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Rasul S, Hartenbach M, Wollenweber T, Kretschmer-Chott E, Grubmüller B, Kramer G, Shariat S, Wadsak W, Mitterhauser M, Pichler V, Vraka C, Hacker M, Haug AR. Prediction of response and survival after standardized treatment with 7400 MBq 177Lu-PSMA-617 every 4 weeks in patients with metastatic castration-resistant prostate cancer. Eur J Nucl Med Mol Imaging 2020; 48:1650-1657. [PMID: 33128131 PMCID: PMC8113146 DOI: 10.1007/s00259-020-05082-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/18/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS [177Lu]Lu-PSMA-617 radioligand therapy (PSMA-RLT) is a new therapy for patients with metastatic castration-resistant prostate cancer (mCRPC). However, identification of reliable prognostic factors is hampered by heterogeneous treatment regimens applied in previous studies. Hence, we sought clinical factors able to predict response and survival to PSMA-RLT in a homogenous group of patients, all receiving 7400 MBq every 4 weeks. PATIENTS AND METHODS Data of 61 patients (mean age 71.6 ± 6.9 years, median basal PSA 70.7 [range 1.0-4890 μg/L]), pretreated with abiraterone/enzalutamide (75.4%) and docetaxel/cabazitaxel (68.9%), received three cycles of PSMA-RLT (mean 7321 ± 592 MBq) at four weekly intervals and were analyzed retrospectively. General medical conditions and laboratory parameters of every patients were regularly assessed. Response to therapy was based on PSA levels 1 month after the 3rd cycle. Binary logistic regression test and Kaplan-Meier estimates were used to evaluate predictors and overall survival (OS). RESULTS Forty-nine (80.3%) patients demonstrated a therapy response in terms of any PSA decline, while 21 (19.7%) patients showed increase or no changes in their PSA levels. Baseline hemoglobin (Hb) significantly predicted PSA reductions of ≥ 50% 4 weeks after receiving the 3rd PSMA-RLT (P = 0.01, 95% CI: 1.09-2.09) with an AUC of 0.68 (95% CI: 0.54-0.81). The levels of basal Hb and basal PSA were able to predict survival of patients, both P < 0.05 (relative risk 1.51 and 0.79, 95% CI: 1.09-2.09 and 0.43-1.46), respectively. In comparison to patients with reduced basal Hb, patients with normal basal Hb levels lived significantly longer (median survival not reached vs. 89 weeks, P = 0.016). Also, patients with basal PSA levels ≤ 650 μg/L had a significantly longer survival than patients with basal PSA levels > 650 μg/L (median survival not reached vs. 97 weeks, P = 0.031). Neither pretreatments with abiraterone/enzalutamide or docetaxel/cabazitaxel nor distribution of metastasis affected survival and rate of response to PSMA-RLT. CONCLUSION Basal Hb level is an independent predictor for therapy response and survival in patients receiving PSMA-RLT every 4 weeks. Both baseline PSA ≤ 650 μg/L and normal Hb levels were associated with longer survival.
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Affiliation(s)
- Sazan Rasul
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus Hartenbach
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Tim Wollenweber
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Kretschmer-Chott
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Gero Kramer
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Shahrokh Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria
- Department of Urology, Weill Cornell Medical College, New York, NY, USA
- Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Wolfgang Wadsak
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
- Center for Biomarker Research in Medicine, CBmed GmbH, Graz, Austria
| | - Markus Mitterhauser
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute Applied Diagnostics, Vienna, Austria
| | - Verena Pichler
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Chrysoula Vraka
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Marcus Hacker
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Alexander R Haug
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria.
- Christian Doppler Laboratory for Applied Metabolomics (CDL AM), Medical University of Vienna, Vienna, Austria.
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152
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Privé BM, Janssen MJR, van Oort IM, Muselaers CHJ, Jonker MA, de Groot M, Mehra N, Verzijlbergen JF, Scheenen TWJ, Zámecnik P, Barentsz JO, Gotthardt M, Noordzij W, Vogel WV, Bergman AM, van der Poel HG, Vis AN, Oprea-Lager DE, Gerritsen WR, Witjes JA, Nagarajah J. Lutetium-177-PSMA-I&T as metastases directed therapy in oligometastatic hormone sensitive prostate cancer, a randomized controlled trial. BMC Cancer 2020; 20:884. [PMID: 32928177 PMCID: PMC7490874 DOI: 10.1186/s12885-020-07386-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 09/07/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In recent years, there is increasing evidence showing a beneficial outcome (e.g. progression free survival; PFS) after metastases-directed therapy (MDT) with external beam radiotherapy (EBRT) or targeted surgery for oligometastatic hormone sensitive prostate cancer (oHSPC). However, many patients do not qualify for these treatments due to prior interventions or tumor location. Such oligometastatic patients could benefit from radioligand therapy (RLT) with 177Lu-PSMA; a novel tumor targeting therapy for end-stage metastatic castration-resistant prostate cancer (mCRPC). Especially because RLT could be more effective in low volume disease, such as the oligometastatic status, due to high uptake of radioligands in smaller lesions. To test the hypothesis that 177Lu-PSMA is an effective treatment in oHSPC to prolong PFS and postpone the need for androgen deprivation therapy (ADT), we initiated a multicenter randomized clinical trial. This is globally, the first prospective study using 177Lu-PSMA-I&T in a randomized multicenter setting. METHODS & DESIGN This study compares 177Lu-PSMA-I&T MDT to the current standard of care (SOC); deferred ADT. Fifty-eight patients with oHSPC (≤5 metastases on PSMA PET) and high PSMA uptake (SUVmax > 15, partial volume corrected) on 18F-PSMA PET after prior surgery and/or EBRT and a PSA doubling time of < 6 months, will be randomized in a 1:1 ratio. The patients randomized to the interventional arm will be eligible for two cycles of 7.4GBq 177Lu-PSMA-I&T at a 6-week interval. After both cycles, patients are monitored every 3 weeks (including adverse events, QoL- and xerostomia questionnaires and laboratory testing) at the outpatient clinic. Twenty-four weeks after cycle two an end of study evaluation is planned together with another 18F-PSMA PET and (whole body) MRI. Patients in the SOC arm are eligible to receive 177Lu-PSMA-I&T after meeting the primary study objective, which is the fraction of patients who show disease progression during the study follow up. A second primary objective is the time to disease progression. Disease progression is defined as a 100% increase in PSA from baseline or clinical progression. DISCUSSION This is the first prospective randomized clinical study assessing the therapeutic efficacy and toxicity of 177Lu-PSMA-I&T for patients with oHSPC. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT04443062 .
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Affiliation(s)
- Bastiaan M Privé
- Department of Radiology and Nuclear Medicine, Radboudumc, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Marcel J R Janssen
- Department of Radiology and Nuclear Medicine, Radboudumc, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Inge M van Oort
- Department of Urology, Radboudumc, Nijmegen, The Netherlands
| | | | - Marianne A Jonker
- Department of Health Evidence, Radboudumc, Nijmegen, The Netherlands
| | - Michel de Groot
- Department of Radiology and Nuclear Medicine, Radboudumc, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Niven Mehra
- Department of Medical Oncology, Radboudumc, Nijmegen, The Netherlands
| | - J Fred Verzijlbergen
- Department of Radiology and Nuclear Medicine, Radboudumc, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Tom W J Scheenen
- Department of Radiology and Nuclear Medicine, Radboudumc, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Patrik Zámecnik
- Department of Radiology and Nuclear Medicine, Radboudumc, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Jelle O Barentsz
- Department of Radiology and Nuclear Medicine, Radboudumc, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Martin Gotthardt
- Department of Radiology and Nuclear Medicine, Radboudumc, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Walter Noordzij
- Department of Radiology and Nuclear Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Wouter V Vogel
- Department of Radiology and Nuclear Medicine, NKI Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Radiation Oncology, NKI Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Andries M Bergman
- Department of Medical Oncology, NKI Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Henk G van der Poel
- Department of Urology, NKI Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - André N Vis
- Department of Urology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Daniela E Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - J Alfred Witjes
- Department of Urology, Radboudumc, Nijmegen, The Netherlands
| | - James Nagarajah
- Department of Radiology and Nuclear Medicine, Radboudumc, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.
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153
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Prostate-specific membrane antigen-targeted endoradiotherapy in metastatic prostate cancer. Curr Opin Urol 2020; 30:98-105. [PMID: 31644433 DOI: 10.1097/mou.0000000000000685] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW In this review, we present an update on the safety and efficacy of prostate-specific membrane antigen (PSMA) radioligand therapy (PRLT) of metastatic castration-resistant prostate cancer (mCRPC). RECENT FINDINGS Treatment of mCRPC with approved treatment agents leads to a survival advantage. The disease often progresses despite these treatments. PRLT with Lutetium-177 and Actinium-225 labeled with PSMA (LuPSMA and AcPSMA) have recently been shown to be effective and well tolerated for mCRPC treatment. LuPSMA is currently applied in patients who have exhausted approved treatment options or in whom these approved treatments are contraindicated. In this category of heavily pretreated patients, prostate-specific antigen (PSA) response (≥50% decline) is achieved in about 46% of patients. Side-effects are tolerable with rare reports of grade III-IV treatment-induced toxicity. AcPSMA is currently applied on a smaller scale in patients who relapsed after LuPSMA or in whom LuPSMA is contraindicated. PSA response occurs in up to 88% of patients treated with AcPSMA. SUMMARY PRLT with LuPSMA and AcPSMA is a well-tolerated and effective treatment modality for mCRPC. Prospective randomized control trials are necessary to facilitate its application as an approved therapy option.
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154
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Marinova M, Alamdar R, Ahmadzadehfar H, Essler M, Attenberger U, Mücke M, Conrad R. Improving quality of life in patients with metastatic prostate cancer following one cycle of 177Lu-PSMA-617 radioligand therapy: a pilot study. Nuklearmedizin 2020; 59:409-414. [PMID: 32823294 DOI: 10.1055/a-1234-5891] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION To evaluate the clinical therapeutic response of PSMA targeted radioligand therapy with 177Lu-PSMA-617 in patients with metastatic castration-resistant prostate cancer. The current study analyzed disease-related quality of life (QoL) in patients undergoing PSMA therapy with a special focus on the association with simultaneous PSA response. METHODS Thirty patients (age range 50-87 years, median 73.5 years) undergoing 177Lu-PSMA-617 therapy from 2014 to 2016 at our institution were included in this pilot study. Health-related QoL was assessed by EORTC QLQ-C30 questionnaire filled in at baseline and two months after initializing the PSMA-therapy. The treatment response was evaluated under three categories with regard to changes in (a) global health status and other functional scales, (b) disease-related symptoms, and (c) effects of PSA values. RESULTS Most patients underwent three treatment cycles (n = 12); at least 2 cycles (n = 6) or at most 8 cycles (n = 1) were performed. Out of 30 cases, PSA response after the first cycle was observed in 73 % (n = 22). Compared to baseline, QoL was significantly improved at 2-month follow-up revealing increase in global health status (p = 0.025), role functioning (p = 0.017) and emotional functioning (0.010), and decrease in pain (p = 0.033). Global health status variation can be explained up to 20.5 % by response in PSA (p = 0.012), this improved with PSA reduction. CONCLUSION PSMA radioligand therapy seems to be an effective treatment option of metastatic castration-resistant prostate cancer patients as it improves their QoL in terms of increasing global health and mitigation of disease-related pain.
