Radiation enhancement of radiolabelled antibody deposition in tumors

Results from a phase I study of 4-l-[131I]iodo-phenylalanine ([131I]IPA) with external radiation therapy in patients with recurrent glioblastoma (IPAX-1)

Background

Glioblastoma (GBM), the most common malignant brain tumor, is associated with devastating outcomes. IPAX-1 was a multicenter, open-label, single-arm phase I study to evaluate carrier-added 4-L-[131I]iodo-phenylalanine ([131I]IPA) plus external radiation therapy (XRT) in recurrent GBM.

Methods

A total of 10 adults with recurrent GBM who had received first-line debulking surgery plus radio-chemotherapy, were randomized to a single-dose regimen (1f; 131I-IPA 2 GBq before XRT); a fractionated parallel dose regimen (3f-p; 3 131I-IPA 670 MBq fractions, in parallel with second-line XRT), or a fractionated sequential dose regimen (3f-s; 3 131I-IPA 670 MBq fractions before and after XRT). Metabolic tumor responses were determined using O-(2-[18F]fluoroethyl)-l-tyrosine positron emission tomography, while single-photon emission computed tomography was used to guide [131I]IPA tumor dosimetry.

Results

All dose regimens were well tolerated. Organ-absorbed radiation doses in red marrow (0.38 Gy) and kidney (1.28 Gy) confirmed no radiation-based toxicity. Stable disease was observed in 4 of the 9 patients at 3 months post-treatment (3-month follow-up [FU], 1 patient did not reach protocol-mandated end of study), yielding a response rate of 44.4%. At the 3-month FU, 6 patients demonstrated metabolic stable disease. Median progression-free survival was 4.3 months (95% confidence interval [CI]: 3.3-4.5), while median overall survival was 13 months (95% CI: 7.1-27).

Conclusions

Single or fractionated doses of [131I]IPA plus XRT were associated with acceptable tolerability and specific tumor targeting in patients with recurrent GBM, warranting further investigation.

[Combination of internal and external beam radiotherapy]

External beam radiation therapy and internal vectorized radiation therapy are two types of radiotherapy that can be used to treat cancer. They differ in the way they are administered, and the type of radiation used. Although they can be effective in treating cancer, they each have their own advantages and disadvantages, and their combination could be synergistic. Preclinical studies on combined internal and external beam radiation therapy have mainly used radiolabelled antibodies, whose bone marrow toxicity remains the limiting factor in increasing the administered activities. The use of small radioligands in clinical trials has shown to be better tolerated and more effective, which explains their rapid development. The results of preclinical studies on combined internal and external beam radiation therapy appear heterogeneous, making it impossible to determine an ideal therapeutic sequencing scheme, and complicating the transposition to clinical studies. The few clinical studies on combined internal and external beam radiation therapy available to date have demonstrated feasibility and tolerability. More work remains to be done in the fields of dosimetry and radiobiology, as well as in the sequencing of these two irradiation modalities to optimize their combination.

Effects of radiation on tumor vasculature

Radiation has been utilized as a direct cytotoxic tumorcidal modality, however, the effect of radiation on tumor vasculature influences response to anticancer therapies. Although numerous reports have demonstrated vascular changes in irradiated tumors, the findings and implications are extensive and at times contradictory depending on the radiation dose, timing, and models used. In this review, we focus on the radiation-mediated effects on tumor vasculature with respect to doses used, timing postradiation, vasculogenesis, adhesion molecule expression, permeability, and pericyte coverage, including the latest findings.

Combining External Beam Radiation and Radionuclide Therapies: Rationale, Radiobiology, Results and Roadblocks

The emergence of effective radionuclide therapeutics, such as radium-223 dichloride, [¹⁷⁷Lu]Lu-DOTA-TATE and [¹⁷⁷Lu]Lu-PSMA ligands, over the last 10 years is driving a rapid expansion in molecular radiotherapy (MRT) research. Clinical trials that are underway will help to define optimal dosing protocols and identify groups of patients who are likely to benefit from this form of treatment. Clinical investigations are also being conducted to combine new MRT agents with other anticancer drugs, with particular emphasis on DNA repair inhibitors and immunotherapeutics. In this review, the case is presented for combining MRT with external beam radiotherapy (EBRT). The technical and dosimetric challenges of combining two radiotherapeutic modalities have impeded progress in the past. However, the need for research into the specific radiobiological effects of radionuclide therapy, which has lagged behind that for EBRT, has been recognised. This, together with innovations in imaging technology, MRT dosimetry tools and EBRT hardware, will facilitate the future use of this important combination of treatments.

Radiation-Induced Transformation of Immunoregulatory Networks in the Tumor Stroma

The implementation of novel cancer immunotherapies in the form of immune checkpoint blockers represents a major advancement in the treatment of cancer, and has renewed enthusiasm for identifying new ways to induce antitumor immune responses in patients. Despite the proven efficacy of neutralizing antibodies that target immune checkpoints in some refractory cancers, many patients do not experience therapeutic benefit, possibly owing to a lack of antitumor immune recognition, or to the presence of dominant immunosuppressive mechanisms in the tumor microenvironment (TME). Recent developments in this field have revealed that local radiotherapy (RT) can transform tumors into in situ vaccines, and may help to overcome some of the barriers to tumor-specific immune rejection. RT has the potential to ignite tumor immune recognition by generating immunogenic signals and releasing neoantigens, but the multiple immunosuppressive forces in the TME continue to represent important barriers to successful tumor rejection. In this article, we review the radiation-induced changes in the stromal compartments of tumors that could have an impact on tumor immune attack. Since different RT regimens are known to mediate strikingly different effects on the multifarious elements of the tumor stroma, special emphasis is given to different RT schedules, and the time after treatment at which the effects are measured. A better understanding of TME remodeling following specific RT regimens and the window of opportunity offered by RT will enable optimization of the design of novel treatment combinations.

Improved outcome of 131I-mIBG treatment through combination with external beam radiotherapy in the SK-N-SH mouse model of neuroblastoma

PURPOSE

To assess the efficacy of different schedules for combining external beam radiotherapy (EBRT) with molecular radiotherapy (MRT) using 131I-mIBG in the management of neuroblastoma.

MATERIALS AND METHODS

BALB/c nu/nu mice bearing SK-N-SH neuroblastoma xenografts were assigned to five treatment groups: 131I-mIBG 24h after EBRT, EBRT 6days after 131I-mIBG, EBRT alone, 131I-mIBG alone and control (untreated). A total of 56 mice were assigned to 3 studies. Study 1: Vessel permeability was evaluated using dynamic contrast-enhanced (DCE)-MRI (n=3). Study 2: Tumour uptake of 131I-mIBG in excised lesions was evaluated by γ-counting and autoradiography (n=28). Study 3: Tumour volume was assessed by longitudinal MR imaging and survival was analysed (n=25). Tumour dosimetry was performed using Monte Carlo simulations of absorbed fractions with the radiation transport code PENELOPE.

