MONTHLY SCAN
Volume XV Issue III
May 2010
In This Issue
Ceretec Scintigraphy
Tl-201 vs ECHO
Filtered Sulfur Colloid and Lidocaine
NRC Report: I131 in Feeding Tube
Hepatobiliary Scintigraphy: Sources of Error
I-123 MIBG Has Value
Medicare Cuts Delayed
CE Opportunity: Evansville Seminar
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Case Study of the Month

Neuroblastoma (I-123 MIBG Imaging



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March 2009
January 2009

Previous Issues 

Free Continuing Education
(see article to below)

Anatomy and Physiology Review for Nuclear Medicine Technology - 2009 Update

Cardiac Electrophysiology for Nuclear Medicine Technology - 2007 Update

Correct Coding for Diagnostic Nuclear Medicine Procedures, Part 1
 
Myocardial Perfusion Imaging - 2009 Update

 Stress Testing in Cardiac Nuclear Medicine Technology - 2009 Update




Technetium-99m (Tc-99m) Supply Update

Dear Radiopharmacy Customer,

Below is updated, and hopefully more easily understandable, forecast of the Technetium-99m (Tc-99m) supply for the next three months.  Please keep in mind that the above are only estimates that we have received from our suppliers.  Their estimates in the past have not always been accurate, and the weekly situations can change for the better or worse.  We will continue to keep you informed as we receive updated information.


Normal Tc99m:  sufficient Tc99m supply to schedule all patients

 

Normal non-cardiac Tc99m/Rationed Tc99m cardiac:  Tl201 available for cardiac studies

 

Possible rationed Tc99m:  Tl201 available for cardiac studies.  Limited supply of Tc99m for non-cardiac studies

 

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99mTc-Exametazime (HMPAO)-Labeled Leukocyte Scintigraphy:  
Interpretation Criteria
Accurate interpretation of labeled leukocyte scintigraphy requires knowledge of the normal and abnormal variants of leukocyte localization.
Tc99m Ceretec WBC Whole Body Scan.  Normal.

1. Normal Findings
  • The blood clearance half-life of 99mTc-leukocytes is about 4 h, and delayed images (longer than 4 h) may be preferred for detection of vascular graft or dialysis shunt infection. 111In-leukocytes may be preferred for detection of vascular graft or dialysis shunt infection, because blood pool activity is much lower relative to sites of abnormal localization (especially on 18-24-h delayed images)
  • Bowel activity secondary to secretion of 99mTc complexes is seen in 20%-30% of children by 1 h but is usually not seen in adults before 4 h. In adults, physiologic bowel activity is usually faint if seen at 4 h and is usually seen in the terminal ileum or right colon, increasing over time.
  • Renal and bladder activity is seen by 15-30 min in all patients with normal renal function. The patient should try to empty his/her bladder before pelvic imaging.
  • Uniform physiologic gallbladder activity can be seen in 4% of patients by 2-4-h and up to 10% of patients by 24 h. A curvilinear pattern at the margin is suspicious for inflammation of the gallbladder wall.
  • The spleen, liver, bone marrow, kidneys, bowel, bladder, and major blood vessels will normally be visualized.
2. Abnormal Findings
  • Abnormal bowel localization may be seen by 15-30 min and usually increases in intensity over the next 2-3 h.
  • The degree and extent of bowel disease is usually demonstrated by 1-2 h.
  • Shifting patterns of bowel activity on later images usually indicates distal transit of labeled granulocytes or, at times, bleeding within the bowel lumen.
  • Lung activity usually clears by 4 h, unless there is pulmonary edema, diffuse inflammatory lung disease, atelectasis, renal failure, sepsis, or adult respiratory distress syndrome.
  • Focal abdominal activity outside the liver and bowel is likely to indicate infection/ inflammation but can vary greatly in intensity depending on the degree of inflammation.
  • Caution should be used in interpretation of a focal site of abnormal localization, as indicating a drainable abscess and correlation with other imaging modalities is recommended.
  • Infection involving the spine may present as areas of increased or decreased activity compared with normal bone marrow localization.
  • Photopenic or "cold" defects may indicate osteomyelitis, but other causes, such as compression fracture, neoplasm, postirradiation changes, or postsurgical or anatomic deformities, should also be considered.   

