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🌍
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Tracked countries
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9
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FR, BE, CH, LU, NL, DE, ES, IT, PT
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🎯
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Tracked targets
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10
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PSMA, SSTR, FAP, GRPR, CXCR4, NIS, NET-norepi, CCK2, integrin αvβ6, HER2
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\n \n Concept fondateur\n
\n What is theranostics?
\n \n Theranostics refers to a medical approach combining diagnosis and treatment around the same biological target. In nuclear medicine, it takes a particularly accomplished form: a radiotracer identifies the target through imaging, then a therapeutic radioligand uses the same target to deliver personalized treatment.\n
\n \n Diagnostic\n →\n Therapy\n →\n Follow-up\n
\n ","\n \n \n Therapeutic application\n
\n What is targeted radionuclide therapy (RIV)?
\n \n Targeted radionuclide therapy (RIV) is a nuclear medicine treatment approach that uses a targeted radiopharmaceutical to deliver radiation directly inside diseased cells or tissues. The treatment combines a carrier molecule, capable of recognizing a specific biological target, with a therapeutic radioactive isotope, enabling selective irradiation of the disease from inside the body.\n
\n \n RIV is the major therapeutic application of theranostics in nuclear medicine.\n
\n "],"recommendations":{"molecules":[{"key":"Lu177-PSMA-617","label":"¹⁷⁷Lu-PSMA-617","sub":"PSMA · prostate","color":"blue"},{"key":"Lu177-DOTATATE","label":"¹⁷⁷Lu-DOTATATE","sub":"SSTR · NET","color":"green"},{"key":"I131-cancer","label":"¹³¹I thyroid cancer","sub":"post-thyroidectomy","color":"purple"},{"key":"I131-hyper","label":"¹³¹I hyperthyroidism","sub":"Graves · TMNG · toxic adenoma","color":"orange"}],"professions":[{"key":"medecin-nucleaire","label":"Nuclear medicine physician","sub":"indication · decision · follow-up","color":"green"},{"key":"merm","label":"Nuclear medicine technologist","sub":"pathway · injection · safety","color":"blue"},{"key":"radiopharmacien","label":"Radiopharmacist","sub":"preparation · quality control","color":"purple"},{"key":"radiophysicien","label":"Medical physicist","sub":"dosimetry · radiation protection","color":"orange"}],"sourcesReco":[{"abbr":"EANM","title":"EANM/SNMMI PSMA RLT guideline 2023","url":"https://doi.org/10.1007/s00259-023-06255-8"},{"abbr":"SNM","title":"SNMMI Consensus PSMA RLT 2023","url":"https://jnm.snmjournals.org/content/64/9/1417"},{"abbr":"EMA","title":"EMA Pluvicto EPAR","url":"https://www.ema.europa.eu/en/medicines/human/EPAR/pluvicto"},{"abbr":"IAEA","title":"IAEA Radiopharmaceutical Therapy","url":"https://www.iaea.org/topics/radiopharmaceuticals-therapy"},{"abbr":"DGN","title":"DGN Leitlinien","url":"https://www.nuklearmedizin.de/leistungen/leitlinien/"},{"abbr":"SFMN","title":"SFMN Recommandations","url":"https://www.sfmn.org/index.php/component/eventgallery/medias/category/40-recommandations"}],"sourceUrlMap":{"EANM/SNMMI PSMA RLT guideline":"https://doi.org/10.1007/s00259-023-06255-8","Joint EANM/SNMMI PSMA RLT guideline":"https://doi.org/10.1007/s00259-023-06255-8","EANM/SNMMI PSMA RLT joint guideline 2023":"https://doi.org/10.1007/s00259-023-06255-8","SNMMI Appropriate Use Criteria":"https://jnm.snmjournals.org/content/64/9/1417","SNMMI Appropriate Use Criteria Table 4":"https://jnm.snmjournals.org/content/64/9/1417","SNMMI Appropriate Use Criteria toxicity section":"https://jnm.snmjournals.org/content/64/9/1417","SNMMI AUC":"https://jnm.snmjournals.org/content/64/9/1417","VISION criteria in SNMMI AUC":"https://jnm.snmjournals.org/content/64/9/1417","EMA Pluvicto EPAR":"https://www.ema.europa.eu/en/medicines/human/EPAR/pluvicto","EMA Pluvicto Product Information":"https://www.ema.europa.eu/en/medicines/human/EPAR/pluvicto","EMA Product Information":"https://www.ema.europa.eu/en/medicines/human/EPAR/pluvicto","PSMA PET EANM/SNMMI procedure standard":"https://doi.org/10.1007/s00259-022-06089-w","EANM 2022 PRRT guideline":"https://doi.org/10.1007/s00259-022-05727-7","EMA Lutathera EPAR":"https://www.ema.europa.eu/en/medicines/human/EPAR/lutathera","EMA Lutathera Product Information":"https://www.ema.europa.eu/en/medicines/human/EPAR/lutathera","NETTER-1 trial (NEJM)":"https://www.nejm.org/doi/full/10.1056/NEJMoa1607427","ENETS guidelines":"https://www.enets.org/guidelines.html","SNMMI procedure standard":"https://snmmi.org/ClinicalPractice/content.aspx?ItemNumber=15960","EANM 2022 DTC guideline":"https://doi.org/10.1007/s00259-021-05660-1","ATA 2015 guidelines":"https://www.liebertpub.com/doi/10.1089/thy.2015.0020","ESMO guidelines":"https://www.esmo.org/guidelines/guidelines-by-topic/endocrine-and-neuroendocrine-cancers","EANM 2022 Hyperthyroidism guideline":"https://doi.org/10.1007/s00259-022-05707-x","ATA 2016 Hyperthyroidism guidelines":"https://www.liebertpub.com/doi/10.1089/thy.2016.0229","IAEA Radiopharmaceutical Therapy":"https://www.iaea.org/topics/radiopharmaceuticals-therapy"},"recommandationsData":{"Lu177-PSMA-617":{"medecin-nucleaire":{"molecule":"¹⁷⁷Lu-PSMA-617","profession":"Nuclear medicine physician","criteria":["Confirm PSMA expression on recent PET","Verify mCRPC and prior treatment lines","Check CBC, eGFR and liver function","Discuss borderline cases at MDT","Document decision and consent"],"warnings":[{"emoji":"🩸","label":"Haematology","text":"monitor CBC before each cycle"},{"emoji":"💧","label":"Kidney","text":"check eGFR and hydration"},{"emoji":"☢️","label":"Radiation protection","text":"patient and household guidance"},{"emoji":"💊","label":"Coordination","text":"oncologist / ARPI / ADT"},{"emoji":"📋","label":"Traceability","text":"MDT, consent, local protocol"}],"sections":[{"key":"indications","icon":"🎯","accent":"var(--blue)","title":"Indications & regulatory framework","intro":"¹⁷⁷Lu-PSMA-617 (Pluvicto) is indicated in adults with metastatic castration-resistant prostate cancer (mCRPC) expressing PSMA on imaging. The exact indications evolve according to local marketing authorisation, national reimbursement, taxane / pre-taxane status and MDT decision. Always check the current regulatory framework before each indication.","bullets":["Adults with PSMA+ mCRPC on imaging","According to local authorisation and reimbursement","Taxane / pre-taxane status to verify","Combination with ADT ± ARPI per MA","MDT-validated decision"],"sources":["EMA Pluvicto EPAR","EANM/SNMMI PSMA RLT guideline","SNMMI Appropriate Use Criteria"]},{"key":"selection","icon":"👥","accent":"var(--blue)","title":"Clinical patient selection","intro":"Beyond PSMA marking, patient selection takes into account performance status, tumour burden, marrow reserve, renal function, symptoms and prior treatments. Borderline cases must be discussed at a multidisciplinary team meeting.","bullets":["Compatible performance status (typically ≤2)","Adequate marrow and renal reserve","Assess tumour burden and symptoms","Identify discordant PSMA-negative disease","Discuss available competing options"],"sources":["SNMMI Appropriate Use Criteria","EANM/SNMMI PSMA RLT guideline"]},{"key":"imagerie","icon":"🔬","accent":"var(--orange)","title":"Pre-treatment imaging","intro":"Selection relies on recent PSMA imaging. The VISION criteria required PSMA uptake above the liver and excluded measurable PSMA-negative lesions. Additional FDG imaging may be useful if discordant aggressive disease is suspected.","bullets":["Recent PSMA PET (ideally <3 months)","Check uptake-above-liver criterion","Compare with morphological CT/MRI","Consider FDG if discordance suspected","Report detailing targets and distribution"],"sources":["EANM/SNMMI PSMA RLT guideline","VISION criteria in SNMMI AUC","PSMA PET EANM/SNMMI procedure standard"]},{"key":"biologie","icon":"🧪","accent":"var(--blue)","title":"Pre-cycle laboratory work-up","intro":"Before each cycle, verify that haematological and renal parameters meet the SNMMI consensus thresholds, to be adapted to local protocol. Marrow function is of particular concern given the risk of cumulative myelosuppression across 6 cycles.","bullets":["Hb ≥ 8 g/dL (consensus threshold, adapt locally)","WBC ≥ 2.0 ×10⁹/L or ANC ≥ 1.0 ×10⁹/L","Platelets ≥ 75 ×10⁹/L","eGFR ≥ 30 mL/min","Minimum check every 6 weeks"],"sources":["SNMMI Appropriate Use Criteria Table 4","EMA Pluvicto EPAR"]},{"key":"prescription","icon":"📋","accent":"var(--gold)","title":"Prescription & treatment plan","intro":"The label-recommended regimen is 7,400 MBq IV every 6 weeks ±1 week, up to 6 cycles, unless progression or unacceptable toxicity. The prescription must integrate clinical status, between-cycle work-ups and local marketing authorisation.","bullets":["Standard activity 7,400 MBq per cycle","Interval 6 weeks ± 1 week","Up to 6 cycles based on response and tolerance","Cycle delays possible if toxicity or borderline labs","Administration by an authorised team"],"sources":["EMA Pluvicto Product Information","EMA Pluvicto EPAR"]},{"key":"toxicites","icon":"🩸","accent":"var(--red)","title":"Toxicity monitoring","intro":"Expected toxicities include myelosuppression, fatigue, nausea, dry mouth and potential renal toxicity. Management must be anticipated and documented for each cycle.","bullets":["Haematological monitoring before each cycle","Renal monitoring (creatinine/eGFR)","Clinical assessment of xerostomia","Manage fatigue, nausea, pain","Delay cycle if G3/G4 toxicity"],"sources":["SNMMI Appropriate Use Criteria toxicity section","EMA Pluvicto EPAR"]},{"key":"reponse","icon":"📊","accent":"var(--green)","title":"Response assessment","intro":"Response is assessed on the combination of clinical, biochemical (PSA) and imaging data. PSA alone should not drive a stopping decision if imaging or clinical findings do not confirm progression.","bullets":["PSA monitoring between cycles","Response imaging per protocol","Systematic clinical assessment","Decision after 2-3 cycles then end of protocol","Post-6-cycles strategy at MDT"],"sources":["EANM/SNMMI PSMA RLT guideline","SNMMI Appropriate Use Criteria"]},{"key":"tracabilite","icon":"📁","accent":"var(--navy2)","title":"Decision traceability","intro":"Every decision linked to ¹⁷⁷Lu-PSMA-617 must be documented: indication, MDT validation, informed consent, information provided to the patient, local protocol applied. This traceability is essential from a medico-legal and regulatory perspective.","bullets":["MDT report with reasoned decision","Signed informed consent","Information to patient and household","Reference to validated local protocol","Documentation of dose adjustments"],"sources":["EANM/SNMMI PSMA RLT guideline","EMA Pluvicto Product Information"]},{"key":"contre-indications","icon":"⛔","accent":"var(--red)","title":"Contraindications & precautions","intro":"Several situations contraindicate or limit the use of ¹⁷⁷Lu-PSMA-617. Check them systematically before each cycle and document the absence of active contraindication in the patient record. Any relative contraindication must be discussed at MDT.","bullets":["PSMA-negative disease on imaging","Severe pre-existing marrow insufficiency","Severe renal impairment (eGFR < 30)","Active secondary malignancy","Poor performance status"],"sources":["EMA Pluvicto Product Information","SNMMI Appropriate Use Criteria","EANM/SNMMI PSMA RLT guideline"]}]},"merm":{"molecule":"¹⁷⁷Lu-PSMA-617","profession":"Nuclear medicine technologist","criteria":["Room and materials ready before patient arrival","Verify identity and signed consent","Reliable IV line before