MI Gateway Volume 12, Issue 4 (December 2018)

Volume 12, Issue 4

MI Gateway is a quarterly member information service published under the direction of the Center for Molecular Imaging Innovation and Translation leadership and SNMMI.
Volume 12 • Issue 4 • 2018-4

 In This Issue

 MI Gateway

Editorial Board

Walter Akers, DVM, PhD
Cathy S. Cutler, PhD
Leslie Flynt, MD
Anthony Giamis, PhD
Catalin I. Grigore, MIS, NMAA, CNMT
Alexander L. Klibanov, PhD


©2018 by SNMMI


President's Message

Kimberly A. Kelly, PhD, CMIIT President

  Kimberly A. Kelly, PhD, CMIIT President

Welcome to the Center for Molecular Imaging, Innovation, and Translation (CMIIT).

The primary mission of our center is to promote the translation of molecular imaging and therapeutics from bench to bedside and to aid in the dissemination to the community. Our members form a diverse community from the fields of chemistry, biology, radiochemistry, engineering, physicians, and technologists. Together we strive to transform patient care and improve quality of life.

It’s an exciting time to be involved in CMIIT! The success of Lutathera opens the door for future innovations in imaging and therapy, so this issue’s lead article and Tech Corner are on this topic.


Overview of Clinical Workflow for Administration of 177Lu-DOTATATE at the Washington University School of Medicine in St. Louis

Sai Duriseti, MD, PhD; Jacqueline Zoberi, PhD; Nikolaos Trikalinos, MD; Hyun Kim, MD; Michael C. Roach, MD

The Department of Radiation Oncology at the Washington University School of Medicine in Saint Louis regularly treats patients with somatostatin receptor 2 (SSR2)–expressing neuroendocrine tumors (NETs) using 177Lu-DOTA0-Tyr3-octreotate (177Lu-DOTATATE, or Lutathera®). 177Lu-DOTATATE is a somatostatin analog peptide conjugated with the metal chelating moiety 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) that coordinates a 177Lu atom. 177Lu-DOTATATE has a high affinity for SSR2, thus treating SSR2-overexpressing malignant cells with a medium-energy β-emitting radionuclide with mean path length of 2.2 mm (mean penetration of 0.67 mm). These physiologic and physical properties allow for effective killing of tumor cells with a limited effect on neighboring normal cells.

Our clinical workflow starts with evaluation of the patient in our clinic. As per description of the population in the NETTER-1 trial, patients with well-differentiated midgut NETs who demonstrate radiographic progression of DOTATATE-avid (as ascertained from 68Ga-DOTATATE PET/CT), biopsy-proven disease while on SSR2 agonist are eligible for treatment. Patients must also demonstrate creatinine greater than 50 milliliters per minute, hemoglobin ≥ 8.0 grams per deciliter, leukocyte count greater than 2000 per cubic millimeters, platelets greater than 75,000 cubic millimeters, and total bilirubin less than three times our institutional upper limit of normal.

177Lu-DOTATATE is supplied as a sterile, ready-to-use radiopharmaceutical solution for infusion. The product is manufactured in Turin, Italy, by Advanced Accelerator Applications, Inc. We place orders 10 business days in advance of the scheduled treatment date, which is in the middle of the week to allow appropriate time for manufacturing and delivery.

We deliver treatment in the outpatient setting. Treatment is delivered via central access, gained the day prior to each planned infusion. Per NETTER-1 protocol, a treatment regimen consists of a total of four treatments of 177Lu-DOTATATE, each treatment to deliver approximately 200 mCi. Each infusion is administered with concurrent amino acid cocktail for renal protection and antiemetic to mitigate accompanying nausea. The interval between infusions is approximately eight weeks, with intervening usage of long-acting SSR2 agonist as needed.

Our day of treatment workflow is summarized briefly. After confirming pretreatment activity in our brachytherapy suite, the dose is transported to our treatment rooms, located in our main clinic. The patient’s central access is assessed for patency and flow; subsequently, we begin our amino acid cocktail infusion. Antiemetic is administered for nausea, a side effect of both amino acid formulation and sometimes the radiopharmaceutical, depending on the patient’s disease.

