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Ekmekcioglu O, Hughes S, Fendler WP, Verzijlbergen F, Kong G, Hofman MS. May the Nuclear Medicine be with you! Neuroendocrine tumours and the return of nuclear medicine. Eur J Nucl Med Mol Imaging 2024:10.1007/s00259-024-06877-6. [PMID: 39158585 DOI: 10.1007/s00259-024-06877-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Affiliation(s)
- Ozgul Ekmekcioglu
- Department of Nuclear Medicine, University of Health Sciences, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey.
| | - Simon Hughes
- Department of Nuclear Medicine, Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Wolfgang P Fendler
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, Essen, Germany
| | - Fred Verzijlbergen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Grace Kong
- Molecular Imaging and Therapeutic Nuclear Medicine, Cancer Imaging, Peter MacCallum Centre Melbourne, and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael S Hofman
- Molecular Imaging and Therapeutic Nuclear Medicine, Cancer Imaging, Peter MacCallum Centre Melbourne, and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
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2
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Santo G, Di Santo G, Virgolini I. Peptide Receptor Radionuclide Therapy of Neuroendocrine Tumors: Agonist, Antagonist and Alternatives. Semin Nucl Med 2024; 54:557-569. [PMID: 38490913 DOI: 10.1053/j.semnuclmed.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/14/2024] [Accepted: 02/14/2024] [Indexed: 03/17/2024]
Abstract
Peptide receptor radionuclide therapy (PRRT) today is a well-established treatment strategy for patients with neuroendocrine tumors (NET). First performed already more than 30 years ago, PRRT was incorporated only in recent years into the major oncology guidelines, based on its proven efficacy and safety in clinical trials. Following the phase 3 NETTER-1 trial, which led to the final registration of the radiopharmaceutical Luthatera® for G1/G2 NET patients in 2017, the long-term results of the phase 3 NETTER-2 trial may pave the way for a new treatment option also for advanced G2/G3 patients as first-line therapy. The growing knowledge about the synergistic effect of combined therapies could also allow alternative (re)treatment options for NET patients, in order to create a tailored treatment strategy. The evolving thera(g)nostic concept could be applied for the identification of patients who might benefit from different image-guided treatment strategies. In this scenario, the use of dual tracer PET/CT in NET patients, using both [18F]F-FDG/[68Ga]Ga-DOTA-somatostatin analog (SSA) for diagnosis and follow-up, is under discussion and could also result in a powerful prognostic tool. In addition, alternative strategies based on different metabolic pathways, radioisotopes, or combinations of different medical approaches could be applied. A number of different promising "doors" could thus open in the near future for the treatment of NET patients - and the "key" will be thera(g)nostic!
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Affiliation(s)
- Giulia Santo
- Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria; Department of Experimental and Clinical Medicine, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Gianpaolo Di Santo
- Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Irene Virgolini
- Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria.
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3
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Di Franco M, Zanoni L, Fortunati E, Fanti S, Ambrosini V. Radionuclide Theranostics in Neuroendocrine Neoplasms: An Update. Curr Oncol Rep 2024; 26:538-550. [PMID: 38581469 PMCID: PMC11063107 DOI: 10.1007/s11912-024-01526-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE OF REVIEW This paper aims to address the latest findings in neuroendocrine tumor (NET) theranostics, focusing on new evidence and future directions of combined diagnosis with positron emission tomography (PET) and treatment with peptide receptor radionuclide therapy (PRRT). RECENT FINDINGS Following NETTER-1 trial, PRRT with [177Lu]Lu-DOTATATE was approved by FDA and EMA and is routinely employed in advanced G1 and G2 SST (somatostatin receptor)-expressing NET. Different approaches have been proposed so far to improve the PRRT therapeutic index, encompassing re-treatment protocols, combinations with other therapies and novel indications. Molecular imaging holds a potential added value in characterizing disease biology and heterogeneity using different radiopharmaceuticals (e.g., SST and FDG) and may provide predictive and prognostic parameters. Response assessment criteria are still an unmet need and new theranostic pairs showed preliminary encouraging results. PRRT for NET has become a paradigm of modern theranostics. PRRT holds a favorable toxicity profile, and it is associated with a prolonged time to progression, reduction of symptoms, and improved patients' quality of life. In light of further optimization, different new strategies have been investigated, along with the development of new radiopharmaceuticals.
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Affiliation(s)
- Martina Di Franco
- Nuclear Medicine, Alma Mater Studiorum, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
| | - Lucia Zanoni
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Emilia Fortunati
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Stefano Fanti
- Nuclear Medicine, Alma Mater Studiorum, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Valentina Ambrosini
- Nuclear Medicine, Alma Mater Studiorum, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
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4
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Yadav S, Lawhn-Heath C, Paciorek A, Lindsay S, Mirro R, Bergsland EK, Hope TA. The Impact of Posttreatment Imaging in Peptide Receptor Radionuclide Therapy. J Nucl Med 2024; 65:409-415. [PMID: 38428966 DOI: 10.2967/jnumed.123.266614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 12/20/2023] [Indexed: 03/03/2024] Open
Abstract
Posttreatment imaging of γ-emissions after peptide receptor radionuclide therapy (PRRT) can be used to perform quantitative dosimetry as well as assessment response using qualitative measures. We aimed to assess the impact of qualitative posttreatment imaging on the management of patients undergoing PRRT. Methods: In this retrospective study, we evaluated 100 patients with advanced well-differentiated neuroendocrine tumors undergoing PRRT, who had posttreatment SPECT/CT imaging at 24 h. First, we evaluated the qualitative assessment of response at each cycle. Then using a chart review, we determined the impact on management from the posttreatment imaging. The changes in management were categorized as major or minor, and the cycles at which these changes occurred were noted. Additionally, tumor grade was also evaluated. Results: Of the 100 sequential patients reviewed, most (80% after cycle 2, 79% after cycle 3, and 73% after cycle 4) showed qualitatively stable disease during PRRT. Management changes were observed in 27% (n = 27) of patients; 78% of those (n = 21) were major, and 30% (n = 9) were minor. Most treatment changes occurred after cycle 2 (33% major, 67% minor) and cycle 3 (62% major, 33% minor). Higher tumor grade correlated with increased rate of changes in management (P = 0.006). Conclusion: In this retrospective study, qualitative analysis of posttreatment SPECT/CT imaging informed changes in management in 27% of patients. Patients with higher-grade tumors had a higher rate of change in management, and most of the management changes occurred after cycles 2 and 3. Incorporating posttreatment imaging into standard PRRT workflows could potentially enhance patient management.
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Affiliation(s)
- Surekha Yadav
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Courtney Lawhn-Heath
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Alan Paciorek
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Sheila Lindsay
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
- Department of Medicine, Division of Medical Oncology, University of California San Francisco, San Francisco, California
| | - Rebecca Mirro
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Emily K Bergsland
- Department of Medicine, Division of Medical Oncology, University of California San Francisco, San Francisco, California
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California; and
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California;
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California; and
- Department of Radiology, San Francisco VA Medical Center, San Francisco, California
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5
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di Santo G, Santo G, Sviridenko A, Virgolini I. Peptide receptor radionuclide therapy combinations for neuroendocrine tumours in ongoing clinical trials: status 2023. Theranostics 2024; 14:940-953. [PMID: 38250038 PMCID: PMC10797289 DOI: 10.7150/thno.91268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/04/2023] [Indexed: 01/23/2024] Open
Abstract
A growing body of literature reports on the combined use of peptide receptor radionuclide therapy (PRRT) with other anti-tumuor therapies in order to anticipate synergistic effects with perhaps increased safety issues. Combination treatments to enhance PRRT outcome are based on improved tumour perfusion, upregulation of somatostatin receptors (SSTR), radiosensitization with DNA damaging agents or targeted therapies. Several Phase 1 or 2 trials are currently recruiting patients in combined regimens. The combination of PRRT with cytotoxic chemotherapy, capecitabine and temozolomide (CAPTEM), seems to become clinically useful especially in pancreatic neuroendocrine tumours (pNETs) with acceptable safety profile. Neoadjuvant PRRT prior to surgery, PRRT combinations of intravenous and intraarterial routes of application, combinations of PRRT with differently radiolabelled (alpha, beta, Auger) SSTR-targeting agonists and antagonists, inhibitors of immune checkpoints (ICIs), poly (ADP-ribose) polymerase-1 (PARP1i), tyrosine kinase (TKI), DNA-dependent protein kinase, ribonucleotide reductase or DNA methyltransferase (DMNT) are tested in currently ongoing clinical trials. The combination with [131I]I-MIBG in rare NETs (such as paraganglioma, pheochromocytoma) and new non-SSTR-targeting radioligands are used in the personalization process of treatment. The present review will provide an overview of the current status of ongoing PRRT combination treatments.
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Affiliation(s)
- Gianpaolo di Santo
- Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Giulia Santo
- Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria
- Department of Experimental and Clinical Medicine, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Anna Sviridenko
- Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Irene Virgolini
- Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Halfdanarson TR, Mallak N, Paulson S, Chandrasekharan C, Natwa M, Kendi AT, Kennecke HF. Monitoring and Surveillance of Patients with Gastroenteropancreatic Neuroendocrine Tumors Undergoing Radioligand Therapy. Cancers (Basel) 2023; 15:4836. [PMID: 37835530 PMCID: PMC10571645 DOI: 10.3390/cancers15194836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 10/15/2023] Open
Abstract
Radioligand therapy (RLT) with [177Lu]Lu-DOTA-TATE is a standard of care for adult patients with somatostatin-receptor (SSTR)-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs). Taking advantage of this precision nuclear medicine approach requires diligent monitoring and surveillance, from the use of diagnostic SSTR-targeted radioligand imaging for the selection of patients through treatment and assessments of response. Published evidence-based guidelines assist the multidisciplinary healthcare team by providing acceptable approaches to care; however, the sheer heterogeneity of GEP-NETs can make these frameworks difficult to apply in individual clinical circumstances. There are also contradictions in the literature regarding the utility of novel approaches in monitoring and surveilling patients with GEP-NETs receiving RLT. This article discusses the emerging evidence on imaging, clinical biochemistry, and tumor assessment criteria in the management of patients receiving RLT for GEP-NETs; additionally, it documents our own best practices. This allows us to offer practical guidance on how to effectively implement monitoring and surveillance measures to aid patient-tailored clinical decision-making.