RESULTS

Given alone, both 131I-mIBG and EBRT resulted in a seven-day delay in tumour regrowth. Following EBRT, vessel permeability was evaluated by DCE-MRI and showed an increase at 24h post irradiation that correlated with an increase in 131I-mIBG tumour uptake, absorbed dose and overall survival in the case of combined treatment. Similarly, EBRT administered seven days after MRT to coincide with tumour regrowth, significantly decreased the tumour volume and increased overall survival.

CONCLUSIONS

This study demonstrates that combining EBRT and MRT has an enhanced therapeutic effect and emphasizes the importance of treatment scheduling according to pathophysiological criteria such as tumour vessel permeability and tumour growth kinetics.

Targeted radionuclide therapy in combined-modality regimens

Targeted radionuclide therapy (TRT) is a branch of cancer medicine concerned with the use of radioisotopes, radiolabelled molecules, nanoparticles, or microparticles that either naturally accumulate in or are designed to target tumours. TRT combines the specificity of molecular and sometimes physical targeting with the potent cytotoxicity of ionising radiation. Targeting vectors for TRT include antibodies, antibody fragments, proteins, peptides, and small molecules. The diversity of available carrier molecules, together with the large panel of suitable radioisotopes with unique physicochemical properties, allows vector-radionuclide pairings to be matched to the molecular, pathological, and physical characteristics of a tumour. Some pairings are designed for dual therapeutic and diagnostic applications. Use of TRT is increasing with the adoption into practice of radium-223 dichloride for the treatment of bone metastases and with the ongoing clinical development of, among others, 177Lu-dodecanetetraacetic acid tyrosine-3-octreotate (DOTATATE) for the treatment of neuroendocrine tumours and 90Y-microspheres for the treatment of hepatic tumours. The increasing use of TRT raises the question of how best to integrate TRT into multimodality protocols. Achievements in this area and the future prospects of TRT are evaluated in this Review.

Improving external beam radiotherapy by combination with internal irradiation

The efficacy of external beam radiotherapy (EBRT) is dose dependent, but the dose that can be applied to solid tumour lesions is limited by the sensitivity of the surrounding tissue. The combination of EBRT with systemically applied radioimmunotherapy (RIT) is a promising approach to increase efficacy of radiotherapy. Toxicities of both treatment modalities of this combination of internal and external radiotherapy (CIERT) are not additive, as different organs at risk are in target. However, advantages of both single treatments are combined, for example, precise high dose delivery to the bulk tumour via standard EBRT, which can be increased by addition of RIT, and potential targeting of micrometastases by RIT. Eventually, theragnostic radionuclide pairs can be used to predict uptake of the radiotherapeutic drug prior to and during therapy and find individual patients who may benefit from this treatment. This review aims to highlight the outcome of pre-clinical studies on CIERT and resultant questions for translation into the clinic. Few clinical data are available until now and reasons as well as challenges for clinical implementation are discussed.

Radionuclide therapy via SSTR: future aspects from experimental animal studies

There is need for better therapeutic options for neuroendocrine tumours. The aim of this review was to summarize results of experimental animal studies and raise ideas for future radionuclide therapy based on high expression of somatostatin (SS) receptors by many neuroendocrine tumours. In summary, one of the major options is individualized treatment for each patient, including choice of SS analogues, radionuclides and treatment schedules. Other options are methods to increase the treatment effect on tumour tissue (increasing tumour uptake and retention by upregulation of receptor expression and avoiding saturation of receptor binding), methods to increase the tumour tissue response (by choice of radionuclides, SS analogues or combined therapies), and methods to reduce side effects (diminished uptake and retention in critical organs and reduced normal tissue response). Furthermore, combination therapy with other radiopharmaceuticals, cytotoxic drugs or radiosensitizers can be considered to enhance the effects of radiolabelled SS analogues.

Irradiation-dependent effects on tumor perfusion and endogenous and exogenous hypoxia markers in an A549 xenograft model

PURPOSE

Hypoxia is a major determinant of tumor radiosensitivity, and microenvironmental changes in response to ionizing radiation (IR) are often heterogenous. We analyzed IR-dependent changes in hypoxia and perfusion in A549 human lung adenocarcinoma xenografts.

MATERIALS AND METHODS

Immunohistological analysis of two exogenously added chemical hypoxic markers, pimonidazole and CCI-103F, and of the endogenous marker Glut-1 was performed time dependently after IR. Tumor vessels and apoptosis were analyzed using CD31 and caspase-3 antibodies. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and fluorescent beads (Hoechst 33342) were used to monitor vascular perfusion.

RESULTS

CCI-103F signals measuring the fraction of hypoxic areas after IR were significantly decreased by approximately 50% when compared with pimonidazole signals, representing the fraction of hypoxic areas from the same tumors before IR. Interestingly, Glut-1 signals were significantly decreased at early time point (6.5 h) after IR returning to the initial levels at 30.5 h. Vascular density showed no difference between irradiated and control groups, whereas apoptosis was significantly induced at 10.5 h post-IR. DCE-MRI indicated increased perfusion 1 h post-IR.

CONCLUSIONS

The discrepancy between the hypoxic fractions of CCI-103F and Glut-1 forces us to consider the possibility that both markers reflect different metabolic alterations of tumor microenvironment. The reliability of endogenous markers such as Glut-1 to measure reoxygenation in irradiated tumors needs further consideration. Monitoring tumor microvascular response to IR by DCE-MRI and measuring tumor volume alterations should be encouraged.

