Treatments

Nuclear medicine

Nuclear medicine uses small amounts of radioactive substances to detect or treat disease. At Seattle Cancer Care Alliance (SCCA), our nuclear medicine specialists are part of nearly every patient’s care. They do imaging scans and read them to diagnose, stage and monitor cancer. They also provide therapies to stop or reverse cancer growth.

Imaging In medicine, a process that makes pictures of areas inside the body. Imaging uses methods such as X-rays (high-energy radiation), ultrasound (high-energy sound waves) and radio waves. Stage The extent of a cancer in the body. Staging is usually based on the size of the tumor, whether lymph nodes contain cancer and whether the cancer has spread from the original site to other parts of the body.

Nuclear medicine imaging

Imaging methods like X-ray, ultrasound and computed tomography (CT) are good at showing structures inside your body. They tell us about the size, shape and position of things. This includes both normal structures, like bones and organs, and abnormal masses, like cancerous tumors.

Nuclear medicine scans do something else, too. Along with making pictures of the structures, these scans give your physicians details about your body’s function, or how it is working. They allow us to measure processes in and around your cells. The results tell us about the cells’ health.

Computed tomography A procedure that uses a computer linked to an X-ray machine to make a series of detailed pictures of areas inside the body. The pictures are used to create three-dimensional (3-D) views of tissues and organs. A procedure that uses a computer linked to an X-ray machine to make a series of detailed pictures of areas inside the body. The pictures are taken from different angles and are used to create three-dimensional (3-D) views of tissues and organs. A dye may be injected into a vein or swallowed to help the tissues and organs show up more clearly. This scan may be used to help diagnose disease, plan treatment or find out how well treatment is working. Imaging In medicine, a process that makes pictures of areas inside the body. Imaging uses methods such as X-rays (high-energy radiation), ultrasound (high-energy sound waves) and radio waves. Ultrasound A procedure that uses high-energy sound waves to look at tissues and organs inside the body. The sound waves make echoes that form pictures of the tissues and organs on a computer screen. A procedure that uses high-energy sound waves to look at tissues and organs inside the body. The sound waves make echoes that form pictures of the tissues and organs on a computer screen (sonogram). Ultrasound may be used to help diagnose diseases, such as cancer. It may also be used during pregnancy to check the fetus (unborn baby) and during medical procedures, such as biopsies. Also called ultrasonography.

“Looking at a CT scan is like looking at a light fixture to see whether there’s a bulb. A nuclear medicine scan is like turning on the electricity to see whether the bulb lights up.”

— Delphine Chen, MD, nuclear medicine specialist

How do nuclear medicine scans work?

Before a nuclear medicine scan, a small amount of a radioactive drug is put into your bloodstream. This is done by intravenous (IV) injection.

Radioactive drugs are drugs that are linked with radioactive elements (radionuclides). They are also called radiopharmaceuticals. When they are given in small amounts, such as for scans, they may also be called radiotracers.

The radioactive drug travels through your body and builds up in certain places. For example, it may build up in one organ or in cells that have points (receptors) on their surface where that drug can attach. Diseased cells take up the drug in a different way than healthy cells.

Given in such a small amount, the radioactive drug has no effect on your body. But the energy it gives off can be detected by a scanner. This lets your team see where the diseased cells are.

The scan is made by a machine with a special camera that detects radiation. Using data from the scanner, a computer makes a picture of the inside of your body showing where the radiation is. Then your nuclear medicine specialist reviews this picture.

It is common to call places with more radiation “hot spots” or to say they “light up” on the scan. Either hot spots or cold spots may be signs of cancer or other disease.

What can these scans tell us?