After an appropriate amount of amino acid cocktail has been delivered, we begin infusion of the 177Lu-DOTATATE. Vital signs and clinical symptoms, such as flushing, are monitored periodically to assess hemodynamic stability, particularly for patients who may have adverse reactions due to tumors that produce vasoactive or cardiotoxic effects. Patients often feel the need to urinate given, the intravenous volume input, and must do so in a specially designated bathroom given the renal excretion pattern of 177Lu-DOTATATE.

The entire procedure takes four to six hours. At the end of infusion of the radiopharmaceutical and amino acid cocktail, temporary central access is removed, and a survey of the patient, all personnel, and the treatment room is done. All disposable treatment materials are collected and assayed to determine activity administered to the patient. The patient, considered releasable since the exposure rate usually satisfies NRC regulations, is discharged when he or she feels well enough to travel. Upon discharge, the patient is given information about expected symptoms, with treatment recommendations, and provided with radiation safety precautions.

The patient, in discussion with their medical oncologist, may continue SSR2-directed therapy within 4-24 hours after completion of treatment. Additional SSR2-directed therapy will continue between 177Lu-DOTATATE administrations regardless of symptomatology. As 177Lu also emits medium- and low-energy gamma radiation, we take advantage of this property for in vivo dosimetry. After the first treatment, the patient proceeds for imaging with nuclear medicine to allow clinical assessment of radiopharmaceutical distribution.

We do not have an established protocol for monitoring disease progression or response during the treatment regimen. Typically, at the discretion of the medical oncologist, the patient may undergo CT, MR, or 68Ga-DOTATATE PET/CT imaging. The patient is seen for regular follow-up by both a medical oncologist and the treating radiation oncologist. In follow-up we monitor for effects to the liver, kidney, and hematopoietic stem cells. Given known transformative properties of ionizing radiation, especially on radiosensitive bone marrow, we are also cautious to consider development of myelodysplastic syndromes and leukemia.


Nuclear Medicine in Australia – What’s Being Done Down Under?

Elizabeth Bailey, PhD, MBA, BAppSc (MRS)

Internationally nuclear medicine has undergone rapid change and growth in the past 5 years with the introduction and development of new radiopharmaceuticals that have been incorporated into routine clinical practice. The greatest change has been seen in the area of theranostics and personalized medicine, aided by the improved availability of the gallium-68 (68Ga) and lutetium-177 (177Lu) theranostics pairs in recent years.


Nuclear medicine in Australia has followed a similar path, with active work on the development and validation of many new PET and therapeutic tracers both in the clinic and in the lab. Molecular imaging using PET is a growing area, and there has been a rapid expansion in the number of clinical PET services throughout Australia. Recently, the focus has been on increasing access for patients in rural and non-metropolitan areas that predominantly offer 18F-FDG PET, with very limited access to 68Ga-labeled tracers and other niche products such as 18F amyloid, 18F-FET, and 68Ga-DOTA SSR. In the major capital cities, patients have access to the full spectrum of nuclear medicine, PET, and therapeutic radiopharmaceuticals.

Australia is a country with a small population of approximately 25 million and a large land mass similar to that of the United States. The population is aging, increasing the burden on public health—including nuclear medicine—to access new diagnostics and treatments to maintain quality of life. Introducing new tracers and therapeutics can be a cost-prohibitive and lengthy process, including the approval for reimbursement. As a result, patients may need to incur out-of-pocket expense to access these new tracers and treatments. Many facilities initiate a broad range of clinical trials to increase access for patients.

We are very lucky to have access to a low-enriched uranium nuclear reactor based in Sydney that can supply molydenum-99 for generators, 177Lu and iodine-131 on a regular basis. There are also several commercial cyclotrons that supply predominantly 18F-FDG as well as limited quantities of other 18F-labeled tracers including 18F-PSR, 18F -FET, 18F -FLT; multiple 18F amyloid tracers (e.g., florbetaben, flutemetamol) for clinical use; and other niche investigational products such as tau tracers and DaTscan to be brought to market over the next 12 to 18 months. The majority of the non-FDG PET tracers have no reimbursement either from the government or from private health insurance and, therefore, can be accessed only by participating in a clinical trial, through funding from university teaching hospitals, or through personal financing by the patient.

