Neuroendocrine tumors of the bronchopulmonary system (typical and atypical carcinoid tumors): current strategies in diagnosis and treatment. Conclusions of an expert meeting February 2011 in Weimar, Germany

Neuroendocrine tumors (NETs; syn. carcinoid tumors) are highly or moderately differentiated neoplasms. They comprise a large variety of rare and heterogeneous tumors with an estimated incidence of 3-5/100,000/year. They can arise in virtually every internal organ, but mainly occur in the gastroenteropancreatic and bronchopulmonary systems. Around 25% of the NETs are localized in the bronchopulmonary system. Approximately 2% of all lung tumors are NETs. According to the World Health Organization (WHO) classification of lung tumors, bronchopulmonary NETs are subdivided into typical carcinoids (TCs) and atypical carcinoids (ACs). The parameter with the highest impact on NET behavior and prognosis is the histological classification and staging according to the tumor/node/metastasis (TNM) system. The diagnosis of NETs is established by histological examination and the immunohistochemical detection of general neuroendocrine markers, such as chromogranin A (CgA) and synaptophysin. Serum markers and the use of functional imaging techniques are important additive tools to establish the diagnosis of a NET. The only curative option for lung NETs is complete surgical resection. Beyond that, the currently available interdisciplinary therapeutic options are local ablation, biotherapy (somatostatin analogues), or chemotherapy. New therapeutic options such as peptide receptor radionuclide therapy (PRRT) and molecularly targeted therapies achieve promising results and are under further evaluation. This report is a consensus summary of the interdisciplinary symposium 'Neuroendocrine Tumors of the Lung and of the Gastroenteropancreatic System (GEP NET) - Expert Dialogue' held on February 25-26, 2011 in Weimar, Germany. At this conference, a panel of 23 German experts shared their knowledge and exchanged their thoughts about research, diagnosis, and clinical management of NETs, whereby special attention was paid to NETs of the respiratory tract.

Gallium-68 DOTATOC PET/CT in vivo characterization of somatostatin receptor expression in the prostate

AIM

The aim was to investigate somatostatin receptor (sstr) expression in normal prostate by determining the maximum standardized uptake value (SUVmax) of (68)Ga-DOTATOC PET/CT in neuroendocrine tumor (NET) patients, without NET involvement of the prostate gland, for establishing the reference standard.

METHODS

Sixty-four NET patients underwent (68)Ga-DOTATOC PET/CT. SUVmax of the prostate gland, normal liver, testes, and gluteus muscles were evaluated. The prostate gland size was measured. Statistical analysis was performed using dedicated software (SPSS13).

RESULTS

Mean/median (68)Ga-DOTATOC SUVmax values were as follows: normal prostate 2.6 ± 0.0, slightly enlarged prostate 4.2 ± 1.6, prostatic hypertrophy 4.9 ± 1.6, prostatic hyperplasia 5.0 ± 1.5, prostate cancer 9.5 ± 2.1, normal liver 7.3 ± 1.8, testes 1.8 ± 0.5, and gluteus 1.0 ± 0.2. The normal prostate gland had three times less sstr expression than normal liver tissue. Strong correlation was found between patient age and sstr expression in prostate/prostate size. No significant difference existed in sstr expression between prostatic hypertrophy and hyperplasia. Much higher sstr expression was found in prostatic cancer compared with normal prostate.

CONCLUSION

(68)Ga-DOTATOC PET/CT defines the baseline sstr uptake in prostate not affected by NET (significantly lower than in the liver). Higher values were established in prostatic hyperplasia and hypertrophy. Only concomitant prostate cancer was associated with higher SUVmax in comparison with non-neoplastic liver.

