2nd ARC Workshop: Roanoke and the Future of Theranostics

Beyond Lutetium: The Next Wave of Theranostic Innovation

If you've been following theranostics for the last few years, you know the story: Lutetium-177 PSMA therapy for prostate cancer. Lutetium-177 DOTATATE for neuroendocrine tumors. Two FDA-approved therapies that have fundamentally changed how we think about treating advanced disease.

And now everyone's asking: what's next?

That's what we're building the second ARC workshop around and my counterpart at Carilion Clinic, James Crowley, is taking the lead on this ambitious workshop. On June 26th in Roanoke, and in collaaboaboration with Fralin Biomedical Research Center, we're dedicating the entire day to where the field is heading. Astatine-211 as the next generation of alpha therapy. Brain tumor theranostics as an emerging frontier. Girentuximab and novel renal cell targets. Advanced drug delivery mechanisms that could reshape how we think about targeted therapy.

These are agents and approaches already in clinical trials, already showing results, already positioning themselves as the next standard-of-care options. If you're a referring physician wondering what's coming for your patients, or a nuclear medicine professional trying to stay ahead of the curve, this is the landscape you need to understand.

Let me walk through what we're covering and why it matters.

Astatine-211: Why Alpha Particles Are Having Their Moment in the Spotlight

Session one of the workshop is dedicated entirely to astatine-211, and there's a reason we're starting here.

Lutetium-177 emits beta particles. They travel a few millimeters in tissue, deposit energy along that path, and damage DNA through indirect mechanisms (mostly free radicals). They're effective. They're proven. But they're not the end of the story.

Alpha particles are different. They travel only 50 to 100 microns (a few cell diameters), but they pack dramatically higher energy into that short range. A single alpha particle traversing a cell nucleus can cause irreparable double-strand DNA breaks. This means higher potency per decay, potentially lower administered activity to achieve therapeutic effect, and the ability to target micrometastases or circulating tumor cells that beta emitters might not fully be able to kill.

Astatine-211 is emerging as a leading alpha-emitting candidate for several reasons. Its 7.2-hour half-life is long enough for radiopharmaceutical synthesis and distribution but short enough to minimize prolonged radiation exposure and waste management concerns. It can be produced in medical cyclotrons (unlike actinium-225, which requires reactors or thorium generators). And it's been successfully conjugated to antibodies, peptides, and small molecules targeting a range of tumor types.

Brain Tumor Theranostics: The Frontier Nobody Expected

Brain tumors have always been a challenging problem in oncology. Surgery. Radiation. Chemotherapy. The blood-brain barrier makes systemic drug delivery difficult. Recurrence rates are high. Survival rates are poor. And we've had very few tools that directly target the molecular characteristics of these tumors.

Theranostics might change that.

Session two focuses on brain tumor applications. We're seeing early clinical data on radiolabeled peptides and antibodies that cross the blood-brain barrier, target disrupted barrier regions, or methods that can be used increase bloo-brain barrier crossing. Imaging agents that can visualize tumor metabolism, receptor expression, or therapeutic response in real time. The biology is complex, the delivery mechanisms are challenging, but the potential impact is significant.

Dr. Cara Rogers and Dr. Nasser Mohammed from Carilion will cover the clinical need from the oncology and neurosurgery perspectives. What are the patients who aren't responding to current therapies? What biomarkers identify good candidates for targeted approaches? Dr. Jenny Munson from Virginia Tech will discuss innovations in brain tumor imaging that make theranostic approaches feasible.

I don't know if brain tumor theranostics will be a standard-of-care option in five years. But I know we're at the point where it's worth planning for.

Urology Beyond PSMA: Girentuximab and the Renal Cell Story

Lutetium-177 PSMA has dominated the urology conversation, and for good reason. But PSMA isn't the only target in urologic cancers, and prostate cancer isn't the only urologic malignancy.

Session three shifts to urology more broadly, including renal cell carcinoma (RCC) and the emerging role of girentuximab as a therapeutic target.

Girentuximab is a monoclonal antibody that binds to carbonic anhydrase IX (CAIX), a protein overexpressed in clear cell renal cell carcinoma. The imaging version (zirconium-89 labeled girentuximab) is already approved by the FDA for imaging renal masses. ¹ The therapeutic version, radiolabeled with lutetium-177 or other isotopes, is in clinical trials.

