AACE/ACE/ CBNE
NUCLEAR MEDICINE
COURSE
OVERVIEW- 2013
J. Woody Sistrunk, MD, FACE, ECNU
Radiation Safety Officer
Jackson Thyroid & Endocrine Clinic,
PLLC
Jackson, Mississippi
woodysistrunk@gmail.com
AACE NUCLEAR MEDICINE COURSE
Kansas City, Missouri
August 17-24, 2013
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NUCLEAR MEDICINE IN THE OUTPATIENT PRACTICE
OF ENDOCRINOLOGY
OUTLINE
•History
•Licensure
•AACE Course•Equipment
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Why Nuclear Medicine in
Endocrinology?
• WE ARE NOT GYNECOLOGISTS TREATING SPIDER VEINS WITH
A LASER.
• WE ARE NOT INTERNISTS PERFORMING ACCUPUNTURE.
• WE ARE NOT FAMILY PHYSICIANS PERFORMING DEXA/ Bone
Density.
• WE ARE NOT OPHTHALMOLOGISTS INJECTING BOTOX.
• WE ARE NOT ORTHOPEDISTS RUNNING A WEIGHT LOSS
CLINIC.
• WE ARE THYROID DOCTORS
EVALUATING/ TREATING THYROID
DISEASE.
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NUCLEAR MEDICINE HISTORY
• 1896 Henri Becquerel
– Discovered “rays” from
uranium.
• 1897 Madam Curie
– Named mysterious rays
“radioactivity”.
• 1903 Alexander Graham Bell
– Suggested placing sources
containing radium in or near
tumors.
– Occupation– “Teacher”
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1920
• Thyroid disease was primarily a
clinical diagnosis.
• No commercial TSH assay
until 1973.
• Exophthalmic goiter was a
significant concern to the medical
minds of the day.
• Mortality from hyperthyroidism
far exceeded the mortality from
thyroid cancer.
• Personal Communication.
2005. Baskin, Gharib, Hay,
Mazzaferri and Scholtz.
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CHARLES H. MAYO 1918
• Stated he had 3 patients with
exophthalmic goiter die from
injections of boiling water into
the goiter.
• “They were treated in their
beds to prevent shock, the
water was probably not hot
enough to coagulate
albumin, and possibly more
easily enabled the gland to
throw off the hormones of
secretion.”
• JAMA September 14, 1918.
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George Crile, MD
Founder of the Cleveland Clinic
• “If an individual with
exophthalmic goiter could
be made to hibernate like a
bear, he would probably
come out cured, for the
driving mechanism, the
brain, rests, then the
organism as a whole rests;
and if the rest is long
enough, certainly the
pathologic states tend to
revert to the normal state.”
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“EXOPHTHALMIC GOITER”
• 1920s Methods of Treatment
– Rest
– Hydrotherapy
• “A daily lukewarm bath is to be encouraged in every case…”
– Gastrointestinal Hygiene
• “After food is taken, an hour’s rest in an armchair..”
– Mental Hygiene
• “… all factors conducive to a state of excitation of the emotions are
promptly to be eliminated.”
• This included unannounced surgical dates.- or as it was called
“Stealing a thyroid.”
• Exophthalmic Goiter and Its Non-surgical Treatment.
Israel Bram, MD. 1920
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1931
External beam
Radiation for
Graves’ Disease.
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RADIOACTIVITY? WHY, WHEN WE HAVE THE BMR???
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1938-Glenn Seaborg discovered I131
•
•
•
•
•
1951 Nobel Prize Recipient
“We created isotopes that did not
exist the day before, with uses yet to
be discovered.
One day a pioneer in nuclear
medicine complained that his
studies of thyroid metabolism were
limited by the 25-minute half-life of
the tracer he was using.
When I asked what duration he
needed, he replied, "Oh, about a
week."
Soon thereafter, my partner and I
synthesized iodine-131, with a halflife of eight days. Iodine-131 is still
widely used for diagnosis and
treatment of diseases--and
prolonged my own mother's life by
many years. “
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HISTORY --1941-- Evaluation
• Joseph Gilbert Hamilton, Mayo
Soley and Robley Evans measured
uptake giving 24-100uCi of
radioactive iodine and 14 mg of
sodium iodide orally.
• A Geiger counter was placed over
the thyroid and the proportion of
the dose taken up by the thyroid
was calculated.