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Affiliation(s)
- Milka Marinova
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Germany
| | - Reza Alamdar
- Department of Nuclear Medicine, University Hospital Bonn, Germany
| | - Hojjat Ahmadzadehfar
- Department of Nuclear Medicine, University Hospital Bonn, Germany.,Department of Nuclear Medicine, Klinikum Westfalen, Dortmund, Germany
| | - Markus Essler
- Department of Nuclear Medicine, University Hospital Bonn, Germany
| | - Ulrike Attenberger
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Germany
| | - Martin Mücke
- Center for Rare Diseases Bonn (ZSEB), University Hospital of Bonn, Germany
| | - Rupert Conrad
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Bonn, Germany
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155
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Mayor N, Sathianathen NJ, Buteau J, Koschel S, Antón Juanilla M, Kapoor J, Azad A, Hofman MS, Murphy DG. Prostate-specific membrane antigen theranostics in advanced prostate cancer: an evolving option. BJU Int 2020; 126:525-535. [PMID: 32559353 DOI: 10.1111/bju.15143] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To review current data for the role of prostate specific membrane antigen (PSMA) radioligand therapy (RLT) for patients with advanced prostate cancer. This review provides an update for multidisciplinary teams on the current and potential future applications of theranostics in prostate cancer. METHODS Narrative review focussing on PSMA as a target for RLT, and data using RESULTS: RLT with PSMA is an exciting therapeutic alternative to the existing management options already in use for patients with metastatic castrate-resistant prostate cancer (mCRPC). To date, most evidence exists regarding small-molecule PSMA inhibitors bound to beta-emitting radioisotopes such as 177Lu (Lu-PSMA). Prospective phase II data supports the safety and efficacy of Lu-PSMA in men with heavily pre-treated progressive mCRPC, and several late-phase randomised trials of Lu-PSMA are underway, with many more in the pipeline. Early results are encouraging, indicating that the theranostic approach may play a vital role in management of advanced prostate cancer and perhaps even in much earlier disease states. CONCLUSIONS PSMA RLT is a promising new treatment option for men with mCPRC, and may also have utility in less advanced prostate cancer.
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Affiliation(s)
- Nikhil Mayor
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | | | - James Buteau
- Molecular Imaging and Nuclear Medicine Therapeutics, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Samantha Koschel
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Marta Antón Juanilla
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jada Kapoor
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Arun Azad
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | - Michael S Hofman
- Molecular Imaging and Nuclear Medicine Therapeutics, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | - Declan G Murphy
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
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156
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Sørensen MA, Andersen VL, Hendel HW, Vriamont C, Warnier C, Masset J, Huynh THV. Automated synthesis of 68 Ga/ 177 Lu-PSMA on the Trasis miniAllinOne. J Labelled Comp Radiopharm 2020; 63:393-403. [PMID: 32374450 DOI: 10.1002/jlcr.3846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/20/2020] [Accepted: 04/29/2020] [Indexed: 02/03/2023]
Abstract
Prostate-specific membrane antigen (PSMA)-based radioligands for positron emission tomography (PET)/computed tomography (CT) studies represent the gold standard for detection of recurrent prostate cancer (PCa). [68 Ga]PSMA-HBED-CC is a PET radiotracer suitable for detection of PCa, and its clinical use has become widespread over the last few years. In this contribution, we detail our GMP-compliant production of [68 Ga]PSMA-HBED-CC using the Trasis miniAllinOne radiosynthesizer and report synthetic and clinical data for the first 100 productions of 2019. Additionally, we detail our efforts towards a GMP-compliant production of the radiotherapeutic [177 Lu]PSMA-I&T using the same synthesis module. PSMA-based radioligand therapy (RLT) offers a possible future treatment in cases of metastatic castration-resistant PCa, and GMP-compliant routine production methods are therefore called for. This report highlights how PSMA-based agents for theranostic purposes can be conveniently produced at a single radiochemistry Good Manufacturing Practice (GMP) site, thereby facilitating optimized detection and treatment of PCa.
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Affiliation(s)
- Mikkel A Sørensen
- Department of Nuclear Medicine, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Valdemar L Andersen
- Department of Nuclear Medicine, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Helle Westergren Hendel
- Department of Nuclear Medicine, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Charles Vriamont
- Department of Research and Development, Trasis Radiopharmacy Instruments, Ans, Belgium
| | - Corentin Warnier
- Department of Research and Development, Trasis Radiopharmacy Instruments, Ans, Belgium
| | - Julien Masset
- Department of Research and Development, Trasis Radiopharmacy Instruments, Ans, Belgium
| | - Tri Hien Viet Huynh
- Department of Nuclear Medicine, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
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157
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Fact Checking on 177Lu Prostate-Specific Membrane Antigen Nephrotoxicity. AJR Am J Roentgenol 2020; 215:W2. [PMID: 32568577 DOI: 10.2214/ajr.19.22271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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158
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Wang B, Liu C, Wei Y, Meng J, Zhang Y, Gan H, Xu X, Wan F, Pan J, Ma X, Hu S, Freedland SJ, Song S, Ye D, Zhu Y. A Prospective Trial of 68Ga-PSMA and 18F-FDG PET/CT in Nonmetastatic Prostate Cancer Patients with an Early PSA Progression During Castration. Clin Cancer Res 2020; 26:4551-4558. [PMID: 32527944 DOI: 10.1158/1078-0432.ccr-20-0587] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/06/2020] [Accepted: 06/03/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Tumor heterogeneity and burden, which impact treatment outcome in prostate cancer, are rarely evaluated using next-generation imaging. EXPERIMENTAL DESIGN The trial prospectively included 37 patients who had an early PSA progression (≤2 ng/mL) during castration and high-risk (PSA doubling time ≤10 months) nonmetastatic disease by conventional imaging. All patients underwent both 68Ga-PSMA and 18F-FDG PET/CT. Lesions were classified into PSMA+FDG± lesions and PSMA-FDG+ lesions. The primary endpoint was the prevalence of PSMA-FDG+ disease. Tumor burden, predictors for positive imaging, and suitability for oligometastases-directed therapy (OMDT) were also evaluated. RESULTS All patients were treated with RP and the median duration of castration was 23 months. The median PSA at imaging was 0.57 ng/mL. Overall, 114 lesions were detected in 29 of the 37 patients. A high prevalence (73%) of N+/M+ disease was observed. Of the 114 lesions, 81 were PSMA+FDG± and 33 were PSMA-FDG+. Per patient level, 9 men (24%; 95% confidence interval: 10%-39%) showed at least one new PSMA-FDG+ lesions. A short PSA doubling time (P = 0.009, OR = 8.000) was associated with PSMA+FDG± disease, while a high Gleason grade group (P = 0.022, OR = 13.091) with PSMA-FDG+ disease. Nineteen patients (51%) with 51 lesions, including 10 PSMA-FDG+ lesions, could be enrolled for OMDT. Among different disease stages, PSMA-FDG+ disease was rarely detected in the hormone-sensitive cohort, but frequently found in the castration-resistant cohort. CONCLUSIONS Using 68Ga-PSMA and 18F-FDG PET, we observed a high prevalence of N+/M+ disease and a significant proportion of PSMA-FDG+ disease in patients with an early PSA progression during castration (ChiCTR1900022634).
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Affiliation(s)
- Beihe Wang
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Chang Liu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yu Wei
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jin Meng
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Radiotherapy, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yingjian Zhang
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Hualei Gan
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai China
| | - Xiaoping Xu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Fangning Wan
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jian Pan
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xuejun Ma
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Radiotherapy, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Silong Hu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Stephen J Freedland
- Department of Surgery, Division of Urology and Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California.,Urology Section, Department of Surgery, Veterans Affairs Medical Center, Durham, North Carolina
| | - Shaoli Song
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China. .,Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Shanghai, China
| | - DingWei Ye
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China. .,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yao Zhu
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China. .,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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159
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Gafita A, Fendler WP, Hui W, Sandhu S, Weber M, Esfandiari R, Calais J, Rauscher I, Rathke H, Tauber R, Delpassand ES, Weber WA, Herrmann K, Czernin J, Eiber M, Hofman MS. Efficacy and Safety of 177Lu-labeled Prostate-specific Membrane Antigen Radionuclide Treatment in Patients with Diffuse Bone Marrow Involvement: A Multicenter Retrospective Study. Eur Urol 2020; 78:148-154. [PMID: 32532512 DOI: 10.1016/j.eururo.2020.05.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/05/2020] [Indexed: 11/15/2022]
Abstract
The 177Lu-labeled prostate-specific membrane antigen (LuPSMA) radionuclide therapy for metastatic castration-resistant prostate cancer is under investigation in a phase III trial (VISION: NCT03511664). However, patients with diffuse bone involvement, diagnosed with a "superscan" by bone scintigraphy at baseline, were excluded due to a lack of efficacy and safety data. We therefore aimed to investigate the feasibility of LuPSMA in patients with diffuse bone marrow involvement on baseline PSMA-targeted positron emission tomography. The primary end points were prostate-specific antigen (PSA) response (Prostate Cancer Working Group 3 [PCWG3]), hematologic safety profile (Common Terminology Criteria for Common Adverse Events [CTCAE]), and overall survival. Secondary end points of quality of life (assessed with Brief Pain Inventory-Short Form questionnaires) and radiologic response (Response Evaluation Criteria in Solid Tumors [RECIST]) were assessed. Through retrospective screening of databases, we identified 43 eligible patients across four centers worldwide who received 154 cycles of LuPSMA under clinical trials or compassionate access programs. Median baseline PSA was 1000 (interquartile range 431-2151) ng/ml. PSA decline of at least 50% at 12 wk was achieved in 22 (58%) patients, while median time to pain progression was 8.3 (95% confidence interval [CI] 4.1-12.6) mo. Median overall survival was 11.6 (95% CI 8.8-14.3) mo. Objective response in nodal or visceral disease was reported in seven (39%) of 18 patients with RECIST measurable disease. Grade 3 anemia, thrombocytopenia, and neutropenia occurred in nine (22%), seven (17%), and three (8%) patients, respectively. Grade 4 thrombocytopenia was noticed in three (8%) patients. In conclusion, patients with diffuse bone marrow involvement demonstrated similar LuPSMA efficacy and safety to phase II evidence. Acceptable safety outcomes do not support exclusion of patients with a superscan from future LuPSMA treatment protocols. PATIENT SUMMARY: In this report, we investigated the feasibility of prostate-specific membrane antigen (PSMA)-directed radionuclide treatment in patients with metastatic castration-resistant prostate cancer and diffuse bone involvement. We found that, despite a high load of bone metastases, PSMA-targeted therapy remains efficacious and safe when compared with the current phase II trial results.
