Promising Scandium Radionuclides for Nuclear Medicine: A Review on the Production and Chemistry up to In Vivo Proofs of Concept

Production and purification of 43Sc and 47Sc from enriched [46Ti]TiO2 and [50Ti]TiO2 targets

The radioscandium isotopes, 43Sc and 47Sc, compose a promising elementally matched theranostic pair that can be used for the development of imaging and therapeutic radiopharmaceuticals with identical structures. This study aimed to investigate the production of high radionuclidic purity 43Sc from enriched [46Ti]TiO2 targets and 47Sc from enriched [50Ti]TiO2 targets and establish a target recycling technique. Enriched [46Ti]TiO2 targets were irradiated with 18 MeV protons, and enriched [50Ti]TiO2 targets were bombarded with 24 MeV protons. 43Sc and 47Sc were purified using ion chromatography attaining recovery yields of 91.7 ± 7.4% and 89.9 ± 3.9%, respectively. The average radionuclidic purity for 43Sc was 98.8 ± 0.3% and for 47Sc 91.5 ± 0.6%, while the average recovery of enriched titanium target material was 96 ± 4.0%. The highest apparent molar activity for [43Sc]Sc-DOTA was 23.2 GBq/µmol and 3.39 GBq/µmol for [47Sc]Sc-DOTA. This work demonstrates the feasibility of using enriched recycled [46Ti]TiO2 and [50Ti]TiO2 targets to produce high purity 43Sc and 47Sc as an elementally matched theranostic isotope pair.

Scandium-44: Diagnostic Feasibility in Tumor-Related Angiogenesis

Angiogenesis-related cell-surface molecules, including integrins, aminopeptidase N, vascular endothelial growth factor, and gastrin-releasing peptide receptor (GRPR), play a crucial role in tumour formation. Radiolabelled imaging probes targeting angiogenic biomarkers serve as valuable vectors in tumour identification. Nowadays, there is a growing interest in novel radionuclides other than gallium-68 (⁶⁸Ga) or copper-64 (⁶⁴Cu) to establish selective radiotracers for the imaging of tumour-associated neo-angiogenesis. Given its ideal decay characteristics (E_β⁺_average: 632 KeV) and a half-life (T_1/2 = 3.97 h) that is well matched to the pharmacokinetic profile of small molecules targeting angiogenesis, scandium-44 (⁴⁴Sc) has gained meaningful attention as a promising radiometal for positron emission tomography (PET) imaging. More recently, intensive research has been centered around the investigation of ⁴⁴Sc-labelled angiogenesis-directed radiopharmaceuticals. Previous studies dealt with the evaluation of ⁴⁴Sc-appended a_vb₃ integrin-affine Arg-Gly-Asp (RGD) tripeptides, GRPR-selective aminobenzoyl-bombesin analogue (AMBA), and hypoxia-associated nitroimidazole derivatives in the identification of various cancers using experimental tumour models. Given the tumour-related hypoxia- and angiogenesis-targeting capability of these PET probes, ⁴⁴Sc seems to be a strong competitor of the currently used positron emitters in radiotracer development. In this review, we summarize the preliminary preclinical achievements with ⁴⁴Sc-labelled angiogenesis-specific molecular probes.

Development of purification of no-carrier-added 47Sc of theranostic interest: selective separation study from the natTi(n,p) process

Scandium-47 is one of the most promising medical radioisotopes, and its production and trace separation make it an attractive candidate for theranostic application. In this study, the production of no-carrier-added (NCA) 47Sc through the natTi(n,p) reaction and subsequent purification using liquid–liquid extraction was done for the theranostic application. The comparative separation of NCA 47Sc after the dissolution of an activated Ti target using Di-2-Ethylhexyl Phosphoric Acid (HDEHP) in kerosene was evaluated. The extraction process was optimized in terms of the concentration of extractant, extraction time, pH, and reaction temperature to achieve the maximum possible separation. HDEHP is efficient and promising for rapid extraction and separation of NCA 47Sc from Ti ions at low acidity (pH 0.85) with high extraction percent (>99%), contaminated with 22.3% of Ti ions after 5 min of extraction time. Different stripping reagents were used to separate loaded 47Sc and Ti ions. Firstly, 5 M HCl was enough for stripping the loaded Ti ions. Then the loaded 47Sc was separated with a purity of 100% using 0.05 M NaOH. The obtained results find the HDEHP a promising extractant for efficient separation of 47Sc from irradiated Ti target for preparing the 47Sc radiopharmaceuticals for theranostics applications.

