This month, ICE Magazine asked several imaging leaders to share their insights regarding nuclear medicine. This is an exciting modality with lots of advances and new technology. Participants in the Director’s Circle article are:
- Misty Bartolotti, lead technologist, nuclear medicine at Tripler Army Medical Center
- Meredith Henderson, CNMT, nuclear medicine supervisor at Cabell Huntington Hospital
- Rylie Pattison, radiology technologist-breast health, MRI, Nuclear Medicine and Ultrasound at St. John Medical Center; and
- Patrick F. Wojtylak, MSHA, CNMT, radiology system manager-nuclear medicine at University Hospitals of Cleveland.
1. What are some of the latest advances in nuclear medicine?
Bartolotti: The most exciting advances in nuclear medicine right now are directed at theranostics. Oncology has been leading the way with PSMA which is used for castration-resistant prostate cancer. Although there is a potential for neurology, cardiology, inflammatory and infectious diseases to all utilize the combination of radionuclide imaging and therapy. There is a lot of research for new isotope options on an international level going on right now. I anticipate the majority of nuclear medicine studies in the future will be geared towards theranostics. While the cost of the therapy can be on the high end, the opportunity to zone in on a specific cancer just enhances the patient’s treatment plan with the possibility to provide substantial results. An opportunity to live a healthy life is priceless.
Henderson: Advancements of radio gland therapies such as the new therapies for PSMA prostate and neuroendocrine cancers.
Pattison: The wonderful thing about nuclear medicine is that there are many advancements being made every day. Nuclear medicine has found itself to be a very crucial field that with time and research will only grow. It was not too long ago that PET/CT was just a research procedure, and now it is a basic protocol of cancer treatment. There is constant research being conducted to figure out which radioisotopes can effectively achieve the results intended, whether it be accurate imaging or therapies that are more efficient. There will always be a need to improve camera function and a need to develop better, more effective radioisotopes. There have been several developments of treatments that target prostate cancer that have promising results. PET/MRI is also improving and helps to reduce the percentage of biopsies for prostate cancer patients.
Wojtylak: Theranostics is a rapidly growing field that combines diagnostic imaging and targeted therapy. The theranostic agents are designed to both diagnose and treat patient’s cancer by delivering radioactive isotopes directly to diseased cells. This method allows for personalized treatment plans tailored to individual patients. Prostate-specific membrane antigen (PSMA) is a protein found at high levels on prostate cancer cells. PSMA-PET imaging, which utilizes radiotracers targeting PSMA, offers enhanced detection of prostate cancer lesions compared to traditional imaging modalities like CT or MRI. This technology helps in more accurate staging and treatment planning for prostate cancer patients. Also, this has a therapy to go along with it, a theranostic. On the research side, Alpha-emitting radionuclide therapy. Alpha-emitting radionuclides have high linear energy transfer and short path lengths, making them effective for targeting and destroying cancer cells while minimizing damage to surrounding healthy tissue. We are part of many clinical trials that have shown promising results in the treatment of many different cancers.
2. What are the 2 or 3 of the most important factors when selecting a new nuclear medicine device?
Bartolotti: Three of the most important factors when selecting a nuclear medicine device specific for a military treatment facility is security number one, a valid ATO is critical followed by reliability, and versatility. Even though we are a military facility, we have such a diverse range of patients that we need equipment that we can depend on for patients from age 0-99. We have zero interest in putting anyone of our active-duty military, family members, dependents or VA at risk.
Henderson: Deciding what best fits your department’s needs is the starting point. Because price is usually going to be the deciding factor, purchasing a piece of equipment that will work well with your existing, older equipment is helpful. Can I get a comparable machine that is refurbished? Will it work with our current processing software? Another big factor I have to consider is whether or not it will fit in my space.
Pattison: The number one priority in any nuclear medicine device is patient safety. A dose calibrator is expected to relay accurate dose information, which is crucial for administration to a patient. A GM meter must be able to accurately relay measurements of rem. A camera must provide conclusive imaging while being safe and practical. SPECT/CT has proven to be a great usage in nuclear medicine. When selecting a new camera, one with SPECT/CT capabilities is preferred.
Wojtylak: Here are the important factors:
- Image Quality and Performance – One of most important factors of any nuclear medicine device is to produce high-quality images for accurate diagnosis and treatment planning. There are different factors such as spatial resolution, sensitivity, contrast resolution, and image acquisition speed that are critical in assessing image quality. The system should be capable of providing clear and detailed images while minimizing artifacts and noise. Additionally, consider the device’s ability to perform a wide range of imaging studies and its compatibility with various radiotracers and imaging protocols is another factor when selecting systems.
