Nuclear medicine’S

Radioisotopes can be used to locate tumours and to deliver targeted therapeutic radiation
internally. Sounds ideal for cancer, yet nuclear medicine remains an underdeveloped field, held
back by irrational fears of all things nuclear, false perceptions of its potential, and bureaucratic and
cost barriers to accessing agents.


It is a given that a complex field such as cancer
spawns an increasing number of sub-specialities
– and that therewill inevitably be debates
aboutwhich aremost deserving of resources.
Thoseworking in fields that do not command
much support can nevertheless spend many years
quietly building a solid scientific and clinical reputationagainst
the odds to emerge eventuallywithvery
important work – which arguably now applies to
nuclearmedicine, and in particular its application in
therapeutic oncology.
GiovanniPaganelli, director of nuclearmedicine
at the European Institute of Oncology in Milan,
describeswhat the specialtymeans for cancer. “It is
theuse of radioisotopes tobothlocate cancer cells for
diagnosis and to deliver energy to the target cells to
destroy them. I liken my field to an aircraft – to
make it take off we need both diagnostic and therapeuticwings.”
Theproblemfornuclear oncology,he adds, is that
too many professionals – including oncologists –
seemainly the diagnostic side of the subject,where
practitioners often come from radiology, and not
from internalmedicine (as Paganelli himself does).
This perception is reinforced by the fact that nuclear

medicine departments are often located in the
darkest bowels of hospitals – where large and possibly
dangerous equipment often lurks – divorcing
specialists from the multidisciplinary discussions
taking place on the floors above.
Together with a public suspicion of anything
‘nuclear’insome countries, the technical andbureaucratic
difficulties of sourcing and preparing radioisotopes,
the cost of equipment and agents, and to date
fairly narrow progress in truly therapeutic applications,
nuclear oncology has faced tough challenges.
And asPaganellinotes, the specialists themselves are
partly to blame. “We tend to spendmost of our time
talking to other colleagues innuclearmedicine – and
not getting ourmessages across tomedical oncologists
and surgeons at the rightmeetings,” he says.
“If you had talked tome 10 years ago Iwould have
been quite depressed about our prospects. But in
the last fewyears therehasbeenmuchmoreprogress.”
The arrival ofPET(positronemissiontomography) and
SPECT(single photon emission computed tomography)
as widespread techniques has triggered new
awareness in the medical profession of the use of
radioisotopes, says Paganelli, although again this is
largely because of diagnostic potential. “What excites

me – and what I consider true nuclearmedicine – is
the growing use of targeted diagnosis and therapy, and
it is one of the fewareas inoncologywherewe are really
doing translationalmedicine frombench to bedside.”
It is aboldclaim, butPaganellihas a20-year track
record in researching the targeting potential of
radioisotopes in combinationwith other agents, and
while he concedes that clinical applications are currently
limited, no one who visits his department in
Milan could fail to be infected with his enthusiasm
–andhispersuasive arguments about the tremendous
potential for tackling some of the most difficult
oncology problems. Work on high-grade brain
tumours, lymphoma andneuroendocrine treatments

are intrain,while a sequence of clinical researchprojects
to aid breast-conserving surgery is a landmark at
the Institute.
Paganelli always intended to become a doctor –
“Itwasmy dreamas a boy to do research and understand
why people get ill” – although he was later to
discover that science does indeed follow Edison’s
famousmaxim: 1%inspiration, 99%perspiration.He
chose to pursue internalmedicinewhile at theUniversity
of Bologna, and further selected geriatrics as
a speciality – the growing ‘market’of an aging population
being a draw. He recognises a logical and
philosophical link betweenaging and cancer – “After
we have reproduced, maybe the DNA doesn’t care.