[Show abstract][Hide abstract] ABSTRACT: As hospital nuclear medicine departments were established in the 1960s and 1970s, each department developed detailed policies and procedures to meet the specialized and specific handling requirements of radiopharmaceuticals. In many health systems, radiopharmaceuticals are still unique as the only drugs not under the control of the health system pharmacy; however, the clear trend--and now an accreditation requirement--is to merge radiopharmaceutical management with the overall health system medication management system. Accomplishing this can be a challenge for both nuclear medicine and pharmacy because each lacks knowledge of the specifics and needs of the other field. In this paper we will first describe medication management standards, what they cover, and how they are enforced. We will describe how we created a nuclear medicine and pharmacy team to achieve compliance, and we will present the results of their work. We will examine several specific issues raised by incorporating radiopharmaceuticals in the medication management process and describe how our team addressed those issues. Finally, we will look at how the medication management process helps ensure ongoing quality and safety to patients through multiple periodic reviews. The reader will gain an understanding of medication management standards and how they apply to nuclear medicine, learn how a nuclear medicine and pharmacy team can effectively merge nuclear medicine and pharmacy processes, and gain the ability to achieve compliance at the reader's own institution.
Journal of Nuclear Medicine Technology 03/2012; 40(1):1-10. DOI:10.2967/jnmt.111.094268
[Show abstract][Hide abstract] ABSTRACT: The thyroid gland was one of the first organs imaged in nuclear medicine, beginning in the 1940s. Thyroid scintigraphy is based on a specific phase or prelude to thyroid hormone synthesis, namely trapping of iodide or iodide analogues (ie, Tc99m pertechnetate), and in the case of radioactive iodine, eventual incorporation into thyroid hormone synthesis within the thyroid follicle. Moreover, thyroid scintigraphy is a reflection of the functional state of the gland, as well as the physiological state of any structure (ie, nodule) within the gland. Scintigraphy, therefore, provides information that anatomical imaging (ie, ultrasound, computed tomography [CT], magnetic resonance imaging) lacks. Thyroid scintigraphy plays an essential role in the management of patients with benign or malignant thyroid disease. In the former, the structure or architecture of the gland is best demonstrated by anatomical or cross-sectional imaging, such as ultrasound, CT, or even magnetic resonance imaging. The role of scintigraphy, however, is to display the functional state of the thyroid gland or that of a clinically palpable nodule within the gland. Such information is most useful in (1) patients with thyrotoxicosis, and (2) those patients whose thyroid nodules would not require tissue sampling if their nodules are hyperfunctioning. In neoplastic thyroid disease, thyroid scintigraphy is often standard of care for postthyroidectomy remnant evaluation and in subsequent thyroid cancer surveillance. Planar radioiodine imaging, in the form of the whole-body scan (WBS) and posttherapy scan (PTS), is a fundamental tool in differentiated thyroid cancer management. Continued controversy remains over the utility of WBS in a variety of patient risk groups and clinical scenarios. Proponents on both sides of the arguments compare WBS with PTS, thyroglobulin, and other imaging modalities with differing results. The paucity of large, randomized, prospective studies results in dependence on consensus expert opinion and retrospective analysis with inherent bias. With a growing trend not to ablate low-risk patients, so that a PTS cannot be performed, some thyroid carcinoma patients may never have radioiodine imaging. In routine clinical practice, however, imaging plays a critical role in patient management both before and after treatment. Moreover, as evidenced by the robust flow of publications concerning WBS and PTS, planar imaging of thyroid carcinoma remains a topic of great interest in this modern age of rapidly advancing cross sectional and hybrid imaging with single-photon emission computed tomography, single-photon emission computed tomography/CT, and positron emission tomography/CT.