Enhanced tumour uptake of radiolabelled antibodies by hyperthermia: Part I: Timing of injection relative to hyperthermia

Improving drug and macromolecular delivery of anti-cancer agents to tumours results in greater efficacy without increased toxicity. The current study was undertaken to assess the effects of the timing of injection of tumour specific and non-specific monoclonal antibodies (mAbs) relative to a hyperthermia treatment on tumour and normal tissue uptake. Using a local hyperthermia protocol of 45 min at 43 degrees C, uptake in tumour and normal tissues was measured at 1, 4, 12, 24, 48 and 72 h after injection. An anti-tenascin chimeric mAb, ch81C6, served as the specific mAb in a D-54 MG glioma xenograft mouse model. The chimeric mAb chTPS3.2 served as the control. A five-to-eight-fold increase in uptake of the tumour-targeted mAb was achieved in the heated tumours when compared with the non-heated tumours at 1 h. Differences in absolute tumour uptake of the specific mAb between the mice injected prior to hyperthermia and mice injected post-hyperthermia were seen only at 1 and 12 h. The median uptakes in the tumours of mice injected pre-heat were 25%ID/g at 1 h and 43.5%ID/g at 12 h, while in the animals injected post-hyperthermia the median uptakes were 45.5%ID/g and 80.2%ID/g, respectively. Blood levels of both the specific and non-specific mAbs were consistently higher over the initial 12 h period in the mice injected post-hyperthermia. Normal tissue uptake was also increased at most time points in the mice injected post-hyperthermia. The clinical importance of the differences in specific mAb uptake in tumour detected statistically at 1 and 12 h is questionable, given the highly variable nature of mAb uptake in vivo. Tumour targeting mAbs administered in combination with heat may be injected either prior to or immediately following hyperthermia treatment, with the expectation that levels of uptake in tumour will be relatively equivalent. Absolute normal tissue levels will be higher in patients receiving the mAb post-hyperthermia.

Enhanced tumour uptake of radiolabelled antibodies by hyperthermia. Part II: Application of the thermal equivalency equation

Clinical application of local hyperthermia as a means for modulating drug and macro-molecular tumour uptake have been slow to develop, due in part to the difficulty in designing and comparing heating protocols. The thermal isodose formula developed by Sapareto and Dewey is used in cytotoxicity and radiosensitization hyperthermia protocols to compare different time/temperature combinations; however, its relevance to other end-points has not been evaluated. The current study was undertaken to determine whether heating protocols of different time and temperature, but predicted to be thermally equivalent by this formula, had similar effects on the tumour and normal tissue distribution of radiolabelled tumour-specific (anti-tenascin 81C6) and non-specific (anti-dansyl TPS3.2) monoclonal antibodies (mAbs). Two thermally equivalent heating protocols, 4 h at 41.8 degrees C and 45 min at 43 degrees C, were compared in mice with subcutaneous D54 MG human glioma xenografts. A 4-fold increase in xenograft localization of 81C6 mAb was achieved relative to that in non-heated control groups with both heating protocols. Both hyperthermia protocols also resulted in improved tumour:normal tissue ratios. However, differences in absolute tumour and normal tissue uptake were seen, suggesting that the thermal isodose formula has limited usefulness in the design and comparison of hyperthermia protocols for enhancing the tumour uptake of radiolabelled mAbs.

Systemic targeted radionuclide therapy: potential new areas

Radiation oncology is entering an exciting new era with therapies being delivered in a targeted fashion through an increasing number of novel approaches. External beam radiotherapy now integrates functional and anatomic tumor imaging to guide delivery of conformal radiation to the tumor target. Systemic targeted radionuclide therapy (STaRT) adds an important new dimension by making available to the radiation oncologist biologically targeted radiation therapy. Impressive clinical results with antibody-targeted radiotherapy, leading to the Food and Drug Administration's approval of two anti-CD20 radiolabeled antibodies, highlight the potential of STaRT. Optimization strategies will further improve the efficacy of STaRT by improving delivery systems, modifying the tumor microenvironment to increase targeted dose, and maximizing dose effect. Ultimately, the greatest potential for STaRT will not be as monotherapy, but as therapy integrated into established multimodality regimens and used as adjuvant or consolidative therapy in patients with minimal or micrometastatic disease.

Application of a macromolecular contrast agent for detection of alterations of tumor vessel permeability induced by radiation

Permeability of tumor vasculature can be a major barrier to successful drug delivery, particularly for high molecular weight agents such as monoclonal antibodies and their diagnostic or therapeutic conjugates. In this study, changes in permeability of SCCVII tumor vessels after radiation treatment were evaluated by dynamic magnetic resonance imaging as a function of time after irradiation using a generation-8 polyamidoamine dendrimer (G8-Gd-D)-based magnetic resonance imaging contrast agent shown previously to be confined to tumor blood vessels. Tumor irradiation consisted of either single doses (2-15 Gy) or various daily fractionated doses (5 days). A single radiation dose of 15 Gy resulted in significant transient image enhancement of the tumor tissue with a maximum occurring between 7 and 24 hours after radiation treatment. No observable enhancement was recorded for fractionated radiation doses. Use of dynamic magnetic resonance imaging coupled with G8-Gd-D provides an exquisite methodology capable of defining the timing of enhanced permeability of macromolecules in tumors after irradiation. Such information might be applied to optimize the efficacy of subsequent or concurrent therapies including radiolabeled antibodies or other anticancer agents in combination with external beam therapies.

The effect of irradiation on the biodistribution of radiolabeled pegylated liposomes

PURPOSE

The effect of total-body irradiation (TBI) on the biodistribution and pharmacokinetics of (111)In-DTPA-labeled pegylated liposomes (IDLPL) was evaluated in tumor-bearing nude mice as part of an ongoing effort to develop liposome-targeted radiosensitizers.

METHODS AND MATERIALS

Mice received TBI (2 Gy or 5 Gy) according to two protocols: (1) to test the effect of radiation delivered 30 min before liposome injection on the time course of IDLPL biodistribution to tumor and normal tissues over 96 h; (2) to test the effect of radiation at times ranging from 72 h to 1 h before liposome injection on tumor and normal tissue uptake of IDLPL at 24 h. Tumor and tissue/organ levels of liposome uptake were measured by dissection and quantitation in a gamma counter.

RESULTS

For most tissues (tumor, liver, kidney, lung, skin, heart, and central nervous system), irradiation did not alter IDLPL biodistribution. Splenic uptake appeared to be increased by TBI, but further analysis revealed that this effect was due to reduced splenic weight in irradiated mice. IDLPL uptake was increased in the small intestine, stomach, musculoskeletal system, female reproductive tract, and adrenal glands in irradiated mice.

CONCLUSION

These findings suggest that concomitant administration of liposomal radiosensitizers during radical radiotherapy is likely to be safe. However, caution should be exercised in situations in which significant volumes of small intestine or hemopoietic tissue will be irradiated.

