Nuclear Medicine & Radiopharmaceuticals Investment Thesis

INVESTMENT COMMITTEE PRESENTATION

NUCLEAR MEDICINE

A Comprehensive Strategic & Investment Overview

Technology  ·  Radiopharmaceuticals  ·  Theranostics  ·  Market Structure  ·  Investment Thesis

CONFIDENTIAL — FOR AUTHORIZED RECIPIENTS ONLY

~$17B

Global Market 2024

~15%

Annual Growth Rate (CAGR)

111

PET Scanners in Brazil

8 Sections

Strategic Deep-Dive

May 2026

AGENDA

Presentation Overview

01

What Is Nuclear Medicine

Technical Foundations & Historical Context

02

Radiopharmaceuticals

Isotopes, Mechanism & Supply Chain

03

Clinical Applications & Theranostics

Precision Oncology & Targeted Therapy

04

Industry Structure

Value Chain & Market Economics

05

Suppliers & Production

Cyclotrons, GMP & Logistics

06

Service Providers in Brazil

Business Models & Market Dynamics

07

PET-CT Distribution in Brazil

Geographic Access & Expansion

08

Growth Outlook & Investment Thesis

Drivers, Pipeline & Opportunities

CONFIDENTIAL

Nuclear Medicine | Investment Committee

SECTION 01

What Is

Nuclear Medicine

From Historical Origins to Molecular Imaging

Historical Timeline

Technology vs. Traditional Radiology

PET-CT & SPECT Principles

Clinical Foundations

CONFIDENTIAL

Nuclear Medicine | Investment Committee

SECTION 01 — WHAT IS NUCLEAR MEDICINE

Nuclear Medicine Was Born From Physics — And Is Now Transforming Oncology

A century of scientific breakthroughs converging at the intersection of biology, chemistry, and physics

1896

Discovery of Radioactivity

(Becquerel & Curie)

1934

Artificial Radioactivity

(Joliot-Curie)

1946

First Therapeutic Use

of I-131 (thyroid cancer)

1950s

Technetium-99m

Development phase

1973

First PET Scanner

Prototype (Phelps & Hoffman)

1990s

FDG-PET Clinical Use

Enters standard for oncology

2000s

PET-CT Hybrid Imaging

Becomes standard practice

2013

Lutathera (Lu-177)

Phase III trials begin

2022

Pluvicto FDA Approval

For prostate cancer (Novartis)

2024+

Radioligand Therapy

Pipeline explosion

Nuclear medicine has evolved from diagnostic tool to precision therapeutic platform — a structural shift driving its emergence as a high-growth investment category.

CONFIDENTIAL

03

SECTION 01 — WHAT IS NUCLEAR MEDICINE

Nuclear Medicine Sees What Other Imaging Cannot — Function, Not Just Anatomy

CT SCAN

Anatomical Imaging

X-ray attenuation through tissue

Structure, density, size

Fast, widely available

Cannot show metabolic activity

Low-Medium

MRI

Anatomical + Soft Tissue

Magnetic resonance of hydrogen atoms

Tissue contrast, structure

Excellent soft tissue detail

No functional/metabolic data

High

PET-CT / Nuclear Medicine

FUNCTIONAL + Metabolic Imaging

Radiotracer uptake by active cells

Metabolic activity, receptor expression, cell function

Detects disease EARLIER, guides therapy

Requires radiopharmaceutical supply

Premium

Precision Medicine Standard

While CT and MRI reveal WHERE disease is located, nuclear medicine reveals HOW disease is behaving at the cellular level — enabling earlier detection and personalized treatment decisions.

SECTION 01 — HOW IT WORKS

How Nuclear Medicine Works — A Molecular Targeting System

Isotope Production

Radioactive isotopes produced in cyclotron or nuclear reactor (e.g., F-18, Ga-68, Lu-177)

Half-life: minutes to days

Radiopharmaceutical Synthesis

Isotope is bonded to a biological carrier molecule targeting specific receptors or metabolic pathways

Administration to Patient

Injected intravenously; the active compound travels safely through the bloodstream to reach target tissue

Molecular Targeting

Radiopharmaceutical accumulates in target cells (e.g., tumors), strictly guided by binding biological affinity

Imaging / Therapy

PET-CT or SPECT scanner detects gamma rays emitted → creates an exact functional image

Beta or alpha particle emissions selectively destroy the target cells locally while sparing healthy tissue

The same molecular targeting mechanism enables both diagnosis AND treatment — this is the foundation of Theranostics, the fastest-growing segment of nuclear medicine.