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Affiliation(s)
- Andrei Gafita
- Department of Nuclear Medicine, Technical University Munich, Klinikum rechts der Isar, Munich, Germany.
| | - Wolfgang P Fendler
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, Essen, Germany
| | - Wang Hui
- Department of Nuclear Medicine, Technical University Munich, Klinikum rechts der Isar, Munich, Germany
| | - Shahneen Sandhu
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Manuel Weber
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, Essen, Germany
| | | | - Jeremie Calais
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, University of California Los Angeles, Los Angeles, CA, USA
| | - Isabel Rauscher
- Department of Nuclear Medicine, Technical University Munich, Klinikum rechts der Isar, Munich, Germany
| | - Hendrik Rathke
- Department of Nuclear Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Robert Tauber
- Department of Urology, Technical University Munich, Klinikum rechts der Isar, Munich, Germany
| | | | - Wolfgang A Weber
- Department of Nuclear Medicine, Technical University Munich, Klinikum rechts der Isar, Munich, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, Essen, Germany
| | - Johannes Czernin
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, University of California Los Angeles, Los Angeles, CA, USA
| | - Matthias Eiber
- Department of Nuclear Medicine, Technical University Munich, Klinikum rechts der Isar, Munich, Germany
| | - Michael S Hofman
- Department of Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Jones W, Griffiths K, Barata PC, Paller CJ. PSMA Theranostics: Review of the Current Status of PSMA-Targeted Imaging and Radioligand Therapy. Cancers (Basel) 2020; 12:E1367. [PMID: 32466595 PMCID: PMC7352725 DOI: 10.3390/cancers12061367] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/17/2020] [Accepted: 05/22/2020] [Indexed: 01/03/2023] Open
Abstract
Prostate-specific membrane antigen (PSMA) has been the subject of extensive investigation in the past two decades as a promising molecular target for prostate cancer (PCa). Its appealing molecular features have enabled the development of a novel diagnostic and therapeutic-thus "theranostic"-approach to PCa. There is now substantial evidence of the high sensitivity of PSMA-targeted imaging for PCa lesions and growing evidence of the therapeutic efficacy of PSMA radioligand therapy for metastatic castration-resistant prostate cancer. This article presents a broad overview of the current status of PSMA theranostics, including current evidence, potential clinical impact, and active areas of research.
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Affiliation(s)
- Wallace Jones
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA;
| | - Kelly Griffiths
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21231, USA;
| | - Pedro C. Barata
- Department of Hematology-Oncology, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Channing J. Paller
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21231, USA;
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Rosar F, Ribbat K, Ries M, Linxweiler J, Bartholomä M, Maus S, Schreckenberger M, Ezziddin S, Khreish F. Neuron-specific enolase has potential value as a biomarker for [ 18F]FDG/[ 68Ga]Ga-PSMA-11 PET mismatch findings in advanced mCRPC patients. EJNMMI Res 2020; 10:52. [PMID: 32449086 PMCID: PMC7246282 DOI: 10.1186/s13550-020-00640-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/04/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND PSMA-targeted radioligand therapy (PSMA-RLT) yielded impressive results in the metastasized castration-resistant prostate carcinoma (mCRPC) setting. High expression of PSMA is essential for successful PSMA-RLT. However, some patients develop [18F]FDG-avid lesions with low or no PSMA expression ([18F]FDG/[68Ga]Ga-PSMA-11 mismatch findings on PET/CT) in the course of treatment. Those lesions are not affected by PSMA-RLT and a change in therapy management is needed. To enable early mismatch detection, possible blood parameters as indicators for the occurrence of [18F]FDG/[68Ga]Ga-PSMA-11 mismatch findings on PET/CT were evaluated. METHODS Retrospective study of N = 66 advanced mCRPC patients with dual [68Ga]Ga-PSMA-11 and [18F]FDG PET/CT imaging within 4 weeks, who were referred for or received [177Lu]Lu-PSMA-617 radioligand therapy. Prostate-specific antigen (PSA), neuron-specific enolase (NSE), gamma-glutamyltransferase (GGT), and alkaline phosphatase (ALP) were tested as indicators for the occurrence of [18F]FDG/[68Ga]Ga-PSMA-11 mismatch findings. Additional to absolute values, relative changes (ΔPSA, ΔNSE, ΔGGT, ΔALP) over a period of 4 ± 1 weeks prior to [18F]FDG PET/CT were analyzed. RESULTS In total, 41/66 (62%) patients revealed at least one [18F]FDG/[68Ga]Ga-PSMA-11 mismatch finding on PET/CT. These mismatch findings were detected in 13/41 (32%) patients by screening for and in 28/41 (68%) patients during PSMA-RLT. NSE serum level (55.4 ± 44.6 μg/l vs. 18.5 ± 8 μg/l, p < 0.001) and ΔNSE (93.8 ± 124.5% vs. 2.9 ± 39.5%, p < 0.001) were significantly higher in the mismatch group than in the non-mismatch group. No significant differences were found for serum PSA (p = 0.424), ΔPSA (p = 0.417), serum ALP (p = 0.937), ΔALP (p = 0.611), serum GGT (p = 0.773), and ΔGGT (p = 0.971). For NSE and ΔNSE, the maximum value of the Youden index in ROC analysis was at a cut-off level of 26.8 μg/l (sensitivity 78%, specificity 96%) and at + 13.9% (sensitivity 84%, specificity 75%), respectively. An introduced scoring system of both parameters achieved a sensitivity of 90% and a specificity of 88% for the occurrence of [18F]FDG/[68Ga]Ga-PSMA-11 mismatch. CONCLUSION We observed a significantly higher absolute serum concentration and a higher relative increase of NSE in advanced mCRPC patients with [18F]FDG-avid and insufficient PSMA expressing metastases ([18F]FDG/[68Ga]Ga-PSMA-11 mismatch findings on PET/CT) in our cohort. NSE might be used as a potential laboratory indicator for [18F]FDG/[68Ga]Ga-PSMA-11 mismatch findings, if this observation is confirmed in future, ideally prospective, studies in larger patient cohorts.
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Affiliation(s)
- Florian Rosar
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. 100, Geb. 50, 66421, Homburg, Germany.
| | - Kalle Ribbat
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. 100, Geb. 50, 66421, Homburg, Germany
| | - Martin Ries
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. 100, Geb. 50, 66421, Homburg, Germany
| | | | - Mark Bartholomä
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. 100, Geb. 50, 66421, Homburg, Germany
| | - Stephan Maus
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. 100, Geb. 50, 66421, Homburg, Germany
| | | | - Samer Ezziddin
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. 100, Geb. 50, 66421, Homburg, Germany
| | - Fadi Khreish
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. 100, Geb. 50, 66421, Homburg, Germany
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Schaefer N, Prior JO, Schottelius M. From Theranostics to Immunotheranostics: the Concept. Nucl Med Mol Imaging 2020; 54:81-85. [PMID: 32377259 DOI: 10.1007/s13139-020-00639-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/24/2020] [Accepted: 03/27/2020] [Indexed: 10/24/2022] Open
Abstract
Immunotheranostics will be an important development in the future of nuclear medicine and medical oncology. It describes the synergy of theranostic procedures in nuclear medicine and immune oncology (IO) treatment. In brief, it takes advantage of molecular imaging and subsequent targeted modulation of the-in most cases immunosuppressive-tumor microenvironment (TME) by diagnostic and therapeutic radioisotopes. This is of high importance since only a fraction of patients receiving IO is currently being cured by this exciting therapy option. We therefore envision the concept of immunotheranostics as a powerful mean to augment the success of IO treatment in the future and thus the urgent need to further develop the interaction and joint action of nuclear medicine and medical oncology for substantially improved therapy outcome for cancer patients.
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Affiliation(s)
- Niklaus Schaefer
- 1Nuclear Medicine and Molecular Imaging Department, Lausanne University Hospital, University of Lausanne, Bugnon 46, 1011 Lausanne, Switzerland
| | - John O Prior
- 1Nuclear Medicine and Molecular Imaging Department, Lausanne University Hospital, University of Lausanne, Bugnon 46, 1011 Lausanne, Switzerland
| | - Margret Schottelius
- 1Nuclear Medicine and Molecular Imaging Department, Lausanne University Hospital, University of Lausanne, Bugnon 46, 1011 Lausanne, Switzerland.,2Translational Radiopharmaceutical Science Laboratory, Lausanne University Hospital, Rue du Bugnon 25A, CH-1011 Lausanne, Switzerland
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163
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Ahmadzadehfar H, Rahbar K, Baum RP, Seifert R, Kessel K, Bögemann M, Kulkarni HR, Zhang J, Gerke C, Fimmers R, Kratochwil C, Rathke H, Ilhan H, Maffey-Steffan J, Sathekge M, Kabasakal L, Garcia-Perez FO, Kairemo K, Maharaj M, Paez D, Virgolini I. Prior therapies as prognostic factors of overall survival in metastatic castration-resistant prostate cancer patients treated with [ 177Lu]Lu-PSMA-617. A WARMTH multicenter study (the 617 trial). Eur J Nucl Med Mol Imaging 2020; 48:113-122. [PMID: 32383093 PMCID: PMC7835179 DOI: 10.1007/s00259-020-04797-9] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/27/2020] [Indexed: 12/05/2022]
Abstract
Introduction The impact of prior therapies, especially chemotherapy, on overall survival (OS) in patients with castration-resistant prostate cancer (CRPC) receiving [177Lu]Lu-PSMA-617 therapy has been the subject of controversy. Therefore, WARMTH decided to plan a multicenter retrospective analysis (the “617 trial”) to evaluate response rate and OS as well as the impact of prior therapies on OS in more than 300 patients treated with 177Lu-PSMA-617. Materials and methods The data of 631 metastatic CRPC (mCRPC) patients from 11 different clinics were evaluated. According to the inclusion and exclusion criteria, all patients had to have received at least abiraterone or enzalutamide prior to [177Lu]Lu-PSMA-617 therapy. The patients were divided into three groups: patients who had received prior chemotherapy, patients who avoided chemotherapy, and patients for whom a chemotherapy was contraindicated. Results The analysis included the data of 416 patients, with a median age of 71.9 years. At the time of analysis, 87 patients (20,9%) were still alive. A total of 53.6% of patients had received both abiraterone and enzalutamide; 75.5% and 26.4% had a history of chemotherapy with docetaxel and cabazitaxel, respectively. A total of 20.4% had had Ra-223. The median OS was 11.1 months. Prior chemotherapy, the existence of bone and liver metastases, as well as Eastern Cooperative Oncology Group (ECOG) status, were significant prognosticators of worse overall survival in both univariate and multivariate analyses. Patients without any prior chemotherapy showed a significantly longer OS (14.6 months). The median OS in patients who received one or two lines of chemotherapy with docetaxel or docetaxel followed by cabazitaxel, respectively, was 10.9 months and 8.9 months. There was no difference in OS between patients who had not received chemotherapy and patients for whom chemotherapy was contraindicated. The other prior therapies did not have any significant impact on OS. Conclusion In the present multicenter analysis, chemotherapy-naïve mCRPC patients receiving [177Lu]Lu-PSMA-617 therapy had a significantly longer OS than patients with a history of chemotherapy. This remained independent in the multivariate analysis besides presence of bone and liver metastases as negative prognosticators for survival, whereas an ECOG of 0–1 is associated with a longer OS. Electronic supplementary material The online version of this article (10.1007/s00259-020-04797-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hojjat Ahmadzadehfar
- Department of Nuclear Medicine, University Hospital Bonn, Bonn, Germany.