AAZTA-Derived Chelators for the Design of Innovative Radiopharmaceuticals with Theranostic Applications

With the development of 68Ga and 177Lu radiochemistry, theranostic approaches in modern nuclear medicine enabling patient-centered personalized medicine applications have been growing in the last decade. In conjunction with the search for new relevant molecular targets, the design of innovative chelating agents to easily form stable complexes with various radiometals for theranostic applications has gained evident momentum. Initially conceived for magnetic resonance imaging applications, the chelating agent AAZTA features a mesocyclic seven-membered diazepane ring, conferring some of the properties of both acyclic and macrocyclic chelating agents. Described in the early 2000s, AAZTA and its derivatives exhibited interesting properties once complexed with metals and radiometals, combining a fast kinetic of formation with a slow kinetic of dissociation. Importantly, the extremely short coordination reaction times allowed by AAZTA derivatives were particularly suitable for short half-life radioelements (i.e., 68Ga). In view of these particular characteristics, the scope of this review is to provide a survey on the design, synthesis, and applications in the nuclear medicine/radiopharmacy field of AAZTA-derived chelators.

Radioactive nuclei for β + γ PET and theranostics: selected candidates

Positron emission tomography (PET) is an established medical diagnostic imaging method. Continuous improvements are aimed at refining image reconstruction, reducing the amount of radioactive tracer and combining with targeted therapy. Time-of-flight (TOF)-PET provides the localization of the tracer through improved time resolution, nuclear physics may contribute to this goal via selection of radioactive nuclei emitting additional γ-rays. This additional radiation, when properly detected, localizes the decay of the tracer at the line of response (LoR) determined by two detected 511 keV quanta. Selected candidates are presented. Some are particularly interesting, as they are strong candidates for theranostic applications.

New Radionuclides and Technological Advances in SPECT and PET Scanners

Simple Summary

Advances in nuclear medicine are made by technological and radionuclide improvements. Throughout nuclear medicine’s history, these advances were often intertwined and complementary based on different clinical questions, availability and need. This paper covers some of these developments in radionuclides and instrumentation.

Abstract

Developments throughout the history of nuclear medicine have involved improvements in both instrumentation and radionuclides, which have been intertwined. Instrumentation developments always occurred during the search to improving devices’ sensitivity and included advances in detector technology (with the introduction of cadmium zinc telluride and digital Positron Emission Tomography—PET-devices with silicon photomultipliers), design (total body PET) and configuration (ring-shaped, Single-Photon Emission Computed Tomography (SPECT), Compton camera). In the field of radionuclide development, we observed the continual changing of clinically used radionuclides, which is sometimes influenced by instrumentation technology but also driven by availability, patient safety and clinical questions. Some areas, such as tumour imaging, have faced challenges when changing radionuclides based on availability, when this produced undesirable clinical findings with the introduction of unclear focal uptakes and unspecific uptakes. On the other end of spectrum, further developments of PET technology have seen a resurgence in its use in nuclear cardiology, with rubidium-82 from strontium-82/rubidium-82 generators being the radionuclide of choice, moving away from SPECT nuclides thallium-201 and technetium-99m. These continuing improvements in both instrumentation and radionuclide development have helped the growth of nuclear medicine and its importance in the ever-evolving range of patient care options.

