Theranostics in Nuclear Medicine in the Era of Precision Oncology

Targeted CE per ARRT’s Discipline, Category, and Subcategory classification:

Nuclear Medicine Technology: 3.50
Procedures: 3.50
Radionuclides and Radiopharmaceuticals: 1.00
Endocrine and Oncology Procedures: 2.50

Outline

1. Introduction
2. Contextualization of Nuclear Theranostics
3. Classic Theranostic Agents
   1. Radioiodine for Differentiated Thyroid Cancer
      1. Rationale and Clinical Aspects
      2.  ¹³¹I-MIBG for Neural Crest-Derived Tumors
      3. Rationale and Clinical Aspects
      4. Neuroblastoma
      5. Pheochromocytoma and Paraganglioma
   2. Bone-Seeking Therapeutic Radiopharmaceuticals
4. From Classic to Modern Theranostic Agents
   1. Somatostatin Analog Radioligands
      1. Rationale and Clinical Aspects
   2. PSMA Radioligands for Prostate Cancer
      1. Rationale and Clinical Aspects
   3. Bone-Seeking Agents Revisited
   4. Hepatic Radioembolization
5. FDG: The Antitheranostic Agent
6. Advantages and Limitations of Theranostics
   1. Advantages
   2. Limitations
7. Perspectives
8. Recently Introduced Agents
9. Combining Theranostics with Other Diagnostic and Treatment Modalities
10. Dosimetry
11. Conclusion

Objectives

Upon completion of this course, students will:

1. identify the year in which Paul Ehrlich proposed the concept of the “magic bullet”
2. identify the year in which the approach of theranostics was first proposed
3. describe the criteria that determine the imaging or therapeutic capability of radioisotopes
4. describe the types of radiation used for therapeutic nuclear medicine applications
5. identify isotopes that emit both electromagnetic and particulate radiation
6. list the therapeutic agents used for prostate cancer
7. list the diseases that are treated with ⁹⁰Y-labeled therapeutic agents
8. list examples of diagnostic or therapeutic components that comprise hybrid theranostic pairs
9. list the diseases that are managed using theranostic pairs associated with chemokine receptor type 4
10. identify the year in which radioactive iodine treatment for hyperthyroidism began
11. identify the physical half-life of ¹³¹I
12. identify the most used iodine radioisotope for diagnostic scintigraphy in the United States
13. describe the modality of choice for treating differentiated thyroid cancer in the postoperative setting
14. list the MIBG radiopharmaceuticals that are limited to use for diagnostic purposes only
15. identify the radioisotope that requires thyroid blocking with potassium iodide prior to use
16. describe the disease-free survival at 5 years for most patients with stage IV neuroblastoma
17. describe the type of radiation associated with the bone-seeking agents rhenium-186 HEDP, rhenium-188 HEDP, samarium-153 EDTMP, and strontium-89 chloride
18. list the bone-seeking therapeutic radiopharmaceuticals that are calcium analogs
19. identify the year in which the US Food and Drug administration approved the use of OctreoScan as an imaging radiopharmaceutical
20. describe the radiation emissions from ¹¹¹In that led to its use in the first PRRT procedures in 1992
21. list the DOTA-chelated peptides that were used in the first study of PRRT with ⁹⁰Y
22. identify the year in which ⁶⁸Ga-labeled SSTR analogs emerged
23. describe the most common noncutaneous cancer in males
24. describe the percentage of prostate cancer patients that develop metastatic disease
25. identify the cancer type for which ²²³Ra has been used to treat bone metastases
26. list the radioisotopes that have a similar mechanism of uptake as ²²³Ra
27. list the radiopharmaceuticals that are necessary to predict uptake of therapeutic radioisotopes by metastatic lesions
28. describe the composition of currently available radioactive microspheres
29. list the negative outcomes that are avoided by accurate placement of microspheres in the tumor region
30. identify the common molecular feature that is imaged by FDG PET/CT
31. list the cancer types for which FDG PET is a component of the theranostic algorithms
32. list the imaging system parameters that are limitations associated with the diagnostic portion of theranostic pairs
33. list the PET radiotracers for which there are currently no clear and sufficiently studied criteria for response assessment
34. describe the assessment standards for treatment response applied to anatomic imaging
35. identify the PET radiotracer for which PERCIST 1.1 criteria applies
36. describe the unit of measurement for the dose of radiation energy absorbed by a determined tissue
37. list the diagnostic PET agents used in clinical trials for neuroendocrine tumors
38. identify the clinical trial that compared radiotherapy to best supportive care in patients with prostate cancer
39. describe the approximate radiation dose limit to the kidneys in patients without risk factors for renal toxicity
40. describe the approximate radiation dose limit to the bone marrow