Technetium-99m Availability: Production and Industry UpdatePosted on: 12.19.19
Overall this year, there has been some unsteadiness in the supply chain for Moly-99 (Mo-99), which in turn affects the supply of technetium-99m (Tc-99m). For operators of gamma cameras, availability of the radiopharmaceutical gives cause for concern.
David Pellicciarini, Vice President, Pharmacy Safety, Practice & Technical Operations for Cardinal Health, spoke to us about the current situation with Tc-99m and what is expected in the future.
Origins and nature of Tc-99m
To understand why the supply chain is so sensitive, it helps to understand the Tc-99m production process. It is produced as a decay product of Mo-99. Mo-99 does not exist in nature but is most-often created using a nuclear reactor. It is developed by either fissioning uranium targets or bombarding non-radioactive molybdenum targets with neutrons.
The isotopes of Mo-99 and technetium-99m have short half-lives – 66 hours for Mo-99 and just 6 hours for Tc-99m. This means they must be produced continuously and cannot be stockpiled. As a result, whatever is happening at the reactor can impact the Mo-99 and technetium-99m supply. Anything that might prevent the production of Mo-99 can very quickly impact the supply chain.
There have been intermittent interruptions over the last several months, and our team, in partnership with Cardinal Health, works together to minimize any customer impact. “During a shortage, we have staff working overtime and delivery drivers running irregular routes to maximize the reach of the supply we have,” says David Pellicciarini.
The supply chain
The majority of suppliers of Mo-99 are located outside of the United States. Just one Mo-99 manufacturer has recently been approved in the U.S., and they are expanding their operations.
After the Mo-99 is produced at the reactor, it is sent to Tc-99m generator manufacturers. From there, the Tc-99m generators are shipped to radiopharmacies, where the generators are used to prepare the Tc-99m-based radiopharmaceuticals for patient use.
The short, six-hour half-life means that radiopharmacies such as Cardinal Health need to continually be preparing radiopharmaceuticals to deliver to customers. When there is a disruption upstream in the supply chain, such as a reactor issue or a delay in the production of generators, the radiopharmacies may be challenged to fill all customer orders.
Domestic Production of Mo-99
The supply chain is complex, but we do anticipate that there will be more U.S.-based Mo-99 suppliers in the future. In addition to the one current US-based Mo-99 supplier, there are several other companies who are working on getting approval to supply Mo-99. We’re encouraged to see multiple companies taking the initiative and making the investment to improve the domestic supply.
You might wonder why we don’t already have reliable domestic production of Mo-99. In the past, we relied heavily on supply from Canada as they are so close to us geographically. However, Canada stopped producing Mo-99 for the global market, which meant other suppliers had to step up production. It also meant our other suppliers were much further away.
“I think because Canada did such a great job and were so reliable for decades, domestic production wasn’t seen as an urgent issue in the U.S.,” says Pellicciarini. “Supply issues aren’t nearly as bad as they were a decade ago, but they still happen. We work hard to mitigate any impact to our customers and patients, and most of the time, we’re able to do that.”
Needless to say, we look forward to the availability of more domestic Mo-99 suppliers, but it does take a fair amount of time for them to get set up. They have many facets to organize, including manufacturing operations, licensing and regulatory requirements, transport, and even specialized containers needed to carry the product. Ultimately, they also need FDA approval. This creates a two-to five-year window from now for new suppliers to be up and running.
The American Medical Isotopes Production Act
The premise of the American Medical Isotopes Production Act is: “To promote the production of molybdenum-99 in the United States for medical isotope production, and to condition and phase out the export of highly enriched uranium for the production of medical isotopes.”
Under the Act, the Secretaries for Energy and Health and Human Services have to make an assessment on whether there are adequate supplies of Mo-99 coming into the U.S. from sources other than highly enriched uranium (HEU) sources.
There is a date of January 2, 2020 for the secretaries making a recommendation on this. No more licenses are meant to be issued for the export of highly enriched uranium to produce Mo-99 unless there is an inability of the U.S. market to be supplied by low enriched uranium (LEU) sources.
