History of the Cyprus Society of Nuclear Medicine

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The origins of nuclear medicine in Cyprus

Nuclear medicine was introduced in Cyprus in 1972 by Dr. Aristides Costeas, who returned

to Cyprus in 1968 with a PhD in Biophysics from the Sloan Kettering Institute,

Cornell University.

At that time, the Sloan Kettering Institute had a close association with the Memorial

Hospital in many fields. Both institutions collaborated closely in teaching and training

medical doctors and graduate students. In the field of nuclear medicine, the cooperation

was even closer. Clinical nuclear medicine was just being established, and research and

clinical applications were developing in parallel. At the Memorial Hospital there was

a close relationship between medical doctors and medical physicists, and a variety of

procedures were being tried and the results evaluated and discussed. Dr. Costeas participated

in these groups; his own research project was to study the comparative kinetics

of calcium and fluorine in bone using 18F and 47Ca, and his results proved very useful in

the development of the clinical procedures.

National milestones in nuclear medicine

1964 he Radiation therapy Department opened at Nicosia General Hospital.

1968 Dr. A. Costeas returned to Cyprus with a PhD in Biophysics from the Sloan Kettering

Institute, Cornell University.

1970 Cyprus Ministry of Health approval given for a radioisotope laboratory.

1971 Two IAEA fellowships granted to assist with the training of George and Pandelitsa

Maifoshi as technicians.

1972 The radioisotope laboratory was established at Nicosia General Hospital, the irst

equipment being a collimated gamma detector for 131I thyroid uptake and a well

gamma counter.

A three-head gamma counter was purchased for renography.

A dual-head linear scanner with a six-colour printer was purchased.

1980 Dr. Krinos Trokoudes, a nuclear medicine and endocrinology specialist, returned

to Cyprus from Canada and established a private practice with a gamma camera

(Figs. 1 and 2 are drawn from his archive). He performed therapies with 131I.

1987 A gamma camera was purchased for the radioisotope laboratory at Nicosia General

Hospital.

1991 Dr. Charalampos Koursaros became the first nuclear medicine specialist to return

to Cyprus after finishing training in Greece. He started working at the radioisotope

laboratory in Nicosia General Hospital.

1992 the Cyprus Ministry of Health and the Society of Cancer Patients and Friends

provided a fellowship for Dr. Ourania Demetriadou, a radiologist, to be trained

in nuclear medicine in England.

1993 Dr. Ourania Demetriadou returned to Cyprus and commenced practice in

nuclear medicine.

1996 Dr. Savvas Frangos, nuclear medicine specialist, and Dr. Kypros Kouris, medical

physicist, established a private practice in Limassol.

Dr. Sofoclis Sofocleous, nuclear medicine specialist, established a private practice

in Nicosia, with the first dual-head camera in Cyprus.

1999–today he American Heart Institute in Nicosia purchased a gamma camera and

provides nuclear cardiology services.

The Nuclear Medicine Department and the Thyroid Cancer Unit started working at

the Bank of Cyprus Oncology Centre under the leadership of Dr. Savvas Frangos.

A new dual-head gamma camera was purchased for the radioisotope laboratory

in Nicosia General Hospital.

The new Nuclear Medicine Department started working at Limassol General

Hospital, equipped with a dual-head camera.

Dr. Charalampos Koursaros established a new private practice in Nicosia with a

dual-head camera.

Establishment of the Cyprus Society of Nuclear Medicine

he Cyprus Society of Nuclear Medicine was formed in 1999 in Nicosia. Founding

members were nuclear medicine specialists, medical physicists, nuclear medicine technicians

and other doctors (cardiologists, oncologists) with a special interest in nuclear

medicine. The first president was Dr. Savvas Frangos. The society became a member of

the European Association of Nuclear Medicine and the World Federation of Nuclear

Medicine and Biology. The current president is Dr. Ourania Demetriadou.

Development of nuclear medicine in Cyprus

Whilst working in the Radiotherapy Department at Nicosia General Hospital following

his PhD and return to Cyprus, Dr Costeas’s first responsibility was to organise medical

physics for the Ministry of Health. However, his interest in nuclear medicine was such

that he considered returning to the USA. He informed the Ministry of Health of his

plans and explained the importance and the future of nuclear medicine. The Minister

was impressed, and gave his immediate approval for the creation of a Nuclear Medicine

Department in Nicosia General Hospital. Thereafter, Dr Costeas’s proposals were rapidly

implemented.

The IAEA assisted with fellowships for training of the required personnel. In particular,

Dr. Costeas worked at the Royal Marsden Hospital with Dr. Trod (Director of Medical

Physics) and Dr. McCready (Director of Nuclear Medicine). Two IAEA fellowships were

granted for the training of two technicians, namely George and Pandelitsa Maifoshi.