• THE BIRTH OF THE
THYROID UPTAKE.
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1941- A Truly Amazing DiscoveryTreatment of Hyperthyroidism.
• Hertz, Roberts, and
Chapman in Boston and
Soley in San Francisco.
• Initially used a mixture of 2
isotopes I131(T1/2= 8 Days)
and I130(T1/2= 9 minutes).
• Usual dose 14.5 mCi.
•
Chapman, E.M., and Evans, R.D. :
Treatment of hyperthyroidism with
radioactive iodine. JAMA 131:8691(May 11) 1946.
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1946– Thyroid Cancer Therapy
• Samuel M. Seiden
• Leo D. Marinelli
• Eleanor Oshry
– Treated a patient with
thyroid cancer with
Iodine 131, an “atomic
cocktail”
1945- 78 rpm JAZZ
Slim Gaillard also wrote the
“Penicillin Boogie” in 1945.
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1947
American Association for the Study of Goiter
George Crile, Jr. Discussing anti-thyroid drugs
• “In closing, I should like to say that the mortality
following operation for hyperthyroidism has been about
10 to 20 times that of simple goiter.
• Unless a drug can be proved to result in mortality which
is higher than the difference between the mortality of
simple goiter and hyperthyroidism, I will continue to
prepare the majority of patients for operation with antithyroid drugs.”
• Little did he know that 131-I it would change it all
forever.
•
P. 196 Transactions of the American Association for the Study of Goiter.
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History of
131I
Therapy
• 1946-1970
– Endocrinology
• 1970-1993
–Nuclear
Medicine
• 1993-Present
–♠AACE Initiative
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History—
Nuclear Medicine Era
• Missed diagnosis
• Failure to discuss other
treatments
• Failure to discuss non-thyroid
problems
• Misadministration
• Loss to follow-up
• “Thyroid uptake is low
consistent with
hypothyroidism.”
• “Thyroid uptake is low,
r/o paraneoplastic
process.”
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Why Nuclear Medicine in Endocrinology?
• Who knows more about the
thyroid than an endocrinologist
??
• Making sure OUR patients are
treated appropriately.
• HORRORS:
• “In that room you will
find a box. In that box
you will find a lead
container. In that
container is a pill. Take
it and leave.”
PUBLIC PERCEPTION
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NUCLEAR
ENDOCRINOLOGY
LICENSURE/ DEFINITIONS
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Agreement State vs. Non-Agreement State
• Agreement State
– A state that has signed an
agreement with the Nuclear
Regulatory Commission under
which the state regulates the
use of byproduct , source,
and small quantities of
special nuclear material in
that state.
• Non-Agreement State
– The state is governed by the
applicable laws of the
Nuclear
Regulatory
Commission
(NRC).
Source: www.nrc.gov
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What is a Radioactive Materials (RAM) License ?
Issued to your clinic, or the hospital
where you have privileges, by the NRC or
Agreement State.
Allows the facility to order, receive,
possess and use radioactive materials.
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Who is an
Authorized User ?
Authorized Users are physicians
listed on the radioactive materials
license who are authorized to
prescribe and administer particular
radiopharmaceuticals for specific
diagnostic or therapeutic
procedures.
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What will I be able to do as an Authorized User of
Radioactive iodine?
1. Thyroid Uptakes (I131, I123 )
NO
SCANS
2. Radioactive Iodine
(I131)treatment for
Hyperthyroidism.
3. Radioactive Iodine
(I131)treatment for thyroid
cancer / thyroid gland ablation.
NOTE: YOU WILL
NOT HAVE
THE ABILITY TO
PERFORM THYROID
SCANS. ********
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NO SCANS repeat NO SCANS
• If you need a scan,
Nuclear Medicine in
your hospital can
accommodate you.
• 800 hours for the
imaging part of the
Nuclear Medicine
License.
Remember,
If they don’t have a nodule is a scan much help??
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What Do I Have To Do To Become An
Authorized User ?
80 hours of classroom instruction with
an emphasis on radiation safety, physics
and math.
• AACE 80 HOUR COURSE.
Board certification by a medical
specialty board.
Supervised treatment of 3 patients
with less than 33 mCi.
(Hyperthyroidism)
Supervised treatment of 3 patients
with more than 33 mCi. (Thyroid
cancer).
