PET-CT in Scotland

Dr Fergus McKiddieJohn Mallard PET CentreAberdeen Royal Infirmary

What is PET?

PET is Positron Emission Tomography

A specialised form of Nuclear Medicine

Requires specialist imaging and radiopharmacy equipment

Proton rich radioisotope decaysby positron emission

Proton decays to a neutron, a positron and a neutrino

Positron loses energy until it annihilates with an electron to produce two colinear 511 keV photons

Positron Producing Radioisotopes

Isotope half-life

(min)

Maximum positron energy

(MeV)

Positron range in water (FWHM in

mm)

Production method

11C 20.3 0.96 1.1 cyclotron

13N 9.97 1.19 1.4 cyclotron

15O 2.03 1.70 1.5 cyclotron

18F 109.8 0.64 1.0 cyclotron

68Ga 67.8 1.89 1.7 generator

82Rb 1.26 3.15 1.7 generator

2-fluoro-2-deoxy-D-glucose, commonly called Fluorodeoxyglucose or FDG

Similar metabolic pathway to glucose in vivo, but remains trapped within tissue

Useful in oncology as proliferating cancer cells have a higher than average rate of glucose metabolism

(O Warburg 1931 "The metabolism of tumors" New York: Richard Smith;129-161)

18F-FDG

Proton bombardment of 18O enriched water

18F produced as hydrofluoric acid

Synthesis completed in automatedrig within ‘hot cell’

18F-FDG Synthesis

Multimodality Imaging

18F-FDG PET

18F-FDG PET

CT

Fused PET-CT

1985 - Research PET scanner installed at Aberdeen University2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET2003 - Scottish Government commits £5 million for provision of PET in Scotland2005 - Ordered placed for first two scanners2006 - 26th March, first patient scanned at Aberdeen Royal Infirmary2007 - Scanner opens at Beatson Oncology Centre, Glasgow2010 - Scanners opened in Edinburgh and Dundee2014 - Funding for all future scanners confirmed from central funding moving forward

Timeline for PET in Scotland

1985 - Research PET scanner installed at Aberdeen University

2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET2003 - Scottish Government commits £5 million for provision of PET in Scotland2005 - Ordered placed for first two scanners2006 - 26th March, first patient scanned at Aberdeen Royal Infirmary2007 - Scanner opens at Beatson Oncology Centre, Glasgow2010 - Scanners opened in Edinburgh and Dundee2014 - Funding for all future scanners confirmed from central funding moving forward

Timeline for PET in Scotland

1985 - Research PET scanner installed at Aberdeen University

2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET2003 - Scottish Government commits £5 million for provision of PET in Scotland2005 - Ordered placed for first two scanners2006 - 26th March, first patient scanned at Aberdeen Royal Infirmary2007 - Second scanner opens at Beatson Oncology Centre, Glasgow2010 - Scanners opened in Edinburgh and Dundee2014 - Funding for all future scanners confirmed from central funding moving forward

Timeline for PET in Scotland

1985 - Research PET scanner installed at Aberdeen University2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET

2003 - Scottish Government commits £5 million for provision of PET in Scotland2005 - Ordered placed for first two scanners2006 - 26th March, first patient scanned at Aberdeen Royal Infirmary2007 - Scanner opens at Beatson Oncology Centre, Glasgow2010 - Scanners opened in Edinburgh and Dundee2014 - Funding for all future scanners confirmed from central funding moving forward

Timeline for PET in Scotland

1985 - Research PET scanner installed at Aberdeen University2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET

2003 - Scottish Government commits £5 million for provision of PET in Scotland2005 - Ordered placed for first two scanners2006 - 26th March, first patient scanned at Aberdeen Royal Infirmary2007 - Scanner opens at Beatson Oncology Centre, Glasgow2010 - Scanners opened in Edinburgh and Dundee2014 - Funding for all future scanners confirmed from central funding moving forward

Timeline for PET in Scotland

1985 - Research PET scanner installed at Aberdeen University2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET2003 - Scottish Government commits £5 million for provision of PET in Scotland

2005 - Ordered placed for first two scanners2006 - 26th March, first patient scanned at Aberdeen Royal Infirmary2007 - Scanner opens at Beatson Oncology Centre, Glasgow2010 - Scanners opened in Edinburgh and Dundee2014 - Funding for all future scanners confirmed from central funding moving forward

