Nuclear Medicine in Indonesia 2015

SEMINAR NASIONAL XI SDM TEKNOLOGI NUKLIR YOGYAKARTA, 15 SEPTEMBER 2015 ISSN 1978-0176 ________________________ ________________________________________________ _____________________________________________

School of Medicine Universitas Padjadjaran Dr. Hasan Sadikin Hospital Bandung

Johan S. Masjhur Dept. of Nuclear Medicine and Molecular Imaging

Nuclear Medicine in Indonesia 2015

STTN BATAN Yogya Sept 2015

Apakah itu Kedokteran Nuklir : Cabang ilmu kedokteran yang menggunakan sumber radiasi terbuka berasal dari disintegrasi inti radionuklida buatan, untuk mempelajari perubahan fisiologi dan biokimia pada tingkat sel dan molekul, yang digunakan untuk tujuan diagnostik, terapi dan penelitian. Kata kunci : - Sumber radiasi terbuka – disintegrasi inti radionuklida buatan - Perubahan fisiologi dan biokimia – sel dan molekul  functional morphology - Diagnostik, terapi dan penelitian

________________________ ________________________________________________ _____________________ 346


Nuclear Medicine

Medical Physicists Radiopharmacists

________________________ ________________________________________________ _____________________ 347


Nuclear Era in Indonesia 1965 : First atomic reactor in Indonesia Reactor Triga Mark 2000 – 2 MW Bandung Atomic Center (Pusat Reaktor Atom Bandung) 1967 : First Nuclear Medicine Service located in Bandung Atomic Center

1982: Kartini Reactor in Yogyakarta – 300 kW

1988 : Multipurpose Atomic Reactor “GA Siwabessy” in Jakarta

Historical Milestones “Nuclear Medicine Era in Indonesia”

* 1971

: The First Nuclear Medicine Department in Indonesia Dr. Hasan Sadikin Hospital School of Medicine Universitas Padjadjaran Bandung - Indonesia

________________________ ________________________________________________ _____________________ 348


NUCLEAR ERA IN INDONESIA Prof. Dr. G.A. Siwabessy (1914-1982) Bapak Atom Indonesia -

1954 : Direktur, Lembaga Tenaga Atom

-

1963-1965 : Dekan pertama FMIPA UI

-

1962 : Direktur Jenderal pertama Badan Tenaga Atom Nasional;

-

1965 : Menteri Badan Tenaga Atom Nasional;

- 1966 – 1978 : Menteri Kesehatan

Prof. Dr. Achmad Baiquni (1923-1998) Fisikawan Atom Pertama Indonesia 1973 – 1984 Direktur Jenderal BATAN

IR. DJALI AHIMSA Direktur Jenderal Badan Tenaga Atom Nasional Periode 1984 - 1996

IR. IYOS R. SUBKI Direktur Jenderal Badan Tenaga Atom Nasional Periode 1996 - 2002

________________________ ________________________________________________ _____________________ 349


K AN UN

ED O KT E

RA

N

KL IR

PE RH

NU

IM P

ORGANISASI PROFESI PKNI/PKBNI

IN

Prof. Dr. Sutarman Ketua Umum PKBNI 1976 - 1984

Prof. Dr. Djokowoerjo Sastradipradja Ketua Umum PKBNI 1984 -1988

Dr. A. Hussein S. Kartamihardja, SpKN Ketua Umum PKBNI/PKNI 2004 - 2012

IA DO NES

Prof. Dr. Johan S. Masjhur, SpPD-KEMD, SpKN Ketua Umum PKBNI 1988 -2004 Ketua Umum PKNI 1988 - 2004

