Practical Tools for Patient-specific Characterization and Dosimetry of Radiopharmaceutical Extravasation

Wilson, Sean; Osborne, Dustin; Long, Misty; Knowland, Josh; Fisher, Darrell R.

doi:10.1097/hp.0000000000001600

Cited by 10 publications

(12 citation statements)

References 31 publications

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“…Therapy delivery characteristics were assessed by using an external radiation detector system (Lucerno Dynamics, Cary, NC) that uses modular detectors connected to a readout where results can be uploaded and displayed. This system is an FDA listed device for injection monitoring with which our group has extensive operational experience having used these systems for nearly ten years and published many conference abstracts and peer-reviewed publications using these devices (14)(15)(16)(17)(18). The platform also includes a real-time readout of the count rate during acquisition (Figure 2A).…”

Section: Therapy Deliverymentioning

confidence: 99%

Insights into handling and delivery of Y-90 radioembolization therapies

et al. 2023

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IntroductionThe use of Y-90 radioembolization techniques has become a standard tool for the treatment of liver cancer and metastatic diseases that result in liver lesions. As there are only two approved forms of radioembolization therapy, the procedures for use are also fairly standardized even though exact international and interdepartmental procedures can vary. What has been less published over the years are the nuanced differences in delivery techniques and handling of the two available Y90 radioembolization therapies. This paper seeks to examine various aspects of delivery techniques, product handling, and radiation exposure that differ between the available and approved products. Understanding these differences can assist with providing more efficient treatment, confirmation of accurate therapy, more informed handling of the products, and improved training of physicians and other hospital staff.MethodsTwo commercially available and approved radioembolization devices were compared to assess nuanced, but key differences between the available products regarding therapy delivery, handling of the products, and radiation exposure to patients and staff. This work is broken into two sections: (1) Therapy Delivery, (2) Radiation Safety. Therapy delivery characteristics were assessed by using an external radiation detector system with detectors placed inside of each delivery system facing the dose vial and on the output catheter lines to the patient. Additional detectors were placed near the liver of the patient and on top of the foot to measure extremities. Data were acquired continuously throughout therapy delivery to collect time activity curves (TACs) for the characterization of each therapy. These data were analyzed to assess if (a) real-time monitoring of radiation could be used to provide an accurate assessment of residual dose before the patient leaves the procedure room, and (b) can dose delivery characteristics be observed that enable improved training and quality control. Calculation of residual dose using the external detector TACs was performed by analyzing initial and final activity peaks to determine measured count rate differences. Radiation safety aspects were assessed by monitoring radiation exposure to staff handling each of the available therapy products. Nuclear medicine technologists and interventional radiology physician body and hand doses were measured for each delivered therapy using standard body and ring dosimeters. The TACs noted above collected for the liver and extremities were used to assess if any off-target or leached Y90 activity could be detected for each therapy. Blood was collected at times before, during, and after treatment and then counted on a gamma counter to assess differences in free Y90 circulating in the blood. Each patient in this study also received a post-treatment whole-body PET/CT at 2–4 h post-infusion to assess for any aggregate free Y90 deposition that may have resulted from circulating free Y90 in the subject following therapy.ResultsCalculations of residual dose in the vial following therapy using the real-time detection methods resulted in values that were not statistically different from the values calculated by nuclear medicine following the procedure (p>0.05). Real-time collection of dose delivery data enabled observation of key characteristics related to each delivery method. For SIR-spheres procedures, the cycle of pushing the dose and visualizing with fluoro can easily be seen with each push resulting in a smaller and smaller peak with intermittent fluoroscopy pulses. TheraSpheres infusions show a rapid bolus with nearly all of the measurable injected activity being infused in the first push of the dose. Staff radiation exposure assessments showed statistically significant differences between glass and resin spheres for hand doses of physicians and technologists (p > 0.05), but no statistical difference between body doses for both products (p>0.05). Assessments of free Y90 circulating during therapy showed that patients undergoing therapies with resin spheres had post-infusion blood levels that were 120% higher than pre-infusion levels while glass sphere therapy patients only saw a 7% rise in post-infusion blood levels. The coefficients of variation (COVs) across glass sphere measurements pre, during, and post, were only 0.008 while resin sphere measures saw much greater variability with a COV of 0.45. Both glass and resin therapies showed blood levels at 2–4 h post-injection to be similar to levels measured pre-injection. Neither therapy showed any signs of focal aggregation at 2–4 h post-infusion on whole-body PET/CT.ConclusionAlthough glass and resin radioembolization therapies are similar, they both have unique characteristics related to their administration and handling by staff. Understanding the nuances can assist in providing more efficient delivery, better staff education, and reducing radiation exposure to everyone involved with these therapies. The use of near real-time monitoring is feasible and can be used to obtain critical information about the delivery success of a therapy and can inform physicians on their techniques to optimize their practice as well as provide more consistent training to residents.