- Workflow Efficiency and Integration – Efficiency and workflow optimization are essential for maximizing productivity and throughput in a clinical setting. This is very important to make sure the department chooses a nuclear medicine system that offers intuitive user interfaces, streamlined workflows, and automation features to simplify image acquisition, processing, and interpretation. In reality, you are looking for future proofing so the system can grow with the hospital or practice. Also the system must be able to integrate with existing hospital information systems (HIS), picture archiving and communication systems (PACS), and electronic medical records (EMR) seamlessly. This is crucial for data management and communication across departments in the hospital system.
- Safety and Radiation Dose Management – Patient safety is paramount in nuclear medicine practice as in any radiology department. When purchasing systems, we look for devices equipped with advanced radiation dose reduction technologies, such as dose modulation algorithms, iterative reconstruction techniques, and patient-specific dose optimization tools. This is to make sure you are giving the lowest amount of radiation to the patients, monitoring the amount of radiation given and creating the best images with the most up to date processing tools. The system should adhere to established radiation safety guidelines and regulatory requirements to ensure safe and appropriate use of ionizing radiation. Also consider dose monitoring and dose tracking capabilities to minimize radiation exposure for both patients and health care providers.
3. What are some tips for creating an efficient nuclear medicine workflow?
Bartolotti: Some tips for creating an efficient nuclear medicine workflow start with our reception desk. The support staff is responsible to get all our patients scheduled with proper prep instructions and checked in on a timely manner. We have organized a scheduling template that has allowed us to maximize the use of our radiopharmaceuticals and camera availability for each day. Teamwork makes the dream work here in the nuclear medicine department at Tripler Army Medical Center.
Henderson: Good scheduling is the easiest way to create an efficient workflow. Because most of our studies have different circulating times and not all exams require imaging, some tests can be scheduled at the same time.
Pattison: Workflow can be difficult to navigate at times, especially when issues arise such as a camera being down or numerous add on in-patients. Truthfully, working as a team and being willing to help and each play a part can help to make the day go smoothly. Writing out a general outline of the day with plans of what times patients will need to be injected or imaged and in what rooms each part will be happening can help to balance out the day and know exactly when and where things need to be, helping to avoid overload and delay. Having an outlined schedule can help to navigate when any add on can be accounted for. Knowing that patient safety is always a number one priority, taking it one patient at a time and focusing on the task at hand rather than being stressed about all that needs to happen will also provide a positive workflow. Being too overwhelmed will only cause more mistakes which will cause more work and can be harmful to patients. Communicating with patients the time their exam will take and if any disturbances in that time occur will provide a healthy environment to work.
Wojtylak: First and foremost are standardized protocols and procedures. Establish standardized protocols and procedures for each type of nuclear medicine study. This includes patient preparation, radiopharmaceutical administration, image acquisition parameters, and image processing techniques. Standardization helps reduce variability, improves consistency, and enhances the efficiency of the workflow. Another important part of making an efficient workflow is pre-appointment preparation. Providing clear instructions to patients regarding preparation requirements for specific nuclear medicine studies, such as fasting, medication restrictions, and hydration protocols is essential. Another important part is educating patients. Having clear instructions about the procedure, including potential risks and benefits, to ensure compliance and minimize delays on the day of the appointment. Last, but not least, is continuing to improve your process. Regularly monitor key performance indicators (KPIs) such as patient throughput, wait times, and study turnaround times to identify bottlenecks and areas for improvement. Collecting feedback from staff and patients to identify workflow inefficiencies and implement targeted interventions to address them is key. Continuously review and refine processes to optimize workflow efficiency and enhance overall departmental performance. Adopting a systematic approach to workflow optimization, nuclear medicine departments can enhance efficiency, improve patient satisfaction, and deliver high-quality care effectively.
4. What role do you see AI playing in nuclear medicine?
Bartolotti: There is a future for AI in nuclear medicine. It is already playing a role in processing software capabilities. The possibility for improved algorithms for disease detection, with increased accuracy in analyzing the data in a shorter time frame has always been the focus of new product development, aiding in better sensitivity and resolution. Our team could also foresee AI playing a significant role in nuclear medicine in the near future because it’s application could significantly reduce imaging time on both planar and SPECT acquisitions which could lead to an increase in patient volume and lower patient dose. It could help with faster processing and early diagnosis and prognosis by predicting where a lesion might appear or where it would spread. AI could perform mock trials with different treatment scenarios improving therapeutic effects. AI could be trained to predict equipment errors and or detect patterns that could help improve clinic processes and minimize equipment downtime.
Henderson: I think the role of AI will most affect planning and post processing. It is already present, and it is important that we learn to grow the role of AI in the future.
Pattison: AI could be a huge advantage to nuclear medicine. The technology that AI provides could help to make diagnosis and treatment more accurate and improve the efficacy of nuclear medicine studies. It will also change the landscape and allow us to improve on other areas of medicine.