Update on Preclinical Development and Clinical Translation of Cholecystokinin-2 Receptor Targeting Radiopharmaceuticals

Simple Summary

Peptide analogs, derived from the natural peptide hormone gastrin, are promising candidates for improving the visualization and treatment of tumors. Gastrin specifically binds to the cholecystokinin-2 receptor, a G-protein-coupled receptor expressed on the cell surface of different tumors. This enables specific targeting of tumor cells using gastrin analogs, labeled with radioisotopes. The receptor is expressed at high incidence in medullary thyroid carcinoma, a rare form of thyroid cancer lacking effective treatments at an advanced stage. Different radiolabeled gastrin analogs as well as nonpeptidic compounds targeting CCK2R have been developed. Specific modifications have been introduced in order to safely deliver the radiation to the tumor site. In this review, recent strategies applied to improve the targeting properties are described. These developments enabled the introduction of new radiolabeled peptide analogs for imaging and therapy in cancer patients. In addition to highlighting the current clinical trials, the perspectives for future applications are given.

Abstract

The cholecystokinin-2 receptor (CCK2R) has been a target of interest for molecular imaging and targeted radionuclide therapy for two decades. However, so far CCK2R targeted imaging and therapy has not been introduced in clinical practice. Within this review the recent radiopharmaceutical development of CCK2R targeting compounds and the ongoing clinical trials are presented. Currently, new gastrin derivatives as well as nonpeptidic substances are being developed to improve the properties for clinical use. A team of specialists from the field of radiopharmacy and nuclear medicine reviewed the available literature and summarized their own experiences in the development and clinical testing of CCK2R targeting radiopharmaceuticals. The recent clinical trials with novel radiolabeled minigastrin analogs demonstrate the potential for both applications, imaging as well as targeted radiotherapy, and reinforce the clinical applicability within a theranostic concept. The intense efforts in optimizing CCK2R targeting radiopharmaceuticals has led to new substances for clinical use, as shown in first imaging studies in patients with advanced medullary thyroid cancer. The first clinical results suggest that the wider clinical implication of CCK2R-targeted radiopharmaceuticals is reasonable.

Separation of 44Sc from 44Ti in the Context of A Generator System for Radiopharmaceutical Purposes with the Example of [44Sc]Sc-PSMA-617 and [44Sc]Sc-PSMA-I&T Synthesis

Today, ⁴⁴Sc is an attractive radionuclide for molecular imaging with PET. In this work, we evaluated a ⁴⁴Ti/⁴⁴Sc radionuclide generator based on TEVA resin as a source of ⁴⁴Sc. The generator prototype (5 MBq) exhibits high ⁴⁴Ti retention and stable yield of ⁴⁴Sc (91 ± 6 %) in 1 mL of eluate (20 bed volumes, eluent—0.1 M oxalic acid/0.2 M HCl) during one year of monitoring (more than 120 elutions). The breakthrough of ⁴⁴Ti did not exceed 1.5 × 10⁻⁵% (average value was 6.5 × 10⁻⁶%). Post-processing of the eluate for further use in radiopharmaceutical synthesis was proposed. The post-processing procedure using a combination of Presep^® PolyChelate and TK221 resins made it possible to obtain ⁴⁴Sc-radioconjugates with high labeling yield (≥95%) while using small precursor amounts (5 nmol). The proposed method takes no more than 15 min and provides ≥90% yield relative to the ⁴⁴Sc activity eluted from the generator. The labeling efficiency was demonstrated on the example of [⁴⁴Sc]Sc-PSMA-617 and [⁴⁴Sc]Sc-PSMA-I&T synthesis. Some superiority of PSMA-I&T over PSMA-617 in terms of ⁴⁴Sc labeling efficiency was demonstrated (likely due to presence of DOTAGA chelator in the precursor structure). It was also shown that microwave heating of the reaction mixture considerably shortened the reaction time and improved radiolabeling yield and reproducibility of [⁴⁴Sc]Sc-PSMA-617 and [⁴⁴Sc]Sc-PSMA-I&T synthesis.

Studies on production of 43,44,44mSc from 12C+natCl reactions up to 64 MeV projectile energy

For the first-time production of ^43,44,44mSc radionuclides via ¹²C + ^natCl reaction have been reported. Production yield and experimental cross sections of ^natCl(¹²C,xn)^43,44,44mSc up to 64 MeV have been reported. Experimental cross sections have been found comparable with the theoretically evaluated data using PACE4 and EMPIRE3.2.2 codes.

