Theranostics in Nuclear Medicine

The event kicked off with welcoming words and introductions. Dr Carsten-Michael Walbiner, Director of the DAAD Regional Office Cairo, emphasised the importance of addressing health issues in Egypt, a country with over 100 million people and significant disparities between rural and urban areas. The COSIMENA project, particularly the health cluster, plays a crucial role in prioritizing health issues, given their frequent immediate impact, leading to tangible improvements in both people’s well-being and institutional conditions.

Subsequently, Dr Walbiner mentioned that through the DAAD they are ‘trying to use science and research as a tool of diplomacy of getting people together.’ He stressed the relevance of scientific cooperation in fostering peace and its increasing importance in the current regional context.

Lorena Mohr, Head of Science and Protocol at the Embassy of the Federal Republic of Germany in Cairo, highlighted the ‘broad array of cooperation’ between Egypt and Germany in the scientific sector’, particularly in medicine. She referred to the presence of experts from both countries, who facilitate a two-way exchange of knowledge and experiences. Mohr emphasized the value of events organised by the COSIMENA project, which brings people together to network, exchange ideas, and establish personal connections. These connections, she noted, serve as the foundation for future cooperation, scientific insights, and institutional partnerships. The COSIMENA project, with its various clusters, exemplifies how it unites people across different fields of expertise.

Prof. Dr Markus Luster from Philipps-Universität Marburg presented the evolving landscape of nuclear medicine, with a focus on the intricate field of theranostics. Identifying himself as Marcus Lustas, Prof. Dr Luster, the current President of the national society, acknowledged the paperwork-intensive nature of his role. Despite spending less time with patients, he emphasised the fulfilling aspects of gaining influence and insight into behind-the-scenes activities. Prof. Dr Luster introduced the term “Theranostics” and the ongoing debate about its spelling, highlighting its Greek origin. Theranostics serves as a diagnostic testing form leading to the right therapy, emphasizing individual patient needs and the right dosage, crucial in nuclear medicine.

The birth of nuclear medicine, exemplified by radioactive iodine therapy, marked the beginning of theranostics. This method involves testing patients for potential treatment responses and tailoring therapies based on the results. Prof. Dr Luster stressed the role of pharmacogenetics, proteomics, biomarker profiling, and functional imaging in the theranostics approach.

He detailed the ease of applying theranostics in nuclear medicine, emphasising the importance of identifying treatment sites through diagnostic scans and confirming their treatment through posttherapy scans, known as Radiotheranostics. The role of FDG-PET/CT in theranostics, especially in identifying radioiodine-negative tumor foci, and theFlip-Flop Phenomenon were emphasised by Prof. Dr Luster. His presentation also touched upon redifferentiation strategies in differentiated thyroid cancer.

Prof. Dr Luster explained the use of prostate-specific membrane antigen (PSMA) as a target in progressive radioiodine refractory thyroid cancer. He discussed the potential role of Lu-177-PSMA ligands as a treatment option, highlighting the need for further elucidation. The presentation elucidated the principles of molecular imaging and therapy, involving radioactive probes for diagnostics and therapeutic radionuclides for treatments. Prof. Dr Luster stressed the importance of optimization in prostate cancer management with PSMA radionuclide therapy.

In addition, Prof. Dr Luster addressed patient concerns, including life expectancy queries, therapy success, safety, and the impact on the quality of life. He emphasised the importance of molecular profiling and survival analysis related to glycolytic metabolism.

The discussion, led by Prof. Dr Markus Luster, explored the use of alpha emitters, emphasizing their higher energy and shorter tissue range. Prof. Dr Luster introduced the concept of tandem therapy, specifically with Ac-225 and Lu-177 PSMA, stressing the importance of patient selection, dosimetry, and shared decision-making. Additionally, he anticipated a transformative shift in the field from “nuclear radiology” to authentic “nuclear medicine,” underscoring the dynamic and evolving nature of theranostics in shaping the future of medical practices.

In a dynamic Q&A session following his presentation at the “Theranostics in Nuclear Medicine Public lecture,” Prof. Dr Markus Luster answered a question about the significance of Standardized Uptake Value (SUV) max in diagnosis and treatment, acknowledging its complexity. He highlighted SUV’s role in predicting therapy response and potential use in diagnosis. However, he cautioned about challenges, such as variations due to scan timing and the need to adapt to different SUVs with evolving technologies.

Responding to concerns about the shortage of Lutetium-177 PSMA Therapy, Prof. Dr Luster emphasised the importance of developing new compounds. He expressed hope that the shortage is temporary and suggested academia’s role in large-scale production. Prof. Dr Luster stressed the need for industry and political intervention, calling for awareness to address the pressing issue affecting patient care.

When asked about experience with carrier and non-carrier Lutetium therapy, Prof. Dr Luster anticipated a shift towards non-carrier therapies in the long run. Therefore, he acknowledged the complexities in handling waste associated with Lutetium, emphasizing the seriousness of the issue.

Explaining the German approach, Prof. Dr Luster detailed the practice of hospitalizing patients for 48 hours after Lutetium therapy for prostate cancer. He justified this cautious approach, citing the importance of patient care, especially during the night, when various supportive measures might be necessary.

Addressing the query about the number of doses of radiation therapy, Prof. Dr Luster clarified that there is no set limit. The decision depends on various factors like patient response, tumour load, and the absence of side effects. He emphasised the wide spectrum of approaches, with some patients undergoing multiple courses based on individual circumstances.

Responding to a question about multiple doses of fractinum, Prof. Dr Luster clarified that this approach is experimental. In Germany, practitioners are not obligated to follow established protocols, allowing flexibility based on patient consent. He stressed the importance of shared decision-making, especially in experimental treatments where patient communication plays a key role.

Offering advice to early-career oncologists on convincing colleagues, Prof. Dr Luster highlighted the importance of open-mindedness among neurooncologists. He acknowledged the challenges in gaining recognition but emphasised showcasing the impact of nuclear medicine therapies through patient-oriented outcomes.

When discussing the preference for out-patient vs. in-patient Lutetium therapy, Prof. Dr Luster recognized the global variation in radiation protection measures. He pointed out the existing discrepancies in guidelines across different countries and advocated for clear rules, regardless of the chosen approach. He acknowledged both the advantages and disadvantages of hospitalization.

In response to a question about exploring alternative tumor markers, Prof. Dr Luster mentioned the rising significance of FAPI (Fibroblast Activation Protein Inhibitors). He highlighted its potential in detecting various cancers and hinted at its effectiveness in pancreatic cancer. However, he acknowledged the complexity of FAPI for non-nuclear medicine practitioners.

In conclusion, Prof. Dr Luster comprehensive responses during the engaging Q&A session further emphasised the complex yet promising nature of nuclear medicine therapies, calling for collaborative efforts in research, development, and global standardization to ensure optimal patient care and advance the field.