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Osborne D, Lattanze R, Knowland J, Bryant TE, Barvi I, Fu Y, Kiser JW. The Scientific and Clinical Case for Reviewing Diagnostic Radiopharmaceutical Extravasation Long-Standing Assumptions. Front Med (Lausanne) 2021; 8:684157. [PMID: 34262915 PMCID: PMC8273265 DOI: 10.3389/fmed.2021.684157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/02/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The patient benefit from a diagnostic nuclear medicine procedure far outweighs the associated radiation risk. This benefit/risk ratio assumes a properly administered radiopharmaceutical. However, a significant diagnostic radiopharmaceutical extravasation can confound the procedure in many ways. We identified three current extravasation hypotheses espoused by medical societies, advisory committees, and hundreds of individual members of the nuclear medicine community: diagnostic extravasations do not cause harm, do not result in high absorbed dose to tissue, and require complex dosimetry methods that are not readily available in nuclear medicine centers. We tested these hypotheses against a framework of current knowledge, recent developments, and original research. We conducted a literature review, searched regulatory databases, examined five clinical cases of extravasated patients, and performed dosimetry on those extravasations to test these globally accepted hypotheses. Results: A literature review found 58 peer-reviewed documents suggesting patient harm. Adverse event/vigilance report database reviews for extravasations were conducted and revealed 38 adverse events which listed diagnostic radiopharmaceutical extravasation as a factor, despite a regulatory exemption for required reporting. In our own case material, assessment of care was evaluated for five extravasated patients who underwent repeat imaging. Findings reflected results of literature review and included mis- or non-identification of lesions, underestimation of Standardized Uptake Values (SUVs) by 19-73%, classification of scans as non-diagnostic, and the need to repeat imaging with the associated additional radiation exposure, inconvenience, or delays in care. Dosimetry was performed for the same five cases of diagnostic radiopharmaceutical extravasation. Absorbed doses to 5 cm3 of tissue were between 1.1 and 8.7 Gy, and shallow dose equivalent for 10 cm2 of skin was as high as 4.2 Sv. Conclusions: Our findings suggest that significant extravasations can or have caused patient harm and can irradiate patients' tissue with doses that exceed medical event reporting limits and deterministic effect thresholds. Therefore, diagnostic radiopharmaceutical injections should be monitored, and dosimetry of extravasated tissue should be performed in certain cases where thresholds are thought to have been exceeded. Process improvement efforts should be implemented to reduce the frequency of extravasation in nuclear medicine.
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Affiliation(s)
- Dustin Osborne
- Radiology Department, University of Tennessee Graduate School of Medicine, Knoxville, TN, United States
| | | | | | | | - Iryna Barvi
- Lucerno Dynamics LLC, Cary, NC, United States
| | - Yitong Fu
- Radiology Department, University of Tennessee Graduate School of Medicine, Knoxville, TN, United States
| | - Jackson W. Kiser
- Department of Molecular Imaging, Carilion Clinic, Roanoke, VA, United States
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Osborne DR, Acuff SN, Fang M, Weaver MD, Fu Y. Assessing and reducing PET radiotracer infiltration rates: a single center experience in injection quality monitoring methods and quality improvement. BMC Med Imaging 2020; 20:3. [PMID: 31924179 PMCID: PMC6954558 DOI: 10.1186/s12880-020-0408-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 12/31/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Successful injection of radiolabeled compounds is critical for positron emission tomography (PET) imaging. A poor quality injection limits the tracer availability in the body and can impact diagnostic results. In this study, we attempt to quantify our infiltration rates, develop an actionable quality improvement plan to reduce potentially compromised injections, and compare injection scoring to PET/CT imaging results. METHODS A commercially available system that uses external radiation detectors was used to monitor and score injection quality. This system compares the time activity curves of the bolus relative to a control reading in order to provide a score related to the quality of the injection. These injection scores were used to assess infiltration rates at our facility in order to develop and implement a quality improvement plan for our PET imaging center. Injection scores and PET imaging results were reviewed to determine correlations between image-based assessments of infiltration, such as liver SUVs, and injection scoring, as well as to gather infiltration reporting statistics by physicians. RESULTS A total of 1033 injections were monitored at our center. The phase 1 infiltration rate was 2.1%. In decision tree analysis, patients < 132.5lbs were associated with infiltrations. Additional analyses suggested patients > 127.5 lbs. with non-antecubital injections were associated with lower quality injections. Our phase 2 infiltration rate was 1.9%. Comparison of injection score to SUV showed no significant correlation and indicated that only 63% of suspected infiltrations were visible on PET/CT imaging. CONCLUSIONS Developing a quality improvement plan and monitoring PET injections can lead to reduced infiltration rates. No significant correlation between reference SUVs and injection score provides evidence that determination of infiltration based on PET images alone may be limited. Results also indicate that the number of infiltrated PET injections is under-reported.