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Affiliation(s)
| | - Nadine Mallak
- Division of Molecular Imaging and Therapy, Oregon Health and Science University, Portland, OR 97239, USA;
| | | | | | - Mona Natwa
- Langone Health, New York University, New York, NY 10016, USA
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Waldeck K, Van Zuylekom J, Cullinane C, Gulati T, Simpson KJ, Tothill RW, Blyth B, Hicks RJ. A genome-wide CRISPR/Cas9 screen identifies DNA-PK as a sensitiser to 177Lutetium-DOTA-octreotate radionuclide therapy. Theranostics 2023; 13:4745-4761. [PMID: 37771787 PMCID: PMC10526672 DOI: 10.7150/thno.84628] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/17/2023] [Indexed: 09/30/2023] Open
Abstract
Peptide receptor radionuclide therapy (PRRT) using 177Lutetium-DOTA-octreotate (LuTate) for neuroendocrine tumours (NET) is now an approved treatment available in many countries, though primary or secondary resistance continue to limit its effectiveness or durability. We hypothesised that a genome-wide CRISPR/Cas9 screen would identify key mediators of response to LuTate and gene targets that might offer opportunities for novel combination therapies for NET patients. Methods: We utilised a genome-wide CRISPR-Cas9 screen in LuTate-treated cells to identify genes that impact on the sensitivity or resistance of cells to LuTate. Hits were validated through single-gene knockout. LuTate-resistant cells were assessed to confirm LuTate uptake and retention, and persistence of somatostatin receptor 2 (SSTR2) expression. Gene knockouts conferring LuTate sensitivity were further characterised by pharmacological sensitisation using specific inhibitors and in vivo analysis of the efficacy of these inhibitors in combination with LuTate. Results: The CRISPR-Cas9 screen identified several potential targets for both resistance and sensitivity to PRRT. Two gene knockouts which conferred LuTate resistance in vitro, ARRB2 and MVP, have potential mechanisms related to LuTate binding and retention, and modulation of DNA-damage repair (DDR) pathways, respectively. The screen showed that sensitivity to LuTate treatment in vitro can be conferred by the loss of a variety of genes involved in DDR pathways, with loss of genes involved in Non-Homologous End-Joining (NHEJ) being the most lethal. Loss of the key NHEJ gene, PRKDC (DNA-PK), either by gene loss or inhibition by two different inhibitors, resulted in significantly reduced cell survival upon exposure of cells to LuTate. In SSTR2-positive xenograft-bearing mice, the combination of nedisertib (a DNA-PK specific inhibitor) and LuTate produced a more robust control of tumour growth and increased survival compared to LuTate alone. Conclusions: DDR pathways are critical for sensing and repairing radiation-induced DNA damage, and our study shows that regulation of DDR pathways may be involved in both resistance and sensitivity to PRRT. Additionally, the use of a DNA-PK inhibitor in combination with LuTate PRRT significantly improves the efficacy of the treatment in pre-clinical models, providing further evidence for the clinical efficacy of this combination.
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Affiliation(s)
- Kelly Waldeck
- Models of Cancer Translational Research Centre, Research Division, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, Victoria, Australia, 3000
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia, 3010
| | - Jessica Van Zuylekom
- Models of Cancer Translational Research Centre, Research Division, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, Victoria, Australia, 3000
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia, 3010
| | - Carleen Cullinane
- Models of Cancer Translational Research Centre, Research Division, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, Victoria, Australia, 3000
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia, 3010
| | - Twishi Gulati
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia, 3010
- Victorian Centre for Functional Genomics, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, Victoria, Australia, 3000
| | - Kaylene J. Simpson
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia, 3010
- Victorian Centre for Functional Genomics, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, Victoria, Australia, 3000
- Department of Biochemistry and Pharmacology, The University of Melbourne, Parkville, Victoria, Australia, 3010
| | - Richard W. Tothill
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia, 3010
- Department of Clinical Pathology and University of Melbourne Centre for Cancer Research, The University of Melbourne, Parkville, Victoria, Australia, 3010
| | - Benjamin Blyth
- Models of Cancer Translational Research Centre, Research Division, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, Victoria, Australia, 3000
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia, 3010
| | - Rodney J. Hicks
- St Vincent's Hospital Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia, 3010
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8
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Alipour R, Jackson P, Bressel M, Hogg A, Callahan J, Hicks RJ, Kong G. The relationship between tumour dosimetry, response, and overall survival in patients with unresectable Neuroendocrine Neoplasms (NEN) treated with 177Lu DOTATATE (LuTate). Eur J Nucl Med Mol Imaging 2023; 50:2997-3010. [PMID: 37184682 PMCID: PMC10382388 DOI: 10.1007/s00259-023-06257-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 04/30/2023] [Indexed: 05/16/2023]
Abstract
Peptide Receptor Radionuclide Therapy (PRRT) delivers targeted radiation to Somatostatin Receptor (SSR) expressing Neuroendocrine Neoplasms (NEN). We sought to assess the predictive and prognostic implications of tumour dosimetry with respect to response by 68 Ga DOTATATE (GaTate) PET/CT molecular imaging tumour volume of SSR (MITVSSR) change and RECIST 1.1, and overall survival (OS). METHODS Patients with gastro-entero-pancreatic (GEP) NEN who received LuTate followed by quantitative SPECT/CT (Q-SPECT/CT) the next day (Jul 2010 to Jan 2019) were retrospectively reviewed. Single time-point (STP) lesional dosimetry was performed for each cycle using population-based pharmacokinetic modelling. MITVSSR and RECIST 1.1 were measured at 3-months post PRRT. RESULTS Median of 4 PRRT cycles were administered to 90 patients (range 2-5 cycles; mean 27.4 GBq cumulative activity; mean 7.6 GBq per cycle). 68% received at least one cycle with radiosensitising chemotherapy (RSC). RECIST 1.1 partial response was 24%, with 70% stable and 7% progressive disease. Cycle 1 radiation dose in measurable lesions was associated with local response (odds ratio 1.5 per 50 Gy [95% CI: 1.1-2.0], p = 0.002) when adjusted by tumour grade and RSC. Median change in MITVSSR was -63% (interquartile range -84 to -29), with no correlation with radiation dose to the most avid lesion on univariable or multivariant analyses (5.6 per 10 Gy [95% CI: -1.6, 12.8], p = 0.133). OS at 5-years was 68% (95% CI: 56-78%). Neither baseline MITVSSR (hazard ratio 1.1 [95% CI: 1.0, 1.2], p = 0.128) nor change in baseline MITVSSR (hazard ratio 1.0 [95% CI: 1.0, 1.1], p = 0.223) were associated with OS when adjusted by tumour grade and RSC but RSC was (95% CI: 0.2, 0.8, p = 0.012). CONCLUSION Radiation dose to tumour during PRRT was predictive of radiologic response but not survival. Survival outcomes may relate to other biological factors. There was no evidence that MITVSSR change was associated with OS, but a larger study is needed.
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Affiliation(s)
- R Alipour
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia.
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.
| | - P Jackson
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - M Bressel
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - A Hogg
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - J Callahan
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - R J Hicks
- Department of Medicine, St Vincent's Medical School, The University of Melbourne, Melbourne, Australia
| | - G Kong
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
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9
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Fortunati E, Bonazzi N, Zanoni L, Fanti S, Ambrosini V. Molecular imaging Theranostics of Neuroendocrine Tumors. Semin Nucl Med 2023; 53:539-554. [PMID: 36623974 DOI: 10.1053/j.semnuclmed.2022.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/23/2022] [Indexed: 01/08/2023]
Abstract
Neuroendocrine neoplasms (NEN) are rare and heterogeneous tumors, originating mostly from the gastro-entero-pancreatic (GEP) tract followed by the lungs. Multidisciplinary discussion is mandatory for optimal diagnostic and therapeutic management. Well-differentiated NEN (NET) present a high expression of somatostatin receptors (SSTR) and can be studied with [68Ga]-DOTA-peptides ([68Ga]Ga-DOTANOC, [68Ga]Ga-DOTATOC, [68Ga]Ga-DOTATATE) PET/CT to assess disease extension and the eligibility for peptide receptor radionuclide therapy (PRRT). SSTR-analogues labelled with 90Y or 177Lu have been used since mid-90s for NET therapy. PRRT is now considered an effective and safe treatment option for SSTR-expressing NET: following the approval of 177Lu-DOTATATE by FDA and EMA, PRRT is now part of the therapeutic algorithms of the main scientific societies. New strategies to improve PRRT efficacy and to reduce its toxicity are under evaluation (eg, personalization of treatment schemes, the selection of the most suitable patients, improvement of response assessment criteria, optimization of treatment sequencing, feasibility of PRRT-retreatment, combination of PRRT with other treatments options). Recently, several emerging radiopharmaceuticals showed encouraging results for both imaging and therapy (eg, SSTR-analogues labelled with 18F, SSTR-antagonists for both diagnosis and therapy, alpha-labelling for therapy, radiopharmaceuticals binding to new cellular targets). Aim of this review is to focus on current knowledge and to outline emerging perspectives for NEN's diagnosis and therapy.
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Affiliation(s)
- Emilia Fortunati
- Nuclear Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy.
| | - Norma Bonazzi
- Nuclear Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Lucia Zanoni
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Stefano Fanti
- Nuclear Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy; Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Valentina Ambrosini
- Nuclear Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy; Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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10
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Pomykala KL, Hadaschik BA, Sartor O, Gillessen S, Sweeney CJ, Maughan T, Hofman MS, Herrmann K. Next generation radiotheranostics promoting precision medicine. Ann Oncol 2023; 34:507-519. [PMID: 36924989 DOI: 10.1016/j.annonc.2023.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/03/2023] [Indexed: 03/17/2023] Open
Abstract
Radiotheranostics is a field of rapid growth with some approved treatments including 131I for thyroid cancer, 223Ra for osseous metastases, 177Lu-DOTATATE for neuroendocrine tumors, and 177Lu-PSMA (prostate-specific membrane antigen) for prostate cancer, and several more under investigation. In this review, we will cover the fundamentals of radiotheranostics, the key clinical studies that have led to current success, future developments with new targets, radionuclides and platforms, challenges with logistics and reimbursement and, lastly, forthcoming considerations regarding dosimetry, identifying the right line of therapy, artificial intelligence and more.
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Affiliation(s)
- K L Pomykala
- Institute for Artificial Intelligence in Medicine, University Hospital Essen, Essen, Germany
| | - B A Hadaschik
- Department of Urology, University Hospital Essen, Essen, Germany
| | - O Sartor
- School of Medicine, Tulane University, New Orleans, USA
| | - S Gillessen
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland; Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - C J Sweeney
- Dana-Farber Cancer Institute, Boston, USA; Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - T Maughan
- Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - M S Hofman
- Prostate Cancer Theranostics and Imaging Centre of Excellence (ProsTIC), Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - K Herrmann
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, Essen, Germany.
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11
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Tan C, Triay J. Ectopic adrenocorticotrophic hormone syndrome secondary to treatment-related neuroendocrine differentiation of metastatic castrate-resistant prostate cancer. Endocrinol Diabetes Metab Case Rep 2023; 2023:22-0347. [PMID: 36625254 PMCID: PMC9874952 DOI: 10.1530/edm-22-0347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
Summary A 64-year-old man with progressive metastatic castrate-resistant prostate adenocarcinoma presented with recurrent fluid overload, severe hypokalaemia with metabolic alkalosis and loss of glycaemic control. Clinical features were facial plethora, skin bruising and proximal myopathy. Plasma adrenocorticotrophic hormone (ACTH), serum cortisol and 24-h urinary cortisol levels were elevated. Low-dose dexamethasone failed to suppress cortisol. Pituitary MRI was normal and 68Gallium-DOTATATE PET-CT scan showed only features of metastatic prostate cancer. He was diagnosed with ectopic ACTH syndrome secondary to treatment-related neuroendocrine prostate cancer differentiation. Medical management was limited by clinical deterioration, accessibility of medications and cancer progression. Ketoconazole and cabergoline were utilised, but cortisol remained uncontrolled. He succumbed 5 months following diagnosis. Treatment-related neuroendocrine differentiation of prostate adenocarcinoma is a rare cause of ectopic ACTH syndrome. Learning points Neuroendocrine differentiation following prostate adenocarcinoma treatment with androgen deprivation has been described. Ectopic adrenocorticotrophic hormone (ACTH) syndrome should be considered where patients with metastatic prostate cancer develop acute electrolyte disturbance or fluid overload. Ketoconazole interferes with adrenal and gonadal steroidogenesis and can be used in ectopic ACTH syndrome, but the impact may be insufficient. Inhibition of gonadal steroidogenesis is favourable in prostate cancer. More data are required to evaluate the use of cabergoline in ectopic ACTH syndrome. Ectopic ACTH syndrome requires prompt management and is challenging in the face of metastatic cancer.