Diagnosis

Early Imaging

Delayed Imaging

16-24 hr Imaging

 

 

 

Abdominal Abscess

 

0.5-1h for Adults

 

20-40 min for children

 

 

 

Sequential to 4 h

 

Rarely, if early images are negative (requires longer imaging times)

 

 

Inflammatory or Ischemic Bowel Disease

 

0.5 - 1 h for adults

 

20-40 min for children

 

Sequential up to 4 h;

physiologic bowel activity may interfere on later images

 

Usually not indicated, because physiologic bowel activity is present

 

 

Chest-Pulmonary infection

 

Physiologic lung activity may interfere

 

 

 

4-8 h

 

If early images are negative (requires longer imaging times)

 

 

 

Osteomyletis

May not have sufficient localization

 

 

 

4-8 h

 

If early images are negative or equivocal (requires longer imaging times)

 



201Tl-Gated SPECT vs Echo in LVEF Assessment
The February issue of the Clinical Cardiology reported on a study comparing 2-dimensional echocardiography (2-DE) with 201Tl-gated SPECT in assessment of left ventricular ejection fraction (LVEF). The study included 402 patients, all of whom underwent 201Tl-gated SPECT in the same laboratory and then underwent 2-DE in either a tertiary hospital or a community laboratory. LVEF evaluations were similar between SPECT and 2-DE, regardless of the site at which 2-DE was performed. Because patients who underwent in-hospital 2-DE had higher rates of past myocardial infarction than the community group (46.7% and 22.2%, respectively), the latter group had higher average LVEFs, reflected in both types of imaging. The authors concluded that because ''201Tl-gated SPECT is a reliable clinical tool for LVEF assessment, with good correlation when compared to 2 DE'' it may be ''routinely used as an alternative for patients with poor acoustic visualization and should be performed systematically in patients undergoing myocardial perfusion imaging with 201Tl.''

--Clinical Cardiology

Evaluation of Radiochemical Purity and Particle Size of 99mTc-Sulfur Colloid Subsequent to the Addition of Lidocaine 
The following is an abstract from the most recent JNM issue.

The use of 99mTc-sulfur colloid lymphoscintigraphy for the determination of lymph flow patterns from a tumor site and localization of the sentinel node has been widely adopted. However, the effects of multiple injections of the radiopharmaceutical can range from mild discomfort to painful. Lidocaine HCl co-administered with 99mTc-sulfur colloid can help alleviate this problem but may potentially introduce instability of the radiopharmaceutical, which could lead to aggregation, possibly impeding the kinetics of lymphatic drainage from the tumor site.
Methods: In the present study, lidocaine was added to 99mTc-sulfur colloid radiopharmaceutical to evaluate effects on radiochemical purity and particle size.  
Results: The study revealed that the formulation of lidocaine added to 99mTc-sulfur colloid did not effect particle size or radiochemical purity.
Conclusion:  The results showed that pH-adjusted lidocaine-99mTc-sulfur colloid had comparable results to the two samples without lidocaine in both areas tested (particle size & radiochemical purity).

--J Nucl Med Technol. 2010 Mar;38(1):49-52.



NRC Report:  131I in Feeding Tube
The San Diego Union Tribune reported recently the case of a patient at the San Diego Veterans Affairs (VA) Medical Center (La Jolla, CA) being treated for thyroid cancer, the patient received an unusually large dose of radiation after 80 mCi of 131I-sodium iodide ''became stuck in his feeding tube for nearly 4 days,'' physicians at the VA reported that the patient was not injured. ''Any occurrence from radiation exposure we would have expected to see already,'' said Ernest Belezzuoli, MD, who heads the hospital's nuclear medicine program. ''The patient is doing well, with no adverse effects.'' The incident occurred late in 2009 and was reported to the Nuclear Regulatory Commission (NRC). The hospital indicated to reporters that the practice of administering radioactive iodine through feeding tubes had been halted. Only a small number of thyroid cancer patients receive radioactive iodine therapy through feeding tubes. At the San Diego VA Medical Center Belezzuoli estimated the rate to be as low as 1 every 5 y. It is not clear why the dose became stuck in the tube. The standard practice of flushing the tube with water usually ensures dose delivery. Radiation monitors picked up the problem. ''We noticed in our standard monitoring that the radioactivity levels were not going down as expected,'' Belezzuoli said. ''When we realized the atypical nature of that, we had the feeding tube removed.  We may never know exactly the entire situation.'' Investigators for the NRC spent several days at the VA hospital, commission spokesperson Viktoria Mitlyng told the press.  --San Diego Union Tribune