- Department of Nuclear Medicine, Klinikum Westfalen, Am Knappschaftskrankenhaus 1, 44309, Dortmund, Germany.
| | - Kambiz Rahbar
- Department of Nuclear Medicine, University Hospital Muenster, Muenster, Germany
| | - Richard P Baum
- Center for Radiomolecular Precision Oncology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Robert Seifert
- Department of Nuclear Medicine, University Hospital Muenster, Muenster, Germany
| | - Katharina Kessel
- Department of Nuclear Medicine, University Hospital Muenster, Muenster, Germany
| | - Martin Bögemann
- Department of Urology, University Hospital Münster, Muenster, Germany
| | - Harshad R Kulkarni
- Center for Radiomolecular Precision Oncology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Jingjing Zhang
- Center for Radiomolecular Precision Oncology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Carolin Gerke
- Department of Nuclear Medicine, University Hospital Bonn, Bonn, Germany
| | - Rolf Fimmers
- Institute for Medical Biometry, Informatics and Epidemiology, University of Bonn, Bonn, Germany
| | - Clemens Kratochwil
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Hendrik Rathke
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Harun Ilhan
- Department of Nuclear Medicine, LMU, University Hospital Munich, Munich, Germany
| | | | - Mike Sathekge
- Department of Nuclear Medicine, University of Pretoria & Steve Biko Academic Hospital, Pretoria, South Africa
| | - Levent Kabasakal
- Department of Nuclear Medicine, Istanbul University, Istanbul, Turkey
| | - Francisco Osvaldo Garcia-Perez
- Department of Nuclear Medicine and Molecular Imaging, Instituto Nacional de Cancerología Mexico City, Mexico City, Mexico
| | | | - Masha Maharaj
- Department of Nuclear Medicine, Imaging and Therapy Centre, Durban, KwaZulu-Natal, South Africa
| | - Diana Paez
- Department of Nuclear Sciences and Applications, Nuclear Medicine and Diagnostic Imaging Section, IAEA, Vienna, Austria
| | - Irene Virgolini
- Department of Nuclear Medicine, Medical University Innsbruck, Innsbruck, Austria
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Derlin T, Sommerlath Sohns JM, Schmuck S, Henkenberens C, von Klot CAJ, Ross TL, Bengel FM. Influence of short-term dexamethasone on the efficacy of 177 Lu-PSMA-617 in patients with metastatic castration-resistant prostate cancer. Prostate 2020; 80:619-631. [PMID: 32187729 DOI: 10.1002/pros.23974] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/07/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Corticosteroids alone or in combination therapy are associated with favorable biochemical responses in metastatic castration-resistant prostate cancer (mCRPC). We speculated that the intermittent addition of dexamethasone may also enhance the antitumor effect of radioligand therapy (RLT) with 177 Lu-prostate-specific membrane antigen (PSMA)-617. PATIENTS AND METHODS Seventy-one patients with mCRPC were treated with 1 to 5 cycles of 177 Lu-PSMA-617 (6.0-7.4 GBq per cycle) at 6 to 8 weeks intervals. Based on the clinical decision (eg, in the case of vertebral metastases), 56% of patients received 4 mg of dexamethasone for the first 5 days of each cycle. Biochemical response rates, PSA decline and progression-free survival (PFS) were analyzed after one, three, and five cycles of RLT. RESULTS PSA response rates were not significantly different between patients receiving 177 Lu-PSMA-617 plus dexamethasone and those receiving 177 Lu-PSMA-617 alone after one, three, and five cycles (33% vs 39%, P = .62; 45% vs 45%, P = 1.0; and 38% vs 42%, P = .81). However, there was a nonsignificant trend for a more pronounced PSA decline in patients with bone metastases receiving adjunct dexamethasone (-21% ± 50% vs +11% ± 90%, P = .08; -21% ± 69% vs +22% ± 116%, P = .07; -13% ± 76% vs +32% ± 119%, P = .07). Median PFS tended to be longer in patients with bone metastases receiving 177 Lu-PSMA-617 plus dexamethasone (146 vs 81 days; hazard ratio: 0.87 [95% confidence interval: 0.47-1.61]; P = .20). Multiple regression analysis showed that age (P = .0110), alkaline phosphatase levels (P = .0380) and adjunct dexamethasone (P = .0285) were independent predictors of changes in PSA in patients with bone metastases. CONCLUSIONS We observed high response rates to 177 Lu-PSMA-617 RLT in men with mCRPC. The short-term addition of dexamethasone to 177 Lu-PSMA-617 had no striking antitumor effect but might enhance biochemical responses in patients with bone metastases. Future trials are warranted to test this hypothesis in a prospective setting.
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Affiliation(s)
- Thorsten Derlin
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | | | - Sebastian Schmuck
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
- Department of Radiology, DIAKOVERE Friederikenstift, Hannover, Germany
| | | | | | - Tobias L Ross
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Frank M Bengel
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
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165
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Zang J, Liu Q, Sui H, Wang R, Jacobson O, Fan X, Zhu Z, Chen X. 177Lu-EB-PSMA Radioligand Therapy with Escalating Doses in Patients with Metastatic Castration-Resistant Prostate Cancer. J Nucl Med 2020; 61:1772-1778. [PMID: 32358086 DOI: 10.2967/jnumed.120.242263] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/06/2020] [Indexed: 11/16/2022] Open
Abstract
This study was designed to assess the safety and therapeutic response to 177Lu-labeled Evans blue-modified prostate-specific membrane antigen (PSMA) 617 (EB-PSMA-617) treatment with escalating doses in patients with metastatic castration-resistant prostate cancer. Methods: With institutional review board approval and informed consent, patients were randomly divided into 3 groups: group A (n = 10) was treated with a 1.18 ± 0.09 GBq dose of 177Lu-EB-PSMA. Group B (n = 10) was treated with a 2.12 ± 0.19 GBq dose of 177Lu-EB-PSMA. Group C (n = 8) was treated with a 3.52 ± 0.58 GBq dose of 177Lu-EB-PSMA. Eligible patients received up to 3 cycles of 177Lu-EB-PSMA therapy, at 8-wk intervals. Results: Because of disease progression or bone marrow suppression, 4 of 10, 5 of 10, and 5 of 8 patients completed 3 cycles of therapy as planned in groups A, B, and C, respectively. The prostate-specific antigen response was correlated with treatment dose, and the prostate-specific antigen disease control rates were higher in groups B (70%) and C (75%) than in group A (10%) (P = 0.007), but no correlation between groups B and C was found. 68Ga-PSMA PET/CT showed a response in all treatment groups; however, there was no significant difference among the 3 groups. A hematologic toxicity study found that platelets decreased more in groups B and C than in group A and that grade 4 thrombocytopenia occurred in 2 (25.0%) patients in group C. No serious nephritic or hepatic side effects were observed. Conclusion: This study demonstrated that a 2.12-GBq dose of 177Lu-EB-PSMA seems to be safe and adequate in tumor treatment. Further investigations with an increased number of patients are warranted.
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Affiliation(s)
- Jie Zang
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Qingxing Liu
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Huimin Sui
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Rongxi Wang
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Orit Jacobson
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, Maryland; and
| | - Xinrong Fan
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhaohui Zhu
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Xiaoyuan Chen
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, Maryland; and
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166
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Gadot M, Davidson T, Aharon M, Atenafu EG, Malki A, Levartovsky M, Saad A, Domachevsky L, Berger R, Leibowitz R. Clinical Variables Associated with PSA Response to Lutetium-177-PSMA ([177Lu]-PSMA-617) Radionuclide Treatment in Men with Metastatic Castration-Resistant Prostate Cancer. Cancers (Basel) 2020; 12:cancers12051078. [PMID: 32357427 PMCID: PMC7281592 DOI: 10.3390/cancers12051078] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/12/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022] Open
Abstract
Lutetium-177-PSMA ([177Lu]-PSMA-617), a radiolabeled small molecule, binds with high affinity to prostate-specific membrane antigen (PSMA), enabling targeted radiation therapy to metastatic prostate lesions. Our objective was to retrospectively analyze the activity of [177Lu]-PSMA-617 given off-trial to men with metastatic castration resistant prostate cancer (mCRPC) and identify clinical factors associated with PSA response. Electronic medical records of all men treated with [177Lu]-PSMA-617 were reviewed and analyzed. Overall survival was calculated using the Kaplan-Meier method. The association between potential variables and PSA response was analyzed by univariate analysis, using either logistic regression or χ2/Fisher's exact test. Multivariable analysis was carried out using logistic regression on all categorical variables with a P-value of <0.1 on univariate analysis. Variables found to be statistically significant were then used to define a categorical score. A total of 52 patients received at least one cycle of [177Lu]-PSMA-617. Clinical benefit was observed in 28 patients (52%). PSA decline ≥20% and ≥50% was observed in 26 (50%) and 18 patients (35%), respectively. Achievement of any PSA decline at first measurement was significantly associated with survival. There was a negative association between the number of previous chemotherapy lines and PSA decline above 20%. Univariate analysis followed by multivariable analysis showed that older age and higher hemoglobin were significantly associated with a PSA decline >20%. A score combining these two parameters was significantly associated with PSA response. In summary, [177Lu]-PSMA-617 is active in the 'real-life' setting of heavily pretreated men with mCRPC.
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Affiliation(s)
- Moran Gadot
- Oncology Institute, Sheba Medical Center, Tel-Hashomer 52621, Israel
| | - Tima Davidson
- Department of Nuclear Medicine, Sheba Medical Center, Tel-Hashomer 52621, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Margalit Aharon
- Oncology Institute, Sheba Medical Center, Tel-Hashomer 52621, Israel
| | - Eshetu G. Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
| | - Avraham Malki
- Department of Nuclear Medicine, Sheba Medical Center, Tel-Hashomer 52621, Israel
| | | | - Akram Saad
- Oncology Institute, Sheba Medical Center, Tel-Hashomer 52621, Israel
| | - Liran Domachevsky
- Department of Nuclear Medicine, Sheba Medical Center, Tel-Hashomer 52621, Israel
| | - Raanan Berger
- Oncology Institute, Sheba Medical Center, Tel-Hashomer 52621, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
- Correspondence: (R.B.); (R.L.); Tel.:+972-8-9779715 (R.L.); Fax: +972-8-9779714 (R.L.)
| | - Raya Leibowitz
- Oncology Institute, Sheba Medical Center, Tel-Hashomer 52621, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
- Correspondence: (R.B.); (R.L.); Tel.:+972-8-9779715 (R.L.); Fax: +972-8-9779714 (R.L.)
