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Maughan NM, Zoberi JE, Garcia-Ramirez JL, Michalski JM, Baumann BC, Amurao M, Luechtefeld D, Marko A, Nestel A, Kim H. Handling Patient Emergencies During Radiopharmaceutical Therapy. Pract Radiat Oncol 2024:S1879-8500(24)00038-9. [PMID: 38354977 DOI: 10.1016/j.prro.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 02/16/2024]
Abstract
PURPOSE Radiopharmaceutical therapy (RPT) is a rapidly growing treatment modality. Though uncommon, patients may experience complications during their RPT treatment, which may trigger a rapid response from the hospital team. However, members of this team are typically not familiar with precautions for radiation safety. During these events, it is important to prioritize the patient's health over all else. There are some practices that can help minimize the risk of radiation contamination spread and exposure to staff while tending to the patient. METHODS AND MATERIALS We formed a team to develop a standard protocol for handling patient emergencies during RPT treatment. This team consisted of an authorized user, radiation safety officer, medical physicist, nurse, RPT administration staff, and a quality/safety coordinator. The focus for developing this standardized protocol for RPT patient emergencies was 3-fold: (1) stabilize the patient; (2) reduce radiation exposure to staff; and (3) limit the spread of radiation contamination. RESULTS We modified our hospital's existing rapid response protocol to account for the additional staff and tasks needed to accomplish all 3 of these goals. Each team member was assigned specific responsibilities, which include serving as a gatekeeper to restrict traffic, managing the crash cart, performing chest compressions, timing chest compressions, documenting the situation, and monitoring/managing radiation safety in the area. We developed a small, easy-to-read card for rapid response staff to read while they are en route to the area so they can be aware of and prepare for the unique circumstances that RPT treatments present. CONCLUSIONS Though rapid response events with RPT patients are uncommon, it is important to have a standardized protocol for how to handle these situations beforehand rather than improvise in the moment. We have provided an example of how our team adapted our hospital's current rapid response protocol to accommodate RPT patients.
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Affiliation(s)
- Nichole M Maughan
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri; Department of Radiation Oncology, Intermountain Health, Provo, Utah.
| | - Jacqueline E Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jose L Garcia-Ramirez
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Brian C Baumann
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Maxwell Amurao
- Division of Radiation Safety, Department of Environmental Health and Safety, Washington University School of Medicine, St Louis, Missouri
| | - David Luechtefeld
- Division of Radiation Safety, Department of Environmental Health and Safety, Washington University School of Medicine, St Louis, Missouri
| | - Areti Marko
- Department of Radiation Oncology, Barnes Jewish Hospital, St Louis, Missouri
| | - Angela Nestel
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
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Busse NC, Al‐Ghazi MSAL, Abi‐Jaoudeh N, Alvarez D, Ayan AS, Chen E, Chuong MD, Dezarn WA, Enger SA, Graves SA, Hobbs RF, Jafari ME, Kim SP, Maughan NM, Polemi AM, Stickel JR. AAPM Medical Physics Practice Guideline 14.a: Yttrium-90 microsphere radioembolization. J Appl Clin Med Phys 2024; 25:e14157. [PMID: 37820316 PMCID: PMC10860558 DOI: 10.1002/acm2.14157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/19/2023] [Accepted: 08/25/2023] [Indexed: 10/13/2023] Open
Abstract
Radioembolization using Yttrium-90 (90 Y) microspheres is widely used to treat primary and metastatic liver tumors. The present work provides minimum practice guidelines for establishing and supporting such a program. Medical physicists play a key role in patient and staff safety during these procedures. Products currently available are identified and their properties and suppliers summarized. Appropriateness for use is the domain of the treating physician. Patient work up starts with pre-treatment imaging. First, a mapping study using Technetium-99m (Tc-99m ) is carried out to quantify the lung shunt fraction (LSF) and to characterize the vascular supply of the liver. An MRI, CT, or a PET-CT scan is used to obtain information on the tumor burden. The tumor volume, LSF, tumor histology, and other pertinent patient characteristics are used to decide the type and quantity of 90 Y to be ordered. On the day of treatment, the appropriate dose is assayed using a dose calibrator with a calibration traceable to a national standard. In the treatment suite, the care team led by an interventional radiologist delivers the dose using real-time image guidance. The treatment suite is posted as a radioactive area during the procedure and staff wear radiation dosimeters. The treatment room, patient, and staff are surveyed post-procedure. The dose delivered to the patient is determined from the ratio of pre-treatment and residual waste exposure rate measurements. Establishing such a treatment modality is a major undertaking requiring an institutional radioactive materials license amendment complying with appropriate federal and state radiation regulations and appropriate staff training commensurate with their respective role and function in the planning and delivery of the procedure. Training, documentation, and areas for potential failure modes are identified and guidance is provided to ameliorate them.
