Volume 26, Issue 1

  

SNMMI-TS is dedicated to the advancement of molecular and nuclear medicine technologists by providing education, advocating for the profession, and supporting research to achieve clinical excellence and optimal patient outcomes.

 

IN THIS ISSUE

Radiation Safety Considerations with Emerging Therapies and Radiopharmaceuticals

Message from the President-Elect: Nuclear Medicine—A Decade in Review

Specialty Rep: Diffusion Imaging in PET/MR

NMTCB's Cross-Sectional Salary Survey Identifies New Trends in Salaries

SNMMI-TS 50th Anniversary Celebratory Activities

Advocacy Corner: The 2020 Outlook for the Technologist Scope of Practice

Calendar of Events

 

 

UPTAKE Editorial Board Jessica Williams, CNMT, RT(N), FSNMMI-TS Paul S. Riley, Jr., MPH, CNMT, NCT Erin B. Beloin, CNMT, RT(CT) Krystle W. Glasgow, CNMT, NMTCB(CT), NMAA Eleanor Mantel, CNMT, RT(N), FSNMMI-TS Matthew C. McMahon, MS, CNMT, RT(CT) Elizabeth C. Romero, RT(N)(CT), FSNMMI-TS Tommy Lieu, RTNM, CNMT Issue Editor Erin B. Beloin, CNMT, RT(CT) Managing Editor Rebecca Maxey Uptake is published six times a year by SNMMI-TS. All editorial communications should be directed to Jessica Williams, CNMT, RT(N), FSNMMI-TS, at jess_williams@mac.com. ©2020 by SNMMI

 

Radiation Safety Considerations with Emerging Therapies and Radiopharmaceuticals

By Mark F. Walsh, MS, CHP, and Renee Saranteas, RT(N)

	Mark F. Walsh, MS, CHP
	Renee Saranteas, RT(N)

Updated literature regarding the safe use and administration of many recently produced state-of-the-art therapeutic radiopharmaceuticals shows evidence that procedures can be performed successfully and safely if proper radiation safety handling techniques are implemented into common practice [1].

Medical caregivers (primarily nursing staff) should be included in the design and implementation process of the safety standards associated with radiopharmaceutical administration. To ensure successful implementation across a medical institution, caregivers should be trained on the risks of inadvertent exposure, both internal (from a source within the body) and external (from a source outside the body), and how this exposure can be minimized. Radiation safety staff should provide a thorough explanation of common scenarios and a clear, concise description of necessary steps to take while treating these patients.

There are currently four common isotopes being used for intravenous radiotherapy: iodine-131 (¹³¹I), lutetium-177 (¹⁷⁷Lu), radium-223 (²²³Ra) and yttrium-90 (⁹⁰Y) [2–5]. All of these isotopes can expose personnel to internal radiation if basic laboratory hygiene is not observed; two of them, ¹³¹I and ¹⁷⁷Lu, can present an external radiation safety hazard due to their characteristic gamma-ray emissions, which have sufficient energy to escape the body and expose personnel and family [6].

A common and potentially rising issue is that a radiopharmaceutical therapy patient can present unannounced in any medical department, either with associated or unassociated medical issues, from one to several days after administration of the radiopharmaceutical. What radiation safety precautions, if any, should be taken if this situation is encountered?

In a likely hypothetical scenario, a patient enters a hospital for radiopharmaceutical administration and subsequently is discharged and released into the general public. Three days later, the patient presents in a radiology department for an unaffiliated concern and sits within close proximity to an intake worker for a period of time. It is determined that the patient requires a CT with contrast and also requires anesthesia. Altogether, the patient interacts with 8 different members of medical staff while acquiring medical care. All necessary routine procedures are completed, and the patient is discharged. A member of the medical staff then contacts radiation safety staff, and it is then communicated that the patient had been administered a radiopharmaceutical 3 days beforehand, with potential exposure of these staff members, leading to concern among those caregivers about their exposure to radiation, with the uncertainty of possible short- and long-term health affects [7].