Peptide receptor radionuclide therapy of treatment-refractory metastatic thyroid cancer using (90)Yttrium and (177)Lutetium labeled somatostatin analogs: toxicity, response and survival analysis

The overall survival rate of non-radioiodine avid differentiated (follicular, papillary, medullary) thyroid carcinoma is significantly lower than for patients with iodine-avid lesions. The purpose of this study was to evaluate toxicity and efficacy (response and survival) of peptide receptor radionuclide therapy (PRRT) in non-radioiodine-avid or radioiodine therapy refractory thyroid cancer patients. Sixteen non-radioiodine-avid and/or radioiodine therapy refractory thyroid cancer patients, including follicular thyroid carcinoma (n = 4), medullary thyroid carcinoma (n = 8), Hürthle cell thyroid carcinoma (n = 3), and mixed carcinoma (n = 1) were treated with PRRT by using (90)Yttrium and/or (177)Lutetium labeled somatostatin analogs. (68)Ga somatostatin receptor PET/CT was used to determine the somatostatin receptor density in the residual tumor/metastatic lesions and to assess the treatment response. Hematological profiles and renal function were periodically examined after treatment. By using fractionated regimen, only mild, reversible hematological toxicity (grade 1) or nephrotoxicity (grade 1) were seen. Response assessment (using EORTC criteria) was performed in 11 patients treated with 2 or more (maximum 5) cycles of PRRT and showed disease stabilization in 4 (36.4%) patients. Two patients (18.2%) showed partial remission, in the remaining 5 patients (45.5%) disease remained progressive. Kaplan-Meier analysis resulted in a mean survival after the first PRRT of 4.2 years (95% CI, range 2.9-5.5) and median progression free survival of 25 months (inter-quartiles: 12-43). In non-radioiodine-avid/radioiodine therapy refractory thyroid cancer patients, PRRT is a promising therapeutic option with minimal toxicity, good response rate and excellent survival benefits.

[Hereditary syndromes of neuroendocrine tumours]

Diffuse localised neuroendocrinal cells represent the largest population of endocrinally active cells and can degenerate to malignant neuroendocrine tumours (NET). In this review the most important hereditary syndromes that predispose for endocrine and neuroendocrine tumours are presented and discussed. NET occur mainly as sporadic tumours. Current investigations on the pathogenesis of sporadic neuroendocrine tumours have revealed a close relationship between hereditary and sporadic neuroendocrine tumours. In the course of hereditary syndromes, such as multiple endocrine neoplasia, endocrine and neuroendocrine tumours as well as non-endocrine neoplasias can occur. In order to recognise these syndromes in good time a knowledge of the predisposing syndromes and their cardinal symptoms is essential. In this way not only individualised diagnosis and therapy can be planned but also an appropriate early management of first degree relatives can be initiated.

Is there a correlation between peptide receptor radionuclide therapy-associated hematological toxicity and spleen dose?

AIM

The spleen receives a high mean absorbed radiation dose during peptide receptor radionuclide therapy (PRRNT). The aim of this study is to correlate the radiation dose to spleen with the effect on blood cell count after PRRNT.

METHODS

Fifty-three neuroendocrine tumor (NET) patients were treated with 3.8-8.5 GBq (177)Lu-DOTATATE or (177)Lu-DOTATOC. Dosimetry was performed according to MIRD scheme. Eleven NET patients who had undergone splenectomy before PRRNT and who received 4.7-7.6 GBq (177)Lu-DOTATATE or (177)Lu-DOTATOC were selected as controls. RBC, WBC (total and differential), and platelet counts before and after each cycle of PRRNT were documented.

RESULTS

The median dose to the spleen in the study group was 6.34 Gy (2.32-20.06 Gy). There was no significant difference in the posttherapy changes in the blood cell counts (RBC, WBC, or platelets) between the study group and the control group. Mild hematological toxicity was found in 7 of the 53 (13.2%) patients in the study group and in 1 out of the 11 patients (9.1%) in the control group. However, there was no correlation between the incidence or grade of hematological toxicity and the dose to the spleen.

CONCLUSION

This study demonstrates for the first time that hematological toxicity after PRRNT is not related to the radiation dose to the spleen.

