Leveraging Radiopharmaceutical Programmatic Collaboration for Management of Pretherapy and On-treatment Urinary Incontinence.

ABSTRACT: Many parenteral radiopharmaceuticals available as anticancer therapy are filtered by the kidneys and excreted in the urine. Here, physician leaders of radiation medicine, nuclear medicine/molecular imaging, and the radiotheranostics programs as well as radiation safety officers, collaborated to develop a decision-making guideline for the administration of therapeutic radiopharmaceuticals in patients with pretherapy or day-of-treatment incontinence. We discussed challenges and opportunities in the screening of patients in urine collection strategies according to grade of urinary incontinence and in subsequent coordination of care. Lutetium-177 ( 177 Lu)-based radiopharmaceutical therapies provided clinical examples of how our procedures were operationalized. Our key management issues of urinary incontinence were cutaneous radiation injury and redness, infection, or pain. In response, we developed clinical practice guidelines for the recognition and management of incontinence-related adverse events. Common adverse events of urinary incontinence were noted in this study. Our how-to guideline for the safe administration of therapeutic radiopharmaceuticals for patients with urinary incontinence warrants further investigation and should continue to be evaluated across all radiopharmaceutical therapy agents.

Medical workforce in the United States.

This section focuses on the professional workforce comprised of the primary medical specialties that utilize ionizing radiation in their practices. Those discussed include the specialties of radiology and radiation oncology, as well as the subspecialties of radiology, namely diagnostic radiology, interventional radiology, nuclear radiology, and nuclear medicine. These professionals provide essential health care services, for example, the interpretation of imaging studies, the provision of interventional procedures, radionuclide therapeutic treatments, and radiation therapy. In addition, they may be called on to function as part of a radiologic emergency response team to care for potentially exposed persons following radiation events, for example, detonation of a nuclear weapon, nuclear power plant accidents, and transportation incidents. For these reasons, maintenance of an adequate workforce in each of these professions is essential to meeting the nation's future needs. Currently, there is a shortage for all physicians in the medical radiology workforce.

68Ga-DOTATATE PET/CT: The Optimum Standardized Uptake Value (SUV) Internal Reference.

RATIONALE AND OBJECTIVES: Standardized Uptake Value (SUV) is an important semiquantitative measurement used in the clinical and research domains to assess radiopharmaceutical concentration in tumors versus normal organs, but is susceptible to many factors beyond the tumor biological environment. So, the aim of this study is to identify the optimum internal reference among organs with physiological uptake in 68Ga-DOTATATE PET/CT (DOTA PET/CT) scans. MATERIALS AND METHODS: This HIPAA-compliant, IRB-approved study with waiver of consent included retrospective imaging review of 180 consecutive patients with neuroendocrine tumors presenting for DOTA PET/CT image acquisition: Ga-68 DOTATATE dose was reported as (0.054 mCi/Kg) scans between September 2018 and May 2019. Mean value of body weight normalized SUV (SUVbw) and lean body mass normalized SUV (SUL) of liver and spleen were measured. Information about the patients and scan characteristics were collected. The paired Grambsch test was used to compare variance among the measured SUVs. Spearman's rank correlation coefficient was used to assess correlation between SUVs and potential patient- and scan-specific confounding factors. RESULTS: Variance of SUL was significantly lower than variance of SUVbw in both liver and spleen (p-value < 0.0001). Variances of liver SUVbw and SUL were significantly lower than the corresponding spleen SUVs. Liver SUL showed the lowest variance (3.69% ± 1.25%) among all measured SUVs. CONCLUSION: SUL is a more reproducible, less variable, and therefore more reliable quantitative measure in DOTA PET/CT scans, compared SUVbw. Among the available organs with physiological uptake, liver SUL is the optimum internal reference given the liver's larger size and uniform SUL values resulting in lower variability and better reproducibility.

Authentic gold: Celebrating the life and career of Cheri L. Canon, MD, FACR, FAAWR.

