PakistanDr. Shabana Saeed

Prof, Head, Dept of Medical Sciences

Pakistan Institute of Eng & Applied Sciences (PIEAS)

Pakistan Atomic Energy Commission

Current Status of Nuclear

Medicine and Radiation Therapy

in Pakistan and Future Actions

Pakistan

Pakistan

Total Population 220 million

Estimated New Cancer cases/yr >148K

People dying from cancer /yr: >101K

Data from IARC GlobalCan (2012)

The Beginning

• First Nuclear Medical & Oncology

centre established at Karachi (Sindh)

in 1960 in JPMC, Karachi in two

room barracks

• Second at Lahore (Punjab) in 1963 in

basement of Mayo Hospital OPD.

Medical Isotope Institute (now called

CENUM)

• Third centre at Jamshoro (Sindh) in

1965. First PAEC centre to have

diagnostic as well as therapy

facilities

Nuclear Medicine & Radiation Therapy in Pakistan

NUCLEAR MEDICINE

Current Situation46

NM

Institutes/Dept

18

*PAEC

25

Non-

PAEC/private

03

Armed

Forces

03 PAEC NM Centres in pipeline

Nuclear Medicine Institutes / Departments

in Pakistan

Multan

Lahore (2)Faisalabad

Peshawar

Nawabshah

Larkana

Quetta

Bahawalpur

Islamabad

Karachi (2)

Abbottabad

Swat

Bannu

D I Khan Gujranwala

Gilgit

Jamshoro

*Pakistan Atomic Energy Commission

Nuclear Medicine--Human Resources

*Fellow of College of Physicians & Surgeons, Pakistan

Nuclear Physicians(Currently working in Pakistan)

134

Medical Physicists >30

NM Technicians >130

123—MSc (PIEAS)

05 ----MSc (UK)

21-- *FCPS NM

(16 with MSc NM)

7- PhD NM

(All with MSc NM)

01-American Diplomat

13- Radiotherapy

06- Radiology

Gamma camera >90

SPECT-CT 05

PET-CT Scanner 06

Cyclotron 05

NM Main Medical Equipment

In Pipe Line:

SPECT-CT 05

PET-CT Scanner 02

Cyclotron 01

PET-CT Facilities in Pakistan

Centre/Institution PET-CT Camera Cyclotron

Shaukat Khanum Memorial Trust Hospital,

Lahore

Philips ToF Gemini (LSO)

with 16 slice CT

18 MeV IBA

Institute of Nuclear Medicine & Oncology Lahore Discovery STE (BGO), 16 slice CT 16.5 MeV

GE

Neuro Medical Institute, Karachi Siemens (LSO), 64 slice CT 11 MeV CTI

Sindh Institute of Urology, Karachi Philips Gemini TF Astonish (LySO), 64

slice CT

18 MeV

Agha Khan Hospital, Karachi Toshiba Celesteion ToF, High

performance 3D, Lu-based scintillator

32 slice CT

In Pipe Line1. Karachi Institute of Radiotherapy and Nuclear Medicine (KIRAN), Khi

2. Nuclear Medicine Oncology Radiotherapy Institute (NORI), Isl

Radioisotopes & Radiopharmaceuticals in Pakistan

Isotope Production Division (IPD)

Pakistan Institute of Nuclear Science &

Technology(PINSTECH), Islamabad December 21, 1965

Production of Radioisotopes

Pakistan Institute of Nuclear

Science and Technology

(PINSTECH) ---two research

reactors (PARR-1 and 2)

Production of radioisotopes in

Pakistan Research Reactor-1

(since1965)

Radioisotope Processing Facilities

Iodine-131 Production Cell (Technique).(Wet Distillation )

Iodine-131 Production Cell (Dry Distillation Technique).

Phosphorus-32 Production Cell (Dry Distillation Technique).

Sulpher-35 Production Glove Box

Molybdenum-99 Loading Facility for preparation of 99mTc

generators.(100Ci/batch)

Mo-99 Production facility. Hot Cell with Master Slave Manipulators.

Fume Hoods and Glove Boxes (for small scale production of different

radionuclides and R&D work)

Workshop for target preparation and sealed source fabrication

Laboratories for determination of radionuclidic, radiochemical and

biological purity

131I Processing Plant (Wet Distillation)

Maximum capacity per batch 10 Ci/370

GBq.

