1
|
Moraitis A, Jentzen W, Fragoso Costa P, Kersting D, Himmen S, Coelho M, Meckel M, van Echteld CJA, Fendler WP, Herrmann K, Sraieb M. Safety and Efficacy of Para-Aminohippurate Coinfusion for Renal Protection During Peptide Receptor Radiotherapy in Patients with Neuroendocrine Tumors. J Nucl Med 2024; 65:931-937. [PMID: 38637142 DOI: 10.2967/jnumed.123.266619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 03/04/2024] [Indexed: 04/20/2024] Open
Abstract
Para-aminohippurate, also known as p-aminohippuric acid (PAH), is used clinically to measure effective renal plasma flow. Preclinically, it was shown to reduce 177Lu-DOTATOC uptake in the kidneys while improving bioavailability compared with amino acid (AA) coinfusion. We report the safety and efficacy of PAH coinfusion during peptide receptor radiotherapy in patients with neuroendocrine tumors. Methods: Twelve patients with metastatic or unresectable gastroenteropancreatic neuroendocrine tumors received 177Lu-DOTATOC in 33 treatment cycles. Either 8 g of PAH or a mixture of 25 g of arginine and 25 g of lysine were coinfused. Safety was assessed by monitoring laboratory data, including hematologic and renal data, as well as electrolytes obtained before and 24 h after treatment. For radiation dosimetry, whole-body scans were performed at 1, 24, and 48 h and a SPECT/CT scan was performed at 48 h, along with blood sampling at 5 min and 0.5, 2, 4, 24, and 48 h after administration. Absorbed dose estimations for the kidneys and bone marrow were performed according to the MIRD concept. Results: In 15 treatment cycles, PAH was coinfused. No changes in mean creatinine level, glomerular filtration rate, and serum electrolytes were observed before or 24 h after treatment when using PAH protection (P ≥ 0.20), whereas serum chloride and serum phosphate increased significantly under AA (both P < 0.01). Kidney-absorbed dose coefficients were 0.60 ± 0.14 Gy/GBq with PAH and 0.53 ± 0.16 Gy/GBq with AA. Based on extrapolated cumulative kidney-absorbed doses for 4 cycles, 1 patient with PAH protection and 1 patient with AA protection in our patient group would exceed the 23-Gy conservative threshold. The bone marrow-absorbed dose coefficient was 0.012 ± 0.004 Gy/GBq with PAH and 0.012 ± 0.003 Gy/GBq with AA. Conclusion: PAH is a promising alternative to AA for renal protection during peptide receptor radiotherapy. Further research is required to systematically investigate the safety profile and radiation dosimetry at varying PAH plasma concentrations.
Collapse
Affiliation(s)
- Alexandros Moraitis
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany;
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Walter Jentzen
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Pedro Fragoso Costa
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - David Kersting
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Stephan Himmen
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Marta Coelho
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Marian Meckel
- ITM Isotope Technologies Munich SE, Garching/Munich, Germany; and
| | | | - Wolfgang P Fendler
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Miriam Sraieb
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| |
Collapse
|
2
|
Blakkisrud J, Peterson AB, Wildermann SJ, Kingkiner G, Wong KK, Wang C, Frey KA, Stokke C, Dewaraja YK. SPECT/CT Image-Derived Absorbed Dose to Red Marrow Correlates with Hematologic Toxicity in Patients Treated with [ 177Lu]Lu-DOTATATE. J Nucl Med 2024; 65:753-760. [PMID: 38548350 PMCID: PMC11064826 DOI: 10.2967/jnumed.123.266843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/21/2024] [Indexed: 05/03/2024] Open
Abstract
Hematologic toxicity, although often transient, is the most common limiting adverse effect during somatostatin peptide receptor radionuclide therapy. This study investigated the association between Monte Carlo-derived absorbed dose to the red marrow (RM) and hematologic toxicity in patients being treated for their neuroendocrine tumors. Methods: Twenty patients each receiving 4 treatment cycles of [177Lu]Lu-DOTATATE were included. Multiple-time-point 177Lu SPECT/CT imaging-based RM dosimetry was performed using an artificial intelligence-driven workflow to segment vertebral spongiosa within the field of view (FOV). This workflow was coupled with an in-house macroscale/microscale Monte Carlo code that incorporates a spongiosa microstructure model. Absorbed dose estimates to RM in lumbar and thoracic vertebrae within the FOV, considered as representations of the whole-body RM absorbed dose, were correlated with hematologic toxicity markers at about 8 wk after each cycle and at 3- and 6-mo follow-up after completion of all cycles. Results: The median of absorbed dose to RM in lumbar and thoracic vertebrae within the FOV (D median,vertebrae) ranged from 0.019 to 0.11 Gy/GBq. The median of cumulative absorbed dose across all 4 cycles was 1.3 Gy (range, 0.6-2.5 Gy). Hematologic toxicity was generally mild, with no grade 2 or higher toxicity for platelets, neutrophils, or hemoglobin. However, there was a decline in blood counts over time, with a fractional value relative to baseline at 6 mo of 74%, 97%, 57%, and 97%, for platelets, neutrophils, lymphocytes, and hemoglobin, respectively. Statistically significant correlations were found between a subset of hematologic toxicity markers and RM absorbed doses, both during treatment and at 3- and 6-mo follow-up. This included a correlation between the platelet count relative to baseline at 6-mo follow up: D median,vertebrae (r = -0.64, P = 0.015), D median,lumbar (r = -0.72, P = 0.0038), D median,thoracic (r = -0.58, P = 0.029), and D average,vertebrae (r = -0.66, P = 0.010), where D median,lumbar and D median,thoracic are median absorbed dose to the RM in the lumbar and thoracic vertebrae, respectively, within the FOV and D average,vertebrae is the mass-weighted average absorbed dose of all vertebrae. Conclusion: This study found a significant correlation between image-derived absorbed dose to the RM and hematologic toxicity, including a relative reduction of platelets at 6-mo follow up. These findings indicate that absorbed dose to the RM can potentially be used to understand and manage hematologic toxicity in peptide receptor radionuclide therapy.
Collapse
Affiliation(s)
- Johan Blakkisrud
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan;
- Department of Physics and Computational Radiology, Oslo University Hospital, Oslo, Norway
| | - Avery B Peterson
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan
- Department of Radiation Oncology, Wayne State University, Detroit, Michigan
| | - Scott J Wildermann
- Department of Nuclear Engineering and Radiologic Science, University of Michigan, Ann Arbor, Michigan
| | - Griffen Kingkiner
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Ka Kit Wong
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Chang Wang
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan; and
| | - Kirk A Frey
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Caroline Stokke
- Department of Physics and Computational Radiology, Oslo University Hospital, Oslo, Norway
- Department of Physics, University of Oslo, Oslo, Norway
| | - Yuni K Dewaraja
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
3
|
Li M, Robles-Planells C, Liu D, Graves SA, Vasquez-Martinez G, Mayoral-Andrade G, Lee D, Rastogi P, Marks BM, Sagastume EA, Weiss RM, Linn-Peirano SC, Johnson FL, Schultz MK, Zepeda-Orozco D. Pre-clinical evaluation of biomarkers for the early detection of nephrotoxicity following alpha-particle radioligand therapy. Eur J Nucl Med Mol Imaging 2024; 51:1395-1408. [PMID: 38095674 PMCID: PMC10957612 DOI: 10.1007/s00259-023-06559-9] [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: 05/07/2023] [Accepted: 12/01/2023] [Indexed: 12/26/2023]
Abstract
PURPOSE Cancer treatment with alpha-emitter-based radioligand therapies (α-RLTs) demonstrates promising tumor responses. Radiolabeled peptides are filtered through glomeruli, followed by potential reabsorption of a fraction by proximal tubules, which may cause acute kidney injury (AKI) and chronic kidney disease (CKD). Because tubular cells are considered the primary site of radiopeptides' renal reabsorption and potential injury, the current use of kidney biomarkers of glomerular functional loss limits the evaluation of possible nephrotoxicity and its early detection. This study aimed to investigate whether urinary secretion of tubular injury biomarkers could be used as an additional non-invasive sensitive diagnostic tool to identify unrecognizable tubular damage and risk of long-term α-RLT nephrotoxicity. METHODS A bifunctional cyclic peptide, melanocortin 1 ligand (MC1L), labeled with [203Pb]Pb-MC1L, was used for [212Pb]Pb-MC1L biodistribution and absorbed dose measurements in CD-1 Elite mice. Mice were treated with [212Pb]Pb-MC1L in a dose-escalation study up to levels of radioactivity intended to induce kidney injury. The approach enabled prospective kidney functional and injury biomarker evaluation and late kidney histological analysis to validate these biomarkers. RESULTS Biodistribution analysis identified [212Pb]Pb-MC1L reabsorption in kidneys with a dose deposition of 2.8, 8.9, and 20 Gy for 0.9, 3.0, and 6.7 MBq injected [212Pb]Pb-MC1L doses, respectively. As expected, mice receiving 6.7 MBq had significant weight loss and CKD evidence based on serum creatinine, cystatin C, and kidney histological alterations 28 weeks after treatment. A dose-dependent urinary neutrophil gelatinase-associated lipocalin (NGAL, tubular injury biomarker) urinary excretion the day after [212Pb]Pb-MC1L treatment highly correlated with the severity of late tubulointerstitial injury and histological findings. CONCLUSION Urine NGAL secretion could be a potential early diagnostic tool to identify unrecognized tubular damage and predict long-term α-RLT-related nephrotoxicity.
Collapse
Affiliation(s)
- Mengshi Li
- Viewpoint Molecular Targeting, Inc. Dba Perspective Therapeutics, Coralville, IA, USA
| | - Claudia Robles-Planells
- Kidney and Urinary Tract Center, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA
| | - Dijie Liu
- Viewpoint Molecular Targeting, Inc. Dba Perspective Therapeutics, Coralville, IA, USA
| | - Stephen A Graves
- Department of Radiology, The University of Iowa, Iowa City, IA, USA
| | - Gabriela Vasquez-Martinez
- Kidney and Urinary Tract Center, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA
| | - Gabriel Mayoral-Andrade
- Kidney and Urinary Tract Center, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA
| | - Dongyoul Lee
- Department of Physics and Chemistry, Korea Military Academy, Seoul, Republic of Korea
| | - Prerna Rastogi
- Department of Pathology, The University of Iowa, Iowa City, IA, USA
| | - Brenna M Marks
- Viewpoint Molecular Targeting, Inc. Dba Perspective Therapeutics, Coralville, IA, USA
| | - Edwin A Sagastume
- Viewpoint Molecular Targeting, Inc. Dba Perspective Therapeutics, Coralville, IA, USA
| | - Robert M Weiss
- Department of Internal Medicine, The University of Iowa, Iowa City, IA, USA
| | - Sarah C Linn-Peirano
- Kidney and Urinary Tract Center, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA
- Department of Veterinary Biosciences, The Ohio State University College of Veterinary Medicine Columbus, Columbus, OH, USA
| | - Frances L Johnson
- Viewpoint Molecular Targeting, Inc. Dba Perspective Therapeutics, Coralville, IA, USA
| | - Michael K Schultz
- Viewpoint Molecular Targeting, Inc. Dba Perspective Therapeutics, Coralville, IA, USA.
- Department of Radiology, The University of Iowa, Iowa City, IA, USA.
- Department of Radiation Oncology, Free Radical, and Radiation Biology Program, The University of Iowa, Iowa City, IA, USA.
| | - Diana Zepeda-Orozco
- Kidney and Urinary Tract Center, Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
- Division of Nephrology and Hypertension, Nationwide Children's Hospital, Columbus, OH, USA.
| |
Collapse
|
4
|
Persson M, Hindorf C, Ardenfors O, Larsson M, Nilsson JN. Risk of treatment-altering haematological toxicity and its dependence on bone marrow doses in peptide receptor radionuclide therapy. EJNMMI Res 2024; 14:13. [PMID: 38319478 PMCID: PMC10847080 DOI: 10.1186/s13550-024-01077-7] [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: 10/31/2023] [Accepted: 01/25/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Peptide receptor radionuclide therapy is effective in treating neuroendocrine tumours, but treatment may be limited by kidney and bone marrow toxicity. In this work, the absorbed dose burden to the bone marrow was estimated using image-based dosimetry and its potential use for predicting treatment-altering toxicity was studied. Peripheral blood samples taken before and after 229 treatments with 177Lu-DOTATATE in 59 patients were studied. In connection to the treatments, a total of 940 blood sample occasions provided data on white blood cell, neutrophil granulocyte, platelet, erythrocyte and haemoglobin concentrations. SPECT/CT image data were collected at two or three time points after each treatment. Absorbed doses to bone marrow were calculated from the activity concentration in a metastasis-free lumbar vertebra. The rate of delayed and aborted treatments was analysed based on medical records. RESULTS The average absorbed dose to the bone marrow was 0.42 Gy (median 0.33 Gy, SD 0.27 Gy) per treatment. Dose-response relationships between white blood cells, neutrophil granulocytes and haemoglobin concentrations were observed, most prominently at 31-45 days after each treatment. The correlations were stronger in patients with skeletal metastases. The rates of haematological toxicity-related delays and aborted treatments were 6% and 12%, respectively. None of the studied bone marrow dosimetric parameters could clearly predict treatment-related toxicity. However, patients with skeletal metastases had higher risk of treatment-altering toxicity (odds ratio = 6.0). CONCLUSIONS Treatment-altering haematological toxicity in peptide receptor radionuclide therapy is relatively rare and appears difficult to fully predict from post-therapeutic image-based dosimetry. However, for patients with skeletal metastases, the haematological dose-response relationships are stronger. Future studies may focus on this patient group, to further investigate the usefulness of dosimetry in predicting decreases in blood values.
Collapse
Affiliation(s)
- Märta Persson
- Medicinsk Fysik och Teknik, Mälarsjukhuset, Eskilstuna, Sweden
| | - Cecilia Hindorf
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176, Stockholm, Sweden
| | - Oscar Ardenfors
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Martin Larsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Joachim N Nilsson
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176, Stockholm, Sweden.
| |
Collapse
|
5
|
Salvadori J, Allegrini O, Opsommer T, Carullo J, Sarrut D, Porot C, Ritzenthaler F, Meyer P, Namer IJ. Anatomy-based correction of kidney PVE on [Formula: see text] SPECT images. EJNMMI Phys 2024; 11:15. [PMID: 38316677 PMCID: PMC11266336 DOI: 10.1186/s40658-024-00612-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/15/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND In peptide receptor radionuclide therapy (PRRT), accurate quantification of kidney activity on post-treatment SPECT images paves the way for patient-specific treatment. Due to the limited spatial resolution of SPECT images, the partial volume effect (PVE) is a significant source of quantitative bias. In this study, we aimed to evaluate the performance and robustness of anatomy-based partial volume correction (PVC) algorithms to recover the accurate activity concentration of realistic kidney geometries on [Formula: see text]Lu SPECT images recorded under clinical conditions. METHODS Based on the CT scan data from patients, three sets of fillable kidneys with surface-to-volume (S:V) ratios ranging from 1.5 to 2.8 cm-1, were 3D printed and attached in a IEC phantom. Quantitative [Formula: see text]Lu SPECT/CT acquisitions were performed on a GE Discovery NM CT 870 DR camera for the three modified IEC phantoms and for 6 different Target-To-Background ratios (TBRs: 2, 4, 6, 8, 10, 12). Two region-based (GTM and Labbé) and five voxel-based (GTM + MTC, Labbé + MTC, GTM + RBV, Labbé + RBV and IY) methods were evaluated with this data set. Additionally, the robustness of PVC methods to Point Spread Function (PSF) discrepancies, registration mismatches and background heterogeneity was evaluated. RESULTS Without PVC, the average kidney RCs across all TBRs ranged from 0.66 ± 0.05 (smallest kidney) to 0.80 ± 0.03 (largest kidney). For a TBR of 12, all anatomy-based method were able to recover the kidneys activity concentration with an error < 6%. All methods result in a comparable decline in RC restoration with decreasing TBR. The Labbé method was the most robust against PSF and registration mismatches but was also the most sensitive to background heterogeneity. Among the voxel-based methods, MTC images were less uniform than RBV and IY images at the outer edge of high uptake areas (kidneys and spheres). CONCLUSION Anatomy-based PVE correction allows for accurate SPECT quantification of the [Formula: see text]Lu activity concentration with realistic kidney geometries. Combined with recent progress in deep-learning algorithms for automatic anatomic segmentation of whole-body CT, these methods could be of particular interest for a fully automated OAR dosimetry pipeline with PVE correction.
