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Coronavirus Pandemic: What Nuclear Medicine Departments Should Know

Gopinath Gnanasegaran, Hian Liang Huang, Jessica Williams and Jamshed Bomanji
Journal of Nuclear Medicine Technology June 2020, 48 (2) 89-97; DOI: https://doi.org/10.2967/jnmt.120.247296

Article Figures & Data

Figures

  • FIGURE 1.
    FIGURE 1.

    Basic contingency for nuclear medicine imaging. (Adapted from (41).)

  • FIGURE 2.
    FIGURE 2.

    (A) Unenhanced axial CT image from 36‐year‐old man shows bilateral ground‐glass opacities in upper lobes with rounded morphology (arrows). (B) Axial CT image from 44‐year‐old man shows larger ground-glass opacities bilaterally in lower lobes with rounded morphology (arrows). (C) Axial CT image from 65‐year‐old woman shows bilateral ground‐glass and consolidative opacities with striking peripheral distribution. (Reprinted with permission of (32).)

  • FIGURE 3.
    FIGURE 3.

    Unenhanced axial CT image from 56‐year‐old woman shows ground‐glass opacities with rounded morphology (arrows) in right middle and lower lobes. Left lung was normal. (Reprinted with permission of (32).)

  • FIGURE 4.
    FIGURE 4.

    Unenhanced axial CT image from 42‐year‐old man in late time group (10 d from symptom onset to this scan) shows bilateral consolidative opacities with striking peripheral distribution in right lower lobe (solid arrows) and with rounded morphology in left lower lobe (dashed arrow). (Reprinted with permission of (32).)

  • FIGURE 5.
    FIGURE 5.

    (A) Unenhanced axial CT image from 43-y-old woman shows crazy‐paving pattern as manifested by right-lower-lobe ground‐glass opacification with interlobular septal thickening (arrows) and intralobular lines. (B) Axial CT image from 22‐year-old woman shows area of faint ground‐glass opacification in left upper lobe, with ring of denser consolidation (arrow, reverse halo sign). (Reprinted with permission of (32).)

Tables

  • TABLE 1

    Consensus Guidance for Nuclear Medicine Departments, Staff, and Patients (6,17,20–25)

    Managing nuclear medicine departmentNuclear medicine staffPatients attending nuclear medicine center
    Promote and practice social distancing (2 m or 6 ft)Train in infection controlScreen patients and visitors before they enter department
    Assess risk at local level, with local context taken into consideration (should not replace or reduce ability to provide optimal patient or staff safety)Promote and practice social distancing (2 m or 6 ft)Make initial risk assessment of patient by phone, when possible
    Coordinate transmission of information between hospital information control department and nuclear medicine departmentMinimize crowding in workplace (e.g., tea or lunch breaks)Ask patients to inform nuclear medicine department if patient or family members develop symptoms before scheduled appointment
    Ask referring clinicians to clearly indicate whether scans are urgent or nonurgent when requesting themMaintain (6 ft or 2 m) distance in all patient and staff interactions when possibleDisplay posters in department reception area to promote hand washing and good respiratory hygiene measures
    Train all staff members to ensure maximum compliance and vigilance in line with local guidanceConsider need for contact and droplet precautions (based on nature of task being undertaken)Promote social distancing (2 m or 6 ft)
    Provide clear guidance to staff on how to proceed when patient COVID-19 status is unknown and COVID-19 is circulating at high levelsPractice strict hand hygiene, which should be extended to exposed forearms, after removing any element of PPERecommend patient use of fluid-resistant surgical face mask (to minimize dispersal of respiratory secretions and to reduce both direct transmission risk and environmental contamination)
    Establish local policy to reschedule nonurgent appointmentsHave access to PPEAsk patients to maintain strict hand hygiene
    Display posters to promote hand washing and good respiratory hygiene measures within departmentTrain on donning and doffing PPEAsk patients to minimize accompanying visitors and patient escorts
    Allocate or make provision for separate space for patients with suspected or known COVID-19 statusPut on appropriate PPE before providing careGive patients telehealth option (teleclinics to provide reassurance and guidance)
    Develop clear escalation pathway to ensure cases are identified in timely manner and triagedKnow what PPE staff should wear for each setting and contextInform and reschedule nonurgent appointments
    Implement stringent local hospital policy for screening of staff, patients, and visitors before they enter departmentAdopt single-use policy for gloves and apronsInform and reschedule elective therapies
    Implement stringent local hospital policy to minimize nonessential visitors in departmentTake regular breaks and rest periodsEnsure that patients spend minimum time in department (do not allow patients to remain for long periods in waiting area)
    Provide PPE for staff and patients (because of concern about asymptomatic transmission of COVID-19)Remain connected with rest of staff or with friends and family via group email, e-portal or social media
    Make sure supplies are available, and check stock every day and during day (centralize storage and distribution)Make sure nuclear medicine physicians or radiologists are familiar with CT appearance of COVID-19
    Implement robust policy for cleaning and decontaminating imaging equipmentCheck PET/CT and SPECT/CT scans for CT changes in lungs before sending patient home
    Explore options and encourage reporting of scans from remote sites or home, whenever feasible, according to local policyBe supportive and caring; nominate staff to look after staff well-being
    Encourage use of virtual conference tools for multidisciplinary or educational meetings
    Provide for flexible staff-schedule rotation (on-site and off-site work, work in small groups)
    Provide relevant, regular, and reliable updates daily
    Develop contingency and business continuity plan