Your physicians use nuclear medicine scans to tell what is happening in your organs and tissues and how well they are working. The scans can tell your physicians things like:

If cancer cells are present (even if the tumor is too small to show up on other types of imaging)
Where tumors are and how large they are
Where cancer cells have spread beyond the main site
If the cancer will respond to certain medicines you have not had yet
How well the cancer responded to treatments you already had
If the cancer is shrinking or growing compared to earlier scans or if it has come back after it seemed to be gone

By telling us about what is happening in and around your cells, a nuclear medicine scan can give us important information. It can tell us about your health before there are structural changes that would show up on CT or magnetic resonance imaging (MRI).

Computed tomography A procedure that uses a computer linked to an X-ray machine to make a series of detailed pictures of areas inside the body. The pictures are used to create three-dimensional (3-D) views of tissues and organs. A procedure that uses a computer linked to an X-ray machine to make a series of detailed pictures of areas inside the body. The pictures are taken from different angles and are used to create three-dimensional (3-D) views of tissues and organs. A dye may be injected into a vein or swallowed to help the tissues and organs show up more clearly. This scan may be used to help diagnose disease, plan treatment or find out how well treatment is working. Imaging In medicine, a process that makes pictures of areas inside the body. Imaging uses methods such as X-rays (high-energy radiation), ultrasound (high-energy sound waves) and radio waves. Magnetic resonance imaging A procedure in which radio waves and a powerful magnet linked to a computer are used to create detailed pictures of areas inside the body. A procedure in which radio waves and a powerful magnet linked to a computer are used to create detailed pictures of areas inside the body. These pictures can show the difference between normal and diseased tissue. MRI makes better images of organs and soft tissue than other scanning techniques, such as computed tomography (CT) or X-ray. MRI is especially useful for imaging the brain, the spine, the soft tissue of joints and the inside of bones.

Which scans does SCCA offer?

SCCA physicians use nuclear medicine scans to check for cancer in many parts of the body, such as the bones, endocrine (hormone) system, liver, lungs, heart, brain and other organs.

The scan we use most often is a PET/CT (positron emission tomography/computed tomography) scan. In a PET/CT, both PET and CT scans are done. Then the two types of pictures are put together into a single set of images. This combines details about structure and function.

We also perform SPECT (single-photon emission computed tomography) scans. Usually, we do a CT scan at the same time (SPECT/CT). These scans are useful for seeing how well a tumor has taken up a radioactive drug so we know whether a patient should keep getting nuclear medicine therapy. Sometimes a SPECT/CT can tell us if tumors are responding during treatment.

Another scan we use is a planar imaging scan. A planar imaging scan is often done to:

Detect cancer in the bones. This may be called a bone scan.
Check that heart function is normal before starting treatment that might damage the heart. This is also called a multigated acquisition (MUGA) scan or radionuclide ventriculogram (RVG).

For some planar scans, we may add a SPECT/CT scan to help detect an abnormality.

Bone scan A procedure to check for abnormal areas or damage in the bones. A bone scan may be used to diagnose bone tumors or cancer that has spread to the bone. A procedure to check for abnormal areas or damage in the bones. A very small amount of radioactive material is injected into a vein and travels through the blood. The radioactive material collects in the bones and is detected by a scanner (a special camera that takes pictures of the inside of the body). A bone scan may be used to diagnose bone tumors or cancer that has spread to the bone. It may also be used to help diagnose fractures, bone infections or other bone problems. [removed comma] Computed tomography A procedure that uses a computer linked to an X-ray machine to make a series of detailed pictures of areas inside the body. The pictures are used to create three-dimensional (3-D) views of tissues and organs. A procedure that uses a computer linked to an X-ray machine to make a series of detailed pictures of areas inside the body. The pictures are taken from different angles and are used to create three-dimensional (3-D) views of tissues and organs. A dye may be injected into a vein or swallowed to help the tissues and organs show up more clearly. This scan may be used to help diagnose disease, plan treatment or find out how well treatment is working. Computed tomography A procedure that uses a computer linked to an X-ray machine to make a series of detailed pictures of areas inside the body. The pictures are used to create three-dimensional (3-D) views of tissues and organs. A procedure that uses a computer linked to an X-ray machine to make a series of detailed pictures of areas inside the body. The pictures are taken from different angles and are used to create three-dimensional (3-D) views of tissues and organs. A dye may be injected into a vein or swallowed to help the tissues and organs show up more clearly. This scan may be used to help diagnose disease, plan treatment or find out how well treatment is working. Computed tomography A procedure that uses a computer linked to an X-ray machine to make a series of detailed pictures of areas inside the body. The pictures are used to create three-dimensional (3-D) views of tissues and organs. A procedure that uses a computer linked to an X-ray machine to make a series of detailed pictures of areas inside the body. The pictures are taken from different angles and are used to create three-dimensional (3-D) views of tissues and organs. A dye may be injected into a vein or swallowed to help the tissues and organs show up more clearly. This scan may be used to help diagnose disease, plan treatment or find out how well treatment is working. Imaging In medicine, a process that makes pictures of areas inside the body. Imaging uses methods such as X-rays (high-energy radiation), ultrasound (high-energy sound waves) and radio waves.