Dr. Trias Nugrahadi, SpKN Ketua Umum PKBNI/PKNI 2012 - 2016

K AN UN

ED O KT E

RA

N

KL IR

PE RH

NU

IM P

PIONIR KEDOKTERAN NUKLIR DI INDONESIA

IN

Prof.Dr. Sutarman RSP Pertamina

Prof. Dr. Asmino Widjaja FK Unair / RS Dr. Sutomo

IA DO NES

Dr. LF Luhulima, SpOG FK Unpad / RSHS

Dr. Erie FKUI / RSCM

________________________ ________________________________________________ _____________________ 350

Kol. Dr. Jusuf RSGS

Dr. Setiono Diran FK Unair/RSD Dr. Sutomo Sardjito

Dr. Nifa Wahid FK Unair/RSD Dr. Sutomo

Dr. Subur Budiman FKUI/RSCM

Dr. Subowo RSP Pertamina

Dr. Bagaswoto Pudjomartono FK UGM/RS Prof.Dr. Sardjito

Dr. Manufris Kasim RS Jantung Harapan Kita Nuclear Cardiology

RA

N

KL IR

IN

Dr. Ruchijat Suwarno RSP Pertamina

ED O KT E

PE RH

PIONIR KEDOKTERAN NUKLIR DI INDONESIA

K AN UN

NU

IM P


IA DO NES

Dr. Tenri Abeng FKUI/RSCM

Dr. Kahar S. FKUI/RSCM

Dr. Gogot Suyitno FK UGM/RS Prof.Dr.

Prof. Dr. Nursal Asbiran FK Unand Radioimmunoassay

________________________ ________________________________________________ _____________________ 351


Tokoh Radiofarmasi Indonesia

Drs. Anhar Yunus

Prof. Dr. Aang Hanafiah

Historical Milestones of “Nuclear Medicine Era in Indonesia” 1971

1967 The first NM unit in Indonesia – “Balai Kedokteran Nuklir” at Bandung Reactor

moved to Dr. Hasan Sadikin Hospital – Dept. of Nuclear Medicine

1976 The Indonesian Society of Nuclear Medicine & Biology

1997

1992

1989

Recognition of NM as a medical specialty

The 5th Asia-Oceania Nuclear Medicine and Biology Congress in Jakarta

The Indonesian Society of Nuclear Medicine

1999 : # Center of Specialist Program : NM Physicians # National Referral Center for Nuclear Medicine at Dr. Hasan Sadikin Hospital –Faculty of Medicine Universitas Padjadjaran Bandung

________________________ ________________________________________________ _____________________ 352


Historical Milestones “Nuclear Medicine Era in Indonesia”

The 5th Asia Oceania Congress of Nuclear Medicine and Biology Jakarta, 26 – 30 October 1992.

2010 - …. New Era of Nuclear Medicine in Indonesia PET/CT

RS Gading Pluit

RS Kanker Dharmais

RS MRCCC Siloam

RS Dr. Hasan Sadikin

________________________ ________________________________________________ _____________________ 353


Manpower Development First generation of nuclear medicine physicians : had their education and training abroad 1999 – now : Education and training: “in house/local” Dept. of Nuclear Medicine and Molecular Imaging Faculty of Medicine Universitas Padjadjaran Dr. Hasan Sadikin Hospital Bandung

2015 (September 2015) In house/local NM physicians : 29 NM Residents : 12 Education and Training Program for Technologists : NONE

Nuclear Medicine in Indonesia …………………………..Tomorrow

________________________ ________________________________________________ _____________________ 354


Do we need Nuclear Medicine ?

Key factors for a good Nuclear Medicine service !

Challenges !

The evolution of diagnostic imaging

PAST

PRESENT

Anatomic

Functional

Hybrid

plain films, CT, MRI, US

angiography, doppler US, NM, MRI, PET

PET/CT, SPECT/CT, PET/MR

“FUTURE”

Molecular NM, PET, SPECT, MRS, optical, PET/MRI contrast-enhanced MRI/US/CT

________________________ ________________________________________________ _____________________ 355


Nuclear Medicine is a Bridge ! Molecular Medicine

Basic Science Research

Nuclear Medicine

Clinical Medicine

Medical Technology Technology

PET-CT Scanner  Dr. Ron Nutt and Dr. David Townsend

F-18 FDG PET

CT

________________________ ________________________________________________ _____________________ 356


Molecular Biology

Molecular Medicine

Molecular Nuclear Medicine

Changing concept of medicine Organ oriented  Molecular oriented

Focus of interest : Metabolism Immunology Receptor study

(endocrine, tumor, and neurotransmitter)

