FINAL REPORT OF VIET NAM NATIONAL PROJECT COORDINATOR Prof., MD., PhD. Mai Trong Khoa. 1 Kathmandu - Nepal , November, 2013

VIET NAM 2

Bach Mai Hospital, Hanoi, Vietnam 3

Bach Mai Hospital (PET/CT: 1) Cho Ray Hospital in Ho Chi Minh City (PET/CT: 1) 115 People Hospital, HCM City (PET/CT: 1) Hospital of The Medical University in HCM City Military Central Hospital No 108 (Hanoi) (PET/CT: 1) Viet Duc Hospital (Hanoi) (PET/CT: 1) 103 Military Medical University Army Institute of Radiation Medicine Viet Tiep Hospital, Hai Phong City Central Hospital in Thai Nguyen City Da Nang provincial Hosp. (PET/CT: 1) French- Vietnamese Hospital in Ho Chi Minh City Others provincial Hospitals (14) Major Nuclear Medicine Depts. in VN (The Yellows have PET/CT) 4 Cyclotron: (2013) Hanoi: 3 HCM City: 1 PET/CT: 4 Cyclotron (2014): 1: Hanoi 1: Danang PET/CT: 2

CURRENT STATUS OF NUCLEAR MEDICINE IN VIET NAM Nuclear medicine (NM) has been playing an important role in diagnosis and treatment of diseases: Endocrine, cardiovascular, gastrointestinal, muscle skeletal diseases and cancer: in vivo tests and scintigraphy. Radioimmunoassay and immunoradio-metric assay are used to determinate the serum hormones level, tumor markers, and some specific biosubtances for diagnosis and research. Treatment of thyroid carcinoma and metastases, primary hepatocellular carcinomas (initial use of microspheres). Using PET/CT not only for diagnosis, staging, follow up, evaluation of treatment responses but also PET/CT simulation for radiotherapy planning in cancer patients Despite certain achievements, nuclear medicine in Vietnam still has to face with the difficulties: Lack of equipments especially for NM imaging. A great part of radiopharmaceuticals is demanded to import. Inadequate of our qualified medical physicists and engineers. Poorly provided quality control and maintenance for radiation equipments and radiopharmaceutical production. Lack of formal standard training program for NM staffs. 5

RCA/UNDP Project ImplementationProject Results: National Activities D D Workshop/ Training Courses: -Technology/Knowledge Transfer - Education Workshop/ Training Courses: -Technology/Knowledge Transfer - Education Participants: -NPC/NPT -Trainers -Trainee Participants: -NPC/NPT -Trainers -Trainee -Transfer gained Technology/Knowledg e Skills/Information -Human Resource Development -Laws, Guidelines, Protocols Participants Training, Workshops, Education, etc -Doctors -Specialists (nuclear/non- nuclear) - Fellows, Residents, Students -Regional Communities Patients Application of gained new technologies, skills and knowledge in diagnosing and treating patients Dissemination of gained new technologies, skills, knowledge Capacity Development 6

National Activities 2011 Activity NameWhen, WhereResults: purpose, topics, organization/processing, output National Project Team Meeting Training and seminars on Management and radiation therapy using PET/CT IPET 2011 conference of IAEA ICRT 2011 of WARMT H Improving Education and training Nuclear Medicine 21 May, 2011, Bach Mai Hospital 03 June, 2011 at Bach Mai Hospital 10 June, 2011 at Bach Mai Hospital 17 June, 2011 at Bach Mai Hospital 09 Sept, 2011 at Bach Mai Hospital 16 Sept, 2011 at Bach Mai Hospital 23 Sept, 2011 at Bach Mai Hospital October, 2011, Hanoi 8-11 November, 2011 at Vienna, Austria 28 Nov-2 Dec, 2011 at Hochiminh city, Vietnam From 2010, Hanoi Constructed National Work Plan and National Project Team - Training “Basic principle of PET/CT” - Training “Radiopharmaceuticals using in PET/CT” - Training “Overview of PET/CT applicatons in radiation therapy plan ning and management of lung cancer” - Training “Procedures of PET/CT in diagnostic of lung cancer” - Training “Equipment of PET/CT” - Training “Technique of PET/CT imaging in lung cancer” - Training “Radiation safety in PET/CT in lung cancer” -Workshop “Application of PET/CT in diagnostic and radition therapy of lung cancer” Aprovals from the MoH to conduct study about Values of PET/CT in radiation planning of the Nasopharyngeal cancer Poster presentation: “Application of PET/CT simulation for radiation therapy planning at the Nuclear Medicine and Oncology Center” Poster Presentation: “Efficacy of I-131 in the treatment of Differentiat ed Thyroid Carcinoma (DTC): Results of 655 patients at the nuclear medicine and oncology centre of Bach Mai Hospital.” After 2015, we would have 5 more PhD and 1 Master specilized in Nuclear Medicine Two PET/CT book is being pubished 7

