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Alcorn S, Cortés ÁA, Bradfield L, Brennan M, Dennis K, Diaz DA, Doung YC, Elmore S, Hertan L, Johnstone C, Jones J, Larrier N, Lo SS, Nguyen QN, Tseng YD, Yerramilli D, Zaky S, Balboni T. External Beam Radiation Therapy for Palliation of Symptomatic Bone Metastases: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024; 14:377-397. [PMID: 38788923 DOI: 10.1016/j.prro.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024]
Abstract
PURPOSE This guideline provides evidence-based recommendations for palliative external beam radiation therapy (RT) in symptomatic bone metastases. METHODS The ASTRO convened a task force to address 5 key questions regarding palliative RT in symptomatic bone metastases. Based on a systematic review by the Agency for Health Research and Quality, recommendations using predefined consensus-building methodology were established; evidence quality and recommendation strength were also assessed. RESULTS For palliative RT for symptomatic bone metastases, RT is recommended for managing pain from bone metastases and spine metastases with or without spinal cord or cauda equina compression. Regarding other modalities with RT, for patients with spine metastases causing spinal cord or cauda equina compression, surgery and postoperative RT are conditionally recommended over RT alone. Furthermore, dexamethasone is recommended for spine metastases with spinal cord or cauda equina compression. Patients with nonspine bone metastases requiring surgery are recommended postoperative RT. Symptomatic bone metastases treated with conventional RT are recommended 800 cGy in 1 fraction (800 cGy/1 fx), 2000 cGy/5 fx, 2400 cGy/6 fx, or 3000 cGy/10 fx. Spinal cord or cauda equina compression in patients who are ineligible for surgery and receiving conventional RT are recommended 800 cGy/1 fx, 1600 cGy/2 fx, 2000 cGy/5 fx, or 3000 cGy/10 fx. Symptomatic bone metastases in selected patients with good performance status without surgery or neurologic symptoms/signs are conditionally recommended stereotactic body RT over conventional palliative RT. Spine bone metastases reirradiated with conventional RT are recommended 800 cGy/1 fx, 2000 cGy/5 fx, 2400 cGy/6 fx, or 2000 cGy/8 fx; nonspine bone metastases reirradiated with conventional RT are recommended 800 cGy/1 fx, 2000 cGy/5 fx, or 2400 cGy/6 fx. Determination of an optimal RT approach/regimen requires whole person assessment, including prognosis, previous RT dose if applicable, risks to normal tissues, quality of life, cost implications, and patient goals and values. Relatedly, for patient-centered optimization of treatment-related toxicities and quality of life, shared decision making is recommended. CONCLUSIONS Based on published data, the ASTRO task force's recommendations inform best clinical practices on palliative RT for symptomatic bone metastases.
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Affiliation(s)
- Sara Alcorn
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota.
| | - Ángel Artal Cortés
- Department of Medical Oncology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | | | - Kristopher Dennis
- Division of Radiation Oncology, Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Dayssy A Diaz
- Department of Radiation Oncology, Ohio State University, Columbus, Ohio
| | - Yee-Cheen Doung
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon
| | - Shekinah Elmore
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Lauren Hertan
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Candice Johnstone
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Joshua Jones
- Department of Radiation Oncology, Rochester Regional Health, Rochester, New York
| | - Nicole Larrier
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, University of Texas - MD Anderson Cancer Center, Houston, Texas
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Divya Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sandra Zaky
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Tracy Balboni
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
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Mahajan S, Gavane S, Pandit-Taskar N. Targeted Radiopharmaceutical Therapy for Bone Metastases. Semin Nucl Med 2024; 54:497-512. [PMID: 38937221 DOI: 10.1053/j.semnuclmed.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 05/22/2024] [Indexed: 06/29/2024]
Abstract
Radiopharmaceutical approaches for targeting bone metastasis have traditionally focused on palliation of pain. Several agents have been clinically used over the last several decades and have proven value in pain palliation providing pain relief and improving quality of life. The role is well established across several malignancies, most commonly used in osteoblastic prostate cancer patients. These agents have primarily based on targeting and uptake in bone matrix and have mostly included beta emitting isotopes. The advent alpha emitter and FDA approval of 223Ra-dichloride has created a paradigm shift in clinical approach from application for pain palliation to treatment of bone metastasis. The approval of 223Ra-dichloride given the survival benefit in metastatic prostate cancer patients, led to predominant use of this alpha emitter in prostate cancer patients. With rapid development of radiopharmaceutical therapies and approval of other targeted agents such as 177Lu-PSMA the approach to treatment of bone metastasis has further evolved and combination treatments have increasingly been applied. Novel approaches are needed to improve and expand the use of such therapies for treatment of bone metastasis. Combination therapies with different targeting mechanisms, combining chemotherapies and cocktail of alpha and beta emitters need further exploration.
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Affiliation(s)
- Sonia Mahajan
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Somali Gavane
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Neeta Pandit-Taskar
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY.
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Saganich C, Zgaljardic M. Radium-223 Dichloride in Peritoneal Dialysate Following Treatment of Metastatic Castration-resistant Prostate Cancer. HEALTH PHYSICS 2022; 122:433-439. [PMID: 34999662 DOI: 10.1097/hp.0000000000001518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
ABSTRACT Radium-223 dichloride was administrated to a patient with castration-resistant metastatic prostate cancer (mCRPC) undergoing in-home peritoneal dialysis. The peritoneal dialysate and tubing sets were collected following four treatment cycles and analyzed for removable contamination, dose rate, and radioactivity. The purpose of the study was to assess radiation safety concerns and compare data with patients having normal renal function. Sixty-two liters of dialysate in 22 samples were collected over 4 mo. The mean surface dose rate of the dialysate bags was 0.16 μSv h-1 (range 0.11-0.23 μSv h-1). The highest measured removable surface activity was 150 dpm per 100 cm2. The mean cumulative percent of administered activity was 1.7% (range 1.4-1.9%). The mean concentration of 223Ra in dialysate was 4.0 kBq L-1 (range 0.56-14.1 kBq L-1). There was no association between the measured 223Ra activity in dialysate with peritoneal dwell time or the number of exchanges following administration. The measurement of the 211Bi and 223Ra ratio in the dialysate compared with a standard showed an increase of 23% by 40 h post administration. The data presented suggest that 223Ra dialysate can be safely managed in the home without risk of radiation dose or contamination if minimal precautions are taken. Patients with normal renal function have been shown to excrete up to six times more 223Ra in urine compared to those undergoing hemodialysis or peritoneal dialysis. A potential consequence may be an increase in 223Ra activity transiting GI tract leading to intestinal effects.
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Affiliation(s)
- Christopher Saganich
- Medical Health Physics, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065
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Sarnelli A, Belli ML, Azzali I, Loi E, Severi S, Strigari L. Alpha-Emitter Radiopharmaceuticals and External Beam Radiotherapy: A Radiobiological Model for the Combined Treatment. Cancers (Basel) 2022; 14:cancers14041077. [PMID: 35205825 PMCID: PMC8870677 DOI: 10.3390/cancers14041077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 11/16/2022] Open
Abstract
Previously published studies combined external beam radiotherapy (EBRT) treatments with different activities of 223Ra. The data of two-year overall survival (2y-OS) and neutropenia (TOX) incidence when combining EBRT and 223Ra are not homogeneous in literature. We adapted the linear-quadratic model (LQ) to 223Ra therapy using brachytherapy formalism for a mixture of radionuclides, considering the contribution of all daughter isotopes in the decay chain. A virtual cohort of patients undergoing 223Ra therapy was derived using data from the literature. The doses delivered using 223Ra and EBRT were converted into biologically equivalent doses. Fixed-effect logistic regression models were derived for both the 2y-OS and TOX and compared with available literature. Based on the literature search, four studies were identified to have reported the 223Ra injection activity levels varying from the placebo (0) to 80 kBq/kg, associated or not with EBRT. Logistic regression models revealed a dose-dependent increase in both the 2y-OS (intercept = -1.364; slope = 0.006; p-value ≤ 0.05) and TOX (-5.035; 0.018; ≤0.05) using the EBRT schedule of 8 Gy in 1 fr. Similar results were obtained for other schedules. Discrepancies between our TOX model and those derived for EBRT combined with chemotherapy are discussed. Radiobiological models allow us to estimate dose-dependent relationships, to predict the OS and TOX following combined 223Ra + EBRT treatment, which will guide future treatment optimization.
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Affiliation(s)
- Anna Sarnelli
- Medical Physics Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, 47014 Meldola, Italy; (A.S.); (E.L.)
| | - Maria Luisa Belli
- Medical Physics Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, 47014 Meldola, Italy; (A.S.); (E.L.)
- Correspondence:
| | - Irene Azzali
- Biostatistics and Clinical Trials Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, 47014 Meldola, Italy;
| | - Emiliano Loi
- Medical Physics Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, 47014 Meldola, Italy; (A.S.); (E.L.)
| | - Stefano Severi
- Nuclear Medicine Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, 47014 Meldola, Italy;
| | - Lidia Strigari
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
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Hijab A, Curcean S, Tunariu N, Tovey H, Alonzi R, Staffurth J, Blackledge M, Padhani A, Tree A, Stidwill H, Finch J, Chatfield P, Perry S, Mu Koh D, Hall E, Parker C. Fracture Risk in Men with Metastatic Prostate Cancer Treated With Radium-223. Clin Genitourin Cancer 2021; 19:e299-e305. [PMID: 33958296 PMCID: PMC8514085 DOI: 10.1016/j.clgc.2021.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/17/2021] [Accepted: 03/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Radium-223 is a bone-seeking, alpha-emitting radionuclide used in metastatic castration-resistant prostate cancer (mCRPC). Radium-223 increases the risk of fracture when used in combination with abiraterone and prednisolone. The risk of fracture in men receiving radium-223 monotherapy is unclear. PATIENTS AND METHODS This was a prospective, multicenter phase II study of radium-223 in 36 men with mCRPC and a reference cohort (n = 36) matched for fracture risk and not treated with radium-223. Bone fractures were assessed using whole-body magnetic resonance imaging. The primary outcome was risk of new fractures. RESULTS Thirty-six patients were treated with up to six 4-week cycles of radium-223. With a median follow-up of 16.3 months, 74 new fractures were identified in 20 patients. Freedom from fracture was 56% (95% confidence interval, 35.3-71.6) at 12 months. On multivariate analysis, prior corticosteroid use was associated with risk of fracture. In the reference cohort (n = 36), 16 new fractures were identified in 12 patients over a median follow-up of 24 months. Across both cohorts, 67% of all fractures occurred at uninvolved bone. CONCLUSIONS Men with mCRPC, and particularly those treated with radium-223, are at risk of fracture. They should receive a bone health agent to reduce the risk of fragility fractures.
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Affiliation(s)
- Adham Hijab
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Nina Tunariu
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - Holly Tovey
- The Institute of Cancer Research, London, UK
| | | | | | | | - Anwar Padhani
- Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, Northwood, UK
| | - Alison Tree
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | | | | | - Dow Mu Koh
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - Emma Hall
- The Institute of Cancer Research, London, UK
| | - Chris Parker
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK.