MOLECULAR MEDICINE Molecular Imaging Targeted Therapy Theranostics

Personalized Medicine Pencitraan molekuler : visualisasi, karakterisasi dan pengukuran proses biologik pada tingkat molekuler dan seluler dari manusia atau makhluk hidup lain. Task Force of the Molecular Imaging Center of Excellence of the Society of Nuclear Medicine

________________________ ________________________________________________ _____________________ 357


MOLECULAR IMAGING PENCITRAAN MOLEKULER

Pencitraan molekuler berawal pada teknik pencitraan radionuklida yang digunakan dalam prosedur kedokteran nuklir. Kamera PET, single photon emission computed tomography (SPECT), dan kamera gamma planar telah sejak lama digunakan untuk mendeteksi probe bertanda radionuklida.

________________________ ________________________________________________ _____________________ 358


________________________ ________________________________________________ _____________________ 359


Molecular imaging has its roots in Nuclear Medicine ; and in many ways is a direct extension of Nuclear Medicine. Through the use of state-of-the-art molecular and cell biology, we can now better design molecular probes (tracers) that can target specific cellular/molecular events. We can also engineer cells so that they will specifically accumulate tracers of choice.

Pencitraan Molekuler • Nuclear Medicine  radiolabelled molecules

PET/CT

SPECT/CT

MR Spectroscopy

Optical Imaging

• Ultrasound  sound • Magnetic Resonance Imaging  magnetism • Optical Imaging  light

Targeted ultrasound

________________________ ________________________________________________ _____________________ 360




~90 % of clinical molecular imaging is PET and SPECT



Optical, other modalities on the horizon



Nanoparticles, bacteria, new probes used to image critical cancer processes (cell death, tumor proliferation, angiogenesis, hypoxia) on the horizon



Reporter-probe pairs are being generated for molecular-genetic imaging

MOLECULAR IMAGING IN ONCOLOGY Pencitraan Molekuler dalam Onkologi

________________________ ________________________________________________ _____________________ 361


The Evolving Role of Nuclear Medicine in Oncology See & Treat See: Tag gamma-emitter to molecular agent, inject in patient, goes to the target molecule, make images.

Nuclear: [18F]FHBG for tracking T cells

S. Gambhir

Treat: Add beta-emitter to molecular agent, inject, goes to the target molecule and delivers the therapy.

Nuclear: PSMA imaging for prostate cancer J. Babich

Optical: Activatable fluorescence for intestinal adenoma

MR: Amide proton transfer imaging to assess brain tumor characteristics

U. Mahmood

P. Van Zijl

PET / CT Camera Clinical application in Oncology - staging and location of lesions - evaluation and monitoring - viability versus fibrosis

 Cancer : lung, breast, colorectal, lymphoma, melanoma, head and neck, thyroid, neuroendocrine

________________________ ________________________________________________ _____________________ 362


Theseus Tc-99m Apomate Annexin V Lung Ca

See • Measure efficacy of Rx • Results 6 hrs after 1st treatment • Avoid unsuccessful Rx

Treat

48h Post ChemoRx

• Add Re-188 guided missile • Boost effects of initial Rx • Eliminate debilitating effects of ChemoRx Courtesy Dr. Abdel-Dayem, St. Vincent’s, NY

