Radioactive Therapies :Radioactive Therapies Presented By: Gipsy Morales Alex Ramos Viviana Gonzalez Meylen Reyes


Objectives :Objectives To Discuss Radiopharmaceuticals, Methods of Administrations, Dosages, Localizations, Indications, Contraindications, Normal Results, Abnormal results, Artifacts, etc. of these Procedures: Intracavity (Serosal) Therapy Polycythemia Vera Therapy Zevalin (radioimminotherapy) Ablation Therapy


Serosal Cavity Therapy RadioPPharmacy :Serosal Cavity Therapy RadioPPharmacy Radionuclide 32P / ⁹⁹mTc Type IT, γ, generator. Radiopharmaceutical 32P- Chromic Phosphate as a colloid ⁹⁹mTc- SC Localization Compartmental to serosal cavity. Quality Control 32P Chromic Phosphate>95% Radiochemical purity ⁹⁹mTC-SC: >92% Radiochemical Purity. Adult Dose Range ⁹⁹mTC-SC: 2-3 mCi (74-111MBq) 32P- Chromic Phosphate Pleura 10-15mCi Pericardium: 5-10mCi Peritoneum: 15-20mCi Method of Administration Intracath placement into cavity of concern through which the therapy is administered.


Indications and contraindications :Indications and contraindications Indications Palliative reduction recurrent fluid production in serosal cavities secondary to malignant disease. Prevention of recurrence of malignant diseases on serosal surface Treatment of cystic neoplasms. Treatment of malignant ascites. Treatment, in limit role, of ovarian cancer. Contraindications Patients with intraperitoneal infection. Patients with 6 months life expectancy. Detection of the presence of loculated fluid.


Patient Preparation and equipment :Patient Preparation and equipment ID Patient / Verify Dr’s order and explain the procedure to the patient. Written directive must be signed by an authorized user. Signed consent from patient. Patients receiving intrapleural administration must have a thoracentesis to remove the effusion. Camera large field of view. Collimator: Low energy, all purpose Low energy, high resolution Computer Set-Up ⁹⁹mTC-SC: 140 keV 20% window Statstics 250,000 counts or 180 seconds images


Procedure… :Procedure… Time: Injection 30min, imaging ~15min/section supine position Anesthesia of the skin Lidocaine 1% Intracatheter into cavity and secure it with tape. Connecting tube to the intracatheter Three way stopcock to the connecting tube Attach the second connective tube to the three way stopcock. Attach the collecting bag to the free end of the connecting tube. 50ml syringe To the stopcock to withdraw the bulk of the fluid (not all) Document free flow of injected fluid within cavity iodinated contrast material and obtaining a radiograph or by injecting ⁹⁹mTC-SC or ⁹⁹mTC MAA and acquiring a gamma camera image. Attach the syringe containing the ⁹⁹mTC-SC, if imaging is desired, to the stopcock.


…Procedure :…Procedure 1mci ⁹⁹mTC-SC Serosal cavity for imaging. Obtain static images. (Optional) 32P Chromic phosphate (into saline bag if used) (optionally) any remaining ⁹⁹mTC-SC to ensure uniform distribution within the cavity. Peritoneum or pleura cavity: Patient needs to roll side to side to ensure adequate distribution of the radiotherapy throughout the cavity. Heart motion ensures adequate distribution in the pericardial cavity. By injecting water soluble radiopaque agent and taking a KUB we can confirm if the fluid dispersed. To confirm dispersal we can image peritoneum or pleural cavity using x-rays from 32P (1710KeV). Use a high energy collimator.


