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IAEA Support Helps Pakistan to Conduct Novel Theranostic Interventions for the First Time, Expanding Cancer Care and Improving Outcomes

1.	Phong Truong, an international expert, and Dr Irfan Khan prepare the synthesizer for installation at INMOL

Phong Truong, an international expert, and Dr Irfan Khan prepare the synthesizer for installation at INMOL. (Photo: INMOL)

Pakistan’s Institute of Nuclear Medicine and Oncology (INMOL) in Lahore and its Nuclear Medicine Oncology and Radiotherapy Centre (INOR) in Abbottabad are now producing novel radiopharmaceuticals for use in theranostic procedures, using equipment and training provided through the IAEA’s technical cooperation (TC) programme1/. Theranostics is an emerging field of medicine which relies on a patient-centred and targeted approach, focussing on the precise treatment of cancers or infection sites. Theranostics experts use radiopharmaceuticals to either simultaneously or sequentially diagnose and then treat medical conditions.

Non-communicable diseases such as cancer, neurological disorders and cardiac dysfunction are of increasing concern to national health authorities in Pakistan because, taken together, these illnesses are responsible for more than 70% of age-standardized deaths in the country. The incidence of non-communicable disease is expected to double in the country by 2025 if appropriate diagnostics and treatment are not introduced.

The World Health Organization estimates that approximately 1.5 million cancer patients live in Pakistan, a number which is increasing by 150 000 patients per year.

Theranostic interventions have been shown to produce more accurate diagnoses, facilitate the tumour-specific delivery of drugs and reduce hazards to normal, healthy tissue. In addition, by eliminating multi-step procedures and by consolidating diagnosis and treatment into a single process, theranostics also help to reduce delays in treatment and improve the outcomes and experiences of clinical patients.

Building radiopharmaceutical production capacity

Since its launch in 2018, an ongoing, national IAEA project2/ has been helping to improve the capacities of cancer treatment facilities by supporting expert needs assessments, procuring new equipment and providing on-the-job training to specialists.

Before the launch of the project, there were only two PET-CT centres in the whole of Pakistan, both located in Lahore and both relying on fluorodeoxyglucose (18F-FDG ). This radiopharmaceutical is used to image glucose-consumption in tumours, such as lung, colon and lymphomas. “Patients whose disease is not specific to 18F-FDG had to fly abroad for diagnosis, if their finances permitted, or to leave their cancer unmanaged, if they did not,” explained Abdulghani Shakhashiro, IAEA Programme Management Officer for Pakistan.

The first steps on the road to theranostic capacities in Pakistan were taken in July 2019, with the procurement of an automated production platform for PET tracers and other radiopharmaceuticals, made on behalf of INMOL. The plug-and-play system allows experts to synthesize drugs in precise quantities and concentrations, according to the needs of individual patients. “I am happy to report that the synthesizer system, provided by the Agency, is already providing excellent results. For the first time in Pakistan, we are producing so many novel radiopharmaceuticals,” said Dr Irfan Khan, the Principal Scientist at INMOL.

Following this, in February 2020, a TC Expert Mission was organized to assess existing capacities and services for the management and treatment of cancer in Pakistan, and to develop a roadmap toward the application of modern molecular imaging techniques by local clinics.

Later in 2020, four radiopharmacists from INMOL were awarded scientific visits hosted by the University Medical Center Groningen, in Groningen, Netherlands. During this intensive training, the INMOL radiopharmacists received on-the-job training and learned how to produce and quality-control a broad range of radiopharmaceuticals.

Today, following the launch of these training courses and the installation of procured equipment, Pakistani experts are able to produce a growing number of radiopharmaceuticals and radioisotopes to facilitate the accurate diagnosis and treatment of various cancers.

The Theranostics Team at the Institute of Nuclear Medicine and Oncology is a multidisciplinary team which comprises radiopharmacists, technologists and medical imaging specialists. (Photo: INMOL)

Combining diagnosis with treatment

When combined with traditional PET imaging, radiopharmaceuticals allow specialists to produce detailed images of body biochemistry, metabolism and cell function in both organs and tissues. The versatile applications of these radiopharmaceuticals in oncology, cardiology and neurology rely on short-lived isotopes which were previously not available to the experts at INMOL and INOR. These isotopes include Fluorine-18, Carbon-11, Nitrogen-13, Oxygen-15, Copper-64 and Rubidium-82, which are now being produced by local experts, following IAEA support.

“Already, we have established the means to produce radiopharmaceuticals for bone scans, including 18F-Sodium Flouride, for the diagnosis of prostate cancer, such as Gallium-68 PSMA, and for the staging of breast cancers, 18F-Fluoroestradiol, and much more,” said Khan. “It is envisaged that this theranostic modality will bring a revolution in the diagnosis and treatment of cancer patients.”

A team of experts from INMOL also visited and trained at the Institute of Nuclear Sciences Applied to Health (ICNAS) — a Research Unit of the University of Coimbra in Portugal and an IAEA Collaborating Centre — to gain expertise and experiences for emerging PET theranostic radiopharmaceuticals and to explore plans for the future expansion of their services in Lahore3/.

In the coming months, new training courses will be organized virtually to support the clinical application of PET-based radiopharmaceuticals, two further INMOL radiopharmacists will be trained, and the Institute will begin to provide new imaging modalities using the newly-available biomolecules.

1/ PAK6023, ‘Strengthening the Positron Emission Tomography (PET) Imaging Facility by Developing Gallium-68 Labelled Biomolecules’

2/ PAK6024, ‘Strengthening Cancer Diagnosis and Treatment Facilities through Positron Emission Tomography Based Molecular Imaging and Radiotherapy Techniques and Image Guided Radiation Therapy’

3/New IAEA Collaborating Centre in Radioisotope and Radiopharmaceutical Production

Located in Lahore, INMOL is one of two cancer treatment facilities in Pakistan offering PET imaging services. (Photo: INMOL)

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