Radiopharmaceutical Switch Maintenance for Relapsed Ovarian Carcinoma

Switch maintenance, or using alternative therapeutic agents that were not administered during a prior course of cancer treatment, has emerged as an active clinical research and regulatory agency-approvable path in the National Cancer Institute (NCI) Cancer Therapy Evaluation Program (CTEP) drug-development sequence. To better inform the design of therapeutic radiopharmaceutical trials, we reviewed academic scholarship discussing the clinical use of maintenance approaches to cancer treatment. Women with advanced-stage primary platinum-refractory or platinum-resistant ovarian carcinoma and their courses of treatment provide context for our discussion. Twenty-four (10%) out of 244 trials for women with ovarian carcinoma fit our search terms for maintenance trials. Five (2%) trials studied radiopharmaceuticals as switch maintenance. In our opinion, radiopharmaceutical switch maintenance merits further testing in prospective trials for women with advanced-stage primary platinum recurrent or refractory ovarian carcinoma.

Usefulness of PET With [18F]LBT-999 for the Evaluation of Presynaptic Dopaminergic Neuronal Loss in a Clinical Environment

Purpose: The density of the neuronal dopamine transporter (DAT) is directly correlated with the presynaptic dopaminergic system injury. In a first study, we evaluated the brain distribution and kinetics of [¹⁸F]LBT-999, a DAT PET radioligand, in a group of eight healthy subjects. Taking into account the results obtained in healthy volunteers, we wanted to evaluate whether the loss of presynaptic striatal dopaminergic fibers could be estimated, under routine clinical conditions, using [¹⁸F]LBT-999 and a short PET acquisition.

Materials and methods: Six patients with Parkinson's disease (PD) were compared with eight controls. Eighty-nine minutes of dynamic PET following an intravenous injection of [¹⁸F]LBT-999 were acquired. Using regions of interest for striatal nuclei, substantia nigra (SN), cerebellum, and occipital cortex, defined over each T1 3D MRI, time–activity curves (TACs) were obtained. From TACs, binding potential (BP_ND) using the simplified reference tissue model and distribution volume ratios (DVRs) using Logan graphical analysis were calculated. Ratios obtained for a 10-min image, acquired between 30 and 40 min post-injection, were also calculated. Cerebellum activity was used as non-specific reference region.

Results: In PD patients and as expected, striatal uptake was lower than in controls which is confirmed by BP_ND, DVR, and ratios calculated for both striatal nuclei and SN, significantly inferior in PD patients compared with controls (p < 0.001).

Conclusions: PET with [¹⁸F]LBT-999 could be an alternative to assess dopaminergic presynaptic injury in a clinical environment using a single 10 min acquisition.

Phase 0 Radiopharmaceutical-Agent Clinical Development

The evaluation of antibody-targeted or peptide-targeted radiopharmaceuticals as monotherapy or in oncological drug combinations requires programmatic collaboration within the National Cancer Institute (NCI) clinical trial enterprise. Phase 0 trials provide a flexible research platform for the study of radiopharmaceutical–drug pharmacokinetics, radiation dosimetry, biomarkers of DNA damage response modulation, and pharmacodynamic benchmarks predictive of therapeutic success. In this article, we discuss a phase 0 clinical development approach for human antibody-targeted or peptide-targeted radiopharmaceutical–agent combinations. We expect that early-phase radiopharmaceutical–agent combination trials will become a more tactical and more prevalent part of radiopharmaceutical clinical development in the near-term future for the NCI Cancer Therapy Evaluation Program.

Financial Toxicity Encountered in Therapeutic Radiopharmaceutical Clinical Development for Ovarian Cancer

Financial toxicity or the debt a cancer survivor incurs from the costs of their medical cancer care is an understudied aspect in the clinical development of experimental therapeutic agents. The United States National Cancer Institute (NCI) Cancer Therapy Evaluation Program studies experimental therapeutic agents like radiopharmaceuticals in both early and late phase trials, which provide opportunities to comprehend more clearly the possible sources of financial toxicity incurred by cancer survivors. We reviewed the academic scholarship describing fiscal and social costs involved in the development of therapeutic radiopharmaceuticals. Because many ovarian cancer survivors outlive their disease through initial and, perhaps, multiple treatment courses, these women and their treatments provide context for our discussion on financial toxicity. 16 (27%) of 60 articles discuss financial toxicity incurred by women with ovarian cancer; none described financial toxicity associated with regulatory agency-approved or experimental therapeutic radiopharmaceuticals. Fiscal costs of radiopharmaceutical dose and schedule and social costs of individual productivity loss or asset expenditure arose as primary financial toxicities. The development of radiopharmaceuticals for women with ovarian cancer remains a high priority for the NCI Cancer Therapy Evaluation Program. Weighing radiopharmaceutical clinical benefit against measures of financial toxicity is challenging and warrants further study in prospective radiopharmaceutical clinical trials.