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Affiliation(s)
- Dustin R Osborne
- University of Tennessee Graduate School of Medicine, 1924 Alcoa Highway, Knoxville, TN, 37920, USA.
| | - Shelley N Acuff
- University of Tennessee Graduate School of Medicine, 1924 Alcoa Highway, Knoxville, TN, 37920, USA
| | - Michael Fang
- University of Tennessee Graduate School of Medicine, 1924 Alcoa Highway, Knoxville, TN, 37920, USA
| | - Melissa D Weaver
- University of Tennessee Graduate School of Medicine, 1924 Alcoa Highway, Knoxville, TN, 37920, USA
| | - Yitong Fu
- University of Tennessee Graduate School of Medicine, 1924 Alcoa Highway, Knoxville, TN, 37920, USA
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Knowland J, Lipman S, Lattanze R, Kingg J, Ryan K, Perrin S. Technical Note: Characterization of technology to detect residual injection site radioactivity. Med Phys 2019; 46:2690-2695. [PMID: 30972762 PMCID: PMC6850203 DOI: 10.1002/mp.13536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 02/13/2019] [Accepted: 04/03/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Each year in the United States, approximately 18.5 million nuclear medicine procedures are performed. Various quality control measures are implemented to reduce image errors and improve quantification of radiotracer distribution. However, there is currently no routine or timely feedback about the quality of the radiotracer injection. One potential solution to evaluate the injection quality is to place a topical scintillation sensor near the injection site to record the presence of residual activity. This work investigates a sensor design for identification of injections where the prescribed radioactive activity is not fully delivered into the patient's circulation (an infiltration). METHODS The sensor consists of a single unshielded bismuth germanate (BGO) crystal (3 mm × 3 mm × 3 mm). Using radioactive sources with gamma energies that span the range commonly used in nuclear medicine, we quantified energy resolution and linearity. Additionally, we computed sensitivity by comparing the calculated incident activity to the activity measured by the sensor. Sensor output linearity was calculated by comparing measured data against the radioactive decay of a source over multiple half-lives. The sensor incorporates internal temperature feedback used to compensate for ambient temperature fluctuations. We investigated the performance of this compensation over the range of 15°C-35°C. RESULTS Energy spectra from four sensors were used to calculate the energy resolution: 67% for 99m Tc (141 keV), 67% for 133 Ba (344 keV), 42% for 18 F (511 keV), and 32% for 137 Cs (662 keV). Note that the energy used for 133 Ba is a weighted average of the three photon emissions nearest to the most abundant (356 keV). Sensor energy response was linear with a difference of 1%-2% between measured and predicted values. Energy-dependent detector sensitivity, defined as the ratio of measured photons to incident photons for a given isotope, decreased with increasing photon energy from 55.4% for 99m Tc (141 keV) to 3.3% for 137 Cs (662 keV). Without compensation, error due to temperature change was as high as 53%. Temperature compensation reduced the error to less than 1.4%. Sensor output linearity was tested to as high as 210 kcps and the maximum magnitude error was 4%. CONCLUSIONS The performance of the sensor was adequate for identification of excessive residual activity at an injection site. Its ability to provide feedback may be useful as a quality control measure for nuclear medicine injections.
