Further considerations on adverse reactions to radiopharmaceuticals

Anaphylactic Shock Due to Technetium (99mTc)-Tetrofosmin During Myocardial Perfusion Scintigraphy: A Case Report

Myocardial perfusion scintigraphy is a popular minimally invasive method for evaluating chronic coronary disease (CCD). We performed myocardial scintigraphy to assess CCD in a 74-year-old man with a history of allergy to contrast media. The patient developed anaphylactic shock immediately after the administration of the technetium (99mTc)-tetrofosmin preparation. This is the first report of anaphylactic shock due to 99mTc-tetrofosmin administration during myocardial perfusion scintigraphy.

Applications and Safety of Sentinel Lymph Node Biopsy in Endometrial Cancer

Lymph node status is important in predicting the prognosis and guiding adjuvant treatment in endometrial cancer. However, previous studies showed that systematic lymphadenectomy conferred no therapeutic values in clinically early-stage endometrial cancer but might lead to substantial morbidity and impact on the quality of life of the patients. The sentinel lymph node is the first lymph node that tumor cells drain to, and sentinel lymph node biopsy has emerged as an acceptable alternative to full lymphadenectomy in both low-risk and high-risk endometrial cancer. Evidence has demonstrated a high detection rate, sensitivity and negative predictive value of sentinel lymph node biopsy. It can also reduce surgical morbidity and improve the detection of lymph node metastases compared with systematic lymphadenectomy. This review summarizes the current techniques of sentinel lymph node mapping, the applications and oncological outcomes of sentinel lymph node biopsy in low-risk and high-risk endometrial cancer, and the management of isolated tumor cells in sentinel lymph nodes. We also illustrate a revised sentinel lymph node biopsy algorithm and advocate to repeat the tracer injection and explore the presacral and paraaortic areas if sentinel lymph nodes are not found in the hemipelvis.

Analysis of Unusual Adverse Effects After Radium-223 Dichloride Administration

BACKGROUND

To our knowledge, no previous study or literature review has been performed about the effects of the extravasation of therapeutic radiopharmaceutical agents and its potential consequences, especially regarding alpha-particle emitting radiopharmaceuticals.

METHODS

Even if Radium-223 dichloride is known to be a relatively safe drug to manage, despite the correctness of the procedures applied , unexpected delayed adverse effects can occur. In our vast experience, we rarely observed lymphedema, even after some time, at the site of administration.

RESULTS

Management of lymphedema caused by radiopharmaceuticals administration has been addressed through clinical examples. The sudden intervention allowed a fast remission of the signs and symptoms complained by patients treated with Radium-223 dichloride.

CONCLUSION

The management of adverse effects after radiopharmaceuticals administration as in case of lymphedema onset, is extremely simple. These data confirm the safety of Radium-223 treatment.

American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy

BACKGROUND

Venous thromboembolism (VTE) complicates ∼1.2 of every 1000 deliveries. Despite these low absolute risks, pregnancy-associated VTE is a leading cause of maternal morbidity and mortality.

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and others in decisions about the prevention and management of pregnancy-associated VTE.

METHODS

ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations.

RESULTS

The panel agreed on 31 recommendations related to the treatment of VTE and superficial vein thrombosis, diagnosis of VTE, and thrombosis prophylaxis.

CONCLUSIONS

There was a strong recommendation for low-molecular-weight heparin (LWMH) over unfractionated heparin for acute VTE. Most recommendations were conditional, including those for either twice-per-day or once-per-day LMWH dosing for the treatment of acute VTE and initial outpatient therapy over hospital admission with low-risk acute VTE, as well as against routine anti-factor Xa (FXa) monitoring to guide dosing with LMWH for VTE treatment. There was a strong recommendation (low certainty in evidence) for antepartum anticoagulant prophylaxis with a history of unprovoked or hormonally associated VTE and a conditional recommendation against antepartum anticoagulant prophylaxis with prior VTE associated with a resolved nonhormonal provoking risk factor.

