European nuclear medicine services respond to technetium supply crisis

European hospitals and nuclear medicine clinics are taking action to prevent an acute shortage of medical isotopes from harming patients.

Ongoing problems with access to technetium-99m are leading to the postponement of nonurgent scans, reintroduction of procedures that had been phased out, and off-label use of other radiopharmaceuticals.

Tc-99m is used in 70% to 80% of all nuclear medicine procedures, and demand is growing. It is produced naturally during the decay of the radioisotope molybdenum-99, which itself is generated as a byproduct of uranium fission.

All three European nuclear reactors that generate Mo-99 are shut at present. The Osiris reactor in Saclay, France, and the BR-2 reactor in Mol, Belgium, are closed for scheduled maintenance until mid- and late September, respectively. Meanwhile, the High Flux Reactor at Petten, the Netherlands, was also shut after a routine inspection revealed escaping gas bubbles in its cooling system. It will not restart Mo-99 production until the end of October at the earliest.

To make matters worse, one of the two sites in Europe that refines Mo-99 and distributes Tc-99m generators to hospitals and clinics is closed as well. The shutdown of the Institut des Radioéléments (IRE) in Fleurus, Belgium, follows a 40-GBq leak of iodine-131 through the plant's chimney. The IRE administration hopes to resume isotope delivery by the beginning of October, but this decision is in the hands of Belgium's Agency for Nuclear Control.

Nuclear medicine physicians at the Manchester Royal Infirmary in the U.K. are now working with 30% of their usual Tc-99m supply. This should be sufficient to cover urgent clinical cases, said Dr. Robert Shields, manager of the hospital's nuclear medicine department. Some nonurgent tests are being rescheduled, and, where possible, myocardial perfusion imaging is being performed with thallium-201.

"Tl-201 can give perfectly acceptable results for these heart scans. It takes a little longer, and the procedure is different, so we have had to train our staff to do these studies. But by making this switch, we are able to preserve our capacity for about 70% of our work," he said.

The situation at Antwerp University Hospital (UZA) is stable at the moment but looks likely to deteriorate next week, according to Dr. Laurens Carp, a nuclear medicine physician at UZA and secretary general of the Belgian Society for Nuclear Medicine.

The available Tc-99m will have to be prioritized, he said. Doctors may also try harvesting Tc-99m twice a day from its Mo-99 source instead of just once.

No imaging appointments have yet been canceled at the University Hospital Copenhagen, despite a 50% drop in isotope supply levels, said Prof. Liselotte Højgaard, director of clinical physiology, nuclear medicine, and PET. The need for Tc-99m is being assessed on a case-by-case basis. Fluorine-18 sodium fluoride PET is replacing bone scintigraphy, I-123 has been ordered for thyroid scans, and Tl-201 has been reintroduced for myocardial scintigraphy.

"I have been in this area for about 25 years, and I have never experienced anything like it," Højgaard said. "As doctors, it is very important that we adopt a proactive approach and do the very best for our patients, instead of sitting back and saying 'I have to cancel.'"

Large university hospitals with cyclotron facilities that can make alternative radioisotopes may be in a better position to ride out the shortage than smaller clinics, said Prof. Wolfram Knapp, president-elect of the European Association of Nuclear Medicine (EANM) and director of the nuclear medicine clinic at Hanover Medical School in Germany.

The EANM is advising all institutions that wish to substitute Tc-99m with a product that does not have marketing authorization to clarify the position with the appropriate regulatory authorities.

For more information from the Diagnostic Imaging archives:

Covidien advises customers about impending molybdenum shortage

Nuclear medicine braces for effects of Petten reactor shutdown