Theranostics in the Arab World; Achievements & Challenges

In nuclear medicine, theranostics (combining therapy and diagnostics in one platform) is made possible through the utilization of radiopharmaceuticals for both therapeutic and diagnostic purposes by targeting one specific tumor receptor or certain molecular pathway. To make radiopharmaceuticals biologically relevant compounds, receptor ligands must be labeled with radionuclides. The possible applications are multifold and include: in vivo visualization of tumor biology; diagnosis and tumor staging; therapy planning and treatment of specific tumors. The application of theranostics results in giving the right treatment to the right patient at the right time, which is expected to improve therapeutic efficacy and increase overall compliance to therapy. For example, theranostics can be used to determine the heterogeneity of cancer lesions, which is one of the most difficult aspects of therapeutic success, allow the identification of patients who will benefit from therapy, avoid unnecessary conventional therapies, and implement salvage treatments for those who need them. The use of theranostics has seen unprecedented value for cancer patients in the last decade. Several radiopharmaceuticals are currently in use in clinical practice (e.g., [68Ga/177Lu] DOTATATE), while dozens more are still in the preclinical stages. The goal of this review article is to cover the current and future status of nuclear theranostics, particularly in the Arab world, with a focus on expanding the discipline beyond neuroendocrine tumors, castration-resistant prostate cancers, and differentiated thyroid cancers. Furthermore, representatives from different Arab countries were invited to describe their recent understanding and contributions to drive innovation in this evolving field © 2022 University of Jordan,Deanship of Scientific Research. All rights reserved

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Skeletal Metastasis as Detected by 18F-FDG PET with Negative CT of the PET/CT: Frequency and Impact on Cancer Staging and/or Management

Objectives: The aim of our study is to assess the frequency of detection of PET positive CT negative skeletal metastases (SM) and determine the impact of such detection on staging and/or management in patients who had FDG PET/CT as part of the cancer work up.Methods: We retrospectively reviewed 2000 18F-FDG PET/CT scans of known cancer patients. A log was kept to record cases of suspected SM with or without bone changes from the low-dose non-contrast CT. The presence or absence of SM was evaluated based on available pathological and clinical data. The impact of detection of such lesions on cancer staging and/or management was evaluated by a board certified oncologist.Results: Of the 2000 cases, 18F-FDG PET/CT suggested SM in 146/2000 (7.3%). Of those 146 cases, 105 (72%) were positive on both PET and CT. The remaining 41 (28%) had PET positive CT negative bone lesions. SM was confirmed in 36/41 (88%) PET positive/CT negative cases. This was based on biopsy, imaging or clinical follow-up. The detection of PET positive CT negative SM did not change staging or management in 7/36 (19.4%). However, staging and/or management was affected in 29/36 (80.6%). Conclusions: SM is not uncommon in 18F-FDG PET/CT, as it accounts for 146/2000 (7.3%) of cases. PET demonstrated FDG-avid SM without a CT abnormality in at least 36/146 (25%). Patients staging and or management changed in 29/36 (80.5%). We concluded that 18F-FDG PET is sensitive in detection of SM with significant impact on staging & or management. Key words18F-FDG PET/CT, Skeletal metastasis, PET positive, CT negativ

Radiolabeled FAPI

This chapter describes the interesting role of PET with radiolabeled fibroblast activation protein inhibitors (FAPIs), underlining the potential clinical indications. Furthermore, the emerging role of FAPI PET is highlighted with interesting clinical cases. In addition synthesis, pharmacokinetics and physiological distribution of FAPIs, and PET acquisition protocols are described as well

68Ga-Pentixafor

In recent years, some new positron emission tomography (PET) radiopharmaceuticals have come to attention as possible alternatives to fluorine-18-fluoro-2-deoxyglucose (18F-FDG) PET.In this context, this chapter describes the role of PET with gallium-68 (68Ga)-Pentixafor, describing potential clinical indications, with interesting clinical cases. Moreover, synthesis, pharmacokinetics and physiological distribution of 68Ga-Pentixafor, and PET acquisition protocols are described as well.In recent years, some new positron emission tomography (PET) radiopharmaceuticals have come to attention as possible alternatives to fluorine-18-fluoro-2-deoxyglucose (18F-FDG) PET.In this context, this chapter describes the role of PET with gallium-68 (68Ga)-Pentixafor, describing potential clinical indications, with interesting clinical cases. Moreover, synthesis, pharmacokinetics and physiological distribution of 68Ga-Pentixafor, and PET acquisition protocols are described as well

Current Status of Theranostics in West Asia: A Country-based Surveillance Study

This surveillance study examined the status of theranostics in West Asia, analyzing data from 15 countries. The research assessed availability, production, coverage, staff density, infrastructure density, financial and political impacts. All surveyed countries except Yemen offered theranostic services, with 452 centers and 1,426 theranostic physicians across the region. Over half of the countries reported densities exceeding one theranostician, nuclear medicine technologist, physicist, and nurse per million inhabitants. Scientific and social activities were available in nine and ten countries, respectively. Countries with gross domestic product (GDP) below $200 billion showed significantly lower infrastructure and manpower resources, particularly in cyclotron availability and theranostic agents (p < 0.05), compared to those with higher GDP. Politically stable countries demonstrated statistically higher densities of theranostic personnel than unstable nations (p < 0.05). The study emphasizes the importance of collaboration between model countries and those lacking adequate services to enhance theranostic practice and availability in West Asia

