Do You Know What You Drink? Comparative Research on the Contents of Radioisotopes and Heavy Metals in Different Types of Tea from Various Parts of the World

The aim of this study was to assess the potential health risks of radioactive elements and heavy metals ingested through the consumption of various types of tea imported to the Polish market (black, green, red, oolong and white). The concentrations [Bq/kg] of radionuclides (40K, 137Cs, 226Ra, 210Pb and 228Th) in tea leaves before and after brewing were measured using γ-ray spectrometry with high-purity germanium (HPGe). The concentrations [mg/kg] of the studied elements (Fe, Cr, Cu, Mo, Al, Mn, Ni, P, V, Cd and Pb) were determined using a microwave-induced plasma optical emission spectrometer (MIP-OES). The results presented here will help to expand the database of heavy metals and radioactivity in teas. With regard to the potential health risk, the percentage of leaching of individual elements in different types of tea infusions was determined, and the assessment of the consumption risk was estimated. Since the calculated exposure factors, namely the HQ (Hazard Quotient) and THQ (Target Hazard Quotient), do not exceed critical levels, teas can still be considered health-beneficial products (most of the radionuclides as well as elements remain in the leaves (65-80%) after brewing).

The concentration of radioisotopes (Potassium-40, Polonium-210, Radium-226, and Thorium-230) in fillet tissue carp fishes: A systematic review and probabilistic exposure assessment

Chemical contamination of seafood has become a global health concern. Carp fish is one of the most widely consumed globally, and several studies have been conducted on the contamination of carp fish with radioisotopes. In the current study, a meta-analysis and probabilistic exposure assessment regarding the Potassium-40 (40K), Polonium-210 (210Po), Radium-226 (226Ra), and Thorium-230 (230Th) in the fillet tissue of carp fish were performed. In this regard, Scopus and PubMed were screened to retrieve the associated citations with on the concentration of radioisotopes in the fillet tissue of carp fish until October 2021. The rank order of radioisotopes in fillet tissue carp fish was 40K (103.49 Bq kg-1) > 210Po (9.39 Bq kg-1) > 226Ra (0.62 Bq kg-1) > 230Th (0.39 Bq kg-1). The highest effective dose due to 210Po ingestion was observed in Spain (male; 4.44E-05 Sv y-1, female; 2.67E-06 Sv y-1); 40K (female, 5.07E-07 Sv y-1); 226Ra (male, 9.93E-09 Sv y-1). The mean of effective dose (ED) in the male and females in India due to ingestion of 230Th as result of carp fish consumption was (1.70E-06 Sv y-1) and (7.01E-08 Sv y-1), respectively. The probabilistic exposure assessment by the Monte Carlo simulation method revealed that consumers of fillet tissue carp fish content of radioisotopes are at a safe range (0.001 Sv y-1).

Accelerator-Based Production of Scandium Radioisotopes for Applications in Prostate Cancer: Toward Building a Pipeline for Rapid Development of Novel Theranostics

In the field of nuclear medicine, the β+ -emitting 43Sc and β- -emitting 47Sc are promising candidates in cancer diagnosis and targeted radionuclide therapy (TRT) due to their favorable decay schema and shared pharmacokinetics as a true theranostic pair. Additionally, scandium is a group-3 transition metal (like 177Lu) and exhibits affinity for DOTA-based chelators, which have been studied in depth, making the barrier to implementation lower for 43/47Sc than for other proposed true theranostics. Before 43/47Sc can see widespread pre-clinical evaluation, however, an accessible production methodology must be established and each isotope's radiolabeling and animal imaging capabilities studied with a widely utilized tracer. As such, a simple means of converting an 18 MeV biomedical cyclotron to support solid targets and produce 43Sc via the 42Ca(d,n)43Sc reaction has been devised, exhibiting reasonable yields. The NatTi(γ,p)47Sc reaction is also investigated along with the successful implementation of chemical separation and purification methods for 43/47Sc. The conjugation of 43/47Sc with PSMA-617 at specific activities of up to 8.94 MBq/nmol and the subsequent imaging of LNCaP-ENZaR tumor xenografts in mouse models with both 43/47Sc-PSMA-617 are also presented.

Liquid scintillation counting at the limit of detection in biogeosciences

Liquid scintillation is widely used to quantify the activity of radioisotopes. We present an overview of the technique and its application to biogeosciences, particularly for turnover rate measurements. Microbial communities and their metabolism are notoriously difficult to analyze in low energy environments as biomass is exceedingly sparse and turnover rates low. Highly sensitive methods, such as liquid scintillation counting, are required to investigate low metabolic rates and conclusively differentiate them from the background noise of the respective analyzer. We conducted a series of experiments to explore the effects of luminescence, measurement time and temperature on scintillation measurements. Luminescence, the spontaneous emission of photons, disproportionally affects samples within the first few hours after sample preparation and can be minimized by following simple guidelines. Short measurement times will negatively affect liquid scintillation analysis or if background noise makes up a significant proportion of the detected events. Measurement temperature affected liquid scintillation analysis only when the temperature during the measurement reached approximately 30°C or higher, i.e. the liquid scintillation analyzer was placed in an environment without temperature control, but not in cases where chemicals were stored at elevated temperatures prior to measurement. Basic understanding on the functionality of a liquid scintillation analyzer and simple precautions prior to the measurement can significantly lower the minimum detection limit and therefore allow for determination of low turnover rates previously lost in the background noise.

Lights and Shadows on the Sourcing of Silver Radioisotopes for Targeted Imaging and Therapy of Cancer: Production Routes and Separation Methods

The interest in silver radioisotopes of medical appeal (silver-103, silver-104m,g and silver-111) has been recently awakened by the versatile nature of their nuclear decays, which combine emissions potentially suitable for non-invasive imaging with emissions suited for cancer treatment. However, to trigger their in vivo application, the production of silver radioisotopes in adequate amounts, and with high radionuclidic purity and molar activity, is a key prerequisite. This review examines the different production routes of silver-111, silver-103 and silver-104m,g providing a comprehensive critical overview of the separation and purification strategies developed so far. Aspects of quality (radiochemical, chemical and radionuclidic purity) are also emphasized and compared with the aim of pushing towards the future implementation of this theranostic triplet in preclinical and clinical contexts.

Radiotheranostics in oncology: Making precision medicine possible

A quintessential setting for precision medicine, theranostics refers to a rapidly evolving field of medicine in which disease is diagnosed followed by treatment of disease-positive patients using tools for the therapy identical or similar to those used for the diagnosis. Against the backdrop of only-treat-when-visualized, the goal is a high therapeutic index with efficacy markedly surpassing toxicity. Oncology leads the way in theranostics innovation, where the approach has become possible with the identification of unique proteins and other factors selectively expressed in cancer versus healthy tissue, advances in imaging technology able to report these tissue factors, and major understanding of targeting chemicals and nanodevices together with methods to attach labels or warheads for imaging and therapy. Radiotheranostics-using radiopharmaceuticals-is becoming routine in patients with prostate cancer and neuroendocrine tumors who express the proteins PSMA (prostate-specific membrane antigen) and SSTR2 (somatostatin receptor 2), respectively, on their cancer. The palpable excitement in the field stems from the finding that a proportion of patients with large metastatic burden show complete and partial responses, and this outcome is catalyzing the search for more radiotheranostics approaches. Not every patient will benefit from radiotheranostics; but, for those who cross the target-detected line, the likelihood of response is very high.

