Potential Ways to Address Shortage Situations of 99Mo/99mTc.

99mTc, the most common radioisotope used in nuclear medicine, is produced in a nuclear reactor from the decay of 99Mo. There are only a few aging nuclear reactors around the world that produce 99Mo, and one of the major contributors, the National Research Universal (Canada), ceased production on October 31, 2016. The National Research Universal produced approximately 40% of the world's 99Mo supply, so with its shut down, shortages of 99Mo/99mTc are expected. Methods: Nuclear pharmacies and nuclear medicine departments throughout the United States were contacted and asked to provide their strategies for coping with a shortage of 99Mo/99mTc. Each of these strategies was evaluated on the basis of its effectiveness for conserving 99mTc while still meeting the needs of the patients. Results: From the responses, the following 6 categories of strategies, in order of importance, were compiled: contractual agreements with commercial nuclear pharmacies, alternative imaging protocols, changes in imaging schedules, software use, generator management, and reduction of ordered doses or elimination of backup doses. Conclusion: The supply chain of 99Mo/99mTc is quite fragile; therefore, being aware of the most appropriate coping strategies is crucial. It is essential to build a strong collaboration between the nuclear pharmacy and nuclear medicine department during a shortage situation. With both nuclear medicine departments and nuclear pharmacies implementing viable strategies, such as the ones proposed, the amount of 99mTc available during a shortage situation can be maximized.

Assessment of Using 99Mo and 99mTc Isotopes in Kuwait Medical Sector.

The Ministry of Health (MOH) in the state of Kuwait currently depends on importing the radioisotope molybdenum (Mo) in its isotopic form (Mo) to fulfill its demands. The present study was conducted on all nuclear medicine departments in the state of Kuwait. Daily, weekly, and monthly data were analyzed to statistically determine the current and future demands for the isotope Tc. This analysis was performed by collecting and analyzing data on MOH consumption of Tc for different diagnostic applications. The overall results indicate a partial decrease of 1.012% in the overall total demand for Tc up to the year 2018 for the state of Kuwait.

Diversification of 99Mo/99mTc separation: non­fission reactor production of 99Mo as a strategy for enhancing 99mTc availability.

This paper discusses the benefits of obtaining (99m)Tc from non-fission reactor-produced low-specific-activity (99)Mo. This scenario is based on establishing a diversified chain of facilities for the distribution of (99m)Tc separated from reactor-produced (99)Mo by (n,γ) activation of natural or enriched Mo. Such facilities have expected lower investments than required for the proposed chain of cyclotrons for the production of (99m)Tc. Facilities can receive and process reactor-irradiated Mo targets then used for extraction of (99m)Tc over a period of 2 wk, with 3 extractions on the same day. Estimates suggest that a center receiving 1.85 TBq (50 Ci) of (99)Mo once every 4 d can provide 1.48-3.33 TBq (40-90 Ci) of (99m)Tc daily. This model can use research reactors operating in the United States to supply current (99)Mo needs by applying natural (nat)Mo targets. (99)Mo production capacity can be enhanced by using (98)Mo-enriched targets. The proposed model reduces the loss of (99)Mo by decay and avoids proliferation as well as waste management issues associated with fission-produced (99)Mo.

["Technetium crisis" -  causes, possible solutions and consequences for planar scintigraphy and SPECT diagnostics]. / "Techneciová krize" -  príciny, mozná resení a dopad na dia-gnostiku planární scintigrafií a SPECT.

Nuclear medicine is an important field of nuclear medicine, especially thanks to its role in in vivo imaging of important processes in human organism. An overwhelming majority of nuclear medicine examinations comprises of planar scintigraphy and single photon emission computed tomography, for decades relying on the labeling by metastable technetium nuclide (99mTc), used with a great diversity of ligands for various applications. Nuclear medicine departments utilize commercially available molybdenum technetium generators, being able to elute the nuclide at any time and prepare the radiopharmaceutical. The mother nuclide, molybdenum-99 (99Mo), is produced in just a handful of places around the world. The production places are without exception research nuclear reactors working far past their life expectancy. A concurrent temporary shutdown of two of them in the year 2009 caused a critical worldwide shortage of 99mTc. An unavoidable permanent shutdown of part of these capacities in the second decade of the 21st century will cause the second, and this time rather permanent "technetium crisis". The article focuses on history, present, potential future and possible solutions in regard to SPECT diagnostics.