Seminars in nuclear medicine 01/2012; 42(1):49-61. DOI:10.1053/j.semnuclmed.2011.07.004 · 3.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Indium-111 leukocyte scintigraphy is used widely in the setting of fever of unknown origin. This modality has variable reported ranges of sensitivity and specificity; however, it is a useful technique in establishing the cause of fever of unknown origin. We describe a case of 47-year-old woman who presented with fever and leukocytosis and was subsequently found to have tubo-ovarian abscess detected by Indium-111 leukocyte scintigraphy. The anatomic imaging in this case was nonspecific. We conclude that Indium-111 leukocyte scintigraphy is useful in diagnosis of tubo-ovarian abscess, and positive findings warranted surgical exploration in this patient.
Clinical nuclear medicine 04/2011; 36(4):300-2. DOI:10.1097/RLU.0b013e31820a9f13 · 3.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Survival from differentiated thyroid carcinoma is generally good, but postoperative management plays an important role in minimizing the likelihood of disease recurrence. Postoperative management is generally performed by endocrinologists and nuclear medicine physicians, who exploit thyroid cells' inherent iodineavidity and sensitivity to hormonal manipulation in a unique cancer management paradigm. Endocrinologists manage thyroid hormone replacement/thyroid stimulating hormone suppression and coordinate surveillance. Nuclear physicians administer targeted therapy with radioactive iodine and perform imaging studies to assess disease status. This article provides an overview of the postoperative assessment, treatment, and follow-up of patients who have thyroid carcinoma.
Surgical Oncology Clinics of North America 02/2008; 17(1):197-218, x. DOI:10.1016/j.soc.2007.10.003 · 1.81 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Blood volume studies using the indicator dilution technique and radioactive tracers have been performed in nuclear medicine departments for over 50 y. A nuclear medicine study is the gold standard for blood volume measurement, but the classic dual-isotope blood volume study is time-consuming and can be prone to technical errors. Moreover, a lack of normal values and a rubric for interpretation made volume status measurement of limited interest to most clinicians other than some hematologists. A new semiautomated system for blood volume analysis is now available and provides highly accurate results for blood volume analysis within only 90 min. The availability of rapid, accurate blood volume analysis has brought about a surge of clinical interest in using blood volume data for clinical management. Blood volume analysis, long a low-volume nuclear medicine study all but abandoned in some laboratories, is poised to enter the clinical mainstream. This article will first present the fundamental principles of fluid balance and the clinical means of volume status assessment. We will then review the indicator dilution technique and how it is used in nuclear medicine blood volume studies. We will present an overview of the new semiautomated blood volume analysis technique, showing how the study is done, how it works, what results are provided, and how those results are interpreted. Finally, we will look at some of the emerging areas in which data from blood volume analysis can improve patient care. The reader will gain an understanding of the principles underlying blood volume assessment, know how current nuclear medicine blood volume analysis studies are performed, and appreciate their potential clinical impact.
Journal of Nuclear Medicine Technology 07/2007; 35(2):55-63; quiz 77, 79. DOI:10.2967/jnmt.106.035972
[Show abstract][Hide abstract] ABSTRACT: Positron emission tomography (PTE) and PET/CT imaging with (18)F-fluorodeoxyglucose are metabolic imaging modalities that depict tissues based on their level of glucose uptake. PET provides useful information in the primary staging of disease. PET performance in detecting locoregional nodal metastases is limited; however, it is the most accurate single noninvasive modality for detecting distant metastases. It is the imaging modality of choice for whole-body scanning in high-risk patients or patients who have clinically suspected recurrence, and is particularly helpful in determining which patients are the best candidates for surgical cure.
Surgical Oncology Clinics of North America 11/2006; 15(4):733-49. DOI:10.1016/j.soc.2006.07.013 · 1.81 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: PURPOSE
To determine if stunning occurs with a diagnostic dose of 5mCi of I-131 in patients with well-differentiated thyroid cancer (WDTC), and if stunning does occur, does it impact I-131 therapeutic efficacy and patient outcome?