SECTION 02

Radiopharmaceuticals

The Critical Infrastructure Behind Nuclear Medicine

Mechanism of Action & Isotope Classes

Diagnostic vs. Therapeutic Applications

Half-Life Dynamics & Logistics

Key Isotopes: FDG, Ga-68, Lu-177, Tc-99m

CONFIDENTIAL — FOR AUTHORIZED RECIPIENTS ONLY

SECTION 02 — RADIOPHARMACEUTICALS

Radiopharmaceuticals Are Purpose-Built Molecular Agents — Each Designed for a Specific Clinical Mission

Isotope

Type

Half-Life

Production Source

Primary Clinical Use

Strategic Notes

FDG (F-18)

Diagnostic

110 min

Cyclotron

Oncology: metabolic tumor imaging (PET-CT)

Most widely used PET tracer globally; ~$1B+ market

Technetium-99m

Diagnostic

6 hours

Generator (Mo-99)

Cardiology, bone, thyroid SPECT imaging

Highest volume isotope worldwide; ~30M procedures/year

Gallium-68

Diagnostic

68 min

Cyclotron or Generator

Neuroendocrine tumors, PSMA prostate cancer

Fastest growing diagnostic tracer; replacing older tracers

Lutetium-177

Therapeutic

6.7 days

Reactor

NETs, Prostate cancer (PSMA); Pluvicto (Novartis)

Blockbuster therapeutic; $1.4B revenue 2024 for Pluvicto alone

Iodine-131

Therapeutic

8 days

Reactor

Thyroid cancer, hyperthyroidism

Oldest therapeutic isotope; still widely used

Short half-lives create critical logistics dependencies — a defining competitive moat

Therapeutic isotopes command 10-20x higher revenue per dose than diagnostics

Supply chain mastery is a strategic advantage in this market

CONFIDENTIAL — FOR AUTHORIZED RECIPIENTS ONLY

02

SECTION 02 — HALF-LIFE & LOGISTICS

Half-Life Is the Invisible Hand Governing the Entire Radiopharmaceutical Supply Chain

Radioactive Decay Profiles by Isotope

From Production to Patient: The Race Against Decay

Isotope Produced at Cyclotron / Reactor

Quality Control & Synthesis

~1-2 hrs

Packaging & Labeling

~30 min

Courier Transport

1-4 hrs

Dose Preparation at Nuclear Pharmacy

~30 min

PATIENT ADMINISTRATION

<strong>For F-18:</strong> total window = ~8 half-lives max

<strong>Warning:</strong> Any supply disruption = appointment cancellation

Half-life constraints create structural moats: only operators with local production or optimized logistics infrastructure can reliably serve clinical demand — a key competitive differentiator.

CONFIDENTIAL — FOR AUTHORIZED RECIPIENTS ONLY

Q2 DEEP-DIVE STRATEGY

SECTION 03

Clinical Applications

& Theranostics

Precision Oncology's Most Powerful Emerging Paradigm

Diagnostic & Therapeutic Applications

The Theranostics Revolution

Prostate Cancer & NETs Case Studies

Economic Comparison vs. Standard of Care

CONFIDENTIAL — FOR AUTHORIZED RECIPIENTS ONLY

SECTION 03 — THERANOSTICS

Theranostics: The Same Molecule That Finds the Cancer Also Destroys It

Theranostics merges THERApeutics + diagNOSTICS — a paradigm shift from systemic to precision-targeted treatment

Ga-68 PSMA PET-CT Scan

LOCATES receptor-expressing cancer cells

Confirms PSMA expression → Patient eligible for therapy

Lu-177 PSMA Therapy

DELIVERS lethal radiation to same receptor

Targeted cell destruction, minimal collateral damage

One Target. One Molecule. Two Powers.

The PSMA receptor serves as both the GPS and the delivery address

1. PROSTATE CANCER (PSMA)

Lu-177 PSMA; Pluvicto approved FDA 2022

2. NEUROENDOCRINE TUMORS (SSTR)

Lu-177 DOTATATE; Lutathera approved

3. THYROID CANCER

I-131; classic theranostic pair with diagnostic I-123

VISION Trial

Pluvicto + std care → 38% reduction in death vs std care alone

NETTER-1 Trial

Lutathera → 79% disease control rate in NETs

First major oncology approvals based on theranostic pairs

Theranostics represents the first true implementation of precision medicine at scale — combining diagnostic accuracy with therapeutic precision in a single biological framework.

