Monthly Scans

2011 3rd Quarter 

2011 2nd Quarter  

2011 1st Quarter   

2010 3rd Quarter

May 2010  

February 2010  

January 2010  

December 2009  

November 2009 

October 2009  

September 2009 

August 2009 

July 2009 

June 2009 

March 2009 

January 2009 

Previous Issues 

Recent advances in molecular imaging technologies and therapies are greatly improving the ability of physicians to diagnose and treat lymphoma.   

What is lymphoma?

Lymphoma is a cancer of the lymphatic system-the body's main defense against infection-a complex series of lymph nodes encompassing the spleen, thymus and bone marrow. It is estimated that each year, more than 180,000 people die from various types of lymphoma.

The two main types of lymphoma are Hodgkin lymphoma-which often strikes teens and young adults and is highly treatable-and non-Hodgkin lymphoma-which has many different forms and is the fifth most common cancer in the United States. Non-Hodgkin lymphoma, which can afflict individuals of any age, is classified as B-cell or T-cell-malignancies that bind to a specific molecular structure and can significantly impact the lymph nodes. About 85 percent of non-Hodgkin lymphomas in adults are B-cell in origin. B-cell non-Hodgkin lymphomas include Burkitt lymphoma, diffuse large B-cell lymphoma, follicular lymphoma, immunoblastic large cell lymphoma, precursor B-lymphoblastic lymphoma and mantle cell lymphoma. The prognosis and treatment of lymphoma depend on the stage and type of disease.

New and emerging radioimmunotherapy (RIT), continue to provide major breakthroughs for patients with non-Hodgkin lymphoma by allowing tailored treatments at the molecular level.

What is radioimmunotherapy (RIT), and how is it used to treat lymphoma?

RIT is an exciting and relatively new personalized cancer treatment that combines the cancer-killing ability of radiation therapy with the precise targeting capacity of immunotherapy. One of the most promising areas for RIT is in the treatment of relapsed or refractory B-cell non-Hodgkin's lymphoma. Two RIT agents-yttrium-90-ibritumomab tiuxetan (Zevalin) and iodine131-tositumomab (Bexxar)-are currently approved by the Food and Drug Administration to treat these types of non-Hodgkin lymphoma and are used after conventional chemotherapies have failed.

How does RIT work?

A tumor-killing dose of a radioactive substance is linked to a specific kind of cell called a monoclonal antibody that, when injected into a patient, hones in on and attaches to cancerous tumor cells. The ability of the antibody to bind to a tumor-associated antigen-a molecule that can stimulate an immune response-ensures that the tumor gets a high dose of radiation, which kills the targeted cancer cells and nearby cancer cells. RIT is a more highly targeted therapy than traditional treatments because molecular imaging techniques and therapies can pinpoint the exact location of disease.

What advantages can RIT treatments offer over traditional lymphoma treatments?

When lymphoma is first diagnosed, treatment choices depend on the cell type, extent of disease and rate of progression. Traditional management may include a 'watch and wait' approach or include a combination of external radiation, chemotherapy and monoclonal antibody therapy. Although patients usually respond to initial treatment, many patients with slow-growing lymphoma relapse and require additional treatments; these individuals often experience progressively shorter remissions and ultimately die.

Now, clinical trials are showing that patients treated with Zevalin and Bexxar after a relapse have some significant advantages. While it won't be known for a few more years whether patients have been completely cured, initial results indicate that Zevalin and Bexxar can provide

prolonged remission.

Virtually all non-Hodgkin lymphoma patients who receive RIT live longer because of their treatments. For example, according to one clinical trial, patients with follicular lymphoma who received standard treatment achieved remission 36 percent of the time. Yet when Zevalin was added, the remission rate soared to 89 percent. Disease-free survival was prolonged by two years using Zevalin in a recent randomized trial of over 400 patients. In a separate study, Bexxar produced at least some response in 97 percent of patients. Another clinical trial that examined the use of Bexxar in treating primary cutaneous B-cell lymphoma indicated that patients had a median of 47 months of remission after Bexxar, compared with 6 months after chemotherapy. These results indicate that patients who receive Zevalin or Bexxar can enjoy years of disease-free survival, which is not commonly the case with any other form of therapy.