Nuclear medicine therapies

Physicians are always working on better ways to stop cancer cells while doing the least harm to the body’s healthy cells. Nuclear medicine therapies are one of these ways. They deliver radiation directly to cancer cells using radioactive drugs.

This is an area of active research among scientists and physicians. Studies are happening right now, including at SCCA, to find new options for treating many types of cancer. SCCA is a leader in offering nuclear medicine therapies for neuroendocrine tumors (NETs), prostate cancer and other diseases.

“SCCA offers specialized nuclear medicine therapies, some of which are generally offered only at major academic centers. Patients here get a unique opportunity to receive new therapies by taking part in clinical trials.”

— Delphine Chen, MD, nuclear medicine specialist

How do nuclear medicine therapies work?

A radiopharmaceutical is a drug linked with a radioactive element. It is put into your bloodstream by infusion (injection). The drug travels through your body and builds up in certain places. For example, it may build up in one organ or in cells that have points (receptors) where that drug can attach. Then the drug delivers the radiation into these cells.

The key is to use a drug that binds to your type of cancer cells. The drug acts as a delivery method, taking “packages” of radiation where they are needed to treat your disease.

The radiation given for treatment is stronger than the radiation for scans. Because the goal is to kill cancer cells, larger amounts are given to damage the cells the drug binds to. This can also damage a small number of nearby cells.

Nuclear medicine therapies are more targeted than conventional chemotherapy or radiation therapy. Ideally, they work better at the level of your tumor cells with fewer side effects and less damage to your healthy cells.

Chemotherapy Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. It may be given alone or with other treatments. Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy may be given by mouth, injection, infusion or on the skin, depending on the type and stage of the cancer being treated. It may be given alone or with other treatments, such as surgery, radiation therapy or biologic therapy. Infusion An injection of medications or fluids into a vein over a period of time. Radiation therapy The use of high-energy radiation from X-rays, gamma rays, neutrons, protons and other sources to kill cancer cells and shrink tumors. The use of high-energy radiation from x-rays, gamma rays, neutrons, protons and other sources to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy or brachytherapy). Systemic radiation therapy uses a radioactive substance, such as a radiolabeled monoclonal antibody, that travels in the blood to tissues throughout the body. Side effects A problem that occurs when treatment affects healthy tissues or organs. Some side effects of cancer treatment are nausea, vomiting, fatigue, pain, decreased blood cell counts, hair loss and mouth sores.

Which cancers can these therapies treat?

For this type of treatment to work, scientists first need to find targets on cancer cells. Then they need to find or develop drugs that will seek those targets. So far, radiopharmaceuticals are approved by the U.S. Food and Drug Administration to treat a few types of cancer. These include certain neuroendocrine tumors (such as neuroendocrine tumors from the gastrointestinal system, paragangliomas and pheochromocytomas), prostate cancer that has spread to other parts of the body and non-Hodgkin lymphoma.

