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Iori M, Grassi E, Piergallini L, Meglioli G, Botti A, Sceni G, Cucurachi N, Verzellesi L, Finocchiaro D, Versari A, Fraboni B, Fioroni F. Safety injections of nuclear medicine radiotracers: towards a new modality for a real-time detection of extravasation events and 18F-FDG SUV data correction. EJNMMI Phys 2023; 10:31. [PMID: 37221434 DOI: 10.1186/s40658-023-00556-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 05/15/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND 18F-FDG PET/CT imaging allows to study oncological patients and their relative diagnosis through the standardised uptake value (SUV) evaluation. During radiopharmaceutical injection, an extravasation event may occur, making the SUV value less accurate and possibly leading to severe tissue damage. The study aimed to propose a new technique to monitor and manage these events, to provide an early evaluation and correction to the estimated SUV value through a SUV correction coefficient. METHODS A cohort of 70 patients undergoing 18F- FDG PET/CT examinations was enrolled. Two portable detectors were secured on the patients' arms. The dose-rate (DR) time curves on the injected DRin and contralateral DRcon arm were acquired during the first 10 min of injection. Such data were processed to calculate the parameters ΔpinNOR = (DRinmax- DRinmean)/DRinmax and ΔRt = (DRin(t) - DRcon(t)), where DRinmax is the maximum DR value, DRinmean is the average DR value in the injected arm. OLINDA software allowed dosimetric estimation of the dose in the extravasation region. The estimated residual activity in the extravasation site allowed the evaluation of the SUV's correction value and to define an SUV correction coefficient. RESULTS Four cases of extravasations were identified for which ΔRt [(390 ± 26) µSv/h], while ΔRt [(150 ± 22) µSv/h] for abnormal and ΔRt [(24 ± 11) µSv/h] for normal cases. The ΔpinNOR showed an average value of (0.44 ± 0.05) for extravasation cases and an average value of (0.91 ± 0.06) and (0.77 ± 0.23) in normal and abnormal classes, respectively. The percentage of SUV reduction (SUV%CR) ranges between 0.3% and 6%. The calculated self-tissue dose values range from 0.027 to 0.573 Gy, according to the segmentation modality. A similar correlation between the inverse of ΔpinNOR and the normalised ΔRt with the SUV correction coefficient was found. CONCLUSIONS The proposed metrics allowed to characterised the extravasation events in the first few minutes after the injection, providing an early SUV correction when necessary. We also assume that the characterisation of the DR-time curve of the injection arm is sufficient for the detection of extravasation events. Further validation of these hypotheses and key metrics is recommended in larger cohorts.
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Affiliation(s)
- Mauro Iori
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Elisa Grassi
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Lorenzo Piergallini
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Greta Meglioli
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Andrea Botti
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Giada Sceni
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
- Department of Physics, University of Bologna, Bologna, Italy
| | - Noemi Cucurachi
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy.
- Department of Physics, University of Padova, Padua, Italy.
| | - Laura Verzellesi
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
- Department of Physics, University of Bologna, Bologna, Italy
| | - Domenico Finocchiaro
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
- Department of Physics, University of Bologna, Bologna, Italy
| | - Annibale Versari
- Nuclear Medicine Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Federica Fioroni
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
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Hirata I, Mazzotta A, Makvandi P, Cesini I, Brioschi C, Ferraris A, Mattoli V. Sensing Technologies for Extravasation Detection: A Review. ACS Sens 2023; 8:1017-1032. [PMID: 36912628 PMCID: PMC10043935 DOI: 10.1021/acssensors.2c02602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/27/2023] [Indexed: 03/14/2023]
Abstract
Peripheral intravenous catheters are administered for various purposes, such as blood sampling or the infusion of contrast agents and drugs. Extravasation happens when the catheter is unintentionally directed outside of the vein due to movement of the intravascular catheter, enhanced vascular permeability, or occlusion of the upstream vein. In this article, extravasation and its mechanism are discussed. Subsequently, the sensorized devices (e.g., single sensor and multimodal detection) to identify the extravasation phenomena are highlighted. In this review article, we have shed light on both physiological and engineering points of view of extravasation and its detection approaches. This review provides an overview on the most recent and relevant technologies that can help in the early detection of extravasation.
