Article Figures & Data
Figures
- FIGURE 1.
Therapy process. CBC = complete blood count; diff = differential.
- FIGURE 2.
Decay schema for 223Ra-dichloride.
Tables
Clinical metric Requirement Castration-resistant prostate cancer metastatic to bone Symptomatic No visceral metastatic disease Whole-body bone scan with at least 2 lesions Complete blood count with differential Before first treatment: Absolute neutrophil count ≥ 1.5 × 109/L Platelet count ≥ 100 × 109/L Hemoglobin ≥ 10 g/dL Before subsequent administration: Absolute neutrophil count = 1 × 109/L Platelet count = 50 × 109/L No hemoglobin requirement Item Reason Documentation of bone scan demonstrating uptake in osseous metastatic disease Required by package insert; if there is no uptake on bone scan, therapeutic radionuclide will not localize in suspected areas of metastatic disease Documentation of no visceral metastatic disease Required by package insert; therapeutic radionuclide treats not visceral metastatic disease but osseous metastatic disease, given its mechanism of localization (guidelines suggest CT of chest, abdomen, and pelvis before therapy) Documentation of complete blood count with differential counts Required by package insert and serves as baseline before other therapies, given potential myelosuppression of this therapy Plan or order for follow-up laboratory analysis before planned upcoming therapies Required by package insert; some lab tests may be organized by clinician who refers patient, but where to find this information should be known before upcoming doses are ordered (these lab tests are needed at least 1 wk before each planned treatment) Documentation of Eastern Cooperative Oncology Group or Zubrod performance status Helpful for future reference before starting therapy Review of patient continence of urine and stool Helpful when giving directed radiation safety instructions (therapy excreted mostly via gastrointestinal tract and, to lesser degree, urinary tract) Review of such factors as home situation, travel, and occupational considerations Helpful when giving directed radiation safety instructions Review of side effects, with recommendation for relevant as-needed medications Should be done for any medical therapy as part of consent Plan for follow-up weight measurements and documentation of patient weight Helpful to know ahead of time because doses are weight-based and patient weight may vary because of a variety of circumstances during therapy Signed consent form Should be done for any medical therapy as part of consent and understanding of potential risks and benefits Radiation safety instructions Should be done for any radionuclide therapy Completed written directive for sixth therapy Should be done for any medical therapy (ensure updated weight is used for calculation) Element Reason Review consultation To better understand new patient or refresh memory of previous patient Review complete blood count with differential To ensure parameters are within appropriate range for therapy Confirm weight and accuracy of administered activity calculation To ensure correct dose Verify patient identity per institutional protocol To ensure correct patient receives therapy Confirm that pretherapy and posttherapy medications have been given as needed To ensure patient comfort in event of side effects Provide radiation safety instructions To ensure patient has instructions and opportunity to ask questions Provide as-needed medications To ensure patient has as-needed medication and instructions on when to use Determine how well patient tolerated previous therapies To review symptoms and needs for pain medication and to preview current therapy (e.g., if patient is no longer constipated because less pain medication is needed than previously, there could be higher risk of soft stools or diarrhea during current therapy) Organ Absorbed dose (Gy/Bq) Dose coefficient (Gy/Bq) Contribution of β/γ dose to total dose (%) α-particles (high LET) β/γ dose (low LET) Adrenals 3.2E–09 2.4E–10 1.6E–08 7 Bladder wall 3.3E–09 4.1E–10 1.7E–08 11 Bone endosteum 3.3E–09 1.1E–10 3.8E–06 1 Brain 3.2E–09 1.8E–10 1.6E–08 5 Breast 3.2E–09 1.6–10 1.6E–08 5 Gastrointestinal tract Esophagus 3.2E–09 1.7E–10 1.6E–08 5 Stomach wall 3.2E–09 3.9E–10 1.6E–08 6 Small intestine wall 3.2E–09 3.9E–10 1.7E–08 11 Upper large intestine wall 6.8E–09 1.4E–08 4.8E–08 67 Lower large intestine wall 1.3E–08 4.0E–08 1.1E–07 75 Colon 9.5E–09 2.5E–08 7.3E–08 72 Kidneys 3.4E–09 2.4E–10 1.7E–08 7 Liver 3.6E–09 1.5E–10 1.8E–08 4 Muscle 3.2E–09 2.0E–10 1.6E–08 6 Pancreas 3.2E–09 2.2E–10 1.6E–08 6 Red marrow 7.2E–08 5.5E–09 3.7E–07 7 Respiratory tract Airways 3.2E–09 1.7E–10 1.6E–08 5 Lungs 3.2E–09 1.9E–10 1.6E–08 6 Skin 3.2E–09 1.6E–10 1.6E–08 5 Spleen 3.2E–09 1.9E–10 1.6E–08 6 Testes 3.2E–09 1.8E–10 1.6E–08 5 Thymus 3.2E–09 1.7E–10 1.6E–08 5 Thyroid 3.2E–09 1.7E–10 1.6E–08 8 LET = linear energy transfer.
- TABLE 5.
Dose Rates Comparing 99mTc Vs. 223Ra Derived from Exposure Rate Constants (μSv/h per MBq) (31)
Distance from point source 99mTc 223Ra 223Ra + progeny 1 m 0.02 ∼0.02 0.047 10 cm 2 ∼2 4.7 1 cm 200 ∼200 470 Code Purpose CPT code 99242 (new, outpatient, problem-focused, 30 min) Code for evaluation and management (dependent on type and length of consultation) CPT code 79101 Code for radiopharmaceutical therapy by intravenous administration Radiopharmaceutical code A9606 Code for therapeutic 223Ra-dichloride, per microcurie JW modifier Code to report wasted product and ensure ability to report full cost of ordered dose* ICD-10-CM codes (C61: malignant neoplasm of prostate; C79.51: secondary malignant neoplasm of bone) Codes to support the above codes and ensure correct indication ↵* Given long half-life, may not be needed, but Society of Nuclear Medicine and Molecular Imaging supports use of this modifier.
CPT = Current Procedural Terminology; JW modifier = Healthcare Common Procedure Coding System (HCPCS) Level II modifier used on Medicare Part B drug claim to report amount of drug or biological that is discarded and eligible for payment under the discarded drug policy (32); ICD-10-CM = International Classification of Diseases, tenth revision, clinical modification.
In this issue
Jump to section
- Article
- Abstract
- PATIENT SELECTION, CLINICAL CONSIDERATIONS, AND PROTOCOL
- RADIOPHARMACEUTICAL THERAPY PROPERTIES AND DOSIMETRY
- RADIATION SAFETY PRECAUTIONS, PATIENT CONSENT, AND AS-NEEDED MEDICATIONS
- DAY-OF-THERAPY TECHNICAL CONSIDERATIONS
- CREATING A SUCCESSFUL RADIONUCLIDE THERAPY PROGRAM WITH 223RA-DICHLORIDE
- LOOKING AHEAD
- EDUCATION AND RECOMMENDED READING
- CONCLUSION
- DISCLOSURE
- Footnotes
- REFERENCES
- Figures & Data
- Info & Metrics