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Affiliation(s)
| | | | - Ron Lattanze
- Lucerno Dynamics, LLC140 Towerview CtCaryNC27513USA
| | - Jesse Kingg
- Lucerno Dynamics, LLC140 Towerview CtCaryNC27513USA
| | - Kelley Ryan
- Lucerno Dynamics, LLC140 Towerview CtCaryNC27513USA
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Consequences of radiopharmaceutical extravasation and therapeutic interventions: a systematic review. Eur J Nucl Med Mol Imaging 2017; 44:1234-1243. [PMID: 28303300 PMCID: PMC5434120 DOI: 10.1007/s00259-017-3675-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 03/07/2017] [Indexed: 11/29/2022]
Abstract
Purpose Radiopharmaceutical extravasation can potentially lead to severe soft tissue damage, but little is known about incidence, medical consequences, possible interventions, and effectiveness of these. The aims of this study are to estimate the incidence of extravasation of diagnostic and therapeutic radiopharmaceuticals, to evaluate medical consequences, and to evaluate medical treatment applied subsequently to those incidents. Methods A sensitive and elaborate literature search was performed in Embase and PubMed using the keywords “misadministration”, “extravasation”, “paravascular infiltration”, combined with “tracer”, “radionuclide”, “radiopharmaceutical”, and a list of keywords referring to clinically used tracers (i.e. “Technetium-99m”, “Yttrium-90”). Reported data on radiopharmaceutical extravasation and applied interventions was extracted and summarised. Results Thirty-seven publications reported 3016 cases of diagnostic radiopharmaceutical extravasation, of which three cases reported symptoms after extravasation. Eight publications reported 10 cases of therapeutic tracer extravasation. The most severe symptom was ulceration. Thirty-four different intervention and prevention strategies were performed or proposed in literature. Conclusions Extravasation of diagnostic radiopharmaceuticals is common. 99mTc, 123I, 18F, and 68Ga labelled tracers do not require specific intervention. Extravasation of therapeutic radiopharmaceuticals can give severe soft tissue lesions. Although not evidence based, surgical intervention should be considered. Furthermore, dispersive intervention, dosimetry and follow up is advised. Pharmaceutical intervention has no place yet in the immediate care of radiopharmaceutical extravasation.
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Abstract
Radiopharmaceuticals are widely accepted to be a very safe class of drugs, with very few adverse reactions and unexpected biodistributions. However, problems can arise because of technical issues in manufacture or reconstitution, patient preparation, or drug administration. This review presents highlights of issues that have arisen in the newer classes of radiopharmaceuticals in the last 20 years and expands the scope of the previous report to include PET and therapeutic radiopharmaceuticals. Variations in the "quality" of the eluate of a (99)Mo/(99m)Tc generator remain a major issue. Several of the newer (99m)Tc tracers require a heating step in preparation that can also lead to unacceptably low radiochemical purity. Radiolytic breakdown can be a problem with all classes of radiopharmaceuticals. Many of the newer radiopharmaceuticals localize by receptor- or transporter-mediated processes and thus can be affected by other drugs, making patient preparation more important than ever. Therapeutic radiopharmaceuticals may require coadministration of radioprotectant regimens, such as the use of lysine-arginine infusions with radiopeptide therapy. Extravasation can have serious consequences with therapeutic radiopharmaceuticals. Adverse reactions to newer radiopharmaceuticals remain rare, though may increase because of coadministration of agents such as contrast media. However, there is known to be underreporting of minor adverse reactions. Knowledge of the pitfalls that can occur with radiopharmaceuticals is important in the interpretation of nuclear medicine images and optimal patient care.
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Affiliation(s)
- James R Ballinger
- Department of Nuclear Medicine, Guy's and St Thomas' Hospital, London, UK; Division of Imaging Sciences, King's College London School of Medicine, London, UK.