Status of radioimmunotherapy in the new millennium

This synopsis attempts to summarize progress made in radioimmunotherapy (RIT) by the end of the 20th century addressing the problems, possible solutions, and recent developments. The reduction of minimal residual disease in an adjuvant setting appears to be a feasible goal for RIT utilizing short-range alpha-emitters. RIT has been more successful in the radiosensitive hematologic malignancies, for example lymphomas and leukemias as compared with small solid tumors. Several radiopharmaceuticals seem near approval for RIT in patients with non-Hodgkin's lymphoma (NHL) as therapeutic responses, including complete responses, are common. Obstacles to successful RIT have been recognized and strategies to overcome these hurdles and to improve efficacy are continuously being developed resulting in encouraging outcome particularly with locoregional routes of administration in solid tumors. Systemic RIT for solid tumors will need manipulating the tumor-host to improve the tumor uptake and retention of radioimmunoconjugates (RICs). The utilization of radiometals, stable chelators, biodegradable linkers and bone marrow transplantation should be able to deliver the radiation dose required for successful treatment. In conjunction with additional synergistic agents, RIT is likely to have a great impact on the treatment of solid tumors. The ability to generate new constructs, such as bivalent antibodies or fusion proteins incorporating two different functional proteins opens exciting opportunities for new therapeutic modalities. These developments will hopefully offset the impediments to the successful use of RIT.

Single-fraction irradiation has no effect on uptake of radiolabeled pegylated liposomes in a tumor xenograft model

PURPOSE

These studies were performed with the intention of examining the effect of single-fraction doses of radiotherapy (RT) on the tumor deposition of radiolabeled pegylated liposomes in an animal xenograft tumor model.

METHODS AND MATERIALS

Human KB head-and-neck xenograft tumors were established in female nude mice. The effect of single fraction tumor RT doses (5, 10, 15, and 20 Gy) on the tumor uptake of intravenously administered (111)In-DTPA-labeled pegylated liposomes (IDLPL) was examined using two protocols: (1) to test the effect of RT delivered 30 min before liposome injection on the time course of tumor uptake over a 96-h period; (2) to test the effect of RT at times ranging from 72-h to 1-h before liposome injection on the levels of liposome uptake at 24 h. Tumor and normal tissue/organ (blood, liver, spleen, lung, and kidney) liposome uptake was determined by dissection and quantitation in a gamma counter.

RESULTS

There was no demonstrable effect of RT on tumor uptake of IDLPL (p > 0.1 for all comparisons). Reassuringly, neither was there an effect of RT on the pharmacokinetics and biodistribution of radiolabeled liposomes to normal tissues.

CONCLUSIONS

Single fraction doses of RT appear to have no effect on tumor or normal tissue biodistribution and pharmacokinetics of radiolabeled pegylated liposomes in this animal model.

Pharmacological aspects of targeting cancer gene therapy to endothelial cells

Targeting cancer gene therapy to endothelial cells seems to be a rational approach, because (a) a clear correlation exists between proliferation of tumor vessels and tumor growth and malignancy, (b) differences of cell membrane structures between tumor endothelial cells and normal endothelial cells exist which could be used for targeting of vectors and (c) tumor endothelial cells are accessible to vector vehicles in spite of the peculiarities of the transvascular and interstitial blood flow in tumors. Based on the knowledge on the pharmacokinetics of macromolecules it can be concluded that vectors targeting tumor endothelial cells should own a long blood residence time after intravascular application. This precondition seems to be fulfilled best by vectors exhibiting a slight anionic charge. A long blood residence time would allow the formation of a high amount of complexes between tumor endothelial cells and vector particles. Such high amount of complexes should enable a high transfection rate of tumor endothelial cells. In view of their pharmacokinetic behavior nonviral vectors seem to be more suitable for in vivo targeting tumor endothelial cells than viral vectors. Specific binding of nonviral vectors to tumor endothelial cells should be enhanced by multifunctional ligands and the transduction efficiency should be improved by cationic carriers. Effector genes should encode proteins potent enough to induce reactions which eliminate the tumor tissue. To be effective to that degree such proteins should induce self-amplifying antitumor reactions. Examples for proteins which have the potential to induce such self-amplifying tumor reactions are proteins endowed with antiangiogenic and antiproliferative activity, enzymes which convert prodrugs into drugs and possibly also proteins which induce embolization of tumor vessels. The pharmacological data for such examples are discussed in detail.

Transduction of hepatocellular carcinoma (HCC) using recombinant adeno-associated virus (rAAV): in vitro and in vivo effects of genotoxic agents

BACKGROUND/AIMS

Adeno-associated virus (AAV) is an attractive tool for gene therapy. Here we investigated the in vitro and in vivo transduction of hepatocellular carcinoma (HCC) cells by an AAV vector and the efficacy of different strategies to enhance the transduction of the tumor.

METHODS

Transduction efficiency was determined by analyzing AAV-mediated beta-galactosidase gene (rAAV/lacZ) expression.

RESULTS

Adenovirus help or pretreatment of HCC cells with y-irradiation or with the topoisomerase inhibitor etoposide resulted in marked enhancement of cell transduction in vitro. In vivo studies in nude mice with subcutaneous HCC tumors showed that HCC cells were not transduced by AAV vector alone. However, co-infection of the tumor with adenovirus allowed an efficient expression of the reporter gene but only at the sites of vector injection. Previous gamma-irradiation of subcutaneous tumors with 1800 rad was able to improve transduction of HCC cells (up to 30%) using recombinant AAV. Continuous i.p. infusion of etoposide in buffalo rats harboring HCC tumors in the liver resulted in transduction of normal liver tissue and also of very small neoplastic lesions (<2 mm) but no transduction was observed in tumors bigger than 2 mm. To analyze this phenomenon we determined etoposide concentration in hepatic tissue. Our results revealed high concentrations of the drug in non-tumoral tissue but almost undetectable levels in big tumor nodules.

CONCLUSIONS

Our results indicate that while both radiotherapy and etoposide enhance transduction of tumor cells by rAAV in vitro, only radiotherapy increases tumor transduction in vivo. Our data suggest the existence of a barrier which limits in vivo the diffusion of chemotherapeutic agents to well-established HCC nodules.

Clinical radioimmunotherapy

Radioimmunotherapy (RIT) is a promising new therapy for the treatment of a variety of malignancies. General principles of RIT are discussed, including important considerations in the selection of monoclonal antibodies (MAb) and radionuclides for RIT. Results of clinical trials using RIT for the treatment of lymphoma, leukemia, and solid tumors are summarized. The results from many of these trials are promising, especially for the treatment of lymphohematopoietic malignancies, in which a variety of MAb, radionuclides, and study designs have resulted in high response rates with a number of durable responses. Encouraging results have also been obtained using RIT to treat some solid tumors, primarily in patients with relatively low tumor burdens. RIT is generally well tolerated, with the primary toxicity being transient reversible myelosuppression in most nonmyeloablative studies. Nonhematologic toxicity, especially at nonmyeloablative doses, has been minimal in most studies. Approaches for increasing the therapeutic index of RIT are reviewed, which may further potentiate the efficacy and decrease the toxicity of RIT.

