International Atomic Energy Agency Radiation Medicine The human

International Atomic Energy Agency Radiation Medicine The “human side” of nuclear applications Pedro Andreo, Director Division of Human Health (NAHU) Department of Nuclear Sciences and Applications Radiation Medicine

BACKGROUND • The utilization of radiation in medicine for diagnosis and treatment dates from the 19 th 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 Radiation Medicine 2 International Atomic Energy Agency

THE DIVISION OF HUMAN HEALTH • Nuclear Medicine & Diagnostic imaging • Radiation Oncology & Cancer Treatment • Medical Physics & Dosimetry • Nutrition Radiation Medicine 3 International Atomic Energy Agency

CONTENTS • “Nuclear” techniques in medicine: Radiation Medicine ØWhat is and what is not “Nuclear Medicine” • The birth of PACT (Program of Action for Cancer Therapy) Radiation Medicine 4 International Atomic Energy Agency

THREE DISTINCT FIELDS • Diagnostic radiology Ø 100% diagnostic • Radiotherapy Ø 100% treatment • Nuclear medicine Ø 80% diagnostic Ø 10% treatment Ø 10% lab tests Multidisciplinary team: physicians, physicists, radiographers, . . Radiation Medicine 5 International Atomic Energy Agency

THREE DIFFERENT TYPES OF RADIATION SOURCES • Diagnostic radiology ØX-rays • Radiotherapy ØHigh-activity sealed sources radioisotopes, solid, capsule ØMedical accelerators • Nuclear medicine ØLow-activity unsealed sources (*) radioisotopes, mostly liquid radiopharmaceuticals (*) except for therapeutic uses Radiation Medicine 6 International Atomic Energy Agency

DIAGNOSTIC X-RAYS The left hand of Mrs Roentgen, some 100 years ago(1895) Radiation Medicine Modern pelvic and thorax X-ray examinations using digital techniques 7 International Atomic Energy Agency

Are X-rays atomic/nuclear? bremsstrahlung interaction electron N x-ray characteristic x-rays added Radiation Medicine 8 International Atomic Energy Agency

The goal of Diagnostic Radiology A. L. A. R. A. To produce an anatomical or functional patient image (using x-rays) which is clinically useful …. Radiation Medicine …. delivering As Low radiation dose to the patient As Reasonably Achievable 9 International Atomic Energy Agency

Mammography - the “ultimate” challenge with regard to X-ray image quality typically 25 -30 k. V; special anode-filter microcalcifications Radiation Medicine 10 International Atomic Energy Agency

High-resolution imaging in 3 D using multi-slice Computed Tomography techniques and helical scanning 80 -140 k. V; typically 120 k. V 1895 X Ray tube Detector array Radiation Medicine 11 International Atomic Energy Agency

Angiography and interventional procedures are performed using image intensifiers or flat panel detectors ~ 70 -100 k. V Radiation Medicine 12 International Atomic Energy Agency

The goal of Radiotherapy A. H. A. R. A. … while keeping the dose to other regions and organs as low as possible. To deliver As High radiation dose As possible (Reasonably Achievable) to a “clinical target”… Radiation Medicine 13 International Atomic Energy Agency

Teletherapy Sealed Co-60 source or electron/photon accelerator Radiation Medicine 14 International Atomic Energy Agency

Modern accelerator teletherapy Radiation Medicine 15 International Atomic Energy Agency

Brachytherapy sources Brachytherapy applicators Radiation Medicine 16 International Atomic Energy Agency

Brachytherapy treatments Nasopharynx applicator Afterloader system (nasopharynx) Cervix applicator Afterloader system (cervix) Radiation Medicine 17 International Atomic Energy Agency

Nuclear Medicine Diagnosis Oncology Cardiology Neurology Radiation Medicine Therapy 18 Laboratory Tumour markers Molecular biology Gene expression International Atomic Energy Agency

NUCLEAR MEDICINE IN-VIVO APPLICATIONS (90%): Diagnosis and Therapy The fundamental principle is the use of “agents”, which localize in specific organs or tissues on the basis of their biochemical or physiological properties (radiopharmaceuticals) Radiation Medicine 19 International Atomic Energy Agency

Detector: gamma camera Position X Position Y -> computer Energy Z PM-tubes Detector Collimator Radioactive source is inside the patient Radiation Medicine 20 International Atomic Energy Agency

Tomographic acquisition - anatomical Radiation Medicine 21 International Atomic Energy Agency

Dynamic acquisition - funcional Radiation Medicine 22 International Atomic Energy Agency

Nuclear Cardiology Chronic Syndromes Stable angina; previous myocardial infarction • • Diagnosis of Coronary Artery Disease (CAD) • Management of patients with known or suspected chronic CAD: Assessment of specific risk conditions: diabetes § § Assessment of disease severity Risk stratification Prognosis Evaluation effects medical therapy and/or surgery Radiation Medicine 23 International Atomic Energy Agency

