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Doornhof KR, de Lussanet de la Sablonière Q, Koolen SLW, Konijnenberg MW. Treatment of [99mTc]Tc-hydroxy-diphosphonate ([99mTc]Tc-HDP) extravasation using hyaluronidase. Pharmacol Res Perspect 2024; 12:e1232. [PMID: 39054750 PMCID: PMC11272945 DOI: 10.1002/prp2.1232] [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: 02/22/2024] [Revised: 06/03/2024] [Accepted: 06/10/2024] [Indexed: 07/27/2024] Open
Abstract
Extravasation of 99mTc-labeled radiopharmaceuticals is generally considered to require no specific intervention. In the presented case, the use of hyaluronidase could have minimized the adverse effects resulting from such an extravasation. Currently, no guidelines exist regarding the use of hyaluronidase after extravasation of [99mTc]Tc-HDP. Considering the low risk of administering hyaluronidase, it should be considered to limit the risk of injury after extravasation of [99mTc]Tc-HDP.
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Affiliation(s)
- Kevin R. Doornhof
- Department of Radiology and Nuclear Medicine, Erasmus Medical CenterUniversity Medical Center RotterdamRotterdamThe Netherlands
| | | | - Stijn L. W. Koolen
- Department of Radiology and Nuclear Medicine, Erasmus Medical CenterUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Mark W. Konijnenberg
- Department of Radiology and Nuclear Medicine, Erasmus Medical CenterUniversity Medical Center RotterdamRotterdamThe Netherlands
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Pham TD, Tsunoyama T. Exploring Extravasation in Cancer Patients. Cancers (Basel) 2024; 16:2308. [PMID: 39001371 PMCID: PMC11240416 DOI: 10.3390/cancers16132308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 06/17/2024] [Accepted: 06/21/2024] [Indexed: 07/16/2024] Open
Abstract
Extravasation, the unintended leakage of intravenously administered substances, poses significant challenges in cancer treatment, particularly during chemotherapy and radiotherapy. This comprehensive review explores the pathophysiology, incidence, risk factors, clinical presentation, diagnosis, prevention strategies, management approaches, complications, and long-term effects of extravasation in cancer patients. It also outlines future directions and research opportunities, including identifying gaps in the current knowledge and proposing areas for further investigation in extravasation prevention and management. Emerging technologies and therapies with the potential to improve extravasation prevention and management in both chemotherapy and radiotherapy are highlighted. Such innovations include advanced vein visualization technologies, smart catheters, targeted drug delivery systems, novel topical treatments, and artificial intelligence-based image analysis. By addressing these aspects, this review not only provides healthcare professionals with insights to enhance patient safety and optimize clinical practice but also underscores the importance of ongoing research and innovation in improving outcomes for cancer patients experiencing extravasation events.
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Affiliation(s)
- Tuan D. Pham
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AD, UK
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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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van der Pol JAJ, Mottaghy FM. Extravasation of Diagnostic Radiopharmaceuticals: A Wolf in Sheep's Clothing? J Nucl Med 2023; 64:491-492. [PMID: 36522187 PMCID: PMC10071801 DOI: 10.2967/jnumed.122.265038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Jochem A J van der Pol
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands; and
| | - Felix M Mottaghy
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands; and
- Department of Nuclear Medicine, University Hospital RWTH Aachen, and Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Aachen, Germany
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Crowley JR, Barvi I, Greulich D, Kiser JW. Detection of Excess Presence of 99m Tc-MDP Near Injection Site-A Case Report. Front Med (Lausanne) 2021; 8:728542. [PMID: 34604265 PMCID: PMC8484323 DOI: 10.3389/fmed.2021.728542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/20/2021] [Indexed: 11/13/2022] Open
Abstract
Nuclear medicine extravasations and prolonged venous stasis may cause poor quality and quantification errors that can affect image interpretation and patient management. Radiopharmaceutical remaining near the administration site means that some portion of the radioactivity is not circulating as required for the prescribed uptake period. This case describes how detection of excess presence of 99mTc-MDP near the injection site enabled the technologist to apply mitigation tactics early in the uptake process. It also suggests that detecting an extravasation or stasis early in the injection process can be important for image interpretation and minimizing radiation dose to tissue.
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Affiliation(s)
- James R Crowley
- Department of Molecular Imaging, Carilion Clinic, Roanoke, VA, United States
| | - Iryna Barvi
- Lucerno Dynamics LLC, Cary, NC, United States
| | | | - Jackson W Kiser
- Department of Molecular Imaging, Carilion Clinic, Roanoke, VA, United States
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