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Wakabayashi N, Watanabe S, Abe T, Takenaka J, Hirata K, Kimura R, Sakamoto K, Shinohara N, Kudo K. Safety and efficacy of multiple-dose versus single-dose MIBG therapy in patients with refractory pheochromocytoma and paraganglioma: a single-center retrospective analysis. Ann Nucl Med 2024:10.1007/s12149-024-01928-2. [PMID: 38656630 DOI: 10.1007/s12149-024-01928-2] [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: 01/23/2024] [Accepted: 03/28/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE To investigate the incidence of adverse events (AEs) following single and multiple administrations of I-131 metaiodobenzylguanidine (MIBG) therapy for inoperable pheochromocytomas and paragangliomas (PPGLs). METHODS A single-center retrospective study was conducted on patients with inoperable PPGLs who underwent I-131 MIBG therapy between January 2000 and December 2020. A total of 28 patients with available electronic medical records were included. The treatment consisted of a single intravenous administration of 150 mCi (5.55 GBq) of I-131 MIBG. We evaluated the first MIBG treatment and repeated MIBG treatments performed within 200 days of the previous treatment. AEs for each treatment were evaluated using CTCAE version 4.0, and the statistical analysis was conducted at a significance level of p < 0.05. Objective response based on RECIST 1.1 criteria and biochemical response based on urinary catecholamines were assessed. RESULTS The study included a total of 63 administrations, consisting of 28 single administrations (SAs), including the first administration for all 28 cases, and 35 multiple administrations (MAs), which included the second or later administrations. Hematological AEs were evaluable for 23 SAs and 29 MAs. Grade 3 or higher leukopenia occurred in 9.8% of all administrations, and Grade 3 or higher lymphopenia in 23.5%; both were manageable through observation. There were no significant differences in clinical AE Grades 1-2 (p = 0.32), hematological AE Grades 1-2 (p = 0.22), or hematological AE Grades 3-4 (p = 0.12) between MAs and SAs. Statistical analysis for each type of AE revealed significant increases in leukopenia (p < 0.01) and lymphopenia (p = 0.04). No significant difference in anemia, thrombocytopenia, or neutropenia was observed between MAs and SAs. There was no significant increase in the incidence rate of Grade 3 or higher hematological AEs for any of the parameters. The objective response rate was 0% for SAs and 36% for MAs. Biochemical response rates were 18% for SAs and 67% for MAs. CONCLUSION In I-131 MIBG therapy for PPGLs, multiple administrations significantly increased only Grade 1 or 2 lymphopenia and leukopenia compared to single administration.
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Affiliation(s)
- Naoto Wakabayashi
- Department of Nuclear Medicine, Hokkaido University Hospital, Kita14, Nishi5, Kita-Ku, Sapporo, Hokkaido, 060-8648, Japan
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita14, Nishi5, Kita-Ku, Sapporo, Hokkaido, 060-8648, Japan
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University, Kita15, Nishi7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Shiro Watanabe
- Department of Nuclear Medicine, Hokkaido University Hospital, Kita14, Nishi5, Kita-Ku, Sapporo, Hokkaido, 060-8648, Japan.
