Radioimmunoscintigraphy of squamous carcinomas of the head and neck

Targeted radionuclide therapy in head and neck cancer

There is great potential for targeted radionuclide therapy (TRT) in the treatment of head and neck cancer. In recent years, developments in fields such as antigen screening, protein engineering, and cancer biology have facilitated the rational design of targeted pharmaceuticals, with monoclonal antibodies forming the most rapidly expanding category. TRT may be a promising way to improve targeted treatment, especially in head and neck cancer, because of the intrinsic radiosensitivity of this tumor type. TRT may also provide a good foundation on which to build rational biologic combination therapies. In the next few years the use of TRT may offer new opportunities for further improvement of the therapeutic ratio that potentially may obviate or reduce the need for conventional cytotoxics.

Radioimmunodetection and radioimmunotherapy of head and neck cancer

Radiolabeled monoclonal antibodies (MAbs) can add a dimension to diagnostic imaging and staging of metastatic head and neck cancer, as well as in eradication of this disease. The vast majority of malignancies arising in the oral cavity, pharynx and larynx are squamous cell carcinomas. This common cellular origin makes it attractive to search for appropriate tumor-associated antigens, which are preferentially expressed in these neoplasms. Radiolabeled MAbs directed against these antigens can be used for tumor detection and selective therapy, known as radioimmunoscintigraphy and radioimmunotherapy, respectively. The combination of MAbs with positron emission tomography (PET) is an attractive novel option to improve tumor detection and to facilitate MAb quantification in a therapeutic setting. Basic aspects of tumor targeting with MAbs, as well as a review of the clinical trials reported in the literature, including own results, are presented.

Technetium-99m labeled epidermal growth factor-tumor imaging in mice

We have shown previously that the epidermal growth factor peptide (EGF) may be radiolabeled with 99mTc at room temperature and neutral pH by using the N-hydroxysuccinimide ester of S-acetyl mercaptoacetyltriglycine (MAG3) as a bifunctional chelator. By a competition binding assay, we found that MAG3-conjugated EGF retained biological activity. Furthermore, the labeled peptide exhibited saturation binding to EGF receptor-positive tumor cell lines which could be inhibited by presaturation of the cells with unlabeled, native EGF. Biodistribution in normal mice at 3 h postadministration showed rapid clearance with minimal retention of the label in sampled organs. We have now investigated the tumor localization properties in mice of this labeled peptide. Nude mice implanted with the EGF receptor-positive tumors A431 and LS-174T were administered labeled EGF and a labeled control peptide (BPTI, aprotinin). Tumor uptake at 12 h postadministration was 0.44% injected dose/g for EGF/g vs. 0.09 for the control. Pretreatment of tumored mice with unlabeled EGF blocked about half the tumor uptake. Animals were also administered an anti-EGF receptor antibody labeled with 99mTc via MAG3. Relative to the antibody, tumor-to-muscle ratios were improved from 6 to 15 and tumor-to-blood ratios from 0.4 to 7 with EGF. These favorable results along with documented evidence of overexpression of the EGF receptor in many human tumors suggest that 99mTc-EGF should be considered further for tumor detection.

Imaging and staging of head and neck cancer using a low pH In-111-bleomycin complex