New producers are using non-HEU methods, and the majority of current suppliers have already converted to non-HEU production of Mo-99.
David Pellicciarini notes that Cardinal Health participates in several industry associations and groups, including the Organization for Economic Co-operation and Development (OECD) to help influence policy and communicate critical messages about the needs of the U.S. market.
They hope to see less of the Mo-99 supply issues that have impacted customers and patients in the past and are hopeful for a more stable supply in the near future.
How Nuctrac Is Allowing Nuclear Medicine to Move to the CloudPosted on: 10.03.19
It’s no secret that the ordering and management of radioisotopes for nuclear imaging is a complicated and often cumbersome process. Nuctrac™ is a new, cloud-based software tool that nuclear departments are leveraging to simplify and streamline these tasks.
The Basics of Nuctrac’s Nuclear Medicine Cloud
Developed by Cardinal Health, Nuctrac is a cloud-based system that helps nuclear medicine departments keep records, place orders, and manage compliance.
Cardinal Health is a well known and leading provider for the sale and distribution of radioisotopes. For years they offered radiopharmaceutical management software but decided to reboot their whole effort and take it to the next level with a move to the cloud. Nuctrac™ is the result of that development.
At a high level, Nuctrac is a cloud-based nuclear medicine management solution that helps nuclear medicine departments provide patients a higher level of care, keep up with complicated compliance and regulatory standards, and improve care coordination and communication with other medical staff.
The application is browser-based and best viewed on a desktop computer or tablet. Because it’s cloud-based, you don’t have to go back and forth between imaging rooms and fixed locations where your records are stored. Instead, you can get access to the data you need anywhere, at any time.
Nuctrac can integrate directly with your EHR and uses advanced barcode technology to reduce potential medication errors, so patients are kept safe.
Nuctrac and Your Practice
Though technologists love spending time their patients, they certainly don’t enjoy the administrative work that the care often involves.
Nuctrac handles patient scheduling, ordering doses, and even documents exactly how much radiation a patient received. The software guides users through all of the math, half-life, measurements, and also sends reminders about when you need to place orders, perform compliance activities, and more.
These features help technologists streamline their process and save time by eliminating the need for mounds of paperwork.
But what’s most valuable about the software in the eyes of many professionals is the fact that it makes you well-prepared for an audit from the NRC or another regulatory agency.
The documentation is readily available to an auditor in both paper and electronic format, and you can prove that you’re in compliance with the Code of Federal Regulations (CFR.)
Having the documentation readily available when you need it makes the auditing process less stressful and allows you to get back to your patients quickly.
Security and Nuctrac
A significant concern for all nuclear medicine departments is data safety and security — especially when it comes to sensitive medical records that could result in a HIPAA violation.
Thankfully, Cardinal Health utilizes a SOC 2 program for Nuctrac to ensure the data is secure. This means that an outside auditing firm closely examines the software and processes to ensure that they are operating under industry best practices.
Upon request, your IT department can receive a SOC 2 certification report confirming that there are no major, preventable gaps when it comes to the security of the data.
In a sense, Nuctrac™ is in a constant state of security audit under the SOC 2 program.
In short, you can rest easy knowing that the data in your nuclear medicine cloud software is secure.
Is Nuctrac the Right Fit for Your Nuclear Imaging Department?
Technology and cloud-based software have revolutionized many areas of our lives, and with Nuctrac™, the cloud is being fully realized for nuclear medicine and many practices are seeing tremendous time savings by letting software do much of the leg work.
If you are interested in learning more about Nuctrac contact the Cardinal Health team or schedule a demo.
What is SPECT imaging and how does it work?Posted on: 03.07.19
SPECT stands for single-photon emission computerized tomography. In layman’s terms, it’s a type of non-invasive nuclear imaging test that allows your doctor to see how well your internal organs are functioning. It uses a radioactive substance and a special gamma camera to create 3-D pictures of your organs at different angles.