…Procedure :…Procedure Cystic volume measurement in brain neoplasm can be obtained with a CT scan After injection pt is repositioned repeatedly in first hour several times each hour for the next 24hrs


Normal and abnormal results :Normal and abnormal results Normal Results Palliation of the pain caused by excess fluid within affected cavity. Max effect (3months) Therapeutic treatment of cancer causing the production of excess fluid within the affected cavity. With the use of ⁹⁹mTC-Sc imaging, serosal cavity is presented as thoroughly and evenly perfused as possible. Abnormal results Little or no relief of the pain Cancer causing the production of excess fluid within the affected cavity. Images may have clumping or subspaces with more activity than others


Artifacts :Artifacts Do not use as IV injection. Radiotherapy colloid will localize in liver. The preparation should be a cloudy , brownish-green colloidal suspension. Any leakage from the therapy site must be treated as a radioactive spill and cleaned in accordance with precautions pertaining to beta emitters. Important: Tumors in the peritoneal or pleura cavity cause serosal irritation, resulting in excess cavity transudation. This fluid causes extreme discomfort to the patient. The beta emitter ₃₂P –Chromic phosphate is used a palliative treatment, irradiation the surface of cavity and reducing the production of fluid.


The role of the nmt in therapy :The role of the nmt in therapy Order and receive the radiopharmaceutical. Prepare the pt and paperwork for physician and therapy. Provide sterile area and proper equipment for injection. Assay the therapy dose and confirm the amount of activity with physician. Low-energy x-ray radiation can be used to assay the dose. Record the time, dose, pt, doctor and any pertinent information about the therapy. Be ready to take post-therapy dose images of area of interest if that avenue is being pursued.


Patient History: :Patient History: Do you have history or family history of cancer? Y N If yes, what type and for how long?______________________ Are you presently experiencing pain? Y N If yes, where and for how long?_________________________ Do you feel you have fluid build-up? Y N If yes, where and for how long?_________________________ Do you have the results of any other related examinations? Y N Do you have the results of any resent Laboratory test? Y N Have you had any other therapy? Y N If so, what type and when?_________________________________ Female: Are you pregnant or nursing? Y N


Polycythemia VeraRadiopharmacy :Polycythemia VeraRadiopharmacy Radionuclide P32 t1/2 =14.26 days Energies: 1710 kev (max), 694.9 kev (mean) Type: B- Radiopharmaceutical P32 sodium phosphate Radionuclide P32 t1/2 =14.26 days Energies: 1710 kev (max), 694.9 kev (mean) Type: B- Radiopharmaceutical P32 sodium phosphate Polycythemia VeraRadiopharmacy


Radiopharmacy :Radiopharmacy Localization Bone tissue Quality Control Administered dose must be within 10% of requested dose Adult Dose Range 2.3 mCi per square meter body surface 3-5 mCi, during any 6 month period Method of administration Intravenous injection


Indications and Contraindications :Indications and Contraindications Indications Palliation of erythrocytosis Treatment of thrombocytosis -platelet counts Extramedullary hematopoiesis - painful spleen, hypersplenism, abdominal pain Treatment of cardiovascular problems Contraindications Treatment should not be use if: Platelet counts is 15,000 Reticulocyte count is < 0.2% White blood cell count is <3000


PATIENT PREPARATION :PATIENT PREPARATION Identify the patient Verify doctor's order Explain the procedure The written directive must be signed by an authorized user Obtain a signed consent from the patient


Procedure :Procedure Three-way stopcock to the line Attach a syringe 10ml saline Chucks needed Authorized user Performs injection inject the radiopharmaceutical 30 to 60 seconds Observe injection Take account of before proper disposal IV catheter, the saline syringe, tubing, and radiopharmaceutical syringe


Normal and abnormal results, :Normal and abnormal results, Normal results Patient's blood chemistry returns to normal levels within 4 to 6 weeks. It may stay in remission for 2 years or more Abnormal results No reduction of production of red blood cells even after repeated doses of the therapy


Artifacts :Artifacts Extravagation of the therapy dose 10% to 20% of P32 patients treated with P32 is 10 to 16 years, Myelofibrosis with myeloid metaplasia occurs in 10% to 20% of Polycythemia patients


Role of the NMT :Role of the NMT Order and receive the radiopharmaceutical Properly prepare patient Start the IV catheter and tubing for patency Provide a sterile area Confirm the amount of activity with the injecting physician Record the time, dose, patient, doctor, and any pertinent information about the therapy


Patient History :Patient History The patient should answer the following questions: (yes or no) Do you have a history or family history of cancer? If so, what type and for how long? Do you have documentation of a bone disorder? Do you have the results of any related examinations? Do you have the results of any laboratory test? Have you received any recent therapy? If so, what type and when? Female: are you pregnant or nursing?