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University, Kita15, Nishi7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Takashige Abe
- Department of Renal and Genitourinary Surgery, Hokkaido University Graduate School of Medicine, Kita15, Nishi7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Junki Takenaka
- Department of Nuclear Medicine, Hokkaido University Hospital, Kita14, Nishi5, Kita-Ku, Sapporo, Hokkaido, 060-8648, Japan
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University, Kita15, Nishi7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Kenji Hirata
- Department of Nuclear Medicine, Hokkaido University Hospital, Kita14, Nishi5, Kita-Ku, Sapporo, Hokkaido, 060-8648, Japan
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University, Kita15, Nishi7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Rina Kimura
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita14, Nishi5, Kita-Ku, Sapporo, Hokkaido, 060-8648, Japan
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University, Kita15, Nishi7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Keita Sakamoto
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita14, Nishi5, Kita-Ku, Sapporo, Hokkaido, 060-8648, Japan
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University, Kita15, Nishi7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Nobuo Shinohara
- Department of Renal and Genitourinary Surgery, Hokkaido University Graduate School of Medicine, Kita15, Nishi7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Kohsuke Kudo
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita14, Nishi5, Kita-Ku, Sapporo, Hokkaido, 060-8648, Japan
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University, Kita15, Nishi7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
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Fishbein L, Del Rivero J, Else T, Howe JR, Asa SL, Cohen DL, Dahia PLM, Fraker DL, Goodman KA, Hope TA, Kunz PL, Perez K, Perrier ND, Pryma DA, Ryder M, Sasson AR, Soulen MC, Jimenez C. The North American Neuroendocrine Tumor Society Consensus Guidelines for Surveillance and Management of Metastatic and/or Unresectable Pheochromocytoma and Paraganglioma. Pancreas 2021; 50:469-493. [PMID: 33939658 DOI: 10.1097/mpa.0000000000001792] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABSTRACT This manuscript is the result of the North American Neuroendocrine Tumor Society consensus conference on the medical management and surveillance of metastatic and unresectable pheochromocytoma and paraganglioma held on October 2 and 3, 2019. The panelists consisted of endocrinologists, medical oncologists, surgeons, radiologists/nuclear medicine physicians, nephrologists, pathologists, and radiation oncologists. The panelists performed a literature review on a series of questions regarding the medical management of metastatic and unresectable pheochromocytoma and paraganglioma as well as questions regarding surveillance after resection. The panelists voted on controversial topics, and final recommendations were sent to all panel members for final approval.
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Affiliation(s)
- Lauren Fishbein
- From the Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jaydira Del Rivero
- Developmental Therapeutics Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Tobias Else
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - James R Howe
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center and University Health Network, Toronto, Case Western Reserve University, Cleveland, OH
| | - Debbie L Cohen
- Renal Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Patricia L M Dahia
- Division of Hematology and Medical Oncology, Department of Medicine, University of Texas Health San Antonio, San Antonio, TX
| | - Douglas L Fraker
- Division of Endocrine and Oncologic Surgery, Department of Surgery, University of Pennsylvania and Abramson Cancer Center, Philadelphia, PA
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Pamela L Kunz
- Division of Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Kimberly Perez
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Nancy D Perrier
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel A Pryma
- Department of Radiology and Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mabel Ryder
- Endocrine Oncology Tumor Group, Division of Medical Oncology, Mayo Clinic, Rochester, MN
| | - Aaron R Sasson
- Division of Surgical Oncology, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY
| | - Michael C Soulen
- Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX
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Abstract
OPINION STATEMENT Neuroendocrine tumors (NETs) are relatively rare, with 12,000-15,000 new cases diagnosed annually in the USA. Although NETs are a diverse group of neoplasms, they share common molecular targets that can be exploited using nuclear medicine techniques for both imaging and therapy. NETs have traditionally been imaged with SPECT imaging using 111In-labeled octreotide analogs to detect neoplasms with somatostatin receptors. In addition, certain NETs (pheochromocytomas, paragangliomas, and neuroblastomas) are also effectively imaged using 123I- or 131I-labeled metaiodobenzylguanidine (MIBG), an analog of guanethidine. More recently, PET imaging with 68Ga-labeled somatostatin receptor (SSR) analogs allows neuroendocrine tumors to be imaged with much higher sensitivity. 68Ga-DOTATATE was approved as a PET tracer by the FDA in June 2016. In addition to imaging, both MIBG and DOTATATE can be labeled with therapeutic radionuclides to deliver targeted radiation selectively to macroscopic and microscopic tumor sites. The incorporation of the same molecular probe for imaging and therapy provides a radio-theranostic approach to identifying, targeting, and treating tumors. Over the years, several centers have experience treating NETs with high-dose 131I-MIBG. 177Lu-DOTATATE was approved by the FDA in 2018 for treatment of gastroenteropancreatic NETs and constitutes a major advancement in the treatment of these diseases. In this paper, we provide an overview of imaging and treating neuroendocrine tumors using MIBG and SSR probes. Although uncommon, neuroendocrine tumors have provided the largest experience for targeted radionuclide imaging and therapy (with the exception of radioiodine treatment for thyroid disease). In addition to benefitting patients with these rare tumors, the knowledge gained provides a blueprint for the development of future paired diagnostic/therapeutic probes for treating other diseases, such as prostate cancer.
