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Turner JH. Theranostic Innovation by Humane N-of-One Cancer Care in Real-World Patients. Cancer Biother Radiopharm 2024; 39:323-329. [PMID: 38324047 DOI: 10.1089/cbr.2023.0198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
Patients with relapsed or refractory metastatic cancer unresponsive to standard therapies have motivated nuclear physicians to develop innovative radioligands, precisely targeted to tumor molecular receptors, for effective treatment of specific advanced malignancies. Individual practitioners in departments of nuclear medicine across the world have performed first-in-human studies on compassionate patient usage N-of-One protocols. These physician-sponsored studies then evolved into early-phase clinical trials and obtained real-world data to demonstrate real-world evidence of effectiveness in prolonging survival and enhancing quality of life of many so-called "End-Stage" cancer patients. Virtually all the therapeutic radiopharmaceuticals in current clinical oncology have been discovered and developed into effective specific treatments of targetable cancers by individual doctors in the course of their hospital practice. Pharma industry was not involved until many years later when performance of mandated Phase 3 randomized controlled trials became necessary to achieve regulatory agency approval. This article traces the history of several novel theranostic agents developed from compassionate N-of-One studies by hospital physicians over the past 36 years. It acknowledges the collegiality and collaboration of individual nuclear medicine specialists, worldwide, in pioneering effective humane therapy of particular advanced cancers unresponsive to conventional treatments.
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Affiliation(s)
- J Harvey Turner
- Department of Nuclear Medicine, The University of Western Australia, Fiona Stanley Fremantle Hospitals Group, Murdoch, Australia
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AghaAmiri S, Ghosh SC, Hernandez Vargas S, Halperin DM, Azhdarinia A. Somatostatin Receptor Subtype-2 Targeting System for Specific Delivery of Temozolomide. J Med Chem 2024; 67:2425-2437. [PMID: 38346097 PMCID: PMC10896214 DOI: 10.1021/acs.jmedchem.3c00223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 12/04/2023] [Accepted: 12/12/2023] [Indexed: 02/23/2024]
Abstract
Temozolomide (TMZ) is a DNA alkylating agent that produces objective responses in patients with neuroendocrine tumors (NETs) when the DNA repair enzyme O6-methylguanine-DNA methyltransferase (MGMT) is inactivated. At high doses, TMZ therapy exhausts MGMT activity but also produces dose-limiting toxicities. To reduce off-target effects, we converted the clinically approved radiotracer 68Ga-DOTA-TOC into a peptide-drug conjugate (PDC) for targeted delivery of TMZ to somatostatin receptor subtype-2 (SSTR2)-positive tumor cells. We used an integrated radiolabeling strategy for direct quantitative assessment of receptor binding, pharmacokinetics, and tissue biodistribution. In vitro studies revealed selective binding to SSTR2-positive cells with high affinity (5.98 ± 0.96 nmol/L), internalization, receptor-dependent DNA damage, cytotoxicity, and MGMT depletion. Imaging and biodistribution analysis showed preferential accumulation of the PDC in receptor-positive tumors and high renal clearance. This study identified a trackable SSTR2-targeting system for TMZ delivery and utilizes a modular design that could be broadly applied in PDC development.
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Affiliation(s)
- Solmaz AghaAmiri
- The
Brown Foundation Institute of Molecular Medicine, McGovern Medical
School, The University of Texas Health Science
Center at Houston, 1881 East Road, 3SCR6.4680, Houston, Texas 77054, United States
| | - Sukhen C. Ghosh
- The
Brown Foundation Institute of Molecular Medicine, McGovern Medical
School, The University of Texas Health Science
Center at Houston, 1881 East Road, 3SCR6.4680, Houston, Texas 77054, United States
| | - Servando Hernandez Vargas
- The
Brown Foundation Institute of Molecular Medicine, McGovern Medical
School, The University of Texas Health Science
Center at Houston, 1881 East Road, 3SCR6.4680, Houston, Texas 77054, United States
| | - Daniel M. Halperin
- Department
of Gastrointestinal Medical Oncology, The
University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Ali Azhdarinia
- The
Brown Foundation Institute of Molecular Medicine, McGovern Medical
School, The University of Texas Health Science
Center at Houston, 1881 East Road, 3SCR6.4680, Houston, Texas 77054, United States
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Turner JH. Cancer Care by Committee to be Superseded by Personal Physician-Patient Partnership Informed by Artificial Intelligence. Cancer Biother Radiopharm 2023; 38:497-505. [PMID: 37366774 DOI: 10.1089/cbr.2023.0058] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Multidisciplinary tumor boards (MTBs) have become the reference standard of cancer management, founded upon randomized controlled trial (RCT) evidence-based guidelines. The inordinate delays inherent in awaiting formal regulatory agency approvals of novel therapeutic agents, and the rigidities and nongeneralizability of this regimented approach, often deny cancer patients timely access to effective innovative treatment. Reluctance of MTBs to accept theranostic care of patients with advanced neuroendocrine tumors (NETs) and metastatic castrate-resistant prostate cancer resulted in decades of delay in the incorporation of 177Lu-octreotate and 177Lu-prostate-specific membrane antigen (PSMA) into routine clinical oncology practice. Recent developments in immunotherapy and molecular targeted precision therapy, based on N-of-One individual multifactorial genome analyses, have greatly increased the complexity of decision-making. Burgeoning specialist workload and tight time frames now threaten to overwhelm the logistically, and emotionally, demanding MTB system. It is hypothesized that the advent of advanced artificial intelligence technology and Chatbot natural language algorithms will shift the cancer care paradigm from a MTB management model toward a personal physician-patient shared-care partnership for real-world practice of precision individualized holistic oncology.
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Affiliation(s)
- J Harvey Turner
- Department of Nuclear Medicine, Fiona Stanley Fremantle Hospitals Group, The University of Western Australia, Murdoch, Australia
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Arrivi G, Verrico M, Roberto M, Barchiesi G, Faggiano A, Marchetti P, Mazzuca F, Tomao S. Capecitabine and Temozolomide (CAPTEM) in Advanced Neuroendocrine Neoplasms (NENs): A Systematic Review and Pooled Analysis. Cancer Manag Res 2022; 14:3507-3523. [PMID: 36575665 PMCID: PMC9790144 DOI: 10.2147/cmar.s372776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/09/2022] [Indexed: 12/24/2022] Open
Abstract
Background Retrospective studies and single center experiences suggest a role of capecitabine combined with temozolomide (CAPTEM) in neuroendocrine tumors (NENs). Methods We performed a systematic review to assess the efficacy and safety of CAPTEM in patients affected with NENs, with the aim to better clarify the role of this regimen in the therapeutic algorithm of NENs. Results A total of 42 articles and 1818 patients were included in our review. The overall disease control rate was 77% (range 43.5%-100%). The median progression free survival ranged from 4 to 38.5 months, while the median overall survival ranged from 8 to 103 months. Safety analysis showed an occurrence of G3-G4 toxicities in 16.4% of the entire population. The most common toxicities were hematological (27.2%), gastrointestinal (8.3%,) and cutaneous (3.2%). Conclusion This systematic review demonstrated that CAPTEM was an effective and relatively safe treatment for patients with advanced well-moderate differentiated NENs of gastroenteropancreatic, lung and unknown origin.
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Affiliation(s)
- Giulia Arrivi
- Department of Clinical and Molecular Medicine, Oncology Unit, Sant’ Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Monica Verrico
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, Medical Oncology Unit A, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Michela Roberto
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, Medical Oncology Unit A, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Giacomo Barchiesi
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, Medical Oncology Unit A, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Antongiulio Faggiano
- Department of Clinical and Molecular Medicine, Endocrinology Unit, Sant ‘Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Paolo Marchetti
- Department of Clinical and Molecular Medicine, Oncology Unit, Sant’ Andrea University Hospital, Sapienza University of Rome, Rome, Italy
- Istituto Dermopatico dell’Immacolata (IDI-IRCCS), Rome, Italy
| | - Federica Mazzuca
- Department of Clinical and Molecular Medicine, Oncology Unit, Sant’ Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Silverio Tomao
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, Medical Oncology Unit A, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
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Navalkissoor S, Gnanasegaran G, Grossman A. Optimisation of radioligand therapy in neuroendocrine tumours: Current and evolving evidence. J Neuroendocrinol 2022; 34:e13208. [PMID: 36346690 DOI: 10.1111/jne.13208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/23/2022] [Accepted: 10/02/2022] [Indexed: 11/27/2022]
Abstract
Treatment of neuroendocrine tumours (NETs) with radioligand therapy (RLT) for example, 177 Lu-DOTATATE is generally well-tolerated and prolongs time to progression in most patients. However, approximately 20% of patients are nonresponders. In addition, complete responses are rare (<5% of patients), and durable responses beyond 3-4 years are uncommon. This article will discuss factors which may improve the outcomes of PRRT by using biomarkers to identify patients at high risk to be nonresponders (imaging and liquid biomarkers) and will examine mechanisms to potentially improve/optimise current RLT treatment strategies. These include mechanisms to potentiate the effects of RLT, increase tumour absorbed dose, overcoming radio-resistance and upregulation of somatostatin receptors, although larger studies will be required to demonstrate which techniques are going to be most efficacious in clinical practice.
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Affiliation(s)
- Shaunak Navalkissoor
- Department of Nuclear Medicine, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | - Gopinath Gnanasegaran
- Department of Nuclear Medicine, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | - Ashley Grossman
- NET Unit, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
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McClellan K, Chen EY, Kardosh A, Lopez CD, Del Rivero J, Mallak N, Rocha FG, Koethe Y, Pommier R, Mittra E, Pegna GJ. Therapy Resistant Gastroenteropancreatic Neuroendocrine Tumors. Cancers (Basel) 2022; 14:4769. [PMID: 36230691 PMCID: PMC9563314 DOI: 10.3390/cancers14194769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/24/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are a heterogenous group of malignancies originating from neuroendocrine cells of the gastrointestinal tract, the incidence of which has been increasing for several decades. While there has been significant progress in the development of therapeutic options for patients with advanced or metastatic disease, these remain limited both in quantity and durability of benefit. This review examines the latest research elucidating the mechanisms of both up-front resistance and the eventual development of resistance to the primary systemic therapeutic options including somatostatin analogues, peptide receptor radionuclide therapy with lutetium Lu 177 dotatate, everolimus, sunitinib, and temozolomide-based chemotherapy. Further, potential strategies for overcoming these mechanisms of resistance are reviewed in addition to a comprehensive review of ongoing and planned clinical trials addressing this important challenge.
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Affiliation(s)
- Kristen McClellan
- School of Medicine, Oregon Health & Science University, Portland, OR 97239, USA
| | - Emerson Y. Chen
- Division of Hematology Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Adel Kardosh
- Division of Hematology Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Charles D. Lopez
- Division of Hematology Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Jaydira Del Rivero
- Developmental Therapeutics Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Nadine Mallak
- Division of Molecular Imaging and Therapy, Oregon Health & Science University, Portland, OR 97239, USA
| | - Flavio G. Rocha
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science University, Portland, OR 97239, USA
| | - Yilun Koethe
- Dotter Department of Interventional Radiology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Rodney Pommier
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science University, Portland, OR 97239, USA
| | - Erik Mittra
- Division of Molecular Imaging and Therapy, Oregon Health & Science University, Portland, OR 97239, USA
| | - Guillaume J. Pegna
- Division of Hematology Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
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Bartolomei M, Berruti A, Falconi M, Fazio N, Ferone D, Lastoria S, Pappagallo G, Seregni E, Versari A. Clinical Management of Neuroendocrine Neoplasms in Clinical Practice: A Formal Consensus Exercise. Cancers (Basel) 2022; 14:cancers14102501. [PMID: 35626105 PMCID: PMC9140035 DOI: 10.3390/cancers14102501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/16/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Well-structured international guidelines are currently available regarding the management of patients with neuroendocrine neoplasms (NENs). However, in relation to the multiplicity of treatments and the relative rarity and heterogeneity of NENs, there are many controversial issues in which clinical evidence is insufficient and for which expert opinion can be of help. A group of experts selected 14 relevant topics and formulated relative statements concerning controversial issues in several areas on diagnosis, prognosis, therapeutic strategies, and patient follow-up. Specific statements have also been formulated regarding patient management on radioligand therapy (RLT), as well as in the presence of co-morbidities or bone metastases. All the statements were drafted, discussed, modified, and then approved. The Nominal Group Technique (NGT) method was used to obtain consensus. The results of this paper can facilitate the clinical approach of patients with NENs in daily practice in areas where there is scarcity or absence of clinical evidence. Abstract Many treatment approaches are now available for neuroendocrine neoplasms (NENs). While several societies have issued guidelines for diagnosis and treatment of NENs, there are still areas of controversy for which there is limited guidance. Expert opinion can thus be of support where firm recommendations are lacking. A group of experts met to formulate 14 statements relative to diagnosis and treatment of NENs and presented herein. The nominal group and estimate-talk-estimate techniques were used. The statements covered a broad range of topics from tools for diagnosis to follow-up, evaluation of response, treatment efficacy, therapeutic sequence, and watchful waiting. Initial prognostic characterization should be based on clinical information as well as histopathological analysis and morphological and functional imaging. It is also crucial to optimize RLT for patients with a NEN starting from accurate characterization of the patient and disease. Follow-up should be patient/tumor tailored with a shared plan about timing and type of imaging procedures to use to avoid safety issues. It is also stressed that patient-reported outcomes should receive greater attention, and that a multidisciplinary approach should be mandatory. Due to the clinical heterogeneity and relative lack of definitive evidence for NENs, personalization of diagnostic–therapeutic work-up is crucial.
