meeting. Plan to come to the meeting and try to stay for the finale. If you would like to show one of your cases, please contact Dr. Kotlyarov, our capable Assistant Editor, at (248) 338-5604. If you cannot attend the meeting, we will publish a summary of the cases in a later edition of the ACNM Report, but will not have the films. [Editor's Note: The Society of Nuclear Medicine will hold their Mid-Winter Symposium "Nuclear Medicine in the 21st Century" at the Fort Lauderdale Marina Marriott on February 8-9, 1999. It will follow the ACNM meeting. You can get two courses with one trip to Florida. For SNM meeting materials, phone (703) 708-9000, Ext. 229, or fax (703) 709-9274.]
NUCLEAR MEDICINE AND NUCLEAR RADIOLOGY SCIENTIFIC EXHIBITS AT THE ANNUAL MEETING OF THE RADIOLOGICAL SOCIETY OF NORTH AMERICA
Twenty-three scientific exhibits were presented during RSNA 1998 which took pace at McCormick Place in Chicago, Illinois on November 28 through December 4, 1998. Six scientific exhibits were dedicated to positron emission tomography with FDG F-18. The exhibit of Dr. Hossein Jadvar and Dr. George Segall of Stanford University entitled "False-Negative and False-Positive in FDG-PET Oncology" emphasized high uptake of radiopharmaceutical in the bowel which could be seen on occasion to represent a false positive finding. False positive findings also include increased bone marrow radioactivity, increased radioactivity in the urinary system, working skeletal muscles, salivary glands, and cervical and shoulder muscles. The authors recommend the patient should be fully relaxed; excluding speech and mastication after the injection and during the imaging. The false positive processes include: Paget's Disease, trauma, thyroiditis, parathyroid adenoma, gastritis, scar and fractures, also inflammation and abscesses, granuloma (TB, cocidiodomyoses, histoplasmosis, sarcoidosis) as well as pneumonia and bleomycin pneumonitis. False negative results we see in small size nodules (less than one cm for dedicated PET and less than 1.5 cm for camera based coincidence imaging). Nonhypermetabolic malignancies will also be a source of false negative results. This will include: Hepatocellular CA, renal CA, prostatic CA, broncho-alveolar CA, carcinoid and other neuroendocrine tumors. Dr. John R. Mernagh and co-authors from McMaster University Medical School presented an exhibit entitled "Problem Solving With PET Scanning". This presentation emphasized high sensitivity of FDG PET scan for bony metastasis where patients with a negative bone scan showed a 50 to 80% rate of abnormality on PET scanner. A sensitivity of 94% and a specificity of 81% for differential diagnosis of lung nodules and 90% of positive predicted value for pancreatic CA in patients with known pancreatic mass of an unknown origin. Sensitivity and specificity for adrenal metastasis was respectively 198%. Axillary metastasis for breast carcinoma has a sensitivity between 85 to 90% and specificity between 91 to 100%. The authors emphasize that significant FDG uptake seen in a surgical bed in patients with rectal CA six weeks post surgery is a strong evidence of residual or recurrent neoplasm. Dr. Ana I. Nicolas and co-authors from Clinica Universitaria de Navarra (Spain), in the exhibit entitled "Role of CT and FDG-PET Staging of Patients With Bronchogenic Carcinoma" emphasized the importance of differentiation of non-small cell: Carcinomas of stage 1 through 3A and 4 which are non-resectable. They remind us that CT sensitivity and specifically for mediastinal lymph node involvement using one cm as the shortest diameter for a threshold are only 67% and 73%, respectively. Surgical mediastinoscopy is only 80% accurate due to the inability to visualize all mediastinal lymph nodes. Dr. Woo K. Moon and co-authors from Seoul National University Hospital (South Korea) presented the exhibit "FDG-PET in the Staging of Recurrent Breast Cancer: Comparison with Radiological Studies". The sensitivity of FDG was reported as 87.5% and a specificity of 89.4% as compared to CT, Nuclear Medicine and MRI which, in combination, brings a sensitivity of 75% and a specificity of 84%. The higher accuracy of 88.5% for PET compared with an accuracy of 80% for routine non-PET evaluation. Andrea L. Brown from McMaster University Medical Centre presented an exhibit entitled "Imaging Features of Primary and Recurrent Esophageal Cancer Using F18-Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET)". This study used fifty patients for their evaluation and emphasized that Esophageal CA usually presents in an advanced stage in 75% of patients. The five year survival rate is approximately 42% in node negative vs 3% in node positive. 