Johannes Czernin, MD

The global healthcare environment is rapidly changing. This is prompted by the overall economic situation and also by the change in healthcare policies and politics that undoubtedly will have a substantial impact on the way medicine is practiced worldwide. Over the last decade, technology has advanced at a rapid pace which resulted in the development and adoption of large and expensive imaging equipment for nuclear medicine and radiology. Hybrid imaging devices such as PET/CT, and in the future PET/MRI systems, have led to improvements in diagnostic accuracy, especially in initial and subsequent treatment strategy decisions in cancer. It is, however, still unknown whether the combination of high-end PET systems with highest end MRI or CT scanners will result in improved patient outcomes.

At the same time, numerous imaging probes have been developed that may or may not impact patient care and outcomes. However, almost all diseases imaged with conventional nuclear medicine equipment can now be studied with PET and various molecular imaging probes.

The recent shortage of molybdenum generators and 99Technetium has led to worldwide difficulties in providing appropriate diagnostic tests to hundreds of thousands of patients with cardiovascular, oncologic, neurologic and other diseases. While unfortunate in the short term, this crisis provides an important opportunity to rethink and redesign the practice of nuclear medicine.

Clinical PET/(CT) has emerged as the standard of care for the assessment of cancer and neurological disorders, and has the potential to become the standard in cardiac imaging. The emergence of electronic radiopharmaceutical generators that are self-shielded, small and automated has enabled the widespread use of PET imaging. In essence, all major conventional diagnostic nuclear medicine applications could now be replaced by PET.

In addition to glucose metabolic imaging of cancer and the brain with 18F-FDG, PET probes for bone imaging (18F-NaF), thyroid imaging (124I), imaging of infection/inflammation (18F-FDG), among others are now readily available. The portfolio for cancer imaging now includes 18F-FDOPA (neuroendocrine and brain tumors; but not yet available commercially in the U.S.), 18F-FLT (tumor cell proliferation) and others. In Europe, peptide imaging is already used for the phenotyping of neuroendocrine tumors. Movement disorders can be characterized with high accuracy by using 18F-FDOPA PET. Fluorinated probes of myocardial blood flow for stress/rest myocardial perfusion scans are in late-stage clinical trials and provide images of amazing quality and clarity.

Industry is now challenged to change regulatory processes and reimbursement policies that currently delay the clinical utilization of novel PET probes.

—Johannes Czernin, MD, Professor, Molecular & Medical Pharmacology, Director, Nuclear Medicine Clinic, Positron Emission Tomography/Computed Tomography, David Geffen School of Medicine at UCLA, Los Angeles, Calif.