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Benabdallah N, Scheve W, Dunn N, Silvestros D, Schelker P, Abou D, Jammalamadaka U, Laforest R, Li Z, Liu J, Ballard DH, Maughan NM, Gay H, Baumann BC, Hobbs RF, Rogers B, Iravani A, Jha AK, Dehdashti F, Thorek DLJ. Practical considerations for quantitative clinical SPECT/CT imaging of alpha particle emitting radioisotopes. Theranostics 2021; 11:9721-9737. [PMID: 34815780 PMCID: PMC8581409 DOI: 10.7150/thno.63860] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/15/2021] [Indexed: 02/05/2023] Open
Abstract
Rationale: Alpha particle emitting radiopharmaceuticals are generating considerable interest for the treatment of disseminated metastatic disease. Molecular imaging of the distribution of these agents is critical to safely and effectively maximize the clinical potential of this emerging drug class. The present studies aim to investigate the feasibility and limitations of quantitative SPECT for 223Ra, 225Ac and 227Th. Methods: Three state-of-the-art SPECT/CT systems were investigated: the GE Discovery NM/CT 670, the GE Optima NM/CT 640, and the Siemens Symbia T6. A series of phantoms, including the NEMA IEC Body phantom, were used to compare and calibrate each camera. Additionally, anthropomorphic physical tumor and vertebrae phantoms were developed and imaged to evaluate the quantitative imaging protocol. Results: This work describes and validates a methodology to calibrate each clinical system. The efficiency of each gamma camera was analyzed and compared. Using the calibration factors obtained with the NEMA phantom, we were able to quantify the activity in 3D-printed tissue phantoms with an error of 2.1%, 3.5% and 11.8% for 223Ra, 225Ac, and 227Th, respectively. Conclusion: The present study validates that quantitative SPECT/CT imaging of 223Ra, 225Ac, and 227Th is achievable but that careful considerations for camera configuration are required. These results will aid in future implementation of SPECT-based patient studies and will help to identify the limiting factors for accurate image-based quantification with alpha particle emitting radionuclides.
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Affiliation(s)
- Nadia Benabdallah
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
- Program in Quantitative Molecular Therapeutics, Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | | | - Diane Abou
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
- Program in Quantitative Molecular Therapeutics, Washington University School of Medicine, St. Louis, Missouri
| | - Uday Jammalamadaka
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Richard Laforest
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Zekun Li
- Department of Biomedical Engineering, Washington University, St. Louis, Missouri
| | - Jonathan Liu
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - David H. Ballard
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Nichole M. Maughan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Hiram Gay
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Brian C. Baumann
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Robert F. Hobbs
- Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Buck Rogers
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Amir Iravani
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Abhinav K. Jha
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
- Department of Biomedical Engineering, Washington University, St. Louis, Missouri
- Oncologic Imaging Program, Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Farrokh Dehdashti
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
- Oncologic Imaging Program, Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel L. J. Thorek
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
- Program in Quantitative Molecular Therapeutics, Washington University School of Medicine, St. Louis, Missouri
- Department of Biomedical Engineering, Washington University, St. Louis, Missouri
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- Oncologic Imaging Program, Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
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Anderson PM, Scott J, Parsai S, Zahler S, Worley S, Shrikanthan S, Subbiah V, Murphy E. 223-Radium for metastatic osteosarcoma: combination therapy with other agents and external beam radiotherapy. ESMO Open 2021; 5:S2059-7029(20)30059-4. [PMID: 32303572 PMCID: PMC7199915 DOI: 10.1136/esmoopen-2019-000635] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 12/31/2022] Open
Abstract
Background Bone-seeking radiopharmaceuticals can deposit radiation selectively to some osteosarcoma tumours because of the bone-forming nature of this cancer. Objectives This is the first report of using 223-radium, an alpha-emitting calcium analogue with a high therapeutic index, in combination therapy with other agents in 15 patients with metastatic osteoblastic osteosarcoma. Methods Candidates for alpha-radiotherapy if 99mTc-MDP bone scan had avid bone-forming lesions and no therapy of higher priority (eg, definitive surgery). Monthly 223-radium infusions (1.49 μCi/kg or 55.13 kBq/kg) were given. Results The median infusion number was three and the average time to progression was 4.3 months for this cohort receiving 223-radium+other agents. Agents provided during 223-radium included (1) drugs to reduce skeletal complications: monthly denosumab (n=13) or zolendronate (n=1); (2) agents with antivascular endothelial growth factor activity, pazopanib (n=8) or sorafenib (n=1), (3) alkylating agents: oral cyclophosphamide (n=1) or ifosfamide, given as a 14-day continuous infusion (n=1, two cycles), (4) high-dose methotrexate (n=1), pegylated liposomal doxorubicin (n=1); and (5) two other combinations: nivolumab and everolimus (n=1) and rapamycin and auranofin (n=1). Radiation therapy, including stereotactic body radiotherapy (SBRT), was also given to 11 patients concurrently with 223-radium (n=2), after 223-radium completion (n=3), or both concurrently and then sequentially for other sites (n=6). After 223-radium infusions, patients without RT had a median overall survival of 4.3 months compared with those with SBRT and/or RT, who had a median overall survival of 13.5 months. Conclusion Although only 1/15 of patients with osteoblastic osteosarcoma still remain alive after 223-radium, overall survival
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Affiliation(s)
- Pete M Anderson
- Pediatric Hematology/Oncology/BMT, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jacob Scott
- Radiation Oncology and Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shireen Parsai
- Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stacey Zahler
- Pediatric Hematology/Oncology and BMT, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sarah Worley
- Quantative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Erin Murphy
- Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
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Klain M, Gaudieri V, Petretta M, Zampella E, Storto G, Nappi C, Buonerba C, Crocetto F, Gallicchio R, Volpe F, Pace L, Schlumberger M, Cuocolo A. Combined bone scintigraphy and fluorocholine PET/computed tomography predicts response to radium-223 therapy in patients with prostate cancer. Future Sci OA 2021; 7:FSO719. [PMID: 34295537 PMCID: PMC8288237 DOI: 10.2144/fsoa-2021-0053] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/07/2021] [Indexed: 11/23/2022] Open
Abstract
Aim To assess the value of bone scintigraphy and 18F-fluorocholine PET/computed tomography (CT) in predicting outcome in patients with prostate cancer and bone metastases treated with 223radium. Materials & methods Retrospective analysis of 48 patients that underwent 223radium therapy. End points were pain relief and overall survival. Results After therapy, pain relief was observed in 27 patients. Patients without pain relief had more bone lesions at PET/CT than at bone scintigraphy (pretherapy imaging mismatch). In 39 patients who completed treatment protocol, post-therapy alkaline phosphatase and pretherapy imaging mismatch were independent predictors of poor overall survival. Conclusion Patients with more lesions at 18F-fluorocholine PET/CT than at bone scintigraphy had a poor prognosis. The combined imaging approach could be useful to predict outcome after 223radium therapy.
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Affiliation(s)
- Michele Klain
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Valeria Gaudieri
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | - Emilia Zampella
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Giovanni Storto
- Nuclear Medicine Unit, IRCCS, Referral Cancer Center of Basilicata, Rionero in Vulture, Italy
| | - Carmela Nappi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Carlo Buonerba
- Department of Oncology & Hematology, Regional Reference Center for Rare Tumors, AOU Federico II of Naples, Naples, Italy
| | - Felice Crocetto
- Department of Neurosciences, Human Reproduction & Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Rosj Gallicchio
- Nuclear Medicine Unit, IRCCS, Referral Cancer Center of Basilicata, Rionero in Vulture, Italy
| | - Fabio Volpe
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Leonardo Pace
- Department of Medicine, Surgery & Dentistry, University of Salerno, Salerno, Italy
| | - Martin Schlumberger
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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Yadav MP, Ballal S, Meckel M, Roesch F, Bal C. [ 177Lu]Lu-DOTA-ZOL bone pain palliation in patients with skeletal metastases from various cancers: efficacy and safety results. EJNMMI Res 2020; 10:130. [PMID: 33113035 PMCID: PMC7593375 DOI: 10.1186/s13550-020-00709-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/21/2020] [Indexed: 12/29/2022] Open
Abstract
Background [177Lu]Lu-DOTA-ZOL has shown promising results from the dosimetry and preclinical aspects, but data on its role in the clinical efficacy are limited. The objective of this study is to evaluate the efficacy and safety of [177Lu]Lu-DOTA-ZOL as a bone pain palliation agent in patients experiencing pain due to skeletal metastases from various cancers. Methods In total, 40 patients experiencing bone pain due to skeletal metastases were enrolled in this study. The patients were treated with a mean cumulative dose of 2.1 ± 0.6 GBq (1.3–2.7 GBq) [177Lu]Lu-DOTA-ZOL in a median follow-up duration of 10 months (IQR 8–14 months). The primary outcome endpoint was response assessment according to the visual analogue score (VAS). Secondary endpoints included analgesic score (AS), global pain assessment score, Eastern Cooperative Oncology Group Assessment performance status (ECOG), Karnofsky performance status, overall survival, and safety assessment by the National Cancer Institute’s Common Toxicity Criteria V5.0. Results In total, 40 patients (15 males and 25 females) with a mean age of 46.6 ± 15.08 years (range 24–78 years) were treated with either 1 (N = 15) or 2 (N = 25) cycles of [177Lu]Lu-DOTA-ZOL. According to the VAS response assessment criteria, complete, partial, and minimal responses were observed in 11 (27.5%), 20 (50%), and 5 patients (12.5%), respectively with an overall response rate of 90%. Global pain assessment criteria revealed complete, partial, minimal, and no response in 2 (5%), 25 (62.5%), 9 (22.5%), and 4 (10%) patients, respectively. Twenty-eight patients died and the estimated median overall survival was 13 months (95% CI 10–14 months). A significant improvement was observed in the VAS, AS, and ECOG status when compared to baseline. None of the patients experienced grade III/IV haematological, kidney, or hepatotoxicity due to [177Lu]Lu-DOTA-ZOL therapy. Conclusion [177Lu]Lu-DOTA-ZOL shows promising results and is an effective radiopharmaceutical in the treatment of bone pain due to skeletal metastases from various cancers.
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Affiliation(s)
- Madhav Prasad Yadav
- Department of Nuclear Medicine, Room No: 59-A, Thyroid Clinic, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India
| | - Sanjana Ballal
- Department of Nuclear Medicine, Room No: 59-A, Thyroid Clinic, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India
| | - Marian Meckel
- Department of Nuclear Chemistry, Johannes Gutenberg University, Fritz-Strassmann-Weg 2, 55126, Mainz, Germany
| | - Frank Roesch
- Department of Nuclear Chemistry, Johannes Gutenberg University, Fritz-Strassmann-Weg 2, 55126, Mainz, Germany
| | - Chandrasekhar Bal
- Department of Nuclear Medicine, Room No: 59-A, Thyroid Clinic, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India.
