Radiation Medicine T he “human side ” of nuclear applications

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

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


THE DIVISION OF HUMAN HEALTH THE DIVISION OF HUMAN HEALTH

•Nuclear Medicine & Diagnostic imaging

•Radiation Oncology & Cancer Treatment

•Medical Physics & Dosimetry

•Nutrition


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)


THREE DISTINCT FIELDSTHREE DISTINCT FIELDS

• Diagnostic radiology100% diagnostic

• Radiotherapy100% treatment

• Nuclear medicine80% diagnostic

10% treatment

10% lab tests

Multidisciplinary team: physicians, physicists, radiographers,..


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


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


Are X-rays atomic/nuclear?Are X-rays atomic/nuclear?

bremsstrahlunginteraction

N

x-ray

electron

characteristicx-rays added


…. 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..


microcalcifications

Mammography - the “ultimate” challenge with regard to X-ray image quality

typically 25-30 kV;special anode-filter


1895

High-resolution imaging in 3D usingmulti-slice Computed Tomography

techniquesand helical scanning

X Ray tube

Detector array

80-140 kV;typically 120 kV


Angiography and interventional proceduresare performed using image intensifiers orflat panel detectors

~ 70-100 kV


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..


TeletherapyTeletherapy

Sealed Co-60 source or electron/photon accelerator


Modern accelerator teletherapyModern accelerator teletherapy


Brachytherapy sourcesBrachytherapy sources

Brachytherapy applicators


Nasopharynx applicator

Cervix applicator

Afterloader system (nasopharynx)

Afterloader system (cervix)

Brachytherapy treatmentsBrachytherapy treatments


Nuclear Medicine

Diagnosis Oncology

Cardiology Neurology

Therapy LaboratoryTumour markers

Molecular biologyGene

expression


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)


PM-tubesDetectorCollimator

Position XPosition Y -> computerEnergy Z

Detector: gamma cameraDetector: gamma camera

Radioactive source is

inside the patient


Tomographic acquisition - anatomicalTomographic acquisition - anatomical


Dynamic acquisition - funcionalDynamic acquisition - funcional


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


Nuclear NeurologyNuclear Neurology

In several cerebral diseases:

• Integrated diagnosis

• Therapy assessment

• Early detection ofdegenerative diseases

MRI 18-FDG-PET 3D

E Tremor ParkinsonControl MSA


Radionuclide TherapyRadionuclide Therapy

Thyroid Cancer Metastatic cancers

Iodine-131: the silver bullet


• 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


Radionuclide Therapy: Radionuclide Therapy: emerging applicationsemerging applications

Radio Immuno Therapy (RIT)Radio Immuno Therapy (RIT)


MMolecular olecular bbiologyiology n nuclear techniques uclear techniques are used in to detect drug resistanceare used in to detect drug resistance


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)


PET imagingPET imaging


Multimodality imaging (image fusion)Multimodality imaging (image fusion)

CT: anatomy

PET: function


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


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


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.


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


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


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


approx 150 million in developing countries

100 million will be 100 million will be suitable for suitable for radiation radiation treatmenttreatment

0

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4

6

8

10

1990 1995 2000 2005 2010 2015 2020

ne

w c

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cer

case

s p

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ear

(mill

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year

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


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


Programme of Action on Cancer Therapy(PACT)

One House: Meeting Global Needs


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


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 T he “human side ” of nuclear applications