Radiologist Shares Procedures for Radioactive Injections, Extravasation

The practice of Jackson W. Kiser, MD, requires monitoring for all therapeutic and diagnostic injections, something that the Nuclear Medicine Clarification Act of 2025, or H.R. 2541, is seeking to standardize across practice in the US.

CancerNetwork® spoke with Kiser, diagnostic radiologist and chief of Molecular Imaging at Carilion Roanoke Memorial Hospital in Roanoke, Virginia, about how his practice manages and prevents extravasation when administering radioactive therapies, as well as adverse effects (AEs) related to extravasation.

Kiser initially highlighted his practice’s procedures, explaining that he uses a device that monitors injections for extravasations, as well as whether it occurs within the field of view. He further remarked that a physicist measures the dose to the local tissue and credits another exam to patients, free of charge, if the image quality is unsatisfactory. Kiser additionally expressed that patients within his site receive follow-up calls after extravasation to monitor potential AEs.

Kiser then suggested that issues may emerge with the use of beta emitters, which can exceed the dose of radiation that might be used in traditional imaging techniques. He explained that major AEs, such as skin necrosis, can arise from extravasation with beta emitters, potentially requiring plastic surgery or skin grafts, among other corrective procedures.

He concluded by iterating that he requires his practice to monitor radioactive injections for extravasations, something that H.R. 2541 would mandate across all practices. Finally, he expressed that although he was unsure about the details, he suggested that the bill would require extravasations be reported to a health department like the Nuclear Regulatory Commission (NRC).

Transcript:

In my practice, I have been using a device that monitors my injections, or my technologist’s injections, for 7 or 8 years, so we know when it happens and whether the injection site is in the field of view. When it happens, we can measure the dose to the local tissue there. We have a physicist that can do that. If the image quality is not satisfactory, we will credit that patient’s exam and repeat it at no additional charge to them. We also tell the patient here, which everybody else does to my knowledge, that if they did get extravasated, we are going to do follow-up calls to the patient to make sure they had no [adverse] effects from the injection such as redness of the injection site, pain, or anything like that.

Where it is [especially] going to become problematic is not just diagnostic stuff that we’re doing now. We’re doing stuff where we’re infusing these extremely large doses of what’s called a beta emitter. It’s tagged to different types of pharmaceuticals, and instead of 10 millicuries, [which is what] we might inject for a PET scan, we are injecting 200 millicuries of beta emitter into these patients.

You can imagine, if that extravasated, you can have some major issues such as skin necrosis. You may need to have plastic surgery [across] the area, do skin grafts, and all that [other] stuff. I require we monitor all these therapeutic injections as well as our diagnostic injections. That is what the [Nuclear Medicine Clarification Act of 2025] is stating, that we are going to be required to report these things to either our local health department, to the NRC, or to somebody [else]. I am not sure who we will be reporting to, I guess the devil’s in the details there, but that’s what that bill is about.

Reference

H.R.2541 - Nuclear Medicine Clarification Act of 2025. Congress.gov. Accessed April 17, 2025. https://tinyurl.com/mss6h3h5