Since 1927, the American College of Radiology (ACR) has awarded Gold Medals to up to four individuals each year in recognition of their distinguished and extraordinary service to the ACR or to the discipline of radiology (American College of Radiology, n.d. [1]). As of 2019, only 10 of 194 Gold Medalists have been women. In May 2021, Dr. Cheri L. Canon will become the eleventh woman in ACR history to receive this prestigious award. Contemporaneously, in November 2020, she received the highest honor bestowed by the American Association for Women in Radiology (AAWR), the Marie Sklodowska-Curie Award, presented annually to an individual who has made outstanding contributions to the advancement of women in radiology or radiation oncology (American Association for Women in Radiology, n.d. [2]). Herein we celebrate Dr. Canon's remarkable life and impressive career achievements, and learn important lessons from her shared wisdom.

Skeletal Scintigraphy in Radiation-Induced Fibrosis With Lymphedema.

Despite increasing reliance on CT, MRI, and FDG PET/CT for oncological imaging, whole-body skeletal scintigraphy remains a frontline modality for staging and surveillance of osseous metastatic disease. We present a 54-year-old woman with metastatic breast cancer who received palliative external-beam radiation to the left ilium. Serial follow-up Tc-MDP bone scans demonstrated progressive soft-tissue uptake in her left lower extremity, extending from thigh to leg, with associated enlargement and skin thickening, consistent with lymphedema related to radiation-induced fibrosis. Correlative abdominopelvic CT scans confirmed fibrotic changes in the left thigh.

Entrepreneurial Women in Radiology: Role Models of Success.

Radiology is undeniably male dominated. Alongside surgery and orthopedic surgery, academic radiology ranks near the bottom in having the lowest proportion of full-time female faculty members. Despite many efforts to recruit talented women, the pipeline entering the radiologic disciplines continues to flow at a trickle. One factor is the relative lack of role models for female medical students. Entrepreneurial women in radiology can lead the field with their innovation and creativity, courage, and commitment. In this article, the authors highlight two entrepreneurial female radiologists who shared their success stories at the American Association for Women Radiologists' session at the 2015 ACR annual meeting. Their successes underscore the potential for such women to serve as role models to female medical students and even college undergraduates. Despite the gender gap in radiology, the field has yielded some exceptional women who can take on challenges, overcome barriers and assume risks, create strategies and processes to operationalize their visions, secure funding, and expand their enterprises to make sustainable impacts both at home and abroad. As we move toward more patient- and family-centered care models and become increasingly visible to diverse populations, there is no better time for female leaders in radiology to inspire the next generation to join our essential and rewarding specialty.

ACR/ABR clinical statement on credentialing and privileging of radiologists for therapeutic nuclear medicine.

Processes for credentialing physicians and criteria used for delineating their practice-specific clinical privileges vary widely across the United States. The ACR and the ABR have jointly developed this resource document to define the requisite credentials for specialty board-certified diagnostic radiologists and subspecialty board-certified nuclear radiologists to be privileged to practice therapeutic nuclear medicine. Through its initial specialty and subspecialty certification processes and its maintenance of certification programs for practicing certificate holders, the ABR assures the competence of its professional diplomates for clinical practice. On the basis of their education, training, and clinical work experience, board-certified radiologists have the qualifications to supervise and perform therapies using unsealed radioisotopes. Optimum patient care is best served by a physician with training and expertise in supervising and performing radioisotope therapies in conjunction with multimodality imaging technologies for initial diagnosis and follow-up.

Initial staging of differentiated thyroid carcinoma: continued utility of posttherapy 131I whole-body scintigraphy.