Gamma cameras like the Digirad Cardius® 3 XPO and the X-ACT+ employ advanced solid-state technology that uses a silicon-based photodiode, coupled with cesium iodide (CsI). The technology not only offers better sensitivity and high energy resolution, but it also makes the camera smaller in size than a traditional MRI machine. And, with their open and upright design, they’re much more ergonomic and patient-friendly.
While an x-ray takes a picture of what your organs look like at a given point in time, a SPECT image shows blood flowing to and from the heart or blood flow restrictions due to narrow or blocked arteries. It can also be used to evaluate brain and neurological conditions and bone disorders.
In what cases is SPECT imaging ordered?
Not only can SPECT imaging capture how well your heart is performing, but it can also help diagnose disease processes that may be underway, including narrowing of the arteries, clogged arteries, identifying scar tissue due to heart attacks, or evaluating the success of surgeries like bypass surgery.
How does SPECT imaging work?
SPECT scans use a radioactive material called a tracer. The tracer is injected intravenously and mixes with your blood. As your blood moves through your body, it’s “taken up” or absorbed by your living heart muscle.
The Digirad Cardius® 3 XPO and the X-ACT+ allow for patients to be imaged in a comfortable seated position but other gamma cameras require you to lie down on a table. During the scan, the SPECT camera rotates around you. It picks up signals from the radioactive tracer, which are then converted to 3-D images by a computer.
When you undergo a nuclear stress test, a SPECT scan will be taken while you’re exercising and again when you’re at rest. The comparison of the images will allow your physician to evaluate blood flow under different levels of exertion.
Your images may show different shades of color that will indicate which areas of your heart absorbed more of the radioactive tracer and which areas absorbed less. A normal test result indicates there is sufficient and unrestricted blood flow to your heart, while an abnormal result means your heart’s blood flow is insufficient. Once your physician reviews your images, you’ll meet to discuss the results and any necessary treatment plan.
What are the risks of SPECT imaging?
SPECT imaging is generally safe and most patients can go back to their normal activity right away. The amount of radioactive material injected into your bloodstream is small and your body will expel it through your kidneys in 24 to 72 hours. Be sure to drink plenty of water for a few days following the procedure.
If you are pregnant, think you may be pregnant, or are a nursing mother, be sure to notify your doctor prior to the scan. The test uses a low-dose of radiation, which is contraindicated for pregnant women. Nursing mothers may be advised to wait additional time before nursing again so that your body can excrete the tracer.
Patients may also have an allergic reaction to the radioactive tracer, although it’s uncommon.
SPECT imaging is a popular, cost-effective, and safe method of evaluating your heart and diagnosing disease. While you may be a little anxious, be assured that the scan is painless and it provides important clinical value to your physician.
UPMC Launches First Mobile Xe-133 Lung Ventilation Scan System in the United StatesPosted on: 01.24.19
In a recent issue of Pediatric Insights, Michael R. Czachowski, MBA, CNMT, NCT, PET, ASCP(N), R.T.(N)(BD) (ARRT), discussed the idea and the execution of the first portable Xenon-133 lung ventilation exam performed in the United States on a patient in a pediatric cardiac intensive care unit.
Czachowski is the supervisor of the Nuclear Medicine and Molecular Imaging Departments at UPMC Children’s Hospital, where the groundbreaking procedure was performed. The process, which was implemented to allow technicians to perform portable ventilation lung exams in the CICU and to alleviate the need to move medically fragile patients to the nuclear medicine department, was made possible with the use of the Digirad Ergo™ portable nuclear camera.
Ventilation lung exams the CICU were previously prohibited because of the inability to safely deliver the Tc-99m DTPA (diethylenetriamine pentaacetic acid) aerosol and the risk of radiation contamination.
Collaboration overcomes obstacles
During a previous portable perfusion lung exam in the CICU, Czachowski’s team was questioned about the possibility of performing a portable ventilation lung exam. The challenge sparked some thought–and a lot of innovation among his team. Through much discussion, brainstorming, option searching, and evaluation, Czachowski and his collaborators agreed that the use of Xenon-133 gas in conjunction with the patient’s ventilator and the Pulmonex system was the most highly viable solution.