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Affiliation(s)
- Ikue Hirata
- Center for
Materials Interfaces, Istituto Italiano
di Tecnologia, 56025 Pontedera, Pisa, Italy
| | - Arianna Mazzotta
- Center for
Materials Interfaces, Istituto Italiano
di Tecnologia, 56025 Pontedera, Pisa, Italy
- The
Biorobotics Institute, Scuola Superiore
Sant’Anna, Pontedera 56025, Italy
| | - Pooyan Makvandi
- Center for
Materials Interfaces, Istituto Italiano
di Tecnologia, 56025 Pontedera, Pisa, Italy
| | - Ilaria Cesini
- Center for
Materials Interfaces, Istituto Italiano
di Tecnologia, 56025 Pontedera, Pisa, Italy
| | - Chiara Brioschi
- IIT-Bracco
Joint Lab, Istituto Italiano di Tecnologia, 16163 Genova, Italy
- Bracco
S.p.A., 20134 Milano, Italy
| | - Andrea Ferraris
- IIT-Bracco
Joint Lab, Istituto Italiano di Tecnologia, 16163 Genova, Italy
- Bracco
S.p.A., 20134 Milano, Italy
| | - Virgilio Mattoli
- Center for
Materials Interfaces, Istituto Italiano
di Tecnologia, 56025 Pontedera, Pisa, Italy
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Strigari L, Marconi R, Solfaroli-Camillocci E. Evolution of Portable Sensors for In-Vivo Dose and Time-Activity Curve Monitoring as Tools for Personalized Dosimetry in Molecular Radiotherapy. SENSORS (BASEL, SWITZERLAND) 2023; 23:2599. [PMID: 36904802 PMCID: PMC10007630 DOI: 10.3390/s23052599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/19/2023] [Accepted: 02/21/2023] [Indexed: 06/18/2023]
Abstract
Treatment personalization in Molecular Radiotherapy (MRT) relies on pre- and post-treatment SPECT/ PET-based images and measurements to obtain a patient-specific absorbed dose-rate distribution map and its evolution over time. Unfortunately, the number of time points that are available per patient to investigate individual pharmacokinetics is often reduced by limited patient compliance or SPECT or PET/CT scanner availability for dosimetry in busy departments. The adoption of portable sensors for in-vivo dose monitoring during the entire treatment could improve the assessment of individual biokinetics in MRT and, thus, the treatment personalization. The evolution of portable devices, non-SPECT/PET-based options, already used for monitoring radionuclide activity transit and accumulation during therapy with radionuclides (i.e., MRT or brachytherapy), is presented to identify valuable ones, which combined with conventional nuclear medicine imaging systems could be effective in MRT. External probes, integration dosimeters and active detecting systems were included in the study. The devices and their technology, the range of applications, the features and limitations are discussed. Our overview of the available technologies encourages research and development of portable devices and dedicated algorithms for MRT patient-specific biokinetics study. This would represent a crucial advancement towards personalized treatment in MRT.
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Affiliation(s)
- Lidia Strigari
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Giuseppe Massarenti 9, 40138 Bologna, Italy
| | - Raffaella Marconi
- Scientific Direction, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy
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Sanchez S, Currie GM. Detection of 18F-FDG Dose Leakage Using a Topical Device. J Nucl Med Technol 2020; 48:283-284. [DOI: 10.2967/jnmt.119.240283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/05/2020] [Indexed: 11/16/2022] Open
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Currie GM, Sanchez S. Topical sensor metrics for 18F-FDG positron emission tomography dose extravasation. Radiography (Lond) 2020; 27:178-186. [PMID: 32768325 DOI: 10.1016/j.radi.2020.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Extravasation or partial extravasation of the positron emission tomography (PET) tracer negatively effects image quality in PET and the accuracy of the standard uptake value (SUV). A commercially available topical sensor has been validated using a number of metrics to characterise injection quality. This evaluation explores contributing factors for extravasation and refines metrics to predict extravasation based on the time-activity-curves (TAC) of the topical sensor device. METHODS A multi-site, multi-national pooling of 18F FDG PET/CT data was undertaken with 863 patients from 6 sites in the USA and 2 sites in Australia. A number of dose migration metrics determined with topical application of Lara sensors were retrospectively analysed using conventional statistical analysis. Deeper insights into the complex relationship between variables was further explored using an artificial neural network. RESULTS Extravasation was independently predicted by the time taken for the injection sensor counts to reach double the counts of the reference sensor (tc50), the normalised difference between injection and reference sensors counts at 4 min post injection (ndAvgN), or the ratio of injection sensor counts to reference sensor counts at the end of data collection (CEnd ratio). The algorithm developed using the artificial neural network produced 100% sensitivity and 100% specificity against grounded truth for detecting extravasation by weighting and scaling these 3 key metrics; CEnd ratio, ndAvgN and tc50. CONCLUSION Partial extravasation of a PET dose is readily detected and differentiated using TAC metrics and these metrics could provide deeper insight into the impact of partial extravasation on image quality or quantitation. Further validation of key metrics developed in this study are recommended in a larger and more diverse cohort. IMPLICATIONS FOR PRACTICE Partial extravasation undermines image quality and accuracy of quantitation, impacting efficacy of outcomes for patients. Characterisation of extravasation informs decision making to optimise protocol and procedure, enhancing patient outcomes. Awareness provides the opportunity for education and training to minimise impact. The information can be used to drive policy and regulations to support improved techniques in practice.