    • These are examples based on consensus only, and responsibility lies with each institution or hospital to ensure its written policy adheres to that outlined by national public health guidance in its respective country and hospital.

  • TABLE 2

    Scheduling Nuclear Medicine Procedures That Use SPECT Tracers

    Type of scan (referrals must be reviewed by nuclear medicine consultant)Scans that can be booked and performed as requested (unless patient is at risk of infection)Scans that require liaison with clinical team for canceling or rescheduling (inform patient)Scans that must be postponed or rescheduled (inform patient and clinical team)
    SkeletalBone scans in cancer patientsScans for severe pain pre- and postprocedural orthopedic indications (if there is a question of infection, offer 18F-FDG PET/CT as alternate)Scans for pre- and postprocedural orthopedic indications; metabolic bone disease; inflammatory arthropathy
    Endocrine99mTc04 thyroid scans in patients not on antithyroid medications or if question of ectopic or neonatal hypothyroidism99mTc04 thyroid scans in patients on antithyroid medications; 99mTc-MIBI parathyroid scans for preoperative localization
    Cardiovascular (avoid exercise nuclear stress testing because of risk of droplet exposure; consider using pharmacologic stress agents; consider 1-d protocols (e.g., stress–rest)Myocardial perfusion scans in cases of recent acute coronary syndrome (moderate- to high-risk patients) for urgent coronary revascularization; scans in patients with new or increasing chest pain; scans for preoperative assessment (moderate- to high-risk patients); MUGA scans in oncology patients (before initiation of or subsequent chemotherapy)Myocardial perfusion scans in patients awaiting liver transplant surgery; scans in patients with stable angina requiring follow-up evaluation; cardiac amyloid DPD scans123I-MIBG heart scans; myocardial perfusion scans in patients awaiting renal transplant surgery; cardiac amyloid DPD scans for follow-up evaluation
    BrainDaTscan (123I-FP-CIT) scans
    Respiratory (discuss decision to proceed with ventilation–perfusion scan with referrer before booking)Lung perfusion scans in pregnant patients; lung shunt scans for 90Y-SIRTVentilation–perfusion scans in patients with pulmonary hypertension or chronic PE on treatmentVentilation–perfusion scans if question of resolution of PE in patients receiving thromboprophylaxis
    GastrointestinalGastrointestinal-bleed Meckel scansGastric-emptying esophageal transit scintigraphy; gastroesophageal reflux scintigraphy; SeHCAT small-bowel or colonic transit scans
    HepatobiliaryHIDA scans in patients with biliary leakHIDA scans if question of acute cholecystitisLiver or spleen scans; HIDA scans in patients with, for example, cystic duct syndrome or sphincter-of-Oddi dysfunction; liver SPECT in patients with hemangioma; 99mTc-denatured RBC scans
    Genitourinary99mTc-DMSA scans in patients with radiotherapy to abdomen or prior renal surgery; 99mTc-MAG3 scans in patients with urinary leak or transplant rejection; testicular scans in patients with torsionMAG3 scans if question of obstruction; DMSA scans for donor assessment99mTc-MAG3 scans for routine follow-up; 99mTc-DMSA scan for follow-up; captopril renogram scans
    Infection or inflammationScans if question of sepsis in COVID-19–negative patients (suggest FDG PET/CT); scans if question of infection of prosthesis
    Lymphatic systemSentinel lymph node injections and scansLymphoscintigram scans if question of lymphedema
    Oncology111In-pentetreotide and 99mTcEDDA/HYNIC-Tyr3-Octreotide scans before PRRTOctreotide/Tektrotyd scans in patients with NET; 123I-MIBG scans in patients with pheochromocytoma or paraganglioma
    MiscellaneousGFR studies in oncology patients before initiation of or subsequent chemotherapyDacryoscintigraphy scans; salivary gland scintigraphy; DXA scans

    • Referrals must be reviewed by nuclear medicine consultants or in multidisciplinary setting. These are examples based on consensus only, and responsibility lies with each institution or hospital to ensure its written policy adheres to that outlined by national public health guidance in its respective country and hospital.