EDIM-TKTL1 blood test: a noninvasive method to detect upregulated glucose metabolism in patients with malignancies

AIM

To determine whether the TKTL1 protein epitope detection in monocytes (EDIM) test allows detection of upregulated glucose metabolism in malignancies.

MATERIALS & METHODS

The EDIM-TKTL1 blood test was conducted in 240 patients with 17 different confirmed or suspected malignancies. Test scores were compared with (18)F-fluoro-2-deoxy-D-glucose (FDG)-PET/computed tomography (CT) results.

RESULTS

EDIM-TKTL1 score and FDG-PET results showed a concordance of 90% with a sensitivity of 94% and specificity of 81%. Including CT data, all values were enhanced. A subgroup analysis of non-small-cell lung cancer patients showed a significant correlation between the EDIM-TKTL1 score and the primary tumor size determined by FDG-PET/CT.

CONCLUSION

EDIM-TKTL1 blood test revealed good concordance with FDG-PET/CT results in patients with malignancies demonstrating its efficacy to detect upregulation of glucose metabolism in primary tumors or metastases.

Role of PET/CT in the functional imaging of endocrine pancreatic tumors

Endocrine pancreatic tumors (EPTs) are a heterogeneous group of neoplasms with variable clinical and biological features and prognosis, ranging from very slow-growing tumors to highly aggressive and very malignant ones. As other neuroendocrine tumors, EPTs are characterized by the presence of neuroamine uptake mechanisms and/or peptide receptors at the cell membrane and these features constitute the basis of the clinical use of specific radiolabeled ligands, both for imaging and therapy. The more widespread use of hybrid machines, i.e., positron emission tomography/computed tomography (PET/CT), allows to perform imaging with high resolution and high diagnostic accuracy especially for small lesions, and to correlate anatomic location with function. The recent WHO recommendations for classification and prognostic factors help the selection of tracers likely to show a positive image on PET; therefore, tracers exploiting specific metabolic patterns ((18)F-DOPA and (11)C-5-HTP) or specific receptor expression ((68)Ga-DOTA-peptides) are suited to well-differentiated tumors, while the use of (18)F-FDG is preferred for poorly-differentiated neoplasms with high proliferative activity and loss of neuroendocrine features. In differentiated EPTs, (11)C-5-HTP performs better than (18)F-DOPA even though its use is hampered by its complex production and limited availability and experience; (68)Ga-peptides are indicated for all type of gastroenteropancreatic (GEP) neuroendocrine tumors, regardless of their functional activity. In addition, (68)Ga-DOTA-peptides play a distinctive role in planning peptide receptor radionuclide therapy.

The joint IAEA, EANM, and SNMMI practical guidance on peptide receptor radionuclide therapy (PRRNT) in neuroendocrine tumours

Peptide receptor radionuclide therapy (PRRNT) is a molecularly targeted radiation therapy involving the systemic administration of a radiolabelled peptide designed to target with high affinity and specificity receptors overexpressed on tumours. PRRNT employing the radiotagged somatostatin receptor agonists (90)Y-DOTATOC ([(90)Y-DOTA(0),Tyr(3)]-octreotide) or (177)Lu-DOTATATE ([(177)Lu-DOTA(0),Tyr(3),Thr(8)]-octreotide or [(177)Lu-DOTA(0),Tyr(3)]-octreotate) have been successfully used for the past 15 years to target metastatic or inoperable neuroendocrine tumours expressing the somatostatin receptor subtype 2. Accumulated evidence from clinical experience indicates that these tumours can be subjected to a high absorbed dose which leads to partial or complete objective responses in up to 30 % of treated patients. Survival analyses indicate that patients presenting with high tumour receptor expression at study entry and receiving (177)Lu-DOTATATE or (90)Y-DOTATOC treatment show significantly higher objective responses, leading to longer survival and improved quality of life. Side effects of PRRNT are typically seen in the kidneys and bone marrow. These, however, are usually mild provided adequate protective measures are undertaken. Despite the large body of evidence regarding efficacy and clinical safety, PRRNT is still considered an investigational treatment and its implementation must comply with national legislation, and ethical guidelines concerning human therapeutic investigations. This guidance was formulated based on recent literature and leading experts' opinions. It covers the rationale, indications and contraindications for PRRNT, assessment of treatment response and patient follow-up. This document is aimed at guiding nuclear medicine specialists in selecting likely candidates to receive PRRNT and to deliver the treatment in a safe and effective manner. This document is largely based on the book published through a joint international effort under the auspices of the Nuclear Medicine Section of the International Atomic Energy Agency.