injection","Immediate post-administration monitoring","Hand out written radiation protection instructions"],"warnings":[{"emoji":"💉","label":"Extravasation","text":"monitor injection site"},{"emoji":"😮💨","label":"Adverse reaction","text":"vital signs, escalate to physician"},{"emoji":"☢️","label":"Contamination","text":"urine, gloves, surfaces"},{"emoji":"🗑️","label":"Waste","text":"dedicated containers and signage"},{"emoji":"📞","label":"Escalation","text":"call physician if incident"}],"sections":[{"key":"preparation-salle","icon":"🏥","accent":"var(--blue)","title":"Room preparation & patient pathway","intro":"Before the patient arrives, verify that the room is ready: injection equipment, shielding, waste containers, signage, dedicated toilets if applicable. The patient pathway must be anticipated to limit staff exposure and area contamination.","bullets":["Shielded room ready, equipment available","Patient toilets identified and signposted","Contaminated-waste containers in place","Active controlled-area signage","Timing coordinated with the radiopharmacist"],"sources":["EANM/SNMMI PSMA RLT guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"accueil-patient","icon":"👤","accent":"var(--blue)","title":"Reception & patient preparation","intro":"On arrival, verify patient identity, confirm signed consent, review current medications and hydration. Re-explain procedure information, radiation protection instructions and expected effects.","bullets":["Identity-vigilance check","Signed consent on file","Oral hydration recommended pre-injection","Procedure information review","Check for same-day contraindications"],"sources":["EANM/SNMMI PSMA RLT guideline"]},{"key":"administration-iv","icon":"💉","accent":"var(--orange)","title":"IV access & administration","intro":"Establish a reliable peripheral IV line, ideally of good calibre. ¹⁷⁷Lu-PSMA-617 is administered slowly with flushing. The injection site is continuously monitored to detect any possible extravasation.","bullets":["Reliable IV, suitable calibre, tested flow","Slow injection per protocol","Saline flush after dose","Continuous monitoring of injection site","Documentation of time and activity"],"sources":["EMA Pluvicto Product Information","EANM/SNMMI PSMA RLT guideline"]},{"key":"surveillance-immediate","icon":"🩺","accent":"var(--blue)","title":"Immediate monitoring","intro":"After administration, monitor vital signs and immediate tolerance. Nausea, pain, malaise or abrupt changes must be reported to the physician. The patient only leaves the area after medical clearance.","bullets":["Post-injection vital signs","Assess tolerance (nausea, pain, fatigue)","Check for delayed extravasation","Monitor behaviour and consciousness","Medical clearance before leaving area"],"sources":["EANM/SNMMI PSMA RLT guideline"]},{"key":"radioprotection-patient","icon":"☢️","accent":"var(--orange)","title":"Patient & household radiation protection","intro":"Hand the patient written instructions: distances from household members (especially pregnant women and children), precaution durations, management of urine and effluents at home. Document hand-over of these instructions.","bullets":["Written instructions handed over and explained","Distances and durations per local recommendations","Special precautions for vulnerable household members","Urine management and domestic hygiene","Contact details for questions"],"sources":["EANM/SNMMI PSMA RLT guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"dechets-contamination","icon":"🗑️","accent":"var(--red)","title":"Waste & contamination","intro":"Contaminated waste (syringes, gloves, swabs, initial urine) must be disposed of via the dedicated circuit. Surfaces and patient-toilet floors must be checked. Any detected contamination must be reported and documented.","bullets":["Dedicated contaminated-waste containers","Surface decontamination if needed","Radiometric check of at-risk areas","Decay storage before disposal","Traceability of contamination incidents"],"sources":["IAEA Radiopharmaceutical Therapy","EANM/SNMMI PSMA RLT guideline"]},{"key":"escalade-incidents","icon":"📞","accent":"var(--red)","title":"Escalation & incidents","intro":"In case of extravasation, patient adverse reaction, identity error or any abnormal situation, apply the escalation procedure: call the nuclear medicine physician, the medical physicist if contamination, internal reporting and systematic documentation.","bullets":["Extravasation procedure known and accessible","Nuclear physician phone number posted","Call medical physicist if contamination","Systematic internal reporting","Detailed documentation of the incident"],"sources":["EANM/SNMMI PSMA RLT guideline","IAEA Radiopharmaceutical Therapy"]}]},"radiopharmacien":{"molecule":"¹⁷⁷Lu-PSMA-617","profession":"Radiopharmacist","criteria":["Anticipated and documented supply chain","Reception and parcel conformity check","Aseptic preparation in shielded enclosure","Quality control before release","Complete batch/patient/activity traceability"],"warnings":[{"emoji":"📦","label":"Supply","text":"short delays and shelf-life"},{"emoji":"⚠️","label":"Non-conformity","text":"isolate and report immediately"},{"emoji":"☢️","label":"Handling","text":"operator radiation protection"},{"emoji":"📋","label":"Documentation","text":"batch, patient, activity, operator"},{"emoji":"🗑️","label":"Decay","text":"waste storage before disposal"}],"sections":[{"key":"commande-approvisionnement","icon":"📦","accent":"var(--blue)","title":"Order & supply","intro":"The order for ¹⁷⁷Lu-PSMA-617 (commercial product) must be anticipated according to patient schedule, prescribed activity and logistic constraints. The delivery slot and the expected activity at the reference time must be coordinated with the department.","bullets":["Valid and documented patient-named prescription","Activity ordered at reference time","Delivery slot coordinated with patient schedule","Supplier availability check","Complete administrative documentation"],"sources":["EMA Pluvicto Product Information","EANM/SNMMI PSMA RLT guideline"]},{"key":"reception-stockage","icon":"📥","accent":"var(--blue)","title":"Reception & storage","intro":"On reception, check parcel integrity, absence of external contamination, batch conformity, expiry and activity at reference time. The product must be stored in a dedicated shielded area until use.","bullets":["Parcel integrity and leak-tightness check","External contamination measurement","Batch, expiry, activity verification","Storage in dedicated shielded enclosure","Reception documentation"],"sources":["IAEA Radiopharmaceutical Therapy","EMA Pluvicto Product Information"]},{"key":"preparation-dispensation","icon":"🧪","accent":"var(--purple)","title":"Preparation / dispensing","intro":"Preparation is performed in a shielded enclosure under aseptic conditions, with appropriate PPE. The final activity dispensed for each patient must be adjusted to the prescription, taking decay into account.","bullets":["Handling in lead-shielded enclosure","Aseptic conditions maintained","Activity calculation adjusted for decay","PPE: lead apron, gloves, goggles","Final volume and activity verification"],"sources":["IAEA Radiopharmaceutical Therapy","EMA Pluvicto Product Information"]},{"key":"controle-qualite","icon":"✅","accent":"var(--green)","title":"Quality control & release","intro":"Before dispensing, verify the final activity, container integrity and concordance with the prescription. Batch release for administration must be documented and signed by the radiopharmacist.","bullets":["Final activity measurement at calibrator","Visual container check","Prescription / dispensing concordance","Signed release document","Batch documentary conformity"],"sources":["EMA Pluvicto Product Information","IAEA Radiopharmaceutical Therapy"]},{"key":"etiquetage-tracabilite","icon":"🏷️","accent":"var(--gold)","title":"Labelling & traceability","intro":"Each dispensing carries a patient-named label: patient identity, batch number, final activity, calibration time, operator. Traceability must allow tracing back of every step in case of pharmacovigilance.","bullets":["Patient-named label","Radiopharmaceutical batch number","Final activity and calibration time","Operator identity","Durable document archiving"],"sources":["EMA Pluvicto Product Information","IAEA Radiopharmaceutical Therapy"]},{"key":"dechets-decroissance","icon":"🗑️","accent":"var(--red)","title":"Waste & decay","intro":"Empty vials, syringes and contaminated consumables must be stored in a decay area until they reach the regulatory disposal thresholds. Documented waste management is mandatory and auditable.","bullets":["Dedicated shielded containers","Storage in a controlled decay area","Radiometric measurement before disposal","Documentation of the waste circuit","Compliance with local regulations"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"non-conformites","icon":"⚠️","accent":"var(--red)","title":"Non-conformities & pharmacovigilance","intro":"Any non-conformity (delivery delay, product defect, activity discrepancy, contamination, preparation incident) must be isolated, reported and documented. Pharmacovigilance contributes to continuous improvement and patient safety.","bullets":["Immediately isolate any non-conforming product","Systematic internal reporting","Notify supplier if product defect","Pharmacovigilance via official channels","Documented lessons learned"],"sources":["EMA Pluvicto Product Information","IAEA Radiopharmaceutical Therapy"]}]},"radiophysicien":{"molecule":"¹⁷⁷Lu-PSMA-617","profession":"Medical physicist","criteria":["Patient dosimetry assessed or estimated","Monitoring of organs at risk over 6 cycles","Equipment calibration up to date","Individual staff dosimetry","Facilities compliant with regulatory requirements"],"warnings":[{"emoji":"💧","label":"Kidneys","text":"cumulative dose over cycles"},{"emoji":"🦴","label":"Marrow","text":"dose and haematology monitoring"},{"emoji":"☢️","label":"Staff","text":"time, distance, shielding"},{"emoji":"🏥","label":"Facilities","text":"effluents and zoning"},{"emoji":"📋","label":"Incidents","text":"reporting and follow-up"}],"sections":[{"key":"dosimetrie-patient","icon":"📏","accent":"var(--blue)","title":"Patient dosimetry","intro":"For ¹⁷⁷Lu-PSMA-617, administration uses a standardised activity (7,400 MBq) with individual dosimetry not mandatory for in-label use. Personalised dosimetry remains possible and useful in selected cases (organ impairment, cumulative dose).","bullets":["Standardised activity 7,400 MBq per cycle","Individual dosimetry not mandatory in-label","Personalisation possible if organ fragility","Cumulative dose estimation across cycles","Documentation of dosimetric choices"],"sources":["EANM/SNMMI PSMA RLT guideline","EMA Pluvicto EPAR"]},{"key":"organes-risque","icon":"🫘","accent":"var(--red)","title":"Organs at risk","intro":"The main organs at risk are the kidneys, bone marrow and salivary glands. Cumulative monitoring across the 6 cycles must anticipate possible late adverse effects. Organ constraints remain matter of debate and are not strictly mandatory.","bullets":["Kidneys: cumulative dose to monitor","Marrow: haematology / dose correlation","Salivary glands: possible xerostomia","Cumulative monitoring over 6 cycles","Constraints to discuss within the team"],"sources":["EANM/SNMMI PSMA RLT guideline"]},{"key":"mesures-post-therapie","icon":"📊","accent":"var(--orange)","title":"Post-therapy measurements","intro":"After administration, the dose rate at 1 m can be measured to validate patient discharge criteria and radiation protection instructions. Post-therapy imaging (SPECT/CT) provides information on tracer distribution and kinetics.","bullets":["Dose