Diversification in the Supply Chain of (99)Mo Ensures a Future for (99m)Tc.

The uncertain availability of (99m)Tc has become a concern for nuclear medicine departments across the globe. An issue for the United States is that currently it is dependent on a supply of (99m)Tc (from (99)Mo) that is derived solely by production outside the United States. Since the United States uses half the world's (99)Mo production, the U.S. (99)Mo supply chain would be greatly enhanced if a producer were located within the United States. The fragility of the old (99)Mo supply chain is being addressed as new facilities are constructed and new processes are developed to produce (99)Mo without highly enriched uranium. The conversion to low-enriched uranium is necessary to minimize the potential misuse of highly enriched uranium in the world for nonpeaceful means. New production facilities, new methods for the production of (99)Mo, and a new generator elution system for the supply of (99m)Tc are currently being pursued. The progress made in all these areas will be discussed, as they all highlight the need to embrace diversity to ensure that we have a robust and reliable supply of (99m)Tc in the future.

A study of technetium-99m wastage in selected private sector nuclear medicine imaging departments.

BACKGROUND: South African nuclear medicine imaging departments have been fortunate in being able to receive an uninterrupted supply of molybdenum-99 (99Mo)/technetium-99m (99mTc) generators. Nuclear medicine radiographers practising in private sector services in the northern Gauteng region indicated a possible problem with the quantities of wasted and unused 99mTc radiopharmaceuticals returned to the radiopharmaceutical supply laboratory. Daily radiopharmaceutical deliveries are a combination of ordered packages and standard packages. The purpose of the standard package is to accommodate emergency and after-hours nuclear medicine services. The purpose of the study was to interrogate the unconfirmed reports of 99mTc radiopharmaceutical wastage. METHODS: A descriptive quantitative research design was conducted in six private sector nuclear medicine imaging practices in the northern Gauteng region. Overt observations of the quantities of radiopharmaceutical supply, usage and wastage were conducted over 2 days in each of these practices. RESULTS: Ordered packages comprised 14% of the total 99mTc radiopharmaceutical deliveries to these six nuclear medicine imaging departments. It was identified that:(1) a total of 83.2% of ordered packages and 35.1% of standard packages of preprepared syringes were utilized;(2) a total of 36% of ordered packages and 22.6% of standard packages of bulk 99mTc were utilized; and (3) a total of 70.6% of the total quantity of radiopharmaceuticals was returned to the radiopharmaceutical laboratory. The total wastage represented 45.5% of the ordered packages and 75.8% of the standard packages. CONCLUSION: Wastage of 74 GBq of 99mTc from six sites over 12 days should raise concerns for the nuclear medicine industry. A review of the system framework that supports communication between the radiopharmaceutical supplier/s and the nuclear medicine imaging practices is recommended.

Lessons from the Tc-99m shortage: implications of substituting Tl-201 for Tc-99m single-photon emission computed tomography.