Activity Name (Training Course, Workshop, Seminar, Education,Mentoring, etc.) Objectives When Where Context : Topics, outcomes, accomplishments Training and seminars June to Dece- mber Bach Mai hosp. Management and radiation therapy using PET/CT for Lung Cancer. Management and radiation therapy using PET/CT for Nasopharyngeal Cancer. Radiological protection aspects Published PET/CT book To increase public awareness To increase awarenes s about NM among non-NM physicians followed by augmented referral of patients to the NM procedures March to May Bach Mai hospital “Atlas of PET/CT images in Vietname se cancer patients” Education Start to train NM post graduate residency Nove- mber Bach Mai hospital One Master specialized in NM has been approved Two PhD participants are reported preliminary study in hospital National Activities

Activity Name (Training Cours e, Worksho p, Seminar, Ed ucation, Mentori ng, etc.) Objectives When Where Context : Topics, outcomes, accomplishments Training cour se To expand the ap plication of PET/ CT in radiotherapy planning Febru ary Bach Mai Hosp. Topic: Application of PET/CT in radiotherapy planning Outcomes: 20 NM technicians and medical physicists have comleted the course Accomplishments: Certificate Workshop To update of SPECT, PET/CT applications 04/ 2013 Bach Mai Hosp. Topic: Update of SPECT, PET/CT applications Outcomes: 30 NM physicians, technician and have comleted the course Accomplishments Certificate National Activities

Project Results: No. of patients diagnosed and treated by participants in the project training (NPC/NPT: doctors/specialists) using gained knowledge, skills and technologies from the project training courses SPECT imaging – about 800 patients per month Radioiodine therapy – about 200 patients per month RIA test – about 20 patients per month Impacts (quality improvement, cost, and results treated patient - differences between before and after) - Imaging report is improved - Radiation planning as well as management for lung cancer is improved Patient numbers to be diagnosed and treated in future for a) and b) annually a) Approximately b) N/A 10

Projects Results: NPC has been participated in the Kick-off meeting Six nuclear medicine specialists have taken part in the regional training courses and given the positive feedback to the national activities and their nuclear medicine center. A total of approximately 2500 patients have been treated by the participants 2 PET/CT books in Vietnamese and 2 NM text books have been published Establish cooperation with WARMTH and regional NM society such as Japan and Korea The Nuclear Medicine & Oncology Center of Bach Mai Hospital is responsible for transferring the benefits of the project to the beneficiaries, the Nuclear Medicine physician trainees in diagnosing and treating patients with radionuclide’s. Work plan of national project team (NPT) is to streamline the teaching of Nuclear Medicine with the teaching material generated by this project. The training material generated by the inaugural training course conducted in August 2011, June 2012 and June 2013 in Seoul, South Korea is being incorporated into the local Nuclear Medicine physician training program Knowledge of NM and non-NM professionals increased: about participants from more than 10 hospital and institute had joined the NM seminars, including the Ministry of Health, Ministry of Science. Standardize the protocol of PET/CT for diagnostic and simulation in cancer (lung cancer, NPC) have been approved by the MoH and used in other units. 11