rate measurement at 1 m","Discharge criteria per local regulation","Post-therapy SPECT/CT if protocol-defined","Documented tracer kinetics if dosimetry","Tailoring of instructions to each case"],"sources":["EANM/SNMMI PSMA RLT guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"calibration-equipements","icon":"⚙️","accent":"var(--blue)","title":"Equipment calibration","intro":"Dose calibrators, contamination probes and dose-rate meters must be calibrated and verified to a documented schedule. Periodic checks ensure reliability of activity and contamination measurements.","bullets":["Traceable dose calibrator calibration","Documented periodic checks","Verification of probes and contamination meters","Calibration per applicable standard","Documentation of detected drifts"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"radioprotection-professionnels","icon":"☢️","accent":"var(--orange)","title":"Staff radiation protection","intro":"ALARA principles apply: time, distance, shielding. Each exposed worker wears a passive and operational dosimeter according to their category. PPE (lead aprons, gloves, glasses) must be available and used systematically.","bullets":["ALARA principles: time, distance, shielding","Individual passive and operational dosimetry","PPE available: lead apron, gloves","Mandatory initial and continuing training","Specific medical follow-up (category A/B)"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"locaux-environnement","icon":"🏥","accent":"var(--blue)","title":"Facilities & environment","intro":"Facilities must comply with regulatory zoning (controlled area), with suitable ventilation, effluent management (patient toilets with decay tank if applicable) and clear signage. The external environment must be protected.","bullets":["Displayed regulatory zoning","Suitable ventilation and filtration","Decay tanks if applicable","Compliant signage","Contingency plan in case of contamination"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"incidents-reporting","icon":"📋","accent":"var(--red)","title":"Incidents & regulatory reporting","intro":"Any significant incident (major extravasation, contamination, abnormal exposure, activity discrepancy) must be analysed, documented and reported to the competent authorities according to national regulations (national regulator).","bullets":["Classification of the significant event","Reporting to the national regulator","Documented root-cause analysis","Corrective and preventive actions","Lessons learned shared in the team"],"sources":["IAEA Radiopharmaceutical Therapy"]}]}},"Lu177-DOTATATE":{"medecin-nucleaire":{"molecule":"¹⁷⁷Lu-DOTATATE","profession":"Nuclear medicine physician","criteria":["Confirm SSTR expression (SSTR-PET)","Verify well-differentiated GEP-NET (G1/G2, G3 to discuss)","Assess progression on SSA","Check marrow and renal reserve","MDT-validated decision (NET tumour board)"],"warnings":[{"emoji":"🦠","label":"Carcinoid crisis","text":"prophylaxis in secreting NETs"},{"emoji":"💧","label":"Kidney","text":"amino-acid nephroprotection"},{"emoji":"🩸","label":"Haematology","text":"monitor late MDS/AML"},{"emoji":"☢️","label":"Radiation protection","text":"patient and household guidance"},{"emoji":"📋","label":"Coordination","text":"NET oncologist / endocrinologist"}],"sections":[{"key":"indications","icon":"🎯","accent":"var(--blue)","title":"Indications & regulatory framework","intro":"¹⁷⁷Lu-DOTATATE (Lutathera) is indicated in adults with well-differentiated gastroenteropancreatic neuroendocrine tumours (GEP-NETs) expressing somatostatin receptors (SSTR+), progressing on a somatostatin analogue. The precise indications and combinations evolve according to local marketing authorisation and MDT decision.","bullets":["Well-differentiated SSTR+ GEP-NET","Mainly G1/G2; well-differentiated G3 to discuss","Progression on a somatostatin analogue","Adults according to local authorisation","Decision at the multidisciplinary NET tumour board"],"sources":["EMA Lutathera EPAR","EANM 2022 PRRT guideline","NETTER-1 trial (NEJM)"]},{"key":"selection","icon":"👥","accent":"var(--blue)","title":"Clinical patient selection","intro":"Selection takes into account tumour grade, tumour burden, performance status, prior treatments (SSA, everolimus, chemotherapy, embolisation) and marrow and renal reserve. Borderline cases must be discussed at the tumour board.","bullets":["Compatible performance status (typically ≤2)","Adequate marrow and renal reserve","Documented prior treatments","Tumour burden and symptoms assessed","Nutritional status and comorbidities"],"sources":["EANM 2022 PRRT guideline","ENETS guidelines"]},{"key":"imagerie","icon":"🔬","accent":"var(--orange)","title":"Pre-treatment imaging","intro":"Selection relies on recent SSTR imaging: ⁶⁸Ga-DOTATATE/DOTANOC/DOTATOC PET preferred over the OctreoScan scintigraphy. Sufficient SSTR uptake (typically above-liver per local protocol) is required on target lesions. FDG may be useful when a grade-3 component (aggressive subclones) is suspected.","bullets":["Recent SSTR-PET (ideally <3 months)","SSTR uptake above the liver (per protocol)","FDG if aggressive grade ≥2 suspected","Complementary morphological imaging","Report detailing targets and distribution"],"sources":["EANM 2022 PRRT guideline","SNMMI procedure standard"]},{"key":"biologie","icon":"🧪","accent":"var(--blue)","title":"Pre-cycle laboratory work-up","intro":"Before each cycle, check haematological, renal and hepatic parameters and specific biomarkers (chromogranin A, markers according to primary site). Marrow function must be monitored given the risk of cumulative myelosuppression and late MDS/AML.","bullets":["Hb ≥ 8 g/dL, adequate WBC and platelets","Adequate eGFR per local protocol","Liver function within normal ranges","Chromogranin A and site-specific markers","Check before each cycle"],"sources":["EANM 2022 PRRT guideline","EMA Lutathera EPAR"]},{"key":"prescription","icon":"📋","accent":"var(--gold)","title":"Prescription & treatment plan","intro":"The label-recommended regimen is 4 cycles of 7,400 MBq intravenously every 8 weeks ±1 week, co-administered with an amino-acid solution (L-lysine + L-arginine) for nephroprotection. Somatostatin analogues are continued between cycles.","bullets":["4 cycles × 7,400 MBq IV","Interval 8 weeks ± 1 week","Mandatory amino-acid co-administration","SSA continued between cycles","Systematic antiemetic prophylaxis"],"sources":["EMA Lutathera Product Information","EANM 2022 PRRT guideline"]},{"key":"toxicites","icon":"🩸","accent":"var(--red)","title":"Toxicity monitoring","intro":"Expected toxicities include nausea and vomiting (very common, linked to the amino-acid infusion), myelosuppression, renal and hepatic toxicity, fatigue, hyperkalaemia and carcinoid crisis in secreting patients. The risk of late MDS/AML must be anticipated and documented.","bullets":["Nausea / vomiting linked to amino acids","Haematological monitoring between cycles","Renal and hepatic monitoring","Carcinoid crisis risk (secreting NETs)","Long-term MDS/AML follow-up"],"sources":["EANM 2022 PRRT guideline","EMA Lutathera EPAR"]},{"key":"reponse","icon":"📊","accent":"var(--green)","title":"Response assessment","intro":"Response is assessed by SSTR imaging (and FDG if grade ≥2), RECIST/morphological criteria, serum biomarkers and clinical evaluation. Chromogranin A kinetics must be interpreted cautiously according to treatment.","bullets":["SSTR imaging at mid- and end-protocol","RECIST on morphological imaging","Chromogranin A and site-specific markers","Systematic clinical assessment","Post-4-cycles strategy at the tumour board"],"sources":["EANM 2022 PRRT guideline","ENETS guidelines"]},{"key":"tracabilite","icon":"📁","accent":"var(--navy2)","title":"Decision traceability","intro":"Every decision linked to ¹⁷⁷Lu-DOTATATE must be documented: indication, NET tumour board validation, informed consent, information provided to the patient, local protocol applied. Traceability is essential medico-legally and for long-term follow-up.","bullets":["NET tumour board report with reasoned decision","Signed informed consent","Information to patient and household","Reference to validated local protocol","Documentation of between-cycle adjustments"],"sources":["EANM 2022 PRRT guideline","EMA Lutathera Product Information"]},{"key":"contre-indications","icon":"⛔","accent":"var(--red)","title":"Contraindications & precautions","intro":"Several situations contraindicate or limit the use of ¹⁷⁷Lu-DOTATATE. Check them systematically before each cycle. Pregnancy is an absolute contraindication; breastfeeding must be interrupted.","bullets":["Pregnancy / breastfeeding","SSTR-negative tumour on imaging","Severe renal impairment","Severe marrow insufficiency","Active secondary malignancy"],"sources":["EMA Lutathera Product Information","EANM 2022 PRRT guideline"]}]},"merm":{"molecule":"¹⁷⁷Lu-DOTATATE","profession":"Nuclear medicine technologist","criteria":["Room ready with double IV access","Amino acids prepared and programmed","Antiemetics available","Reliable IV lines before administration","Radiation protection instructions handed over"],"warnings":[{"emoji":"🤢","label":"Nausea","text":"very common with amino acids"},{"emoji":"⚡","label":"Hyperkalaemia","text":"monitor K+/Na+"},{"emoji":"💉","label":"Extravasation","text":"monitor injection site"},{"emoji":"🦠","label":"Carcinoid crisis","text":"secreting NETs"},{"emoji":"📞","label":"Escalation","text":"call physician if incident"}],"sections":[{"key":"preparation-salle","icon":"🏥","accent":"var(--blue)","title":"Room preparation & pathway","intro":"Before the patient arrives, verify the room is ready for a long infusion (4-5 hours): double-line equipment, pumps for amino acids, pre-loaded antiemetics, shielding, waste containers, signage. The pathway must allow toilet access during the infusion.","bullets":["Double IV access (amino acids + Lutathera)","Programmed pumps available","Antiemetics and emergency kit","Identified patient toilets","Active controlled-area signage"],"sources":["EANM 2022 PRRT guideline"]},{"key":"perfusion-aa","icon":"💧","accent":"var(--orange)","title":"Amino-acid infusion","intro":"The amino-acid solution (L-lysine + L-arginine) must be started 30 minutes before Lutathera and continued during and after. It provides nephroprotection by blocking tubular reabsorption of the radiopharmaceutical. The total duration is usually 4 hours.","bullets":["Start 30 min before Lutathera","L-lysine + L-arginine solution","Total duration ~4 hours","Electrolyte monitoring (K+/Na+)","Systematic prophylactic antiemetic"],"sources":["EANM 2022 PRRT guideline","EMA Lutathera Product Information"]},{"key":"administration-iv","icon":"💉","accent":"var(--blue)","title":"IV access & administration","intro":"Two IV lines are required: one for amino acids (long infusion), one for Lutathera (~30-minute infusion). The Lutathera line must be of good calibre, tested and flushed after administration. The injection site is continuously monitored.","bullets":["Two reliable, tested IVs","Lutathera over ~30 minutes","Saline flush after dose","Continuous injection-site monitoring","Documentation of time and activity"],"sources":["EMA Lutathera Product Information","EANM 2022 PRRT guideline"]},{"key":"surveillance-immediate","icon":"🩺","accent":"var(--blue)","title":"Immediate monitoring","intro":"During and after administration, monitor vital signs, digestive tolerance (very common nausea), the appearance of signs of hyperkalaemia or carcinoid crisis. Medical clearance is required before patient discharge.","bullets":["Regular vital signs","Digestive tolerance (nausea, vomiting)","Possible hyperkalaemia signs","Vigilance for carcinoid crisis (secreting