The newest radionuclide to be produced locally in Australia is copper-64 (64Cu). Copper-64 is a positron emitter with a longer half-life (12 h) than 68Ga (68 min), which allows it to be transported across the country. Similar to 68Ga, 64Cu also has good radiolabeling properties, except that different bifunctional chelators (e.g., NOTA or sarcophagines) are preferred for 64Cu. There are several locally initiated clinical trials of new 64Cu-labeled PET tracers currently under way for imaging of neuroendocrine tumors and meningioma. There are very few facilities with on-site cyclotrons, and because of their very short half-life, PET tracers such as oxygen-15, nitrogen-13, and carbon-11 are rarely used.

General nuclear medicine is still widely used in Australia, especially with the ready availability of quantitative SPECT/CT gamma cameras and other software-based quantitative algorithms that have expanded the clinical applications for existing tests such as bone scans, lung scans, and more recently cardiac amyloidosis (ATTR) using readily available tracers such as 99mTc-PyP and 99mTc-HDP. Functional imaging is being included in the preassessment workup of patients prior to treatment with chemotherapy, TACE, radiotherapy, and Yttrium-90 (SIR-Spheres/TheraSpheres). An expanding area is the use of 99mTc-mebrofenin or 99mTc-disofenin to assess whole liver and future remnant liver volume and uptake rate as a marker of liver function prior to liver-directed therapy or portal vein embolization.

Peptide receptor radionuclide therapy (PRRT) using 177Lu-DOTA SSR has been used in Australia for the treatment of neuroendocrine tumors for more than 10 years at limited specialist centers across Australia, depending on funding resources. There is a strong trend toward utilizing a variety of molecular imaging tools on a single patient to better characterize disease and target personalized therapy. The combination of 18F-FDG, 68Ga-DOTA SSR and 18F-MISO with anatomical imaging, pathology/biopsy, and cellular proliferation indices such as Ki67 is part of the standard workup for PRRT. Australian-based multicenter trials comparing traditional chemotherapy with PRRT in the PNET and small-bowel NET groups have recently been completed, with the data being analyzed, and will be used to support future submissions for national reimbursement and equity of access.

The area of theranostics is expanding rapidly, predominantly with the advent of 177Lu-PSMA both in clinical trials and the clinical realm, with rapid growth especially in the private setting with patients self-funding treatment. The Australian and New Zealand Urogenital and Prostate Cancer Clinical Trials Group (ANZUP), in conjunction the Australasian Radiopharmaceutical Trials Network (ARTnet), has taken the lead in a large multicenter, phase 2 randomized trial of 177Lu PSMA-617 theranostics versus cabazitaxel for imaging progressive metastatic castration-resistant prostate cancer. The study will include 200 participants across 11 centers and is actively recruiting. This is ground-breaking research, and the results are eagerly awaited. The use of the alpha-emitting therapies in Australia is rare and limited to a few facilities that are participating in clinical trials. Xofigo (223Ra-dichloride) is very expensive and has limited reimbursement, so it is rarely used.

There are currently three PET/MR cameras in Australia, with one in a pediatric hospital, one in a large adult teaching hospital, and the last at a university research facility that also offers PET/CT and 3T MR imaging. The research PET/MR imaging facility focuses primarily on neurology, using new biomarkers to investigate “neuropathy, brain injury and abnormal brain development” and oncologic focus on brain, breast, head and neck, ovarian, and prostate cancer. The pediatric hospital was one of the first pediatric facilities in the world to install a clinical PET/MR imaging system. Focusing primarily on oncology and epilepsy, the hospital has performed more studies than many other equivalent pediatric facilities. This is a very exciting, but expensive, technology that will be slow to be incorporated into routine clinical practice. In the short term, PET/MR scanners are likely to be installed in large university-based research centers associated with academic institutions.

Molecular imaging and theranostics in Australia continue to expand, and the future challenges are very exciting.



CMIIT is now accepting nominations for the CMIIT Lab Professional Recognition Award for Contributions to Molecular Imaging. This unique award recognizes a laboratory professional in a staff-level position who has made a significant contribution to molecular imaging and therapy while working in the laboratory of a principal investigator and who may not have the opportunity to receive recognition in other arenas.

The award is granted for contributions in any molecular imaging category, including but not limited to biomarker development, CT, MRI, optical, PET, SPECT, and ultrasound imaging. Nominations should focus on the individual’s accomplishments achieved in the laboratory of the principal investigator and how those contributions have advanced an area of molecular imaging and therapy.