In an attempt to understand the actual risk, we can start by looking at the known external exposure rates from therapeutic radiopharmaceuticals and what precautions if any, are warranted. Given common administered doses, the exposure rates from these patients can range from 1.5 to 200 mrem per hour at a distance of 1 meter [8,9]. This wide range of potential exposure highlights the importance of utilizing the correct administered isotope, activity, and time post-injection in determining risk.

These patients can also represent a contamination hazard and a potential source of internal contamination, which can occur when family or staff come in contact with the patient’s bodily fluids without practicing proper standard precautions. The Nuclear Regulatory Commission (NRC) provides dose conversion factors for almost all isotopes based on route of exposure, including the quantity or activity of the isotope taken up into the body that will result in an exposure of 5 rem, which is the annual limit for occupational workers [10]. ¹³¹I remains the most radiotoxic radiopharmaceutical in use today, with an annual limit on intake of only 30 microcuries. A typical dose of ¹³¹I is on the order of 100 mCi, which is enough activity to overexpose more than 3,300 people and can produce an exposure rate of up to 20 mrem/hr at a meter from the patient. To exacerbate the exposure potential, a recently developed ¹³¹I radiopharmaceutical (AZEDRA) [11] containing metaiodobenzylguanidine (MIBG) has been approved for adult use with administered doses upwards of 1,000 mCi. This level of activity represents a significant increase in the external and potential internal exposure. Therefore, radiation safety precautions utilizing decreased time, increased distance, and Pb shielding are vital and appropriate to maintain radiation exposure as low as reasonably achievable.

The most recent addition to the radiopharmaceutical world is ¹⁷⁷Lu (Lutathera), and its use is becoming more frequent and more widespread. Although this administration has been given successfully on an outpatient basis for some time, some patients have adverse reactions and can present in an emergency department immediately and/or up to several days following the infusion. A typical ¹⁷⁷Lu dose of 100 mCi produces an exposure rate of 1.5 mrem/hr at 1 meter and can be compared to our annual background radiation exposure of 1 mrem/day [12]. The radiotoxicity of ¹⁷⁷Lu is much less than ¹³¹I, as a typical dose of ¹⁷⁷Lu represents enough activity to overexpose approximately 400 people. Given the low external exposure rate from ¹⁷⁷Lu, the use of standard precautions is adequate protection. Time reduction, increase of distance, and peripheral dose shielding are not needed.

Although they can create an internal radiation hazard potential, particles emitted by ²²³Ra and ⁹⁰Y do not exit the body and do not represent an external radiation hazard [13,14]. A typical dose of ²²³Ra or ⁹⁰Y represents only about half of the radiotoxicity produced from ¹⁷⁷Lu. Given the non-existent external exposure rate and modest radiotoxicity as compared to ¹⁷⁷Lu and ¹³¹I, standard precautions are adequate protection from ²²³Ra and ⁹⁰Y.

For diagnostic radiopharmaceutical administration, standard precautions are adequate to protect medical caregivers. Although most diagnostic radiopharmaceuticals emit gamma-rays and most patients exhibit a measurable exposure rate, the radiation exposure rate is considerably smaller and typically decreases rapidly [15].

If a patient who was administered an unknown isotope—with an unknown activity and an unknown administration date—presents in your medical facility and it is determined that radiation safety precautions are necessary, how do you move forward with an informed, safe handling technique to ensure safety across the board? Which radiation protection technique of time, distance, and shielding will provide staff the best and most appropriate protection? Each protection action can reduce an exposure rate to a desired level. In most cases, a combination of the techniques is used to reduce radiation levels to as low as reasonably achievable. In all cases requiring an immediate response, the judicious use of standard precautions will be the most reliable and effective protection method until the isotope and the risk can be identified.

