Theranostics in Nuclear Medicine: Emerging and Re-emerging Integrated Imaging and Therapies in the Era of Precision Oncology

Differentiated Thyroid Cancer after Thyroidectomy

The widespread use of neck US and other imaging modalities has contributed to a phenomenon of increased detection of differentiated thyroid cancer (DTC). Most of these cancers remain indolent, without requiring surgical intervention. Nonetheless, a subset of patients who require surgical treatment experience subsequent disease recurrence. This most commonly occurs in the cervical lymph nodes and thyroid bed, followed by distant metastasis to the lungs and bones. Because imaging is an integral part of postoperative surveillance, radiologists play a central role in the detection of recurrent tumors and in guiding treatment in these patients. US is the primary imaging modality used for postoperative evaluation. Other modalities such as CT, MRI, radioactive iodine imaging, and PET/CT aid in the accurate diagnosis and characterization of recurrent disease. Therefore, radiologists must have a thorough understanding of the utility of these imaging techniques and the imaging characteristics of recurrent DTC when interpreting these multimodality studies. The interpretation of imaging findings should also be correlated with the clinical status of patients and their biochemical markers to minimize interpretative errors. The authors present a broad overview of the postoperative evaluation of DTC, including its initial primary management, staging, and prognostication; clinical risk stratification for recurrent disease; postoperative surveillance with imaging and evaluation of biochemical markers; and management of recurrent DTC. Published under a CC BY 4.0 license. Supplemental material is available for this article.

Navigating the landscape of theranostics in nuclear medicine: current practice and future prospects

Theranostics refers to the combination of diagnostic biomarkers with therapeutic agents that share a specific target expressed by diseased cells and tissues. Nuclear medicine is an exciting component explored for its applicability in theranostic concepts in clinical and research investigations. Nuclear theranostics is based on the employment of radioactive compounds delivering ionizing radiation to diagnose and manage certain diseases employing binding with specifically expressed targets. In the realm of personalized medicine, nuclear theranostics stands as a beacon of potential, potentially revolutionizing disease management. Studies exploring the theranostic profile of radioactive compounds have been presented in this review along with a detailed explanation of radioactive compounds and their theranostic applicability in several diseases. It furnishes insights into their applicability across diverse diseases, elucidating the intricate interplay between these compounds and disease pathologies. Light is shed on the important milestones of nuclear theranostics beginning with radioiodine therapy in thyroid carcinomas, MIBG labelled with iodine in neuroblastoma, and several others. Our perspectives have been put forth regarding the most important theranostic agents along with emerging trends and prospects.

Adsorption of terbium (III) on DGA and LN resins: Thermodynamics, isotherms, and kinetics

Two commercially available extraction chromatography (EXC) resins containing N,N,N',N'-tetra-n-octyldiglycolamide (DGA Resin, Normal, 50 - 100 μm) and Bis(2-ethylhexyl) phosphate (LN Resin, 100 - 150 μm) were used as adsorbents to study fundamental adsorption properties such as thermodynamic values, equilibrium isotherms, and kinetic uptake models for terbium(III) adsorption. Weight distribution ratios (Dw) for terbium on DGA and LN resins were measured using a [160Tb]Tb3+radiometric tracer in nitric acid as a function of acidity, temperature, initial analyte concentration, and equilibrium time. The Dw values showed increasing binding affinity for DGA resin at high nitric acid concentrations and decreasing binding affinity for LN resins. Thermodynamic studies for DGA and LN resins revealed that the Gibbs free energy (ΔG) increased consistently with temperature. To model equilibrium data, increasingly higher parameter equilibrium isotherm models (Henry (1) < Langmuir, Freundlich (2) < Redlich-Peterson (3) < Fritz-Schluender (4)) were compared on their root mean squared errors (RMSE) and adjusted determination coefficients to determine the most applicable model. In all cases, the empirical four-parameter Fritz-Schluender isotherm demonstrated a superior fit. Similar comparisons for reaction-based kinetic models (Pseudo-first-order < Pseudo-second-order < Pseudo-n-order) revealed that the higher-order PNO model yielded a superior fit of kinetic data for both resins. However, in some cases, adsorption isotherms and kinetic models could also be modeled by a lower-order model with minimal change in error parameters. Weber-Morris plots revealed that two linear sections are observed for each resin, where the first linear segment is attributed to fast (film diffusion) adsorption of terbium, followed by slower intraparticle diffusion of terbium through the pores as the rate-limiting step. Based on the Weber-Morris plot, both film and intraparticle diffusion are involved in controlling the kinetic rate of adsorption for DGA and LN resins.

Biodistribution of PET radiotracers in tumor-bearing TRAMP mice administered by retroorbital or jugular vein injections

Nuclear medicine is an important tool for use in molecular imaging of important biological processes. Methods for intravenous delivery of radiotracers remains a challenge, with tail vein injections demonstrated to be technically difficult and lacking in reproducibility. Other intravenous methods include jugular vein (JV) injection, which requires a more invasive and precise microsurgical technique. Although the retroorbital (RO) sinus drains directly into the JV, and RO injections are minimally invasive and simpler to perform, they remain underutilized, perhaps due to a lack of studies demonstrating their performance. This study provides a comprehensive comparison of dynamic tissue biodistribution of three categories of commonly utilized radiopharmaceuticals between JV and RO injection methods in prostate tumor-bearing mice using PET-CT imaging. Results show that JV and RO injections have equivalent dynamic tissue biodistributions across the three categories of radiopharmaceuticals used: (1) small molecule measuring tumor metabolism (18F-flurodeoxyglucose [FDG]); (2) peptide-based probe measuring angiogenesis (64Cu-NOTA-PEG4-cRGD2); and (3) dextran-based nanocarrier (64Cu-NOTA-D20). Although RO injections present with some limitations such as type of injectate and difficulty for measuring acute, dynamic pharmacokinetics, this study demonstrates that RO injections are a viable, minimally invasive or stressful, and efficient alternative intravenous delivery technique for molecular imaging.

Radioimmunotheragnosis in Cancer Research

The combination of immunoPET-where an antibody (Ab) is labeled with an isotope for PET imaging-and radioimmunotherapy (RIT), using the same antibody with a therapeutic isotope, offers significant advantages in cancer management. ImmunoPET allows non-invasive imaging of antigen expression, which aids in patient selection for subsequent radioimmunotherapy. It also facilitates the assessment of tumor response to therapy, allowing for treatment adjustments if necessary. In addition, immunoPET provides critical pharmacokinetic data, including antibody biodistribution and clearance rates, which are essential for dosimetry calculations and treatment protocol optimization. There are still challenges to overcome. Identifying appropriate target antigens that are selectively expressed on cancer cells while minimally expressed on normal tissues remains a major hurdle to reduce off-target toxicity. In addition, it is critical to optimize the pharmacokinetics of radiolabeled antibodies to maximize tumor uptake and minimize normal tissue uptake, particularly in vital organs such as the liver and kidney. This approach offers the potential for targeted and personalized cancer therapy with reduced systemic toxicity by exploiting the specificity of monoclonal antibodies and the cytotoxic effects of radiation. However, further research is needed to address remaining challenges and to optimize these technologies for clinical use.