131I Processing Plant (Dry Distillation)

Maximum capacity per batch 10 Ci/370

GBq.

99mTc/99Mo Generators Production in

Pakistan

Regular production of 99mTc/99Mo Generators since 2003

Production of 99mTc/99Mo Generators from locally

produced fission Moly since 2010

Weekly production of 32/34 generators---300-600mCi

PAKGEN

Mo-99 extraction process atPINSTECH

Developed at PINSTECH with the help of Germanexpert for separation of Mo-99 from fission products

Optimization of parameters was achieved in IPDlaboratory

Fission Iodine-131 and Xenon-133 as by-product

Spent HEU in small SS container for easy disposal

Step1: Target Irradiation

Target platesTarget Holder for

PARR-1PARR-1 Core

Target basket for

transportationTarget Container

Step2: Target transportation from PARR-1 to Mo-99 Facility & container docking

Fork lifter for transportation

of target containerMo-99 Hot-

cell (1-3)Target basket

for dissolverDocking of container

below hot cell-1 of

Mo-99 Facility

99Mo Production Facility

Step3: Hot Cell 1 Processes (Dissolution, Filtration, Iodine removal & acidification)

In-cell equipment of Hot cell 1

Filter tower for retaining

radio-iodine

Xenon delay and

decay cascade

Filter cake Solid waste container

In-cell equipment of Hot cell-1

99Mo Production Facility (Continued)

Step 4: Hot Cell 2 Processes (Mo-99 Separation and Purification)

In-cell equipment of Hot cell-2

Medium level

waste container

Intermediate decay and storage

system for liquid radioactive

waste

99Mo Production Facility (Continued)

Step 5: Hot Cell 3 Processes (Mo-99 Dispensing and transportation to

generator production facility )

In-cell equipment of Hot cell-3

Product container Transport of

Product container

99Mo Production Facility (Continued)

Step 6: Mo-99/Tc-99m Generator production facility and its use in medical

center for scanning

Mo-99/Tc-99m

generator

Mo-99/Tc-99m Generator

production facility

Nuclear

Medical Center

Gamma camera

Imaging

Scan

99Mo Production Facility (Continued)

Radioisotopes produced in PARR-1Radio

nuclide

Chemical form Maximum

Activity / Batch

Year

Zn-65 Zinc chloride mCi 1989

Se-75 L-Selenomethionine 10 mCi 1982

As-77 Arsenic chloride mCi 2007

Br-82 Potassium bromide

Ammonium bromide

Dibromobenzene

~ 1 Ci

~ 1 Ci

~ 1 Ci

1972

Mo-99 99mTc-Generator (n,γ) 150 mCi 1973

Mo-99 99mTc-Generator fission

Local production

1Ci 500 mCi 2002

2010

Ag-111 Silver chloride 5 mCi 1995

Sn-113 Tin chloride mCi 1996

Cd-115 Cadmium chloride 15 mCi 1996

Radioisotopes produced in PARR-1

Radio nuclide Chemical form Max Activity

Batch

Year

Sb-125 Antimony chloride mCi 1989

I-131 Sodium Iodide, oral sol

Sodium ortho-

idohippurate

MIBG

7 Ci

20 mCi

30 mCi

1979

1980

2000

Ba-133 Barium chloride micro Ci 1996

Cs-134 Cesium chloride 100 mCi 1993

La-140 Lanthanum chloride 1Ci 2003

Sm-153 EDTMP 1Ci 1999

Eu-152/154 Metal 10 mCi 1995

Ho-166m Holmium oxide Micro Ci 1995

Ho-166 particles >100 mCi 1995

Radioisotopes produced in PARR-1

Radio

nuclide

Chemical form Max Activity

Batch

Year

Lu-177 EDTMP 500 mCi 2008

Re-

186/188

EHDP 100 mCi 1995

W-188 Re-188 generator 5 mCi 1995

Au-198 Colloidal, gold chloride,

Potassium auro cyanide

1Ci 1974

Au-199 Gold chloride 1Ci 2003

Hg-197 Neohydrin 100 mCi 1977

Hg-203 Neohydrin 10 mCi 1977

Po-210 metal Ci 1982

KITS Production at PINSTECH

Radiation Therapy

Linear Accelerators 27

Cobolt-60 units 31

Brachytherapy Units 11

Heavy ion units 0

Radiation Therapy

Main Medical Equipment

In Pipe Line:

LINACS 05

Brachytherapy Units 02

Radiation Therapy Centers--------26

Pakistan & Status of Radiotherapy

Facilities in the Region

Country RT

Cent

res

LINA

C

Co-

60

CT

simul.