Vandetanib therapy in medullary thyroid cancer

The U.S. Food and Drug Administration (FDA) approved vandetanib in April 2011 for the treatment of unresectable, locally advanced or metastatic medullary thyroid cancer (MTC). In Europe it was approved in March 2012, but only for the treatment of aggressive and symptomatic MTC. This small molecule is a tyrosine kinase inhibitor of several growth factors involved in cellular proliferation and angiogenesis, including the epidermal growth factor receptor (EGFR) and the vascular endothelial growth factor receptors 2 and 3 (VEGFR-2, VEGFR-3). In addition, vandetanib is an inhibitor of the RET (rearranged during transfection) gene, a proto-oncogene often mutated in familial MTC. Since MTC is a rare disease, for which no previous medical therapies are approved, vandetanib is the first drug shown to be effective in a large phase III trial treating patients with metastatic or locally advanced MTC. Common adverse events are diarrhea, nausea, hypertension, headache and QT prolongation that are manageable and are commonly outweighed by the benefits of vandetanib in terms of delaying disease progression and inducing tumor response.

Purification and labeling strategies for (68)Ga from (68)Ge/ (68)Ga generator eluate

For successful labeling, (68)Ge/(68)Ga generator eluate has to be concentrated (from 10 mL or more to less than 1 mL) and to be purified of metallic impurities, especially Fe(III), and (68)Ge breakthrough. Anionic, cationic and fractional elution methods are well known. We describe two new methods: (1) a combined cationic-anionic purification and (2) an easy-to-use and reliable cationic purification with NaCl solution. Using the first method, (68)Ga from 10 mL generator eluate was collected on a SCX cartridge, then eluted with 1.0 mL 5.5 M HCl directly on an anion exchanger (30 mg AG1X8). After drying with a stream of helium, (68)Ga was eluted with 0.4 mL water into the reaction vial. We provide as an example labeling of BPAMD. Using the second method, (68)Ga from 10 mL generator eluate was collected on a SCX cartridge, then eluted with a hydrochloric solution of sodium chloride (0.5 mL 5 M NaCl, 12.5 μL 5.5 M HCl) into the reaction vial, containing 40 μg DOTATOC and 0.5 mL 1 M ammonium acetate buffer pH 4.5. After heating for 7 min at 90°C, the reaction was finished. Radiochemical purity was higher than 95% without further purification. No (68)Ge breakthrough was found in the final product.

Molecular Imaging using PET/CT Applying 68Ga-Labeled Tracers and Targeted Radionuclide Therapy: Theranostics on the Way to Personalized Medicine

Theranostics is an acronym, which exemplifies the togetherness of diagnostics and therapeutics in the individualized management of disease. The key to personalized medicine in cancer is to determine the molecular phenotypes of neoplasms, so that specific probes can be selected to target the tumor and its microenvironment. Molecular imaging and radionuclide therapy using a particular probe is based on this premise. Neuroendocrine neoplasms express somatostatin receptors, enabling the use of somatostatin analogs for molecular imaging, when labeled with the positron-emitter 68Ga for receptor positron emission tomography/computed tomography (PET/CT), and targeted radionuclide therapy, when labeled with beta-emitters 90Y and 177Lu.