Combination vascular targeted and tumor targeted radioimmunotherapy

Rat MAb 201B, which binds to murine thrombomodulin, can deliver up to 50% of the injected dose of attached radioisotopes to the lung vascular endothelium. We have shown previously that intravenous injection of about 30 microCi of 213Bi-MAb 201B, which delivers about 15 Gy of alpha irradiation to the lung, is capable of eradicating small lung colonies (500-1000 cells) of the mammary tumor line, EMT-6. Larger tumors (> 5000 cells) were not completely cured by this vascular targeted radioimmunotherapy (VT-RAIT) approach. We reasoned that VT-RAIT might make the lung vessels serving the tumor cells more permeable, allowing MAb targeted to the tumor cells to extravasate more readily and mediate more efficient standard radioimmunotherapy (RAIT). Distribution experiments with the tumor targeted MAb 13A (RAIT MAb), following VT-RAIT, did not demonstrate a large increase in tumor uptake; however, microautoradiography did indicate that MAb 13A was distributed more evenly throughout the tumor when administered after VT-RAIT. Therapy experiments on lung tumors of approximately 5000 cells each, combining 213Bi-MAb 201B (VT-RAIT) with 213Bi-MAb 13A (RAIT) 24 hours later, resulted in a better outcome (3 cured/10 at risk) than for control groups: RAIT only (0/10), VT-RAIT only (1/10), or no therapy (0/10). RAIT therapy delivered 48 hours after VT-RAIT had no apparent benefit. 213Bi-MAb 201B VT-RAIT followed by 90Y-MAb 13A Fab' RAIT showed only a slight improvement in tumor cures (2/10) over that in control groups: (0/9), (0/10), (0/10), respectively. These results suggest that optimal timing, dosage, and choice of MAb for RAIT should enhance the double MAb therapy approach significantly.

In vivo modulators of antibody kinetics

The aim of the present study was to summarize the effect of in vivo modulation of antibody kinetics and to present new data on the in vivo effect of the cell membrane active detergent Tween 80 and the cytokine interleukin-2 (IL-2) on the accumulation and clearance of a radioactive antibody. Mice bearing Lewis lung carcinoma xenografts and rats bearing DMBA-induced mammary carcinomas were studied after injecting I-125 labeled IgG1 monoclonal antibody (3c4c7g6) raised against a tyrosine kinase receptor protein Tie. Expression of Tie is known to be abundant in vascular endothelia and possibly related to malignant angiogenesis. Tween 80 was administered intratumorally (0.04% of tumor volume), whereas IL-2 was administered intraperitoneally. In the Lewis lung tumor model, the absolute tumor uptake varied between 2 and 5% ID/g, and maximum uptake was achieved after 24 h with Tween, and after 48 h without Tween. Tween manipulation did not increase the uptake in any normal organ, but it enhanced antibody clearance from the blood. In the DMBA rat model, IL-2 had no effect on blood clearance, but enhanced the uptake of Tie antibody into the tumor from 2.5-0.9 to 4.5-0.4% ID/g at 48 h. These data indicate that antibody biodistribution and pharmacokinetics can be modulated by a surface detergent and a cytokine, giving decreased exposure to critical organs, and increased uptake into the tumor. This type of manipulation provides an opportunity to optimize radioimmunotherapy.

Pharmacokinetics of regional angiotensin-II: a novel biologic response modifier

BACKGROUND

The splanchnic vasoconstrictor angiotensin-II (A-II) has been shown to redistribute blood flow to hepatoma during systemic infusions. The hepatoma tumor derives all blood flow from the hepatic artery, whereas the normal liver has a dual blood supply from both the portal vein and the hepatic artery. We hypothesized that the pharmacokinetics of regional intrahepatic arterial A-II infusion could favorably distribute blood flow to the tumor while preserving portal flow to normal liver.

METHODS

ACI rats had 10(6) cultured H4IIE cells inoculated into the liver 10-14 days before study. Both systemic and splanchnic hemodynamics were measured by the radio-labeled microsphere technique during intrahepatic arterial or intravenous infusion of angiotensin-II or normal saline. The tumor-to-normal liver hepatic artery blood flow ratio was calculated.

RESULTS

Regional A-II produced a proportionately less systemic effect than did intravenous infusion. The tumor vasoconstrictive response to A-II was minimal, and the tumor-to-normal blood flow ratio was greater with intrahepatic arterial or intravenous A-II infusion than with normal saline. Cardiac output and portal vein flow were decreased dramatically during intravenous, but not during intrahepatic, arterial A-II.

CONCLUSION

Intrahepatic arterial A-II exhibits saturation kinetics with a system effect observed only after hepatic receptor saturation. Furthermore, the pharmacokinetics of intrahepatic arterial versus intravenous A-II indicate that intrahepatic arterial A-II will preferentially redistribute arterial blood flow to the tumor while synchronously preserving portal blood flow to the normal liver.

Effect of increasing vascular hydraulic conductivity on delivery of macromolecular drugs to tumor cells

PURPOSE

To examine the assumption that increasing the hydraulic conductivity Lp of microvessels (by such strategies as radiation, hyperthermia, or inducing inflammation) improves the transport of macromolecular drugs to tumors.

METHODS AND MATERIALS

A theoretical model is used to investigate the effect of varying Lp on macromolecular transport in spherical tumor nodules. The model is generalized to nonspherical tumors. The equations governing fluid flow in the tumors are solved numerically to obtain the pressure in the interior, and macromolecule fluxes are deduced using Starling's equation.

RESULTS

Because of the interaction of two opposing effects, the filtration rate at the tumor center is maximized at an "optimum" value of Lp, which depends strongly on tumor size. Only for tumor nodules smaller than about 0.2 cm across is this value lower than the actual estimated value. By considering spheroidal tumor nodules, it is found that dependence on shape is much weaker than dependence on size, except for extremely elongated or flattened shapes.

CONCLUSIONS

While total fluid filtration for the entire tumor region always increases with increasing Lp, the local filtration rate at points inside the tumor decreases if the tumor is larger than about 0.2 cm, leading to a less uniform distribution of the drug, and therapeutic disadvantage. Increased vessel leakiness is an unlikely explanation for reported experimental findings that hyperthermia and inflammation result in more uniform distributions of monoclonal antibodies throughout tumors much larger than 0.2 cm.

Vascular targeting--a new approach to the therapy of solid tumors

An attractive approach to the therapy of solid tumors is to attack the endothelial cells of the tumor vascular bed rather than the tumor cells themselves, which circumvents the problem of poor penetration of tumor masses by monoclonal antibodies and other macromolecules. In this review, we will discuss the drawbacks of targeting solid tumors and the advantages of the 'vascular targeting' approach, describe the validation of the concept in a mouse model and summarize the properties of tumor endothelial cell markers, which are candidates for vascular targeting in humans.

