Critical Challenges in Pluvicto Therapy: Incontinent and Anticoagulated Patients.

As molecular therapy continues to grow, unanticipated challenges may arise, requiring the institution's therapeutic team to reevaluate its therapeutic protocol to identify and address potential situations and challenges that may occur. This practical pointer will focus on the novel prostate cancer therapy Pluvicto (177Lu-vipivotide tetraxetan) and 2 unique situations and challenges of treating patients at the Theranostic Center at Carilion Clinic, an outpatient facility dedicated to targeted molecular therapy.

Active monitoring improves radiopharmaceutical administration quality.

Introduction: In 2016, our center adopted technology to routinely monitor 18F-FDG radiopharmaceutical administrations. Within six months of following basic quality improvement methodology, our technologists reduced extravasation rates from 13.3% to 2.9% (p < 0.0001). These same technologists administer other radiopharmaceuticals (without monitoring technology) for general nuclear medicine procedures in a separate facility at the clinic. Our hypothesis was that they would apply 18F-FDG lessons-learned to 99mTc-MDP administrations and that 99mTc-MDP manual injection extravasation rate would be consistent with the ongoing 18F-FDG manual injection extravasation rate (3.4%). We tested our hypothesis by following the same quality improvement methodology and added monitoring equipment to measure extravasation rates for 99mTc-MDP administrations. Results: 816 99mTc-MDP administrations were monitored during 16-month period (four 4-month periods: A, B, C, D). Period A (first four months of active monitoring) extravasation rate was not statistically different from the Measure Phase extravasation rate of the previously completed PET/CT QI Project: 12.75% compared to 13.3% (p-0.7925). Period A extravasation rate was statistically different from Period C (months 9-12) extravasation rate and Period D (months 13-16) extravasation rate: 12.75% compared to 2.94% and to 3.43% (p < 0.0001). During Period C and D technologists achieved extravasation rates comparable to the longstanding manual 18F-FDG injection extravasation rate (3.4%). Conclusion: Our initial hypothesis, that awareness of a problem and the steps need to correct it would result in process improvement, was not accurate. While those factors are important, they are not sufficient. Our findings suggest that active monitoring and the associated display of results are critical to quality improvement efforts to reduce and sustain radiopharmaceutical extravasation rates.

Radiopharmaceutical administration practices-Are they best practice?

Background: The nuclear medicine community has stated that they are using best practices to gain venous access and administer radiopharmaceuticals, and therefore do not contribute to extravasations. We tested this hypothesis qualitatively and quantitatively by evaluating four different perspectives of current radiopharmaceutical administration practices: (1) clinical observations of nuclear medicine technologists on the job, (2) quality improvement (QI) projects, (3) a high-level survey of current practices in 10 acute care hospitals, (4) intravenous (IV) access site data for 29,343 procedures. These four areas were compared to the gold standard of pharmaceutical administration techniques. Results: From clinical observations of radiopharmaceutical administrations in adult populations, technologists extensively used 24-gauge peripheral intravenous catheters (PIVCs) and butterfly needles. They also performed direct puncture (straight stick). Technologists predominantly chose veins in areas of flexion (hand, wrist, and antecubital fossa), rather than forearm vessels for IV access placement; in many circumstances, antecubital fossa vessels are chosen first, often without prior assessment for other suitable vessels. For selecting the injection vein, technologists sometimes used infrared vein finders but primarily performed blind sticks. Review of QI projects suggested that smaller gauge needles were contributing factors to extravasations. Additionally, the review of surveys from 10 hospitals revealed an absence of formalized protocols, training, knowledge, and skills necessary to ensure the safety/patency of IV devices prior to the administration of radiopharmaceuticals. Finally, findings from a review of IV access data for 29,343 procedures supported the observations described above. Conclusions: We expect that nuclear medicine technologists have the best intentions when providing patient care, but many do not follow venous access best practices; they lack formal protocols, have not received the latest comprehensive training, and do not use the best placement tools and monitoring equipment. Thus, the presumption that most nuclear medicine technologists use best practices may not be accurate. In order to improve radiopharmaceutical administration and patient care, the nuclear medicine community should update technical standards to address the most recent peripheral IV access and administration best practices, provide technologists with vascular visualization tools and the proper training, develop and require annual vascular access competency, and provide active monitoring with center and patient-specific data to create ongoing feedback.

Reimbursement Approaches for Radiopharmaceutical Dosimetry: Current Status and Future Opportunities.

Interest in performing dosimetry for clinical radiopharmaceutical therapy procedures has grown in recent years. Several approved therapies include dosimetry in the Food and Drug Administration-approved label instructions, and other therapies are best used under a patient-tailored paradigm. This paper, which is a product of the Society of Nuclear Medicine and Molecular Imaging Dosimetry Task Force, presents motivations and general workflows for radiopharmaceutical therapy dosimetry, as well as existing strategies for obtaining reimbursement for clinical activities related to dosimetry. Several specific patient examples are provided, including suggested codes for reimbursement. In addition to current reimbursement approaches, key dosimetry services that are not supported under the current coding structure are presented and suggested as areas of focus in the coming years.

Detection of Excess Presence of 99m Tc-MDP Near Injection Site-A Case Report.

Nuclear medicine extravasations and prolonged venous stasis may cause poor quality and quantification errors that can affect image interpretation and patient management. Radiopharmaceutical remaining near the administration site means that some portion of the radioactivity is not circulating as required for the prescribed uptake period. This case describes how detection of excess presence of 99mTc-MDP near the injection site enabled the technologist to apply mitigation tactics early in the uptake process. It also suggests that detecting an extravasation or stasis early in the injection process can be important for image interpretation and minimizing radiation dose to tissue.

Impact of an 18F-FDG PET/CT Radiotracer Injection Infiltration on Patient Management-A Case Report.

Major management decisions in patients with solid tumors and lymphomas are often based on 18F-fluorodeoxyglucose (18F-FDG) PET/CT. The misadministration of 18F-FDG outside the systemic circulation can have an adverse impact on this test's sensitivity (1) and is not uncommon (2-7). This report describes how an 18F-FDG misadministration led to a repeat PET/CT study, resulting in the visualization of distant metastases that changed the original treatment plan. The findings suggest that routine injection monitoring is indicated whenever sensitivity is critical, and support claims that infiltrations can confound interpretation of semi-quantitative PET outcome measures in patients who are followed longitudinally (2).