References

1. Nelson KL, Sheetz MA. Radiation Safety Observations Associated with ¹⁷⁷Lu Dotatate Patients. Health Phys. 2019;117(6):680-687.
2. Tonnonchiang S, Sritongkul N, Chaudakshetrin P, Tuntawiroon M. Radiation Exposure to Relatives of Patients Treated with Iodine-131 for Thyroid Cancer at Siriraj Hospital. J Med Assoc Thai. 2016;99(2):220-224.
3. Hennrich U, Kopka K. Lutathera®: The First FDA- and EMA-Approved Radiopharmaceutical for Peptide Receptor Radionuclide Therapy. Pharmaceuticals (Basel). 2019;12(3):E114.
4. Parker C, Nilsson S, Heinrich D, et al. Alpha emitter radium-223 and survival in metastatic prostate cancer. N Engl J Med. 2013;369(3):213–223.
5. Tafti BA, Padia SA. Dosimetry of Y-90 Microspheres Utilizing Tc-99m SPECT and Y-90 PET. Semin Nucl Med. 2019;49(3):211–217.
6. Shleien B. The Health Physics and Radiological Health Handbook. Revised ed. Silver Spring, MD: Scinta; 1992.
7. Murakami M, Hirosaki M, Suzuki Y, Maeda M, Yabe H, Yasumura S, Ohira T. Reduction of radiation-related anxiety promoted wellbeing after the 2011 disaster: 'Fukushima Health Management Survey'. J Radiol Prot. 2018;38(4):1428–1440.
8. Liu YL, Zhao ZX, Huo MH, Yin C, Tan J, Zhang WY, Jiao L. Study of the External Dose Rate and Retained Body Activity of Patients with Hyperthyroidism Who Are Receiving I-131 Therapy. Biomed Environ Sci. 2018;31(12):913-916.
9. Abdel-Rahman O, Elsayed Z. Yttrium-90 microsphere radioembolisation for unresectable hepatocellular carcinoma. Cochrane Database Syst Rev. 2020;1:CD011313.
10. Nuclear Regulatory Commission. Standards for Protection Against Radiation. Codified at 10 CFR 20.1003. https://www.nrc.gov/reading-rm/doc-collections/cfr/part020/full-text.html#part020-1003.
11. FDA Approves AZEDRA Specified Use in Pheochromocytomas/Paragangliomas. J Nucl Med. 2018;59(10):17N.
12. National Council on Radiation Protection and Measurements. NCRP report No. 160—Ionizing Radiation Exposure of the Population of the United States. Bethesda, MD: NCRP; 2009.
13. Jødal L. Beta emitters and radiation protection. Acta Oncol. 2009;48(2):308–13.
14. Dauer LT, Williamson MJ, Humm J, O'Donoghue J, Ghani R, Awadallah R, Carrasquillo J, Pandit-Taskar N, Aksnes AK, Biggin C, Reinton V, Morris M, St Germain J. Radiation safety considerations for the use of ²²³RaCl₂ DE in men with castration-resistant prostate cancer. Health Phys. 2014;106(4):494–504.
15. Young AM. Dose rates in nuclear medicine and the effectiveness of lead aprons: updating the department's knowledge on old and new procedures. Nucl Med Commun. 2013;34(3):254-64.

 

Message from the President-Elect Nuclear Medicine: A Decade in Review

By Tina Buehner, MS, CNMT, NMTCB(CT)(RS), RT(N)(CT), FSNMMI-TS

	Tina Buehner, MS, CNMT, NMTCB(CT)(RS), RT(N)(CT), FSNMMI-TS

As we start this New Year, I’d like to briefly reflect on where we have been. There have been a lot of changes in nuclear medicine over the past ten years. We began the early part of the decade with the name change of our society from The Society of Nuclear Medicine (SNM) to The Society of Nuclear Medicine and Molecular Imaging (SNMMI). This signified the evolution of our profession from basic physiological imaging to a more personalized approach to medical imaging at the cellular level. Over the course of the decade, there was a significant expansion of new PET tracers, and as a result PET imaging became a truly integral part of the management of many disease processes. Nuclear medicine (NM) and molecular imaging (MI) also made their mark on neuroimaging, including the use of DatScan to diagnose Parkinson’s Disease and the introduction of amyloid imaging for the evaluation of Alzheimer’s Disease. The last few years of the decade ended with the advent of promising new tracers that gave rise to the concept of “theranostics”—the ability to image disease, treat it, and then evaluate and quantify response to that treatment. These new capabilities are often discussed as “precision medicine” or “targeted therapy.”