Collapse
Affiliation(s)
- Julien Salvadori
- Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France.
| | - Oreste Allegrini
- Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Thomas Opsommer
- Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Josefina Carullo
- Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - David Sarrut
- Université de Lyon, CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, Université Lyon 1, Centre Léon Bérard, Lyon, France
| | - Clemence Porot
- Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | | | - Philippe Meyer
- Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
- ICUBE, CNRS UMR-7357, University of Strasbourg, Strasbourg, France
| | - Izzie-Jacques Namer
- Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
- ICUBE, CNRS UMR-7357, University of Strasbourg, Strasbourg, France
| |
Collapse
|
6
|
Plachouris D, Eleftheriadis V, Nanos T, Papathanasiou N, Sarrut D, Papadimitroulas P, Savvidis G, Vergnaud L, Salvadori J, Imperiale A, Visvikis D, Hazle JD, Kagadis GC. A radiomic- and dosiomic-based machine learning regression model for pretreatment planning in 177 Lu-DOTATATE therapy. Med Phys 2023; 50:7222-7235. [PMID: 37722718 DOI: 10.1002/mp.16746] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 09/01/2023] [Accepted: 09/07/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Standardized patient-specific pretreatment dosimetry planning is mandatory in the modern era of nuclear molecular radiotherapy, which may eventually lead to improvements in the final therapeutic outcome. Only a comprehensive definition of a dosage therapeutic window encompassing the range of absorbed doses, that is, helpful without being detrimental can lead to therapy individualization and improved outcomes. As a result, setting absorbed dose safety limits for organs at risk (OARs) requires knowledge of the absorbed dose-effect relationship. Data sets of consistent and reliable inter-center dosimetry findings are required to characterize this relationship. PURPOSE We developed and standardized a new pretreatment planning model consisting of a predictive dosimetry procedure for OARs in patients with neuroendocrine tumors (NETs) treated with 177 Lu-DOTATATE (Lutathera). In the retrospective study described herein, we used machine learning (ML) regression algorithms to predict absorbed doses in OARs by exploiting a combination of radiomic and dosiomic features extracted from patients' imaging data. METHODS Pretreatment and posttreatment data for 20 patients with NETs treated with 177 Lu-DOTATATE were collected from two clinical centers. A total of 3412 radiomic and dosiomic features were extracted from the patients' computed tomography (CT) scans and dose maps, respectively. All dose maps were generated using Monte Carlo simulations. An ML regression model was designed based on ML algorithms for predicting the absorbed dose in every OAR (liver, left kidney, right kidney, and spleen) before and after the therapy and between each therapy session, thus predicting any possible radiotoxic effects. RESULTS We evaluated nine ML regression algorithms. Our predictive model achieved a mean absolute dose error (MAE, in Gy) of 0.61 for the liver, 1.58 for the spleen, 1.30 for the left kidney, and 1.35 for the right kidney between pretherapy 68 Ga-DOTATOC positron emission tomography (PET)/CT and posttherapy 177 Lu-DOTATATE single photon emission (SPECT)/CT scans. Τhe best predictive performance observed was based on the gradient boost for the liver, the left kidney and the right kidney, and on the extra tree regressor for the spleen. Evaluation of the model's performance according to its ability to predict the absorbed dose in each OAR in every possible combination of pretherapy 68 Ga-DOTATOC PET/CT and any posttherapy 177 Lu-DOTATATE treatment cycle SPECT/CT scans as well as any 177 Lu-DOTATATE SPECT/CT treatment cycle and the consequent 177 Lu-DOTATATE SPECT/CT treatment cycle revealed mean absorbed dose differences ranges from -0.55 to 0.68 Gy. Incorporating radiodosiomics features from the 68 Ga-DOTATOC PET/CT and first 177 Lu-DOTATATE SPECT/CT treatment cycle scans further improved the precision and minimized the standard deviation of the predictions in nine out of 12 instances. An average improvement of 57.34% was observed (range: 17.53%-96.12%). However, it's important to note that in three instances (i.e., Ga,C.1 → C3 in spleen and left kidney, and Ga,C.1 → C2 in right kidney) we did not observe an improvement (absolute differences of 0.17, 0.08, and 0.05 Gy, respectively). Wavelet-based features proved to have high correlated predictive value, whereas non-linear-based ML regression algorithms proved to be more capable than the linear-based of producing precise prediction in our case. CONCLUSIONS The combination of radiomics and dosiomics has potential utility for personalized molecular radiotherapy (PMR) response evaluation and OAR dose prediction. These radiodosiomic features can potentially provide information on any possible disease recurrence and may be highly useful in clinical decision-making, especially regarding dose escalation issues.
Collapse
Affiliation(s)
- Dimitris Plachouris
- 3DMI Research Group, Department of Medical Physics, School of Medicine, University of Patras, Rion, Greece
| | | | - Thomas Nanos
- 3DMI Research Group, Department of Medical Physics, School of Medicine, University of Patras, Rion, Greece
| | | | | | | | | | | | | | | | | | - John D Hazle
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - George C Kagadis
- 3DMI Research Group, Department of Medical Physics, School of Medicine, University of Patras, Rion, Greece
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
7
|
Li M, Robles-Planells C, Liu D, Graves SA, Vasquez-Martinez G, Mayoral-Andrade G, Lee D, Rastogi P, Marks BM, Sagastume EA, Weiss RM, Linn-Peirano SC, Johnson FL, Schultz MK, Zepeda-Orozco D. Pre-clinical Evaluation of Biomarkers for Early Detection of Nephrotoxicity Following Alpha-particle Radioligand Therapy. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.09.27.559789. [PMID: 37808634 PMCID: PMC10557737 DOI: 10.1101/2023.09.27.559789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Purpose Cancer treatment with alpha-emitter-based radioligand therapies (α-RLTs) demonstrates promising tumor responses. Radiolabeled peptides are filtered through glomeruli, followed by potential reabsorption of a fraction by proximal tubules, which may cause acute kidney injury (AKI) and chronic kidney disease (CKD). Because tubular cells are considered the primary site of radiopeptides' renal reabsorption and potential injury, the current use of kidney biomarkers of glomerular functional loss limits the evaluation of possible nephrotoxicity and its early detection. This study aimed to investigate whether urinary secretion of tubular injury biomarkers could be used as additional non-invasive sensitive diagnostic tool to identify unrecognizable tubular damage and risk of long-term α-RLTs nephrotoxicity. Methods A bifunctional cyclic peptide, melanocortin ligand-1(MC1L), labeled with [ 203 Pb]Pb-MC1L, was used for [ 212 Pb]Pb-MC1L biodistribution and absorbed dose measurements in CD-1 Elite mice. Mice were treated with [ 212 Pb]Pb-MC1L in a dose escalation study up to levels of radioactivity intended to induce kidney injury. The approach enabled prospective kidney functional and injury biomarker evaluation and late kidney histological analysis to validate these biomarkers. Results Biodistribution analysis identified [ 212 Pb]Pb-MC1L reabsorption in kidneys with a dose deposition of 2.8, 8.9, and 20 Gy for 0.9, 3.0, and 6.7 MBq injected [ 212 Pb]Pb-MC1L doses, respectively. As expected, mice receiving 6.7 MBq had significant weight loss and CKD evidence based on serum creatinine, cystatin C, and kidney histological alterations 28 weeks after treatment. A dose-dependent urinary Neutrophil gelatinase-associated lipocalin (NGAL, tubular injury biomarker) urinary excretion the day after [ 212 Pb]Pb-MC1L treatment highly correlated with the severity of late tubulointerstitial injury and histological findings. Conclusion urine NGAL secretion could be a potential early diagnostic tool to identify unrecognized tubular damage and predict long-term α-RLT-related nephrotoxicity.
Collapse
|
8
|
Wang C, Peterson AB, Wong KK, Roseland ME, Schipper MJ, Dewaraja YK. Single-Time-Point Imaging for Dosimetry After [ 177Lu]Lu-DOTATATE: Accuracy of Existing Methods and Novel Data-Driven Models for Reducing Sensitivity to Time-Point Selection. J Nucl Med 2023; 64:1463-1470. [PMID: 37500260 PMCID: PMC10478823 DOI: 10.2967/jnumed.122.265338] [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: 12/22/2022] [Revised: 04/27/2023] [Indexed: 07/29/2023] Open
Abstract
Estimation of the time-integrated activity (TIA) for dosimetry from imaging at a single time point (STP) facilitates the clinical translation of dosimetry-guided radiopharmaceutical therapy. However, the accuracy of the STP methods for TIA estimation varies on the basis of time-point selection. We constructed patient data-driven regression models to reduce the sensitivity to time-point selection and to compare these new models with commonly used STP methods. Methods: SPECT/CT performed at time period (TP) 1 (3-5 h), TP2 (days 1-2), TP3 (days 3-5), and TP4 (days 6-8) after cycle 1 of [177Lu]Lu-DOTATATE therapy involved 27 patients with 100 segmented tumors and 54 kidneys. Influenced by the previous physics-based STP models of Madsen et al. and Hänscheid et al., we constructed an STP prediction expression, TIA = A(t) × g(t), in a SPECT data-driven way (model 1), in which A(t) is the observed activity at imaging time t, and the curve, g(t), is estimated with a nonparametric generalized additive model by minimizing the normalized mean square error relative to the TIA derived from 4-time-point SPECT (reference TIA). Furthermore, we fit a generalized additive model that incorporates baseline biomarkers as auxiliary data in addition to the single activity measurement (model 2). Leave-one-out cross validation was performed to evaluate STP models using mean absolute error (MAE) and mean square error between the predicted and reference TIA. Results: At days 3-5, all evaluated STP methods performed very well, with an MAE of less than 7% (between-patient SD of <10%) for both kidneys and tumors. At other TPs, the Madsen method and data-driven models 1 and 2 performed reasonably well (MAEs < 17% for kidneys and < 32% for tumors), whereas the error with the Hänscheid method was substantially higher. The proof of concept of adding baseline biomarkers to the prediction model was demonstrated and showed a moderate enhancement at TP1, especially for estimating kidney TIA (MAE ± SD from 15.6% ± 1.3% to 11.8% ± 1.0%). Evaluations on 500 virtual patients using clinically relevant time-activity simulations showed a similar performance. Conclusion: The performance of the Madsen method and proposed data-driven models is less sensitive to TP selection than is the Hänscheid method. At the earliest TP, which is the most practical, the model incorporating baseline biomarkers outperforms other methods that rely only on the single activity measurement.
Collapse
Affiliation(s)
- Chang Wang
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan;
| | - Avery B Peterson
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
- Department of Radiation Oncology, Wayne State University, Detroit, Michigan; and
| | - Ka Kit Wong
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Molly E Roseland
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Matthew J Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Yuni K Dewaraja
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
9
|
Keuper-Navis M, Walles M, Poller B, Myszczyszyn A, van der Made TK, Donkers J, Eslami Amirabadi H, Wilmer MJ, Aan S, Spee B, Masereeuw R, van de Steeg E. The application of organ-on-chip models for the prediction of human pharmacokinetic profiles during drug development. Pharmacol Res 2023; 195:106853. [PMID: 37473876 DOI: 10.1016/j.phrs.2023.106853] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/11/2023] [Accepted: 07/14/2023] [Indexed: 07/22/2023]
Abstract
Organ-on-chip (OoC) technology has led to in vitro models with many new possibilities compared to conventional in vitro and in vivo models. In this review, the potential of OoC models to improve the prediction of human oral bioavailability and intrinsic clearance is discussed, with a focus on the functionality of the models and the application in current drug development practice. Multi-OoC models demonstrating the application for pharmacokinetic (PK) studies are summarized and existing challenges are identified. Physiological parameters for a minimal viable platform of a multi-OoC model to study PK are provided, together with PK specific read-outs and recommendations for relevant reference compounds to validate the model. Finally, the translation to in vivo PK profiles is discussed, which will be required to routinely apply OoC models during drug development.
Collapse
Affiliation(s)
- Marit Keuper-Navis
- Department of Metabolic Health Research, Netherlands Organisation for Applied Scientific Research (TNO), Leiden, the Netherlands; Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Markus Walles
- Pharmacokinetic Sciences, Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Birk Poller
- Pharmacokinetic Sciences, Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Adam Myszczyszyn
- Faculty of Veterinary Medicine & Regenerative Medicine Center Utrecht (RMCU), Utrecht University, Utrecht, the Netherlands
| | - Thomas K van der Made
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Joanne Donkers
- Department of Metabolic Health Research, Netherlands Organisation for Applied Scientific Research (TNO), Leiden, the Netherlands
| | | | | | - Saskia Aan
- Stichting Proefdiervrij, Den Haag, the Netherlands
| | - Bart Spee
- Faculty of Veterinary Medicine & Regenerative Medicine Center Utrecht (RMCU), Utrecht University, Utrecht, the Netherlands
| | - Rosalinde Masereeuw
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Evita van de Steeg
- Department of Metabolic Health Research, Netherlands Organisation for Applied Scientific Research (TNO), Leiden, the Netherlands.
| |
Collapse
|
10
|
Weissinger M, Seyfried KC, Ursprung S, Castaneda-Vega S, Seith F, von Beschwitz S, Vogel J, Ghibes P, Nikolaou K, la Fougère C, Dittmann H. Non-invasive estimation of split renal function from routine 68Ga-SSR-PET/CT scans. Front Med (Lausanne) 2023; 10:1169451. [PMID: 37448797 PMCID: PMC10337782 DOI: 10.3389/fmed.2023.1169451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/30/2023] [Indexed: 07/15/2023] Open
Abstract
Objective Patients with impaired kidney function are at elevated risk for nephrotoxicity and hematotoxicity from peptide receptor radionuclide therapy (PPRT) for advanced neuroendocrine tumors. Somatostatin receptor (SSR)-PET/CT imaging is the method of choice to identify sufficient SSR expression as a prerequisite for PRRT. Therefore, our study aimed to explore whether split renal function could be evaluated using imaging data from routine SSR-PET/CT prior to PRRT. Methods In total, 25 consecutive patients who underwent SSR-PET/CT (Siemens Biograph mCT®) before PRRT between June 2019 and December 2020 were enrolled in this retrospective study. PET acquisition in the caudocranial direction started at 20 ± 0.5 min after an i.v. injection of 173 ± 20 MBq [68Ga]Ga-ha DOTATATE, and the kidneys were scanned at 32 ± 0.5 min p.i. The renal parenchyma was segmented semi-automatically using an SUV-based isocontour (SUV between 5 and 15). Multiple parameters including SUVmean of renal parenchyma and blood pool, as well as parenchyma volume, were extracted, and accumulation index (ACI: renal parenchyma volume/SUVmean) and total kidney accumulation (TKA: SUVmean x renal parenchyma volume) were calculated. All data were correlated with the reference standard tubular extraction rate (TER-MAG) from [99mTc]Tc-MAG3 scintigraphy and glomerular filtration rate (GFRCDK - EPI). Results SUVmean of the parenchymal tracer retention showed a negative correlation with TERMAG (r: -0.519, p < 0.001) and GFRCDK - EPI (r: -0.555, p < 0.001) at 32 min p.i. The herein-introduced ACI revealed a significant correlation (p < 0.05) with the total tubular function (r: 0.482), glomerular renal function (r: 0.461), split renal function (r: 0.916), and absolute single-sided renal function (r: 0.549). The mean difference between the split renal function determined by renal scintigraphy and ACI was 1.8 ± 4.2 % points. Conclusion This pilot study indicates that static [68Ga]Ga-ha DOTATATE PET-scans at 32 min p.i. may be used to estimate both split renal function and absolute renal function using the herein proposed "Accumulation Index" (ACI).