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Affiliation(s)
- Mirco Bartolomei
- Azienda Ospedaliero-Universitaria di Ferrara, Presidio Ospedaliero Arcispedale Sant’Anna di Cona, 44124 Ferrara, Italy;
| | - Alfredo Berruti
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Medical Oncology, University of Brescia, ASST Spedali Civili di Brescia, 25123 Brescia, Italy
- Correspondence:
| | - Massimo Falconi
- Pancreas Surgical Unit, ENETS Center of Excellence, San Raffaele Hospital IRCCS, Vita Salute University, 20132 Milan, Italy;
| | - Nicola Fazio
- Division of Gastrointestinal Medical Oncologya and Neuroendocrine Tumors, European Institute of Oncology, 20132 Milan, Italy;
| | - Diego Ferone
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, IRCCS, Ospedale Policlinico San Martino, Università di Genova, 16132 Genova, Italy;
| | - Secondo Lastoria
- Nuclear Medicine Unit, Istituto Nazionale Tumori, Fondazione G. Pascale, 80131 Naples, Italy;
| | - Giovanni Pappagallo
- School of Clinical Methodology IRCCS “Sacred Heart–Don Calabria” Hospital; 37024 Negrar di Valpolicella, Italy;
| | - Ettore Seregni
- Nuclear Medicine Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20132 Milano, Italy;
| | - Annibale Versari
- Nuclear Medicine Unit, Azienda Unità Sanitaria Locale-IRCCS of Reggio Emilia, 42100 Reggio Emilia, Italy;
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Syguła A, Ledwon A, Hasse-Lazar K, Jurecka-Lubieniecka B, Michalik B, Paliczka-Cieślik E, Zeman M, Chmielik E, Sczasny J, Jarzab B, Handkiewicz-Junak D. In patients with well-differentiated neuroendocrine tumours, there is no apparent benefit of somatostatin analogues after disease control by peptide receptor radionuclide therapy. Eur J Nucl Med Mol Imaging 2022; 49:3841-3851. [PMID: 35503379 DOI: 10.1007/s00259-022-05792-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/03/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE Peptide receptor radionuclide therapy (PRRT) and somatostatin analogues (SSAs) are commonly combined as primary treatment for neuroendocrine neoplasms (NEN), and SSAs given as maintenance. We sought to evaluate whether sequential therapy with PRRT followed by SSAs has progression or survival benefits in patients with NEN after disease control by PRRT. METHODS This prospective, randomised, single-centre study had as principal eligibility criteria: unresectable, locally advanced, or metastatic, histologically confirmed well-differentiated NEN; no symptoms/biochemical diagnosis of carcinoid syndrome; no SSAs or ≤ 3 months of SSAs before PRRT; and stable disease or partial or complete response after PRRT. Altogether, 115 patients were randomised 2:1 to an SSA group (n = 74) given octreotide acetate LAR every 4 weeks, or a control group (n = 41) receiving only best supportive care. Octreotide treatment was to stop upon intolerable toxicity or patient refusal, or, at physician/patient discretion, upon NEN progression. The primary endpoint was progression-free survival (PFS), the secondary endpoint, and overall survival (OS). RESULTS Median (25th-75th percentile) follow-up from the first PRRT activity to death or latest observation was 6.6 (3.18-10.22) years. During that time, 71/115 patients (62%) progressed, 52/74 (70%) in the SSA group, and 19/41 (46%) in the control group (p = 0.01). Eighty-eight/115 patients (76%) died, 58/74 (78%) in the SSA group, and 30/41 (73%) in the control group (p = 0.52). Median (95% CI) PFS was 4.7 (2.8-7.7) years in the SSA group, and 6.4 (4.1-not reached) years in controls. Overall, median OS was 6.6 years. Neither PFS nor OS differed between groups (p = 0.129, p = 0.985, respectively). CONCLUSIONS In patients with disease control after PRRT, subsequent SSA treatment appeared not to be associated with better PFS or OS. Whether to continue SSA administration upon progression after PRRT requires evaluation in a prospective, randomised, controlled multicentre study with a relatively homogeneous sample.
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Affiliation(s)
- Aleksandra Syguła
- Department of Nuclear Medicine and Endocrine Oncology, Gliwice Branch, Maria Sklodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 16, 44-101, Gliwice, Poland
| | - Aleksandra Ledwon
- Department of Nuclear Medicine and Endocrine Oncology, Gliwice Branch, Maria Sklodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 16, 44-101, Gliwice, Poland
| | - Kornelia Hasse-Lazar
- Department of Nuclear Medicine and Endocrine Oncology, Gliwice Branch, Maria Sklodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 16, 44-101, Gliwice, Poland
| | - Beata Jurecka-Lubieniecka
- Department of Nuclear Medicine and Endocrine Oncology, Gliwice Branch, Maria Sklodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 16, 44-101, Gliwice, Poland
| | - Barbara Michalik
- Department of Nuclear Medicine and Endocrine Oncology, Gliwice Branch, Maria Sklodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 16, 44-101, Gliwice, Poland
| | - Ewa Paliczka-Cieślik
- Department of Nuclear Medicine and Endocrine Oncology, Gliwice Branch, Maria Sklodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 16, 44-101, Gliwice, Poland
| | - Marcin Zeman
- The Oncologic and Reconstructive Surgery Clinic, Gliwice Branch, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Ewa Chmielik
- Tumor Pathology Department, Gliwice Branch, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Joanna Sczasny
- Radiology and Diagnostic Imaging Department, Gliwice Branch, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Barbara Jarzab
- Department of Nuclear Medicine and Endocrine Oncology, Gliwice Branch, Maria Sklodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 16, 44-101, Gliwice, Poland
| | - Daria Handkiewicz-Junak
- Department of Nuclear Medicine and Endocrine Oncology, Gliwice Branch, Maria Sklodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 16, 44-101, Gliwice, Poland.
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Kennedy KR, Turner JH, MacDonald WBG, Claringbold PG, Boardman G, Ransom DT. Long-term survival and toxicity in patients with neuroendocrine tumors treated with 177 Lu-octreotate peptide radionuclide therapy. Cancer 2022; 128:2182-2192. [PMID: 35363879 DOI: 10.1002/cncr.34191] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Peptide receptor radionuclide therapy (PRRT) has shown favorable results in neuroendocrine tumors (NETs). Long-term safety and efficacy data for 177 Lu-octreotate PRRT, particularly in combination with chemotherapy, is lacking. METHODS The authors conducted a retrospective review of the long-term toxicity and survival outcomes of 104 patients with advanced NETs treated on 4 phase 2 clinical trials with Lutetium-177-octreotate (177 Lu-octreotate) PRRT, mostly in combination with chemotherapy. Median follow-up was 68 months, which represents the longest follow-up study of 177 Lu-octreotate PRRT for NETs to date. RESULTS Median progression-free survival (PFS) was 37 months, and median overall survival (OS) was 71 months. Five- and 10-year OS were 62% and 29%, and 5- and 10-year PFS were 36% and 21%, respectively, demonstrating 177 Lu-octreotate can provide durable responses. PRRT was well tolerated with 1.9% of patients developing chronic renal impairment and 1% of patients developing long-term thrombocytopenia. Interestingly, there was a relatively high rate of myelodysplasia (MDS)/leukemia (6.7%), possibly attributable to the longer follow-up (with all except 1 case occurring more than 4 years after PRRT treatment) or to the addition of concurrent chemotherapy. CONCLUSIONS Lutetium-177-Octreotate PRRT remains an efficacious and well tolerated treatment in long-term follow-up. For clinicians deciding on the timing of PRRT for individual patients, the 6.7% long-term risk of MDS/leukemia needs to be balanced against the 21% PFS at 10 years.
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Affiliation(s)
- Kim R Kennedy
- Fiona Stanley Hospital, Cancer Centre, Murdoch, Western Australia, Australia
| | - John Harvey Turner
- Fiona Stanley Hospital, Cancer Centre, Murdoch, Western Australia, Australia
| | | | | | - Glenn Boardman
- Fiona Stanley Hospital, Cancer Centre, Murdoch, Western Australia, Australia
| | - David T Ransom
- Fiona Stanley Hospital, Cancer Centre, Murdoch, Western Australia, Australia
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10
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Merola E, Michielan A, Rozzanigo U, Erini M, Sferrazza S, Marcucci S, Sartori C, Trentin C, de Pretis G, Chierichetti F. Therapeutic strategies for gastroenteropancreatic neuroendocrine neoplasms: State-of-the-art and future perspectives. World J Gastrointest Surg 2022; 14:78-106. [PMID: 35317548 PMCID: PMC8908345 DOI: 10.4240/wjgs.v14.i2.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 10/18/2021] [Accepted: 01/25/2022] [Indexed: 02/06/2023] Open
Abstract
Although gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) have always been considered rare tumors, their incidence has risen over the past few decades. They represent a highly heterogeneous group of neoplasms with several prognostic factors, including disease stage, proliferative index (Ki67), and tumor differentiation. Most of these neoplasms express somatostatin receptors on the cell surface, a feature that has important implications in terms of prognosis, diagnosis, and therapy. Although International Guidelines propose algorithms aimed at guiding therapeutic strategies, GEP-NEN patients are still very different from one another, and the need for personalized treatment continues to increase. Radical surgery is always the best option when feasible; however, up to 80% of cases are metastatic upon diagnosis. Regarding medical treatments, as GEP-NENs are characterized by relatively long overall survival, multiple therapy lines are adopted during the lifetime of these patients, but the optimum sequence to be followed has never been clearly defined. Furthermore, although new molecular markers aimed at predicting the response to therapy, as well as prognostic scores, are currently being studied, their application is still far from being part of daily clinical practice. As they represent a complex disease, with therapeutic protocols that are not completely standardized, GEP-NENs require a multidisciplinary approach. This review will provide an overview of the available therapeutic options for GEP-NENs and attempts to clarify the possible approaches for the management of these patients and to discuss future perspectives in this field.
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Affiliation(s)
- Elettra Merola
- Department of Gastroenterology, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), Trento 38122, Italy
| | - Andrea Michielan
- Department of Gastroenterology, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), Trento 38122, Italy
| | - Umberto Rozzanigo
- Department of Radiology, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), Trento 38122, Italy
| | - Marco Erini
- Department of Nuclear Medicine, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), Trento 38122, Italy
| | - Sandro Sferrazza
- Department of Gastroenterology, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), Trento 38122, Italy
| | - Stefano Marcucci
- Department of Surgery, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), Trento 38122, Italy
| | - Chiara Sartori
- Department of Pathology, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), Trento 38122, Italy
| | - Chiara Trentin
- Department of Medical Oncology, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), Trento 38122, Italy
| | - Giovanni de Pretis
- Department of Gastroenterology, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), Trento 38122, Italy
| | - Franca Chierichetti
- Department of Nuclear Medicine, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), Trento 38122, Italy
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Ambrosini V, Zanoni L, Filice A, Lamberti G, Argalia G, Fortunati E, Campana D, Versari A, Fanti S. Radiolabeled Somatostatin Analogues for Diagnosis and Treatment of Neuroendocrine Tumors. Cancers (Basel) 2022; 14:1055. [PMID: 35205805 PMCID: PMC8870358 DOI: 10.3390/cancers14041055] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/10/2022] [Accepted: 02/17/2022] [Indexed: 02/04/2023] Open
Abstract
Neuroendocrine neoplasms (NENs) are rare and heterogeneous tumors that require multidisciplinary discussion for optimal care. The theranostic approach (DOTA peptides labelled with 68Ga for diagnosis and with 90Y or 177Lu for therapy) plays a crucial role in the management of NENs to assess disease extension and as a criteria for peptide receptor radionuclide therapy (PRRT) eligibility based on somatostatin receptor (SSTR) expression. On the diagnostic side, [68Ga]Ga-DOTA peptides PET/CT (SSTR PET/CT) is the gold standard for imaging well-differentiated SSTR-expressing neuroendocrine tumors (NETs). [18F]FDG PET/CT is useful in higher grade NENs (NET G2 with Ki-67 > 10% and NET G3; NEC) for more accurate disease characterization and prognostication. Promising emerging radiopharmaceuticals include somatostatin analogues labelled with 18F (to overcome the limits imposed by 68Ga), and SSTR antagonists (for both diagnosis and therapy). On the therapeutic side, the evidence gathered over the past two decades indicates that PRRT is to be considered as an effective and safe treatment option for SSTR-expressing NETs, and is currently included in the therapeutic algorithms of the main scientific societies. The positioning of PRRT in the treatment sequence, as well as treatment personalization (e.g., tailored dosimetry, re-treatment, selection criteria, and combination with other alternative treatment options), is warranted in order to improve its efficacy while reducing toxicity. Although very preliminary (being mostly hampered by lack of methodological standardization, especially regarding feature selection/extraction) and often including small patient cohorts, radiomic studies in NETs are also presented. To date, the implementation of radiomics in clinical practice is still unclear. The purpose of this review is to offer an overview of radiolabeled SSTR analogues for theranostic use in NENs.