As we enter not only another new year but also a new decade, there are exciting developments on the horizon for our field. The use of artificial intelligence (AI) in medical imaging is growing rapidly. In fact, this year’s Radiologic Society of North America (RSNA) meeting featured an entire exhibit hall dedicated to AI in radiology applications. I believe the next decade will bring a new era in AI for NM and MI as well. Perhaps many of the initial applications will be more strongly felt by the physicians, with interpretation support through computer-assisted database systems. These systems may be used for improved volumetric analysis and dosimetry, identification of disease patterns, and guidance of appropriate use in diagnostic medical imaging. However, there will be AI applications impacting the technologists on the imaging side as well. These may lead to abandoning the ‘one-size fits all’ imaging protocols for more personalized imaging parameters through the incorporation of patient data and demographic information into the imaging systems.

While the use of AI in imaging and interpretation is certainly promising to improve these processes, there have been valid concerns raised by both physicians and technologists. Although the use of AI in other industries has shown to serve as a replacement for human workforce, this is unlikely to occur in the world of medical imaging. Algorithms used to reduce error, improve efficiency, and assist in providing cost-effective imaging are the most likely near-term outputs for AI integration—and these outputs cannot replace the empathy or experienced intuition in clinical practice. Another concern is the use of big data in AI, which may pose ethical questions and considerations regarding patient privacy and dissemination of information. As a society, we will continue to work together to develop best practice guidelines to address these concerns.

Our profession has grown so much over the last ten years, and I am honored to be serving as the president-elect of the SNMMI-TS as we enter into the next decade. These are such exciting times, and I know that we will continue to advance precision medicine and see further growth in the areas of personalized imaging and theranostics. Additionally, I am hopeful that the integration of AI in NM and MI will prove to be advantageous both in clinical applications and in research.

As we continue to grow as a profession, I will continue to support and encourage nuclear medicine technologists (NMTs) to grow as professionals. By furthering their education and advancing their certifications in other areas of medical imaging, NMTs will ensure they are well-prepared to meet the demands of continued growth in our specialty and to utilize new tracers and hybrid imaging equipment.

 

Specialty Rep Diffusion Imaging in PET/MR

By Kimberly Jackson, BS, LNMT, RT(N)(MR), and Elcin Zan, MD

	Kimberly Jackson, BS, LNMT, RT(N)(MR), and Elcin Zan, MD

PET/MR is a powerful hybrid modality that has the potential to significantly advance patient care. Its greatest strengths are high soft-tissue resolution, lower ionizing radiation exposure, and simultaneous, multiparametric imaging compared to PET/CT. One parameter that is quantifiable on MRI and used in most, if not all, PET/MR imaging is diffusion weighted imaging (DWI). DWI holds a critically practical role in narrowing the diagnosis. Its fast acquisition, quantifiability on PACS systems, and stark signal difference in cases of pathology make it an excellent tool. Although DWI has proven its importance in MR imaging of the neuroaxis, prostate, and liver, we see room for hybrid PET/MR imaging where it could potentially provide complementary value.