PURPOSE: To retrospectively compare pretherapy iodine 123 ((123)I) and posttherapy iodine 131 ((131)I) sodium iodide whole-body scintigraphy of patients with newly diagnosed differentiated thyroid cancer to determine if there is significant and clinically relevant discordance of nonphysiologic iodide-avid foci (IAFs) between the two examinations. MATERIALS AND METHODS: This study was approved by the Institutional Review Board, the requirement for informed consent was waived, and the study complied with HIPAA. The authors identified 108 patients (88 women, 20 men; age range, 16-86 years; mean, 47.5 years; 45 patients younger than 45 years, 63 patients 45 years and older) who previously had undergone total or near-total thyroidectomy for differentiated thyroid carcinoma. Each patient had undergone a pretherapy ( 123)I whole-body scan followed by a posttherapy ( 131)I whole-body scan. The number and location of IAFs were recorded on both scans. Data were compared by using a Wilcoxon signed rank test for paired data and assessed clinical relevance based on changes in tumor staging. RESULTS: Posttherapy ( 131)I whole-body scans revealed additional IAFs outside the thyroid bed not detected on pretherapy ( 123)I scans in 21 (19%, P < .001) of 108 patients. Nineteen (90%) of these 21 had IAFs in new locations (P < .001), with tumor upstaging of 11 (59%, 10% of total) of those 19 patients; six (55%, 6% of total) of those 11 had scintigraphic patterns consistent with unsuspected metastatic disease. Concordant scintigraphic patterns were observed in 87 (81%) of 108. CONCLUSION: In patients with newly diagnosed differentiated thyroid cancer who had undergone thyroidectomy and ( 131)I ablation, posttherapy ( 131)I whole-body scintigraphy revealed new IAFs in 18% and clinical upstaging occurred in 10% of patients compared with pretherapy ( 123)I whole-body scintigraphy. Therefore, posttherapy ( 131)I whole-body scintigraphy provides incremental clinically relevant information as it helps to establish the true extent of IAFs and may contribute to altering of staging.

Endocrine neoplasm scintigraphy: added value of fusing SPECT/CT images compared with traditional side-by-side analysis.

PURPOSE: Positron emission tomography (PET)/computed tomography (CT) imaging integrates physiology and anatomy, providing a powerful dual-modality approach. Analogously, fusing independently acquired single photon emission computed tomography (SPECT) and CT images can overcome interpretive challenges in characterizing and localizing abnormalities by either modality alone, potentially enhancing diagnostic confidence. This study explores the added value of SPECT/CT image fusion compared with traditional "side-by-side" SPECT/CT image review for a variety of endocrine neoplasms. METHODS AND MATERIALS: We identified 11 abnormal endocrine neoplasm SPECT scans in 10 patients with contemporary relevant CT scans. These cases included: 4 I-131 (posttherapy thyroid cancer), 2 I-123 (pretherapy thyroid cancer), 2 In-111 OctreoScan (neuroendocrine neoplasm), one Tc-99m sestamibi (thyroid cancer), one Tc-99m tetrofosmin (parathyroid adenoma), and one I-123 MIBG (adrenergic neoplasm). SPECT and CT images were uploaded onto side-by-side workstations, one with fusion software. Two experienced nuclear radiologists first reviewed "side-by-side" SPECT/CT images followed by fused SPECT/CT images. They scored 2 parameters-anatomic localization and diagnostic confidence-using a 4-point scale (1 "not helpful" to 4 "very helpful"). Score differences > or =1 indicated "added value"; < or =0 indicated "lack of added value." RESULTS: Compared with "side-by-side" SPECT/CT images, fused SPECT/CT images yielded "added value" for anatomic localization and diagnostic confidence in two thirds of cases. Fusion led to altered diagnoses in 4 of 11 examinations. Greater confidence was also achieved in 3 of 4 when the interpretation was changed and in 4 of 7 cases when it was not. CONCLUSIONS: CT correlation can be helpful in interpreting endocrine neoplasm SPECT imaging. SPECT/CT image fusion outperformed "side-by-side" SPECT/CT analysis for neoplasm anatomic localization and diagnostic confidence. Therefore, SPECT/CT fusion should be performed routinely because it potentially influences clinical decision-making and patient management.

Optimized scintigraphic evaluation of infection and inflammation: role of single-photon emission computed tomography/computed tomography fusion imaging.