The awardee will be honored during the CMIIT Business Meeting at the SNMMI 2019 Annual Meeting (June 22-25, Anaheim, CA). The award includes free registration for the meeting and travel reimbursement of up to $1,000 to attend.

Read more about eligibility and the nomination process here: Lab Professional Recognition Award for Contributions to Molecular Imaging. Nominations are due by January 4, 2019.

Past recipients of this award include:

  • Shelley Acuff, CNMT, RT(R)(CT), University of Tennessee Medical Center, Clinical Research Leader, Molecular Imaging and Translational Research/Radiology: Ms. Acuff was recognized for her leadership in a number of critical research and clinical elements, including:
    • Designing and supervising investigator-initiated research projects, including IRB requirements
    • Facilitating MITRP clinical trials
    • Overseeing day-to-day PET/CT research operations
    • Coordinating patients, residents, students, and physicians involved in research studies
    • And conducting her own independent research studies with a key emphasis on healthcare education and improving patient care.
  • Erin Snay, BS, CNMT, Senior Research Technologist in the Small Animal Imaging Lab (SAIL) of Boston Children's Hospital: With 13 years of experience in the lab, Ms. Snay was recognized for her involvement in innovative projects to enhance SAIL’s imaging capabilities to meet the needs of investigators at the hospital.


MI in the Literature

Each month, the CMIIT Editorial Board selects some of the top molecular imaging research papers from all papers indexed by PubMed. Below are links to these papers (free full text available).

Visualisation of interstitial lung disease by molecular imaging of integrin αvβ3 and somatostatin receptor 2. Schniering J, Benešová M, Brunner M, Haller S, Cohrs S, Frauenfelder T, Vrugt B, Feghali-Bostwick CA, Schibli R, Distler O, Mueller C, Maurer B. Ann Rheum Dis. 2018 Nov 17. PMID: 30448769

Radiolabeled Molecular Imaging Probes for the In Vivo Evaluation of Cellulose Nanocrystals for Biomedical Applications. Imlimthan S, Otaru S, Keinänen O, Correia A, Lintinen K, Santos HA, Airaksinen AJ, Kostiainen MA, Sarparanta M. Biomacromolecules. 2018 Nov 9. PMID: 30380842

Evaluating Nonintegrating Lentiviruses as Safe Vectors for Noninvasive Reporter-Based Molecular Imaging of Multipotent Mesenchymal Stem Cells. Hamilton AM, Foster PJ, Ronald JA. Hum Gene Ther. 2018 Oct. PMID: 30101620

Surface-Enhanced Raman Scattering Nanoparticles for Multiplexed Imaging of Bladder Cancer Tissue Permeability and Molecular Phenotype. Davis RM, Kiss B, Trivedi DR, Metzner TJ, Liao JC, Gambhir SS. ACS Nano. 2018 Oct 23. PMID: 30203645

A Novel Engineered Small Protein for Positron Emission Tomography Imaging of Human Programmed Death Ligand-1 : Validation in Mouse Models and Human Cancer Tissues. Natarajan A, Patel CB, Ramakrishnan S, Panesar PS, Long SR, Gambhir SS. Clin Cancer Res. 2018 Oct 29. PMID: 30373750

Visualisation of interstitial lung disease by molecular imaging of integrin αvβ3 and somatostatin receptor 2. Schniering J, Benešová M, Brunner M, Haller S, Cohrs S, Frauenfelder T, Vrugt B, Feghali-Bostwick CA, Schibli R, Distler O, Mueller C, Maurer B. Ann Rheum Dis. 2018 Nov 17. PMID: 30448769

Ultrasound molecular imaging as a non-invasive companion diagnostic for netrin-1 interference therapy in breast cancer. Wischhusen J, Wilson KE, Delcros JG, Molina-Peña R, Gibert B, Jiang S, Ngo J, Goldschneider D, Mehlen P, Willmann JK, Padilla F. Theranostics. 2018 Oct 6. PMID: 30429890