Bleomycin (BLM), a natural antibiotic toxic to dividing cells has been used for treatment of several forms of cancer. BLM has been labelled with various cations but most have turned out to be unstable in vivo. In-BLM has demonstrated high bone marrow uptake, but by using an In-111-bleomycin complex (BLMC) formed at low pH, the low in vivo stability and high bone marrow uptake can be avoided. Our premise is to combine radiotherapy and chemotherapy by using radionuclide-BLMC. In this study we used In-111-A'2a-c-BLMC in 28 head and neck cancer patients. Scintigraphic findings were compared to those of surgery, pre-operative radiology and proliferation markers. The injected patient activity was approximately 85 MBq, 100 MBq/mg. The half-life of In-111 activity in serum varied from 1.5 to 3.1 h, and in urine from 1.4 to 3.7 h. More than 95% of the urine activity was excreted within 24 h. From biopsies obtained from surgical specimens of 22 patients the absolute uptakes in tumour tissues varied between 0.10 and 0.95 x 10(-3)% ID/g. Uptakes in normal tissues varied from 0.01 to 0.32 x 10(-3)% ID/g, and were always lower than in malignant tissues of the same patients. All patients were examined on the injection day with ultrasonography of the neck. Using In-111-BLMC we missed small metastatic lymph nodes (< 1 cm) in 2 patients, but there were no false positive findings. The critical organ from the dosimetric point of view was the kidney. The absorbed radiation doses with these injected activities were 19 mGy in liver, 75 mGy in kidney and 1.0 mGy in whole body (5 h mean residence time). Our results indicate that In-111-BLMC targets head and neck cancer, and identifies metastatic spread. It could possibly be applied with higher activities for adjuvant Auger-electron therapy of head and neck cancer.

Phase I trial and tumour localisation of the anti-EGFR monoclonal antibody ICR62 in head and neck or lung cancer

The purpose of this study was to determine the effect of the first rat monoclonal antibody (MAb ICR62) to the epidermal growth factor receptor (EGFR) in a phase I clinical trial in patients with unresectable squamous cell carcinomas. This antibody effectively blocks the binding of EGF, transforming growth factor (TGF)-alpha and HB-EGF to the EGFR, inhibits the growth in vitro of tumour cell lines which overexpress the EGFR and eradicates such tumours when grown as xenografts in athymic mice. Eleven patients with squamous cell carcinoma of the head and neck and nine patients with squamous cell carcinoma of the lung, whose tumours expressed EGFR, were recruited. Groups of three patients were treated with 2.5 mg, 10 mg, 20 mg or 40 mg of ICR62 and a further eight patients received 100 mg. All patients were evaluated for toxicity using WHO criteria. Patients' sera were tested for the clearance of MAb ICR62 and the development of human anti-rat antibodies (HARA). No serious (WHO Grade III-IV) toxicity was observed in patients treated with up to 100 mg of antibody ICR62. Antibody ICR62 could be detected at 4 h and 24 h in the sera of patients treated with 40 mg or 100 mg of ICR62. Only 4/20 patients showed HARA responses (one at 20 mg, one at 40 mg and two at 100 mg doses) and of these only the former two were anti-idiotypic responses. In four patients receiving doses of ICR62 at 40 mg or greater, biopsies were obtained from metastatic lesions 24 h later and examined for the localisation of ICR62 using anti-rat antibody reagent. In these patients we showed the localisation of MAb ICR62 to the membranes of tumour cells; this appeared to be more prominent at the higher dose of 100 mg. On the basis of these data we conclude that MAb ICR62 can be administered safely to patients with squamous cell carcinomas and that it can localise efficiently to metastases even at relatively low doses.

Radioimmunodetection of malignant solid tumours

An increased clinical utility of radiolabelled monoclonal antibodies (MoAb), recognizing a variety of different antigens expressed preferentially in malignant tissue, for localizing primary, metastatic and recurrent cancer has been documented in many recent investigations. This review focuses on both basic and practical aspects of radioimmunodetection in oncology and is a status report on the performance and limitations of radiolabelled antibody procedures currently applied to the clinical detection of malignant solid tumours. At this time clinically validated radioimmunodetection methods are available for colorectal, ovarian, breast, lung, thyroid medullary, and head and neck carcinoma, and melanoma. Recent advances in humanization of MoAb significantly improve the prospects of effective antibody-guided radiotherapy in the near future.