Gallium-67 citrate and radiolabeled white blood cells have become standard inflammation/infection-seeking agents whereas other agents, such as (99m)Tc diphosphonates, commonly are used to infer an infectious process. These radiopharmaceuticals reflect physiologic and pathologic function rather than anatomical abnormality. In the clinical setting, it is often necessary to correlate these functional studies with anatomical imaging. The advent of single-photon emission computed tomography, as well as positron emission tomography, provides tomographic images for direct correlation to anatomic modalities such as computed tomography and magnetic resonance imaging. The methods by which these functional and anatomic imaging modalities are correlated include side-by-side, software, and hardware fusion. Clinically, fusion imaging has been applied primarily to oncologic and neurologic applications. The literature supports the premise that multimodality fusion would increase the specificity of the physiologic modality and increase the sensitivity of the anatomic modality. Our institution uses software fusion to aid in the diagnosis of infection and inflammation. Through case vignettes, we illustrate applications for single-photon emission computed tomography/computed tomography fusion for the diagnosis of infection and inflammation in multiple organ systems.

123I thyroid uptake and thyroid size at 24, 48, and 72 hours after the administration of recombinant human thyroid-stimulating hormone to normal volunteers.

CONTEXT: Recombinant human TSH (rhTSH) is used to evaluate thyroid carcinoma patients and off-label for (131)I thyroid ablation and nontoxic goiter therapy. OBJECTIVE: Our objective was to determine the optimal time for (131)I administration after rhTSH. PARTICIPANTS: Twenty-five euthyroid nongoitrous volunteers participated in the study. DESIGN: Baseline 24-h thyroid (123)I uptake (RAIU) was measured, and then 0.1 mg rhTSH was administered. (123)I was administered 24, 48, or 72 h after rhTSH, and a repeat 24-h RAIU was obtained. SETTING: The study was conducted at an academic research center. MAIN OUTCOME MEASURES: Thyroid function tests, thyroid ultrasounds, and electrocardiograms were measured before rhTSH, then daily for 4 d, and finally 7 d after rhTSH. RESULTS: Serum TSH concentrations 24 h after rhTSH increased from 1.7 +/- 0.5 muU/ml (mean +/- sd) to 13.3 +/- 4. The 24-h RAIUs rose from 25 +/- 5 to 47 +/- 8% (88% increase) when the (123)I was given at 24 h after rhTSH and from 29.8 +/- 7 to 40.5 +/- 13% (36% increase) when the (123)I was given at 48 h and were unchanged when the (123)I was given at 72 h. The post-rhTSH RAIU increase was greater at 24 than at 72 h (P < 0.005) and marginally greater than at 48 h (P = 0.057). Thyroid volumes significantly increased 48 h after rhTSH (10 +/- 3.8 vs. 11.1 +/- 3.7 ml; P < 0.009). Electrocardiograms were normal. CONCLUSIONS: Marked increases in RAIU occurred when (123)I was given 24 h after rhTSH administration to euthyroid volunteers. Smaller increases were observed at 48 h and none at 72 h.

Radionuclide imaging of the parathyroid glands: patterns, pearls, and pitfalls.

Optimal parathyroid scintigraphy requires an understanding of (a) the embryologic, anatomic, and physiologic features of the parathyroid glands and (b) the properties of the two common imaging agents, technetium-99m sestamibi and Tc-99m tetrofosmin. Normal parathyroid glands are too small to be visualized, but parathyroid disease often produces visibly enlarged glands. Enlarged parathyroid glands may be found near the thyroid gland or outside their expected locations. Characteristic abnormal scintigraphic patterns may be described as focal or multifocal, usual or ectopic in location, and associated with a normal or abnormal thyroid gland. Patients who are referred for parathyroid imaging should have an abnormal biochemical profile. The first step in evaluating images of a patient suspected to have parathyroid disease is correlating the normal or abnormal scintigraphic patterns with the clinical and surgical history. By integrating the interpretative and technical pearls and pitfalls of parathyroid scintigraphy, the radiologist can be more confident in establishing a correct diagnosis and can precisely guide the surgeon to a single parathyroid adenoma, multiple parathyroid adenomas, or multigland hyperplasia.