	Figure 1
	Figure 2

Diffusion, also known as Brownian motion, is the random and unrestricted movement of particles in fluids driven by their thermal energy and concentration gradients in compartments [1–3]. In the human body, there is an abundance of water molecules, which move freely and randomly collide with other water molecules in an unrestricted fashion; this is known as isotropic motion. However, in tumors or infarcts the diseased environment restricts this motion; that is known as anisotropic diffusion. DWI can be used to evaluate and quantify this molecular diffusion in the body within a voxel of tissue. A minimum of three diffusion-sensitizing gradients (x, y and z planes) are applied in MRI to confirm reduced diffusibility in that voxel. The signal from the three different gradient planes is compared to an image, known as b = 0, which is acquired without diffusion gradients. If any of the three gradient directions shows signal loss compared to the b = 0 image, then that part of the tissue will be reflected as mid-gray color, known as free diffusion (Fig. 1). Nevertheless, if all three gradient plane directions show no signal loss, this will show as restricted diffusion (Fig. 2) and will reflect as a white color on trace DWI images.

	Figure 3

DWI has a long echo time (TE), thus its signal characteristics behave similar to T2-weighted imaging. Despite its advantages, DWI has relatively poor spatial resolution, lacks cancer specificity, and is sometimes confounded by T2 shine-through effect. To tell the difference between true diffusion restriction versus an artifact where there is inherently high T2 signal, apparent diffusion coefficient (ADC) maps are created (Fig. 3). ADC is independent of T2 effects and derived from two or more DWIs.

DWI is the most sensitive technique for detecting early brain injury during infarct. Prostate cancer and liver metastasis also are easily picked up by different b-values applied during DWI. When MRI is combined with PET, specificity increases by the radiotracer used for each indication.

	Clockwise, starting at left: Figure 4, Figure 5, Figure 6

¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) is the most commonly used tracer for neurological applications, including Alzheimer disease, frontotemporal lobar degeneration, and Lewy body dementia. Due to the high sensitivity of ¹⁸F-FDG, which may be missed or uncertain due to spatial distortion or inhomogeneities on DWI, the PET offers complementary information [Fig. 4, 5, 6]. What we can get from FDG is the extent of lobar-specific hypometabolism, which precedes the structural changes on MRI that wouldn't be identified otherwise. However, in a rare form of rapidly progressive dementia, Creutzfeld–Jacob disease, DWI alone gives the diagnosis away without much of a doubt.

Figure 7

One of the most common applications of DWI for the oncology workup is low-volume disease that would not otherwise be apparent on conventional sequences. When combined with PET, the diagnostic specificity increases in certain cancers, such as neuroendocrine tumor of pancreas and small bowel. In those cancers, there is an abundance of somatostatin receptor type 2 (SSTR2) on the surface of the neoplastic cells, making them perfect targets for PET imaging using ⁶⁸Ga-DOTATATE [4]. Whether they originate from pancreas, retroperitoneum, or intestines, these masses sometimes blend in with the organs from which they originate, making visual interpretation difficult. The PET MRI, enhanced by DWI, can pick up subcentimeter lesions that would have been missed on other pulse sequences. Figure 7 shows an image of a 77-year-old female with history of recently biopsied multiple small bowel neuroendocrine tumors in the mid-ileum. Referred for staging, the patient underwent MRI-only imaging in which numerous NETs were missed, but this was rectified in PET/MR DOTATATE imaging.

	From top: Figures 8, 9, and 10

In PET/MR ¹⁸F-fluciclovine imaging for recurrent prostate cancer [Fig. 8, 9,10], the DWI and ¹⁸F-fluciclovine increase the diagnostic specificity despite the small size of the lesions that would have not been picked up by other MR pulse sequences.

The MRI portion of ¹⁸F-fluciclovine PET/MR showed a lesion in the prostate gland only on the DWI sequence. The radiotracer activity has great importance in nodal and distant metastatic workup but falls short for local disease evaluation. DWI sequence is paramount in diagnosing prostate cancer with restricted diffusion, even in cases of subcentimeter cancer.

In conclusion, PET/MR technology is becoming widely available in many institutions owing to its indispensable role in dementia, epilepsy, and oncology in staging workup and candidacy determination for theranostics. Although most MRI-only protocols are designed to involve DWI, in hybrid PET/MR imaging, simultaneously acquired PET images from injected radiotracer provide complementary information that increases the diagnostic precision.