The Pulmonex system, which when used in the nuclear medicine department, safely captures exhaled radioactive Xenon-133 through a lead-lined trap. The hurdle was finding a way to capture the gas from the patient, contain it, and maintain the patient’s ventilator dependency, all while remaining in the CICU.
Leveraging the expertise of Alvin Saville, RRT, Respiratory Education Coordinator at UPMC Children’s Hospital, a tubing adaptor placed between the patient’s ventilator circuit and the endotracheal tube was added. It successfully trapped the patient’s exhaled radioactive Xenon-133 inside the Pulmonex system, which ensured a safe environment for the patient, staff, and family.
Innovation pays off in the CICU
In April 2018, after months of development and testing, the successfully modified system was used for the first time on a patient in the CICU. Although they continue to refine the protocol, “to do the lung ventilation exam with no interruption of the patient’s physiological and physical environment in the CICU or elsewhere is quite an accomplishment,” said Czachowski. It has created a seamless process that is both safe and efficient.
You can find the original announcement about the First Mobile Xe-133 Lung Ventilation Scan System in the United States here.
How to Reduce Gut Activity with Myocardial Perfusion ImagingPosted on: 11.15.18
We’re all familiar with the obstacles that radiotracers and subsequent gut activity presents during Myocardial Prefusion Imaging. When the radioisotope expands beyond the coronary arteries, it’s difficult to obtain quality SPECT MPI imaging of the heart. It’s a common problem that plagues many patients and physicians. So what do we do?
We’ve heard of everything from half & half, cold water, and even a certain type of soda post injection to reduce the dreaded gut activity. Since we weren’t aware of any tried and true solution, we polled our fellow nuclear specialists on LinkedIn to see if they could provide some tips, tricks and home remedies.
Wait Time is always going to be your best practice to assist with clearance but if that or your go-to response doesn’t always work, check out these suggestions and add them to your list:
If it is a bowel loop, we give them another cup of cold water and have them walk the hallway if they can. If they have a hiatal hernia or liver disease, we give them a longer wait time prior to scan to try to avoid the need for rescan. And we ask them all not to lay down, but to sit up instead when possible when waiting.
In my experience, the most effective method for reducing gut uptake and obtaining separation from the inferior margin is the combination of walking and ice cold water consumption. I have also heard of technologist giving patient’s Boost/Ensure after rest dosing and obtaining great images. This is done at the discretion of exercise stress, however.
Additional cold water – approximately 8 ounces. Drink fast. Walk around for 5-10 minutes, then have the patient lay on their right side to see if the loop will pull away from the bottom half of the heart. I had a tech that worked for me that came from Ohio State, and they would try this. Sometimes it would work and sometimes it wouldn’t. Always feed them. That, of course, helps for most.
We find that waiting is the best remedy but not always practical. Cold water gulped down for resting scan. Snack and a drink for the stress scan. Sometimes, particularly with hot livers, lying the patient on 2 pillows behind the shoulders, raising them will drop the activity away from the heart.
I have used carbonated sodas if walking and drinking water didn’t help. I used to use Diet Sprite, but I guess ginger ale is an option too. For stress images, fatty foods, ice cream, coffee, anything that helps bowel movement.
I’ve often placed a broad strip of pliable soft lead shielding over the patient’s abdomen at an angle, and this has often helped mitigate proximal intestinal activity. Otherwise, if you have the time, waiting 45-60 minutes post-injection to perform resting MPI has been fairly beneficial.
I like for my patients to have a drink of their choice (soda, water, coffee, etc.) and some crackers or small snack before their stress images. Some water only before rest images. Extra wait time for Cardiolite vs. Myoview, especially for liver clearance.
What is the Role of Cardiac Cath in Value-Based Care?Posted on: 10.04.18
It’s an undeniable fact that the move to value-based care is changing cardiology. Cardiac catheterization, in particular, has evolved as appropriate use criteria and value-based care have continued to advance in the healthcare system.