NETs)","Medical clearance before discharge"],"sources":["EANM 2022 PRRT guideline"]},{"key":"radioprotection-patient","icon":"☢️","accent":"var(--orange)","title":"Patient & household radiation protection","intro":"Hand the patient written instructions: distances (especially pregnant women and children), precaution durations, generous hydration to promote urinary tracer elimination, urine management at home.","bullets":["Written instructions handed over and explained","Distances and durations per local protocol","Generous oral hydration","Urine management and domestic hygiene","Contact details for questions"],"sources":["EANM 2022 PRRT guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"dechets-contamination","icon":"🗑️","accent":"var(--red)","title":"Waste & contamination","intro":"Contaminated waste (syringes, amino-acid tubing, gloves, initial urine) must be disposed of via the dedicated circuit. Surfaces and patient toilets must be checked. Any detected contamination is reported and documented.","bullets":["Dedicated contaminated-waste containers","Surface decontamination if needed","Radiometric check of at-risk areas","Decay storage","Traceability of incidents"],"sources":["IAEA Radiopharmaceutical Therapy","EANM 2022 PRRT guideline"]},{"key":"escalade-incidents","icon":"📞","accent":"var(--red)","title":"Escalation & incidents","intro":"In case of extravasation, carcinoid crisis, symptomatic hyperkalaemia, malaise or any abnormal situation, apply the escalation procedure: call the nuclear medicine physician, the medical physicist if contamination. Documentation is systematic.","bullets":["Accessible extravasation procedure","Vigilance for carcinoid crisis (secreting NETs)","Nuclear physician phone number posted","Call medical physicist if contamination","Detailed documentation"],"sources":["EANM 2022 PRRT guideline","IAEA Radiopharmaceutical Therapy"]}]},"radiopharmacien":{"molecule":"¹⁷⁷Lu-DOTATATE","profession":"Radiopharmacist","criteria":["Verified ready-to-use commercial product","Reception and conformity check","QC and release before dispensing","Complete batch/patient/activity traceability","Documentation and pharmacovigilance"],"warnings":[{"emoji":"📦","label":"Supply","text":"short delays and shelf-life"},{"emoji":"⚠️","label":"Non-conformity","text":"isolate and report immediately"},{"emoji":"☢️","label":"Handling","text":"operator radiation protection"},{"emoji":"📋","label":"Documentation","text":"batch, patient, activity, operator"},{"emoji":"🗑️","label":"Decay","text":"half-life 6.65 days"}],"sections":[{"key":"commande-approvisionnement","icon":"📦","accent":"var(--blue)","title":"Order & supply","intro":"The order of ¹⁷⁷Lu-DOTATATE (Lutathera, commercial ready-to-use product) must be anticipated according to patient schedule and coordinated with the delivery slot. The activity ordered is calculated at reference time, accounting for decay.","bullets":["Valid and documented patient-named prescription","Activity ordered at reference time","Coordinated delivery slot","Supplier availability check","Complete administrative documentation"],"sources":["EMA Lutathera Product Information"]},{"key":"reception-stockage","icon":"📥","accent":"var(--blue)","title":"Reception & storage","intro":"On reception, check parcel integrity, absence of external contamination, batch conformity, expiry and activity at reference time. The product is stored in a dedicated shielded area until use.","bullets":["Parcel integrity and leak-tightness check","External contamination measurement","Batch, expiry, activity verification","Storage in dedicated shielded enclosure","Reception documentation"],"sources":["IAEA Radiopharmaceutical Therapy","EMA Lutathera Product Information"]},{"key":"controle-qualite","icon":"✅","accent":"var(--green)","title":"Quality control & release","intro":"As Lutathera is a ready-to-use commercial product, QC focuses on final activity at the calibrator, container integrity, concordance with the prescription and batch documentation. Release is documented and signed by the radiopharmacist before dispensing.","bullets":["Final activity measurement at calibrator","Visual container check","Prescription / dispensing concordance","Signed release document","Batch documentary conformity"],"sources":["EMA Lutathera Product Information","IAEA Radiopharmaceutical Therapy"]},{"key":"etiquetage-tracabilite","icon":"🏷️","accent":"var(--gold)","title":"Labelling & traceability","intro":"Each dispensing carries a patient-named label: patient identity, batch number, final activity, calibration time, operator. Traceability must allow tracing back of every step in case of pharmacovigilance.","bullets":["Patient-named label","Radiopharmaceutical batch number","Final activity and calibration time","Operator identity","Durable document archiving"],"sources":["EMA Lutathera Product Information","IAEA Radiopharmaceutical Therapy"]},{"key":"dechets-decroissance","icon":"🗑️","accent":"var(--red)","title":"Waste & decay","intro":"Empty vials, syringes and contaminated consumables must be stored in a decay area (¹⁷⁷Lu half-life = 6.65 days, practical decay ~80 days) before disposal per regulation. Documented management is mandatory and auditable.","bullets":["Dedicated shielded containers","Controlled decay area","Radiometric measurement before disposal","Documentation of the waste circuit","Compliance with local regulations"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"non-conformites","icon":"⚠️","accent":"var(--red)","title":"Non-conformities & pharmacovigilance","intro":"Any non-conformity (delivery delay, product defect, activity discrepancy, contamination, incident) must be isolated, reported and documented. Pharmacovigilance contributes to patient safety and lessons learned.","bullets":["Immediately isolate any non-conforming product","Systematic internal reporting","Notify supplier if defect","Pharmacovigilance via official channels","Documented lessons learned"],"sources":["EMA Lutathera Product Information","IAEA Radiopharmaceutical Therapy"]}]},"radiophysicien":{"molecule":"¹⁷⁷Lu-DOTATATE","profession":"Medical physicist","criteria":["Activity calculation validated per protocol","Enhanced renal monitoring (nephroprotection)","Equipment calibration up to date","Individual staff dosimetry","Compliant facilities"],"warnings":[{"emoji":"💧","label":"Kidney","text":"cumulative dose over 4 cycles"},{"emoji":"🦴","label":"Marrow","text":"long-term MDS monitoring"},{"emoji":"☢️","label":"Staff","text":"long infusions 4-5h"},{"emoji":"🏥","label":"Facilities","text":"effluents and ventilation"},{"emoji":"📋","label":"Incidents","text":"reporting and follow-up"}],"sections":[{"key":"dosimetrie-patient","icon":"📏","accent":"var(--blue)","title":"Patient dosimetry & activity calculation","intro":"For ¹⁷⁷Lu-DOTATATE, administration uses a standardised activity (4 × 7,400 MBq) with individual dosimetry not mandatory for in-label use. Personalisation remains possible and useful in selected cases (borderline renal function, high tumour burden, cumulative renal dose considerations).","bullets":["Standardised activity 7,400 MBq × 4 cycles","Individual dosimetry not mandatory","Personalisation if renal fragility","Cumulative dose estimation across 4 cycles","Documentation of dosimetric choices"],"sources":["EANM 2022 PRRT guideline","EMA Lutathera EPAR"]},{"key":"organes-risque","icon":"🫘","accent":"var(--red)","title":"Organs at risk (kidney++, marrow)","intro":"The main organs at risk are the kidneys (protected by the amino acids) and bone marrow. Cumulative monitoring across the 4 cycles must anticipate late adverse effects (renal toxicity, MDS/AML). Organ constraints are discussed and not strictly mandatory.","bullets":["Kidneys: amino-acid protection","Marrow: haematology / dose correlation","Long-term renal clearance follow-up","Multi-year haematological monitoring","Constraints to discuss within the team"],"sources":["EANM 2022 PRRT guideline"]},{"key":"mesures-post-therapie","icon":"📊","accent":"var(--orange)","title":"Post-therapy measurements","intro":"After administration, the dose rate at 1 m can be measured to validate discharge criteria and tailor radiation protection instructions. Post-therapy SPECT/CT imaging informs on tracer distribution and possible dosimetry.","bullets":["Dose rate measurement at 1 m","Discharge criteria per regulation","Optional post-therapy SPECT/CT","Tracer kinetics if dosimetry","Tailoring of instructions per case"],"sources":["EANM 2022 PRRT guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"calibration-equipements","icon":"⚙️","accent":"var(--blue)","title":"Equipment calibration","intro":"Dose calibrators, contamination probes and dose-rate meters must be calibrated and verified to a documented schedule. Periodic checks ensure reliability of activity and contamination measurements.","bullets":["Traceable dose calibrator calibration","Documented periodic checks","Verification of probes and contamination meters","Calibration per applicable standard","Documentation of detected drifts"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"radioprotection-professionnels","icon":"☢️","accent":"var(--orange)","title":"Staff radiation protection","intro":"ALARA principles apply: time, distance, shielding. The Lutathera specificity is exposure duration (4-5h infusion). Each exposed worker wears passive and operational dosimetry according to their category, and uses appropriate PPE.","bullets":["ALARA principles: time, distance, shielding","Specificity: long infusion (4-5h)","Passive and operational dosimetry","PPE: lead apron, gloves, glasses","Medical follow-up (category A/B)"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"locaux-environnement","icon":"🏥","accent":"var(--blue)","title":"Facilities & environment","intro":"Facilities must comply with regulatory zoning with suitable ventilation, effluent management (patient toilets in controlled area), clear signage. Management of abundant urine output in the first hours post-injection requires dimensioned decay tanks.","bullets":["Displayed regulatory zoning","Suitable ventilation and filtration","Dimensioned decay tanks","Compliant signage","Contingency plan in case of contamination"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"incidents-reporting","icon":"📋","accent":"var(--red)","title":"Incidents & regulatory reporting","intro":"Any significant incident (major extravasation, contamination, abnormal exposure, activity discrepancy) must be analysed, documented and reported to the competent national authority.","bullets":["Classification of significant event","Reporting to national regulator","Documented root-cause analysis","Corrective and preventive actions","Lessons learned shared in the team"],"sources":["IAEA Radiopharmaceutical Therapy"]}]}},"I131-cancer":{"medecin-nucleaire":{"molecule":"¹³¹I thyroid cancer","profession":"Nuclear medicine physician","criteria":["Confirm differentiated histology","Verify post-thyroidectomy status","ATA risk stratification established","Negative β-hCG in women of childbearing age","Patient preparation respected"],"warnings":[{"emoji":"🤰","label":"Pregnancy","text":"β-hCG mandatory before treatment"},{"emoji":"💧","label":"Salivary glands","text":"sialadenitis, dry mouth"},{"emoji":"🩸","label":"Haematology","text":"possible myelosuppression"},{"emoji":"🍴","label":"Diet","text":"low-iodine for 1-2 weeks"},{"emoji":"⏱️","label":"Contraception","text":"6-12 months post-treatment"}],"sections":[{"key":"indications","icon":"🎯","accent":"var(--blue)","title":"Indications & regulatory framework","intro":"Iodine-131 is used in adults after total or near-total thyroidectomy (depending on context) for differentiated thyroid cancer (papillary or