Harnessing Biopolymer Gels for Theranostic Applications: Imaging Agent Integration and Real-Time Monitoring of Drug Delivery

Biopolymer gels have gained tremendous potential for therapeutic applications due to their biocompatibility, biodegradability, and ability to adsorb and bind biological fluids, making them attractive for drug delivery and therapy. In this study, the versatility of biopolymer gels is explored in theranostic backgrounds, with a focus on integrating imaging features and facilitating real-time monitoring of drug delivery. Different methods of delivery are explored for incorporating imaging agents into biopolymer gels, including encapsulation, surface functionalization, nanoparticle encapsulation, and layer-by-layer assembly techniques. These methods exhibit the integration of agents and real-time monitoring drug delivery. We summarize the synthesis methods, general properties, and functional mechanisms of biopolymer gels, demonstrating their broad applications as multimodal systems for imaging-based therapeutics. These techniques not only enable multiple imaging but also provide signal enhancement and facilitate imaging targets, increasing the diagnostic accuracy and therapeutic efficacy. In addition, current techniques for incorporating imaging agents into biopolymer gels are discussed, as well as their role in precise drug delivery and monitoring.

Approach to the Patient: Concept and Application of Targeted Radiotherapy in the Paraganglioma Patient

Paragangliomas can metastasize, posing potential challenges both in symptomatic management and disease control. Systemic targeted radiotherapies using 131I-MIBG and 177Lu-DOTATATE are a mainstay in the treatment of metastatic paragangliomas. This clinical scenario and discussion aim to enhance physicians' knowledge of the stepwise approach to treat these patients with paraganglioma-targeted radiotherapies. It comprehensively discusses current approaches to selecting paraganglioma patients for targeted radiotherapies and how to choose between the two radiotherapies based on specific patient and tumor characteristics, when either therapy is feasible, or one is superior to another. The safety, efficacy, toxicity profiles, and optimization of these radiotherapies are also discussed, along with other therapeutic options including radiotherapies, available for patients besides these two therapies. Perspectives in radiotherapies of paraganglioma patients are outlined since they hold promising approaches in the near future that can improve patient outcomes.

A phase 2, single-arm trial evaluating 131 I-PSMA-1095 targeted radioligand therapy for metastatic castration-resistant prostate cancer

BACKGROUND

Metastatic castration-resistant prostate cancer (mCRPC) remains uniformly lethal. Prostate specific membrane antigen (PSMA) is a transmembrane glycoprotein overexpressed in prostate cancer. 131 I-PSMA-1095 (also known as 131 I-MIP-1095) is a PSMA-targeted radioligand which selectively delivers therapeutic radiation to cancer cells and the tumor microenvironment.

METHODS

We conducted a single-arm, phase 2 trial to assess efficacy and tolerability of 131 I-PSMA-1095 in mCRPC patients who had exhausted all lines of approved therapy. All patients underwent 18 F-DCFPyL PET and 18 F-FDG PET to determine PSMA-positive tumor volume, and patients with >50% PSMA-positive tumor volume were treated with up to four doses of 131 I-PSMA-1095. The primary endpoint was the response rate of prostate specific antigen (PSA). Secondary endpoints included rates of radiographic response and adverse events. Overall and radiographic progression-free survival were also analyzed.

RESULTS

Eleven patients were screened for inclusion and nine patients received 131 I-PSMA-1095. The median baseline PSA was 162 µg/l, and six patients demonstrated a >50% PSA decrease. One patient demonstrated a confirmed radiographic response. Median overall survival was 10.3 months, and median progression-free survival was 5.4 months. Four patients experienced adverse events of grade 3 or higher, the most frequent being thrombocytopenia and anemia.

CONCLUSION

131 I-PSMA-1095 is highly active against heavily-pretreated PSMA-positive mCRPC, significantly decreasing tumor burden as measured by PSA. Adverse events, mainly hematologic toxicity, were not infrequent, likely related to off-target irradiation. This hematologic toxicity, as well as a higher logistical burden associated with use, could represent relative disadvantages of 131 I-PSMA-1095 compared to 177 Lu-PSMA-617.

5-aminolevulinic acid induced photodynamic reactions in diagnosis and therapy for female lower genital tract diseases

Since the patients suffering from female lower genital tract diseases are getting younger and younger and the human papilloma virus (HPV) infection is becoming more widespread, the novel non-invasive precise modalities of diagnosis and therapy are required to remain structures of the organ and tissue, and fertility as well, by which the less damage to normal tissue and fewer adverse effects are able to be achieved. In all nucleated mammalian cells, 5-Aminolevulinic acid (5-ALA) is an amino acid that occurs spontaneously, which further synthesizes in the heme biosynthetic pathway into protoporphyrin IX (PpIX) as a porphyrin precursor and photosensitizing agent. Exogenous 5-ALA avoids the rate-limiting step in the process, causing PpIX buildup in tumor tissues. This tumor-selective PpIX distribution after 5-ALA application has been used successfully for tumor photodynamic diagnosis (PDD) and photodynamic therapy (PDT). Several ALA-based drugs have been used for ALA-PDD and ALA-PDT in treating many (pre)cancerous diseases, including the female lower genital tract diseases, yet the ALA-induced fluorescent theranostics is needed to be explored further. In this paper, we are going to review the studies of the mechanisms and applications mainly on ALA-mediated photodynamic reactions and its effectiveness in treating female lower genital tract diseases.

Demystifying the potential of lipid-based nanocarriers in targeting brain malignancies

Drug targeting for brain malignancies is restricted due to the presence of the blood-brain barrier (BBB) and blood-brain tumor barrier (BBTB), which act as barriers between the blood and brain parenchyma. Certainly, the limited therapeutic options for brain malignancies have made notable progress with enhanced biological understanding and innovative approaches, such as targeted therapies and immunotherapies. These advancements significantly contribute to improving patient prognoses and represent a promising shift in the landscape of brain malignancy treatments. A more comprehensive understanding of the histology and pathogenesis of brain malignancies is urgently needed. Continued research focused on unraveling the intricacies of brain malignancy biology holds the key to developing innovative and tailored therapies that can improve patient outcomes. Lipid nanocarriers are highly effective drug delivery systems that significantly improve their solubility, bioavailability, and stability while also minimizing unwanted side effects. Surface-modified lipid nanocarriers (liposomes, niosomes, solid lipid nanoparticles, nanostructured lipid carriers, lipid nanocapsules, lipid-polymer hybrid nanocarriers, lipoproteins, and lipoplexes) are employed to improve BBB penetration and uptake through various mechanisms. This systematic review illuminates and covers various topics related to brain malignancies. It explores the different methods of drug delivery used in treating brain malignancies and delves into the benefits, limitations, and types of brain-targeted lipid-based nanocarriers. Additionally, this review discusses ongoing clinical trials and patents related to brain malignancy therapies and provides a glance into future perspectives for treating this condition.

Guiding principles on the education and practice of theranostics

PURPOSE

The recent development and approval of new diagnostic imaging and therapy approaches in the field of theranostics have revolutionised nuclear medicine practice. To ensure the provision of these new imaging and therapy approaches in a safe and high-quality manner, training of nuclear medicine physicians and qualified specialists is paramount. This is required for trainees who are learning theranostics practice, and for ensuring minimum standards for knowledge and competency in existing practising specialists.

METHODS

To address the need for a training curriculum in theranostics that would be utilised at a global level, a Consultancy Meeting was held at the IAEA in May 2023, with participation by experts in radiopharmaceutical therapy and theranostics including representatives of major international organisations relevant to theranostics practice.

RESULTS

Through extensive discussions and review of existing curriculum and guidelines, a harmonised training program for theranostics was developed, which aims to ensure safe and high quality theranostics practice in all countries.

CONCLUSION

The guiding principles for theranostics training outlined in this paper have immediate relevance for the safe and effective practice of theranostics.

Reactive oxygen species-responsive nano-platform with dual-targeting and fluorescent lipid-specific imaging capabilities for the management of atherosclerotic plaques

Atherosclerosis (AS), a pathological cause of cardiovascular disease, results from endothelial injury, local progressive inflammation, and excessive lipid accumulation. AS plaques rich in foam cells are prone to rupture and form thrombus, which can cause life-threatening complications. Therefore, the assessment of atherosclerotic plaque vulnerability and early intervention are crucial in reducing the mortality rates associated with cardiovascular disease. In this work, A fluorescent probe FC-TPA was synthesized, which switches the fluorescence state between protonated and non-protonated, reducing background fluorescence and enhancing imaging signal-to-noise ratio. On this basis, FC-TPA is loaded into cyclodextrin (CD) modified with phosphatidylserine targeting peptide (PTP) and coated with hyaluronic acid (HA) to construct the intelligent responsive diagnostic nanoplatform (HA@PCFT). HA@PCFT effectively targets atherosclerotic plaques, utilizing dual targeting mechanisms. HA binds strongly to CD44, while PTP binds to phosphatidylserine, enabling nanoparticle aggregation at the lesion site. ROS acts as a smart release switch for probes. Both in vitro and in vivo evaluations confirm impressive lipid-specific fluorescence imaging capabilities of HA@PCFT nanoparticles (NPs). The detection of lipid load in atherosclerotic plaque by fluorescence imaging will aid in assessing the vulnerability of atherosclerotic plaque. STATEMENT OF SIGNIFICANCE: Currently, numerous fluorescent probes have been developed for lipid imaging. However, some challenges including inadequate water solubility, nonspecific distribution patterns, and fluorescence background interference, have greatly limited their further applications in vivo. To overcome these limitations, a fluorescent molecule has been designed and synthesized, thoroughly investigating its photophysical properties through both theoretical and experimental approaches. Interestingly, this fluorescent molecule exhibits the reversible fluorescence switching capabilities, mediated by hydrogen bonds, which effectively mitigate background fluorescence interference. Additionally, the fluorescent molecules has been successfully loaded into nanocarriers functionalized with the active targeting abilities, which has significantly improved the solubility of the fluorescent molecules and reduced their nonspecific distribution in vivo for an efficient target imaging in atherosclerosis. This study provides a valuable reference for evaluating the performance of such fluorescent dyes, and offers a promising perspective on the design of the target delivery systems for atherosclerosis.

Radioiodine Uptake at Suture Site Granuloma Mimicking Neck Node Metastasis on 131 I Whole-Body Iodine Scintigraphy

ABSTRACT

Differentiated thyroid carcinoma constitutes over 90% of all thyroid cancers. The standard treatment approach involves total or near-total thyroidectomy with or without neck dissection followed by 131 I whole-body scintigraphy (WBS) to detect local or distant metastases. Radioiodine offers high sensitivity and specificity for detection of metastatic disease in well differentiated thyroid carcinoma. However, despite its high accuracy, 131 I WBS demonstrates false-positive results, mostly at inflammatory or infective site. These false-positive radioiodine accumulation can lead to misdiagnosis and unwarranted radioiodine treatment. This case presents localization of 131 I to the suture site granuloma leading to false-positive results on 131 I WBS.

Clinical Theranostics in Recurrent Gliomas: A Review

Gliomas represent the most commonly occurring tumors in the central nervous system and account for approximately 80% of all malignant primary brain tumors. With a high malignancy and recurrence risk, the prognosis of high-grade gliomas is poor, with a mean survival time of 12-18 months. While contrast-enhanced MRI serves as the standard diagnostic imaging modality for gliomas, it faces limitations in the evaluation of recurrent gliomas, failing to distinguish between treatment-related changes and tumor progression, and offers no direct therapeutic options. Recent advances in imaging modalities have attempted to address some of these limitations, including positron emission tomography (PET), which has demonstrated success in delineating tumor margins and guiding the treatment of recurrent gliomas. Additionally, with the advent of theranostics in nuclear medicine, PET tracers, when combined with therapeutic agents, have also evolved beyond a purely diagnostic modality, serving both diagnostic and therapeutic roles. This review will discuss the growing involvement of theranostics in diagnosing and treating recurrent gliomas and address the associated impact on quality of life and functional recovery.

Clinical Positron Emission Tomography/Computed Tomography: Quarter-Century Transformation of Prostate Cancer Molecular Imaging

Although positron emission tomography/computed tomography (PET/CT) underwent rapid growth during the last quarter-century, becoming a new standard-of-care for imaging most cancer types, CT and bone scan remained the gold standard for patients with prostate cancer. This occurred as 2-fluorine-18-fluoro-2-deoxy-d-glucose was perceived to have a limited role owing to low sensitivity in many patients. A resurgence of interest occurred with the use of fluorine-18-sodium-fluoride PET/CT as a replacement for bone scintigraphy, and then choline, fluciclovine, and dihydrotestosterone (DHT) PET/CT as prostate "specific" radiotracers. The last decade, however, has seen a true revolution with the meteoric rise of prostate-specific membrane antigen PET/CT.

Evaluation of prostate-specific membrane antigen expression in locally advanced or metastatic breast carcinoma with 68 Ga-PSMA-11 positron-emission tomography/computed tomography imaging for potential theranostics

BACKGROUND AND AIM

Prostate-specific membrane antigen (PSMA) is ubiquitously expressed in tumor-associated neovasculature and may be a potential theranostic in many solid cancers, including breast carcinoma (BC). Herein, we analyzed the presence of PSMA in BC, through qualitative and quantitative parameters on 68 Ga-PSMA-11 positron-emission tomography/computed tomography (PET/CT), across various hormonal subtypes.

METHODS

This study examined 41 female patients of BC. All underwent 68 Ga-PSMA-11 PET/CT. For qualitative analysis, a visual estimation of PSMA expression was performed as per miPSMA scoring system (VISION trial) and a score ≥2 was considered eligible for lutetium-177 ( 177 Lu)-PSMA-617 radioligand therapy (Lu-PRLT). For quantitative analysis, maximum standardized uptake values (SUVmax) were determined and ratios >1 for SUVmax lesion to SUVmax liver were considered eligible for Lu-PRLT. PSMA expression was correlated with hormonal status using Chi-square test. The sensitivity, specificity and area under curve (AUC) of PSMA expression were determined using receiver-operating characteristics analysis ( P < 0.05).

RESULTS

A total of 19 patients (46.3%) and 15 patients (36.7%) in stage IV were found eligible for Lu-PRLT based on qualitative and quantitative analyses, respectively. Strong PSMA expression was detected in triple-negative and hormonal receptors-negative/human epidermal growth factor receptor 2-positive status on qualitative PSMA expression analysis. A sensitivity of 65.5%, specificity of 93.3% and AUC of 0.857 for SUVmax 6.5 on 68 Ga-PSMA-11 PET/CT were detected for PSMA expression for considering Lu-PRLT.

CONCLUSION

We found a modest number of BC patients suited for Lu-PRLT, indicating that PSMA PET/CT imaging may be a valuable modality for selecting theranostics in a carefully selected group of breast carcinoma.

Blood-brain barrier disruption in dementia: Nano-solutions as new treatment options

Candidate drugs targeting the central nervous system (CNS) demonstrate extremely low clinical success rates, with more than 98% of potential treatments being discontinued due to poor blood-brain barrier (BBB) permeability. Neurological conditions were shown to be the second leading cause of death globally in 2016, with the number of people currently affected by neurological disorders increasing rapidly. This increasing trend, along with an inability to develop BBB permeating drugs, is presenting a major hurdle in the treatment of CNS-related disorders, like dementia. To overcome this, it is necessary to understand the structure and function of the BBB, including the transport of molecules across its interface in both healthy and pathological conditions. The use of CNS drug carriers is rapidly gaining popularity in CNS research due to their ability to target BBB transport systems. Further research and development of drug delivery vehicles could provide essential information that can be used to develop novel treatments for neurological conditions. This review discusses the BBB and its transport systems and evaluates the potential of using nanoparticle-based delivery systems as drug carriers for CNS disease with a focus on dementia.

Early investigation of a novel SI306 theranostic prodrug for glioblastoma treatment

Glioblastoma multiforme (GBM) is one of the most aggressive malignancies with a high recurrence rate and poor prognosis. Theranostic, combining therapeutic and diagnostic approaches, arises as a successful strategy to improve patient outcomes through personalized medicine. Src is a non-receptor tyrosine kinase (nRTK) whose involvement in GBM has been extensively demonstrated. Our previous research highlighted the effectiveness of the pyrazolo[3,4-d]pyrimidine SI306 and its more soluble prodrug CMP1 as Src inhibitors both in in vitro and in vivo GBM models. In this scenario, we decided to develop a theranostic prodrug of SI306, ProSI-DOTA(68 Ga) 1, which was designed to target GBM cells after hydrolysis and follow-up on the disease's progression and improve the therapy's outcome. First, the corresponding nonradioactive prodrug 2 was tested to evaluate its ADME profile and biological activity. It showed good metabolic stability, no inhibition of CYP3A4, suboptimal aqueous solubility, and slight gastrointestinal and blood-brain barrier passive permeability. Compound 2 exhibited a drastic reduction of cell vitality after 72 h on two different GBM cell lines (GL261 and U87MG). Then, 2 was subjected to complexation with the radionuclide Gallium-68 to give ProSI-DOTA(68 Ga) 1. The cellular uptake of 1 was evaluated on GBM cells, highlighting a slight but significant time-dependent uptake. The data obtained from our preliminary studies reflect the physiochemical properties of 1. The use of an alternative route of administration, such as the intranasal route, could overcome the physiochemical limitations and enhance the pharmacokinetic properties of 1, paving the way for its future development.

Rare Earths-The Answer to Everything

Rare earths, scandium, yttrium, and the fifteen lanthanoids from lanthanum to lutetium, are classified as critical metals because of their ubiquity in daily life. They are present in magnets in cars, especially electric cars; green electricity generating systems and computers; in steel manufacturing; in glass and light emission materials especially for safety lighting and lasers; in exhaust emission catalysts and supports; catalysts in artificial rubber production; in agriculture and animal husbandry; in health and especially cancer diagnosis and treatment; and in a variety of materials and electronic products essential to modern living. They have the potential to replace toxic chromates for corrosion inhibition, in magnetic refrigeration, a variety of new materials, and their role in agriculture may expand. This review examines their role in sustainability, the environment, recycling, corrosion inhibition, crop production, animal feedstocks, catalysis, health, and materials, as well as considering future uses.

Radiopharmaceuticals: navigating the frontier of precision medicine and therapeutic innovation

This review article explores the dynamic field of radiopharmaceuticals, where innovative developments arise from combining radioisotopes and pharmaceuticals, opening up exciting therapeutic possibilities. The in-depth exploration covers targeted drug delivery, delving into passive targeting through enhanced permeability and retention, as well as active targeting using ligand-receptor strategies. The article also discusses stimulus-responsive release systems, which orchestrate controlled release, enhancing precision and therapeutic effectiveness. A significant focus is placed on the crucial role of radiopharmaceuticals in medical imaging and theranostics, highlighting their contribution to diagnostic accuracy and image-guided curative interventions. The review emphasizes safety considerations and strategies for mitigating side effects, providing valuable insights into addressing challenges and achieving precise drug delivery. Looking ahead, the article discusses nanoparticle formulations as cutting-edge innovations in next-generation radiopharmaceuticals, showcasing their potential applications. Real-world examples are presented through case studies, including the use of radiolabelled antibodies for solid tumors, peptide receptor radionuclide therapy for neuroendocrine tumors, and the intricate management of bone metastases. The concluding perspective envisions the future trajectory of radiopharmaceuticals, anticipating a harmonious integration of precision medicine and artificial intelligence. This vision foresees an era where therapeutic precision aligns seamlessly with scientific advancements, ushering in a new epoch marked by the fusion of therapeutic resonance and visionary progress.

Gallium68-Labeled Fibroblast Activation Protein Inhibitor (68Ga-FAPI) PET/CT as an Alternative to Fluoro18-Fluorodeoxyglucose (18F-FDG) PET/CT: Discussion in a Case of Metastatic Adenocarcinoma of Pancreas

Positron emission tomography (PET) is an integral part of the imaging of solid tumors in today's oncology practice. The most commonly used PET radiotracer is 18F-Fluorodeoxyglucose (18F-FDG). FDG PET has imaging characteristics of a high tumor-to-background uptake ratio and is used in the detection of primary as well as metastatic sites. However, a significant pitfall is its inability to differentiate between neoplastic and infective lesions. To address this concern, many PET radiotracers have been developed and tried over time, a promising one being radiolabelled fibroblast activation protein inhibitor (FAPI). Fibroblast-activated protein (FAP) is a type II transmembrane glycoprotein expressed by cancer-associated fibroblasts (CAFs); it forms a significant component of the tumor stroma. Since there is over-expression of CAF in the majority of malignancies, it is a potential target for molecular imaging using PET. Several radiolabeled FAP inhibitors have been developed for PET imaging of malignancies and have also been used in theranostic applications.

Unveiling a Biomarker Signature of Meningioma: The Need for a Panel of Genomic, Epigenetic, Proteomic, and RNA Biomarkers to Advance Diagnosis and Prognosis

Meningiomas are the most prevalent primary intracranial tumors. The majority are benign but can undergo dedifferentiation into advanced grades classified by World Health Organization (WHO) into Grades 1 to 3. Meningiomas' tremendous variability in tumor behavior and slow growth rates complicate their diagnosis and treatment. A deeper comprehension of the molecular pathways and cellular microenvironment factors implicated in meningioma survival and pathology is needed. This review summarizes the known genetic and epigenetic aberrations involved in meningiomas, with a focus on neurofibromatosis type 2 (NF2) and non-NF2 mutations. Novel potential biomarkers for meningioma diagnosis and prognosis are also discussed, including epigenetic-, RNA-, metabolomics-, and protein-based markers. Finally, the landscape of available meningioma-specific animal models is overviewed. Use of these animal models can enable planning of adjuvant treatment, potentially assisting in pre-operative and post-operative decision making. Discovery of novel biomarkers will allow, in combination with WHO grading, more precise meningioma grading, including meningioma identification, subtype determination, and prediction of metastasis, recurrence, and response to therapy. Moreover, these biomarkers may be exploited in the development of personalized targeted therapies that can distinguish between the 15 diverse meningioma subtypes.

Optimized Methods for the Production of High-Purity 203Pb Using Electroplated Thallium Targets

203Pb is a surrogate imaging match for 212Pb. This elementally matched pair is emerging as a suitable pair for imaging and targeted radionuclide therapy in cancer care. Because of the half-life (51.9 h) and low-energy γ-rays emitted, 203Pb is suitable for the development of diagnostic radiopharmaceuticals. The aim of this work was to optimize the production and separation of high-specific-activity 203Pb using electroplated thallium targets. We further investigated the radiochemistry optimization using a suitable chelator, tetraazacyclododecane-1,4,7-triacetic acid (DO3A), and targeting vector, VMT-α-NET (lead-specific chelator conjugated to tyr3-octreotide via a polyethylene glycol linker). Methods: Targets were prepared by electroplating of natural or enriched (205Tl) thallium metal. Scanning electron microscopy was performed to determine the structure and elemental composition of electroplated targets. Targets were irradiated with 24-MeV protons with varying current and beam time to investigate target durability. 203Pb was purified from the thallium target material using an extraction resin (lead resin) column followed by a second column using a weak cation-exchange resin to elute the lead isotope as [203Pb]PbCl2 Inductively coupled plasma mass spectrometry studies were used to further characterize the separation for trace metal contaminants. Radiolabeling efficiency was also investigated for DO3A chelator and VMT-α-NET (a peptide-based targeting conjugate). Results: Electroplated targets were prepared at a high plating density of 76-114 mg/cm2 using a plating time of 5 h. A reproducible separation method was established with a final elution in HCl (400 μL, 1 M) suitable for radiolabeling. Greater than 90% recovery yields were achieved, with an average specific activity of 37.7 ± 5.4 GBq/μmol (1.1 ± 0.1 Ci/μmol). Conclusion: An efficient electroplating method was developed to prepare thallium targets suitable for cyclotron irradiation. A simple and fast separation method was developed for routine 203Pb production with high recovery yields and purity.

AI and machine learning ethics, law, diversity, and global impact

Artificial intelligence (AI) and its machine learning (ML) algorithms are offering new promise for personalized biomedicine and more cost-effective healthcare with impressive technical capability to mimic human cognitive capabilities. However, widespread application of this promising technology has been limited in the medical domain and expectations have been tampered by ethical challenges and concerns regarding patient privacy, legal responsibility, trustworthiness, and fairness. To balance technical innovation with ethical applications of AI/ML, developers must demonstrate the AI functions as intended and adopt strategies to minimize the risks for failure or bias. This review describes the new ethical challenges created by AI/ML for clinical care and identifies specific considerations for its practice in medicine. We provide an overview of regulatory and legal issues applicable in Europe and the United States, a description of technical aspects to consider, and present recommendations for trustworthy AI/ML that promote transparency, minimize risks of bias or error, and protect the patient well-being.

Evaluation of the therapeutic efficacy of 213Bi-labelled DOTA-conjugated alpha-melanocyte stimulating hormone peptide analogues in melanocortin-1 receptor positive preclinical melanoma model

Melanocortin-1 receptor (MC1-R) targeting alpha-melanocyte stimulating hormone-analogue (α-MSH) biomolecules labelled with α-emitting radiometal seem to be valuable in the targeted radionuclide therapy of MC1-R positive melanoma malignum (MM). Herein is reported the anti-tumor in vivo therapeutic evaluation of MC1-R-affine [213Bi]Bi-DOTA-NAPamide and HOLDamide treatment in MC1-R positive B16-F10 melanoma tumor-bearing C57BL/6J mice. On the 6th, 8th and 10th days post tumor cell inoculation; the treated groups of mice were intravenously injected with approximately 5 MBq of both amide derivatives. Beyond body weight and tumor volume assessment, [68Ga]Ga-DOTA-HOLDamide and NAPamide-based PET/MRI scans, and ex vivo biodistribution studies were executed 30,- and 90 min postinjection. In the PET/MRI imaging studies the B16-F10 tumors were clearly visualized with both 68Ga-labelled tracers, however, significantly lower tumor-to-muscle (T/M) ratios were observed by using [68Ga]Ga-DOTA-HOLDamide. After alpha-radiotherapy treatment the tumor size of the control group was larger relative to both treated cohorts, while the smallest tumor volumes were observed in the NAPamide-treated subclass on the 10th day. Relatively higher [213Bi]Bi-DOTA-NAPamide accumulation in the B16-F10 tumors (%ID/g: 2.71 ± 0.15) with discrete background activity led to excellent T/M ratios, particularly 90 min postinjection. Overall, the therapeutic application of receptor selective [213Bi]Bi-DOTA-NAPamide seems to be feasible in MC1-R positive MM management.

Precision medicine in gastroenteropancreatic neuroendocrine neoplasms: Where are we in 2023?

Precision medicine describes a target-related approach to tailoring diagnosis and treatment of the individual patient. While this personalized approach is revoluzionizing many areas of oncology, it is quite late in the field of gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs), in which there are few molecular alterations to be therapeutically targeted. We critically reviewed the current evidence about precision medicine in GEP NENs, focusing on potential clinically relevant actionable targets for GEP NENs, such as the mTOR pathway, MGMT, hypoxia markers, RET, DLL-3, and some general agnostic targets. We analysed the main investigational approaches with solid and liquid biopsies. Furthermore, we reviewed a model of precision medicine more specific for NENs that is the theragnostic use of radionuclides. Overall, currently no true predictive factors for therapy have been validated so far in GEP NENs, and the personalized approach is based more on clinical thinking within a NEN-dedicated multidisciplinary team. However, there is a robust background to suppose that precision medicine, with the theragnostic model will yield new insights in this context soon.

Head-to-Head Comparison of FDG and Radiolabeled FAPI PET: A Systematic Review of the Literature

FAPI-based radiopharmaceuticals are a novel class of tracers, mainly used for PET imaging, which have demonstrated several advantages over [18F]FDG, especially in the case of low-grade or well-differentiated tumors. We conducted this systematic review to evaluate all the studies where a head-to-head comparison had been performed to explore the potential utility of FAPI tracers in clinical practice. FAPI-based radiopharmaceuticals have shown promising results globally, in particular in detecting peritoneal carcinomatosis, but studies with wider populations are needed to better understand all the advantages of these new radiopharmaceuticals.

Predicting [177Lu]Lu-HA-DOTATATE kidney and tumor accumulation based on [68Ga]Ga-HA-DOTATATE diagnostic imaging using semi-physiological population pharmacokinetic modeling

BACKGROUND

Prediction of [177Lu]Lu-HA-DOTATATE kidney and tumor uptake based on diagnostic [68Ga]Ga-HA-DOTATATE imaging would be a crucial step for precision dosing of [177Lu]Lu-HA-DOTATATE. In this study, the population pharmacokinetic (PK) differences between [177Lu]Lu-HA-DOTATATE and [68Ga]Ga-HA-DOTATATE were assessed and subsequently [177Lu]Lu-HA-DOTATATE was predicted based on [68Ga]Ga-HA-DOTATATE imaging.

METHODS

A semi-physiological nonlinear mixed-effects model was developed for [68Ga]Ga-HA-DOTATATE and [177Lu]Lu-HA-DOTATATE, including six compartments (representing blood, spleen, kidney, tumor lesions, other somatostatin receptor expressing organs and a lumped rest compartment). Model parameters were fixed based on a previously developed physiologically based pharmacokinetic model for [68Ga]Ga-HA-DOTATATE. For [177Lu]Lu-HA-DOTATATE, PK parameters were based on literature values or estimated based on scan data (four time points post-injection) from nine patients. Finally, individual [177Lu]Lu-HA-DOTATATE uptake into tumors and kidneys was predicted based on individual [68Ga]Ga-HA-DOTATATE scan data using Bayesian estimates. Predictions were evaluated compared to observed data using a relative prediction error (RPE) for both area under the curve (AUC) and absorbed dose. Lastly, to assess the predictive value of diagnostic imaging to predict therapeutic exposure, individual prediction RPEs (using Bayesian estimation) were compared to those from population predictions (using the population model).

RESULTS

Population uptake rate parameters for spleen, kidney and tumors differed by a 0.29-fold (15% relative standard error (RSE)), 0.49-fold (15% RSE) and 1.43-fold (14% RSE), respectively, for [177Lu]Lu-HA-DOTATATE compared to [68Ga]Ga-HA-DOTATATE. Model predictions adequately described observed data in kidney and tumors for both peptides (based on visual inspection of goodness-of-fit plots). Individual predictions of tumor uptake were better (RPE AUC -40 to 28%) compared to kidney predictions (RPE AUC -53 to 41%). Absorbed dose predictions were less predictive for both tumor and kidneys (RPE tumor and kidney -51 to 44% and -58 to 82%, respectively). For most patients, [177Lu]Lu-HA-DOTATATE tumor accumulation predictions based on individual PK parameters estimated from diagnostic imaging outperformed predictions based on population parameters.

CONCLUSION

Our semi-physiological PK model indicated clear differences in PK parameters for [68Ga]Ga-HA-DOTATATE and [177Lu]Lu-HA-DOTATATE. Diagnostic images provided additional information to individually predict [177Lu]Lu-HA-DOTATATE tumor uptake compared to using a population approach. In addition, individual predictions indicated that many aspects, apart from PK differences, play a part in predicting [177Lu]Lu-HA-DOTATATE distribution.

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.

Comparison of the Effects of DOTA and NOTA Chelators on 64Cu-Cudotadipep and 64Cu-Cunotadipep for Prostate Cancer

BACKGROUND

This study compared the effects of 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) and 1,4,7-triazacyclononane-1,4,7-triacetic acid (NOTA) as 64Cu-chelating agents in newly developed prostate-specific membrane antigen (PSMA) target compounds, 64Cu-cudotadipep and 64Cu-cunotadipep, on pharmacokinetics.

METHODS

The in vitro stability of the chelators was evaluated using human and mouse serum. In vitro PSMA-binding affinity and cell uptake were compared using human 22Rv1 cells. To evaluate specific PSMA-expressing tumor-targeting efficiency, micro-positron emission tomography (mcroPET)/computed tomography (CT) and biodistribution analysis were performed using PSMA+ PC3-PIP and PSMA- PC3-flu tumor xenografts.

RESULTS

The serum stability of DOTA- or NOTA-conjugated 64Cu-cudotadipep and 64Cu-cunotadipep was >97%. The Ki value of the NOTA derivative, cunotadipep, in the in vitro affinity binding analysis was higher (2.17 ± 0.25 nM) than that of the DOTA derivative, cudotadipep (6.75 ± 0.42 nM). The cunotadipep exhibited a higher cellular uptake (6.02 ± 0.05%/1 × 106 cells) compared with the cudotadipep (2.93 ± 0.06%/1 × 106 cells). In the biodistribution analysis and microPET/CT imaging, the 64Cu-labeled NOTA derivative, 64Cu-cunotadipep, demonstrated a greater tumor uptake and lower liver uptake than the DOTA derivative.

CONCLUSIONS

This study indicates that the PSMA-targeted 64Cu-cunotadipep can be applied in clinical practice owing to its high diagnostic power for prostate cancer.

FAPI PET/CT Imaging-An Updated Review

Despite revolutionizing the field of oncological imaging, Positron Emission Tomography (PET) with [¹⁸F]Fluorodeoxyglucose (FDG) as its workhorse is limited by a lack of specificity and low sensitivity in certain tumor subtypes. Fibroblast activation protein (FAP), a type II transmembrane glycoprotein, is expressed by cancer-associated fibroblasts (CAFs) that form a major component of the tumor stroma. FAP holds the promise to be a pan-cancer target, owing to its selective over-expression in a vast majority of neoplasms, particularly epithelial cancers. Several radiolabeled FAP inhibitors (FAPI) have been developed for molecular imaging and potential theranostic applications. Preliminary data on FAPI PET/CT remains encouraging, with extensive multi-disciplinary clinical research currently underway. This review summarizes the existing literature on FAPI PET/CT imaging with an emphasis on diagnostic applications, comparison with FDG, pitfalls, and future directions.

NEMA NU 1-2018 performance characterization and Monte Carlo model validation of the Cubresa Spark SiPM-based preclinical SPECT scanner

BACKGROUND

The Cubresa Spark is a novel benchtop silicon-photomultiplier (SiPM)-based preclinical SPECT system. SiPMs in SPECT significantly improve resolution and reduce detector size compared to preclinical cameras with photomultiplier tubes requiring highly magnifying collimators. The NEMA NU 1 Standard for Performance Measurements of Gamma Cameras provides methods that can be readily applied or extended to characterize preclinical cameras with minor modifications. The primary objective of this study is to characterize the Spark according to the NEMA NU 1-2018 standard to gain insight into its nuclear medicine imaging capabilities. The secondary objective is to validate a GATE Monte Carlo simulation model of the Spark for use in preclinical SPECT studies.

METHODS

NEMA NU 1-2018 guidelines were applied to characterize the Spark's intrinsic, system, and tomographic performance with single- and multi-pinhole collimators. Phantoms were fabricated according to NEMA specifications with deviations involving high-resolution modifications. GATE was utilized to model the detector head with the single-pinhole collimator, and NEMA measurements were employed to tune and validate the model. Single-pinhole and multi-pinhole SPECT data were reconstructed with the Software for Tomographic Image Reconstruction and HiSPECT, respectively.

RESULTS

The limiting intrinsic resolution was measured as 0.85 mm owing to a high-resolution SiPM array combined with a 3 mm-thick scintillation crystal. The average limiting tomographic resolution was 1.37 mm and 1.19 mm for the single- and multi-pinhole collimators, respectively, which have magnification factors near unity at the center of rotation. The maximum observed count rate was 15,400 cps, and planar sensitivities of 34 cps/MBq and 150 cps/MBq were measured at the center of rotation for the single- and multi-pinhole collimators, respectively. All simulated tests agreed well with measurement, where the most considerable deviations were below 7%.

CONCLUSIONS

NEMA NU 1-2018 standards determined that a SiPM detector mitigates the need for highly magnifying pinhole collimators while preserving detailed information in projection images. Measured and simulated NEMA results were highly comparable with differences on the order of a few percent, confirming simulation accuracy and validating the GATE model. Of the collimators initially provided with the Spark, the multi-pinhole collimator offers high resolution and sensitivity for organ-specific imaging of small animals, and the single-pinhole collimator enables high-resolution whole-body imaging of small animals.

Triple modality image reconstruction of PET data using SPECT, PET, CT information increases lesion uptake in images of patients treated with radioembolization with [Formula: see text] micro-spheres

PURPOSE

Nuclear medicine imaging modalities like computed tomography (CT), single photon emission CT (SPECT) and positron emission tomography (PET) are employed in the field of theranostics to estimate and plan the dose delivered to tumors and the surrounding tissues and to monitor the effect of the therapy. However, therapeutic radionuclides often provide poor images, which translate to inaccurate treatment planning and inadequate monitoring images. Multimodality information can be exploited in the reconstruction to enhance image quality. Triple modality PET/SPECT/CT scanners are particularly useful in this context due to the easier registration process between images. In this study, we propose to include PET, SPECT and CT information in the reconstruction of PET data. The method is applied to Yttrium-90 ([Formula: see text]Y) data.

METHODS

Data from a NEMA phantom filled with [Formula: see text]Y were used for validation. PET, SPECT and CT data from 10 patients treated with Selective Internal Radiation Therapy (SIRT) were used. Different combinations of prior images using the Hybrid kernelized expectation maximization were investigated in terms of VOI activity and noise suppression.

RESULTS

Our results show that triple modality PET reconstruction provides significantly higher uptake when compared to the method used as standard in the hospital and OSEM. In particular, using CT-guided SPECT images, as guiding information in the PET reconstruction significantly increases uptake quantification on tumoral lesions.

CONCLUSION

This work proposes the first triple modality reconstruction method and demonstrates up to 69% lesion uptake increase over standard methods with SIRT [Formula: see text]Y patient data. Promising results are expected for other radionuclide combination used in theranostic applications using PET and SPECT.

5-Aminolevulinic Acid as a Theranostic Agent for Tumor Fluorescence Imaging and Photodynamic Therapy

5-Aminolevulinic acid (ALA) is a naturally occurring amino acid synthesized in all nucleated mammalian cells. As a porphyrin precursor, ALA is metabolized in the heme biosynthetic pathway to produce protoporphyrin IX (PpIX), a fluorophore and photosensitizing agent. ALA administered exogenously bypasses the rate-limit step in the pathway, resulting in PpIX accumulation in tumor tissues. Such tumor-selective PpIX disposition following ALA administration has been exploited for tumor fluorescence diagnosis and photodynamic therapy (PDT) with much success. Five ALA-based drugs have now received worldwide approval and are being used for managing very common human (pre)cancerous diseases such as actinic keratosis and basal cell carcinoma or guiding the surgery of bladder cancer and high-grade gliomas, making it the most successful drug discovery and development endeavor in PDT and photodiagnosis. The potential of ALA-induced PpIX as a fluorescent theranostic agent is, however, yet to be fully fulfilled. In this review, we would like to describe the heme biosynthesis pathway in which PpIX is produced from ALA and its derivatives, summarize current clinical applications of ALA-based drugs, and discuss strategies for enhancing ALA-induced PpIX fluorescence and PDT response. Our goal is two-fold: to highlight the successes of ALA-based drugs in clinical practice, and to stimulate the multidisciplinary collaboration that has brought the current success and will continue to usher in more landmark advances.

Activatable dual-functional molecular agents for imaging-guided cancer therapy

Theranostics has attracted great attention due to its ability to combine the real-time diagnosis of cancers with efficient treatment modalities. Activatable dual-functional molecular agents could be synthesized by covalently conjugating imaging agents, therapeutic agents, stimuli-responsive linkers and/or targeting molecules together. They could be selectively activated by overexpressed physiological stimuli or external triggers at the tumor sites to release imaging agents and cytotoxic drugs, thus offering many advantages for tumor imaging and therapy, such as a high signal-to-noise ratio, low systemic toxicity, and improved therapeutic effects. This review summarizes the recent advances of dual-functional molecular agents that respond to various physiological or external stimuli for cancer theranostics. The molecular designs, synthetic strategies, activatable mechanisms, and biomedical applications of these molecular agents are elaborated, followed by a brief discussion of the challenges and opportunities in this field.

Imaging biomarkers for clinical applications in neuro-oncology: current status and future perspectives

Biomarker discovery and development are popular for detecting the subtle diseases. However, biomarkers are needed to be validated and approved, and even fewer are ever used clinically. Imaging biomarkers have a crucial role in the treatment of cancer patients because they provide objective information on tumor biology, the tumor's habitat, and the tumor's signature in the environment. Tumor changes in response to an intervention complement molecular and genomic translational diagnosis as well as quantitative information. Neuro-oncology has become more prominent in diagnostics and targeted therapies. The classification of tumors has been actively updated, and drug discovery, and delivery in nanoimmunotherapies are advancing in the field of target therapy research. It is important that biomarkers and diagnostic implements be developed and used to assess the prognosis or late effects of long-term survivors. An improved realization of cancer biology has transformed its management with an increasing emphasis on a personalized approach in precision medicine. In the first part, we discuss the biomarker categories in relation to the courses of a disease and specific clinical contexts, including that patients and specimens should both directly reflect the target population and intended use. In the second part, we present the CT perfusion approach that provides quantitative and qualitative data that has been successfully applied to the clinical diagnosis, treatment and application. Furthermore, the novel and promising multiparametric MR imageing approach will provide deeper insights regarding the tumor microenvironment in the immune response. Additionally, we briefly remark new tactics based on MRI and PET for converging on imaging biomarkers combined with applications of bioinformatics in artificial intelligence. In the third part, we briefly address new approaches based on theranostics in precision medicine. These sophisticated techniques merge achievable standardizations into an applicatory apparatus for primarily a diagnostic implementation and tracking radioactive drugs to identify and to deliver therapies in an individualized medicine paradigm. In this article, we describe the critical principles for imaging biomarker characterization and discuss the current status of CT, MRI and PET in finiding imaging biomarkers of early disease.

Green Synthesis, Characterization and Bioactivity of Mangifera indica Seed-Wrapped Zinc Oxide Nanoparticles

In the realm of nanoparticles, metal-based nanoparticles have traditionally been regarded as the pioneering category. Compared to other nanoparticles, zinc oxide nanoparticles have several advantages, including optical and biological properties, which provide them a significant competitive advantage in clinical and biological applications. In the current investigation, we used an aqueous Mangifera indica seed extract to synthesize nanoparticles of zinc oxide (ZnO NPs). UV-Vis spectroscopy, Fourier transform infrared spectroscopy analysis, atomic force spectroscopy, X-ray diffraction, scanning electron microscopy, and transmission electron microscopy were used to characterize the synthesized ZnO NPs. The nanoparticles were assessed for their potential to inhibit bacterial growth and protect cells from free radical damage. According to the current study's findings, zinc oxide nanoparticles that had been modified with the aid of mango seeds were very efficient in preventing the development of the tested bacteria and were also powerful antioxidants.

Advances in Radionuclides and Radiolabelled Peptides for Cancer Therapeutics

Radiopharmaceutical therapy, which can detect and treat tumours simultaneously, was introduced more than 80 years ago, and it has changed medical strategies with respect to cancer. Many radioactive radionuclides have been developed, and functional, molecularly modified radiolabelled peptides have been used to produce biomolecules and therapeutics that are vastly utilised in the field of radio medicine. Since the 1990s, they have smoothly transitioned into clinical application, and as of today, a wide variety of radiolabelled radionuclide derivatives have been examined and evaluated in various studies. Advanced technologies, such as conjugation of functional peptides or incorporation of radionuclides into chelating ligands, have been developed for advanced radiopharmaceutical cancer therapy. New radiolabelled conjugates for targeted radiotherapy have been designed to deliver radiation directly to cancer cells with improved specificity and minimal damage to the surrounding normal tissue. The development of new theragnostic radionuclides, which can be used for both imaging and therapy purposes, allows for more precise targeting and monitoring of the treatment response. The increased use of peptide receptor radionuclide therapy (PRRT) is also important in the targeting of specific receptors which are overexpressed in cancer cells. In this review, we provide insights into the development of radionuclides and functional radiolabelled peptides, give a brief background, and describe their transition into clinical application.

Main challenges in radiation protection with emerging radionuclide therapies

The recent development of radionuclide therapy and radioligand therapy has raised a call for achieving the highest quality standards, for either radiopharmacy or radiation protection. Novel radionuclides are now being used, either under the form of in-house production radiopharmaceuticals or available from companies. Over the last 20 years, they include radiolabeled microspheres for selective internal radiotherapy (SIRT), the introduction of the first commercially available alpha emitter radiopharmaceutical, ²²³Ra, and the radiosynoviorthesis which is highly variable across Europe. More important is the development of radioligand therapy, often called theranostics. In this concept, a diagnostic radiopharmaceutical can determine the chance of success of a therapeutic one. Typically, diagnostic radiopharmaceuticals for positron emission tomography, are labeled with ¹⁸F or ⁶⁸Ga, such as the PSMA ligands or somatostatin analogs, and the therapeutic radiopharmaceutical is labeled with ¹⁷⁷Lu. This has revolutionized the world of Nuclear Medicine, but also all concepts that shall be applied to properly apply quality assurance and radiation protection in the field. This article will follow the example of ¹³¹I as the main used radionuclide for therapy during the last 80 years. Proposals can be general, and in parallel expert's articles will give specific guidance on issues with particular radionuclides, i.e., alpha emitters and ¹⁷⁷Lu. This article will also give insight in the radiation protection issues related to the use of microspheres radiolabeled with either ⁹⁰Y or ¹⁶⁶Ho.

Evaluation of Therapeutic Efficacy and Imaging Capabilities of 153Sm2O3-Loaded Polystyrene Microspheres for Intra-Tumoural Radionuclide Therapy of Liver Cancer Using Sprague-Dawley Rat Model

Introduction: Neutron-activated samarium-153-oxide-loaded polystyrene ([¹⁵³Sm]Sm₂O₃-PS) microspheres has been developed in previous study as a potential theranostic agent for hepatic radioembolization. In this study, the therapeutic efficacy and diagnostic imaging capabilities of the formulation was assessed using liver cancer Sprague-Dawley (SD) rat model. Methods: Twelve male SD rats (150-200 g) that implanted with N1-S1 hepatoma cell line orthotopically were divided into two groups (study versus control) to monitor the tumour growth along 60 days of treatment. The study group received an intra-tumoural injection of approximately 37 MBq of [¹⁵³Sm]Sm₂O₃-PS microspheres, while control group received an intra-tumoural injection of 0.1 mL of saline solution. A clinical single photon emission computed tomography/computed tomography (SPECT/CT) system was used to scan the rats at Day 5 post-injection to investigate the diagnostic imaging capabilities of the microspheres. All rats were monitored for change in tumour volume using a portable ultrasound system throughout the study period. Histopathological examination (HPE) was performed after the rats were euthanized at Day 60. Results: At Day 60, no tumour was observed on the ultrasound images of all rats in the study group. In contrast, the tumour volumes in the control group were 24-fold larger compared to baseline. Statistically significant difference was observed in tumour volumes between the study and control groups (p < 0.05). The SPECT/CT images clearly displayed the location of [¹⁵³Sm]Sm₂O₃-PS in the liver tumour of all rats at Day 5 post-injection. Additionally, the [¹⁵³Sm]Sm₂O₃-PS microspheres was visible on the CT images and this has added to the benefits of ¹⁵³Sm as a CT contrast agent. The HPE results showed that the [¹⁵³Sm]Sm₂O₃-PS microspheres remained concentrated at the injection site with no tumour cells observed in the study group. Conclusions: Neutron-activated [¹⁵³Sm]Sm₂O₃-PS microspheres demonstrated excellent therapeutic and diagnostic imaging capabilities for theranostic treatment of liver cancer in a SD rat model. Further studies with different animal and tumour models are planned to validate this finding.

Automation: A revolutionary vision of artificial intelligence in theranostics

The last two decades have witnessed an extraordinary evolution of automation and artificial intelligence (AI), which has become an integral part of our daily lives. Lately, AI has also been assimilated in the field of medicine to upgrade overall healthcare system and encourage personalized treatment. Theranostics literally meaning combination of diagnosis and therapeutics, is a targeted pharmacotherapy, based on specific targeted diagnostic tests. Numerous theranostic agents/biomarkers are available which can identify the most beneficial treatment, correct dose or predict response to a medicine, thus, maximizing drug efficacy, minimizing toxicity and providing informed treatment choice. For instance, a statistics based Cluster-FLIM technology provides precise data on drug-receptor binding behavior in biological tissues using fluorescence real experimental imaging. Automated Idylla™ qPCR System is another approach in oncology to determine the EGFR mutations at initial stage as well as during the treatment and also assists the oncologist in designing the treatment protocol. Recent incorporation of automation and AI in theranostics has brought a drastic change in early detection and treatment protocols for various diseases such as cancer and diabetes. Also, it leads to quick analysis of number of diverse experimental datum with accuracy. The approach mainly uses computer algorithms to unveil relevant and significant information from clinical data, thereby assisting in making accurate, logical and pertinent decisions. This review highlights the emerging uses/role of automation and AI in theranostics, technical difficulties and focuses on its future prospects to facilitate a patient specific, reliable and efficient pharmacotherapy.

Practical Approaches to Advancing Health Equity in Radiology, From the AJR Special Series on DEI

Despite significant advances in healthcare, many patients from medically underserved populations are impacted by existing healthcare disparities. Radiologists are uniquely positioned to decrease health disparities and advance health equity efforts in their practices. However, literature on practical tools for advancing radiology health equity efforts applicable to a wide variety of patient populations and care settings is lacking. Therefore, this article seeks to equip radiologists with an evidence-based and practical knowledge toolkit of health equity strategies, presented in terms of four pillars of research, clinical care, education, and innovation. For each pillar, equity efforts across diverse patient populations and radiology practice settings are examined through the lens of existing barriers, current best practices, and future directions, incorporating practical examples relevant to a spectrum of patient populations. Health equity efforts provide an opportune window to transform radiology through personalized care delivery that is responsive to diverse patient needs. Guided by compassion and empathy as core principles of health equity, leveraging the four pillars provides a helpful framework to advance health equity efforts as a step towards social justice in health.

A Theranostic Approach in SIRT: Value of Pre-Therapy Imaging in Treatment Planning

Selective internal radiation therapy (SIRT) is one of the treatment options for liver tumors. Microspheres labelled with a therapeutic radionuclide (⁹⁰Y or ¹⁶⁶Ho) are injected into the liver artery feeding the tumor(s), usually achieving a high tumor absorbed dose and a high tumor control rate. This treatment adopts a theranostic approach with a mandatory simulation phase, using a surrogate to radioactive microspheres (^99mTc-macroaggregated albumin, MAA) or a scout dose of ¹⁶⁶Ho microspheres, imaged by SPECT/CT. This pre-therapy imaging aims to evaluate the tumor targeting and detect potential contraindications to SIRT, i.e., digestive extrahepatic uptake or excessive lung shunt. Moreover, the absorbed doses to the tumor(s) and the healthy liver can be estimated and used for planning the therapeutic activity for SIRT optimization. The aim of this review is to evaluate the accuracy of this theranostic approach using pre-therapy imaging for simulating the biodistribution of the microspheres. This review synthesizes the recent publications demonstrating the advantages and limitations of pre-therapy imaging in SIRT, particularly for activity planning.

Organ dose calculator for diagnostic nuclear medicine patients based on the ICRP reference voxel phantoms and biokinetic models

The exponential growth in the use of nuclear medicine procedures represents a general radiation safety concern and stresses the need to monitor exposure levels and radiation-related long term health effects in NM patients. In the current study, following our previous work on NCINM version 1 based on the UF/NCI hybrid phantom series, we calculated a comprehensive library of S values using the ICRP reference pediatric and adult voxel phantoms and established a library of biokinetic data from multiple ICRP Publications, which were then implemented into NCINM version 2. We calculated S values in two steps: calculation of specific absorbed fraction (SAF) using a Monte Carlo radiation transport code combined with the twelve ICRP pediatric and adult voxel phantoms for a number of combinations of source and target region pairs; derivation of S values from the SAFs using the ICRP nuclear decay data. We also adjusted the biokinetic data of 105 radiopharmaceuticals from multiple ICRP publications to match the anatomical description of the ICRP voxel phantoms. Finally, we integrated the ICRP phantom-based S values and adjusted biokinetic data into NCINM version 2. The ratios of cross-fire SAFs from NCINM 2 to NCINM 1 for the adult phantoms varied widely from 0.26 to 5.94 (mean = 1.24, IQR = 0.77-1.55) whereas the ratios for the pediatric phantoms ranged from 0.64 to 1.47 (mean = 1.01, IQR = 0.98-1.03). The ratios of absorbed dose coefficients from NCINM 2 over those from ICRP publications widely varied from 0.43 (colon for99mTc-ECD) to 2.57 (active marrow for99mTc-MAG3). NCINM 2.0 should be useful for dosimetrists and medical physicists to more accurately estimate organ doses for various nuclear medicine procedures.