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Buscombe J, Gillett D, Bird N, Powell A, Heard S, Aloj L. Quantifying the survival benefit of completing all the six cycles of radium-223 therapy in patients with castrate-resistant prostate cancer with predominant bone metastases. World J Nucl Med 2020; 20:139-144. [PMID: 34321965 PMCID: PMC8286012 DOI: 10.4103/wjnm.wjnm_74_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 01/16/2023] Open
Abstract
A retrospective analysis was performed of epidemiological data assessing the survival of patients who had received radium-223 for castrate-resistant metastatic prostate cancer treated at a regional tertiary referral center over a 5-year period. The patients' age, date of first treatment, and the number of cycles of radium-223 given were obtained from the patients' electronic patient record (EPR). Data on the date of death were provided by national death registrations which update the EPR via a unique national health service number. A total of 187 patients (mean age on the date of first treatment: 73 years; range: 56-93) were treated from April 1, 2014, to June 30, 2019. The median overall survival of the 119 patients (71%) who had died by December 31, 2019, was 15 months. There was no significant age difference between those who had died and survivors (72 vs. 74 years). On a further analysis, it was found that the median overall survival of the 107 patients who had received all the six cycles of radium-223 was 31 months, significantly longer than the median overall survival of only 6 months for those eighty patients who had received less than the full course of six cycles of radium-223 (P = 0.001). Of those who received all the six cycles of treatment, 58 patients had died (58%) and the 1-year survival was 87%. This was compared to the group of patients receiving <6 cycles of radium-223 where 61 patients (76%) had died and the 1-year survival was 30%. Therefore, the hazard ratio of dying before 1 year if the patient did not receive all the six cycles of treatment was 2.9. Where the reason for stopping treatment was recorded on the EPR the most common cause for the cessation of treatment was because of the side effects caused by the treatment itself. Other causes were hospitalization with comorbidities, disease progression, or patient choice. Given the survival advantage of receiving the full course of all the six cycles of treatment, this should be administered if possible and the patients should be managed in such a way as to allow the complete treatment course to be given.
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Affiliation(s)
- John Buscombe
- Department of Nuclear Medicine, Cambridge University Hospitals, Cambridge, UK
| | - Daniel Gillett
- Department of Nuclear Medicine, Cambridge University Hospitals, Cambridge, UK
| | - Nick Bird
- Department of Nuclear Medicine, Cambridge University Hospitals, Cambridge, UK
| | - Anne Powell
- Department of Nuclear Medicine, Cambridge University Hospitals, Cambridge, UK
| | - Sarah Heard
- Department of Nuclear Medicine, Cambridge University Hospitals, Cambridge, UK
| | - Luigi Aloj
- Department of Nuclear Medicine, Cambridge University Hospitals, Cambridge, UK.,Department of Radiology, University of Cambridge, Cambridge, UK
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Spine and Non-spine Bone Metastases - Current Controversies and Future Direction. Clin Oncol (R Coll Radiol) 2020; 32:728-744. [PMID: 32747153 DOI: 10.1016/j.clon.2020.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/21/2020] [Accepted: 07/10/2020] [Indexed: 02/06/2023]
Abstract
Bone is a common site of metastases in advanced cancers. The main symptom is pain, which increases morbidity and reduces quality of life. The treatment of bone metastases needs a multidisciplinary approach, with the main aim of relieving pain and improving quality of life. Apart from systemic anticancer therapy (hormonal therapy, chemotherapy or immunotherapy), there are several therapeutic options available to achieve palliation, including analgesics, surgery, local radiotherapy, bone-seeking radioisotopes and bone-modifying agents. Long-term use of non-steroidal analgesics and opiates is associated with significant side-effects, and tachyphylaxis. Radiotherapy is effective mainly in localised disease sites. Bone-targeting radionuclides are useful in patients with multiple metastatic lesions. Bone-modifying agents are beneficial in reducing skeletal-related events. This overview focuses on the role of surgery, including minimally invasive treatments, conventional radiotherapy in spinal and non-spinal bone metastases, bone-targeting radionuclides and bone-modifying agents in achieving palliation. We present the clinical data and their associated toxicity. Recent advances are also discussed.
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The five “W”s and “How” of Targeted Alpha Therapy: Why? Who? What? Where? When? and How? RENDICONTI LINCEI-SCIENZE FISICHE E NATURALI 2020. [DOI: 10.1007/s12210-020-00900-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Vidal M, Delgado A, Martinez C, Correa JJ, Durango IC. Overall survival prediction in metastatic castration-resistant prostate cancer treated with radium-223. Int Braz J Urol 2020; 46:599-611. [PMID: 32213206 PMCID: PMC7239273 DOI: 10.1590/s1677-5538.ibju.2019.0343] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/22/2019] [Indexed: 01/05/2023] Open
Abstract
Objective Radium-223(223Ra) is indicated for patients (p) with metastatic castration resistant prostate cancer (mCRCP). Objectives The aim of this study was to evaluate the role of baseline clinical variables associated with overall survival (OS) and toxicity of 223Ra. Its purpose was to identify the factors that can predict a better response to treatment and provide information regarding the most appropriate time for the application of 223Ra. Materials and Methods Prospective study in 40p with mCRPC treated with 223Ra. End points were OS, progression-free survival and time to progression. The follow-up parameters were: doses received, hemoglobin (Hb), absolute neutrophil count (ANC), platelet count (PC), prostate specific antigen (PSA), alkaline phosphatase (ALP), Visual Analogue Scale for pain, Eastern Cooperative Oncology Group (ECOG) and WHO’s Cancer Pain Ladder. The use of other treatments was also evaluated. Results Median OS was 17.1 months(mo) (CI95%6.5-27.7); 26/40p received complete treatment of 223Ra, without reaching a median OS and 14p received incomplete treatment with a median OS 13.6mo(CI95%1.6-25.6). Median follow-up was 11.2mo (range:1.3-45.2). The univariate analysis showed that factors as VAS, ECOG, Hb and ALP values were independently associated with OS. First line treatment with 223Ra was started in 11/40p, while 19p had been heavily pre-treated and 13p received concomitant treatment. Conclusions 223Ra therapy require an adequate selection of patients to obtain the greatest clinical benefit. Low basal Hb, hight basal ALP, bone marrow involvement and an altered ECOG were the main factors that decreased OS in our patients. 223Ra should be considered relatively early in the course of treatment.
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Affiliation(s)
- Monica Vidal
- Department of Radiology, Hospital Pablo Tobon Uribe, Medellin, Antioquia, Colombia
| | - Alejandro Delgado
- Department of Radiology, Hospital Pablo Tobon Uribe, Medellin, Antioquia, Colombia
| | - Carlos Martinez
- Department of Urology, Hospital Pablo Tobon Uribe, Medellin, Antioquia, Colombia
| | - José Jaime Correa
- Department of Urology, Hospital Pablo Tobon Uribe, Medellin, Antioquia, Colombia
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Brito AE, Etchebehere E. Radium-223 as an Approved Modality for Treatment of Bone Metastases. Semin Nucl Med 2020; 50:177-192. [PMID: 32172803 DOI: 10.1053/j.semnuclmed.2019.11.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Radium-223 dichloride (223Ra) is an α-emitter radionuclide approved for treatment of osteoblastic metastases in castrate-resistant prostate cancer (mCRPC) patients. 223Ra increases overall survival, improves bone pain, increases the median time to the first skeletal-related event, reduces the use of external beam radiation therapy for bone pain palliation, reduces the rates of spinal cord compression, and hospitalization. 223Ra therapy has minimal side effects; the most common hematological side effects are anemia, thrombocytopenia and neutropenia while the nonhematological side effects that may occur are bone pain flare, nausea, fatigue, and diarrhea. Alongside 223Ra therapy there are currently a variety of first-line therapeutic options available to treat mCRPC patients and much debate regarding the appropriate treatment algorithm for these patients and the possible combination of therapies among the ones available. In this article, we review the rationale behind 223Ra therapy as well as 223Ra mechanisms of action, biodistribution and dosimetry, optimal timing possibilities to initiate 223Ra in contrast to other treatments available, the association of 223Ra with other therapies and the means of evaluating patients in order to properly deliver to 223Ra therapy. Furthermore, we will discuss 223Ra dose administration possibilities, patient and dose preparation and the challenges of treatment response evaluation during and after 223Ra.
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Affiliation(s)
- Ana Emília Brito
- Real Nuclear, Real Hospital Português de Beneficência em Pernambuco, Recife, Brazil
| | - Elba Etchebehere
- Division of Nuclear Medicine, The University of Campinas (UNICAMP), Campinas, Brazil.
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Anderson PM. Radiopharmaceuticals for Treatment of Osteosarcoma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1257:45-53. [PMID: 32483729 DOI: 10.1007/978-3-030-43032-0_4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Although trace amounts of radioactivity are routinely used to detect osteosarcoma, the use of larger therapeutic amounts of radiation is often an unrecognized opportunity to treat metastatic osteosarcoma. This chapter will review a number of approaches to use ionizing radiation in the form of injectable radiopharmaceuticals. Since bone metastases are a common pattern of metastatic spread of cancer in general, a number of bone-seeking radiopharmaceuticals have been developed and FDA approved for treatment of bone metastases. Although osteosarcoma, a bone-forming cancer, would seem ideally suited to be treated with bone seekers, patterns of relapse involving non-ossifying metastases remain a major problem to be overcome. Thus, this review will not only describe experience using a number of bone-seeking radiopharmaceuticals such as 153-samarium-EDTMP, 153-samarium-DOTMP, and 223-radium against osteosarcoma, but also approaches to identify patients who may benefit as well as some means to the improve overall efficacy including combination therapy with routine agents and using nuclear imaging to develop best strategy for use. These include imaging with not only 99mTc-MDP standard bone scans, but also 99mTc-MDP bone scans with SPECT CT, bone-specific sodium fluoride PET-CT (Na18F), and 18FDG-PET-CT. Accurate knowledge of oligometastatic active disease can facilitate more effective use of combination therapy, including radiosensitizers and local control measures, for example, stereotactic body radiotherapy (SBRT) and/or cryoablation to reduce disease burden as well as manage and prevent micrometastatic disease from growing and metastasizing. Finally, a new tumor-specific radiopharmaceutical, CLR 131, may also provide another radiopharmaceutical to treat both osteoblastic and non-ossifying areas of osteosarcoma.
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Affiliation(s)
- Peter M Anderson
- Pediatric and Taussig Cancer Institutes, Department of Pediatric Hematology, Oncology and BMT, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA.
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Ra-223 Treatment for Bone Metastases in Castrate-Resistant Prostate Cancer: Practical Management Issues for Patient Selection. Am J Clin Oncol 2019; 42:399-406. [PMID: 30844849 PMCID: PMC6445613 DOI: 10.1097/coc.0000000000000528] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Bone metastases are common in men with metastatic castrate-resistant prostate cancer (mCRPC), occurring in 30% of patients within 2 years of castrate resistance and in >90% of patients over the disease course. There are 6 US Food and Drug Administration-approved therapies for mCRPC with demonstrated survival benefit. Of these, only radium-223 (Ra-223) specifically targets bone metastases, delays development of skeletal-related events, and improves survival. This review discusses key data from the ALSYMPCA trial, which contributed to the approval of Ra-223. Data from other trials are highlighted to provide further insight into which patients might benefit from Ra-223. Special patient populations are described, as well as other considerations for the administration of Ra-223. Finally, ongoing trials of Ra-223 combined with other therapies for mCRPC are discussed. These include combining Ra-223 with sipuleucel-T or immunooncology agents, to enhance immune responses, and trials in mildly symptomatic or asymptomatic patients. To date, the optimal timing, sequence, and combinations of Ra-223 with other agents are yet to be determined. The goals of this review are to provide insight into practical aspects of patient selection for Ra-223 treatment and to discuss key therapeutic strategies using the 6 approved mCRPC agents in patients with bone metastases. Results from ongoing trials should help guide the practitioner in using Ra-223 in patients with mCRPC.