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Affiliation(s)
- Valentina Ambrosini
- Department of Experimental Diagnostic and Specialized Medicine, University of Bologna, 40138 Bologna, Italy; (V.A.); (G.L.); (G.A.); (E.F.); (D.C.); (S.F.)
- Nuclear Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Lucia Zanoni
- Nuclear Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Angelina Filice
- Nuclear Medicine Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.F.); (A.V.)
| | - Giuseppe Lamberti
- Department of Experimental Diagnostic and Specialized Medicine, University of Bologna, 40138 Bologna, Italy; (V.A.); (G.L.); (G.A.); (E.F.); (D.C.); (S.F.)
- Division of Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Giulia Argalia
- Department of Experimental Diagnostic and Specialized Medicine, University of Bologna, 40138 Bologna, Italy; (V.A.); (G.L.); (G.A.); (E.F.); (D.C.); (S.F.)
| | - Emilia Fortunati
- Department of Experimental Diagnostic and Specialized Medicine, University of Bologna, 40138 Bologna, Italy; (V.A.); (G.L.); (G.A.); (E.F.); (D.C.); (S.F.)
| | - Davide Campana
- Department of Experimental Diagnostic and Specialized Medicine, University of Bologna, 40138 Bologna, Italy; (V.A.); (G.L.); (G.A.); (E.F.); (D.C.); (S.F.)
- Division of Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Annibale Versari
- Nuclear Medicine Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.F.); (A.V.)
| | - Stefano Fanti
- Department of Experimental Diagnostic and Specialized Medicine, University of Bologna, 40138 Bologna, Italy; (V.A.); (G.L.); (G.A.); (E.F.); (D.C.); (S.F.)
- Nuclear Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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12
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Nagel I, Herrmann K, Lahner H, Rischpler C, Weber F. Combined medical therapy, nuclear medicine therapy and other therapies in metastatic neuroendocrine tumor. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00156-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Peptide Receptor Radionuclide Therapy Targeting the Somatostatin Receptor: Basic Principles, Clinical Applications and Optimization Strategies. Cancers (Basel) 2021; 14:cancers14010129. [PMID: 35008293 PMCID: PMC8749814 DOI: 10.3390/cancers14010129] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/13/2021] [Accepted: 12/22/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Peptide receptor radionuclide therapy (PRRT) is a systemic treatment consisting of the administration of a tumor-targeting radiopharmaceutical into the circulation of a patient. The radiopharmaceutical will bind to a specific peptide receptor leading to tumor-specific binding and retention. This will subsequently cause lethal DNA damage to the tumor cell. The only target that is currently used in widespread clinical practice is the somatostatin receptor, which is overexpressed on a range of tumor cells, including neuroendocrine tumors and neural-crest derived tumors. Academia played an important role in the development of PRRT, which has led to heterogeneous literature over the last two decades, as no standard radiopharmaceutical or regimen has been available for a long time. This review focuses on the basic principles and clinical applications of PRRT, and discusses several PRRT-optimization strategies. Abstract Peptide receptor radionuclide therapy (PRRT) consists of the administration of a tumor-targeting radiopharmaceutical into the circulation of a patient. The radiopharmaceutical will bind to a specific peptide receptor leading to tumor-specific binding and retention. The only target that is currently used in clinical practice is the somatostatin receptor (SSTR), which is overexpressed on a range of tumor cells, including neuroendocrine tumors and neural-crest derived tumors. Academia played an important role in the development of PRRT, which has led to heterogeneous literature over the last two decades, as no standard radiopharmaceutical or regimen has been available for a long time. This review provides a summary of the treatment efficacy (e.g., response rates and symptom-relief), impact on patient outcome and toxicity profile of PRRT performed with different generations of SSTR-targeting radiopharmaceuticals, including the landmark randomized-controlled trial NETTER-1. In addition, multiple optimization strategies for PRRT are discussed, i.e., the dose–effect concept, dosimetry, combination therapies (i.e., tandem/duo PRRT, chemoPRRT, targeted molecular therapy, somatostatin analogues and radiosensitizers), new radiopharmaceuticals (i.e., SSTR-antagonists, Evans-blue containing vector molecules and alpha-emitters), administration route (intra-arterial versus intravenous) and response prediction via molecular testing or imaging. The evolution and continuous refinement of PRRT resulted in many lessons for the future development of radionuclide therapy aimed at other targets and tumor types.
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Kesavan M, Turner JH. Myeloid Toxicity of Radionuclide Cancer Therapy. Cancer Biother Radiopharm 2021; 37:164-172. [PMID: 34871036 DOI: 10.1089/cbr.2021.0286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Emergent genomic analytic techniques in patients with cancer offer the potential to define the risk of myelo dysplastic syndrome (MDS) and acute leukemia (AL) manifesting following targeted radionuclide therapy of metastatic lymphoma, neuroendocrine tumors (NETs), and prostate cancer. Characterization of the genetic profile will allow risk stratification of patients before theranostic radionuclide management of advanced cancers and offers the opportunity to minimize toxicity while preserving optimal individualized efficacy in the practice of personalized precision nuclear oncology. Our review of a single-center experience of prospective radionuclide theranostic management of metastatic non-Hodgkin lymphoma (NHL), NETs, and castration-resistant prostate cancer (metastatic castrate-resistant prostate cancer [mCRPC]) over the past decade, and comparison with published studies, shows that while the risk of significant myelotoxicity is generally low, at <3%, the consequences in the small minority of patients who develop MDS or AL are substantial, and survival is poor. Timely identification of patients at heightened risk of hematologic toxic complication, using novel genomic technology before institution of radionuclide therapy, will facilitate amelioration of myelotoxicity. In current clinical practice, the minimal hematological toxicity of chemo-free theranostic management of advanced cancer is significantly less compared with newly adopted chemotherapy -immunotherapy regimens, and the financial toxicity associated with these novel agents is avoided.
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Affiliation(s)
- Murali Kesavan
- Department of Hematology, School of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | - J Harvey Turner
- Department of Hematology, School of Health and Medical Sciences, The University of Western Australia, Perth, Australia
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15
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Marini I, Sansovini M, Bongiovanni A, Nicolini S, Grassi I, Ranallo N, Monti M, DI Iorio V, Germanò L, Caroli P, Sarnelli A, Paganelli G, Severi S. Theragnostic in neuroendocrine tumors. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2021; 65:342-352. [PMID: 34881852 DOI: 10.23736/s1824-4785.21.03426-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
In the last few decades, the incidence and prevalence of neuroendocrine tumors has been increasing. The theragnostic approach, that allows the diagnosis and treatment of different neoplasms with the same ligand, is a typical nuclear medicine tool. Applied for years, is also pivotal in neuroendocrine tumors (NETs) where it has improved the diagnostic accuracy and the therapeutic efficacy with impact on patient's survival. Theragnostic also allows the identification of important prognostic factors such as tumor location and burden, presence of liver metastases and intensity of somatostatin receptors (SSTR) expression to consider in new and possibly combined studies to ameliorate patient's outcome. Moreover, the possibility to evaluate receptor expression even in non-NET malignancies has de facto widened the possible indications for PRRT. We believe that this innovative therapeutic approach will be implemented in next years by radiomics and biological tumors characterization to better address PRRT applications.
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Affiliation(s)
- Irene Marini
- Unit of Nuclear Medicine, IRCCS Istituto Romagnolo per lo Studio dei Tumori - IRST Dino Amadori, Meldola, Forlì-Cesena, Italy
| | - Maddalena Sansovini
- Unit of Nuclear Medicine, IRCCS Istituto Romagnolo per lo Studio dei Tumori - IRST Dino Amadori, Meldola, Forlì-Cesena, Italy
| | - Alberto Bongiovanni
- Osteoncology and Rare Tumors Center - CDO-TR, IRCCS Istituto Romagnolo per lo Studio dei Tumori - IRST Dino Amadori, Meldola, Forlì-Cesena, Italy
| | - Silvia Nicolini
- Unit of Nuclear Medicine, IRCCS Istituto Romagnolo per lo Studio dei Tumori - IRST Dino Amadori, Meldola, Forlì-Cesena, Italy
| | - Ilaria Grassi
- Unit of Nuclear Medicine, IRCCS Istituto Romagnolo per lo Studio dei Tumori - IRST Dino Amadori, Meldola, Forlì-Cesena, Italy
| | - Nicoletta Ranallo
- Osteoncology and Rare Tumors Center - CDO-TR, IRCCS Istituto Romagnolo per lo Studio dei Tumori - IRST Dino Amadori, Meldola, Forlì-Cesena, Italy
| | - Manuela Monti
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori - IRST Dino Amadori, Meldola, Forlì-Cesena, Italy
| | - Valentina DI Iorio
- Unit of Oncological Pharmacy, IRCCS Istituto Romagnolo per lo Studio dei Tumori - IRST Dino Amadori, Meldola, Forlì-Cesena, Italy
| | - Luca Germanò
- Unit of Nuclear Medicine, IRCCS Istituto Romagnolo per lo Studio dei Tumori - IRST Dino Amadori, Meldola, Forlì-Cesena, Italy
| | - Paola Caroli
- Unit of Nuclear Medicine, IRCCS Istituto Romagnolo per lo Studio dei Tumori - IRST Dino Amadori, Meldola, Forlì-Cesena, Italy
| | - Anna Sarnelli
- Unit of Medical Physics, IRCCS Istituto Romagnolo per lo Studio dei Tumori - IRST Dino Amadori, Meldola, Forlì-Cesena, Italy
| | - Giovanni Paganelli
- Unit of Nuclear Medicine, IRCCS Istituto Romagnolo per lo Studio dei Tumori - IRST Dino Amadori, Meldola, Forlì-Cesena, Italy
| | - Stefano Severi
- Unit of Nuclear Medicine, IRCCS Istituto Romagnolo per lo Studio dei Tumori - IRST Dino Amadori, Meldola, Forlì-Cesena, Italy -
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Optimizing the Schedule of PARP Inhibitors in Combination with 177Lu-DOTATATE: A Dosimetry Rationale. Biomedicines 2021; 9:biomedicines9111570. [PMID: 34829796 PMCID: PMC8615768 DOI: 10.3390/biomedicines9111570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022] Open
Abstract
177Lu-DOTATATE for neuroendocrine tumours is considered a low-toxicity treatment and may therefore be combined with other pharmaceuticals to potentiate its efficacy. One approach is to add a poly-[ADP-ribose]-polymerase (PARP) inhibitor to decrease the ability of tumour cells to repair 177Lu-induced DNA damage. To decrease the risk of side effects, the sequencing should be optimized according to the tumour-to-normal tissue enhanced dose ratio (TNED). The aim of this study was to investigate how to enhance 177Lu-DOTATATE by optimal timing of the addition of a PARP inhibitor. Biokinetic modelling was performed based on the absorbed dose to the bone marrow, kidneys and tumour; determined from SPECT/CT and planar images from 17 patients treated with 177Lu-DOTATATE. To investigate the theoretical enhanced biological effect of a PARP inhibitor during 177Lu-DOTATATE treatment, the concept of relative biological effectiveness (RBE) was used, and PARP inhibitor administration was simulated over different time intervals. The absorbed dose rate for the tumour tissue demonstrated an initial increase phase until 12 h after infusion followed by a slow decrease. In contrast, the bone marrow showed a rapid initial dose rate decrease. Twenty-eight days after infusion of 177Lu-DOTATATE, the full absorbed dose to the bone marrow and kidney was reached. Using an RBE value of 2 for both the tumour and normal tissues, the TNED was increased compared to 177Lu-DOTATATE alone. According to the modelling, the PARP inhibitor should be introduced approximately 24 h after the start of 177Lu-DOTATATE treatment and be continued for up to four weeks to optimize the TNED. Based on these results, a phase I trial assessing the combination of olaparib and 177Lu-DOTATATE in somatostatin receptor-positive tumours was launched in 2020 (NCT04375267).