18% of the patients will have distant metastasis. 81.6% of metastasis were not seen on conventional computer tomography; at the same time sensitivity for local/regional lymph nodes of the breast were up to 90%. The poor discrimination of small focus radioactivity, such as lymph nodes which are adjacent to large primary tumor masses, were mentioned. An exhibit by Dr. John Mernagh entitled "Assessment of Inflammation in Inflammatory Bowel Disease with PET" from McMaster University Medical Centre "examined" 896 patients, ages 2 through 48, at the time of initial presentation and flare-up. Endoscopic correlation of the sensitivity of the PET study was 98% (with one false negative in a patient with gastric Chron's disease) and specificity of 83%. Patients who were on steroids were excluded from the study. The author concluded that PET-FDG can reliably identify inflammatory bowel disease and has the potential for monitoring therapy. Dr. Javier Villaneuva-Meyer and co-authors from the University of Texas Medical Branch presented an exhibit on "Evolving Nuclear Breast Imaging". They gave excellent examples of benign and malignant lesions and presented illustrations of "Miraluma-Tc99m Scintigraphy". They also listed PTA codes for the study: 78800 for tumor localization limited; 78001 for tumor localization multiple; and A 9500 Tc-MIBI per dose of radiopharmaceutical. The authors gave a very good literature review. Data on sensitivity and specifically positive and negative predicted values were tabulated. Dr. Kathleen L. McDonald and co-authors from Mercy Hospital presented an exhibit entitled "Sentinel Lymph Node Localization in Breast Cancer: Use of Combined Filtered Technetium 99m Sulfur Colloid and Isosulfan Blue Dye for Localization and Prediction of Axillary Lymph Node Status". Excellent correlation of dye and radio-isotope technique shows that radio-isotope technique by itself should give a prediction of sentinel node in 69% of axillary lymph nodes where dye alone is effective in 13%. The authors used subdermal injection at the tumor plus three other injections of an equal or larger dose on axillary aspect of the tumor side. The patient was scanned with gamma-camera images as well as with a hand-held probe for verification. This exhibit was recommended for publication in Radiographic. Two scientific exhibits were dedicated to renal Nuclear Medicine studies. The first: "Imaging of Renovascular Hypertension: Respective Value of Renal Dopplersonography, Renal Scintigraphy and Magnetic Resonance Angiography" and the second: "Renal Transplant Imaging: Ultrasonographic and Radionuclide Evaluation". These two exhibits presented well known data to Nuclear Medicine physicians but stresses the leading role of Nuclear Medicine studies in radiological correlations. Dr. Vittorio P. Antonacci and co-authors from Boston University/Boston Medical Center presented "Sequential Thallium and Gallium Scintigraphy in the Immunocompromised Patient" exhibit. In summary, positive Thallium and Gallium scan is characteristic for lymphoma; negative Thallium and positive Gallium scan is indicative of TB, microbacterium avium intracellulare, PCP and toxoplasmosis. Negative Thallium and Gallium scans are characteristic of progressive multifocal nueroehcephalopathy. A presentation by Doctors Simi R. Anidjar, Lamk M. Lamki, Bruce J. Barron, and Bing Fang, from the University of Texas Medical School, was particularly interesting for the illustration of various patterns of cerebral perfusion in the diagnosis of brain death. It illustrated the advantages and pitfalls of using Neurolite-Tc99m for this purpose. Two other presentations dealt with visualization of motor activation with SPECT CT and MRI. This short review does not allow the description of the highlights of all the exhibits, but overall, the Nuclear Medicine and Nuclear Radiology scientific exhibits at the RSNA reflect the leading role of Positron Emission Computer Tomography FDG-F18 in general clinical activities, emphasizing routine daily clinical practice.