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12
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Kong G, Hicks RJ. PRRT for higher-grade neuroendocrine neoplasms: What is still acceptable? Curr Opin Pharmacol 2022; 67:102293. [PMID: 36195008 DOI: 10.1016/j.coph.2022.102293] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/25/2022] [Accepted: 09/01/2022] [Indexed: 01/25/2023]
Abstract
Peptide receptor radionuclide therapy (PRRT) is a widely accepted treatment for progressive grade 1 and 2 (G1-2) gastroenteropancreatic neuroendocrine tumors (NET). There is increasing evidence that PRRT is effective for selected patients with well-differentiated (WD) G3 NET, which are now separated from neuroendocrine carcinoma (NEC). These preliminary data have led to prospective PRRT trials currently in progress. This article provides an update of the current role of PRRT for patients with WD-G3 NET, highlighting the importance of patient selection based on molecular imaging phenotype, as well as outlining some potential future directions in this field. Upcoming prospective trials will help define the role, sequencing, and optimization of PRRT to improve outcomes of patients with WD-G3 NET.
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Affiliation(s)
- Grace Kong
- Department of Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Victoria, Australia; The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | - Rodney J Hicks
- The University of Melbourne Department of Medicine, St Vincent's Hospital, Melbourne, Australia.
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13
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Iravani A, Parihar AS, Akhurst T, Hicks RJ. Molecular imaging phenotyping for selecting and monitoring radioligand therapy of neuroendocrine neoplasms. Cancer Imaging 2022; 22:25. [PMID: 35659779 PMCID: PMC9164531 DOI: 10.1186/s40644-022-00465-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 05/26/2022] [Indexed: 11/10/2022] Open
Abstract
Neuroendocrine neoplasia (NEN) is an umbrella term that includes a widely heterogeneous disease group including well-differentiated neuroendocrine tumours (NETs), and aggressive neuroendocrine carcinomas (NECs). The site of origin of the NENs is linked to the intrinsic tumour biology and is predictive of the disease course. It is understood that NENs demonstrate significant biologic heterogeneity which ultimately translates to widely varying clinical presentations, disease course and prognosis. Thus, significant emphasis is laid on the pre-therapy evaluation of markers that can help predict tumour behavior and dynamically monitors the response during and after treatment. Most well-differentiated NENs express somatostatin receptors (SSTRs) which make them appropriate for peptide receptor radionuclide therapy (PRRT). However, the treatment outcomes of PRRT depend heavily on the adequacy of patient selection by molecular imaging phenotyping not only utilizing pre-treatment SSTR PET but 18F-Fluorodeoxyglucose (18F-FDG) PET to provide insights into the intra- or inter-tumoural heterogeneity of the metastatic disease. Molecular imaging phenotyping may go beyond patient selection and provide useful information during and post-treatment for monitoring of temporal heterogeneity of the disease and dynamically risk-stratify patients. In addition, advances in the understanding of genomic-phenotypic classifications of pheochromocytomas and paragangliomas led to an archetypical example in precision medicine by utilizing molecular imaging phenotyping to guide radioligand therapy. Novel non-SSTR based peptide receptors have also been explored diagnostically and therapeutically to overcome the tumour heterogeneity. In this paper, we review the current molecular imaging modalities that are being utilized for the characterization of the NENs with special emphasis on their role in patient selection for radioligand therapy.
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14
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Bartolomei M, Berruti A, Falconi M, Fazio N, Ferone D, Lastoria S, Pappagallo G, Seregni E, Versari A. Clinical Management of Neuroendocrine Neoplasms in Clinical Practice: A Formal Consensus Exercise. Cancers (Basel) 2022; 14:cancers14102501. [PMID: 35626105 PMCID: PMC9140035 DOI: 10.3390/cancers14102501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/16/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Well-structured international guidelines are currently available regarding the management of patients with neuroendocrine neoplasms (NENs). However, in relation to the multiplicity of treatments and the relative rarity and heterogeneity of NENs, there are many controversial issues in which clinical evidence is insufficient and for which expert opinion can be of help. A group of experts selected 14 relevant topics and formulated relative statements concerning controversial issues in several areas on diagnosis, prognosis, therapeutic strategies, and patient follow-up. Specific statements have also been formulated regarding patient management on radioligand therapy (RLT), as well as in the presence of co-morbidities or bone metastases. All the statements were drafted, discussed, modified, and then approved. The Nominal Group Technique (NGT) method was used to obtain consensus. The results of this paper can facilitate the clinical approach of patients with NENs in daily practice in areas where there is scarcity or absence of clinical evidence. Abstract Many treatment approaches are now available for neuroendocrine neoplasms (NENs). While several societies have issued guidelines for diagnosis and treatment of NENs, there are still areas of controversy for which there is limited guidance. Expert opinion can thus be of support where firm recommendations are lacking. A group of experts met to formulate 14 statements relative to diagnosis and treatment of NENs and presented herein. The nominal group and estimate-talk-estimate techniques were used. The statements covered a broad range of topics from tools for diagnosis to follow-up, evaluation of response, treatment efficacy, therapeutic sequence, and watchful waiting. Initial prognostic characterization should be based on clinical information as well as histopathological analysis and morphological and functional imaging. It is also crucial to optimize RLT for patients with a NEN starting from accurate characterization of the patient and disease. Follow-up should be patient/tumor tailored with a shared plan about timing and type of imaging procedures to use to avoid safety issues. It is also stressed that patient-reported outcomes should receive greater attention, and that a multidisciplinary approach should be mandatory. Due to the clinical heterogeneity and relative lack of definitive evidence for NENs, personalization of diagnostic–therapeutic work-up is crucial.
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Affiliation(s)
- Mirco Bartolomei
- Azienda Ospedaliero-Universitaria di Ferrara, Presidio Ospedaliero Arcispedale Sant’Anna di Cona, 44124 Ferrara, Italy;
| | - Alfredo Berruti
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Medical Oncology, University of Brescia, ASST Spedali Civili di Brescia, 25123 Brescia, Italy
- Correspondence:
| | - Massimo Falconi
- Pancreas Surgical Unit, ENETS Center of Excellence, San Raffaele Hospital IRCCS, Vita Salute University, 20132 Milan, Italy;
| | - Nicola Fazio
- Division of Gastrointestinal Medical Oncologya and Neuroendocrine Tumors, European Institute of Oncology, 20132 Milan, Italy;
| | - Diego Ferone
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, IRCCS, Ospedale Policlinico San Martino, Università di Genova, 16132 Genova, Italy;
| | - Secondo Lastoria
- Nuclear Medicine Unit, Istituto Nazionale Tumori, Fondazione G. Pascale, 80131 Naples, Italy;
| | - Giovanni Pappagallo
- School of Clinical Methodology IRCCS “Sacred Heart–Don Calabria” Hospital; 37024 Negrar di Valpolicella, Italy;
| | - Ettore Seregni
- Nuclear Medicine Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20132 Milano, Italy;
| | - Annibale Versari
- Nuclear Medicine Unit, Azienda Unità Sanitaria Locale-IRCCS of Reggio Emilia, 42100 Reggio Emilia, Italy;
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15
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Naik M, Al-Nahhas A, Khan SR. Treatment of Neuroendocrine Neoplasms with Radiolabeled Peptides-Where Are We Now. Cancers (Basel) 2022; 14:761. [PMID: 35159027 PMCID: PMC8833798 DOI: 10.3390/cancers14030761] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/20/2022] [Indexed: 02/04/2023] Open
Abstract
Peptide receptor radionuclide therapy (PRRT) has been one of the most successful and exciting examples of theranostics in nuclear medicine in recent decades and is now firmly embedded in many treatment algorithms for unresectable or metastatic neuroendocrine neoplasms (NENs) worldwide. It is widely considered to be an effective treatment for well- or moderately differentiated neoplasms, which express high levels of somatostatin receptors that can be selectively targeted. This review article outlines the scientific basis of PRRT in treatment of NENs and describes its discovery dating back to the early 1990s. Early treatments utilizing Indium-111, a γ-emitter, showed promise in reduction in tumor size and improvement in biochemistry, but were also met with high radiation doses and myelotoxic and nephrotoxic effects. Subsequently, stable conjugation of DOTA-peptides with β-emitting radionuclides, such as Yttrium-90 and Lutetium-177, served as a breakthrough for PRRT and studies highlighted their potential in eliciting progression-free survival and quality of life benefits. This article will also elaborate on the key trials which paved the way for its approval and will discuss therapeutic considerations, such as patient selection and administration technique, to optimize its use.
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Affiliation(s)
- Mitesh Naik
- Department of Imaging, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK;
| | | | - Sairah R. Khan
- Department of Imaging, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK;
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16
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Imaging of Neuroendocrine Neoplasms: Monitoring Treatment Response—AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2022; 218:767-780. [DOI: 10.2214/ajr.21.27159] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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17
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Peptide Receptor Radionuclide Therapy Targeting the Somatostatin Receptor: Basic Principles, Clinical Applications and Optimization Strategies. Cancers (Basel) 2021; 14:cancers14010129. [PMID: 35008293 PMCID: PMC8749814 DOI: 10.3390/cancers14010129] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/13/2021] [Accepted: 12/22/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Peptide receptor radionuclide therapy (PRRT) is a systemic treatment consisting of the administration of a tumor-targeting radiopharmaceutical into the circulation of a patient. The radiopharmaceutical will bind to a specific peptide receptor leading to tumor-specific binding and retention. This will subsequently cause lethal DNA damage to the tumor cell. The only target that is currently used in widespread clinical practice is the somatostatin receptor, which is overexpressed on a range of tumor cells, including neuroendocrine tumors and neural-crest derived tumors. Academia played an important role in the development of PRRT, which has led to heterogeneous literature over the last two decades, as no standard radiopharmaceutical or regimen has been available for a long time. This review focuses on the basic principles and clinical applications of PRRT, and discusses several PRRT-optimization strategies. Abstract Peptide receptor radionuclide therapy (PRRT) consists of the administration of a tumor-targeting radiopharmaceutical into the circulation of a patient. The radiopharmaceutical will bind to a specific peptide receptor leading to tumor-specific binding and retention. The only target that is currently used in clinical practice is the somatostatin receptor (SSTR), which is overexpressed on a range of tumor cells, including neuroendocrine tumors and neural-crest derived tumors. Academia played an important role in the development of PRRT, which has led to heterogeneous literature over the last two decades, as no standard radiopharmaceutical or regimen has been available for a long time. This review provides a summary of the treatment efficacy (e.g., response rates and symptom-relief), impact on patient outcome and toxicity profile of PRRT performed with different generations of SSTR-targeting radiopharmaceuticals, including the landmark randomized-controlled trial NETTER-1. In addition, multiple optimization strategies for PRRT are discussed, i.e., the dose–effect concept, dosimetry, combination therapies (i.e., tandem/duo PRRT, chemoPRRT, targeted molecular therapy, somatostatin analogues and radiosensitizers), new radiopharmaceuticals (i.e., SSTR-antagonists, Evans-blue containing vector molecules and alpha-emitters), administration route (intra-arterial versus intravenous) and response prediction via molecular testing or imaging. The evolution and continuous refinement of PRRT resulted in many lessons for the future development of radionuclide therapy aimed at other targets and tumor types.