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Affiliation(s)
- G M Currie
- Faculty of Science, Charles Sturt University, Wagga Wagga, Australia.
| | - S Sanchez
- Faculty of Science, Charles Sturt University, Port Macquarie, Australia
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Whisenant JG, Williams JM, Kang H, Arlinghaus LR, Abramson RG, Abramson VG, Fakhoury K, Chakravarthy AB, Yankeelov TE. Quantitative Comparison of Prone and Supine PERCIST Measurements in Breast Cancer. ACTA ACUST UNITED AC 2020; 6:170-176. [PMID: 32548293 PMCID: PMC7289244 DOI: 10.18383/j.tom.2020.00002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Positron emission tomography (PET) is typically performed in the supine position. However, breast magnetic resonance imaging (MRI) is performed in prone, as this improves visibility of deep breast tissues. With the emergence of hybrid scanners that integrate molecular information from PET and functional information from MRI, it is of great interest to determine if the prognostic utility of prone PET is equivalent to supine. We compared PERCIST (PET Response Criteria in Solid Tumors) measurements between prone and supine FDG-PET in patients with breast cancer and the effect of orientation on predicting pathologic complete response (pCR). In total, 47 patients were enrolled and received up to 6 cycles of neoadjuvant therapy. Prone and supine FDG-PET were performed at baseline (t0; n = 46), after cycle 1 (t1; n = 1) or 2 (t2; n = 10), or after all neoadjuvant therapy (t3; n = 19). FDG uptake was quantified by maximum and peak standardized uptake value (SUV) with and without normalization to lean body mass; that is, SUVmax, SUVpeak, SULmax, and SULpeak. PERCIST measurements were performed for each paired baseline and post-treatment scan. Receiver operating characteristic analysis for the prediction of pCR was performed using logistic regression that included age and tumor size as covariates. SUV and SUL metrics were significantly different between orientation (P < .001), but were highly correlated (P > .98). Importantly, no differences were observed with the PERCIST measurements (P > .6). Overlapping 95% confidence intervals for the receiver operating characteristic analysis suggested no difference at predicting pCR. Therefore, prone and supine PERCIST in this data set were not statistically different.
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Affiliation(s)
- Jennifer G Whisenant
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jason M Williams
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN
| | - Hakmook Kang
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Lori R Arlinghaus
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN
| | - Richard G Abramson
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN.,Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN.,Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Vandana G Abramson
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Kareem Fakhoury
- Department of Radiation Oncology, University of Colorado Cancer Center-Anschutz Medical Campus, Aurora, CO
| | - A Bapsi Chakravarthy
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN.,Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN; and
| | - Thomas E Yankeelov
- Oden Institute for Computational Engineering and Sciences; Livestrong Cancer Institutes; Department of Biomedical Engineering; Department of Diagnostic Medicine; and Department of Oncology, The University of Texas, Austin, TX
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Sanchez S, Currie GM. Topical Sensor for the Assessment of PET Dose Administration: Metric Performance with an Autoinjector. J Nucl Med Technol 2020; 48:363-371. [PMID: 32518121 DOI: 10.2967/jnmt.120.245043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/16/2020] [Indexed: 12/22/2022] Open
Abstract
Extravasation or partial extravasation of the radiopharmaceutical dose in PET can undermine SUV and image quality. A topical sensor has been validated using several metrics to characterize injection quality after manual injection. The performance of these metrics for autoinjector administration has been assessed. Methods: A single PET/CT scanner at a single site was used to characterize injections using an autoinjector with standardized apparatus, flush volume, and infusion rate (1-min infusion followed by 2 syringe flushes) for 18F-FDG, 68Ga-prostate-specific membrane antigen, and 68Ga-DOTATATE. In total, 296 patients with topical application of sensors were retrospectively analyzed using conventional statistical analysis and an artificial neural network. Results: Partial extravasation was noted in 1.3% of studies, with 9.1% (inclusive of partial extravasation) identified to have an injection anomaly (e.g., venous retention). Extravasation was independently predicted by the time that elapsed as the counts recorded by the injection sensor fell from the maximum value to within 200% of the reference sensor counts greater than 1,200 s; as the difference in counts for injection and reference sensors, normalized by dose, from 4 min after injection greater than 25; and as the ratio of the average counts per second recorded by the injection sensor at the end of a monitoring period to those of the reference sensor greater than 2. Conclusion: Extravasation and partial extravasation of PET doses are readily detected and differentiated using time-activity curve metrics. The metrics can provide the insight that could inform image quality or SUV accuracy issues. Further validation of key metrics is recommended in a larger and more diverse cohort.