References Maas LC, Mukherjee P. Diffusion MRI: Overview and clinical applications in neuroradiology. Appl Radiology.2005;34(11):44. Hagmann P, Jonasson L, Maeder P, Thiran JP, Wedeen VJ, Meuli R. Understanding diffusion MR imaging techniques: from scalar diffusion-weighted imaging to diffusion tensor imaging and beyond. 2006;26(suppl_1):S205-S223. Chilla GS, Tan CH, Xu C, Poh CL. Diffusion weighted magnetic resonance imaging and its recent trend—a survey. Quant Imaging Med Surg.2015;5(3):407–422. Pauwels E, Cleeren F, Bormans G, Deroose CM. Somatostatin receptor PET ligands—the next generation for clinical practice. Am J Nucl Med Mol Imaging. 2018;8(5):311–331.

NMTCB’s Cross-Sectional Salary Survey Identifies New Trends in Salaries for Nuclear Medicine Technologists The Nuclear Medicine Technology Certification Board (NMTCB) comprehensive salary survey, published in the December 2019 issue of JNMT, provided the technologist community with important information regarding the state of the profession in terms of salaries paid to technologists across the country.  The report provides detailed analysis of information received from 5626 technologist respondents including: Median salaries by technology skills/job classification: Hospital-based general imaging PET, PET/CT Nuclear cardiology Administrators Educators Applications/sales Median salaries by state and region Median salaries by education Median salaries by gender Median salaries by age To view this full report, go to http://tech.snmjournals.org/content/47/4/9A.full.pdf+html (requires log-in).

 

SNMMI-TS 50th Anniversary Year (1970-2020) Celebratory Activities

By Norman E. Bolus, MSPH, MPH, CNMT, FSNMMI-TS—Chair, SNMMI-TS 50th Anniversary Task Force

A new year and a new decade have arrived! With it comes the unbelievable milestone for the Society of Nuclear Medicine and Molecular Imaging Technologist Section (SNMMI-TS) as we celebrate 50 years of being in existence. It is hard to think about how much our SNMMI-TS has and has not changed over the last 5 decades, but perhaps the biggest thing is that our basic structure (despite a name change from SNM to SNMMI) and goal have remained relatively the same: technologists working together to advance, educate and protect our profession.

To celebrate our golden anniversary, a special 50th Anniversary Task Force was formed last year, which I was asked to chair, and I am excited to do it! Many activities for the year have been and are being planned and implemented. Kathy Thomas and I are working on a supplement to the Journal of Nuclear Medicine Technology (JNMT) that will commemorate and highlight the Technologist Section, our history, and advances within our organization since the beginning.

Many activities will surround the Annual Meeting of the SNMMI in New Orleans, Louisiana, June 13-16, 2020. A history exhibit will showcase artifacts spanning all 5 decades since 1970, including items associated with the Technologist Section, such as old t-shirts and swag from previous years. An interactive memory wall will include three panels of rotating pictures, videos, and a live Twitter feed so anyone can comment on the last 50 years even if they are unable to attend the meeting.  Everything will be captured and preserved for future anniversaries.

On Saturday, June 13, at the Opening Ceremony of the Annual Meeting, we will recognize past Technologist Section presidents, fellows and other guests and have a celebratory balloon drop before proceeding to the exhibit hall in a "Second Line Dance" (a New Orleans tradition) following a jazz band playing "When the Saints Come Marching In."  

At the Technologist Section (TS) plenary session on Sunday, June 14, we are planning on a 50th anniversary cake with as many sparklers as the convention center will allow us to have! On Monday, June 15, 8:00 pm, at The Fillmore (located at 6 Canal Street, above Harrah's Casino), the Thallium Stallions (sponsored by Sirona Complete Care) will highlight our 50th Anniversary Celebration Party. We are planning this as a "not to be missed" epic event and celebration that will include dancing, drinking, celebrating and the unique flair of our one-of-a-kind band. Wear comfortable shoes and perhaps dress up in clothes from your favorite decade from the 1970s to the 2020s. Be on the lookout for unique, 50th anniversary swag during the party and the meeting—including a deck of playing cards that highlights all 50 presidents of the SNMMI-TS.