This is the model that theranostics was built on: develop an imaging agent, validate the target, then attach a therapeutic isotope. If it works, you've got a paired diagnostic and therapy for a cancer type that has historically been difficult to treat once metastatic.

Dr. Jackson Kiser from Carilion will cover the girentuximab data and other emerging urologic targets. Dr. David Buck, a urologist working with Carilion, will discuss patient selection and how these tools change treatment decision-making from the referring physician perspective. I'll cover the dosimetry and imaging considerations for PSMA and beyond, because the physics doesn't change just because the target does.

The urology session is important because it shows that theranostics isn't a one-disease phenomenon. If you can identify the target, image it, and deliver radiation to it, the approach scales.

Advanced Drug Delivery: It's More Than Just the Isotope

The final session of the day is titled "Theranostic Potpourri," which is James' way of saying "everything else that doesn't fit in a neat category but matters a lot."

Dr. Fred Wu from Virginia Tech will discuss advanced drug delivery mechanisms. This is about nanoparticles, liposomes, and engineered carriers that can improve radiopharmaceutical biodistribution, reduce off-target dose, or enable combination therapies. It's not about replacing peptides or antibodies. It's about making them more effective.

The reality is that current radiopharmaceuticals aren't perfect delivery vehicles. They often accumulate in kidneys, bone marrow, or salivary glands. They don't always achieve therapeutic concentrations in poorly vascularized tumors. Improving delivery could mean lower administered doses, fewer side effects, and broader patient eligibility.

Dr. Kiser will also cover extravasation in therapy, which is a topic that doesn't get enough attention. When you're administering a therapeutic radiopharmaceutical, an extravasation isn't just a failed IV. It's localized radiation dose to healthy tissue. Understanding recognition, risk factors, and response protocols is critical for patient safety.

James Crowley closes the day with "The Business of Nuclear Medicine," which is his way of talking about sustainability, reimbursement, program economics, and long-term viability. Because even the most exciting therapeutic agent doesn't help patients if the program delivering it isn't financially sustainable.

Why We're Dedicating a Full Day to This

The April workshop in Knoxville focused on fundamentals: patient selection, workflow, dosimetry, regulatory basics. It was "here's how to implement what's already approved."

The Roanoke workshop is different. It's "here's what's coming and how to prepare for it."

Not every community hospital needs to be ready to deliver astatine-211 therapies in 2027. Not every nuclear medicine department will be treating brain tumors with targeted radiopharmaceuticals next year. But if you're building a theranostics program now, you need to understand what the pipeline looks like, because the infrastructure you're setting up today determines what you'll be able to offer five years from now. At the least it is excellent training for you brain to begin wrapping your mind around they dynamic concepts at play related to the future of theranostics.

The programs that succeed long-term are going to be the ones that position themselves as "we do targeted radiopharmaceutical therapy" rather than "we do Pluvicto and Lutathera."

As Always: This Is Also About Regional Collaboration

We've structured the Roanoke workshop with significant Virginia Tech and Carilion Clinic participation. That's deliberate.

Virginia Tech has expertise in drug delivery, biomedical engineering, and translational research. Carilion has expertise in community-based oncology, neurosurgery, and urology. UT Medical Center brings theranostics clinical experience, dosimetry infrastructure, and physics support.

The novel agents we're discussing at this workshop aren't going to be developed, validated, and implemented by any single institution. They're going to require collaboration between academic research programs, community clinical sites, industry partners, and regulatory bodies.

ARC exists to build that collaboration and education regionally. The workshop is where we make those connections tangible.

Who This Workshop Is For

If you're a nuclear medicine physician, physicist, or technologist, this is the continuing education that positions you for the next five years of the field.

If you're a referring physician(oncologist, urologist, neurosurgeon, endocrinologist), this is the overview of what's about to become available for your patients and how to think about incorporating it into treatment planning.

If you're a hospital administrator evaluating whether to invest in theranostics infrastructure, this is the business case for why "future-proofing" matters and what that actually looks like.