H4HBEDpa: Octadentate Chelate after A. E. Martell

H₄HBEDpa, a new octadentate chelator inspired by the 1960s ligand HBED of Arthur E. Martell, has been investigated for a selection of trivalent metal ions useful in diagnostic and therapeutic applications (Sc³⁺, Fe³⁺, Ga³⁺, In³⁺, and Lu³⁺). Complex formation equilibria were thoroughly investigated using combined potentiometric and UV-vis spectrophotometric titrations which revealed effective chelation and high metal-sequestering capacity, in particular for Fe³⁺, log K_FeL = 36.62, [Fe(HBEDpa)]^-. X-ray diffraction study of single crystals revealed that the ligand is preorganized and forms hexa-coordinated complexes with Fe³⁺ and Ga³⁺ at acidic pH. Density functional theory (DFT) calculations were applied to probe the geometries and energies of all the possible conformers of [M(HBEDpa)]^- (M = Sc³⁺, Fe³⁺, Ga³⁺, In³⁺, and Lu³⁺). DFT calculations confirmed the experimental findings, indicating that [Fe(HBEDpa)]^- is bound tightly in an asymmetric pattern as compared to the symmetrically bound and more open [Ga(HBEDpa)]^-, prone to hydrolysis at higher pH. DFT calculations also showed that a large metal ion such as Lu³⁺ fully coordinates with HBEDpa^4-, forming a binary octadentate complex in its lowest-energy form. Smaller metal ions form six or seven coordinate complexes with HBEDpa^4-.

CERN-MEDICIS: A Review Since Commissioning in 2017

The CERN-MEDICIS (MEDical Isotopes Collected from ISolde) facility has delivered its first radioactive ion beam at CERN (Switzerland) in December 2017 to support the research and development in nuclear medicine using non-conventional radionuclides. Since then, fourteen institutes, including CERN, have joined the collaboration to drive the scientific program of this unique installation and evaluate the needs of the community to improve the research in imaging, diagnostics, radiation therapy and personalized medicine. The facility has been built as an extension of the ISOLDE (Isotope Separator On Line DEvice) facility at CERN. Handling of open radioisotope sources is made possible thanks to its Radiological Controlled Area and laboratory. Targets are being irradiated by the 1.4 GeV proton beam delivered by the CERN Proton Synchrotron Booster (PSB) on a station placed between the High Resolution Separator (HRS) ISOLDE target station and its beam dump. Irradiated target materials are also received from external institutes to undergo mass separation at CERN-MEDICIS. All targets are handled via a remote handling system and exploited on a dedicated isotope separator beamline. To allow for the release and collection of a specific radionuclide of medical interest, each target is heated to temperatures of up to 2,300°C. The created ions are extracted and accelerated to an energy up to 60 kV, and the beam steered through an off-line sector field magnet mass separator. This is followed by the extraction of the radionuclide of interest through mass separation and its subsequent implantation into a collection foil. In addition, the MELISSA (MEDICIS Laser Ion Source Setup At CERN) laser laboratory, in service since April 2019, helps to increase the separation efficiency and the selectivity. After collection, the implanted radionuclides are dispatched to the biomedical research centers, participating in the CERN-MEDICIS collaboration, for Research & Development in imaging or treatment. Since its commissioning, the CERN-MEDICIS facility has provided its partner institutes with non-conventional medical radionuclides such as Tb-149, Tb-152, Tb-155, Sm-153, Tm-165, Tm-167, Er-169, Yb-175, and Ac-225 with a high specific activity. This article provides a review of the achievements and milestones of CERN-MEDICIS since it has produced its first radioactive isotope in December 2017, with a special focus on its most recent operation in 2020.

Emerging Radionuclides in a Regulatory Framework for Medicinal Products - How Do They Fit?