Finally, at the end of 2020 we are planning to produce a 50th Anniversary Yearbook that will document everything we have done this year so that future generations will have this as a resource from this very special golden year.

To help defray costs associated with all of the respective activities we are having and have planned, the SNMMI-TS is asking for sponsorships and other donations. There are five categories and ways you can help—the Scintillating Level of $10,000, Platinum Level at $7,500, Gold Level at $5,000, Silver Level at $2,500, and Friends of the SNMMI-TS Level from $150–$2,499. If you make a commitment by March 19, you will be recognized in the JNMT Anniversary Supplement and the end of the year 50th Anniversary Yearbook. For the most up-to-date information on all of the 50th Anniversary planned activities and information on ways you can donate to help the celebration, go to: www.snmmi.org/tech50

Advocacy Corner The 2020 Outlook for the Technologist Scope of Practice

By Dmitry Beyder, MPA, CNMT, and Tricia Peters, BS, CNMT, RT(CT)

	Dmitry Beyder, MPA, CNMT
	Tricia Peters, BS, CNMT, RT(CT)

The Driver’s Manual released by the Department of Motor Vehicles gives rules and guidelines for driving a car in the United states. Pharmaceuticals come with a package insert that breaks down the many components one needs to consider and follow in order to prepare and administer a drug. For nuclear medicine technologists (NMTs), a manual is presented in the form of a Scope of Practice (SOP), which describes the procedures and actions performed in the technologist’s job. This document is written and approved based on education, testing, and demonstration of competency that a technologist completes on their way to certification—therefore, states and institutions often use the SOP to regulate and license what an NMT is allowed to do when practicing in their profession. In order for something to be included in an SOP, that skill must be taught in schools, tested by licensing exams, and practiced in the field.

The Society of Nuclear Medicine and Molecular Imaging (SNMMI) SOP document is always evolving in response to the ongoing changes in our field, and it is dynamic in nature to adjust for the evolution of nuclear medicine and healthcare as a whole. This document is intended to be used as a tool in an NMT’s arsenal, should there be questions on competency of scope to perform a specified task. However, as you will appreciate in this article, such questions are not straightforward, and interpretation is often questioned by other professional groups, institutions, states, and many other entities.

Along with the SOP, to support the NMT on a state licensing front, the SNMMI SOP Committee several years back developed a Model Practice Act (MPA), which is used for state legislative guidelines. There are still many states in the U.S. that do not license nuclear medicine technologists, with different rules and regulations that a nuclear medicine technologist must follow—causing practice differences and confusion throughout the United States on our profession. To be clear, unless a state uses language to explicitly prohibit an NMT from performing a specific duty, final approval of what you can practice is up to your institution’s medical board. Additionally, even if specified in the SOP or MPA, the medical institution has ultimate authority on what an NMT is allowed to do in their facility.

Adding to the confusion, states and institutions can choose to accept, limit, or modify what an NMT does in their practice, and this is not always consistent with the NMT SOP. Therefore, responsibilities of NMTs vary from state to state, from institution to institution, and even sometimes within the same organization. Nevertheless, it is critical to the profession to have an SOP that provides an overview and backdrop for NMTs’ expected training, knowledge, and expertise. SNMMI-TS’s Advocacy Committee and SOP Task Force are constantly working to ensure that as new technology and drugs are developed and as new clinical needs arise, NMTs are not left behind and are able to perform the tasks necessary to take care of patients to the highest extent of our scope. Much of that work is done through SOP updates.

