Metrics & MoreArticle Recommendations CONSPECTUS: Nuclear medicine harnesses radioisotopes for the diagnosis and treatment of disease. While the isotopes 99m Tc and 111 In have enabled the clinical diagnosis of millions of patients over the past 3 decades, more recent clinical translation of numerous 68 Ga/ 177 Lu-based radiopharmaceuticals for diagnostic imaging and therapy underscores the clinical utility of metal-based radiopharmaceuticals in mainstream cancer treatment. In addition to such established radionuclides, advancements in radioisotope production have enabled the production of radionuclides with a broad range of half-lives and emission properties of interest for nuclear medicine. Chemical means to form kinetically inert, in vivo-compatible species that can be modified with disease-targeting vectors is imperative. This presents a challenge for radiosiotopes of elements where the aqueous chemistry is still underdeveloped and poorly understood. Here, we discuss our efforts to date in exploring the aqueous, radioactive coordination chemistry of highly Lewis acidic metal ions and how our discoveries apply to the diagnosis and treatment of cancer in preclinical models of disease. The scope of this Account includes approaches to aqueous coordination of to-date understudied highly Lewis acidic metal ions with radioisotopes of emerging interest and the modulation of well-understood coordination environments of radio-coordination complexes to induce metal-catalyzed reactivity for separation and pro-drug applications. First, we discuss the development of seven-coordinate, small-cavity macrocyclic chelator platform mpatcn/picaga as an exemplary case study, which forms robust complexes with 44 Sc/ 47 Sc isotopes. Due to the high chemical hardness and pronounced Lewis acidity of the Sc 3+ ion, the displacement of ternary ligand H 2 O by 18/nat F − can be achieved to form an inert Sc− 18/nat F bond. Corresponding coordination complex nat Sc− 18 F is in vivo compatible and forms a theranostic tetrad with corresponding 44 Sc/ 47 Sc, 177 Lu complexes all exhibiting homologous biodistribution profiles. Another exceptionally hard, highly Lewis acidic ion with underdeveloped aqueous chemistry and emerging interest in nuclear medicine is 45 Ti 4+ . To develop de novo approaches to the mononuclear chelation of this ion under aqueous conditions, we employed a fragment-based bidentate ligand screening approach which identified two leads. The screen successfully predicted the formation of [ 45 Ti][Ti(TREN-CAM)], a Ti-triscatechol complex that exhibits remarkable in vivo stability. Furthermore, the fragment-based screen also identified approaches that enabled solid-phase separation of Ti 4+ and Sc 3+ of interest in streamlining the isotope production of 45 Ti and accessing new ways to separate 44 Ti/ 44 Sc for the development of a longlived generator system. In addition to establishing the inert chelation of Ti 4+ and Sc 3+ , we introduce controlled, metal-induced reactivity of corresponding coordination complexes on macrosc...