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Where Do We See Alpha Emitters in Clinical Practice? A Radiation Oncology Perspective. J Med Imaging Radiat Sci 2019; 50:S31-S33. [DOI: 10.1016/j.jmir.2019.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/05/2019] [Accepted: 06/11/2019] [Indexed: 11/20/2022]
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Tafreshi NK, Doligalski ML, Tichacek CJ, Pandya DN, Budzevich MM, El-Haddad G, Khushalani NI, Moros EG, McLaughlin ML, Wadas TJ, Morse DL. Development of Targeted Alpha Particle Therapy for Solid Tumors. Molecules 2019; 24:molecules24234314. [PMID: 31779154 PMCID: PMC6930656 DOI: 10.3390/molecules24234314] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 12/11/2022] Open
Abstract
Targeted alpha-particle therapy (TAT) aims to selectively deliver radionuclides emitting α-particles (cytotoxic payload) to tumors by chelation to monoclonal antibodies, peptides or small molecules that recognize tumor-associated antigens or cell-surface receptors. Because of the high linear energy transfer (LET) and short range of alpha (α) particles in tissue, cancer cells can be significantly damaged while causing minimal toxicity to surrounding healthy cells. Recent clinical studies have demonstrated the remarkable efficacy of TAT in the treatment of metastatic, castration-resistant prostate cancer. In this comprehensive review, we discuss the current consensus regarding the properties of the α-particle-emitting radionuclides that are potentially relevant for use in the clinic; the TAT-mediated mechanisms responsible for cell death; the different classes of targeting moieties and radiometal chelators available for TAT development; current approaches to calculating radiation dosimetry for TATs; and lead optimization via medicinal chemistry to improve the TAT radiopharmaceutical properties. We have also summarized the use of TATs in pre-clinical and clinical studies to date.
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Affiliation(s)
- Narges K. Tafreshi
- Department of Cancer Physiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (N.K.T.); (M.L.D.); (C.J.T.); (E.G.M.)
| | - Michael L. Doligalski
- Department of Cancer Physiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (N.K.T.); (M.L.D.); (C.J.T.); (E.G.M.)
| | - Christopher J. Tichacek
- Department of Cancer Physiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (N.K.T.); (M.L.D.); (C.J.T.); (E.G.M.)
| | - Darpan N. Pandya
- Department of Cancer Biology, Wake Forest University Health Sciences, Winston-Salem, NC 27157, USA; (D.N.P.); (T.J.W.)
| | - Mikalai M. Budzevich
- Small Animal Imaging Laboratory, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Ghassan El-Haddad
- Depts. of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Nikhil I. Khushalani
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Eduardo G. Moros
- Department of Cancer Physiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (N.K.T.); (M.L.D.); (C.J.T.); (E.G.M.)
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
- Department of Physics, University of South Florida, Tampa, FL 33612, USA
- Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA
| | - Mark L. McLaughlin
- Department of Pharmaceutical Sciences, West Virginia University, Health Sciences Center, Morgantown, WV & Modulation Therapeutics Inc., 64 Medical Center Drive, Morgantown, WV 26506, USA;
| | - Thaddeus J. Wadas
- Department of Cancer Biology, Wake Forest University Health Sciences, Winston-Salem, NC 27157, USA; (D.N.P.); (T.J.W.)
| | - David L. Morse
- Department of Cancer Physiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (N.K.T.); (M.L.D.); (C.J.T.); (E.G.M.)
- Department of Physics, University of South Florida, Tampa, FL 33612, USA
- Small Animal Imaging Laboratory, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
- Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA
- Correspondence: ; Tel.: +1-813-745-8948; Fax: +1-813-745-8375
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Serretta V, Valerio MR, Costa R, Tripoli V, Murabito A, Princiotta A, Scalici Gesolfo C, Borsellino N, Verderame F, Gebbia V, Licari M, Sanfilippo C. Radium-223 treatment in castration resistant bone metastatic prostate cancer. Should be the primary tumor always treated? Urol Oncol 2019; 37:964-969. [PMID: 31601517 DOI: 10.1016/j.urolonc.2019.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 08/13/2019] [Accepted: 08/18/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Radium-223 (223Ra) improves symptoms and survival in patients with bone metastatic castration-resistant prostate cancer (mCRPC). STUDY AIM To evaluate the impact of a previous radical prostatectomy (RP) on the outcome of 223Ra therapy in mCRPC patients. The primary prostate tumor left untreated could progress during 223Ra treatment. MATERIALS AND METHODS mCRPC symptomatic patients treated with 223Ra were enrolled. Luteinizing Hormone-Releasing Hormone analogue was maintained. No other anticancer therapy was given. 223Ra was administered i.v. at the dose of 55 kBq/kg every 4 weeks for 6 cycles. Patients were stratified according to previous RP or not. Hematological toxicity was monitored. Statistical analysis of 223Ra discontinuations, progressions, and deaths were performed. RESULTS Forty-four patients were enrolled, 16 (36.4%) previously received RP, 5 (11.3%) prostate radiotherapy and 23 (52.3%) maintained the primary prostate tumor after local treatment. All patients presented only bone metastases, 24 patients (54.5%) had more than 20. Twenty-six (59.1%) patients were treated after first or second line systemic chemotherapy. Treatment interruptions occurred in 14 patients (50%) with prostate and in 4 (25%) without (P = 0.04). After a median follow-up of 18 months (6-30 months), 15 (53.6%), and 7 (43.7%) progressions (P = 0.34) and 13 and 1 (6.2%) deaths (P = 0.04) occurred in patients with and without prostate respectively. CONCLUSION The presence of the primary prostate tumor seems to play a detrimental role in mCRPC patients undergoing 223Ra treatment in absence of other concomitant anticancer therapy. On the other hand a previous RP might play a protective role.
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Affiliation(s)
- Vincenzo Serretta
- Department of Surgical, Oncological and Oral Sciences, Urology Unit, University of Palermo, Italy; GSTU Foundation, Statistics, Palermo, Italy.
| | - Maria Rosaria Valerio
- Department of Surgical, Oncological and Oral Sciences, Medical Oncology Unit, University of Palermo, Italy
| | - Renato Costa
- Nuclear Medicine Unit, University of Palermo, Italy
| | | | | | - Alessandro Princiotta
- Department of Surgical, Oncological and Oral Sciences, Urology Unit, University of Palermo, Italy
| | - Cristina Scalici Gesolfo
- Department of Surgical, Oncological and Oral Sciences, Urology Unit, University of Palermo, Italy
| | - Nicolò Borsellino
- Oncology Unit, "Buccheri La Ferla Fatebenefratelli" Civic Hospital, Palermo, Italy
| | | | | | - Maria Licari
- Nuclear Medicine Unit, University of Palermo, Italy
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The Mode-of-Action of Targeted Alpha Therapy Radium-223 as an Enabler for Novel Combinations to Treat Patients with Bone Metastasis. Int J Mol Sci 2019; 20:ijms20163899. [PMID: 31405099 PMCID: PMC6720648 DOI: 10.3390/ijms20163899] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 12/12/2022] Open
Abstract
Bone metastasis is a common clinical complication in several cancer types, and it causes a severe reduction in quality of life as well as lowering survival time. Bone metastases proceed through a vicious self-reinforcing cycle that can be osteolytic or osteoblastic in nature. The vicious cycle is characterized by cancer cells residing in bone releasing signal molecules that promote the differentiation of osteoclasts and osteoblasts either directly or indirectly. The increased activity of osteoclasts and osteoblasts then increases bone turnover, which releases growth factors that benefit metastatic cancer cells. In order to improve the prognosis of patients with bone metastases this cycle must be broken. Radium-223 dichloride (radium-223), the first targeted alpha therapy (TAT) approved, is an osteomimetic radionuclide that is incorporated into bone metastases where its high-linear energy transfer alpha radiation disrupts both the activity of bone cells and cancer cells. Therefore, radium-223 treatment has been shown preclinically to directly affect cancer cells in both osteolytic breast cancer and osteoblastic prostate cancer bone metastases as well as to inhibit the differentiation of osteoblasts and osteoclasts. Clinical studies have demonstrated an increase in survival in patients with metastatic castration-resistant prostate cancer. Due to the effectiveness and low toxicity of radium-223, several novel combination treatment strategies are currently eliciting considerable research interest.
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Fanti S, Minozzi S, Antoch G, Banks I, Briganti A, Carrio I, Chiti A, Clarke N, Eiber M, De Bono J, Fizazi K, Gillessen S, Gledhill S, Haberkorn U, Herrmann K, Hicks RJ, Lecouvet F, Montironi R, Ost P, O'Sullivan JM, Padhani AR, Schalken JA, Scher HI, Tombal B, van Moorselaar RJA, Van Poppel H, Vargas HA, Walz J, Weber WA, Wester HJ, Oyen WJG. Consensus on molecular imaging and theranostics in prostate cancer. Lancet Oncol 2019; 19:e696-e708. [PMID: 30507436 DOI: 10.1016/s1470-2045(18)30604-1] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/09/2018] [Accepted: 08/09/2018] [Indexed: 10/27/2022]
Abstract
Rapid developments in imaging and treatment with radiopharmaceuticals targeting prostate cancer pose issues for the development of guidelines for their appropriate use. To tackle this problem, international experts representing medical oncologists, urologists, radiation oncologists, radiologists, and nuclear medicine specialists convened at the European Association of Nuclear Medicine Focus 1 meeting to deliver a balanced perspective on available data and clinical experience of imaging in prostate cancer, which had been supported by a systematic review of the literature and a modified Delphi process. Relevant conclusions included the following: diphosphonate bone scanning and contrast-enhanced CT are mentioned but rarely recommended for most patients in clinical guidelines; MRI (whole-body or multiparametric) and prostate cancer-targeted PET are frequently suggested, but the specific contexts in which these methods affect practice are not established; sodium fluoride-18 for PET-CT bone scanning is not widely advocated, whereas gallium-68 or fluorine-18 prostate-specific membrane antigen gain acceptance; and, palliative treatment with bone targeting radiopharmaceuticals (rhenium-186, samarium-153, or strontium-89) have largely been replaced by radium-223 on the basis of the survival benefit that was reported in prospective trials, and by other systemic therapies with proven survival benefits. Although the advances in MRI and PET-CT have improved the accuracy of imaging, the effects of these new methods on clinical outcomes remains to be established. Improved communication between imagers and clinicians and more multidisciplinary input in clinical trial design are essential to encourage imaging insights into clinical decision making.
