Re: Strontium Therapy on In

["Mike Bohan" <mike.bohan@yale.edu>]

        Reply to:   RE>>Strontium Therapy on In

Kent,

Yes, we saw our first in-patient strontium soon after our first Sr-89
administration.  Although, it's supposed to be an "out-patient" procedure,
many of these patients have other problems besides intractable pain which
require their stay in-house.  We have tried to limit administrations to the
end of the patient's hospitalization, but I have "ethical" problems telling a
patient they need to stay drugged up on morphine or other pain meds to make my
life easier.  Somehow, the quality of their short time left seems more
important.  

I personally draw my program's line on diagnostic or therapeutic
administrations.  In-patient procedures with diagnostic intent --- I don't
take special precautions.  In-patient procedures with therapeutic intent --- I
use some modification of our I-131 procedure.   

For example, in-patient I-131 treatments (< 30 mCi) for Graves disease are put
in modified isolation for 24 hrs.  We have recently embarked on an In-111
Octeotride therapy research protocol involving the administration of 150 - 300
mCi of In-111.  We also isolate them for 24 hrs.  We haven't noted a "contact"
contamination problem with these patients, but, I must admit we haven't looked
very hard to find if there is one.  We depend upon the Nurses' universal
precaution procedures and haven't seen the problem when we bioassay our nurses
after "Special I-131 Cases". 

I'm currently faced with a protocol for a "Gamma Probe" in which a Tc-99m
labeled pharmaceutical (~20 mCi) is injected into breast tumors a few hours
before surgical resection.  The gamma probe is going to be used in the O.R. as
an in-vivo detector to identify the sentinel nodes involved with the tumor to
allow limited mastectomy.  I haven't decided what I'm going to do about this,
yet!!!   (This is the gray area between diagnostic and therapeutic intent!!!)

So even when I put on my x-ray glasses, I can't get past these gray areas and
feel confident that I've met the conditions of our license and the intent of
the regulations.  If only we could convince everybody about hormesis,  we
could tell everyone that a little contamination is good for you and be done
with it!!!  %*)

P.S. - We still haven't heard any non-binding opinions out there, from the
regulators...  Hint! Hint!

<><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><
Michael J. Bohan, RSO   |  e-mail: mike.bohan@yale.edu
Yale-New Haven Hospital |    Tele: (203) 785-2950
Radiological Physics    |     FAX: (203) 737-4252
20 York St. - WWW 204   |    As usual, everything I say may be plausibly
New Haven, CT    06504  |    denied at my employer's convenience ...
><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><>
Hard working RSO, on the front lines of the gray ZONE!!!
--------------------------------------
Date: 27/02/97 4:59 PM
To: Mike Bohan
From: radsafe@romulus.ehs.uiuc.edu
Mike,

I agree with you that this is a grey area in the regulations and in
guidance.  But, is there really any difference between the
administration of a sub 35.75 therapeutic quantity and the
administration of a diagnostic imaging agent?  Do you subscribe to
monitoring NM in-patients in a similar manner?  For example, do you
follow patients receiving Tl-201 for tumor imaging and subsequently
undergoing surgery to remove the tumor?  At my former employer we were
going crazy trying to figure out how I-125 seed(s) (in dissolvable
suture material) was ALL OVER the operating room after a permanent brain
implant.  Of course, it was thallium that had been administered earlier
in the day.  

We also modify our I-131 inpatient requirements but more so than you
do.  For example, we do not paper the room or survey upon discharge,
(although, we will reconsider it) but we do give the nurses instructions
to follow universal precautions and contact isolation procedures.  Have
you seen contamination from simple patient contact?  They are also
instructed to contact Radiation Safety if there is a "spill" (e.g.,
patient is incontinent).

I have noticed more inpatients undergoing Sr-89 therapy recently, which
makes sense to me.  A patient with terminal CA and bone pain is likely
to have other medical problems requiring hospitalization.  Have you seen
this trend, too?

Hopefully, the RSO section of HPS will be a forum for discussions of
this sort through presentation of papers in special sessions at HPS
meetings.  

Regards, 
--
Kent N. Lambert, CHP
lambert@allegheny.edu