1. PET-CT in Scotland Dr Fergus McKiddie John Mallard PET Centre Aberdeen Royal Infirmary

2. What is PET? PET is Positron Emission Tomography A specialised form of Nuclear Medicine Requires specialist imaging and radiopharmacy equipment

3. Proton rich radioisotope decays by 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

4. Positron Producing Radioisotopes

5. 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) 18 F-FDG

7. Proton bombardment of 18 O enriched water 18 F produced as hydrofluoric acid Synthesis completed in automated rig within ‘hot cell’ 18 F-FDG Synthesis

10. Multimodality Imaging 18 F-FDG PET

11. CT

12. Fused PET-CT

13. 1985 - Research PET scanner installed at Aberdeen University 2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET 2003 - Scottish Government commits £5 million for provision of PET in Scotland 2005 - Ordered placed for first two scanners 2006 - 26 th March, first patient scanned at Aberdeen Royal Infirmary 2007 - Scanner opens at Beatson Oncology Centre, Glasgow 2010 - Scanners opened in Edinburgh and Dundee 2014 - Funding for all future scanners confirmed from central funding moving forward Timeline for PET in Scotland

14. 1985 - Research PET scanner installed at Aberdeen University 2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET 2003 - Scottish Government commits £5 million for provision of PET in Scotland 2005 - Ordered placed for first two scanners 2006 - 26 th March, first patient scanned at Aberdeen Royal Infirmary 2007 - Scanner opens at Beatson Oncology Centre, Glasgow 2010 - Scanners opened in Edinburgh and Dundee 2014 - Funding for all future scanners confirmed from central funding moving forward Timeline for PET in Scotland

15. 1985 - Research PET scanner installed at Aberdeen University 2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET 2003 - Scottish Government commits £5 million for provision of PET in Scotland 2005 - Ordered placed for first two scanners 2006 - 26 th March, first patient scanned at Aberdeen Royal Infirmary 2007 - Second scanner opens at Beatson Oncology Centre, Glasgow 2010 - Scanners opened in Edinburgh and Dundee 2014 - Funding for all future scanners confirmed from central funding moving forward Timeline for PET in Scotland

16. 1985 - Research PET scanner installed at Aberdeen University 2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET 2003 - Scottish Government commits £5 million for provision of PET in Scotland 2005 - Ordered placed for first two scanners 2006 - 26 th March, first patient scanned at Aberdeen Royal Infirmary 2007 - Scanner opens at Beatson Oncology Centre, Glasgow 2010 - Scanners opened in Edinburgh and Dundee 2014 - Funding for all future scanners confirmed from central funding moving forward Timeline for PET in Scotland

17. 1985 - Research PET scanner installed at Aberdeen University 2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET 2003 - Scottish Government commits £5 million for provision of PET in Scotland 2005 - Ordered placed for first two scanners 2006 - 26 th March, first patient scanned at Aberdeen Royal Infirmary 2007 - Scanner opens at Beatson Oncology Centre, Glasgow 2010 - Scanners opened in Edinburgh and Dundee 2014 - Funding for all future scanners confirmed from central funding moving forward Timeline for PET in Scotland

18. 1985 - Research PET scanner installed at Aberdeen University 2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET 2003 - Scottish Government commits £5 million for provision of PET in Scotland 2005 - Ordered placed for first two scanners 2006 - 26 th March, first patient scanned at Aberdeen Royal Infirmary 2007 - Scanner opens at Beatson Oncology Centre, Glasgow 2010 - Scanners opened in Edinburgh and Dundee 2014 - Funding for all future scanners confirmed from central funding moving forward Timeline for PET in Scotland

19. 1985 - Research PET scanner installed at Aberdeen University 2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET 2003 - Scottish Government commits £5 million for provision of PET in Scotland 2005 - Ordered placed for first two scanners 2006 - 26 th March, first patient scanned at Aberdeen Royal Infirmary 2007 - Scanner opens at Beatson Oncology Centre, Glasgow 2010 - Scanners opened in Edinburgh and Dundee 2014 - Funding for all future scanners confirmed from central funding moving forward Timeline for PET in Scotland

20. 1985 - Research PET scanner installed at Aberdeen University 2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET 2003 - Scottish Government commits £5 million for provision of PET in Scotland 2005 - Ordered placed for first two scanners 2006 - 26 th March, first patient scanned at Aberdeen Royal Infirmary 2007 - Scanner opens at Beatson Oncology Centre, Glasgow 2010 - Scanners opened in Edinburgh and Dundee 2014 - Funding for all future scanners confirmed from central funding moving forward Timeline for PET in Scotland

21. 1985 - Research PET scanner installed at Aberdeen University 2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET 2003 - Scottish Government commits £5 million for provision of PET in Scotland 2005 - Ordered placed for first two scanners 2006 - 26 th March, first patient scanned at Aberdeen Royal Infirmary 2007 - Scanner opens at Beatson Oncology Centre, Glasgow 2010 - Scanners opened in Edinburgh and Dundee 2014 - Funding for all future scanners confirmed from central funding moving forward Timeline for PET in Scotland

22. 1985 - Research PET scanner installed at Aberdeen University 2001 - Scottish Government commissions Health Technology Assessment into cost effectiveness of PET 2003 - Scottish Government commits £5 million for provision of PET in Scotland 2005 - Ordered placed for first two scanners 2006 - 26 th March, first patient scanned at Aberdeen Royal Infirmary 2007 - Scanner opens at Beatson Oncology Centre, Glasgow 2010 - Scanners opened in Edinburgh and Dundee 2014 - Funding for all future scanners confirmed from central funding moving forward Timeline for PET in Scotland

23. 1.John Mallard PET Centre, ARI Scanner (NHS), Cyclotron (Uni) 2.Beatson West of Scotland Cancer Centre, Gartnavel 2 x Scanner + Cyclotron (NHS) 3.Clinical Research Imaging Centre, ERI Scanner + Cyclotron (NHS/Uni) 4.Clinical Research Imaging Facility, Ninewells Scanner (NHS/Uni) 1 2 3 4

24. 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

25. Additional indications added as evidence becomes available 2014: Lung, Lymphoma, Recurrent colorectal, Oesophageal, Head and neck, Gynaecological Clinical Indications for PET in Scotland

26. Additional indications added as evidence becomes available 2014: Lung, Lymphoma, Recurrent colorectal, Oesophageal, Head and neck, Gynaecological Clinical Indications for PET in Scotland

27. Funding has always been provided for justifiable ‘Other’ indications Examples include Melanoma, Vasculitis, Sarcoidosis, Unknown Primary ca, PUO Clinical Indications for PET in Scotland

29. Royal College of Radiology Guidelines Published 2013 Provide guidance for 23 cancer indications Additionally 6 non-cancer indications Information about other non-FDG tracers

30. Royal College of Radiology Guidelines Published 2013 Provide guidance for 23 cancer indications Additionally 6 non-cancer indications Information about other non-FDG tracers

31. Royal College of Radiology Guidelines CancerNon -Cancer BrainMyelomaNeurological Head and NeckSkinCardiological ThyroidMusculoskeletalVasculitis LungParaneoplastic syndromesSarcoidosis PleuralNeuroendocrineInfection ThymicUnknown PrimaryPUO Oesophago-gastricRare tumours in children GI Stromal Breast Hepato-pancreatico-biliary Colorectal Urological Gynaecological Testicular Anal and Penile Lymphoma

32. 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

33. 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

34. Anticipated that current 10-15% annual workload uplift will continue Many indications already covered by ‘Other’ category Future Indications for PET in Scotland