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Affiliation(s)
- Stefano Fanti
- Nuclear Medicine Division, Policlinico S Orsola, University of Bologna, Bologna, Italy.
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University of Dusseldorf, Dusseldorf, Germany
| | - Ian Banks
- European Cancer Organisation and European Men's Health Forum, Ulster, UK
| | - Alberto Briganti
- Division of Oncology and Unit of Urology, Urological Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Ignasi Carrio
- Department of Nuclear Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Arturo Chiti
- Humanitas University and Humanitas Research Hospital, Milan, Italy
| | | | - Matthias Eiber
- Department of Nuclear Medicine, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | | | - Karim Fizazi
- Department of Cancer Medicine, Institut Gustave Roussy, Paris, France
| | - Silke Gillessen
- Division of Cancer Sciences, University of Manchester and The Christie Hospital, Manchester, UK; Division of Oncology and Division of Haematology, Kantonsspital St Gallen and University of Bern, Bern, Switzerland
| | | | - Uwe Haberkorn
- Department of Nuclear Medicine and German Cancer Research Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, Universitätsklinikum Essen, Essen, Germany
| | - Rodney J Hicks
- Cancer Imaging, Peter MacCallum Cancer Institute, Melbourne, VIC, Australia
| | - Frederic Lecouvet
- Institut de Recherche Expérimentale et Clinique, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Rodolfo Montironi
- Genitourinary Cancer Program, Institute of Pathological Anatomy and Histopathology, Polytechnic University of the Marche Region, Ancona, Italy
| | - Piet Ost
- Genitourinary Program, Ghent University Hospital, Ghent, Belgium
| | - Joe M O'Sullivan
- Department of Radiotherapy and Experimental Cancer Research, Queen's University, Belfast, UK
| | - Anwar R Padhani
- Mount Vernon Cancer Centre, Mount Vernon Hospital, London, UK
| | - Jack A Schalken
- Department of Experimental Urology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Howard I Scher
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Bertrand Tombal
- Institut de Recherche Expérimentale et Clinique, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | | | - Heindrik Van Poppel
- Urology, University Hospital Katholieke Universiteit Leuven, Leuven, Belgium
| | - Hebert Alberto Vargas
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Jochen Walz
- Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France
| | - Wolfgang A Weber
- Department of Nuclear Medicine, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Hans-Jürgen Wester
- Lehrstuhl für Pharmazeutische Radiochemie, Technische Universität München, Garching, Germany
| | - Wim J G Oyen
- Department of Nuclear Medicine, Radboud University Medical Centre, Nijmegen, Netherlands; Department of Nuclear Medicine, The Institute of Cancer Research and The Royal Marsden National Health Service Foundation Trust, London, UK
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Abstract
Cancers are not composed merely of cancer cells alone; instead, they are complex 'ecosystems' comprising many different cell types and noncellular factors. The tumour stroma is a critical component of the tumour microenvironment, where it has crucial roles in tumour initiation, progression, and metastasis. Most anticancer therapies target cancer cells specifically, but the tumour stroma can promote the resistance of cancer cells to such therapies, eventually resulting in fatal disease. Therefore, novel treatment strategies should combine anticancer and antistromal agents. Herein, we provide an overview of the advances in understanding the complex cancer cell-tumour stroma interactions and discuss how this knowledge can result in more effective therapeutic strategies, which might ultimately improve patient outcomes.
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Benabdallah N, Bernardini M, Bianciardi M, de Labriolle-Vaylet C, Franck D, Desbrée A. 223Ra-dichloride therapy of bone metastasis: optimization of SPECT images for quantification. EJNMMI Res 2019; 9:20. [PMID: 30790144 PMCID: PMC6384291 DOI: 10.1186/s13550-019-0488-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 02/04/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND 223Ra imaging is crucial to evaluate the successfulness of the therapy of bone metastasis of castration-resistant prostate cancer (CRPC). The goals of this study were to establish a quantitative tomographic 223Ra imaging protocol with clinically achievable conditions, as well as to investigate its usefulness and limitations. We performed several experiments using the Infinia Hawkeye 4 gamma camera (GE) and physical phantoms in order to assess the optimal image acquisition and reconstruction parameters, such as the windows setting, as well as the iteration number and filter of the reconstruction algorithm. Then, based on the MIRD pamphlet 23, we used a NEMA phantom and an anthropomorphic TORSO® phantom to calibrate the gamma camera and investigate the accuracy of quantification. RESULTS Experiences showed that the 85 keV ± 20%, 154 keV ± 10%, and 270 keV ± 10% energy windows are the most suitable for 223Ra imaging. The study with the NEMA phantom showed that the OSEM algorithm with 2 iterations, 10 subsets, and the Butterworth filter offered the best compromise between contrast and noise. Moreover, the calibration factors for different sphere sizes (26.5 ml, 11.5 ml, and 5.6 ml) were constant for 223Ra concentrations ranging between 6.5 and 22.8 kBq/ml. The values found are 73.7 cts/s/MBq, 43.8 cts/s/MBq, and 43.4 cts/s/MBq for 26.5 ml, 11.5 ml, and 5.6 ml sphere, respectively. For concentration lower than 6.5 kBq/ml, the calibration factors exhibited greater variability pointing out the limitations of SPECT/CT imaging for quantification. By the use of a TORSO® phantom, we simulated several tumors to normal tissue ratios as close as possible to clinical conditions. Using the calibration factors obtained with the NEMA phantom, for 223Ra concentrations higher than 8 kBq/ml, we were able to quantify the activity with an error inferior to 18.8% in a 5.6 ml lesion. CONCLUSIONS Absolute quantitative 223Ra SPECT imaging appears feasible once the dimension of the target is determined. Further evaluation should be needed to apply the calibration factor-based quantitation to clinical 223Ra SPECT/CT imaging. This will open the possibility for patient-specific 223Ra treatment planning and therapeutic outcome prediction in patients.
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Affiliation(s)
- Nadia Benabdallah
- Internal Dose Assessment Laboratory, Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Michela Bernardini
- Nuclear Medicine Department, European Hospital George Pompidou (HEGP), Paris, France
| | - Marta Bianciardi
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Claire de Labriolle-Vaylet
- UPMC, Univ Paris 06 Biophysics, Paris, France
- Nuclear Medicine Department, Trousseau Hospital, Paris, France
| | - Didier Franck
- Internal Dose Assessment Laboratory, Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Aurélie Desbrée
- Internal Dose Assessment Laboratory, Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
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Dash A, Das T, Knapp FFR. Targeted Radionuclide Therapy of Painful Bone Metastases: Past Developments, Current Status, Recent Advances and Future Directions. Curr Med Chem 2019; 27:3187-3249. [PMID: 30714520 DOI: 10.2174/0929867326666190201142814] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/29/2018] [Accepted: 12/06/2018] [Indexed: 12/13/2022]
Abstract
Bone pain arising from secondary skeletal malignancy constitutes one of the most common types of chronic pain among patients with cancer which can lead to rapid deterioration of the quality of life. Radionuclide therapy using bone-seeking radiopharmaceuticals based on the concept of localization of the agent at bone metastases sites to deliver focal cytotoxic levels of radiation emerged as an effective treatment modality for the palliation of symptomatic bone metastases. Bone-seeking radiopharmaceuticals not only provide palliative benefit but also improve clinical outcomes in terms of overall and progression-free survival. There is a steadily expanding list of therapeutic radionuclides which are used or can potentially be used in either ionic form or in combination with carrier molecules for the management of bone metastases. This article offers a narrative review of the armamentarium of bone-targeting radiopharmaceuticals based on currently approved investigational and potentially useful radionuclides and examines their efficacy for the treatment of painful skeletal metastases. In addition, the article also highlights the processes, opportunities, and challenges involved in the development of bone-seeking radiopharmaceuticals. Radium-223 is the first agent in this class to show an overall survival advantage in Castration-Resistant Prostate Cancer (CRPC) patients with bone metastases. This review summarizes recent advances, current clinical practice using radiopharmaceuticals for bone pain palliation, and the expected future prospects in this field.
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Affiliation(s)
- Ashutosh Dash
- Radiopharmaceuticals Division, Bhabha Atomic Research Centre, Trombay, Mumbai 400085, India.,Homi Bhabha National Institute, Anushaktinagar, Mumbai 400094, India
| | - Tapas Das
- Radiopharmaceuticals Division, Bhabha Atomic Research Centre, Trombay, Mumbai 400085, India.,Homi Bhabha National Institute, Anushaktinagar, Mumbai 400094, India
| | - Furn F Russ Knapp
- Medical Isotopes Program, Isotope Development Group, MS 6229, Bldg. 4501, Oak Ridge National Laboratory, PO Box 2008, 1 Bethel Valley Road, Oak Ridge, TN 37831, United States
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Gayed I, Salama V, Dawood L, Canfield S, Wan D, Cai C, Joseph U, Amato R. Can bone scans guide therapy with radium-223 dichloride for prostate cancer bone metastases? Cancer Manag Res 2018; 10:3317-3324. [PMID: 30233247 PMCID: PMC6135075 DOI: 10.2147/cmar.s166218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Radium-223 dichloride (Ra-223 Xofigo) has recently been approved as an addition to the host of available therapies in the USA as a treatment option for metastatic castrate-resistant prostate cancer (mCRPC) with bone metastases. This study describes our initial experience in patients treated with Ra-223 dichloride. It attempts to optimize patients' selection for the best outcome from Ra-223 dichloride therapy. METHODS Consecutive patients who were referred for treatment with Ra-223 dichloride were prospectively followed. Patients' demographics, functional status per the Eastern Cooperative Oncology Group (ECOG) performance score, pain level per the numeric rating score (NRS), prostate-specific antigen (PSA), creatinine, and hematological values were compared at baseline and at the end of therapy. Patients also had a bone scan before starting therapy and at the end of therapy. Patients were divided into the favorable response (FR) group if their pain and/or functional status improved and the unfavorable response (UR) group if they did not improve, deteriorated, or deceased. Bone scan findings before and after Ra-223 dichloride therapy were compared in both the FR and UR groups. RESULTS Twenty patients were treated with Ra-223 dichloride. Twelve patients had innumerable bone metastases, three patients had super scans, and three patients had two to seven bone lesions. Two patients were lost to follow-up after the first injection. There were eight patients in the FR group and 10 patients in the UR group. Patients with UR had mean ECOG and NRS pain scores of 1.3 and 5.0 versus 0.8 and 4.4 in the FR group. The mean PSA and creatinine levels in the UR group were 445.2 ng/mL and 1.2 mg/dL versus 22.7 ng/mL and 1.1 mg/dL in the FR group. The mean hemoglobin, platelets, and absolute neutrophil values were 11.2 g/dL, 314.9 K/cmm, and 7.3 K/cmm in the UR group versus 11.6 g/dL, 207.0 K/cmm, and 6.2 K/cmm in the FR group. Seven of the eight patients with FR had a bone scan at the end of therapy showing improvement in five patients, a mixed response in one patient, and progression in another patient. Five patients in the UR group completed five or six injections and had bone scans showing flare of bone metastases in three patients, progression in one patient, and improvement in the fifth patient. Three patients in the UR group died after the first or second injections. Two of these patients had baseline super scans and the third one had widespread bone metastases. CONCLUSION mCRPC patients with lower PSA levels at baseline and fewer bone lesions are more likely to respond favorably to Ra-223 dichloride therapy.