Reduction of cardiac imaging tests during the COVID-19 pandemic: The case of Italy. Findings from the IAEA Non-invasive Cardiology Protocol Survey on COVID-19 (INCAPS COVID)

Background: In early 2020, COVID-19 massively hit Italy, earlier and harder than any other European country. This caused a series of strict containment measures, aimed at blocking the spread of the pandemic. Healthcare delivery was also affected when resources were diverted towards care of COVID-19 patients, including intensive care wards. Aim of the study: The aim is assessing the impact of COVID-19 on cardiac imaging in Italy, compare to the Rest of Europe (RoE) and the World (RoW). Methods: A global survey was conducted in May–June 2020 worldwide, through a questionnaire distributed online. The survey covered three periods: March and April 2020, and March 2019. Data from 52 Italian centres, a subset of the 909 participating centres from 108 countries, were analyzed. Results: In Italy, volumes decreased by 67% in March 2020, compared to March 2019, as opposed to a significantly lower decrease (p &lt; 0.001) in RoE and RoW (41% and 40%, respectively). A further decrease from March 2020 to April 2020 summed up to 76% for the North, 77% for the Centre and 86% for the South. When compared to the RoE and RoW, this further decrease from March 2020 to April 2020 in Italy was significantly less (p = 0.005), most likely reflecting the earlier effects of the containment measures in Italy, taken earlier than anywhere else in the West. Conclusions: The COVID-19 pandemic massively hit Italy and caused a disruption of healthcare services, including cardiac imaging studies. This raises concern about the medium- and long-term consequences for the high number of patients who were denied timely diagnoses and the subsequent lifesaving therapies and procedures

Impact of COVID-19 on Diagnostic Cardiac Procedural Volume in Oceania: The IAEA Non-Invasive Cardiology Protocol Survey on COVID-19 (INCAPS COVID)

Objectives: The INCAPS COVID Oceania study aimed to assess the impact caused by the COVID-19 pandemic on cardiac procedure volume provided in the Oceania region. Methods: A retrospective survey was performed comparing procedure volumes within March 2019 (pre-COVID-19) with April 2020 (during first wave of COVID-19 pandemic). Sixty-three (63) health care facilities within Oceania that perform cardiac diagnostic procedures were surveyed, including a mixture of metropolitan and regional, hospital and outpatient, public and private sites, and 846 facilities outside of Oceania. The percentage change in procedure volume was measured between March 2019 and April 2020, compared by test type and by facility. Results: In Oceania, the total cardiac diagnostic procedure volume was reduced by 52.2% from March 2019 to April 2020, compared to a reduction of 75.9% seen in the rest of the world (p&lt;0.001). Within Oceania sites, this reduction varied significantly between procedure types, but not between types of health care facility. All procedure types (other than stress cardiac magnetic resonance [CMR] and positron emission tomography [PET]) saw significant reductions in volume over this time period (p&lt;0.001). In Oceania, transthoracic echocardiography (TTE) decreased by 51.6%, transoesophageal echocardiography (TOE) by 74.0%, and stress tests by 65% overall, which was more pronounced for stress electrocardiograph (ECG) (81.8%) and stress echocardiography (76.7%) compared to stress single-photon emission computerised tomography (SPECT) (44.3%). Invasive coronary angiography decreased by 36.7% in Oceania. Conclusion: A significant reduction in cardiac diagnostic procedure volume was seen across all facility types in Oceania and was likely a function of recommendations from cardiac societies and directives from government to minimise spread of COVID-19 amongst patients and staff. Longer term evaluation is important to assess for negative patient outcomes which may relate to deferral of usual models of care within cardiology

International Impact of COVID-19 on the Diagnosis of Heart Disease

Background: The coronavirus disease 2019 (COVID-19) pandemic has adversely affected diagnosis and treatment of noncommunicable diseases. Its effects on delivery of diagnostic care for cardiovascular disease, which remains the leading cause of death worldwide, have not been quantified. Objectives: The study sought to assess COVID-19's impact on global cardiovascular diagnostic procedural volumes and safety practices. Methods: The International Atomic Energy Agency conducted a worldwide survey assessing alterations in cardiovascular procedure volumes and safety practices resulting from COVID-19. Noninvasive and invasive cardiac testing volumes were obtained from participating sites for March and April 2020 and compared with those from March 2019. Availability of personal protective equipment and pandemic-related testing practice changes were ascertained. Results: Surveys were submitted from 909 inpatient and outpatient centers performing cardiac diagnostic procedures, in 108 countries. Procedure volumes decreased 42% from March 2019 to March 2020, and 64% from March 2019 to April 2020. Transthoracic echocardiography decreased by 59%, transesophageal echocardiography 76%, and stress tests 78%, which varied between stress modalities. Coronary angiography (invasive or computed tomography) decreased 55% (p &lt; 0.001 for each procedure). In multivariable regression, significantly greater reduction in procedures occurred for centers in countries with lower gross domestic product. Location in a low-income and lower–middle-income country was associated with an additional 22% reduction in cardiac procedures and less availability of personal protective equipment and telehealth. Conclusions: COVID-19 was associated with a significant and abrupt reduction in cardiovascular diagnostic testing across the globe, especially affecting the world's economically challenged. Further study of cardiovascular outcomes and COVID-19–related changes in care delivery is warranted