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18
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Combination Therapies with PRRT. Pharmaceuticals (Basel) 2021; 14:ph14101005. [PMID: 34681229 PMCID: PMC8538931 DOI: 10.3390/ph14101005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/26/2021] [Accepted: 09/27/2021] [Indexed: 02/06/2023] Open
Abstract
Peptide receptor radionuclide therapy (PRRT) is a successful targeted radionuclide therapy in neuroendocrine tumors (NETs). However, complete responses remain elusive. Combined treatments anticipate synergistic effects and thus better responses by combining ionizing radiation with other anti-tumor treatments. Furthermore, multimodal therapies often have a balanced toxicity profile. To date, few studies have evaluated the effect of combination therapies with PRRT, some of them phase I/II trials. This review will focus on several clinically tested, tailored approaches to improving the effects of PRRT. The aim is to help clinicians in the treatment planning of NETs to choose the most effective and safe treatment for each patient in the sense of personalized medicine. Current promising combination partners of PRRT are somatostatin analogues (SSAs), chemotherapy, molecular targeted treatment, liver radioembolization, and dual radionuclide PRRT (Lutetium-177-PRRT combined with Yttrium-90-PRRT).
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19
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Abstract
Consensus guidelines acknowledge the role of gallium Ga-68 (68Ga) 1,4,7,10-tetraazacyclododecane-N,N',N'',N'''-tetraacetic (DOTA) somatostatin receptor (SSTR) positron emission tomography/computed tomography (PET/CT) in management of neuroendocrine tumor (NET) patients. 68Ga-DOTA-SSTR PET/CT demonstrates superior performance to conventional imaging in initial detection, staging, detection of recurrent tumor, and detection of unknown primary in known metastatic disease. 68Ga-DOTA-SSTR PET/CT is low yield for NET detection in the setting of symptoms or elevated biomarkers when conventional imaging is negative, but may still guide management. The role of 68Ga-DOTA-SSTR PET/CT is not established in monitoring response to systemic therapy but may identify progression through detection of new metastases.
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Affiliation(s)
- Janet Pollard
- Department of Radiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Parren McNeely
- Department of Radiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Yusuf Menda
- Department of Radiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA
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20
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Assi HA, Hornbacker K, Shaheen S, Wittenberg T, Silberman R, Kunz PL. Rapid Progression After 177Lu-DOTATATE in Patients With Neuroendocrine Tumors. Pancreas 2021; 50:890-894. [PMID: 34398071 DOI: 10.1097/mpa.0000000000001841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
ABSTRACT Peptide receptor radionuclide therapy (PRRT) is a treatment option for somatostatin receptor-positive, unresectable or metastatic neuroendocrine tumors (NETs). Despite high disease control rates seen with PRRT, a subset of the NET population seems to have a short progression-free interval. We hypothesize that patients with NETs with rapid progression post-PRRT may have mixed low- and high-grade cell populations, and PRRT treats the lower-grade component, allowing the more aggressive high-grade component to progress.We report 7 patients with biopsy-proven NET who received PRRT with 177Lu-DOTATATE at the Stanford Cancer Center who had evidence of progressive disease (PD) on or within 6 months of therapy.All patients had primary pancreatic, metastatic, well-differentiated NET on diagnosis and were heavily pretreated before receiving PRRT. Two patients had PD while on PRRT; 5 had PD within 6 months of completing PRRT. The median time from the last cycle to PD was 3.2 months (range, 1.1-4.6 months). The median progression-free survival was 7.7 months (95% confidence interval, 5.7-9.8 months). Three patients had a repeat biopsy post-PRRT, 2 of which demonstrated higher disease grade compared with their initial pathology. Further evaluation in larger patient cohorts is warranted to elucidate predictive factors of PRRT response/nonresponse to enable better patient selection.
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Affiliation(s)
- Hussein A Assi
- From the Section of Hematology/Oncology, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Kathleen Hornbacker
- Section of Medical Oncology, Department of Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, CT
| | - Shagufta Shaheen
- Section of Medical Oncology, Department of Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, CT
| | - Theresa Wittenberg
- Section of Medical Oncology, Department of Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, CT
| | - Robyn Silberman
- Section of Medical Oncology, Department of Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, CT
| | - Pamela L Kunz
- Section of Medical Oncology, Department of Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, CT
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21
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Suman SK, Subramanian S, Mukherjee A. Combination radionuclide therapy: A new paradigm. Nucl Med Biol 2021; 98-99:40-58. [PMID: 34029984 DOI: 10.1016/j.nucmedbio.2021.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 04/23/2021] [Accepted: 05/06/2021] [Indexed: 12/15/2022]
Abstract
Targeted molecular radionuclide therapy (MRT) has shown its potential for the treatment of cancers of multiple origins. A combination therapy strategy employing two or more distinct therapeutic approaches in cancer management is aimed at circumventing tumor resistance by simultaneously targeting compensatory signaling pathways or bypassing survival selection mutations acquired in response to individual monotherapies. Combination radionuclide therapy (CRT) is a newer application of the concept, utilizing a combination of radiolabeled molecular targeting agents with chemotherapy and beam radiation therapy for enhanced therapeutic index. Encouraging results are reported with chemotherapeutic agents in combination with radiolabeled targeting molecules for cancer therapy. With increasing awareness of the various survival and stress response pathways activated after radionuclide therapy, different holistic combinations of MRT agents with radiosensitizers targeting such pathways have also been explored. MRT has also been studied in combination with beam radiotherapy modalities such as external beam radiation therapy and carbon ion radiation therapy to enhance the anti-tumor response. Nanotechnology aids in CRT by bringing together multiple monotherapies on a single nanostructure platform for treating cancers in a more precise or personalized way. CRT will be a key player in managing cancers if correctly tailored to the individual patient profile. The success of CRT lies in an in-depth understanding of the radiobiological principles and pathways activated in response.
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Affiliation(s)
- Shishu Kant Suman
- Radiopharmaceuticals Division, Bhabha Atomic Research Centre; Homi Bhabha National Institute, Mumbai 400094, India
| | - Suresh Subramanian
- Radiopharmaceuticals Division, Bhabha Atomic Research Centre; Homi Bhabha National Institute, Mumbai 400094, India
| | - Archana Mukherjee
- Radiopharmaceuticals Division, Bhabha Atomic Research Centre; Homi Bhabha National Institute, Mumbai 400094, India.
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22
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Peptide receptor radionuclide therapy for GEP-NET: consolidated knowledge and innovative applications. Clin Transl Imaging 2021. [DOI: 10.1007/s40336-021-00443-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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23
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Lu X, Lu C, Yang Y, Shi X, Wang H, Yang N, Yang K, Zhang X. Current Status and Trends in Peptide Receptor Radionuclide Therapy in the Past 20 Years (2000-2019): A Bibliometric Study. Front Pharmacol 2021; 12:624534. [PMID: 33986664 PMCID: PMC8111084 DOI: 10.3389/fphar.2021.624534] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 02/15/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Peptide receptor radionuclide therapy (PRRT) is an emerging therapeutic option for the treatment of neuroendocrine tumors (NETs), and the number of publications in this field has been increasing in recent years. The aim of the present study was to present the research status and summarize the key topics through bibliometric analysis of published PRRT literature. Methods: A literature search for PRRT research from 2000 to 2019 was conducted using the Science Citation Index Expanded of Web of Science Core Collection (limited to SCIE) on August 4, 2020. The VOSviewer, R-bibliometrix, and CiteSpace software were used to conduct the bibliometric analysis. Results: From 2000 to 2019, a total of 681 publications (523 articles and 158 reviews) were retrieved. Annual publication outputs grew from three to 111 records. Germany had the largest number of publications, making the largest contribution to the field (n = 151, 22.17%). Active cooperation between countries/regions was observed. Kwekkeboom from the Erasmus Medical Center is perhaps a key researcher in the field of PRRT. The European Journal of Nuclear Medicine and Molecular Imaging and Journal of Nuclear Medicine ranked first for productive (n = 84, 12.33%) and co-cited (n = 3,438) journals, respectively. Important topics mainly included matters related to the efficacy of PRRT (e.g., 90Y-dotatoc and 177Lu-dotatate), the long-term adverse effects of PRRT (e.g., hematologic and renal toxicities), standardization of NETs and PRRT in practice, the development of medical imaging techniques, and the individual dose optimization of PRRT. Conclusion: Using bibliometric analysis, we gained deep insight into the global status and trends of studies investigating PRRT for the first time. The PRRT field is undergoing a period of rapid development, and our study provides a valuable reference for clinical researchers and practitioners.
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Affiliation(s)
- Xiaojing Lu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Cuncun Lu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yongjie Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiangfen Shi
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haibo Wang
- School of Integrated Traditional Chinese and Western Medicine, Gansu University of Chinese Medicine, Lanzhou, China
| | - Nan Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Xiaojian Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Clinical Utility of 18F-FDG PET in Neuroendocrine Tumors Prior to Peptide Receptor Radionuclide Therapy: A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13081813. [PMID: 33920195 PMCID: PMC8069875 DOI: 10.3390/cancers13081813] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/05/2021] [Accepted: 04/08/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Functional imaging with 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) has evolved into a major clinical tool in cancer diagnosis and management for many malignancies in diverse clinical settings, providing valuable information on tumor behavior and aggressiveness. In the field of neuroendocrine tumors (NETs), recent advances in molecular imaging and targeted treatments with novel theranostic agents favor a more patient-tailored approach. Although peptide receptor radionuclide therapy (PRRT) has recently become an established therapy for progressive NETs, the role of 18F-FDG PET prior to PRRT in patients with NETs of different origins and grades remains to be determined. Herein, we provide a comprehensive summary of available evidence in contemporary literature by means of a systematic review and meta-analysis, demonstrating that dual-functional imaging with 68Ga-DOTA-peptides and 18F-FDG prior to PRRT appears to be a useful tool in NET management by delineating tumor somatostatin receptor expression and glycolytic metabolic activity, and predicting tumor response and survival outcomes. Abstract The role of 18F-FDG PET in patients with variable grades of neuroendocrine tumors (NETs) prior to peptide receptor radionuclide therapy (PRRT) has not been adequately elucidated. We aimed to evaluate the impact of 18F-FDG PET status on disease control rate (DCR), progression-free survival (PFS), and overall survival (OS) in neuroendocrine tumor (NET) patients receiving PRRT. We searched the MEDLINE, Embase, Cochrane Library, and Web of Science databases up to July 2020 and used the Newcastle-Ottawa scale (NOS) criteria to assess quality/risk of bias. A total of 5091 articles were screened. In 12 studies, 1492 unique patients with NETs of different origins were included. The DCR for patients with negative 18F-FDG PET status prior to PRRT initiation was 91.9%, compared to 74.2% in patients with positive 18F-FDG PET status (random effects odds ratio (OR): 4.85; 95% CI: 2.27–10.36). Adjusted analysis of pooled hazard ratios (HRs) confirmed longer PFS and OS in NET patients receiving PRRT with negative 18F-FDG PET (random effects HR:2.45; 95%CIs: 1.48–4.04 and HR:2.25; 95% CIs:1.55–3.28, respectively). In conclusion, 18F-FDG PET imaging prior to PRRT administration appears to be a useful tool in NET patients to predict tumor response and survival outcomes and a negative FDG uptake of the tumor is associated with prolonged PFS and OS.
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25
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Özdirik B, Amthauer H, Schatka I, Goretzki PE, Mogl MT, Fehrenbach U, Tacke F, Jann H, Roderburg C. A rare case of a patient with a high grade neuroendocrine tumor developing neutropenic sepsis after receiving PRRT combined with Capecitabine or Temozolomide: A case report. Mol Clin Oncol 2020; 14:20. [PMID: 33363730 PMCID: PMC7725216 DOI: 10.3892/mco.2020.2182] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 08/28/2020] [Indexed: 12/16/2022] Open
Abstract
Neuroendocrine tumors (NET) are rare and demonstrate variable clinical behavior depending on the degree of tumor differentiation. Patients with poorly differentiated tumors (NET G3) have a poor prognosis. Systemic treatment with cytotoxic chemotherapy is considered to be the treatment of choice. In patients that are refractory or intolerant to first-line therapy, experts recommend peptide receptor radionuclide therapy (PRRT) in tumors that express somatostatin receptors. Recently, combinations of PRRT and chemotherapy were tested in patients with NET. Available data have reported promising tumor control rates and an excellent toxicity profile in cases where PRRT had been administered with capecitabine/temozolomide, even when administered as salvage therapy. The current study reported an exceptional case of advanced NET G3 with severe toxicity upon receiving PRRT in combination with capecitabine/temozolomide as third line therapy. The patient developed a life-threatening neutropenic fever, fungal pneumonia and necrotizing mastitis 23 days after the first cycle of therapy was administered. However, the treatment led to a significant reduction in tumor size. A total of 5 months after treatment initiation, the patient was alive and in excellent clinical condition with sustained tumor response. In summary, the current study presented a rare case of high grade NET exhibiting an almost complete response to PRRT in combination capecitabine/temozolomide, despite facing unexpected severe toxicity.