How to cite this article

Kulkarni HR, Baum RP. Molecular Imaging using PET/CT Applying 68Ga-Labeled Tracers and Targeted Radionuclide Therapy: Theranostics on the Way to Personalized Medicine. J Postgrad Med Edu Res 2013; 47(1):47-53.

Peptide receptor radionuclide therapy with (177)Lu labeled somatostatin analogs DOTATATE and DOTATOC: contrasting renal dosimetry in the same patient

AIM

The aim of this study is to correlate the uptake, residence time, and resulting mean absorbed dose in the kidneys with the posttherapy effect on renal function using the two most commonly used somatostatin analogs, (177)Lu-DOTATATE and (177)Lu-DOTATOC, during consecutive cycles of peptide receptor radionuclide therapy (PRRNT) in the same patient.

METHODS

22 patients with metastatic neuroendocrine tumors underwent PRRNT with (177)Lu-DOTATATE and (177)Lu-DOTATOC. Dosimetry (MIRD scheme) was performed using OLINDA software. The patients were followed up for 6-12 months with serum creatinine, BUN, tubular extraction rate (TER) using (99m)Tc-MAG3, and glomerular filtration rate (GFR) using (99m)Tc-DTPA before and after therapy. Age, hypertension, and diabetes mellitus were the associated risk factors for renal toxicity, which were taken into account.

RESULTS

Uptake, residence time, and mean absorbed dose to the kidney were slightly, but significantly, higher for DOTATATE (actual absorbed dose 1.9-9.2 Gy) as compared with DOTATOC (dose 2.3-7.8 Gy) in 19 out of the 22 (86%) patients (p < 0.05). The tumor-to-kidney ratio was higher for DOTATOC in 23 out of 43 (53%) of the lesions analyzed; however, this difference was not statistically significant. There were no statistically significant changes in serum creatinine, BUN, TER or GFR pre and post-therapy with either DOTATATE or DOTATOC. Five of the 22 patients had mildly elevated serum creatinine after PRRNT, of whom 3 had history of hypertension, 1 had diabetes, and 1 was more than 65 years of age.

CONCLUSIONS

(177)Lu-DOTATATE and (177)Lu-DOTATOC are safe radiopharmaceuticals concerning renal toxicity. (177)Lu-DOTATOC delivers a slightly, but significantly, lower renal dose.

High uptake of (68)Ga-DOTATOC in spleen as compared to splenosis: measurement by PET/CT

AIM

The aim of this study is to ascertain the high somatostatin receptor (SSTR) uptake in spleen and to compare the uptake in spleen and splenosis using SSTR PET/CT using( 68)Ga-DOTATOC.

MATERIALS AND METHODS

SUV(max) of spleen on (68)Ga-DOTATOC SSTR PET/CT (acquired for initial staging) in 10 patients with known neuroendocrine neoplasm of pancreatic tail was analyzed. All patients underwent left pancreatectomy and splenectomy. Diagnosis of splenosis was confirmed on CT, and SUV(max) was noted on follow-up SSTR PET/CT.

RESULTS

SUV(max)was 28.8 ± 12.5 in normal spleen and 10.5 ± 4.3 in splenosis.

CONCLUSION

The high uptake of( 68)Ga-DOTATOC (which has a high affinity to SSTR 2) in the spleen as compared to splenosis, which has a different histology, suggests white pulp as the probable site of high SSTR 2 expression.

The Bad Berka dose protocol: comparative results of dosimetry in peptide receptor radionuclide therapy using (177)Lu-DOTATATE, (177)Lu-DOTANOC, and (177)Lu-DOTATOC

PURPOSE

The objective of this study is to analyze the in vivo behavior of the (177)Lu-labeled peptides DOTATATE, DOTANOC, and DOTATOC used for peptide receptor radionuclide therapy (PRRNT) of neuroendocrine tumors (NETs), by measuring organ and tumor kinetics and by performing dosimetric calculations.