SECTION 03 — ECONOMIC & CLINICAL COMPARISON

Theranostics Outperforms Conventional Oncology on Every Dimension That Matters

Theranostics (Lu-177 PSMA)

Chemotherapy (Cabazitaxel)

Immunotherapy (Pembrolizumab)

Hormone Therapy (Enzalutamide)

Overall Survival Benefit

✓✓✓ Best

✓ Modest

✓✓ Moderate

✓✓ Moderate

Radiographic PFS

8.7 months gain

2.8 months

4.2 months

5.6 months

Adverse Effects

Targeted, low systemic tox

High systemic toxicity

Immune-related AEs

Fatigue, falls

Quality of Life

↑ Preserved/Improved

↓ Significantly impacted

Variable

Moderate impact

Response Rate (PSA)

~80%

~35%

~25%

~55%

Cost per Cycle (USD)

~$42,000

~$8,000

~$15,000

~$5,000

Total Course Cost (USD)

~$200,000

~$50,000

~$120,000

~$60,000

Value per Outcome

HIGH (vs standard)

Medium

Medium-High

Medium

Despite higher per-cycle cost, theranostics delivers superior outcomes per dollar spent — and reduced hospitalization costs narrow the net cost differential significantly.

Source: VISION Trial (NEJM, 2021); NETTER-1 Trial; comparative oncology analyses

Reimbursement expansion by payers is accelerating as health-economic evidence accumulates

SECTION 03 — CLINICAL APPLICATIONS

Nuclear Medicine Serves Four Major Specialties — Oncology Dominates But Cardiology and Neurology Are Fast-Growing

Oncology

~65% of procedures

<div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">PET-CT staging & restaging</div></div><div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Response assessment</div></div><div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Theranostics (PSMA, SSTR)</div></div><div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Bone metastases detection</div></div>

FDG, Ga-68, Lu-177, Ra-223

Fastest growing due to theranostics expansion

Cardiology

~20% of procedures

<div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Myocardial perfusion imaging</div></div><div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Viability assessment</div></div><div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Cardiac sarcoidosis</div></div><div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Amyloidosis</div></div>

Tc-99m, Thallium-201, F-18

Stable demand, digital SPECT driving efficiency

Neurology

~10% of procedures

<div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Alzheimer's / dementia (Amyloid PET)</div></div><div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Parkinson's disease</div></div><div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Epilepsy focus localization</div></div><div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Brain tumors</div></div>

F-18 (amyloid tracers), DaTscan (I-123)

High growth potential with aging population

Endocrinology

~5% of procedures

<div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Thyroid cancer</div></div><div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Hyperthyroidism</div></div><div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Parathyroid adenoma</div></div><div style="display: flex; gap: 10px; margin-bottom: 8px; align-items: flex-start;"><div style="color: #C9A84C; font-size: 18px; line-height: 1.2;">&bull;</div><div style="line-height: 1.3;">Adrenal imaging</div></div>

I-131, I-123, Tc-99m

Foundational segment, highly established

The clinical breadth of nuclear medicine — spanning oncology to neurology — provides structural revenue diversification unavailable to single-specialty diagnostic modalities.

SECTION 04

Industry Structure

Value Chain Economics & Market Organization

End-to-End Sector Value Chain

Service Providers vs. Radiopharmaceutical Suppliers

Revenue Models & Economics

Vertical Integration Dynamics

CONFIDENTIAL — FOR AUTHORIZED RECIPIENTS ONLY

SECTION 04 — VALUE CHAIN

The Nuclear Medicine Value Chain Spans Five Layers — Each With Distinct Economics and Barriers

ISOTOPE PRODUCTION

Nuclear reactors (Mo-99/Tc-99m), Cyclotrons (F-18, Ga-68), Research reactors

Key players: NRU Canada, OPAL Australia, BR2 Belgium, IRR Brazil (IPEN)

Very high capex ($50-500M+), heavily regulated, limited global supply

Barrier to entry: EXTREME

RADIOPHARMACEUTICAL MANUFACTURING

Pharma manufacturers, specialty radiopharmaceutical companies

Brazil: CMR Pharma, R2 Pharma, multinational distributors

High capex, GMP compliance, 24/7 operations

Barrier: VERY HIGH

DISTRIBUTION & LOGISTICS

Cold chain logistics, dose calibration, courier networks

Key constraint: Half-life driven time pressure

Recurring cost, geography-dependent

Barrier: HIGH (specialized infrastructure)

NUCLEAR MEDICINE SERVICES

Hospitals, diagnostic clinics, standalone PET centers

Services: PET-CT, SPECT, dosimetry, therapy administration

High equipment capex ($1-3M per PET-CT), licensed physicians required

Barrier: HIGH

CLINICAL INTEGRATION

Oncologist referrals, treatment planning, follow-up imaging

Fee-per-service, reimbursement-dependent

Note: Increasing integration with tumor boards

VERTICAL INTEGRATION OPPORTUNITY

Integrated players (like Novartis / Advanced Accelerator Applications) span multiple layers.