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Affiliation(s)
- Burcin Özdirik
- Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Holger Amthauer
- Department of Nuclear Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Imke Schatka
- Department of Nuclear Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Peter E Goretzki
- Department of Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Martina T Mogl
- Department of Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Uli Fehrenbach
- Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Henning Jann
- Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
| | - Christoph Roderburg
- Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany
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Sundlöv A, Sjögreen-Gleisner K. Peptide Receptor Radionuclide Therapy - Prospects for Personalised Treatment. Clin Oncol (R Coll Radiol) 2020; 33:92-97. [PMID: 33189510 DOI: 10.1016/j.clon.2020.10.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/03/2020] [Accepted: 10/26/2020] [Indexed: 12/16/2022]
Abstract
Peptide receptor radionuclide therapy is a type of molecular radiotherapy that has been used in the treatment of patients with neuroendocrine tumours for over two decades. It is not until recently, however, that it has achieved regulatory approval. The currently approved treatment regimen is a one-size-fits-all scheme, i.e. all patients receive a fixed activity of the radiopharmaceutical (177Lu-DOTATATE) and a fixed number of treatment cycles. Several research groups around the world have studied different approaches of further improving on the results of peptide receptor radionuclide therapy, with many promising retrospective and prospective clinical studies having been published over the years. In this overview, we summarise some of the most promising strategies identified so far.
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Affiliation(s)
- A Sundlöv
- Department of Oncology, Skåne University Hospital, Lund, Sweden; Department of Medical Radiation Physics, Clinical Sciences, Lund University, Lund, Sweden.
| | - K Sjögreen-Gleisner
- Department of Medical Radiation Physics, Clinical Sciences, Lund University, Lund, Sweden
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Parghane RV, Ostwal V, Ramaswamy A, Bhandare M, Chaudhari V, Talole S, Shrikhande SV, Basu S. Long-term outcome of "Sandwich" chemo-PRRT: a novel treatment strategy for metastatic neuroendocrine tumors with both FDG- and SSTR-avid aggressive disease. Eur J Nucl Med Mol Imaging 2020; 48:913-923. [PMID: 32876706 DOI: 10.1007/s00259-020-05004-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/17/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The primary aims of this study were to evaluate the long-term outcome of a "sandwich chemo-PRRT (SCPRRT)" regimen with regard to therapeutic response rate, progression-free survival (PFS), and overall survival (OS) rates in metastatic neuroendocrine tumors (NETs) with both somatostatin receptor (SSTR)- and fluorodeoxyglucose (FDG)-avid aggressive disease. Additionally, health-related quality of life (HRQoL) scales, clinical toxicity, and association of PFS and disease control rate (DCR) with various variables were also evaluated. MATERIALS AND METHODS A total of 38 patients of the aforementioned cohort, who received SCPRRT (at least 2 cycles of each PRRT and chemotherapy) at our institute between January 2012 and December 2018, were included and analyzed in this retrospective study. Between two cycles of 177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT), two cycles of oral capecitabine and temozolomide (CAPTEM) were sandwiched. Therapeutic responses following SCPRRT were assessed by using pre-defined criteria. PFS and OS after first SCPRRT were determined. Eastern Cooperative Oncology Group (ECOG) and Karnofsky score were used for evaluation of HRQoL before and after SCPPRT in all 38 patients. Any adverse events were graded according to the Common Terminology Criteria for Adverse Events version 5.0 (CTCAE v5.0) of the National Cancer Institute. Associations of PFS and DCR with various variables were evaluated. RESULTS Response (complete response and partial response) to SCPRRT was seen in 28 patients (73%), 15 patients (39%), and 16 patients (42%) on symptomatic, biochemical, and molecular imaging response evaluation criteria respectively. A total of 17 patients (45%) had anatomical imaging response with DCR of 84% based upon the RECIST 1.1 criteria. Pre-therapy mean ECOG and KPS was 2.0 and 68, which changed to 1.0 and 75 respectively following SCPRRT. Long-term follow-up data was available and ranged from 12 to 65 months after the first SCPRRT. Median PFS and OS were not reached at a median follow-up of 36 months. An estimated PFS rate of 72.5% and OS rate of 80.4% was found at 36 months. Longer PFS was dependent upon high SSTR uptake and number of CAPTEM cycle (≥ 7 cycles), absence of skeletal metastasis, and no previous external beam radiotherapy (EBRT) exposure with significant P value. Higher DCR was dependent upon absence of skeletal metastasis with significant P value. SCPRRT was tolerated well with none developing grade 4 hematotoxicity and nephrotoxicity of any grade. Anemia (grade 3), thrombocytopenia (grade 3), and leukopenia (grade 3) were noticed in 1 patient (2.5%), 2 patients (5%), and 1 patient (2.5%) respectively in this study. CONCLUSION Thus, favorable response rates with effective control of symptoms and longer PFS and OS without high-grade or life-threatening toxicities were important observations in the present study following SCPRRT in NET patients with aggressive, both FDG- and SSTR-avid, metastatic progressive disease. The study results indicate the potential role of "sandwich chemo-PRRT" in future therapeutic algorithms of aggressive, both SSTR- and FDG-positive subset of neuroendocrine tumors.
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Affiliation(s)
- Rahul V Parghane
- Radiation Medicine Centre (BARC), Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Jerbai Wadia Road, Parel, Mumbai, 400012, India.,Homi Bhabha National Institute, Mumbai, India
| | - Vikas Ostwal
- Homi Bhabha National Institute, Mumbai, India.,Department of Medical Gastroenterology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Anant Ramaswamy
- Homi Bhabha National Institute, Mumbai, India.,Department of Medical Gastroenterology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Manish Bhandare
- Homi Bhabha National Institute, Mumbai, India.,Department of Surgical Oncology, Gastrointestinal and Hepato-Pancreato-Biliary Service, Tata Memorial Hospital, Mumbai, India
| | - Vikram Chaudhari
- Homi Bhabha National Institute, Mumbai, India.,Department of Surgical Oncology, Gastrointestinal and Hepato-Pancreato-Biliary Service, Tata Memorial Hospital, Mumbai, India
| | - Sanjay Talole
- Homi Bhabha National Institute, Mumbai, India.,Department of Biostatistics, ACTREC, Tata Memorial Centre, Mumbai, India
| | - Shailesh V Shrikhande
- Homi Bhabha National Institute, Mumbai, India.,Department of Surgical Oncology, Gastrointestinal and Hepato-Pancreato-Biliary Service, Tata Memorial Hospital, Mumbai, India
| | - Sandip Basu
- Radiation Medicine Centre (BARC), Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Jerbai Wadia Road, Parel, Mumbai, 400012, India. .,Homi Bhabha National Institute, Mumbai, India.
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28
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Basu S, Parghane RV, Kamaldeep, Chakrabarty S. Peptide Receptor Radionuclide Therapy of Neuroendocrine Tumors. Semin Nucl Med 2020; 50:447-464. [PMID: 32768008 DOI: 10.1053/j.semnuclmed.2020.05.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Peptide receptor radionuclide therapy (PRRT), over the years, has evolved as an important modality in the therapeutic armamentarium of advanced, metastatic or inoperable, progressive Neuroendocrine Neoplasms (NENs). This review deliberates on the basic understanding and applied clinical aspects of PRRT in NENs, with special reference to (1) tumor biology and receptor characteristics, (2) molecular PET-CT imaging (in particular the invaluable role of dual-tracer PET with [68Ga]-DOTA-TATE/NOC and [18F]-FDG for exploring tumor biology in continuum and individualizing treatment decision making) and NEN theranostics, (3) relevant radiochemistry of different therapeutic radionuclides (both beta emitting 177Lu-DOTATATE and 90Y-DOTATATE and alpha emitting 225Ac-DOTATATE), and (4) related dosimetric considerations. Successful clinical management of the NENs would require multifactorial considerations, and all the aforementioned points pertaining to the disease process and available logistics are key considerations for state-of-the-art clinical practice and delivering personalized care in this group of patients. Emphasis has been placed on relatively intriguing areas such as (1) NET grade 3 of WHO 2017 classification (ie, Ki-67>20% but well-differentiation features), (2) "Neoadjuvant PRRT," (3) combining chemotherapy and PRRT, (4) 'Sandwich Chemo-PRRT', (5) duo-PRRT and tandem PRRT, (6) resistant functioning disease with nuances in clinical management and how one can advocate PRRT rationally in such clinical settings and individualize the management in a patient specific manner. Relevant clinical management issues related to some difficult case scenarios, which the Nuclear Medicine attending physician should be aware of to run an efficient clinical PRRT services, are described.
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Affiliation(s)
- Sandip Basu
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Mumbai, India; Homi Bhabha National Institute, Mumbai, India.
| | - Rahul V Parghane
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Mumbai, India; Homi Bhabha National Institute, Mumbai, India
| | - Kamaldeep
- Homi Bhabha National Institute, Mumbai, India; Health Physics Division, Bhabha Atomic Research Centre Mumbai, India
| | - Sudipta Chakrabarty
- Homi Bhabha National Institute, Mumbai, India; Radiochemicals Section, Radiopharmaceuticals Division, Bhabha Atomic Research Centre Mumbai, India
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Basu S, Chakraborty S, Parghane RV, Kamaldeep, Ranade R, Thapa P, Asopa RV, Sonawane G, Nabar S, Shimpi H, Chandak A, Vimalnath KV, Ostwal V, Ramaswamy A, Bhandare M, Chaudhari V, Shrikhande SV, Sirohi B, Dash A, Banerjee S. One decade of 'Bench-to-Bedside' peptide receptor radionuclide therapy with indigenous [ 177Lu]Lu-DOTATATE obtained through 'Direct' neutron activation route: lessons learnt including practice evolution in an Indian setting. AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2020; 10:178-211. [PMID: 32929396 PMCID: PMC7486551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 08/14/2020] [Indexed: 03/30/2024]
Abstract
The present treatise chronicles one decade of experience pertaining to clinical PRRT services in a large-volume tertiary cancer care centre in India delivering over 4,000 therapies, an exemplar of successful PRRT programme employing indigenous 177Lutetium production and resources. For the purpose of systematic discussion, we have sub-divided the communication into 3 specific parts: (a) Radiopharmaceutical aspects that describes 177Lutetium production through 'Direct' Neutron Activation Route and the subsequent radiolabeling procedures, (b) The specific clinical nuances and finer learning points (apart from the routine standard procedure) based upon clinical experience and how it has undergone practice evolution in our setting and (c) Dosimetry results with this indigenous product and radiation safety/health physics aspects involved in PRRT services. Initiated in 2010 at our centre, the PRRT programme is a perfect example of affordable quality health care delivery, with indigenous production of the radionuclide (177Lu) in the reactor and subsequent radiolabeling of the radiopharmaceutical ([177Lu]Lu-DOTATATE) at the hospital radiopharmacy unit of the centre, which enabled catering to the needs of a large number of patients of progressive, metastatic and advanced Neuroendocrine Neoplasms (NENs) and related malignancies.