follicular), based on the risk of recurrence per the ATA stratification: remnant ablation, adjuvant treatment, treatment of residual or metastatic disease. The precise indication is validated at the MDT meeting and per local protocol.","bullets":["Differentiated cancer after total or near-total thyroidectomy","Established ATA risk stratification","Thyroid cancer MDT decision","Per marketing authorisation and local protocol","Patient information and consent"],"sources":["EANM 2022 DTC guideline","ATA 2015 guidelines","ESMO guidelines"]},{"key":"selection","icon":"👥","accent":"var(--blue)","title":"Clinical selection (ablation / adjuvant / metastatic)","intro":"Three distinct clinical contexts guide the indication and activity: post-surgical remnant ablation (low risk), adjuvant treatment (intermediate risk), treatment of residual or metastatic disease (high risk). Each context has its own goals and follow-up.","bullets":["Remnant ablation (low risk)","Adjuvant (intermediate risk)","Residual / metastatic disease","Histology pT, pN, margins","Thyroid cancer MDT"],"sources":["ATA 2015 guidelines","EANM 2022 DTC guideline"]},{"key":"imagerie-bilan","icon":"🔬","accent":"var(--orange)","title":"Imaging & pre-treatment work-up","intro":"Before treatment, the work-up includes neck ultrasound (search for remnants and lymphadenopathy), measurement of thyroglobulin (Tg) and anti-Tg antibodies, TSH (elevated by withdrawal or rhTSH). A diagnostic remnant scan can be discussed on a case-by-case basis. β-hCG is mandatory in women of childbearing age.","bullets":["Neck ultrasound","Serum Tg and anti-Tg","Elevated TSH (withdrawal or rhTSH)","Diagnostic scan if relevant","Mandatory β-hCG"],"sources":["EANM 2022 DTC guideline","ATA 2015 guidelines"]},{"key":"preparation-patient","icon":"📝","accent":"var(--gold)","title":"Patient preparation (diet, T4 withdrawal vs rhTSH)","intro":"Preparation includes a low-iodine diet for 1-2 weeks to enhance uptake, and TSH elevation either by hormonal withdrawal (T4 stopped about 4 weeks with or without T3 bridging) or by rhTSH stimulation (Thyrogen), which avoids clinical hypothyroidism. The choice depends on context, comorbidities and availability.","bullets":["Low-iodine diet for 1-2 weeks","T4 withdrawal (~4 weeks) or rhTSH (Thyrogen)","Avoid recent iodinated contrast media","Active contraception","Detailed patient information"],"sources":["EANM 2022 DTC guideline","ATA 2015 guidelines"]},{"key":"prescription","icon":"📋","accent":"var(--gold)","title":"Prescription & therapeutic regimen","intro":"The activity is tailored to the indication (ablation, adjuvant, residual / metastatic), to the local protocol and to the clinical strategy. Individual dosimetry can be indicated in selected situations (metastatic disease, frail patients). Orders of magnitude remain within the marketing authorisation and recommendations.","bullets":["Activity per clinical indication","Local protocol and MDT strategy","Dosimetry if metastatic disease","Adjustment to comorbidities","Patient-named prescription validation"],"sources":["EANM 2022 DTC guideline","ATA 2015 guidelines"]},{"key":"hospitalisation-sortie","icon":"🏥","accent":"var(--orange)","title":"Hospitalisation & discharge criteria","intro":"Depending on the prescribed activity and local regulations, treatment may require hospitalisation in a lead-shielded room (typically for higher activities) or be performed as outpatient (for lower activities). Discharge criteria are determined by dose-rate measurement and patient situation (household, transport).","bullets":["Inpatient vs outpatient depending on activity","Lead-shielded room if inpatient","Length of stay per decay","Discharge criteria (dose rate)","Discharge document and instructions"],"sources":["EANM 2022 DTC guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"toxicites","icon":"🩸","accent":"var(--red)","title":"Toxicity monitoring","intro":"Expected toxicities include sialadenitis (salivary glands++), transient hypogeusia / ageusia, nausea, myelosuppression (rare at standard activities), and in some patients a gonadal risk. A rare risk of second cancer exists, depending on cumulative activity and context, and must be discussed with the patient.","bullets":["Sialadenitis and dry mouth","Transient hypogeusia / ageusia","Nausea (rare)","Gonadal risk (fertility)","Rare second-cancer risk (per cumulative activity)"],"sources":["EANM 2022 DTC guideline","ATA 2015 guidelines"]},{"key":"suivi","icon":"📊","accent":"var(--green)","title":"Post-treatment follow-up","intro":"Follow-up includes the post-therapy whole-body scan (often around D3-D10 per local protocol) which provides valuable diagnostic information, thyroglobulin (and anti-Tg) measurement, neck ultrasound and, if elevated Tg, complementary imaging (FDG-PET per context).","bullets":["Post-therapy scan per protocol (often D3-D10)","Tg and anti-Tg at defined intervals","Neck ultrasound follow-up","FDG-PET if Tg elevated and imaging negative","Long-term follow-up per ATA"],"sources":["EANM 2022 DTC guideline","ATA 2015 guidelines"]},{"key":"contre-indications","icon":"⛔","accent":"var(--red)","title":"Contraindications & precautions","intro":"Pregnancy is an absolute contraindication (mandatory β-hCG). Breastfeeding must be interrupted. Recent exposure to iodinated contrast media or a non-respected diet compromises efficacy. Contraception after treatment (duration 6 to 12 months per recommendations) must be adapted to patient sex and local recommendations.","bullets":["Pregnancy (mandatory β-hCG)","Breastfeeding (to be stopped)","Recent iodinated contrast media","Non-respected low-iodine diet","Post-treatment contraception per sex and local reco"],"sources":["EANM 2022 DTC guideline","ATA 2015 guidelines"]}]},"merm":{"molecule":"¹³¹I thyroid cancer","profession":"Nuclear medicine technologist","criteria":["Lead-shielded room checked if inpatient","Verify patient preparation (diet, withdrawal)","β-hCG checked on file","Oral administration documented","Extended radiation protection instructions handed over"],"warnings":[{"emoji":"🤰","label":"Pregnancy","text":"check β-hCG on file"},{"emoji":"🍴","label":"Diet","text":"check compliance"},{"emoji":"☢️","label":"Contamination","text":"effluents and linen"},{"emoji":"🤢","label":"Vomiting","text":"post-administration risk"},{"emoji":"📞","label":"Escalation","text":"call physician if incident"}],"sections":[{"key":"preparation-chambre","icon":"🏥","accent":"var(--blue)","title":"Lead-shielded room preparation","intro":"For high activities requiring hospitalisation, verify the conformity of the shielded room: mobile shielding, dedicated sanitary facilities with decay tank, ventilation, TV / patient connection, signage, single-use equipment. The waste circuit must be anticipated.","bullets":["Room and shielding check","Dedicated sanitary / decay tank","Single-use equipment prepared","Controlled-area signage","Operational waste circuit"],"sources":["IAEA Radiopharmaceutical Therapy","EANM 2022 DTC guideline"]},{"key":"accueil-administration","icon":"💊","accent":"var(--blue)","title":"Patient reception & oral administration","intro":"Check compliance with the low-iodine diet, hormonal withdrawal or rhTSH injection, and the presence of the β-hCG result. Administration is by the oral route (capsule or solution) with a glass of water, under direct supervision. Ingestion is documented. Watch for any vomiting in the hours that follow.","bullets":["Patient preparation check","β-hCG on file","Supervised oral administration","Traceability of activity, batch, time","Post-administration vomiting monitoring"],"sources":["EANM 2022 DTC guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"radioprotection-patient","icon":"☢️","accent":"var(--orange)","title":"Patient & household radiation protection","intro":"Radiation protection instructions are long (several days to weeks) given the long half-life and prolonged elimination. Distances (children, pregnant women), avoidance durations, hygiene, separate use of sanitary facilities if possible. Written instructions must be tailored to the individual case.","bullets":["Tailored written instructions","Distances from children and pregnant women","Prolonged avoidance durations","Enhanced domestic hygiene","Contact details"],"sources":["EANM 2022 DTC guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"dechets-contamination","icon":"🗑️","accent":"var(--red)","title":"Waste & contamination (effluents++)","intro":"Urine and stools are highly radioactive in the first days and are the main contamination source. Linen, dishes and used equipment are managed per local protocol. Radiometric checks of at-risk areas are systematic. Any contamination is documented.","bullets":["Highly radioactive urine/stools D0-D3","Linen and dish management","Dedicated waste containers","Systematic radiometric check","Documentation of incidents"],"sources":["IAEA Radiopharmaceutical Therapy","EANM 2022 DTC guideline"]},{"key":"sortie-domicile","icon":"🚪","accent":"var(--green)","title":"Hospital discharge & home instructions","intro":"Discharge is authorised after dose-rate measurement at 1 m and once regulatory criteria are met. A discharge document is handed over with home instructions, contact details and follow-up appointments (post-therapy scan, biochemistry, consultation).","bullets":["Dose-rate measurement at 1 m","Discharge document handed over","Tailored home instructions","Post-therapy scan appointment","Contact details"],"sources":["EANM 2022 DTC guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"escalade-incidents","icon":"📞","accent":"var(--red)","title":"Escalation & incidents","intro":"In case of post-administration vomiting (potentially massive contamination), area contamination, patient malaise or any abnormal situation, apply the escalation procedure. Immediate management must limit dispersion and protect staff.","bullets":["Post-administration vomiting","Decontamination procedure","Call nuclear medicine physician","Call medical physicist if contamination","Detailed documentation"],"sources":["EANM 2022 DTC guideline","IAEA Radiopharmaceutical Therapy"]}]},"radiopharmacien":{"molecule":"¹³¹I thyroid cancer","profession":"Radiopharmacist","criteria":["Suitable pharmaceutical form (capsule or solution)","Reception and conformity check","QC and release before dispensing","Complete traceability","Documentation and pharmacovigilance"],"warnings":[{"emoji":"💊","label":"Form","text":"capsule vs solution per protocol"},{"emoji":"📦","label":"Supply","text":"¹³¹I half-life = 8 days"},{"emoji":"☢️","label":"Handling","text":"suitable shielding, PPE"},{"emoji":"📋","label":"Documentation","text":"batch, patient, activity, operator"},{"emoji":"🗑️","label":"Decay","text":"several months per activity"}],"sections":[{"key":"commande","icon":"📦","accent":"var(--blue)","title":"Order & supply","intro":"The order of iodine-131 (capsule or solution per protocol and activity) must be anticipated according to patient schedule and coordinated with the delivery slot. The activity ordered is calculated at reference time, accounting for decay (half-life 8 days).","bullets":["Valid patient-named prescription","Pharmaceutical form (capsule or solution)","Activity at reference time","Coordinated delivery slot","Administrative documentation"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"reception-stockage","icon":"📥","accent":"var(--blue)","title":"Reception & storage","intro":"On reception, check parcel integrity, absence of external contamination, batch conformity, expiry and activity at reference time. Storage is in a dedicated shielded enclosure adapted to the pharmaceutical form (capsule or solution).","bullets":["Parcel integrity check","External contamination