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Affiliation(s)
| | | | - Nadine Abi‐Jaoudeh
- Department of Radiological SciencesUniversity of CaliforniaIrvineCaliforniaUSA
| | - Diane Alvarez
- Baptist HospitalMiami Cancer InstituteMiamiFloridaUSA
| | - Ahmet S. Ayan
- Department of Radiation OncologyOhio State UniversityColumbusOhioUSA
| | - Erli Chen
- Department of Radiation OncologyCheshire Medical CenterKeeneNew HampshireUSA
| | - Michael D. Chuong
- Department of Radiation OncologyMiami Cancer InstituteMiamiFloridaUSA
| | - William A. Dezarn
- Department of Radiation OncologyWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
| | | | | | - Robert F. Hobbs
- Department of Radiation OncologyJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Mary Ellen Jafari
- Diagnostic Physics, Atlantic Health SystemMorristown Medical CenterMorristownNew JerseyUSA
| | - S. Peter Kim
- Medical Physics UnitMcGill UniversityMontrealCanada
| | - Nichole M. Maughan
- Department of Radiation OncologyWashington University in St. LouisSaint LouisMissouriUSA
| | - Andrew M. Polemi
- Department of RadiologyUniversity of VirginiaCharlottesvilleVirginiaUSA
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Zoberi JE, Garcia‐Ramirez J, Luechtefeld D, Maughan NM, Amurao M, Oyama R, Baumann BC, Gay HA, Michalski JM. Logistical, technical, and radiation safety aspects of establishing a radiopharmaceutical therapy program: A case in Lutetium-177 prostate-specific membrane antigen (PSMA) therapy. J Appl Clin Med Phys 2023; 24:e13899. [PMID: 36637862 PMCID: PMC10113704 DOI: 10.1002/acm2.13899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/15/2022] [Accepted: 12/23/2022] [Indexed: 01/14/2023] Open
Abstract
Prostate-specific membrane antigen (PSMA) is a cell surface protein highly expressed in nearly all prostate cancers, with restricted expression in some normal tissues. The differential expression of PSMA from tumor to non-tumor tissue has resulted in the investigation of numerous targeting strategies for therapy of patients with metastatic prostate cancer. In March of 2022, the FDA granted approval for the use of lutetium-177 PSMA-617 (Lu-177-PSMA-617) for patients with PSMA-positive metastatic castration-resistant prostate cancer (mCRPC) who have been treated with androgen receptor pathway inhibition and taxane-based chemotherapy. Therefore, the use of Lu-177-PSMA-617 is expected to increase and become more widespread. Herein, we describe logistical, technical, and radiation safety considerations for implementing a radiopharmaceutical therapy program, with particular focus on the development of operating procedures for therapeutic administrations. Major steps for a center in the U.S. to implement a new radiopharmaceutical therapy (RPT) program are listed below, and then demonstrated in greater detail via examples for Lu-177-PSMA-617 therapy.