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167
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von Eyben FE, Kulkarni HR, Baum RP. Metastatic extent predicts survival as patients with metastatic castration-resistant prostate cancer are treated with 177Lu-PSMA radioligand therapy. Theranostics 2020; 10:4900-4902. [PMID: 32308757 PMCID: PMC7163457 DOI: 10.7150/thno.44568] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/12/2020] [Indexed: 11/22/2022] Open
Abstract
PSMA based radioligand is a new investigational drug for treatment of metastatic multidrug-resistant and castration-resistant prostate cancer. Prognostic factors point to above and below average overall survival (OS) after the treatment. Kessel et al. [Theranostics 2019;9:4841-8] reported for the first time that two sites of visceral metastases, lungs and liver, differed in impact on OS after treatment with 177Lu PSMA 617. Treatment with established drugs showed the same trend. The difference in OS between the sites is independent of the type of treatment and can reflect changes in tumor biology during the progression of metastatic prostate cancer.
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Affiliation(s)
| | - Harshad R. Kulkarni
- Theranostics Center for Molecular Radiotherapy and Molecular Imaging, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Richard P. Baum
- Theranostics Center for Molecular Radiotherapy and Molecular Imaging, Zentralklinik Bad Berka, Bad Berka, Germany
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Derlin T, Werner RA, Lafos M, Henkenberens C, von Klot CAJ, Sommerlath Sohns JM, Ross TL, Bengel FM. Neuroendocrine Differentiation and Response to PSMA-Targeted Radioligand Therapy in Advanced Metastatic Castration-Resistant Prostate Cancer: A Single-Center Retrospective Study. J Nucl Med 2020; 61:1602-1606. [PMID: 32169910 DOI: 10.2967/jnumed.120.241588] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/05/2020] [Indexed: 11/16/2022] Open
Abstract
Neuroendocrine differentiation is associated with treatment failure and poor outcome in metastatic castration-resistant prostate cancer. We investigated the effect of circulating neuroendocrine biomarkers on the efficacy of prostate-specific membrane antigen (PSMA)-targeted radioligand therapy (RLT). Methods: Neuroendocrine biomarker profiles (progastrin-releasing peptide, neuron-specific enolase, and chromogranin-A) were analyzed in 50 patients commencing 177Lu-PSMA-617 RLT. The primary endpoint was a prostate-specific antigen response in relation to baseline neuroendocrine marker profiles. An additional endpoint was progression-free survival. Tumor uptake on posttherapeutic scans, a known predictive marker for response, was used as a control variable. Results: Neuroendocrine biomarker profiles were abnormal in most patients. Neuroendocrine biomarker levels did not predict treatment failure or early progression (P ≥ 0.13). By contrast, intense PSMA-ligand uptake in metastases predicted both treatment response (P = 0.0030) and reduced risk of early progression (P = 0.0111). Conclusion: Neuroendocrine marker profiles do not predict an adverse outcome from RLT. By contrast, high ligand uptake was confirmed to be crucial for achieving a tumor response.
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Affiliation(s)
- Thorsten Derlin
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Rudolf A Werner
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Marcel Lafos
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Christoph Henkenberens
- Department of Radiotherapy and Special Oncology, Hannover Medical School, Hannover, Germany; and
| | | | | | - Tobias L Ross
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Frank M Bengel
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
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169
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Ferdinandus J, Violet J, Sandhu S, Hicks RJ, Ravi Kumar AS, Iravani A, Kong G, Akhurst T, Thang SP, Murphy DG, Williams S, Hofman MS. Prognostic biomarkers in men with metastatic castration-resistant prostate cancer receiving [177Lu]-PSMA-617. Eur J Nucl Med Mol Imaging 2020; 47:2322-2327. [PMID: 32140802 DOI: 10.1007/s00259-020-04723-z] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 02/10/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE We analysed quantitative biomarkers derived from both baseline whole-body imaging and blood serum to identify prognostic markers in patients treated within the lutetium-177 prostate-specific membrane antigen (LuPSMA) phase 2 trial. METHODS PET image analysis was carried out using whole-body segmentation quantifying molecular tumour volume (SUV > 3 threshold for PSMA, SUV > liver+2sd for fluorodeoxyglucose (FDG) including SUVmax and SUVmean. For baseline bone scans, EXINI bone scan index (BSI) was used to calculate the percentage of involved bone. Baseline alkaline phosphatase (ALP), lactate dehydrogenase (LDH), prostate specific antigen (PSA) and PSA doubling time were also used in this analysis. We used univariate cox regression analysis and log-rank comparison with optimised cut-offs to find suitable biomarkers prognostic of overall survival from time of enrolment. RESULTS This analysis identified FDG-positive tumour volume (FDGvol; HR 2.6; 95% CI, 1.4-4.8), mean intensity of PSMA-avid tumour uptake (PSMAmean; HR 0.89; 95% CI, 0.8-0.98), bone scan index (BSI; HR 2.3; 95% CI, 1.2-4.4), ALP (HR 1.1; 95% CI, 1-1.2) and LDH (HR 1.2; 95% CI, 1-1.5) as biomarkers prognostic of overall survival. CONCLUSIONS In addition to established biomarkers, both FDG and PSMA PET/CT parameters have prognostic significance for survival in men undergoing LuPSMA therapy.
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Affiliation(s)
- Justin Ferdinandus
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany.,Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - John Violet
- Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Shahneen Sandhu
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, Australia
| | - Rodney J Hicks
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, Australia
| | - Aravind S Ravi Kumar
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, Australia
| | - Amir Iravani
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, Australia
| | - Grace Kong
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, Australia
| | - Tim Akhurst
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, Australia
| | - Sue Ping Thang
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Declan G Murphy
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, Australia.,Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Scott Williams
- Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, Australia
| | - Michael S Hofman
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia. .,Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, Australia.
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170
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(Radio)Theranostic Patient Management in Oncology Exemplified by Neuroendocrine Neoplasms, Prostate Cancer, and Breast Cancer. Pharmaceuticals (Basel) 2020; 13:ph13030039. [PMID: 32151049 PMCID: PMC7151671 DOI: 10.3390/ph13030039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/01/2020] [Accepted: 03/03/2020] [Indexed: 12/18/2022] Open
Abstract
The role of nuclear medicine in the management of oncological patients has expanded during last two decades. The number of radiopharmaceuticals contributing to the realization of theranostics/radiotheranostics in the context of personalized medicine is increasing. This review is focused on the examples of targeted (radio)pharmaceuticals for the imaging and therapy of neuroendocrine neoplasms (NENs), prostate cancer, and breast cancer. These examples strongly demonstrate the tendency of nuclear medicine development towards personalized medicine.
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171
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Iravani A, Violet J, Azad A, Hofman MS. Lutetium-177 prostate-specific membrane antigen (PSMA) theranostics: practical nuances and intricacies. Prostate Cancer Prostatic Dis 2020; 23:38-52. [PMID: 31595044 DOI: 10.1038/s41391-019-0174-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 07/23/2019] [Accepted: 07/26/2019] [Indexed: 01/01/2023]
Abstract
Theranostic principles utilize a molecular biomarker specific for a tumor target, initially for imaging to assess target expression and, if deemed suitable, for targeted therapy. This presents an exciting opportunity for a highly personalized treatment strategy in the era of precision medicine. Prostate-specific membrane antigen (PSMA) theranostics has attracted increasing attention as a promising targeted treatment in metastatic prostate cancer (PC). 177Lu-DOTA-PSMA-617 (177Lu-PSMA-617) is a PSMA-targeted small molecule with favorable properties and is the most extensively investigated PSMA radioligand for radionuclide therapy (RNT) in PC. Since 2014 multiple retrospective studies and more recently a phase II prospective study demonstrated safety and impressive efficacy of 177Lu-PSMA RNT. The evidence generated by these trials led to two currently underway randomized trials in metastatic castrate-resistant PC: TheraP (NCT03392428) and VISION (NCT03511664). While we wait for these pivotal trials to read out, nuclear medicine physicians, medical oncologists, radiation oncologists, and urologists are facing a steep learning curve to master the intricacies and nuances of this novel therapeutic strategy. This review article aims to share and discuss the evolving experience in practical aspects of PSMA theranostics.
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Affiliation(s)
- Amir Iravani
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - John Violet
- Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Arun Azad
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia.,Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Michael S Hofman
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia. .,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia.
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172
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Gafita A, Heck MM, Rauscher I, Tauber R, Cala L, Franz C, D'Alessandria C, Retz M, Weber WA, Eiber M. Early Prostate-Specific Antigen Changes and Clinical Outcome After 177Lu-PSMA Radionuclide Treatment in Patients with Metastatic Castration-Resistant Prostate Cancer. J Nucl Med 2020; 61:1476-1483. [PMID: 32111687 DOI: 10.2967/jnumed.119.240242] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 02/06/2020] [Indexed: 11/16/2022] Open
Abstract
Prostate-specific antigen (PSA) is widely used to monitor treatment response in patients with metastatic castration-resistant prostate cancer. However, PSA measurements are considered only after 12 wk of treatment. We aimed to evaluate the prognostic value of early PSA changes after 177Lu-labeled prostate-specific membrane antigen (177Lu-PSMA) radionuclide treatment in metastatic castration-resistant prostate cancer patients. Methods: Men who were treated with 177Lu-PSMA under a compassionate-access program at our institution and had available PSA values at baseline and at 6 wk after treatment initiation were included in this retrospective analysis. Patients were assigned to 3 groups on the basis of PSA changes: response (≥30% decline), progression (≥25% increase), and stable (<30% decline and <25% increase). The coprimary endpoints were overall survival and imaging-based progression-free survival. The secondary endpoints were PSA changes at 12 wk and PSA flare-up. Results: We identified 124 eligible patients with PSA values at 6 wk. A greater than or equal to 30% decline in PSA at 6 wk was associated with longer overall survival (median, 16.7 mo; 95% CI, 14.4-19.0) than stable PSA (median, 11.8 mo; 95% CI, 8.6-15.1) (P = 0.007) or PSA progression (median, 6.5 mo; 95% CI, 5.2-7.8) (P < 0.001). Patients with a greater than or equal to 30% decline in PSA at 6 wk also had a lower risk of imaging-based progression than patients with stable PSA (hazard ratio, 0.60; 95% CI, 0.38-0.94) (P = 0.02), whereas patients with PSA progression had a higher risk of imaging-based progression than patients with stable PSA (hazard ratio, 3.18; 95% CI, 1.95-5.21) (P < 0.001). The percentage changes in PSA at 6 and 12 wk were highly associated (r = 0.90; P < 0.001). Of 31 patients who experienced early PSA progression at 6 wk, 29 (94%) showed biochemical progression at 12 wk. Overall, only 1 (3%) of 36 patients with PSA progression at 6 wk achieved any PSA decline at 12 wk (1% of the entire cohort). The limitations of the study included its retrospective nature and the single-center experience. Conclusion: PSA changes at 6 wk after 177Lu-PSMA initiation are an early indicator of long-term clinical outcome. Patients with PSA progression after 6 wk of treatment could benefit from a very early decision to switch treatment. PSA flare-up during 177Lu-PSMA treatment is very uncommon. Prospective studies are now warranted to validate our findings and potentially inform clinicians earlier on the effectiveness of 177Lu-PSMA.