Imaging Bacteria with Radiolabelled Probes: Is It Feasible?

Bacterial infections are the main cause of patient morbidity and mortality worldwide. Diagnosis can be difficult and delayed as well as the identification of the etiological pathogen, necessary for a tailored antibiotic therapy. Several non-invasive diagnostic procedures are available, all with pros and cons. Molecular nuclear medicine has highly contributed in this field by proposing several different radiopharmaceuticals (antimicrobial peptides, leukocytes, cytokines, antibiotics, sugars, etc.) but none proved to be highly specific for bacteria, although many agents in development look promising. Indeed, factors including the number and strain of bacteria, the infection site, and the host condition, may affect the specificity of the tested radiopharmaceuticals. At the Third European Congress on Infection/Inflammation Imaging, a round table discussion was dedicated to debate the pros and cons of different radiopharmaceuticals for imaging bacteria with the final goal to find a consensus on the most relevant research steps that should be fulfilled when testing a new probe, based on experience and cumulative published evidence.

Automated GMP production and long-term experience in radiosynthesis of CB1 tracer [18 F]FMPEP-d2

Here, we describe the development of an in-house-built device for the fully automated multistep synthesis of the cannabinoid CB1 receptor imaging tracer (3R,5R)-5-(3-([18 F]fluoromethoxy-d2 )phenyl)-3-(((R)-1-phenylethyl)amino)-1-(4-(trifluoromethyl)phenyl)pyrrolidin-2-one ([18 F]FMPEP-d2 ), following good manufacturing practices. The device is interfaced to a HPLC and a sterile filtration unit in a clean room hot cell. The synthesis involves the nucleophilic 18 F-fluorination of an alkylating agent and its GC purification, the subsequent 18 F-fluoroalkylation of a precursor molecule, the semipreparative HPLC purification of the 18 F-fluoroalkylated product, and its formulation for injection. We have optimized the duration and temperature of the 18 F-fluoroalkylation reaction and addressed the radiochemical stability of the formulated product. During the past 5 years (2013-2018), we have performed a total of 149 syntheses for clinical use with a 90% success rate. The activity yield of the formulated product has been 1.0 ± 0.4 GBq starting from 11 ± 2 GBq and the molar activity 600 ± 300 GBq/μmol at the end of synthesis.

Synthesis and Fundamental Evaluation of Radioiodinated Rociletinib (CO-1686) as a Probe to Lung Cancer with L858R/T790M Mutations of Epidermal Growth Factor Receptor (EGFR)

Rociletinib (CO-1686), a 2,4-diaminopyrimidine derivative, is a highly potent tyrosine kinase inhibitor (TKI) that acts on epidermal growth factor receptor (EGFR) with L858R/T790M mutations. We supposed radioiodinated CO-1686 would function as a useful tool for monitoring EGFR L858R/T790M mutations. To aid in patient selection before therapy with EGFR-TKIs, this study aimed to develop a 125I-labeled derivative of CO-1686, N-{3-[(2-{[4-(4-acetylpiperazin-1-yl)-2-methoxyphenyl]amino}-5-(trifluoromethyl)pyrimidine-4-yl] amino}-5-([125I]iodophenyl)acrylamide ([125I]ICO1686) and evaluate its selectivity toward EGFR L858R/T790M. Radiosynthesis was performed by iododestannylation of the corresponding tributylstannyl precursor with [125I]NaI and N-chlorosuccinimide. The selectivity of the tracer for detecting EGFR L858R/T790M was evaluated using three relevant non-small cell lung cancer (NSCLC) cell lines-H1975, H3255 and H441 overexpressing the dual mutation EGFR L858R/T790M, active mutant EGFR L858R and wild-type EGFR, respectively. The nonradioactive ICO1686 and the precursor compound were successfully synthesized. A novel radiolabeled probe, [125I]ICO1686, was prepared with high radiochemical yield (77%) and purity (>99%). ICO1686 exhibited high cytotoxicity toward H1975 (IC50 0.20 ± 0.05 μM) and H3255 (IC50 0.50 ± 0.21 μM), which is comparable to that of CO-1686. In contrast, the cytotoxicity of ICO1686 toward H441 was 10-fold lower than that toward H1975. In the cell uptake study, the radioactivity uptake of [125I]ICO1686 in H1975 was 101.52% dose/mg, whereas the uptakes in H3255 and H441 were 33.52 and 8.95% dose/mg, respectively. The uptake of [125I]ICO1686 in H1975 was greatly reduced to 45.61% dose/mg protein by treatment with excess CO-1686. In vivo biodistribution study of the radiotracer found that its accumulation in H1975 tumor (1.77 ± 0.43% ID/g) was comparable to that in H3255 tumor (1.63 ± 0.23% ID/g) and the accumulation in H1975 tumor was not reduced by pretreatment with an excess dose of CO-1686. Although this radiotracer exhibited highly specific in vitro uptake in target cancer cells, structural modification is required to improve in vivo biodistribution.

