Present Status and Future Trends of Nuclear Medicine Bangladesh Perspective

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Present Status and Future Trendsof Nuclear
Medicine - Bangladesh Perspective

• By
• Dr Faridul Alam
• Institute of Nuclear Medicine

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Nuclear Medicine, We take it

• As an integral part of patient care, nuclear
  medicine is used in the diagnosis, management,
  treatment, and prevention of serious disease.
• Nuclear medicine procedures often identify
  abnormalities very early in the progression of a
  disease -long before some medical problems are
  apparent with other diagnostic tests.
• This early detection allows a disease to be
  treated early in its course when there may be a
  more successful prognosis.

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Brief History of Nuclear Medicine

• Origin of nuclear medicine stem from many
  scientific discoveries, most notably
• x-rays in 1895
• "artificial radioactivity" in 1934.
• The first clinical use of "artificial
  radioactivity" was carried out in 1937 for the
  treatment of a patient with leukemia.
• In 1946 a thyroid cancer patient's treatment with
  radioactive iodine caused complete disappearance
  of the spread of the patient's cancer.
• A landmark event for nuclear medicine.
• Considered by some as the true beginning of
  nuclear medicine.
• Wide spread clinical use, however, did not start
  until 1950s.

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Development in sixties

• In the mid-sixties and the years that followed,
  the growth of nuclear medicine as a specialty
  discipline was phenomenal.
• The advances in nuclear medicine technology and
  instrument manufacturers were critical to this
  development.

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Nuclear Medicine in our country

• We also have a glorious history of Nuclear
  Medicine. The first nuclear medicine center of
  the country was established in 1962 in Dhaka
  Medical College.
• The establishment was developed under PAEC
  named Atomic Energy Medical Centre.
• The patients were those with thyroid disease.

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Development in seventies

• The 1970s brought the visualization of most other
  organs of the body with nuclear medicine,
  including liver and spleen scanning, brain tumor
  localization, and studies of the gastrointestinal
  track.
• In 1970 two more Centres were established, one in
  Chittagong one in Rajshahi.

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Development in eighties

• The 1980s provided the use of radiopharmaceuticals
  for such critical diagnoses as heart disease and
  the development of cutting-edge nuclear medicine
  cameras and computers.
• By 1980 we have Centre in Dinajpur, Sylhet the
  prestigious Institute of NM in IPGMR.
• First computerized gamma camera was established
  in INM under the able leadership of Dr Kamal
  Uddin Ahmed.
• RIA non-radiating US was first time introduced
  in Bangladesh by the same Institute.

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Development in nineties

• Presently
• 17 nuclear medicine, of them 14 run by Bangladesh
  Atomic Energy commission, One by Ministry of
  Health, 2 by private sectors.

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Nuclear medicine today

• Today, nuclear medicine became an integral part
  of patient care, and an important diagnostic and
  therapeutic specialty in the armamentarium of
  medical science through out the world.
• In our country, we have 14 different NM
  establishments under the umbrella of BAEC today
  along with two privately run NM departments.
• If you look at the map you will see that we cover
  all flanks of the country with Centre from
  Dinajpur to Chittagong, from Sylhet to Khulna.

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Society of Nuclear Medicine BANGLDESH

• 130 AVTIVE MEMBERS
• PUBLISH 2 JOURNAL PER YEAR
• IT HAS HOSTED 3 DAYS AGM G ARCCNM
• THIS YEAR 90 FOREIGN PARTICIPANT
• PROF AK PADHY WAS ONE OF THE PARTICIPANT

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Dhaka ARCCNM conference
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Instrumentations currently available in the
country

• Most of the BAEC controlled NMC INM has few
  common equipments
• Thyroid uptake system
• Rectlinear scanner /organ imaging system (not
  available in all NMC)
• 2 or 3 channel Probe renography system
• Gamma camera
• SPECT camera (not available in all NMC).

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Instrumentations currently available in the
country

• 2D grayscale US
• Color Doppler US (not available in all NMC)
• Gamma well counter for in vitro studies
• Bone densitometer (not available in all NMC)
• Dose calibrator
• Laboratory survey meter
• At present BAEC has 20 gamma cameras. Out of
  these, 10 cameras have got SPECT facility. In the
  private sector two SPECT cameras are dual headed.
  