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Aerts A, Eberlein U, Holm S, Hustinx R, Konijnenberg M, Strigari L, van Leeuwen FWB, Glatting G, Lassmann M. EANM position paper on the role of radiobiology in nuclear medicine. Eur J Nucl Med Mol Imaging 2021; 48:3365-3377. [PMID: 33912987 PMCID: PMC8440244 DOI: 10.1007/s00259-021-05345-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 03/28/2021] [Indexed: 12/16/2022]
Abstract
With an increasing variety of radiopharmaceuticals for diagnostic or therapeutic nuclear medicine as valuable diagnostic or treatment option, radiobiology plays an important role in supporting optimizations. This comprises particularly safety and efficacy of radionuclide therapies, specifically tailored to each patient. As absorbed dose rates and absorbed dose distributions in space and time are very different between external irradiation and systemic radionuclide exposure, distinct radiation-induced biological responses are expected in nuclear medicine, which need to be explored. This calls for a dedicated nuclear medicine radiobiology. Radiobiology findings and absorbed dose measurements will enable an improved estimation and prediction of efficacy and adverse effects. Moreover, a better understanding on the fundamental biological mechanisms underlying tumor and normal tissue responses will help to identify predictive and prognostic biomarkers as well as biomarkers for treatment follow-up. In addition, radiobiology can form the basis for the development of radiosensitizing strategies and radioprotectant agents. Thus, EANM believes that, beyond in vitro and preclinical evaluations, radiobiology will bring important added value to clinical studies and to clinical teams. Therefore, EANM strongly supports active collaboration between radiochemists, radiopharmacists, radiobiologists, medical physicists, and physicians to foster research toward precision nuclear medicine.
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Affiliation(s)
- An Aerts
- Radiobiology Unit, Institute for Environment, Health and Safety, Belgian Nuclear Research Centre (SCK CEN), Mol, Belgium
| | - Uta Eberlein
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany.
| | - Sören Holm
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University Hospital Copenhagen, Copenhagen, Denmark
| | - Roland Hustinx
- Division of Nuclear Medicine and Oncological Imaging, University Hospital of Liège, GIGA-CRC in vivo Imaging, University of Liège, Liège, Belgium
| | - Mark Konijnenberg
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Lidia Strigari
- Medical Physics Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gerhard Glatting
- Medical Radiation Physics, Department of Nuclear Medicine, Ulm University, Ulm, Germany
| | - Michael Lassmann
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
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18
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Combination Therapies with PRRT. Pharmaceuticals (Basel) 2021; 14:ph14101005. [PMID: 34681229 PMCID: PMC8538931 DOI: 10.3390/ph14101005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/26/2021] [Accepted: 09/27/2021] [Indexed: 02/06/2023] Open
Abstract
Peptide receptor radionuclide therapy (PRRT) is a successful targeted radionuclide therapy in neuroendocrine tumors (NETs). However, complete responses remain elusive. Combined treatments anticipate synergistic effects and thus better responses by combining ionizing radiation with other anti-tumor treatments. Furthermore, multimodal therapies often have a balanced toxicity profile. To date, few studies have evaluated the effect of combination therapies with PRRT, some of them phase I/II trials. This review will focus on several clinically tested, tailored approaches to improving the effects of PRRT. The aim is to help clinicians in the treatment planning of NETs to choose the most effective and safe treatment for each patient in the sense of personalized medicine. Current promising combination partners of PRRT are somatostatin analogues (SSAs), chemotherapy, molecular targeted treatment, liver radioembolization, and dual radionuclide PRRT (Lutetium-177-PRRT combined with Yttrium-90-PRRT).
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Das S, Al-Toubah T, Strosberg J. Chemotherapy in Neuroendocrine Tumors. Cancers (Basel) 2021; 13:4872. [PMID: 34638356 PMCID: PMC8507720 DOI: 10.3390/cancers13194872] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 12/16/2022] Open
Abstract
The role for cytotoxic chemotherapy in patients with well-differentiated neuroendocrine tumors (NETs) remains debated. Compared to patients with poorly differentiated neuroendocrine carcinomas (NECs) where chemotherapy is utilized ubiquitously, chemotherapy may play a more select role in patients with certain types of NETs (e.g., pancreatic tumors, higher grade tumors, and tumors possessing DNA damage repair defects). The primary types of chemotherapy that have been tested in patients with NETs include alkylating agent- and platinum agent-based combinations. Across regimens, chemotherapy appears to elicit greater antitumor activity in patients with pancreatic or grade 3 NETs. The role for chemotherapy in lower grade extra-pancreatic NETs remains undefined. Furthermore, while chemotherapy has demonstrated clinically meaningful benefit for patients in the systemic setting, its role in the adjuvant or neoadjuvant setting is as-of-yet undetermined. Finally, efforts to combine chemotherapy with targeted therapy and peptide receptor radionuclide therapy are ongoing, in hopes of improving the cytoreductive treatment options for patients with NETs.
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Affiliation(s)
- Satya Das
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN 37209, USA;
| | - Taymeyah Al-Toubah
- Moffitt Cancer Center, Department of Gastrointestinal Oncology, Tampa, FL 33612, USA;
| | - Jonathan Strosberg
- Moffitt Cancer Center, Department of Gastrointestinal Oncology, Tampa, FL 33612, USA;
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Espinosa-Olarte P, La Salvia A, Riesco-Martinez MC, Anton-Pascual B, Garcia-Carbonero R. Chemotherapy in NEN: still has a role? Rev Endocr Metab Disord 2021; 22:595-614. [PMID: 33843007 PMCID: PMC8346445 DOI: 10.1007/s11154-021-09638-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 02/07/2023]
Abstract
Neuroendocrine neoplasms (NENs) comprise a broad spectrum of tumors with widely variable biological and clinical behavior. Primary tumor site, extent of disease, tumor differentiation and expression of so matostatin receptors, proliferation and growth rates are the major prognostic factors that determine the therapeutic strategy. Treatment options for advanced disease have considerably expanded in recent years, particularly for well differentiated tumors (NETs). Novel drugs approved over the past decade in this context include somatostatin analogues and 177Lu-oxodotreotide for somatostatin-receptor-positive gastroenteropancreatic (GEP) NETs, sunitinib for pancreatic NETs (P-NETs), and everolimus for P-NETs and non-functioning lung or gastrointestinal NETs. Nevertheless, chemotherapy remains an essential component of the treatment armamentarium of patients with NENs, particularly of patients with P-NETs or those with bulky, symptomatic or rapidly progressive tumors (generally G3 or high-G2 NENs). In this manuscript we will comprehensively review available evidence related to the use of chemotherapy in lung and GEP NENs and will critically discuss its role in the treatment algorithm of this family of neoplasms.
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Affiliation(s)
- Paula Espinosa-Olarte
- Oncology Department, Hospital Universitario, 12 de Octubre, Imas12, UCM, Madrid, Spain
| | - Anna La Salvia
- Oncology Department, Hospital Universitario, 12 de Octubre, Imas12, UCM, Madrid, Spain
| | | | - Beatriz Anton-Pascual
- Oncology Department, Hospital Universitario, 12 de Octubre, Imas12, UCM, Madrid, Spain
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Suman SK, Subramanian S, Mukherjee A. Combination radionuclide therapy: A new paradigm. Nucl Med Biol 2021; 98-99:40-58. [PMID: 34029984 DOI: 10.1016/j.nucmedbio.2021.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 04/23/2021] [Accepted: 05/06/2021] [Indexed: 12/15/2022]
Abstract
Targeted molecular radionuclide therapy (MRT) has shown its potential for the treatment of cancers of multiple origins. A combination therapy strategy employing two or more distinct therapeutic approaches in cancer management is aimed at circumventing tumor resistance by simultaneously targeting compensatory signaling pathways or bypassing survival selection mutations acquired in response to individual monotherapies. Combination radionuclide therapy (CRT) is a newer application of the concept, utilizing a combination of radiolabeled molecular targeting agents with chemotherapy and beam radiation therapy for enhanced therapeutic index. Encouraging results are reported with chemotherapeutic agents in combination with radiolabeled targeting molecules for cancer therapy. With increasing awareness of the various survival and stress response pathways activated after radionuclide therapy, different holistic combinations of MRT agents with radiosensitizers targeting such pathways have also been explored. MRT has also been studied in combination with beam radiotherapy modalities such as external beam radiation therapy and carbon ion radiation therapy to enhance the anti-tumor response. Nanotechnology aids in CRT by bringing together multiple monotherapies on a single nanostructure platform for treating cancers in a more precise or personalized way. CRT will be a key player in managing cancers if correctly tailored to the individual patient profile. The success of CRT lies in an in-depth understanding of the radiobiological principles and pathways activated in response.
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Affiliation(s)
- Shishu Kant Suman
- Radiopharmaceuticals Division, Bhabha Atomic Research Centre; Homi Bhabha National Institute, Mumbai 400094, India
| | - Suresh Subramanian
- Radiopharmaceuticals Division, Bhabha Atomic Research Centre; Homi Bhabha National Institute, Mumbai 400094, India
| | - Archana Mukherjee
- Radiopharmaceuticals Division, Bhabha Atomic Research Centre; Homi Bhabha National Institute, Mumbai 400094, India.
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22
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Peptide receptor radionuclide therapy for GEP-NET: consolidated knowledge and innovative applications. Clin Transl Imaging 2021. [DOI: 10.1007/s40336-021-00443-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Neuroendocrine Tumor Theranostics: An Update and Emerging Applications in Clinical Practice. AJR Am J Roentgenol 2021; 217:495-506. [PMID: 34076455 DOI: 10.2214/ajr.20.23349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE. Theranostics have shown great promise for delivering precision medicine, particularly in neuroendocrine tumors (NETs). The clinical applications of radiolabeled somatostatin analogues in imaging and radionuclide therapy have been rapidly increasing over the past 2 decades and are currently integrated into the management guidelines of NETs. This article summarizes the available literature on different somatostatin receptor-targeting radiopharmaceuticals with theranostic potential in NETs, pheochromocytomas, and paragangliomas. We discuss the clinical application, administration, and toxicity of recent FDA-approved radionuclide therapies, including 177Lu-DOTATATE in advanced gastroenteropancreatic NETs and 131I-MIBG in advanced paragangliomas and pheochromocytomas. CONCLUSION. Several studies support the safety and clinical efficacy of peptide receptor radionuclide therapies in disease control and quality-of-life improvement in patients with NETs and report potential benefits of combined radionuclide treatment approaches. The utility and pitfalls of functional imaging in therapy response assessment and surveillance of NETs remain to be established.
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Damiana TST, Dalm SU. Combination Therapy, a Promising Approach to Enhance the Efficacy of Radionuclide and Targeted Radionuclide Therapy of Prostate and Breast Cancer. Pharmaceutics 2021; 13:pharmaceutics13050674. [PMID: 34067215 PMCID: PMC8151894 DOI: 10.3390/pharmaceutics13050674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/30/2021] [Accepted: 05/05/2021] [Indexed: 12/21/2022] Open
Abstract
In recent years, radionuclide therapy (RT) and targeted radionuclide therapy (TRT) have gained great interest in cancer treatment. This is due to promising results obtained in both preclinical and clinical studies. However, a complete response is achieved in only a small percentage of patients that receive RT or TRT. As a consequence, there have been several strategies to improve RT and TRT outcomes including the combination of these treatments with other well-established anti-cancer therapies, for example, chemotherapy. Combinations of RT and TRT with other therapies with distinct mechanisms of action represent a promising strategy. As for prostate cancer and breast cancer, the two most prevalent cancer types worldwide, several combination-based therapies have been evaluated. In this review, we will provide an overview of the RT and TRT agents currently used or being investigated in combination with hormone therapy, chemotherapy, immunotherapy, and external beam radiation therapy for the treatment of prostate cancer and breast cancer.
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Marini F, Giusti F, Tonelli F, Brandi ML. Pancreatic Neuroendocrine Neoplasms in Multiple Endocrine Neoplasia Type 1. Int J Mol Sci 2021; 22:4041. [PMID: 33919851 PMCID: PMC8070788 DOI: 10.3390/ijms22084041] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 12/12/2022] Open
Abstract
Pancreatic neuroendocrine tumors (pNETs) are a rare group of cancers accounting for about 1-2% of all pancreatic neoplasms. About 10% of pNETs arise within endocrine tumor syndromes, such as Multiple Endocrine Neoplasia type 1 (MEN1). pNETs affect 30-80% of MEN1 patients, manifesting prevalently as multiple microadenomas. pNETs in patients with MEN1 are particularly difficult to treat due to differences in their growth potential, their multiplicity, the frequent requirement of extensive surgery, the high rate of post-operative recurrences, and the concomitant development of other tumors. MEN1 syndrome is caused by germinal heterozygote inactivating mutation of the MEN1 gene, encoding the menin tumor suppressor protein. MEN1-related pNETs develop following the complete loss of function of wild-type menin. Menin is a key regulator of endocrine cell plasticity and its loss in these cells is sufficient for tumor initiation. Somatic biallelic loss of wild-type menin in the neuroendocrine pancreas presumably alters the epigenetic control of gene expression, mediated by histone modifications and DNA hypermethylation, as a driver of MEN1-associated pNET tumorigenesis. In this light, epigenetic-based therapies aimed to correct the altered DNA methylation, and/or histone modifications might be a possible therapeutic strategy for MEN1 pNETs, for whom standard treatments fail.