Recent years have seen the establishment of several radionuclides as medicinal products in particular in the setting of theranostics and PET. [¹⁷⁷Lu]Lutetium Chloride or [⁶⁴Cu]Copper Chloride have received marketing authorization as radionuclide precursor, [⁶⁸Ga]Gallium Chloride has received regulatory approval in the form of different ⁶⁸Ge/⁶⁸Ga generators. This is a formal requirement by the EU directive 2001/83, even though for some of these radionuclide precursors no licensed kit is available that can be combined to obtain a final radiopharmaceuticals, as it is the case for Technetium-99m. In view of several highly promising, especially metallic radionuclides for theranostic applications in a wider sense, the strict regulatory environment poses the risk of slowing down development, in particular for radionuclide producers that want to provide innovative radionuclides for clinical research purposes, which is the basis for their further establishment. In this paper we address the regulatory framework for novel radionuclides within the EU, the current challenges in particular related to clinical translation and potential options to support translational development within Europe and worldwide.

Production of scandium radionuclides for theranostic applications: towards standardization of quality requirements

In the frame of "precision medicine", the scandium radionuclides have recently received considerable interest, providing personalised adjustment of radiation characteristics to optimize the efficiency of medical care or therapeutic benefit for particular groups of patients. Radionuclides of scandium, namely scandium-43 and scandium-44 (43/44Sc) as positron emitters and scandium-47 (47Sc), beta-radiation emitter, seem to fit ideally into the concept of theranostic pair. This paper aims to review the work on scandium isotopes production, coordination chemistry, radiolabeling, preclinical studies and the very first clinical studies. Finally, standardized procedures for scandium-based radiopharmaceuticals have been proposed as a basis to pave the way for elaboration of the Ph.Eur. monographs for perspective scandium radionuclides.

State of the Art in Radiolabeling of Antibodies with Common and Uncommon Radiometals for Preclinical and Clinical Immuno-PET

Inert and stable radiolabeling of monoclonal antibodies (mAb), antibody fragments, or antibody mimetics with radiometals is a prerequisite for immuno-PET. While radiolabeling is preferably fast, mild, efficient, and reproducible, especially when applied for human use in a current Good Manufacturing Practice compliant way, it is crucial that the obtained radioimmunoconjugate is stable and shows preserved immunoreactivity and in vivo behavior. Radiometals and chelators have extensively been evaluated to come to the most ideal radiometal–chelator pair for each type of antibody derivative. Although PET imaging of antibodies is a relatively recent tool, applications with ⁸⁹Zr, ⁶⁴Cu, and ⁶⁸Ga have greatly increased in recent years, especially in the clinical setting, while other less common radionuclides such as ⁵²Mn, ⁸⁶Y, ⁶⁶Ga, and ⁴⁴Sc, but also ¹⁸F as in [¹⁸F]AlF are emerging promising candidates for the radiolabeling of antibodies. This review presents a state of the art overview of the practical aspects of radiolabeling of antibodies, ranging from fast kinetic affibodies and nanobodies to slow kinetic intact mAbs. Herein, we focus on the most common approach which consists of first modification of the antibody with a chelator, and after eventual storage of the premodified molecule, radiolabeling as a second step. Other approaches are possible but have been excluded from this review. The review includes recent and representative examples from the literature highlighting which radiometal–chelator–antibody combinations are the most successful for in vivo application.

An Active Irradiation System with Automatic Beam Positioning and Focusing for a Medical Cyclotron

A novel active focusing system was developed for enhancing the irradiation performance of the 18 MeV medical cyclotron in operation at the Bern University Hospital in view of the production of non-conventional medical radioisotopes using solid targets. In several cases, such as the production of 43Sc and 44Sc, the beam has to be kept stable within a very small target of about 5 mm diameter. For this purpose, we conceived and realized an apparatus based on a compact focusing and steering magnet system followed by a two-dimensional beam monitoring detector and a specific feedback software that drives the magnet to optimize the beam for a given irradiation set-up. We report on the design, realization and validation beam tests performed using the research beam transfer line of the Bern cyclotron. We demonstrated that the beam spot can be kept on target thanks to the fact that the system automatically reacts to perturbations. Compactness is one of the key features of this system, allowing its use in accelerator facilities with limited space, such as medical cyclotrons for radioisotope production.