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Nuclear Medicine procedures currently carried in
Bangladesh

• Nuclear Medicine activities mainly concerned with
  routine diagnostic procedures.
• Therapeutic procedures are also done in almost
  all centers.
• Thyroid Function Studies
• Bangladesh is an endemic area of iodine
  deficiency. In fact nuclear medicine activities
  in Bangladesh started with the investigation of
  goiter. Nulcear Medicine Centres INM now
  offering complete range of thyroid studies in
  Bangladesh
• By volume, thyroid is still the number one
  nuclear medicine investigation of the country.

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Bone Scan

• Radionuclide bone scan is the second most common
  study at present. For detection of bone
  metastasis, particularly from breast prostatic
  cancer bone scan is a widely asked investigation
  through out the world. Few indications for bone
  scans are
• Primary metastatic bone disease
• Benign bone disease
• Occult fracture
• Athletic injury /stress fracture
• Metabolic bone disease

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Nuclear nephrology

• In last few years, number of renal studies have
  increased many fold. Studies under this head
  include
• DTPA Renogram,
• DMSA cortical studies
• GFR estimation
• ERPF study
• Split renal function
• Evaluation of renal transplant
• Vesicouereteric reflux study micturating
  cystourethrogram

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Liver Scan

• Liver diseases are common in Bangladesh. Though
  with the spread of US to almost all the corner of
  the country and available CT MRI in Dhaka, the
  number of liver scan has reduced in recent time.
• However, it is a routine procedure in all nuclear
  medicine centers using sulfur or tin colloid.
• Its role in diagnosing cirrhosis is still
  continued to be important as US, CT FNAC is
  frequently indeterminate in early, stage I II
  cirrhosis.

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Central Nervous System Studies

• Previously brain scan was a routine procedure.
• Conventional brain scan is done mainly in
  peripheral centres.
• The country is gradually switching towards
  functional SPECT study using HMPAO.
• high cost.

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Gastro-Intestinal Tract Studies

• Studies like GI bleeding study, Meckle's
  diverticulum identification, esophageal transit
  time gastric emptying time study are done in
  most of the Centres.
• Scintimammography
• Scintimammography is routinely done in two
  centers. In Bangladesh breast cancer is the
  second most common cancer in women and the
  initial experience shows that this will be a
  popular investigation in near future.

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Other in vivo studies

• Other than the studies described above the
  following studies are also regularly done but in
  less frequency.
• a. Testicular scan
• b. Salivary gland scan
• c. Parathyroid scan etc.

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Therapeutic Nuclear Medicine

• Almost all the centers are engaged with
  therapeutic cases.
• Mainly I-131 treatment for thyrotoxicosis and
  thyroid cancer are done. Institute of Nuclear
  Medicine (INM), Dhaka takes the lion share of the
  therapeutic part.
• P-32 treatment for polycythemia vera are
  routinely done at INM.
• Post operative Sr-89 therapy is given for
  prevention of pterigium in all Centres.

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Ultrasonogram

• In Bangladesh are pioneer in US.
• In the beginning the instrument was added to the
  department as an allied imaging technique to
  evaluate thyroid liver.
• Later on, it has occupied a major workload of the
  centers and emerged as a separate department in
  all the centers. A large number of patients are
  taking this service of ultrasonogram routinely in
  all the 14 centers.

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Academic and Research Activities

• Institute of Nuclear Medicine, Dhaka mainly looks
  the academic aspects.
• At present it is running a post graduate course
  for nuclear medicine physicians. It is also
  conducting a distance education course for
  nuclear medicine technologists. Besides, it
  conducts various training programs on nuclear
  medicine.
• Research projects are mainly taken in conjunction
  with IAEA. A few local projects are also taken.
  The projects are mainly related with thyroid,
  bone, breast diseases and tumor.

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• Manpower
• At present about 70 nuclear medicine physicians
  are working in different centers. 10 medical
  physicists, 5 radiochemists and about 150
  technologists are also engaged in nuclear
  medicine service.
• The nuclear medicine physicians and physicists
  are mainly trained from abroad. The technologists
  are locally trained.
• Isotope and Radiopharmaceuticals
• Till now we mainly imports radio-isotopes and
  kits. Only a small portion of our demand is
  produced locally.

