Nuclear Medicine

With more than 30 years experience, the Nuclear Medicine Unit (NMU) of Ospedale San Raffaele provides conventional Nuclear Medicine and PET investigations for referred patients at a local, national and international level. The NMU has been one of the first PET-Cyclotron Centres in Italy contributing to the development and diffusion of the technique all over the Country. The NMU is recognized as a Centre of excellence with a national and international reputation in Molecular Imaging for its high quality clinical, research and training activities.

NMU mission is to offer the most accurate diagnosis helping the assessment and management of treatment strategy, and to contribute, with a high quality translational/clinical research in oncology, neurology and cardiology, to the understanding of the mechanisms of disease and the development of new diagnostic techniques to be translated into clinical practice. To achieve these goals, NMU is always up to date both technologically as well as in the clinical and scientific education of the staff. One of the major strengths of the Unit consists in the multidisciplinary expertise, including Nuclear Medicine physicians, radiochemists, physicists and engineers, all having a common objective which has its center in the patient care. NMU activity over the years is characterized by constant qualitative and quantitative developments and improvements. Currently, approximately 18.000 studies are performed every year, including SPECT, SPECT/CT, PET and contrast-enhanced CT (ce-CT) scans.

Clinical investigations performed

The clinical activity of the NMU includes all the standard Nuclear Medicine and PET investigations. Here below are listed the principal PET/CT and Conventional Nuclear Medicine investigations performed:

Principal PET/CT Investigations:

  • Total body PET/CT with [18F]FDG (6.000 investigations/year)
  • Total body PET/CT with [11C]Choline (1.100 investigations/year)
  • Total body PET/CT with [18F]Fluoride
  • Brain PET/CT with [18F]FDG
  • Brain PET/CT with [11C]PIB
  • Myocardial PET/CT with [18F]FDG
  • Myocardial PET/CT with [13NH]Ammonia

Principal Conventional Nuclear Medicine Investigations:

  • Myocardial SPECT perfusion Imaging, Rest and Stress (4000 investigations/year)
  • Total body and poliphasic bone scintigraphy
  • Gastrointestinal scintigraphy (Gastric Emptying; Meckel’s diverticulum; Gastrointesintal bleeding; Gastro-oesophageal reflux)
  • Dopamine transporter (DAT) SPECT brain studies
  • Lymphoscintigraphy, breast and melanoma Protocol

In general, the main clinical interests are focused on oncology, neurology and cardiology with some specificities:

  • Oncology:

In addition to the conventional PET/CT procedures for staging, restaging, monitoring and patient follow-up, at our Unit an integrated service of PET and contrast enhanced CT, performed in the same session, is also offered. Currently this opportunity, being available for both [18F]FDG and [11C]Choline studies, allows significant clinical and logistic advantages for patients who may have a complete staging of their disease in a single session examination.

Moreover, in the NMU a strong support to radiation oncology procedures is also present by providing PET functional information for radiation planning, patient monitoring and patient selection for personalized radiation treatment. These achievements are possible thanks to the strong collaboration of Nuclear Medicine and Radiation Oncology physicians and physicists. In particular, PET/CT procedures may also be performed in 4D modality (respiratory gated). The 4D PET/CT images provide information not only about the targets but also on its motion due to patient breathing. These information are used by Radiation Oncology physicians for a more accurate and personalized design of the treatment plan, avoiding under-irradiation of the target as well as over-irradiation of healthy surrounding normal tissues.

  • Neurology:

The staff is able to apply and integrate advanced nuclear medicine neuroimaging to neurological patients with a tight network of experts. The Nuclear Medicine Unit Neurology Section at Ospedale San Raffaele is considered a Centre of Excellence in Italy, Europe and abroad and it is one of the leading centre for molecular and functional brain imaging in neurological diseases. Here, validation and optimization procedures for [18F]FDG PET assessment of brain metabolic functions in cognitive decline and dementias have been obtained with high sensitivity and specificity for accurate early and differential diagnosis. Such procedures are routinely applied for clinical diagnosis and prognosis at single subject level. [18F]FDG PET scans are routinely performed in subjects with cognitive decline and early dementia for diagnosis and prognosis by using these advanced and validated analysis methods. Amyloid PET scans can be also performed using [11C]PIB a validated tracer for measures of amyloid burden (the Nuclear Medicine Unit was part of a multicentre European study for the validation of the amyloid PET methods in AD and early cognitive decline. In Parkinson’s diseases and parkinsonism we use DAT SPECT scan for presynaptic dopaminergic assessment for diagnosis and differential diagnosis.