Simul. TPS LDR

Manual

LDR

Remot

e

HDR

Ir-192

HD

R

Co-

60

Bangladesh 15 15 12 7 6 14 0 0 4 2

India 333 242 345 68 80 299 80 41 118 3

Nepal 5 6 2 3 3 6 0 0 2 0

Pakistan 26 27 31 5 10 12 3 1 4 3

Srilanka 7 2 11 2 2 7 0 1 2 0

Accelerators in Pakistan

28

Electron Accelerators

Medical Centers of PAEC

Private sector medical centre having LINACS

Cyclotron for isotope production : 5

Not a single electron accelerator for academic/research

Ion Accelerators

NCP, Islamabad (5 MeV Pelletron tandem, NEC, USA)

GCU, Lahore (2 MeV Pelletron tandem, NEC, USA)

GCU, Lahore (1.2 MeV Cockroft-Walton)

PINSTECH (250 keV locally developed)

Near Future Demands 3 times the present number

27

Radiation Oncology-Human Resources

Radiation Oncologists 80 (>55 are MSc

RMO from PIEAS)

Medical Physicists >70 (>65 are MSc

MP from PIEAS)

RT Technicians >145

Future Actions

Completion of Indigenous Medical Linear

Accelerator

At PINSTECH, Islamabad

Few Milestone Achieved

RF Accelerator Design 6 MeV

Indegenous Pulse Modulator 48 kV

Electron Gun 30 keV, 50 keV

Magnetron operation upto 2.5 MW

Pulse Measurements (HV, Microwave)

Electron beam dynamics/diagnostics

Magnetron Assembly

Electron gun & RF Cavities

Vacuum System

RF Pulse Measurement

System

RF Power Control system

4 Port Circulator

• Demonstration of a completely functional proof-of-principle 6 MeV LINAC system

• Cavity conditioning, Frequency tuning and high power transmission up to 2 MW

• Completely indigenous control system for 6 MeV LINAC

6 MeV LINAC Integration & Operation

Collaboration with CERN

CERN is a major Collaborator.

CERN provided trainings in areas:

Accelerator Physics and Accelerator Operations,

Magnets, Simulation,

RF Systems and Controls.

Mechanical

Lectures delivered by CERN officials at Int.

Nathiagali Summer College, Pakistan.

Visits and technical feed back.

Future Actions……

Utilizaion of international support (CERN) to improve nuclear

medicine and radiotherapy services as well as to encourage

research in radiopharmaceuticals and modern radiation

treatments such as Particle Therapy in a number of ways:

Training of personals on accelerator technology---Magnets,

Diagnostics, Rf technology, Electronics for LINAC and in future,

accelerators for advance particle therapy.

Clinical coordination of PAEC hospitals with established Particle

Therapy Centers in developed countries to enroll patients in

heavy ion therapy based clinical trials.

Future Actions……

Better utilization of cell culture labs in Pakistan. The lab along with

relevant expertise in molecular and tumor biology can be utilized

to collaborate internationally on research projects pertaining to

particle therapy, especially its radiobiological aspects.

Use of high speed teleconferencing facility for knowledge sharing.

Willing experts from across the world can be invited by PIEAS in

person or online, to deliver talks to a large audience comprising of

virtually linked PAEC and most private sector cancer hospitals in

the country as well as to universities that are engaged in relevant

radiation research and education.

Future Actions……

Setting up a local team to build a “compact proton

accelerator” with the aim of initiating proton therapy of

ocular tumors etc while minimizing set up cost.

Production of novel radioisotopes for diagnostics and

eventually theronostics

Accelerator-based alternatives to production of

99Mo/99mTc

Production of novel therapeutic radionuclides

Accelerator driven neutron activation------β-emitting

radioisotopes for brachytherapy

Few suggestions

Summary and Conclusion

Pakistan has developed good nuclear medicine and

radiotherapy programmes

It has a skilled and technology driven human resource

Adequate infrastructure for promotion of NM and Radiation

Oncology

A will to provide best and latest health care to the people

for improving the quality of life in Pakistan

CERN Support in our Future Actions/Strategy

THANK YOU