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Affiliation(s)
- Jacqueline E. Zoberi
- Department of Radiation OncologyWashington University School of MedicineSaint LouisMissouriUSA
| | - Jose Garcia‐Ramirez
- Department of Radiation OncologyWashington University School of MedicineSaint LouisMissouriUSA
| | - David Luechtefeld
- Environmental Health and SafetyWashington University School of MedicineSaint LouisMissouriUSA
| | - Nichole M. Maughan
- Department of Radiation OncologyWashington University School of MedicineSaint LouisMissouriUSA
| | - Maxwell Amurao
- Environmental Health and SafetyWashington University School of MedicineSaint LouisMissouriUSA
| | - Reiko Oyama
- MIR Cyclotron Facility and Nuclear PharmacyWashington University School of MedicineSaint LouisMissouriUSA
| | - Brian C. Baumann
- Department of Radiation OncologyWashington University School of MedicineSaint LouisMissouriUSA
| | - Hiram A. Gay
- Department of Radiation OncologyWashington University School of MedicineSaint LouisMissouriUSA
| | - Jeff M. Michalski
- Department of Radiation OncologyWashington University School of MedicineSaint LouisMissouriUSA
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Maughan NM, Garcia-Ramirez JL, Huang FS, Willis DN, Iravani A, Amurao M, Luechtefeld D, Mhlanga JC, Perkins SM, Zoberi JE. Failure modes and effects analysis of pediatric I-131 MIBG therapy: Program design and potential pitfalls. Pediatr Blood Cancer 2022; 69:e29996. [PMID: 36102748 DOI: 10.1002/pbc.29996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND There is growing interest among pediatric institutions for implementing iodine-131 (I-131) meta-iodobenzylguanidine (MIBG) therapy for treating children with high-risk neuroblastoma. Due to regulations on the medical use of radioactive material (RAM), and the complexity and safety risks associated with the procedure, a multidisciplinary team involving radiation therapy/safety experts is required. Here, we describe methods for implementing pediatric I-131 MIBG therapy and evaluate our program's robustness via failure modes and effects analysis (FMEA). METHODS We formed a multidisciplinary team, involving pediatric oncology, radiation oncology, and radiation safety staff. To evaluate the robustness of the therapy workflow and quantitatively assess potential safety risks, an FMEA was performed. Failure modes were scored (1-10) for their risk of occurrence (O), severity (S), and being undetected (D). Risk priority number (RPN) was calculated from a product of these scores and used to identify high-risk failure modes. RESULTS A total of 176 failure modes were identified and scored. The majority (94%) of failure modes scored low (RPN <100). The highest risk failure modes were related to training and to drug-infusion procedures, with the highest S scores being (a) caregivers did not understand radiation safety training (O = 5.5, S = 7, D = 5.5, RPN = 212); (b) infusion training of staff was inadequate (O = 5, S = 8, D = 5, RPN = 200); and (c) air in intravenous lines/not monitoring for air in lines (O = 4.5, S = 8, D = 5, RPN = 180). CONCLUSION Through use of FMEA methodology, we successfully identified multiple potential points of failure that have allowed us to proactively mitigate risks when implementing a pediatric MIBG program.
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Affiliation(s)
- Nichole M Maughan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jose L Garcia-Ramirez
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Frederick S Huang
- Division of Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel N Willis
- Division of Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Amir Iravani
- Division of Nuclear Medicine, Department of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Maxwell Amurao
- Division of Radiation Safety, Department of Environmental Health and Safety, Washington University in St. Louis, St. Louis, Missouri, USA
| | - David Luechtefeld
- Division of Radiation Safety, Department of Environmental Health and Safety, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Joyce C Mhlanga
- Division of Nuclear Medicine, Department of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stephanie M Perkins
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jacqueline E Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
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Chin RI, Bommireddy A, Fraum TJ, Ludwig DR, Huang Y, Zoberi JE, Garcia-Ramirez JL, Maughan NM, Chapman W, Korenblat K, Henke LE, Kim H, Badiyan SN. Clinical Outcomes of Patients With Unresectable Primary Liver Cancer Treated With Yttrium-90 Radioembolization With an Escalated Dose. Adv Radiat Oncol 2022; 7:100948. [PMID: 35814852 PMCID: PMC9260102 DOI: 10.1016/j.adro.2022.100948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/15/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose Yttrium-90 (90Y) radioembolization with an escalated dose has been shown to improve clinical outcomes compared with standard dose radioembolization, but there are few data on the local control of primary liver tumors. We reported the clinical outcomes of patients with unresectable primary liver tumors treated with 90Y radioembolization with an escalated dose. Methods and Materials Clinical data of patients with unresectable hepatocellular carcinoma (HCC), cholangiocarcinoma (CC), and biphenotypic tumors (cHCC-CC) treated with radioembolization with an escalated dose (≥150 Gy) between 2013 and 2020 with >3 months follow-up were retrospectively reviewed. The primary endpoint was freedom from local progression. Clinical response was defined by Modified Response Evaluation Criteria in Solid Tumours and toxic effects were assessed using Common Terminology Criteria for Adverse Events version 5.0. Results Fifty-three patients with HCC and 15 patients with CC/cHCC-CC were analyzed. The median dose delivered was 205 Gy (interquartile range, 183-253 Gy) and 198 Gy (interquartile range, 154-234 Gy) for patients with HCC and CC/cHCC-CC, respectively. The 1-year freedom from local progression rate was 54% (95% confidence interval [CI], 38%-78%) for patients with HCC and 66% (95% CI, 42%-100%) for patients with CC/cHCC-CC. For patients with HCC, United Network for Organ Sharing nodal stage 1 (P = .01), nonsolitary tumors (P = .02), pretreatment α-fetoprotein of >7.7 ng/mL (P = .006), and ≤268 Gy dose delivered (P = .003) were predictors for local progression on multivariate Cox analysis. No patients with HCC who received a dose >268 Gy had a local tumor progression. The 1-year overall survival for patients with HCC was 74% (95% CI, 61%-89%). After radioembolization, 5 (7%) patients had grade 3 ascites, and 4 (6%) patients had grade 3/4 hyperbilirubinemia. Conclusions Treatment of unresectable primary liver tumors with 90Y radioembolization with an escalated dose was safe and well tolerated. Delivery of >268 Gy may improve local tumor control of HCC. Determination of the maximum tolerated dose needs to be performed in the context of future prospective dose-escalation trials to further evaluate the safety and efficacy of such an approach.