Correlation between genomic index lesions and mpMRI and 68Ga-PSMA-PET/CT imaging features in primary prostate cancer. Kesch C, Radtke JP, Wintsche A, Wiesenfarth M, Luttje M, Gasch C, Dieffenbacher S, Pecqueux C, Teber D, Hatiboglu G, Nyarangi-Dix J, Simpfendörfer T, Schönberg G, Dimitrakopoulou-Strauss A, Freitag M, Duensing A, Grüllich C, Jäger D, Götz M, Grabe N, Schweiger MR, Pahernik S, Perner S, Herpel E, Roth W, Wieczorek K, Maier-Hein K, Debus J, Haberkorn U, Giesel F, Galle J, Hadaschik B, Schlemmer HP, Hohenfellner M, Bonekamp D, Sültmann H, Duensing S. Sci Rep. 2018 Nov 12. PMID: 30420756

18Fluorine sodium fluoride positron emission tomography, a potential biomarker of transthyretin cardiac amyloidosis. Morgenstern R, Yeh R, Castano A, Maurer MS, Bokhari S. J Nucl Cardiol. 2018 Oct. PMID: 28176254

Quantitative biomarkers for liver metastases: comparison of MRI diffusion-weighted imaging heterogeneity index and fluorine-18-fluoro-deoxyglucose standardised uptake value in hybrid PET/MR. Stein D, Goldberg N, Domachevsky L, Bernstine H, Nidam M, Abadi-Korek I, Guindy M, Sosna J, Groshar D. Clin Radiol. 2018 Sep. PMID: 29859634

Positron Emission Tomography 18F-Fluorodeoxyglucose Uptake Correlates with KRAS and EMT Gene Signatures in Operable Esophageal Adenocarcinoma. Heiden BT, Patel N, Nancarrow DJ, Hermann M, Brown RKJ, Orringer MB, Lin J, Chang AC, Carrott PW, Lynch WR, Zhao L, Beer DG, Reddy RM. J Surg Res. 2018 Dec. PMID: 30463782

Assessment of tumor redox status through (S)-4-(3-[18F]fluoropropyl)-L-glutamic acid positron emission tomography imaging of system xc- activity. McCormick PN, Greenwood HE, Glaser M, Maddocks ODK, Gendron T, Sander K, Gowrishankar G, Hoehne A, Zhang T, Shuhendler AJ, Lewis DY, Berndt M, Koglin N, Lythgoe MF, Gambhir SS, Årstad E, Witney TH. Cancer Res. 2018 Nov 6. PMID: 30401715


MI in the News

MI Gateway presents a sampling of research and news of interest to the community of molecular imaging scientists.

PET/MRI links neuroinflammation to fatigue in fibromyalgia
Health Imaging
US and Swedish researchers who used PET/MRI with a translocator protein-binding PET tracer found that individuals with fibromyalgia had increased glial activation in several brain regions, indicating widespread neuroinflammation, compared with healthy controls, and TSPO levels in the cingulate gyrus, which is a neuroinflammation target among individuals with chronic fatigue syndrome, were tied to patient-reported fatigue levels. The findings in the journal Brain, Behavior, and Immunity "could lead to the development of innovative, more effective therapies," said researcher Marco Loggia.

PET study examines breakthrough Parkinson's gene therapy
Medical Xpress
Researchers examined metabolic PET scans of 35 individuals with Parkinson's disease and found that those who received the AAV2-GAD gene therapy, but not those who underwent sham surgery, developed new neural circuits linking the brain's motor regions, prompting up to 12 months of better motor symptoms. The findings were published in Science Translational Medicine.

PET study links Mediterranean diet to lower beta-amyloid buildup
Australian researchers who used PET with C-11 Pittsburgh compound B found that every point increase in Mediterranean diet score, indicating greater adherence, among older adults was associated with a 20% decline and an up to 60% decrease in cerebral beta-amyloid accumulation associated with Alzheimer's disease over one year and three years, respectively. However, the findings in Translational Psychiatry showed that elevated fruit intake was the only individual Mediterranean diet component with a significant link to reduced beta-amyloid buildup.

Robot arm-assisted biopsy with PET/CT shows promise in bone lesions
A study in the American Journal of Roentgenology showed that an FDG-PET/CT-guided robotic arm-assisted needle biopsy yielded 98% sensitivity, 100% specificity, 99% accuracy, 100% positive predictive value and 95% negative predictive value in determining malignant bone and bone marrow lesions. Researchers also found that the approach helped identify treatment plans for 92% of cancer patients and didn't result in any major complications.