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Affiliation(s)
- Sandip Basu
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital AnnexeParel, Mumbai, India
- Homi Bhabha National InstituteMumbai, India
| | - Sudipta Chakraborty
- Homi Bhabha National InstituteMumbai, India
- Radiopharmaceuticals Division, BARCMumbai, India
| | - Rahul V Parghane
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital AnnexeParel, Mumbai, India
- Homi Bhabha National InstituteMumbai, India
| | - Kamaldeep
- Homi Bhabha National InstituteMumbai, India
- Health Physics Division, Bhabha Atomic Research CentreMumbai, India
| | - Rohit Ranade
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital AnnexeParel, Mumbai, India
- Homi Bhabha National InstituteMumbai, India
| | - Pradeep Thapa
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital AnnexeParel, Mumbai, India
- Homi Bhabha National InstituteMumbai, India
| | - Ramesh V Asopa
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital AnnexeParel, Mumbai, India
- Homi Bhabha National InstituteMumbai, India
| | - Geeta Sonawane
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital AnnexeParel, Mumbai, India
- Homi Bhabha National InstituteMumbai, India
| | - Swapna Nabar
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital AnnexeParel, Mumbai, India
- Homi Bhabha National InstituteMumbai, India
| | - Hemant Shimpi
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital AnnexeParel, Mumbai, India
- Homi Bhabha National InstituteMumbai, India
| | - Ashok Chandak
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital AnnexeParel, Mumbai, India
- Homi Bhabha National InstituteMumbai, India
| | - KV Vimalnath
- Radiopharmaceuticals Division, BARCMumbai, India
| | - Vikas Ostwal
- Homi Bhabha National InstituteMumbai, India
- Department of Medical Oncology, Tata Memorial CentreMumbai, Maharashtra, India
| | - Anant Ramaswamy
- Homi Bhabha National InstituteMumbai, India
- Department of Medical Oncology, Tata Memorial CentreMumbai, Maharashtra, India
| | - Manish Bhandare
- Homi Bhabha National InstituteMumbai, India
- Department of Surgical Oncology, Gastrointestinal and Hepato-Pancreato-Biliary Service, Tata Memorial HospitalMumbai, India
| | - Vikram Chaudhari
- Homi Bhabha National InstituteMumbai, India
- Department of Surgical Oncology, Gastrointestinal and Hepato-Pancreato-Biliary Service, Tata Memorial HospitalMumbai, India
| | - Shailesh V Shrikhande
- Homi Bhabha National InstituteMumbai, India
- Department of Surgical Oncology, Gastrointestinal and Hepato-Pancreato-Biliary Service, Tata Memorial HospitalMumbai, India
| | - Bhawna Sirohi
- Department of Medical Oncology, Tata Memorial CentreMumbai, Maharashtra, India
- Apollo Proton Cancer CentreChennai, India
| | - Ashutosh Dash
- Homi Bhabha National InstituteMumbai, India
- Radiopharmaceuticals Division, BARCMumbai, India
| | - Sharmila Banerjee
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital AnnexeParel, Mumbai, India
- Homi Bhabha National InstituteMumbai, India
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Huizing DMV, Aalbersberg EA, Versleijen MWJ, Tesselaar MET, Walraven I, Lahaye MJ, de Wit-van der Veen BJ, Stokkel MPM. Early response assessment and prediction of overall survival after peptide receptor radionuclide therapy. Cancer Imaging 2020; 20:57. [PMID: 32778165 PMCID: PMC7418334 DOI: 10.1186/s40644-020-00335-w] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/29/2020] [Indexed: 01/19/2023] Open
Abstract
Background Response after peptide receptor radionuclide therapy (PRRT) can be evaluated using anatomical imaging (CT/MRI), somatostatin receptor imaging ([68Ga]Ga-DOTA-TATE PET/CT), and serum Chromogranin-A (CgA). The aim of this retrospective study is to assess the role of these response evaluation methods and their predictive value for overall survival (OS). Methods Imaging and CgA levels were acquired prior to start of PRRT, and 3 and 9 months after completion. Tumour size was measured on anatomical imaging and response was categorized according to RECIST 1.1 and Choi criteria. [68Ga]Ga-DOTA-TATE uptake was quantified in both target lesions depicted on anatomical imaging and separately identified PET target lesions, which were either followed over time or newly identified on each scan with PERCIST-based criteria. Response evaluation methods were compared with Cox regression analyses and Log Rank tests for association with OS. Results A total of 44 patients were included, with median follow-up of 31 months (IQR 26–36 months) and median OS of 39 months (IQR 32mo-not reached)d. Progressive disease after 9 months (according to RECIST 1.1) was significantly associated with worse OS compared to stable disease [HR 9.04 (95% CI 2.10–38.85)], however not compared to patients with partial response. According to Choi criteria, progressive disease was also significantly associated with worse OS compared to stable disease [HR 6.10 (95% CI 1.38–27.05)] and compared to patients with partial response [HR 22.66 (95% CI 2.33–219.99)]. In some patients, new lesions were detected earlier with [68Ga]Ga-DOTA-TATE PET/CT than with anatomical imaging. After 3 months, new lesions on [68Ga]Ga-DOTA-TATE PET/CT which were not visible on anatomical imaging, were detected in 4/41 (10%) patients and in another 3/27 (11%) patients after 9 months. However, no associations between change in uptake on 68Ga-DOTA-TATE PET/CT or serum CgA measurements and OS was observed. Conclusions Progression on anatomical imaging performed 9 months after PRRT is associated with worse OS compared to stable disease or partial response. Although new lesions were detected earlier with [68Ga]Ga-DOTA-TATE PET/CT than with anatomical imaging, [68Ga]Ga-DOTA-TATE uptake, and serum CgA after PRRT were not predictive for OS in this cohort with limited number of patients and follow-up time.
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Affiliation(s)
- Daphne M V Huizing
- Department of Nuclear Medicine, Netherlands Cancer Institute, ENETS Center of Excellence, Amsterdam, The Netherlands.
| | - Else A Aalbersberg
- Department of Nuclear Medicine, Netherlands Cancer Institute, ENETS Center of Excellence, Amsterdam, The Netherlands
| | - Michelle W J Versleijen
- Department of Nuclear Medicine, Netherlands Cancer Institute, ENETS Center of Excellence, Amsterdam, The Netherlands
| | - Margot E T Tesselaar
- Department of Medical Oncology, Netherlands Cancer Institute, ENETS Center of Excellence, Amsterdam, The Netherlands
| | - Iris Walraven
- Department of Radiotherapy, Netherlands Cancer Institute, ENETS Center of Excellence, Amsterdam, The Netherlands
| | - Max J Lahaye
- Department of Radiology, Netherlands Cancer Institute, ENETS Center of Excellence, Amsterdam, The Netherlands
| | | | - Marcel P M Stokkel
- Department of Nuclear Medicine, Netherlands Cancer Institute, ENETS Center of Excellence, Amsterdam, The Netherlands
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Cullinane C, Waldeck K, Kirby L, Rogers BE, Eu P, Tothill RW, Hicks RJ. Enhancing the anti-tumour activity of 177Lu-DOTA-octreotate radionuclide therapy in somatostatin receptor-2 expressing tumour models by targeting PARP. Sci Rep 2020; 10:10196. [PMID: 32576907 PMCID: PMC7311440 DOI: 10.1038/s41598-020-67199-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 06/02/2020] [Indexed: 01/25/2023] Open
Abstract
Peptide receptor radionuclide therapy (PRRT) is an important treatment option for patients with somatostatin receptor-2 (SSTR2)-expressing neuroendocrine tumour (NET) though tumour regression occurs in only a minority of patients. Therefore, novel PRRT regimens with improved therapeutic activity are needed. Radiation induced DNA damage repair is an attractive therapeutic target to increase PRRT efficacy and consequently, we have characterised a panel of preclinical models for their SSTR2 expression, in vivo growth properties and response to 177Lu-DOTA-octreotate (LuTate) PRRT to identify models with features suitable for evaluating novel therapeutic combinations. In vitro studies using the SSTR2 expressing AR42J model demonstrate that the combination of LuTate and the small molecule Poly(ADP-ribose) polymerase-1 (PARP) inhibitor, talazoparib led to increased DNA double strand breaks, as assessed by γ-H2AX foci formation, as compared to LuTate alone. Furthermore, using the AR42J tumour model in vivo we demonstrate that the combination of LuTate and talazoparib significantly improved the anti-tumour efficacy of LuTate alone. These findings support the clinical evaluation of the combination of LuTate and PARP inhibition in SSTR2-expressing NET.
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Affiliation(s)
- Carleen Cullinane
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.
| | - Kelly Waldeck
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Laura Kirby
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Buck E Rogers
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO, 63110, USA
| | - Peter Eu
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Richard W Tothill
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Clinical Pathology and Centre for Cancer Research, University of Melbourne, Parkville, Victoria, Australia
| | - Rodney J Hicks
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
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32
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Lin E, Chen T, Little A, Holliday L, Roach P, Butler P, Hosking E, Bailey E, Elison B, Currow D. Safety and outcomes of 177 Lu-DOTATATE for neuroendocrine tumours: experience in New South Wales, Australia. Intern Med J 2020; 49:1268-1277. [PMID: 31062490 DOI: 10.1111/imj.14336] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/14/2019] [Accepted: 04/14/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Peptide receptor radionuclide therapy with 177 Lu-DOTATATE is a promising treatment for inoperable or metastatic neuroendocrine tumours (NET). In 2015, the NSW Ministry of Health provided funding for 177 Lu-DOTATATE treatment of NET under an evaluation framework. AIMS To examine the safety and outcomes of NET patients treated with 177 Lu-DOTATATE under the evaluation framework and assess the statewide implementation of the NSW Lutate therapy referral and protocol for neuroendocrine cancer patients. METHODS A quality of care clinical audit was conducted on all NET patients treated with 177 Lu-DOTATATE from October 2010 to October 2015 at St George Hospital, and from August 2013 to March 2017 at Royal North Shore Hospital. Percentage of patients who met protocol selection criteria was calculated. Survival was estimated using the Kaplan-Meier method. Adjusted regression analyses assessed associations between key clinical factors and outcomes. RESULTS A total of 279 patients was treated. Statewide protocol implementation led to an increase from 60.5 to 83.8% in patients meeting selection criteria. Estimated median overall survival was significantly longer for patients who met selection criteria compared with those who did not (50.7 vs 34.2 months) (P = 0.018). This was driven by the significantly worse overall survival in patients who failed exclusion criteria (P < 0.001). 177 Lu-DOTATATE was well tolerated with haematological, renal and hepatic treatment-related serious adverse events experienced by 9.7, 0.4 and 0.4% of patients respectively. CONCLUSIONS 177 Lu-DOTATATE is a promising treatment for advanced NET. Superior survival in patients who met selection criteria emphasise the importance of protocol adherence.