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Affiliation(s)
- Stephanie Sanchez
- Faculty of Science, Charles Sturt University, Port Macquarie, Australia; and
| | - Geoffrey M Currie
- Faculty of Science, Charles Sturt University, Wagga Wagga, Australia
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8
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Sanchez S, Currie GM. Topical Sensor for the Assessment of Injection Quality for 18F-FDG, 68Ga-PSMA and 68Ga-DOTATATE Positron Emission Tomography. J Med Imaging Radiat Sci 2020; 51:247-255. [PMID: 32089515 DOI: 10.1016/j.jmir.2020.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/03/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Calculation of the standard uptake value (SUV) and image quality in positron emission tomography (PET) hinges on accurate dose delivery. Extravasation or partial extravasation of the radiopharmaceutical dose can undermine SUV and image quality, and contribute to unnecessary imaging (time and CT dose). Topical sensor characterisation of injections has been reported, with extravasation rates ranging from 9% to 23% for 18F-FDG after manual injection. METHOD A single site, single PET/CT scanner was used to characterise injections using an autoinjector with standardised apparatus, flush volume and infusion rate using 18F-FDG, 68Ga-PSMA and 68Ga-DOTATATE; more reflective of Australian PET facilities. 296 patients with topical application of LARA sensors were retrospectively analysed. RESULTS Only 1.1% of studies showed evidence of partial dose extravasation. In total, 9.1% were identified to have an injection anomaly (including venous retention). No statistically significant differences were noted across the radiopharmaceuticals for demographic data. Although not demonstrating a statistically significant correlation, there was more extravasated doses associated with female patients (P = .334), right side (P = .372), and hand injections (P = .539). Extravasation was independent of dose administered (P = .495), the radiopharmaceutical (P = .887), who injected the dose (P = .343), height (P = .438), weight (P = .607) or age (P = .716). Extravasation was associated with higher glucose levels (P < .001), higher t-half (P = .019) and higher aUCR10, tc50, aUCR1 and c1 (all P < .001). CONCLUSION Topical monitoring and characterisation of PET dose administration is possible and practical with the LARA device. Extravasation and partial extravasation of PET doses are not only readily detected but they are also preventable. The LARA device can provide the insights into variables that could eliminate extravasation as a cause of image quality or SUV accuracy issues.
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Affiliation(s)
- Stephanie Sanchez
- Faculty of Science, Charles Sturt University, Port Macquarie, Australia
| | - Geoffrey M Currie
- Faculty of Science, Charles Sturt University, Wagga Wagga, Australia.
