Terence Wong, MD, PhD, right, meets with a patient before his PSMA PET/CT scan
Terence Wong, MD, PhD, right, meets with a patient before his PSMA PET/CT scan. Duke is a leader in this type of imaging, which is used in combination with a radiotracer to identify if there's a druggable molecular target. (A version of this photo originally appeared in a Duke Health article in February 2022: "PSMA PET/CT Scan Improves Prostate Cancer Detection and Treatment")

Nuclear Medicine at Duke Garners National Recognition

Terence Wong, MD, PhD, and Stacy Wood, a Duke Health nuclear medicine technologist, provides treatment to a patient
Duke Cancer Institute nuclear radiologist Terence Wong, MD, PhD, and Stacy Wood, a Duke Health nuclear medicine technologist, provides treatment to a patient. Duke is currently the leading site for treating prostate cancer patients with Pluvicto, a new radiopharmaceutical therapy. (The above photo originally appeared in a Duke Health article in June 2022: "Duke Cancer Center Offers New Treatment for Metastatic Prostate Cancer")

The Society of Nuclear Medicine & Molecular Imaging has designated the Division of Nuclear Medicine and Radiotheranostics at Duke Health as a Comprehensive Radiopharmaceutical Therapy Center of Excellence.  A national leader in radiopharmaceutical therapy (RPT), the Division is currently one of only 14 Centers in the U.S. to receive this recognition.  

In addition to having technical expertise and appropriate treatment facilities, Centers must meet rigorous training, regulatory, and performance criteria, and are required to provide education and scientific contributions to this growing field. They must administer more than 40 RPT treatments per year in at least two of these disease-specific therapy areas — thyroid, neuro-endocrine tumor, and prostate.

“Duke has a long history of research and clinical experience with radiopharmaceutical therapies; dating back to the late 1990s when radio-labeled antibodies were developed at Duke by Darell Bigner (Preston Robert Tisch Brain Tumor Center) and Michael R. Zalutsky (Department of Radiology) to treat malignant brain tumors,” notes Duke Cancer Institute nuclear radiologist Terence Z. Wong, MD, PhD, FACR, chief of the Division of Nuclear Medicine and Radiotheranostics, a clinical division of Duke Radiology. “The designation as a Comprehensive Radiopharmaceutical Therapy Center of Excellence reflects the culmination of many years of teamwork.”

The Division has utilized radioiodine to treat thyroid diseases (including cancer) for decades and has been one of the leaders in the field using 131I-MIBG (a drug containing a form of radioactive iodine, also called AzedraTM and iobenguane I 131) to treat pheochromocytomas (cancer of the adrenal gland) and carcinoid tumors (a type of neuroendocrine tumor). Duke has been a national leader in treating patients with neuroendocrine tumors using LutatheraTM (177Lu-DOTATATE) since 2018, when it was approved by the FDA. More recently, Duke was one of the first cancer centers to offer PluvictoTM (177Lu-PSMA) to treat metastatic prostate cancer following its FDA approval in March 2022, and is currently the leading site in the U.S. for treating prostate cancer patients with this new radiopharmaceutical therapy. 

“Large clinical trials have shown that the radiotheranostic approach can provide clinical benefit for patients with neuroendocrine tumors and prostate cancer, even in patients with advanced disease that is refractory (unresponsive) to other treatments,” explains Wong, who has a secondary faculty appointment as a professor in the Duke Department of Medicine, Division of Medical Oncology. “As a National Cancer Institute-Designated Comprehensive Cancer Center, Duke Cancer Institute is well-equipped to provide these novel treatments.”

“Radiotheranostics” is the concept of using a molecular probe directed at cancer cells to both identify and treat that cancer. Azedra, Lutathera, and Pluvicto are all delivered this way.

First the molecular probe is labeled with a small amount of radioactivity called a radiotracer, which allows the potential treatment sites to be identified by imaging. Duke has been a leader in this type of imaging; 68Ga-DOTATATE PET/CT for neuroendocrine tumors and PSMA PET/CT in prostate cancer.

If the imaging shows that the tumor cells have a druggable molecular target, the area can then be treated with the targeted radiopharmaceutical therapy using the same or similar molecular probe — delivering a high radiation dose to the specific tumor sites while sparing adjacent normal tissue.

Radiotheranostics has progressed rapidly over the last decade and is moving quickly into the mainstream of cancer therapeutics. It was this “recognition of the present and future potential of radiolabeled targeted therapy,” notes Wong, that led to the Division of Nuclear Medicine being renamed the Division of Nuclear Medicine and Radiotheranostics in 2020.

Your Nuclear Oncologist

In a recent email message, Wong congratulated Division and DCI colleagues for their “tireless work” on achieving the Comprehensive Radiopharmaceutical Therapy Center of Excellence designation and for “making Duke a leader in this field.”

He stresses that the Division of Nuclear Medicine and Radiotheranostics is only one component of the Comprehensive Radiopharmaceutical Center of Excellence recognition.

“It is important to note that our Division is fully integrated with the Duke Cancer Institute, working closely with the neuroendocrine GI Oncology group and the DCI Center for Prostate & Urologic Cancers,” says Wong. “Patients at DCI are evaluated by multidisciplinary teams to provide individualized treatment plans and to determine whether radiopharmaceutical therapy is the best option.”

In addition to an experienced team of nuclear medicine physicians, technologists, nurses, and physician assistants, Duke has a dedicated Radiopharmacy to manage ordering and scheduling the delivery of radiotracers and radiopharmaceuticals. Every high dose radiopharmaceutical administration is also overseen by a member of the Duke Radiation Safety Division who meets with the patient to provide individualized post-treatment recommendations.

The SNMMI website lists the Comprehensive Radiopharmaceutical Therapy Centers of Excellence, provides educational resources (research articles and continuing education) about radiopharmaceutical therapies for technologists and has recently added a Patient Resources portal where patients and families can access easy-to-understand fact sheets, guidelines, and informational videos to help better understand nuclear medicine treatment.

“The goal of the (SNMMI) program is to ensure patients have reliable access to high quality radiopharmaceutical therapy, well-integrated into their pathway of care, delivered by highly qualified therapy teams, at technically qualified sites, and led by physicians appropriately trained in nuclear medicine acting as the patient’s ‘nuclear oncologist,’” wrote SNMMI president Richard L. Wahl, MD, FACR, in an official letter this May notifying Wong of the newly-earned designation. “SNMMI is delighted that you and your colleagues share in this important endeavor.”

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