Epidermal growth factor receptor expression by human squamous cell carcinomas of the head and neck, cell lines and xenografts

Epidermal growth factor receptor (EGFR) overexpression has been associated frequently with squamous cell carcinomas (SCC) and SCC cell lines. In most cases the level of EGFR on the tumours from which the cell lines were derived has not been determined, nor have EGFR levels been determined for xenograft tumours from the cell lines. In this study we determined EGFR expression on a new series of head and neck SCC (SCCHN)-derived cell lines, which were obtained from tumours representing a spectrum of malignant progression, and two cell strains derived from erythroplakia premalignant lesions. The level of EGFR on cell lines was determined by [125I]EGF competitive binding assays. EGFR levels on some of the original tumours and xenografts of the cell lines were determined on cryosections by a competitive binding assay based on [125I]EGFR1, an EGFR-specific monoclonal antibody. EGFR expression on the tumour cryosections was compared with expression on cryosections of skin and buccal mucosa. Eight of the ten tumour cell lines had elevated EGFR. Two of the tumour-derived cell lines and the two erythroplakia-derived cell strains expressed EGFR at levels similar to that detected on normal keratinocytes in tissue culture. Only two of the tumours overexpressed EGFR when compared with normal tissue. The other tumours had levels similar to that detected on the basal layers of skin or buccal mucosa. The xenografts expressed EGFR, as did the original tumours, even though they were derived from cell lines that displayed significant overexpression of EGFR. This study suggests that most tumours have a latent potential to overexpress EGFR which is realised in tissue culture.

The feasibility of radioimmunotherapy of head and neck cancer

Since the introduction of the hybridoma technology by Kohler and Milstein (Nature 1975, 256, 495-497), tremendous effort has been put in the realisation of Ehrlich's concept of the magic bullet, which was proposed as early as the beginning of the century. The first clinical studies for radioimmunoscintigraphy (RIS) and radioimmunotherapy (RIT) with radiolabelled antibodies were undertaken in the early 1980s. Since then, RIS has been performed on thousands of patients with various types of malignancies, like colon carcinoma, lung carcinoma, breast carcinoma, neuroblastoma, T-cell lymphoma and ovarian carcinoma. In addition, a substantial number of therapy trials with radiolabelled antibodies have been performed. The developments for head and neck squamous cell carcinoma (HNSCC) have only recently been able to catch up with these events to some extent. One of the main reasons for this slow progress has been the lack of monoclonal antibodies (Mab) with specificity for HNSCC. Although there are as yet no real tumour specific antigens known for HNSCC, which also holds true for the majority of malignancies arising from other tissues, we now have the availability of a number of Mab with high specificity for HNSCC and with a very restricted reaction pattern with normal tissues. Labelled with 131I, these Mab have been shown to be highly capable to localise in HNSCC xenografts in nude mice. Based on these promising data, patient studies with one of these Mab, designated Mab E48, labelled with 99mTc, were started to evaluate the feasibility of RIS in patients with head and neck cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunotherapy of human tumour xenografts overexpressing the EGF receptor with rat antibodies that block growth factor-receptor interaction

Athymic mice bearing xenografts of human tumours that overexpress the receptor (EGFR) for EGF and TGF alpha have been used to evaluate the therapeutic potential of three new rat monoclonal antibodies (mAbs) directed against two distinct epitopes on the extracellular domain of the human EGFR. The antibodies, ICR16 (IgG2a), ICR62 (IgG2b) and ICR64 (IgG1), have been shown (Modjtahedi et al., 1993) to be potent inhibitors of the growth in vitro of a number of human squamous cell carcinomas because they block receptor-ligand interaction. When given i.p. at 200 micrograms dose, the three antibodies were found to induce complete regression of xenografts of the HN5 tumour if treatment with antibody commenced at the time of tumour implantation (total doses: ICR16, 3.0 mg; ICR62, 1.2 mg; ICR64, 2.2 mg). More importantly when treatment was delayed until the tumours were established (mean diam. 0.5 cm) both ICR16 and ICR62 induced complete or almost complete regression of the tumours. Furthermore, treatment with a total dose of only 0.44 mg of ICR62 was found to induce complete remission of xenografts of the breast carcinoma MDA-MB 468, but ICR16 was less effective at this dose of antibody and only 4/8 tumours regressed completely. ICR16 and ICR62 were poor inhibitors of the growth in vitro of the vulval carcinoma A431, but both induced a substantial delay in the growth of xenografts of this tumour and 4/8 tumours regressed completely in the mice treated with ICR62 (total dose 2.2 mg). Although ICR16 and ICR64 were more effective than ICR62 as growth inhibitors in vitro, ICR62 was found to be substantially better at inducing regression of the tumour xenografts due perhaps to additional activation of host immune effector functions by the IgG2b antibody. We conclude that these antibodies may be useful therapeutic agents that can be used alone without conjugation to other cytotoxic moieties.