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Wong TZ, Benefield T, Masters S, Kiser JW, Crowley J, Osborne D, Mawlawi O, Barnwell J, Gupta P, Mintz A, Ryan KA, Perrin SR, Lattanze RK, Townsend DW. Quality Improvement Initiatives to Assess and Improve PET/CT Injection Infiltration Rates at Multiple Centers. J Nucl Med Technol 2019; 47:326-331. [PMID: 31182666 PMCID: PMC6894099 DOI: 10.2967/jnmt.119.228098] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 05/28/2019] [Indexed: 12/29/2022] Open
Abstract
PET/CT radiotracer infiltration is not uncommon and is often outside the imaging field of view. Infiltration can negatively affect image quality, image quantification, and patient management. Until recently, there has not been a simple way to routinely practice PET radiopharmaceutical administration quality control and quality assurance. Our objectives were to quantify infiltration rates, determine associative factors for infiltration, and assess whether rates could be reduced at multiple centers and then sustained. Methods: A “design, measure, analyze, improve, and control” quality improvement methodology requiring novel technology was used to try to improve PET/CT injection quality. Teams were educated on the importance of quality injections. Baseline infiltration rates were measured, center-specific associative factors were analyzed, team meetings were held, improvement plans were established and executed, and rates remeasured. To ensure that injection-quality gains were retained, real-time feedback and ongoing monitoring were used. Sustainability was assessed. Results: Seven centers and 56 technologists provided data on 5,541 injections. The centers’ aggregated baseline infiltration rate was 6.2% (range, 2%–16%). On the basis of their specific associative factors, 4 centers developed improvement plans and reduced their aggregated infiltration rate from 8.9% to 4.6% (P < 0.0001). Ongoing injection monitoring showed sustainability. Significant variation was found in center- and technologist-level infiltration rates (P < 0.0001 and P = 0.0020, respectively). Conclusion: A quality improvement approach with new technology can help centers measure infiltration rates, determine associative factors, implement interventions, and improve and sustain injection quality. Because PET/CT images help guide patient management, the monitoring and improvement of radiotracer injection quality are important.
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Affiliation(s)
- Terence Z Wong
- Duke University, Durham, North Carolina.,University of North Carolina, Chapel Hill, North Carolina
| | - Thad Benefield
- University of North Carolina, Chapel Hill, North Carolina
| | - Shane Masters
- Wake Forest Baptist Medical Center, Winston Salem, North Carolina
| | | | | | - Dustin Osborne
- Radiology/Molecular Imaging and Translational Research, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee
| | - Osama Mawlawi
- Department of Imaging Physics, M.D. Anderson Cancer Center, University of Texas, Houston, Texas
| | | | - Pawan Gupta
- Division of Nuclear Medicine, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA Health, Los Angeles, California
| | - Akiva Mintz
- Columbia University Medical Center, New York, New York
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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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Lattanze RK, Osman MM, Ryan KA, Frye S, Townsend DW. Usefulness of Topically Applied Sensors to Assess the Quality of 18F-FDG Injections and Validation Against Dynamic Positron Emission Tomography (PET) Images. Front Med (Lausanne) 2018; 5:303. [PMID: 30443549 PMCID: PMC6221940 DOI: 10.3389/fmed.2018.00303] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 10/15/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Infiltrations of 18F-fluorodeoxyglucose (FDG) injections affect positron emission tomography/computed tomography (PET/CT) image quality and quantification. A device using scintillation sensors (Lucerno Dynamics, Cary, NC) provides dynamic measurements acquired during FDG uptake to identify and characterize radioactivity near the injection site prior to patient imaging. Our aim was to compare sensor measurements against dynamic PET image acquisition, our proposed reference in assessing injection quality during the uptake period. Methods: Subjects undergoing routine FDG PET/CT imaging were eligible for this Institutional Review Board approved prospective study. After providing informed consent, subjects had sensors topically placed on their arms. FDG was injected into subjects' veins directly on the PET imaging table. Dynamic images of the injection site were acquired during 45 min of the uptake period. These dynamic image acquisitions and subjects' routine standard static images were evaluated by nuclear medicine physicians for abnormal FDG accumulation near the injection site. Sensor measurements were interpreted independently by Lucerno staff. Dynamic image acquisition interpretation results were compared to the sensor measurement interpretations and to static image interpretations. Results: Twenty-four subjects were consented and enrolled. Data from 21 subjects were gathered. During dynamic image acquisition review, physicians interpreted 4 subjects with no FDG accumulation at the injection site, whereas 17 showed evidence of accumulation. In 10 of the 17 cases that showed FDG accumulation, the FDG presence at the injection site resolved completely during uptake corresponding to venous stasis, the temporary sequestration of blood from circulation. Static image interpretation agreed with dynamic images interpretation in 11/21 (52%) subjects. Sensor measurement interpretations agreed with the dynamic images interpretations in 18/21 (86%) subjects. Conclusions: Sensor measurements can be an effective way to identify and characterize infiltrations and venous stasis. Comparable to an infiltration, venous stasis may produce spurious and clinically meaningful measurement bias and possibly even scan misinterpretation. Since the quality and quantification of PET/CT studies are of clinical importance, sensor measurements acquired during the FDG uptake may prove to be a useful quality control measure to reduce infiltration rates and potentially improve patient care. Registration: Clinicaltrials.gov, Identifier: NCT03041090.