Collapse
Affiliation(s)
- Matthias Weissinger
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Tuebingen, Germany
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, Tuebingen, Germany
| | - Kyra Celine Seyfried
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, Tuebingen, Germany
| | - Stephan Ursprung
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Salvador Castaneda-Vega
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, Tuebingen, Germany
- Department of Preclinical Imaging and Radiopharmacy, Werner Siemens Imaging Center, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Ferdinand Seith
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Sebastian von Beschwitz
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, Tuebingen, Germany
| | - Jonas Vogel
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Tuebingen, Germany
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, Tuebingen, Germany
| | - Patrick Ghibes
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Tuebingen, Germany
- iFIT-Cluster of Excellence, Eberhard Karls University Tuebingen, Tuebingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tuebingen, Tuebingen, Germany
| | - Christian la Fougère
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, Tuebingen, Germany
- iFIT-Cluster of Excellence, Eberhard Karls University Tuebingen, Tuebingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tuebingen, Tuebingen, Germany
| | - Helmut Dittmann
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, Tuebingen, Germany
| |
Collapse
|
11
|
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.
Collapse
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.
| |
Collapse
|
12
|
Alattar AG, Kristiansson A, Karlsson H, Vallius S, Ahlstedt J, Forssell-Aronsson E, Åkerström B, Strand SE, Flygare J, Gram M. Recombinant α 1-Microglobulin (rA1M) Protects against Hematopoietic and Renal Toxicity, Alone and in Combination with Amino Acids, in a 177Lu-DOTATATE Mouse Radiation Model. Biomolecules 2023; 13:928. [PMID: 37371508 DOI: 10.3390/biom13060928] [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: 04/19/2023] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT) is used clinically to treat metastasized or unresectable neuroendocrine tumors (NETs). Although 177Lu-DOTATATE is mostly well tolerated in patients, bone marrow suppression and long-term renal toxicity are still side effects that should be considered. Amino acids are often used to minimize renal radiotoxicity, however, they are associated with nausea and vomiting in patients. α1-microglobulin (A1M) is an antioxidant with heme- and radical-scavenging abilities. A recombinant form (rA1M) has previously been shown to be renoprotective in preclinical models, including in PRRT-induced kidney damage. Here, we further investigated rA1M's renal protective effect in a mouse 177Lu-DOTATATE model in terms of administration route and dosing regimen and as a combined therapy with amino acids (Vamin). Moreover, we investigated the protective effect of rA1M on peripheral blood and bone marrow cells, as well as circulatory biomarkers. Intravenous (i.v.) administration of rA1M reduced albuminuria levels and circulatory levels of the oxidative stress-related protein fibroblast growth factor-21 (FGF-21). Dual injections of rA1M (i.e., at 0 and 24 h post-177Lu-DOTATATE administration) preserved bone marrow cellularity and peripheral blood reticulocytes. Administration of Vamin, alone or in combination with rA1M, did not show any protection of bone marrow cellularity or peripheral reticulocytes. In conclusion, this study suggests that rA1M, administered i.v. for two consecutive days in conjunction with 177Lu-DOTATATE, may reduce hematopoietic and kidney toxicity during PRRT with 177Lu-DOTATATE.
Collapse
Affiliation(s)
- Abdul Ghani Alattar
- Division of Hematology and Transfusion Medicine, Department of Laboratory Medicine, Lund University, 221 84 Lund, Sweden
- Division of Molecular Medicine and Gene Therapy, Lund Stem Cell Center, Lund University, 221 84 Lund, Sweden
| | - Amanda Kristiansson
- Pediatrics, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, 221 84 Lund, Sweden
| | - Helena Karlsson
- Pediatrics, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, 221 84 Lund, Sweden
| | - Suvi Vallius
- Pediatrics, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, 221 84 Lund, Sweden
| | - Jonas Ahlstedt
- Department of Clinical Sciences Lund, CIPA, Lund University, 221 84 Lund, Sweden
| | - Eva Forssell-Aronsson
- Department of Medical Radiation Sciences, Sahlgrenska Cancer Center, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45 Gothenburg, Sweden
| | - Bo Åkerström
- Department of Clinical Sciences Lund, Section for Infection Medicine, Lund University, 221 84 Lund, Sweden
| | - Sven-Erik Strand
- Department of Clinical Sciences Lund, Oncology, Lund University, 222 42 Lund, Sweden
- Department of Clinical Sciences Lund, Medical Radiation Physics, Lund University, 221 85 Lund, Sweden
| | - Johan Flygare
- Division of Molecular Medicine and Gene Therapy, Lund Stem Cell Center, Lund University, 221 84 Lund, Sweden
| | - Magnus Gram
- Pediatrics, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, 221 84 Lund, Sweden
| |
Collapse
|
13
|
Peterson AB, Wang C, Wong KK, Frey KA, Muzik O, Schipper MJ, Dewaraja YK. 177Lu-DOTATATE Theranostics: Predicting Renal Dosimetry From Pretherapy 68Ga-DOTATATE PET and Clinical Biomarkers. Clin Nucl Med 2023; 48:393-399. [PMID: 37010563 PMCID: PMC10353839 DOI: 10.1097/rlu.0000000000004599] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
PURPOSE Pretreatment predictions of absorbed doses can be especially valuable for patient selection and dosimetry-guided individualization of radiopharmaceutical therapy. Our goal was to build regression models using pretherapy 68Ga-DOTATATE PET uptake data and other baseline clinical factors/biomarkers to predict renal absorbed dose delivered by 177Lu-DOTATATE peptide receptor radionuclide therapy (177Lu-PRRT) for neuroendocrine tumors. We explore the combination of biomarkers and 68Ga PET uptake metrics, hypothesizing that they will improve predictive power over univariable regression. PATIENTS AND METHODS Pretherapy 68Ga-DOTATATE PET/CTs were analyzed for 25 patients (50 kidneys) who also underwent quantitative 177Lu SPECT/CT imaging at approximately 4, 24, 96, and 168 hours after cycle 1 of 177Lu-PRRT. Kidneys were contoured on the CT of the PET/CT and SPECT/CT using validated deep learning-based tools. Dosimetry was performed by coupling the multi-time point SPECT/CT images with an in-house Monte Carlo code. Pretherapy renal PET SUV metrics, activity concentration per injected activity (Bq/mL/MBq), and other baseline clinical factors/biomarkers were investigated as predictors of the 177Lu SPECT/CT-derived mean absorbed dose per injected activity to the kidneys using univariable and bivariable models. Leave-one-out cross-validation (LOOCV) was used to estimate model performance using root mean squared error and absolute percent error in predicted renal absorbed dose including mean absolute percent error (MAPE) and associated standard deviation (SD). RESULTS The median therapy-delivered renal dose was 0.5 Gy/GBq (range, 0.2-1.0 Gy/GBq). In LOOCV of univariable models, PET uptake (Bq/mL/MBq) performs best with MAPE of 18.0% (SD = 13.3%), and estimated glomerular filtration rate (eGFR) gives an MAPE of 28.5% (SD = 19.2%). Bivariable regression with both PET uptake and eGFR gives LOOCV MAPE of 17.3% (SD = 11.8%), indicating minimal improvement over univariable models. CONCLUSIONS Pretherapy 68Ga-DOTATATE PET renal uptake can be used to predict post-177Lu-PRRT SPECT-derived mean absorbed dose to the kidneys with accuracy within 18%, on average. Compared with PET uptake alone, including eGFR in the same model to account for patient-specific kinetics did not improve predictive power. Following further validation of these preliminary findings in an independent cohort, predictions using renal PET uptake can be used in the clinic for patient selection and individualization of treatment before initiating the first cycle of PRRT.
Collapse
Affiliation(s)
- Avery B. Peterson
- Department of Radiology, University of Michigan, Ann Arbor
- Department of Radiation Oncology, Wayne State University, Detroit
| | - Chang Wang
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Ka Kit Wong
- Department of Radiology, University of Michigan, Ann Arbor
| | - Kirk A. Frey
- Department of Radiology, University of Michigan, Ann Arbor
| | - Otto Muzik
- Department of Pediatrics, Wayne State University, Detroit, MI
| | | | | |
Collapse
|
14
|
Hemmingsson J, Svensson J, van der Meulen NP, Müller C, Bernhardt P. Active bone marrow S-values for the low-energy electron emitter terbium-161 compared to S-values for lutetium-177 and yttrium-90. EJNMMI Phys 2022; 9:65. [PMID: 36153386 PMCID: PMC9509518 DOI: 10.1186/s40658-022-00495-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Based on theoretical and preclinical results, terbium-161 may be a valid alternative to lutetium-177 and yttrium-90 in radionuclide therapies. The large low-energy electron emission from terbium-161 is a favorable feature in the treatment of disseminated disease, but its impact on the radiosensitive bone marrow needs to be evaluated. Using voxel-based skeletal dosimetry models in which active bone marrow is defined as regions containing stem cells and progenitor cells of the hematopoietic lineage, we generated S-values (absorbed dose per decay) for terbium-161 and evaluated its distribution-dependence in bone marrow cavities.
Methods
S-values in the active bone marrow were calculated for terbium-161, lutetium-177, and yttrium-90 irradiation using two (male/female) image-based bone marrow dosimetry models. The radionuclides were distributed to one of the three structures that define the spongiosa bone region in the skeletal models: (i) active bone marrow, (ii) inactive bone marrow, or (iii) surface or whole volume of the trabecular bone. Decay data from ICRP 107 were combined with specific absorbed fractions to calculate S-values for 13 skeletal sites. To increase the utility, the skeletal site-specific S-values were averaged to produce whole-body average S-values and spongiosa average S-values.
Results
For yttrium-90, the high-energy β particles irradiate the active marrow regardless of the source compartment, consistently generating the highest S-values (65–90% higher). Between terbium-161 and lutetium-177, the largest differences in S-values were with an active marrow source (50%), such as self-irradiation, due to the contribution of the short-ranged conversion and Auger electrons from terbium-161. Their influence decreased as the source moved to inactive marrow or the surface or volume of the trabecular bone, reducing the S-values and the differences between terbium-161 and lutetium-177 (15–35%).
Conclusion
The S-values of terbium-161 for active bone marrow and, consequently, the bone marrow toxicity profile were more dependent on the radionuclide distribution within the bone marrow cavity than the S-values of lutetium-177 and yttrium-90. This effect was attributed to the considerable low-energy electron emission of terbium-161. Therefore, it will be critical to investigate the bone marrow distribution of a particular radiopharmaceutical for accurate estimation of the active bone marrow dose.
Collapse
|
15
|
Ramonaheng K, van Staden JA, du Raan H. Accuracy of two dosimetry software programs for 177Lu radiopharmaceutical therapy using voxel-based patient-specific phantoms. Heliyon 2022; 8:e09830. [PMID: 35865988 PMCID: PMC9293745 DOI: 10.1016/j.heliyon.2022.e09830] [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: 10/27/2021] [Revised: 02/18/2022] [Accepted: 06/24/2022] [Indexed: 12/01/2022] Open
Abstract
Purpose Virtual dosimetry using voxel-based patient-specific phantoms and Monte Carlo (MC) simulations offer the advantage of having a gold standard against which absorbed doses may be benchmarked to establish the dosimetry accuracy. Furthermore, these reference values assist in investigating the accuracy of the absorbed dose methodologies from different software programs. Therefore, this study aimed to compare the accuracy of the absorbed doses computed using LundADose and OLINDA/EXM 1.0. Methods The accuracy was based on 177Lu-DOTATATE distributions of three voxel-based phantoms. SPECT projection images were simulated for 1, 24, 96, and 168 h post-administration and reconstructed with LundADose using 3D OS-EM reconstruction. Mono-exponential curves were fitted to the bio-kinetic data for the kidneys, liver, spleen, and tumours resulting in SPECT time-integrated activity (SPECT-TIA). The SPECT-TIA were used to compute mean absorbed doses using LundADose (LND-DSPECT) and OLINDA (OLINDA-DSPECT) for the organs. Pre-defined true activity images, were used to obtain TRUE-TIA and, together with full MC simulations, computed the true doses (MC-DTrue). The dosimetry accuracy was assessed by comparing LND-DSPECT and OLINDA-DSPECT to MC-DTrue. Results Overall, the results presented an overestimation of the mean absorbed dose by LND-DSPECT compared to the MC-DTrue with a dosimetry accuracy ≤6.6%. This was attributed to spill-out activity from the reconstructed LND-DSPECT, resulting in a higher dose contribution than the MC-DTrue. There was a general underestimation (<8.1%) of OLINDA-DSPECT compared to MC-DTrue attributed to the geometrical difference in shape between the voxel-based phantoms and the OLINDA models. Furthermore, OLINDA-DSPECT considers self-doses while MC-DTrue reflects self-doses plus cross-doses. Conclusion The better than 10% accuracy suggests that the mean dose values obtained with LND-DSPECT and OLINDA-DSPECT approximate the true values. The mean absorbed doses of the two software programs, and the gold standard were comparable. This work shall be of use for optimising 177Lu dosimetry for clinical applications.
Collapse
Affiliation(s)
- Keamogetswe Ramonaheng
- Department of Medical Physics, Faculty of Health Sciences, University of the Free State, P.O. Box 339, Bloemfontein, 9300, South Africa
| | - Johannes A van Staden
- Department of Medical Physics, Faculty of Health Sciences, University of the Free State, P.O. Box 339, Bloemfontein, 9300, South Africa
| | - Hanlie du Raan
- Department of Medical Physics, Faculty of Health Sciences, University of the Free State, P.O. Box 339, Bloemfontein, 9300, South Africa
| |
Collapse
|
16
|
Phase II trial demonstrates the efficacy and safety of individualized, dosimetry-based 177Lu-DOTATATE treatment of NET patients. Eur J Nucl Med Mol Imaging 2022; 49:3830-3840. [PMID: 35451612 PMCID: PMC9399027 DOI: 10.1007/s00259-022-05786-w] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/28/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE Radionuclide therapy with 177Lu-DOTATATE is well established for patients with advanced somatostatin receptor-positive neuroendocrine tumors with a standard schedule of 7.4 GBq at four occasions. However, this approach does not consider individual variability affecting the tumor radiation dose or dose to organs at risk. Therefore, it is important to assess more personalized strategies. The aim of this phase II trial was to evaluate individualized 177Lu-DOTATATE for which the number of cycles varied based on renal dosimetry. METHODS Patients were eligible if they had a progressive, somatostatin receptor-positive neuroendocrine tumor with a Ki 67 labeling index < 20%. They received cycles of 7.4 GBq of 177Lu-DOTATATE at 10 ± 2-week intervals until a predefined radiation dose to the kidneys was reached. The primary endpoint was objective tumor response (RECIST v 1.1). Secondary endpoints included progression-free survival (PFS), overall survival (OS), and toxicity (CTCAE v. 4.0). RESULTS Ninety-six patients who had received a median of 5 cycles (range 1-9) were evaluable for efficacy. The objective tumor response was 16% partial response, 66% stable disease, and 19% progressive disease. The median PFS and OS were 29 months and 47 months, respectively, and were significantly associated with kidney dose, performance status, and Ki 67 levels but not with tumor origin. The overall toxicity was mild, and the most common events were grade 1-2 anemia, thrombocytopenia, fatigue, nausea, and diarrhea. Grade 3-4 toxicity occurred in < 10% of patients and was mostly hematological, with no grade 3-4 renal toxicity. CONCLUSION Individualized treatment with 177Lu-DOTATATE based on renal dosimetry is clearly feasible with low toxicity and promising efficacy, showing the potential to further improve outcome beyond the standard approach, and should be further assessed in randomized trials. TRIAL REGISTRATION EudraCT 2011-000,240-16. NCT01456078. https://clinicaltrials.gov/ct2/show/NCT01456078.