A novel technetium-99m labeled monoclonal antibody (174H.64) for staging head and neck cancer by immuno-SPECT

A novel murine monoclonal antibody (MAb 174H.64) was labeled with 99mTc by a direct method. MAb 174H.64 detects a cytokeratin-associated antigen which is expressed by over 90% of all squamous cell carcinomas. Panendoscopy, sonography and computerized tomography scan were performed in all cases as well as magnetic resonance imaging (in selected patients). Pre-operative immunoscintigraphy was performed in 21 patients with histologically proven primary carcinomas (18 with remaining primary tumors and 3 with lymph node recurrences). Scintigraphic images were obtained 4-6 h after injection of 1.1 GBq of the 99mTc-labeled antibody (2 mg). Late images were acquired 18 to 24 h after injection. Single-Photon-Emission-Computed Tomography (SPECT) of the head and thorax was performed in all patients. The primary tumors were immunoscintigraphically visualized in all 18 patients with remaining primary tumor. Fifteen of 18 loco-regional lymph node metastases were visualized by immunoscintigraphy (the smallest lesions had a diameter of < 1 cm), in one patient lymph node metastases were detected by immunoscan only. Two metastatically involved lymph nodes were identified by histology only (micrometastases). Distant metastases were present in 3 patients, of which two were identified by immunoscintigraphy. Immuno-SPECT according to this method was a sensitive and specific imaging modality for preoperative staging of patients with squamous cell carcinoma of the head and neck and detected lymph node metastases with higher accuracy than conventional clinical and imaging modalities.

Radioimmunodetection of head and neck cancer. A review

Radiolabeled antibodies can add a dimension in the diagnostic imaging and staging of metastatic head and neck malignancies. In the oral cavity, oropharynx and larynx the vast majority of malignancies are squamous cell carcinomas. This common cellular origin makes it feasible to search these neoplasms for appropriate tumor-associated antigens which can be used for radioimmunoscintigraphy. The pretherapeutic staging of head and neck malignancies, including salivary gland tumors, is based on clinical findings and conventional radiology (computerized tomography, magnetic resonance imaging, ultrasonography). The routine use of monoclonal antibodies for imaging head and neck malignancies was made possible by the production of several monoclonal antibodies to tumor-associated membrane antigens. A review of the clinical trials reported in the literature, and our own results with 111In-labeled anti-carcinoembryonic antigen (CEA) antibody in 42 patients are presented.

Radioimmunotherapy of human head and neck squamous cell carcinoma xenografts with 131I-labelled monoclonal antibody E48 IgG

