1. Logistical Problems in Project managing a Nuclear Medicine Department - A Physician's Perspective
Dr P Shanmuga Sundaram,
MBBS, DRM, DNB (N Med), MNAMS
Head, Dept. of Nuclear Medicine & PET CT,
Amrita Institute of Medical Sciences, Cochin

2. What is Nuclear Medicine
A subspecialty of medicine, which uses minute amounts of radioisotopes to image various organs of the human body & to treat specific diseases
Superior to anatomical imaging by its physiological basis & ability to identify diseases at an early stage
But very name ‘nuclear’ has negative connotations
Diagnostic & Therapeutic Nuclear medicine
Gamma & Beta Emitting Radioisotopes
Thallium Heart scan – Diagnostic test
Radio iodine Therapy

3. Diagnostic Nuclear Medicine
99m Technetium the most extensively used diagnostic medical isotope
Provides high-quality image mapping
blood flow to the heart,
spread of cancer to bones etc
Delivers low radiation doses to patients
A decay product of another reactor produced radioactive element Molybdenum
Molybdenum produced & supplied as
99Moly - 99mTc generator on a weekly basis

5. Myocardial Perfusion imaging

6. To detect Skeletal Metastases

7. Therapeutic Nuclear Medicine
Radioactive Iodine (131I) in thyroid cancer & hyperthyroidism treatment
In bone pain alleviation, liver cancer, Rheumatoid arthritis management etc.
Targeted delivery of high radiation to diseased cells & sparing normal cells
Most of therapeutic radio isotopes are nuclear reactor produced
Have relatively longer half life

8. Present status of 99mTc generators in India
Indian Nuclear reactors NOT capable of producing “High specific activity Molybdenum”
Dependent completely on Imported Molybdenum
Worldwide short supply as there are only 5 nuclear reactors capable of Moly production
70% of world’s 99mTc need met by Canada & Netherlands nuclear reactors
Right now worldwide 99mTc resource crunch & % price increase in 99mTc weekly consignment
Financial strain on Indian nuclear-medicine centres

9. So What is the solution?
99mTc crisis may not be completely solved even if existing nuclear reactors restart production
High time for India, a nuclear empowered country to have its own nuclear reactor
India can supply isotopes to other SAARC & ASEAN countries
Also, better to have regional dispensing centres
It is possible to ensure affordable & uninterrupted supply of medical isotopes

10. Ultimate NM Diagnostic - PET CT Imaging
“Investigation of this Century” - PET CT
Positron Emission Tomography with CT
PET CT modality has revolutionized cancer care
ability to detect early malignancy
for cancer staging
its response to therapy
in cardiology & neurology
AIMS – only PET CT centre in state of Kerala
18FFlouro Deoxy Glucose (FDG), half-life 110 minutes
The flip side of PET CT
high cost & short half-life of PET isotopes

11. PET CT SCANNER
FDG TRANSPORT
CONTAINER

12. Whole body PETCT showing multiple metastases

13. Issues in PET Isotopes Establishing & maintaining a cyclotron
a financially challenging and daunting task
Limited number of cyclotrons located mainly in metros
No cyclotron in Cochin but it is a prerequisite to ensure uninterrupted supply of FDG
Possible to air transfer FDG from other metros
In spite of its short half life

14. FDG transport a logistical nightmare
FDG transported only on large aircraft with exclusive cargo carriage sections (i.e. smaller ATR flights cannot)
FDG categorized as “Dangerous Goods Regulations” (DGR)
Both pilots of transport carrier needs to be ‘DGR certified’
Mandatory cooling period in airport cargo area

15. FDG transport a logistical nightmare
Smooth workflow mandatory at FDG production site
at the cyclotron facility
local transport team
air cargo ground staff
Smooth workflow at destination
Ground cargo handling staff
Hospital transport team
At the user department

16. Logistics of FDG air transport from Mumbai cyclotron to our centre
Mumbai preferred because of its better air connectivity
An early morning flight preferred
Patients fast overnight
Early morning FDG production at a cyclotron facility
Cyclotron to airport road transfer faster in early morning

17. Time chart of FDG production & transport
1-3 AM – Production, QC & FDG Packaging
3-4 AM – cyclotron facility to airport cargo terminal
4-5 AM – Cooling time
AM – Aircraft loading
5.30 – 7.20 AM – In flight
7.20 – 7.40 AM – Clearance & handing over of FDG consignment to hospital staff waiting at Cochin airport
7.40 – 8.15 AM – Road transport of FDG from Cochin airport to PET CT Centre
8.15 am – AM – FDG Injection to patients in batches

18. Problems faced by our PET CT centre in FDG supply and transport logistics
Only Mumbai & Delhi cyclotron facilities are ideally located & able to supply FDG through air
Nearby facilities (Hyderabad, Chennai & Bangalore) have no ideal air connectivity in terms of aircraft size, departure time etc.
Only AI & Jet carry radioactive consignments (DGR)
So only one (Monopoly) Mumbai supplier

19. Problems faced by our PET CT centre in FDG supply and transport logistics
Cyclotron breakdown
QC failure
Pilot on flight not DGR certified
Any security alert
Any transport delay
Ultimately leads to postponement of scheduled patients for the day

20. Possible Solutions
Regional cyclotrons in Govt & Public/Private sectors so that affordable FDG available
All private carriers should carry radioisotopes routinely with commitment
Ensure DGR certified pilots available on specific routes & flights carrying radioactive substances
Sensitisation of all personnel involved in FDG transport logistics

21. Conclusion Molecular Imaging - future of cancer imaging
94 % success rate in patient scheduling
Be a Project management professional yourself
Sensitise your health management professional
Ultimately Be an optimist

22. Thank You