-----------------------American Journal of Surgery

Hepatobiliary Scintigraphy: Sources of Error
1. The causes of a false-positive study (gallbladder non visualization in
Acute Cholecystitis: Right Lateral View
theabsence of acute cholecystitis) include:
  • Insufficient fasting (<2-4 hr)
  • Prolonged fasting (>24-48 hr), especially total parenteral nutrition (despite Sincalide pre-treatment and Morphine augmentation)                                               
  • Severe hepatocellular disease
  • High grade common bile duct obstruction
  • Severe intercurrent illness (despite sincalide pre-treatment and morphine augmentation)
  • Pancreatitis (rare)
  • Rapid biliary-to-bowel transit (insufficient tracer activity remaining in the liver for delayed imaging)
  • Severe chronic cholecystitis
  • Previous cholecystectomy
2. The causes of a false-negative study (gallbladder visualization in the presence of acute cholecystitis) are rare, but include:
  • Bowel loop simulating gallbladder (drinking 100-200 ml water may remove the radiopharmaceutical from the duodenum and allow differentiation of gall bladder from bowel).
  • Acute acalculous cholecystitis
  • The presence of the "dilated cystic duct" sign simulating gallbladder. If this sign is present, morphine should not be given.
  • Bile leak due to gallbladder perforation
  • Congenital anomalies simulating gallbladder
  • Activity in the kidneys simulating gallbladder or small bowel (may be clarified by a lateral image).
123I-MIBG Has Value
Researchers who conducted a meta-analysis of studies using 123I-MIBG
Anterior and Posterior I-123
                Whole Body Images
caption text here.
scintigraphy found the imaging method exhibited 97% and 96% sensitivity in identifying patients with neuroblastoma and pheochromocytoma, respectively. The results of the meta-analysis and of a trial published last year are concordant with clinical       experience, a researcher said. The meta-analysis was conducted to provide           complementary data for a trial conducted last year. 

- SNM Website                                           Go to Case Study

President Signs Bill to Temporarily Postpone Medicare Payment Cuts

The President has signed into law legislation that would once again temporarily postpone cuts to Medicare physician payments. The 21% cut will now be poised to go into effect on June 1, 2010. The hold that the Centers for Medicare and Medicaid Services (CMS) had placed on processing April claims technically had already expired before the President signed the bill. Effective immediately, claims with dates of service April 1 and later, which were being held by Medicare contractors, are being released for processing and payment. 

CE Opportunity
Saturday, May 22, 2010 - ISRT One Day Educational Seminar
St. Mary's Medical Center
Evansville, Indiana


  • 6:45 - 7:45 a.m. Registration, St. Mary's Hospital Amphitheater
  • 7:45 a.m. Opening Remarks and Instructions, Attendees must be seated in the Amphitheater at this time
  • 8:00 - 9:00 a.m. What Does The CT Show Us? Jeffrey Hemmerlein M.D.
  • 9:15 - 10:15 a.m. Review of Thyroid Anatomy & Pathology for the imaging professional, Claudine Fairchild M.S., RDMS, RT(R)(M)
  • 10:30 - 11:30 a.m. MRI 3 T: Safety and Pathology Chris Schmidt B.S., RT(R), CT(R), MR(R)
  • 11:40 - 12:40 p.m. Lunch
On your own, local dining locations will be provided at the Seminar
  • 12:45 - 1:45 p.m. Radiologist Assistants: Facts, Frustrations, and the Future, Tracy Ferrara RRA, RT(R)
  • 2:00 - 3:00 p.m. Mo-99 Supply Update: What Happened & What to Expect, Timothy Quinton B.C.N.P., Pharm D, M.S.
  • 3:15 - 4:15 p.m. Advances in Computed Tomography: Existing and Upcoming Procedures, Chad Bayer B.S., R.T. (R)(CT)