Slide 22:Overview of reported cases of resolution of Polycythemia before and after treatment of hydronephrosis by nephrectomy


Therapy: Zevalin (Radioimmunotherapy for B-cell non-Hodgkin's Lymphoma) :Therapy: Zevalin (Radioimmunotherapy for B-cell non-Hodgkin's Lymphoma)


Radiopharmacy :Radiopharmacy Radionuclides In111 Half-life: 2.8 days Energies: 173 keV, 247 keV EC, gamma Y90 Half-life: 64.1 hours 2.284 Mev (β-)Beta-emitter Radiopharmaceutical In111 Chloride (Zevalin) Y90 Chloride (Zevalin) Y90 Beta travels about 5mm in soft tissue (100-200 cell diameters) Localization Compartmental, blood flow Antibody Binding CD20 Antigen Target Normal and Malignant B-lymphocytes of non-Hodgkin’s lymphoma CD20 only expressed on B-cells Plays a role in B-cell activation and proliferation


Radiopharmacy :Radiopharmacy Adult Dose Range In111 5mCi Y90 .4mCi/kg For therapy, not to exceed 32 mCi Y-90 Zevalin should not be used in CHILDREN safety and effectiveness in children have not been confirmed. Quality Control In111 - Within 12 hrs Y90 - Within 8 hrs Kit made- TLC ≥ 95% Method of Administration I.V. Butterfly (18-22 ga.) Over 10 minutes with a .2um micropore filter on syringe Or infusion pump 10ml Saline flush Have (1mg) epinephrine in case of allergic reaction Follow vital signs 5min baseline then 15,30,60 minutes Look or redness of injection site and nausea or vomiting


Indications :Indications Confirm biodistribution of In111 Zevalin for Y90 Zevalin In-111 Zevalin is used for imaging (gamma) No excess amounts go to the marrow, liver, etc. No altered biodistribution Y-90 Zevalin has cell-killing beta radiation Treatment of patient includes Rituxan Rituximab destroys both normal and malignant B lymphocytes Treatment of low grade, follicular or transformed B-cell non-Hodgkins lymphoma


Contraindications :Contraindications Known anaphylactic or hypersensitivity to murine proteins Rituximab ≥ 25% lymphoma marrow involvement impaired marrow reserves Patients with Leukemia, HIV, or AIDS Y-90 Zevalin may lower ability to fight infection Patients with low cell counts If counts are 100,000 to 149,000/mm3 then dose is adjusted to .3mCi/kg Altered Biodistribution 12 out of 953 registered


Patient Preparation :Patient Preparation Identify, Verify order, Explain procedure Signed Consent Supplies list of history of allergies and prior exams Platelet and neutrophil counts taken pretreatment Avoid becoming pregnant during therapy Patient to receive Rituxan therapy at physician’s office 4 hours before receiving the In-111 dosage and again before the Y-90 dosage Pre-depletion of B-cells Well hydrated Patient Void before imaging


Equipment :Equipment Camera Large Filed of View Collimator Medium energy, all-purpose Static Indium peaks (172-247 kev) 15%-20% window 1282 or 2562 matrix > 1 million counts per view (600 seconds) Whole body 10cm/ min or slower 30 minutes minimum