Targeted Alpha Therapy: Current Clinical Applications

α-Emitting radionuclides have been approved for cancer treatment since 2013, with increasing degrees of success. Despite this clinical utility, little is known regarding the mechanisms of action of α particles in this setting, and accurate assessments of the dosimetry underpinning their effectiveness are lacking. However, targeted alpha therapy (TAT) is gaining more attention as new targets, synthetic chemistry approaches, and α particle emitters are identified, constructed, developed, and realized. From a radiobiological perspective, α particles are more effective at killing cells compared to low linear energy transfer radiation. Also, from these direct effects, it is now evident from preclinical and clinical data that α emitters are capable of both producing effects in nonirradiated bystander cells and stimulating the immune system, extending the biological effects of TAT beyond the range of α particles. The short range of α particles makes them a potent tool to irradiate single-cell lesions or treat solid tumors by minimizing unwanted irradiation of normal tissue surrounding the cancer cells, assuming a high specificity of the radiopharmaceutical and good stability of its chemical bonds. Clinical approval of ²²³RaCl₂ in 2013 was a major milestone in the widespread application of TAT as a safe and effective strategy for cancer treatment. In addition, ²²⁵Ac-prostate specific membrane antigen treatment benefit in metastatic castrate-resistant prostate cancer patients, refractory to standard therapies, is another game-changing piece in the short history of TAT clinical application. Clinical applications of TAT are growing with different radionuclides and combination therapies, and in different clinical settings. Despite the remarkable advances in TAT dosimetry and imaging, it has not yet been used to its full potential. Labeled ²²⁷Th and ²²⁵Ac appear to be promising candidates and could represent the next generation of agents able to extend patient survival in several clinical scenarios.

Safety and outcomes of 177 Lu-DOTATATE for neuroendocrine tumours: experience in New South Wales, Australia

BACKGROUND

Peptide receptor radionuclide therapy with ¹⁷⁷ Lu-DOTATATE is a promising treatment for inoperable or metastatic neuroendocrine tumours (NET). In 2015, the NSW Ministry of Health provided funding for ¹⁷⁷ Lu-DOTATATE treatment of NET under an evaluation framework.

AIMS

To examine the safety and outcomes of NET patients treated with ¹⁷⁷ Lu-DOTATATE under the evaluation framework and assess the statewide implementation of the NSW Lutate therapy referral and protocol for neuroendocrine cancer patients.

METHODS

A quality of care clinical audit was conducted on all NET patients treated with ¹⁷⁷ Lu-DOTATATE from October 2010 to October 2015 at St George Hospital, and from August 2013 to March 2017 at Royal North Shore Hospital. Percentage of patients who met protocol selection criteria was calculated. Survival was estimated using the Kaplan-Meier method. Adjusted regression analyses assessed associations between key clinical factors and outcomes.

RESULTS

A total of 279 patients was treated. Statewide protocol implementation led to an increase from 60.5 to 83.8% in patients meeting selection criteria. Estimated median overall survival was significantly longer for patients who met selection criteria compared with those who did not (50.7 vs 34.2 months) (P = 0.018). This was driven by the significantly worse overall survival in patients who failed exclusion criteria (P < 0.001). ¹⁷⁷ Lu-DOTATATE was well tolerated with haematological, renal and hepatic treatment-related serious adverse events experienced by 9.7, 0.4 and 0.4% of patients respectively.