This once go-to procedure is now being replaced by new methods and less invasive techniques. In this post, we’ll take a look at where cardiac cath fits in today’s value-based landscape.
How we got here
Years ago it was common for the cath lab to be the first stop for patients experiencing symptoms of cardiovascular disease. It was a valuable diagnostic procedure with solid reimbursements and relatively little oversight from payers. Today, the rules have changed.
In many ways, the cardiac cath landscape changed after the American College of Cardiology published the 2009 AUC for Coronary Revascularization.
As Medicare and CMS developed their guidelines, the criteria became more and more a part of the cardiology landscape. Additionally, the way payers approach cardiac catheterization has continued to evolve. Increased scrutiny is being added to the procedure while reimbursement rates continue to decline.
Lately, these factors have been compounded as significant penalties for patient readmission and not following AUC have been added.
The move to non-invasive techniques
It’s said that necessity is the mother of invention, and this has held true for how cardiologists are approaching cardiac catheterization in the current market.
We are seeing a rise of new non-invasive diagnostic tools as a way to mitigate lower reimbursements, penalties, and improve patient care.
Cath is still an essential tool for both patients and cardiologists, but now physicians are wanting more evidence and clarity before ordering the test. Non-invasively obtaining proof that disease exists has now become step one in the process.
The impetus behind these changes makes sense on a number of levels. The net result of doing more tests before the cath lab is that cardiologists are performing fewer invasive and unnecessary procedures. This is good for the patients and the healthcare system as a whole. While a reduced study volume does affect the bottom line, it is also resulting in the practice experiencing lower readmission fees and penalties for not following AUC.
Non-invasive methods gaining traction
Fractional Flow Reserve
Many cardiologists are choosing to utilize fractional flow reserve, or FFR, as a way to diagnose heart disease and guide clinical management. It non-invasively measures the difference between the maximum achievable blood flow in the presence of stenosis and the theoretical normal maximum blood flow in terms of pressure using coronary artery images.
FFR simulation is able to more accurately identify those patients who have a high likelihood of disease. So, not only does the method comply with the stricter enforcement of AUC, but it has also improved the percentage of catheterizations that ultimately result in an intervention.
Advances in SPECT
Nuclear SPECT studies play a vital role in the diagnosis of cardiovascular disease. The nature of SPECT makes it a perfect fit for value-based care, but too often the clinical value of SPECT depended on the reader.
New advances in SPECT imaging are bringing Attenuation Correction into this modality. The addition of Attenuation Correction is making images clearer and easier to read.
The studies and the cameras, such as the Digirad X-ACT+, are considerably more affordable compared to traditional CT imaging. This creates a tremendous amount of value – both clinically and for the healthcare system.
As imaging technology continues to advance, Cardiac PET MPI is gaining more awareness in today’s clinical market. In recent years, the modality has seen growth and is generating interest among cardiologists.
While the diagnostic benefits of Cardiac PET are clear, the cost and complexity of offering the modality have kept it from being a realistic option for most practices.
It’s also important to consider how medical therapy is changing cardiology. Research has shown that moving straight to medication as opposed to investing in diagnostic procedures is an effective way to treat patients.
The Bottom Line on Cardiac Catheterization
Cardiac Catheterization and Percutaneous Coronary Intervention will obviously continue to play a vital role in cardiology. As technology continues to advance, non-invasive methods will become more effective and more affordable.
As an industry, we may continue to see fewer cath tests ordered but they will be ordered with more clinical confidence. In the end, these changes benefit the patient while also reducing the financial risk to the practice and the healthcare industry as a whole.
This post was written in partnership with MedAxiom and includes contributions from Jacob Turmell DNP, RN, NP-C, ACNS-BC, CCRN-CMC and Joel Sauer.