    • 99mTc04 = 99mTc-pertechnetate; MIBI = methoxyisobutylisonitrile; MIBG = metaiodobenzylguanidine; DPD = 3,3-diphosphono-1,2-propanodicarboxylic acid; [123I]β-CIT = [123I]2β-carboxymethoxy-3β-(4-iodo-phenyl)tropane; [123I]FP-CIT = [123I]N-ω-fluoropropyl-2β-carbome-thoxy-3β-(4-iodophenyl)nortropane; MUGA = multigated acquisition; SIRT = selective internal radiation therapy; PE = pulmonary embolism; HIDA = hepatobiliary iminodiacetic acid; SeHCAT = selenium homocholic acid taurine; GFR = glomerular filtration rate; MAG3 = mercaptoacetyltriglycine; DMSA = dimercaptosuccinic acid; PRRT = peptide receptor radionuclide therapy; NET= neuroendocrine tumor; DXA = dual-energy X-ray absorptiometry; RBC = red blood cells.

  • TABLE 3

    Scheduling Nuclear Medicine Studies That Use PET/CT

    Type of PET/CT scan (referrals must be reviewed by nuclear medicine consultant)Scans that can be booked and performed as requested (unless patient is at risk of COVID-19 infection) Scans that require liaison with clinical team for canceling or rescheduling (inform patient)
    Oncology18F-FDG for staging, restaging, response assessment, and radiotherapy planning18F-FDG, 68Ga-DOTATATE/DOTATOC, 18F-PSMA, 68Ga-PSMA, 18F-choline, 18F-NaF, or 18F-DOPA for follow-up evaluation
    18F-PSMA, 68Ga-PSMA, or 18F-choline for biochemical recurrence
    68Ga-DOTATATE/DOTATOC for staging, restaging, and selecting patients for PRRT
    18F-NaF for bone metastases
    18F-DOPA for diagnosis and staging
    Nononcology18F-FDG for pyrexia of unknown origin in COVID-19–negative patients, for sepsis, for viability testing in symptomatic patients awaiting CABG, for suspected device or prosthetic infection, or for cardiac sarcoidosis18F-FDG for known sarcoidosis in patients on treatment, for polymyalgia rheumatica, or for follow-up of known cardiac sarcoidosis in patients on treatment

    • These are examples based on consensus only, and responsibility lies with each institution or hospital to ensure its written policy adheres to that outlined by national public health guidance in its respective country and hospital.

    • FDG = fluorodeoxyglucose; PSMA = prostate-specific membrane antigen; PRRT = peptide receptor radionuclide therapy; DOPA = 3,4-dihydroxyphenylalnine; CABG = coronary artery bypass grafting; NaF = sodium fluoride.

  • TABLE 4

    Scheduling Radionuclide Therapy (20,22)

    Therapies might be performed as scheduled. However, each patient must be assessed individually by clinical team or MDT prior to schedulingTherapy requiring cancellation or rescheduling –each patient must be assessed individually, followed by liaison with clinical team or MDT. Inform patient
    177Lu-DOTATATE peptide receptor radionuclide therapy for metastatic neuroendocrine tumors (consider marrow depletion after procedure)131I therapy for thyroid cancer (follow thyroid cancer management guide for various risk categories)
    Selective internal 90Y radioembolization therapy for hepatocellular carcinoma or liver metastases131I therapy for benign thyroid disease (most treatments can be postponed; give consideration to patients who cannot tolerate antithyroid medication)
    131I-metaiodobenzylguanidine therapy for metastatic pheochromocytoma or paragangliomaRadiosynovectomy for arthritis, hemophilia, and similar conditions
    177Lu-prostate-specific membrane antigen therapy for metastatic prostate cancer
    225Ac-prostate-specific membrane antigen therapy for metastatic prostate cancer
    223Ra therapy for prostate cancer with skeletal metastases (consider comorbidities)

    • Referrals must be reviewed by nuclear medicine consultants or in multidisciplinary setting. These are examples based on consensus only, and responsibility lies with each institution or hospital to ensure its written policy adheres to that outlined by national public health guidance in its respective country and hospital.

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