Lymphoscintigraphy for Breast and Indications | Technetium-99 (Tc-99m): A Versatile Isotope
Lymphoscintigraphy for Breast and Indications | Technetium-99 (Tc-99m): A Versatile Isotope
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Moving on to breast lymphoscintigraphy or breast mapping.

We use sulfur colloid for this. Indications for it is the patient's probably getting the surgery, either the day of or the day after and the doctors need to know which sentinel node biopsy do they need to do. It shows the first draining lymph node.

We do two kind of mapping. One is the same day surgery mapping and the second it's a day before as it says, same day is for the patients who are having surgery today and day before is the patients who are having surgery the day, the next day.

Doses, same day surgery at 0.1 millicuries, and day before is 0.5, it's tiny. Yes, we do use that little syringe. For procedure, you confirm the patient, you confirm the order, and the breast laterality, not just with the patient but also their chart.

Because how many times has it happened, the patient is like, "But I'm getting surgery "on both breasts." The order is for right because there is a reason. They're only doing breast biopsy on the right. Also, it can eliminate them of the wrong orders

that might happen in the system. You wanna confirm. We have a tendency at MSK to look at the consents, the mammograms, the CIS order and so this pathology reports just to make sure everything is in order. I like to educate my patients beforehand.

A lot of patients come in, oh it's a test, it's a nuclear medicine test, they have no clue. I like to just go over it. Any patient that come in after I confirm everything with them, I'd tell them, "So today we are doing "breast mapping, I will be injecting

"a little bit of radioactive isotope "right underneath the skin so it's intradermal, "it goes at the six o'clock perioral, sorry, "peri-areolar area." You can show it on yourself and most patients know what six o'clock is, they're adults.

When I inject, there will be a little pinch and a burning stinging sensation. If the patient has had a recent biopsy or a recent radioactive seed placement, they are more sensitive than others, so at that point, if I know they have had it,

or they say, "Oh yeah, I have had this today," we tell them, "Yes you might be more sensitive to it "than a regular patient. "But just be patient, it will pass. "It is not that long." You inject the isotope, it's like I said,

it's intradermal, so even though that's a PPD test, it kinda looks like that. You do see a little bubble as you inject. After the injection, I'd cover it with gauze, put some paper tape on it, because I really don't want anything else, and I use a couple fingers,

put it at the point and start a pointed massage. It doesn't matter which way you move, just as well you keep it moving, so that it facilitates the isotope to go towards the first draining left node. It disperses the isotope.

I show the patient as I'm doing it, this is how you're doing it, and then I wait there for about 30 seconds to a minute to make sure they're doing it. Some patients, as soon as they start doing it, they go like this, they're caressing,

they're not actually moving it. Some people are being really vigilant and they are like just kinda digging it and you don't want them to get tired before the 10 minutes are up. I just make sure they're doing it right,

tell them, if this hand tires, you can use your second hand and then leave the room. We have, thankfully, we have volunteers whom I can say, "Hey, in 10 minutes, "at exactly this time, can you let the patient know "to get dressed and wait in the waiting area

"until one of our technologist bring them back in "for a 10 to 15 minutes scan." If I do not have the volunteers, I have used a timer, because God knows we have all forgotten whether the patient was in there for more than 10 minutes massaging their breast.

Happens, unfortunately it happens. Someone calls you for something else, and you get busy in that. This is the view, and this is actually, I especially chose this one because you can actually see almost three lymph nodes.

The first, the lower part is the point of injection, and there are a couple up there, that's the anterior and the lateral view. The next day, when the patient goes into the OR, their doctors just have to use their wand to see where the radioactive isotope is.

This picture is actually for us to make sure that it has drained into the lymph nodes.

Leave that a bit for later. While we were doing all the work in interventional radiology

we were asked to train a private practice MRI team north of Boston because they further wanted to reduce their claustrophobia rate and that's how we got into this whole issue of using Comfort Talk in the MRI setting

and what we are finding out now more and more is that patients who are claustrophobic it's PTSD. So for the one's of you who are doing nursing and are called in there, that's what it is. The situation, in one way shape or the other reminds them of past trauma.

There is now a fair amount of trauma exposure therapy, particularly these veterans who are coming back from the various wars where they go to the psychologist's office and they are re-introduced to the setting and this is reframed and then the hope is that they walk out of the office and feel better.

That's hard to do. However, when the patient shows up at your doorstep and is completely freaked out, they are in the trauma, they're in it, and all you can do is actually make it better because it is the setting where they are the very most motivated to improve it

and this is also why it kind of works. We had done a recent trial at Boston Medical Center, Tufts and Ohio State where we basically just look at what happens if you train a team in just changing their vocabulary a little bit, sometimes they would read a script

but most often not, what is gonna happen to the outcomes? And we didn't even insist that people would use the techniques, we said okay you get the training, do with it what you want but it kind of changes after you see how things work

that you are gonna see your results and then adaption becomes more. So we saw the incomplete and no show rates going down and a significant improvement in patient satisfaction and there's nothing that improves your stress level

more than if a patient comes and says, hey thank you very much you really helped me through that. Or they really express their appreciation. And we then moved on and did a randomized trial and I think that gets a bit back to the original slides I did

in you are not alone in this. You are in this environment of commercial pressures of patients who come in who are not coming and then what is happening to your practice base. The fascinating thing about this, and that was in Columbus, Ohio, that the trial,

we trained three teams in Comfort Talk and three teams we didn't and that was in one healthcare system of MRI and what had happened at time zero is a fascinating event which I call the adverse effects

that philanthropy can have. For those of you who have come from the Columbus area there is so much money out there, there are more wealthy people probably than in New York that don't show it, but there is a lot of richness, so for somebody to give a hundred million

to build a new tower for the hospital is not a big deal. So they build a new tower but then the competitor in town obviously couldn't let this go by and they also got this beautiful nine story newer tower. Obviously all of them having MRI.