CONCLUSIONS

¹⁷⁷ Lu-DOTATATE is a promising treatment for advanced NET. Superior survival in patients who met selection criteria emphasise the importance of protocol adherence.

Nanoparticulate formulations of radiopharmaceuticals: Strategy to improve targeting and biodistribution properties

Application of nanotechnology principles in drug delivery has created opportunities for treatment of several diseases. Nanotechnology offers the advantage of overcoming the adverse biopharmaceutics or pharmacokinetic properties of drug molecules, to be determined by the transport properties of the particles themselves. Through the manipulation of size, shape, charge, and type of nanoparticle delivery system, variety of distribution profiles may be obtained. However, there still exists greater need to derive and standardize definitive structure property relationships for the distribution profiles of the delivery system. When applied to radiopharmaceuticals, the delivery systems assume greater significance. For the safety and efficacy of both diagnostics and therapeutic radiopharmaceuticals, selective localization in target tissue is even more important. At the same time, the synthesis and fabrication reactions of radiolabelled nanoparticles need to be completed in much shorter time. Moreover, the extensive understanding of the several interesting optical and magnetic properties of materials in nanoscale provides for achieving multiple objectives in nuclear medicine. This review discusses the various nanoparticle systems, which are applied for radionuclides and analyses the important bottlenecks that are required to be overcome for their more widespread clinical adaptation.

Zn Complex of Diaminedithiol Tetradentate Ligand as a Stable Precursor for 99mTc-Labeled Compounds

The diaminedithiol (N₂S₂) tetradentate ligand constitutes a useful chelating molecule for preparing ^99mTc-labeled compounds of high in vivo stability in high radiochemical yields. However, since the thiol groups in the N₂S₂ ligand are easy to be oxidized to disulfide bonds, they need to be protected with an appropriate protecting group, which hinders the broad applications of the N₂S₂ ligand for radiopharmaceuticals. In this study, a Zn chelate of N₂S₂ was evaluated as a precursor for purification-free ^99mTc-labeled N₂S₂ under the mild and simple procedure. Zn-N₂S₂ was prepared by reacting Zn acetate with N₂S₂, and the Zn-N₂S₂ remained stable under aerobic conditions at room temperature. ^99mTc-N₂S₂ was obtained over 90% radiochemical yields at room temperature by a one-pot reaction, consisting of Zn-N₂S₂ (10⁻⁵ M), ^99mTcO₄⁻, ethylenediaminetetraacetic acid (EDTA), and a reducing agent (Sn²⁺) at pH = 5.5 to 7.5. ^99mTc-N₂S₂ was also obtained over 90% radiochemical yields when the reaction was conducted in the presence of an equimolar amount of IgG antibody. These findings indicate the Zn complex of N₂S₂ ligand constitutes a stable and useful precursor to prepare ^99mTc-labeled N₂S₂ compounds in high yields under the mild and simple procedure.

Systematic Assessment of the Adsorption of 99mTc-Radiopharmaceuticals onto Plastic Syringes

The phenomenon of adsorption of several ^99mTc-radiopharmaceuticals onto disposable syringes is common knowledge and can reach a level of up to 50%, with the result being inadequate dosing. The resulting underdosing has a substantial influence on the quality of imaging, especially in pediatric patients. Therefore, we aimed to establish a standardized in vitro assessment to investigate the adsorption of several ^99mTc-radiopharmaceuticals on various brands of syringes. Methods: The ^99mTc-radiopharmaceuticals were prepared according to manufacturer instructions. For the assessment, the disposable syringes (n = 3) were filled to one third of capacity with the ^99mTc preparation and incubated for 30 min at room temperature. The syringes were emptied into evacuated vials, and the radioactivity of the syringes was measured before and after they were emptied. Furthermore, the dilution effect of ^99mTc preparations was studied. We used 2 different brands of syringes and systematically examined ^99mTc-pertechnetate, ^99mTc-butedronate, ^99mTc-oxidronate, ^99mTc-medronate, ^99mTc-tetrofosmin, ^99mTc-sestamibi, ^99mTc(V)-dimercaptosuccinic acid, and ^99mTc-succimer. Additionally, ^99mTc-succimer was retested with 5 brands of syringes. Results: ^99mTc-pertechnetate, ^99mTc-phosphonates, and ^99mTc(V)-dimercaptosuccinic acid showed no significant adsorption. The measured radioactive retention of 2%-5% was equivalent to the determined dead volume. Using ^99mTc-tetrofosmin, we found a slight but significant adsorption of 4%-7%. The ^99mTc-sestamibi preparation showed a nonsignificant retention of 3%-5%. However, when the ^99mTc-sestamibi was diluted 1:10 with saline, the adsorption rate increased to 9%-13%. ^99mTc-succimer displayed different adsorption levels depending on the brand of syringe and the preparation technique. The adsorption of ^99mTc-succimer, prepared from kits according to the instructions, did not exceed 15%. The 1:10 saline dilution of a ^99mTc-succimer kit preparation, as well as an in-house preparation, demonstrated a radioactive syringe adsorption rate of more than 30%. Conclusion: The results revealed the significance of syringe adsorption of radiopharmaceuticals in the prevention of underdosing. Therefore, a quality assurance assessment is recommended before the introduction of new brands of plastic syringes or routine application of diluted or in-house radiopharmaceuticals.