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Future plan trend

• If we compare nuclear medicine services of
  developed world, we are lagging far behind.
• But if we compare countries of our dimension of
  similar GDP, we are not far behind. Most of our
  mid senior label physicians physicists have
  got training in world renown NM departments of
  USA, UK, Australia Japan, under direct
  supervision of big names like H Wagner jr., K
  Britton, D J Heertum, John Morris, T P Hayne.
• They are capable of performing all sorts of SPECT
  even PET studies.

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Future plan trend

• Nuclear medicine is one of the most vibrant
  branches of Atomic Energy Commission.
• Atomic Energy Commission itself is committed to
  introducing cutting edge technology high
  standard of nuclear medicine service in the
  country.

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Peace

• The pace with which nuclear medicine has
  progressed over the last 20 years is phenomenal.
  For next ten to fifteen years tremendous
  development is expected in the field of nuclear
  medicine therapy targeted radionuclide therapy,
  radio-pharmacy, radioligand, PET
  radiopharmaceutical, nuclear oncology, pediatric
  nuclear medicine, nuclear nephrology, nuclear
  cardiology foremost, nuclear instrumentation.
  In next 15 years the population in the country
  would be around 170 millions we have to take
  the major share of Nuclear Medicine services. It
  is certain that Bangladesh Atomic Energy
  Commission will contribute significantly in the
  health sector of the country in the form of
  nuclear medicine.

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Our target will be

• Expansion of diagnostic capability
• Therapeutic capability
• Academic activity
• Research development
• Human resource development
• Expansion modernization of NM establishments

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Expansion modernization

• five new NM centres
• in CMH,
• ICVD,
• National Cancer institute,
• Dhaka Child hospital,
• Rangamati General Hospital.
• Nuclear medicine service in private sector shall
  also be encouraged.

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Expansion modernization

• NMC, Dhaka NMC, Chittagong is undergoing
  mordernization right now.
• Six NMCs (Rajshahi, Sylhet, Mymensingh, Barisal,
  Khulna, Rangpur) are going to go through
  modernization schemes soon.
• SPECT cameras
• performing most modern studies on oncology,
  cadiology, nephrology cerebral studies.

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Institute of Nuclear Medicine

• INM is going to be established as Centre of
  excellence.
• PET centre for INM by next five to ten years.
• new dimension to the nuclear medicine services in
  Bangladesh.

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Nuclear Therapy

• Nuclear therapy is a rapidly expanding field
• Therapy of metastases bone pain using Sm-201
• Treatment of liver cancer using Re 188
• Radiosynovectomy for arthritis
• Prevention of re-stenosis after percuteneous
  transluminal angioplasty.

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Nuclear Therapy

• W-188/Re-188 is a new generator already
  considered as a break through for RN for NM
  therapy.
• 1 meV beta (suitable for therapy),
• 155 keV gamma (suitable for imaging),
• T ½ 16.7 hrs.
• Generator T ½ 6 m
• Can be eluted daily.
• Already this has been developed as a
  radionuclide for treatment of liver cancer.

• It expected that in recent future a large number
  of cancer will be suitably treated with this
  generator based radiopharmaceutical.
• Our dispensing laboratories isotope stores are
  to be modified /fortified with adequate shielding
  to handle this generator.
• Overall supervision of radiation protection by
  health physics division NSRC will be sought.

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Academic activities

• We need to continue.. training our doctors
  physicists in developed overseas nuclear medicine
  laboratories.
• Post graduation courses will expand.
• post-graduation courses in NMC, Dhaka,
  Chittagong, Mymensingh, Mitford Rajshahi.
• There are a number ongoing research projects
  under INM other NMCs.
• Steps has already been taken to expand research
  works in all the NMCs.
• Further participation in government
  international research projects are expected in
  all the nuclear medicine laboratories.

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Manpower

• A number of nuclear medicine physicians
  physicists are currently completing PhD programs
  in the country overseas.
• With the introduction of post graduation courses
  more number of qualified nuclear medicine
  physicians will be available in the country.
• DAT program developed by Australian Brian Hutton
  group will be utilized in to run local training
  program. Affiliation from University will be
  sought for this program.

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Thank you all