METHOD AND MATERIALS
A retrospective review involved 166 post-thyroidectomy patients for WDTC. Diagnostic whole-body scans were performed 48 hours after 5 mCi of I-131. The therapeutic doses of I-131 ranged from 100 to 250 mCi, gien on 5 to 7 days after the diagnostic scan. A post-therapy scan was then obtained 7 days later. Stunning was defined when the diagnostic scan showed activity that was subsequently decreased on the post-therapy scan. The patients were divided into 2 groups: Group NS did not show stunning and Group S revealed stunning. Patient outcome was considered successful if no functioning thyroid tissue and/or metastases were seen on subsequent one-year follow-up diagnostic I-131 scans. The treatment success rate for each group was defined as the total number of patients in the group divided by the number of patients with successful outcomes.
Group NS consisted of 135 patients, of whom 36 were lost to follow-up. Group S included 31 patients of whom 8 were lost to follow-up. Of the 99 patients studied in Group NS, 87 demonstrated a successful outcome at 12-month follow-up, resulting in a treatment success ratio of 87.9%. Of the 23 patients studied in Group S, 20 demonstrated a successful outcome 12 months later, yielding a treatment success rate of 87.0%. Overall, there was no statistically significant difference (p=0.56) in treatment success rates between Group NS (87.9%) and Group S (87.0%). Treatment success rates for metastases (mostly lymph nodes) were 88.06% (39/44) for Group NS and 83.3% (10/12) for Group S (p=0.55).
Thyroid stunning can occur with 5mCi of I-131 for diagnostic imaging. However, stunning has no signigicant effect on I-131 treatment efficacy, and therefore does not significantly impact patient outcome.
Radiological Society of North America 2005 Scientific Assembly and Annual Meeting; 12/2005
[Show abstract][Hide abstract] ABSTRACT: The management of patients with differentiated thyroid cancer has changed significantly over the last few decades. Mortality has decreased as the result of earlier detection, refined surgical approaches, subsequent radioiodine ablation, and the development of more sensitive methods for detecting and monitoring disease recurrence. The latter has been facilitated by serum thyroglobulin measurements, the use of recombinant human thyrotropin, and the use of 18F-deoxyglucose/positron emission tomography in selected instances where radioiodine imaging fails to locate known or suspected recurrent or metastatic disease.
Seminars in Nuclear Medicine 11/2005; 35(4):257-65. DOI:10.1053/j.semnuclmed.2005.05.003 · 3.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine if stunning can be seen with a 185-MBq (5-mCi) dose of iodine 131 (131I) at diagnostic whole-body scanning and, if stunning is seen, determine if there is any 131I therapeutic efficacy.
A retrospective review of findings involving 166 patients who underwent thyroidectomy for differentiated thyroid carcinoma was performed. Diagnostic 131I scans were compared with postablation scans for evidence of stunning. Stunning was defined when the diagnostic scan showed activity that was subsequently decreased on the postablation scan. The sample population was divided into two groups: group NS, patients with no stunning, and group S, patients with stunning. Patients were considered successfully treated if no functioning thyroid tissue and/or metastases were seen on follow-up diagnostic scans. Fisher exact and Student t tests were used to evaluate the statistical significance of therapy success rates, clinical characteristics, and scanning parameters between the two groups.
Group NS included 135 (81.3%) of 166 patients, with 36 (26.7%) of 135 lost to follow-up. Group S included 31 (18.7%) of 166 patients, with eight (26%) of 31 patients lost to follow-up. There was no significant difference (P =.61) in treatment success rates between group NS (87 of 99, 88%) and group S (21 of 23, 91%). The treatment success rates for thyroid remnants were 87% (48 of 55) for group NS and 91% (10 of 11) for group S (P =.63). Treatment success rates for metastases (mostly lymph nodes) were 89% (39 of 44) for group NS and 83% (10 of 12) for group S (P =.55).
Thyroid stunning can occur with 185 MBq of 131I in diagnostic imaging. However, data did not show any effect of stunning on the efficacy of 131I therapy for differentiated thyroid carcinoma.