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  • 1. Learning Solutions from GE Medical Systems Program Supplement NM: Lymphoscintigraphy GEMS 983 TiP-TV TM GE Training in Partnership Television © 2002 General Electric Company. All rights reserved.
  • 2. 2 of 13 © 2002 General Electric Company. All rights reserved. Learning Solutions from GE Medical Systems NM: Lymphoscintigraphy Program Supplement REV 1 TABLE OF CONTENTS SECTION PAGE PREFACE TABLE OF CONTENTS ......................................................................................................... 2 PRESENTER BIOGRAPHIES ................................................................................................ 3 PROGRAM OBJECTIVES, TARGET AUDIENCE, AND PRODUCTIVITY STATEMENT .............. 4 PROGRAM OUTLINE ............................................................................................................ 5 BASIC PRINCIPLES............................................................................................................................... 6 IMAGING TECHNIQUES........................................................................................................................ 8 INTRAOPERATIVE GAMMA PROBES ................................................................................................ 11 PATIENT MANAGEMENT .................................................................................................................... 13
  • 3. 3 of 13 © 2002 General Electric Company. All rights reserved. Learning Solutions from GE Medical Systems NM: Lymphoscintigraphy Program Supplement REV 1 PRESENTER BIOGRAPHIES Lisa K. Armstrong - BS, CNMT, GE Medical Systems Program Manager, PET/NM Clinical Learning Lisa received a Bachelor of Science degree in Allied Health from Oregon Institute of Technology. She obtained her certification in Nuclear Medicine in 1982. Before joining GEMS in early 1990, Lisa held positions as the Assistant Technical Director at the University of Utah and as the Chief Technologist at the Salt Lake Clinic. Within GEMS, Lisa has held a variety of positions including Applications Specialist, Sales Specialist, a position in Marketing and recently, her current position, as the Program Manager for PET/Nuclear Medicine Clinical Learning. In this role, Lisa is responsible for managing clinical learning offerings including web-based products, satellite broadcasts, and CD ROM for the PET/Nuclear Medicine modality. Gilberto A. Prudencio, BSc, MRT(N), RTNM, CNMT, GEMS Nuclear Applications Online Support Specialist Gilberto received his Bachelor of Science degree in Biophysics in 1992 from the University of Toronto (Toronto, Canada). He then successfully completed the Nuclear Medicine Technology Program at the Michener Institute of Applied Health Sciences in 1996. Gilberto is currently licensed by the Canadian Association of Medical Radiation Technologists (CAMRT) and is an active member of the College of Medical Radiation Technologists of Ontario (CMRTO). Upon graduation, Gilberto worked at the Ottawa Civic Hospital and Ottawa Heart Institute as a general duty technologist. He has provided applications training for Elscint Canada as an Applications Specialist and for GEMS Canada as a Customer Education Specialist in Nuclear Medicine. Currently he provides applications support to customers at the GEMS Nuclear Application Answerline. Jean A. Schmitz, BS, CNMT – GE Medical Systems Lead System Designer – Clinical Learning Jean holds a Bachelor of Science degree in Nuclear Medicine Technology with a Chemistry minor from the University of Wisconsin – LaCrosse. She worked as a staff nuclear medicine technologist and clinical instructor at St. Joseph's Hospital/Marshfield Clinic in Marshfield, Wisconsin for five years. Jean joined GE Medical Systems in 1988 and was responsible for training applications personnel world-wide, and assisted in product development and validation. Jean was a member of the team that developed and implemented the TiP, Training in Partnership, education program platform. As the Nuclear and Mammography TiP-TV Program Manager, Jean was responsible for coordinating, developing, and presenting training programs to nuclear medicine and mammography personnel via the TiP-TV satellite network. Currently, she is responsible for designing multi-modality and electronic training programs for GEMS Learning Solutions.
  • 4. 4 of 13 © 2002 General Electric Company. All rights reserved. Learning Solutions from GE Medical Systems NM: Lymphoscintigraphy Program Supplement REV 1 PROGRAM OBJECTIVES, TARGET AUDIENCE, AND PRODUCTIVITY STATEMENT Program Objectives By the end of this program, the viewer should be able to • State the basic principles of lymphoscintigraphy. • Explain the techniques used for imaging. • Describe the use of intraoperative gamma probes. • Discuss the effects lymphoscintigraphy has on patient management. Target Audience Course objectives for this program specifically target nuclear medicine personnel. While not limited to this audience group, the technical content will be most effective when applied to people with this training. NOTE: Viewers who apply for continuing education (CE) credit and meet the application requirements are eligible for credit, regardless of their audience status. Productivity Statement This program was developed to enhance your professional and educational level, and increase your productivity and skills.