Collapse
|
17
|
Dose-Limiting Bone Marrow Toxicities After Peptide Receptor Radionuclide Therapy Are More Prevalent in Women Than in Men. Clin Nucl Med 2022; 47:599-605. [DOI: 10.1097/rlu.0000000000004203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
18
|
Early Complications of Radioisotope Therapy with Lutetium-177 and Yttrium-90 in Patients with Neuroendocrine Neoplasms-A Preliminary Study. J Clin Med 2022; 11:jcm11040919. [PMID: 35207193 PMCID: PMC8874379 DOI: 10.3390/jcm11040919] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/06/2022] [Accepted: 02/07/2022] [Indexed: 12/12/2022] Open
Abstract
Neuroendocrine neoplasms (NENs) constitute a heterogenous group of tumors originating from neuroendocrine cells scattered throughout the body. Peptide Receptor Radionuclide Therapy (PRRT) is a treatment of choice of unresectable metastasized progressive and well-differentiated NENs. The aim of the study was to assess early bone marrow and kidney injury after administration of Lutetium-177 or Lutetium-177 combined with Yttrium-90. Thirty-one patients received treatment with [177Lu]Lu-DOTATATE with the activity of 7.4 GBq. Eleven patients received tandem treatment with [90Y]Y-DOTATATE with the activity of 1.85 GBq + [177Lu]Lu-DOTATATE with the activity of 1.85 GBq. After PRRT a significant decrease in leukocyte, neutrophil, and lymphocyte counts was noted. Tandem treatment demonstrated a more marked decrease in white blood cell count compared to Lutetium-177 therapy only. Conversely, no significant influence on glomerular filtration was found in this assessment. However, PRRT triggered acute renal tubule dysfunction, regardless of the treatment type. Regarding the acute complications, PRRT appeared to be a safe modality in the treatment of patients with NEN.
Collapse
|
19
|
Sakulpisuti C, Chamroonrat W, Tepmongkol S. Cutaneous Management after Extravasation of High-Concentrated Amino Acid Solution Administered for Renal Protection in PRRT. Tomography 2022; 8:356-363. [PMID: 35202194 PMCID: PMC8880062 DOI: 10.3390/tomography8010029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 11/25/2022] Open
Abstract
High-concentrated amino acid solution is used to protect the kidneys during peptide receptor radionuclide therapy (PPRT) in patients with neuroendocrine tumors (NETs). Extravasation of the solution can cause cutaneous complications. In this study, we described a 66-year-old man with metastatic medullary thyroid cancer and a 32-year-old woman with metastatic pancreatic NET who developed cutaneous lesions caused by the extravasation of an amino acid solution (25 g of lysine and 25 g of arginine in 1 L of normal saline) during PRRT with [177Lu]Lu-DOTA-TATE. Both were treated conservatively, and these cutaneous lesions gradually improved. The patient with metastatic pancreatic NET rejected the amino acid infusion in subsequent cycles of PRRT and therefore received [177Lu]Lu-DOTA-TATE alone, and her serum creatinine level and estimated glomerular filtration rate (eGFR) remained normal for 2 months after the last treatment. These two cases revealed cutaneous complications resulting from high-concentrated amino acid solution during PRRT because of hyperosmolarity. Health care providers should be aware of this complication to ensure its prevention and appropriate management. Preserved renal function was demonstrated after [177Lu]Lu-DOTA-TATE treatment in the absence of the infusion of a high-concentrated amino acid solution. However, long-term follow-up of renal function is suggested.
Collapse
Affiliation(s)
- Chaninart Sakulpisuti
- Division of Nuclear Medicine, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
| | - Wichana Chamroonrat
- Division of Nuclear Medicine, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
- Correspondence:
| | - Supatporn Tepmongkol
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand;
- Chulalongkorn University Biomedical Imaging Group (CUBIG), Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| |
Collapse
|
20
|
Hartrampf PE, Weinzierl FX, Serfling SE, Pomper MG, Rowe SP, Higuchi T, Seitz AK, Kübler H, Buck AK, Werner RA. Hematotoxicity and Nephrotoxicity in Prostate Cancer Patients Undergoing Radioligand Therapy with [ 177Lu]Lu-PSMA I&T. Cancers (Basel) 2022; 14:cancers14030647. [PMID: 35158913 PMCID: PMC8833540 DOI: 10.3390/cancers14030647] [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: 11/04/2021] [Revised: 12/01/2021] [Accepted: 01/25/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Radioligand therapy (RLT) with prostate-specific membrane antigen (PSMA)-directed agents has shown remarkable results in patients with advanced prostate cancer. Our objective was to provide data on the side effect profile of PSMA-directed RLT using the therapeutic radiotracer [177Lu]Lu-PSMA I&T. We evaluated patients with castration-resistant metastatic prostate cancer treated with at least three cycles of [177Lu]Lu-PSMA I&T. A substantial fraction of the patients already had impaired renal function and/or reduced white blood cell counts at baseline, but the degree of nephrotoxicity or hematotoxicity under RLT was low. No severe toxicities occurred under RLT. Abstract (1) Background: Prostate-specific membrane antigen (PSMA)-directed radioligand therapy (RLT) has shown remarkable results in patients with advanced prostate cancer. We aimed to evaluate the toxicity profile of the PSMA ligand [177Lu]Lu-PSMA I&T. (2) Methods: 49 patients with metastatic, castration-resistant prostate cancer treated with at least three cycles of [177Lu]Lu-PSMA I&T were evaluated. Prior to and after RLT, we compared leukocytes, hemoglobin, platelet counts, and renal functional parameters (creatinine, eGFR, n = 49; [99mTc]-MAG3-derived tubular extraction rate (TER), n = 42). Adverse events were classified according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0 and KDIGO Society. To identify predictive factors, we used Spearman’s rank correlation coefficient. (3) Results: A substantial fraction of the patients already showed impaired renal function and reduced leukocyte counts at baseline. Under RLT, 11/49 (22%) patients presented with nephrotoxicity CTCAE I or II according to creatinine, but 33/49 (67%) according to eGFR. Only 5/42 (13%) showed reduced TER, defined as <70% of the age-adjusted mean normal values. Of all renal functional parameters, absolute changes of only 2% were recorded. CTCAE-based re-categorization was infrequent, with creatinine worsening from I to II in 2/49 (4.1%; GFR, 1/49 (2%)). Similar results were recorded for KDIGO (G2 to G3a, 1/49 (2%); G3a to G3b, 2/49 (4.1%)). After three cycles, follow-up eGFR correlated negatively with age (r = −0.40, p = 0.005) and the eGFR change with Gleason score (r = −0.35, p < 0.05) at baseline. Leukocytopenia CTCAE II occurred only in 1/49 (2%) (CTCAE I, 20/49 (41%)) and CTCAE I thrombocytopenia in 7/49 (14%), with an absolute decrease of 15.2% and 16.6% for leukocyte and platelet counts. Anemia CTCAE II occurred in 10/49 (20%) (CTCAE I, 36/49 (73%)) with a decrease in hemoglobin of 4.7%. (4) Conclusions: After PSMA-targeted therapy using [177Lu]Lu-PSMA I&T, no severe (CTCAE III/IV) toxicities occurred, thereby demonstrating that serious adverse renal or hematological events are unlikely to be a frequent phenomenon with this agent.
Collapse
Affiliation(s)
- Philipp E. Hartrampf
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (F.-X.W.); (S.E.S.); (T.H.); (A.K.B.); (R.A.W.)
- Correspondence: ; Tel.: +49-931-201-35001
| | - Franz-Xaver Weinzierl
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (F.-X.W.); (S.E.S.); (T.H.); (A.K.B.); (R.A.W.)
| | - Sebastian E. Serfling
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (F.-X.W.); (S.E.S.); (T.H.); (A.K.B.); (R.A.W.)
| | - Martin G. Pomper
- The Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N Caroline Str., Baltimore, MD 21205, USA; (M.G.P.); (S.P.R.)
| | - Steven P. Rowe
- The Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N Caroline Str., Baltimore, MD 21205, USA; (M.G.P.); (S.P.R.)
| | - Takahiro Higuchi
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (F.-X.W.); (S.E.S.); (T.H.); (A.K.B.); (R.A.W.)
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama 700-8530, Japan
| | - Anna Katharina Seitz
- Department of Urology and Paediatric Urology, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (A.K.S.); (H.K.)
| | - Hubert Kübler
- Department of Urology and Paediatric Urology, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (A.K.S.); (H.K.)
| | - Andreas K. Buck
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (F.-X.W.); (S.E.S.); (T.H.); (A.K.B.); (R.A.W.)
| | - Rudolf A. Werner
- Department of Nuclear Medicine, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080 Wurzburg, Germany; (F.-X.W.); (S.E.S.); (T.H.); (A.K.B.); (R.A.W.)
| |
Collapse
|
21
|
Miller C, Rousseau J, Ramogida CF, Celler A, Rahmim A, Uribe CF. Implications of physics, chemistry and biology for dosimetry calculations using theranostic pairs. Theranostics 2022; 12:232-259. [PMID: 34987643 PMCID: PMC8690938 DOI: 10.7150/thno.62851] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/18/2021] [Indexed: 12/15/2022] Open
Abstract
Theranostics is an emerging paradigm that combines imaging and therapy in order to personalize patient treatment. In nuclear medicine, this is achieved by using radiopharmaceuticals that target identical molecular targets for both imaging (using emitted gamma rays) and radiopharmaceutical therapy (using emitted beta, alpha or Auger-electron particles) for the treatment of various diseases, such as cancer. If the therapeutic radiopharmaceutical cannot be imaged quantitatively, a “theranostic pair” imaging surrogate can be used to predict the absorbed radiation doses from the therapeutic radiopharmaceutical. However, theranostic dosimetry assumes that the pharmacokinetics and biodistributions of both radiopharmaceuticals in the pair are identical or very similar, an assumption that still requires further validation for many theranostic pairs. In this review, we consider both same-element and different-element theranostic pairs and attempt to determine if factors exist which may cause inaccurate dose extrapolations in theranostic dosimetry, either intrinsic (e.g. chemical differences) or extrinsic (e.g. injecting different amounts of each radiopharmaceutical) to the radiopharmaceuticals. We discuss the basis behind theranostic dosimetry and present common theranostic pairs and their therapeutic applications in oncology. We investigate general factors that could create alterations in the behavior of the radiopharmaceuticals or the quantitative accuracy of imaging them. Finally, we attempt to determine if there is evidence showing some specific pairs as suitable for theranostic dosimetry. We show that there are a variety of intrinsic and extrinsic factors which can significantly alter the behavior among pairs of radiopharmaceuticals, even if they belong to the same chemical element. More research is needed to determine the impact of these factors on theranostic dosimetry estimates and on patient outcomes, and how to correctly account for them.
Collapse
|
22
|
Widjaja L, Derlin T, Ross TL, Bengel FM, Werner RA. Pretherapeutic estimated glomerular filtration rate predicts development of chronic kidney disease in patients receiving PSMA-targeted radioligand therapy. Prostate 2022; 82:86-96. [PMID: 34633090 DOI: 10.1002/pros.24250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/03/2021] [Accepted: 09/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prostate-specific membrane antigen (PSMA)-targeted radioligand therapy (RLT) may be associated with renal toxicity. We aimed to identify predictive parameters for the development of chronic kidney disease (CKD) in patients with metastatic castration resistant prostate cancer (mCRPC) undergoing RLT. METHODS In 46 mCRPC patients scheduled for Lu-177-PSMA-RLT, pretherapeutic estimated glomerular filtration rate (eGFR [ml/min/1.73 m2 ]), Tc-99m-mercaptoacetyltriglycine (Tc-99m-MAG3) clearance and baseline Ga-68-PSMA-ligand positron emission tomography (PET)-derived renal cortical uptake and PSMA-tumor volume (TV) were determined. We tested the predictive capability of these parameters and clinical risk factors for the occurrence of CKD (defined as CTCAE vers. 5.0 grade 2 or higher) during follow-up. RESULTS After 4 ± 3 cycles of RLT average eGFR declined from 76 ± 17 to 72 ± 20 ml/min/1.73 m2 (p = 0.003). Increased estimated renal radiation dose (eRRD) was significantly associated with renal functional decline (p = 0.008). During follow-up, 16/46 (30.4%) developed CKD grade 2 (no grade 3 or higher). In receiver operating characteristic (ROC) analysis, pretherapeutic eGFR was highly accurate in identifying the occurrence of CKD vs no CKD with an area under the curve (AUC) of 0.945 (p < 0.001; best threshold, 77 ml/min/1.73 m2 ), followed by Tc-99m-MAG3-derived tubular extraction rate (TER; AUC, 0.831, p < 0.001; best threshold, 200 ml/min/1.73 m2 ). Renal PET signal (p = 0.751) and PSMA-TV (p = 0.942), however, were not predictive. Kaplan-Meier analyses revealed adverse renal outcome for patients with lower eGFR (p = 0.001) and lower scintigraphy-derived TER (p = 0.009), with pretherapeutic eGFR emerging as the sole predictive parameter in multivariate analysis (p = 0.007). CONCLUSION Serious adverse renal events are not a frequent phenomenon after PSMA-targeted RLT. However, in patients developing moderate CKD after RLT, pretherapeutic eGFR is an independent predictor for renal impairment during follow-up.
Collapse
Affiliation(s)
- Liam Widjaja
- Department of Nuclear Medicine Medical School Hannover, Hannover, Germany
| | - Thorsten Derlin
- Department of Nuclear Medicine Medical School Hannover, Hannover, Germany
| | - Tobias L Ross
- Department of Nuclear Medicine Medical School Hannover, Hannover, Germany
| | - Frank M Bengel
- Department of Nuclear Medicine Medical School Hannover, Hannover, Germany
| | - Rudolf A Werner
- Department of Nuclear Medicine Medical School Hannover, Hannover, Germany
| |
Collapse
|
23
|
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.
Collapse
|
24
|
Xu L, Meng Q, Yao X, Yang R, Zhang P, Li R, Wang F. Dosimetry of 177Lu-DOTATOC first circle treatment in patients with advanced metastatic neuroendocrine tumors: A pilot study in China. Appl Radiat Isot 2021; 179:109975. [PMID: 34741954 DOI: 10.1016/j.apradiso.2021.109975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/19/2021] [Accepted: 09/14/2021] [Indexed: 12/20/2022]
Abstract
First cycle dosimetry calculation of 177Lu-DOTATOC (single activity:1.59-3.49 GBq) was carried out in eight patients with advanced neuroendocrine tumors (NETs) who underwent whole-body planar (0.5, 24, 48, 72 h) and SPECT/CT scans (24 h). Focal uptake of 177Lu-DOTATOC was found in primary and metastatic tumors. Organs with the highest absorbed doses per injected activity were tumors (1.293 ± 0.862 mGy/MBq) and spleen (0.461 ± 0.408 mGy/MBq), while low absorbed doses were observed in kidneys (0.384 ± 0.112 mGy/MBq) and bone marrow (0.0297 ± 0.0123 mGy/MBq). 177Lu-DOTATOC is safe, well-tolerated and appropriate in Chinese NETs patients for PRRT.