BACKGROUND: In 2009, the Chalk River nuclear reactor closed for repairs that led to a critical shortage of technetium-99m (Tc-99m). Several centers used thallium-201 (Tl-201) as an alternative radiotracer for myocardial perfusion imaging. Because Tl-201 is considered by many as a suboptimal radiotracer, we sought to understand the impact of using Tl-201 (during the Tc-99m shortage) on downstream resource utilization. METHODS AND RESULTS: We performed a retrospective study at the Ottawa Heart Institute of 7402 patients (60% men; mean age, 62.6 ± 11.8 years), patients were referred for myocardial perfusion imaging between May 2008 and January 2011 (PRE_Tc-99m [2938 patients]), during (DURING_Tl-201 [2959 patients]), and after (POST_Tc-99m [1505 patients]) the Tc-99m shortage. Patients were followed for 6 months after their index myocardial perfusion imaging to determine subsequent rates of cardiac catheterization or noninvasive imaging. More downstream testing was seen in the Tl-201 cohort (639 [21.4%] patients) than the Tc-99m cohort (537 [12.1%] patients; P<0.001). After adjustment using propensity scores, differences in downstream referral rates were maintained. The downstream investigations resulted in an estimated increase in per-patient costs ($165.22; 95% confidence interval, 153.00-177.42) in the DURING_Tl-201 cohort compared with the Tc-99m cohort ($90.97; 95% confidence interval, 83.42-98.90; P<0.001). As well, the mean effective radiation dose per-patient was higher in DURING_Tl-201 (23.57 mSv; 95% confidence interval, 23.16-23.96) than in Tc-99m (12.92 mSv; 95% confidence interval, 12.55-13.40; P<0.001). CONCLUSIONS: In this single-center study, the use of Tl-201 during the Tc-99m shortage was associated with an increase in downstream testing, cost, and patient radiation exposure, but these findings may not be generalizable to other centers. Although Tl-201 provided a short-term solution to the unexpected Tc-99m shortage, long-term cost-effective solutions should be areas of future study.

Technetium-99m -- new production and processing strategies to provide adequate levels for SPECT imaging.

The most important radioisotope for use in Nuclear Medicine is (99m)Tc, supplied in the form of a (99)Mo/(99m)Tc generator. After the supply crisis of (99)Mo starting in 2008 the availability of (99)Mo became a worldwide concern. The purpose of this work is to do a brief story of the availability of (99)Mo in the world followed by an overview of the production routes of (99)Mo and the generators technology.

Future of low specific activity molybdenum-99/technetium-99m generator.

In last few years, the shortage of molybdenum-99 (99Mo) was felt in the developed and developing countries hospitals, where diagnostic nuclear medicine is practiced. To overcome the shortage of 99Mo various routes of its production by accelerators and reactors generating low and high specific activity products have been planned. High specific activity 99Mo obtained by fission of uranium-235 (235U) has completely dominated in the manufacturing of technetium-99m (99mTc) generators in last 3-4 decades, but due to proliferation and dirty bomb, issues non fission routes of 99Mo production are emphasized. Future of low specific activity 99Mo is discussed.

Molybdenum-99/technetium-99m management: race against time.

Molybdenum-99 is a parent of diagnostic nuclear medicine. It decays to technetium-99m, which used in over 30 million investigations per year around the world. Supplies of Tc-99m remained fragile in the last few years, which may occur again in the short and long term. Few suggestions have been registered in this letter to cope inadequate supply of the most wanted radionuclide for patient care.

[Situation of supply and boom of PET imaging: what is the future for technetium-99m in nuclear medicine?]. / Conjoncture d'approvisionnement et essor de l'imagerie TEP : quel avenir pour le technétium-99m en médecine nucléaire ?

Molecular imaging has shown its interest in the diagnosis, staging and therapy monitoring of many diseases, especially in the field of cancer. This imaging modality can detect non-invasively early molecular changes specific to these diseases. Its expansion includes two aspects linked firstly with the advanced techniques of imaging modalities and secondly with the development of tracers as radio pharmaceuticals for imaging new molecular targets. Technetium-99m ((99m)Tc), because of its physical characteristics, its widespread availability and low cost, is the most used radionuclide in molecular imaging with the technique of single photon emission computed tomography (SPECT). Nevertheless, the current difficulty concerning the supply and the great interest of Positron Emission Tomography (PET), the "competitor" imaging modality-using molecules labelled with fluorine-18 ((18)F), legitimates the question about the future of (99m)Tc, its supremacy and the emergence of new tracer labelled with (99m)Tc. Focusing on the actual and future supply situation, the place of SPECT imaging in nuclear medicine, as well as the development of new molecules labelled with (99m)Tc is necessary to show that this radionuclide will remain essential for the speciality in the next years.