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Getting Licensed– POINTERS
GET INTERESTED!!!!!
• Transfer of License–
– Fellows in Training can obtain a license or “User Status” in the training
institution, then transfer the license upon completion.
– Identify and meet with your institution’s Radiation Safety Officer.
• Get to know a local licensee.
– Ask AACE for help or call me.
• Call your state agency, explain your desire for licensure, and
ask for an application.
– Remember, you are a TAXPAYER, and they are a state agency.
• Call the Nuclear Pharmacy in your area.
– Remember, they want your business.
– They will help you to get your business.
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How to Get Started
• What to Know?
• License requirements in your state.
• Equipment required.
• Layout of nuclear medicine hot lab.
• Who to contact?
• State nuclear regulatory agency
• Physicist
• Nuclear Pharmacy
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NUCLEAR
ENDOCRINOLOGY
EQUIPMENT
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So now it’s time to set up a
HOT LAB!
• WHAT WILL I NEED
TO PURCHASE??
– Uptake System
– Dose Calibrator
– Geiger Counter
• WHAT ARE THESE
THINGS?
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UPTAKE SYSTEM
THYROID UPTAKE
PROBE
• Some are fancy
• Some are simple
• Some can make your life
complicated or easy.
• All based on 1940’s (or
earlier) iodine crystal
technology.
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Variety of Uptake Systems
$10,000-$14,000
COMPUTER BASED
MOVEABLE
WALL MOUNT
SIMPLE “CALCULATOR”
BASED, MOVEABLE
DESK TOP MODEL
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GEIGER COUNTER with Pancake Probe–
COST $1000
DOSE
ARRIVES IN
TUNGSTEN
PIG
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NECK PHANTOM-- $275
• An “Artificial Neck”
used to check the
activity of a uptake
capsule prior to
administration.
• Previously made of
wood, these are
characteristically now
made of solid plastic, or
filled with water.
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DOSE CALIBRATOR
$6500
• Necessary to verify that the dose
ordered is correct.
• This will no longer required by a
new NRC ruling if “unit doses” are
ordered. (Is this a good idea??)
• “UNIT DOSE” is a specific dose
(capsule) ordered and prepared
for a specific patient.
– These doses are prepared by
injecting a capsule with liquid
I131 (with an insulin syringe)
until the desired dose is
achieved.
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Total Hot Lab Setup
$20,000- $24,000
• Uptake System
$10,000-$14,000
• Dose Calibrator
$6000-$8000
• Neck Phantom
$275
• Geiger Counter
$1000
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FILM BADGES $350/year
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SIMPLE “HOT LAB” LAYOUT
• Essentials include a sink and a few electrical outlets.
• This can be the same room used for ultrasound
exams.
• The same stretcher can even be used.
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SIMPLE “HOT LAB” LAYOUT
SIMPLE “HOT LAB” LAYOUT
SIMPLE “HOT LAB” LAYOUT
SIMPLE “HOT LAB” LAYOUT
Nothing this Fancy, Nothing this complicated.
•No special leadlined room.
•No special
facilities needed.
•But this is
impressive!!!!!!!!!
HOW MUCH EXPOSURE WILL I RECEIVE??–
• Minimal !!! If any.
• VERY SAFE♠♠
• HOW DO YOU KNOW IF YOU
ARE EXPOSED??
• Film Badges.
• WEEKLY Bioassay- which is
simply placing the uptake
probe over the neck will be
performed weekly to
confirm that radioactive
iodine is not absorbed.
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HOW TO INCORPORATE THYROID
NUCLEAR MEDICINE PROCEDURES INTO
AN OFFICE PRACTICE
WEEKLY CALENDER
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Tuesday
• – Verify that all patients
are scheduled and
coming. Precertification with
insurance company.
Uptake Doses are
ordered.
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Wednesday
• 7AM– Up and ready10-15 minutes
– Uptake system
calibration– 4 minutes
– Dose calibrator
calibration– 1 minute
– Calibration of each dose
and RX written.
• Up to 10 minutes,
depending on the number
of uptakes.
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BOX INSPECTION
• Basically a verification
that the dose received
does not have any
radioactive
contamination on the
packaging.
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DOSE CALIBRATOR
How does it work?