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Affiliation(s)
- Andrei Gafita
- Department of Nuclear Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany; and
| | - Matthias M Heck
- Department of Urology, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Isabel Rauscher
- Department of Nuclear Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany; and
| | - Robert Tauber
- Department of Urology, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Lisena Cala
- Department of Nuclear Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany; and
| | - Charlott Franz
- Department of Nuclear Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany; and
| | - Calogero D'Alessandria
- Department of Nuclear Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany; and
| | - Margitta Retz
- Department of Urology, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Wolfgang A Weber
- Department of Nuclear Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany; and
| | - Matthias Eiber
- Department of Nuclear Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany; and
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173
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Stuparu AD, Meyer CA, Evans-Axelsson SL, Lückerath K, Wei LH, Kim W, Poddar S, Mona CE, Dahlbom M, Girgis MD, Radu CG, Czernin J, Slavik R. Targeted alpha therapy in a systemic mouse model of prostate cancer - a feasibility study. Theranostics 2020; 10:2612-2620. [PMID: 32194823 PMCID: PMC7052903 DOI: 10.7150/thno.42228] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/07/2020] [Indexed: 12/18/2022] Open
Abstract
225Ac-PSMA-617 targeted-therapy has demonstrated efficacy in 75-85% of patients; however, responses are not durable. We aimed to establish translatable mouse models of disseminated prostate cancer (PCa) to evaluate effectiveness of 225Ac-PSMA-617 at various disease stages. Methods: C4-2, C4-2B, or 22Rv1 cells were injected into the left ventricle of male NSG mice. Disease progression was monitored using bioluminescence imaging (BLI). For treatment, mice were injected with 40 kBq 225Ac-PSMA-617 at one (early treatment cohort) or three weeks (late treatment cohort) post-inoculation. Treatment efficacy was monitored by BLI of whole-body tumor burden. Mice were sacrificed based on body conditioning score. Results: C4-2 cells yielded metastases in liver, lungs, spleen, stomach, bones, and brain - achieving a clinically relevant model of widespread metastatic disease. The disease burden in the early treatment cohort was stable over 27 weeks in 5/9 mice and progressive in 4/9 mice. These mice were sacrificed due to brain metastases. Median survival of the late treatment cohort was superior to controls (13 vs. 7 weeks; p<0.0001) but inferior to that in the early treatment cohort (13 vs. 27 weeks; p<0.001). Late cohort mice succumbed to extensive liver involvement. The 22Rv1 and C4-2B systemic models were not used for treatment due to high kidney metastatic burden or low take rate, respectively. Conclusion: C4-2 cells reproduced metastatic cancer spread most relevantly. Early treatment with 225Ac-PSMA-617 prevented liver metastases and led to significant survival benefit. Late treatment improved survival without reducing tumor burden in the liver, the main site of metastasis. The current findings suggest that early 225Ac-PSMA-617 intervention is more efficacious in the setting of widespread metastatic PCa.
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Affiliation(s)
- Andreea D. Stuparu
- Ahmanson Translational Theranostic Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at University of California, Los Angeles (UCLA), CA, USA
| | - Catherine A.L. Meyer
- Ahmanson Translational Theranostic Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at University of California, Los Angeles (UCLA), CA, USA
| | - Susan L. Evans-Axelsson
- Department of Translational Medicine, Division of Urological Cancers, Skåne University Hospital Malmö, Lund University, Sweden
| | - Katharina Lückerath
- Ahmanson Translational Theranostic Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at University of California, Los Angeles (UCLA), CA, USA
| | - Liu H. Wei
- Ahmanson Translational Theranostic Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at University of California, Los Angeles (UCLA), CA, USA
| | - Woosuk Kim
- Ahmanson Translational Theranostic Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at University of California, Los Angeles (UCLA), CA, USA
| | - Soumya Poddar
- Ahmanson Translational Theranostic Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at University of California, Los Angeles (UCLA), CA, USA
| | - Christine E. Mona
- Ahmanson Translational Theranostic Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at University of California, Los Angeles (UCLA), CA, USA
| | - Magnus Dahlbom
- Ahmanson Translational Theranostic Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at University of California, Los Angeles (UCLA), CA, USA
| | - Mark D. Girgis
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA), CA, USA
| | - Caius G. Radu
- Ahmanson Translational Theranostic Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at University of California, Los Angeles (UCLA), CA, USA
| | - Johannes Czernin
- Ahmanson Translational Theranostic Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at University of California, Los Angeles (UCLA), CA, USA
| | - Roger Slavik
- Ahmanson Translational Theranostic Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at University of California, Los Angeles (UCLA), CA, USA
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174
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Rangger C, Haubner R. Radiolabelled Peptides for Positron Emission Tomography and Endoradiotherapy in Oncology. Pharmaceuticals (Basel) 2020; 13:E22. [PMID: 32019275 PMCID: PMC7169460 DOI: 10.3390/ph13020022] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 02/07/2023] Open
Abstract
This review deals with the development of peptide-based radiopharmaceuticals for the use with positron emission tomography and peptide receptor radiotherapy. It discusses the pros and cons of this class of radiopharmaceuticals as well as the different labelling strategies, and summarises approaches to optimise metabolic stability. Additionally, it presents different target structures and addresses corresponding tracers, which are already used in clinical routine or are being investigated in clinical trials.
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Affiliation(s)
| | - Roland Haubner
- Department of Nuclear Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria;
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175
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Abstract
Samenvatting177Lu-PSMA is een nieuwe, veelbelovende therapie bij patiënten met een gemetastaseerd castratieresistent prostaatcarcinoom (mCRPC). Het radioactief gelabelde medicijn wordt intraveneus toegediend in 1–6 cycli waarbij de β‑stralen zorgen voor intracellulaire DNA-schade en celdood van prostaatkankercellen met PSMA-expressie. Voornamelijk retrospectieve onderzoeken tonen aan dat het serum-PSA met ≥ 50 % daalt bij 40–60 % van deze vaak intensief behandelde patiëntengroep. Mogelijk is er een overlevingswinst in vergelijking met een niet-behandelde groep. De toxiciteit van 177Lu-PSMA is relatief gering. Er trad met name graad I–II CTCAE-xerostomie op bij 30–50 % van de patiënten, en veelal voorbijgaande graad III–IV CTCAE-hematologische toxiciteit (trombocytopenie, leukopenie) bij 0–15 %. De behandeling wordt momenteel onderzocht in meerdere prospectieve studies bij patiënten met mCRPC en in een gerandomiseerde studie. Het gebruik in vroegere fasen van prostaatkanker wordt geëvalueerd. Tot meer bekend is over de uitkomst van deze studies, blijft het gebruik van 177Lu-PSMA experimenteel.
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176
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Siva S, Udovicich C, Tran B, Zargar H, Murphy DG, Hofman MS. Expanding the role of small-molecule PSMA ligands beyond PET staging of prostate cancer. Nat Rev Urol 2020; 17:107-118. [PMID: 31937920 DOI: 10.1038/s41585-019-0272-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2019] [Indexed: 12/25/2022]
Abstract
Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) is rapidly being established as arguably the leading contemporary imaging modality in the management of prostate cancer. Outside of its conventional use in the de novo staging of localized disease and detection of biochemical recurrence, additional applications for the use of PSMA PET are emerging. Uptake of PSMA tracers in other genitourinary malignancies, particularly renal cell carcinoma, has led to new fields of investigation. Therapeutic delivery of radiolabelled PSMA small molecules has shown considerable promise in advanced prostate cancer. The ability to use the same molecule for imaging and therapy - theranostics - enables a highly personalized approach. PSMA PET can also have a considerable influence in the selection and guidance of radiotherapy fields for high-risk and recurrent disease. Intriguingly, changes in intensity of PSMA uptake during systemic therapy might provide early response assessment or novel insight into the biological responses of genitourinary malignancies to treatment. An evolving range of radiolabelled PSMA radiopharmaceuticals is emerging in the multiple facets of modern clinical practice.
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Affiliation(s)
- Shankar Siva
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia. .,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.
| | - Cristian Udovicich
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Ben Tran
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Division of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.,Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
| | - Homi Zargar
- Department of Urology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Declan G Murphy
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Michael S Hofman
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
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177
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Todenhöfer T, Gratzke C. Re: Prostate-specific Membrane Antigen Heterogeneity and DNA Repair Defects in Prostate Cancer. Eur Urol 2019; 77:559-560. [PMID: 31874727 DOI: 10.1016/j.eururo.2019.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Tilman Todenhöfer
- Studienpraxis Urologie, Nuertingen, Germany; Eberhard-Karls University Medical School, Tuebingen, Germany
| | - Christian Gratzke
- Department of Urology, Albert-Ludwigs University, Freiburg, Germany.
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178
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Rathke H, Holland-Letz T, Mier W, Flechsig P, Mavriopoulou E, Röhrich M, Kopka K, Hohenfellner M, Giesel FL, Haberkorn U, Kratochwil C. Response Prediction of 177Lu-PSMA-617 Radioligand Therapy Using Prostate-Specific Antigen, Chromogranin A, and Lactate Dehydrogenase. J Nucl Med 2019; 61:689-695. [PMID: 31653712 DOI: 10.2967/jnumed.119.231431] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/27/2019] [Indexed: 11/16/2022] Open
Abstract
Neuroendocrinelike transdifferentiation of prostate cancer adenocarcinomas correlates with serum levels of chromogranin A (CgA) and drives treatment resistance. The aim of this work was to evaluate whether CgA can serve as a response predictor for 177Lu-prostate-specific membrane antigen 617 (PSMA) radioligand therapy (RLT) in comparison with the established tumor markers. Methods: One hundred consecutive patients with metastasized castration-resistant prostate cancer scheduled for PSMA RLT were evaluated for prostate-specific antigen (PSA), lactate dehydrogenase (LDH), and CgA at baseline and in follow-up of PSMA RLT. Tumor uptake of PSMA ligand, a known predictive marker for response, was assessed as a control variable. Results: From the 100 evaluated patients, 35 had partial remission, 16 stable disease, 15 mixed response, and 36 progression of disease. Tumor uptake above salivary gland uptake translated into partial remission, with an odds ratio (OR) of 60.265 (95% confidence interval [CI], 5.038-720.922). Elevated LDH implied a reduced chance for partial remission, with an OR of 0.094 (95% CI, 0.017-0.518), but increased the frequency of progressive disease (OR, 2.717; 95% CI, 1.391-5.304). All patients who achieved partial remission had a normal baseline LDH. Factor-2 elevation of CgA increased the risk for progression, with an OR of 3.089 (95% CI, 1.302-7.332). Baseline PSA had no prognostic value for response prediction. Conclusion: In our cohort, baseline PSA had no prognostic value for response prediction. LDH was the marker with the strongest prognostic value, and elevated LDH increased the risk for progression of disease under PSMA RLT. Elevated CgA demonstrated a moderate impact as a negative prognostic marker in general but was explicitly related to the presence of liver metastases. Well in line with the literature, sufficient tumor uptake is a prerequisite to achieve tumor response.