Collapse
Affiliation(s)
- Lei Xu
- Department of Nuclear Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, China
| | - Qingle Meng
- Department of Nuclear Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, China
| | - Xiaochen Yao
- Department of Nuclear Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, China
| | - Rui Yang
- Department of Nuclear Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, China
| | - Pengjun Zhang
- Department of Nuclear Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, China
| | - Rushuai Li
- Department of Nuclear Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, China
| | - Feng Wang
- Department of Nuclear Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, China.
| |
Collapse
|
25
|
Geenen L, Nonnekens J, Konijnenberg M, Baatout S, De Jong M, Aerts A. Overcoming nephrotoxicity in peptide receptor radionuclide therapy using [ 177Lu]Lu-DOTA-TATE for the treatment of neuroendocrine tumours. Nucl Med Biol 2021; 102-103:1-11. [PMID: 34242948 DOI: 10.1016/j.nucmedbio.2021.06.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 06/21/2021] [Accepted: 06/21/2021] [Indexed: 12/29/2022]
Abstract
Peptide receptor radionuclide therapy (PRRT) is used for the treatment of patients with unresectable or metastasized somatostatin receptor type 2 (SSTR2)-expressing gastroenteropancreatic neuroendocrine tumours (GEP-NETs). The radiolabelled somatostatin analogue [177Lu]Lu-DOTA-TATE delivers its radiation dose to SSTR2-overexpressing tumour cells, resulting in selective cell killing during radioactive decay. While tumour control can be achieved in many patients, complete remissions remain rare, causing the majority of patients to relapse after a certain period of time. This raises the question whether the currently fixed treatment regime (4 × 7.4 GBq) leaves room for dose escalation as a means of improving therapy efficacy. The kidneys have shown to play an important role in defining a patient's tolerability to PRRT. As a consequence of the proximal tubular reabsorption of [177Lu]Lu-DOTA-TATE, via the endocytic megalin/cubilin receptor complex, the radionuclides are retained in the renal interstitium. This results in extended retention of radioactivity in the kidneys, generating a risk for the development of radiation nephropathy. In addition, a decreased kidney function has shown to be associated with a prolonged circulation of [177Lu]Lu-DOTA-TATE, causing increased irradiation to the bone marrow. This can on its turn lead to myelosuppression and haematological toxicity, owing to the marked radio sensitivity of the rapidly proliferating cells in the bone marrow. In contrast to external beam radiotherapy (EBRT), the exact absorbed dose limits for these critical organs (kidneys and bone marrow) in PRRT with [177Lu]Lu-DOTA-TATE are still unclear. Better insights into these uncertainties, can help in optimizing PRRT to reach its maximum therapeutic potential, while avoiding severe adverse events, like nephropathy and hematologic toxicities. In this review we focus on the nephrotoxic effects of PRRT with [177Lu]Lu-DOTA-TATE for the treatment of GEP-NETs. If the absorbed dose to the kidneys can be lowered, higher activities can be administered, enlarging the therapeutic window for PRRT. Therefore, we evaluated the renal protective potential of current and promising future strategies and discuss the importance of (renal) dosimetry in PRRT.
Collapse
Affiliation(s)
- Lorain Geenen
- Radiobiology Unit, Interdisciplinary Biosciences, Institute for Environment, Health and Safety, Belgian Nuclear Research Centre (SCK CEN), Mol, Belgium; Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Julie Nonnekens
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands; Department of Molecular Genetics, Erasmus MC, Rotterdam, the Netherlands; Oncode Institute, Erasmus MC, Rotterdam, the Netherlands
| | - Mark Konijnenberg
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands; Department of Medical Imaging, Radboud UMC, Nijmegen, the Netherlands
| | - Sarah Baatout
- Radiobiology Unit, Interdisciplinary Biosciences, Institute for Environment, Health and Safety, Belgian Nuclear Research Centre (SCK CEN), Mol, Belgium; Department of Molecular Biotechnology, Faculty of Bioengineering Sciences, Ghent University, Belgium.
| | - Marion De Jong
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - An Aerts
- Radiobiology Unit, Interdisciplinary Biosciences, Institute for Environment, Health and Safety, Belgian Nuclear Research Centre (SCK CEN), Mol, Belgium
| |
Collapse
|
26
|
Optimizing the Schedule of PARP Inhibitors in Combination with 177Lu-DOTATATE: A Dosimetry Rationale. Biomedicines 2021; 9:biomedicines9111570. [PMID: 34829796 PMCID: PMC8615768 DOI: 10.3390/biomedicines9111570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022] Open
Abstract
177Lu-DOTATATE for neuroendocrine tumours is considered a low-toxicity treatment and may therefore be combined with other pharmaceuticals to potentiate its efficacy. One approach is to add a poly-[ADP-ribose]-polymerase (PARP) inhibitor to decrease the ability of tumour cells to repair 177Lu-induced DNA damage. To decrease the risk of side effects, the sequencing should be optimized according to the tumour-to-normal tissue enhanced dose ratio (TNED). The aim of this study was to investigate how to enhance 177Lu-DOTATATE by optimal timing of the addition of a PARP inhibitor. Biokinetic modelling was performed based on the absorbed dose to the bone marrow, kidneys and tumour; determined from SPECT/CT and planar images from 17 patients treated with 177Lu-DOTATATE. To investigate the theoretical enhanced biological effect of a PARP inhibitor during 177Lu-DOTATATE treatment, the concept of relative biological effectiveness (RBE) was used, and PARP inhibitor administration was simulated over different time intervals. The absorbed dose rate for the tumour tissue demonstrated an initial increase phase until 12 h after infusion followed by a slow decrease. In contrast, the bone marrow showed a rapid initial dose rate decrease. Twenty-eight days after infusion of 177Lu-DOTATATE, the full absorbed dose to the bone marrow and kidney was reached. Using an RBE value of 2 for both the tumour and normal tissues, the TNED was increased compared to 177Lu-DOTATATE alone. According to the modelling, the PARP inhibitor should be introduced approximately 24 h after the start of 177Lu-DOTATATE treatment and be continued for up to four weeks to optimize the TNED. Based on these results, a phase I trial assessing the combination of olaparib and 177Lu-DOTATATE in somatostatin receptor-positive tumours was launched in 2020 (NCT04375267).
Collapse
|
27
|
Khan J, Rydèn T, Van Essen M, Svensson J, Bernhardt P. ACTIVITY CONCENTRATION ESTIMATION IN AUTOMATED KIDNEY SEGMENTATION BASED ON CONVOLUTION NEURAL NETWORK METHOD FOR 177LU-SPECT/CT KIDNEY DOSIMETRY. RADIATION PROTECTION DOSIMETRY 2021; 195:164-171. [PMID: 34080002 DOI: 10.1093/rpd/ncab079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 06/12/2023]
Abstract
For 177Lu-DOTATATE treatments, dosimetry based on manual kidney segmentation from computed tomography (CT) is accurate but time consuming and might be affected by misregistration between CT and SPECT images. This study develops a convolution neural network (CNN) for automated kidney segmentation that accurately aligns CT segmented volume of interest (VOI) to the kidneys in SPECT images. The CNN was trained with SPECT/CT images performed over the abdominal area of 137 patients treated with 177Lu-DOTATATE. Activity concentrations in automated and manual segmentations were strongly correlated for both kidneys (r > 0.96, p < 0.01) in the testing cohort (n = 20). The Bland-Altman analyses demonstrated higher accuracy for the CNN segmentation compared to the manual segmented kidneys without VOI adjustment. The CNN demonstrated a potential for accurate kidney segmentation. The CNN was a fast and robust approach for assessment of activity concentrations in SPECT images, and performed equally well as the manual segmentation method.
Collapse
Affiliation(s)
- Jehangir Khan
- Department of Medical Physics and Biomedical Engineering (MFT), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Tobias Rydèn
- Department of Medical Physics and Biomedical Engineering (MFT), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Martijn Van Essen
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johanna Svensson
- Department of Oncology, Institution of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Peter Bernhardt
- Department of Medical Physics and Biomedical Engineering (MFT), Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden
| |
Collapse
|
28
|
Baum RP, Singh A, Kulkarni HR, Bernhardt P, Rydén T, Schuchardt C, Gracheva N, Grundler PV, Köster U, Müller D, Pröhl M, Zeevaart JR, Schibli R, van der Meulen NP, Müller C. First-in-Humans Application of 161Tb: A Feasibility Study Using 161Tb-DOTATOC. J Nucl Med 2021; 62:1391-1397. [PMID: 33547209 PMCID: PMC8724898 DOI: 10.2967/jnumed.120.258376] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/19/2021] [Indexed: 12/16/2022] Open
Abstract
161Tb has decay properties similar to those of 177Lu but, additionally, emits a substantial number of conversion and Auger electrons. The aim of this study was to apply 161Tb in a clinical setting and to investigate the feasibility of visualizing the physiologic and tumor biodistributions of 161Tb-DOTATOC. Methods:161Tb was shipped from Paul Scherrer Institute, Villigen-PSI, Switzerland, to Zentralklinik Bad Berka, Bad Berka, Germany, where it was used for the radiolabeling of DOTATOC. In 2 separate studies, 596 and 1,300 MBq of 161Tb-DOTATOC were administered to a 35-y-old male patient with a metastatic, well-differentiated, nonfunctional malignant paraganglioma and a 70-y-old male patient with a metastatic, functional neuroendocrine neoplasm of the pancreatic tail, respectively. Whole-body planar γ-scintigraphy images were acquired over a period of several days for dosimetry calculations. SPECT/CT images were reconstructed using a recently established protocol and visually analyzed. Patients were observed for adverse events after the application of 161Tb-DOTATOC. Results: The radiolabeling of DOTATOC with 161Tb was readily achieved with a high radiochemical purity suitable for patient application. Planar images and dosimetry provided the expected time-dependent biodistribution of 161Tb-DOTATOC in the liver, kidneys, spleen, and urinary bladder. SPECT/CT images were of high quality and visualized even small metastases in bones and liver. The application of 161Tb-DOTATOC was well tolerated, and no related adverse events were reported. Conclusion: This study demonstrated the feasibility of imaging even small metastases after the injection of relatively low activities of 161Tb-DOTATOC using γ-scintigraphy and SPECT/CT. On the basis of this essential first step in translating 161Tb to clinics, further efforts will be directed toward the application of 161Tb for therapeutic purposes.
Collapse
Affiliation(s)
- Richard P Baum
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany;
| | - 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 Medical Center, Maastricht, The Netherlands
| | - Harshad R Kulkarni
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Peter Bernhardt
- Department of Radiation Physics, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medical Physics and Medical Bioengineering, Sahlgrenska University Hospital, Gothenburg, Gothenburg, Sweden
| | - Tobias Rydén
- Department of Radiation Physics, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medical Physics and Medical Bioengineering, Sahlgrenska University Hospital, Gothenburg, Gothenburg, Sweden
| | - Christiane Schuchardt
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Nadezda Gracheva
- Center for Radiopharmaceutical Sciences ETH-PSI-USZ, Paul Scherrer Institute, Villigen-PSI, Switzerland
| | - Pascal V Grundler
- Center for Radiopharmaceutical Sciences ETH-PSI-USZ, Paul Scherrer Institute, Villigen-PSI, Switzerland
| | | | - Dirk Müller
- Department of Radiopharmacy, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Michael Pröhl
- Department of Radiopharmacy, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Jan Rijn Zeevaart
- Radiochemistry, South African Nuclear Energy Corporation (Necsa), Pelindaba, South Africa
| | - Roger Schibli
- Center for Radiopharmaceutical Sciences ETH-PSI-USZ, Paul Scherrer Institute, Villigen-PSI, Switzerland
- Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland; and
| | - Nicholas P van der Meulen
- Center for Radiopharmaceutical Sciences ETH-PSI-USZ, Paul Scherrer Institute, Villigen-PSI, Switzerland
- Laboratory of Radiochemistry, Paul Scherrer Institute, Villigen-PSI, Switzerland
| | - Cristina Müller
- Center for Radiopharmaceutical Sciences ETH-PSI-USZ, Paul Scherrer Institute, Villigen-PSI, Switzerland;
| |
Collapse
|
29
|
Zhang M, Ye J, Xie Z, Yan Y, Wang J, Chen X. Optimization of Enzymolysis Clearance Strategy To Enhance Renal Clearance of Radioligands. Bioconjug Chem 2021; 32:2108-2116. [PMID: 34486879 DOI: 10.1021/acs.bioconjchem.1c00392] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The kidney is the main dose-limiting organ in radioligand therapy (RLT), and there is an urgent need for reducing renal radioactivity accumulation. According to the enzymolysis clearance strategy, the first objective of this study is to test whether enzymolysis efficiency can be improved by introducing a hydrophobic amino acid with a bulkier side chain to the second position of the cleavable sequence, and the second objective is to screen an optimal sequence to minimize the renal uptake. Four exendin 4 (Ex4) peptide analogues with different cleavable sequences were synthesized and labeled with 68Ga. Both in vitro and in vivo metabolism studies were performed using either the model compounds or the complete probes. The in vitro stabilities of the tracers were evaluated in PBS and mouse serum. The microPET images were acquired in the INS-1 tumor model at different time points, and the radioactivity uptakes of the probes in tumors and kidneys were determined and compared. All the probes were stable in both PBS and mouse serum for at least 1 h. The in vitro cleavage study for both model compounds and intact probes showed enzymolysis efficiency in the following order: MWK > MFK > MVK > MGK. The in vivo metabolism study confirmed that a fragment of 68Ga-NOTA-Met-OH appeared in both kidney and urine samples for all analogues with MVK, MFK, and MWK sequences. The microPET images showed that the tumor uptakes of all the modified probes were comparable to those of the control, while the kidney uptakes were significantly reduced by inserting the MWK, MFK, or MVK linker. The tumor-to-kidney ratios at 0.5, 1, and 2 h time points showed the following order: 68Ga-NOTA-MWK-Ex4 > 68Ga-NOTA-MFK-Ex4 > 68Ga-NOTA-MVK-Ex4. In this study, based on the enzymolysis clearance strategy and the preference of the enzyme, different sequences were designed and compared both in vitro and in vivo. The results indicated that the larger the steric hindrance of the second hydrophobic amino acid side chain, the more effective the enzymatic hydrolysis, with enzymolysis efficiency in the following order: MWK > MFK > MVK > MGK. MWK appears to be the most effective sequence in reducing renal radioactivity accumulation of exendin 4 peptide derivatives.
Collapse
Affiliation(s)
- Mingru Zhang
- Department of Nuclear Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi710032, China
- Departments of Diagnostic Radiology, Surgery, Chemical and Biomolecular Engineering, and Biomedical Engineering, Yong Loo Lin School of Medicine and Faculty of Engineering, National University of Singapore, Singapore, 119074, Singapore
| | - Jiajun Ye
- Department of Nuclear Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi710032, China
| | - Zhaojuan Xie
- Department of Nuclear Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi710032, China
| | - Yuhao Yan
- Department of Nuclear Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi710032, China
| | - Jing Wang
- Department of Nuclear Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi710032, China
| | - Xiaoyuan Chen
- Departments of Diagnostic Radiology, Surgery, Chemical and Biomolecular Engineering, and Biomedical Engineering, Yong Loo Lin School of Medicine and Faculty of Engineering, National University of Singapore, Singapore, 119074, Singapore
- Clinical Imaging Research Centre, Centre for Translational Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117599, Singapore
- Nanomedicine Translational Research Program, NUS Center for Nanomedicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| |
Collapse
|
30
|
Abstract
Peptide receptor radionuclide therapy (PRRT) is an effective form of treatment of patients with metastatic neuroendocrine tumors, delivering modest objective tumor response rates but notable survival and symptomatic benefits. The first PRRT approved by the US Food and Drug Administration was lutetium 177-DOTATATE and is for use in adults with somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors. The treatment paradigm typically leads to significant improvement in symptomology coupled with an extended period of progression-free survival. Side effects are limited, with a small fraction of individuals experiencing clinically significant long-term renal or hematologic toxicity.
