UK Mo-99 and I-131 Radioisotope supply Impacted by repair of High Flux Reactor, The Netherlands

Many of you are aware of current problems with the UK’s supply of radioisotopes from Europe. In a statement on the 14th of October, Nuclear Medicine Europe’s Emergency Response Team confirmed that this is because of a problem with the High Flux Reactor (HFR) in The Netherlands, operated by NRG. At present, they cannot restart the reactor until degradation of one of the key components of the reactor is repaired. 

In the coming weeks, shortages could be as high as 40% of usual requirements, although it will vary in different geographic regions with some areas experiencing little or no impact. It is advised that you communicate with your nuclear medicine department to understand the likely impact to your service. 

During this period of uncertainty and if your unit is affected, the ABS recommends that you discuss the radioisotope shortage with the members of your multidisciplinary team and consider the following measures after a documented discussion with the patient on a case by cases basis. We also strongly recommend that you read the referenced evidence in order to advise patients of the performance and risks of each technique. 

1.    If you routinely use a radioisotope tracer as part of your standard intra-operative method of Sentinel lymph node identification:

• Consider postponing the surgery for a couple of weeks until supply has resumed with or without bridging endocrine therapy as appropriate.
• Consider using blue dye only but inform the patient of the reduced sensitivity of finding sentinel lymph nodes (8.6% vs 5.9% for blue-dye and isotope – 2012 World J Surg 36(9):2239-2251).

2.    If you routinely use other tracers/ techniques as part of your standard pre-operative or intra-operative method of Sentinel lymph node identification:

• Continue with your standard localisation technique.

3.    Consider using other available intra-operative tracers although there may be an added training/ cost requirement if these are not used as part of standard practice in your unit:

• Fluorescent indocyanine green (ICG) – The results of The INFLUENCE Trial indicate that the performance of ICG alone for SLN identification is similar to that of ICG combined with radioisotope (2024 Ann Surg Oncol; doi:10.1245/s10434-024-16176-x).
• Magtrace and Sentimag – NICE recommend Magtrace and Sentimag as an option to locate sentinel lymph nodes for breast cancer in hospitals with limited or no access to radiopharmacy (5th October 2022 – www.nice.org.uk/guidance/mtg72).