RIT treatments take about a week to administer on an outpatient basis, which is significantly shorter than most courses of chemotherapy or radiation. In addition, RIT minimizes toxicity to normal tissues because it kills targeted and nearby cancer cells, while normal tissue gets only a minimal dose. Chemotherapy, on the other hand, destroys any rapidly dividing cells, which often include non-cancerous cells as well as cancer cells. Because the cells of the immune system tend to be especially sensitive to the effects of chemotherapy, they are often damaged or destroyed along with the cancer cells. Damage of these non-cancerous cells by intensive chemotherapy may lead to side effects such as a low blood cell counts and risk of infection, mouth ulcers, diarrhea, nausea and vomiting, rashes and hair loss.

What are the side effects of RIT?

Flu-like symptoms

About a third of people experience mild flu-like symptoms, including: weakness, chills, fevers, aches and pains.

     These side effects are usually easy to treat and should not last long (usually around 24-48 hours).

Low blood count

     RIT can lower the numbers of healthy cells in your blood, in particular your white cells and platelets, but also sometimes your red blood cells. A low white blood cell count can make you prone to develop infections, low platelet numbers can lead to a tendency to easy bruising and bleeding, and a low red cell count can mean you become anaemic.

     Your blood count should be checked weekly after treatment with RIT. The impact on your blood count is usually greatest about 4-8 weeks after treatment. This is unlike chemotherapy, when the blood count goes down much sooner. The blood counts can become quite low and this sometimes lasts for a long time, but they usually start to recover between 8 and 12 weeks after the RIT.

     Patients should be instructed to notify care givers if they experience any signs of an infection, such as:

● a temperature above 38°C

● feeling generally unwell, even with a normal temperature

● symptoms such as sore throat, cough, diarrhoea or a burning sensation on passing urine.

How is RIT administered?

The treatment is given in one or two doses. Treatments are administered intravenously by a team of medical professionals-an oncologist, a nuclear medicine physician and a radiation safety officer-and tailored specifically for each patient.

How should patients prepare for the treatments?

Patients can eat and drink as usual. Patients may be asked to stop medications that could interfere with blood coagulation such as aspirin, non-steroidal analgesics and blood thinners. Patients taking Bexxar will be asked to take a medication that helps protect their thyroid gland.

How many patients are currently receiving RIT?

It is estimated that only 5-10 percent of patients who are eligible for RIT are actually receiving it. Some experts speculate that RIT is being under-prescribed because some doctors are uncomfortable with the idea of radioactive drugs. In addition, the drugs can't be given to patients with cancer that has spread extensively to the bone marrow, and there are concerns about causing secondary malignancies or precluding later treatments if the bone marrow is destroyed. However, fewer than half of follicular lymphoma patients have clinically significant bone marrow involvement, and fears of high secondary malignancy risk and marrow destruction have so far not been borne out by clinical trial follow up.

How expensive is RIT for non-Hodgkin lymphoma and is it reimbursed by health insurance?

Bexxar and Zevalin are FDA-approved radiommunotherapies for the treatment of non-Hodgkin lymphoma. Estimates suggest that RIT is no more expensive than chemotherapy plus rituximab, the current standard of care for newly diagnosed non-Hodgkin lymphoma patients. Nonprofit medical organizations such as SNM are working with the Center for Medicare and Medicaid Services to ensure that these life-extending therapies are appropriately classified as well as to expand coverage for other highly effective compounds.

Benefits of RIT

Chemotherapy, currently the most common and widely known treatment for cancer, is a non-targeted therapy that kills not only cancer cells but normal, healthy cells, as well. This leads to severe side effects for patients including nausea, vomiting, hair loss, diminished white blood cell and platelet counts, and severe loss of energy. Chemotherapy is typically given over many months. By contrast, RIT has fewer, less severe side effects than chemotherapy and has the ability to directly target and kill the cancer cells. This is why this new generation of cancer treatment is appropriately referred to as targeted therapy. Researchers have found that RIT increases the ability of the therapy to target and eradicate tumors throughout the body, offering promise to patients who nearly lost hope when their chemotherapy treatments proved ineffective. And whereas chemotherapy necessitates enduring weeks or months of harsh and disabling treatments, RIT is administered in only a few doses over a two-week period.