12

PET/CT Unit The Nuclear Medicine and Oncology Center Bach Mai Hospital 13

Unknown primary cancer Trinh Th. T. L., female, 66 ys, tinnitus, mass in the neck. FDG high uptake in the left nasopharynx and lymph node→ Biopsy: Squamous cell carcinoma 14

Lung cancer Tran Th. D., female, 48 ys., Tumor in the lung PET/CT: heterogeneous high uptake FDG in the tumor and atelectasis Biopsy in the high uptake region: Squamous cell carcinoma 15

Recurrence Breast Cancer Pham Th. L., 49ys, breast cancer have underwent surgery, radiation and chemotherapy 5 years ago; appearance mass on the chest PET/CT: local recurrence and metastasis in the chest wall 16

Appendix Cancer Pham V. D., male, 29 ys., underwent appendectomy Histopathology: adenoma carcinoma PET/CT indication: staging → 2 high FDG uptake foci in the abdomen Surgery to remove lymph nodes. Histopathology confirmed PET/CT 17

Tuberculosis Tran Th. Th. H., 44ys. Mass in the lung on CT PET/CT: cave-shaped lesion in the right lower lobe, peripheral hyperactivity, no uptake in the central → Biopsy: Tuberculosis 18

Applcation of PET/CT stimulation Case1: Lung cancer Tumor and atelectasis CT: difficult to distinguish tumor from atelectasis PET/CT: easy to determine tumor and atelectasis ? 19

Tran D.Ch. Male, age: 65, Lung cancer T2N0M0 MSCT: Unable to define tumor clearly PET image: high uptake FDG lesion max SUV= 8 PET/CT: BTV more accurate and visual ? BTV 20

Nguyen Q. B., male, 65ys Lung cancer CT: negative PET: positive PET/CT: Mediastinal lymph node involvement ? 21

With CT sim, define radiation targets: GTV – Gross tumor volume on CT or MRI CTV – Clinical target volume PTV – Planning treatment volume. With PET/CT sim: BTV: biologic target volume – biological tumor volume): image at metabolical level  appear more early and exactly Radiation Planning PET/CT image CT image GTVBTV 22

Hoang Ng. L., Male, Age: 489 Esophageal cancer T2NoMo, refused surgery On CT: can not see lesions but PET/CT help determining BTV to make radiation planning ? 23

After treatment Before treatment Application of PET/CT stimulation in radiation planning for esophageal cancer 24

PET/CT simulation for IMRT in treatment of lung cancer Before treatment SUV=6,89 After chemoradiation: Complete response After 3 chemotherapy cycles: SUV=3,24 25

CONCLUSIONS Lesson learned Significant needs to improve recent NM knowledge among both NM and non-NM doctors: we could use the mass media and the internet Nuclear Medicine techniques on Oncology in Vietnam are still limited and not adequate to the needs Needs to convince the government that it is time a) to upgrade NM facilities; b) to start planning establishment of NM and Oncology network Remains There is no budget to replace or upgrade the existing NM equipments in small hospital. Formal educational and training materials, standardize the NM procedures are still missing. Small amount of patients would have benefit with high techniques such as PET/CT due to high cost, health insurance policy (only partial support for cancer patients), and awareness of NM and PET/CT in the community (even in clinical physician) is still limited. NM development and research are still weak due to high cost and no research budget. Insufficient knowledge of non-NM physicians about Nuclear Medicine 26

RECOMMENDATIONS Personal training: fellowships, professional visits or postgraduate educations, scholarships for: –Medical physicists –Engineers –Technologists (new techniques and new equipment) –Physicians of Radiology, Radiotherapy, N.M and Oncology Expert exchange with specific missions (new equipment, new techniques) 27

RECOMMENDATIONS Supporting scholarships for NM education and training. Organizing workshops, training seminars on PET/CT in clinical application and cyclotron practice for NM. physicians, physicists, radiochemists and radiopharmaceutists.... Exchange of experts on functioning, QC / QA practice of cyclotron, PET/CT for NM. medical physicists and technicians Organizing multi-center studies on radioisotopes production especially some new products and clinical applications 28

29

Thank you for your attention 30 Hanoi, Vietnam