A Closer Look at the Digirad Ergo (Infographic)Posted on: 08.23.18
Understanding Your Nuclear Medicine Stress TestPosted on: 06.21.18
Myocardial Perfusion Imaging, also called a Nuclear Stress Test, is used to assess coronary artery disease, or CAD. CAD is the narrowing of arteries to the heart by the build up of fatty materials.
CAD may prevent the heart muscle from receiving adequate blood supply during stress or periods of exercise. This frequently results in chest pain, which is called angina pectoris. Perfusion imaging usually consists of stress and rest tests.
Images are taken of your heart while at rest and after exercising or under stress. The comparison allows your physician to evaluate blood flow under different levels of exertion. After the images are reviewed, they’ll meet with you to discuss the results.
Normal or abnormal, what does it mean?
A normal test result indicates there is sufficient and unrestricted blood flow to your heart, both during periods of rest and exercise. Generally, there’s little concern for coronary artery disease and, in most cases, you won’t require any further testing.
An abnormal result, which means your heart’s blood flow is insufficient, may occur only during the exercise phase of your stress test. During rest, your blood flow may be normal, but during strenuous activity, when your heart is working harder, it may not be getting the blood supply it needs. It’s likely that there is some level of coronary artery disease or blockage.
An abnormal result in both phases of your stress test is an indication that your heart’s blood flow is poor, regardless of your exertion level. The restricted blood flow suggests significant coronary artery disease. If your stress test images show areas of the heart that are not highlighted with the radioactive isotope, it may also be an indication of scar or damaged tissue caused by a previous heart attack.
Regardless of the results, your doctor will explain the findings and address your concerns. If necessary, they’ll recommend a treatment plan that can potentially improve or better manage your heart’s function.
Seven mistakes to avoid when choosing between a new and refurbished nuclear cameraPosted on: 04.26.18
With the continual advancements in healthcare technology and service, investing in your cardiac practice, upgrading equipment, and improving efficiency is an ongoing process. One of the most significant considerations is not only when to replace a camera, but also if refurbished, or new equipment might be a better decision.
It’s important to take the time to look beyond your immediate imaging needs and consider the long-term goals of your practice. Both refurbished and new camera systems come with advantages, but be sure to consider these factors before signing on the dotted line:
1. Focusing only on purchase price vs. the long-term cost of ownership
A nuclear gamma camera is a significant investment for any practice, so it’s natural to focus on the cost. There are times when prioritizing price is a smart idea, but only when the product still retains an acceptable level of value. There are many refurbished cameras that have a considerable amount of life left and could be a wise investment.
When you evaluate new versus used equipment, consider how much image quality has improved in recent years, the availability of new software programs, and the viability of the camera’s current operating system. When the camera is in need of repair, will parts be readily available and will the manufacturer agree to service it? Some manufacturers include a firm end-of-service date on their equipment, which leaves you at the mercy of third-party service providers and replacement parts. Some service companies may even decline service because of age, limited part availability, and the associated risk.
2. Overlooking the ability to maintain image quality
Older, refurbished cameras may undoubtedly be in working order, but their boards and analog methodologies could be less effective. With age, the camera’s light pipe, which includes crystals that eventually yellow and crack, will no longer respond, sometimes without warning. Replacement crystals for older cameras may not be available. Even with newer refurbished cameras, the crystals have already aged, may be hydrated, and are potentially unfixable. Be sure to inquire about and examine the crystals if you’ve considering a refurbished camera.
3. Putting your HIPAA compliance at risk
Another important factor to consider is HIPAA compliance. Many refurbished cameras cannot be upgraded to current software versions, and, because they’re no longer supported by the manufacturer, they can’t they be patched securely. Consequently, the camera cannot be connected to a network because internet access imposes new risks. You also may not be able to add additional processing programs and, in the end, may be forced to purchase an entirely new software package, which will be costly.
4. Not factoring in the credit rating of the practice
While many physicians may have excellent credit, they may not be willing to put their personal credit history on the line when purchasing capital equipment such as a nuclear gamma camera. Instead, they opt to leverage the business credit, and this can have a direct impact on the approval process and interest rate.