Collapse
|
31
|
Chen L, Navalkissoor S, Quigley AM, Gnanasegaran G, Mandair D, Toumpanakis C, Caplin ME, Hayes AR. 177Lu-DOTATATE in older patients with metastatic neuroendocrine tumours: safety, efficacy and health-related quality of life. Eur J Nucl Med Mol Imaging 2021; 48:3582-3594. [PMID: 33835221 DOI: 10.1007/s00259-021-05332-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/23/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE The safety and efficacy of 177Lu-DOTATATE in older patients with advanced neuroendocrine tumours (NET) are not well understood. METHODS Patients ≥70 years of age and treated with 177Lu-DOTATATE were included. Toxicity, health-related quality of life (HRQoL), objective response, progression-free survival (PFS) and overall survival (OS) were assessed. The relationship between baseline characteristics and PFS and OS was analysed using the Kaplan-Meier method. Univariate analyses were performed using the Cox proportional hazards model. RESULTS In total, 71 patients were included (76.1% midgut primary). The median age at diagnosis and age at 177Lu-DOTATATE treatment were 70 and 74 years, respectively. The majority (78.9%) of patients completed 4 cycles of 177Lu-DOTATATE. Clinically significant myelosuppression was rare (2.8%). There was no deterioration in HRQoL and 'disease-specific worries' significantly improved (P = 0.029). Radiological response assessment was available in 66 patients. Partial response, stable disease and progression of disease were found in 10 (15.2%), 52 (78.8%) and 4 patients (6.1%), respectively. Median PFS and OS were 36.0 and 47.0 months, respectively. Increased baseline alkaline phosphatase was associated with poorer PFS (P = 0.002) and OS (P = 0.006). CONCLUSION Patients ≥70 years of age with advanced NET treated with 177Lu-DOTATATE have efficacy and toxicity profiles similar to the wider NET population, without deterioration of HRQoL.
Collapse
Affiliation(s)
- Luohai Chen
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, NW3 2QG, UK.,Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Institute for Liver and Digestive Disease, Royal Free Hospital, University College London, London, UK
| | - Shaunak Navalkissoor
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, NW3 2QG, UK.,Department of Nuclear Medicine, Royal Free Hospital, London, UK
| | - Ann-Marie Quigley
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, NW3 2QG, UK.,Department of Nuclear Medicine, Royal Free Hospital, London, UK
| | - Gopinath Gnanasegaran
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, NW3 2QG, UK.,Department of Nuclear Medicine, Royal Free Hospital, London, UK
| | - Dalvinder Mandair
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, NW3 2QG, UK
| | - Christos Toumpanakis
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, NW3 2QG, UK
| | - Martyn E Caplin
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, NW3 2QG, UK
| | - Aimee R Hayes
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, NW3 2QG, UK. .,Department of Oncology, Royal Free Hospital, London, UK.
| |
Collapse
|
32
|
Nephrotoxicity/renal failure after therapy with 90Yttrium- and 177Lutetium-radiolabeled somatostatin analogs in different types of neuroendocrine tumors: a systematic review. Nucl Med Commun 2021; 41:601-617. [PMID: 32404645 DOI: 10.1097/mnm.0000000000001198] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND/OBJECTIVE Data regarding the nephrotoxicity of the peptide receptor radionuclide therapy (PRRT) with Yttrium- and Lutetium-radiolabeled somatostatin analogs (RSA) are inconclusive. We aimed to evaluate the short- and long-term nephrotoxicity following PRRT usage in patients with all types of neuroendocrine tumors (NETs). METHODS A systematic review of observational studies reporting data about nephrotoxicity after treatment with Yttrium and Lutetium RSA was performed. Data on serum creatinine, creatinine clearance, glomerular filtration rate (GFR) and need for renal replacement therapy were compiled. We included patients with progressive, inoperable symptomatic G1, G2 and G3 different types of NETs. After searching in three electronic databases PubMed, Scopus and the Cochrane Library, from 1 January 1978 to November 2018, data were extracted and summarized using a random-effects model. RESULTS The final analysis included 34 studies, comprising 5386 participants, enrolling patients with G1, G2, G3 NETs and a follow-up from 12 up to 191 months. Compared with renal function before treatment, measured/estimated glomerular filtration rate (m/eGFR) values changed after PRRT, with a mean annual decrease following PRRT between 2 and 4 mL/min/1.73 m suggesting different grades of nephrotoxicity after PRRT. When compared, Y-RSA and the Y-RSA-Lu-RSA combination are associated with a higher m/eGFR decline compared to Lu-RSA alone. CONCLUSIONS PRRT can be followed by potentially serious long-term nephrotoxicity, despite kidney protection. The use of the quantified renal function combined with a long follow-up period and personalized dosimetry-based PRRT can reduce nephrotoxicity, in order to use the whole PRRT potential in the management of NETs.
Collapse
|
33
|
Ambrosini V, Kunikowska J, Baudin E, Bodei L, Bouvier C, Capdevila J, Cremonesi M, de Herder WW, Dromain C, Falconi M, Fani M, Fanti S, Hicks RJ, Kabasakal L, Kaltsas G, Lewington V, Minozzi S, Cinquini M, Öberg K, Oyen WJG, O'Toole D, Pavel M, Ruszniewski P, Scarpa A, Strosberg J, Sundin A, Taïeb D, Virgolini I, Wild D, Herrmann K, Yao J. Consensus on molecular imaging and theranostics in neuroendocrine neoplasms. Eur J Cancer 2021; 146:56-73. [PMID: 33588146 DOI: 10.1016/j.ejca.2021.01.008] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/31/2020] [Accepted: 01/07/2021] [Indexed: 02/07/2023]
Abstract
Nuclear medicine plays an increasingly important role in the management neuroendocrine neoplasms (NEN). Somatostatin analogue (SSA)-based positron emission tomography/computed tomography (PET/CT) and peptide receptor radionuclide therapy (PRRT) have been used in clinical trials and approved by the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA). European Association of Nuclear Medicine (EANM) Focus 3 performed a multidisciplinary Delphi process to deliver a balanced perspective on molecular imaging and radionuclide therapy in well-differentiated neuroendocrine tumours (NETs). NETs form in cells that interact with the nervous system or in glands that produce hormones. These cells, called neuroendocrine cells, can be found throughout the body, but NETs are most often found in the abdomen, especially in the gastrointestinal tract. These tumours may also be found in the lungs, pancreas and adrenal glands. In addition to being rare, NETs are also complex and may be difficult to diagnose. Most NETs are non-functioning; however, a minority present with symptoms related to hypersecretion of bioactive compounds. NETs often do not cause symptoms early in the disease process. When diagnosed, substantial number of patients are already found to have metastatic disease. Several societies' guidelines address Neuroendocrine neoplasms (NENs) management; however, many issues are still debated, due to both the difficulty in acquiring strong clinical evidence in a rare and heterogeneous disease and the different availability of diagnostic and therapeutic options across countries. EANM Focus 3 reached consensus on employing 68gallium-labelled somatostatin analogue ([68Ga]Ga-DOTA-SSA)-based PET/CT with diagnostic CT or magnetic resonance imaging (MRI) for unknown primary NET detection, metastatic NET, NET staging/restaging, suspected extra-adrenal pheochromocytoma/paraganglioma and suspected paraganglioma. Consensus was reached on employing 18fluorine-fluoro-2-deoxyglucose ([18F]FDG) PET/CT in neuroendocrine carcinoma, G3 NET and in G1-2 NET with mismatched lesions (CT-positive/[68Ga]Ga-DOTA-SSA-negative). Peptide receptor radionuclide therapy (PRRT) was recommended for second line treatment for gastrointestinal NET with [68Ga]Ga-DOTA-SSA uptake in all lesions, in G1/G2 NET at disease progression, and in a subset of G3 NET provided all lesions are positive at [18F]FDG and [68Ga]Ga-DOTA-SSA. PRRT rechallenge may be used for in patients with stable disease for at least 1 year after therapy completion. An international consensus is not only a prelude to a more standardised management across countries but also serves as a guide for the direction to follow when designing new research studies.
Collapse
Affiliation(s)
- Valentina Ambrosini
- IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Italy; Nuclear Medicine, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Jolanta Kunikowska
- Nuclear Medicine Department, Medical University of Warsaw, Warsaw, Poland
| | - Eric Baudin
- Endocrine Oncolgy Unit, Institut Gustave Roussy, Villejuif Cedex, France
| | - Lisa Bodei
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Catherine Bouvier
- International Neuroendocrine Cancer Alliance (INCA), Leamington Spa, UK
| | - Jaume Capdevila
- Medical Oncology Department, Vall Hebron University Hospital, Vall Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Marta Cremonesi
- Radiation Research Unit, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | - Wouter W de Herder
- Erasmus MC & Erasmus MC Cancer Center, ENETS Center of Excellence Rotterdam, Rotterdam, the Netherlands
| | | | - Massimo Falconi
- Pancreas Translational & Research Institute, Scientific Institute San Raffaele Hospital and University Vita-Salute, Milan, Italy
| | - Melpomeni Fani
- Division of Radiopharmaceutical Chemistry, University Hospital Basel, Basel, Switzerland
| | - Stefano Fanti
- IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Italy; Nuclear Medicine, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Rodney J Hicks
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Levent Kabasakal
- Istanbul University-Cerrahpaşa, Faculty of Medicine, Department of Nuclear Medicine, Turkey
| | - Gregory Kaltsas
- National and Kapodistrian University of Athens, Athens, Greece
| | | | - Silvia Minozzi
- Laboratory of Clinical Research Methodology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Michela Cinquini
- Laboratory of Clinical Research Methodology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Kjell Öberg
- Dept of Endocrine Oncology, University Hospital Uppsala, Sweden
| | - Wim J G Oyen
- Humanitas University and Humanitas Clinical and Research Center, Milan, Italy; Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands; Department of Radiology and Nuclear Medicine, Rijnstate Hospital Arnhem, the Netherlands
| | | | - Marianne Pavel
- Friedrich Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Philippe Ruszniewski
- Department of Pancreatology, Beaujon Hospital, Université de Paris, Clichy, France
| | - Aldo Scarpa
- ARC-NET Centre for Applied Research on Cancer and Department of Pathology, University of Verona, Italy
| | | | - Anders Sundin
- Department of Surgical Sciences, Uppsala University, University Hospital, Sweden
| | - David Taïeb
- Department of Nuclear Medicine, La Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Irene Virgolini
- Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Damian Wild
- Division of Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Ken Herrmann
- Department of Nuclear Medicine, Universitätsklinikum, Essen, Germany.
| | - James Yao
- Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
34
|
Mohan AM, Lukas M, Albrecht J, Dorau-Rutke V, Koziolek EJ, Huang K, Prasad S, Brenner W, Beindorff N. Relationship of Renal Function in Mice to Strain, Sex and 177Lutetium-Somatostatin Receptor Ligand Treatment. Nuklearmedizin 2020; 59:381-386. [PMID: 32074660 DOI: 10.1055/a-1103-1661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AIM Aim of the study was to establish parameters for 99mTc-MAG3 SPECT renal uptake kinetics in healthy SCID mice as a function of mouse strain and sex and to evaluate the feasibility of this method for detecting 177Lu-somatostatin receptor ligand (177Lu-SRL) treatment effects on kidney function. MATERIALS AND METHODS Dynamic semi-stationary SPECT acquisitions (68 frames, total duration 35 min) was started prior to i. v. injection of 99mTc-MAG3 in 12 female and 12 male SCID mice. Additionally, 6 female SCID mice with neuroendocrine tumors were imaged 1-5 months after 177Lu-SRL (5 DOTATOC, 1 DOTA-JR11) treatment. Kidney function is expressed as maximum time to peak (Tmax), T50 and T25 in minutes (median [interquartile range]). Differences between groups were tested using the Mann-Whitney-U test, and SCID mouse parameters were compared with data for C57BL/6N mice from a recent publication. RESULTS Significant sex-based differences in Tmax between strains were observed (females: C57BL/6N 1.6 [1.4-1.7], SCID 1.4 [1.3-1.5], p = 0.05; males: C57BL/6N 1.4 [1.3-1.4], SCID 1.6 [1.4-1.7], p = 0.04). In C57BL/6N mice, females showed a later Tmax (p < 0.01) than males. SCID mice showed no difference (p = 0.14). Treated SCID mice showed no significant delay in Tmax (2.0 [1.4-2.7], p = 0.15) but a significant delay in T50 (p = 0.02) and T25 (p = 0.01) compared to healthy untreated mice. CONCLUSION This study demonstrated significant sex-related differences between SCID and C57BL/6N mouse strains in kidney function. Establishment of normal values for different strains and sexes therefore is important for experimental therapy studies. Renal SPECT imaging with 99mTc-MAG3 was sufficiently sensitive to detect 177Lu-SRL treatment toxic effects on kidney function in SCID mice.
Collapse
Affiliation(s)
- Ajay-Mohan Mohan
- Department of Nuclear Medicine, Charité-Universitätsmedizin Berlin, Germany
| | - Mathias Lukas
- Department of Nuclear Medicine, Charité-Universitätsmedizin Berlin, Germany
| | - Jakob Albrecht
- Department of Nuclear Medicine, Charité-Universitätsmedizin Berlin, Germany
- German Cancer Consortium (DKTK), partner site Berlin, Germany
| | - Viktoria Dorau-Rutke
- Department of Nuclear Medicine, Charité-Universitätsmedizin Berlin, Germany
- Department of Internal Medicine, Military Hospital Hamburg, Germany
| | - Eva J Koziolek
- Department of Nuclear Medicine, Charité-Universitätsmedizin Berlin, Germany
- German Cancer Consortium (DKTK), partner site Berlin, Germany
- German Cancer Research Center (DKFZ) Heidelberg, Germany
| | - Kai Huang
- Department of Nuclear Medicine, Charité-Universitätsmedizin Berlin, Germany
| | - Sonal Prasad
- Department of Nuclear Medicine, Charité-Universitätsmedizin Berlin, Germany
- Berlin Experimental Radionuclide Imaging Center (BERIC), Charité-Universitätsmedizin Berlin, Germany
| | - Winfried Brenner
- Department of Nuclear Medicine, Charité-Universitätsmedizin Berlin, Germany
- German Cancer Consortium (DKTK), partner site Berlin, Germany
| | - Nicola Beindorff
- Berlin Experimental Radionuclide Imaging Center (BERIC), Charité-Universitätsmedizin Berlin, Germany
| |
Collapse
|
35
|
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: 21] [Impact Index Per Article: 5.3] [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.
Collapse
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
| |
Collapse
|
36
|
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.
Collapse
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
| |
Collapse
|
37
|
Castillo Seoane D, de Saint-Hubert M, Crabbe M, Struelens L, Koole M. Targeted alpha therapy: a critical review of translational dosimetry research with emphasis on actinium-225. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2020; 64:265-277. [PMID: 32441067 DOI: 10.23736/s1824-4785.20.03266-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This review provides a general overview of the current achievements and challenges in translational dosimetry for targeted alpha therapy (TAT). The concept of targeted radionuclide therapy (TRNT) is described with an overview of its clinical applicability and the added value of TAT is discussed. For TAT, we focused on actinium-225 (225Ac) as an example for alpha particle emitting radionuclides and their features, such as limited range within tissue and high linear energy transfer, which make alpha particle emissions more effective in targeted killing of tumour cells compared to beta radiation. Starting with the state-of-the-art dosimetry for TRNT and TAT, we then describe the challenges that still need to be met in order to move to a personalized dosimetry approach for TAT. Specifically for 225Ac, we discuss the recoiled daughter effect which may provoke significant damage to healthy tissue or organs and should be considered. Next, a broad overview is given of the pre-clinical research on 225Ac-TAT with an extensive description of tools which are only available in a pre-clinical setting and their added value. In addition, we review the preclinical biodistribution and dosimetry studies that have been performed on TAT-agents and more specifically of 225Ac and its multiple progeny, and describe their potential role to better characterize the pharmacokinetic (PK) profile of TAT-agents and to optimize the use of theranostic approaches for dosimetry. Finally, we discuss the support pre-clinical studies may provide in understanding dose-effect relationships, linking radiation dose quantities to biological endpoints and even moving away from macro- to microdosimetry. As such, the translation of pre-clinical findings may provide valuable information and new approaches for improved clinical dosimetry, thus paving the way to personalized TAT.
