Nuclear Medicine Senior Ii 2013 Intravenous P-32 Tx

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Intravenous P-32 Therapy Indications

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Palliation/treatment of specific blood disorders (excessive cell production; polycythemia vera) not controlled by phlebotomy or traditional medications
Treatment of patients with a risk of thrombosis

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Intravenous P-32 Anatomy & Physiology

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Blood comprises 7-8% of the total body weight
Plasma & cellular components must remain in balance for health to be maintained
1% total RBC mass must be replaced daily

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Polycythemia Vera Anatomy & Physiology

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Bone marrow can produce red cells at a rate up to 8xs greater than what's required
P-32 therapy may be used to decrease the production of RBCs through local irradiation of bone marrow

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IV P-32 Therapy RP & Dosage

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P-32 sodium phosphate @ 2.3 mCi/m2 (body surface area)
3-5 mCi, not to exceed 7 mCi during 6 months
Half life: 14.3 days
Pure B-emitter with 1710 keV max energy & 650 keV mean energy
CLEAR IN COLOR

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IV P-32 Therapy Route of Admin, Incorporation, Excretion, & RAD

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21 gauge butterfly with 3 way stopcock & 10 ml saline flush (DO NOT INFILTRATE due to skin necrosis)
Incorporation: Phosphate compound with natural affinity for the bone matrix (chemisorption)
Renal excretion
RAD: Skeleton (bone matrix)

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IV P-32 Therapy Procedure Patient Prep

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Written informed consent; written directive; NM Physician/radiologist explains expected benefits & complications

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IV P-32 Therapy Procedure Contraindications

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Should not be used if:
Platelets under 15,000
Reticulocyte under 2%
WBC Count under 3,000

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IV P-32 Therapy Procedure Dose Admin Techniques

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Authorized user typically injects dose after tech has established IV access
Dose delivered over 30-60 sec & flushed well to avoid retention in the butterfly tubing resulting in a reduction of administered dose & possible recordable event

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IV P-32 Therapy Procedure RAD Safety

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Does not have to be admitted (Pure B-emitter)
Urinary precaution instructions for 2-3 days post-inj
Injection materials should be measured to determine if they are at background
Must be stored for 10 half lives if above background

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Polycythemia Vera Facts

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AKA Erythrocytosis
Bone marrow overproduces RBCs making blood too viscous & increasing risk for thrombi formation with associated organ infarction
Predominately found in males more than females; 40-60 yrs
Symptoms: flushed/redness, dizziness, & distended veins
P-32 Therapy should reduce RBC production

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Retreatment with IV P-32 Therapy

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Results typically 10-12 weeks post-therapy
Retreatment can occur in 3 months if no response; second dose should be 25% greater than first
DO NOT EXCEED 7 MCI IN 6 MONTH PERIOD due to damaged bone marrow

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Intra-Cavitary/Intra-Articular P-32 Therapy Indications

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Palliation of recurrent effusions in serosal cavities (peritoneal, pericardial, pleural) secondary to malignant disease
Prevention of recurrent malignant disease on serosal surfaces
Treatment of cystic neoplasms & malignant ascites on serosal surfaces (ovarian)
Palliation of joint pain due to rheumatoid arthritis, hemophilic arthropathy due to bleeding or villonodular synovitis

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Serosal spaces

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Serosal spaces include pericardial, pleural, & peritoneal
Each contains membranes which produce serous fluid at specific rates to reduce friction between structures
Certain pathologies (i.e. malignancies) cause increased fluid production resulting in significant fluid accumulation

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Articular spaces

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Within joints
Painful synovitis can occur due to altered synovial membrane texture or bleeding into the synovial space

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IC & IA P-32 RP

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P-32 chromic phosphate colloid; milky brownish-green in color
DO NOT USE FOR IV; dose will localize in liver

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P-32 chromic phosphate dosages to specific areas

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Elbow = 250-500 uCi
Knee = 0.5-1.0 mCi
Pericardial = 5-10 mCi
Pleural = 10-15 mCi
Peritoneal = 15-20 mCi

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IC & IA P-32 Therapy Route of Administration

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Through a catheter or needle into the cavity of interest
In some patients a drainage or chemo port into the cavity of interest may be present & can be utilized
For IA: needle must be inserted by physician

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IC & IA P-32 Therapy Dose Incorporation & Excretion

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Compartmental by diluting in fluid within the cavity; coats the serosal surfaces delivering high radiation levels that decrease fluid production & irradiate malignant cells
Joint studies are also compartmental but they are meant to palliate pain by damaging nerve endings in the area

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IC & IA P-32 Therapy RAD

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The cavity the dose is injected into receives the highest rads
Peritoneum = 6K rads/10 mCi dose
Knee = 4K rads/1 mCi dose

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IC & IA P-32 Therapy Patient Prep

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Informed consent, written directive
Catheter or other access device must be placed into cavity of interest if not already present
Excess fluid drained so the dose is not excessively diluted but some fluid must remain for the dose to travel in
Should at least have 3-6 month minimal life expectancy to undergo this procedure for RAD safety procedures

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Intra-cavitary P-32 Therapy Contraindications

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ONLY INTRA-CAVITARY
Intraperitoneal infection
Less than 6 months life expectancy
Detection of the presence of loculated fluid (fluid walled off from the rest of the fluid/layered)

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IC & IA P-32 Therapy Dose Assessment

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Determine if the dose can adequately distribute within the cavity
Inject approx. 2 mCi of Tc-99m sulfur colloid into the line & flush
Have pt roll on bed to distribute dose through cavity or move limb if intra-articular
3-5 min static image (typically anterior) to demonstrate dose distribution quality

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IC & IA P-32 Therapy dose administration

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Therapy can proceed if sulfur colloid distributes well
Authorized user administers dose
Remove catheter immediately after therapy
Patient should lie supine & flat for the next 4-6 hrs

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IC & IA P-32 Therapy RAD Safety

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Check administration devices for contamination following procedure