Multi-isotope SPECT imaging of the 225Ac decay chain: feasibility studies

A whole gamma imaging prototype for higher quantitative imaging of89Zr-labeled antibodies in a tumor mouse model

Objective.Positron emission tomography (PET) has become an important clinical modality, but it is limited to imaging the annihilation radiation from positron-electron collisions. Recently, PET imaging with89Zr, which has a half-life of 3 d, has attracted much attention in immuno-PET to visualize immune cells and cancer cells by targeting specific antibodies on the cell surface. However,89Zr emits a single gamma ray at 909 keV four times more frequently than positrons, causing image quality (IQ) degradation in conventional PET. To overcome this drawback, use of such single gamma rays for imaging was previously proposed as whole gamma imaging (WGI). In WGI, a single gamma ray is detected by Compton imaging; by inserting a scatter detector ring inside the PET ring, WGI can realize both PET imaging and Compton imaging in one modality. A prototype for WGI was developed and Compton imaging of a mouse after intravenous administration of89Zr oxalate was demonstrated. However, the Compton imaging of the single gamma ray still presented a challenge due to its low IQ compared to PET.Approach.In this study, the scatter detector insert of the earlier WGI prototype was redesigned with the aim of improving Compton imaging performance. The new prototype produced WGI images by additive averaging of PET and Compton images after optimizing the ratio of each iteration in the image reconstruction. WGI IQ was then evaluated using the NEMA NU4 IQ phantom, and a tumor-burdened mouse was imaged with WGI up to 12 d after89Zr labeled antibody injection.Main results.Consequently, the Compton imaging performance was improved by lowering the angular resolution measure from 6.7 degrees to 6.4 degrees and the sensitivity from 0.11% to 0.18% compared to the previous prototype WGI. The phantom images with WGI showed a 15% reduction in noise and a 3% increase in contrast recovery under low-statistical conditions compared to images reconstructed by PET data alone.Significance. In-vivomouse imaging with the new prototype WGI was successfully performed. This successful imaging leads to the expectation that future whole-body WGI imaging will enable more sensitive and better quantitative89Zr antigen-antibody reaction imaging to be obtained.

Preclinical Evaluation of 226Ac as a Theranostic Agent: Imaging, Dosimetry, and Therapy

226Ac (t½ = 29.37 h) has been proposed as a theranostic radioisotope leveraging both its diagnostic γ-emissions and therapeutic α-emissions. 226Ac emits 158 and 230 keV γ-photons ideal for quantitative SPECT imaging and acts as an in vivo generator of 4 high-energy α-particles. Because of these nuclear decay properties, 226Ac has potential to act as a standalone theranostic isotope. In this proof-of-concept study, we evaluated a preclinical 226Ac-radiopharmaceutical for its theranostic efficacy and present the first 226Ac-targeted α-therapy study. Methods: 226Ac was produced at TRIUMF and labeled with the chelator-peptide bioconjugate crown-TATE. [226Ac]Ac-crown-TATE was selected to target neuroendocrine tumors in male NRG mice bearing AR42J tumor xenografts for SPECT imaging, biodistribution, and therapy studies. A preclinical SPECT/CT scanner acquired quantitative images reconstructed from both the 158 and the 230 keV emissions. Mice in the biodistribution study were euthanized at 1, 3, 5, 24, and 48 h after injection, and internal radiation dosimetry was derived for the tumor and organs of interest to establish appropriate therapeutic activity levels. Mice in the therapy study were administered 125, 250, or 375 kBq treatments and were monitored for tumor size and body condition. Results: We present quantitative SPECT images of the in vivo biodistribution of [226Ac]Ac-crown-TATE, which showed agreement with ex vivo measurements. Biodistribution studies demonstrated high uptake (>30%IA/g at 5 h after injection) and retention in the tumor, with an estimated mean absorbed dose coefficient of 222 mGy/kBq. [226Ac]Ac-crown-TATE treatments significantly extended the median survival from 7 d in the control groups to 16, 24, and 27 d in the 125, 250, and 375 kBq treatment groups, respectively. Survival was prolonged by slowing tumor growth, and no weight loss or toxicities were observed. Conclusion: This study highlights the theranostic potential of 226Ac as a standalone therapeutic isotope in addition to its demonstrated diagnostic capabilities to assess dosimetry in matched 225Ac-radiopharmaceuticals. Future studies will investigate maximum dose and toxicity to further explore the therapeutic potential of 226Ac-radiopharmaceuticals.

From cyclotrons to chromatography and beyond: a guide to the production and purification of theranostic radiometals

Recent clinical success with metal-based radiopharmaceuticals has sparked an interest in the potential of these drugs for personalized medicine. Although often overlooked, the success and global impact of nuclear medicine is contingent upon the purity and availability of medical isotopes, commonly referred to as radiometals. For nuclear medicine to reach its true potential and change patient lives, novel production and purification techniques that increase inventory of radiometals are desperately needed. This tutorial review serves as a resource for those both new and experienced in nuclear medicine by providing a detailed explanation of the foundations for the production and purification of radiometals, stemming from nuclear physics, analytical chemistry, and so many other fields, all in one document. The fundamental science behind targetry, particle accelerators, nuclear reactors, nuclear reactions, and radiochemical separation are presented in the context of the field. Finally, a summary of the latest breakthroughs and a critical discussion of the threats and future potential of the most utilized radiometals is also included. With greater understanding of the fundamentals, fellow scientists will be able to better interpret the literature, identify knowledge gaps or problems and ultimately invent new production and purification pathways to increase the global availability of medical isotopes.

Quantitative SPECT imaging of 155Tb and 161Tb for preclinical theranostic radiopharmaceutical development

BACKGROUND

Element-equivalent matched theranostic pairs facilitate quantitative in vivo imaging to establish pharmacokinetics and dosimetry estimates in the development of preclinical radiopharmaceuticals. Terbium radionuclides have significant potential as matched theranostic pairs for multipurpose applications in nuclear medicine. In particular, 155Tb (t1/2 = 5.32 d) and 161Tb (t1/2 = 6.89 d) have been proposed as a theranostic pair for their respective applications in single photon emission computed tomography (SPECT) imaging and targeted beta therapy. Our study assessed the performance of preclinical quantitative SPECT imaging with 155Tb and 161Tb. A hot rod resolution phantom with rod diameters ranging between 0.85 and 1.70 mm was filled with either 155Tb (21.8 ± 1.7 MBq/mL) or 161Tb (23.6 ± 1.9 MBq/mL) and scanned with the VECTor preclinical SPECT/CT scanner. Image performance was evaluated with two collimators: a high energy ultra high resolution (HEUHR) collimator and an extra ultra high sensitivity (UHS) collimator. SPECT images were reconstructed from photopeaks at 43.0 keV, 86.6 keV, and 105.3 keV for 155Tb and 48.9 keV and 74.6 keV for 161Tb. Quantitative SPECT images of the resolution phantoms were analyzed to report inter-rod contrast, recovery coefficients, and contrast-to-noise metrics.

RESULTS

Quantitative SPECT images of the resolution phantom established that the HEUHR collimator resolved all rods for 155Tb and 161Tb, and the UHS collimator resolved rods ≥ 1.10 mm for 161Tb and ≥ 1.30 mm for 155Tb. The HEUHR collimator maintained better quantitative accuracy than the UHS collimator with recovery coefficients up to 92%. Contrast-to-noise metrics were also superior with the HEUHR collimator.

CONCLUSIONS

Both 155Tb and 161Tb demonstrated potential for applications in preclinical quantitative SPECT imaging. The high-resolution collimator achieves < 0.85 mm resolution and maintains quantitative accuracy in small volumes which is advantageous for assessing sub organ activity distributions in small animals. This imaging method can provide critical quantitative information for assessing and optimizing preclinical Tb-radiopharmaceuticals.

A Technique to Quantify Very Low Activities in Regions of Interest With a Collimatorless Detector

We present a new method to measure sub-microcurie activities of photon-emitting radionuclides in organs and lesions of small animals in vivo. Our technique, named the collimator-less likelihood fit, combines a very high sensitivity collimatorless detector with a Monte Carlo-based likelihood fit in order to estimate the activities in previously segmented regions of interest along with their uncertainties. This is done directly from the photon projections in our collimatorless detector and from the region of interest segmentation provided by an x-ray computed tomography scan. We have extensively validated our approach with 225Ac experimentally in spherical phantoms and mouse phantoms, and also numerically with simulations of a realistic mouse anatomy. Our method yields statistically unbiased results with uncertainties smaller than 20% for activities as low as ~111Bq (3nCi) and for exposures under 30 minutes. We demonstrate that our method yields more robust recovery coefficients when compared to SPECT imaging with a commercial pre-clinical scanner, specially at very low activities. Thus, our technique is complementary to traditional SPECT/CT imaging since it provides a more accurate and precise organ and tumor dosimetry, with a more limited spatial information. Finally, our technique is specially significant in extremely low-activity scenarios when SPECT/CT imaging is simply not viable.

In vivoquantitative SPECT imaging of actinium-226: feasibility and proof-of-concept

Objective.225Ac radiopharmaceuticals have tremendous potential for targeted alpha therapy, however,225Ac (t1/2= 9.9 d) lacks direct gamma emissions forin vivoimaging.226Ac (t1/2= 29.4 h) is a promising element-equivalent matched diagnostic radionuclide for preclinical evaluation of225Ac radiopharmaceuticals.226Ac has two gamma emissions (158 keV and 230 keV) suitable for SPECT imaging. This work is the first feasibility study forin vivoquantitative226Ac SPECT imaging and validation of activity estimation.Approach.226Ac was produced at TRIUMF (Vancouver, Canada) with its Isotope Separator and Accelerator (ISAC) facility. [226Ac]Ac3+was radiolabelled with the bioconjugate crown-TATE developed for therapeutic targeting of neuroendocrine tumours. Mice with AR42J tumour xenografts were injected with either 2 MBq of [226Ac]Ac-crown-TATE or 4 MBq of free [226Ac]Ac3+activity and were scanned at 1, 2.5, 5, and 24 h post injection in a preclinical microSPECT/CT. Quantitative SPECT images were reconstructed from the 158 keV and 230 keV photopeaks with attenuation, background, and scatter corrections. Image-based226Ac activity measurements were assessed from volumes of interest within tumours and organs of interest. Imaging data was compared withex vivobiodistribution measured via gamma counter.Main results. We present, to the best of our knowledge, the first everin vivoquantitative SPECT images of226Ac activity distributions. Time-activity curves derived from SPECT images quantify thein vivobiodistribution of [226Ac]Ac-crown-TATE and free [226Ac]Ac3+activity. Image-based activity measurements in the tumours and organs of interest corresponded well withex vivobiodistribution measurements.Significance. Here in, we established the feasibility ofin vivo226Ac quantitative SPECT imaging for accurate measurement of actinium biodistribution in a preclinical model. This imaging method could facilitate more efficient development of novel actinium labelled compounds by providing accurate quantitativein vivopharmacokinetic information essential for estimating toxicities, dosimetry, and therapeutic potency.

Image-based dosimetry for [225Ac]Ac-PSMA-I&T therapy and the effect of daughter-specific pharmacokinetics

PURPOSE

Although 221Fr and 213Bi have sufficient gamma emission probabilities, quantitative SPECT after [225Ac]Ac-PSMA-I&T therapy remains challenging due to low therapeutic activities. Furthermore, 221Fr and 213Bi may underlie a different pharmacokinetics due to alpha recoil. We conducted a quantitative SPECT study and a urine analysis to investigate the pharmacokinetics of 221Fr and 213Bi and the impact on image-based lesion and kidney dosimetry.

METHODS

Five patients (7.7 ± 0.2 MBq [225Ac]Ac-PSMA-I&T) underwent an abdominal SPECT/CT (1 h) at 24 and 48 h (Siemens Symbia T2, high-energy collimator, 440 keV/218 keV (width 20%), 78 keV (width 50%)). Quantitative SPECT was reconstructed using MAP-EM with attenuation and transmission-dependent scatter corrections and resolution modelling. Time-activity curves for kidneys (CT-based) and lesions (80% isocontour 24 h) were fitted mono-exponentially. Urine samples collected along with each SPECT/CT were measured in a gamma counter until secular equilibrium was reached.

RESULTS

Mean kidney and lesion effective half-lives were as follows: 213Bi, 27 ± 6/38 ± 10 h; 221Fr, 24 ± 6/38 ± 11 h; 78 keV, 23 ± 7/39 ± 13 h. The 213Bi-to-221Fr kidney SUV ratio increased by an average of 9% from 24 to 48 h. Urine analysis revealed an increasing 213Bi-to-225Ac ratio (24 h, 0.98 ± 0.15; 48 h, 1.08 ± 0.09). Mean kidney and lesion absorbed doses were 0.17 ± 0.06 and 0.36 ± 0.1 Sv RBE = 5 /MBq using 221Fr and 213Bi SPECT images, compared to 0.16 ± 0.05/0.18 ± 0.06 and 0.36 ± 0.1/0.38 ± 0.1 Sv RBE = 5 /MBq considering either the 221Fr or 213Bi SPECT.

CONCLUSION

SPECT/CT imaging and urine analysis showed minor differences of up to 10% in the daughter-specific pharmacokinetics. These variances had a minimal impact on the lesion and kidney dosimetry which remained within 8%.

Advances in PSMA Alpha Theragnostics

Alpha theranostics offer an attractive alternative form of therapy, which has best been investigated and documented with 225Ac-PSMA in patients with prostate cancer. Advantages offered by targeted alpha therapy include overcoming radiation resistance, oxygen independence, effecting double-stranded DNA breakages within the tumors with anticipated improved clinical outcomes and an acceptable side effect profile. The previous Seminars article on this topic, published in 2020, had to rely mostly on published case reports and small observational studies. In the last few years, however, several meta-analyses have emerged that evaluate the safety and efficacy of 225Ac-PSMA in prostate cancer patients, followed most recently by a multi-center retrospective study initiated by WARMTH. The findings of these publications, together with the exploration of TAT offered in clinical conditions other than as a last resort, is the focus of this updated overview. Unresolved clinical issues that remain, include the appropriate selection of patients that would benefit most from treatment with 225Ac-PSMA, treatment timing within the disease landscape, optimal dosing schedule, dosimetry, when and how to best use combination therapies and minimization and treatment of side effects, particularly that of xerostomia.

EANM guidance document: dosimetry for first-in-human studies and early phase clinical trials

The numbers of diagnostic and therapeutic nuclear medicine agents under investigation are rapidly increasing. Both novel emitters and novel carrier molecules require careful selection of measurement procedures. This document provides guidance relevant to dosimetry for first-in human and early phase clinical trials of such novel agents. The guideline includes a short introduction to different emitters and carrier molecules, followed by recommendations on the methods for activity measurement, pharmacokinetic analyses, as well as absorbed dose calculations and uncertainty analyses. The optimal use of preclinical information and studies involving diagnostic analogues is discussed. Good practice reporting is emphasised, and relevant dosimetry parameters and method descriptions to be included are listed. Three examples of first-in-human dosimetry studies, both for diagnostic tracers and radionuclide therapies, are given.

Dual-isotope imaging method for Actinium-225 and Bismuth-213 using alpha imaging detector

Recently, 225Ac has received considerable attention for its use in targeted alpha therapy because it has a relatively long half-life and yields four more alpha-particles from the daughter nuclides. The performance evaluation should separately assess the distribution of 225Ac and 213Bi because daughter nuclides, including 213Bi, can cause renal toxicity, which may hinder the widespread use of 225Ac for targeted alpha therapy. In this study, we describe and validate a spectrum decomposition method for dual-isotope imaging of 225Ac and 213Bi using an alpha imaging detector. We implemented an experiment to demonstrate the feasibility of using the alpha imaging detector to obtain distribution images using therapeutic amounts of 225Ac. In addition, we designed and conducted a Monte Carlo simulation under realistic conditions based on the experimental results to evaluate the spectrum decomposition method for dual-isotope imaging. The alpha imaging detector exhibited a detection efficiency of 18.5% and an energy resolution of 13.4% at 5.5 MeV. In the simulation, the distributions of 225Ac and 213Bi were obtained in each region with a relative error of 5%. The results of this study confirmed the feasibility of the dual-isotope imaging method for discriminating alpha-emitters using small amounts of 225Ac.

Gamma radiation effects on AG MP-50 cation exchange resin and sulfonated activated carbon for bismuth-213 separation

Medical 225Ac/213Bi radionuclide generators are designed to provide a local supply of the short-lived 213Bi for cancer treatment. However, radiation-induced damage to the sorbents commonly used in such radionuclide generators remains a major concern. In this study, the effects of gamma radiation on AG MP-50 cation exchange resin and sulfonated activated carbon (SAC) were studied by analyzing the changes in the morphological characteristics, functional groups, and the La3+/Bi3+ sorption performance, with La3+ being a suitable non-radioactive substitute for Ac3+. The surface sulfonic acid groups of AG MP-50 resin suffered from severe radiation-induced degradation, while the particle morphology was changed markedly after being exposed to absorbed doses of approximately 11 MGy. As a result, the sorption performance of irradiated AG MP-50 for La3+ and Bi3+ was significantly decreased with increasing absorbed doses. In contrast, no apparent changes in acquired morphological characteristics were observed for pristine and irradiated SAC based on SEM and XRD characterization. The surface oxygen content (e.g., O-C[double bond, length as m-dash]O) of irradiated SAC increased for an absorbed dose of 11 MGy due to free radical-induced oxidation. The sorption performance of pristine and irradiated SAC materials for La3+ and Bi3+ remained generally the same at pH values of 1 and 2. Furthermore, the applicability of AG MP-50 and SAC in the 225Ac/213Bi generators was illustrated in terms of their radiolytic stability. This study provides further evidence for the practical implementation of both AG MP-50 and SAC in 225Ac/213Bi radionuclide generators.

Radiometals in Imaging and Therapy: Highlighting Two Decades of Research

The present article highlights the important progress made in the last two decades in the fields of molecular imaging and radionuclide therapy. Advancements in radiometal-based positron emission tomography, single photon emission computerized tomography, and radionuclide therapy are illustrated in terms of their production routes and ease of radiolabeling. Applications in clinical diagnostic and radionuclide therapy are considered, including human studies under clinical trials; their current stages of clinical translations and findings are summarized. Because the metalloid astatine is used for imaging and radionuclide therapy, it is included in this review. In regard to radionuclide therapy, both beta-minus (β-) and alpha (α)-emitting radionuclides are discussed by highlighting their production routes, targeted radiopharmaceuticals, and current clinical translation stage.

Coded aperture and Compton imaging for the development of 225 Ac-based radiopharmaceuticals

BACKGROUND

Targeted alpha-particle therapy (TAT) has great promise as a cancer treatment. Arguably the most promising TAT radionuclide that has been proposed is 225 Ac. The development of 225 Ac-based radiopharmaceuticals has been hampered due to the lack of effective means to study the daughter redistribution of these agents in small animals at the preclinical stage.

PURPOSE

The ability to directly image the daughters, namely 221 Fr and 213 Bi, via their gamma-ray emissions would be a boon for preclinical studies. That said, conventional medical imaging modalities, including single photon emission computed tomography (SPECT) based on nonmultiplexed collimation, cannot be employed due to sensitivity limitations.

METHODS

As an alternative, we propose the use of both coded aperture and Compton imaging with the former modality suited to the 218-keV gamma-ray emission of 221 Fr and the latter suited to the 440-keV gamma-ray emission of 213 Bi.

RESULTS

This work includes coded aperture images of 221 Fr and Compton images of 213 Bi in tumor-bearing mice injected with 225 Ac-based radiopharmaceuticals.

CONCLUSIONS

These results are the first demonstration of visualizing and quantifying the 225 Ac daughters in small animals through the application of coded aperture and Compton imaging.

A GATE simulation study for dosimetry in cancer cell and micrometastasis from the 225Ac decay chain

BACKGROUND

Radiopharmaceutical therapy (RPT) with alpha-emitting radionuclides has shown great promise in treating metastatic cancers. The successive emission of four alpha particles in the ²²⁵Ac decay chain leads to highly targeted and effective cancer cell death. Quantifying cellular dosimetry for ²²⁵Ac RPT is essential for predicting cell survival and therapeutic success. However, the leading assumption that all ²²⁵Ac progeny remain localized at their target sites likely overestimates the absorbed dose to cancer cells. To address limitations in existing semi-analytic approaches, this work evaluates S-values for ²²⁵Ac's progeny radionuclides with GATE Monte Carlo simulations.

METHODS

The cellular geometries considered were an individual cell (10 µm diameter with a nucleus of 8 µm diameter) and a cluster of cells (micrometastasis) with radionuclides localized in four subcellular regions: cell membrane, cytoplasm, nucleus, or whole cell. The absorbed dose to the cell nucleus was scored, and self- and cross-dose S-values were derived. We also evaluated the total absorbed dose with various degrees of radiopharmaceutical internalization and retention of the progeny radionuclides ²²¹Fr (t_1/2 = 4.80 m) and ²¹³Bi (t_1/2 = 45.6 m).

RESULTS

For the cumulative ²²⁵Ac decay chain, our self- and cross-dose nuclear S-values were both in good agreement with S-values published by MIRDcell, with per cent differences ranging from - 2.7 to - 8.7% for the various radionuclide source locations. Source location had greater effects on self-dose S-values than the intercellular cross-dose S-values. Cumulative ²²⁵Ac decay chain self-dose S-values increased from 0.167 to 0.364 GyBq^-1 s^-1 with radionuclide internalization from the cell surface into the cell. When progeny migration from the target site was modelled, the cumulative self-dose S-values to the cell nucleus decreased by up to 71% and 21% for ²²¹Fr and ²¹³Bi retention, respectively.

CONCLUSIONS

Our GATE Monte Carlo simulations resulted in cellular S-values in agreement with existing MIRD S-values for the alpha-emitting radionuclides in the ²²⁵Ac decay chain. To obtain accurate absorbed dose estimates in ²²⁵Ac studies, accurate understanding of daughter migration is critical for optimized injected activities. Future work will investigate other novel preclinical alpha-emitting radionuclides to evaluate therapeutic potency and explore realistic cellular geometries corresponding to targeted cancer cell lines.

Biodistribution and dosimetry for combined [177Lu]Lu-PSMA-I&T/[225Ac]Ac-PSMA-I&T therapy using multi-isotope quantitative SPECT imaging

PURPOSE

Quantitative SPECT for patient-specific dosimetry is a valuable tool in the scope of radionuclide therapy, although its clinical application for ²²⁵Ac-based treatments may be limited due to low therapeutic activities. Therefore, the aim of this study was to demonstrate the feasibility of clinical quantitative low-count SPECT imaging during [¹⁷⁷Lu]Lu-PSMA-I&T/[²²⁵Ac]Ac-PSMA-I&T treatment.

METHODS

Eight prostate cancer patients (1000 MBq/8 MBq [¹⁷⁷Lu]Lu-PSMA-I&T/[²²⁵Ac]Ac-PSMA-I&T) received a single-bed quantitative ¹⁷⁷Lu/²²⁵Ac SPECT/CT acquisition (1 h) at 24 h post treatment (high-energy collimator, 16 projections p. head à 3.5 min, 128 × 128 pixel). The gamma peak at 440 keV (width: 10%) of the progeny ²¹³Bi was imaged along with the peak at 208 keV (width: 15%) of ¹⁷⁷Lu. Quantification included CT-based attenuation and window-based scatter correction plus resolution modelling. Gaussian post-filtering with a full-width-half-maximum of 30 mm and 40-45 mm was employed to match the signal-to-noise ratio of ²²⁵Ac and ¹⁷⁷Lu, respectively.

RESULTS

Kidney (r = 0.96, p < 0.01) and lesion (r = 0.94, p < 0.01) SUV for [¹⁷⁷Lu]Lu-PSMA-I&T and [²²⁵Ac]Ac-PSMA-I&T showed a strong and significant correlation. Kidney SUV were significantly higher (p < 0.01) for [²²⁵Ac]Ac-PSMA-I&T (2.5 ± 0.8 vs. 2.1 ± 0.9), while for [¹⁷⁷Lu]Lu-PSMA-I&T lesion SUV were significantly higher (p = 0.03; 1.8 ± 1.1 vs. 2.1 ± 1.5). For absorbed dose estimates, significant differences regarding the kidneys remained, while no significant differences for lesion dosimetry were found.

CONCLUSION

Quantitative low-count SPECT imaging of the peak at 440 keV during [²²⁵Ac]Ac-PSMA-I&T therapy is feasible. Multi-isotope imaging for [¹⁷⁷Lu]Lu-PSMA-I&T/[²²⁵Ac]Ac-PSMA-I&T therapy indicates accumulation of free ²¹³Bi in the kidneys.

225Ac-Labeled Somatostatin Analogs in the Management of Neuroendocrine Tumors: From Radiochemistry to Clinic

The widespread use of peptide receptor radionuclide therapy (PRRT) represents a major therapeutic breakthrough in nuclear medicine, particularly since the introduction of 177Lu-radiolabeled somatostatin analogs. These radiopharmaceuticals have especially improved progression-free survival and quality of life in patients with inoperable metastatic gastroenteropancreatic neuroendocrine tumors expressing somatostatin receptors. In the case of aggressive or resistant disease, the use of somatostatin derivatives radiolabeled with an alpha-emitter could provide a promising alternative. Among the currently available alpha-emitting radioelements, actinium-225 has emerged as the most suitable candidate, especially regarding its physical and radiochemical properties. Nevertheless, preclinical and clinical studies on these radiopharmaceuticals are still few and heterogeneous, despite the growing momentum for their future use on a larger scale. In this context, this report provides a comprehensive and extensive overview of the development of 225Ac-labeled somatostatin analogs; particular emphasis is placed on the challenges associated with the production of 225Ac, its physical and radiochemical properties, as well as the place of 225Ac-DOTATOC and 225Ac-DOTATATE in the management of patients with advanced metastatic neuroendocrine tumors.

Development of radiopharmaceuticals for targeted alpha therapy: Where do we stand?

Targeted alpha therapy is an oncological treatment, where cytotoxic doses of alpha radiation are locally delivered to tumor cells, while the surrounding healthy tissue is minimally affected. This therapeutic strategy relies on radiopharmaceuticals made of medically relevant radionuclides chelated by ligands, and conjugated to targeting vectors, which promote the drug accumulation in tumor sites. This review discusses the state-of-the-art in the development of radiopharmaceuticals for targeted alpha therapy, breaking down their key structural components, such as radioisotope, targeting vector, and delivery formulation, and analyzing their pros and cons. Moreover, we discuss current drawbacks that are holding back targeted alpha therapy in the clinic, and identify ongoing strategies in field to overcome those issues, including radioisotope encapsulation in nanoformulations to prevent the release of the daughters. Lastly, we critically discuss potential opportunities the field holds, which may contribute to targeted alpha therapy becoming a gold standard treatment in oncology in the future.

SPECT imaging of 226Ac as a theranostic isotope for 225Ac radiopharmaceutical development

Objective. The development of alpha-emitting radiopharmaceuticals using 225Ac (t ½ = 9.92 d) benefits from the quantitative determination of its biodistribution and is not always easy to directly measure. An element-equivalent matched-pair would allow for more accurate biodistribution and dosimetry estimates. 226Ac (t ½ = 29.4 h) is a candidate isotope for in vivo imaging of preclinical 225Ac radiopharmaceuticals, given its 158 keV and 230 keV gamma emissions making it suitable for quantitative SPECT imaging. This work aimed to conduct a performance assessment for 226Ac imaging and presents the first-ever 226Ac SPECT images. Approach. To establish imaging performance with regards to contrast and noise, image quality phantoms were scanned using a microSPECT/CT system. To assess the resolution, a hot rod phantom with cylindrical rods with diameters between 0.85 and 1.70 mm was additionally imaged. Two collimators were evaluated: a high-energy ultra-high resolution (HEUHR) collimator and an extra ultra-high sensitivity (UHS) collimator. Images were reconstructed from two distinct photopeaks at 158 keV and 230 keV. Main results. The HEUHR SPECT image measurements of high activity concentration regions were consistent with values determined independently via gamma spectroscopy, within 9% error. The lower energy 158 keV photopeak images demonstrated slightly better contrast recovery. In the resolution phantom, the UHS collimator only resolved rods ≥1.30 mm and ≥1.50 mm for the 158 keV and 230 keV photopeaks, respectively, while the HEUHR collimator clearly resolved all rods, with resolution <0.85 mm. Significance. Overall, the feasibility of preclinical imaging with 226Ac was demonstrated with quantitative SPECT imaging achieved for both its 158 keV and 230 keV photopeaks. The HEUHR collimator is recommended for imaging 226Ac activity distributions in small animals due to its resolution <0.85 mm. Future work will explore the feasibility of using 226Ac both as an element-equivalent isotope for 225Ac radiopharmaceuticals, or as a standalone therapeutic isotope.

Dosimetry in targeted alpha therapy. A systematic review: current findings and what is needed

Objective. A systematic review of dosimetry in Targeted Alpha Therapy (TAT) has been performed, identifying the common issues. Approach. The systematic review was performed in accordance with the PRISMA guidelines, and the literature was searched using the Scopus and PubMed databases. Main results. From the systematic review, three key points should be considered when performing dosimetry in TAT. (1) Biodistribution/Biokinetics: the accuracy of the biodistribution data is a limit to accurate dosimetry in TAT. The biodistribution of alpha-emitting radionuclides throughout the body is difficult to image directly, with surrogate radionuclide imaging, blood/faecal sampling, and animal studies able to provide information. (2) Daughter radionuclides: the decay energy of the alpha-emissions is sufficient to break the bond to the targeting vector, resulting in a release of free daughter radionuclides in the body. Accounting for daughter radionuclide migration is essential. (3) Small-scale dosimetry and microdosimetry: due to the short path length and heterogeneous distribution of alpha-emitters at the target site, small-scale/microdosimetry are important to account for the non-uniform dose distribution in a target region, organ or cell and for assessing the biological effect of alpha-particle radiation. Significance. TAT is a form of cancer treatment capable of delivering a highly localised dose to the tumour environment while sparing the surrounding healthy tissue. Dosimetry is an important part of treatment planning and follow up. Being able to accurately predict the radiation dose to the target region and healthy organs could guide the optimal prescribed activity. Detailed dosimetry models accounting for the three points mentioned above will help give confidence in and guide the clinical application of alpha-emitting radionuclides in targeted cancer therapy.

Preliminary evaluation of alpha-emitting radioembolization in animal models of hepatocellular carcinoma

Hepatocellular carcinoma is the most common primary liver cancer and the fifth most frequently diagnosed cancer worldwide. Most patients with advanced disease are offered non-surgical palliative treatment options. This work explores the first alpha-particle emitting radioembolization for the treatment and monitoring of hepatic tumors. Furthermore, this works demonstrates the first in vivo simultaneous multiple-radionuclide SPECT-images of the complex decay chain of an [225Ac]Ac-labeled agent using a clinical SPECT system to monitor the temporal distribution. A DOTA chelator was modified with a lipophilic moiety and radiolabeled with the α-particle emitter Actinium-225. The resulting agent, [225Ac]Ac-DOTA-TDA, was emulsified in ethiodized oil and evaluated in vivo in mouse model and the VX2 rabbit technical model of liver cancer. SPECT imaging was performed to monitor distribution of the TAT agent and the free daughters. The [225Ac]Ac-DOTA-TDA emulsion was shown to retain within the HEP2G tumors and VX2 tumor, with minimal uptake within normal tissue. In the mouse model, significant improvements in overall survival were observed. SPECT-imaging was able to distinguish between the Actinium-225 agent (Francium-221) and the loss of the longer lived daughter, Bismuth-213. An α-particle emitting TARE agent is capable of targeting liver tumors with minimal accumulation in normal tissue, providing a potential therapeutic agent for the treatment of hepatocellular carcinoma as well as a variety of hepatic tumors. In addition, SPECT-imaging presented here supports the further development of imaging methodology and protocols that can be incorporated into the clinic to monitor Actinium-225-labeled agents.

Implications of physics, chemistry and biology for dosimetry calculations using theranostic pairs

Theranostics is an emerging paradigm that combines imaging and therapy in order to personalize patient treatment. In nuclear medicine, this is achieved by using radiopharmaceuticals that target identical molecular targets for both imaging (using emitted gamma rays) and radiopharmaceutical therapy (using emitted beta, alpha or Auger-electron particles) for the treatment of various diseases, such as cancer. If the therapeutic radiopharmaceutical cannot be imaged quantitatively, a “theranostic pair” imaging surrogate can be used to predict the absorbed radiation doses from the therapeutic radiopharmaceutical. However, theranostic dosimetry assumes that the pharmacokinetics and biodistributions of both radiopharmaceuticals in the pair are identical or very similar, an assumption that still requires further validation for many theranostic pairs. In this review, we consider both same-element and different-element theranostic pairs and attempt to determine if factors exist which may cause inaccurate dose extrapolations in theranostic dosimetry, either intrinsic (e.g. chemical differences) or extrinsic (e.g. injecting different amounts of each radiopharmaceutical) to the radiopharmaceuticals. We discuss the basis behind theranostic dosimetry and present common theranostic pairs and their therapeutic applications in oncology. We investigate general factors that could create alterations in the behavior of the radiopharmaceuticals or the quantitative accuracy of imaging them. Finally, we attempt to determine if there is evidence showing some specific pairs as suitable for theranostic dosimetry. We show that there are a variety of intrinsic and extrinsic factors which can significantly alter the behavior among pairs of radiopharmaceuticals, even if they belong to the same chemical element. More research is needed to determine the impact of these factors on theranostic dosimetry estimates and on patient outcomes, and how to correctly account for them.

A suitable time point for quantifying the radiochemical purity of 225Ac-labeled radiopharmaceuticals

BACKGROUND

As 225Ac-labeled radiopharmaceuticals continue to show promise as targeted alpha therapeutics, there is a growing need to standardize quality control (QC) testing procedures. The determination of radiochemical purity (RCP) is an essential QC test. A significant obstacle to RCP testing is the disruption of the secular equilibrium between actinium-225 and its daughter radionuclides during labeling and QC testing. In order to accelerate translation of actinium-225 targeted alpha therapy, we aimed to determine the earliest time point at which the RCP of an 225Ac-labeled radiopharmaceutical can be accurately quantified.

RESULTS

Six ligands were conjugated to macrocyclic metal chelators and labeled with actinium-225 under conditions designed to generate diverse incorporation yields. RCP was determined by radio thin layer chromatography (radioTLC) followed by exposure of the TLC plate on a phosphor screen either 0.5, 2, 3.5, 5, 6.5, or 26 h after the plate was developed. The dataset was used to create models for predicting the true RCP for any pre-equilibrium measurement taken at an early time point. The 585 TLC measurements span RCP values of 1.8-99.5%. The statistical model created from these data predicted an independent data set with high accuracy. Predictions made at 0.5 h are more uncertain than predictions made at later time points. This is primarily due to the decay of bismuth-213. A measurement of RCP > 90% at 2 h predicts a true RCP > 97% and guarantees that RCP will exceed 90% after secular equilibrium is reached. These findings were independently validated using NaI(Tl) scintillation counting and high resolution gamma spectroscopy on a smaller set of samples with 10% ≤ RCP ≤ 100%.

CONCLUSIONS

RCP of 225Ac-labeled radiopharmaceuticals can be quantified with acceptable accuracy at least 2 h after radioTLC using various methods of quantifying particle emissions. This time point best balances the need to accurately quantify RCP with the need to safely release the batch as quickly as possible.

Practical considerations for quantitative clinical SPECT/CT imaging of alpha particle emitting radioisotopes

Rationale: Alpha particle emitting radiopharmaceuticals are generating considerable interest for the treatment of disseminated metastatic disease. Molecular imaging of the distribution of these agents is critical to safely and effectively maximize the clinical potential of this emerging drug class. The present studies aim to investigate the feasibility and limitations of quantitative SPECT for 223Ra, 225Ac and 227Th. Methods: Three state-of-the-art SPECT/CT systems were investigated: the GE Discovery NM/CT 670, the GE Optima NM/CT 640, and the Siemens Symbia T6. A series of phantoms, including the NEMA IEC Body phantom, were used to compare and calibrate each camera. Additionally, anthropomorphic physical tumor and vertebrae phantoms were developed and imaged to evaluate the quantitative imaging protocol. Results: This work describes and validates a methodology to calibrate each clinical system. The efficiency of each gamma camera was analyzed and compared. Using the calibration factors obtained with the NEMA phantom, we were able to quantify the activity in 3D-printed tissue phantoms with an error of 2.1%, 3.5% and 11.8% for 223Ra, 225Ac, and 227Th, respectively. Conclusion: The present study validates that quantitative SPECT/CT imaging of 223Ra, 225Ac, and 227Th is achievable but that careful considerations for camera configuration are required. These results will aid in future implementation of SPECT-based patient studies and will help to identify the limiting factors for accurate image-based quantification with alpha particle emitting radionuclides.

Recent Advances in Radiometals for Combined Imaging and Therapy in Cancer

Nuclear medicine is defined as the use of radionuclides for diagnostic and therapeutic applications. The imaging modalities positron emission tomography (PET) and single-photon emission computed tomography (SPECT) are based on γ-emissions of specific energies. The therapeutic technologies are based on β^- -particle-, α-particle-, and Auger electron emitters. In oncology, PET and SPECT are used to detect cancer lesions, to determine dosimetry, and to monitor therapy effectiveness. In contrast, radiotherapy is designed to irreparably damage tumor cells in order to eradicate or control the disease's progression. Radiometals are being explored for the development of diagnostic and therapeutic radiopharmaceuticals. Strategies that combine both modalities (diagnostic and therapeutic), referred to as theranostics, are promising candidates for clinical applications. This review provides an overview of the basic concepts behind therapeutic and diagnostic radiopharmaceuticals and their significance in contemporary oncology. Select radiometals that significantly impact current and upcoming cancer treatment strategies are grouped as clinically suitable theranostics pairs. The most important physical and chemical properties are discussed. Standard production methods and current radionuclide availability are provided to indicate whether a cost-efficient use in a clinical routine is feasible. Recent preclinical and clinical developments and outline perspectives for the radiometals are highlighted in each section.

Lipophilicity Determines Routes of Uptake and Clearance, and Toxicity of an Alpha-Particle-Emitting Peptide Receptor Radiotherapy

Lipophilicity is explored in the biodistribution (BD), pharmacokinetics (PK), radiation dosimetry (RD), and toxicity of an internally administered targeted alpha-particle therapy (TAT) under development for the treatment of metastatic melanoma. The TAT conjugate is comprised of the chelator DOTA (1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetate), conjugated to melanocortin receptor 1 specific peptidic ligand (MC1RL) using a linker moiety and chelation of the ²²⁵Ac radiometal. A set of conjugates were prepared with a range of lipophilicities (log D _7.4 values) by varying the chemical properties of the linker. Reported are the observations that higher log D _7.4 values are associated with decreased kidney uptake, decreased absorbed radiation dose, and decreased kidney toxicity of the TAT, and the inverse is observed for lower log D _7.4 values. Animals administered TATs with lower lipophilicities exhibited acute nephropathy and death, whereas animals administered the highest activity TATs with higher lipophilicities lived for the duration of the 7 month study and exhibited chronic progressive nephropathy. Changes in TAT lipophilicity were not associated with changes in liver uptake, dose, or toxicity. Significant observations include that lipophilicity correlates with kidney BD, the kidney-to-liver BD ratio, and weight loss and that blood urea nitrogen (BUN) levels correlated with kidney uptake. Furthermore, BUN was identified as having higher sensitivity and specificity of detection of kidney pathology, and the liver enzyme alkaline phosphatase (ALKP) had high sensitivity and specificity for detection of liver damage associated with the TAT. These findings suggest that tuning radiopharmaceutical lipophilicity can effectively modulate the level of kidney uptake to reduce morbidity and improve both safety and efficacy.

Positron range-free and multi-isotope tomography of positron emitters

Despite improvements in small animal PET instruments, many tracers cannot be imaged at sufficiently high resolutions due to positron range, while multi-tracer PET is hampered by the fact that all annihilation photons have equal energies. Here we realize multi-isotope and sub-mm resolution PET of isotopes with several mm positron range by utilizing prompt gamma photons that are commonly neglected. A PET-SPECT-CT scanner (VECTor/CT, MILabs, The Netherlands) equipped with a high-energy cluster-pinhole collimator was used to image ¹²⁴I and a mix of ¹²⁴I and ¹⁸F in phantoms and mice. In addition to positrons (mean range 3.4 mm) ¹²⁴I emits large amounts of 603 keV prompt gammas that-aided by excellent energy discrimination of NaI-were selected to reconstruct ¹²⁴I images that are unaffected by positron range. Photons detected in the 511 keV window were used to reconstruct ¹⁸F images. Images were reconstructed iteratively using an energy dependent matrix for each isotope. Correction of ¹⁸F images for contamination with ¹²⁴I annihilation photons was performed by Monte Carlo based range modelling and scaling of the ¹²⁴I prompt gamma image before subtracting it from the ¹⁸F image. Additionally, prompt gamma imaging was tested for ⁸⁹Zr that emits very high-energy prompts (909 keV). In Derenzo resolution phantoms 0.75 mm rods were clearly discernable for ¹²⁴I, ⁸⁹Zr and for simultaneously acquired ¹²⁴I and ¹⁸F imaging. Image quantification in phantoms with reservoirs filled with both ¹²⁴I and ¹⁸F showed excellent separation of isotopes and high quantitative accuracy. Mouse imaging showed uptake of ¹²⁴I in tiny thyroid parts and simultaneously injected ¹⁸F-NaF in bone structures. The ability to obtain PET images at sub-mm resolution both for isotopes with several mm positron range and for multi-isotope PET adds to many other unique capabilities of VECTor's clustered pinhole imaging, including simultaneous sub-mm PET-SPECT and theranostic high energy SPECT.

Theranostics: The Role of Quantitative Nuclear Medicine Imaging

Theranostics is a precision medicine discipline that integrates diagnostic nuclear medicine imaging with radionuclide therapy in a manner that provides both a tumor phenotype and personalized therapy to patients with cancer using radiopharmaceuticals aimed at the same target-specific biological pathway or receptor. The aim of quantitative nuclear medicine imaging is to plan the alpha or beta-emitting therapy based on an accurate 3-dimensional representation of the in-vivo distribution of radioactivity concentration within the tumor and normal organs/tissues in a noninvasive manner. In general, imaging may be either based on positron emission tomography (PET) or single photon emission computed tomography (SPECT) invariably in combination with X-ray CT (PET/CT; SPECT/CT) or, to a much lesser extent, MRI. PET and SPECT differ in terms of the radionuclides and physical processes that give rise to the emission of high energy photons, as well as the sets of technologies involved in their detection. Using a variety of standardized quantitative parameters, system calibration, patient preparation, imaging acquisition and reconstruction protocols, and image analysis protocols, an accurate quantification of the tracer distribution can be obtained, which helps prescribe the therapeutic dose for each patient.

Targeted alpha therapy: a critical review of translational dosimetry research with emphasis on actinium-225

This review provides a general overview of the current achievements and challenges in translational dosimetry for targeted alpha therapy (TAT). The concept of targeted radionuclide therapy (TRNT) is described with an overview of its clinical applicability and the added value of TAT is discussed. For TAT, we focused on actinium-225 (225Ac) as an example for alpha particle emitting radionuclides and their features, such as limited range within tissue and high linear energy transfer, which make alpha particle emissions more effective in targeted killing of tumour cells compared to beta radiation. Starting with the state-of-the-art dosimetry for TRNT and TAT, we then describe the challenges that still need to be met in order to move to a personalized dosimetry approach for TAT. Specifically for 225Ac, we discuss the recoiled daughter effect which may provoke significant damage to healthy tissue or organs and should be considered. Next, a broad overview is given of the pre-clinical research on 225Ac-TAT with an extensive description of tools which are only available in a pre-clinical setting and their added value. In addition, we review the preclinical biodistribution and dosimetry studies that have been performed on TAT-agents and more specifically of 225Ac and its multiple progeny, and describe their potential role to better characterize the pharmacokinetic (PK) profile of TAT-agents and to optimize the use of theranostic approaches for dosimetry. Finally, we discuss the support pre-clinical studies may provide in understanding dose-effect relationships, linking radiation dose quantities to biological endpoints and even moving away from macro- to microdosimetry. As such, the translation of pre-clinical findings may provide valuable information and new approaches for improved clinical dosimetry, thus paving the way to personalized TAT.

Medical isotope collection from ISAC targets

The ISAC facility (Isotope Separation and Acceleration) at TRIUMF has recently started to provide isotopes for pre-clinical nuclear medicine studies. By irradiating ISOL (Isotope Separation OnLine) targets with a 480 MeV proton beam from the TRIUMF H- cyclotron, the facility can deliver a large variety of radioactive isotope beams (RIB) for research in the fields of nuclear astrophysics, nuclear structure and material science with half-lives down to a few milliseconds via an electrostatic beamline network. For the collection of medical isotopes, typically with half-lives in the range of hours or days, we have developed a compact apparatus for the implantation of mass-separated RIB on a target disc at energies between 20-55 keV. In this paper, we also discuss two different retrieval methods of the implanted activity from the implantation target: by chemical etching of the target surface and by recoil collection of implanted alpha emitters.

Quantitative Imaging of Alpha-Emitting Therapeutic Radiopharmaceuticals

Targeted alpha therapy (TAT) is an active area of drug development as a highly specific and highly potent therapeutic modality that can be applied to many types of late-stage cancers. In order to properly evaluate its safety and efficacy, understanding biokinetics of alpha-emitting radiopharmaceuticals is essential. Quantitative imaging of alpha-emitting radiopharmaceuticals is often possible via imaging of gammas and positrons produced during complex decay chains of these radionuclides. Analysis of the complex decay chains for alpha-emitting radionuclides (Tb-149, At-211, Bi-212 (decayed from Pb-212), Bi-213, Ra-223, Ac-225, and Th-227) with relevance to imageable signals is attempted in this mini-review article. Gamma camera imaging, single-photon emission computed tomography, positron emission tomography, bremsstrahlung radiation imaging, Cerenkov luminescence imaging, and Compton cameras are briefly discussed as modalities for imaging alpha-emitting radiopharmaceuticals.

Melanocortin 1 Receptor-Targeted α-Particle Therapy for Metastatic Uveal Melanoma

New effective therapies are greatly needed for metastatic uveal melanoma, which has a very poor prognosis with a median survival of less than 1 y. The melanocortin 1 receptor (MC1R) is expressed in 94% of uveal melanoma metastases, and a MC1R-specific ligand (MC1RL) with high affinity and selectivity for MC1R was previously developed. Methods: The ²²⁵Ac-DOTA-MC1RL conjugate was synthesized in high radiochemical yield and purity and was tested in vitro for biostability and for MC1R-specific cytotoxicity in uveal melanoma cells, and the lanthanum-DOTA-MC1RL analog was tested for binding affinity. Non-tumor-bearing BALB/c mice were tested for maximum tolerated dose and biodistribution. Severe combined immunodeficient mice bearing uveal melanoma tumors or engineered MC1R-positive and -negative tumors were studied for biodistribution and efficacy. Radiation dosimetry was calculated using mouse biodistribution data and blood clearance kinetics from Sprague-Dawley rat data. Results: High biostability, MC1R-specific cytotoxicity, and high binding affinity were observed. Limiting toxicities were not observed at even the highest administered activities. Pharmacokinetics and biodistribution studies revealed rapid blood clearance (<15 min), renal and hepatobillary excretion, MC1R-specific tumor uptake, and minimal retention in other normal tissues. Radiation dosimetry calculations determined pharmacokinetics parameters and absorbed α-emission dosages from ²²⁵Ac and its daughters. Efficacy studies demonstrated significantly prolonged survival and decreased metastasis burden after a single administration of ²²⁵Ac-DOTA-MC1RL in treated mice relative to controls. Conclusion: These results suggest significant potential for the clinical translation of ²²⁵Ac-DOTA-MC1RL as a novel therapy for metastatic uveal melanoma.

Development of 225Ac Radiopharmaceuticals: TRIUMF Perspectives and Experiences

Background:

The development of radiopharmaceuticals containing 225Ac for targeted alpha therapy is an active area of academic and commercial research worldwide.

Objectives:

Despite promising results from recent clinical trials, 225Ac-radiopharmaceutical development still faces significant challenges that must be overcome to realize the widespread clinical use of 225Ac. Some of these challenges include the limited availability of the isotope, the challenging chemistry required to isolate 225Ac from any co-produced isotopes, and the need for stable targeting systems with high radio-labeling yields.

Results:

Here we provide a review of available literature pertaining to these challenges in the 225Ac-radiopharmaceutical field and also provide insight into how performed and planned efforts at TRIUMF - Canada’s particle accelerator centre - aim to address these issues

Radioactive Main Group and Rare Earth Metals for Imaging and Therapy

Radiometals possess an exceptional breadth of decay properties and have been applied to medicine with great success for several decades. The majority of current clinical use involves diagnostic procedures, which use either positron-emission tomography (PET) or single-photon imaging to detect anatomic abnormalities that are difficult to visualize using conventional imaging techniques (e.g., MRI and X-ray). The potential of therapeutic radiometals has more recently been realized and relies on ionizing radiation to induce irreversible DNA damage, resulting in cell death. In both cases, radiopharmaceutical development has been largely geared toward the field of oncology; thus, selective tumor targeting is often essential for efficacious drug use. To this end, the rational design of four-component radiopharmaceuticals has become popularized. This Review introduces fundamental concepts of drug design and applications, with particular emphasis on bifunctional chelators (BFCs), which ensure secure consolidation of the radiometal and targeting vector and are integral for optimal drug performance. Also presented are detailed accounts of production, chelation chemistry, and biological use of selected main group and rare earth radiometals.

Progress in Targeted Alpha-Particle Therapy. What We Learned about Recoils Release from In Vivo Generators

This review summarizes recent progress and developments as well as the most important pitfalls in targeted alpha-particle therapy, covering single alpha-particle emitters as well as in vivo alpha-particle generators. It discusses the production of radionuclides like ²¹¹At, ²²³Ra, ²²⁵Ac/²¹³Bi, labelling and delivery employing various targeting vectors (small molecules, chelators for alpha-emitting nuclides and their biomolecular targets as well as nanocarriers), general radiopharmaceutical issues, preclinical studies, and clinical trials including the possibilities of therapy prognosis and follow-up imaging. Special attention is given to the nuclear recoil effect and its impacts on the possible use of alpha emitters for cancer treatment, proper dose estimation, and labelling chemistry. The most recent and important achievements in the development of alpha emitters carrying vectors for preclinical and clinical use are highlighted along with an outlook for future developments.