Preparation and In Vitro Evaluation of Neutron-Activated, Theranostic Samarium-153-Labeled Microspheres for Transarterial Radioembolization of Hepatocellular Carcinoma and Liver Metastasis

Introduction: Transarterial radioembolization (TARE) has been proven as an effective treatment for unresectable liver tumor. In this study, neutron activated, ¹⁵³Sm-labeled microspheres were developed as an alternative to ⁹⁰Y-labeled microspheres for hepatic radioembolization. ¹⁵³Sm has a theranostic advantage as it emits both therapeutic beta and diagnostic gamma radiations simultaneously, in comparison to the pure beta emitter, ⁹⁰Y. Methods: Negatively charged acrylic microspheres were labeled with ¹⁵²Sm ions through electrostatic interactions. In another formulation, the Sm-labeled microsphere was treated with sodium carbonate solution to form the insoluble ¹⁵²Sm carbonate (¹⁵²SmC) salt within the porous structures of the microspheres. Both formulations were neutron-activated in a research reactor. Physicochemical characterization, gamma spectrometry, and radiolabel stability tests were carried out to study the performance and stability of the microspheres. Results: The Sm- and SmC-labeled microspheres remained spherical and smooth, with a mean size of 35 µm before and after neutron activation. Fourier transform infrared (FTIR) spectroscopy indicated that the functional groups of the microspheres remained unaffected after neutron activation. The ¹⁵³Sm- and ¹⁵³SmC-labeled microspheres achieved activity of 2.53 ± 0.08 and 2.40 ± 0.13 GBq·g⁻¹, respectively, immediate after 6 h neutron activation in the neutron flux of 2.0 × 10¹² n·cm⁻²·s⁻¹. Energy-dispersive X-ray (EDX) and gamma spectrometry showed that no elemental and radioactive impurities were present in the microspheres after neutron activation. The retention efficiency of ¹⁵³Sm in the ¹⁵³SmC-labeled microspheres was excellent (~99% in distilled water and saline; ~97% in human blood plasma), which was higher than the ¹⁵³Sm-labeled microspheres (~95% and ~85%, respectively). Conclusion: ¹⁵³SmC-labeled microspheres have demonstrated excellent properties for potential application as theranostic agents for hepatic radioembolization.

Is There a Role for GPCR Agonist Radiotracers in PET Neuroimaging?

Positron emission tomography (PET) is a molecular imaging modality that enables in vivo exploration of metabolic processes and especially the pharmacology of neuroreceptors. G protein-coupled receptors (GPCRs) play an important role in numerous pathophysiologic disorders of the central nervous system. Thus, they are targets of choice in PET imaging to bring proof concept of change in density in pathological conditions or in pharmacological challenge. At present, most radiotracers are antagonist ligands. In vitro data suggest that properties differ between GPCR agonists and antagonists: antagonists bind to receptors with a single affinity, whereas agonists are characterized by two different affinities: high affinity for receptors that undergo functional coupling to G-proteins, and low affinity for those that are not coupled. In this context, agonist radiotracers may be useful tools to give functional images of GPCRs in the brain, with high sensitivity to neurotransmitter release. Here, we review all existing PET radiotracers used from animals to humans and their role for understanding the ligand-receptor paradigm of GPCR in comparison with corresponding antagonist radiotracers.