  • 5. 5 of 13 © 2002 General Electric Company. All rights reserved. Learning Solutions from GE Medical Systems NM: Lymphoscintigraphy Program Supplement REV 1 PROGRAM OUTLINE NM: Lymphoscintigraphy I. Basic Principles II. Imaging Techniques III. Intraoperative Gamma Probes IV. Patient Management
  • 6. 6 of 13 © 2002 General Electric Company. All rights reserved. Learning Solutions from GE Medical Systems NM: Lymphoscintigraphy Program Supplement REV 1 BASIC PRINCIPLES • The lymphatic system covers your entire body and is responsible for maintaining fluid balance in the tissues – It does this by carrying fluid away from tissues via lymph vessels that lead to the lymph nodes – This fluid sometimes contains metastatic cells, which then can be spread throughout your body • The presence or absence of regional lymph node involvement often determines the staging and therapy of many malignant tumors • Lymphatic imaging using radiographic contrast and nuclear medicine techniques has been around since the 1960s • Recently, the frequency of lymphoscintigraphy procedures has risen due to three primary causes – The validation of the sentinel node concept – The availability of the intraoperative gamma probe to localize previously radiolabeled sentinel lymph nodes – Cost effectiveness (surgical procedures are modified based on the results of lymphoscintigraphy) • The sentinel node concept was introduced by Cabanas in 1977 and has three basic premises – The first lymph node to receive lymphatic drainage from a tumor is the sentinel node – If there is lymphatic spread, the sentinel node is the first node to have metastatic involvement – Sampling the sentinel node is sufficient for evaluating a lymph bed • Basic concept of the sentinel lymph node – The sentinel lymph node concept has to be distinguished from 40 years of trying to image every single lymph node in the lymph node basin – People perform lymphoscintigraphy, which is a word to describe the imaging of lymph nodes in a particular territory – What has recently come into this new field is an attempt to detect and/or image the very first lymph node which receives direct lymph drainage from the tumor – By achieving that, one can identify the first lymph node with the highest chance of receiving the metastatic cells from the primary tumor; that lymph node has been called the sentinel node – The very first, or the first one or two lymph nodes, could directly receive the drainage from a tumor – Sentinel lymph node detection has been declared the most important advance in surgical oncology of the decade • Indications for performing lymphoscintigraphy or sentinel lymph node detection – Investigation of patients with melanoma skin cancer – Breast cancer – Tumors, such as colorectal tumors • Limitations of sentinel lymph node detection – The limitations of sentinel lymph node detection have mostly to do with the needs of learning (learning curve) – There is also a definite need to work with a team (nuclear medicine practitioner, the radiation physicist, the technologist, the surgeons, etc.) ! The team must be able to create an environment where the technique can be successfully transferred from the nuclear medicine imaging center to the operating room
  • 7. 7 of 13 © 2002 General Electric Company. All rights reserved. Learning Solutions from GE Medical Systems NM: Lymphoscintigraphy Program Supplement REV 1 • The other limitations have to do not so much with the lack of success of the data obtained so far, but with the time it will take to ultimately test the impact of the technology in patient management – The aim is to reduce surgery without increasing the risk that patients will escape detection of cancer that has spread
  • 8. 8 of 13 © 2002 General Electric Company. All rights reserved. Learning Solutions from GE Medical Systems NM: Lymphoscintigraphy Program Supplement REV 1 IMAGING TECHNIQUES • Studies in the early 1950s used gold (198 Au) colloids for imaging – Gold has many limitations as an imaging agent • Since the 1970s, various materials have been labeled with technetium-99m – The most widely used were 99m Tc-labeled radiocolloids • It is important to understand the bio-kinetics of radiocolloids in order to better understand lymphoscintigraphy – Radiocolloids travel in the lymphatic vessels to lymph nodes, where they are accumulated within macrophages – Tumor-involved nodes show decreased uptake because of the depressed macrophage function • There are three agents used for lymphoscintigraphy: – In the United States, the two agents currently being used are sulfur colloid and human serum albumin – Tc-99m antimony trisulfide colloid, which is used in Australia, is currently not available in the United States because the FDA-approved manufacturer is no longer in business • Different radiopharmaceuticals are used throughout the world, and there is no consensus on what is the best agent today • There is also a big controversy regarding the best particle size, which should be used with these tracers – The real difficulty is to obtain and make use of the formulations that are stable and reproducible – You can use filters to separate out the particles of a reasonable maximum size – Within each preparation, there is still a big range of particle size • Sulfur colloid is well suited to tumor drainage studies, because it has a particle size in the desired range – The preparation of sulfur colloid is different than what we normally used for liver studies – Notes: • Regardless of the type of agent used, it is usually injected either intradermally or subcutaneously – Only a physician or trained personnel should perform the injection • Injection technique guidelines for a melanoma patient – Notes:
  • 9. 9 of 13 © 2002 General Electric Company. All rights reserved. Learning Solutions from GE Medical Systems NM: Lymphoscintigraphy Program Supplement REV 1 • Imaging procedure guidelines for a melanoma patient – Flow image (for about 10 minutes) – Five minute static images, for up to an hour – Notes: • Injection technique for breast cancer – Notes: • Imaging procedure guidelines for a breast cancer patient – Begin imaging five minutes post injection – Five minute static images, for up to an hour – Oblique view will help to separate the injection site from the axillary area – Use cobalt sheet source to obtain body contour information – Notes: • One factor to consider is handling of the radioactive patient in the surgical suite – In general, the radiation risk to people who are working with the patient is very minimal – The first time non-nuclear personnel hear the squelching noise or the squeaking noise of the probe, everyone thinks there is a lot of radiation present • In the case of sentinel node detection, there is some controversy whether to image or not image prior to sending the patient to the surgical suite – One advantage of imaging and mapping in the nuclear medicine department is that the images can help you more easily localize the node – It will take longer, if the mapping is done in the surgical suite, without the assistance of the images – Notes:
  • 10. 10 of 13 © 2002 General Electric Company. All rights reserved. Learning Solutions from GE Medical Systems NM: Lymphoscintigraphy Program Supplement REV 1 • This procedure involves nuclear medicine, pathology, and surgery; teamwork is a critical component – It is helpful to develop a procedural plan with all involved functions, prior to performing the first lymphoscintigraphy examination – Notes: • Helpful hints for technologists or facilities that are just starting to perform this procedure – Have patience while learning this new technique – Work with the surgery team and do a few procedures as a trial run, to increase the confidence level for both sides
  • 11. 11 of 13 © 2002 General Electric Company. All rights reserved. Learning Solutions from GE Medical Systems NM: Lymphoscintigraphy Program Supplement REV 1 INTRAOPERATIVE GAMMA PROBES • The first use of a counting probe during a surgical procedure occurred in 1949 – A Geiger Mueller counter was used to identify an astrocytoma after the intravenous injection of P-32 • Since then, many different types of probes have been developed and used – However, there was no practical application for this technology, so their use was limited • In the past decade, the use of intraoperative probes has significantly increased – This is due to the development of new tumor imaging agents and acceptance of the sentinel lymph node concept • Prior to the availability of a radiotracer and intraoperative gamma probe, the surgeon relied on a vital blue dye to visualize the lymphatic drainage • Vital blue dye was introduced by Dr. Don Morton in 1992 – Lymphazurin blue, or isosulfan blue, is used for an intradermal injection at the primary site – It is especially unique because not all dyes, for instance Methylene blue, travel the lymphatic channels and particularly don’t do so in a timely fashion – It becomes retained in the first lymph node in the neighboring bed that the dye visits – It helps us get visual identification of the sentinel node • The intraoperative gamma probe plays an important role in the identification of the lymph nodes to be removed during surgery – The use of this device decreases surgical time and patient morbidity, and improves staging accuracy • There are several potential future applications being investigated: – Use of the probe with some of the other antibody-specific cancer imaging isotopes – Localization of a tumor from breast cancer – Colorectal cancer – Parathyroid adenomas in the operating room suite – Use of the probe in the operating room with more organ specific isotopes • The intraoperative probe consists of several components – Detector – Collimator – Digital or analog display – Audio signal generator • Some designs of probes are scintillator-based and have either a sodium iodide (NaI) or cesium iodide (CsI) scintillation crystal • Some designs are semiconductor-based and have a cadmium zinc telluride (CdZnTe) or cadmium telluride (CdTe) semiconductor detector
  • 12. 12 of 13 © 2002 General Electric Company. All rights reserved. Learning Solutions from GE Medical Systems NM: Lymphoscintigraphy Program Supplement REV 1 • The performance of these probes depends on several factors – Detector sensitivity – Collimation – Spatial resolution – Scatter rejection capability • The user-friendliness of the probe depends on several factors: – Size of the probe – Weight of the equipment – Nature of its audio signal generator • There are several other factors to consider when evaluating intraoperative probes: – Sterility requirements – Longevity of the battery pack – Cost of consumables (sterile sheaths, etc.) • Demonstration of various intraoperative probes
  • 13. 13 of 13 © 2002 General Electric Company. All rights reserved. Learning Solutions from GE Medical Systems NM: Lymphoscintigraphy Program Supplement REV 1 PATIENT MANAGEMENT • Accurately identifying the sentinel lymph node can have a major impact on the management of your patient – This could mean the difference between a complete or a selective lymph node dissection – Notes: • An important part of learning any new technique involves becoming familiar with the images – What structures can you see or not see? – What is normal versus abnormal uptake? • Case review – Notes: