Radioisotopic Purity of Sodium Pertechnetate 99mTc Produced with a Medium-Energy Cyclotron: Implications for Internal Radiation Dose, Image Quality, and Release Specifications

New strategies for a sustainable 99mTc supply to meet increasing medical demands: Promising solutions for current problems

The continuing rapid expansion of ^99mTc diagnostic agents always calls for scaling up ^99mTc production to cover increasing clinical demand. Nevertheless, ^99mTc availability depends mainly on the fission-produced ⁹⁹Mo supply. This supply is seriously influenced during renewed emergency periods, such as the past ⁹⁹Mo production crisis or the current COVID-19 pandemic. Consequently, these interruptions have promoted the need for ^99mTc production through alternative strategies capable of providing clinical-grade ^99mTc with high purity. In the light of this context, this review illustrates diverse production routes that either have commercially been used or new strategies that offer potential solutions to promote a rapid production growth of ^99mTc. These techniques have been selected, highlighted, and evaluated to imply their impact on developing ^99mTc production. Furthermore, their advantages and limitations, current situation, and long-term perspective were also discussed. It appears that, on the one hand, careful attention needs to be devoted to enhancing the ⁹⁹Mo economy. It can be achieved by utilizing ⁹⁸Mo neutron activation in commercial nuclear power reactors and using accelerator-based ⁹⁹Mo production, especially the photonuclear transmutation strategy. On the other hand, more research efforts should be devoted to widening the utility of ⁹⁹Mo/^99mTc generators, which incorporate nanomaterial-based sorbents and promote their development, validation, and full automization in the near future. These strategies are expected to play a vital role in providing sufficient clinical-grade ^99mTc, resulting in a reasonable cost per patient dose.

Analysis of radioactive waste generated during the cyclotron production of 99mTc

Past and prospective shortages of medical radioisotopes have driven recent developments in the direct production of ^99mTc via the ¹⁰⁰Mo(p,2n)^99mTc reaction. The cyclotron-based production method has been shown to successfully produce ^99mTc, however trace impurities present in the enriched molybdenum target can also lead to the unintended creation of other radioisotopes which constitute waste. The isotopic composition of the waste has to be investigated in order to determine how it can be handled, transported and safely stored. In this article, we report which waste radioisotopes are created alongside ^99mTc during target irradiation. Results are based on the gamma spectroscopy of waste produced. Significant complexities in the emission spectra made automated identification of radioisotopes inaccurate; complexities were resolved using a manual radioisotope identification procedure. The impact of target composition, integrated beam current and duration of target irradiation on the waste produced was studied. Results indicate that an average of 0.059  ±  0.003 GBq of waste is generated per 1 GBq of ^99mTc produced. Two-thirds of the total waste activity produced was attributed to ⁹⁹Mo (T _1/2  =  66 h) alone, while a total of fifty radioisotopes were found in the waste. Long-lived isotopes (T _1/2  >  2 months) constituted only 1% of the total waste activity at end of beam (EOB). In conclusion, it was determined that the waste generated during cyclotron-based ^99mTc production was acceptably low for routine clinical production.

Radioactive Transition Metals for Imaging and Therapy

Nuclear medicine is composed of two complementary areas, imaging and therapy. Positron emission tomography (PET) and single-photon imaging, including single-photon emission computed tomography (SPECT), comprise the imaging component of nuclear medicine. These areas are distinct in that they exploit different nuclear decay processes and also different imaging technologies. In PET, images are created from the 511 keV photons produced when the positron emitted by a radionuclide encounters an electron and is annihilated. In contrast, in single-photon imaging, images are created from the γ rays (and occasionally X-rays) directly emitted by the nucleus. Therapeutic nuclear medicine uses particulate radiation such as Auger or conversion electrons or β^- or α particles. All three of these technologies are linked by the requirement that the radionuclide must be attached to a suitable vector that can deliver it to its target. It is imperative that the radionuclide remain attached to the vector before it is delivered to its target as well as after it reaches its target or else the resulting image (or therapeutic outcome) will not reflect the biological process of interest. Radiochemistry is at the core of this process, and radiometals offer radiopharmaceutical chemists a tremendous range of options with which to accomplish these goals. They also offer a wide range of options in terms of radionuclide half-lives and emission properties, providing the ability to carefully match the decay properties with the desired outcome. This Review provides an overview of some of the ways this can be accomplished as well as several historical examples of some of the limitations of earlier metalloradiopharmaceuticals and the ways that new technologies, primarily related to radionuclide production, have provided solutions to these problems.

In-house cyclotron production of high-purity Tc-99m and Tc-99m radiopharmaceuticals

In the last years, the technology for producing the important medical radionuclide technetium-99m by cyclotrons has become sufficiently mature to justify its introduction as an alternative source of the starting precursor [^99mTc][TcO₄]^- ubiquitously employed for the production of ^99mTc-radiopharmaceuticals in hospitals. These technologies make use almost exclusively of the nuclear reaction ¹⁰⁰Mo(p,2n)^99mTc that allows direct production of Tc-99m. In this study, it is conjectured that this alternative production route will not replace the current supply chain based on the distribution of ⁹⁹Mo/^99mTc generators, but could become a convenient emergency source of Tc-99m only for in-house hospitals equipped with a conventional, low-energy, medical cyclotron. On this ground, an outline of the essential steps that should be implemented for setting up a hospital radiopharmacy aimed at the occasional production of Tc-99m by a small cyclotron is discussed. These include (1) target production, (2) irradiation conditions, (3) separation/purification procedures, (4) terminal sterilization, (5) quality control, and (6) Mo-100 recovery. To address these issues, a comprehensive technology for cyclotron-production of Tc-99m, developed at the Legnaro National Laboratories of the Italian National Institute of Nuclear Physics (LNL-INFN), will be used as a reference example.

95gTc and 96gTc as alternatives to medical radioisotope 99mTc

We studied 95gTc and 96gTc as alternatives to the medical radioisotope 99mTc. 96gTc (95gTc) can be produced by (p, n) reactions on an enriched 96Mo (95Mo) target with a proton beam provided by a compact accelerator such as a medical cyclotron that generate radioisotopes for positron emission tomography (PET). The γ-rays are measured with an electron-tracking Compton camera (ETCC). We calculated the relative intensities of the γ-rays from 95gTc and 96gTc. The calculated γ-ray intensity of a 96gTc (95gTc) nucleus is as high as 63% (70%) of that of a 99mTc nucleus. We also calculated the patient radiation doses of 95gTc and 96gTc, which were larger than that of 99mTc by a factor of 2-3 based on the applied assumptions. A medical PET cyclotron which can provide proton beams with energies of 11-12 MeV and a current of 100 μA can produce 12 GBq (39 GBq) of 96gTc (95gTc) for operation time of 8 h, which can be used for 240 (200) diagnostic scans.

Recent achievements in Tc-99m radiopharmaceutical direct production by medical cyclotrons

^99mTc is the most commonly used radionuclide in the field of diagnostic imaging, a noninvasive method intended to diagnose a disease, assess the disease state and monitor the effects of treatments. Annually, the use of ^99mTc, covers about 85% of nuclear medicine applications. This isotope releases gamma rays at about the same wavelength as conventional X-ray diagnostic equipment, and owing to its short half-life (t_½ = 6 h) is ideal for diagnostic nuclear imaging. A patient can be injected with a small amount of ^99mTc and within 24 h almost 94% of the injected radionuclide would have decayed and left the body, limiting the patient's radiation exposure. ^99mTc is usually supplied to hospitals through a ⁹⁹Mo/^99mTc radionuclide generator system where it is produced from the β decay of the parent nuclide ⁹⁹Mo (t_½ = 66 h), which is produced in nuclear reactors via neutron fission. Recently, the interruption of the global supply chain of reactor-produced ⁹⁹Mo, has forced the scientific community to investigate alternative production routes for ^99mTc. One solution was to consider cyclotron-based methods as potential replacement of reactor-based technology and the nuclear reaction ¹⁰⁰Mo(p,2n)^99mTc emerged as the most worthwhile approach. This review reports some achievements about ^99mTc produced by medical cyclotrons. In particular, the available technologies for target design, the most efficient extraction and separation procedure developed for the purification of ^99mTc from the irradiated targets, the preparation of high purity ^99mTc radiopharmaceuticals and the first clinical studies carried out with cyclotron produced ^99mTc are described.

Imaging study of using radiopharmaceuticals labeled with cyclotron-produced 99mTc

Cyclotron-produced ^99mTc (CPTc) has been recognized as an attractive and practical substitution of reactor/generator based ^99mTc. However, the small amount of ^92-98Mo in the irradiation of enriched ¹⁰⁰Mo could lead to the production of other radioactive technetium isotopes (Tc-impurities) which cannot be chemically separated. Thus, these impurities could contribute to patient dose and affect image quality. The potential radiation dose caused by these Tc-impurities produced using different targets, irradiation conditions, and corresponding to different injection times have been investigated, leading us to create dose-based limits of these parameters for producing clinically acceptable CPTc. However, image quality has been not considered. The aim of the present work is to provide a comprehensive and quantitative analysis of image quality for CPTc. The impact of Tc-impurities in CPTc on image resolution, background noise, and contrast is investigated by performing both Monte-Carlo simulations and phantom experiments. Various targets, irradiation, and acquisition conditions are employed for investigating the image-based limits of CPTc production parameters. Additionally, the relationship between patient dose and image quality of CPTc samples is studied. Only those samples which meet both dose- and image-based limits should be accepted in future clinical studies.