Vertically integrated operators capturing both radiopharmaceutical production and service delivery command superior margins and supply security — the primary consolidation thesis in this sector.

SECTION 05

Suppliers &

Radiopharmaceutical Production

Critical Infrastructure, Regulatory Complexity & Competitive Moats

Cyclotron Technology & Radiochemistry

GMP Compliance & Regulatory Requirements

ANVISA & CNEN Regulatory Framework

Barriers to Entry & Capital Requirements

CONFIDENTIAL — FOR AUTHORIZED RECIPIENTS ONLY

SECTION 05 — PRODUCTION INFRASTRUCTURE

Radiopharmaceutical Production Is One of Healthcare's Most Regulated and Capital-Intensive Operations

The Production Process

Target Material Preparation

O-18 enriched water for F-18 isotopes<br>Solid metal targets for Ga-68 processing

Cyclotron Bombardment

Proton beam (16-18 MeV) bombards target<br>Nuclear reaction produces radioisotope<br><span style='color:#C9A84C; font-weight:600; font-size:14px; margin-top:4px; display:inline-block;'>Time: ~60-90 minutes</span>

Hot Cell Processing

Lead-shielded, remote-controlled synthesis<br>Isotope bonded to precise biological vector

Quality Control (QC)

Sterility, radionuclidic & chemical purity tests<br>Strict Good Manufacturing Practice (GMP)<br><span style='color:#C9A84C; font-weight:600; font-size:14px; margin-top:4px; display:inline-block;'>Time: ~30-60 minutes</span>

Dispensing & Packaging

Unit doses prepared for specific patient needs<br>Loaded into transport vials & shielded syringes<br><span style='color:#C9A84C; font-weight:600; font-size:14px; margin-top:4px; display:inline-block;'>Time: ~30 minutes</span>

Dispatch & Logistics

Temperature-controlled certified delivery<br>Radiation-labeled packaging (IAEA standards)

Barriers to Entry Framework

Initial Capex (cyclotron + hot cells)

●●●●●

$3-8M USD

GMP Facility Construction

●●●●●

$2-5M USD

ANVISA Pharmaceutical License

●●●●○

18-36 months

CNEN Radioactive Materials Lic.

●●●●●

Strict standards

Qualified Technical Staff

●●●●○

Scarce locally

24/7 Operations Requirement

●●●●○

High fixed OPEX

Supply Chain Dependencies

●●●●○

Critical agreements

Geographic Reach Constraints

●●●●●

Half-life limits

CAPEX SUMMARY

Cyclotron (IBA Cyclone 18 MeV)

~$3.5-5M

Hot cell suite

~$1.5-2M

GMP lab infrastructure

~$1-2M

Licensing & validation

~$0.5-1M

Total Minimum Capex

~$7-12M USD

Capital requirements, regulatory timelines, and specialized technical expertise combine to create near-impenetrable barriers — protecting incumbents and limiting competitive entry.

SECTION 05 — BRAZIL SUPPLIER LANDSCAPE

Brazil's Radiopharmaceutical Landscape Is Concentrated, Strategically Critical, and Poised for Consolidation

PUBLIC / INSTITUTIONAL

IPEN / CNEN

Brazil's national nuclear research institute

Produces Mo-99/Tc-99m generators nationally

Cyclotron facility in São Paulo

Critical national infrastructure

Strategic importance: National supply security

PRIVATE SECTOR

CMR Pharma

Leading private Brazilian company

Multiple cyclotron sites nationally

FDG, Ga-68, and other PET tracers

Nuclear pharmacy network

Serving major PET centers across Brazil

PRIVATE SECTOR

R2 Pharma

Growing Brazilian radiopharmaceutical supplier

Cyclotron-based production

Cold kit portfolio (Tc-99m, Ga-68, Lu-177)

Turnkey on-site programs for hospitals

CNEN-approved Ga-68 program

Nuclear pharmacy services

INTERNATIONAL

International Players

Novartis / AAA (Advanced Accelerator) — Pluvicto import

Curium Pharma (European supplier)

GE HealthCare (Tc-99m generators imported)

Limited direct presence; mostly via distributors

The Brazilian radiopharmaceutical supply market is oligopolistic — dominated by 2-3 players with cyclotron infrastructure. This concentration creates both risk (supply disruption) and opportunity (platform M&A).