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Benabdallah N, Scheve W, Dunn N, Silvestros D, Schelker P, Abou D, Jammalamadaka U, Laforest R, Li Z, Liu J, Ballard DH, Maughan NM, Gay H, Baumann BC, Hobbs RF, Rogers B, Iravani A, Jha AK, Dehdashti F, Thorek DLJ. Practical considerations for quantitative clinical SPECT/CT imaging of alpha particle emitting radioisotopes. Theranostics 2021; 11:9721-9737. [PMID: 34815780 PMCID: PMC8581409 DOI: 10.7150/thno.63860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/15/2021] [Indexed: 02/05/2023] Open
Abstract
Rationale: Alpha particle emitting radiopharmaceuticals are generating considerable interest for the treatment of disseminated metastatic disease. Molecular imaging of the distribution of these agents is critical to safely and effectively maximize the clinical potential of this emerging drug class. The present studies aim to investigate the feasibility and limitations of quantitative SPECT for 223Ra, 225Ac and 227Th. Methods: Three state-of-the-art SPECT/CT systems were investigated: the GE Discovery NM/CT 670, the GE Optima NM/CT 640, and the Siemens Symbia T6. A series of phantoms, including the NEMA IEC Body phantom, were used to compare and calibrate each camera. Additionally, anthropomorphic physical tumor and vertebrae phantoms were developed and imaged to evaluate the quantitative imaging protocol. Results: This work describes and validates a methodology to calibrate each clinical system. The efficiency of each gamma camera was analyzed and compared. Using the calibration factors obtained with the NEMA phantom, we were able to quantify the activity in 3D-printed tissue phantoms with an error of 2.1%, 3.5% and 11.8% for 223Ra, 225Ac, and 227Th, respectively. Conclusion: The present study validates that quantitative SPECT/CT imaging of 223Ra, 225Ac, and 227Th is achievable but that careful considerations for camera configuration are required. These results will aid in future implementation of SPECT-based patient studies and will help to identify the limiting factors for accurate image-based quantification with alpha particle emitting radionuclides.