measurement","Batch, expiry, activity verification","Dedicated shielded storage","Reception documentation"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"preparation-dispensation","icon":"💊","accent":"var(--purple)","title":"Preparation / dispensing (capsules vs solution)","intro":"The capsule is usually ready to use and requires only check and labelling. The solution may require fractionation with final activity measurement at the calibrator. Any handling is in a shielded area with appropriate PPE.","bullets":["Capsule: ready to use","Solution: fractionation possible","Handling in shielded area","PPE: lead apron, gloves","Final activity measurement"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"controle-qualite","icon":"✅","accent":"var(--green)","title":"Quality control & release","intro":"Before dispensing: final activity measurement at the calibrator, visual container check, concordance with the prescription. Release is documented and signed by the radiopharmacist. Batch documentary conformity is preserved.","bullets":["Activity measurement at calibrator","Visual container check","Prescription / dispensing concordance","Signed release document","Batch documentary conformity"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"etiquetage","icon":"🏷️","accent":"var(--gold)","title":"Labelling & traceability","intro":"Each dispensing carries a patient-named label: patient identity, batch number, final activity, calibration time, operator. Traceability must allow tracing back of every step in case of pharmacovigilance or audit.","bullets":["Patient-named label","Batch number","Final activity and calibration time","Operator identity","Durable archiving"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"dechets-decroissance","icon":"🗑️","accent":"var(--red)","title":"Waste & decay","intro":"Empty vials, syringes and contaminated consumables must be stored in a decay area for several months (half-life 8 days, practical decay ~3 months to reach regulatory thresholds). Documented waste management is mandatory and auditable.","bullets":["Dedicated shielded containers","Controlled decay area","~3-month storage per activity","Radiometric measurement before disposal","Documentation of waste circuit"],"sources":["IAEA Radiopharmaceutical Therapy"]}]},"radiophysicien":{"molecule":"¹³¹I thyroid cancer","profession":"Medical physicist","criteria":["Activity calculation per method (fixed or dosimetry)","Organs at risk assessed (salivary++)","Discharge criteria validated","Effluents and tanks managed","Compliant facilities (lead-shielded room)"],"warnings":[{"emoji":"💧","label":"Salivary glands","text":"critical organ for I131"},{"emoji":"🚪","label":"Discharge","text":"dose rate at 1 m"},{"emoji":"🛢️","label":"Effluents","text":"decay tanks"},{"emoji":"☢️","label":"Staff","text":"room, linen management"},{"emoji":"📋","label":"Incidents","text":"reporting to regulator"}],"sections":[{"key":"dosimetrie-patient","icon":"📏","accent":"var(--blue)","title":"Patient dosimetry & activity calculation","intro":"For ¹³¹I thyroid cancer, several approaches are possible: fixed empirical activity (ablation, some adjuvant settings), individual lesional dosimetry or organ-constraint dosimetry (metastatic disease, Maxon/Benua method). The choice depends on indication, clinical context and local protocol.","bullets":["Empirical activity per indication","Individual dosimetry if metastatic","Blood-dose or lesional method","Adaptation to comorbidities","Documentation of choices"],"sources":["EANM 2022 DTC guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"organes-risque","icon":"🫘","accent":"var(--red)","title":"Organs at risk (salivary++, marrow, gonads)","intro":"The main organs at risk are the salivary glands (sialadenitis, chronic hyposalivation), bone marrow (classic 2 Gy blood-dose constraint in single fraction), gonads (fertility) and lacrimal pathways. Constraints remain matter of discussion and are adapted to context.","bullets":["Salivary glands: sialadenitis","Marrow: blood dose (ref. 2 Gy)","Gonads and fertility","Lacrimal pathways","Constraints to discuss within the team"],"sources":["EANM 2022 DTC guideline"]},{"key":"criteres-sortie","icon":"🚪","accent":"var(--orange)","title":"Discharge criteria & dose rate","intro":"Discharge criteria are based on dose-rate measurement at 1 metre from the patient. Regulatory thresholds vary by country (FR, BE, other EU countries) and patient situation (household with children or pregnant women, transport). A discharge document is delivered.","bullets":["Dose-rate measurement at 1 m","Country-variable regulatory thresholds","Adaptation to household situation","Regulatory discharge document","Measurement traceability"],"sources":["EANM 2022 DTC guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"effluents-cuves","icon":"🛢️","accent":"var(--red)","title":"Effluents & decay tanks","intro":"Dedicated ¹³¹I decay tanks are essential: they collect the urinary effluents of inpatient cases. Management involves tank activity monitoring, compliance with release thresholds and strict regulatory traceability (periodic reports).","bullets":["Dimensioned dedicated tanks","Tank activity monitoring","Respected release thresholds","Regulatory traceability","Periodic reports to authorities"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"calibration","icon":"⚙️","accent":"var(--blue)","title":"Equipment calibration","intro":"Dose calibrators, contamination probes and survey meters must be calibrated and verified to a documented schedule. The ¹³¹I specificity (high-energy gamma) requires checks adapted to the instruments used in the area and the inpatient room.","bullets":["Traceable dose calibrator calibration","Contamination probes","Survey meters suited to I131 gamma","Documented periodic checks","Documentation of detected drifts"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"radioprotection-pro","icon":"☢️","accent":"var(--orange)","title":"Staff radiation protection","intro":"ALARA principles apply with particular attention to the management of the lead-shielded room (limited entries, care duration, linen and effluent management). Individual passive and operational dosimetry is essential for exposed staff.","bullets":["ALARA: time, distance, shielding","Limited entries to shielded room","Passive and operational dosimetry","Suitable PPE (apron, gloves)","Medical follow-up (category A/B)"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"locaux-chambre","icon":"🏥","accent":"var(--blue)","title":"Facilities & environment (lead-shielded room)","intro":"The lead-shielded room must meet regulatory requirements: shielding adapted to delivered activities, ventilation and filtration, dedicated sanitary facilities with decay tank, signage, contingency plan for contamination or patient emergency. Periodic checks are documented.","bullets":["Shielding adapted to activities","Ventilation and filtration","Dedicated sanitary / decay tank","Signage and zoning","Emergency contingency plan"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"incidents-reporting","icon":"📋","accent":"var(--red)","title":"Incidents & regulatory reporting","intro":"Any significant incident (contamination, post-administration vomiting, abnormal exposure, activity discrepancy, significant event) must be analysed, documented and reported to the competent authorities (national regulator). Corrective actions are documented.","bullets":["Significant-event classification","Reporting to national regulator","Documented root-cause analysis","Corrective and preventive actions","Lessons learned"],"sources":["IAEA Radiopharmaceutical Therapy"]}]}},"I131-hyper":{"medecin-nucleaire":{"molecule":"¹³¹I hyperthyroidism","profession":"Nuclear medicine physician","criteria":["Identify the aetiology (Graves, TMNG, toxic adenoma)","Negative β-hCG in women of childbearing age","Anticipated antithyroid drug (ATD) withdrawal","Patient preparation respected","Patient information and consent"],"warnings":[{"emoji":"🤰","label":"Pregnancy","text":"absolute contraindication"},{"emoji":"👁️","label":"Orbitopathy","text":"vigilance in Graves"},{"emoji":"💊","label":"ATD","text":"withdrawal per drug and protocol"},{"emoji":"🍴","label":"Diet","text":"low-iodine"},{"emoji":"⏱️","label":"Hypothyroidism","text":"common post-treatment"}],"sections":[{"key":"indications","icon":"🎯","accent":"var(--blue)","title":"Indications & regulatory framework","intro":"Iodine-131 is a therapeutic option for persistent or recurrent hyperthyroidism, in case of intolerance or contraindication to antithyroid drugs, or as a first-line choice based on patient preference. Surgical alternatives must be discussed. The decision is shared and individualised according to aetiology and context.","bullets":["Persistent / recurrent hyperthyroidism","Intolerance or failure of ATDs","Patient choice and discussed alternatives","Per local marketing authorisation","Information and consent"],"sources":["EANM 2022 Hyperthyroidism guideline","ATA 2016 Hyperthyroidism guidelines"]},{"key":"etiologie","icon":"🔬","accent":"var(--blue)","title":"Selection by aetiology (Graves, TMNG, toxic adenoma)","intro":"Three main aetiologies guide work-up and modalities: Graves' disease (autoimmune, diffuse hyperfixation, positive TSI antibodies), toxic multinodular goitre (nodular hyperfixation, variable extent), toxic adenoma (single hyperfunctioning nodule). Imaging (scintigraphy or ultrasound depending on availability) and antibodies allow characterisation.","bullets":["Graves' disease (autoimmune, TSI+)","Toxic multinodular goitre (TMNG)","Toxic adenoma (single nodule)","Scintigraphy or ultrasound","Anti-TSI / anti-TPO antibodies"],"sources":["EANM 2022 Hyperthyroidism guideline","ATA 2016 Hyperthyroidism guidelines"]},{"key":"bilan-pre","icon":"🧪","accent":"var(--blue)","title":"Pre-treatment work-up","intro":"The work-up includes hormonal assays (TSH, FT4, FT3), antibodies (TSI++, anti-TPO), thyroid imaging (scintigraphy with uptake measurement and/or ultrasound with volume), β-hCG in women of childbearing age. Cardiac evaluation may be indicated in at-risk patients.","bullets":["TSH, FT4, FT3","TSI, anti-TPO","Scintigraphy ± ultrasound (volume)","Mandatory β-hCG","Cardiac evaluation if at risk"],"sources":["EANM 2022 Hyperthyroidism guideline","ATA 2016 Hyperthyroidism guidelines"]},{"key":"preparation","icon":"📝","accent":"var(--gold)","title":"Patient preparation (ATD withdrawal, diet)","intro":"Antithyroid drug (ATD) withdrawal is recommended before treatment to enhance iodine-131 uptake. The duration of withdrawal varies according to the drug (methimazole/carbimazole, PTU), clinical context, risk of rebound and endocrinology advice. A low-iodine diet may be useful per context (less central than in thyroid cancer). β-blockers can be maintained.","bullets":["ATD withdrawal per drug and local protocol","Joint endocrinology advice","Low-iodine diet per context","β-blockers maintained if needed","Detailed patient information"],"sources":["EANM 2022 Hyperthyroidism guideline","ATA 2016 Hyperthyroidism guidelines"]},{"key":"choix-therapeutique","icon":"📋","accent":"var(--gold)","title":"Therapeutic choice & clinical strategy","intro":"The choice of strategy (euthyroid vs targeted hypothyroidism), follow-up planning (TSH, FT4 at 6 weeks, 3 months, 6 months) and anticipation of replacement therapy are defined before administration. The actual activity calculation is the medical physicist's responsibility per available methods (fixed, per gram, individual dosimetry).","bullets":["Goal: euthyroid vs hypothyroid","Follow-up planning","Anticipation of replacement therapy","Information on expected course","Activity calculation by the medical