The sleeping giant of molybdenum production is grinding to a halt and the world is wondering how this happened. Someone must have been asleep at the proverbial wheel. We in the nuclear medicine field are chronically aware of how technetium-99m (Tc99m)--a product of molybdenum-99(Mo99)--shortages come and go, so we are somewhat desensitized. However, the acute and worsening shortage moving into the first quarter of 2010 has not only impacted patient access to care, new student enrollments (in learning our technology) and paychecks of technologists, but has some countries wondering about the future of nuclear medicine.

The U.S FDA's posting of the shortage gave hospital and imaging center administrators proof that the country indeed has a real issue obtaining Tc99m, the basis of approximately 80 percent of nuclear medicine radiopharmaceuticals. Many technologists who were well aware of the impending shortage tried to prepare their units were met by resistance and called "chicken littles."

The U.S. didn't take on the project of making its own medical isotope production because Canada had promised the construction of two nuclear reactors called Maple I and Maple II. Unfortunately, the construction ran over its budget deadlines so the project was halted in May 2008. As a result, we were no closer to reliable, new reactors.

The Atomic Energy of Canada Limited (AECL) believes the Chalk River reactor can be repaired and returned to service although some skeptics aren't so sure. Shock from the news of the heavy water leak lead some to believe the reactor was offline for good. To date, a full scale replica of the walls needing repair have been built. A test run repair using a specific welding tool has been performed on the mock-up and further tests are required to see if that repair is sufficient. Once the repairs are complete on the actual outer walls of Chalk River, testing must occur to verify the repairs are solid.  The target online date is sometime in the first quarter of 2010. Unfortunately, the second largest nuclear reactor that produces Mo99 will be going offline during the first quarter.

It's possible that both the largest and second largest Mo99 producers in the world will be shutdown simultaneously. The High Flux Reactor (HFR), located in Petten, the Netherlands, recently underwent a one month scheduled downtime for inspection and maintenance. The Chalk River reactor was also offline at this time, creating a month-long crisis for our nuc med community. As a result of the HFR inspection, experts identified safety issues and scheduled repairs--for the first quarter of 2010, the same time Chalk River is scheduled to come back online. This is a three month potential overlap--best case scenario--that both reactors will be down. Realizing that the HFR is planning on a six month repair and that there is a strong possibility that Chalk River will still be down, the community is bracing for a critical Mo99 shortage not seen in recent history. Perhaps only 10 percent of the usual amount of Tc99m will be available for use.

There is potential good news: The U.S. is considering homeland Mo99 production. While a few reactors are potential favorites, including the MURR reactor in Missouri, it's possible there'll be an allowance for emergent manufacturing of Mo99 on a temporary basis. The issue is not the technology of actual production; it's the use of weapons-grade uranium needed. Highly enriched uranium (HEU) is used in all but two reactors; Petten is capable and the Opal in Austria uses low enriched uranium fulltime. The American Medical Isotopes Production Act (AMIPA), which has not yet passed Congress, appropriates approximately $160 million to foster homeland Mo99 suppliers.

Cindi Luckett-Gilbert, MHA, CNMT, PET, RT(N), FSNMTS, is the supervisor of PET/CT Presbyterian Hospital, Charlotte, N.C., and SNM PET Learning Center faculty member.