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Fernandes D, Santos M, Pinheiro M, Duarte H, Fontes F. Radiopharmaceutical extravasation in bone scintigraphy: a cross-sectional study. Nucl Med Commun 2023; 44:870-875. [PMID: 37464878 DOI: 10.1097/mnm.0000000000001738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJETIVES Tc-99m Hydroxymethylene diphosphonate (HMDP) bone scintigraphy is commonly used to diagnose bone disorders. We aimed to quantify and characterize the occurrence of radiopharmaceutical extravasation in bone scintigraphy, using Tc-99m HMDP, as well as to compare the visual classification of the events with an independent analysis using image processing software. METHODS We conducted a cross-sectional study, using data from a total of 400 (9.1%) exams, randomly selected from all the procedures performed in 2018 in the Portuguese Institute of Oncology of Porto, Portugal. Prevalence estimate and the corresponding 95% confidence interval (CI) was computed for the presence of extravasation. Odds ratios and 95% CI were computed to quantify the association between demographic and clinical characteristics, and the occurrence of extravasation. RESULTS The prevalence of Tc-99m HMDP extravasation was 26.5% (95% CI: 22.4-31.0). Those from an inpatient setting had almost seven-fold higher odds of extravasation than those from an outpatient setting. When the wrist was used for administration, there was three times more odds of extravasation when compared to the use of hand. There were statistically significant differences in the median scores of extravasations severity obtained from image processing software according to the different grades attributed by visual appreciation ( P < 0.001). CONCLUSION Tc-99m HMDP extravasation occurred in one out of four patients, being more frequent among those from an inpatient setting and when the wrist was used for administration. Visual appreciation of the extravasation seems to be acceptable to classify its severity.
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Affiliation(s)
| | - Márcia Santos
- Imaging Department, Portuguese Oncology Institute of Porto
| | | | - Hugo Duarte
- Imaging Department, Portuguese Oncology Institute of Porto
| | - Filipa Fontes
- Oncology Nursing Research Unit, IPO Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto)
- Porto Comprehensive Cancer Centre (Porto.CCC) & RISE@CI-IPOP (Health Research Network)
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Universidade do Porto, Porto, Portugal
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Sunderland JJ, Graves SA, York DM, Mundt CA, Bartel TB. Multicenter Evaluation of Frequency and Impact of Activity Infiltration in PET Imaging, Including Microscale Modeling of Skin-Absorbed Dose. J Nucl Med 2023; 64:1095-1101. [PMID: 37230534 PMCID: PMC10315693 DOI: 10.2967/jnumed.123.265891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 04/26/2023] [Indexed: 05/27/2023] Open
Abstract
There has been significant recent interest in understanding both the frequency of nuclear medicine injection infiltration and the potential for negative impact, including skin injury. However, no large-scale study has yet correlated visualized injection site activity with actual activity measurement of an infiltrate. Additionally, current skin dosimetry approaches lack sufficient detail to account for critical factors that impact the dose to the radiosensitive epidermis. Methods: From 10 imaging sites, 1,000 PET/CT patient studies were retrospectively collected. At each site, consecutive patients with the injection site in the field of view were used. The radiopharmaceutical, injected activity, time of injection and imaging, injection site, and injection method were recorded. Net injection site activity was calculated from volumes of interest. Monte Carlo image-based absorbed dose calculations were performed using the actual geometry from a patient with a minor infiltration. The simulation model used an activity distribution in the skin microanatomy based on known properties of subcutaneous fat, dermis, and epidermis. Simulations using several subcutaneous fat-to-dermis concentration ratios were performed. Absorbed dose to the epidermis, dermis, and fat were calculated along with relative γ- and β-contributions, and these findings were extrapolated to a hypothetical worst-case (470 MBq) full-injection infiltration. Results: Only 6 of 1,000 patients had activity at the injection site in excess of 370 kBq (10 μCi), with no activities greater than 1.7 MBq (45 μCi). In 460 of 1,000 patients, activity at the injection site was clearly visualized. However, quantitative assessment of activities averaged only 34 kBq (0.9 μCi), representing 0.008% of the injected activity. Calculations for the extrapolated 470-MBq infiltration resulted in a hypothetical absorbed dose to the epidermis of below 1 Gy, a factor of 2 lower than what is required for deterministic skin reactions. Analysis of the dose distribution demonstrates that the dermis acts as a β-shield for the radiation-sensitive epidermis. Dermal shielding is highly effective for low-energy 18F positrons but less so with the higher-energy positrons of 68Ga. Conclusion: When quantitative activity measurement criteria are used rather than visual, the frequency of PET infiltration appears substantially below frequencies previously published. Shallow doses to the epidermis from infiltration events are also likely substantially lower than previously reported because of absorption of β-particles in the dermis.