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Section: Therapy Deliverymentioning

confidence: 99%

Insights into handling and delivery of Y-90 radioembolization therapies

et al. 2023

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“…Cases of negligible extravasation can be quickly confirmed to have no impact on the patient or imaging procedure. For more severe examples, a simple process of characterization can be used to assess not only the need for reimaging, but also the potential radiological affects to the patient (9,10). Based on the criteria discussed above, only one case warranted reimaging.…”

Section: The Decision-making Processmentioning

confidence: 99%

“…When properly administered, radiopharmaceuticals are dispersed throughout the body and result in very low radiation dose for the patient. However, for cases of extravasation, dose to the injection site tissue can be substantial (9)(10)(11)(12)(13)(14)(15)(16). The published literature includes examples where radiopharmaceutical extravasation has caused tissue damage such as erythema, desquamation, and necrosis (13,14,(17)(18)(19)(20)(21) as well as increased risk of cancer (22).…”

Section: Introductionmentioning

confidence: 99%

The decision to reimage following extravasation in diagnostic nuclear medicine

Kiser

2023

Front. Nucl. Med.

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The primary goal of diagnostic nuclear medicine is to provide complete and accurate reports without equivocation or disclaimers. If specific clinical questions cannot be answered because of radiopharmaceutical extravasation, the imaging study may have to be repeated. The decision to reimage is based on several factors including the diagnostic quality of the images, additional patient radiation dose, patient burden, and administrative constraints. Through process improvement efforts, nuclear medicine departments can significantly reduce the frequency of extravasation and thereby also the need for reimaging. Communication with the patient is important any time extravasation may impact their immediate or future care. The circumstances and potential ramifications should be explained, and patient concerns should be addressed. Although recent arguments have been made in favor of investigating and addressing only those extravasations which result in serious patient injury, patients and their referring physicians deserve to know any time their nuclear medicine study may have been impacted.

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“…Additional modifiable and non-modifiable risk factors that have been reported to increase risk of contrast-related extravasation, such as with CT, PET and/or MRI, have been reported to be female sex, inpatient status, older age, high injection rates, catheter location, high-density contrast, failing to warm up viscous contrast media, and indwelling site [51][52][53]56,59,[61][62][63]. In reference to radiotracers, the dose absorbed into the tissues depends on the initial amount of paravenous radioactivity, the mass of infiltrated tissue, the type of radiopharmaceutical, and the length of time the extravasated product remains near the injection site [64]. The length of time is influenced by the patient's anatomy, vascular health, and injection rate [64].…”

Section: Infiltrationmentioning

confidence: 99%

The Clinical and Economic Burdens of Infiltration and Extravasation with Peripheral Intravenous Catheters: A Contemporary Narrative Review

2023

Int J Nurs Health Care Res

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Infiltration and extravasation are complications of peripheral intravenous catheter (PIVC) use, and some of the most common causes of catheter failure. The objective of this contemporary review is to characterize the incidence, risk factors, and clinical and economic consequences of PIVC-related infiltration and extravasation, as well as strategies for prevention. Recent evidence demonstrates that infiltration incidence ranges from 13% to 20%. Extravasation is less frequent, with a reported incidence of up to 4.5%. There are numerous patient and procedure-related factors that increase the risk of infiltration and extravasation, which are caused by the infusion of either a non-vesicant or vesicant, respectively. Infiltration is often perceived as a minor complication, but can result in skin damage (e.g., scars, blisters), infections, and nerve damage, amongst other injuries, while extravasation can occasionally lead to severe consequences such as tissue necrosis and even limb loss. Both infiltration and extravasation may require additional venipunctures, resulting in treatment delays and patient discomfort. In addition to the clinical consequences, infiltration and extravasation are associated with high economic burden. This review also highlights how different considerations should be taken based on the type of extravasations that may occur with PIVC administration of contrast media, radiopharmaceuticals, vasopressors, and chemotherapy. Ultimately, use of PIVCs requires careful risk assessment and mitigation, effective monitoring and diagnosis, and timely treatment to prevent or minimize the unnecessary burdens of infiltration and extravasation for the patient and healthcare system.

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Practical Tools for Patient-specific Characterization and Dosimetry of Radiopharmaceutical Extravasation

Cited by 10 publications

References 31 publications

Insights into handling and delivery of Y-90 radioembolization therapies

Insights into handling and delivery of Y-90 radioembolization therapies

The decision to reimage following extravasation in diagnostic nuclear medicine

The Clinical and Economic Burdens of Infiltration and Extravasation with Peripheral Intravenous Catheters: A Contemporary Narrative Review

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