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Paradigm shift in theranostics of neuroendocrine tumors: conceptual horizons of nanotechnology in nuclear medicine. Ann Nucl Med 2018; 32:151-164. [PMID: 29374820 DOI: 10.1007/s12149-018-1235-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 01/22/2018] [Indexed: 01/18/2023]
Abstract
We present a comprehensive review of Neuroendocrine Tumors (NET) and the current and developing imaging and therapeutic modalities for NET with emphasis on Nuclear Medicine modalities. Subsequently, nanotechnology and its emerging role in cancer management, especially NET, are discussed. The article is both educative and informative. The objective is to provide an insight into the developments made in nuclear medicine and nanotechnology towards management of NET, individually as well as combined together.
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Abstract
This article discusses the important role of nuclear medicine imaging and therapy in the management of neuroendocrine tumours (NETs). Somatostatin receptor scintigraphy has a high impact on patient management versus conventional imaging. Molecular radiotherapy is an important part of the management of patients with NETs. Selection of patients for molecular radiotherapy in NETs is based on uptake on their radionuclide imaging study. The imaging agent has the same mechanism of uptake as the therapeutic agent. Thus, the imaging study preselects patients that are likely to concentrate radiation within their tumours.
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Affiliation(s)
| | - Glenn Flux
- Royal Marsden Hospital & Institute of Cancer Research, London, UK
| | - Jamshed Bomanji
- University College London Hospitals NHS Foundation Trust, London, UK
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Mulholland N, Chakravartty R, Devlin L, Kalogianni E, Corcoran B, Vivian G. Long-term outcomes of (131)Iodine mIBG therapy in metastatic gastrointestinal pancreatic neuroendocrine tumours: single administration predicts non-responders. Eur J Nucl Med Mol Imaging 2015; 42:2002-12. [PMID: 26142730 DOI: 10.1007/s00259-015-3116-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 06/10/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND (131)Iodine (I131)-metaiodobenzylguanidine (mIBG) is a radionuclide-based treatment option for metastatic gastrointestinal-pancreatic neuroendocrine tumours (GEP NET). This study aimed at identifying prognostic indicators of long-term outcome based on initial evaluation following a first mIBG treatment (7400 MBq) in a patient cohort with such tumours, with a secondary aim of evaluating progression-free survival (PFS) and overall survival (OS) following mIBG therapy. METHODS Retrospective review of the hospital records was performed to identify a cohort of 38 adult patients who underwent (131)Iodine-mIBG therapy over a 9-year period for metastatic GEP NETs and neuroendocrine tumours with an unknown primary. Treatment response was evaluated based on radiological criteria (RECIST1.1), biochemical markers [serum Chromogranin A (CgA)/urinary 5HIAA] and symptomatic response at clinical follow-up, all evaluated at 3-6 months from first mIBG treatment. Progression-free survival (PFS) and overall survival (OS) from the first mIBG treatment were recorded. RESULTS At 3-6 months following a single mIBG therapy, 75%, 67%, and 63% of patients showed either a partial response (PR) or stable disease (SD) on radiological, biochemical, and symptomatic criteria, respectively. Complete response (CR) was not seen in any patient. OS from the date of diagnosis and from the first therapy was 8 years +/-1.1 (95% CI 5.7 to 10.2 years) and 4 years+/-0.69 (95% CI 2.6-5.3 years), respectively. Twenty-nine percent of patients were alive at 10 years. Significant survival advantage was seen in patients with SD/PR as compared to those who had progressive disease (PD) for each of these three criteria. CONCLUSION Biochemical, radiological (RECIST 1.1) and symptomatic assessment of disease status at 3 to 6 months after first I131-mIBG therapy stratifies patients with a poor prognosis. This can be used to identify patients who may benefit from alternative strategies of treatment.