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Affiliation(s)
- Francesca Marini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy; (F.M.); (F.G.)
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Via Reginaldo Giuliani 195/A, 50141 Florence, Italy;
| | - Francesca Giusti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy; (F.M.); (F.G.)
| | - Francesco Tonelli
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Via Reginaldo Giuliani 195/A, 50141 Florence, Italy;
| | - Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Via Reginaldo Giuliani 195/A, 50141 Florence, Italy;
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Clinical Utility of 18F-FDG PET in Neuroendocrine Tumors Prior to Peptide Receptor Radionuclide Therapy: A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13081813. [PMID: 33920195 PMCID: PMC8069875 DOI: 10.3390/cancers13081813] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/05/2021] [Accepted: 04/08/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Functional imaging with 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) has evolved into a major clinical tool in cancer diagnosis and management for many malignancies in diverse clinical settings, providing valuable information on tumor behavior and aggressiveness. In the field of neuroendocrine tumors (NETs), recent advances in molecular imaging and targeted treatments with novel theranostic agents favor a more patient-tailored approach. Although peptide receptor radionuclide therapy (PRRT) has recently become an established therapy for progressive NETs, the role of 18F-FDG PET prior to PRRT in patients with NETs of different origins and grades remains to be determined. Herein, we provide a comprehensive summary of available evidence in contemporary literature by means of a systematic review and meta-analysis, demonstrating that dual-functional imaging with 68Ga-DOTA-peptides and 18F-FDG prior to PRRT appears to be a useful tool in NET management by delineating tumor somatostatin receptor expression and glycolytic metabolic activity, and predicting tumor response and survival outcomes. Abstract The role of 18F-FDG PET in patients with variable grades of neuroendocrine tumors (NETs) prior to peptide receptor radionuclide therapy (PRRT) has not been adequately elucidated. We aimed to evaluate the impact of 18F-FDG PET status on disease control rate (DCR), progression-free survival (PFS), and overall survival (OS) in neuroendocrine tumor (NET) patients receiving PRRT. We searched the MEDLINE, Embase, Cochrane Library, and Web of Science databases up to July 2020 and used the Newcastle-Ottawa scale (NOS) criteria to assess quality/risk of bias. A total of 5091 articles were screened. In 12 studies, 1492 unique patients with NETs of different origins were included. The DCR for patients with negative 18F-FDG PET status prior to PRRT initiation was 91.9%, compared to 74.2% in patients with positive 18F-FDG PET status (random effects odds ratio (OR): 4.85; 95% CI: 2.27–10.36). Adjusted analysis of pooled hazard ratios (HRs) confirmed longer PFS and OS in NET patients receiving PRRT with negative 18F-FDG PET (random effects HR:2.45; 95%CIs: 1.48–4.04 and HR:2.25; 95% CIs:1.55–3.28, respectively). In conclusion, 18F-FDG PET imaging prior to PRRT administration appears to be a useful tool in NET patients to predict tumor response and survival outcomes and a negative FDG uptake of the tumor is associated with prolonged PFS and OS.
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Ortiz R, Perazzoli G, Cabeza L, Jiménez-Luna C, Luque R, Prados J, Melguizo C. Temozolomide: An Updated Overview of Resistance Mechanisms, Nanotechnology Advances and Clinical Applications. Curr Neuropharmacol 2021; 19:513-537. [PMID: 32589560 PMCID: PMC8206461 DOI: 10.2174/1570159x18666200626204005] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/17/2020] [Accepted: 06/21/2020] [Indexed: 12/22/2022] Open
Abstract
Temozolomide (TMZ), an oral alkylating prodrug which delivers a methyl group to purine bases of DNA (O6-guanine; N7-guanine and N3-adenine), is frequently used together with radiotherapy as part of the first-line treatment of high-grade gliomas. The main advantages are its high oral bioavailability (almost 100% although the concentration found in the cerebrospinal fluid was approximately 20% of the plasma concentration of TMZ), its lipophilic properties, and small size that confer the ability to cross the blood-brain barrier. Furthermore, this agent has demonstrated activity not only in brain tumors but also in a variety of solid tumors. However, conventional therapy using surgery, radiation, and TMZ in glioblastoma results in a median patient survival of 14.6 months. Treatment failure has been associated with tumor drug resistance. This phenomenon has been linked to the expression of O6-methylguanine-DNA methyltransferase, but the mismatch repair system and the presence of cancer stem-like cells in tumors have also been related to TMZ resistance. The understanding of these mechanisms is essential for the development of new therapeutic strategies in the clinical use of TMZ, including the use of nanomaterial delivery systems and the association with other chemotherapy agents. The aim of this review is to summarize the resistance mechanisms of TMZ and the current advances to improve its clinical use.
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Affiliation(s)
- Raúl Ortiz
- Institute of Biopathology and Regenerative Medicine (IBIMER), Biomedical Research Centre (CIBM), University of Granada, Spain
| | | | - Laura Cabeza
- Institute of Biopathology and Regenerative Medicine (IBIMER), Biomedical Research Centre (CIBM), University of Granada, Spain
| | - Cristina Jiménez-Luna
- Department of Oncology, Ludwig Institute for Cancer Research, University of Lausanne, Epalinges 1066, Switzerland
| | - Raquel Luque
- Medical Oncology Service, Virgen de las Nieves Hospital, Granada, Spain
| | - Jose Prados
- Institute of Biopathology and Regenerative Medicine (IBIMER), Biomedical Research Centre (CIBM), University of Granada, Spain
| | - Consolación Melguizo
- Institute of Biopathology and Regenerative Medicine (IBIMER), Biomedical Research Centre (CIBM), University of Granada, Spain
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Targeted Cancer Therapy: What's New in the Field of Neuroendocrine Neoplasms? Cancers (Basel) 2021; 13:cancers13071701. [PMID: 33916707 PMCID: PMC8038369 DOI: 10.3390/cancers13071701] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 12/18/2022] Open
Abstract
Neuroendocrine tumors (NETs) are a heterogeneous family of neoplasms of increasing incidence and high prevalence due to their relatively indolent nature. Their wide anatomic distribution and their characteristic ability to secrete hormonally active substances pose unique challenges for clinical management. They are also characterized by the common expression of somatostatin receptors, a target that has been extremely useful for diagnosis and treatment (i.e., somatostatin analogues (SSAs) and peptide-receptor radionuclide therapy (PRRT)). Chemotherapy is of limited use for NETs of non-pancreatic origin, and the only approved targeted agents for advanced progressive NETs are sunitinib for those of pancreatic origin, and everolimus for lung, gastrointestinal and pancreatic primaries. Despite recent therapeutic achievements, thus, systemic treatment options remain limited. In this review we will discuss the state-of-the-art targeted therapies in the field of NETs, and also future perspectives of novel therapeutic drugs or strategies in clinical development, including recently presented results from randomized trials of yet unapproved antiangiogenic agents (i.e., pazopanib, surufatinib and axitinib), PRRT including both approved radiopharmaceuticals (177Lu-Oxodotreotide) and others in development (177Lu-Edotreotide, 177Lu-Satoreotide Tetraxetan), immunotherapy and other innovative targeted strategies (antibody-drug conjugates, bites,…) that shall soon improve the landscape of personalized treatment options in NET patients.
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Haider M, Das S, Al-Toubah T, Pelle E, El-Haddad G, Strosberg J. Somatostatin receptor radionuclide therapy in neuroendocrine tumors. Endocr Relat Cancer 2021; 28:R81-R93. [PMID: 33608483 PMCID: PMC8118168 DOI: 10.1530/erc-20-0360] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/10/2021] [Indexed: 12/28/2022]
Abstract
Peptide receptor radionuclide therapy (PRRT) using 177Lu-DOTATATE has been approved for the treatment of gastroenteropancreatic NETs. An understanding of benefits and risks is important for the appropriate implementation of this therapy. This review summarizes study data supporting the use of radiolabeled somatostatin analogs for the treatment of advanced NETs and highlights risks, including potential toxicities in specific populations. Key ongoing clinical trials, including randomized studies, are designed to better define the position of PRRT within the broader therapeutic landscape. Preclinical and early-phase human studies are focused on the development of novel somatostatin-receptor agonists and antagonists, new radionuclides, and radiosensitizing combination therapies.
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Affiliation(s)
- Mintallah Haider
- Moffitt Cancer Center, Department of GI Oncology, Tampa, Florida, USA
| | - Satya Das
- Department of GI Oncology, Vanderbilt University, Nashville, Tennessee, USA
| | | | - Eleonora Pelle
- Department of Oncology, University of Bari, Bari, Puglia, Italy
| | - Ghassan El-Haddad
- Moffitt Cancer Center, Department of Diagnostic Imaging and Interventional Radiology, Tampa, Florida, USA
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Combined use of 177Lu-DOTATATE and metronomic capecitabine (Lu-X) in FDG-positive gastro-entero-pancreatic neuroendocrine tumors. Eur J Nucl Med Mol Imaging 2021; 48:3260-3267. [PMID: 33604690 DOI: 10.1007/s00259-021-05236-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/01/2021] [Indexed: 01/27/2023]
Abstract
PURPOSE FDG-positive neuroendocrine tumors (NETs) have a poorer prognosis and exhibit shorter response duration to peptide receptor radionuclide therapy (PRRT). The aim of this prospective phase II study was to evaluate the efficacy and toxicity of PRRT with 177Lu-DOTATATE associated with metronomic capecitabine as a radiosensitizer agent in patients with advanced progressive FDG-positive gastro-entero-pancreatic (GEP) NETs. PATIENTS AND METHODS Patients with advanced somatostatin receptor- and FDG-positive G1-G3 GEP-NETs (Ki67 < 55%) were treated with a cumulative activity of 27.5 GBq of 177Lu-DOTATATE divided in five cycles of 5.5 GBq each every 8 weeks. Capecitabine (1000-1500 mg daily) was administered orally in the inter-cycle period between 177Lu-DOTATATE treatments. Prior to commencing capecitabine, all patients were triaged with the dihydropyrimidine dehydrogenase (DPD) test. Only DPD-proficient individuals were enrolled. The primary objectives were disease control rate (DCR) and safety. Secondary aims included progression-free (PFS) and overall survival (OS). Treatment response was assessed per Response Evaluation Criteria in Solid Tumors, version 1.1 (RECIST 1.1). Toxicity was assessed by Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. RESULTS From August 2015 to December 2016, 37 subjects were consecutively enrolled. A total of 25 (68%) were affected by pancreatic neuroendocrine tumors (P-NETs), and 12 (32%) had gastrointestinal neuroendocrine tumors (GI-NETs). By grading (WHO 2010 classification), 12 patients (32%) had G1 (Ki67 ≤ 2%), 22 (59%) had G2 (3% < Ki67 ≤ 20%), and 3 patients (9%) had G3 (Ki67 > 20%) NETs. Grade 3 (G3) or 4 (G4) hematological toxicity occurred in 16.2% of patients. Other G3-G4 adverse events were diarrhea in 5.4% of cases and asthenia in 5.4%. No renal toxicity was observed for the duration of follow-up. In 37 patients, 33 were evaluable for response. Objective responses included partial response (PR) in 10 patients (30%) and stable disease (SD) in 18 patients (55%), with a DCR of 85%. The median follow-up was 38 months (range 4.6-51.1 months). The median PFS was 31.4 months (17.6-45.4), and mOS was not reached. CONCLUSIONS This study demonstrated that the combination of PRRT with 177Lu-DOTATATE and metronomic capecitabine is active and well tolerated in patients with aggressive FDG-positive G1-G3 GEP-NETs. These data constitute the basis for a randomized study of PPRT alone vs. PRRT plus metronomic capecitabine.