Wojtylak: The roles we see for AI in nuclear medicine are image reconstruction, therapeutic response and dosimetry of individual therapies. AI algorithms can improve the quality of nuclear medicine images by reconstructing raw data with higher resolution and reducing noise and artifacts. Deep learning techniques can enhance image clarity and improve diagnostic accuracy, particularly in low-dose imaging studies. Another spot we see AI growing is in beta and alpha particle treatments. AI algorithms can analyze pre-treatment imaging data, genetic profiles and clinical parameters to predict patient response to specific therapeutic interventions done by radionuclide therapy. By identifying patients who are most likely to benefit from treatment, AI-driven predictive models can optimize treatment selection and improve patient outcomes. Lastly, is looking at the dose delivered to a patient having these treatments or the dosimetry of the treatment dose. AI algorithms can assist in personalized dosimetry calculations by integrating patient-specific anatomical data, radiotracer kinetics and imaging parameters. These models can predict radiation dose distributions within tissues and organs, guiding treatment planning and optimizing therapeutic efficacy while minimizing the risk of radiation toxicity to healthy tissues. As AI continues to evolve, its integration into routine clinical practice holds promise for improving patient care and advancing the field of nuclear medicine.
5. How can nuclear medicine best achieve ALARA goals?
Bartolotti: The best way to achieve ALARA still to this day is through: time, distance and shielding.
- Time: Being proficient enough to handle radioactive material as fast as you can without compromising safety and quality.
- Distance: Knowing how far away you need to be from a radioactive source and still remain effective.
- Shielding: Using available resources in your work area i.e. lead shields, and lead aprons to protect yourself from unnecessary exposures from radioactive materials.
Posting clear and effective signs and labels on all radioactive material or spaces can also help achieve ALARA goals. Lastly is continuous education and training.
Henderson: Time, distance and shielding! By minimizing the amount of time we spend close to our radiation sources, (doses or patients) as well as using tools to create a barrier between ourselves and the radioactive source, we can greatly decrease our radiation exposure.
Pattison: Time, distance, shielding. One of the very first things you learn in nuclear medicine is time, distance and shielding. Patient care is always a priority, however, limiting the time standing right next to a patient after administration might feel wrong to do, but is crucial in limiting occupational exposure. Any time there is a usage of a radioisotope or CT usage, proper shielding should be used, without exception.
Wojtylak: As we all know in radiology ALARA is crucial. It stands for “As Low As Reasonably Achievable,” which is a principle in radiation safety aimed at minimizing radiation exposure to patients, health care workers and the public while maintaining the necessary diagnostic or therapeutic benefits. One way nuclear medicine follows ALARA is by optimizing protocols. Tailor imaging protocols to achieve diagnostic quality while minimizing radiation exposure is key. Use appropriate radiopharmaceutical doses and imaging parameters based on clinical indication and desired image quality. We also employ low-dose imaging techniques, such as iterative reconstruction algorithms and dose modulation on the CT side, to reduce radiation exposure without compromising image quality. Another way is we have a systemwide radiopharmaceutical dosing chart used by all technologists. This will ensure accurate dosing and precise radiopharmaceutical administration by technologists who will follow the established protocols and guidelines. We use standardized procedures for radiotracer preparation, dose calculation and injection techniques to minimize errors and variability. Employing these dose optimization strategies, such as patient-specific dosimetry calculations, to tailor radiopharmaceutical doses to individual patients while maintaining diagnostic efficacy.
6. What else should ICE Magazine readers know about CT?
Bartolotti: As technology advances the nuclear medicine imaging systems are now more commonly being utilized as hybrid SPECT/CT systems. There are also systems being designed as strictly SPECT/CT cameras without the option of planar imaging and they have capabilities of full body SPECT/CT. It is an exciting time to be a part of so many multi-modality imaging options.
Pattison: Nuclear medicine is an extremely awesome field that provides several large advantages. It is incredible to see how far nuclear medicine has come and to know that there is still so much growth. Working in nuclear medicine does not feel like work at all. It is fun and exciting and working with people to help them navigate their health journey. Nuclear medicine is unique and differs from other imaging modalities. It focuses more on the physiology of the body rather than the anatomy. There are so many fascinating factors and attributes that nuclear medicine contributes and I feel very blessed to work in a field that makes me excited daily.
Wojtylak: I really think most has been covered by the questions above. I feel overall that the future of nuclear medicine looks promising, with continued innovation, collaboration and investment driving advancements in clinical practice, research and patient care. We see many companies now harnessing the power of molecular imaging, targeted therapies and advanced technologies. Nuclear medicine is poised to play a pivotal role in shaping the future of health care. The future looks bright for nuclear medicine.
This month’s article was sponsored by NCSI. For more information on this company, visit nuclearcameraservices.com.