Radio-immunotherapy dosimetry with special emphasis on SPECT quantification and extracorporeal immuno-adsorption

Results from therapeutic trials with radiolabelled monoclonal antibodies are difficult to compare, because of lack of accurate macroscopic and microscopic dosimetry for both tumours and normal tissues. Requirements for such a dosimetry are covered in the paper. Accurate in vivo dosimetric measurement techniques for verification of calculated absorbed doses are also needed to verify treatment planning. In the review, important topics related to dosimetry in therapeutic trials in RIT are covered, such as, absorbed-dose calculations and activity-quantification techniques for planar imaging and SPECT. The latter is particularly discussed, including a summary of different correction techniques. Absorbed-dose calculations and treatment-planning techniques are also discussed. Possible ways of enhancing the therapeutic ratio are reviewed, especially the novel technique with extracorporeal immuno-adsorption. The review could form the basis of the development of future treatment-planning protocols and for dosimetry calculations in radio-immunotherapy, considering some of the most important parameters for approaching an accurate in vivo dosimetry.

A new method for determining dose rate distribution from radioimmuno-therapy using radiochromic media

PURPOSE

To describe and evaluate a new, simple, inexpensive method for directly measuring the radiation dose and its spatial distribution generated from explanted tissues of animals previously injected with radiolabeled immunoconjugates or other agents.

METHODS AND MATERIALS

This technique uses the newly developed radiochromic dye medium (Gafchromic) which responds reproducibly for therapeutic dose exposures, has high spatial resolution, does not require film processing, and is relatively insensitive to ambient light. We have evaluated the dose distribution from LS174T tumors and selected normal tissues in nude mice previously injected with 90Y labeled anti-carcinoembrionic antigen antibodies. Individual tissues from sacrificed animals are halved and the flat section of the tissue is placed onto the dosimetry media and then frozen. The dosimetry medium is exposed to beta and Bremsstrahlung radiation originating from the frozen tissues. The relative darkening of the dosimetry medium depends on the dose deposited in the film. The dosimetry medium is scanned with a commercial flatbed scanner and the image intensity is digitally stored and quantitatively analyzed. Isodose curves are generated and compared to the actual tissue outline.

RESULTS

The absorbed dose distribution due to 90Y exposure show only slight gradients in the interior of the tissue, with a markedly decreasing dose near the edges of the tissue. In addition, the isodose curves follow the tissue outline except in regions having radii of curvature smaller than the range of the beta-particle (R90 = 5 mm). These results suggest that the shape of the tumor, and its curvature, are important in determining the minimum dose delivered to the tumor by radiation from 90Y monoclonal antibodies, and hence in evaluating the tumor response to the radiation. The dose and spatial dose distribution were calculated assuming that the total 90Y activity is distributed uniformly throughout a half ellipsoid. The calculated spatial dose distributions for the half ellipsoids were similar to those observed from the dosimetry media that had been exposed to radioactivity contained in the tumors.

CONCLUSION

This method provides direct dose evaluation without elaborate summary calculations based on activity measurements from serial slices. The measured radiation dose actually indicates the dose rate at the time of animal sacrifice. Quantitative analysis of radiation emitted from the tissues is relatively fast, making it feasible to examine a number of tissues under a variety of conditions.

Intraportal injection of monoclonal antibody in nude mice bearing hepatic metastases

Using a model for hepatic human colorectal carcinoma metastases in athymic mice, we compared the selective [intraportal (ip)] and systemic [intravenous (iv)] injection of radiolabeled monoclonal antibody (mAb) strongly reactive against the cell line. Percent injected dose of radiolabeled antibody per gram (%id/g) of tumor or normal tissues was measured at selected time points (up to 5 days postinjection) within 3 dose levels: 0.1, 1.0, and 2.0 micrograms (micrograms). At each dose level, 3-9 animals were studied in each of 3 groups: animals receiving ip injection (group HT-29-15 ip), those receiving intravenous injection (group HT-29-15 iv), and those receiving isotype-matched control antibody via the intraportal route (group BL-3 ip). Significantly greater (P < 0.005) %id/g in tumor was seen in group HT-29-15 ip at all time points and dose levels compared to those in groups HT-29-15 iv or BL-3 ip. However, immediately after injection of mAb, there was no difference in tumor %id/g between groups HT-29-15 ip and HT-29-15 iv at the highest dose level. There was no increase in %id/g of mAb in normal liver and blood after ip injection compared to iv injection beyond day 1. Therefore ip injection resulted in higher tumor to liver and tumor to blood ratios compared to iv (P < 0.005). We conclude that delivery of mAb to hepatic metastases can be enhanced by selective injection; this has important implications in the design of future clinical trials utilizing radiolabeled mAb in the diagnosis and treatment of hepatic metastases.

Monoclonal antibodies in cancer detection and therapy

Anticancer antibodies have had a long history in the management of cancer, with major applications having been shown in the immunohistochemistry and immunoassay of tumor-associated antigen markers. With the advent of hybridoma-derived monoclonal antibodies, attempts to use these more reproducible reagents in vivo for cancer detection and therapy have intensified. Radiolabeled monoclonal antibodies appear to be gaining a role in the management of cancer by means of imaging methods to detect sites of increased radioactivity, and several products have been developed and tested clinically. In the area of radioimmunotherapy, a number of problems still need to be solved, including low tumor uptake of the radioimmunoconjugate, dose-limiting myelotoxicity, and the induction of an immune response to repeated doses of murine (foreign) immunoglobulins. Similar problems exist for toxin and drug immunoconjugates, but these also fail to benefit from the "bystander" effect of the ionizing radiation delivered with radioimmunoconjugates, and plant and bacterial toxin molecules appear to have additional immunogenicity that restricts repeated injections. Despite these limitations, recombinant engineering and other chemical approaches are making progress in developing second-generation immunoconjugates that may be more efficacious and less immunogenic as cancer-selective therapeutics. Although nonconjugated, "naked", murine monoclonal antibodies have shown limited success in the therapy of human neoplasms, human and "humanized" forms may be more effective, particularly in lymphatic tumors. Some evidence also suggests that anti-idiotype antibodies (antiantibodies) may serve as surrogate antigens in cancer vaccines. Thus, a number of promising immunologic approaches for cancer diagnosis, detection, and therapy have made important progress in recent years.