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Affiliation(s)
- Nicola Mulholland
- Department of Nuclear Medicine, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
| | - Riddhika Chakravartty
- Department of Nuclear Medicine, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Lindsey Devlin
- Department of Nuclear Medicine, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Eleni Kalogianni
- Department of Nuclear Medicine, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Ben Corcoran
- Department of Nuclear Medicine, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Gillian Vivian
- Department of Nuclear Medicine, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
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Nowicki ML, Cwikla JB, Sankowski AJ, Shcherbinin S, Grimmes J, Celler A, Buscombe JR, Bator A, Pech M, Mikołajczak R, Pawlak D. Initial study of radiological and clinical efficacy radioembolization using 188Re-human serum albumin (HSA) microspheres in patients with progressive, unresectable primary or secondary liver cancers. Med Sci Monit 2014; 20:1353-62. [PMID: 25086245 PMCID: PMC4136939 DOI: 10.12659/msm.890480] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background The aim of this initial study was to evaluate the clinical and radiological effectiveness of radioembolization (RE) using 188Re-Human Serum Albumin (HSA) microspheres in patients with advanced, progressive, unresectable primary or secondary liver cancers, not suitable to any other form of therapy. Material/Methods Overall, we included 13 patients with 20 therapy sessions. Clinical and radiological responses were assessed at 6 weeks after therapy, and then every 3 months. The objective radiological response was classified according to Response Evaluation Criteria in Solid Tumors (RECIST) v.1.0 by sequential MRI. Adverse events were evaluated using NCI CTCAE v.4.03. Results There were 4 patients with hepatocellular carcinoma (HCC), 6 with metastatic colorectal cancer (mCRC), 2 with neuroendocrine carcinoma (NEC), and 1 patient with ovarian carcinoma. Mean administered activity of 188Re HSA was 7.24 GBq (range 3.8–12.4) A high microspheres labeling efficacy of over 97±2.1% and low urinary excretion of 188Re (6.5±2.3%) during first 48-h follow-up. Median overall survival (OS) for all patients was 7.1 months (CI 6.2–13.3) and progression-free survival (PFS) was 5.1 months (CI 2.4–9.9). In those patients who had a clinical partial response (PR), stable disease (SD), and disease progression (DP) as assessed 6 weeks after therapy, the median OS was 9/5/4 months, respectively, and PFS was 5/2/0 months, respectively. The treatment adverse events (toxicity) were at an acceptable level. Initially and after 6 weeks, the CTC AE was grade 2, while after 3 months it increased to grade 3 in 4 subjects. This effect was mostly related to rapid cancer progression in this patient subgroup. Conclusions The results of this preliminary study indicate that RE using 188Re HSA is feasible and a viable option for palliative therapy in patients with extensive progressive liver cancer. It was well tolerated by most patients, with a low level of toxicity during the 3 months of follow-up.
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Affiliation(s)
- Mirosław L Nowicki
- Department of Radiology and Diagnostic Imaging, Hospital Ministry of Internal Affairs, Warsaw, Poland
| | - Jarosław B Cwikla
- Faculty of Medical Sciences, University of Varmia and Masuria, Olsztyn, Poland
| | - Artur J Sankowski
- Department of Radiology and Diagnostic Imaging, Hospital Ministry of Internal Affairs, Warsaw, Poland
| | - Sergey Shcherbinin
- Medical Imaging Research Group, University of British Columbia, Vnacouver, Canada
| | - Josh Grimmes
- Medical Imaging Research Group, University of British Columbia, Vnacouver, Canada
| | - Anna Celler
- Medical Imaging Research Group, University of British Columbia, Vnacouver, Canada
| | - John R Buscombe
- Department of Nuclear Medicine and PET, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Andrzej Bator
- Department of Radiology and Diagnostic Imaging, Hospital Ministry of Internal Affairs, Warsaw, Poland
| | - Maciej Pech
- Clinic of Radiology and Nuclear Medicine, Otto-von-Guericke-University, Magdeburg, Germany
| | - Renata Mikołajczak
- Centre POLATOM, National Centre for Nuclear Research Radioisotope, Otwock, Poland
| | - Dariusz Pawlak
- Centre POLATOM, National Centre for Nuclear Research Radioisotope, Otwock, Poland
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Affiliation(s)
- John Buscombe
- Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge.