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AUTOCALIBRATION
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Wednesday
• 8 AM Patients arrive. (7:30 if serum pregnancy test
required)
• Uptake Begins:
– Background counts of thigh and Neck– 5 minutes.
– Measuring capsule in Phantom, and room Background– 3
minutes
– QUALITY MANAGEMENT PROGRAM (QMP) Papers,
Verification of Pt. Name, SS #
– Dose administered.
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THYROID UPTAKE
Background /Dose count / Uptake
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Wednesday
• Noon
– Patients return for 4-6 hour readings.
– 1 minute over thigh, 1 minute over neck.
– Brief review of details with patient.
– Room survey and wipe tests.
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Thursday
• 7:30 Arrive and calibrate uptake system and dose
calibrator. (10 minutes)
• 7:45 Patients arrive to complete the uptake, roughly
5 minutes per patient.
• 8:30 Discussion with patients regarding treatment
options.
• 9:30 Treatments begin, allow 15 -20 minutes per
patient.
• Noon End of day assay and wipe tests.
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Friday
•
•
•
•
End of week survey/ wipe tests.
Auto-callibration of uptake probe.
Bioassay.
6 minutes or less.
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DOCUMENTATION
Yes, they will come looking!
STORE YOUR RECORDS
FOR EASY ACCESS!!!!!!
• Be prepared for your first inspection!!!!!
• Call other AACE members in your area to ask for pointers in preparation
for inspection.
• Ask your dose supplier and/or physicist for pointers or even a mock
inspection.
• It’s all about
ORGANIZATION!!!!
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WILL THIS PAY FOR ITSELF??
3 UPTAKES/ MONTH= Paying for
itself.
• In practice almost 12 years.
• 793 uptakes.
• 893 I131 therapies.
• ********Ultrasound procedures outnumber nuclear
medicine procedures by about
15:1*****************************************
*********
• ♠♠ THYROID ULTRASOUND CAPABILITY IS
ESSENTIAL ♠♠
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Fellows:
WHILE IN TRAINING
• Pursue all of the
requirements needed for
licensure.
• Review this talk with
more detail at aace.com.
• Get to know the
radiation safety officer at
your institution (who
often times is not a
radiologist) and try to be
put on the institution
license as an “official
user”.
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While Interviewing
• Ask about the possibility of
you having a “hot lab” and
doing your own nuclear
medicine procedures.
• Make sure you have access
to a good ultrasound
machine.
• Be specific with monetary
figures, space requirement
and the long term moneymaking potential.
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CERTIFICATION BOARD OF
NUCLEAR ENDOCRINOLOGY (CBNE)
• IN PROGRESS WITH NRC.
• Certification board to assist
in the licensure process of
endocrinologists using
radioactive iodine in the
assessment and treatment
of thyroid disease.
• ANOTHER STEP AACE /ACE
HAS MADE IN PROMOTING
NUCLEAR MEDICINE FOR
ENDOCRINOLGISTS.
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PATHWAY TO LICENSURE
CASES
3 Hyper
3 cancer
80 hour
AACE/DTC
course
ICANL
Intersocietal
Commission for the
Accreditation of
Nuclear Medicine
Laboratories
RAM
LICENSE
STATE/ NRC
ICANL
LAB
CERTIFICATION
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RECAP – CONCLUSIONS:
Nuclear Thyroidology
• A thyroidology practice is a career
option.
• Thyroid ultrasound will be a huge
portion of the practice but
Nuclear Thyroidology is another
practice enhancement available.
• Hyperthyroid and thyroid cancer
patients are already nervous. Put
their minds at ease as you are the
administering doctor explaining
treatment from start to finish
with them.
• RECOMMENDATION P:
• Personal Experience: If I can do
this, ANYONE can do this.
CONCLUSIONS:
• Thyroid Doctors treating
Thyroid Disease.
• With the Revised ATA
guidelines, the internet savvy
patient, and our ability to
“know” the disease process,
• Nuclear Medicine Physicians
will be more than happy to
give it back to us soon.
• BE READY!!!!!!!!!!!
AACE NUCLEAR MEDICINE COURSE
Kansas City, Missouri
August 17-24, 2013.
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AACE NUCLEAR MEDICINE COURSE
Kansas City, Missouri
August 17-24, 2013
66
THE END
• PLEASE E-MAIL ME IF
I CAN HELP.
• woodysistrunk@gmail.com