Impact of prompt gamma emission of 44Sc on quantification in preclinical and clinical PET systems

⁴⁴Sc is an increasingly investigated positron emitter for use in positron emission tomography (PET) imaging. However, ⁴⁴Sc is a non-pure positron emitter, since prompt photons are co-emitted during the decay process. This study investigates coincidence energy spectra of ⁴⁴Sc and its impact on PET quantification on a preclinical and clinical PET system in comparison with ¹⁸F. The raw data of the coincidence events revealed characteristic differences comparing the photon energy distribution of ⁴⁴Sc and ¹⁸F. Due to prompt gamma emission of ⁴⁴Sc, activity recovery is underestimated on PET systems. However, clinical PET imaging of ⁴⁴Sc with acceptable quantitative accuracy appears feasible by using a single, constant correction factor.

Comparison of scandium-44 g with other PET radionuclides in pre-clinical PET phantom imaging

PURPOSE

The decay characteristics of radionuclides in PET studies can impact image reconstruction. ^44gSc has been the topic of recent research due to potential theranostic applications and is a promising radiometal for PET imaging. In this study, the reconstructed images from phantom measurements with scandium in a small-animal PET scanner are compared with ¹⁸F and two prominent radiometals: ⁶⁴Cu and ⁶⁸Ga METHODS: Three phantoms filled with ¹⁸F, ⁶⁴C, ⁶⁸Ga, and ^44gSc were imaged in the Siemens Inveon PET scanner. The NEMA image quality phantom was used to determine the recovery coefficients (RCs), spill-over ratios (SORs), and noise (%SD) under typical pre-clinical imaging conditions. Image contrast was determined using a Derenzo phantom, while the coincidence characteristics were investigated using an NEC phantom. Three reconstruction algorithms were used, namely filtered back projection (FBP), ordered subset expectation maximization (OSEM), and maximum a-posteriori (MAP).

RESULTS

Image quality parameters were measured for ¹⁸F, ⁶⁴Cu, ⁶⁸Ga, and ^44gSc respectively; using FBP, the %SD are 5.65, 5.88, 7.28, and 7.70; the RCs for the 5-mm rod are 0.849, 1.01, 0.615, and 0.825; the SORs in water are 0.0473, 0.0595, 0.141, 0.0923; and the SORs in air are 0.0589, 0.0484, 0.0525, and 0.0509. The contrast measured in the 2.5-mm rods are 0.674, 0.637, 0.196, and 0.347. The NEC rate with ^44gSc increased at a slower rate than ¹⁸F and ⁶⁸Ga as a function of activity in the field of view.

CONCLUSION

^44gSc demonstrates intermediate behavior relative to ¹⁸F and ⁶⁸Ga with regard to RC and contrast measurements. It is a promising radionuclide for preclinical imaging.

The First-Row Transition Metals in the Periodic Table of Medicine

In this manuscript, we describe medical applications of each first-row transition metal including nutritional, pharmaceutical, and diagnostic applications. The 10 first-row transition metals in particular are found to have many applications since there five essential elements among them. We summarize the aqueous chemistry of each element to illustrate that these fundamental properties are linked to medical applications and will dictate some of nature’s solutions to the needs of cells. The five essential trace elements—iron, copper, zinc, manganese, and cobalt—represent four redox active elements and one redox inactive element. Since electron transfer is a critical process that must happen for life, it is therefore not surprising that four of the essential trace elements are involved in such processes, whereas the one non-redox active element is found to have important roles as a secondary messenger.. Perhaps surprising is the fact that scandium, titanium, vanadium, chromium, and nickel have many applications, covering the entire range of benefits including controlling pathogen growth, pharmaceutical and diagnostic applications, including benefits such as nutritional additives and hardware production of key medical devices. Some patterns emerge in the summary of biological function andmedical roles that can be attributed to small differences in the first-row transition metals.