Monoclonal antibody (MAb) E48 reacts with a 22 kD antigen exclusively expressed in squamous and transitional epithelia and their neoplastic counterparts. Radiolabelled with 99mTc, MAb E48 is capable of targeting metastatic and recurrent disease in patients with head and neck cancer. In this study, the capacity of 131I-labelled MAb E48 to eradicate xenografts of human squamous cell carcinoma of the head and neck (HNSCC) in nude mice was examined. Experimental groups received a single i.v. bolus injection of 400 microCi MAb E48 IgG (number of mice (n = 6, number of tumours (t) = 9) or 800 microCi MAb E48 IgG (n) = 5,t = 7), whereas control groups received either diluent (n = 3,t = 5), unlabelled MAb E48 IgG (n = 4,t = 5) or 800 microCi 131I-labelled isotype-matched control MAb (n = 6,t = 9). A 4.1-fold increase in the median tumour volume doubling time and regression of two out of ten tumours (20%) was observed in mice treated with 400 microCi. In mice treated with 800 microCi. In mice treated with 800 microCi, two out of seven tumours (29%) showed complete remission without regrowth during follow-up (greater than 3 months). Median tumour volume doubling time in the remaining five tumours was increased 7.8-fold. No antitumour effects were observed in mice injected with diluent, unlabelled MAb E48 or 131I-labelled control MAb. In the same xenograft model, chemotherapy with doxorubicin, 5-fluorouracil, cisplatin, bleomycin, methotrexate or 2',2'-difluorodeoxycytidine yielded a less profound effect on tumour volume doubling time. Increases in tumour volume doubling time with these chemotherapeutic agents were 4, 2.2, 2.1, 1.7, 0, and 2.6 respectively. Moreover, no cures were observed with any of these chemotherapeutic agents. From the tissue distribution of 800 microCi MAb E48, the absorbed cumulative radiation doses of tumour and various organs were calculated using the trapezoid integration method for the area under the curve. To tumour xenografts, 12,170 cGy was delivered, blood received 2,984 cGy, whereas in every other tissue the accumulated dose was less than 6% of the dose delivered to tumour. These data, describing the first radiolabelled MAb with therapeutic efficacy against HNSCC, suggest radioimmunotherapy with MAb E48 to be a potential therapeutic modality for the treatment of head and neck cancer.

Metastatic squamous carcinoma in the neck: an anatomical and physiological study using CT and SPECT 99Tcm (V) DMSA

Technetium-99m (99Tcm) (V) dimercaptosuccinic acid (DMSA) is a new tumour imaging agent that has been used to image squamous cell carcinoma (SCC) of the head and neck. This study has been undertaken to compare clinical examination with computed tomography (CT) (anatomical) and SPECT 99Tcm (V) DMSA (physiological) imaging in the evaluation of metastatic SCC of the neck. Twenty-five patients with head and neck cancer were studied. Computed tomography was as sensitive but more accurate than clinical examination in predicting the presence of cancer. SPECT 99Tcm (V) DMSA was inferior to both techniques in identifying metastatic disease. There is no role for SPECT 99Tcm (V) DMSA imaging in the management of patients with SCC metastatic to the neck. Combined imaging with CT offered no advantages over anatomical imaging with CT alone. There is no role for CT in the routine evaluation of the clinically N0 neck and the role of CT of the neck in the management of patients with metastatic SCC is discussed.

Metastatic carcinoma in the neck: a clinical, radiological, scintigraphic and pathological study

This study was undertaken to compare clinical evaluation of the neck with 99mTc(v) DMSA planar scintigraphy and computerized tomography (CT) in patients with head and neck carcinoma. Twenty-six patients were studied and in all but one the neck was previously untreated. A total of 31 neck dissections were performed and the specimens examined histopathologically. CT was approximately as accurate (71%) as clinical examination (68%) and more accurate than 99mTc(v) DMSA planar scintigraphy (48%) in predicting which necks contained metastatic carcinoma. Overall, 13% of necks had their staging correctly changed by 99mTc(v) DMSA scintigraphy compared with 10% for CT. Although scintigraphy upstaged 13% of clinically N0 necks compared to 6% for CT, it was less sensitive and specific than either clinical examination or CT. 99mTc(v) DMSA planar scintigraphy has no role to play in the investigation of patients with metastatic carcinoma to include the clinically N0 neck.

