Logistical Problems in Project managing a

Nuclear Medicine Department - A Physician's Perspective

Dr P Shanmuga Sundaram, MBBS, DRM, DNB (N Med), MNAMS

Head, Dept. of Nuclear Medicine & PET CT,

Amrita Institute of Medical Sciences, Cochin

What is Nuclear Medicine• A subspecialty of medicine, which uses minute

amounts of radioisotopes to image various organs of the human body & to treat specific diseases

• Superior to anatomical imaging by its physiological basis & ability to identify diseases at an early stage

• But very name ‘nuclear’ has negative connotations

• Diagnostic & Therapeutic Nuclear medicine

• Gamma & Beta Emitting Radioisotopes

• Thallium Heart scan – Diagnostic test

• Radio iodine Therapy

Diagnostic Nuclear Medicine• 99m Technetium the most extensively

used diagnostic medical isotope

• Provides high-quality image mapping – blood flow to the heart, – spread of cancer to bones etc

• Delivers low radiation doses to patients

• A decay product of another reactor produced radioactive element Molybdenum

• Molybdenum produced & supplied as 99Moly - 99mTc generator on a weekly basis

Myocardial Perfusion imaging

To detect Skeletal Metastases

Therapeutic Nuclear Medicine

• Radioactive Iodine (131I) in thyroid cancer & hyperthyroidism treatment

• In bone pain alleviation, liver cancer, Rheumatoid arthritis management etc.

• Targeted delivery of high radiation to diseased cells & sparing normal cells

• Most of therapeutic radio isotopes are nuclear reactor produced

• Have relatively longer half life

Present status of 99mTc generators in India• Indian Nuclear reactors NOT capable of producing “High specific activity Molybdenum”

• Dependent completely on Imported Molybdenum

• Worldwide short supply as there are only 5 nuclear reactors capable of Moly production

• 70% of world’s 99mTc need met by Canada & Netherlands nuclear reactors

• Right now worldwide 99mTc resource crunch & 300% price increase in 99mTc weekly consignment

• Financial strain on Indian nuclear-medicine centres

So What is the solution?

• 99mTc crisis may not be completely solved even if existing nuclear reactors restart production

• High time for India, a nuclear empowered country to have its own nuclear reactor

• India can supply isotopes to other SAARC & ASEAN countries

• Also, better to have regional dispensing centres

• It is possible to ensure affordable & uninterrupted supply of medical isotopes

Ultimate NM Diagnostic - PET CT Imaging• “Investigation of this Century” - PET CT

Positron Emission Tomography with CT

• PET CT modality has revolutionized cancer care – ability to detect early malignancy– for cancer staging – its response to therapy – in cardiology & neurology

• AIMS – only PET CT centre in state of Kerala

• 18FFlouro Deoxy Glucose (FDG), half-life 110 minutes

• The flip side of PET CT – high cost & short half-life of PET isotopes

PET CT SCANNER

FDG TRANSPORT CONTAINER

Whole body PETCT showing multiple metastases

Issues in PET Isotopes

• Establishing & maintaining a cyclotron a financially challenging and daunting task

• Limited number of cyclotrons located mainly in metros

• No cyclotron in Cochin but it is a prerequisite to ensure uninterrupted supply of FDG

• Possible to air transfer FDG from other metrosIn spite of its short half life

FDG transport a logistical nightmare• FDG transported only on large aircraft with

exclusive cargo carriage sections (i.e. smaller ATR flights cannot)

• FDG categorized as “Dangerous Goods Regulations” (DGR)

• Both pilots of transport carrier needs to be ‘DGR certified’

• Mandatory cooling period in airport cargo area

FDG transport a logistical nightmare• Smooth workflow mandatory at FDG

production site – at the cyclotron facility

– local transport team

– air cargo ground staff

• Smooth workflow at destination– Ground cargo handling staff

– Hospital transport team

– At the user department

Logistics of FDG air transport from

Mumbai cyclotron to our centre• Mumbai preferred because of its better air connectivity

• An early morning flight preferred

– Patients fast overnight

– Early morning FDG production at a cyclotron facility

– Cyclotron to airport road transfer faster in early morning

Time chart of FDG production & transport

• 1-3 AM – Production, QC & FDG Packaging

• 3-4 AM – cyclotron facility to airport cargo terminal

• 4-5 AM – Cooling time

• 5-5.30 AM – Aircraft loading

• 5.30 – 7.20 AM – In flight

• 7.20 – 7.40 AM – Clearance & handing over of FDG consignment to hospital staff waiting at Cochin airport

• 7.40 – 8.15 AM – Road transport of FDG from Cochin airport to PET CT Centre

• 8.15 am – 11.15 AM – FDG Injection to patients in batches

Problems faced by our PET CT centre in FDG supply and

transport logistics• Only Mumbai & Delhi cyclotron facilities are ideally located & able to supply FDG through air

• Nearby facilities (Hyderabad, Chennai & Bangalore) have no ideal air connectivity in terms of aircraft size, departure time etc.

• Only AI & Jet carry radioactive consignments (DGR)

• So only one (Monopoly) Mumbai supplier

Problems faced by our PET CT centre in FDG supply and

transport logistics• Cyclotron breakdown

• QC failure

• Pilot on flight not DGR certified

• Any security alert

• Any transport delay

• Ultimately leads to postponement of scheduled patients for the day

Possible Solutions

• Regional cyclotrons in Govt & Public/Private sectors so that affordable FDG available

• All private carriers should carry radioisotopes routinely with commitment

• Ensure DGR certified pilots available on specific routes & flights carrying radioactive substances

• Sensitisation of all personnel involved in FDG transport logistics

Conclusion

Molecular Imaging - future of cancer imaging

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