Collapse
Affiliation(s)
- Dayana Castillo Seoane
- Unit of Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, Katholieke Universiteit Leuven (KUL), Leuven, Belgium - .,Research Unit in Dosimetric Applications, Belgian Nuclear Research Center (SCK•CEN), Mol, Belgium -
| | - Marijke de Saint-Hubert
- Research Unit in Dosimetric Applications, Belgian Nuclear Research Center (SCK•CEN), Mol, Belgium
| | - Melissa Crabbe
- Research Unit in Dosimetric Applications, Belgian Nuclear Research Center (SCK•CEN), Mol, Belgium
| | - Lara Struelens
- Research Unit in Dosimetric Applications, Belgian Nuclear Research Center (SCK•CEN), Mol, Belgium
| | - Michel Koole
- Unit of Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, Katholieke Universiteit Leuven (KUL), Leuven, Belgium
| |
Collapse
|
38
|
Zhao W, Esquinas PL, Frezza A, Hou X, Beauregard JM, Celler A. Accuracy of kidney dosimetry performed using simplified time activity curve modelling methods: a 177Lu-DOTATATE patient study. Phys Med Biol 2019; 64:175006. [PMID: 31287093 DOI: 10.1088/1361-6560/ab3039] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
177Lu-DOTATATE therapy has been shown to produce encouraging results in treatment of neuroendocrine tumours (NETs). Unfortunately, since dosimetry for radionuclide therapy is considered to be challenging, typically similar amount of radiopharmaceutical is administered to every patient. There is growing evidence that the efficacy of this therapy can be significantly improved by employing personalized protocols, based on the organ-at-risk dosimetry. The aim of this study is to propose a practical and accurate dosimetry protocol based on the simplified acquisition schedules. Data from fifty-three therapy cycles in thirty-nine NET patients were analyzed. Three SPECT/CT scans, acquired at 4 h (D0), 23 h (D1) and 70 h (D3) after injection, were performed. The kidney volume was determined using CT and the activity was determined from quantitative SPECT using an iterative thresholding method. For each dataset, four methods were used to model the time-activity-curves (TAC): M1-two trapezoid segments (0 to D0 and D0 to D1), followed by monoexponential fit to D1 + D3 data; M2-monoexponential fit to D0 + D1 + D3 data; M3 and M4-monoexponential fit to D0 + D3 and D1 + D3 data, respectively. Additionally, kidney doses obtained from single time point method using a monoexponential curve with the population mean effective half-life, normalized to activities at D0 or D1 or D3 points, were calculated. The accuracy of simplified dosimetry methods was assessed as the percentage difference relative to doses calculated from M1. The major contribution to the absorbed dose estimate comes from the area under the late time portion of the TAC (D1 to infinity). Therefore, information from the late scan (D3) is crucial for the determination of kidney absorbed doses. Single time point method using monoexponential TAC, with the population mean effective half-life normalized to the late data point (48-72 h for kidneys) produces <10% deviation in the absorbed dose estimation, thus is recommended for clinical use.
Collapse
Affiliation(s)
- Wei Zhao
- Department of Physics and Astronomy, University of British Columbia, Vancouver, BC, Canada. Medical Imaging Research Group, Department of Radiology, University of British Columbia, Vancouver, BC, Canada. Author to whom any correspondence should be addressed
| | | | | | | | | | | |
Collapse
|
39
|
Hou X, Zhao W, Beauregard JM, Celler A. Personalized kidney dosimetry in 177Lu-octreotate treatment of neuroendocrine tumours: a comparison of kidney dosimetry estimates based on a whole organ and small volume segmentations. Phys Med Biol 2019; 64:175004. [PMID: 31456584 DOI: 10.1088/1361-6560/ab32a1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Peptide receptor radionuclide therapy (PRRT) with 177Lu- radiolabeled octreotate is an effective treatment method for inoperable neuroendocrine tumours (NETs). There is growing evidence that estimates of the organ-at-risks (OARs) doses are necessary for the optimization of personalized PRRT (P-PRRT). Dosimetry, however, requires a complicated and time-consuming procedure, which hinders its implementation in the clinic. The aim of this study is to develop a practical and automatic technique to simplify personalized dosimetry of kidney, the major OAR in 177Lu P-PRRT. The data from 30 NETs patients undergoing 44 personalized 177Lu-DOTA-TATE therapy cycles were analyzed. To determine the biokinetics of the radiopharmaceutical in the kidneys, for each patient three SPECT/CT scans were acquired, at about 4 h, 24 h and 70 h after injection. The kidneys doses were evaluated using three different approaches: (1) a traditional approach based on whole kidney (WK) segmentation; (2) a small volume (SV) manual approach (M-SV) with observer-defined SV location; and (3) a software based SV-approach that automatically defines SV location (A-SV). Four different methods of automatic SV location selections were investigated. The SV kidney doses estimated using M-SV and A-SV approaches was evaluated and the accuracy of these two approaches were compared to the WK dosimetry. The kidney bio-kinetics, in terms of effective half-lives, obtained from both of the A-SV and M-SV approaches agreed to within 10% with those obtained from the WK segmentation. The average ratios of SV doses to WK doses were mostly about 1.8 ± 0.2 for both A-SV and M-SV approaches. The linear correlation coefficients between SV doses (both A-SV and M-SV) and WK doses were up to 0.9 with p < 0.001. The differences between A-SV and M-SV were minor. By comparing different methods of SV location selections, independently selecting SV in images from each of the acquisitions was proved the most appropriate and accurate approach. An automatic, observer-independent method for selecting the location of the small volume in kidneys was developed. The accuracy of this dose estimation approach has been demonstrated by comparing it with the manual SV dosimetry, as well as the WK dosimetry. The proposed automatic approach can potentially be considered as a practical and simple method for dose estimation in the future clinical studies.
Collapse
Affiliation(s)
- Xinchi Hou
- Department of Radiology, University of British Columbia, Vancouver, Canada. The first two authors made equal contribution to this study and would be considered as co-first authors of this paper. Author to whom any correspondence should be addressed. Department of Radiology, University of British Columbia, 828 West 10th Avenue, Rm 366, Vancouver, BC, V5Z1L8, Canada
| | | | | | | |
Collapse
|
40
|
Willowson KP, Eslick E, Ryu H, Poon A, Bernard EJ, Bailey DL. Feasibility and accuracy of single time point imaging for renal dosimetry following 177Lu-DOTATATE ('Lutate') therapy. EJNMMI Phys 2018; 5:33. [PMID: 30569328 PMCID: PMC6300448 DOI: 10.1186/s40658-018-0232-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/19/2018] [Indexed: 12/16/2022] Open
Abstract
Background This study aims to assess both feasibility and accuracy of renal dosimetry imaging protocols in patients receiving Lutate therapy for neuroendocrine tumours (NETs), when data acquisition over multiple days is not possible on all cycles. Method Patients who had received a full 4 cycles of Lutate therapy with complete imaging at each cycle were included. Imaging consisted of quantitative SPECT/CT of the kidneys at 4, 24 and 96–120 h post injection. Renal absorbed dose was calculated for each data set, and in addition, five alternative methods were explored for comparison. Method 1: a patient average clearance time (t1/2 average) derived from the first half of contributing patient data was used to estimate absorbed dose for subsequent patients based on 4 h imaging alone; method 2: t1/2 average was applied to subsequent patients on 24 h imaging alone; method 3: a patient-specific clearance rate (t1/2 patient) was determined from complete image data of cycle 1 and applied subsequently to remaining cycles using 4 h image data alone; method 4: t1/2 patient was applied to 24 h imaging alone in subsequent cycles; method 5: the 120 h data was estimated on subsequent cycles based on the cycle 1 fraction of injected activity (%IA) at 24 and 120 h. Results Twenty treatments from 18 patients, resulting in 80 cycles of therapy, were analysed. The measured average renal absorbed dose per cycle of treatment was 0.38 ± 0.19 Gy/GBq when derived from full imaging data. The use of t1/2 average applied to a single time point led to large deviations of dose estimates from true values (on average 59% and 30%, when using 4 h data and 24 h data, respectively). The use of complete image data on cycle 1 and the derivation of t1/2 patient led to improved dose estimates, with an average deviation from true values of 13% and 2% when using 4 h data only and 24 h data only, respectively. The use of a 120 h %IA derived from cycle 1 led to an average deviation from true dose estimates of 14%. Conclusion In instances where demands on both patients and facilities make multiple time point data acquisition impractical, renal dosimetry is best derived through complete imaging at cycle 1 only followed by a single 24 h imaging time point on subsequent cycles, assuming no significant changes in renal function during the time course of therapy.
Collapse
Affiliation(s)
- Kathy P Willowson
- Department of Nuclear Medicine, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia. .,Institute of Medical Physics, The University of Sydney, Camperdown, NSW, 2006, Australia.
| | - Enid Eslick
- Department of Nuclear Medicine, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Hyunju Ryu
- Faculty of Health Sciences, The University of Sydney, Lidcombe, NSW, 2141, Australia
| | - Aurora Poon
- Department of Molecular Imaging and Therapy, The Austin Hospital, Heidelberg, VIC, 3084, Australia
| | - Elizabeth J Bernard
- Department of Nuclear Medicine, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Dale L Bailey
- Department of Nuclear Medicine, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.,Faculty of Health Sciences, The University of Sydney, Lidcombe, NSW, 2141, Australia
| |
Collapse
|
41
|
Chicheportiche A, Grozinsky-Glasberg S, Gross DJ, Krausz Y, Salmon A, Meirovitz A, Freedman N, Godefroy J. Predictive power of the post-treatment scans after the initial or first two courses of [ 177Lu]-DOTA-TATE. EJNMMI Phys 2018; 5:36. [PMID: 30535780 PMCID: PMC6286905 DOI: 10.1186/s40658-018-0234-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/20/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate the predictive power of the absorbed dose to kidneys after the first course of treatment with [177Lu]-DOTA-TATE for neuroendocrine tumors (NETs) on the cumulative kidney absorbed dose after 3 or 4 cycles of treatment. Post-treatment scans (PTS) are acquired after each cycle of peptide receptor radionuclide therapy (PRRT) with [177Lu]-DOTA-TATE for personalized radiation dosimetry in order to ensure a cumulative absorbed dose to kidneys under a safety threshold of 25 Gy. One hundred eighty-seven patients who completed treatment with [177Lu]-DOTA-TATE and underwent PTS for dosimetry calculation were included in this retrospective study. The correlation between the cumulative absorbed dose to kidneys after the completion of treatment and the absorbed dose after the first cycle(s) was studied. Multilinear regression analysis was done to predict the cumulative absorbed dose to the kidneys of the subsequent cycles, and an algorithm for the follow up of kidney absorbed dose is proposed. RESULTS Patients whose absorbed dose to kidneys after the first cycle of treatment is below 5.6 Gy can receive four cycles of treatment with a cumulative dose less than 25 Gy (p < 0.1). For the other patients, the cumulative absorbed dose after 3 or 4 cycles of treatment can be predicted after the second cycle of treatment to allow for an early decision regarding the number of cycles that may be given. CONCLUSIONS The follow up of kidney absorbed dose after PRRT can be simplified with the algorithm presented in this study, reducing by one-third the number of post-treatment scans and reducing hospitalization time for more than half of the treatment cycles.
Collapse
Affiliation(s)
- Alexandre Chicheportiche
- Department of Nuclear Medicine & Biophysics, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel.
| | - Simona Grozinsky-Glasberg
- Neuroendocrine Tumor Unit, Endocrinology and Metabolism Department, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - David J Gross
- Neuroendocrine Tumor Unit, Endocrinology and Metabolism Department, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Yodphat Krausz
- Department of Nuclear Medicine & Biophysics, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Asher Salmon
- Oncology Department and Radiation Therapy Unit, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Amichay Meirovitz
- Oncology Department and Radiation Therapy Unit, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Nanette Freedman
- Department of Nuclear Medicine & Biophysics, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Jeremy Godefroy
- Department of Nuclear Medicine & Biophysics, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| |
Collapse
|
42
|
Marin G, Vanderlinden B, Karfis I, Guiot T, Wimana Z, Reynaert N, Vandenberghe S, Flamen P. A dosimetry procedure for organs-at-risk in 177Lu peptide receptor radionuclide therapy of patients with neuroendocrine tumours. Phys Med 2018; 56:41-49. [PMID: 30527088 DOI: 10.1016/j.ejmp.2018.11.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/05/2018] [Accepted: 11/02/2018] [Indexed: 01/25/2023] Open
Abstract
PURPOSE Peptide receptor radionuclide therapy with 177Lu-DOTATATE has become a standard treatment modality in neuroendocrine tumours (NETs). No consensus has yet been reached however regarding the absorbed dose threshold for lesion response, the absorbed dose limit to organs-at-risk, and the optimal fractionation and activity to be administered. This is partly due to a lack of uniform and comparable dosimetry protocols. The present article details the development of an organ-at-risk dosimetry procedure, which could be implemented and used routinely in a clinical context. METHODS Forty-seven patients with NETs underwent 177Lu-DOTATATE therapy. Three SPECT/CT images were acquired at 4, 24 and 144-192 h post-injection. Three blood samples were obtained together with the SPECT/CT acquisitions and 2 additional samples were obtained around 30 min and 1 h post-injection. A bi-exponential fit was used to compute the source organ time-integrated activity coefficients. Coefficients were introduced into OLINDA/EXM software to compute organ-at-risk absorbed doses. Median values for all patients were computed for absorbed dose coefficient D/A0 and for late effective half-life T1/2eff for kidneys, spleen and red marrow. RESULTS Dosimetry resulted in a median[interquartile range] of 0.78[0.35], 1.07[0.58] and 0.028[0.010] Gy/GBq for D/A0 and of 55[9], 71[9] and 52[18] h for T1/2eff for kidneys, spleen and red marrow respectively. CONCLUSIONS A dosimetry procedure for organs-at-risk in 177Lu-DOTATATE therapy based on serial SPECT/CT images and blood samples can be implemented routinely in a clinical context with limited patient burden. The results obtained were in accordance with those of other centres.