Clinical Outcome Assessments Toolbox for Radiopharmaceuticals

For nearly 40 years, the U.S. National Cancer Institute (NCI) has funded health-related quality-of-life (HRQOL) and symptom management in oncology clinical trials as a method for including a cancer patient's experience during and after treatment. The NCI's planned scope for HRQOL, symptom and patient-reported outcomes management research is explained as it pertains to radiopharmaceutical clinical development. An effort already underway to support protocol authoring via an NCI Cancer Therapy Evaluation Program (CTEP) Centralized Protocol Writing Service (CPWS) is described as this service aids incorporation of HRQOL, symptom and patient-reported outcomes management research into sponsored protocols.

Radium 223 combined with new hormone therapies for the treatment of castrate-resistant metastatic prostate cancer: scientific evidence and sharing of our experience

Presentation of the interesting case of a patient suffering from castrate-resistant prostate cancer (CRPC) with bone metastasis, who received concomitant treatment with abiraterone acetate (AA) and radium-223. The patient experienced significant clinical improvement in his quality of life and pain relief after beginning the aforementioned treatment, without being affected by adverse toxicities. Currently, the correct selection of patients to receive radium-223 treatment is still a clinical challenge in the case of CRPC with metastasis. In this article, we discuss the future prospects of this treatment, reviewing current evidence about concomitant therapies with radium-223 and its present state, based upon the recent recommendations from the Pharmacovigilance Risk Assessment Committee (PRAC), and the data presented in the ERA-223 study. Based on our clinical experience, we provide practical orientation for the integration of this radiopharmaceutical in the therapeutic plan for this group of patients. We conclude, despite some of the positive results and our excellent experience, that it would be wise to wait for the results of the clinical trials that are studying the safety and benefits of the combined use of radium-223 with new hormone therapies. Bearing in mind that to date, the only published large-scale randomised trial that investigated the combination of AR-axis-targeted therapy with Ra-223 is negative, the harms of the combination outweighed any benefits in ERA-223. Nonetheless, in order to recommend whether or not this treatment should be used, it is essential to define the patient profile that could benefit from this therapeutic option.

Technetium-99m-labeled genistein as a potential radical scavenging agent

The purpose of this study was to determine the optimum conditions for labeling genistein compounds with technetium-99m (^99mTc) radionuclides and the percentage of purity obtained in accordance with the requirements of the United State Pharmacopeia. The method used is optimization of several parameters including pH, SnCl₂.2H₂O as reducing agents, genistein concentration, and incubation time. The results showed that the optimum conditions for labeling ^99mTc-Genistein were obtained under conditions of pH 8, the amount of SnCl₂.2H₂O reducing agents was 30 μg, 0.5 mg genistein, and in 10 min. The optimization of this condition resulted in radiochemical purity in the labeling of ^99mTc-Genistein compounds at 95.43% ± 0.85%. The radiochemical purity of the labeling of ^99mTc-Genistein compounds has met the requirements of the United State Pharmacopeia as a compound marked for diagnosis of more than 90%.

Comparison of 99mTc Injected Activity with Prescribed Activity in Four Types of Nuclear Medicine Exams

BACKGROUND

99mTc is a radioactive isotope that is obtained by eluting a 99Mo/99mTc generator. (PINSTECH, Islamabad) and used for radionuclide scanning.

OBJECTIVES

The objective of this work is to study the uncertainties in 99mTc activity that exist due to time delay between injection preparation and administration to patients, during the process of gamma camera scanning.

METHODS

Lead canisters were used for storing elution vials and dose calibrator for measuring 99mTc activity in mCi. The activity of preparing 99mTc injection and its administration to patients were compared with the prescribed values of activity recommended in the Society of Nuclear Medicine procedure guidelines.

RESULTS

This study showed that uncertainty in the activity existed in one thyroid patient, 38 bone patients, 5 renal patients and 45 cardiac patients.

CONCLUSION

This uncertainty in activity exists due to time delay between injection preparation and administration to patients, as well as due to residual radionuclide that is not injected into patients and remains in the syringe.