Procedure :Procedure Time 30 minutes for In-111 Dose 1 hour each scan day Supine position Image 2-24 hours, 48-72 hours and possibly 96-120 hours post-injection Static 10 min/ position Ant/Post of Thorax, Abdomen, Pelvis, Extremities Whole Body (Preferred) 30 minutes anterior/posterior Patient infused with Y-90 Zevalin 7-10 days after In-111 Injection Takes about 30 minutes


Normal Results :Normal Results Blood Pool activity Day 1 Heart, vascular areas Medium to High Liver/Spleen uptake Low uptake in kidneys, Urinary bladder, bowel Focal areas of tumor uptake Tumor-bearing areas in normal organs Attempting to confirm biodistribution to tumors Note: Five-year survival rates range from 20 - 95% depending on the lymphoma type, stage, age of the patient, and other variables


Abnormal Results :Abnormal Results Altered Biodistribution Uptake in lung space that is more intense than the blood pool Kidneys present with greater intensity than liver Increased uptake in bowels


Artifacts :Artifacts Observe for allergic reactions Hypotension, angioedema, hypoxia, thrombocytopenia, neutropenia Patient motion may distort or obscure possible sites Dose infiltration: Increase acquisition times Plastic or acrylic syringe shield used for Y-90 Beta and Lead syringe shield for In-111.


Patient History :Patient History Do you have a history or family history of cancer? Do you have any pain? If so, Where and for how long? Have you had any recent surgery? Do you have your blood platelet results? Have you had any recent chemotherapy or radiation therapy? Any allergies? Have you received your Rituxan therapy? Any recent abnormal labs? Any recent or planned CT, PET, MRI, X-Ray, US, or NM exams?


Post Therapy Instruction :Post Therapy Instruction For at least 2 days, maximum 3, keep a distance of 3 feet or more between you and any people Do not hold children or animals close for two days Sleep alone or the first two nights but no longer than 3 Flush two times when done with using the toilet You may feel a scratchy throat but that will subside Questions? Call the Nuclear Medicine Department


Thyroid: Ablation :Thyroid: Ablation Radiopharmacy Radionuclide 131I, hl: 8.1 days Energies: 364 keV (γ), 606 keV (β-) Type: β-, γ, fission product Radiopharmaceutical 131I as sodium iodide capsule or liquid Localization Active transport. Organified by thyroid and held in cells or follicular lumen. Te= 3-5 days QC Assay the capsule or vial in the dose calibrator to confirm amount of radioactivity Adult Dose Range 29.9 mCi or less if primary tumor is <1.5 cm 30-300 mCi Method of Administration Oral capsule, through straw from lead container for liquid. May require RSO, nuclear physician


Indications & Contraindications :Indications & Contraindications Indications Residual functioning thyroid carcinoma Residual functioning normal thyroid tissue after total or partial thyroidectomy Contraindications Pregnancy or nursing Allergy to iodine Ionated studies performed recently Patient extremely likely to regurgitate dose Patient taking thyroid medications


Patient Preparation :Patient Preparation ID patient Low iodine diet 1 week b/f therapy Discontinue thyroid medications for 2 to 4 weeks No iodinated studies for 3 weeks Pregnant or nursing


Procedure :Procedure Admit patient into room Explain therapy Obtain consent from patient Assay the capsule or vial Remove family and friends Administer Reglan Obtain written prescription from physician Administer dose to patient quickly Monitor and record assays Small table for charting dosimeter Release patient when appropriate Decontaminate room


Procedure :Procedure Nursing in service No pregnant nurses No housekeeping personnel allowed Explain dosimeter, radiation safety and what 131 I does to the patient Allowed 2 mR/day Patient needs to be hydrated Disposable utensils Problems?


Procedure :Procedure Patient Explanation May experience dry mouth or soreness, nausea vomiting Rinse out cans before throwing to garbage Visitors 20 mins/day 10 ft or at the door No pregnant or < than 18 yrs. old


Procedure :Procedure Room Decontamination Bathroom must be surveyed until < than 5 mR/hr Check sink, waste cans for activity Let housekeeping know when to come in


Patient History :Patient History Do you have a history of adenocarcinoma? Family history of Cancer? Have you recently had thyroid surgery Are you presently taking any thyroid medications? FEMALE PATIENTS Are you pregnant or nursing? When was your lasts menstrual period? Have you experienced any amenorrhea?