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Chemotherapy-Induced Upregulation of Somatostatin Receptor-2 Increases the Uptake and Efficacy of 177Lu-DOTA-Octreotate in Neuroendocrine Tumor Cells. Cancers (Basel) 2021; 13:cancers13020232. [PMID: 33435224 PMCID: PMC7828052 DOI: 10.3390/cancers13020232] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 12/14/2022] Open
Abstract
Simple Summary The peptide receptor radionuclide therapy (PRRT) with 177Lu-DOTA-octreotate (LuTate) is recommended for neuroendocrine tumors (NETs) which overexpress somatostatin receptors (SSTR). A combination of LuTate with chemotherapy improves its objective response in NET patients, and here we characterized chemotherapy-induced upregulation of SSTR2 receptors as a cause for this improved response to LuTate. Using multiple NET and non-NET cell lines, we examined the SSTR2 expression for up to 7 days after exposure to drugs and its effect on LuTate uptake and cell proliferation. We report that the exposure to varying doses of chemotherapeutic drugs such as temozolomide for 24 h or 5 days results in upregulation of SSTR2 receptors between 3–7 days. This effect is more pronounced in low SSTR2 expressing BON-1 cells than in high SSTR2 expressing NCI-H727 or non-NET cancer or non-cancer cells. Thus, a properly-timed pre-treatment with low doses of chemotherapy could improve therapeutic efficacy of LuTate in NET patients. Abstract The peptide receptor radionuclide therapy (PRRT) with 177Lu-DOTA-octreotate (LuTate) is recommended for different types of neuroendocrine tumors (NETs) which overexpress somatostatin receptors (SSTR). A combination with chemotherapy improves objective response to LuTate in NET patients and here we characterized chemotherapy-induced upregulation of SSTR2 receptors as a cause for this improved response to LuTate. The NET cell lines with low (BON-1) or relatively high (NCI-H727) SSTR2-expression levels, and non-NET cancer and normal cells were treated with chemotherapeutic drugs and assessed for upregulation of SSTR2. We report that an exposure to low or high doses of drugs, such as temozolomide for 24 h or 5 day results in upregulation of SSTR2 between 3–7 days, increased LuTate uptake and decreased rate of cell proliferation. This effect is at the level of SSTR2-mRNA and is more pronounced in low SSTR2 expressing BON-1 than in high SSTR2 expressing NCI-H727 or non-NET cancer or normal cells. Thus, a properly timed pre-treatment with low-dose chemotherapy could not only improve therapeutic efficacy of LuTate in NET patients who are presently eligible for PRRT, but also allow PRRT to be administered to patients with low SSTR-expressing NETs, who would otherwise not respond to this modality because of insufficient radiation delivery.
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Raymond LM, Korzun T, Kardosh A, Kolbeck KJ, Pommier R, Mittra ES. The State of Peptide Receptor Radionuclide Therapy and Its Sequencing among Current Therapeutic Options for Gastroenteropancreatic Neuroendocrine Tumors. Neuroendocrinology 2021; 111:1086-1098. [PMID: 33744879 DOI: 10.1159/000516015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 03/17/2021] [Indexed: 11/19/2022]
Abstract
Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are the most common form of neuroendocrine neoplasia, but there is no current consensus for the sequencing of approved therapies, particularly with respect to peptide receptor radionuclide therapy (PRRT). This comprehensive review evaluates the data supporting approved therapies for GEP-NETs and recommendations for therapeutic sequencing with a focus on how PRRT currently fits within sequencing algorithms. The current recommendations for PRRT sequencing restrict its use to metastatic, inoperable, progressive midgut NETs; however, this may change with emerging data to suggest that PRRT might be beneficial as neoadjuvant therapy for inoperable tumors, is more tolerable than other treatment modalities following first-line standard dose somatostatin analogs, and can be used as salvage therapy after disease relapse following prior successful cycles of PRRT. PRRT has also been shown to reduce tumor burden, improve quality of life, and prolong the time to disease progression in a broad spectrum of patients with GEP-NETs. As the various potential benefits of PRRT in GEP-NET therapy continues to expand, it is necessary to review and critically evaluate our treatment algorithms for GEP-NETs.
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Affiliation(s)
- Lauren M Raymond
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA,
| | - Tetiana Korzun
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Adel Kardosh
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Division of Hematology/Medical Oncology, Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Kenneth J Kolbeck
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Department of Interventional Radiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Rodney Pommier
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Erik S Mittra
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Division of Nuclear Medicine & Molecular Imaging, Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Oregon, USA
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Ostwal V, Basu S, Bhargava P, Shah M, Parghane RV, Srinivas S, Chaudhari V, Bhandare MS, Shrikhande SV, Ramaswamy A. Capecitabine-Temozolomide in Advanced Grade 2 and Grade 3 Neuroendocrine Neoplasms: Benefits of Chemotherapy in Neuroendocrine Neoplasms with Significant 18FDG Uptake. Neuroendocrinology 2021; 111:998-1004. [PMID: 33017827 DOI: 10.1159/000511987] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/29/2020] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Capecitabine-temozolomide (CAPTEM) chemotherapy, alone or with concurrent peptide receptor radionuclide therapy (PRRT), has activity in advanced WHO grade 2 and grade 3 neuroendocrine neoplasms (NENs). The objective of this study was to evaluate the activity of the CAPTEM in patients with grade 2 and grade 3 NENs and identify prognostic factors. MATERIALS AND METHODS A retrospective analysis of patients with metastatic grade 2 and grade 3 NENs, who were having baseline significant dual uptake on 68Ga-DOTATATE/18F-fluorodeoxyglucose (FDG)-PET-CT scan and treated with CAPTEM chemotherapy between January 2014 and December 2019 at Tata Memorial Hospital, was conducted. The clinical variables and survival data were collected. Progression-free survival (PFS) was estimated using the Kaplan-Meier method. RESULTS A total of 68 patients received the CAPTEM regimen, of whom 29 patients (43%) received CAPTEM alone and 39 patients (57%) received concurrent PRRT. The primary sites were pancreas in 32 (47%) and small intestine in 12 (18%) patients. Mean Ki-67 index was 12.6% (range: 3-50). Forty-five patients (65%) were treatment naïve. There were no significant differences in baseline clinical variables between patients treated with CAPTEM alone or with CAPTEM-PRRT. Both regimens were well tolerated. With a median follow-up of 22.1 months, the median PFS for the entire cohort was 27.5 months. There was no statistical difference in the median PFS between patients receiving CAPTEM alone or CAPTEM-PRRT (33.7 vs. 22 months; p = 0.199). A Ki-67 index of >5% predicted for inferior PFS on multivariate analysis (24 versus 73.8 months; p = 0.04; hazard ratio -3.77; 95% confidence interval: 1.07-13.26). CONCLUSION CAPTEM, alone or concurrent with PRRT, has a significant activity in grade 2 and grade 3 NENs with dual SSTR and 18FDG expression. A Ki-67 index >5% predicts strongly for inferior outcomes and should be further explored as a prognostic cutoff in grade 2 NENs. Early initiation of CAPTEM should be considered in this group of tumors with significant baseline 18FDG expression.
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Affiliation(s)
- Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Sandip Basu
- Radiation Medicine Centre, Babha Atomic Research Centre, Tata Memorial Hospital Annexe, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Prabhat Bhargava
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Minit Shah
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Rahul Vithalrao Parghane
- Radiation Medicine Centre, Babha Atomic Research Centre, Tata Memorial Hospital Annexe, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Sujay Srinivas
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Vikram Chaudhari
- GI and HPB Surgery, Tata Memorial Hospital (Homi Bhabha National Institute), Mumbai, India
| | - Manish S Bhandare
- GI and HPB Surgery, Tata Memorial Hospital (Homi Bhabha National Institute), Mumbai, India
| | - Shailesh V Shrikhande
- GI and HPB Surgery, Tata Memorial Hospital (Homi Bhabha National Institute), Mumbai, India
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India,
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Abstract
Neuroendocrine tumors (NETs) are a heterogeneous group of tumors that originate in endocrine tissues throughout the body. Peptide receptor radionuclide therapy (PRRT) has emerged as a promising therapeutic option for patients with locally advanced and/or metastatic disease refractory to standard of care treatment. The landmark international phase III NETTER-1 trial led to the approval of 177Lu-DOTATATE (Lutathera) in the treatment of somatostatin receptor-positive gastroenteropancreatic NETs. Similarly, data from the multicenter, phase II Study IB12B led to the approval of meta-[131I]Iodo-Benzyl-Guanidine (I31I-MIBG) for treatment of iobenguane scan-positive, unresectable, locally advanced or metastatic pheochromocytoma or paraganglioma. With the clinical approval of these novel radiopharmaceuticals for managing select patients with NETs, additional studies are needed to refine patient selection, predict and assess therapy response, and optimize radiopharmaceutical delivery and clinical outcomes.
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Affiliation(s)
- Re-I Chin
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Francis S Wu
- Department of Radiology, St. Louis University, St. Louis, MO
| | - Yusuf Menda
- Department of Radiology, University of Iowa, Iowa City, IA
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO.
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Özdirik B, Amthauer H, Schatka I, Goretzki PE, Mogl MT, Fehrenbach U, Tacke F, Jann H, Roderburg C. A rare case of a patient with a high grade neuroendocrine tumor developing neutropenic sepsis after receiving PRRT combined with Capecitabine or Temozolomide: A case report. Mol Clin Oncol 2020; 14:20. [PMID: 33363730 PMCID: PMC7725216 DOI: 10.3892/mco.2020.2182] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 08/28/2020] [Indexed: 12/16/2022] Open
Abstract
Neuroendocrine tumors (NET) are rare and demonstrate variable clinical behavior depending on the degree of tumor differentiation. Patients with poorly differentiated tumors (NET G3) have a poor prognosis. Systemic treatment with cytotoxic chemotherapy is considered to be the treatment of choice. In patients that are refractory or intolerant to first-line therapy, experts recommend peptide receptor radionuclide therapy (PRRT) in tumors that express somatostatin receptors. Recently, combinations of PRRT and chemotherapy were tested in patients with NET. Available data have reported promising tumor control rates and an excellent toxicity profile in cases where PRRT had been administered with capecitabine/temozolomide, even when administered as salvage therapy. The current study reported an exceptional case of advanced NET G3 with severe toxicity upon receiving PRRT in combination with capecitabine/temozolomide as third line therapy. The patient developed a life-threatening neutropenic fever, fungal pneumonia and necrotizing mastitis 23 days after the first cycle of therapy was administered. However, the treatment led to a significant reduction in tumor size. A total of 5 months after treatment initiation, the patient was alive and in excellent clinical condition with sustained tumor response. In summary, the current study presented a rare case of high grade NET exhibiting an almost complete response to PRRT in combination capecitabine/temozolomide, despite facing unexpected severe toxicity.
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Affiliation(s)
- Burcin Özdirik
- Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Holger Amthauer
- Department of Nuclear Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Imke Schatka
- Department of Nuclear Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Peter E Goretzki
- Department of Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Martina T Mogl
- Department of Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Uli Fehrenbach
- Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Henning Jann
- Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Christoph Roderburg
- Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
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Yordanova A, Biersack HJ, Ahmadzadehfar H. Advances in Molecular Imaging and Radionuclide Therapy of Neuroendocrine Tumors. J Clin Med 2020; 9:E3679. [PMID: 33207788 PMCID: PMC7697910 DOI: 10.3390/jcm9113679] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 02/07/2023] Open
Abstract
Neuroendocrine neoplasms make up a heterogeneous group of tumors with inter-patient and intra-patient variabilities. Molecular imaging can help to identify and characterize neuroendocrine tumors (NETs). Furthermore, imaging and treatment with novel theranostics agents offers a new, tailored approach to managing NETs. Recent advances in the management of NETs aim to enhance the effectiveness of targeted treatment with either modifications of known substances or the development of new substances with better targeting features. There have been several attempts to increase the detectability of NET lesions via positron emission tomography (PET) imaging and improvements in pretreatment planning using dosimetry. Especially notable is PET imaging with the radionuclide Copper-64. Increasing interest is also being paid to theranostics of grade 3 and purely differentiated NETs, for example, via targeting of the C-X-C motif chemokine receptor 4 (CXCR4). The aim of this review is to summarize the most relevant recent studies, which present promising new agents in molecular imaging and therapy for NETs, novel combination therapies and new applications of existing molecular imaging modalities in nuclear medicine.
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Affiliation(s)
- Anna Yordanova
- Department of Radiology, St. Marien Hospital Bonn, 53115 Bonn, Germany;
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Chan TG, O'Neill E, Habjan C, Cornelissen B. Combination Strategies to Improve Targeted Radionuclide Therapy. J Nucl Med 2020; 61:1544-1552. [PMID: 33037092 PMCID: PMC8679619 DOI: 10.2967/jnumed.120.248062] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 09/09/2020] [Indexed: 01/20/2023] Open
Abstract
In recent years, targeted radionuclide therapy (TRT) has emerged as a promising strategy for cancer treatment. In contrast to conventional radiotherapy, TRT delivers ionizing radiation to tumors in a targeted manner, reducing the dose that healthy tissues are exposed to. Existing TRT strategies include the use of 177Lu-DOTATATE, 131I-metaiodobenzylguanidine, Bexxar, and Zevalin, clinically approved agents for the treatment of neuroendocrine tumors, neuroblastoma, and non-Hodgkin lymphoma, respectively. Although promising results have been obtained with these agents, clinical evidence acquired to date suggests that only a small percentage of patients achieves complete response. Consequently, there have been attempts to improve TRT outcomes through combinations with other therapeutic agents; such strategies include administering concurrent TRT and chemotherapy, and the use of TRT with known or putative radiosensitizers such as poly(adenosine diphosphate ribose) polymerase and mammalian-target-of-rapamycin inhibitors. In addition to potentially achieving greater therapeutic effects than the respective monotherapies, these strategies may lead to lower dosages or numbers of cycles required and, in turn, reduce unwanted toxicities. As of now, several clinical trials have been conducted to assess the benefits of TRT-based combination therapies, sometimes despite limited preclinical evidence being available in the public domain to support their use. Although some clinical trials have yielded promising results, others have shown no clear survival benefit from particular combination treatments. Here, we present a comprehensive review of combination strategies with TRT reported in the literature to date and evaluate their therapeutic potential.