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Affiliation(s)
- Nadia Benabdallah
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
- Program in Quantitative Molecular Therapeutics, Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | | | - Diane Abou
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
- Program in Quantitative Molecular Therapeutics, Washington University School of Medicine, St. Louis, Missouri
| | - Uday Jammalamadaka
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Richard Laforest
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Zekun Li
- Department of Biomedical Engineering, Washington University, St. Louis, Missouri
| | - Jonathan Liu
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - David H. Ballard
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Nichole M. Maughan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Hiram Gay
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Brian C. Baumann
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Robert F. Hobbs
- Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Buck Rogers
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Amir Iravani
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Abhinav K. Jha
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
- Department of Biomedical Engineering, Washington University, St. Louis, Missouri
- Oncologic Imaging Program, Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Farrokh Dehdashti
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
- Oncologic Imaging Program, Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel L. J. Thorek
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
- Program in Quantitative Molecular Therapeutics, Washington University School of Medicine, St. Louis, Missouri
- Department of Biomedical Engineering, Washington University, St. Louis, Missouri
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- Oncologic Imaging Program, Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
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Mahon RN, Altman MB, Maughan NM, Mazur TR, Yaqoub M, Garcia-Ramirez JL, Zoberi I, Zoberi JE. PO09. Brachytherapy 2021. [DOI: 10.1016/j.brachy.2021.06.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Maughan NM, Kim H, Hao Y, Unangst S, Roach MC, Garcia-Ramirez JL, Amurao M, Luechtefeld D, Abdin K, Altman MB, Banks A, Riepe M, Bovard E, Jenkins S, Zoberi JE. Initial experience and lessons learned with implementing Lutetium-177-dotatate radiopharmaceutical therapy in a radiation oncology-based program. Brachytherapy 2020; 20:237-247. [PMID: 32819853 DOI: 10.1016/j.brachy.2020.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 06/05/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To assist radiation oncology centers in implementing Lutetium-177-dotatate (177Lu) radiopharmaceutical therapy for midgut neuroendocrine tumors. Here we describe our workflow and how it was revised based on our initial experience on an expanded access protocol (EAP). METHODS A treatment team/area was identified. An IV-pump-based infusion technique was implemented. Exposure-based techniques were implemented to determine completion of administration, administered activity, and patient releasability. Acute toxicities were assessed at each fraction. A workflow failure modes and effects analysis (FMEA) was performed. RESULTS A total of 22 patients were treated: 11 patients during EAP (36 administrations) and 11 patients after EAP (44 administrations). Mean 177Lu infusion time was 37 min (range 26-65 min). Mean administered activity was 97% (range 90-99%). Mean patient exposures at 1 m were 1.9 mR/h (range 1.0-4.1 mR/h) post-177Lu and 0.9 mR/h (range 0.4-1.8 mR/h) at discharge, rendering patients releasable with instructions. Treatment area was decontaminated and released same day. All patients in the EAP experienced nausea, and nearly half experienced emesis despite premedication with antiemetics. Peripheral IV-line complications occurred in six treatments (16.7%), halting administration in 2 cases (5.6%). We transitioned to peripherally inserted central catheter (PICC)-lines and revised amino acid formulary after the EAP. The second cohort of 11 patients after EAP were analyzed for PICC-line complications and acute toxicity. Nausea and emesis rates decreased (nausea G1+ 61%-27%; emesis G1+ 23%-7%), and no PICC complications were observed. FMEA revealed that a failure in amino acid preparation was the highest risk. CONCLUSION 177Lu-dotatate can be administered safely in an outpatient radiation oncology department.
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Affiliation(s)
- Nichole M Maughan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO.
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Yao Hao
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | | | - Michael C Roach
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Jose L Garcia-Ramirez
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Max Amurao
- Radiation Safety Division, EH&S Department, Washington University in St. Louis, St Louis, MO
| | - David Luechtefeld
- Radiation Safety Division, EH&S Department, Washington University in St. Louis, St Louis, MO
| | - Kinda Abdin
- Radiation Safety Division, EH&S Department, Washington University in St. Louis, St Louis, MO
| | - Michael B Altman
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Alexis Banks
- Department of Radiation Oncology, Barnes Jewish Hospital, St. Louis, MO
| | - Mary Riepe
- Department of Radiation Oncology, Barnes Jewish Hospital, St. Louis, MO
| | - Erica Bovard
- Department of Radiation Oncology, Barnes Jewish Hospital, St. Louis, MO
| | - Samantha Jenkins
- Department of Radiation Oncology, Barnes Jewish Hospital, St. Louis, MO
| | - Jacqueline E Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