Detection of Shortwave-Infrared Cerenkov Luminescence from Medical Isotopes

Medical radioisotopes produce Cerenkov luminescence (CL) from charged subatomic particles (β+/-) traveling faster than light in dielectric media (e.g., tissue). CL is a blue-weighted and continuous emission, decreasing proportionally to increasing wavelength. CL imaging (CLI) provides an economic PET alternative with the advantage of also being able to image β- and α emitters. Like any optical modality, CLI is limited by the optical properties of tissue (scattering, absorption, and ambient photon removal). Shortwave-infrared (SWIR, 900-1700 nm) CL has been detected from MeV linear accelerators but not yet from keV medical radioisotopes. Methods: Indium-gallium-arsenide sensors and SWIR lenses were mounted onto an ambient light-excluding preclinical enclosure. An exposure and processing pipeline was developed for SWIR CLI and then performed across 6 radioisotopes at in vitro and in vivo conditions. Results: SWIR CL was detected from the clinical radioisotopes 90Y, 68Ga, 18F, 89Zr, 131I, and 32P (biomedical research). SWIR CLI's advantage over visible-wavelength (VIS) CLI (400-900 nm) was shown via increased light penetration and decreased scattering at depth. The SWIR CLI radioisotope sensitivity limit (8.51 kBq/μL for 68Ga), emission spectrum, and ex vivo and in vivo examples are reported. Conclusion: This work shows that radioisotope SWIR CLI can be performed with unmodified commercially available components. SWIR CLI has significant advantages over VIS CLI, with preserved VIS CLI features such as radioisotope radiance levels and dose response linearity. Further improvements in SWIR optics and technology are required to enable widespread adoption.

The photographers' gaze: the Mobile Radioisotope Exhibition in Latin America (1960-1965)

During the IAEA's Mobile Radioisotope Exhibition (1960-1965) through the eventful roads of five Latin American countries (Mexico, Uruguay, Argentina, Brazil, and Bolivia), a variety of photographs were taken by an unknown Mexican official photographer, and by Josef Obermayer, a staff driver from Vienna. The exhibition carried not only bits of nuclear sciences and technologies, but also the political symbolism of the 'friendly atom' as a token of modernization. The photographs embarked on different trajectories, though all of them ended up at the training and exchange official's desk in charge of the exhibition, Argentinian physicist Arturo Cairo. The ones taken in Mexico also had a local circulation as propaganda intended to promote radioisotope applications. The two sets of images were intended to show the contrast between modernity and traditional society, but they did it from different gazes. Our paper argues that, in the case of Mexico, the photographer reinforced representations of the country which were already popularized by Hollywood for foreign and local audiences. On the other hand, the Viennese photographer's gaze delivers an autoethnography of his dutiful journey. We also argue that Obermayer's projection is one of what Roger Bartra has conceptualized as the 'salvage on the mirror'.

Positron-emitting radiotracers spatially resolve unexpected biogeochemical relationships linked with methane oxidation in Arctic soils

Arctic soils are marked by cryoturbic features, which impact soil-atmosphere methane (CH₄ ) dynamics vital to global climate regulation. Cryoturbic diapirism alters C/N chemistry within frost boils by introducing soluble organic carbon and nutrients, potentially influencing microbial CH₄ oxidation. CH₄ oxidation in soils, however, requires a spatio-temporal convergence of ecological factors to occur. Spatial delineation of microbial activity with respect to these key microbial and biogeochemical factors at relevant scales is experimentally challenging in inherently complex and heterogeneous natural soil matrices. This work aims to overcome this barrier by spatially linking microbial CH₄ oxidation with C/N chemistry and metagenomic characteristics. This is achieved by using positron-emitting radiotracers to visualize millimeter-scale active CH₄ uptake areas in Arctic soils with and without diapirism. X-ray absorption spectroscopic speciation of active and inactive areas shows CH₄ uptake spatially associates with greater proportions of inorganic N in diapiric frost boils. Metagenomic analyses reveal Ralstonia pickettii associates with CH₄ uptake across soils along with pertinent CH₄ and inorganic N metabolism associated genes. This study highlights the critical relationship between CH₄ and N cycles in Arctic soils, with potential implications for better understanding future climate. Furthermore, our experimental framework presents a novel, widely applicable strategy for unraveling ecological relationships underlying greenhouse gas dynamics under global change.

Redox Monitoring in Nuclear Medical Imaging

Significance: The imbalance in redox homeostasis is known as oxidative stress, which is relevant to many diseases such as cancer, arteriosclerosis, and neurodegenerative disorders. Overproduction of reactive oxygen species (ROS) is one of the factors that trigger the redox state imbalance in vivo. The ROS have high reactivity and impair biomolecules, whereas antioxidants and antioxidant enzymes, such as ascorbate and glutathione, reduce the overproduction of ROS to rectify the redox imbalance. Owing to this, redox monitoring tools have been developed to understand the redox fluctuations in oxidative stress-related diseases. Recent Advances: In an attempt to monitor redox substances, including ROS and radical species, versatile modalities have been developed, such as electron spin resonance, chemiluminescence, and fluorescence. In particular, many fluorescent probes have been developed that are selective for ROS. This has significantly contributed to understanding the relevance of ROS in disease onset and progression. Critical Issues: To date, the dynamics of ROS and radical fluctuation in in vivo redox states remain unclear, and there are a few methods for the in vivo detection of redox fluctuations. Future Directions: In this review, we summarize the development of radiolabeled probes for monitoring redox-relevant species by nuclear medical imaging that is applicable in vivo. In the future, translational research is likely to be advanced through the development of highly sensitive and in vivo applicable detection methods, such as nuclear medical imaging, to clarify the underlying dynamics of ROS, radicals, and redox substances in many diseases. Antioxid. Redox Signal. 36, 797-810.

Trends in coordination of rhenium organometallic complexes in the Protein Data Bank

Radiopharmaceutical development has similar overall characteristics to any biomedical drug development requiring a compound's stability, aqueous solubility and selectivity to a specific disease site. However, organometallic complexes containing ^188/186Re or ^99mTc involve a d-block transition-metal radioactive isotope and therefore bring additional factors such as metal oxidation states, isotope purity and half life into play. This topical review is focused on the development of radiopharmaceuticals containing the radioisotopes of rhenium and technetium and, therefore, on the occurrence of these organometallic complexes in protein structures in the Worldwide Protein Data Bank (wwPDB). The purpose of incorporating the group 7 transition metals of rhenium/technetium in the protein and the reasons for study by protein crystallography are described, as certain PDB studies were not aimed at drug development. Technetium is used as a medical diagnostic agent and involves the ^99mTc isotope which decays to release gamma radiation, thereby employed for its use in gamma imaging. Due to the periodic relationship among group 7 transition metals, the coordination chemistry of rhenium is similar (but not identical) to that of technetium. The types of reactions the potential model radiopharmaceutical would prefer to partake in, and by extension knowing which proteins and biomolecules the compound would react with in vivo, are needed. Crystallography studies, both small molecule and macromolecular, are a key aspect in understanding chemical coordination. Analyses of bonding modes, coordination to particular residues and crystallization conditions are presented. In our Forward look as a concluding summary of this topical review, the question we ask is: what is the best way for this field to progress?

Magnetometer-Guided Sentinel Lymph Node Dissection in Prostate Cancer: Rate of Lymph Node Involvement Compared with Radioisotope Marking

Simple Summary

Pelvic lymph node dissection is recommended in prostate cancer according to the patients’ individual risk for nodal metastases. Targeted removal of sentinel lymph nodes increases the number of detected lymph node metastases in patients with prostate cancer. We previously established magnetometer-guided sentinel lymph node dissection in patients with prostate cancer to overcome logistical and technical disadvantages associated with the standard radioisotope-guided technique. This retrospective study compared the magnetometer-guided and standard techniques in terms of their ability to detect lymph node metastases. Using the magnetometer-guided technique, more sentinel lymph nodes were detected per patient. The detected rates of lymph node involvement matched the predictions in both techniques equally well. Our findings confirm the reliability of magnetometer-guided sentinel lymph node dissection and highlight the importance of the sentinel technique for detecting lymph node metastases in prostate cancer.