Summary :Summary Intracavity (Serosal) Therapy Tc99m Sulfur Colloid 2-3mCi P-32 Chromic phosphate 5-20mCi depending on Cavity Method of Administration Intracath placement into cavity Localization Serosal Compartment lining Polycythemia Vera P-32 Phosphate 2.3mCi/square meter of body; Max: 7mCi Method of Administration I.V. Injection 10ml Saline flush Localization 85% metabolically localizes in bone tissue (bone marrow)


Summary :Summary Zevalin Radioimmunotherapy In-111 Zevalin, 5mCi For imaging Y-90 Zevalin, .4mCi/kg; Max: 32mCi Localization Antibody binding, CD20 antigen located on B-lymphocytes Method of Administration I.V. Butterfly In-111 Zevalin Infusion Y-90 Zevalin Thyroid Ablation I-131 Sodium Iodide Capsule, 30-300 mCi depending on tumor size Localization Active Transport Thyroid cells Effective T1/2= 3-5 days Method of Administration Oral capsule, through straw from lead container for liquid. May require RSO, Nuclear physician, Nuclear physicist


Questions :Questions Name three serous cavities of the human body Pleural Pericardial Peritoneal (T/F) The maximum effect of Serosal Therapy occurs at 3 months post-therapy True! What is the method of administration or Intracavity(Serosal) Therapy? Intracath placement into cavity of concern For each Serosal cavity, what are the dose ranges for P-32 Chromic Phosphate? Pleura: 10-15 mCi Pericardium: 5-10 mCi Peritoneum: 15-20 mCi (T/F) A (KUB) x-ray exam deals with the Kidneys, Ureter and Bladder True!


Questions :Questions List 3 of the question you should ask to the patient Do you have the results of any related examinations? Do you have the results of any laboratory test? Have you receive any recent therapy? What is the radiopharmaceutical for Polycythemia Vera therapy? P32 In Polycythemia Vera therapy, the time of procedure is: a)injection:30 minute; imaging: 15 minutes/section b) Around 20 minutes c)1 hour d)3-5 days List 3 roles of the NM Technologist in Polycythemia Vera therapy Properly prepare patient and paperwork for the physician and therapy Start the IV catheter and tubing for patency Provide a sterile area and proper equipment for the injection What is the Method of administration for Polycythemia Vera Therapy? Intravenous Injection through a Butterfly needle


Questions :Questions What Radionuclides are used in Zevalin Radioimmunotherapy? In-111 , Y-90 Which radiopharmaceutical is injected and which is infused? Injected, In-111 Zevalin Infused, Y-90 Zevalin (T/F) A child is able to go through Zevalin Radioimmunotherapy safely False! I-131 or Iodide is released from the body in what manners? Urine, Bowel Movement, Perspiration, Saliva What kind of syringe shield is used for Y-90? Plastic or Acrylic


Questions :Questions How is 131I administered for thyroid ablation? - Oral capsule or liquid through a straw from a lead container How long does 131I stay within the cells? - 3 to 5 days Mentions some of the things you cannot eat when you are on a low iodine diet. - egg, milk, seafood… How much radiation is the nurse usually allowed? - 2 mR/day or 1 min/ visit at 3 ft. What are some of the questions you would ask in the patient history of thyroid ablation? - Have you had thyroid surgery? Are you pregnant or nursing?


References :References Shackett, Pete. NMT: Procedures and Quick reference. 2nd Ed.. Baltimore: 2008. "Y-90 Zevalin." Drugs.com. 01 OCT 2008. Wolters Kluwer Health. 20 Oct 2008 . "Yttrium." Wikipedia. 17 OCT 2008. Wikimedia. 20 Oct 2008 .