METHODS

Two hundred fifty-three patients (group 1) with metastasized NET who underwent PRRNT were examined. Out of these, 185 patients received (177)Lu-DOTATATE, 9 were treated with (177)Lu-DOTANOC, and 59 with (177)Lu-DOTATOC. Additionally, 25 patients receiving, in consecutive PRRNT cycles, DOTATATE followed by DOTATOC (group 2) and 3 patients receiving DOTATATE and DOTANOC (group 3) were analyzed. Dosimetric calculations (according to MIRD scheme) were performed using OLINDA software.

RESULTS

In group 1, DOTATOC exhibited the lowest and DOTANOC the highest uptake and therefore mean absorbed dose in normal organs (whole body, kidney, and spleen). In group 2, there was a significant difference between DOTATATE and DOTATOC concerning kinetics and normal organ doses. (177)Lu-DOTATOC had the lowest uptake/dose delivered to normal organs and highest tumor-to-kidney ratio. There were no significant differences between the three peptides concerning tumor kinetics and mean absorbed tumor dose.

CONCLUSIONS

The study demonstrates a correlation between high affinity of DOTANOC in vitro and high uptake in normal organs/whole body in vivo, resulting in a higher whole-body dose. DOTATOC exhibited the lowest uptake and dose delivered to normal tissues and the best tumor-to-kidney ratio. Due to large interpatient variability, individual dosimetry should be performed for each therapy cycle.

Can the Standardized Uptake Values derived from Diagnostic 68Ga-DOTATATE PET/CT Imaging Predict the Radiation Dose delivered to the Metastatic Liver NET Lesions on 177Lu-DOTATATE Peptide Receptor Radionuclide Therapy?

Introduction

Neuroendocrine neoplasms express somatostatin receptors, enabling the use of somatostatin analogs for molecular imaging, when labeled with the positron-emitter 68Ga for receptor positron emission tomography/computed tomography (PET/CT), and targeted radionuclide therapy, when labeled with beta-emitters, e.g. 90Y and 177Lu.

Aim

To investigate if 68Ga-DOTATATE PET-derived standardized uptake values (SUV) correlate with the dose delivered to the liver lesions following 177Lu-DOTATATE radionuclide therapy in patients with neuroendocrine neoplasms.

Materials and methods

Twelve adult (8M: 4F; mean age: 55.9 ± 14.5 years; range: 23-78 years) patients with documented neuroendocrine tumor (NET) disease and liver metastases were enrolled in the study. Ten patients were subjected to 68Ga-DOTATATE and one patient each underwent 68Ga-DOTATOC and 68Ga-DOTANOC diagnostic PET/CT imaging. Subsequently, on the basis of positive PET/CT scan findings for the metastatic NET disease, all these patients were subjected to peptide receptor radionuclide therapy (PRRNT) with 177Lu-DOTATATE. The reconstructed PET/CT data was used to calculate the SUVs on the identifiable liver lesions. The scintigraphic data acquired (anterior and posterior whole body images) following therapeutic doses of 177Lu-DOTATATE were subjected to the quantitative analysis (HERMES workstation and OLINDA/EXM software) to calculate the dose delivered to the hepatic lesions.

Results

The initial results of this preliminary study indicate poor correlation between SUV and the tumor dose and the linear regression analysis provided R2 values which explained only a small fraction of the total variance.

Conclusion

The SUVs derived from 68Ga-DOTA-peptide PET/CT images should be used with caution for the prediction of tumor dose on 177Lu-DOTA-peptide therapy as there are large intra- and interpatient variability. Further studies with large numbers of patients are warranted to establish such a correlation between SUV, tumor dose and the response assessment.

How to cite this article

Singh B, Prasad V, Schuchardt C, Kulkarni H, Baum RP. Can the Standardized Uptake Values derived from Diagnostic 68Ga-DOTATATE PET/CT Imaging Predict the Radiation Dose delivered to the Metastatic Liver NET Lesions on 177Lu-DOTATATE Peptide Receptor Radionuclide Therapy? J Postgrad Med Edu Res 2013;47(1):7-13.