AMA DELEGATE REPORT
The 1998 interim meeting of the House of Delegates of the American Medical Association was completed on the 9th of December. Often the interim meeting is less intense with business than the annual meeting in June, but the last two years have not followed that pattern. Last year the Sunbeam issue was the center of much discussion and debate, and this year the report of the Ad-Hoc Committee on Structure, Governance and Operations was the subject of much interest and lengthy deliberation. The ten delegate committees evaluated the AMA's staff, the House, its councils and the Board of Trustees. A large part of the recommendations focused on efforts to improve the Board's role to strengthen its governance responsibility. The report suggested that indeed serious flaws existed in the AMA's decision-making process. The report of a consulting firm working with the committee supported the findings and concerns of the Ad-Hoc Committee. The recommendations of the report were extensive and addressed strategic planning, fiduciary responsibilities and personal appearances of the Board of Trustees as well as compensation, using AMA staff and council members as representatives, improving communication and over two dozen other pertinent topics. With some relatively minor modifications, these were accepted by the House of Delegates. In general, there was a good feeling that the enactment of these changes will direct the organization properly as it seeks to continue to be the voice of organized medicine as we prepare to enter the next century. None of the many resolutions and reports were directly related to nuclear medicine, but many of the socio-economic issues apply to most all aspects of the practice of medicine. We again represented the College at the Section Council on Nuclear Medicine meeting. At that meeting, the various resolutions and reports were evaluated. Terry Beven, M.D., Chairman of the Section Council, provided good leadership for the group as we discussed the items of business and approved the AMA House of Delegates manual for the Section Council. This was Dr. Beven's final meeting as delegate for the American College of Nuclear Physicians. His wisdom in the Section Council and the House will be missed. An issue that has been of much interest to most all of us, since the "fraud and abuse" efforts of the federal government have intensified, is the ability of physicians to extend professional courtesy without the fear of fraud and abuse charges. Fraud and abuse items were discussed in detail with again the same reasonable position urged. Documented fraud should be prosecuted to the fullest extent of the law, but billing errors should be handled in a much different and reasonable manner. Resolution 6 was approved which calls for the AMA to petition HCFA, the U.S. Attorney General and the U.S. Congress to reverse the unreasonable and intrusive policy of considering professional courtesy among physicians as fraud. The House also went on record as strongly opposing any bill to legalize physician-assisted suicide. Board of Trustees Report 36 was amended by the House to include urging the establishment of a negotiating unit, free of antitrust constraints, within organized medicine and with no affiliation with national trade unions to aggressively advocate in the private and public sector to level the playing field between physicians and healthcare payers. A request was made for a report of progress at the annual meeting in June. Concerns were expressed related to the tobacco settlement and the use of the monies for health care. It was urged that any monies from any tobacco settlements go entirely to supplement and not replace healthcare monies already in place. The problems with E & M guidelines were again discussed at length. The House wanted to go on record with HCFA that we were outraged with proposed guidelines and particularly with the numbers approach and random audits. For a more extensive review of the actions of the House, please read the next few issues of American Medical News or visit the AMA website at http://www.ama-assn.org and look for the "Interim Meeting" icon.
DARWOOD B. HANCE, M.D., F.A.C.N.M., TO RECEIVE GOLD MEDAL AT 1999 ANNUAL MEETING
One of the highlights of our Annual Meeting is always the Convocation. We have had a variety of interesting speakers and the Fellowship Ceremony is always impressive. A very special time occurs at any Convocation when the Gold Medal of the organization is awarded. The Annual Meeting of the College in Fort Lauderdale in February will afford us the opportunity to see the highest honor of the College, the Gold Medal, presented to a very special individual and a friend of all. Darwood B. Hance, M.D., F.A.C.N.M., is indeed a worthy recipient of this highest honor. He has been an active participant in our organization for more than two decades. He has held almost every leadership position in the organization, and for nearly an entire decade has served as the Chairman of the Board of Representatives. Please join your fellow members in Fort Lauderdale and be a part of these events.
26th ANNUAL MEETING OF THE AMERICAN COLLEGE OF NUCLEAR MEDICINE
Hopefully by now you have made your plans to attend the 1999 Annual Meeting in Fort Lauderdale. The contents of this newsletter highlight many of the key activities that will take place during the formal portion of the meeting and its programs. Of course, everyone looks forward to the collegiality which exists at all ACNM annual meetings. This year, of course, will be no exception with chances to get together and share the latest year's happenings. Of particular interest will be the President's Reception honoring our President, Ronald S. Tikofsky, Ph.D., F.A.C.N.M., and the 1999 Gold Medal winner, Darwood B. Hance, M.D., F.A.C.N.M.. As an added feature this year, to assist the spouse and guest attendees, Dr. and Mrs. Herbert Brizel have graciously provided a listing of things to do and places to go while in the Fort Lauderdale area. This list is provided as a separate enclosure with this mailing. Our thanks to the Brizel's for their efforts in making this meeting most enjoyable for all attendees.
MEMBERSHIP
At the recommendation of the Credentials Committee, the Board of Representatives approved the following individuals for membership. We proudly present the following names:
Fidelis Kanayo Ajuda, M.B., CHB
Nigeria
Jay Scott Hiller, M.D.
Gary L. Herzog, M.D.
ANNOUNCEMENTS
off - 1998-1999
MEMBERSHIP...
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