Collapse
Affiliation(s)
- Gwennaëlle Marin
- Department of Medical Physics, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 121 boulevard de Waterloo, 1000 Brussels, Belgium; Medical Imaging and Signal Processing (MEDISIP), Department of Electronics and Information Systems (ELIS), Faculty of Engineering and Architecture (FEA), Ghent University (UGent), 185 De Pintelaan, 9000 Gent, Belgium.
| | - Bruno Vanderlinden
- Department of Medical Physics, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 121 boulevard de Waterloo, 1000 Brussels, Belgium.
| | - Ioannis Karfis
- Department of Nuclear Medicine, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 121 boulevard de Waterloo, 1000 Brussels, Belgium.
| | - Thomas Guiot
- Department of Medical Physics, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 121 boulevard de Waterloo, 1000 Brussels, Belgium.
| | - Zena Wimana
- Department of Nuclear Medicine, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 121 boulevard de Waterloo, 1000 Brussels, Belgium.
| | - Nick Reynaert
- Department of Medical Physics, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 121 boulevard de Waterloo, 1000 Brussels, Belgium.
| | - Stefaan Vandenberghe
- Medical Imaging and Signal Processing (MEDISIP), Department of Electronics and Information Systems (ELIS), Faculty of Engineering and Architecture (FEA), Ghent University (UGent), 185 De Pintelaan, 9000 Gent, Belgium.
| | - Patrick Flamen
- Department of Nuclear Medicine, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 121 boulevard de Waterloo, 1000 Brussels, Belgium.
| |
Collapse
|
43
|
Huizing DMV, de Wit-van der Veen BJ, Verheij M, Stokkel MPM. Dosimetry methods and clinical applications in peptide receptor radionuclide therapy for neuroendocrine tumours: a literature review. EJNMMI Res 2018; 8:89. [PMID: 30159614 PMCID: PMC6115319 DOI: 10.1186/s13550-018-0443-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 08/21/2018] [Indexed: 12/25/2022] Open
Abstract
Background The main challenge for systemic radiation therapy using radiopharmaceuticals (SRT) is to optimise the dose delivered to the tumour, while minimising normal tissue irradiation. Dosimetry could help to increase therapy response and decrease toxicity after SRT by individual treatment planning. Peptide receptor radionuclide therapy (PRRT) is an accepted SRT treatment option for irresectable and metastatic neuroendocrine tumours (NET). However, dosimetry in PRRT is not routinely performed, mainly due to the lack of evidence in literature and clinical implementation difficulties. The goal of this review is to provide insight in dosimetry methods and requirements and to present an overview of clinical aspects of dosimetry in PRRT for NET. Methods A PubMed query including the search criteria dosimetry, radiation dose, peptide receptor radionuclide therapy, and radionuclide therapy was performed. Articles were selected based on title and abstract, and description of dosimetric approach. Results A total of 288 original articles were included. The most important dosimetry methods, their main advantages and limitations, and implications in the clinical setting are discussed. An overview of dosimetry in clinical studies regarding PRRT treatment for NET is provided. Conclusion Clinical dosimetry in PRRT is feasible and can result in improved treatment outcomes. Current clinical dosimetry studies focus on safety and apply non-voxel-based dosimetry methods. Personalised treatment using sophisticated dosimetry methods to assess tumour and normal tissue uptake in clinical trials is the next step towards routine dosimetry in PRRT for NET. Electronic supplementary material The online version of this article (10.1186/s13550-018-0443-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Daphne Merel Valerie Huizing
- Department of Nuclear Medicine, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | | | - Marcel Verheij
- Department of Radiation Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | | |
Collapse
|
44
|
Peptide receptor radionuclide therapy with 177Lu-DOTA-octreotate: dosimetry, nephrotoxicity, and the effect of hematological toxicity on survival. Nucl Med Commun 2018; 39:236-246. [PMID: 29315138 DOI: 10.1097/mnm.0000000000000795] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Peptide receptor radionuclide therapy (PRRT) with lutetium-177 (Lu)-DOTATATE is regarded as a safe treatment option with promising results for patients with neuroendocrine neoplasia (NEN). We aimed to study the absorbed organ and tumor doses, the renal and hematological toxicity as well as their mutual interaction. Another aim was the identification of adverse effects as possible predictors which may affect survival. METHODS A total of 30 (14 female and 16 male) patients with inoperable/metastatic NEN were treated with 7.4 GBq of Lu-DOTATATE. Occurrence of renal and hematological toxicity wasretrospectively studied. Morever, we examined the effects of hematological toxicity on survival after Lu-DOTATATE-PRRT. RESULTS In 49 treatment cycles, the mean absorbed dose to the kidneys was 5.13±2.12, 4.49±2.49 Gy to the liver, and 14.44±8.97 Gy to the spleen, whereas tumor lesions absorbed a mean dose of 31.43±36.86 Gy. Comparing different localizations of metastases, no significant differences in absorbed dose were observed. Clinical response status revealed regressive disease in 47.6%, stable disease in 38.1%, and progressive disease in 14.3% of cases (n=21). Biochemically, 81.3% of patients showed reduced serotonin values (n=16; P<0.05) following Lu-DOTATATE-PRRT. No severe subacute renal or hematological toxicity occurred (one Common Terminology Criteria for Adverse Events-grade 3 for thrombocytopenia and another one for leukocytopenia). No statistically significant relation between baseline kidney function and post-therapeutic hematological changes was identified. CONCLUSION The findings indicate that Lu-DOTATATE-PRRT is a safe and effective treatment method for patients with NEN. Moreover, these data strongly suggest that hematological parameters may affect survival so a further re-evaluation in prospective studies is warranted.
Collapse
|
45
|
Chicheportiche A, Artoul F, Schwartz A, Grozinsky-Glasberg S, Meirovitz A, Gross DJ, Godefroy J. Reducing the number of CTs performed to monitor personalized dosimetry during peptide receptor radionuclide therapy (PRRT). EJNMMI Phys 2018; 5:10. [PMID: 29916115 PMCID: PMC6006002 DOI: 10.1186/s40658-018-0211-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/23/2018] [Indexed: 12/25/2022] Open
Abstract
Background Peptide receptor radionuclide therapy (PRRT) with [177Lu]-DOTA-TATE is an effective treatment of neuroendocrine tumors (NETs). After each cycle of treatment, patient dosimetry evaluates the radiation dose to the risk organs, kidneys, and bone marrow, the most radiosensitive tissues. Absorbed doses are calculated from the radioactivity in the blood and from single photon emission computed tomography (SPECT) images corrected by computed tomography (CT) acquired after each course of treatment. The aim of this work is to assess whether the dosimetry along all treatment cycles can be calculated using a single CT. We hypothesize that the absorbed doses to the risk organs calculated with a single CT will be accurate enough to correctly manage the patients, i.e., whether or not to continue PRRT. Twenty-four patients diagnosed with metastatic NETs undergoing PRRT with [177Lu]-DOTA-TATE were retrospectively included in this study. We compared radiation doses to the kidneys and bone marrow using two protocols. In the “classical” one, dosimetry is calculated based on a SPECT and a CT after each treatment cycle. In the new protocol, dosimetry is calculated based on a SPECT study after each cycle but with the first acquired CT for all cycles. Results The decision whether or not to stop PRRT because of unsafe absorbed dose to the risk organs would have been the same had the classical or the new protocol been used. The agreement between the cumulative doses to the kidneys and bone marrow obtained from the two protocols was excellent with Pearson’s correlation coefficients r = 0.95 and r = 0.99 (P < 0.0001) and mean relative differences of 5.30 ± 6.20% and 0.48 ± 4.88%, respectively. Conclusions Dosimetry calculations for a given patient can be done using a single CT registered to serial SPECTs. This new protocol reduces the need for a hybrid camera in the follow-up of patients receiving [177Lu]-DOTA-TATE.
Collapse
Affiliation(s)
- Alexandre Chicheportiche
- Department of Nuclear Medicine and Biophysics, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel.
| | - Faozi Artoul
- Department of Nuclear Medicine and Biophysics, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Arnon Schwartz
- Department of Nuclear Medicine and Biophysics, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Simona Grozinsky-Glasberg
- Neuroendocrine Tumor Unit, Endocrinology and Metabolism Department, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Amichay Meirovitz
- Oncology Department and Radiation Therapy Unit, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - David J Gross
- Neuroendocrine Tumor Unit, Endocrinology and Metabolism Department, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Jeremy Godefroy
- Department of Nuclear Medicine and Biophysics, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| |
Collapse
|
46
|
Yusuf S, Alsadik S, AL-Nahhas A. Peptide receptor radionuclide therapy for neuroendocrine tumours. Clin Transl Imaging 2018. [DOI: 10.1007/s40336-018-0267-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
47
|
Early efficacy of and toxicity from lutetium-177-DOTATATE treatment in patients with progressive metastatic NET. Nucl Med Commun 2018; 38:593-600. [PMID: 28471845 DOI: 10.1097/mnm.0000000000000685] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Lutetium-177 DOTA-D-Phe1-Tyr3-octreotide (Lu-DOTATATE) is a treatment option for patients with well-differentiated metastatic neuroendocrine tumours. Our centre started administering this therapy in 2012. The aim of this study was therefore to analyse the first cohort of patients treated with Lu-DOTATATE to determine its early efficacy and toxicity. PATIENTS AND METHODS We retrospectively analysed patient, tumour and treatment characteristics, end-of-treatment outcome, time to progression and toxicity in 79 consecutive patients treated with Lu-DOTATATE who had progressive NET according to Response Evaluation Criteria in Solid Tumours criteria. Follow-up time was 12-40 months. Study of Kaplan-Meier plots, analysis of time to progression and multiple regression analysis of factors predictive of time to progression were performed. RESULTS At end-of-treatment radiological restaging, 13% of patients were found to have partial response and 64% to have stable disease; 23% of patients progressed through treatment. Overall, 47% of patients demonstrated a reduction in chromogranin A levels. The overall estimated median time to progression from the start of treatment was 28 months for the entire cohort and 31, 30 and 5 months for those with partial response, stable disease and progressive disease, respectively. On multivariate regression analysis, higher grade of tumour was found to be significantly associated with shorter progression-free survival. Three patients experienced grade 1 haematotoxicity, five grade 1 nephrotoxicity and one grade 2 nephrotoxicity. CONCLUSION Early outcomes of patients treated with Lu-DOTATATE are similar to those in previously published series in terms of end-of-treatment efficacy and toxicity. This provides further evidence that this is a safe and efficacious form of treatment for patients with progressive metastatic neuroendocrine tumours.
Collapse
|
48
|
Werner RA, Beykan S, Higuchi T, Lückerath K, Weich A, Scheurlen M, Bluemel C, Herrmann K, Buck AK, Lassmann M, Lapa C, Hänscheid H. The impact of 177Lu-octreotide therapy on 99mTc-MAG3 clearance is not predictive for late nephropathy. Oncotarget 2018; 7:41233-41241. [PMID: 27259246 PMCID: PMC5173054 DOI: 10.18632/oncotarget.9775] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 05/23/2016] [Indexed: 01/31/2023] Open
Abstract
Peptide Receptor Radionuclide Therapy (PRRT) for the treatment of neuroendocrine tumors may lead to kidney deterioration. This study aimed to evaluate the suitability of 99mTc-mercaptoacetyltriglycine (99mTc-MAG3) clearance for the early detection of PRRT-induced changes on tubular extraction (TE). TE rate (TER) was measured prior to 128 PRRT cycles (7.6±0.4 GBq 177Lu-octreotate/octreotide each) in 32 patients. TER reduction during PRRT was corrected for age-related decrease and analyzed for the potential to predict loss of glomerular filtration (GF). The GF rate (GFR) as measure for renal function was derived from serum creatinine. The mean TER was 234 ± 53 ml/min/1.73 m2 before PRRT (baseline) and 221 ± 45 ml/min/1.73 m2 after a median follow-up of 370 days. The age-corrected decrease (mean: −3%, range: −27% to +19%) did not reach significance (p=0.09) but significantly correlated with the baseline TER (Spearman p=−0.62, p<0.001). Patients with low baseline TER showed an improved TER after PRRT, high decreases were only observed in individuals with high baseline TER. Pre-therapeutic TER data were inferior to plasma creatinine-derived GFR estimates in predicting late nephropathy. TER assessed by 99mTc-MAG3clearance prior to and during PRRT is not suitable as early predictor of renal injury and an increased risk for late nephropathy.
Collapse
Affiliation(s)
- Rudolf A Werner
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - Seval Beykan
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Takahiro Higuchi
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - Katharina Lückerath
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Alexander Weich
- Department of Internal Medicine II, Gastroenterology, University Hospital Würzburg, Würzburg, Germany
| | - Michael Scheurlen
- Department of Internal Medicine II, Gastroenterology, University Hospital Würzburg, Würzburg, Germany
| | - Christina Bluemel
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany.,Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Andreas K Buck
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - Michael Lassmann
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Constantin Lapa
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Heribert Hänscheid
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| |
Collapse
|
49
|
Fast GPU-based Monte Carlo code for SPECT/CT reconstructions generates improved 177Lu images. EJNMMI Phys 2018; 5:1. [PMID: 29302810 PMCID: PMC5754277 DOI: 10.1186/s40658-017-0201-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 12/07/2017] [Indexed: 02/05/2023] Open
Abstract
Background Full Monte Carlo (MC)-based SPECT reconstructions have a strong potential for correcting for image degrading factors, but the reconstruction times are long. The objective of this study was to develop a highly parallel Monte Carlo code for fast, ordered subset expectation maximum (OSEM) reconstructions of SPECT/CT images. The MC code was written in the Compute Unified Device Architecture language for a computer with four graphics processing units (GPUs) (GeForce GTX Titan X, Nvidia, USA). This enabled simulations of parallel photon emissions from the voxels matrix (1283 or 2563). Each computed tomography (CT) number was converted to attenuation coefficients for photo absorption, coherent scattering, and incoherent scattering. For photon scattering, the deflection angle was determined by the differential scattering cross sections. An angular response function was developed and used to model the accepted angles for photon interaction with the crystal, and a detector scattering kernel was used for modeling the photon scattering in the detector. Predefined energy and spatial resolution kernels for the crystal were used. The MC code was implemented in the OSEM reconstruction of clinical and phantom 177Lu SPECT/CT images. The Jaszczak image quality phantom was used to evaluate the performance of the MC reconstruction in comparison with attenuated corrected (AC) OSEM reconstructions and attenuated corrected OSEM reconstructions with resolution recovery corrections (RRC). Result The performance of the MC code was 3200 million photons/s. The required number of photons emitted per voxel to obtain a sufficiently low noise level in the simulated image was 200 for a 1283 voxel matrix. With this number of emitted photons/voxel, the MC-based OSEM reconstruction with ten subsets was performed within 20 s/iteration. The images converged after around six iterations. Therefore, the reconstruction time was around 3 min. The activity recovery for the spheres in the Jaszczak phantom was clearly improved with MC-based OSEM reconstruction, e.g., the activity recovery was 88% for the largest sphere, while it was 66% for AC-OSEM and 79% for RRC-OSEM. Conclusion The GPU-based MC code generated an MC-based SPECT/CT reconstruction within a few minutes, and reconstructed patient images of 177Lu-DOTATATE treatments revealed clearly improved resolution and contrast.
Collapse
|
50
|
Lu-177-Based Peptide Receptor Radionuclide Therapy for Advanced Neuroendocrine Tumors. Nucl Med Mol Imaging 2017; 52:208-215. [PMID: 29942399 DOI: 10.1007/s13139-017-0505-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/31/2017] [Accepted: 11/01/2017] [Indexed: 10/18/2022] Open
Abstract
Peptide receptor radionuclide therapy (PRRT) is a systemic cytotoxic radiation therapy using a compound of β-emitting radionuclide chelated to a peptide for the treatment of tumor with overexpressed specific cell receptor such as somatostatin receptor subtype 2 (SSTR2) of neuroendocrine tumor (NET). Surgical resection should be performed for the curative treatment for NETs when it is feasible; however, a multi-disciplinary approach is needed when locally advanced or metastasized disease. PRRT with lutetium-177 (Lu-177)-labeled somatostatin analogues, as a new treatment modality targeting metastatic or inoperable NETs expressing the SSTR2, have been developed and successfully used for the past two decades. As Lu-177 emits both β- and γ-radiation, it has the ability as a theragnostic agent for NETs compared with only β-emitting yttrium-90 labeled PRRT. Several recent studies reported that Lu-177 gave an overall positive response and improved the patients' quality of life. To fully exploit its potential, large comparative studies are needed for the assessment of distinct efficacies of Lu-177 labeled PRRT. Additionally, for extending the indications and developing new regimens of Lu-177-based PRRT, more dedicated clinical research is required.
Collapse
|