Which therapies does SCCA offer?

At SCCA, we offer all approved nuclear medicine therapies, including these:

Lutetium-177 dotatate (Lutathera). It is used for certain neuroendocrine tumors and certain types of prostate cancer with a neuroendocrine component.
Lutetium-177 vipivotide tetraxetan (Pluvicto). This treats prostate cancer with the PSMA biomarker (prostate-specific membrane antigen) that has spread to other parts of the body.
Radium-223 dichloride (Xofigo). This is given to patients with prostate cancer that has traveled to their bones.
Yttrium-90 ibritumomab tiuxetan (Zevalin). This is used, along with the targeted therapy rituximab, for some forms of non-Hodgkin lymphoma.

SCCA physicians lead and take part in studies testing new therapies or ways to improve existing therapies. This means SCCA patients may have the chance to try treatment options not offered at all treatment centers.

Antigen A foreign substance, such as bacteria, that causes the body’s immune system to respond by making antibodies. Antibodies defend the body against antigens. Targeted therapy A type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells while causing less harm to normal cells. A type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells while causing less harm to normal cells. Some targeted therapies block the action of certain enzymes, proteins or other molecules involved in the growth and spread of cancer cells. Other types of targeted therapies help the immune system kill cancer cells, or they deliver toxic substances directly to cancer cells and kill them. Targeted therapy may have fewer side effects than other types of cancer treatment. Most targeted therapies are either small molecule drugs or monoclonal antibodies.

Lutetium-177 dotatate (Lutathera)

Lu-177 dotatate is a nuclear medicine therapy. It is a type of peptide receptor radionuclide therapy (PRRT) used mainly for neuroendocrine tumors (NETs).

PRRT combines a compound called a peptide with a radioactive element, called a radionuclide. The peptide finds and binds to cancer cells. It delivers the radionuclide. Then the radionuclide emits energy (radioactivity) that damages the cancer cells.

PRRT may:

Help relieve cancer symptoms and improve the quality of life
Stop or slow growth of tumors or shrink tumors

Symptom A physical or mental problem that a person experiences that may indicate a disease or condition. Symptoms cannot be seen and do not show up on medical tests. A physical or mental problem that a person experiences that may indicate a disease or condition. Symptoms cannot be seen and do not show up on medical tests. Some examples of symptoms are headache, fatigue, nausea and pain.

What is Lu-177 dotatate?

In Lu-177 dotatate, the dotatate is the peptide, or delivery system. Lu-177 is the radioactive element that can damage cancer cells.

After this combination is put into your bloodstream, it travels through your body. When it comes to cells with receptors for the hormone somatostatin, the dotatate binds there and goes into the cells. Then it releases the radiation.

Dotatate is good at binding to cells that have many tightly packed somatostatin receptors, avoiding other cells. When drugs are good at binding to certain cells, we say that they target or are “highly selective” for these cells.

Who needs Lu-177 dotatate?

This treatment is only for people whose cancer cells overexpress somatostatin receptors. In most cases, this means people with NETs that started in the stomach, intestine or pancreas. (These are called gastroenteropancreatic NETs, or GEP-NETs.) It can also include people with paragangliomas or pheochromocytomas (types of NETs), some lung carcinoids or prostate cancer.

Your SCCA team can check the level of somatostatin receptors on your cancer cells. We do this with a PET (positron-emission tomography) scan. For the scan, you get the radiotracer gallium-68 dotatate or copper-64 dotatate. If the scan shows that your tumors easily take up either radiotracer, this is a sign they have many somatostatin receptors. It means they will take up Lu-177 dotatate, too.

Usually, physicians use Lu-177 dotatate for patients who:

Have advanced or worsening tumors
Are not eligible for surgery
Do not get enough relief for their symptoms using other methods

Sign In medicine, a sign is something found during a physical exam or from a laboratory test that shows that a person may have a condition or disease. In medicine, a sign is something found during a physical exam or from a laboratory test that shows that a person may have a condition or disease. Some examples of signs are fever, swelling, skin rash, high blood pressure and high blood glucose. Symptom A physical or mental problem that a person experiences that may indicate a disease or condition. Symptoms cannot be seen and do not show up on medical tests. A physical or mental problem that a person experiences that may indicate a disease or condition. Symptoms cannot be seen and do not show up on medical tests. Some examples of symptoms are headache, fatigue, nausea and pain.

Treatment process

Patients get Lu-177 dotatate through an infusion (injection) at SCCA South Lake Union. The entire infusion process takes about five hours. The radioactive drug infusion lasts for about 35 minutes. Most people have one infusion every eight weeks for a total of four infusions. This is an outpatient treatment; patients go home later the same day.

Your care team will include a nuclear medicine specialist, a nuclear medicine technologist and nurses who help with your care and any side effects.

Before you begin treatment, your care team will talk with you in detail about topics such as:

Your diagnosis and how Lu-177 dotatate may fit into your treatment plan.
What to expect during and after treatment.
How to prepare for your infusions, like if and when to stop taking other medicines.
How to relieve any side effects you might have.
How to reach us if you have questions or concerns after you leave the clinic.
Ways to limit the risk of radiation to other people. (The risk is very low but important.)

During your infusions, you will get three medicines:

A medicine to prevent nausea, a common side effect
Amino acids, which help protect your kidneys from radiation
Lu-177 dotatate

In the days and weeks after each treatment, you will have lab tests and imaging scans. Your nuclear medicine specialist uses these to see where the Lu-177 dotatate went in your body and how it is affecting you.

Imaging In medicine, a process that makes pictures of areas inside the body. Imaging uses methods such as X-rays (high-energy radiation), ultrasound (high-energy sound waves) and radio waves. Infusion An injection of medications or fluids into a vein over a period of time. Infusion An injection of medications or fluids into a vein over a period of time. Side effects A problem that occurs when treatment affects healthy tissues or organs. Some side effects of cancer treatment are nausea, vomiting, fatigue, pain, decreased blood cell counts, hair loss and mouth sores. Treatment plan A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A treatment plan may also include information about how much the treatment is likely to cost and about regular follow-up care after treatment ends.

Research

The U.S. Food and Drug Administration approved Lu-177 dotatate for GEP-NETs in 2018. Today, researchers at SCCA and elsewhere continue to study its effects. We want to learn more about the best ways to help people who have neuroendocrine tumors or other cancers that respond to this treatment. For example, researchers are checking whether NET patients who benefited from Lu-177 dotatate will benefit from getting it again later in life if their NETs worsen.

Lutetium-177 vipivotide tetraxetan (Pluvicto)

Lu-177 vipivotide tetraxetan is a nuclear medicine therapy that was approved in 2022 for prostate cancer. It combines a compound called a ligand with a radionuclide. The ligand delivers the radionuclide to cancer cells by finding and binding to these cells. Then the radionuclide emits energy (radioactivity) that damages the cancer cells.

Pluvicto may:

Help you live longer
Delay cancer getting worse or spreading farther

What is Lu-177 vipivotide tetraxetan?

In Lu-177 vipivotide tetraxetan, the vipivotide tetraxetan is the ligand, or delivery system. Lu-177 is the radioactive element that can damage cancer cells.

After this combination is put into your bloodstream, it travels through your body. When it comes to cells with prostate-specific membrane antigen on their surface, the vipivotide tetraxetan binds there and goes into the cells. Then it releases the radiation.

Antigen A foreign substance, such as bacteria, that causes the body’s immune system to respond by making antibodies. Antibodies defend the body against antigens.

Who needs Lu-177 vipivotide tetraxetan?

This treatment is only for people with prostate cancer whose cancer cells are positive for prostate-specific membrane antigen (PSMA+). About 80 percent of men with prostate cancer have this biomarker.

Your SCCA team can check the level of PSMA on your cancer cells. We do this with a PET (positron-emission tomography) scan. For the scan, you get the radiotracer gallium-68 gozetotide. If the scan shows that your tumors easily take up the radiotracer, this is a sign they will take up Lu-177 vipivotide tetraxetan, too.

Physicians use Lu-177 vipivotide tetraxetan for prostate cancer which:

Is PSMA+
Has spread to other parts of the body (metastatic)
Does not respond to treatment to lower testosterone (which may be called castration-resistant disease)

Antigen A foreign substance, such as bacteria, that causes the body’s immune system to respond by making antibodies. Antibodies defend the body against antigens. Sign In medicine, a sign is something found during a physical exam or from a laboratory test that shows that a person may have a condition or disease. In medicine, a sign is something found during a physical exam or from a laboratory test that shows that a person may have a condition or disease. Some examples of signs are fever, swelling, skin rash, high blood pressure and high blood glucose.

Treatment process

Patients get Lu-177 vipivotide tetraxetan through an infusion (injection) at SCCA South Lake Union. The entire visit takes about two to three hours. The radioactive drug infusion lasts for about 20 minutes. Infusions are done every six weeks for up to six cycles. This is an outpatient treatment; patients go home later the same day.

Your care team will include a nuclear medicine specialist, a nuclear medicine technologist and nurses who help with your care and any side effects.

Before you begin treatment, your care team will talk with you in detail about topics such as:

Your diagnosis and how Lu-177 vipivotide tetraxetan may fit into your treatment plan.
What to expect during and after treatment.
How to prepare for your infusions, such as if and when to stop taking other medicines.
How to relieve any side effects you might have.
How to reach us if you have questions or concerns after you leave the clinic.
Ways to limit the risk of radiation to other people. (The risk is very low but important.)

During your infusions, you will receive only one medicine: Lu-177 vipivotide tetraxetan. Side effects are very uncommon, but if you do have any side effects, your care team will help treat or manage them, such as giving you medicine to help with nausea.

In the days and weeks after each treatment, you will have lab tests and imaging scans. Your nuclear medicine specialist uses these to see where the Lu-177 vipivotide tetraxetan went in your body and how it is affecting you.

Imaging In medicine, a process that makes pictures of areas inside the body. Imaging uses methods such as X-rays (high-energy radiation), ultrasound (high-energy sound waves) and radio waves. Infusion An injection of medications or fluids into a vein over a period of time. Infusion An injection of medications or fluids into a vein over a period of time. Side effects A problem that occurs when treatment affects healthy tissues or organs. Some side effects of cancer treatment are nausea, vomiting, fatigue, pain, decreased blood cell counts, hair loss and mouth sores. Treatment plan A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A treatment plan may also include information about how much the treatment is likely to cost and about regular follow-up care after treatment ends.

Research

The U.S. Food and Drug Administration approved Lu-177 vipivotide tetraxetan for metastatic castration-resistant prostate cancer in 2022. At SCCA, we continue to study this medicine to learn more about the best ways to help people with prostate cancers that either do or do not respond to this treatment. Our research includes:

Using blood and tissue samples (with patients’ permission) to collect molecular information on how the therapy works
Studying how to use imaging, such as PSMA PET (prostate-specific membrane antigen positron-emission tomography), to predict which cancers will respond to the therapy
Designing clinical trials to test if Lu-177 vipivotide tetraxetan will work better if combined with other therapies

Antigen A foreign substance, such as bacteria, that causes the body’s immune system to respond by making antibodies. Antibodies defend the body against antigens. Imaging In medicine, a process that makes pictures of areas inside the body. Imaging uses methods such as X-rays (high-energy radiation), ultrasound (high-energy sound waves) and radio waves. Metastatic A metastatic cancer is a cancer that has spread to other areas of the body by way of the lymph system or bloodstream.

Care team

A team of nuclear medicine experts will plan and provide your care and support you throughout the process.

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