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Affiliation(s)
- Tiffany G Chan
- Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Edward O'Neill
- Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Christine Habjan
- Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Bart Cornelissen
- Department of Oncology, University of Oxford, Oxford, United Kingdom
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Peptide Receptor Radionuclide Therapy as First-Line Systemic Treatment in Advanced Inoperable/Metastatic Neuroendocrine Tumors. Clin Nucl Med 2020; 45:e393-e399. [PMID: 32604121 DOI: 10.1097/rlu.0000000000003170] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE Advanced inoperable/metastatic neuroendocrine tumors (NETs) pose a therapeutic challenge with limited treatment options. Peptide receptor radionuclide therapy (PRRT), being specific in targeting the somatostatin receptors, is a promising and viable option in this setting. In this study, we intended to evaluate the role of PRRT as the first-line systemic therapy in advanced inoperable/metastatic NETs. METHODS Data of consecutive patients of advanced inoperable/metastatic NETs treated with first-line Lu-DOTATATE at our center, from September 2012 to August 2019, were collected and analyzed. RESULTS Forty-five patients (median age, 50 years; range, 14-72 years) with treatment-naive advanced NETs received a median cumulative dose of 27 GBq (range, 13.3-41.3 GBq; over 2-7 cycles) Lu-DOTATATE and 1250 mg/m capecitabine from days 0 to 14 of each PRRT cycle. Three patients were lost to follow-up, 2 had nonmeasurable lesions on CT, and hence, radiological response using Response Evaluation Criteria in Solid Tumors version 1.1 could be assessed in 40 patients. Twelve of 40 patients (30%) showed a partial response, whereas stable disease was observed in 22 of 40 patients (55%). Disease progression was limited to 6 of 40 patients (15%). Treatment-related adverse effects were minimal with grade 3/4 anemia, leukopenia, neutropenia, and hepatotoxicity observed in 2%, 2%, 4%, and 4% of the patients, respectively. Median progression-free survival was 48 months (95% confidence interval, 34.7-61.3 months). CONCLUSIONS Our results indicate the efficacy and safety of first-line PRRT in advanced NETs. Future randomized trials, comparing PRRT and somatostatin analogs in treatment-naive patients, are required to identify the definite sequence of treatment options for these patients.
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Chiapponi C, Lürssen N, Cremer B, Wahba R, Drebber U, Faust M, Schmidt M, Stippel DL. Peptide receptor radionuclide therapy as a two-step strategy for initially unresectable liver disease from neuroendocrine tumors: a single-center experience. Endocrine 2020; 70:187-193. [PMID: 32419082 DOI: 10.1007/s12020-020-02341-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/04/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE In this study, we describe our experience with peptide receptor radionuclide therapy (PRRT) for initially unresectable liver disease as a two-steps therapeutic strategy, first in neoadjuvant intention before surgery and then later on in case of disease relapse. METHODS We performed a retrospective evaluation of four cases of unresectable liver metastases of NET of different origins treated with neoadjuvant Lu-177-DotaTATE for conversion into resectability first and as rechallenging treatment after disease relapse. RESULTS After treatment with Lu-177-DotaTAE, resectability was reached in three of four cases. In one case, SIRT was additionally performed preoperatively. Relapse occurred in three of four cases after 32, 34, and 37 months, respectively, and was managed with Re-PRRT-treatment. CONCLUSION Although more data are needed, our retrospective study suggests that treatment with Lu-177-DotaTATE is an important adjunct to surgery not only in neoadjuvant intention but also for treating disease relapse. A register study might deliver more evidence for supporting this strategy.
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Affiliation(s)
- Costanza Chiapponi
- Department for General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Nadine Lürssen
- Department for General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Birgit Cremer
- Department for Hemato-Oncology, University Hospital of Cologne, Univeristy of Cologne, Cologne, Germany
| | - Roger Wahba
- Department for General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Uta Drebber
- Department for Pathology, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Michael Faust
- Polyclinic for Endocrinology, Diabetes and Preventive Medicine, University Hospital of Cologne, Univeristy of Cologne, Cologne, Germany
| | - Matthias Schmidt
- Department of Nuclear Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Dirk L Stippel
- Department for General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
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40
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Parghane RV, Ostwal V, Ramaswamy A, Bhandare M, Chaudhari V, Talole S, Shrikhande SV, Basu S. Long-term outcome of "Sandwich" chemo-PRRT: a novel treatment strategy for metastatic neuroendocrine tumors with both FDG- and SSTR-avid aggressive disease. Eur J Nucl Med Mol Imaging 2020; 48:913-923. [PMID: 32876706 DOI: 10.1007/s00259-020-05004-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/17/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The primary aims of this study were to evaluate the long-term outcome of a "sandwich chemo-PRRT (SCPRRT)" regimen with regard to therapeutic response rate, progression-free survival (PFS), and overall survival (OS) rates in metastatic neuroendocrine tumors (NETs) with both somatostatin receptor (SSTR)- and fluorodeoxyglucose (FDG)-avid aggressive disease. Additionally, health-related quality of life (HRQoL) scales, clinical toxicity, and association of PFS and disease control rate (DCR) with various variables were also evaluated. MATERIALS AND METHODS A total of 38 patients of the aforementioned cohort, who received SCPRRT (at least 2 cycles of each PRRT and chemotherapy) at our institute between January 2012 and December 2018, were included and analyzed in this retrospective study. Between two cycles of 177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT), two cycles of oral capecitabine and temozolomide (CAPTEM) were sandwiched. Therapeutic responses following SCPRRT were assessed by using pre-defined criteria. PFS and OS after first SCPRRT were determined. Eastern Cooperative Oncology Group (ECOG) and Karnofsky score were used for evaluation of HRQoL before and after SCPPRT in all 38 patients. Any adverse events were graded according to the Common Terminology Criteria for Adverse Events version 5.0 (CTCAE v5.0) of the National Cancer Institute. Associations of PFS and DCR with various variables were evaluated. RESULTS Response (complete response and partial response) to SCPRRT was seen in 28 patients (73%), 15 patients (39%), and 16 patients (42%) on symptomatic, biochemical, and molecular imaging response evaluation criteria respectively. A total of 17 patients (45%) had anatomical imaging response with DCR of 84% based upon the RECIST 1.1 criteria. Pre-therapy mean ECOG and KPS was 2.0 and 68, which changed to 1.0 and 75 respectively following SCPRRT. Long-term follow-up data was available and ranged from 12 to 65 months after the first SCPRRT. Median PFS and OS were not reached at a median follow-up of 36 months. An estimated PFS rate of 72.5% and OS rate of 80.4% was found at 36 months. Longer PFS was dependent upon high SSTR uptake and number of CAPTEM cycle (≥ 7 cycles), absence of skeletal metastasis, and no previous external beam radiotherapy (EBRT) exposure with significant P value. Higher DCR was dependent upon absence of skeletal metastasis with significant P value. SCPRRT was tolerated well with none developing grade 4 hematotoxicity and nephrotoxicity of any grade. Anemia (grade 3), thrombocytopenia (grade 3), and leukopenia (grade 3) were noticed in 1 patient (2.5%), 2 patients (5%), and 1 patient (2.5%) respectively in this study. CONCLUSION Thus, favorable response rates with effective control of symptoms and longer PFS and OS without high-grade or life-threatening toxicities were important observations in the present study following SCPRRT in NET patients with aggressive, both FDG- and SSTR-avid, metastatic progressive disease. The study results indicate the potential role of "sandwich chemo-PRRT" in future therapeutic algorithms of aggressive, both SSTR- and FDG-positive subset of neuroendocrine tumors.
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Affiliation(s)
- Rahul V Parghane
- Radiation Medicine Centre (BARC), Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Jerbai Wadia Road, Parel, Mumbai, 400012, India.,Homi Bhabha National Institute, Mumbai, India
| | - Vikas Ostwal
- Homi Bhabha National Institute, Mumbai, India.,Department of Medical Gastroenterology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Anant Ramaswamy
- Homi Bhabha National Institute, Mumbai, India.,Department of Medical Gastroenterology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Manish Bhandare
- Homi Bhabha National Institute, Mumbai, India.,Department of Surgical Oncology, Gastrointestinal and Hepato-Pancreato-Biliary Service, Tata Memorial Hospital, Mumbai, India
| | - Vikram Chaudhari
- Homi Bhabha National Institute, Mumbai, India.,Department of Surgical Oncology, Gastrointestinal and Hepato-Pancreato-Biliary Service, Tata Memorial Hospital, Mumbai, India
| | - Sanjay Talole
- Homi Bhabha National Institute, Mumbai, India.,Department of Biostatistics, ACTREC, Tata Memorial Centre, Mumbai, India
| | - Shailesh V Shrikhande
- Homi Bhabha National Institute, Mumbai, India.,Department of Surgical Oncology, Gastrointestinal and Hepato-Pancreato-Biliary Service, Tata Memorial Hospital, Mumbai, India
| | - Sandip Basu
- Radiation Medicine Centre (BARC), Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Jerbai Wadia Road, Parel, Mumbai, 400012, India. .,Homi Bhabha National Institute, Mumbai, India.
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Somatostatinoma and Neurofibromatosis Type 1-A Case Report and Review of the Literature. Diagnostics (Basel) 2020; 10:diagnostics10090620. [PMID: 32825782 PMCID: PMC7555390 DOI: 10.3390/diagnostics10090620] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/11/2020] [Accepted: 08/17/2020] [Indexed: 02/06/2023] Open
Abstract
Somatostatinomas are rare neuroendocrine tumors (NET) that arise in the gastrointestinal (GI) tract. Because of their insidious growth, they are usually asymptomatic until late stages, presenting as malignant disease. We report the case of a 50-year-old woman who presented with epigastric abdominal pain, diarrhea and significant weight loss in the last two years. On clinical examination the patient met the criteria for neurofibromatosis type 1 (NF1). Abdominal CT and MRI revealed an infiltrative duodenal mass, with pancreatic invasion, locoregional enlarged lymph nodes and disseminated hepatic nodules. Microscopy and immunohistochemistry uncovered a neuroendocrine tumor, staining positive for chromogranin A (CgA), synaptophysin and somatostatin, with a Ki67 = 1%. Somatostatin receptors (SSTRs) type 2 were negative and SSTRs type 5 were positive in less than 50% of tumoral cells. Our patient was classified as a T3N1M1 stage IV metastatic duodenal grade 1 somatostatinoma and treatment with somatostatin analogues and chemotherapy with capecitabine and temozolomide was started, with so far abdominal imaging follow-up showing stable disease. When a patient is diagnosed with a rare NET, such as a somatostatinoma, it is of utmost importance to determine if it is a sporadic tumor or just a feature of a genetic disorder.
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Cullinane C, Waldeck K, Kirby L, Rogers BE, Eu P, Tothill RW, Hicks RJ. Enhancing the anti-tumour activity of 177Lu-DOTA-octreotate radionuclide therapy in somatostatin receptor-2 expressing tumour models by targeting PARP. Sci Rep 2020; 10:10196. [PMID: 32576907 PMCID: PMC7311440 DOI: 10.1038/s41598-020-67199-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 06/02/2020] [Indexed: 01/25/2023] Open
Abstract
Peptide receptor radionuclide therapy (PRRT) is an important treatment option for patients with somatostatin receptor-2 (SSTR2)-expressing neuroendocrine tumour (NET) though tumour regression occurs in only a minority of patients. Therefore, novel PRRT regimens with improved therapeutic activity are needed. Radiation induced DNA damage repair is an attractive therapeutic target to increase PRRT efficacy and consequently, we have characterised a panel of preclinical models for their SSTR2 expression, in vivo growth properties and response to 177Lu-DOTA-octreotate (LuTate) PRRT to identify models with features suitable for evaluating novel therapeutic combinations. In vitro studies using the SSTR2 expressing AR42J model demonstrate that the combination of LuTate and the small molecule Poly(ADP-ribose) polymerase-1 (PARP) inhibitor, talazoparib led to increased DNA double strand breaks, as assessed by γ-H2AX foci formation, as compared to LuTate alone. Furthermore, using the AR42J tumour model in vivo we demonstrate that the combination of LuTate and talazoparib significantly improved the anti-tumour efficacy of LuTate alone. These findings support the clinical evaluation of the combination of LuTate and PARP inhibition in SSTR2-expressing NET.