Technetium-99m(v) dimercaptosuccinic acid planar scintigraphy in head and neck cancer: clinical, scintigraphic and radiological study

Technetium-99m (Tc99m)(v) Dimercaptosuccinic Acid (DMSA) is an imaging agent which has been proposed as a scintigraphic marker for head and neck squamous cell carcinoma. Fifty-four patients were studied of whom 51 had a head and neck tumour. All patients were examined and then imaged using Tc99m(v) DMSA scintigraphy and computerized tomography. Scintigraphy was less sensitive than clinical examination in the detection of patients with cancer, patients with primary tumours and patients with metastatic neck disease. CT was as sensitive and as accurate as clinical examination but more sensitive than Tc99m(v) DMSA in detecting patients with cancer and with primary tumours. CT was more sensitive and more accurate than both clinical examination and Tc99m(v) DMSA scintigraphy in predicting which patients had metastatic neck disease. Although Tc99m(v) DMSA is accumulated by squamous cell carcinoma, its inability to detect low volume disease and apparent low specificity means it has no role to play in the management of patients with head and neck squamous cell carcinoma.

Nuclear medicine in otolaryngology

Nuclear medicine has a distinct role to play in otolaryngological practice. Accurate diagnosis of endocrine conditions is now possible using precise in-vitro hormone measurement. Specific clinical questions can be answered using in-vivo investigations. 99mTcO-4/123I scintigraphy is used to evaluate thyrotoxicosis and solitary thyroid nodules. 99mTc/201T1 subtraction scanning is of value in the preoperative localization of parathyroid adenomas and 99mTcO-4 is particularly useful in assessing salivary and lachrymal gland function and drainage. 99mTc-MDP bone scanning is useful in the evaluation of osteomyelitis, temporomandibular joint dysfunction, bone graft viability and some facial fractures. The role of radioisotopes in the management of differentiated and medullary carcinoma of the thyroid is now well established. Although there are many other agents available to image head and neck cancer, few can actually achieve the required diagnostic sensitivity and specificity. The introduction of monoclonal antibodies into routine imaging has been hampered by distinct practical problems and the search is now on for more sensitive non-specific diagnostic agents. It is now possible to evaluate new 99mTc labelled tumour-imaging agents using animal tumour model systems and the use of radioactivity in all aspects of otolaryngological research adds an extra quantitive dimension. Together with SPECT, and the introduction of positron emission tomography (PET) to image the physiology of normal tissues and tumours, the use of radionuclide investigations can lead only to an increase in ENT diagnostic sensitivity and specificity and, subsequently, to an overall improvement in the way we diagnose, stage and treat head and neck cancer.

The role of tumor markers in the early detection of cancer

Tumor markers include a broad range of substances expressed at different levels and in different biochemical forms. Bence-Jones protein, carcino-embryonic antigen and alpha-fetoprotein are recognized as some of the earlier utilized markers. Recent technologic advances have led to the development of a variety of serum tumor markers, tumor markers in body fluids, tissue tumor markers, and genetic tumor markers, such as protooncogenes.

Epidermal growth factor receptors in cancer tissues of esophagus, lung, pancreas, colorectum, breast and stomach

The levels of epidermal growth factor (EGF) receptors were investigated in surgically resected tumors of various origins including esophagus (n = 33), lung (n = 14), pancreas (n = 9), colorectum (n = 10), breast (n = 23) and stomach (n = 8). The 125I-EGF binding capacities of squamous cell carcinomas of esophagus and lung were exceptionally higher than those of the other cancer tissues. Immunohistochemical staining with an anti-EGF receptor monoclonal antibody detected EGF receptors in the basal cells and parabasal cells of normal esophageal epithelium and in all the cancer cells of squamous cell carcinoma tissues of esophagus and lung. DNA replicating cells were examined by the bromodeoxyuridine staining method and it was found that the basal cells and parabasal cells of normal epithelium and peripheral cells of cancer pearls are proliferating. Contrary to this, a tumor antigen TA-4, known as a specific marker for squamous carcinoma, was detected in the differentiated cancer cells and in middle-layer squamous cells. These results strongly suggest that the increase in EGF receptor levels may be associated with the development of human squamous cell cancers of esophagus and lung. Thus, measurement of EGF receptor expression in tumor tissues has diagnostic value and should prove useful for the development of new therapies.