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Affiliation(s)
- Isis Gayed
- Nuclear Medicine Section, Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston,
| | - Vivian Salama
- Graduate School of Biomedical Sciences, University of Texas MD Anderson Cancer Center
| | - Lydia Dawood
- Nuclear Medicine Section, Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston,
| | | | - David Wan
- Nuclear Medicine Section, Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston,
| | - Chunyan Cai
- Division of Clinical and Translational Science, Department of Internal Medicine
| | - Usha Joseph
- Nuclear Medicine Section, Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston,
| | - Robert Amato
- Division of Oncology, Department of Internal Medicine, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
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Targeted alpha therapy using Radium-223: From physics to biological effects. Cancer Treat Rev 2018; 68:47-54. [PMID: 29859504 DOI: 10.1016/j.ctrv.2018.05.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/22/2018] [Accepted: 05/23/2018] [Indexed: 12/13/2022]
Abstract
With the advance of the use of ionizing radiation in therapy, targeted alpha therapy (TAT) has assumed an important role around the world. This kind of therapy can potentially reduce side effects caused by radiation in normal tissues and increased destructive radiobiological effects in tumor cells. However, in many countries, the use of this therapy is still in a pioneering phase. Radium-223 (223Ra), an alpha-emitting radionuclide, has been the first of its kind to be approved for the treatment of bone metastasis in metastatic castration-resistant prostate cancer. Nevertheless, the interaction mechanism and the direct effects of this radiopharmaceutical in tumor cells are not fully understood neither characterized at a molecular level. In fact, the ways how TAT is linked to radiobiological effects in cancer is not yet revised. Therefore, this review introduces some physical properties of TAT that leads to biological effects and links this information to the hallmarks of cancer. The authors also collected the studies developed with 223Ra to correlate with the three categories reviewed - properties of TAT, 5 R's of radiobiology and hallmarks of cancer- and with the promising future to this radiopharmaceutical.
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Pratt BE, Hindorf C, Chittenden SJ, Parker CC, Flux GD. Excretion and whole-body retention of radium-223 dichloride administered for the treatment of bone metastases from castration resistant prostate cancer. Nucl Med Commun 2018; 39:125-130. [PMID: 29189490 DOI: 10.1097/mnm.0000000000000783] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of the study was to determine the fraction of administered activity that was excreted and retained by a small cohort of patients who each received treatment with radium-223 dichloride (Ra). Ra is an α-emitting radionuclide that has been approved for use in the treatment of bone metastases that are secondary to castration resistant prostate cancer. PATIENTS AND METHODS Six patients received two weight-based administrations of Ra 6 weeks apart. Activity excreted in the urine and faeces during the first 48 h following each treatment was assessed by direct counting of the excreta. During the same period the whole-body retention of Ra was also determined using a single probe counting system. The results of the excreta counting and the whole-body counting were compared to determine whether whole-body counting was a suitable surrogate for assessing excretion. Further whole-body retention counts were made at around 3, 4, 7 and 42 days following treatment. RESULTS Patterns of excretion and retention of Ra varied significantly between patients, but were similar for each patient's pair of treatments. The cumulative maximum activity excreted in the initial 8-h period following the Ra administration was 2.6% that increased to 39% at 48 h. The median excreted activity at ~1 and 6 weeks after treatment was 70 and 86%, respectively. Skeletal retention of Ra at 6 weeks ranged from 11 to 60% of the administered activity.
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Affiliation(s)
- Brenda E Pratt
- Joint Department of Physics, Royal Marsden Hospital and Institute of Cancer Research
| | - Cecilia Hindorf
- Joint Department of Physics, Royal Marsden Hospital and Institute of Cancer Research
| | - Sarah J Chittenden
- Joint Department of Physics, Royal Marsden Hospital and Institute of Cancer Research
| | | | - Glenn D Flux
- Joint Department of Physics, Royal Marsden Hospital and Institute of Cancer Research
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Trabulsi EJ, Jassak P, Tang H, Hwang S, Salinas GD. Therapeutic Patterns and Barriers to the Treatment of Advanced Prostate Cancer: A Survey of Academic and Community Urologists in the United States. UROLOGY PRACTICE 2018. [DOI: 10.1016/j.urpr.2016.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Edouard J. Trabulsi
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
- Astellas Pharma Global Development, Medical Affairs Americas, Northbrook, Illinois
- CE Outcomes, Birmingham, Alabama
| | - Patricia Jassak
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
- Astellas Pharma Global Development, Medical Affairs Americas, Northbrook, Illinois
- CE Outcomes, Birmingham, Alabama
| | - Hong Tang
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
- Astellas Pharma Global Development, Medical Affairs Americas, Northbrook, Illinois
- CE Outcomes, Birmingham, Alabama
| | - Sharon Hwang
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
- Astellas Pharma Global Development, Medical Affairs Americas, Northbrook, Illinois
- CE Outcomes, Birmingham, Alabama
| | - Gregory D. Salinas
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
- Astellas Pharma Global Development, Medical Affairs Americas, Northbrook, Illinois
- CE Outcomes, Birmingham, Alabama
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Aboagye E, Alger K, Archibald S, Bakar N, Barton N, Bergare J, Bloom J, Bragg R, Burke B, Burns M, Carroll L, Calatayud D, Cawthorne C, Cortezon-Tamarit F, Crean C, Crump M, Dilworth J, Domarkas J, Duckett S, Eggleston I, Elmore C, van Es E, Fekete M, Goodwin M, Green G, Grönberg G, Hayes C, Hayes M, Hollis S, Hueting R, Ivanov P, Johnston G, Kerr W, Kohler A, Knox G, Lawrie K, Lee R, Lewis W, Lin B, Lockley W, López-Torres E, Lv K, Maddocks S, Marsh B, Mendiola A, Mirabello V, Miranda C, Norcott P, O'Hagan D, Olaru A, Pascu S, Rayner P, Read D, Ridge K, Ritter T, Roberts I, Samuri N, Sarpaki S, Somers D, Taylor R, Tuttle T, Varcoe J, Willis C. Abstracts of the 25th
International Isotope Society (UK Group) symposium: Synthesis and applications of labelled compounds 2016. J Labelled Comp Radiopharm 2017. [DOI: 10.1002/jlcr.3523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Brito AE, Amorim BJ, Martello M, Bernardo WM, Etchebehere E. Prostate cancer – Therapy with radium-223. Rev Assoc Med Bras (1992) 2017; 63:1019-1023. [DOI: 10.1590/1806-9282.63.12.1019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2017] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Bárbara Juarez Amorim
- Universidade Estadual de Campinas, Brazil; Brazilian Society of Nuclear Medicine, Brazil
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31
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Optimal usage of radium-223 in metastatic castration-resistant prostate cancer. J Formos Med Assoc 2017; 116:825-836. [PMID: 29046247 DOI: 10.1016/j.jfma.2017.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 02/10/2017] [Accepted: 04/11/2017] [Indexed: 11/21/2022] Open
Abstract
Radium-223 is a first-in-class α-emitting radiopharmaceutical that targets bone metastases associated with metastatic castration-resistant prostate cancer (mCRPC). In the pivotal phase III trial ALSYMPCA, radium-223 significantly increased overall survival (OS), compared with placebo (median 14.9 vs 11.3 months; hazard ratio 0.70; 95% CI 0.58-0.83; p < 0.001), in patients with mCRPC and symptomatic bone metastases-with a comparable safety profile. To optimize treatment outcomes, selection of appropriate patients is important. As well as osteoblastic bone metastases, mCRPC patients should be well enough to receive six doses of radium-223 as this treatment duration has been shown to greatly improve OS outcomes compared with administration of four or fewer doses. Additionally, alkaline phosphatase and lactate dehydrogenase are emerging as important biomarkers during radium-223 treatment. Optimal concomitant standard-of-care therapies (such as abiraterone or enzalutamide) to be administered with radium-223 have yet to be defined as does the most efficacious dose and duration of radium-223 treatment. In conclusion, radium-223 is an important addition to the mCRPC treatment landscape and marks a paradigm shift in the treatment of bone metastases.
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Großer OS, Wissel H, Wallbaum T, Genseke P, Kupitz D, Ricke J, Ruf J, Amthauer H. Extraction of 223Radium by haemodialysis after treatment of metastatic castration-resistant prostate cancer. Nuklearmedizin 2017; 56:69-72. [PMID: 28383088 DOI: 10.3413/nukmed-0874-16-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 03/21/2017] [Indexed: 12/13/2022]
Abstract
AIM 223Radium-dichloride (223Ra) administration is an upcoming therapeutic option in patients with castration-resistant metastatic prostate cancer (mCRPC), whose renal and faecal excretion of 223Ra has been primarily estimated from data of a phase-I clinical trial in patients with normal renal function. In the rare case of concomitant renal insufficiency requiring haemodialysis (HD), an estimation of the contamination of dialysate would be beneficial. METHODS The excretion of 223Ra and its concentration in the dialysate in a patient with mCRPC and end-stage renal disease was examined for six consecutive treatment cycles. Dialysate samples were measured using a commercial system with NaI-scintillation detector. RESULTS HD showed a residual activity level in the remaining dialysate. The excreted activity was a median of 46.1 kBq (range = 42.0- 83.4 kBq) and 11.2 kBq (range = 8.4- 19.9 kBq) for the first (24 h post injection p.i.) and second HD (96 h p.i.), respectively. The activity concentration decreased significantly from a median of 4.18 kBq/l (range = 2.98-5.14 kBq/l) to 0.85 kBq/l (range = 0.69- 1.31 kBq/l, p < 0.0001). For all consecutive time points, the activity concentration further decreased significantly (p < 0.0001). The activity concentration of dialysate from HD performed 125.4 h p.i. [95 % confidence interval = 120.5-130.4 h p.i.] reached the threshold for unrestricted waste disposal. CONCLUSION The observed extraction of 223Ra by HD exceeded the data determined from the phase-I study. The activity concentration in the dialysate observed for the first HD's p.i. was above the threshold for unrestricted disposal of radioactive waste in Germany. Therefore, the specific requirement for waste handling has to be followed to fulfil the radiation protection regulations.