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Affiliation(s)
| | - Medhat M. Osman
- Division of Nuclear Medicine, Department of Radiology, Saint Louis University, St. Louis, MO, United States
| | | | - Sarah Frye
- Doisy College of Health Sciences, Saint Louis University, St. Louis, MO, United States
| | - David W. Townsend
- ASTAR-NUS Clinical Imaging Research Centre (ASTAR), Singapore, Singapore
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Kiser JW, Crowley JR, Wyatt DA, Lattanze RK. Impact of an 18F-FDG PET/CT Radiotracer Injection Infiltration on Patient Management-A Case Report. Front Med (Lausanne) 2018; 5:143. [PMID: 29868595 PMCID: PMC5962786 DOI: 10.3389/fmed.2018.00143] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/25/2018] [Indexed: 11/13/2022] Open
Abstract
Major management decisions in patients with solid tumors and lymphomas are often based on 18F-fluorodeoxyglucose (18F-FDG) PET/CT. The misadministration of 18F-FDG outside the systemic circulation can have an adverse impact on this test's sensitivity (1) and is not uncommon (2-7). This report describes how an 18F-FDG misadministration led to a repeat PET/CT study, resulting in the visualization of distant metastases that changed the original treatment plan. The findings suggest that routine injection monitoring is indicated whenever sensitivity is critical, and support claims that infiltrations can confound interpretation of semi-quantitative PET outcome measures in patients who are followed longitudinally (2).
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Muzaffar R, Frye SA, McMunn A, Ryan K, Lattanze R, Osman MM. Novel Method to Detect and Characterize 18F-FDG Infiltration at the Injection Site: A Single-Institution Experience. J Nucl Med Technol 2017; 45:267-271. [PMID: 29127247 DOI: 10.2967/jnmt.117.198408] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/04/2017] [Indexed: 11/16/2022] Open
Abstract
A novel quality control and quality assurance device provides time-activity curves that can identify and characterize PET/CT radiotracer infiltration at the injection site during the uptake phase. The purpose of this study was to compare rates of infiltration detected by the device with rates detected by physicians. We also assessed the value of using the device to improve injection results in our center. Methods: 109 subjects consented to the study. All had passive device sensors applied to their skin near the injection site and mirrored on the contralateral arm during the entire uptake period. Nuclear medicine physicians reviewed standard images for the presence of dose infiltration. Sensor-generated time-activity curves were independently examined and then compared with the physician reports. Injection data captured by the software were analyzed, and the results were provided to the technologists. Improvement measures were implemented, and rates were remeasured. Results: Physician review of the initial 40 head-to-toe field-of-view images identified 15 cases (38%) of dose infiltration (9 minor, 5 moderate, and 1 significant). Sensor time-activity curves on these 40 cases independently identified 22 cases (55%) of dose infiltration (16 minor, 5 moderate, and 1 significant). After the time-activity curve results and the contributing factor analysis were shared with technologists, injection techniques were modified and an additional 69 cases were studied. Of these, physician review identified 17 cases (25%) of infiltration (13 minor, 3 moderate, and 1 significant), a 34% decline. Sensor time-activity curves identified 4 cases (6%) of infiltration (2 minor and 2 moderate), an 89% decline. Conclusion: The device provides valuable quality control information for each subject. Time-activity curves can further characterize visible infiltration. Even when the injection site was out of the field of view, the time-activity curves could still detect and characterize infiltration. Our initial experience showed that the quality assurance information obtained from the device helped reduce the rate and severity of infiltration. The device revealed site-specific contributing factors that helped nuclear medicine physicians and technologists customize their quality improvement efforts to these site-specific issues. Reducing infiltration can improve image quality and SUV quantification, as well as the ability to minimize variability in a site's PET/CT results.
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Affiliation(s)
- Razi Muzaffar
- Division of Nuclear Medicine, Department of Radiology, Saint Louis University, St. Louis, Missouri
| | - Sarah A Frye
- Doisy College of Health Sciences, Saint Louis University, St. Louis, Missouri
| | - Anna McMunn
- SSM Health Saint Louis University Hospital, St. Louis, Missouri; and
| | | | | | - Medhat M Osman
- Division of Nuclear Medicine, Department of Radiology, Saint Louis University, St. Louis, Missouri
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