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Affiliation(s)
| | | | - Dusty M York
- Chattanooga State Community College, Chattanooga, Tennessee; and
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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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Tsorxe IY, Hayes RB. Dose Estimation for Extravasation of 177Lu, 99mTc, and 18F. HEALTH PHYSICS 2023; 124:217-220. [PMID: 36719937 DOI: 10.1097/hp.0000000000001653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
ABSTRACT Extravasation is the situation in which a nuclear medicine injection deposits some fraction of its radioactivity into the soft tissue rather than the bloodstream and may result in a large local radiation dose to tissue. An understanding of localized radiation dose from such unexpected events can be an important aspect of clinical radiation protection. The aim of this study was to estimate and assess absorbed radiation dose to localized soft tissue for hypothetical scenarios of radiopharmaceutical extravasation. Specifically, the goal was to understand whether a radiopharmaceutical extravasation could exceed the US Nuclear Regulatory Commission's medical event reporting limit of 0.5 Sv dose equivalent to tissue or levels at which tissue damage would be anticipated (1.0 Sv dose equivalent). We used the GATE Monte Carlo simulation software to calculate self-dose to spherical volumes containing uniformly distributed amounts of common radiopharmaceutical isotopes. Simulated volumes, radioactivity levels, and effective half-lives represented real-world nuclear medicine procedures. Chosen scenarios consisted of 50 mCi and 100 mCi 177Lu within 20 cm3 and 40 cm3 tissue volumes and a 60 min biological clearance half-time (59.6 min effective half-life), 6 mCi and 12 mCi 99mTc within 1 cm3 and 5 cm3 tissue volumes and a 120 min biological clearance half-time (90 min effective half-life), and 3 mCi and 6 mCi 18F within 1 cm3 and 5 cm3 tissue volumes with a 30 min biological clearance half-time (23.6 min effective half-life). We calculated absorbed doses to be between 5.5 Gy and 23.5 Gy for 177Lu, between 0.9 Gy and 12.4 Gy for 99mTc, and between 1.5 Gy and 16.2 Gy for 18F. Radiopharmaceutical extravasations can result in tissue doses that surpass both medical event reporting limits and levels at which deterministic effects are expected. Radiation safety programs should include identification, mitigation, dosimetry, and documentation of significant extravasation events.
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Wilson S, Osborne D, Long M, Knowland J, Fisher DR. Practical Tools for Patient-specific Characterization and Dosimetry of Radiopharmaceutical Extravasation. HEALTH PHYSICS 2022; 123:343-347. [PMID: 35838538 PMCID: PMC9512231 DOI: 10.1097/hp.0000000000001600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
ABSTRACT Extravasation during radiopharmaceutical injection may occur with a frequency of more than 10%. In these cases, radioactivity remains within tissue and deposits unintended radiation dose. Characterization of extravasations is a necessary step in accurate dosimetry, but a lack of free and publicly available tools hampers routine standardized analysis. Our objective was to improve existing extravasation characterization and dosimetry methods and to create and validate tools to facilitate standardized practical dosimetric analysis in clinical settings. Using Monte Carlo simulations, we calculated dosimetric values for sixteen nuclear medicine isotopes: 11 C, 64 Cu, 18 F, 67 Ga, 68 Ga, 123 I, 131 I, 111 In, 177 Lu, 13 N, 15 O, 82 Rb, 153 Sm, 89 Sr, 99m Tc, and 90 Y. We validated our simulation results against five logical alternative dose assessment methods. We then created three new characterization tools: a worksheet, a spreadsheet, and a web application. We assessed each tool by recalculating extravasation dosimetry results found in the literature and used each of the tools for patient cases to show clinical practicality. Average variation between our simulation results and alternative methods was 3.1%. Recalculation of published dosimetry results indicated an average error of 7.9%. Time required to use each characterization tool ranged from 1 to 5 min, and agreement between the three tools was favorable. We improved upon existing methods by creating new tools for characterization and dosimetry of radiopharmaceutical extravasation. These free and publicly available tools will enable standardized routine clinical analysis and benefit patient care, clinical follow-up, documentation, and event reporting.