Adverse Events of Diagnostic Radiopharmaceuticals: A Systematic Review

Diagnostic radiopharmaceuticals used in nuclear medicine can cause adverse events. Information on these adverse events is available in case reports and databases but may not be readily accessible to healthcare professionals. This systematic review provides an overview of adverse events of diagnostical radiopharmaceuticals and their characteristics. A median frequency for adverse events in diagnostical radiopharmaceuticals of 1.63 (interquartile range: 1.09-2.29) per 100,000 is reported. Most common are skin and subcutaneous tissue disorders, and general disorders and administration site conditions. Many adverse events reported are minor in severity, although 6.7% can be classified as important. In rare cases, adverse events are serious and potentially life-threatening. With the introduction of new radiopharmaceuticals and the increasing use of positron emission tomography-computed tomography, previously unknown adverse events may be detected in daily practice. Future work should cover the experience of the patient with adverse events from diagnostic radiopharmaceuticals.

Inhibition of viability of microorganisms in [18F]-labeled radiopharmaceuticals

INTRODUCTION

Good manufacturing practice (GMP)-compliant production of radiopharmaceuticals for parenteral application requires great efforts in maintenance of clean room infrastructure and equipment in order to reliably guarantee the constant hygienic quality of the product (sterility). Terminal sterilization of the product is not always possible due to short half-life or due to thermal instability of the compound. The typical method for sterilization in these cases is sterile filtration prior to dispensing (distribution of product solution from bulk to patient vials). Therefore, aseptic processing techniques have to be in place in order to ensure sterility. Still, there remains some risk of microbial contamination of the product, and hence a risk for the patient to suffer from infection. Due to the short half-life of the labeling radionuclides, this aspect is aggravated by only retrospectively possible testing for sterility. This work investigated the potential of [¹⁸F]-radiation to intrinsically inactivate microorganisms (MO) that might have slipped through the aseptic process.

METHODS

Defined numbers of viable cells of different bacterial strains and molds were incubated with defined amounts of [¹⁸F]-activity. After decay of radiation the number of surviving viable cells was determined, D₁₀-values were calculated and evaluated.

RESULTS

The MOs tested exhibit a broad range of [¹⁸F]-radiation susceptibility, D₁₀-values range from a sensitive 114MBq/mL (46Gy) to a durable 2,048MBq/mL (790Gy).

CONCLUSION

The intrinsic [¹⁸F]-radiation in radiopharmaceuticals is no safe measure to generally ensure sterility of the product solution in terms of "autosterilization", because of dependence on various parameters.

ADVANCES IN KNOWLEDGE AND IMPLICATIONS FOR PATIENT CARE

This work presents for the first time experimental data on the influence of [¹⁸F]-radiation on MOs. The results suggest, that aseptic processing techniques are essential and that results of determination of sterility in radiopharmaceuticals should be considered with care (emphasis on importance of media fill campaigns).

Sentinel-node mapping in endometrial cancer patients: comparing SPECT/CT, gamma-probe and dye

OBJECTIVE

The aim of this study was to compare preoperative SPECT/CT with gamma-probe and methylene blue-dye (MBD) in the identification of sentinel lymph node (SLN) in early stage endometrial cancer.

METHODS

40 stage-I EC patients (66.7 ± 9.7 years) underwent preoperative lymphoscintigraphy. After about 3 h from Tc-99m-albumin nanocolloid cervical injection, all patients underwent SPECT/CT study. MBD was injected into the cervix just before surgery under general anesthesia. All patients underwent SLN biopsy, hysterectomy, bilateral salpingo-oophorectomy, and radical regional lymphadenectomy. SPECT/CT findings were compared to those of gamma-probe and MBD techniques.

RESULTS

In 2 patients no nodal migration was observed, neither with MBD nor radiotracer. Detection rate of at least one SLN was 90% (36/40 patients) with SPECT/CT, 88% (35/40) intra-operatively with gamma-probe and 80% (32/40) with MBD. Only in 7/40 patients a bilateral migration was obtained with all considered modalities. In particular, bilateral detection was achieved in 26 patients with SPECT/CT, in 24 with gamma-probe and in 10 patients with MBD. The concordance site between SPECT/CT and intraoperative gamma-probe was 73% (29/40 patients: 2 without migration, 21 bilateral and 6 monolateral SLNs); while concordance site with MBD was found in 40% (16/40: 8 bilateral, 6 monolateral SLNs, 2 without SLNs). Overall, 628 LNs were dissected (mean 18 LNs per patient). The median number of SLNs removed was 2 (mean 2.5 per patient). Out of 91 SLNs: 43 were "hot and blue (HB)", 10 were blue only and 38 were hot only. LN metastases rate was 16%: 9/90 SLNs (7 HB, 2 hot only) were positive for metastases in 6 patients. Four non-SLNs were found positive in 3 patients, and all presented concomitant positive SLNs. False negative rate was 0%.