SECTION 06

Service Providers

in Brazil

Business Models, Economics & Competitive Dynamics

Public vs. Private vs. Independent Models

Cost Structures & Revenue Models

Capital Intensity & Workforce Requirements

Consolidation & Expansion Opportunities

CONFIDENTIAL — FOR AUTHORIZED RECIPIENTS ONLY

SECTION 06 — SERVICE PROVIDER MODELS

Three Distinct Business Models Compete in Brazil's Nuclear Medicine Services Market — Each With Different Economic Profiles

PUBLIC / SUS PROVIDERS

Hospitals universitários, INCA, Santa Casa networks

SUS reimbursement (SIGTAP/AIH)

~R$1,500-2,500 per procedure (SUS)

High (but reimbursement insufficient)

Publicly funded

CLT / public servants

Accessibility, volume

Underfunded, long wait times, equipment outdated

Large underserved patient population

HOSPITAL-BASED / DIAGNOSTIC NETWORKS

Fleury, Dasa, Alliar, Hermes Pardini, Einstein, Sírio-Libanês

ANS reimbursement + private pay

~R$3,500-6,000+ per procedure (private)

Medium-High

$1-3M per PET-CT scanner

Employed nuclear medicine physicians, technologists

Brand, insurance contracts, multidisciplinary integration

High overhead, geographic concentration

CONSOLIDATION TARGETS — scale-driven economics

INDEPENDENT NUCLEAR MEDICINE CLINICS

Specialist standalone nuclear medicine centers

ANS + private pay + direct patient

~R$4,000-8,000+ (premium positioning)

Low-Medium (specialized)

$1.5-3M (owned scanner)

Nuclear medicine physician owner-operators

Specialization, efficiency, patient experience

Single location, no scale, succession risk

ACQUISITION OPPORTUNITY — founder-owned, scalable

Low

Medium

High

Low

Medium-High

High

Low

Very High

Low-Medium

Low

★★★★★

★★★★☆

Hospital-based diagnostic networks offer the ideal combination of scale, insurance contracts, and consolidation potential — while independent clinics represent attractive bolt-on acquisition opportunities.

SECTION 07

PET-CT Distribution

in Brazil

Geographic Inequality, Access Gaps & Expansion Opportunity

Scanner Distribution by Region

International Benchmarking

Supply-Demand Imbalance

Strategic Expansion Thesis

CONFIDENTIAL — FOR AUTHORIZED RECIPIENTS ONLY

SECTION 07 — PET-CT DISTRIBUTION

Brazil Has 111 PET Scanners for 215 Million People —

A Structural Supply Gap That Defines the Investment Opportunity

Regional Distribution in Brazil

International Benchmarking — PET Scanners per Million Population (2024)

75 Scanners

0.84 per million (89M pop)

18 Scanners

0.60 per million (30M pop)

11 Scanners

0.19 per million (57M pop)

4 Scanners

0.25 per million (16M pop)

4 Scanners

0.22 per million (18M pop)

10x below US levels

Brazil's nuclear medicine access is concentrated in 3 metropolitan areas — the remaining 60% of the population remains structurally underserved.

Each new PET center in an underserved region immediately captures suppressed demand — implying above-average utilization and rapid payback.

SECTION 08

Growth Outlook &

Investment Thesis

Structural Tailwinds, Market Sizing & Strategic Opportunities

Global & Brazil Market Growth Projections

Key Structural Growth Drivers

Pipeline & Reimbursement Catalysts

M&A Landscape & Investment Thesis

CONFIDENTIAL — FOR AUTHORIZED RECIPIENTS ONLY

SECTION 08 — MARKET SIZING

Nuclear Medicine Is a ~$17B Global Market Growing at 13-15% CAGR — Driven by Oncology, Theranostics, and an Aging Population

Global Nuclear Medicine Market (USD Billions)

Sources: Grand View Research, MarketsandMarkets, GlobalData, 2024

Market Breakdown by Segment (2024)

The sector exhibits the rare combination of high growth, high barriers to entry, and pricing power — characteristics typically associated with exceptional investment returns.