Track Record of Success

While we won't know for a few more years whether or not patients have been completely cured, Zevalin and Bexxar tend to work very well for most lymphoma patients in whom they are indicated. Initial indicators are positive as some patients appear to have been cured, and virtually all of them will live longer because of their RIT treatments. According to one clinical trial, patients with follicular lymphoma who received standard treatment achieved remission 36 percent of the time. Yet, when Zevalin was added, the remission rate soared to 89 percent. Disease free survival was prolonged by two years using Zevalin in a recent randomized trial of over 400 patients, leading the European Regulatory Authorities to grant approval for Zevalin therapy as a key component of treatment of follicular lymphoma. In a separate study, Bexxar produced at least some response in 97 percent of patients. Zevalin and Bexxar are particularly essential for older patients who cannot handle a stem cell transplant.

Underutilization

Despite all its promising benefits and its proven record of saving thousands of lives, RIT is not as widely utilized as it could or should be. Dr. Bruce Cheson, Professor of Medicine and Director of Hematology Research at the Lombardi Comprehensive Cancer Center at Georgetown University Hospital says, "RIT is the most effective, least used treatment in oncology."

The Bottom Line

Radioimmunotherapy (RIT) is a proven cancer treatment that significantly extends the lives of cancer patients, especially those with non-Hodgkin's lymphoma. Molecular imaging plays a major role in this personalized therapy. For the sake of hundreds of thousands of patients with lymphoma, highly-effective RIT medicines such as Zevalin and Bexxar must be reimbursed at a level that allows patients adequate access.  

For questions or more information call Radiopharmacy, Inc.

FDA Approval:  AMYVID   

The FDA has approved Amyvid, a radioactive diagnostic agent from Eli Lilly and Avid Radiopharmaceuticals that is indicated for brain imaging of beta-amyloid plaques in patients with cognitive impairment who are being evaluated for Alzheimer's disease and other causes of cognitive decline.
     Amyvid is tagged with the radioisotope fluorine-18. Amyvid binds to amyloid plaques, a characteristic of Alzheimer's disease, and is detected using PET images of the brain. A negative Amyvid scan indicates sparse to no amyloid plaques are currently present, and reduces the likelihood that a patient's cognitive impairment is due to Alzheimer's.
     Conversely, a positive Amyvid scan indicates moderate to frequent amyloid plaques are present & present in present in patients with other types of neurologic conditions other than Alzheimer's disease and in older people with normal cognition. Lilly has said that a positive Amyvid scan does not establish a diagnosis of Alzheimer's disease or other cognitive disorders. In addition, the safety and effectiveness of Amyvid have not been established for predicting development of dementia or other neurologic condition, or monitoring responses to therapies.      

Amyloid PET/CT study in a patient with cogitive impairment being evaluated for Alzheimer's disease and other causes of cognitive decline shows a high level of tracer binding to amyloid plaques in the brain.  Image obtained with Siemens Healthcare's Biograph mCT and evaluated with 510(k)-pending syngo.PET Amyloid Plaque software.