Same thing happening in Boston. I mean it's amazing how many millions, hundred millions in philanthropy for new stuff and everybody has a new MRI. So now suddenly, and it was at time zero you have more scanners in an area than you have

patients to go around. And what happens, what we found is, and that's the blue line, the people who were trained in Comfort Talk, were able to keep their volume and the others lost volume. So even in big urban areas word gets around

of like where do people go or we see impact on no shows. Most no show are people are frequent offenders but in any event we saw that. So now obviously if you are working in an area where you have fewer and fewer patients showing up

your equipment utilization is going down. And keep in mind that the current regulations are you are supposed to have your equipment running 90% of time, that's what payment is based on, that CMS payment is based on. So if you see this line going down

and you work in a place like that you can count on your five fingers that somebody's gonna get fired making things even worse because that's how administrators really high up solve that situation. And what we have seen is that, in other settings

where we had trained people whose patients are happy and actually send that in, that's actually a very good insurance against being, quotation mark downsized and this is what happened with patient satisfaction. So once you stress out the personnel,

patient satisfaction is gonna go downhill and we had done that and seen that in a prior study too where, in that very first place that had hired us it was a joint venture of two hospitals for an outpatient facility and at the moment the reimbursement changed

to have more reimbursement hospital wise. They told everybody they'll get fired or transfer. That obviously did make a dip down in the patient satisfactions but then they came up again and at least throughout stayed longer than before training. I thought I'm gonna just share this

because that got published last week and our first author, who's actually at UCLA in economics, already has given three press interviews. So you might be hearing about that in the weeks to come. We trained a team at Duke and we looked at,

where do people waste, where does extra time go, where does extra expensive time go? And the two columns on the left side are the hospital based facilities and the two right columns are the free standing facilities.

Pre is before training, post is after training. Now the interesting thing is that in the hospital based places the amount of general anesthesia and conscious sedation didn't change because there are fixed slots, and every month, interestingly enough,

it's exactly the same. But that comes from the fact that places that don't have anesthesia and don't have sedation send them there until the slots are filled. But you might notice that green bar, the oral sedation went down, and particularly

disruptive motion. So the whole idea that you put somebody under general anesthesia and their breathe to you on command is not necessarily going to happen. If you look particularly at the freestanding places you've got a pretty big decrease in all these issues

that cost you extra time and run into money. So if you look at all, I think a paper that came out at Emory, what they call unanticipated events, I mean I don't call it unanticipated if a patient moves around, that's kind of life,

but if you look at those we found a drastic reduction but then also found even if you use Medicare reimbursement data quite a lot of more money. If you do 25,000 patients a year, and you make 12,800 times 25,000

that's nearly 300,000 for that you can keep some extra staff without anything else happening, or at least you can keep your structure intact or invest in new equipment. I think, since now we are all kind of really quiet,

I wasn't sure whether I would be showing you another video but I think you really need it with another great trick which is, if you're doing something and there's a repeat thing gonna happen again, some stimulus that's unpleasant,

and this actually really happened, the one we're playing now. Let's say you have the patient and let's say they're heavy and you know they take a breath in and they're gonna hit the equipment, which is kind of a bit scary for the patient,

or let's say you do a biopsy and you use the gun and it's gonna shoot all the time. So you have repeating, or you do a laser, you have a repeating stimulus coming, you can actually interestingly enough use that stimulus to make what we call an anchor.

Remember when I did the little hypnosis script with you, where I asked you to think either of a color or a sound or of a movement to anchor that with something really pleasant, the same you can use a stimulus that happens to anchor the patient in either getting more relaxed

or use that as a sign to numb the area around even more. It sounds spooky but it works.

So what about if patients have more than just one renal cell carcinoma metastasis? What if they have multiple. So in this study from my institution,

the urology team looked at patients who had all of their tumors resected as opposed to patients who had any of their tumors resected compared to those who had none of them resected. And there was a survival benefit for each of those patients. And these authors wrote a really nice statement

I like in this scenario. And they said limited data exists on the outcomes of these types of patients, and we believe this may result in an unnecessary therapeutic anilism, whereby patients who have multiple lesions

are excluded from an aggressive approach. They're just put onto systemic therapy or comfort care. And why is the literature limited in this case? It's due to the morbidity of surgical resection. So really ablation in these minimally invasive IR techniques provide an opportunity to help this patient population.

So is there any cellular or biologic basis for this understanding? Well over the last couple of decades really, there's been a lot of scientific study into tumors on a genomic basis.

And we find that tumors really have a lot of heterogeneity. So this clump of cells that are multicolored here represent the tumor and really, we see that the metastases that develop from this to the brain, liver, and lungs, and spread from different parts of that tumor.

And each of these parts of the tumor may develop different mutations. And even the tumors that spread, like that green metastasis to the liver, then may develop further mutations that allow it to spread further.

And so if we find patients who have a limited amount of metastatic spread, potentially those patients have a single mutation as a more homogeneous tumor. In which case, we could potentially have a therapeutic window in which we can

prevent them from having spread elsewhere. So if we take this example, patient who has a colon cancer and the colon cancer had spread to the liver, those metastases then develop further mutations that spread to the lung and the bone and then the bone metastasis further spreads to the brain,

we could potentially, if we find a patient who only has a liver metastasis and a bone metastasis, if we actually treat those areas focally potentially we can limit their metastatic progression, improve survival.

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