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Affiliation(s)
- Hendrik Rathke
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Tim Holland-Letz
- Department of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - Walter Mier
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Paul Flechsig
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Eleni Mavriopoulou
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Manuel Röhrich
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Klaus Kopka
- Division of Radiopharmaceutical Chemistry, German Cancer Research Center, Heidelberg, Germany
| | | | - Frederik Lars Giesel
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Uwe Haberkorn
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany.,Department of Urology, University Hospital Heidelberg, Heidelberg, Germany.,Cooperation Unit Nuclear Medicine, German Cancer Research Center, Heidelberg, Germany; and.,Translational Lung Research Center Heidelberg, German Center for Lung Research, Heidelberg, Germany
| | - Clemens Kratochwil
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
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179
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Sachpekidis C, Alberts I, Rominger A, Afshar-Oromieh A. PSMA radioligand therapy in prostate cancer: overview, latest advances and remaining challenges. Immunotherapy 2019; 11:1267-1271. [PMID: 31496329 DOI: 10.2217/imt-2019-0146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Christos Sachpekidis
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ian Alberts
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Axel Rominger
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ali Afshar-Oromieh
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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180
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Hensbergen AW, Buckle T, van Willigen DM, Schottelius M, Welling MM, van der Wijk FA, Maurer T, van der Poel HG, van der Pluijm G, van Weerden WM, Wester HJ, van Leeuwen FWB. Hybrid Tracers Based on Cyanine Backbones Targeting Prostate-Specific Membrane Antigen: Tuning Pharmacokinetic Properties and Exploring Dye-Protein Interaction. J Nucl Med 2019; 61:234-241. [PMID: 31481575 DOI: 10.2967/jnumed.119.233064] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/06/2019] [Indexed: 12/14/2022] Open
Abstract
Prostate cancer surgery is currently being revolutionized by the use of prostate-specific membrane antigen (PSMA)-targeted radiotracers, for example, 99mTc-labeled PSMA tracer analogs for radioguided surgery. The purpose of this study was to develop a second-generation 99mTc-labeled PSMA-targeted tracer incorporating a fluorescent dye. Methods: Several PSMA-targeted hybrid tracers were synthesized: glutamic acid-urea-lysine (EuK)-Cy5-mas3, EuK-(SO3)Cy5-mas3, EuK-Cy5(SO3)-mas3, EuK-(Ar)Cy5-mas3, and EuK-Cy5(Ar)-mas3; the Cy5 dye acts as a functional backbone between the EuK targeting vector and the 2-mercaptoacetyl-seryl-seryl-seryl (mas3) chelate to study the dye's interaction with PSMA's amphipathic entrance funnel. The compounds were evaluated for their photophysical and chemical properties and PSMA affinity. After radiolabeling with 99mTc, we performed in vivo SPECT imaging, biodistribution, and fluorescence imaging on BALB/c nude mice with orthotopically transplanted PC346C tumors. Results: The dye composition influenced the photophysical properties (brightness range 0.3-1.5 × 104 M-1 × cm-1), plasma protein interactions (range 85.0% ± 2.3%-90.7% ± 1.3% bound to serum, range 76% ± 0%-89% ± 6% stability in serum), PSMA affinity (half-maximal inhibitory concentration [IC50] range 19.2 ± 5.8-175.3 ± 61.1 nM) and in vivo characteristics (tumor-to-prostate and tumor-to-muscle ratios range 0.02 ± 0.00-154.73 ± 28.48 and 0.46 ± 0.28-5,157.50 ± 949.17, respectively; renal, splenic, and salivary retention). Even though all tracer analogs allowed tumor identification with SPECT and fluorescence imaging, 99mTc-EuK-(SO3)Cy5-mas3 had the most promising properties (e.g., half-maximal inhibitory concentration, 19.2 ± 5.8, tumor-to-muscle ratio, 5,157.50 ± 949.17). Conclusion: Our findings demonstrate the intrinsic integration of a fluorophore in the pharmacophore in PSMA-targeted small-molecule tracers. In this design, having 1 sulfonate on the indole moiety adjacent to EuK (99mTc-EuK-(SO3)Cy5-mas3) yielded the most promising tracer candidate for imaging of PSMA.
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Affiliation(s)
- Albertus W Hensbergen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tessa Buckle
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Danny M van Willigen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Margret Schottelius
- Pharmazeutische Radiochemie, Technische Universität München, Garching, Germany
| | - Mick M Welling
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Felicia A van der Wijk
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tobias Maurer
- Martini-Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Gabri van der Pluijm
- Department of Urology, Leiden University Medical Centre, Leiden, The Netherlands; and
| | - Wytske M van Weerden
- Department of Urology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hans-Jürgen Wester
- Pharmazeutische Radiochemie, Technische Universität München, Garching, Germany
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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181
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Mori K, Kimura S, Parizi MK, Enikeev DV, Glybochko PV, Seebacher V, Fajkovic H, Mostafaei H, Lysenko I, Janisch F, Egawa S, Shariat SF. Prognostic Value of Lactate Dehydrogenase in Metastatic Prostate Cancer: A Systematic Review and Meta-analysis. Clin Genitourin Cancer 2019; 17:409-418. [PMID: 31558410 DOI: 10.1016/j.clgc.2019.07.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/03/2019] [Accepted: 07/15/2019] [Indexed: 02/08/2023]
Abstract
The purpose of this study was to assess the prognostic value of lactate dehydrogenase (LDH) in patients with metastatic prostate cancer (PC). A systematic review and meta-analysis was performed in March 2019 according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Studies were deemed eligible if they compared patients with PC with high versus low LDH to determine the predictive value of LDH for overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS). We performed a formal meta-analysis for both OS and PFS. A total of 59 articles with 14,851 patients were included in the systematic review and 45 studies with 12,224 patients for the qualitative assessment. High LDH was associated with both worse OS (pooled hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.75-2.44) and PFS (pooled HR, 1.08; 95% CI, 1.01-1.16). In subgroup analyses of both patients with castration-resistant prostate cancer (CRPC) and those with hormone-sensitive prostate cancer (HSPC), LDH was associated with OS (pooled HR, 2.02; 95% CI, 1.69-2.42 and pooled HR, 2.25; 95% CI, 1.78-2.84, respectively). In patients with CRPC, LDH was associated with OS in those treated with docetaxel systemic chemotherapy and androgen receptor-axis-targeting agents (pooled HR, 2.03; 95% CI, 1.37-3.00 and pooled HR, 1.79; 95% CI, 1.25-2.57, respectively). Elevated serum levels of LDH were associated with an increased risk of mortality and progression in patients with metastatic PC. LDH was independently associated with OS in both patients with CRPC and HSPC. LDH could be integrated into prognostic tools that help guide treatment strategy, thereby facilitating the shared decision-making process.
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Affiliation(s)
- Keiichiro Mori
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shoji Kimura
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Mehdi Kardoust Parizi
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Shariati Hospital, Tehran University of Medical Sciences, Teheran, Iran
| | - Dmitry V Enikeev
- Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Petr V Glybochko
- Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Harun Fajkovic
- Department of Urology, Medical University of Vienna, Vienna, Austria; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
| | - Hadi Mostafaei
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Hamburg, Hamburg, Germany
| | - Ivan Lysenko
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Florian Janisch
- Department of Urology, Medical University of Vienna, Vienna, Austria; Research Center for Evidence-based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shin Egawa
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY; Department of Urology, University of Texas Southwestern, Dallas, TX; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia.
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182
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Karamzade-Ziarati N, Manafi-Farid R, Ataeinia B, Langsteger W, Pirich C, Mottaghy FM, Beheshti M. Molecular imaging of bone metastases using tumor-targeted tracers. 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 RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2019; 63:136-149. [PMID: 31315347 DOI: 10.23736/s1824-4785.19.03206-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Bone metastasis is a disastrous manifestation of most malignancies, especially in breast, prostate and lung cancers. Since asymptomatic bone metastases are not uncommon, early detection, precise assessment, and localization of them are very important. Various imaging modalities have been employed in the setting of diagnosis of bone metastasis, from plain radiography and bone scintigraphy to SPECT, SPECT/CT, PET/CT, MRI. However, each modality showed its own limitation providing accurate diagnostic performance. In this regard, various tumor-targeted radiotracers have been introduced for molecular imaging of bone metastases using modern hybrid modalities. In this article we review the strength of different cancer-specific radiopharmaceuticals in the detection of bone metastases. As shown in the literature, among various tumor-targeted tracers, 68Ga DOTA-conjugated-peptides, 68Ga PSMA, 18F DOPA, 18F galacto-RGD integrin, 18F FDG, 11C/18F acetate, 11C/18F choline, 111In octreotide, 123/131I MIBG, 99mTc MIBI, and 201Tl have acceptable capabilities in detecting bone metastases depending on the cancer type. However, different study designs and gold standards among reviewed articles should be taken into consideration.
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Affiliation(s)
- Najme Karamzade-Ziarati
- Research Center for Nuclear Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reyhaneh Manafi-Farid
- Research Center for Nuclear Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahar Ataeinia
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Werner Langsteger
- PET-CT Center Linz, Department of Nuclear Medicine, Ordensklinikum, St. Vincent's Hospital, Linz, Austria
| | - Christian Pirich
- Department of Nuclear Medicine & Endocrinology, Paracelsus Medical University, Salzburg, Austria
| | - Felix M Mottaghy
- Department of Nuclear Medicine, University Hospital, RWTH University, Aachen, Germany.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Mohsen Beheshti
- Department of Nuclear Medicine & Endocrinology, Paracelsus Medical University, Salzburg, Austria - .,Department of Nuclear Medicine, University Hospital, RWTH University, Aachen, Germany
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183
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Kessel K, Seifert R, Schäfers M, Weckesser M, Schlack K, Boegemann M, Rahbar K. Second line chemotherapy and visceral metastases are associated with poor survival in patients with mCRPC receiving 177Lu-PSMA-617. Am J Cancer Res 2019; 9:4841-4848. [PMID: 31410185 PMCID: PMC6691377 DOI: 10.7150/thno.35759] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/07/2019] [Indexed: 12/11/2022] Open
Abstract
The purpose of this study was to identify previous treatments and biomarker profile features that prognosticate overall survival (OS) in patients with mCRPC receiving 177Lu-PSMA-617. Methods: 109 mCRPC patients treated with a median of 3 cycles of 177Lu-PSMA-617 were included. Data were analyzed according to OS as well as PSA response patterns with regard to prior therapies, laboratory biomarkers and metastatic extent in univariate as well as multivariate Cox's proportional hazards models. PSA decline was assessed using the lowest PSA levels after the first cycle of therapy (initial PSA response) and during the entire observation period (best PSA response). Results: In total, 54 patients (49.5%) died during the observation period. First and second line chemotherapy were performed in 85% and 26%, and Abiraterone and Enzalutamide were administered in 83% and 85%, respectively. Any initial PSA decline occurred in 55% while 25% showed a PSA decline of ≥50%. The median estimated OS was 9.9 months (95% CI: 7.2-12.5) for all patients. Any initial decline of PSA was associated with significantly prolonged OS (15.5 vs. 5.7 months, p = 0.002). Second line cabazitaxel chemotherapy (6.7 vs. 15.7 months, p = 0.002) and presence of visceral metastases (5.9 vs. 16.4 months, p<0.001) were associated with shorter OS. Only visceral metastases remained significant in a multivariate analysis. Conclusion:177Lu-PSMA-617 is an effective therapy for patients with mCRPC. However, the present data indicate that its beneficial effects on OS are strongly influenced by pretreatment (history of second line chemotherapy with cabazitaxel) and the presence of visceral metastases at onset of 177Lu-PSMA-617 treatment.