Amyvid was evaluated in three clinical studies that examined images from healthy adult patients as well as patients with a range of cognitive disorders, including some terminally ill patients who had agreed to participate in a postmortem brain donation program.
     Because Amyvid loses over half of its radioactivity every two hours, Amyvid must be distributed directly from a radiopharmacy to the imaging centers where it will be administered. Distribution of Amyvid will begin in June 2012.
     Amyvid images must be interpreted only by readers who have successfully completed Amyvid reader training, Lilly said. The company added that it has worked with the FDA and nuclear medicine experts to identify the appropriate ways to support accurate and consistent interpretation of Amyvid scans by imaging physicians. These efforts resulted in the development and validation by Lilly of both an online and in-person reader training program for physicians using Amyvid. However, according to Lilly, errors may occur in the estimation of plaque density during image interpretation.
     The most common adverse reactions reported in clinical trials were headache (1.8 percent), musculoskeletal pain (0.8 percent), fatigue (0.6 percent), nausea (0.6 percent), anxiety (0.4 percent), back pain (0.4 percent), blood pressure increased  (0.4 percent), claustrophobia (0.4 percent), feeling cold (0.4 percent), insomnia (0.4 percent) and neck pain (0.4 percent).
   Also, the pharmacodynamic drug-drug interaction studies have not been performed in patients to establish the extent, if any, to which concomitant medications may alter Amyvid image results.

----HealthImaging.com 

CMS Rules Contribute to Drug Shortages

According to a survey of pharmacy directors and managers, Federal guidance requiring strict adherence to manufacturer labels for injectable drugs has forced hospitals to throw away perfectly good drugs that are in short supply, according to a survey of pharmacy directors and managers.

     The Institute for Safe Medication Practices, based in Horsham, Pa., has called on the Centers for Medicare & Medicaid Services to review its policies involving stability and beyond-use dating of medicines. The institute surveyed 715 hospital pharmacists and managers who reported that following manufacturer directions has contributed to national drug shortages.

     CMS requires pharmacists to be compliant with Food and Drug Administration-approved labels to avoid the use of expired drugs. But pharmacists who were surveyed said some labels are not current and that newer, evidence-based research supports a longer shelf life in certain circumstances.

     Those studies have shown that diluted drugs remain stable beyond their stated expiration dates, said Allen J. Vaida, PharmD, the institute's executive vice president. Nearly all of the respondents - 97% - said CMS rules requiring strict adherence to manufacturer's directions when evidence-based compendia information recommends longer beyond-use dating increase waste of usable drugs.

     In addition, 36% said following agency regulations often results in unnecessary waste, and 43% said it always results in waste. Six out of 10 respondents said they are compelled to discard injectable medications knowing that the labeling differs from information in national compendia.

   "The survey results mean you're not just wasting an expensive drug, it means you won't be able to get more of he drug to have on hand", Vaida said.

         The institute has sent the survey results to CMS. Vaida said the institute hopes it can set up a meeting with the agency and the FDA to discuss its findings.  

- AMEDNEWS.COM

•  Desired Number of Particles

                 The desired number of particles for a lung perfusion study with MAA is 200,000 to 700,000 particles. Each vial contains 3.5 to 6.5 million particles, so the number of particles must be reduced by about 80 percent in order to prepare a unit dose of MAA.  The easiest way to accomplish this is to add a volume of sodium chloride to reconstitute the particles (5 mL), then withdraw 80 percent of the volume (4 mL) and discard it. This leaves 700,000 to 1,300,000 particles remaining in the vial. Once the particle count in the vial has been reduced, add ~twice the activity needed for a unit dose (~10-12 mCi). This should result in a particle count of 350,000 to 650,000 in the patient unit dose. A reduced number of particles is necessary for pediatric patients and patients with certain lung disorders including pulmonary hypertension.

•  Resuspend particulates

MAA, following reconstitution, is a suspension of particles. Before withdrawing a dose from the vial the particles must be resuspended. The particles in a unit dose may also need to be resuspended if allowed to settle for a length of time.

•  Avoid Foaming

Both Choletec and MAA have a tendency to foam when a volume of liquid is added to the vial.   This can make it difficult to draw the final patient dose. To minimize foaming, try adding volume slowly and down the inside of the vial.

•  Maintain negative pressure at all times

Maintain negative pressure when working with radioactive materials in vials. After adding volume to the vial it is important to remove an equal or greater quantity of air from the vial. When the needle is removed from the vial, the pressure inside will be the same or less than the initial pressure. If the air is not removed, the excess pressure in the vial will expel any liquid that is near the top of the vial. Of course, this would contaminate the work area with radioactivity.