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Affiliation(s)
- Carleen Cullinane
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.
| | - Kelly Waldeck
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Laura Kirby
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Buck E Rogers
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO, 63110, USA
| | - Peter Eu
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Richard W Tothill
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Clinical Pathology and Centre for Cancer Research, University of Melbourne, Parkville, Victoria, Australia
| | - Rodney J Hicks
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
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Abstract
OBJECTIVES The combination chemotherapy regimen capecitabine/temozolomide (CAPTEM) is efficacious for metastatic well-differentiated pancreatic neuroendocrine tumors (PNETs), but its role in the neoadjuvant setting has not been established. METHODS The outcomes of all patients with locally advanced or resectable metastatic PNETs who were treated with neoadjuvant CAPTEM between 2009 and 2017 at 2 high-volume institutions were retrospectively reviewed. RESULTS Thirty patients with locally advanced PNET (n = 10) or pancreatic neuroendocrine hepatic metastases (n = 20) received neoadjuvant CAPTEM. Thirteen patients (43%) exhibited partial radiographic response (PR), 16 (54%) had stable disease, and 1 (3%) developed progressive disease. Twenty-six (87%) patients underwent resection (pancreatectomy [n = 12], combined pancreatectomy and liver resection [n = 8], or major hepatectomy alone [n = 6]); 3 (18%) declined surgery despite radiographic PR, and 1 (3%) underwent aborted pancreatoduodenectomy. Median primary tumor size was 5.5 cm, and median Ki-67 index was 3.5%. Rates of PR were similar across tumor grades (P = 0.24). At median follow-up of 49 months, median progression-free survival was 28.2 months and 5-year overall survival was 63%. CONCLUSIONS Neoadjuvant CAPTEM is associated with favorable radiographic objective response rates for locally advanced or metastatic PNET and may facilitate selection of patients appropriate for surgical resection.
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Karfis I, Marin G, Levillain H, Drisis S, Muteganya R, Critchi G, Taraji-Schiltz L, Guix CA, Shaza L, Elbachiri M, Mans L, Machiels G, Hendlisz A, Flamen P. Prognostic value of a three-scale grading system based on combining molecular imaging with 68Ga-DOTATATE and 18F-FDG PET/CT in patients with metastatic gastroenteropancreatic neuroendocrine neoplasias. Oncotarget 2020; 11:589-599. [PMID: 32110279 PMCID: PMC7021233 DOI: 10.18632/oncotarget.27460] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 01/13/2020] [Indexed: 02/07/2023] Open
Abstract
We investigated on the added prognostic value of a three-scale combined molecular imaging with 68Ga-DOTATATE and 18F-FDG PET/CT, (compared to Ki-67 based histological grading), in gastroenteropancreatic neuroendocrine neoplasia patients. 85 patients with histologically proven metastatic gastroenteropancreatic neuroendocrine neoplasias, who underwent combined PET/CT imaging were retrospectively evaluated. Highest Ki-67 value available at time of 18F-FDG PET/CT was recorded. Patients were classified according to World Health Organization/European Neuroendocrine Tumor Society histological grades (G1, G2, G3) and into three distinct imaging categories (C1: all lesions are 18F-FDG negative/68Ga-DOTATATE positive, C2: patients with one or more 18F-FDG positive lesions, all of them 68Ga-DOTATATE positive, C3: patients with one or more 18F-FDG positive lesions, at least one of them 68Ga-DOTATATE negative). The primary endpoint of the study was Progression-Free Survival, assessed from the date of 18F-FDG PET/CT to the date of radiological progression according to Response Evaluation Criteria In Solid Tumors version 1.1. Classification according to histological grade did not show significant statistical difference in median Progression-Free Survival between G1 and G2 but was significant between G2 and G3 patients. In contrast, median Progression-Free Survival was significantly higher in C1 compared to C2 and in C2 compared to C3 patients, revealing three distinctive imaging categories, each with highly distinctive prognosis. Our three-scale combined 68Ga-DOTATATE/18F-FDG PET imaging classification holds high prognostic value in patients with metastatic gastroenteropancreatic neuroendocrine neoplasias.
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Affiliation(s)
- Ioannis Karfis
- Nuclear Medicine Department, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Gwennaëlle Marin
- Nuclear Medicine Department, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Hugo Levillain
- Nuclear Medicine Department, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Stylianos Drisis
- Radiology/Medical Imaging Department, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Raoul Muteganya
- Nuclear Medicine Department, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Gabriela Critchi
- Nuclear Medicine Department, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Loubna Taraji-Schiltz
- Nuclear Medicine Department, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Carlos Artigas Guix
- Nuclear Medicine Department, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Leila Shaza
- Digestive Oncology Department, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Meriem Elbachiri
- Digestive Oncology Department, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Laura Mans
- Digestive Oncology Department, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Godelieve Machiels
- Digestive Oncology Department, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Alain Hendlisz
- Digestive Oncology Department, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Patrick Flamen
- Nuclear Medicine Department, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
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Haider M, Al-Toubah T, El-Haddad G, Strosberg J. Molecular imaging and radionuclide therapy of neuroendocrine tumors. Curr Opin Endocrinol Diabetes Obes 2020; 27:16-21. [PMID: 31789833 DOI: 10.1097/med.0000000000000519] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW Neuroendocrine tumors are heterogeneous neoplasms with variable prognoses and clinical behaviors. The majority of well differentiated NETs express somatostatin receptors. Identification of these receptors has contributed to advancements in molecular and targeted radiotherapies. RECENT FINDINGS Molecular scans provide important diagnostic, staging, and prognostic data. Somatostatin-receptor imaging aids in selection of patients who are eligible for somatostatin-receptor-targeting therapies. Peptide receptor radionuclide therapy has recently demonstrated robust efficacy in a phase III study of progressive midgut NETs. Current studies are investigating novel receptor agonists and antagonists, new classes of radioactive isotopes, and radiosensitizing combination treatments. SUMMARY The sophistication of molecular imaging is improving and its importance is increasing as a diagnostic, predictive, and prognostic tool. Theranostics, the coupling of molecular imaging with receptor-targeted therapy, represents a novel approach to cancer treatment.
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Affiliation(s)
- Mintallah Haider
- Department of GI Oncology, Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
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46
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Peptide Receptor Radionuclide Therapy. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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47
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Lundsten S, Spiegelberg D, Stenerlöw B, Nestor M. The HSP90 inhibitor onalespib potentiates 177Lu‑DOTATATE therapy in neuroendocrine tumor cells. Int J Oncol 2019; 55:1287-1295. [PMID: 31638190 PMCID: PMC6831206 DOI: 10.3892/ijo.2019.4888] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 07/19/2019] [Indexed: 02/07/2023] Open
Abstract
177Lu-DOTATATE was recently approved for the treatment of somatostatin receptor (SSTR)-positive neuroen-docrine tumors (NETs). However, despite impressive response rates, complete responses are rare. Heat shock protein 90 (HSP90) inhibitors have been suggested as suitable therapeutic agents for NETs, as well as a potential radiosensitizers. Consequently, the aim of this study was to investigate whether the HSP90-inhibitor onalespib could reduce NET cell growth and act as a radiosensitizer when used in combination with 177Lu-DOTATATE. The NET cell lines BON, NCI-H727 and NCI-H460, were first characterized with regards to 177Lu-DOTATATE uptake and sensitivity to onalespib treatment in monolayer cell assays. The growth inhibitory effects of the monotherapies and combination treatments were then examined in three-dimensional multicellular tumor spheroids. Lastly, the molecular effects of the treatments were assessed. 177Lu-DOTATATE uptake was observed in the BON and NCI-H727 cells, while the NCI-H460 cells exhibited no detectable uptake. Accordingly, 177Lu-DOTATATE reduced the growth of BON and NCI-H727 spheroids, while no effect was observed in the NCI-H460 spheroids. Onalespib reduced cell viability and spheroid growth in all three cell lines. Furthermore, the combination of onalespib and 177Lu-DOTATATE exerted synergistic therapeutic effects on the BON and NCI-H727 spheroids. Western blot analysis of BON spheroids revealed the downregulation of epidermal growth factor receptor (EGFR) and the upregulation of γ H2A histone family member X (γH2AX) following combined treatment with onalespib and 177Lu-DOTATATE. Moreover, flow cytometric analyses revealed a two-fold increase in caspase 3/7 activity in the combination group. In conclusion, the findings of this study demonstrate that onalespib exerts antitumorigenic effects on NET cells and may thus be a feasible treatment option for NETs. Furthermore, onalespib was able to synergistically potentiate 177Lu-DOTATATE treatment in a SSTR-specific manner. The radiosensitizing mechanisms of onalespib involved the downregulation of EGFR expression and the induction of apoptosis. Consequently, the combination of onalespib and 177Lu-DOTATATE may prove to be a promising strategy with which to improve therapeutic responses in patients with NETs. Further studies investigating this strategy in vivo regarding the therapeutic effects and potential toxicities are warranted to expand these promising findings.
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Affiliation(s)
- Sara Lundsten
- Department of Immunology, Genetics and Pathology, Uppsala University, 751 87 Uppsala, Sweden
| | - Diana Spiegelberg
- Department of Immunology, Genetics and Pathology, Uppsala University, 751 87 Uppsala, Sweden
| | - Bo Stenerlöw
- Department of Immunology, Genetics and Pathology, Uppsala University, 751 87 Uppsala, Sweden
| | - Marika Nestor
- Department of Immunology, Genetics and Pathology, Uppsala University, 751 87 Uppsala, Sweden
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Abstract
Neuroendocrine tumors (NETs) originate from the neuroendocrine cell system in the bronchial and gastrointestinal tract and can produce hormones leading to distinct clinical syndromes. Systemic treatment of patients with unresectable NETs aims to control symptoms related to hormonal overproduction and tumor growth. In the last decades prognosis has improved as a result of increased detection of early stage disease and the introduction of somatostatin analogs (SSAs) as well as several new therapeutic options. SSAs are the first-line medical treatment of NETs and can control hormonal production and tumor growth. The development of next-generation multireceptor targeted and radiolabelled somatostatin analogs, as well as target-directed therapies (as second-line treatment options) further improve progression-free survival in NET patients. To date, however, a significant prolongation of overall survival with systemic treatment in NET has not been convincingly demonstrated. Several new medical options and treatment combinations will become available in the upcoming years, and although preliminary results of preclinical and clinical trials are encouraging, large, preferrably randomized clinical studies are required to provide definitive evidence of their effect on survival and symptom control.
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49
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Combination treatments to enhance peptide receptor radionuclide therapy of neuroendocrine tumours. Eur J Nucl Med Mol Imaging 2019; 47:907-921. [DOI: 10.1007/s00259-019-04499-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 08/21/2019] [Indexed: 12/11/2022]
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50
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Torniai M, Scortichini L, Tronconi F, Rubini C, Morgese F, Rinaldi S, Mazzanti P, Berardi R. Systemic treatment for lung carcinoids: from bench to bedside. Clin Transl Med 2019; 8:22. [PMID: 31273555 PMCID: PMC6609661 DOI: 10.1186/s40169-019-0238-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 06/21/2019] [Indexed: 12/13/2022] Open
Abstract
In the huge spectrum of lung neuroendocrine neoplasms, typical and atypical carcinoids should be considered as a separate biological entity from poorly differentiated forms, harboring peculiar molecular alterations. Despite their indolent behavior, lung carcinoids correlate with a worse survival. To date, only limited therapeutic options are available and novel drugs are strongly needed. In this work, we extensively reviewed scientific literature exploring available therapeutic options, new molecular targets and future perspectives in the management of well differentiated neoplasms of bronchopulmonary tree. Systemic therapy represents the main option in advanced and unresectable disease; accepted choices are somatostatin analogs, peptide receptor radionuclide therapy, everolimus and chemotherapy. To date, an univocal treatment strategy has not been identified yet, thus tailored therapeutic algorithms should consider treatment efficacy as well as safety profiles. Several molecular alterations found in carcinoid tumors might act as molecular targets leading to development of new therapeutic options. Further studies are necessary to identify new potential “druggable” molecular targets in the selected subset of low-grade lung carcinoids. Furthermore, evaluating the available therapies in more homogeneous population might improve their efficacy through a perfect tailoring of treatment options.
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Affiliation(s)
- Mariangela Torniai
- Clinica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti di Ancona, Via Conca 71, 60126, Ancona, Italy
| | - Laura Scortichini
- Clinica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti di Ancona, Via Conca 71, 60126, Ancona, Italy
| | - Francesca Tronconi
- Clinica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti di Ancona, Via Conca 71, 60126, Ancona, Italy
| | - Corrado Rubini
- Section of Pathological Anatomy and Histopathology, Department of Neuroscience, Università Politecnica delle Marche, AOU Ospedali Riuniti di Ancona, Ancona, Italy
| | - Francesca Morgese
- Clinica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti di Ancona, Via Conca 71, 60126, Ancona, Italy
| | - Silvia Rinaldi
- Clinica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti di Ancona, Via Conca 71, 60126, Ancona, Italy
| | - Paola Mazzanti
- Clinica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti di Ancona, Via Conca 71, 60126, Ancona, Italy
| | - Rossana Berardi
- Clinica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti di Ancona, Via Conca 71, 60126, Ancona, Italy.
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