Nuclear Neurology In several cerebral diseases: MRI • Integrated diagnosis • Therapy assessment • Early detection of degenerative diseases Radiation Medicine Control 24 18 -FDG-PET E Tremor Parkinson 3 D MSA International Atomic Energy Agency

Radionuclide Therapy Thyroid Cancer Metastatic cancers Iodine-131: the silver bullet Radiation Medicine 25 International Atomic Energy Agency

Radionuclide Therapy: Established Role complementary tool to surgery, chemotherapy and radiotherapy • Differentiated thyroid carcinoma 131 I • • Diffuse non-Hodgkin lymphoma Metastatic neuro-endocrine tumours 131 I-Mo. Ab 111 In-Octr • Painful bone metastases Radiation Medicine 153 Sm 26 International Atomic Energy Agency

Radionuclide Therapy: emerging applications Radio Immuno Therapy (RIT) Radiation Medicine 27 International Atomic Energy Agency

Molecular biology nuclear techniques are used in to detect drug resistance Radiation Medicine 28 International Atomic Energy Agency

Nuclear Medicine in-vitro techniques • • Detection of drug resistance: Tuberculosis, malaria, HIV • Diagnosis of genetic disorders: Fragile x-syndrome, thalassemia, sickle cell anemia • • Diagnosis of communicable diseases: Tuberculosis, Hepatitis, Chagas disease, Leishmaniasis, Dengue fever Diagnosis of papilloma virus (associated with cervical cancer) Diagnosis of congenital hypothyroidism (associated with mental retardation) Radiation Medicine 29 International Atomic Energy Agency

PET imaging Radiation Medicine 30 International Atomic Energy Agency

Multimodality imaging (image fusion) PET: function CT: anatomy Radiation Medicine 31 International Atomic Energy Agency

THREE DIFFERENT TYPES OF RADIATION DOSE TO THE PATIENT • Diagnostic radiology (over 2 billions exam) ØLow dose to patient (most exams) ØLarge population dose ØRisk: stochastic effects • Radiotherapy (5. 5 millions treatments) ØHigh dose to patient (intended!) ØRisk: deterministic and stochastic effects • Nuclear medicine (32 millions procedures) ØLow doses (mostly) ØRisk: stochastic effects Radiation Medicine 32 International Atomic Energy Agency

“… it is likely that CT examinations will become the largest contribution 1895 1995 to population dose from man-made exposures in many countries. ” UNSCEAR, 2004 Radiation Medicine 33 International Atomic Energy Agency

QUALITY ASSURANCE AND QUALITY CONTROL MEDICAL PHYSICS: key player for the technical aspects of Radiation Medicine 34 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. International Atomic Energy Agency

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CANCER AND THE UN SYSTEM The IAEA is the only UN player in Nuclear Technology transfer for cancer prevention, diagnosis and treatment • • • International Agency for Research on Cancer (IARC) World Health Organization (WHO) Programme on Cancer Control IAEA research and technical cooperation on nutrition, nuclear medicine and radiation therapy Radiation Medicine 36 International Atomic Energy Agency

Nuclear techniques: an appropriate solution for 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 Radiation Medicine 37 International Atomic Energy Agency

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 Radiation Medicine 38 International Atomic Energy Agency

Of the 260 million new cancer cases in 20 years, there will be approx 150 million in developing countries 100 million will be suitable for radiation treatment WHO-IARC (2003) Radiation Medicine 39 International Atomic Energy Agency

IAEA resources are inadequate to respond to the silent crisis • In 10 years, approx 100 M$ for over 500 projects in 100 developing countries • At least $1 -2 billion needed now • Demand will increase more than 50% over the next 20 years Radiation Medicine 40 International Atomic Energy Agency

Programme of Action on Cancer Therapy (PACT) One House: Meeting Global Needs Radiation Medicine 41 International Atomic Energy Agency

Programme of Action for Cancer Therapy (PACT) • Work with partners • • on prevention and control (Agency: radiation medicine) Raise public awareness Mobilize resources Patient set-up for treatment with a 60 Co teletherapy machine Radiation Medicine 42 International Atomic Energy Agency

Programme of Action for Cancer Therapy (PACT) • Board of Governors approves June 2004 GOV/2004/39 • General Conference resolution Sept 2004 GC (48)13 D • PACT Programme Office (PPO) established Nov 2005 SEC/NOT/2048 Treatment using a High-Dose-Rate 192 Ir brachytherapy machine Radiation Medicine 43 International Atomic Energy Agency

Radiation Medicine 44 International Atomic Energy Agency