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Affiliation(s)
- Oliver Stephan Großer
- Oliver Stephan Großer, PhD, Klinik für Radiologie und Nuklearmedizin, Universitätsklinikum Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany, Tel: +49 391 67 13000, Fax: +49 391 67 13990, E-Mail:
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Picciotto M, Franchina T, Russo A, Ricciardi GRR, Provazza G, Sava S, Baldari S, Caffo O, Adamo V. Emerging role of Radium-223 in the growing therapeutic armamentarium of metastatic castration-resistant prostate cancer. Expert Opin Pharmacother 2017; 18:899-908. [DOI: 10.1080/14656566.2017.1323875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Maria Picciotto
- Medical Oncology Unit A.O. Papardo & Department of Human Pathology, University of Messina, Messina, Italy
| | - Tindara Franchina
- Medical Oncology Unit A.O. Papardo & Department of Human Pathology, University of Messina, Messina, Italy
| | - Alessandro Russo
- Medical Oncology Unit A.O. Papardo & Department of Human Pathology, University of Messina, Messina, Italy
| | | | - Giusy Provazza
- Medical Oncology Unit A.O. Papardo & Department of Human Pathology, University of Messina, Messina, Italy
| | - Serena Sava
- Medical Oncology Unit A.O. Papardo & Department of Human Pathology, University of Messina, Messina, Italy
| | - Sergio Baldari
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, Messina, Italy
| | - Orazio Caffo
- Medical Oncology Department, Santa Chiara Hospital, Trento, Italy
| | - Vincenzo Adamo
- Medical Oncology Unit A.O. Papardo & Department of Human Pathology, University of Messina, Messina, Italy
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Uemura H, Uemura H, Matsubara N, Kinuya S, Hosono M, Yajima Y, Doi T. Safety and efficacy of radium-223 dichloride in Japanese patients with castration-resistant prostate cancer and bone metastases. Int J Clin Oncol 2017; 22:954-963. [PMID: 28478485 PMCID: PMC5608784 DOI: 10.1007/s10147-017-1130-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 04/26/2017] [Indexed: 11/30/2022]
Abstract
Background Radiation therapy with radium-223 dichloride improves overall survival, reduces symptomatic skeletal events in Caucasian patients with castration-resistant prostate cancer (CRPC) and bone metastases, and is well tolerated. We report here the results of the first efficacy and safety study of radium-223 dichloride in a Japanese population. Methods In this open-label, uncontrolled, non-randomized, phase I trial, radium-223 dichloride was given to Japanese patients with CRPC and ≥2 bone metastases in 4-week cycles. The patients were divided into three cohorts, with cohort 1 and the expansion cohort receiving injections of radium-223 dichloride [55 kBq/kg body weight (BW)] every 4 weeks (Q4W) for up to six injections, and cohort 2 receiving an initial single radium-223 dichloride injection of 110 kBq/kg BW followed by up to five injections of 55 kBq/kg BW Q4W. Safety was determined via adverse event (AE) reporting, and biochemical bone markers were assessed for treatment efficacy. Results In total 19 patients received at least one dose of radium-223 dichloride and 18 patients experienced at least one treatment-emergent AE (TEAE) of which the most common were anemia, thrombocytopenia, and lymphocytopenia. Serious AEs were reported in three patients but none were drug-related. In the patients of cohort 1 + expansion cohort (55 kBq/kg BW Q4W treatment; n = 16), prostate-specific antigen levels remained stable or slightly increased while the bone alkaline phosphatase (ALP) level significantly decreased. The response rates of bone ALP (≥30 and ≥50% reductions) were 81.8 and 36.4% at week 12, and 81.3 and 50.0% at the end of treatment. Conclusions Radium-223 dichloride was well tolerated in these Japanese patients and, at a dose of 55 kBq/kg BW, efficacy on biomarkers was as expected. The outcomes in Japanese patients were consistent with those reported in other non-Japanese populations. Trial registration ClinicalTrials.gov record NCT01565746.
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Affiliation(s)
- Hiroji Uemura
- Department of Urology and Renal Transplantation, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, Japan.
| | - Hirotsugu Uemura
- Department of Urology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Nobuaki Matsubara
- Department of Breast and Medical Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Seigo Kinuya
- The Japanese Society of Nuclear Medicine, Tokyo, Japan
| | - Makoto Hosono
- The Japanese Society of Nuclear Medicine, Tokyo, Japan
| | - Yoko Yajima
- Clinical Development Specialty Medicine, Product Development, Bayer Yakuhin, Ltd., Tokyo, Japan
| | - Toshihiko Doi
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Japan
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Alva A, Nordquist L, Daignault S, George S, Ramos J, Albany C, Isharwal S, McDonald M, Campbell G, Danchaivijitr P, Yentz S, Anand A, Yu EY. Clinical Correlates of Benefit From Radium-223 Therapy in Metastatic Castration Resistant Prostate Cancer. Prostate 2017; 77:479-488. [PMID: 27990667 DOI: 10.1002/pros.23286] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/16/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND We sought to identify potential clinical variables associated with outcomes after radium-223 therapy in routine practice. METHODS Consecutive non-trial mCRPC patients who received ≥1 dose of radium dichloride-223 at four academic and one community urology-specific cancer centers from May 2013 to June 2014 were retrospectively identified. Association of baseline and on-therapy clinical variables with number of radium doses received and clinical outcomes including overall survival were analyzed using chi-square statistics, cox proportional hazards, and Kaplan-Meier methods. Bone Scan Index (BSI) was derived from available bone scans using EXINI software. RESULTS One hundred and forty-five patients were included. Radium-223 was administered for six cycles in 74 patients (51%). One-year survival in this heavily pre-treated population was 64% (95%CI: 54-73%). In univariate and multivariate analysis, survival was highly associated with receiving all six doses of Radium-223. Receipt of six doses was associated with ECOG PS of 0-1, lower baseline PSA & pain level, no prior abiraterone/enzalutamide, <5 BSI value, and normal alkaline phosphatase. In patients who reported baseline pain (n = 72), pain declined in 51% after one dose and increased in 7%. PSA declined ≥50% in 16% (18/110). Alkaline phosphatase declined ≥25% in 48% (33/69) and ≥50% in 16/69 patients. BSI declined in 17 (68%) of the 25 patients who had bone scan available at treatment follow-up. Grade ≥3 neutropenia, anemia, and thrombocytopenia occurred in 4% (n = 114), 4% (n = 125), and 5% (n = 123), respectively. CONCLUSIONS Patients earlier in their disease course with <5 BSI, low pain score, and good ECOG performance status are optimal candidates for radium-223. Radium-223 therapy is well tolerated with most patients reporting declines in pain scores and BSI. Prostate 77:479-488, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ajjai Alva
- Division of Hematology/Oncology, University of Michigan, Ann Arbor, Michigan
| | - Luke Nordquist
- Urology Cancer Center and GU Research Network, Omaha, Nebraska
| | - Stephanie Daignault
- Division of Hematology/Oncology, University of Michigan, Ann Arbor, Michigan
| | - Saby George
- Roswell Park Cancer Institute, Buffalo, New York
| | - Jorge Ramos
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Costantine Albany
- Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Indiana
| | - Sudhir Isharwal
- Urology Cancer Center and GU Research Network, Omaha, Nebraska
| | | | - Gregory Campbell
- Division of Hematology/Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Sarah Yentz
- Division of Hematology/Oncology, University of Michigan, Ann Arbor, Michigan
| | - Aseem Anand
- Department of Translational Medicine, Urological Cancer, Lund University, Lund, Sweden
| | - Evan Y Yu
- Fred Hutchinson Cancer Research Center, Seattle, Washington
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36
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Suominen MI, Fagerlund KM, Rissanen JP, Konkol YM, Morko JP, Peng Z, Alhoniemi EJ, Laine SK, Corey E, Mumberg D, Ziegelbauer K, Käkönen SM, Halleen JM, Vessella RL, Scholz A. Radium-223 Inhibits Osseous Prostate Cancer Growth by Dual Targeting of Cancer Cells and Bone Microenvironment in Mouse Models. Clin Cancer Res 2017; 23:4335-4346. [PMID: 28364014 DOI: 10.1158/1078-0432.ccr-16-2955] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/05/2017] [Accepted: 03/29/2017] [Indexed: 01/10/2023]
Abstract
Purpose: Radium-223 dichloride (radium-223, Xofigo), a targeted alpha therapy, is currently used for the treatment of patients with castration-resistant prostate cancer (CRPC) with bone metastases. This study examines the mode-of-action and antitumor efficacy of radium-223 in two prostate cancer xenograft models.Experimental Design: Mice bearing intratibial LNCaP or LuCaP 58 tumors were randomized into groups (n = 12-17) based on lesion grade and/or serum PSA level and administered radium-223 (300 kBq/kg) or vehicle, twice at 4-week intervals. X-rays and serum samples were obtained biweekly. Soft tissue tumors were observed macroscopically at sacrifice. Tibiae were analyzed by gamma counter, micro-CT, autoradiography and histology.Results: Radium-223 inhibited tumor-induced osteoblastic bone growth and protected normal bone architecture, leading to reduced bone volume in LNCaP and abiraterone-resistant LuCaP 58 models. Furthermore, radium-223 resulted in lower PSA values and reduced total tissue and tumor areas, indicating that treatment constrains prostate cancer growth in bone. In addition, radium-223 suppressed abnormal bone metabolic activity as evidenced by decreased number of osteoblasts and osteoclasts and reduced level of the bone formation marker PINP. Mode-of-action studies revealed that radium-223 was deposited in the intratumoral bone matrix. DNA double-strand breaks were induced in cancer cells within 24 hours after radium-223 treatment, and PSA levels were significantly lower 72 hours after treatment, providing further evidence of the antitumor effects.Conclusions: Taken together, radium-223 therapy exhibits a dual targeting mode-of-action that induces tumor cell death and suppresses tumor-induced pathologic bone formation in tumor microenvironment of osseous CRPC growth in mice. Clin Cancer Res; 23(15); 4335-46. ©2017 AACR.
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Affiliation(s)
| | | | | | | | | | - ZhiQi Peng
- Pharmatest Services Ltd., Turku, Finland
| | | | | | - Eva Corey
- Department of Urology, University of Washington, Seattle, Washington
| | - Dominik Mumberg
- Bayer AG, Pharmaceuticals Division, Drug Discovery, Therapeutic Research Groups Oncology, Berlin, Germany
| | - Karl Ziegelbauer
- Bayer AG, Pharmaceuticals Division, Drug Discovery, Therapeutic Research Groups Oncology, Berlin, Germany
| | - Sanna-Maria Käkönen
- Aurexel Life Sciences Ltd., Askainen, Finland.,Department of Cell Biology and Anatomy, University of Turku, Turku, Finland
| | | | - Robert L Vessella
- Department of Urology, University of Washington, Seattle, Washington
| | - Arne Scholz
- Bayer AG, Pharmaceuticals Division, Drug Discovery, Therapeutic Research Groups Oncology, Berlin, Germany.
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Liberal FDCG, Tavares AAS, Tavares JMRS. Computational modeling of radiobiological effects in bone metastases for different radionuclides. Int J Radiat Biol 2017; 93:627-636. [PMID: 28276897 DOI: 10.1080/09553002.2017.1294274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Computational simulation is a simple and practical way to study and to compare a variety of radioisotopes for different medical applications, including the palliative treatment of bone metastases. This study aimed to evaluate and compare cellular effects modelled for different radioisotopes currently in use or under research for treatment of bone metastases using computational methods. METHODS Computational models were used to estimate the radiation-induced cellular effects (Virtual Cell Radiobiology algorithm) post-irradiation with selected particles emitted by Strontium-89 (89Sr), Samarium-153 (153Sm), Lutetium-177 (177Lu), and Radium-223 (223Ra). RESULTS Cellular kinetics post-irradiation using 89Sr β- particles, 153Sm β- particles, 177Lu β- particles and 223Ra α particles showed that the cell response was dose- and radionuclide-dependent. 177Lu beta minus particles and, in particular, 223Ra alpha particles, yielded the lowest survival fraction of all investigated particles. CONCLUSIONS 223Ra alpha particles induced the highest cell death of all investigated particles on metastatic prostate cells in comparison to irradiation with β- radionuclides, two of the most frequently used radionuclides in the palliative treatment of bone metastases in clinical routine practice. Moreover, the data obtained suggest that the used computational methods might provide some perception about cellular effects following irradiation with different radionuclides.