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184
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Murphy DG, Azad AA, Sandhu S, Violet J, Hofman MS. Prostate-specific Membrane Antigen Across the Spectrum of Prostate Cancer: Detection, Surgery, and Theranostics. Eur Urol 2019; 75:927-928. [DOI: 10.1016/j.eururo.2018.12.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 12/20/2018] [Indexed: 01/10/2023]
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185
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Sathekge M, Bruchertseifer F, Vorster M, Lawal IO, Knoesen O, Mahapane J, Davis C, Reyneke F, Maes A, Kratochwil C, Lengana T, Giesel FL, Van de Wiele C, Morgenstern A. Predictors of Overall and Disease-Free Survival in Metastatic Castration-Resistant Prostate Cancer Patients Receiving 225Ac-PSMA-617 Radioligand Therapy. J Nucl Med 2019; 61:62-69. [PMID: 31101746 DOI: 10.2967/jnumed.119.229229] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 05/07/2019] [Indexed: 01/27/2023] Open
Abstract
Metastatic prostate carcinoma overexpresses prostate-specific membrane antigen (PSMA), making this antigen a suitable target for radioligand therapy of the disease. Here we report on our experience with a series of 73 castration-resistant prostate carcinoma patients treated with 225Ac-PSMA-617, identifying variables predictive for overall survival (OS) and progression-free survival (PFS) after 225Ac-PSMA-617 treatment. Methods: 225Ac-PSMA-617 was administered to patients who had metastatic castration-resistant prostate carcinoma and who had exhausted available therapy options for their disease. Full blood count, glomerular filtration rate, and liver function test were obtained at baseline and on follow-up for evaluation of toxicity. 68Ga-PSMA PET/CT was obtained at baseline, before every treatment cycle, and on follow-up for selection of patients for treatment, to determine the activity of the treatment agent to be administered, and for response assessment. Serial prostate-specific antigen (PSA) was obtained for PSA response assessment. Results: Seventy-three men (mean age, 69 y; range, 45-85 y) with metastatic castration-resistant prostate carcinoma were treated with 210 cycles of 225Ac-PSMA-617. In 70% of patients, a PSA decline of greater than or equal to 50% was obtained; 82% of patients had any PSA decline. In 29% of patients, all lesions on 68Ga-PSMA PET resolved in response to treatment. During follow-up, 23 patients experienced disease progression, whereas 13 patients died from their disease. The estimated median PFS and OS were 15.2 mo (95% CI, 13.1-17.4) and 18 mo (95% CI, 16.2-19.9), respectively. In univariate analyses, factors such as baseline PSA, any PSA decline, PSA decline of greater than or equal to 50%, prior chemotherapy, prior radiation therapy, and baseline hemoglobin level were associated with longer PFS and OS (all Ps < 0.05). In multivariate analyses, there was a negative association between prior 177Lu-PSMA therapy and PFS, and a positive association between PSA decline of greater or equal to 50% and PFS. Only a PSA decline of greater than or equal to 50% remained significantly associated with OS on multivariate analyses. Xerostomia was seen in 85% of patients but was not severe enough to warrant discontinuing treatment. Anemia was seen in 27 patients; no patients had grade IV bone marrow toxicity. Renal failure of grade III or IV was seen in 5 patients with baseline renal impairment. Conclusion: In this study, a PSA decline of greater than or equal to 50% after treatment with 225Ac-PSMA-617 was proven by multivariate analyses to be significantly associated with OS and PFS. Furthermore, previous 177Lu-PSMA treatment was negatively associated with PFS in both univariate and multivariate analyses.
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Affiliation(s)
- Mike Sathekge
- Department of Nuclear Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Frank Bruchertseifer
- European Commission, Joint Research Centre, Directorate for Nuclear Safety and Security, Karlsruhe, Germany
| | - Mariza Vorster
- Department of Nuclear Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Ismaheel O Lawal
- Department of Nuclear Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Otto Knoesen
- Nuclear Technology Products (NTP), Pelindaba, South Africa
| | - Johncy Mahapane
- Department of Nuclear Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Cindy Davis
- Department of Nuclear Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Florette Reyneke
- Department of Nuclear Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Alex Maes
- Department of Nuclear Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa.,Katholieke University Leuven, Kortrijk, Belgium
| | | | - Thabo Lengana
- Department of Nuclear Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | | | - Christophe Van de Wiele
- Department of Nuclear Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa.,Ghent University, Ghent, Belgium
| | - Alfred Morgenstern
- Department of Nuclear Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa.,European Commission, Joint Research Centre, Directorate for Nuclear Safety and Security, Karlsruhe, Germany
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186
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Frydenberg M. Re: 68Ga-Labeled Prostate-specific Membrane Antigen Ligand Positron Emission Tomography/Computed Tomography for Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol 2019; 76:405. [PMID: 30955971 DOI: 10.1016/j.eururo.2019.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 03/26/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Mark Frydenberg
- Department of Surgery, Monash University, Clayton, Australia.
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187
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Huang HL, Tong AKT, Thang SP, Yan SX, Lam WWC, Loke KSH, Tang CYL, Cheng LTJ, Ooi GSK, Low HC, Magsombol BM, Tham WY, Goh CXY, Tan CJ, Khor YM, Zaheer S, Bharadwaj P, Xie W, Ng DCE. Current Status and Growth of Nuclear Theranostics in Singapore. Nucl Med Mol Imaging 2019; 53:96-101. [DOI: 10.1007/s13139-019-00580-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 01/13/2019] [Accepted: 01/14/2019] [Indexed: 11/30/2022] Open
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188
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Murphy DG, Sathianathen N, Hofman MS, Azad A, Lawrentschuk N. Where to Next for Theranostics in Prostate Cancer? Eur Urol Oncol 2019; 2:163-165. [PMID: 31017092 DOI: 10.1016/j.euo.2019.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Declan G Murphy
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia; The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.
| | | | - Michael S Hofman
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia; Molecular Imaging and Nuclear Medicine Therapeutics, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Arun Azad
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia; Division of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Nathan Lawrentschuk
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Surgery, University of Melbourne, Austin Hospital, Heidelberg, Australia
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189
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Murphy DG, Padhani AR, Ost P. Adding Colour to the Grey Zone of Advanced Prostate Cancer. Eur Urol Focus 2019; 5:123-124. [DOI: 10.1016/j.euf.2019.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/21/2019] [Accepted: 02/16/2019] [Indexed: 12/30/2022]
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190
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Theranostics for Advanced Prostate Cancer: Current Indications and Future Developments. Eur Urol Oncol 2019; 2:152-162. [PMID: 31017091 DOI: 10.1016/j.euo.2019.01.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 12/24/2018] [Accepted: 01/07/2019] [Indexed: 12/13/2022]
Abstract
CONTEXT Advanced prostate cancer (PCa) is a prominent cause of cancer death in men; positron emission tomography (PET) imaging may play a relevant role in detecting metastases and thus allowing a more tailored therapy in these patients. Radioligand therapy (RLT) may also gain relevance as a treatment strategy in advanced disease. OBJECTIVE The aim of this review is to highlight how the recently developed theranostic processes may become a part of both the available diagnostic and the therapy arsenal in advanced PCa patients. EVIDENCE ACQUISITION An expert panel of nuclear medicine physicians and a urologist, highly experienced in the fields of radionuclide imaging and RLT in advanced PCa, performed a nonsystematic review of the current indications, performance, limitations, and potential future developments of the currently available options in PCa theranostics. EVIDENCE SYNTHESIS Among PET radiotracers, prostate-specific membrane antigen (PSMA)-based compounds in advanced PCa are the focus of a continuously growing interest, mostly due to their potential relevance as theranostic agents. The impact of PSMA-based PET/computed tomography imaging on treatment strategies and prognosis is promising, but still not unquestionably clear. Potential applications may include a role as a gatekeeper to PSMA-directed RLT, as well as monitoring the spread of systemic disease. Currently, initial results seem to substantiate the role of PSMA-directed RLT in terms of feasibility and efficacy. CONCLUSIONS PSMA is a promising molecule for both imaging and therapy in advanced PCa patients; nevertheless, further studies are needed to investigate its role and to determine the impact of its side effects and its overall strategy outcome. PATIENT SUMMARY Prostate-specific membrane antigen (PSMA), a protein, is highly expressed on prostate cancer cells. The possibility to perform diagnostic imaging and subsequently administer therapies by the means of the same molecule is called "theranostics". In patients with advanced prostate cancer, PSMA might have a role in detecting disease spread through both positron emission tomography and single-photon emission computed tomography imaging, while treating prostate cancer systemic localizations with radioligand therapy. Further studies are needed to better determine patients' risks and benefits of these therapeutic approaches.
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191
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Azorín-Vega E, Rojas-Calderón E, Ferro-Flores G, Aranda-Lara L, Jiménez-Mancilla N, Nava-Cabrera MA. Assessment of the radiation absorbed dose produced by 177Lu-iPSMA, 225Ac-iPSMA and 223RaCl 2 to prostate cancer cell nuclei in a bone microenvironment model. Appl Radiat Isot 2019; 146:66-71. [PMID: 30753987 DOI: 10.1016/j.apradiso.2019.01.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/24/2019] [Accepted: 01/24/2019] [Indexed: 10/27/2022]
Abstract
This research aimed to assess the radiation absorbed dose produced by 177Lu-iPSMA (177Lu-prostate specific membrane antigen inhibitor), 225Ac-iPSMA and 223RaCl2 to prostate cancer cell nuclei in a simplified model of bone by using an experimental in-vitro prostate cancer LNCaP cell biokinetic study and Monte Carlo simulation with the MCNPX code. Results showed that 225Ac-iPSMA releases a nine hundred-fold radiation dose greater than 177Lu-iPSMA and 14 times more than 223RaCl2 per unit of activity retained in bone. 225Ac-iPSMA could be the best option for treatment of bone metastases in prostate cancer.
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Affiliation(s)
- Erika Azorín-Vega
- Departamento de Materiales Radiactivos, Instituto Nacional de Investigaciones Nucleares, Ocoyoacac, 52750, Estado de México, Mexico.
| | - Eva Rojas-Calderón
- Departamento de Ciencias Ambientales, Instituto Nacional de Investigaciones Nucleares, Ocoyoacac, 52750, Estado de México, Mexico.
| | - Guillermina Ferro-Flores
- Departamento de Materiales Radiactivos, Instituto Nacional de Investigaciones Nucleares, Ocoyoacac, 52750, Estado de México, Mexico
| | - Liliana Aranda-Lara
- Facultad de Medicina, Universidad Autónoma del Estado de México, Toluca, 50180, Mexico
| | - Nallely Jiménez-Mancilla
- CONACyT, Instituto Nacional de Investigaciones Nucleares, Ocoyoacac, 52750, Estado de México, Mexico
| | - Miguel A Nava-Cabrera
- Departamento de Materiales Radiactivos, Instituto Nacional de Investigaciones Nucleares, Ocoyoacac, 52750, Estado de México, Mexico; Facultad de Medicina, Universidad Autónoma del Estado de México, Toluca, 50180, Mexico
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