Linearity Check
Radiopharmacy, Inc. has a Lineator for performing dose calibrator linearity.  The Lineator allows linearity to be performed in minutes rather than days.  This equipment consists of a set of five lead tubes which are placed around a source of activity to simulate decay by shielding.   When doing a linearity by decay method, it takes days to complete.  This would mean that the loaner dose calibrator should not be used until the linearity is complete.  By using a Lineator the linearity can be done in a much shorter amount of time, so the dose calibrator can be used almost immediately.  Since linearity should be done according to the dose calibrator manufacturers recommendations, usually quarterly and upon installation, each time a substitute dose calibrator is used a linearity should be performed (geometry and accuracy should also be performed).
      The Lineator is available for rent to all Radiopharmacy customers.  The rental cost is $50.00/day, it should not be needed for more than one day.  Hopefully this will be of assistance to some of you in performing linearity on existing dose calibrators and on any loaner dose calibrators. 


Free Continuing Education
There are currently 26 NucMed credits available on the Covidien www.nucmeded.org web site.  All classses are free of charge.  See below some of the offerings.
 
Anatomy and Physiology Review for Nuclear Medicine  Technology - 2009 Update

Cardiac Electrophysiology for Nuclear Medicine Technology - 2007 Update

Correct Coding for Diagnostic Nuclear Medicine Procedures, Part 1

Myocardial Perfusion Imaging - 2009 Update

Stress Testing in Cardiac Nuclear Medicine Technology - 2009 Update

Enrollment Instructions:
Go to www.nucmeded.org
Click on the self-enroll button
Fill out the information and click on submit
A link will pop up taking you back to main page
Login into site.  Go to the site now
For Sale....Slightly used, heavily discounted
Lead Bricks..........$60.00 each

Rectangular Lead Brick; 8" l x 4" w x 2" h (20 x 10 x 5 cm), 27 lb (12.5 kg)/each



Thyroid Uptake Neck Phantom....$295.00

(Complete with Bottle Carrier, Capsule Holder and  12 Polyethylene bottles)    


Lead Apron...................$100.00

......a protective shield of lead and rubber that may be worn by a patient, radiologic technologist or radiologist.
Technologist Job Line
If you are interested in the following position please feel free to contact the department directly, or give us a call at the pharmacy.  Technologists looking for full-time or part-time position.  

Karen Foncannon: 731-661-9287 Wk: 731-541-7866
Contact info: Karen.foncannon@hotmail.com
Radiopharmacy Services
Survey Meter Calibration:  
Radiopharmacy's price for survey meter calibration is $50.00/meter.  Shipping and handling from and back to your location is $20.00.  Shipping will be by FedEx ground unless otherwise specified.  We will pick up the instrument, send it to Mid-America Calibrations, and after calibration return it directly to you.  If required, Radiopharmacy has rental survey meters while your unit is being calibrated.

Co-57 Flood Sources and Dose Calibrator Reference Sources
Don't forget; Radiopharmacy, Inc. sells all types of radioactive sources for all types of cameras and equipment. We supply sources from a variety of major vendors in our efforts to pass along the best products at the lowest cost.  Just give us a call for a price quote or for information about anything your department may need.



Linearity Check
Radiopharmacy, Inc. has a Lineator for performing dose calibrator linearity.  The Lineator allows linearity to be performed in minutes rather than days.  Call Radiopharmacy for more information.
      Radiopharmacy, Inc. is staffed by Board Certified Nuclear Pharmacists (BCNP's) with advanced education, training and experience in the preparation, distribution, and pharmacology of radiopharmaceuticals. Our staff is always available to answer questions or research information regarding radiopharmaceuticals and nuclear medicine studies, unexpected biodistributions, adverse reactions, drug interactions, radiation safety, regulatory requirements, and reimbursement strategies.   We also offer assistance with literature searches, research design preparation, investigational drug procurement, specialized labeling procedures, pharmacokinetic analyses, and dosimetry estimations. 
      Radiopharmacy's services are designed to assist your department in offering the newest, most progressive therapies and diagnostic tests available, and to help you maximize your overall efficiency in order to improve patient satisfaction and your profitability.  To go to our website click on the image above.

NOTE TO READERS: In an effort to keep the Monthly Scan relevant, useful and informative, feedback on the contents of the newsletter is welcome. Readers desiring to contribute articles, suggestions for future articles, bulletins, website postings, and other items of interest to the Monthly Scan readership, should contact a pharmacist at Radiopharmacy, Inc.
 
Sincerely,
 


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