One such practical example on NMT scope confusion and variation in the United States is the administration of adjunctive medications. The 2017 SOP mentions “adjunctive” medications 23 times, and under Clinical Performance Standards the document states that an NMT provides patient care by “administering radioactive, adjunctive, and imaging medications.” There is an entire section in the SOP (section IV) dedicated to the technologist’s role and education for the administration of adjunctive medications during the course of their job. So why, in so many states, are NMTs not allowed to administer drugs like furosemide, cholecystokinin, or regadenoson? For instance, just one of many examples: in the state of Missouri, only nurses and physicians are allowed to inject drugs. Through the Missouri state statute, an NMT cannot inject adjunctive medications that directly align with NM studies, limiting the NMT’s contribution. At this point, even with the SOP and MPA, there is no clear path for NMTs to be able to do this part of their job.

For the benefit of our technologists, it is comforting to know that the SNMMI-TS SOP Task Force has been working with the Education and Quality committees over the past two years to address this need and gap. There has been an initiative to develop an education and competency-based packet to support the NMT and confirm the skills needed to inject various adjunctive medications. The belief is that this packet of educational material, continuing education documentation, and competency-based testing will provide the NMT with proof that they are able to safely administer specific adjunctive medications. This packet can be presented to hospital administrators, councils, and leaders to ask for adjustment of institutional policies to allow the NMT to work up to their license and scope.

A new source of uncertainly and confusion for the NMT scope is the practice of theranostics. Of course, the administration of lutetium-177-DOTATATE, radium-223 (Xofigo®), and I-131 (Azedra®), as well as many others that are coming, is clearly within the NMT scope and everyday practice. However, many theranostics are accompanied with adjunctive medications in order to assist the absorption of the radiolabeled-therapeutic medication. In many cases, these adjunctive medications are amino acids and solutions of various drugs to help the overall therapy administration. These drugs present a new challenge for the NMT's role and practice, as questions are undoubtedly coming regarding privileges, permissions, and training. Many are questioning whether this is something the NMT can do. Professional and department turf battles have already surfaced. The quandary is, should adjunctive medication administration be reserved only for nurses, physicians, practitioners—or can NMTs be involved?

It is no surprise that our belief is that the NMT should be the professional who either owns or directly contributes to these therapies. The proactive question is: what is needed from the SOP, education, and training to allow our professionals to be directing theranostics? The SOP Task Force is working to address the practice of theranostics and adjunctive medications that come with the therapeutic radiolabeled-drugs and looking forward to adjusting the SOP document in 2020. This is a collaborative effort, as anything that goes into the NMT SOP must be part of the NMT education curriculum and part of the board certification test. Much more work is necessary, and the SOP Task Force is proactively taking on that work to ensure that our scope and practice guidelines support the NMT’s role in theranostics.

As you have learned, the SOP is a dynamic document that is accepted by some, challenged by others, and changing constantly to support the practice of nuclear medicine. It is the most comprehensive document to support the NMT profession and field. Nuclear medicine technologists should use it to their advantage to perform what they have been trained to do—and be careful not to perform what is not in the scope. Please support the SNMMI Advocacy Committee and SOP Task Force by providing feedback on your practice and any issues you may encounter, and please consider volunteering to be part of the committee. Invest in your future by using and supporting the SOP, for your professional security and for safe patient care.

 

Calendar of Events

March 21, 2020
2020 Central Chapter Annual Spring Meeting
Milwaukee, WI

March 28, 2020
Pacific Southwest Technologist Chapter Spring Meeting - 2020
Battle Ground, WA

March 28, 2020
Cuyahoga Community College's 15th Annual Nuclear Medicine Symposium
Warrensville Heights, OH

April 17 – 19, 2020
50th Annual Spring MECSNM
Cambridge, MD

April 24 – 26, 2020
ANZSNM 50th Annual Scientific Meeting
Sydney, Australia

June 13 – 16, 2020
SNMMI 2020 Annual Meeting
New Orleans, LA

July 11 – 12, 2020
Viva Las Vegas 2020 (Pacific Southwest Technologist Chapter)
Las Vegas, NV