physicist"],"sources":["EANM 2022 Hyperthyroidism guideline","ATA 2016 Hyperthyroidism guidelines"]},{"key":"suivi-toxicites","icon":"📊","accent":"var(--green)","title":"Follow-up & toxicity monitoring","intro":"Follow-up includes checking thyroid hormones (TSH, FT4) at 6 weeks, 3 months and 6 months. Post-treatment hypothyroidism is common (often a desired goal in Graves' disease) and requires replacement therapy. Particular vigilance is given to Graves' orbitopathy, which may worsen, moderate sialadenitis and the risk of radiation thyroiditis.","bullets":["TSH/FT4 at 6 weeks, 3 months, 6 months","Common post-treatment hypothyroidism","Anticipated replacement therapy","Vigilance for Graves' orbitopathy","Possible sialadenitis and radiation thyroiditis"],"sources":["EANM 2022 Hyperthyroidism guideline","ATA 2016 Hyperthyroidism guidelines"]},{"key":"contre-indications","icon":"⛔","accent":"var(--red)","title":"Contraindications & precautions","intro":"Pregnancy and breastfeeding are absolute contraindications (mandatory β-hCG). Active moderate-to-severe Graves' orbitopathy requires a joint endocrine-ophthalmology assessment before treatment: radioiodine therapy may worsen it, and preventive corticosteroid therapy or an alternative therapeutic choice must be discussed. A non-respected iodine diet or recent contrast media compromise efficacy.","bullets":["Pregnancy / breastfeeding","Active moderate-to-severe orbitopathy: specialist advice","Preventive corticosteroid therapy to discuss","Recent iodinated contrast media","Post-treatment contraception per local reco"],"sources":["EANM 2022 Hyperthyroidism guideline","ATA 2016 Hyperthyroidism guidelines"]}]},"merm":{"molecule":"¹³¹I hyperthyroidism","profession":"Nuclear medicine technologist","criteria":["Verify patient preparation (ATDs, diet)","β-hCG checked on file","Documented oral administration","Radiation protection instructions handed over"],"warnings":[{"emoji":"🤰","label":"Pregnancy","text":"check β-hCG"},{"emoji":"💊","label":"ATDs","text":"withdrawal per drug and protocol"},{"emoji":"☢️","label":"Contamination","text":"first days"},{"emoji":"📞","label":"Escalation","text":"call physician if incident"}],"sections":[{"key":"preparation-salle","icon":"🏥","accent":"var(--blue)","title":"Room preparation & pathway (often outpatient)","intro":"As activities used in hyperthyroidism are generally lower than in cancer, treatment is often performed as outpatient. The room must be prepared for a brief oral administration: single-use equipment, shielding, signage. For higher activities (large TMNG for instance), hospitalisation may be required per local regulation.","bullets":["Often outpatient (lower activities)","Single-use equipment prepared","Shielding and signage","Hospitalisation if high activity","Operational waste circuit"],"sources":["EANM 2022 Hyperthyroidism guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"accueil-administration","icon":"💊","accent":"var(--blue)","title":"Patient reception & oral administration","intro":"Check ATD withdrawal, diet compliance, β-hCG on file and consent. Oral administration (most often capsule) is given with a glass of water, under direct supervision. Ingestion is documented. Watch for any vomiting in the hours that follow.","bullets":["Check ATD withdrawal and diet","β-hCG on file","Supervised oral administration","Traceability of activity, batch, time","Post-administration vomiting monitoring"],"sources":["EANM 2022 Hyperthyroidism guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"radioprotection-patient","icon":"☢️","accent":"var(--orange)","title":"Patient & household radiation protection","intro":"Radiation protection instructions are adapted to the lower activities used in hyperthyroidism (generally shorter avoidance duration, but variable per prescribed activity). Distances from children and pregnant women are specified, durations are calculated by the medical physicist per local regulation. Waste and home effluent management are also covered in these instructions (more active urine in the first days, enhanced domestic hygiene).","bullets":["Activity-tailored written instructions","Distances from children / pregnant women","Avoidance durations per protocol","Hygiene and home urine management","Contact details"],"sources":["EANM 2022 Hyperthyroidism guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"sortie-domicile","icon":"🚪","accent":"var(--green)","title":"Discharge & home instructions","intro":"In outpatient setting, discharge is validated after handing over the discharge document and tailored instructions. In inpatient setting, discharge depends on dose-rate measurement at 1 m. Follow-up appointments (TSH, FT4 at 6 weeks) are planned. In case of incident (vomiting, contamination), apply the escalation procedure.","bullets":["Discharge document handed over","Dose-rate measurement if inpatient","Tailored instructions provided","Planned follow-up appointments","Escalation procedure if incident"],"sources":["EANM 2022 Hyperthyroidism guideline","IAEA Radiopharmaceutical Therapy"]}]},"radiopharmacien":{"molecule":"¹³¹I hyperthyroidism","profession":"Radiopharmacist","criteria":["Capsule most often (lower activity)","Reception and conformity check","QC and release","Complete traceability"],"warnings":[{"emoji":"💊","label":"Form","text":"mainly capsule"},{"emoji":"📦","label":"Supply","text":"half-life 8 days"},{"emoji":"☢️","label":"Handling","text":"operator radiation protection"},{"emoji":"📋","label":"Documentation","text":"batch, patient, activity"}],"sections":[{"key":"commande","icon":"📦","accent":"var(--blue)","title":"Order & supply","intro":"The order of iodine-131 (mainly capsule for hyperthyroidism, lower activities than in cancer) must be anticipated per patient schedule. The activity ordered is calculated at reference time, accounting for decay.","bullets":["Valid patient-named prescription","Capsule (most often)","Activity at reference time","Coordinated delivery slot","Administrative documentation"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"reception-stockage","icon":"📥","accent":"var(--blue)","title":"Reception & storage","intro":"On reception, check parcel integrity, absence of contamination, batch conformity, expiry and activity at reference time. Storage is in a dedicated shielded enclosure adapted to the activity (generally lower than in thyroid cancer).","bullets":["Parcel integrity check","External contamination measurement","Batch, expiry, activity verification","Dedicated shielded storage","Reception documentation"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"preparation-cq","icon":"💊","accent":"var(--purple)","title":"Preparation, quality control & release","intro":"As the capsule is ready to use, preparation is limited to the final check (activity at the calibrator, integrity), labelling and signed release. Handling is brief but must respect radiation protection principles (shielded handling, PPE).","bullets":["Capsule ready to use","Final activity measurement at calibrator","Visual check","Brief shielded handling","Signed release"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"etiquetage-dechets","icon":"🏷️","accent":"var(--gold)","title":"Labelling, traceability & waste","intro":"Each dispensing carries a patient-named label (patient identity, batch, activity, time, operator). Traceability must allow tracing back of every step. Contaminated waste (vials, consumables) is stored in a decay area before disposal per regulation (half-life 8 days).","bullets":["Patient-named label","Batch number and final activity","Operator identity","Durable archiving","Waste in controlled decay"],"sources":["IAEA Radiopharmaceutical Therapy"]}]},"radiophysicien":{"molecule":"¹³¹I hyperthyroidism","profession":"Medical physicist","criteria":["Activity calculation per chosen method","Outpatient vs inpatient criteria","Post-treatment thyroid follow-up","Adapted staff dosimetry","Compliant facilities (per activity)"],"warnings":[{"emoji":"📏","label":"Calculation","text":"3 methods: fixed / per gram / dosimetry"},{"emoji":"🚪","label":"Discharge","text":"criteria per activity"},{"emoji":"☢️","label":"Staff","text":"ALARA"},{"emoji":"🏥","label":"Facilities","text":"adapted effluents"},{"emoji":"📋","label":"Incidents","text":"reporting to regulator"}],"sections":[{"key":"dosimetrie-calcul","icon":"📏","accent":"var(--blue)","title":"Dosimetry & activity calculation","intro":"For hyperthyroidism, three activity-calculation methods coexist according to protocol and aetiology: fixed empirical activity (simple, reproducible), activity per gram of target tissue (based on thyroid volume by ultrasound), individual dosimetry based on uptake and kinetics. The choice depends on local protocol, aetiology and available resources.","bullets":["3 methods: fixed / per gram / dosimetry","Adaptation per aetiology","Lower activity than in cancer","Documentation of the chosen method","Consistency with clinical strategy"],"sources":["EANM 2022 Hyperthyroidism guideline","ATA 2016 Hyperthyroidism guidelines"]},{"key":"organes-risque","icon":"🫘","accent":"var(--red)","title":"Thyroid target & sensitive organs","intro":"The residual thyroid is the therapeutic target (targeted hypothyroidism in Graves', more modulated in TMNG) — therefore not an organ at risk in the strict sense. Sensitive organs to monitor include the salivary glands (moderate involvement at the activities used), gonads (very low risk at usual activities) and bone marrow (rare involvement). Graves' orbitopathy is a clinical vigilance shared with the ophthalmologist.","bullets":["Residual thyroid = therapeutic target","Salivary glands: moderate involvement","Gonads: very low risk","Marrow: rarely affected","Orbitopathy: shared clinical vigilance"],"sources":["EANM 2022 Hyperthyroidism guideline"]},{"key":"criteres-sortie","icon":"🚪","accent":"var(--orange)","title":"Outpatient vs inpatient criteria","intro":"Criteria for outpatient vs inpatient management rest on the prescribed activity, regulatory dose-rate thresholds (variable per country) and patient situation (household with children or pregnant women, transport, autonomy). When inpatient, dose-rate measurement at 1 m validates discharge.","bullets":["Regulatory dose-rate thresholds","Patient situation (household, transport)","Inpatient if high activity","Dose-rate measurement at discharge","Regulatory discharge document"],"sources":["EANM 2022 Hyperthyroidism guideline","IAEA Radiopharmaceutical Therapy"]},{"key":"calibration","icon":"⚙️","accent":"var(--blue)","title":"Equipment calibration","intro":"Dose calibrators, contamination probes and survey meters must be calibrated to a documented schedule. Periodic checks are essential for the reliability of dispensed-activity and discharge dose-rate measurements.","bullets":["Traceable dose calibrator calibration","Contamination probes","Survey meters for discharge measurement","Documented periodic checks","Documentation of detected drifts"],"sources":["IAEA Radiopharmaceutical Therapy"]},{"key":"radioprotection-pro-incidents","icon":"☢️","accent":"var(--orange)","title":"Staff radiation protection, facilities & incidents","intro":"ALARA principles apply (time, distance, shielding) with means adapted to activity (often lower than in cancer). Effluent and linen management is sized according to activity volume. Any significant incident (contamination, abnormal exposure, post-administration vomiting, activity discrepancy) must be analysed and reported to the competent authorities (national regulator).","bullets":["ALARA: time, distance, shielding","PPE and individual dosimetry","Adapted facilities and effluents","Incident reporting to regulator","Lessons learned"],"sources":["IAEA Radiopharmaceutical Therapy"]}]}}}},"trials":[{"name":"AAA817 PSMA alpha","target":"PSMA","targetClass":"psma","isotope":"225Ac","agent":"²²⁵Ac-PSMA-617 (AAA817) + ARPI","indication":"mCRPC · alpha-therapy","countries":["Allemagne","Espagne","France","Italie","Suisse"],"nct":"NCT06780670","ctis":"","sponsor":"Novartis","ctgov":true,"status":"recruiting","comment":"AAA817 alpha-PSMA trial · post-Lu-PSMA, PSMA+ mCRPC phase II/III · multi-EU sites."