If the practice does not have an extensive credit history, it’s more challenging to secure a loan, and interest rates are likely higher on pre-owned equipment. Additionally, if a financial institution feels that you may have issues with part availability on refurbished systems, they may be hesitant to approve a loan for older medical equipment. Be sure to discuss the details and get loan pre-approval before the sales process begins.
5. Failing to consider the true patient volume
Volume is another important factor to evaluate when deciding between used or new equipment-or even whether to outsource your imaging services completely. Not all cardiac practices need a camera on site five days a week. If you’re imaging one, two, or even three days a week, you might consider partnering with a mobile imaging company.
Your volume should factor into your financial investment. Without it, the lack of revenue wouldn’t warrant spending dollars on maintenance costs and might eventually lead to a decline in the integrity of the equipment.
6. Purchasing camera that offers limited use
Any new or used camera that you plan to purchase should be able to expand and grow with your practice. A camera should be able to fill your current imaging needs, but also serve your practice in other ways. Would it lend itself to increased productivity, improved efficiency, and greater patient satisfaction? Sometimes it may be worth the extra investment if it allows you to move forward on another strategy that has the potential to increase revenue or to reach other goals.
7. Not performing your own due diligence
Lastly, knowing from whom you’re purchasing your equipment is of critical importance. An investment of this size should only be made through a reputable company with a proven track record, especially if it’s a refurbished camera. Prepare a due diligence checklist and take the time to get better acquainted with the camera, just as you would with a home, used car, or any other purchase in the second-hand market. Ask to see it, or have it inspected by an independent service company, and ask for the repair and maintenance records.
It’s well within your rights to investigate the camera’s history, current value, and the likelihood of any future issues before making a final commitment. If you don’t, you’re exponentially increasing your chance of winding up with a lemon and having no recourse.
Cost shouldn’t be the only consideration when buying a camera. It may be high on your list, but the value it brings to your practice should be well worth the money you spend.
PET/CT Imaging New Tracer GuidePosted on: 03.30.18
The landscape of PET/CT imaging is rapidly changing. Traditionally, physicians have used a sugar based radiopharmaceutical, 18Fluorodeoxyglucose or 18FDG, to perform the majority of PET/CT imaging. Over the past 20 years, this imaging agent was the only option available to many facilities across the United States.
Recent breakthroughs in research, reimbursement, and radiopharmaceutical manufacturing have made it so that physicians and patients will begin to have access to medicine that is designed for their unique situations.
RECENTLY APPROVED TRACERS
Axumin (18F-Fluciclovine) is indicated for PET imaging in men with suspected prostate cancer recurrence based on elevated blood prostate specific antigen (PSA) levels following prior treatment.
Mechanism of localization
It has been found that there is an over expression of amino acid transporters in certain cancer cells. This overabundance of amino acid transporters is typically easier to identify among normal, healthy tissue than traditional imaging methods. The body recognizes this drug as an amino acid and actively transports it to potential areas of concern.
Why look into this radiopharmaceutical?
- Axumin allows healthcare providers to pinpoint the overexpression of amino acids associated with prostate cancer.
- Increased visualization of the prostate bed— no bladder interference during imaging, as with traditional 18FDG.
- PET imaging with Axumin can lead to quicker detectionof tumors. Other imaging methods rely on physical (structural) changes in the body for tumor detection, whereas Axumin detects changes on the physiological (cellular) level, which can occur weeks, even months quicker than physical changes.
Prescribing information and use
- A standard 10 mCi dose of 18F-Fluciclovine is provided
- Patient is injected and imaged immediately
- Exam takes less than 30 minutes from start to finish
Axumin is a great tool for visualizing the prostate bed which can be challenging using traditional methods.
NETSPOT (68Ga-Dotatate) is indicated for use withPET for localization of somatostatin neureceptor positive neuroendocrine tumors (NETs) in adult and pediatric patients.
Mechanism of localization
68Ga-Dotatate binds to somatostatin receptors, with highest affinity for subtype 2 receptors (sstr2). It binds to cells that express somatostatin receptors including malignant cells, which overexpress sstr2 receptors.