Intraoperative somatostatin receptor detection after peptide receptor radionuclide therapy with (177)Lu- and (90)Y-DOTATOC (tandem PRRNT) in a patient with a metastatic neuroendocrine tumor

AIM

The aim of this chapter is to present the results of the first intraoperative somatostatin receptor detection after peptide receptor radionuclide therapy (PRRNT) with (90)Y- and (177)Lu-DOTATOC using a handheld gamma probe and comparison with the findings of preoperative (68)Ga-DOTATOC PET/CT in a patient with a metastatic neuroendocrine tumor (NET) of the ileum.

MATERIALS AND METHODS

A 56-year-old female patient, treated twice by PRRNT, was admitted for the third cycle and subsequent surgery. Before operation, the following studies were performed for restaging after the second cycle of PRRNT: (99m)Tc-MAG3 + TER, (99m)Tc-DTPA + GFR, abdominal ultrasonography, MRI of the abdomen, (68)Ga-DOTATOC PET/CT as well as (18)F-fluoride PET/CT. Serum tumor markers were measured before and after PRRNT. Tandem PRRNT was performed using 3000 MBq (90)Y-DOTATOC and 6000 MBq (177)Lu-DOTATOC. Whole-body scintigrams were obtained at 23 and 43 h. Five days after PRRNT, the patient was operated using a handheld gamma probe. Immunohistochemistry and histopathology of the resected tissue were performed.

RESULTS

Tandem PRRNT was very well tolerated by the patient. Before PRRNT, (68)Ga-DOTATOC PET/CT revealed the primary tumor in the ileocoecal region as well as bilobular liver metastases and a right iliac bone lesion (osteoblastic on (18)F-fluoride PET/CT). Compared with the previous findings, there was good therapy response (partial remission of the tumor lesions). No nephrotoxicity was observed. Serum chromogranin A (836 μg/l, n < 100) and serotonin (852 μg/l, n < 200) were strongly elevated. Posttherapy scans showed intense uptake in metastases and the primary tumor. Intraoperative gamma probe detected-in addition to the known lesions-bilateral ovarian metastases not visualized by (68)Ga-DOTATOC PET/CT. Bilateral adnexectomy, right hemicolectomy, excision of hepatic metastases in S3, and partial resection of peritoneum were performed. Histopathology confirmed metastases in both ovaries.

CONCLUSIONS

Gamma probe-guided surgery after (177)Lu PRRNT is feasible and appears to be more sensitive than (68)Ga-DOTATOC PET/CT. This technique might aid the surgeon in achieving more complete tumor resection through intraoperative detection of very small lesions (<5 mm) directly after PRRNT.

(68)Ga-DotaTATE PET-CT followed by Peptide Receptor Radiotherapy in combination with capecitabine in two patients with Merkel Cell Carcinoma

Herein, we report about two Caucasian patients with the histopathological diagnosis of Merkel cell carcinoma suffering from extensive lymph node metastases. The extent of the disease was diagnosed by Ga-68-DotaTATE-PET-CT. Both patients had rapid disease progression, one of them despite a three months course of sunitinibe followed by four chemotherapy cycles of cisplatin and etoposide. Both patients were sent for peptide receptor radiotherapy with 90Y-DotaTATE or 177Lu-DotaTATE in combination with capecitabine. Additional external beam radiotherapy of the cervical and inguinal lymph nodes was given to the patient with progressive disease despite chemotherapy. Temporary partial response in both patients was achieved. Despite extensive therapeutic efforts, fatal outcome could not be prevented 10 and 14 months after first clinical symptoms.