These three comprised the team that initiated nuclear medicine in Cyprus. he equipment

was selected and arrived in 1972: a collimated gamma detector for 131I thyroid

uptake and a well gamma counter. Subsequently, a three-head gamma counter was purchased

for renography. Gamma cameras were filtering onto the market at this time, but

the price was beyond the limits of the budget, and so a dual-head linear scanner with a

six-colour printer was purchased.

he greatest challenge was to ensure that medical doctors were well informed about the

applications and about the usefulness of nuclear medicine in general. his was achieved

through lectures and seminars in hospitals, sending information leaflets to doctors, and

visiting their clinics to discuss the clinical significance of different procedures. he response

was very encouraging. New doctors coming from their training in England and

Greece began to arrive with information about nuclear medicine, and they were the arts

to use the tests. Each case was discussed with the referring physician, and especially the

abnormal cases were carefully considered. his approach proved very effective because

close cooperation was established between all departments.

he process was much easier with the in vitro tests. At the time there was no endocrinologist

in Cyprus and the diagnosis of thyroid disorders was based on the clinical

experience of the physician. thyroid function was followed by T3 uptake, T4, TSH and

eventually all radio-immunoassays. All tests were done manually and counted in a single

well counter. The World Health Organisation provided reference standards; the international

system of units was adopted, and a quality control system was set up. The curve

feeding programs used were a logit-Log curve plot program developed by the IAEA for

a tabletop computer from Olivetti. When tabletop computers from Apple became available,

in-house computer programs were developed for four-parameter curve fitting and

estimation of experimental errors.

The dual-head linear scanner was used for thyroid, brain, bone and liver scans. In

Cyprus at the time, echinococcosis was a quite common disease, with many patients

having hydatic cysts in the liver. The department was one of the first centres to use a

dual-isotope procedure to differentiate between vascular and non-vascular lesions in the

liver using labelled red blood cells (RBCs) and technetium colloid.

In 1980 a young doctor, Krinos Trokoudes, returned to Cyprus from Canada. Since his

particular specialisation in Canada had been nuclear medicine and endocrinology, he

obtained a gamma camera and started practicing in Cyprus.

Despite strong recommendations for the acquisition of a gamma camera, the approval

for this purchase repeatedly failed to be granted. The priorities of the governments

after the Turkish invasion in 1974 were to solve the problems of the refugees and to

build houses and new hospitals in areas where refugees settled. Funds were therefore

not allocated for nuclear medicine, and the linear scanner remained in use at Nicosia

General Hospital until 1986. However, the pressure for new and better tests continued

to increase, and in 1987 a gamma camera was finally procured.

Thallium-201 myocardial imaging and radionuclide ventriculography were implemented,

and quantitative SPECT for cardiac imaging followed. The calculated tomographic

images of the let ventricle were divided into 40 sectors and plotted as a bull’s eye plot.

The results were compared with averages taken from normal images and the difference

was plotted in the same way.

In cooperation with the cardiologists, comparative studies were performed with cardiac

angiographic evaluations. The results showed very good correlation. This helped

to convince the medical community of the importance of referring patients for nuclear

medicine studies before referring them for more invasive procedures.

Ventriculography was done using modified in vivo labelled RBCs using stannous

pyrophosphate and 99mTc-pertechnatate and multiple gated equilibrium blood pool imaging.

The end-systolic and end-diastolic multiple images total counts were used to

calculate the let ventricular ejection fraction. The results were considered useful for the

evaluation of patients with CVA.

Nuclear medicine in Cyprus today

thanks to the tremendous involvement of all those working in the field, nuclear medicine

is now a well-established specialty in Cyprus. All nuclear medicine examinations

and therapies, with the exception for the time being of PET applications, can be done

in Cyprus. Greater interest in nuclear medicine has now begun to develop amongst

young physicians. At present there are seven nuclear medicine centres and six nuclear

medicine doctors.

The future for nuclear medicine in Cyprus

The main future goal for nuclear medicine in Cyprus is the establishment of a PET-CT

centre. The problem of delivering FDG to Cyprus should be solved by establishing a

cyclotron on the island.*

Aristides Kosteas

Senior Medical Physicist, Member of the CySNM

*The text was published in the book “Nuclear medicine: fusing the ideas of Democritus and Hippocrates. Anniversary book of 25 years of the EANM”  Editors :E. Bombardieri and S. Frangos in 2012

2017  Dr. Alexis Vrachimis became the Director of Nuclear Medicine  at German Oncology Center Cyprus in Limassol with a PET/CT department and onsite Cyclotron