},{"name":"BET-PSMA-121","target":"PSMA","targetClass":"psma","isotope":"177Lu","agent":"¹⁷⁷Lu-rhPSMA-10.1","indication":"mCRPC · nouveau ligand rhPSMA","countries":["Pays-Bas","Royaume-Uni"],"nct":"NCT05413850","ctis":"2024-511537-35-00","sponsor":"Blue Earth","ctgov":false,"status":"recruiting","comment":"CTIS confirme l'essai · sites Pays-Bas, Royaume-Uni."},{"name":"DUET","target":"PSMA","targetClass":"psma","isotope":"177Lu","agent":"¹⁷⁷Lu-PSMA alternated with ²²³Ra-dichloride","indication":"mCRPC · combinaison β⁻ + α","countries":["Pays-Bas"],"nct":"-","ctis":"2024-518985-29-02","sponsor":"Investigator-initiated","ctgov":false,"status":"recruiting","comment":"CTIS confirms the trial · Dutch registry specifies the transition to CTIS."},{"name":"ECLIPSE","target":"PSMA","targetClass":"psma","isotope":"177Lu","agent":"¹⁷⁷Lu-PSMA-I&T","indication":"mCRPC vs hormone therapy","countries":["Allemagne","Belgique","Espagne","France","Italie","Pays-Bas","Royaume-Uni"],"nct":"NCT05204927","ctis":"2022-501493-19-00","sponsor":"Curium","ctgov":true,"status":"active","comment":"CTIS confirms the ID · Curium and ClinicalTrials.gov confirm FR/ES/IT/DE/BE/NL."},{"name":"FPI-2265 + olaparib","target":"PSMA","targetClass":"psma","isotope":"225Ac","agent":"²²⁵Ac-PSMA-I&T + olaparib","indication":"mCRPC · alpha + PARPi","countries":["Royaume-Uni"],"nct":"NCT06909825","ctis":"","sponsor":"Fusion (AstraZeneca)","ctgov":true,"status":"recruiting","comment":"Essai Fusion (AstraZeneca) post-Lu-PSMA · sites Canada/UK."},{"name":"LUBASKET","target":"PSMA","targetClass":"psma","isotope":"177Lu","agent":"¹⁷⁷Lu-PSMA","indication":"basket trial PSMA PET-positif (tumeurs solides)","countries":["Italie"],"nct":"NCT05867615","ctis":"2024-519346-75-00","sponsor":"Academic (IT)","ctgov":false,"status":"recruiting","comment":"CTIS confirms the basket trial · ClinicalTrials.gov identified as LUBASKET."},{"name":"PSMAddition","target":"PSMA","targetClass":"psma","isotope":"177Lu","agent":"¹⁷⁷Lu-PSMA-617 (Pluvicto®)","indication":"mHSPC (hormono-sensible)","countries":["Allemagne","Belgique","Espagne","France","Italie","Pays-Bas","Royaume-Uni","Suisse"],"nct":"NCT04720157","ctis":"","sponsor":"Novartis (AAA)","ctgov":true,"status":"recruiting","comment":"PSMAddition · first-line mHSPC · FR/DE/IT/ES/NL/UK sites."},{"name":"PSMAfore","target":"PSMA","targetClass":"psma","isotope":"177Lu","agent":"¹⁷⁷Lu-PSMA-617 (Pluvicto®)","indication":"mCRPC pre-taxane","countries":["Allemagne","Belgique","Espagne","France","Italie","Pays-Bas","Royaume-Uni","Suisse"],"nct":"NCT04689828","ctis":"2023-507772-50-00","sponsor":"Novartis (AAA)","ctgov":false,"status":"active","comment":"CTIS: 37 sites in 9 European countries · Active, not recruiting (long-term OS follow-up)."},{"name":"RADIODOSE","target":"PSMA","targetClass":"psma","isotope":"177Lu","agent":"¹⁷⁷Lu-vipivotide tetraxetan (AAA617)","indication":"mCRPC · dosimetric study","countries":["Allemagne","Espagne","Pays-Bas","Suisse"],"nct":"NCT06531499","ctis":"2024-512338-13-00","sponsor":"Novartis","ctgov":false,"status":"recruiting","comment":"CTIS confirms DE/NL/ES · Swiss registry / ICTRP adds Switzerland."},{"name":"SatisfACtion","target":"PSMA","targetClass":"psma","isotope":"225Ac","agent":"²²⁵Ac-PSMA-R2 (alpha)","indication":"mHSPC and PSMA+ mCRPC · phase I/II alpha-therapy","countries":["Allemagne","France","Italie","Suisse"],"nct":"NCT05983198","ctis":"2023-507672-52-00","sponsor":"Novartis","ctgov":false,"status":"active","comment":"CTIS confirms the Ac-225 trial · FR/DE/IT/CH sites."},{"name":"TATCIST / AlphaBreak","target":"PSMA","targetClass":"psma","isotope":"225Ac","agent":"²²⁵Ac-PSMA-I&T (FPI-2265)","indication":"mCRPC post-Lu-PSMA · alpha","countries":["Royaume-Uni"],"nct":"NCT06402331","ctis":"","sponsor":"Fusion (AstraZeneca)","ctgov":true,"status":"recruiting","comment":"Essai TATCIST/AlphaBreak · ²²⁵Ac post-Lu-PSMA · sites UK."},{"name":"VISION","target":"PSMA","targetClass":"psma","isotope":"177Lu","agent":"¹⁷⁷Lu-PSMA-617 (Pluvicto®)","indication":"mCRPC post-taxane","countries":["Allemagne","Belgique","Espagne","France","Italie","Pays-Bas","Royaume-Uni","Suisse"],"nct":"NCT03511664","ctis":"","sponsor":"Novartis (AAA)","ctgov":true,"status":"active","comment":"VISION · essai pivot post-taxane (FDA 2022) · Active, not recruiting · suivi OS · sites multi-EU."},{"name":"¹⁷⁷Lu-PSMA oligometastatic","target":"PSMA","targetClass":"psma","isotope":"177Lu","agent":"¹⁷⁷Lu-PSMA","indication":"hormone-sensitive oligometastatic prostate cancer","countries":["Pays-Bas"],"nct":"NCT04443062","ctis":"2023-509881-39-00","sponsor":"Academic (NL)","ctgov":false,"status":"recruiting","comment":"CTIS confirms the trial · Dutch registry indicates transition to CTIS."},{"name":"AlphaMedix-02","target":"SSTR","targetClass":"sstr","isotope":"212Pb","agent":"²¹²Pb-DOTAMTATE (AlphaMedix™)","indication":"SSTR+ NET · phase II","countries":["France"],"nct":"NCT05153772","ctis":"","sponsor":"RadioMedix / Orano Med","ctgov":true,"status":"active","comment":"AlphaMedix-02 Phase II · ²¹²Pb-DOTAMTATE · sites USA/France."},{"name":"COMPETE","target":"SSTR","targetClass":"sstr","isotope":"177Lu","agent":"¹⁷⁷Lu-edotreotide (ITM-11)","indication":"GEP-NET grade 1/2 · vs everolimus","countries":["Allemagne","Autriche","Belgique","Espagne","France","Italie","Pays-Bas","Royaume-Uni"],"nct":"NCT03049189","ctis":"","sponsor":"ITM","ctgov":true,"status":"completed","comment":"ITM-11 vs everolimus pivotal trial · published results · multi-EU sites."},{"name":"COMPOSE","target":"SSTR","targetClass":"sstr","isotope":"177Lu","agent":"¹⁷⁷Lu-edotreotide (ITM-11)","indication":"GEP-NET grade 2/3 · first-line","countries":["Allemagne","Autriche","Belgique","Espagne","France","Italie","Pays-Bas","Royaume-Uni"],"nct":"NCT04919226","ctis":"","sponsor":"ITM","ctgov":true,"status":"active","comment":"ITM-11 pivotal trial grade 2/3 GEP-NET first-line · multi-EU sites."},{"name":"ELUMEN (meningioma)","target":"SSTR","targetClass":"sstr","isotope":"177Lu","agent":"¹⁷⁷Lu-DOTATATE + everolimus","indication":"refractory meningioma","countries":["France"],"nct":"NCT06126588","ctis":"2023-508400-38-00","sponsor":"Academic (FR)","ctgov":false,"status":"recruiting","comment":"CTIS confirms the trial · identified sites are French."},{"name":"KinLET","target":"SSTR","targetClass":"sstr","isotope":"177Lu","agent":"¹⁷⁷Lu-edotreotide (ITM-11)","indication":"SSTR+ pediatric tumors","countries":["Allemagne","Espagne","France","Italie"],"nct":"NCT06441331","ctis":"","sponsor":"ITM","ctgov":true,"status":"recruiting","comment":"KinLET pediatric trial · ITM-11 in SSTR+ children · FR/DE/IT/ES sites."},{"name":"LuPARPed-HM-2024","target":"SSTR","targetClass":"sstr","isotope":"177Lu","agent":"¹⁷⁷Lu-DOTATATE + olaparib","indication":"combinaison SSTR + inhibiteur PARP","countries":["Espagne"],"nct":"NCT06607692","ctis":"2024-512613-40-00","sponsor":"Academic (ES)","ctgov":false,"status":"recruiting","comment":"CTIS confirms the trial · center identified in Boadilla del Monte / Madrid."},{"name":"Lutathera adolescents","target":"SSTR","targetClass":"sstr","isotope":"177Lu","agent":"¹⁷⁷Lu-DOTATATE (Lutathera®)","indication":"GEP-NET / PPGL adolescents","countries":["Allemagne","France","Italie","Suisse"],"nct":"NCT04711135","ctis":"","sponsor":"Novartis (AAA)","ctgov":true,"status":"active","comment":"Lutathera adolescent · first pediatric GEP-NET/PPGL study · EU sites."},{"name":"NETTER-2","target":"SSTR","targetClass":"sstr","isotope":"177Lu","agent":"¹⁷⁷Lu-DOTATATE (Lutathera®)","indication":"GEP-NET grade 2/3 · 1ère ligne","countries":["Allemagne","Belgique","Espagne","France","Italie","Pays-Bas","Royaume-Uni","Suisse"],"nct":"NCT03972488","ctis":"","sponsor":"Novartis (AAA)","ctgov":true,"status":"active","comment":"NETTER-2 · first-line GEP-NET G2/G3 · Lancet 2024 results · multi-EU sites."},{"name":"NETTER-3","target":"SSTR","targetClass":"sstr","isotope":"177Lu","agent":"¹⁷⁷Lu-DOTATATE + octreotide LAR","indication":"GEP-NET grade 1/2 front-line","countries":["Allemagne","Espagne","France","Italie","Pays-Bas","Suisse"],"nct":"NCT06784752","ctis":"2024-518325-15-00","sponsor":"Novartis (AAA)","ctgov":true,"status":"recruiting","comment":"CTIS lists FR/DE/IT/NL/ES among participating countries — broad European coverage."},{"name":"SANTANA-225","target":"SSTR","targetClass":"sstr","isotope":"225Ac","agent":"²²⁵Ac-SSO110 (alpha)","indication":"SCLC / Merkel cell · maintenance","countries":["Allemagne","Espagne","France","Italie","Royaume-Uni"],"nct":"NCT06939036","ctis":"2024-515041-42-00","sponsor":"Ariceum","ctgov":true,"status":"terminated","comment":"TERMINATED by Ariceum (May 2025) for strategic reasons · follow-up continues for already-treated patients."},{"name":"NeoB + capecitabine","target":"GRPR","targetClass":"grpr","isotope":"177Lu","agent":"¹⁷⁷Lu-NeoB + capecitabine","indication":"ER+/HER2− metastatic breast · GRPR+ · post-endocrine therapy + CDK4/6i","countries":["Allemagne","Belgique","Espagne","France","Italie","Pays-Bas","Portugal","Suisse"],"nct":"NCT06247995","ctis":"2023-506717-21-00","sponsor":"Novartis","ctgov":true,"status":"recruiting","comment":"European NeoB page confirms this distribution FR/DE/IT/NL/PT/ES/BE/CH."},{"name":"LuMIERE","target":"FAP","targetClass":"fap","isotope":"177Lu","agent":"¹⁷⁷Lu-FAP-2286","indication":"tumor stroma (pancreas, cholangio, sarcomas)","countries":["Belgique","Espagne","France","Italie","Suisse"],"nct":"NCT04939610","ctis":"2023-508995-12-01","sponsor":"Novartis (via POINT)","ctgov":true,"status":"recruiting","comment":"CTIS indicates BE/FR/IT/ES — first major European study on FAP target."},{"name":"PENTILULA","target":"CXCR4","targetClass":"cxcr4","isotope":"177Lu","agent":"¹⁷⁷Lu-PentixaTher","indication":"LMA / LAL CXCR4+ rechute","countries":["France"],"nct":"NCT06356922","ctis":"2022-501019-15-00","sponsor":"CHU Nantes (academic) / PentixaTher (PentixaPharm)","ctgov":true,"status":"recruiting","comment":"CTIS confirms the ¹⁷⁷Lu-PentixaTher RLT trial · French sites."},{"name":"PTT101 (lymphome SNC)","target":"CXCR4","targetClass":"cxcr4","isotope":"90Y","agent":"⁹⁰Y-PentixaTher","indication":"primary CNS lymphoma","countries":["Allemagne"],"nct":"NCT06132737","ctis":"2024-512097-98-00","sponsor":"PentixaPharm","ctgov":false,"status":"recruiting","comment":"CTIS confirms ⁹⁰Y-PentixaTher · Pentixapharm reports the first patient treated in Essen."},{"name":"CAM-H2","target":"HER2","targetClass":"her2","isotope":"131I","agent":"¹³¹I-CAM-H2 (sdAb anti-HER2)","indication":"sein / gastrique HER2+","countries":["Belgique","France","Pays-Bas","Royaume-Uni"],"nct":"NCT04467515","ctis":"","sponsor":"Precirix","ctgov":true,"status":"terminated","comment":"TERMINATED (Precirix) · ¹³¹I-CAM-H2 sdAb anti-HER2 · sites BE/NL/UK/FR."},{"name":"NEPC study","target":"MULTI","targetClass":"multi","isotope":"177Lu","agent":"¹⁷⁷Lu-PSMA-617 / ¹⁷⁷Lu-DOTATATE / ¹⁷⁷Lu-NeoB","indication":"NEPC (cancer prostatique neuroendocrine) · selon expression cible","countries":["France","Allemagne","Italie","Espagne"],"nct":"NCT06379217","ctis":"2023-505655-43-00","sponsor":"Academic / Novartis","ctgov":false,"status":"recruiting","comment":"ClinicalTrials.gov confirms NCT · EU/ID-RCB 2023-505655-43-00 to be reconfirmed in public CTIS · sites FR/DE/IT/ES."}],"molecule":["