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Agrawal K, Esmail AA, Gnanasegaran G, Navalkissoor S, Mittal BR, Fogelman I. Pitfalls and Limitations of Radionuclide Imaging in Endocrinology. Semin Nucl Med 2015; 45:440-57. [DOI: 10.1053/j.semnuclmed.2015.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Unusual extracardiac findings detected on myocardial perfusion single photon emission computed tomography studies with Tc-99m sestamibi. Clin Nucl Med 2008; 32:920-6. [PMID: 18030041 DOI: 10.1097/rlu.0b013e318159661b] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The authors describe the incidence and various uptake patterns of Tc-99m sestamibi (MIBI) in the extracardiac area due to unusual causes on myocardial perfusion single photon emission computed tomography (SPECT) studies. Seven patients are presented in whom incidental extracardiac findings were observed during the interpretation of the raw data besides the routine evaluation of myocardial reconstructed SPECT slices. These 7 patients were detected out of 582 consecutive patients (1.2%) who had myocardial perfusion SPECT with Tc-99m MIBI. The findings on the raw data led to additional reconstruction of thoracic SPECT images and eventually detailed examination of the extracardiac area. Two of the patients underwent surgery because of incidental extracardiac findings (thymoma and multinodular goiter) on cardiac scintigraphy. Other causes of increased extracardiac activity were the intestine protruded through the left hemithorax, uptake in the pulmonary arterial wall, and pulmonary interstitial fibrosis due to sarcoidosis. The reasons for decreased Tc-99m MIBI accumulation in the extracardiac area in the 2 other patients were significantly dilated pulmonary arteries and hydatic cyst, which were not defined before to our knowledge. Familiarity with the normal biodistribution and variable uptake patterns in the raw images becomes necessary during the interpretation of myocardial SPECT in order not to miss very unusual incidental extracardiac uptake or information that could lead to alteration in patient management. Potential underlying mechanisms of extracardiac Tc-99m MIBI accumulation are discussed, and the literature about noncardiac Tc-99m MIBI findings detected on myocardial perfusion SPECT studies was reviewed.
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Williams G, Palmer MR, Parker JA, Joyce R. Extravazation of therapeutic yttrium-90-ibritumomab tiuxetan (zevalin): a case report. Cancer Biother Radiopharm 2006; 21:101-5. [PMID: 16706630 DOI: 10.1089/cbr.2006.21.101] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The occurrence of radiation necrosis to the extravasation of therapeutic radionuclide-yttrium-90-ibritumomab tiuxetan-is described, as well as the subsequent steps taken to both address the occurrence and to prevent the re-occurrence of such an adverse event. Published reports on the extravasation of diagnostic and therapeutic radionuclides are reviewed, as are prevention and treatment protocols.
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Affiliation(s)
- Gethin Williams
- Nuclear Medicine, Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA 02215-5400, USA
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Denardo GL. Editorial: "right place, wrong place": extravasation of therapeutic drug for molecular targeted radiotherapy. Cancer Biother Radiopharm 2006; 21:85-7. [PMID: 16706628 DOI: 10.1089/cbr.2006.21.85] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ozalp E, Bluemke D, Civelek AC. (99m)Tc sestamibi accumulation in the chest mimicking an ectopic parathyroid adenoma. Semin Nucl Med 2002; 32:223-7. [PMID: 12105805 DOI: 10.1053/snuc.2002.126034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Elcin Ozalp
- Russell H. Morgan Department of Radiology and Radiological Sciences and the Divisions of Nuclear Medicine and Radiation Health Sciences, The Johns Hopkins Medical Institutions, Baltimore, MD 21287-0817, USA
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Kim W, Yun M, Alnafisi N, Hickeson M, Alavi A. False-negative interpretation of FDG positron emission tomography in a patient with Hodgkin's lymphoma. Clin Nucl Med 2002; 27:367-8. [PMID: 11953577 DOI: 10.1097/00003072-200205000-00015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Woojin Kim
- Division of Nuclear Medicine, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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