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Maughan NM, Garcia-Ramirez J, Arpidone M, Swallen A, Laforest R, Goddu SM, Parikh PJ, Zoberi JE. Validation of post-treatment PET-based dosimetry software for hepatic radioembolization of Yttrium-90 microspheres. Med Phys 2019; 46:2394-2402. [PMID: 30742714 DOI: 10.1002/mp.13444] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 01/27/2019] [Accepted: 01/28/2019] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Yttrium-90 (90 Y) microsphere radioembolization enables selective internal radiotherapy for hepatic malignancies. Currently, there is no standard postdelivery imaging and dosimetry of the microsphere distribution to verify treatment. Recent studies have reported utilizing the small positron yield of 90 Y (32 ppm) with positron emission tomography (PET) to perform treatment verification and dosimetry analysis. In this study, we validated a commercial dosimetry software, MIM SurePlan™ LiverY90 (MIM Software Inc., Cleveland, OH), for clinical use. METHODS A MATLAB-based algorithm for 90 Y PET-based dosimetry was developed in-house and validated for the purpose of commissioning the commercial software. The algorithm is based on voxel S values and dosimetry formalism reported in MIRD Pamphlet 17. We validated the in-house algorithm to establish it as the ground truth by comparing results from a digital point phantom and a digital uniform cylinder to manual calculations. Once we validated our in-house MATLAB-based algorithm, we used it to perform acceptance testing and commissioning of the commercial dosimetry software, MIM SurePlan, which uses the same dosimetry formalism. A 0.4 cm/5% gamma test was performed on PET-derived dose maps from each algorithm of uniform digital and nonuniform physical phantoms filled with 90 Y chloride solution. Average dose (Davg ) and minimum dose to 70% (D70 ) of a given volume of interest (VOI) were compared for the digital phantom, the physical phantom, and five patient cases (27 tumor VOIs), representing different clinical scenarios. RESULTS The gamma-pass rates were 97.26% and 97.66% for the digital and physical phantoms, respectively. The differences between Davg and D70 were 0.076% and 0.10% for the digital phantom, respectively, and <5.2% for various VOIs in the physical phantom. In the clinical cases, 96.3% of the VOIs had a difference <5% for Davg , and 88.9% of the VOIs had a difference <5% for D70 . CONCLUSIONS Dose calculation results from MIM SurePlan were found to be in good agreement with our in-house algorithm. This indicates that MIM SurePlan performs as it should and, hence, can be deemed accepted and commissioned for clinical use for post-implant PET-based dosimetry of 90 Y radioembolization.
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Affiliation(s)
- Nichole M Maughan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Jose Garcia-Ramirez
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | | | | | - Richard Laforest
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - S Murty Goddu
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI, 48202, USA
| | - Jacqueline E Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
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Maughan NM, Eldib M, Faul D, Conti M, Elschot M, Knešaurek K, Leek F, Townsend D, DiFilippo FP, Jackson K, Nekolla SG, Lukas M, Tapner M, Parikh PJ, Laforest R. Multi institutional quantitative phantom study of yttrium-90 PET in PET/MRI: the MR-QUEST study. EJNMMI Phys 2018; 5:7. [PMID: 29616365 PMCID: PMC5882483 DOI: 10.1186/s40658-018-0206-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/16/2018] [Indexed: 12/22/2022] Open
Abstract
Background Yttrium-90 (90Y) radioembolization involves the intra-arterial delivery of radioactive microspheres to treat hepatic malignancies. Though this therapy involves careful pre-treatment planning and imaging, little is known about the precise location of the microspheres once they are administered. Recently, there has been growing interest post-radioembolization imaging using positron-emission tomography (PET) for quantitative dosimetry and identifying lesions that may benefit from additional salvage therapy. In this study, we aim to measure the inter-center variability of 90Y PET measurements as measured on PET/MRI in preparation for a multi-institutional prospective phase I/II clinical trial. Eight institutions participated in this study and followed a standardized phantom filling and imaging protocol. The NEMA NU2-2012 body phantom was filled with 3 GBq of 90Y chloride solution. The phantom was imaged for 30 min in listmode on a Siemens Biograph mMR non-TOF PET/MRI scanner at five time points across 10 days (0.3–3.0 GBq). Raw PET data were sent to a central site for image reconstruction and data analysis. Images were reconstructed with optimal parameters determined from a previous study. Volumes of interest (VOIs) matching the known sphere diameters were drawn on the vendor-provided attenuation map and propagated to the PET images. Recovery coefficients (RCs) and coefficient of variation of the RCs (COV) were calculated from these VOIs for each sphere size and activity level. Results Mean RCs ranged from 14.5 to 75.4%, with the lowest mean RC coming from the smallest sphere (10 mm) on the last day of imaging (0.16 MBq/ml) and the highest mean RC coming from the largest sphere (37 mm) on the first day of imaging (2.16 MBq/ml). The smaller spheres tended to exhibit higher COVs. In contrast, the larger spheres tended to exhibit lower COVs. COVs from the 37 mm sphere were < 25.3% in all scans. For scans with ≥ 0.60 MBq/ml, COVs were ≤ 25% in spheres ≥ 22 mm. However, for all other spheres sizes and activity levels, COVs were usually > 25%. Conclusions Post-radioembolization dosimetry of lesions or other VOIs ≥ 22 mm in diameter can be consistently obtained (< 25% variability) at a multi-institutional level using PET/MRI for any clinically significant activity for 90Y radioembolization.