Leveraging National Cancer Institute Programmatic Collaboration for Single Radiopharmaceutical Drug Master Files

Targeted radiopharmaceutical conjugates intended for therapeutic use often are made of three key components, a decaying radionuclide, a chemical chelator/linker, and a targeted molecular entity. The National Cancer Institute (NCI) Experimental Therapeutics Program has accepted four radiopharmaceutical drug products so far that fit the targeted radiopharmaceutical conjugate class. As the NCI sharpens its thinking about its role as an investigational new drug sponsor for radiopharmaceuticals in clinical development, it has considered the relative merits of modular radiopharmaceutical drug master files. Here, the NCI provides its perspective on modular radiopharmaceutical drug master files as it initiates a clinical development program for such agents and further organizes its radiopharmaceutical Small Business Innovation Research portfolio.

Radiopharmaceuticals for Persistent or Recurrent Uterine Cervix Cancer

Uterine cervix cancers pose therapeutic challenges because of an overactive ribonucleotide reductase, which provides on-demand deoxyribonucleotides for DNA replication or for a DNA damage repair response. Ribonucleotide reductase overactivity bestows cancer cell resistance to the effects of radiotherapy and chemotherapy used to treat disease; but nevertheless, this same biologic overexpression provides opportune vulnerabilities relatively specific to uterine cervix cancers for new therapeutic strategies to take advantage. The discovery of human epidermal growth factor receptor 2 (ErbB2 or HER2) overexpression on metastatic uterine cervix cancer cells provides an opportunity for clinical trials of targeted radiopharmaceuticals in combination with DNA damage response modifying drugs. The National Cancer Institute's clinical trial infrastructure and its experimental therapeutics portfolio can now offer clinical trial evaluation of molecularly-targeted and tolerated radiopharmaceutical-drug combinations for women with persistent or recurrent metastatic uterine cervix cancer. This article discusses the current thinking of the National Cancer Institute in regard to attractive radiopharmaceutical strategies for this disease and others.

Bone-targeted therapies to reduce skeletal morbidity in prostate cancer

Bone metastases are the main driver of morbidity and mortality in advanced prostate cancer. Targeting the bone microenvironment, a key player in the pathogenesis of bone metastasis, has become one of the mainstays of therapy in men with advanced prostate cancer. This review will evaluate the data supporting the use of bone-targeted therapy, including (1) bisphosphonates such as zoledronic acid, which directly target osteoclasts, (2) denosumab, a receptor activator of nuclear factor-kappa B (RANK) ligand inhibitor, which targets a key component of bone stromal interaction, and (3) radium-223, an alpha-emitting calcium mimetic, which hones to the metabolically active areas of osteoblastic metastasis and induces double-strand breaks in the DNA. Denosumab has shown enhanced delay in skeletal-related events compared to zoledronic acid in patients with metastatic castration-resistant prostate cancer (mCRPC). Data are mixed with regard to pain control as a primary measure of efficacy. New data call into question dosing frequency, with quarterly dosing strategy potentially achieving similar effect compared to monthly dosing for zoledronic acid. In the case of radium-223, there are data for both pain palliation and improved overall survival in mCRPC. Further studies are needed to optimize timing and combination strategies for bone-targeted therapies. Ongoing studies will explore the impact of combining bone-targeted therapy with investigational therapeutic agents such as immunotherapy, for advanced prostate cancer. Future studies should strive to develop biomarkers of response, in order to improve efficacy and cost-effectiveness of these agents.

The Story of the Dopamine Transporter PET Tracer LBT-999: From Conception to Clinical Use

The membrane dopamine transporter (DAT) is involved in a number of brain disorders and its exploration by positron emission tomography (PET) imaging is highly relevant for the early and differential diagnosis, follow-up and treatment assessment of these diseases. A number of carbon-11 and fluor-18 labeled tracers are to date available for this aim, the majority of them being derived from the chemical structure of cocaine. The development of such a tracer, from its conception to its use, is a long process, the expected result being to obtain the best radiopharmaceutical adapted for clinical protocols. In this context, the cocaine derivative (E)-N-(4-fluorobut-2-enyl)2β-carbomethoxy-3β-(4′-tolyl)nortropane, or LBT-999, has passed all the required stages of the development that makes it now a highly relevant imaging tool, particularly in the context of Parkinson's disease. This review describes the different steps of the development of LBT-999 which initially came from its non-fluorinated derivative (E)-N-(3-iodoprop-2-enyl)-2-carbomethoxy-3-(4-methylphenyl) nortropane, or PE2I, because of its high promising properties. [¹⁸F]LBT-999 has been extensively characterized in rodent and non-human primate models, in which it demonstrated its capability to explore in vivo the DAT localized at the dopaminergic nerve endings as well as at the mesencephalic cell bodies, in physiological conditions. In lesion-induced rat models of Parkinson's disease, [¹⁸F]LBT-999 was able to precisely quantify in vivo the dopaminergic neuron loss, and to assess the beneficial effects of therapeutic approaches such as pharmacological treatment and cell transplantation. Finally recent clinical data demonstrated the efficiency of [¹⁸F]LBT-999 in the diagnosis of Parkinson's disease.