Timeline for PET in Scotland

1985 - Research PET scanner installed at Aberdeen University2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET2003 - Scottish Government commits £5 million for provision of PET in Scotland2005 - Ordered placed for first two scanners

2006 - 26th March, first patient scanned at Aberdeen Royal Infirmary2007 - Scanner opens at Beatson Oncology Centre, Glasgow2010 - Scanners opened in Edinburgh and Dundee2014 - Funding for all future scanners confirmed from central funding moving forward

Timeline for PET in Scotland

1985 - Research PET scanner installed at Aberdeen University2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET2003 - Scottish Government commits £5 million for provision of PET in Scotland2005 - Ordered placed for first two scanners2006 - 26th March, first patient scanned at Aberdeen Royal Infirmary

2007 - Scanner opens at Beatson Oncology Centre, Glasgow2010 - Scanners opened in Edinburgh and Dundee2014 - Funding for all future scanners confirmed from central funding moving forward

Timeline for PET in Scotland

1985 - Research PET scanner installed at Aberdeen University2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET2003 - Scottish Government commits £5 million for provision of PET in Scotland2005 - Ordered placed for first two scanners2006 - 26th March, first patient scanned at Aberdeen Royal Infirmary2007 - Scanner opens at Beatson Oncology Centre, Glasgow

2010 - Scanners opened in Edinburgh and Dundee2014 - Funding for all future scanners confirmed from central funding moving forward

Timeline for PET in Scotland

1985 - Research PET scanner installed at Aberdeen University2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET2003 - Scottish Government commits £5 million for provision of PET in Scotland2005 - Ordered placed for first two scanners2006 - 26th March, first patient scanned at Aberdeen Royal Infirmary2007 - Scanner opens at Beatson Oncology Centre, Glasgow2010 - Scanners opened in Edinburgh and Dundee

2014 - Funding for all future scanners confirmed from central funding moving forward

Timeline for PET in Scotland

1. John Mallard PET Centre, ARIScanner (NHS), Cyclotron (Uni)

2. Beatson West of Scotland Cancer Centre, Gartnavel2 x Scanner + Cyclotron (NHS)

3. Clinical Research Imaging Centre, ERIScanner + Cyclotron (NHS/Uni)

4. Clinical Research Imaging Facility, NinewellsScanner (NHS/Uni)

1

2 3

4

PET-CT is expensive: £1600 - £2000 per scan

Funding is top-sliced to spread cost

Only indications with proven evidence funded

2006: Lung, Lymphoma, Recurrent colorectal

Clinical Indications for PET in Scotland

Additional indications added as evidence becomes available

2014: Lung, Lymphoma, Recurrent colorectal, Oesophageal, Head and neck, Gynaecological

Clinical Indications for PET in Scotland

Additional indications added as evidence becomes available

2014: Lung, Lymphoma, Recurrent colorectal, Oesophageal, Head and neck, Gynaecological

Clinical Indications for PET in Scotland

Funding has always been provided for justifiable ‘Other’ indications

Examples include Melanoma, Vasculitis, Sarcoidosis, Unknown Primary ca, PUO

Clinical Indications for PET in Scotland

2005/6 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 14/150

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Royal College of Radiology Guidelines

Published 2013

Provide guidance for 23 cancer indications

Additionally 6 non-cancer indications

Information about other non-FDG tracers

Royal College of Radiology Guidelines

Published 2013

Provide guidance for 23 cancer indications

Additionally 6 non-cancer indications

Information about other non-FDG tracers

Royal College of Radiology GuidelinesCancer Non -CancerBrain Myeloma NeurologicalHead and Neck Skin CardiologicalThyroid Musculoskeletal VasculitisLung Paraneoplastic syndromes SarcoidosisPleural Neuroendocrine InfectionThymic Unknown Primary PUOOesophago-gastric Rare tumours in childrenGI StromalBreastHepato-pancreatico-biliaryColorectalUrologicalGynaecologicalTesticularAnal and PenileLymphoma

Historically no national provision

Competitive tender process carried out through 2014

Feb 2015, Collaborative Network, led by Alliance Medical, announced as providers at 31 sites on a 10 yr contract

Also announced that they will fund all indications in the RCR Guidelines

PET in England

Decision made to match NHS England funded criteria i.e., RCR Guidelines

Workgroup established to develop local guidance for each of the 29 indications

Future Indications for PET in Scotland

Anticipated that current 10-15% annual workload uplift will continue

Many indications already covered by ‘Other’ category

Future Indications for PET in Scotland