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Affiliation(s)
- Enmoore Lin
- Cancer Institute NSW, Sydney, New South Wales, Australia
| | - Tina Chen
- Cancer Institute NSW, Sydney, New South Wales, Australia
| | - Alana Little
- Cancer Institute NSW, Sydney, New South Wales, Australia
| | - Laura Holliday
- Cancer Institute NSW, Sydney, New South Wales, Australia
| | - Paul Roach
- Department of Nuclear Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Patrick Butler
- Department of Nuclear Medicine, St George Hospital, Sydney, New South Wales, Australia
| | - Erika Hosking
- Department of Nuclear Medicine, St George Hospital, Sydney, New South Wales, Australia
| | - Elizabeth Bailey
- Department of Nuclear Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Barry Elison
- Agency for Clinical Innovation, Sydney, New South Wales, Australia
| | - David Currow
- Cancer Institute NSW, Sydney, New South Wales, Australia
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Yong MS, Kong G, Ludhani P, Michael M, Morgan J, Hofman MS, Hicks RJ, Larobina M. Early Outcomes of Surgery for Carcinoid Heart Disease. Heart Lung Circ 2020; 29:742-747. [DOI: 10.1016/j.hlc.2019.05.183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
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Starr JS, Sonbol MB, Hobday TJ, Sharma A, Kendi AT, Halfdanarson TR. Peptide Receptor Radionuclide Therapy for the Treatment of Pancreatic Neuroendocrine Tumors: Recent Insights. Onco Targets Ther 2020; 13:3545-3555. [PMID: 32431509 PMCID: PMC7205451 DOI: 10.2147/ott.s202867] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/26/2020] [Indexed: 12/27/2022] Open
Abstract
Peptide receptor radionuclide therapy (PRRT) is a paradigm shifting approach to the treatment of neuroendocrine tumors. Although there are no prospective randomized trials directly studying PRRT in pancreatic neuroendocrine tumors (panNETs), there are data to suggest benefit in this patient population. Collectively, the data, consisting of two prospective and six retrospective studies, show a median PFS ranging from 20 to 39 months and a median OS ranging from 37 to 79 months. There are ongoing (and upcoming) prospective, randomized trials of PRRT in panNETs, which will provide further evidence to support this approach.
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Affiliation(s)
- Jason S Starr
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Timothy J Hobday
- Division of Hematology/Oncology, Mayo Clinic, Rochester, MN, USA
| | - Akash Sharma
- Division of Nuclear Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Ayse Tuba Kendi
- Division of Hematology/Oncology, Mayo Clinic, Rochester, MN, USA
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Zhang J, Liu Q, Singh A, Schuchardt C, Kulkarni HR, Baum RP. Prognostic Value of 18F-FDG PET/CT in a Large Cohort of Patients with Advanced Metastatic Neuroendocrine Neoplasms Treated with Peptide Receptor Radionuclide Therapy. J Nucl Med 2020; 61:1560-1569. [PMID: 32169914 DOI: 10.2967/jnumed.119.241414] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/05/2020] [Indexed: 01/22/2023] Open
Abstract
The objective of this retrospective study was to determine the role of 18F-FDG PET/CT in a large cohort of 495 patients with metastatic neuroendocrine neoplasms (NENs) who were treated with peptide receptor radionuclide therapy (PRRT) with a long-term follow-up. Methods: The 495 patients were treated with 177Lu- or 90Y-DOTATOC/DOTATATE PRRT between February 2002 and July 2018. All subjects received both 68Ga-DOTATOC/TATE/NOC and 18F-FDG PET/CT before treatment and were followed 3-189 mo. Kaplan-Meier analysis, log-rank testing (Mantel-Cox), and Cox regression analysis were performed for overall survival (OS) and progression-free survival (PFS). Results: One hundred ninety-nine patients (40.2%) presented with pancreatic NENs, 49 with cancer of unknown primary, and 139 with midgut NENs, whereas the primary tumor was present in the rectum in 20, in the lung in 38, in the stomach in 8, and in other locations in 42. 18F-FDG PET/CT was positive in 382 (77.2%) patients and negative in 113 (22.8%) before PRRT, whereas 100% were 68Ga-DOTATOC/TATE/NOC-positive. For all patients, the median PFS and OS, defined from the start of PRRT, were 19.6 mo and 58.7 mo, respectively. Positive 18F-FDG results predicted shorter PFS (18.5 mo vs. 24.1 mo; P = 0.0015) and OS (53.2 mo vs. 83.1 mo; P < 0.001) than negative 18F-FDG results. Among the cases of pancreatic NENs, the median OS was 52.8 mo in 18F-FDG-positive subjects and 114.3 mo in 18F-FDG-negative subjects (P = 0.0006). For all patients positive for 18F-FDG uptake, and a ratio of more than 2 for the highest SUVmax on 68Ga-somatostatin receptor (SSTR) PET to the most 18F-FDG-avid tumor lesions, the median OS was 53.0 mo, compared with 43.4 mo in those patients with a ratio of less than 2 (P = 0.030). For patients with no 18F-FDG uptake (complete mismatch imaging pattern), the median OS was 108.3 mo versus 76.9 mo for an SUVmax of more than 15.0 and an SUVmax of 15.0 or less on 68Ga-SSTR PET/CT, respectively. Conclusion: The presence of positive lesions on 18F-FDG PET is an independent prognostic factor in patients with NENs treated with PRRT. Metabolic imaging with 18F-FDG PET/CT complements the molecular imaging aspect of 68Ga-SSTR PET/CT for the prognosis of survival after PRRT. High SSTR expression combined with negative 18F-FDG PET/CT results is associated with the most favorable long-term prognosis.
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Affiliation(s)
- Jingjing Zhang
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Qingxing Liu
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany.,Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; and
| | - Aviral Singh
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany.,GROW-School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Christiane Schuchardt
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Harshad R Kulkarni
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Richard P Baum
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany
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Peptide Receptor Radionuclide Therapy. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
Neuroendocrine tumors (NETs) originate from the neuroendocrine cell system in the bronchial and gastrointestinal tract and can produce hormones leading to distinct clinical syndromes. Systemic treatment of patients with unresectable NETs aims to control symptoms related to hormonal overproduction and tumor growth. In the last decades prognosis has improved as a result of increased detection of early stage disease and the introduction of somatostatin analogs (SSAs) as well as several new therapeutic options. SSAs are the first-line medical treatment of NETs and can control hormonal production and tumor growth. The development of next-generation multireceptor targeted and radiolabelled somatostatin analogs, as well as target-directed therapies (as second-line treatment options) further improve progression-free survival in NET patients. To date, however, a significant prolongation of overall survival with systemic treatment in NET has not been convincingly demonstrated. Several new medical options and treatment combinations will become available in the upcoming years, and although preliminary results of preclinical and clinical trials are encouraging, large, preferrably randomized clinical studies are required to provide definitive evidence of their effect on survival and symptom control.
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Combination treatments to enhance peptide receptor radionuclide therapy of neuroendocrine tumours. Eur J Nucl Med Mol Imaging 2019; 47:907-921. [DOI: 10.1007/s00259-019-04499-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 08/21/2019] [Indexed: 12/11/2022]
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Turner JH. Theranostic Outcomes in Clinical Practice of Oncology: What, So What, Now What? What's More. Cancer Biother Radiopharm 2019; 34:135-140. [PMID: 30973278 DOI: 10.1089/cbr.2019.29006.jht] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Goncalves I, Burbury K, Michael M, Iravani A, Ravi Kumar AS, Akhurst T, Tiong IS, Blombery P, Hofman MS, Westerman D, Hicks RJ, Kong G. Characteristics and outcomes of therapy-related myeloid neoplasms after peptide receptor radionuclide/chemoradionuclide therapy (PRRT/PRCRT) for metastatic neuroendocrine neoplasia: a single-institution series. Eur J Nucl Med Mol Imaging 2019; 46:1902-1910. [PMID: 31187162 DOI: 10.1007/s00259-019-04389-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/31/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Peptide receptor radionuclide/chemoradionuclide therapy (PRRT/PRCRT) is an effective therapy for metastatic neuroendocrine neoplasia (NEN), but therapy-related myeloid neoplasms (t-MN) remain of concern. The study reviewed the clinicopathological features and outcomes of patients who developed t-MN. METHODS Retrospective analysis of all patients diagnosed with t-MN by 2016 WHO classification, from a cohort of 521 patients who received PRRT/PRCRT over a 12-year period. Molecular next-generation sequencing using an in-house 26-gene panel was performed. RESULTS Twenty-five of 521 (4.8%) patients were diagnosed with t-MN, including six acute myeloid leukaemia (AML) and 19 myelodysplastic syndrome (MDS). The median time from first cycle PRRT/PRCRT to diagnosis of t-MN was 26 months (range 4-91). Twenty-two of 25 (88%) patients had grade 1-2 pancreatic or small bowel NEN with moderate metastatic liver burden. Six patients (24%) had prior chemotherapy. Median number of PRRT cycles = 5 (22/25 (88%) with concomitant radiosensitising chemotherapy). All 25 patients achieved disease stabilisation (68%) or partial response (32%) on RECIST 1.1 at 3 months post-PRRT. At t-MN diagnosis, all patients presented with thrombocytopenia (median nadir 33 × 109/L, range 3-75) and 17 (68%) remained NEN progression-free. Marrow genetic analysis revealed unfavourable karyotype in 16/25 (66%) patients with tumour protein 53 (TP53) mutation in nine (36%). Azacitidine therapy was utilised in ten eligible patients, while four received induction chemotherapy for AML. The median overall survival from first PRRT was 62 months (19-94), but from t-MN diagnosis was only 13 months (1-56), with death due primarily to haematological disease progression. CONCLUSIONS The diagnosis of t-MN after PRRT/PRCRT is an infrequent but serious complication with poor overall survival. Most patients present with thrombocytopenia; unfavourable genetic mutations have a poor response to t-MN treatment. Prospective data are needed to explore potential pre-existing genetic factors and predictive biomarkers to minimise the risk of t-MN.
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Affiliation(s)
- Isaac Goncalves
- Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, 3000, Australia.