Radiopharmaceuticals for Relapsed or Refractory Ovarian Cancers

Targeted radiopharmaceuticals for therapeutic use deliver radionuclides directly to tumor anywhere in the body, and therefore, have renewed interest for clinical development in women with disseminated chemorefractory ovarian cancers. About two in every five women with advanced stage ovarian cancer outlive their disease after the first treatment phase, with the rest rendered incurable due to the chemorefractory nature of their disease. The National Cancer Institute (NCI) Cancer Therapy Evaluation Program conducted 67 phase I or phase Ib trials among women with relapsed or refractory ovarian cancer between 1989 and 2017 in an effort to uncover tolerable and effective drug combinations intended to increase survival rates. None of these early clinical development phase trials involved radiopharmaceuticals. Here, the NCI provides its perspective on targeted radiopharmaceutical conjugates alone or in combination with its experimental therapeutics portfolio for women with relapsed or refractory ovarian cancer. An infrastructure build for Federal radiopharmaceutical medical monitoring and adverse event reporting has begun.

Application of 82 Sr/82 Rb generator in neurooncology

INTRODUCTION

The applicability of "Rubidium Chloride, 82 Rb from Generator" radiopharmaceutical for brain tumors (BT) diagnostics is demonstrated on the basis of the application experience of the radiopharmaceutical in neurooncology.

EXPERIMENTAL

A total of 21 patients with various brain tumors and nonneoplastic abnormal brain masses were investigated.

RESULTS AND DISCUSSIONS

The results of the imaging and differential diagnostics of malignant and benign tumors, nonneoplastic abnormal brain masses and lesions revealed the prevalence of high uptake of the radiopharmaceutical in the malignant tumors in comparison with benign glioma and arteriovenous malformations in which 82 Rb-chloride accumulates in the vascular phase but does not linger further. The ultra-short half-life of radionuclide 82 Rb (76 s) along with a low absorbed radiation dose with 82 Rb-chloride by intravenous administration create a new possibility of successive use of two or more radiopharmaceuticals for the examination of the same patient. For instance, PET examination with 18 F-FDG, 11 C-methionine, 11 C-choline, or any other radiopharmaceutical can be carried out in just 7-15 min. after 82 Rb-chloride injection.

CONCLUSION

Research demonstrated an effectiveness of 82 Rb-chloride application as a diagnostic agent in neurooncology. A method of dosing and administration of the generator-produced radiopharmaceutical has been worked out. It is possible to do up to 600 PET sessions using one Russian 82 Rb generator GR-01. The generator is proved to be reliable and easy to use. The interest in 82 Rb-chloride as a tumor-seeking radiopharmaceutical rose due to the active application of the modern devices PET/CT in the routine clinical practice.

Radiopharmaceuticals for Relapsed or Refractory Leukemias

Radiopharmaceuticals, meaning drugs that hold a radionuclide intended for use in cancer patients for treatment of their disease or for palliation of their disease-related symptoms, have gained new interest for clinical development in adult patients with relapsed or refractory leukemia. About one-third of adult patients outlive their leukemia, with the remainder unable to attain complete remission status following the first phase of treatment due to refractory bone marrow or blood residual microscopic disease. The National Cancer Institute (NCI) Cancer Therapy Evaluation Program conducted 49 phase 1-1b trials in adult patients with leukemia between 1986 and 2017 in an effort to discover tolerated and effective therapeutic drug combinations intended to improve remission and mortality rates. None of these trials involved radiopharmaceuticals. In this article, the NCI perspective on the challenges encountered in and on the future potential of radiopharmaceuticals alone or in combination for adult patients with relapsed or refractory leukemia is discussed. An effort is underway already to build-up the NCI's clinical trial enterprise infrastructure for radiopharmaceutical clinical development.