Nuclear Medicine 2020: What Will the Landscape Look Like?
What does the future hold for nuclear medicine? Molecular Imaging Insight asked two nuclear medicine experts—Markus Schwaiger, MD, chairman, Department of Nuclear Medicine and professor of nuclear medicine, at the Technical Universtiy of Munich in Germany and Liselotte Højgaard, MD, DMSc, professor in medicine and technology, University of Copenhagen, and director, department of clinical physiology, nuclear medicine and PET at Rigshospitalet in Copenhagen, Denmark—to share their “vision” of nuclear medicine in 2020. How do their visions compare to each other, and to yours? When Henri Becquerel discovered that uranium emitted “mysterious” rays, did he understand the resounding impact that discovery would have for years to come? Or consider for a moment, the researchers who produced high-speed light ions without the use of high voltages—did they know that it would prove to be a milestone in the production of usable quantities of radionuclides? From the emergence of the first hybrid scanner, to the first installation of the hybrid PET/MR system or the availability of PET/CT fusion images, the “marriage of imaging techniques” and continuing technological advances at once “present opportunities and concerns about future practice” (Q J Nucl Med Mol Imaging 2006;50:1-3).
By incorporating anatomic localization with physiologic information, Strauss cautioned that nuclear medicine had “opened Pandora’s Box.” However, the community has not seen innumerable plagues and sorrows beseech it—in fact, it can be said that developments in nuclear medicine over the last decade are fueling the need for more physicians, more training and more research—and enabling better outcomes for patients. But, how will these developments play out, 11 years down the road? Some say only time will tell, but for others, the vision of nuclear medicine’s future is not that difficult to conjure—and it is a lot closer to being a reality than one might think.
The nuclear medicine melting pot
While hybrid or multimodality imaging continues to evolve and increase in popularity, spurred by evidence-based medicine, in the nuclear medicine landscape of 2020, it won’t matter if it is PET/CT, SPECT/CT, or PET/MR or even SPECT/MR—the border between the imaging modalities “will have disappeared,” says Markus Schwaiger, MD, chairman, Department of Nuclear Medicine and professor of nuclear medicine, at the Technical University of Munich in Germany.
Instead of a modality-specific focus, nuclear medicine in the future will be integrated into organ-specific or disease-specific groups. “While there will be specialists for cardiovascular imaging, oncology as well as for neuroimaging—these experts will not be organized according to methods but instead, by imaging targets or diseases,” he says.
As a consequence, training programs will be adjusted to accommodate the integration, with programs for physicians, radiologists and nuclear medicine specialists that provide cross-training in all modalities, so “they can read across these methodological issues, and read a PET, MR or CT,” Schwaiger adds.
Patients will be reaping the rewards of the transition away from a modality-specific focus to more image fusion within nuclear medicine. “The future will be more and more image fusion so that physicians won’t think so much about it being PET, CT or MRI. Instead, for each individual patient, it will be a more tailored, more individualized protocol using functional imaging with anatomical imaging, regardless of which modality you choose,” says Liselotte Højgaard, MD, DMSc, professor in medicine and technology, University of Copenhagen, and director, department of clinical physiology, nuclear medicine and PET at Rigshospitalet in Copenhagen, Denmark. “It could be functional imaging with nuclear medicine or PET scanning, or functional use of flow CT or flow MRI. The point will be to do many different imaging modalities very quickly, in one patient, so we have the full picture.”
From a research perspective, Schwaiger envisions that the utilization of in vivo and in vitro markers will play a vital role in nuclear medicine in 2020. In vitro tests—which include the genetic analysis of blood samples—will be much more important to identify high-risk patient populations, such as individuals at risk for developing cardiovascular disease or cancer. In vitro tests will be used to predict a patient’s response to a certain type of therapy, followed up with molecular imaging—a research area that is currently supported under an International Atomic Energy Agency (IAEA) Nuclear Medicine Section project. Specifically, the agency is working on five specific project areas including nuclear medicine imaging in the management of incommunicable diseases, the application of PET in molecular imaging, in vitro nuclear medicine, molecular biology and genomic studies applied to communicable diseases, cancer and genetic disorders (J Nuc Med 2009; 50 (5):16N).
The three pillars of nuclear medicine
Looking forward towards 2020, one cannot help but reflect upon the past. PET/CT was invented in 2001 and Højgaard says the university had the “number two PET machine” in Copenhagen that same year. In those early days, the department performed about 200 clinical PET scans a year—and now the department has an annual PET volume of about 5,000 studies.
In those eight years, molecular imaging made significant strides—such as the transition to hybrid modalities—thus, one can only imagine what the next generation of nuclear medicine advances will bring. But, Højgaard speculates that it will involve more than just imaging modalities and radiopharmaceuticals.
“If you look at the evolution and leap forward to 11 years from now, I think we will be using all the knowledge in molecular biology, and cancer biology combined with imaging,” she says. “It will be images, combined with genes, tumor markers and patient data.”
The future also could bring a scanner that can do more than two modalities at the same time. For example, a patient comes in for a blood test; three
imaging tests are performed along with a non-invasive biopsy—all of which will provide “better tumor characteristics than we currently obtain now,” she adds.
By combining the individual genetic and chemical workup of each patient, with imaging and data, such as age, sex, weight, disease susceptibility and family history, “we will see a whole explosion of how patients are diagnosed in the future,” Højgaard notes.
Building IT infrastructure
However, seeing that future become reality is not without significant effort from the nuclear medicine research and vendor community. “We are, at the moment, so focused on developing the molecular imaging—with nuclear med, PET/CT, SPECT/CT, new tracers, diagnosing and staging, treatment evaluations, radiotherapy planning—that we have not really looked upon the next generation enough in relation to the IT infrastructure to support the huge amount of data and the combination of images and molecular biology,” Højgaard says, adding that the greatest challenge to this will be an IT infrastructure strong enough to support the communication, mathematical and computational modeling in an intelligent way.
The community is not quite there yet, she adds. “We have started combining imaging and molecular biology—it will be extremely interesting to see what comes of it.”