| | - Kate Burbury
- Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, 3000, Australia
| | - Michael Michael
- Nuclear Medicine Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Amir Iravani
- Nuclear Medicine Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,Neuroendocrine Tumour Service, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Aravind S Ravi Kumar
- Nuclear Medicine Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Neuroendocrine Tumour Service, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Tim Akhurst
- Nuclear Medicine Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Neuroendocrine Tumour Service, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Ing S Tiong
- Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, 3000, Australia
| | - Piers Blombery
- Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, 3000, Australia
| | - Michael S Hofman
- Nuclear Medicine Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Neuroendocrine Tumour Service, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - David Westerman
- Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, 3000, Australia
| | - Rodney J Hicks
- Nuclear Medicine Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Neuroendocrine Tumour Service, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Grace Kong
- Nuclear Medicine Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Neuroendocrine Tumour Service, Peter MacCallum Cancer Centre, Melbourne, Australia
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Peptide Receptor Radionuclide Therapy Combined With Chemotherapy in Patients With Neuroendocrine Tumors. Clin Nucl Med 2019; 44:e329-e335. [DOI: 10.1097/rlu.0000000000002532] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Mujica-Mota R, Varley-Campbell J, Tikhonova I, Cooper C, Griffin E, Haasova M, Peters J, Lucherini S, Talens-Bou J, Long L, Sherriff D, Napier M, Ramage J, Hoyle M. Everolimus, lutetium-177 DOTATATE and sunitinib for advanced, unresectable or metastatic neuroendocrine tumours with disease progression: a systematic review and cost-effectiveness analysis. Health Technol Assess 2019; 22:1-326. [PMID: 30209002 DOI: 10.3310/hta22490] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Neuroendocrine tumours (NETs) are a group of heterogeneous cancers that develop in cells in the diffuse neuroendocrine system. OBJECTIVES To estimate the clinical effectiveness of three interventions [everolimus (Afinitor®; Novartis International AG, Basel, Switzerland), lutetium-177 DOTATATE (177Lu-DOTATATE) (Lutathera®; Imaging Equipment Ltd, Radstock, UK) and sunitinib (Sutent®; Pfizer Inc., New York, NY, USA)] for treating unresectable or metastatic NETs with disease progression and establish the cost-effectiveness of these interventions. DATA SOURCES The following databases were searched from inception to May 2016: MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE Daily, Epub Ahead of Print, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science. REVIEW METHODS We systematically reviewed the clinical effectiveness and cost-effectiveness literature on everolimus, 177Lu-DOTATATE and sunitinib for treating advanced, unresectable or metastatic progressive NETs. The following NET locations were considered separately: pancreas, gastrointestinal (GI) tract and lung, and GI tract (midgut only). We wrote a survival partition cohort-based economic evaluation in Microsoft Excel® 2013 (Microsoft Corporation, Redmond, WA, USA) from the UK NHS and Personal Social Services perspective. This comprised three health states: (1) progression-free survival (PFS), (2) progressed disease and (3) death. RESULTS Three randomised controlled trials (RCTs), RADIANT-3 [RAD001 in Advanced Neuroendocrine Tumors, Third Trial; pancreatic NETs (pNETs): everolimus vs. best supportive care (BSC)], A6181111 (pNETs: sunitinib vs. BSC) and RADIANT-4 (RAD001 in Advanced Neuroendocrine Tumors, Fourth Trial; GI and lung NETs: everolimus vs. BSC), met the inclusion criteria for the clinical effectiveness systematic review. The risk of bias was low. Although the NETTER-1 (Neuroendocrine Tumors Therapy) RCT, of 177Lu-DOTATATE plus 30 mg of octreotide (Sandostatin®, Novartis) compared with 60 mg of octreotide, was excluded from the review, we nonetheless present the results of this trial, as it informs our estimate of the cost-effectiveness of 177Lu-DOTATATE. The pNETs trials consistently found that the interventions improved PFS and overall survival (OS) compared with BSC. Our indirect comparison found no significant difference in PFS between everolimus and sunitinib. Estimates of OS gain were confounded because of high rates of treatment switching. After adjustment, our indirect comparison suggested a lower, but non-significant, hazard of death for sunitinib compared with everolimus. In GI and lung NETs, everolimus significantly improved PFS compared with BSC and showed a non-significant trend towards improved OS compared with BSC. Adverse events were more commonly reported following treatment with targeted interventions than after treatment with BSC. In the base case for pNETs, assuming list prices, we estimated incremental cost-effectiveness ratios (ICERs) for everolimus compared with BSC of £45,493 per quality-adjusted life-year (QALY) and for sunitinib compared with BSC of £20,717 per QALY. These ICERs increased substantially without the adjustment for treatment switching. For GI and lung NETs, we estimated an ICER for everolimus compared with BSC of £44,557 per QALY. For GI (midgut) NETs, the ICERs were £199,233 per QALY for everolimus compared with BSC and £62,158 per QALY for a scenario analysis comparing 177Lu-DOTATATE with BSC. We judge that no treatment meets the National Institute for Health and Care Excellence's (NICE) end-of-life criteria, although we cannot rule out that sunitinib in the A6181111 trial does. LIMITATIONS A RCT with included comparators was not identified for 177Lu-DOTATATE. The indirect treatment comparison that our economic analysis was based on was of a simple Bucher type, unadjusted for any differences in the baseline characteristics across the two trials. CONCLUSIONS Given NICE's current stated range of £20,000-30,000 per QALY for the cost-effectiveness threshold, based on list prices, only sunitinib might be considered good value for money in England and Wales. FUTURE WORK Further analysis of individual patient data from RADIANT-3 would allow assessment of the robustness of our findings. The data were not made available to us by the company sponsoring the trial. STUDY REGISTRATION This study is registered as PROSPERO CRD42016041303. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Ruben Mujica-Mota
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jo Varley-Campbell
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Irina Tikhonova
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Cooper
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Ed Griffin
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Marcela Haasova
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jaime Peters
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Stefano Lucherini
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Juan Talens-Bou
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Linda Long
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - David Sherriff
- Plymouth Oncology Centre, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Mark Napier
- Exeter Oncology Centre, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - John Ramage
- Neuroendocrine Tumour Service, King's College Hospital NHS Foundation Trust, London, UK
| | - Martin Hoyle
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
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Aalbersberg EA, Huizing DM, Walraven I, de Wit-van der Veen BJ, Kulkarni HR, Singh A, Stokkel MP, Baum RP. Parameters to Predict Progression-Free and Overall Survival After Peptide Receptor Radionuclide Therapy: A Multivariate Analysis in 782 Patients. J Nucl Med 2019; 60:1259-1265. [DOI: 10.2967/jnumed.118.224386] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/15/2022] Open
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Jin XF, Auernhammer CJ, Ilhan H, Lindner S, Nölting S, Maurer J, Spöttl G, Orth M. Combination of 5-Fluorouracil with Epigenetic Modifiers Induces Radiosensitization, Somatostatin Receptor 2 Expression, and Radioligand Binding in Neuroendocrine Tumor Cells In Vitro. J Nucl Med 2019; 60:1240-1246. [DOI: 10.2967/jnumed.118.224048] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/06/2019] [Indexed: 02/06/2023] Open
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Thakral P, Sen I, Pant V, Gupta SK, Dureja S, Kumari J, Kumar S, UN P, Malasani V. Dosimetric analysis of patients with gastro entero pancreatic neuroendocrine tumors (NETs) treated with PRCRT (peptide receptor chemo radionuclide therapy) using Lu-177 DOTATATE and capecitabine/temozolomide (CAP/TEM). Br J Radiol 2018; 91:20170172. [PMID: 30028180 PMCID: PMC6475937 DOI: 10.1259/bjr.20170172] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 07/04/2018] [Accepted: 07/17/2018] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE: Two radiosensitizing chemotherapeutic drugs, capecitabine (CAP) and temozolomide (TEM), are administered concurrently to enhance the therapeutic efficacy of peptide receptor radionuclide therapy (PRRT). This study aims to assess the biodistribution and normal-organ and tumor radiation dosimetry for Lu-177 DOTATATE administered concurrently with CAP/TEM. METHODS: 20 patients with non-resectable histologically confirmed gastroenteropancreatic neuroendocrine tumors with normal kidney function, a normal haematological profile and somatostatin receptor expression of the tumor lesions, as scintigraphically assessed by a Ga-68 DOTANOC scan, were included in two groups-case group (n = 10) and control group (n = 10). Patients included in case group were those who were advised concomitant CAPTEM therapy by the treating medical oncologist. Patients were administered CAP orally at a dose of 600mg m-2 bovine serum albumin twice a day for 14 days starting 9 days prior to PRRT and oral TEM as a single dose at a dose of 75 mg m-2 was given concurrently for the last 5 days commencing on the day of PRRT (days 9-14). In the control group, patients were treated with Lu-177 DOTATATE only. For PRRT, 6.4 GBq-7.6 GBq (173-207 mCi) of Lu-177 DOTATATE was administered as infusion into each patient over 10-15 min in a solution with positively charged amino acids for renal protection. Dosimetric calculations were done using the HERMES software. RESULTS: Physiological uptake of Lu-177 DOTATATE was seen in all patients in liver, spleen kidneys, and bone marrow. Radiation absorbed doses (mean ± standard deviation) were obtained as 0.29 ± 0.12 mGy/MBq for kidneys, 0.30 ± 0.18 mGy/MBq for liver, 0.63 ± 0.37 mGy/MBq for spleen, 0.019 ± 0.001 mGy/MBq for bone marrow and 3.85 ± 1.74 mGy/MBq for tumours in the case group and they were 0.31± 0.26, 0.24 ± 0.14, 0.64 ± 0.42, 0.017 ± 0.016, 5.6 ± 11.27 mGy/MBq in kidneys, liver, spleen, bone marrow and neuroendocrine tumour, respectively, in the control group. Mann-Whitney U test between the variables of two groups showed an insignificant difference (p > 0.05). CONCLUSIONS: The authors demonstrated no significant difference between the tumor and organ doses with Lu-177 DOTATATE in the patients treated with and without concomitant chemotherapy. ADVANCES IN KNOWLEDGE: To our knowledge, this is the first dedicated study exhibiting dosimetric analysis in patients undergoing PRRT in combination with chemotherapy.
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Affiliation(s)
- Parul Thakral
- Department of Nuclear Medicine, Fortis Memorial Research Institute, Gurgaon, India
| | - Ishita Sen
- Department of Nuclear Medicine, Fortis Memorial Research Institute, Gurgaon, India
| | - Vineet Pant
- Department of Nuclear Medicine, Fortis Memorial Research Institute, Gurgaon, India
| | - Santosh Kumar Gupta
- Department of Physics, Guru Ghasidas University Bilaspur, Chattisgarh, India
| | - Sugandha Dureja
- Department of Nuclear Medicine, Fortis Memorial Research Institute, Gurgaon, India
| | - Jyotsna Kumari
- Department of Nuclear Medicine, Fortis Memorial Research Institute, Gurgaon, India
| | - Sunil Kumar
- Department of Nuclear Medicine, Fortis Memorial Research Institute, Gurgaon, India
| | - Pallavi UN
- Department of Nuclear Medicine, Fortis Memorial Research Institute, Gurgaon, India
| | - Vindhya Malasani
- Department of Nuclear Medicine, Fortis Memorial Research Institute, Gurgaon, India
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Highly favourable outcomes with peptide receptor radionuclide therapy (PRRT) for metastatic rectal neuroendocrine neoplasia (NEN). Eur J Nucl Med Mol Imaging 2018; 46:718-727. [DOI: 10.1007/s00259-018-4196-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/11/2018] [Indexed: 12/16/2022]
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Pencharz D, Gnanasegaran G, Navalkissoor S. Theranostics in neuroendocrine tumours: somatostatin receptor imaging and therapy. Br J Radiol 2018; 91:20180108. [PMID: 30102557 DOI: 10.1259/bjr.20180108] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Theranostics and its principles: pre-treatment selection of patients who are most likely to benefit from treatment by the use of a related, specific diagnostic test are integral to the treatment of patients with neuroendocrine tumours (NETs). This is due to NETs' important, but variable, somatostatin receptor (SSTR) expression, their heterogeneity and variation in site of primary and rate of progression. Only patients whose tumours have sufficient expression of SSTRs will benefit from SSTR-based radionuclide therapy and demonstrating this expression prior to therapy is essential. This article provides a relevant overview of NETs and the multiple facets of SSTR based theranostics, including imaging and therapy radionuclides; clinical efficacy and toxicity; patient selection and treatment and finally emerging radiopharmaceuticals and newer clinical applications.
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Affiliation(s)
- Deborah Pencharz
- 1 Department of Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust , Brighton , UK
| | - Gopinath Gnanasegaran
- 2 Department of Nuclear Medicine, Royal Free London NHS Foundation Trust , London , UK
| | - Shaunak Navalkissoor
- 2 Department of Nuclear Medicine, Royal Free London NHS Foundation Trust , London , UK
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Abstract
Peptide receptor radionuclide therapy is a form of systemic radiotherapy shown to be effective in treating neuroendocrine tumors expressing somatostatin receptors. The NETTER-1 trial was the first randomized phase III clinical trial evaluating a radiolabeled somatostatin analog, and demonstrated significant improvement in progression-free survival among patients with midgut neuroendocrine tumors treated with 177Lu-DOTATATE versus high-dose octreotide. This article discusses the evolution of peptide receptor radionuclide therapy, side effects, and potential future treatment approaches.
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Affiliation(s)
- Taymeyah Al-Toubah
- Department of GI Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Jonathan Strosberg
- Department of GI Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA.
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Ramage J, Naraev BG, Halfdanarson TR. Peptide receptor radionuclide therapy for patients with advanced pancreatic neuroendocrine tumors. Semin Oncol 2018; 45:236-248. [DOI: 10.1053/j.seminoncol.2018.08.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/22/2018] [Indexed: 01/14/2023]
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