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¹¹¹In-DTPA⁰-octreotide (Octreoscan), ¹³¹I-MIBG and other agents for radionuclide therapy of NETs. Eur J Nucl Med Mol Imaging 2012; 39 Suppl 1:S113-25. [PMID: 22388626 DOI: 10.1007/s00259-011-2013-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This paper is a critical review of the literature on NET radionuclide therapy with (111)In-DTPA(0)-octreotide (Octreoscan) and (131)I-MIBG, focusing on efficacy and toxicity. Some potential future applications and new candidate therapeutic agents are also mentioned. Octreoscan has been a pioneering agent for somatostatin receptor radionuclide therapy. It has achieved symptomatic responses and disease stabilization, but it is now outperformed by the corresponding β-emitter agents (177)Lu-DOTATATE and (90)Y-DOTATOC. (131)I-MIBG is the radionuclide therapy of choice for inoperable or metastatic phaeochromocytomas/paragangliomas, which avidly concentrate this tracer via the noradrenaline transporter. Symptomatic, biochemical and tumour morphological response rates of 50-89%, 45-74% and 27-47%, respectively, have been reported. (131)I-MIBG is a second-line radiopharmaceutical for treatment of enterochromaffin carcinoids, mainly offering the benefit of amelioration of hormone-induced symptoms. High specific activity, non-carrier-added (131)I-MIBG and meta-astato((211)At)-benzylguanidine (MABG) are tracers with potential for enhanced therapeutic efficacy, yet their integration into clinical practice awaits further exploration. Amongst other promising agents, radiolabelled exendin analogues show potential for imaging and possibly therapy of insulinomas, while preclinical studies are currently evaluating DOTA peptides targeting the CCK-2/gastrin receptors that are overexpressed by medullary thyroid carcinoma cells.
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Abstract
Targeted systemic radiotherapy constitutes the systemic administration of a radioactive agent that targets a molecule expressed preferentially on cancer cells. The archetypal such therapy is 131-iodine ((131)I) therapy for differentiated thyroid cancers. Radiotherapy typically delivers a calculated radiation-absorbed dose to tumor that takes into account (contiguous) normal tissue. Systemic radiotherapy development currently uses schema more analogous to chemotherapy--a radioactivity estimate that does not cause any irreversible toxicity. Historically, arbitrary amounts of radioactivity shown to be effective, on the basis of retrospective review, were used for thyroid cancer therapy with (131)I as well as for neuroendocrine tumor therapy with (131)I-labeled meta-iodo-benzylguanidine (MIBG). Their established safety record has led to adaptations that include repeat therapies with nontoxic amounts of radioactivity. There remains, however, a lack of clear understanding of the safety limits of systemic targeted radiotherapy. This is probably most true in systemic therapy with MIBG in adult neuroendocrine tumors. Bone marrow is the primary critical organ for most targeted systemic radiotherapy; second organ involvement may be renal, as with MIBG and targeted radiopeptide therapy, or pulmonary, as with radioimmunotherapy. Most therapies have tended toward multiple administrations of subtoxic amounts of radioactivity. Therapy with MIBG in pheochromococytoma as well as targeted radiopeptide therapy in medullary thyroid cancer has followed this model. Radioimmunotherapy appears very promising; a definitive Phase 2 study needs completion. All therapy has shown promise in extending disease survival (as compared with historical controls), with few major structural (or biochemical) responses. This review will attempt to compliment the excellent existing literature by providing an overall systemic therapeutic approach to this promising endeavor.
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