  • Cardiology

Our strongest clinical application in cardiological field is represented by SPECT myocardial perfusion studies performed by an innovative gamma camera specifically dedicated to cardiac studies. This system permits a reduction of imaging times and a reduction (more than 50%) of the ionizing radiation exposure of the patient compared to traditional protocols, while maintaining a high image quality and diagnostic accuracy.

Although PET/CT cardiac applications represent a small percentage of NMU PET/CT clinical activity, a full procedure of analysis which allows the absolute quantitative estimation of the MBF (Myocardial Blood Flow) with [13NH]PET and kinetic modelling was implemented. The absolute quantification of MBF with PET allows to perform an objective and accurate evaluation of the whole coronary tree, providing a more complete assessment of the heart functionality than that obtained by visual analysis that can only provide relative information amongst different territories.

Research

The Unit performs translational and applied clinical research in oncology and neurology, being also involved in clinical trials. In addition, a strong methodological research activity is aimed to support both clinical and research applications (in oncological, neurological and cardiological fields) to provide high quality images as well as accurate quantitative data.

Specific researches currently ongoing are:

  • Oncology:
    • Use of PET/CT with [18F]FAZA for the definition of hypoxia in tumour tissue (a phase I study is currently ongoing)
    • Diagnostic value assessment of [11C]Choline PET/CT in prostate cancer patients for the detection of prostate recurrent disease and for its use in guiding and monitoring personalized treatments
    • Development and validation of innovative PET tracers for cancer imaging
    • Use of PET models for predictive assessment of treatment efficacy
    • Diagnostic validation of PET procedures for guiding and monitoring personalized treatment as valuable support for radiation Oncology
  • Neurology:
  • Responsibility for neuroimaging procedures in the Italian Alzheimers Disease Network, a multicentric large scale project funded by the Ministry of Health with the aim of providing standardized operation procedure for PET molecular (FDG and Amylod PET) and MRI structural neurimaging with the best cost/effectiveness.
  • Principal participant in the European Project 7thFramework Program Health Understanding the role of neuroinflammation in neurodegenerative diseases (InMind: Imaging of Neuroinflammation in Neurodegenerative Diseases ) with the aim of carry out collaborative research on molecular mechanisms that link neuroinflammation with neurodegeneration in order to identify novel biological targets for activated microglia, which may serve for both diagnostic and therapeutic purposes, and to translate this knowledge into the clinic.
  • Partner of the JNPD Research Biomarkers for Alzheimer’s disease and Parkinson’s disease aimed at evaluating and standardise the assessment of established and new CSF and PET (amyloid, FDG) biomarkers for Alzheimer’s disease and Parkinson’s disease.
  • Participation in several pharmacological trials which target amyloid deposition by providing neuroimaging evidence of brain amyloid pathology in the entry cases and neuroimaging follow ups during and after therapy. The collaboration is under international approved research protocols with Companies (i.e. Avid/Lilly, General Electric, Piramal).
  • One of the few Nuclear Medicine centre in Europe for the application of experimental new traces for in vivo measurement of brain biomarkers (amyloid and tau brain burden, neuroinflammation as astrocites and microglia activation)
  • Methodology:
    • Image Reconstruction techniques: Analytic and iterative/statistical methods accounting for TOF (Time of Flight), PSF (Point Spread Function) and regularization information
    • Methods for organ motion (respiratory and cardiac) detection and compensation (diagnostic and radiotherapy applications)
    • Methods for absolute image quantification (kinetic modelling)
    • Methods for statistical image analysis

The group, in the last five years (2009-2013), has published more than 200 papers on peer reviewed journals with a total Impact Factor 1.116,82 (Mean I.F= 3,97). The NMU has several collaborations at local national and international level for research purpose and academic training programs including Medical School, Specialty School in Nuclear Medicine and Radiology and Radiochemical Radiology Technicians for University Milano-Bicocca and Vita-Salute San Raffaele University.

Technology

The NMU extends over a 1.500 m2 area including two cyclotrons (18MeV e 11MeV), radiochemistry laboratories dedicated to the synthesis of radiopharmaceuticals and equipped with shielded cells (20) and automated systems for the production of labelled radiopharmaceuticals (i.e. 18F, 11C). PET laboratories are able to ensure the quality and safety of radiopharmaceuticals production for diagnostic use complying with national and European regulations. Furthermore, current procedures are undergoing to obtain full GMP accreditation (Good Manufacturing Production) in order to develop drugs for experimental use. The GMP accreditation in laboratories within a clinical setting will represent an unique scenery at national level. The facility of the Unit also includes 4 Positron Emission Tomography/Computed Tomography (PET/CT), 2 Single Photon Computed Tomography (SPECT), 1 SPECT/CT scanners and a dedicated system for myocardial perfusion SPECT studies. A preclinical SPECT/PET system is also available.