Consequences of radiopharmaceutical extravasation and therapeutic interventions: a systematic review

Abstract

PurposeRadiopharmaceutical extravasation can potentially lead to severe soft tissue damage, but little is known about incidence, medical consequences, possible interventions, and effectiveness of these. The aims of this study are to estimate the incidence of extravasation of diagnostic and therapeutic radiopharmaceuticals, to evaluate medical consequences, and to evaluate medical treatment applied subsequently to those incidents.MethodsA sensitive and elaborate literature search was performed in Embase and PubMed using the keywords “misadministration”, “extravasation”, “paravascular infiltration”, combined with “tracer”, “radionuclide”, “radiopharmaceutical”, and a list of keywords referring to clinically used tracers (i.e. “Technetium-99m”, “Yttrium-90”). Reported data on radiopharmaceutical extravasation and applied interventions was extracted and summarised.ResultsThirty-seven publications reported 3016 cases of diagnostic radiopharmaceutical extravasation, of which three cases reported symptoms after extravasation. Eight publications reported 10 cases of therapeutic tracer extravasation. The most severe symptom was ulceration. Thirty-four different intervention and prevention strategies were performed or proposed in literature.ConclusionsExtravasation of diagnostic radiopharmaceuticals is common. 99mTc, 123I, 18F, and 68Ga labelled tracers do not require specific intervention. Extravasation of therapeutic radiopharmaceuticals can give severe soft tissue lesions. Although not evidence based, surgical intervention should be considered. Furthermore, dispersive intervention, dosimetry and follow up is advised. Pharmaceutical intervention has no place yet in the immediate care of radiopharmaceutical extravasation.

Tissue dose estimation after extravasation of 177Lu-DOTATATE  

“…The purpose of the second one was to get a more accurate result to confront with the patient follow-up. Dosimetric data for extravasation cases are scarce in the literature (1). No data have been published for 177 Lu-DOTATATE, it was then really di cult to estimate the consequences of the extravasation without dosimetric evaluation.…”

“…As any intravenous administration, extravasation may occur during 177 Lu-DOTATATE injection. The retention of beta emitter in soft tissues can lead to very severe tissue damage (1).…”

“…One case was presented as a commented image of the patient 2, 20 and 40 h post injection (5) and the second is a brief case report with low details on dose calculation (6). Dosimetric evaluations are rare in extravasation cases (1). Dose calculation requires several acquisitions, whole body or SPECT/CT, to determine an effective period.…”

EANM guidelines for radionuclide therapy of bone metastases with beta-emitting radionuclides

“…There are very limited data regarding the procedure, but cooling the site of extravasation can prevent radionuclide spread. In case of circulatory or nerve impairment, surgery may be indicated [ 60 ].…”

Technical Note: Characterization of technology to detect residual injection site radioactivity

“…The accuracy of quantitative imaging is assured by processes including clock synchronization, residual syringe activity subtraction, patient weight measurement, and patient blood glucose measurement. [4][5][6][7][8][9] Inaccuracies can introduce image errors that negatively affect disease staging, 1,[10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] interpretation of longitudinal disease progression, 10,[12][13][14][15][30][31][32][33][34][35][36][37][38][39][40][41][42][43] tumor volume measurements, 44 myocardial perfusion measurements, 1,31,...…”