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Affiliation(s)
- Nichole M Maughan
- Department of Radiation Oncology, Washington University School of Medicine, 4921 Parkview Place, Campus Box 8224, St. Louis, MO, 63110, USA
| | - Mootaz Eldib
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY, 10029, USA.,Department of Biomedical Engineering, City College of New York, 160 Convent Ave, New York, NY, 10031, USA
| | - David Faul
- Siemens Healthineers, Siemens Medical Solutions USA, Inc., 40 Liberty Boulevard, Malvern, PA, 19355-9998, USA
| | - Maurizio Conti
- Molecular Imaging, Siemens Healthineers, 810 Innovation Dr, Knoxville, TN, 37932, USA
| | - Mattijs Elschot
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Postboks 8905, 7491, Trondheim, Norway
| | - Karin Knešaurek
- Department of Radiology, Icahn School of Medicine at Mt. Sinai, One G. Levy Pl., Box 1141, New York, NY, 10029, USA
| | - Francesca Leek
- Agency for Science Technology and Research, National University of Singapore Clinical Imaging Research Centre, 14 Medical Drive, #B1-01, Singapore, 117599, Singapore
| | - David Townsend
- Agency for Science Technology and Research, National University of Singapore Clinical Imaging Research Centre, 14 Medical Drive, #B1-01, Singapore, 117599, Singapore
| | - Frank P DiFilippo
- Department of Nuclear Medicine, Cleveland Clinic, Mail Code Jb3, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | | | - Stephan G Nekolla
- Klinik und Poliklinik für Nuklearmedizin, TU München, Strasse 22, 81675, Munich, Germany
| | - Mathias Lukas
- Department of Nuclear Medicine, Charité-Universitätsmedizin Berlin, Charitépl. 1, 10117, Berlin, Germany.,Siemens Healthcare GmbH, Berlin, Germany
| | - Michael Tapner
- Sirtex Medical Ltd, Level 33, 101 Miller St, North Sydney, NSW, 2060, Australia.,ABX-CRO Advanced Pharmaceutical Services, 1 Begonia Road, Normanhurst, NSW, 2076, Australia
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University School of Medicine, 4921 Parkview Place, Campus Box 8224, St. Louis, MO, 63110, USA.
| | - Richard Laforest
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway, Campus Box 8225, St. Louis, MO, 63110, USA
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Maughan NM, Garcia-Ramirez J, Arpidone M, Swallen A, Laforest R, Goddu SM, Parikh PJ, Zoberi JE. Commissioning of Post-Treatment PET-Based Dosimetry Software for Hepatic Radioembolization with Yttrium-90 Microspheres. Brachytherapy 2017. [DOI: 10.1016/j.brachy.2017.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Maughan NM, Eldib M, Conti M, Knešaurek K, Faul D, Parikh PJ, Fayad ZA, Laforest R. Phantom study to determine optimal PET reconstruction parameters for PET/MR imaging of
90
Y microspheres following radioembolization. Biomed Phys Eng Express 2016. [DOI: 10.1088/2057-1976/2/1/015009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Maughan NM, Moody JW, Miller DR. Monte Carlo simulation of near-infrared light propagation through homogeneous mixed media. J Biomed Opt 2013; 18:105007. [PMID: 24145661 DOI: 10.1117/1.jbo.18.10.105007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 10/01/2013] [Indexed: 06/02/2023]
Abstract
ABSTRACT. Noninvasive blood analysis devices that can measure levels of small constituents of blood are of interest in the medical community. An important step in creating these devices is to understand the interaction of photons with human tissue in increasingly greater physiological detail. Models based on layered biological materials give excellent results for many applications but may not be as accurate as needed when those materials are finely intertwined to the point of resembling a homogeneous mixture. To explore the ramifications of treating materials as layers versus a mixture, we have modeled, using a Monte Carlo technique, the interaction of photons through epidermis, blood, and water arranged both in layers and in a homogeneous blend. We confirm the expected linear relation between photon attenuation and material volumetric percentage in two-layer models. However, when the materials are homogeneously mixed together and volumetric percentage is replaced with interaction volume percentage, this relationship becomes nonlinear. These nonlinearities become significant when the values of the interaction coefficient, μt, differ by an order of magnitude or more.
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Affiliation(s)
- Nichole M Maughan
- Brigham Young University, Physics and Astronomy Department, N283 ESC, Provo, Utah 84602
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