Abstract

Sentinel pelvic lymph node dissection (sPLND) enables the targeted removal of lymph nodes (LNs) bearing the highest metastasis risk. In prostate cancer (PCa), sPLND alone or combined with extended PLND (ePLND) reveals more LN metastases along with detecting sentinel LNs (SLNs) outside the conventional ePLND template. To overcome the disadvantages of radioisotope-guided sPLND in PCa treatment, magnetometer-guided sPLND applying superparamagnetic iron oxide nanoparticles as a tracer was established. This retrospective study compared the nodal staging ability between magnetometer- and radioisotope-guided sPLNDs. We analyzed data of PCa patients undergoing radical prostatectomy and magnetometer- (848 patients, 2015–2021) or radioisotope-guided (2092 patients, 2006–2015) sPLND. To reduce heterogeneity among cohorts, we performed propensity score matching and compared data considering sentinel nomogram-based probabilities for LN involvement (LNI). Magnetometer- and radioisotope-guided sPLNDs had SLN detection rates of 98.12% and 98.09%, respectively; the former detected more SLNs per patient. The LNI rates matched nomogram-based predictions in both techniques equally well. Approximately 7% of LN metastases were detected outside the conventional ePLND template. Thus, we confirmed the reliability of magnetometer-guided sPLND in nodal staging, with results comparable with or better than radioisotope-guided sPLND. Our findings highlight the importance of the sentinel technique for detecting LN metastases in PCa.

Pituitary function following peptide receptor radionuclide therapy for neuroendocrine tumours

Peptide receptor radionuclide therapy (PRRT) is an increasingly used treatment for unresectable neuroendocrine tumours (NETs) that express somatostatin receptors. Normal pituitary tissue expresses somatostatin receptors so patients receiving PRRT may be at risk of developing hypopituitarism. The aim was to assess the prevalence of clinically significant hypopituitarism a minimum of 2 years following radioisotope therapy for metastatic NET. This was a multicentre study (Australia and New Zealand). Sixty‐six patients with unresectable NETs were included–34 had received PRRT and 32 comparison patients. Median follow‐up after PRRT was 68 months. Male hypogonadism was the most common hormonal abnormality (16 of 38 men [42%]) from the total cohort. Of these, seven men had primary hypogonadism (five from PRRT group) and nine had secondary hypogonadism (six in PRRT group). There was no difference in either male hypogonadism or other hormonal dysfunction between patients who had received PRRT and those that had not. Patients who have received PRRT out to 68 months following treatment do not show concerning hypopituitarism although there may be the suggestion of growth hormone deficiency developing. However, hypogonadism is common in men with NETs so the gonadal axis should be assessed in men with suggestive symptoms as the treatment of testosterone deficiency may improve the quality of life.

Prospect of positron emission tomography for abdominal aortic aneurysm risk stratification

Abdominal aortic aneurysm (AAA) disease is characterized by an asymptomatic, permanent, focal dilatation of the abdominal aorta progressing towards rupture, which confers significant mortality. Patient management and surgical decisions rely on aortic diameter measurements via abdominal ultrasound surveillance. However, AAA rupture can occur at small diameters or may never occur at large diameters, implying that anatomical size is not necessarily a sufficient indicator. Molecular imaging may help identify high-risk patients through AAA evaluation independent of aneurysm size, and there is the question of the potential role of positron emission tomography (PET) and emerging role of novel radiotracers for AAA. Therefore, this review summarizes PET studies conducted in the last 10 years and discusses the usefulness of PET radiotracers for AAA risk stratification. The most frequently reported radiotracer was [18F]fluorodeoxyglucose, indicating inflammatory activity and reflecting the biomechanical properties of AAA. Emerging radiotracers include [18F]-labeled sodium fluoride, a calcification marker, [64Cu]DOTA-ECL1i, an indicator of chemokine receptor type 2 expression, and [18F]fluorothymidine, a marker of cell proliferation. For novel radiotracers, preliminary trials in patients are warranted before their widespread clinical implementation. AAA rupture risk is challenging to evaluate; therefore, clinicians may benefit from PET-based risk assessment to guide patient management and surgical decisions.

The CERN-MEDICIS Isotope Separator Beamline

CERN-MEDICIS is an off-line isotope separator facility for the extraction of radioisotopes from irradiated targets of interest to medical applications. The beamline, between the ion source and the collection chamber, consists of ion extraction and focusing elements, and a dipole magnet mass spectrometer recovered from the LISOL facility in Louvain-la-Neuve. The latter has been modified for compatibility with MEDICIS, including the installation of a window for injecting laser light into the ion source for resonance photo-ionization. Ion beam optics and magnetic field modeling using SIMION and OPERA respectively were performed for the design and characterization of the beamline. The individual components and their optimal configuration in terms of ion beam extraction, mass separation, and ion transport efficiency is described, along with details of the commissioning and initial performance assessment with stable ion beams.

Synthesis and Properties of Targeted Radioisotope Carriers Based on Poly(Acrylic Acid) Nanogels

Radiation crosslinking was employed to obtain nanocarriers based on poly(acrylic acid)—PAA—for targeted delivery of radioactive isotopes. These nanocarriers are internally crosslinked hydrophilic macromolecules—nanogels—bearing carboxylic groups to facilitate functionalization. PAA nanogels were conjugated with an engineered bombesin-derivative—oligopeptide combined with 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetate chelating moiety, aimed to provide selective radioligand transport. 4-(4,6-Dimethoxy-1,3,5-triazin-2-yl)-4-methylmorpholinium (DMTMM) toluene-4-sulfonate was used as the coupling agent. After tests on a model amine—p-toluidine—both commercial and home-synthesized DOTA-bombesin were successfully coupled to the nanogels and the obtained products were characterized. The radiolabeling efficiency of nanocarriers with ¹⁷⁷Lu, was chromatographically tested. The results provide a proof of concept for the synthesis of radiation-synthesized nanogel-based radioisotope nanocarriers for theranostic applications.

New Isotopes for the Treatment of Pancreatic Cancer in Collaboration With CERN: A Mini Review

The use of radioactivity in medicine has been developed over a century. The discovery of radioisotopes and their interactions with living cells and tissue has led to the emergence of new diagnostic and therapeutic modalities. The CERN-MEDICIS infrastructure, recently inaugurated at the European Center for Nuclear Research (CERN), provides a wide range of radioisotopes of interest for diagnosis and treatment in oncology. Our objective is to draw attention to the progress made in nuclear medicine in collaboration with CERN and potential future applications, in particular for the treatment of aggressive tumors such as pancreatic adenocarcinoma, through an extensive review of literature. Fifty seven out of two hundred and ten articles, published between 1997 and 2020, were selected based on relevancy. Meetings were held with a multi-disciplinary team, including specialists in physics, biological engineering, chemistry, oncology and surgery, all actively involved in the CERN-MEDICIS project. In summary, new diagnostic, and therapeutic modalities are emerging for the treatment of pancreatic adenocarcinoma. Targeted radiotherapy or brachytherapy could be combined with existing therapies to improve the quality of life and survival of these patients. Many studies are still in the pre-clinical stage but open new paths for patients with poor prognosis.

Treatment with Radiopharmaceuticals and Radionuclides in Breast Cancer: Current Options

Radiopharmaceutical therapy (RPT) is an effective and safe treatment for many types of cancer. RPT acts by binding radioactive atoms to tumor-associated antigens, monoclonal antibodies, nanoparticles, peptides, and small molecules. These treatments ensure that a concentrated dose is delivered to the targeted tumor tissue while preserving the normal tissues surrounding the tumor. Given these features, RPT is superior to traditional methods. This review article aimed to performa comprehensive review and evaluation of the potential of radionuclides and radiopharmaceuticals used in breast cancer treatment in preclinical studies conducted in the last five years.

Diagnostics and Therapeutics in Targeting HER2 Breast Cancer: A Novel Approach

Breast cancer is one of the most commonly occurring cancers in women globally and is the primary cause of cancer mortality in females. BC is highly heterogeneous with various phenotypic expressions. The overexpression of HER2 is responsible for 15-30% of all invasive BC and is strongly associated with malignant behaviours, poor prognosis and decline in overall survival. Molecular imaging offers advantages over conventional imaging modalities, as it provides more sensitive and specific detection of tumours, as these techniques measure the biological and physiological processes at the cellular level to visualise the disease. Early detection and diagnosis of BC is crucial to improving clinical outcomes and prognosis. While HER2-specific antibodies and nanobodies may improve the sensitivity and specificity of molecular imaging, the radioisotope conjugation process may interfere with and may compromise their binding functionalities. Aptamers are single-stranded oligonucleotides capable of targeting biomarkers with remarkable binding specificity and affinity. Aptamers can be functionalised with radioisotopes without compromising target specificity. The attachment of different radioisotopes can determine the aptamer's functionality in the treatment of HER2(+) BC. Several HER2 aptamers and investigations of them have been described and evaluated in this paper. We also provide recommendations for future studies with HER2 aptamers to target HER2(+) BC.

Positron Emission Tomography Imaging of Regional Versus Global Myocardial Sympathetic Activity to Improve Risk Stratification in Patients With Ischemic Cardiomyopathy

BACKGROUND

Current risk assessment approaches fail to identify the majority of patients at risk of sudden cardiac arrest (SCA). Noninvasive imaging of the cardiac sympathetic nervous system using single-photon emission computed tomography and positron emission tomography offers the potential for refining SCA risk assessment. While various [11C]meta-hydroxyephedrine quantification parameters have been proposed, it is currently unknown whether regional denervation or global innervation yields greater SCA risk discrimination. The aim of the study was to determine whether the global innervation parameters yield any independent and additive prognostic value over the regional denervation alone.

METHODS

In a post hoc competing-risks analysis of the PAREPET trial (Prediction of Arrhythmic Events With Positron Emission Tomography), we compared global innervation and regional denervation parameters using the norepinephrine analog [11C]meta-hydroxyephedrine for SCA risk discrimination. Patients with ischemic cardiomyopathy (n=174) eligible for an implantable cardioverter-defibrillator for the primary prevention of SCA were recruited into the trial. [11C]meta-hydroxyephedrine uptake and clearance rates were measured to assess global (left ventricle mean) retention index and volume of distribution. Regional defects were quantified as the percentage of the left ventricle having values <75% of the maximum.

RESULTS

During a median follow-up of 4.2 years, there were 56 cardiac-related deaths, of which 26 were SCAs. For any given regional denervation volume, there was substantial heterogeneity in global innervation scores. Global retention index and distribution volume did not decrease until regional defects exceeded 40% left ventricle. Global scale parameters, retention index, and distribution volume (area under the curve=0.61, P=0.034, P=0.046, respectively), yielded inferior SCA risk discrimination compared to regional heterogeneity (area under the curve=0.74).

CONCLUSIONS

Regional denervation volume has superior cause-specific mortality prediction for SCA versus global parameters of sympathetic innervation. These results have widespread implications for future cardiac sympathetic imaging, which will greatly simplify innervation analysis. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01400334.

Basic study of mobile gamma ray imaging using a digital camera and scintillator

Gamma cameras are used in nuclear medicine examinations involving radioisotopes; however, they do not provide real-time feedback. We propose a real-time imaging method based on a commercially available digital camera and a scintillator array to provide simple and accurate measurements of radioisotope accumulation and contamination. We evaluate the sensitivity and resolution of the proposed device using X-rays as a proxy for gamma-rays. The performance of the device is demonstrated using PENTAX KP and ORCA-spark C11440-36U digital cameras. A caesium iodide scintillator array is irradiated with X-rays, with the state of light emission confirmed using live view images. The pixel value is evaluated as a function of dose rate. Furthermore, we investigate the state of light emission in response to amplifying the light signal using an image intensifier. For the PENTAX KP, luminescence is observable for a dose rate of approximately 10 mSv/h, which changes to 2.1 mSv/h when an image intensifier is used. Notably, the ORCA-spark detected emission at a low dose rate of 0.06 mSv/h. However, using an image intensifier resulted in noisier images. Therefore, although the ORCA-spark can observe luminescence at a suitable predicted dose rate for application in nuclear medicine examinations, a collimator is required to control the spread of gamma rays. However, as this causes the sensitivity to decrease, increasing the amount of light emitted by the scintillator and improving the sensitivity of the camera is vital.

Production scheme for diagnostic-therapeutic radioisotopes by accelerator neutrons

Interest has been growing in the development of medical radioisotopes used for noninvasive nuclear medicine imaging of disease and cancer therapy. Especially the development of an alternative production scheme of ⁹⁹Mo, the mother radioisotope of ^99mTc used for imaging, is required, because the current supply chain of the reactor product ⁹⁹Mo is fragile worldwide. We have proposed a new production scheme of ⁹⁹Mo as well as therapeutic radioisotopes, such as ⁶⁴Cu and ⁶⁷Cu, using accelerator neutrons provided by the ^natC(d,n) reaction. Based on this scheme we have obtained high-quality ^99mTc, ⁶⁴Cu, and ⁶⁷Cu suitable for clinical use by developing both production and separation methods of the radioisotopes. We proposed a new facility to constantly and reliably produce a wide variety of high-quality, carrier-free radioisotopes, including ⁹⁹Mo, with accelerator neutrons. We report on the development of the proposed scheme and future prospects of the facility toward the domestic production of medical radioisotopes.

Absorption and distribution of root, fruit, and foliar-applied 45 Ca in 'Clemenules' mandarin trees

BACKGROUND

The mechanisms of calcium (Ca) absorption and transport in plants are still poorly understood. This study focused on assessing the absorption and distribution of Ca in different plant organs after root (soil), foliar, or fruit application to 6-year-old 'Clemenules' mandarin trees, grown in pots, using ⁴⁵ Ca as a tracer.

RESULTS

The rate of ⁴⁵ Ca absorption and transportation in plant tissues varied according to the treatment method. The fruit and shoot Ca supply led to a rate of 97% to 98% ⁴⁵ Ca retention in such organs. In Ca-treated fruits, 22% of the applied ⁴⁵ Ca moved to the pulp and 78% remained in the flavedo and albedo. The fruit peel was examined by scanning electron microscopy and transmission electron microscopy (SEM and TEM) and variations were observed during fruit development. Following ⁴⁵ Ca soil treatment, approximately 56% of ⁴⁵ Ca activity was measured in the soil, with 19.5% determined in the roots, 14.6% in the trunks (90% in bark and sapwood and only 10% in heartwood), 9.6% in shoots, and 0.3% in fruits.

CONCLUSION

Calcium mobility in 'Clemenules' mandarin trees is limited and depends on the mode of Ca fertilizer application. The distribution of Ca to and within the fruits may be limited during development because of structural and functional constraints. © 2020 Society of Chemical Industry.

Tandem Dye-Doped Nanoparticles for NIR Imaging via Cerenkov Resonance Energy Transfer

The detection of the Cerenkov radiation (CR) is an emerging preclinical imaging technique which allows monitoring the in vivo distribution of radionuclides. Among its possible advantages, the most interesting is the simplicity and cost of the required instrumentation compared, e.g., to that required for PET scans. On the other hand, one of its main drawbacks is related to the fact that CR, presenting the most intense component in the UV-vis region, has a very low penetration in biological tissues. To address this issue, we present here multifluorophoric silica nanoparticles properly designed to efficiently absorb the CR radiation and to have a quite high fluorescence quantum yield (0.12) at 826 nm. Thanks to a highly efficient series of energy transfer processes, each nanoparticle can convert part of the CR into NIR light, increasing its detection even under 1.0-cm thickness of muscle.

Changes in Circulation and Particle Scavenging in the Amerasian Basin of the Arctic Ocean over the Last Three Decades Inferred from the Water Column Distribution of Geochemical Tracers

Since the 1980-1990s, international research efforts have augmented our knowledge of the physical and chemical properties of the Arctic Ocean water masses, and recent studies have documented changes. Understanding the processes responsible for these changes is necessary to be able to forecast the local and global consequences of these property evolutions on climate. The present work investigates the distributions of geochemical tracers of particle fluxes and circulation in the Amerasian Basin and their temporal evolution over the last three decades (from stations visited between 1983 and 2015). Profiles of 230-thorium (230Th) and 231-protactinium (231Pa) concentrations and neodymium isotopes (expressed as εNd) measured in the Amerasian Basin prior to 2000 are compared to a new, post-2000s data set. The comparison shows a large scale decrease in dissolved 230Th and 231Pa concentrations, suggesting intensification of scavenging by particle flux, especially in coastal areas. Higher productivity and sediment resuspension from the shelves appear responsible for the concentration decrease along the margins. In the basin interior, increased lateral exchanges with the boundary circulation also contribute to the decrease in concentration. This study illustrates how dissolved 230Th and 231Pa, with εNd support, can provide unique insights not only into changes in particle flux but also into the evolution of ocean circulation and mixing.

Recent Advances in Bioorthogonal Click Chemistry for Efficient Synthesis of Radiotracers and Radiopharmaceuticals

In recent years, several catalyst-free site-specific reactions have been investigated for the efficient conjugation of biomolecules, nanomaterials, and living cells. Representative functional group pairs for these reactions include the following: (1) azide and cyclooctyne for strain-promoted cycloaddition reaction, (2) tetrazine and trans-alkene for inverse-electron-demand-Diels–Alder reaction, and (3) electrophilic heterocycles and cysteine for rapid condensation/addition reaction. Due to their excellent specificities and high reaction rates, these conjugation methods have been utilized for the labeling of radioisotopes (e.g., radiohalogens, radiometals) to various target molecules. The radiolabeled products prepared by these methods have been applied to preclinical research, such as in vivo molecular imaging, pharmacokinetic studies, and radiation therapy of cancer cells. In this review, we explain the basics of these chemical reactions and introduce their recent applications in the field of radiopharmacy and chemical biology. In addition, we discuss the significance, current challenges, and prospects of using bioorthogonal conjugation reactions.

Radium-223 in Metastatic Castration-Resistant Prostate Cancer: Clinical Development and Use in Contemporary Practice

Radium-223 is a first-in-class alpha particle-emitting radionuclide. Unlike the beta emitters whose development preceded it and whose use has largely been limited to symptom palliation, radium-223 has been shown to meaningfully alter the natural history of bone-predominant metastatic castration-resistant prostate cancer and improve overall survival. This review-a précis of a lecture given at the Eleventh International Symposium on Targeted Alpha Therapy in April 2019-discusses the radiobiological properties of radium-223, summarizes its clinical development over the past decade, and situates it in the current therapeutic landscape for metastatic castration-resistant prostate cancer.

Perspectives on the Use of Liquid Extraction for Radioisotope Purification

The reliable and efficient production of radioisotopes for diagnosis and therapy is becoming an increasingly important capability, due to their demonstrated utility in Nuclear Medicine applications. Starting from the first processes involving the separation of ^99mTc from irradiated materials, several methods and concepts have been developed to selectively extract the radioisotopes of interest. Even though the initial methods were based on liquid-liquid extraction (LLE) approaches, the perceived difficulty in automating such processes has slowly moved the focus towards resin separation methods, whose basic chemical principles are often similar to the LLE ones in terms of chelators and phases. However, the emerging field of flow chemistry allows LLE to be easily automated and operated in a continuous manner, resulting in an even improved efficiency and reliability. In this contribution, we will outline the fundamentals of LLE processes and their translation into flow-based apparatuses; in addition, we will provide examples of radioisotope separations that have been achieved using LLE methods. This article is intended to offer insights about the future potential of LLE to purify medically relevant radioisotopes.

Determination of left ventricular ejection fraction by gated 99mTc-MIBI G-SPECT in patients with takotsubo syndrome - comparison with echocardiography

BACKGROUND

Echocardiography is the first exam to establish the myocardial function in patients with takotsubo syndrome (TTS). However, ECG-Gated Myocardial Single-Photon Emission Tomography (G-SPECT) also allows to calculate left ventricular ejection fraction (LVEF) and can be useful in early stadium of TTS.

AIM

To compare LVEF obtained from 99mTc-MIBI G-SPECT and echocardiography in patients with TTS.

MATERIAL AND METHODS

Study population:20 patients in medium age 77(62-89) with TTS were included. In all patients 99mTc-MIBI G-SPECT and echocardiography was performed on the same day.

RESULTS

LVEF measured by G-SPECT and echocardiography ranged from 34 to 83% and 38 to 69%, respectively. The LVEF values for ECHO were significantly lower than for SPECT. The correlation between the LVEF was r = 0.76. The calculated correlation coefficient (r) for linear regression analysis was 0.64. The following equation shows the approximate interdependence of both LVEF calculations: LVEF GSPECT = 10.35 + 0.93 * LVEF Echo.

CONCLUSIONS

G-SPECT tends to overerestimate LVEF compared to echocardiography so these imaging techniques should not be used interchangeably. Calculated equation should be used for comparison of LVEF.

Takotsubo cardiomyopathy: FDG myocardial uptake pattern in fasting patients. Comparison of PET/CT, SPECT, and ECHO results

BACKGROUND

The aim of this study was to assess the accumulation pattern of 18F-FDG in fasting patients with takotsubo cardiomyopathy (TTC) and to correlate the results with perfusion scintigraphy and echocardiography.

METHODS

18 consecutive patients with TTC were identified by clinical symptoms, cardiac catheterization, and echocardiography. Coronary angiography (CA) and transthoracic echocardiography (TTE) were performed on the day of the onset of symptoms. An assessment of myocardial perfusion (99mTc-MIBI) and glucose metabolism (18F-FDG) was performed within 18 days.

RESULTS

SPECT showed no regional perfusion abnormalities in 10/18 patients, and a mild perfusion defect was found in 8/18 patients. Perfusion abnormalities were limited to apical and para-apical regions. In 8/18 cases, there was an increased selective apical 18F-FDG accumulation. In 10/18 cases, in spite of the fastened 18F-FDG protocol, slightly inhomogeneous 18F-FDG uptake was present in the entire myocardium: with relatively reduced uptake of 18F-FDG in the apical region and LV mid-segments.

CONCLUSION

This study demonstrated the heterogeneous nature of myocardial 18F-FDG accumulation in patients with TTC. Selective, preferential apical 18F-FDG uptake in almost half of the patients confirms an existing disorder of glucose metabolism, similar to that observed in stunned or hibernated myocardium.

Nuclear and Optical Bimodal Imaging Probes Using Sequential Assembly: A Perspective

New, targeted imaging tracers enable improved diagnosis, staging, and planning of treatment of disease and represent an important step toward personalized medicine applications. The combination of radioisotopes for nuclear imaging with fluorophores for fluorescence imaging provides the possibility to noninvasively assess disease burden in a patient using positron emission tomography/single-photon emission computed tomography, followed by fluorescence imaging-assisted surgical intervention in close succession. Probes enabling imaging with both modalities pose a design, synthesis, and pharmacokinetics challenge. In this study, the authors strive to summarize recent efforts toward optimized, discrete, bimodal probes as well as a perspective on future directions of this burgeoning subfield of targeted imaging probe development.

Liposomes: Clinical Applications and Potential for Image-Guided Drug Delivery

Liposomes have been extensively studied and are used in the treatment of several diseases. Liposomes improve the therapeutic efficacy by enhancing drug absorption while avoiding or minimizing rapid degradation and side effects, prolonging the biological half-life and reducing toxicity. The unique feature of liposomes is that they are biocompatible and biodegradable lipids, and are inert and non-immunogenic. Liposomes can compartmentalize and solubilize both hydrophilic and hydrophobic materials. All these properties of liposomes and their flexibility for surface modification to add targeting moieties make liposomes more attractive candidates for use as drug delivery vehicles. There are many novel liposomal formulations that are in various stages of development, to enhance therapeutic effectiveness of new and established drugs that are in preclinical and clinical trials. Recent developments in multimodality imaging to better diagnose disease and monitor treatments embarked on using liposomes as diagnostic tool. Conjugating liposomes with different labeling probes enables precise localization of these liposomal formulations using various modalities such as PET, SPECT, and MRI. In this review, we will briefly review the clinical applications of liposomal formulation and their potential imaging properties.

Recent advances in managing differentiated thyroid cancer

The main clinical challenge in the management of thyroid cancer is to avoid over-treatment and over-diagnosis in patients with lower-risk disease while promptly identifying those patients with more advanced or high-risk disease requiring aggressive treatment. In recent years, novel clinical and molecular data have emerged, allowing the development of new staging systems, predictive and prognostic tools, and treatment approaches. There has been a notable shift toward more conservative management of low- and intermediate-risk patients, characterized by less extensive surgery, more selective use of radioisotopes (for both diagnostic and therapeutic purposes), and less intensive follow-up. Furthermore, the histologic classification; tumor, node, and metastasis (TNM) staging; and American Thyroid Association risk stratification systems have been refined, and this has increased the number of patients in the low- and intermediate-risk categories. There is now a need for new, prospective data to clarify how these changing practices will impact long-term outcomes of patients with thyroid cancer, and new follow-up strategies and biomarkers are still under investigation. On the other hand, patients with more advanced or high-risk disease have a broader portfolio of options in terms of treatments and therapeutic agents, including multitarget tyrosine kinase inhibitors, more selective BRAF or MEK inhibitors, combination therapies, and immunotherapy.

WITHDRAWN: Radioisotopes for metastatic bone pain

BACKGROUND

This is an update of the review published in Issue 4, 2003. Bone metastasis cause severe pain as well as pathological fractures, hypercalcaemia and spinal cord compression. Treatment strategies currently available to relieve pain from bone metastases include analgesia, radiotherapy, surgery, chemotherapy, hormone therapy, radioisotopes and bisphosphonates.

OBJECTIVES

To determine efficacy and safety of radioisotopes in patients with bone metastases to improve metastatic pain, decrease number of complications due to bone metastases and improve patient survival.

SEARCH METHODS

We sought randomised controlled trials (RCTs) in MEDLINE, EMBASE, CENTRAL, and the PaPaS Trials Register up to October 2010.

SELECTION CRITERIA

Studies selected had metastatic bone pain as a major outcome after treatment with a radioisotope, compared with placebo or another radioisotope.

DATA COLLECTION AND ANALYSIS

We assessed the risk of bias of included studies by their sequence generation, allocation concealment, blinding of study participants, researchers and outcome assessors, and incomplete outcome data. Two review authors extracted data. We performed statistical analysis as an "available case" analysis, and calculated global estimates of effect using a random-effects model. We also performed an intention-to-treat (ITT) sensitivity analysis.

MAIN RESULTS

This update includes 15 studies (1146 analyzed participants): four (325 participants) already included and 11 new (821 participants). Only three studies had a low risk of bias. We observed a small benefit of radioisotopes for complete relief (risk ratio (RR) 2.10, 95% CI 1.32 to 3.35; Number needed to treat to benefit (NNT) = 5) and complete/partial relief (RR 1.72, 95% CI 1.13 to 2.63; NNT = 4) in the short and medium term (eight studies, 499 participants). There is no conclusive evidence to demonstrate that radioisotopes modify the use of analgesia with respect to placebo. Leucocytopenia and thrombocytopenia are secondary effects significantly associated with the administration of radioisotopes (RR 5.03; 95% CI 1.35 to 18.70; Number needed to treat to harm (NNH) = 13). Pain flares were not higher in the radioisotopes group (RR 0.74; 95% CI 0.27 to 2.06). There are scarce data of moderate quality when comparing Strontium-89 (89Sr) with Samarium-153 (153Sm), Rhenium-186 (186Re) and Phosphorus-32 (32P). We observed no significant differences between treatments. Similarly, we observed no differences when we compared different doses of 153Sm (0.5 versus 1.0 mCi).

AUTHORS' CONCLUSIONS

This update adds new evidence on efficacy of radioisotopes versus placebo, 89Sr compared with other radioisotopes, and dose-comparisons of 153Sm and 188Re. There is some evidence indicating that radioisotopes may provide complete reduction in pain over one to six months with no increase in analgesic use, but severe adverse effects (leucocytopenia and thrombocytopenia) are frequent.

Hybrid Imaging Labels: Providing the Link Between Mass Spectrometry-Based Molecular Pathology and Theranostics

Background: Development of theranostic concepts that include inductively coupled plasma mass spectrometry (ICP-MS) and laser ablation ICP-MS (LA-ICP-MS) imaging can be hindered by the lack of a direct comparison to more standardly used methods for in vitro and in vivo evaluation; e.g. fluorescence or nuclear medicine. In this study a bimodal (or rather, hybrid) tracer that contains both a fluorescent dye and a chelate was used to evaluate the existence of a direct link between mass spectrometry (MS) and in vitro and in vivo molecular imaging findings using fluorescence and radioisotopes. At the same time, the hybrid label was used to determine whether the use of a single isotope label would allow for MS-based diagnostics.

Methods: A hybrid label that contained both a DTPA chelate (that was coordinated with either ¹⁶⁵Ho or ¹¹¹In) and a Cy5 fluorescent dye was coupled to the chemokine receptor 4 (CXCR4) targeting peptide Ac-TZ14011 (hybrid-Cy5-Ac-TZ4011). This receptor targeting tracer was used to 1) validate the efficacy of (¹⁶⁵Ho-based) mass-cytometry in determining the receptor affinity via comparison with fluorescence-based flow cytometry (Cy5), 2) evaluate the microscopic binding pattern of the tracer in tumor cells using both fluorescence confocal imaging (Cy5) and LA-ICP-MS-imaging (¹⁶⁵Ho), 3) compare in vivo biodistribution patterns obtained with ICP-MS (¹⁶⁵Ho) and radiodetection (¹¹¹In) after intravenous administration of hybrid-Cy5-Ac-TZ4011 in tumor-bearing mice. Finally, LA-ICP-MS-imaging (¹⁶⁵Ho) was linked to fluorescence-based analysis of excised tissue samples (Cy5).

Results: Analysis with both mass-cytometry and flow cytometry revealed a similar receptor affinity, respectively 352 ± 141 nM and 245 ± 65 nM (p = 0.08), but with a much lower detection sensitivity for the first modality. In vitro LA-ICP-MS imaging (¹⁶⁵Ho) enabled clear discrimination between CXCR4 positive and negative cells, but fluorescence microscopy was required to determine the intracellular distribution. In vivo biodistribution patterns obtained with ICP-MS (¹⁶⁵Ho) and radiodetection (¹¹¹In) of the hybrid peptide were shown to be similar. Assessment of tracer distribution in excised tissues revealed the location of tracer uptake with both LA-ICP-MS-imaging and fluorescence imaging.

Conclusion: Lanthanide-isotope chelation expands the scope of fluorescent/radioactive hybrid tracers to include MS-based analytical tools such as mass-cytometry, ICP-MS and LA-ICP-MS imaging in molecular pathology. In contradiction to common expectations, MS detection using a single chelate imaging agent was shown to be feasible, enabling a direct link between nuclear medicine-based imaging and theranostic methods.

Initial Size of Metastatic Lesions Is Best Prognostic Factor in Patients with Metastatic Differentiated Thyroid Carcinoma Confined to the Lung

BACKGROUND

For patients with lung metastases of differentiated thyroid carcinoma (DTC), there is no consensus on the maximal size of metastatic lesions to use when determining the intensity of follow-up and additional therapeutic options. This study evaluated the clinical outcomes and survival of patients with metastatic DTC confined to the lung, using the maximal diameter of lung lesions in the initial computed tomography.

METHODS

This retrospective cohort study included 112 DTC patients with metastases confined to the lung. The clinical responses were evaluated according to changes in the serum levels of stimulated thyroglobulin or antithyroglobulin antibody, disease status was evaluated according to radiological findings, progression-free survival (PFS), and cancer-specific survival (CSS).

RESULTS

Macronodular lung metastases (≥1 cm) were observed in 27 (24%) patients, and these patients had significantly poor biochemical responses and disease status (p < 0.001, and p < 0.001, respectively), irrespective of radioactive iodine (RAI) avidity. After adjusting for age, sex, primary tumor size, extrathyroidal invasion, cervical lymph node metastasis, time of lung metastasis, and RAI avidity, the macronodular group also had shorter PFS and CSS (p = 0.009 and p = 0.03, respectively) than the micronodular group. From the multivariate analyses, RAI avidity was not an independent prognostic factor predicting PFS and CSS. In the subgroup analyses, RAI avidity was a significant prognostic factor associated with better PFS and CSS (p = 0.013 and p = 0.021, respectively) in the micronodular group only.

CONCLUSIONS

The initial largest diameter of metastatic lesions is the most important prognostic factor for predicting poor clinical outcomes and survival in patients with metastatic DTC confined to the lung.

Lutetium 177-DOTA-TATE therapy for esthesioneuroblastoma: A case report

Esthesioneuroblastoma (ENB), also known as olfactory neuroblastoma, is a rare malignant tumor that accounts for 3% of all tumors of the nasal cavity. The incidence of ENB is 0.4 cases per million in the general population, and the most common symptoms are nasal obstruction and epistaxis. Previous studies have indicated the presence of somatostatin receptors in this tumor type. Common treatment strategies for ENB include resection and adjuvant radiotherapy and/or chemotherapy (combined treatment); however, the rate of recurrence is high. Treatment of neuroendocrine tumors using radionuclides bound to somatostatin analogues is well established in clinical practice. However, a standard and effective therapeutic approach has not been reported for ENB. The current study described the case of a 74-year-old female with numerous recurrences of ENB following multiple treatments and without possibility of resection. The patient was treated with the radiolabeled-somatostatin analogue, ¹⁷⁷Lutetium-DOTA-octreotate (¹⁷⁷Lu-DOTA-TATE), which successfully controlled the disease. This suggests that ¹⁷⁷Lu-DOTA-TATE is a potential treatment for ENB and may represent an effective alternative and novel therapeutic strategy for this disease.

Mass selective separation applied to radioisotopes of cesium

A technique that uses the intrinsic mass-based separation capability of a quadrupole mass spectrometer has been used to resolve spectral radiometric interference of two isotopes of the same element. In this work the starting sample was a mixture of ¹³⁷ Cs and ¹³⁴ Cs and was (activity) dominated by ¹³⁷ Cs. This methodology separated and 'implanted' ¹³⁴ Cs that was later quantified for spectral features and activity with traditional radiometric techniques. This work demonstrated a ¹³⁴ Cs/¹³⁷ Cs activity ratio enhancement of >4 orders of magnitude and complete removal of ¹³⁷ Cs spectral features from the implanted target mass (i.e. 134). Copyright © 2016 John Wiley & Sons, Ltd.

Predicting Risk Versus Predicting Potential Survival Benefit Using 123I-mIBG Imaging in Patients With Systolic Dysfunction Eligible for Implantable Cardiac Defibrillator Implantation: Analysis of Data From the Prospective ADMIRE-HF Study

BACKGROUND

Cardiac (123)I-metaiodobenzylguanidine ((123)I-mIBG) imaging improves prognostication in patients with left ventricular (LV) dysfunction. Whether (123)I-mIBG can identify optimal candidates for implantable cardiac defibrillator (ICD) placement is unclear. We examined whether (123)I-mIBG enhances risk assessment and identifies patients with enhanced survival with ICD in a patient cohort with reduced LV function who were candidates for ICD implantation.

METHODS AND RESULTS

We identified 777 patients (66 sites, 12 countries) without ICD at the time of enrollment in Adreview Myocardial Imaging for Risk Evaluation in Heart Failure (ADMIRE-HF) and index (123)I-mIBG study. Patients completed prescribed study protocol and follow-up. Heart-to-mediastinum (H/M) ratio was determined from (123)I-mIBG results. Survival modeling used a Cox proportional hazards mixed-effects model, including a propensity score, to adjust for nonrandomized ICD implantation after (123)I-mIBG. All-cause death occurred in 75 patients (9.6%), and 196 (25%) patients had ICD implantation on follow-up. After adjusting for multiple factors, although the H/M ratio added incremental prognostic value and enhanced reclassification, neither H/M results, BNP levels, nor left ventricular ejection fraction interacted with ICD use in the survival model, indicating that these variables did not identify patients with enhanced survival with ICD implantation. Nonetheless, H/M results did identify the number of lives saved by ICD use per 100 treated.

CONCLUSIONS

We found that although (123)I-mIBG imaging enhances the risk stratification of patients with left ventricular dysfunction who are ICD candidates, it does not identify which patients may have improved survival with ICD placement. However, (123)I-mIBG identifies the absolute benefit gained with ICD use, thus may play a role in optimizing the cost-effectiveness of this intervention.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00126425 and NCT00126438.

Differential Assimilation of Inorganic Carbon and Leucine by Prochlorococcus in the Oligotrophic North Pacific Subtropical Gyre

The light effect on photoheterotrophic processes in Prochlorococcus, and primary and bacterial productivity in the oligotrophic North Pacific Subtropical Gyre was investigated using ¹⁴C-bicarbonate and ³H-leucine. Light and dark incubation experiments were conducted in situ throughout the euphotic zone (0–175 m) on nine expeditions to Station ALOHA over a 3-year period. Photosynthetrons were also used to elucidate rate responses in leucine and inorganic carbon assimilation as a function of light intensity. Taxonomic group and cell-specific rates were assessed using flow cytometric sorting. The light:dark assimilation rate ratios of leucine in the top 150 m were ∼7:1 for Prochlorococcus, whereas the light:dark ratios for the non-pigmented bacteria (NPB) were not significant different from 1:1. Prochlorococcus assimilated leucine in the dark at per cell rates similar to the NPB, with a contribution to the total community bacterial production, integrated over the euphotic zone, of approximately 20% in the dark and 60% in the light. Depth-resolved primary productivity and leucine incorporation showed that the ratio of Prochlorococcus leucine:primary production peaked at 100 m then declined steeply below the deep chlorophyll maximum (DCM). The photosynthetron experiments revealed that, for Prochlorococcus at the DCM, the saturating irradiance (E_k) for leucine incorporation was reached at approximately half the light intensity required for light saturation of ¹⁴C-bicarbonate assimilation. Additionally, high and low red fluorescing Prochlorococcus populations (HRF and LRF), co-occurring at the DCM, had similar E_k values for their respective substrates, however, maximum assimilation rates, for both leucine and inorganic carbon, were two times greater for HRF cells. Our results show that Prochlorococcus contributes significantly to bacterial production estimates using ³H-leucine, whether or not the incubations are conducted in the dark or light, and this should be considered when making assessments of bacterial production in marine environments where Prochlorococcus is present. Furthermore, Prochlorococcus primary productivity showed rate to light-flux patterns that were different from its light enhanced leucine incorporation. This decoupling from autotrophic growth may indicate a separate light stimulated mechanism for leucine acquisition.

The potential complementary role of targeted alpha therapy in the management of metastatic melanoma

Standard treatments for metastatic melanoma have recently extended survival although many patients still succumb. Targeted alpha therapy (TAT) is a new therapeutic approach in which a cancer-targeting vector is labeled with an alpha-emitting radioisotope. Alpha-particles have the shortest range and highest energy transfer, and produce localized, high-density and lethal ionization damage to DNA. Thus, the targeted radiation can kill isolated cancer cells circulating in blood and lymphatic vessels, regress metastatic cancer cell clusters, and disrupt the vasculature of solid tumors. Preclinical and clinical studies of TAT for metastatic melanoma demonstrate its safety and anti-tumor activity. We recommend ways in which TAT can be used to treat small-volume disease sometimes in conjunction with cytoreductive anti-melanoma therapies.

18F-Florbetapir Binds Specifically to Myocardial Light Chain and Transthyretin Amyloid Deposits: Autoradiography Study

BACKGROUND

(18)F-florbetapir is a promising imaging biomarker for cardiac light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR). Our aim, using human autopsy myocardial specimens, was to test the hypothesis that (18)F-florbetapir binds specifically to myocardial AL and ATTR amyloid deposits.

METHODS AND RESULTS

We studied myocardial sections from 30 subjects with autopsy-documented AL (n=10), ATTR (n=10), and nonamyloid controls (n=10) using (18)F-florbetapir and cold florbetapir compound and digital autoradiography. Total and nonspecific binding of (18)F-florbetapir was determined using the maximum signal intensity values. Specific binding of (18)F-florbetapir was calculated by subtracting nonspecific from total binding measurements (in decays per minute/mm(2), DPM mm(2)) and was compared with cardiac structure and function on echocardiography and the histological extent of amyloid deposits. Diffuse or focally increased (18)F-florbetapir uptake was noted in all AL and ATTR samples and in none of the control samples. Compared with control samples, mean (18)F-florbetapir-specific uptake was significantly higher in the amyloid samples (0.94±0.43 versus 2.00±0.58 DPM/mm(2); P<0.001), and in the AL compared with the ATTR samples (2.48±0.40 versus 1.52±0.22 DPM/mm(2); P<0.001). The samples from subjects with atypical echocardiographic features of amyloidosis showed quantitatively more intense (18)F-florbetapir-specific uptake compared with control samples (1.50±0.17 versus 0.94±0.43 DPM/mm(2); P=0.004), despite smaller amyloid extent than in subjects with typical echocardiograms.

CONCLUSIONS

(18)F-florbetapir specifically binds to myocardial AL and ATTR deposits in humans and offers the potential to screen for the 2 most common types of myocardial amyloid.

Efficient Radioisotope Energy Transfer by Gold Nanoclusters for Molecular Imaging

Beta-emitting isotopes Fluorine-18 and Yttrium-90 are tested for their potential to stimulate gold nanoclusters conjugated with blood serum proteins (AuNCs). AuNCs excited by either medical radioisotope are found to be highly effective ionizing radiation energy transfer mediators, suitable for in vivo optical imaging. AuNCs synthesized with protein templates convert beta-decaying radioisotope energy into tissue-penetrating optical signals between 620 and 800 nm. Optical signals are not detected from AuNCs incubated with Technetium-99m, a pure gamma emitter that is used as a control. Optical emission from AuNCs is not proportional to Cerenkov radiation, indicating that the energy transfer between the radionuclide and AuNC is only partially mediated by Cerenkov photons. A direct Coulombic interaction is proposed as a novel and significant mechanism of energy transfer between decaying radionuclides and AuNCs.

Medical physics--particle accelerators--the beginning

This chapter outlines the early development of particle accelerators with the redesign from linear accelerator to cyclotron by Ernest Lawrence with a view to reducing the size of the machines as the power increased. There are minibiographies of Ernest Lawrence and his brother John. The concept of artificial radiation is outlined and the early attempts at patient treatment are mentioned. The reasons for trying and abandoning neutron therapy are discussed, and the early use of protons is described.

Radium-223 dichloride: a novel treatment option for castration-resistant prostate cancer patients with symptomatic bone metastases

OBJECTIVE

To review and evaluate the clinical trial efficacy and safety of radium 223 ((223)Ra) along with its place in therapy in men with castration-resistant prostate cancer (CRPC).

DATA SOURCES

A literature search in PubMed/MEDLINE (up to October 2014) was performed using various combinations of the terms radium, hormone-refractory prostate cancer, and castration-resistant prostate cancer. The New Drug Application Medical, Pharmacology, and Clinical Pharmacology and Biopharmaceutics Reviews for radium (223)Ra dichloride were also utilized. The bibliographies of articles were reviewed to identify additional references.

STUDY SELECTION AND DATA EXTRACTION

Phase 1, 2, and 3 studies that assessed the safety and/or efficacy of (223)Ra in patients with CRPC were reviewed. Peer-reviewed articles with clinically relevant information were reviewed for background information.

DATA SYNTHESIS

In May 2013, the Food and Drug Administration approved intravenous use of (223)Ra for the treatment of patients with CRPC, symptomatic bone metastases, and no known visceral metastatic disease. In a phase 3 study comparing (223)Ra and the best standard of care (SOC) versus the best SOC plus placebo, (223)Ra was shown to increase survival. The most commonly seen adverse drug reactions and hematological laboratory abnormalities with (223)Ra include nausea, diarrhea, vomiting, peripheral edema, anemia, lymphocytopenia, leukopenia, thrombocytopenia, and neutropenia.

CONCLUSIONS

(223)Ra is a first-in-class α-particle-emitting radioactive agent that is first-line therapy, providing an extra option for men suffering from CRPC with symptomatic bone metastases and no known visceral metastases. (223)Ra has also been shown to be relatively well tolerated when up to 6 injections are given. Further studies are needed to evaluate whether (223)Ra is safe and effective for more than 6 doses and if it can be used concomitantly with chemotherapy.

Can physicians identify inappropriate nuclear stress tests? An examination of inter-rater reliability for the 2009 appropriate use criteria for radionuclide imaging

BACKGROUND

We sought to determine inter-rater reliability of the 2009 Appropriate Use Criteria for radionuclide imaging and whether physicians at various levels of training can effectively identify nuclear stress tests with inappropriate indications.

METHODS AND RESULTS

Four hundred patients were randomly selected from a consecutive cohort of patients undergoing nuclear stress testing at an academic medical center. Raters with different levels of training (including cardiology attending physicians, cardiology fellows, internal medicine hospitalists, and internal medicine interns) classified individual nuclear stress tests using the 2009 Appropriate Use Criteria. Consensus classification by 2 cardiologists was considered the operational gold standard, and sensitivity and specificity of individual raters for identifying inappropriate tests were calculated. Inter-rater reliability of the Appropriate Use Criteria was assessed using Cohen κ statistics for pairs of different raters. The mean age of patients was 61.5 years; 214 (54%) were female. The cardiologists rated 256 (64%) of 400 nuclear stress tests as appropriate, 68 (18%) as uncertain, 55 (14%) as inappropriate; 21 (5%) tests were unable to be classified. Inter-rater reliability for noncardiologist raters was modest (unweighted Cohen κ, 0.51, 95% confidence interval, 0.45-0.55). Sensitivity of individual raters for identifying inappropriate tests ranged from 47% to 82%, while specificity ranged from 85% to 97%.

CONCLUSIONS

Inter-rater reliability for the 2009 Appropriate Use Criteria for radionuclide imaging is modest, and there is considerable variation in the ability of raters at different levels of training to identify inappropriate tests.

Radium-223 dichloride for the treatment of metastatic prostate cancer

INTRODUCTION

Bone metastases are a frequent complication of many malignancies and are particularly common in metastatic prostate cancer, where they are associated with a high degree of morbidity. Until recently, treatments relied on palliative bone targeting measures with no proven survival-prolonging action or on systemic agents with general anti-prostate cancer activity but significant toxicities. Radium-223 dichloride is a bone-seeking, α-emitting, radionuclide that has recently been licensed in the US and Europe for the treatment of men with castration-resistant prostate cancer, bone metastases and no known visceral metastases. Radium-223 is the first bone-seeking radionuclide therapy proven to result in increased overall survival versus placebo.

AREAS COVERED

The existing market of bone-targeted agents is reviewed before considering what radium-223 adds by examining its pharmacology, pharmacokinetics and clinical efficacy and safety data. Initial relevant papers were identified by searching PubMed using combinations of the terms, 'Radium', 'Prostatic neoplasms', 'Bone', 'Neoplasm metastasis'.

EXPERT OPINION

Consideration is given to further preclinical work needed into the mechanism of action of radium-223 and future clinical directions of the drug including combinations with other agents.