•  No Preservatives

Always use sodium chloride that is preservative free. Preservatives or oxidants will oxidize pertechnetate and reduce labeling.

The following table summarizes manufacturer recommendations for compounding Tc-99m Radiopharmaceuticals commonly prepared in the nuclear medicine department. As always, call Radiopharmacy, Inc. with any further questions.

Nuclear Medicine:  Sources of Error 

Hepatobiliary Imaging

Sources of error

The causes of a false-positive study (gallbladder nonvisualization in the absence of acute cholecystitis) include:

•  Insufficient fasting (2-4 h)
•  Prolonged fasting (24 h), especially total parenteral nutrition (despite sincalide pretreatment and morphine augmentation)
•  Severe hepatocellular disease
•  High-grade common bile duct obstruction
•  Severe intercurrent illness (despite sincalide pretreatment 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

The causes of a false-negative study (gallbladder visualization in the presence of acute cholecystitis) are rare but include:

•  A bowel loop simulating gallbladder (Drinking 100-200 mL water may remove the radiopharmaceutical from the duodenum and allow differentiation of gallbladder from bowel. Review of dynamic images in a cine display may also be helpful. A right lateral view should be obtained to better distinguish activity in the duodenum from that of the gallbladder.)
•  Acute acalculous cholecystitis
•  The presence of the dilated-cystic-duct sign simulating gallbladder (If this sign is present, morphine should not be given.)
•  A bile leak due to gallbladder perforation
•  Congenital anomalies simulating the gallbladder
•  Activity in the kidneys simulating the gallbladder or small bowel (may be clarified by a lateral image)

Gastric Emptying

Sources of Error

•  Vomiting after meal ingestion
•  Poor labeling
•  A nonstandard meal
•  A marked variation in the environment, such as noise, lighting, or temperature, during imaging
•  Emotional fluctuations, such as fear of the medical environment, anxieties about results, anger after a long wait for the study to begin 6. Nausea caused by a meal that may be unfamiliar to the patient
•  A patient who has eaten just before the study
•  Slow movement of the ingested meal from the mouth or esophagus into the stomach
•  Gastroesophageal reflux
•  Overlap of small-bowel activity with the stomach ROI
•  A prolonged time for the patient to ingest the meal
•  Lack of attenuation correction, particularly in obese patients
•  Failure to recognize that the patient has not eaten the entire meal
•  Lack of decay correction for the tracer used
•  Failure of the patient to ingest the entire meal

Sources of Error

•  Urine contamination or a urinary diversion reservoir
•  Injection artifacts
•  Prosthetic implants, radiographic contrast materials, or other attenuating artifacts that might obscure normal structures
•  Homogeneously increased bony activity (e.g.,"superscan")
•  Patient motion
•  Greater than necessary collimator-to-patient distance
•  Imaging too soon after injection, before the radiopharmaceutical has been optimally cleared from the soft tissues
•  Restraint artifacts caused by soft-tissue compression
•  Prior administration of a higher energy radionuclide (¹³¹I, ⁶⁷Ga, ¹¹¹In) or of a 99mTc radiopharmaceutical that accumulates in an organ that could obscure or confound the skeletal activity
•  Radioactivity extraneous to the patient
•  Significant findings outside the area of interest that may be missed if a limited study is performed
•  Radiopharmaceutical degradation
•  Changing bladder activity during SPECT of pelvic region
•  Purely lytic lesions
•  Pubic lesions obscured by underlying bladder activity
•  Renal failure

Diagnosis of Renovascular Hypertension

Sources of Error

•  Include ingestion of food within 4 h of administering captopril
•  Infiltration
•  Pelvic retention
•  Dehydration
•  Hypotension
•  A full bladder impairing drainage
•  Pelvic retention is likely to be related to the patient's state of hydration but will result in an abnormal whole-kidney renogram curve, which may be incorrectly interpreted as representing renovascular hypertension. Dehydration and hypotension may lead to bilateral parenchymal retention and renogram curve abnormalities.