Radioimmunodetection of lung cancer with IMACIS-1, I-131 labeled monoclonal antibodies to CEA and CA19-9. Comparison of accumulations in irradiated and non-irradiated site

IMACIS-1 is a radiopharmaceutical containing a mixture of Iodine-131 labeled monoclonal antibodies to CEA and CA19-9. IMACIS-1 immunoscintigraphy was evaluated for tumor detection in 7 primary lung cancer and 2 metastatic lung cancer patients who received radiotherapy. No adverse side effects due to IMACIS-1 were observed in this study. Positive detection was achieved in 5 of 9 patients (55.6%). It was less, but nearly the same as the detection rate obtained with Gallium-67 citrate (67Ga-citrate) in these patients. There was no clear correlation between IMACIS-1 accumulation and the CEA or CA19-9 serum levels. The IMACIS-1 positive detection rate decreased in many of the irradiated lesions. We considered that the decreased number of tumor cells and changes in blood perfusion are some of the factors controlling accumulation in tumors.

Radioimmunolocalization of hepatic metastases and subcutaneous xenografts from a human colonic cancer in the nude rat. Aspects of tumour implantation site and mode of antibody administration

Antibody localization was analyzed following intraperitoneal (i.p.) or intravenous (i.v.) injection of the 125I-labelled anti-CEA-MAb I-38S1 in 44 nude rats, in order to evaluate the influence of tumour implantation site and the route of MAb administration. The animals were xenografted with a human colonic cancer (LS 174 T), either in the form of hepatic metastases, subcutaneous (s.c.) tumours or both. Tissue measurements, 4 days after MAb injection, showed better uptake for hepatic than for s.c. tumours, irrespective of the route of antibody administration. Antibody accumulation per g liver metastases was not size dependent for noduli weighing between 4 and 1,110 mg. MAb excretion evaluated in 20 animals and blood activity studied in 11 rats were equivalent 24-96 h following i.p. and i.v. injection. Dissimilar autoradiographic patterns were seen in hepatic metastases with predominantly peripherally located clusters following i.p. and more homogeneously distributed grains after i.v. MAb administration. The results indicate that tumour implantation site has a quantitative, and the route of administration at least a qualitative impact on the tumour accretion of anti-CEA MAb I-38S1 in the present xenograft model.

A reproducible rat liver cancer model for experimental therapy: introducing a technique of intrahepatic tumor implantation

To investigate therapeutic strategies for hepatoma, it is necessary to have a reproducible animal model with a tumor growth pattern allowing accurate assessment of results. Many techniques of intrahepatic tumor implantation (IHTI) have been devised for intrahepatic tumor models. Most of them, however, have the disadvantage of high rates of artificial tumor dissemination during tumor implantation, which interferes with the evaluation of therapy. To overcome this problem, we have developed a technique of IHTI in which a piece of Gelfoam is placed into a small incision in the liver for the purpose of both hemostasis and formation of a tension-free pocket to accept the tumor implant. In 583 ACI rats receiving IHTI with Morris hepatoma 3924A, the tumor take rate was 100%. Resembling the natural course of human hepatoma, the implanted tumor grows locally early in the course of disease and eventually invades the surrounding organs causing ascites and also metastasizes to the lung. Liver microangiography demonstrated that the tumor received blood supply mainly from the hepatic artery. This IHTI technique was also compared to two other methods of IHTI: insertion of fragments without using Gelfoam and implantation with a tumor cell suspension. A significantly lower rate of early lung metastases was achieved with our technique (0%) in comparison with other two techniques (41 and 80%). We conclude that this rat liver cancer model is reproducible and allows efficient evaluation of treatment modalities for liver cancer without interference from tumor at undesirable sites.

Radio-immunotargeting in experimental animal models of intraperitoneal cancer

The field of immunotargeting, and the challenges met when this technique is applied in experimental animals or in patients, are reviewed. Even with highly specific monoclonal antibodies, non-specific uptake in normal tissues and high background level of unbound radioactivity in blood and extravascular body fluids remain significant problems. Further experimental work in animal model systems is needed to bring this technique from the state of being an experimental method, with limited clinical application, to a routine diagnostic or therapeutic method. Different animal models are available, and their potential for elucidation of the various methodological problems in radio-immunotargeting are discussed in the present paper. In our laboratory, two intraperitoneal models were devised, having relevance for gynecologic and other forms of intraperitoneal malignancies. These models were elaborated with special emphasis on the possibility for exact measurement of important parameters in immunotargeting reactions. In the first model, hybridoma cells are inoculated intraperitoneally to mimic intraperitoneal carcinomatosis, and the monoclonal antibody produced by the hybridoma is used as serum tumor marker. In the second model the tumor cells are contained within intraperitoneally implanted micropore chambers, resembling a localized tumor. An artificial tumor like this allows control with the antigen load in the target, and measurement of the concentration of the injected antibody in the fluid within the target.

Haemodynamic and transport barriers to the treatment of solid tumours

The efficacy in cancer treatment of novel therapeutic agents such as monoclonal antibodies, cytokines and effector cells has been limited by their inability to reach their target in vivo in adequate quantities. Molecular and cellular biology of neoplastic cells alone has failed to explain the nonuniform uptake of these agents. This is not surprising since a solid tumour in vivo is not just a collection of cancer cells. In fact, it consists of two extracellular compartments: vascular and interstitial. Since no blood-borne molecule or cell can reach cancer cells without passing through these compartments, the vascular and interstitial physiology of tumours has received considerable attention in recent years. Three physiological factors responsible for the poor localization of macromolecules in tumours have been identified: (i) heterogeneous blood supply, (ii) elevated interstitial pressure, and (iii) large transport distances in the interstitium. The first factor limits the delivery of blood-borne agents to well-perfused regions of a tumour; the second factor reduces extravasation of fluid and macromolecules in the high interstitial pressure regions and also leads to an experimentally verifiable, radially outward convection in the tumour periphery which opposes the inward diffusion; and the third factor increases the time required for slowly moving macromolecules to reach distal regions of a tumour. Binding of the molecule to an antigen further lowers the effective diffusion rate by reducing the amount of mobile molecule. Although the effector cells are capable of active migration, peculiarities of the tumour vasculature and interstitium may also be responsible for poor delivery of lymphokine activated killer cells and tumour infiltrating lymphocytes in solid tumours. Due to micro- and macroscopic heterogeneities in tumours, the relative magnitude of each of these physiological barriers would vary from one location to another and from one day to the next in the same tumour, and from one tumour to another. If the genetically engineered macromolecules and effector cells, as well as low molecular weight cytotoxic agents, are to fulfill their clinical promise, strategies must be developed to overcome or exploit these barriers. Some of these strategies are discussed, and situations wherein these barriers may not be a problem are outlined. Finally, some therapies where the tumour vasculature of the interstitium may be a target are pointed out.