Well Differentiated Thyroid Carcinoma



I-131 : Beta & Gamma radiation



Iodine goes to thyroid gland  Na I-131  Given to Thyroid Ca patient  Thyroid Ca disappeared

o o o

Adjuvant Remnant Ablation Therapy

________________________ ________________________________________________ _____________________ 363


Ca Thyroid

October 2002

April 2003 123I

Total Body Scan

Non-Hodgkins Lymphoma

(a) before



(b) after

before

after

The image is actually two sets of before-and-after PET scans of two patients. One patient was treated with (a) Iodine-131 tositumomab (Bexxar®). The other received (b) Yttrium-90 ibritumomab tiuxetan (Zevalin®). The PET images reveal that both patients showed no metabolically active NHL as early as three months after treatment. Courtesy of : A. Iagaru; E. Mittra, M. Goris; 2009

________________________ ________________________________________________ _____________________ 364


In-111 octreotide (penteterotide) study demonstrating uptake in a primary gastrinoma (arrow on anterior image) and a liver metastasis (arrow on posterior image). (Source : Murray and Brooks, 2000).

I-123 MIBG study demonstrating high uptake in a left adrenal phaeochromocytoma. (Source : Murray and Brooks, 2000)

Screening Patients with SSR‐Imaging Normal distribution

________________________ ________________________________________________ _____________________ 365


Imaging gene therapy with PET in unilateral MPTP monkey model of Parkinson’s. Dopamine synthesis was imaged with aromatic amino acid decarboxylase substrate, meta-[18F] fluorotyrosine. (Left) Normal dopamine synthesis in striatum. (Center) Unilateral dopamine MPTP-induced deficit (arrow) before gene therapy. (Right) Restoration of dopamine synthesis (arrow) after gene therapy using a virus that contained the aromatic amino acid decarboylase gene. (Courtesy of K. Baukiewicz, 2000).

MOLECULAR IMAGING IN NEUROSAINS Pencitraan Molekuler dalam Neurosains

________________________ ________________________________________________ _____________________ 366


(Phelps ME, 2000)

MOLECULAR IMAGING IN CARDIOLOGY Pencitraan Molekuler dalam Kardiologi

________________________ ________________________________________________ _____________________ 367


Myocardial Blood Flow Adenosine 82Rb stress-rest study. 82Rb allows highquality images. This study demonstrates normal myocardial perfusion at stress and rest with homogeneous uptake throughout.

Stress/rest Tc 99m sestamibi short-axis, vertical long-axis, and horizontal long-axis left ventricular images showing a severe, fixed myocardial perfusion defect in the inferior wall, consistent with previous infarct or myocardial necrosis.

Cardiac viability study. Top rows (A) represent FDG study; bottom rows (B) represent 82Rb perfusion examination. Short-axis images demonstrate a large perfusion defect in the lateral segments (white arrow). There is uptake of FDG in these segments (yellow arrow), indicating viable myocardium. Horizontal longaxis images demonstrate that the perfusion defect involves the apex as well as the lateral wall; all segments are viable as indicated by FDG uptake. (Weissman G and Sinusas AJ. 2011)

PET patterns of myocardial viability. Left panel, Concordant reductions in myocardial perfusion (rubidium 82) and glucose metabolism (18FDG), reflecting myocardial infarction. Right panel, Preserved glucose metabolism (18FDG) in a territory with decreased myocardial perfusion (rubidium 82), reflecting complete tissue viability.

(From Di Carli MF, Hachamovitch R. New technology for noninvasive evaluation of coronary Artery disease. Circulation 2007; 115:14641480.)

________________________ ________________________________________________ _____________________ 368


TARGETED RADIONUCLIDE THERAPY Terapi Radionuklida Bersasaran

________________________ ________________________________________________ _____________________ 369


Targeted therapy in Nuclear Medicine Radioiodine in Thyroid Carcinoma : • rhTSH-aided • Redifferentiating agents : retinoid acid Radioimmunotherapy with mAbs :  B-cell lymphoma, follicular lymphoma * Y-90 ibritumomab (Zevalin®, IDEC Pharmaceuticals and Schering AG) * I-131 tositumomab (Bexxar®, GSK Philadelphia PA) Radiolabelled MIBG :  Neuroectodermal tumors (neuroblastoma, pheochromocytoma, paraganglioma, medullary thyroid carcinoma, carcinoid tumors,Merkel cell tumors of the skin) * I-131 MIBG