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Affiliation(s)
- Sean Wilson
- Carilion Clinic, Roanoke VA and Blue Ridge Medical Physics, Daleville, VA
| | - Dustin Osborne
- University of Tennessee Graduate School of Medicine, Knoxville TN
| | | | | | - Darrell R. Fisher
- University of Washington Department of Radiology and Versant Medical Physics and Radiation Safety, Richland, WA
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Perrin S, Kiser JW, Knowland J, Bowen SL. Development of a classifier for [18F]fluorodeoxyglucose extravasation severity using semi-quantitative readings from topically applied detectors. EJNMMI Phys 2022; 9:61. [PMID: 36104581 PMCID: PMC9474785 DOI: 10.1186/s40658-022-00488-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 08/22/2022] [Indexed: 11/28/2022] Open
Abstract
Background Radiotracer extravasations, caused largely by faulty tracer injections, can occur in up to 23% of 18F-fluorodeoxyglucose (FDG) PET/CT scans and negatively impact radiological review and tracer quantification. Conventional radiological assessment of extravasation severity on PET has limited performance (e.g., extravasations frequently resolve before scanning) and practical drawbacks. In this study, we develop a new topical detector-based FDG extravasation severity classifier, calibrated from semi-quantitative PET measurements, and assess its performance on human subjects. Methods A retrospective study examined patients whose FDG injections had been monitored as part of their standard workup for PET/CT imaging. Topical uncollimated gamma ray detectors were applied proximal to the injection site and on the same location on the opposing arm, and readings were acquired continuously during radiotracer uptake. Patients were imaged with their arms in the PET field of view and total extravasation activity quantified from static PET images through a volume of interest approach. The image-derived activities were considered ground truth and used to calibrate and assess quantification of topical detector readings extrapolated to the start of PET imaging. The classifier utilizes the calibrated detector readings to produce four extravasation severity classes: none, minor, moderate, and severe. In a blinded study, a radiologist qualitatively labeled PET images for extravasation severity using the same classifications. The radiologist’s interpretations and topical detector classifications were compared to the ground truth PET results. Results Linear regression of log-transformed image-derived versus topical detector tracer extravasation activity estimates showed a strong correlation (R2 = 0.75). A total of 24 subject scans were cross-validated with the quantitatively based classifier through a leave-one-out methodology. For binary classification (none vs. extravasated), the topical detector classifier had the highest overall diagnostic performance for identifying extravasations. Specificity, sensitivity, accuracy, and positive predictive value were 100.0%, 80.0%, 95.8%, and 100.0%, respectively, for the topical detector classifier and 31.6%, 100.0%, 45.8%, and 27.8%, respectively, for the radiological analysis. The topical detector classifier, with an optimal detection threshold, produced a significantly higher Matthews correlation coefficient (MCC) than the radiological analysis (0.87 vs. 0.30). Conclusions The topical detector binary classifier, calibrated using quantitative static PET measurements, significantly improves extravasation detection compared to qualitative image analysis. Supplementary Information The online version contains supplementary material available at 10.1186/s40658-022-00488-6.
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Yamada A, Kojima T. Applicability of precordial Doppler ultrasound to confirm the correct placement of peripheral intravenous access in children. J Clin Anesth 2021; 74:110434. [PMID: 34174640 DOI: 10.1016/j.jclinane.2021.110434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 06/15/2021] [Accepted: 06/19/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Ayu Yamada
- Department of Anesthesiology, Aichi Children's Health and Medical Center, Obu-City, Aichi, Japan
| | - Taiki Kojima
- Department of Anesthesiology, Aichi Children's Health and Medical Center, Obu-City, Aichi, Japan.
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Osborne D, Kiser JW, Knowland J, Townsend D, Fisher DR. Patient-specific Extravasation Dosimetry Using Uptake Probe Measurements. HEALTH PHYSICS 2021; 120:339-343. [PMID: 33443961 PMCID: PMC7837744 DOI: 10.1097/hp.0000000000001375] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
ABSTRACT Extravasation is a common problem in radiopharmaceutical administration and can result in significant radiation dose to underlying tissue and skin. The resulting radiation effects are rarely studied and should be more fully evaluated to guide patient care and meet regulatory obligations. The purpose of this work was to show that a dedicated radiopharmaceutical injection monitoring system can help clinicians characterize extravasations for calculating tissue and skin doses. We employed a commercially available radiopharmaceutical injection monitoring system to identify suspected extravasation of 18F-fluorodeoxyglucose and 99mTc-methylene diphosphonate in 26 patients and to characterize their rates of biological clearance. We calculated the self-dose to infiltrated tissue using Monte Carlo simulation and standard MIRD dosimetry methods, and we used VARSKIN software to calculate the shallow dose equivalent to the epithelial basal-cell layer of overlying skin. For 26 patients, injection-site count rate data were used to characterize extravasation clearance. For each, the absorbed dose was calculated using representative tissue geometries. Resulting tissue-absorbed doses ranged from 0.6 to 11.2 Gy, and the shallow dose equivalent to a 10 cm2 area of adjacent skin in these patients ranged from about 0.1 to 5.4 Sv. Extravasated injections of radiopharmaceuticals can result in unintentional doses that exceed well-established radiation protection and regulatory limits; they should be identified and characterized. An external injection monitoring system may help to promptly identify and characterize extravasations and improve dosimetry calculations. Patient-specific characterization can help clinicians determine extravasation severity and whether the patient should be followed for adverse tissue reactions that may present later in time.
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Affiliation(s)
- Dustin Osborne
- University of Tennessee Graduate School of Medicine, Knoxville TN
| | | | | | | | - Darrell R. Fisher
- Washington State University and Versant Medical Physics and Radiation Safety, Richland, WA
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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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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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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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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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