Lung Scintigraphy

Sources of error

•  Perfusion images can show hot spots in the lung if clotting of blood occurs in the syringe during the injection or if the injection is made through an indwelling catheter that is not well flushed.
•  Ventilation scintigraphy is obtained at a different point in time from perfusion scintigraphy. In the intervening time, there can be changes in ventilation and perfusion. Similarly, ventilation scintigraphy may be obtained with the patient upright, and the radiopharmaceutical for perfusion scintigraphy typically is injected with the patient supine. These changes in position may also affect the comparability of the 2 scintigrams
•  Injection of ^99mTc-MAA through a central line can result in inadequate mixing of activity in the pulmonary artery. This inadequate distribution of activity is especially true if the activity is injected through a pulmonary artery line.
•  A decubitus or oblique patient position can markedly affect the distribution of ventilation and perfusion. If ventilation scintigraphy or the injection for perfusion scintigraphy is performed with the patient in the decubitus or oblique position, mismatched patterns can result. Accordingly, any nonstandard patient positioning should be recorded and considered during subsequent interpretation.
•  Activity in the thyroid is often used as an indicator of free ^99mTc-pertechnetate in the radiopharmaceutical preparation. However, the thyroid is also a high-flow organ and may be visualized in the case of a right-to-left shunt.

-SNM Procedure Guidelines

Customer Appreciation Night 

Wants to Take You Out To The Ballgame

Customer Appreciation Night at

Evansville Otters Game

Friday June 15, 2012

Bosse Field

Gates open @ 6 pm

Picnic starts @ 6:15 pm

Game time is 6:35 pm

Last day to RSVP is Wednesday June 6, 2012

(812) 421-1002

*Tickets available the day of the game at will call table outside main gate. Only names on RSVP list will have tickets at will call.

Focusing on the basic principles and technical aspects of all nuclear cardiac imaging studies, Nuclear Cardiac Imaging: Terminology and Technical Aspects is the perfect companion for veteran technologists and clinicians who have incorporated nuclear cardiology into their practices. New technologists, nuclear medicine and radiology residents, and cardiology fellows will find this new edition to be the ideal resource as they achieve a full comprehension of the technical aspects and practice of nuclear cardiology.

     The SNMTS has reviewed and approved Nuclear Cardiac Imaging for 13.0 VOICE (Category A) credits.  

Featuring New and Updated Chapters on:

•  Pharmacologic Stress
•  Myocardial Perfusion Imaging Protocols: Is There an Ideal Protocol?
•  Image Processing/SPECT Study Reconstruction
•  Gated Blood Pool SPECT
•  Cardiac PET Imaging
•  Drugs for the Cardiovascular System Radiation Exposure from Medical Diagnostic Imaging

Nuclear Cardiac Imaging - 2nd Edition
Member Price: $79.00
Non-Member Price: $99.0

Call Radiopharmacy, Inc. for more information.  

The American Society of Nuclear Cardiology is pleased to announce a

Chaired by Brian G. Abbott, MD, FASNC, this online product features 10 sessions, 23 lectures, and more than 10 hours of audio recordings. Nuclear cardiology and cardiac imaging professionals will obtain the latest information in clinical practice as well as review cutting-edge scientific advances in the field. Sessions include Nuclear Cardiology in an Emerging CT World - Have the Clinical Paradigms Changed?, Basics of Interpretation and Reporting - A Case-Based Presentation, and Radiation Risk from Cardiac CT and Nuclear Cardiology -  Addressing Concerns with Innovative Solutions. To view the complete program content, please click here.

Both CME and ACE credits are available for Conference Highlights Meetings on Demand - order your online copy today!

      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.

Products and Services

• Radiopharmaceuticals - Diagnostic and therapeutic
• Radioactive Sealed Sources
• Brachytherapy Sources (I-125 and Pd-103)
• Lab Testing
• Nuclear Medicine Department Computer Software,
• Reimbursement Assistance
• Continuing Education
• Health Physics Consulting
• ICANL and ACR Accreditation Assistance
• Professional Consultation regarding radiopharmaceuticals and their clinical use.