Targeted therapy in Nuclear Medicine Peptide Receptor Radionuclide Therapy (PRRT) Neuroendocrine tumors Radiolabeled somatostatin analogues : * In-111 DTPA octreotide * Y-90-DOTA, Tyr3 –octreotide (phase I-II clinical trials) * Lu-177-DOTA, Tyr3-octreotate Radionuclide therapy of liver tumors and metastases * I-131 lipiodol (Lipiocis®, Schering S.A., Berlin, Germany) * Re-188 lipiodol (no high energy gamma)

________________________ ________________________________________________ _____________________ 370


THERANOSTICS

________________________ ________________________________________________ _____________________ 371


Theranostics Theranostics = Therapy + Diagnostics Non‐Hodgkin’s Lymphoma Specific‐binding to a tumor‐associated antigen (i.e. CD20)

Diagnostic

Ibritumomab ,tiuxetanTherapy

90Y‐DTPA‐Ibritomoma

111In‐DTPA‐Ibritomomab

The diagnostics is linked to the therapeutic substance to select patients who would be suitable for treatment by a particular drug.

Environmental trigger

Disease progression

Genetic predisposition

First cell mutations

Asymptomatic disease

Diseased cells release biological markers

Mortality & costs

Disease proliferation

Diagnostic (anatomic) imaging, biopsies

Current approach

In vitro markers

Molecular Imaging

Molecular Medicine approach

First symptoms/ manifestation

DNA screens

Protein screens

Molecular Therapy

Monitor Treatment

symptoms diagnosis

• Non-personalized medication • Chemotherapy • Radiotherapy • Surgery

Follow up

Earlier Personalized Integrated Efficient

________________________ ________________________________________________ _____________________ 372


Changing Healthcare Value Chain Current Healthcare Value Chain Self-Directed Patient

Healthcare

Activities Diet, Exercises, Self‐monitoring

Triggers to Physician Advance to Physicians Interaction

Symptoms Periodic checkups Self‐diagnosis

P

Hospital visit Visit healthcare provider facilities

Diagnosis/ Prognosis

Treatment

At point of care Central labs Imaging facilities

Medicine Surgery Other treatment

Future Healthcare Value Chain Disease P Individual Predisposition Assessment

Triggers Management of Predisposed Risk

AdvancePhysician

to

Diagnosis

Prognosis

Treatment

Interaction

Physicians

Genetic testing Other molecular testing

Preemptive therapies Monitoring of risk development

Early diagnosis Molecular level diagnosis

Molecular level tests for staging and progression prediction

More effective and stratified medicine

Sean Xinghua Hu, et al. BioTechniques , 2005, 29(5), doi 10.2144/000112048

KEDOKTERAN NUKLIR DI INDONESIA

________________________ ________________________________________________ _____________________ 373


Do we need nuclear medicine in Indonesia ? * Changing pattern of diseases in Indonesia : Cerebrocardiovascular diseases Degenerative and metabolic diseases Cancer * Basic and applied research in medicine and allied sciences  biomedical research  Significant role of NM technology

Indonesia •17.000 islands •225 million population •52 state universities, and more than 100 private universities •100 state owned hospitals, and more than 200 private hospitals •18 state owned + 17 private teaching hospitals •18 state owned + 17 private Schools of Medicine

•Only 14 nuclear medicine centers (5 inactive) Potential market for health sector business including Nuclear Medicine

________________________ ________________________________________________ _____________________ 374


Adam Malik GH (SPECT) (Medan)

1. Cipto Mangunkusumo (SPECT/CT) 2. Pertamina (SPECT) 3. Gatot Subroto (SPECT) 4. Kanker Dharmais (SPECT/CT, PET/CT) 5. Jantung Harapan Kita (SPECT)

M. Djamil GH (SPECT) (Padang)

6. Gading Pluit (PET/CT) 7. MRC Cancer Center (SPECT, PET/CT)

Kariadi GH (SPECT) (Semarang)