Effect of radiation on the expression of carcinoembryonic antigen of human gastric adenocarcinoma cells

The changes of antigenic expression of cultured human gastric adenocarcinoma MKN45 cells caused by irradiation were investigated to elucidate the immune responses to localized irradiation. The expression of carcinoembryonic antigen (CEA) showed remarkable increases in the culture supernatant and on the surface of the membrane of irradiated cells. The expression of major histocompatibility complex Class I antigen on the membrane also was enhanced by irradiation. In addition, the irradiated cell groups, when analyzed using a CEA-specific probe, showed remarkable increases in the CEA mRNA. These enhancements increased in the 10-Gy and 15-Gy irradiated populations compared with the 5-Gy irradiated population. These results suggest that the enhancement of expression of CEA by radiation takes place at the CEA gene expression (mRNA) level but not at the protein level.

Strategies for enhancement of radioimmunotherapy

Two new strategies for increasing tumor uptake have been investigated. First the effect of interleukin-2 (IL-2) on tumor uptake of 125I-Lym-1 antibody in nude mice was investigated. Secondly, the use of 67Cu-labeled Lym-1 was evaluated in patients. In nude mice implanted with Raji human lymphoma, a greater than 2-fold enhancement of tumor uptake of 125I-Lym-1 was observed after administration of PEG-interleukin-2 (PEG-IL-2). The macrocycle 1,4,8,11-tetraazacylcotetradecane-N,N',N",N"'-tetraacetic acid (TETA), synthesized specifically for copper chelation, has been conjugated to Lym-1 for 67Cu labeling of the monoclonal antibody (MoAb). There was no evidence for bone or normal marrow uptake and the residence time in the tumor was prolonged. Surprisingly, a dose of 4.4 mCi that was intended for imaging induced substantial tumor regression in a patient.

Suppression of tumor vascular activity by radioantibody therapy: implications for multiple cycle treatments

Autoradiographic analysis of the intratumor location of radioiodinated Mu-9 anti-CSAp antibody within 7 days of administration reveals a restricted distribution within 3-6 cell layers surrounding tumor vessels. Within 7-14 days after suboptimal radioantibody treatment (approximately 3000 rads), tumor vessel morphology and physiology are altered. Vessel number is reduced by 60-70%, vessel diameter is reduced, and remaining vessels are surrounded by fibrotic tissue. Vascular volume (VV) is reduced by 75%, blood flow rate (BF) is reduced 65%, and vascular permeability (VP) to an IgG is reduced by 60%. The change in VV is reversible by day 35 but BP and VP remain suppressed. Normal tissue (liver and lung) vasculature experience only small pertubations in physiology. These functional changes in tumor vessels reduce the magnitude of accretion of a second dose of radioantibody in tumor but not in normal tissue.

Vascular and interstitial barriers to delivery of therapeutic agents in tumors

The efficacy in cancer treatment of novel therapeutic agents such as monoclonal antibodies, cytokines and effector cells has been limited by their inability to reach their target in vivo in adequate quantities. Molecular and cellular biology of neoplastic cells alone has failed to explain the nonuniform uptake of these agents. This is not surprising since a solid tumor in vivo is not just a collection of cancer cells. In fact, it consists of two extracellular compartments: vascular and interstitial. Since no blood-borne molecule or cell can reach cancer cells without passing through these compartments, the vascular and interstitial physiology of tumors has received considerable attention in recent years. Three physiological factors responsible for the poor localization of macromolecules in tumors have been identified: (i) heterogeneous blood supply, (ii) elevated interstitial pressure, and (iii) large transport distances in the interstitium. The first factor limits the delivery of blood-borne agents to well-perfused regions of a tumor; the second factor reduces extravasation of fluid and macromolecules in the high interstitial pressure regions and also leads to an experimentally verifiable, radially outward convection in the tumor periphery which opposes the inward diffusion; and the third factor increases the time required for slowly moving macromolecules to reach distal regions of a tumor. Binding of the molecule to an antigen further lowers the effective diffusion rate by reducing the amount of mobile molecule. Although the effector cells are capable of active migration, peculiarities of the tumor vasculature and interstitium may be also responsible for poor delivery of lymphokine activated killer cells and tumor infiltrating lymphocytes in solid tumors. Due to micro- and macroscopic heterogeneities in tumors, the relative magnitude of each of these physiological barriers would vary from one location to another and from one day to the next in the same tumor, and from one tumor to another. If the genetically engineered macromolecules and effector cells, as well as low molecular weight cytotoxic agents, are to fulfill their clinical promise, strategies must be developed to overcome or exploit these barriers. Some of these strategies are discussed, and situations wherein these barriers may not be a problem are outlined. Finally, some therapies where the tumor vasculature or the interstitium may be a target are pointed out.

Systemic radiotherapy--the new frontier

The present day use of systemically administered isotopes and conjugated isotopic combinations are reviewed. Administration of 131Iodine in thyroid cancer led to a 97% local control and 50% complete remission of pulmonary metastases. Specificity directed isotopic therapy (metabolic, hormonal, and antibody) is discussed and includes factors such as tumor physiology and isotopic linkage. The clinical results and new knowledge being gained in Hodgkin's disease, non-Hodgkin's, colorectal, hepatoma, intrahepatic biliary and gliomatous cancers are reviewed. The dose response relationship to tumor remission is demonstrated in Hodgkin's treated with 131I antiferritin (40% partial remission) and more recently 90Yttrium antiferritin (50% complete response). Varied routes of administration, the problem of anti-antibody and bone marrow transplantation are discussed. Finally, the challenge to radiobiologists, physicists, chemists, immunologists, nuclear radiologists, and radiation oncologists is emphasized by definition of the new laboratory and clinical approaches being developed in systemic radiation therapy.

The theoretical implications and experimental and clinical results of radiolabeled antiferritin

Ferritin is produced in malignant and normal tissues. It acts both as an immunosuppressant and as an iron storage protein. As a tumor associated protein, it is related to virally induced tumors, and selective tumor targeting by radiolabeled antiferritin antibodies has led to its use in clinical trials. In patients with advanced Hodgkin's disease who have failed conventional therapy, 131I antiferritin produced partial remissions, while 90Y antiferritin led to complete remissions and a demonstrable dose-response relationship. Combining the variable low-dose radiation patterns produced by radiolabeled antibody therapy with chemotherapy in the treatment of hepatocellular cancer has led to enhanced tumor cytotoxicity and, in some cases, the conversion of non-resectable hepatoma to resectable. Further, the potential for clinical and laboratory investigation of radiolabeled antibody therapy is discussed in light of new findings.