Study: Multimodal imaging could foretell recurrence of glioblastoma
Physics World
Researchers examined F-18 FDG-PET/MRI and F-18 FET-PET/CT scans of individuals with glioblastoma and found that F-18 FET yielded a 0.77 area under the receiver operating characteristic curve in predicting glioblastoma recurrence. The findings in the European Journal of Nuclear Medicine and Molecular Imaging "could be a first step to enable a higher degree of patient-specific planning of dose delivery by specifically targeting areas with high risk of recurrence," researchers wrote.

PET sheds light on transporter tied to growth of lung cancer cells
Medical Xpress
Researchers who used PET found that human lung cancer specimens had abnormally elevated levels of sodium-dependent glucose transporter 2, indicating its role in glucose transport to premalignant lesions and during early tumor growth. The findings in Science Translational Medicine suggest that SGLT2 may be used as a biomarker to enable earlier detection of lung cancer.

Better breast cancer therapies sought in molecular imaging study
Health Imaging
Researchers at the Medical University of South Carolina Hollings Cancer Center will study how the secreted frizzled-related protein 2-activated calcineurin/NFAT mechanism promotes the growth of breast tumors and will use fluorescence imaging to evaluate whether a humanized antibody targeting the mechanism could stop breast tumor development. The study, which was given a three-year, $1.2 million grant by the Defense Department, aims to discover treatments for metastatic breast cancer that have fewer adverse effects, researchers said.

Tau phosphorylation site linked to amyloid development in Alzheimer's
MedPage Today
Researchers looked at PiB-PET scans and cerebrospinal fluid with mass spectrometry and immunoassays of individuals with 50% odds of having a dominantly inherited Alzheimer's disease mutation and found an almost full association between the phosphorylation of tau site T217 and brain amyloid, with T217 phosphorylation prompting changes in other phosphorylated tau sites. The findings, presented at the American Neurological Association annual meeting, suggest that tau phosphorylation changes may be used in defining the stages of Alzheimer's, said researcher Nicolas Barthelemy.

Study compares MRI sequences for PET/MRI in prostate cancer
Canadian researchers found that whole-body fluorocholine-PET/MRI with the gadolinium-enhanced T1-weighted volumetric interpolated breath-hold exam yielded the highest detection rate for conspicuous lesions and the highest time efficiency in staging patients with high-risk prostate cancer, compared with PET/MRI with whole-body diffusion-weighted imaging, coronal T2-weighted turbo inversion-recovery magnitude or coronal T1-weighted 3D Dixon. The findings in the American Journal of Roentgenology may also be applied to prostate-specific membrane antigens and other PET radiotracers, researchers wrote.

PET/CT shows promise in diagnosing giant cell arteritis
Australian researchers found that PET/CT of the temporal, maxillary, occipital and vertebral arteries yielded 92% sensitivity, 85% specificity, 61% negative predictive value and 98% negative predictive value in identifying individuals with giant cell arteritis. The findings, presented at the American College of Rheumatology annual meeting, suggest that PET/CT may be "a suitable first-line test for GCA," said researcher Anthony Sammel.

Prostate cancer may be better detected with Ga-68 PSMA-11 PET/MRI
Health Imaging
Researchers at the University of California at San Francisco found that gallium-68 PSMA-11 PET/MRI yielded region-specific sensitivities of 74% and 73% in localizing prostate tumors using the alternative neighboring approach and population-averaged generalized estimating equation, respectively, compared with sensitivities of 50% and 69% with multiparametric MRI. The findings in a radiology journal, based on scans from 32 men with prostate cancer, also showed similar region-specific specificities between the modalities.


Calendar of Events

13th Winter Conference of the ESMI on “Imaging the Biomechanics of Life“
January 13 – 18, 2019
Les Houches, Charmonix Valley, France

SNMMI 2019 Mid-Winter Meeting
January 17 – 19, 2019
Palm Springs, CA

5th Theranostics World Congress 2019 - TWC2019
March 1 – 3, 2019
Seogwipo-si, Jeju-do, Korea

2019 High Country Nuclear Medicine Conference
March 2 – 6, 2019
Vail, CO

14th European Molecular Imaging Meeting – EMIM 2019
March 19 – 22, 2019
Glasgow, Scotland

SNMMI 2019 Annual Meeting
June 22 – 25, 2019
Anaheim, CA