CONCLUSIONS

SPECT/CT had the highest detection rate and achieved the highest rate of bilateral mapping, compared to gamma-probe and MDB. SPECT/CT had moderate concordance with gamma-probe, and it can help the intraoperative detection of SLNs providing important information about their anatomic location.

Adverse Reactions to Radiopharmaceuticals in France

Background: Radiopharmaceuticals are regarded as safe by the nuclear medicine community, but up to now, no survey has been conducted with from the perspective of pharmacovigilance. Objective: To describe the adverse reactions to radiopharmaceuticals (ARRPs) reported to the French Pharmacovigilance Database (FPVD). Methods: We selected and described all reports encompassing at least one radiopharmaceutical in the FPVD. The annual incidence of reported ARRPs used in diagnosis was also estimated. Results: From 1989 to 2013, 304 reports of ARRPs were identified (43.0% serious, 12 deaths) in 54.6% women and 45.4% men; the median age was 58 years. Five therapeutic radiopharmaceuticals (131I-sodium iodide, 131I-lipiodol, 89Sr-chloride, 153Sm-lexidronam, and 90Y-ibritumomab-tiuxetan) were involved in 48 reports (97 adverse reactions: 86.6% serious, 9 deaths). Pulmonary disorders represented 44.3% of ARRPs used for therapy, mainly related to 131I-lipiodol. There were 34 diagnostic radiopharmaceuticals involved in 256 reports (451 adverse reactions: 38.1% serious, 3 deaths); 8 diagnostic products (99mTc-oxidronate, 18F-fluorodeoxyglucose, 99mTc-tin pyrophosphate, 99mTc-tetrofosmin, 99mTc-dimercaptosuccinic acid, 201Tl-chloride, 99mTc-sestamibi, and 111In-pentetate) accounted for two-thirds of ARRPs. The most frequent adverse reactions were skin (34.4%), general (18.2%), nervous (9.0%), and gastrointestinal disorders (7.0%). There were 25 cases of altered images and 10 medication errors. The annual incidence of reported adverse reactions ranged from 1.2 × 10−5 to 3.4 × 10−5 diagnostic administrations. Conclusions: Reported ARRPs occurred rarely and were more serious in the therapeutic than in the diagnostic field. The notification of ARRPs was able to provide new guidance for safe use, as was the case for 131I-lipiodol. Therefore, it is important to report ARRPs to a pharmacovigilance system.

Prevalence of adverse events to radiopharmaceuticals from 2007 to 2011

We studied the changing patterns of radiopharmaceutical use and the incidence of adverse events (AEs) to PET radiopharmaceuticals, non-PET radiopharmaceuticals, and adjunctive nonradioactive pharmaceuticals in nuclear medicine from 2007 to 2011.

METHODS

Fifteen academic institutions submitted quarterly reports of radiopharmaceutical use and AEs covering 2007-2011.

RESULTS

1,024,177 radiopharmaceutical administrations were monitored: 207,281 diagnostic PET, 803,696 diagnostic non-PET, and 13,200 therapeutic. In addition, 112,830 adjunctive nonradioactive pharmaceutical administrations were monitored. The annual use of bone scintigraphy and radiotracer therapies was unchanged. PET radiopharmaceutical use increased from 17% to 26% of diagnostic procedures (P < 0.01). The incidence of radiopharmaceutical AEs was 2.1/10(5) administrations, with no hospitalizations or deaths.

CONCLUSION

From 2007 to 2011, PET studies increased, and therapeutic radiopharmaceutical use and bone scintigraphy were unchanged. Over 2 decades, the incidence of AEs has remained stable at 2.1-2.3/10(5) dosages.