Hasan Sadikin GH (Bandung) SPECT SPECT/CT PET/CT

Sardjito GH (SPECT) (Jogyakarta)

Soetomo GH (SPECT) (Surabaya)

Nuclear medicine in Indonesia

PERKEMBANGAN KEDOKTERAN NUKLIR DI INDONESIA SANGAT LAMBAT 1980-an

: 14 unit kedokteran nuklir

2013 Active : RSHS, RSCM, RSP Pertamina, RS Gatot Subroto, RS Kanker Dharmais, RS MRCCC, RS Gading Pluit, RS Dr. Kariadi Semi-active : RS Dr. M. Djamil, RS. Adam Malik, RSD Dr.Sutomo, RS Dr. Sardjito, RS Jantung Harapan Kita Non-active : RS Dr. Wahidin

________________________ ________________________________________________ _____________________ 375


Nuclear phobia dan mis-persepsi

Investasi tinggi, bukan prioritas dalam pelayanan kesehatan

Minat kurang dalam ilmu kedokteran nuklir

“bila yang ingin saudara raih dengan menjadi dokter adalah

tingkat kesejahteraan yang setinggi-tingginya, maka kedokteran nuklir agaknya bukan bidang yang tepat untuk itu; namun bila saudara memiliki sedikit idealisme dan minat dalam pengembangan ilmu dan teknologi kedokteran,kedokteran nuklir dapat saudara jadikan salah satu opsi pengembangan karier saudara kelak”

Quality Management Audits in Nuclear Medicine Practices. IAEA 2008.

________________________ ________________________________________________ _____________________ 376


Challenges Nuclear Medicine as a medical specialty faces significant challenges due to the intersection with Radiology, which has accelerated since the introduction of hybrid imaging and the evolution of Molecular Imaging; These pressures are being felt after decades of strong growth for Nuclear Medicine, particularly in Nuclear Cardiology and PET/CT. The emergence of Molecular Imaging with new radiopharmaceuticals and new technologies is likely to result in continued growth in the coming decades. SNM, 2011

OPPORTUNITIES • Nuclear Medicine has had decades of strong growth, particularly in Nuclear Cardiology and Oncology (PET/CT); • The emergence of Molecular Imaging with new radiopharmaceuticals and new technologies is likely to result in continued growth in the coming decades. SNM, 2011

________________________ ________________________________________________ _____________________ 377


Key factors for a good Nuclear Medicine and Molecular Imaging services in Indonesia 1. Supply and logistics of radiopharmaceuticals NM highly depends on good supply and logistics of radiopharmaceuticals; 2. Instrumentations and supporting facilities Updating new technologies; 3. Manpower : NM physicians, Radiopharmacists, Medical Technologists, Medical Physicists Manpower development; 4. Appreciation to NM and MI services Medical community “Nuclear phobia”; 5. Accessibility to NM and MI services 2013 : active centers only in Jakarta and Bandung.

Nuclear medicine bridges basic medical sciences and clinical medicine, and plays an important role in biomedical research.

Nuclear Medicine has an unique contribution in the management of diseases.

The future of NM in Indonesia depends on the good acceptance and appreciation of public authority and medical community, and also good supporting facilities.

________________________ ________________________________________________ _____________________ 378


MIMPIKU 15 TAHUN YANG LALU. FK UNPAD/RSHS MEMILIKI PET/CT CAMERA

“Medicine has moved from whole body to organs to tissues to cells and now to molecules. We are indeed in a revolutionary time in the history of medicine” Henry N. Wagner, Jr., 2008

________________________ ________________________________________________ _____________________ 379


Molecular Nuclear Medicine: We are small, but very focused !

________________________ ________________________________________________ _____________________ 380


Terima kasih Hatur nuhun Matur nuwun

Einstein and me ........

________________________ ________________________________________________ _____________________ 381

Nuclear Medicine in Indonesia 2015

Recommend Documents