Why look into this radiopharmaceutical?
Improved image quality over the traditional Gold Standard
The Gold Standard method of imaging NETs has traditionally been an Octreotide scan
- Often times leaves physicians without answers
- Takes up to a week to acquire the entire exam
- Results are only qualitative
- Results are conclusive
- Improved patient satisfaction: no bowel prep needed or dietary restrictions, 3 hours to complete examination
- Results are quantitative and qualitative
The FDA has recently approved a therapy for NETs that uses the same Dotatate as the PET imaging agent and replaces the 68Ga with 177Lu. The theranostic (see it, treat it) approach to treatment has finally become a reality!
Prescribing information and use
- A patient specific, weight based dose of 68Ga- Dotatate is provided
- Patient is injected and imaged at 40-90 minutes post administration
- Must be off somatostatin receptor blocking agents
Same Patient— Different Outcome
A) Standard imaging using Octreotide
B) Improved tumor visualization and treatment planning using 68Ga-Dotatate
- Adults with cognitive impairment who are being evaluated for Alzheimer’s disease and other possible causes of cognitive decline
- Currently 3 approved PET/CT imaging agents areavailable: Neuraceq (18F-Florbetaben), Amyvid (18F-Florbetapir), Vizamyl (18F-Flutemetamol)
Mechanism of localization
- There are many studies that demonstrate a relationship between increased β-amyloid plaque and Alzheimer’s disease.
- The radiopharmaceuticals bind to this β-amyloid plaque.
Why look into this radiopharmaceutical?
- Until recently, there was no way to image the presence of the physiological changes associated with Alzheimer’s disease:
- A positive scan indicates an increase β-amyloid plaque which is consistent with AD and other cognitive disorders: To be used in conjunction with other neurological testing to establish a diagnosis
- A negative scan indicates that there is a low amountof β- amyloid plaque which is inconsistent with a neuropathological diagnosis of AD
- Helps to rule out the possibility of AD
Prescribing information and use
- Each radiopharmaceutical has its own prescribing and dosing information
- Patient is injected and imaged
- Entire exam takes less than 90 minutes from start to finish
- Cancer—most common
- Infection & inflammation
- Viable myocardium (cardiac)
- Brain – seizure, epilepsy, Alzheimer’s disease, dementia, tumors
Mechanism of localization
18Fluorodeoxyglucose (18FDG) is a sugar molecule that concentrates in areas of high glucose metabolism. Healthcare providers are seeking to determine whether there is an abnormal amount of uptake of this tracer in a particular area of the body which may be indicative of a particular health concern.
Why look into this radiopharmaceutical?
This is the most widely used imaging agent in the world of oncology. Many referring physicians are familiar with this drug and its applications for oncologic purposes. It is generally accepted as the drug to use for most cancers.
Many physicians and facilities are not familiar with the other indications and usages of this imaging agent. Examples include: Viable myocardium—this drug can be used to determine what sections of the heart are still viable and have living, functioning cells.
Brain – Many times, 18FDG can add valuable information that a neurosurgeon needs prior to surgery. Functional changes occur much earlier than physical changes—PET/CT images often compliment CT or MRI images.
This radiopharmaceutical is most commonly used to identify cancers of the bone or cancers that have metastasized (spread) into the bone. The Sodium 18Fluoride (NaF18) ions are deposited directly into the bone matrix and bone surface. Common sites are newly mineralized bone, such as during growth, infection, malignancy (primary or secondary), after trauma, or during inflammation.
Why look into this radiopharmaceutical?
This drug is much better at targeting skeletal activity than FDG and provides a much clearer image than traditional nuclear medicine bone scans. These 3D images are also quantitative which allows physicians to precisely measure the activity within a lesion – allows for a more accurate interpretation of the response to treatment.
Prescribing information and use
- The imaging agent is ordered and delivered for each specific patient
- There is no patient prep
- Patient is injected and imaged
- Entire exam takes roughly 90-120 minutes