A new automated NaCl based robust method for routine production of gallium-68 labeled peptides

A new NaCl based method for preparation of gallium-68 labeled radiopharmaceuticals has been adapted for use with an automated gallium-68 generator system. The method was evaluated based on 56 preparations of [(68)Ga]DOTATOC and compared to a similar acetone-based approach. Advantages of the new NaCl approach include reduced preparation time (<15 min) and removal of organic solvents. The method produces high peptide-bound % (>97%), and specific activity (>40 MBq nmole(-1) [(68)Ga]DOTATOC) and is well-suited for clinical production of radiopharmaceuticals.

Simplified NaCl based (68)Ga concentration and labeling procedure for rapid synthesis of (68)Ga radiopharmaceuticals in high radiochemical purity

A simple sodium chloride (NaCl) based (68)Ga eluate concentration and labeling method that enables rapid, high-efficiency labeling of DOTA conjugated peptides in high radiochemical purity is described. The method utilizes relatively few reagents and comprises minimal procedural steps. It is particularly well-suited for routine automated synthesis of clinical radiopharmaceuticals. For the (68)Ga generator eluate concentration step, commercially available cation-exchange cartridges and (68)Ga generators were used. The (68)Ga generator eluate was collected by use of a strong cation exchange cartridge. 98% of the total activity of (68)Ga was then eluted from the cation exchange cartridge with 0.5 mL of 5 M NaCl solution containing a small amount of 5.5 M HCl. After buffering with ammonium acetate, the eluate was used directly for radiolabeling of DOTATOC and DOTATATE. The (68)Ga-labeled peptides were obtained in higher radiochemical purity compared to other commonly used procedures, with radiochemical yields greater than 80%. The presence of (68)Ge could not be detected in the final product. The new method obviates the need for organic solvents, which eliminates the required quality control of the final product by gas chromatography, thereby reducing postsynthesis analytical effort significantly. The (68)Ga-labeled products were used directly, with no subsequent purification steps, such as solid-phase extraction. The NaCl method was further evaluated using an automated fluid handling system and it routinely facilitates radiochemical yields in excess of 65% in less than 15 min, with radiochemical purity consistently greater than 99% for the preparation of (68)Ga-DOTATOC.

THERANOSTICS: From Molecular Imaging Using Ga-68 Labeled Tracers and PET/CT to Personalized Radionuclide Therapy - The Bad Berka Experience

The acronym THERANOSTICS epitomizes the inseparability of diagnosis and therapy, the pillars of medicine and takes into account personalized management of disease for a specific patient. Molecular phenotypes of neoplasms can be determined by molecular imaging with specific probes using positron emission tomography (PET), single photon emission computed tomography (SPECT), magnetic resonance imaging (MRI), or optical methods, so that the treatment is specifically targeted against the tumor and its environment. To meet these demands, we need to define the targets, ligands, coupling and labeling chemistry, the most appropriate radionuclides, biodistribution modifiers, and finally select the right patients for the personalized treatment. THERANOSTICS of neuroendocrine tumors (NETs) using Ga-68 labeled tracers for diagnostics with positron emission tomography/ computed tomography (PET/CT), and using Lu-177 or other metallic radionuclides for radionuclide therapy by applying the same peptide proves that personalized radionuclide therapy today is already a fact and not a fiction.

Ga-68 Somatostatin Receptor PET/CT in von Hippel-Lindau Disease

Von Hippel-Lindau (VHL) disease is a dominantly inherited familial cancer syndrome with a variety of benign and malignant tumors such as retinal and central nervous system hemangioblastomas, endolymphatic sac tumors, renal cysts and tumors, pancreatic cysts and tumors, pheochromocytomas, and epididymal cystadenomas. Cross-sectional modalities (computed tomography and magnetic resonance imaging) as well as ultrasound play a major role in the initial evaluation and follow-up of the various manifestations of VHL disease. Ga-68-labeled somatostatin receptor analogs already have a significant role in the diagnosis, staging, and therapy management of neuroendocrine neoplasms and neural crest tumors. Herein, we report a case presenting a variety of malignancies in VHL and showing the usefulness of Ga-68 somatostatin receptor PET/CT as a one-stop-shop imaging modality in the management of VHL disease.