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Affiliation(s)
- Francisco D C Guerra Liberal
- a Faculdade de Engenharia , Instituto de Ciência e Inovação em Engenharia Mecânica e Engenharia Industrial, Universidade do Porto , Porto , Portugal
| | - Adriana Alexandre S Tavares
- a Faculdade de Engenharia , Instituto de Ciência e Inovação em Engenharia Mecânica e Engenharia Industrial, Universidade do Porto , Porto , Portugal
| | - João Manuel R S Tavares
- a Faculdade de Engenharia , Instituto de Ciência e Inovação em Engenharia Mecânica e Engenharia Industrial, Universidade do Porto , Porto , Portugal
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38
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Poorthuis MHF, Vernooij RWM, van Moorselaar RJA, de Reijke TM. First-line non-cytotoxic therapy in chemotherapy-naive patients with metastatic castration-resistant prostate cancer: a systematic review of 10 randomised clinical trials. BJU Int 2017; 119:831-845. [PMID: 28063195 DOI: 10.1111/bju.13764] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The aim of this study is to systematically evaluate all available treatment options in chemotherapy-naive patients with metastatic castration-resistant prostate cancer (mCRPC). We systematically searched PubMed, EMBASE, and the Cochrane libraries up to 1 March 2016 for peer-reviewed publications on randomised clinical trials (RCTs). RCTs were included if progression-free survival (PFS), overall survival (OS), quality of life (QoL), or adverse events (AEs) were quantitatively evaluated. We assessed the risk of bias with the Cochrane Collaboration's tool and graded the evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group's approach. We included 25 articles, reporting on 10 unique RCTs describing seven different comparisons. In one RCT, a prolonged OS and PFS (high quality) were found with abiraterone and prednisone compared to placebo plus prednisone. In one RCT, a prolonged OS and PFS (high quality) were found with enzalutamide compared to placebo. In two RCTs, a prolonged OS (high and moderate quality) was found with 223 radium compared to placebo, but its effect on PFS is unknown. In three RCTs, a prolonged OS (moderate quality) was found with sipuleucel-T compared to placebo, but no prolonged PFS (low quality). In one RCT a prolonged PFS (high quality) was found with orteronel compared to placebo, but no prolonged OS (moderate quality). In one RCT, a prolonged OS (moderate quality) was found with bicalutamide compared to placebo, but its effect on PFS is unknown. In one RCT, a prolonged PFS (high quality) was found with enzalutamide compared to bicalutamide, but its effect on OS is unknown. The best evidence was found for abiraterone and enzalutamide for effective prolongation of OS and PFS to treat chemotherapy-naive patients with mCRPC. However, taking both QoL and AEs into consideration, other treatment modalities could be considered for individual patients.
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Affiliation(s)
- Michiel H F Poorthuis
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Robin W M Vernooij
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | | | - Theo M de Reijke
- Department of Urology, Academic Medical Center, Amsterdam, The Netherlands
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Armstrong AJ, Saad F, Phung D, Dmuchowski C, Shore ND, Fizazi K, Hirmand M, Forer D, Scher HI, Bono JD. Clinical outcomes and survival surrogacy studies of prostate-specific antigen declines following enzalutamide in men with metastatic castration-resistant prostate cancer previously treated with docetaxel. Cancer 2017; 123:2303-2311. [PMID: 28171710 PMCID: PMC5484320 DOI: 10.1002/cncr.30587] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 12/15/2016] [Accepted: 12/23/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND In the AFFIRM trial, enzalutamide significantly increased overall survival (OS) for men with metastatic castration‐resistant prostate cancer (mCRPC) after chemotherapy versus placebo and significantly decreased prostate‐specific antigen (PSA) levels. The goal of this post hoc analysis was to associate levels of PSA decline from baseline after enzalutamide with clinical outcomes in the postchemotherapy mCRPC setting. METHODS Men in the AFFIRM trial (n = 1199) were grouped by maximal PSA decline in the first 90 days of treatment. Kaplan‐Meier estimates evaluated the association of defined PSA changes from baseline with OS, progression‐free survival (PFS), radiographic PFS (rPFS), and pain response. Each PSA decline category was assessed for OS surrogacy using Prentice criteria, proportion of treatment effect explained (PTE), and proportion of variation explained. RESULTS Men treated with enzalutamide had improved OS (hazard ratio, 0.63; P < .001) and higher rates of PSA decline (odds ratio, >19.0; P < .001) versus placebo. PSA declines of any, ≥30%, ≥50%, and ≥90% with enzalutamide were strongly associated with greater OS, PSA PFS, rPFS (P < .001), and pain response (P < .026) versus PSA increase/no decline. Any, ≥30%, and ≥50% declines in PSA resulted in the PTE range of 1.07‐1.29, where treatment was no longer significant after adjustment for decline measures (P > .20). CONCLUSIONS PSA declines of any, ≥30%, and ≥50% following enzalutamide were associated with greater clinical and pain response and improvements in PFS and OS. Surrogacy of PSA decline for OS was not fully established, possibly due to lack of PSA declines with placebo, and discordant results between PSA and imaging responses over time, and because some declines were not durable due to rapid resistance development. However, a lack of PSA decline by 90 days following enzalutamide treatment was a poor prognosis indicator in this setting. Conclusions from sensitivity analyses of maximal PSA decline from baseline over the entire treatment period are consistent with PSA declines restricted to the first 90 days. Cancer 2017;123:2303–2311. © 2017 American Cancer Society. A post hoc analysis of the randomized, double‐blind AFFIRM trial revealed that postenzalutamide prostate‐specific antigen declines of any, ≥30%, and ≥50% are associated with greater clinical and pain response. The decline criteria explain a large proportion of treatment effect on survival improvements but do not fulfill the criteria for surrogacy.
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Affiliation(s)
| | - Fred Saad
- Centre Hospitalier de l'Université de Montréal and CRCHUM, Montreal, Quebec, Canada
| | - De Phung
- Astellas Pharma, Inc., Leiden, Netherlands
| | | | - Neal D Shore
- Carolina Urologic Research Center, Myrtle Beach, South Carolina
| | - Karim Fizazi
- Institut Gustave Roussy, University of Paris Sud, Paris, France
| | | | | | - Howard I Scher
- Sidney Kimmel Center for Prostate and Urologic Cancers and Memorial Sloan-Kettering Cancer Center, New York, New York
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Alibhai SMH, Zukotynski K, Walker-Dilks C, Emmenegger U, Finelli A, Morgan SC, Hotte SJ, Winquist E. Bone Health and Bone-targeted Therapies for Prostate Cancer: a Programme in Evidence-based Care - Cancer Care Ontario Clinical Practice Guideline. Clin Oncol (R Coll Radiol) 2017; 29:348-355. [PMID: 28169118 DOI: 10.1016/j.clon.2017.01.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/19/2016] [Accepted: 01/02/2017] [Indexed: 12/12/2022]
Abstract
AIMS To make recommendations with respect to bone health and bone-targeted therapies in men with prostate cancer. MATERIALS AND METHODS A systematic review was carried out by searching MEDLINE, EMBASE and the Cochrane Library from inception to January 2016. Systematic reviews and randomised-controlled trials were considered for inclusion if they involved therapies directed at improving bone health or outcomes such as skeletal-related events, pain and quality of life in patients with prostate cancer either with or without metastases to bone. Therapies included medications, supplements or lifestyle modifications alone or in combination and were compared with placebo, no treatment or other agents. Disease-targeted agents such as androgen receptor-targeted and chemotherapeutic agents were excluded. Recommendations were reviewed by internal and external review groups. RESULTS In men with prostate cancer receiving androgen deprivation therapy, baseline bone mineral density testing is encouraged. Denosumab should be considered for reducing the risk of fracture in men on androgen deprivation therapy with an increased fracture risk. Bisphosphonates were effective in improving bone mineral density, but the effect on fracture was inconclusive. No medication is recommended to prevent the development of first bone metastasis. Denosumab and zoledronic acid are recommended for preventing or delaying skeletal-related events in men with metastatic castration-resistant prostate cancer. Radium-223 is recommended for reducing symptomatic skeletal events and prolonging survival in men with symptomatic metastatic castration-resistant prostate cancer. CONCLUSIONS The recommendations represent a current standard of care that is feasible to implement, with outcomes valued by clinicians and patients.
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Affiliation(s)
- S M H Alibhai
- Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - K Zukotynski
- Departments of Medicine and Radiology, McMaster University, Hamilton, Ontario, Canada.
| | - C Walker-Dilks
- Department of Oncology, Program in Evidence-Based Care, McMaster University, Hamilton, Ontario, Canada
| | - U Emmenegger
- Department of Medicine, Division of Medical Oncology, University of Toronto, Odette Cancer Centre, Toronto, Ontario, Canada
| | - A Finelli
- Department of Surgery, Division of Urology, University of Toronto, Princess Margaret Hospital, Toronto, Ontario, Canada
| | - S C Morgan
- Department of Radiology, Division of Radiation Oncology, University of Ottawa, The Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | - S J Hotte
- Department of Oncology, Division of Medical Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - E Winquist
- Department of Oncology, Division of Medical Oncology, Western University, London Health Sciences Centre, London, Ontario, Canada
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Radium-223 Therapy for Patients with Metastatic Castrate-Resistant Prostate Cancer: An Update on Literature with Case Presentation. INTERNATIONAL JOURNAL OF MOLECULAR IMAGING 2016; 2016:2568031. [PMID: 27774318 PMCID: PMC5059539 DOI: 10.1155/2016/2568031] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/29/2016] [Indexed: 12/20/2022]
Abstract
Background and Purpose. Radium-223 dichloride (Xofigo®, Bayer HealthCare Pharmaceuticals Inc.) is the first α-particle emitter therapeutic agent approved by the FDA, with benefits in overall survival and delay in symptomatic skeletal event for patients with metastatic castrate-resistant prostate cancer (CRPC). Recent post hoc analyses of the phase III ALSYMPCA trial support the previously established safety profile as well as therapeutic effect and clinical outcome of Radium-223. Currently, Radium-223 is approved as a single agent therapy for metastatic CRPC. Clinical trials are currently investigating Radium-223 in additional clinical settings such as earlier asymptomatic disease and in combination with other agents including hormonal therapeutic agents and immunotherapeutic as well as chemotherapeutic agents. Trials are also ongoing in patients with other primary cancers such as breast cancer, thyroid cancer, and renal cancer metastatic to bone. In this article, the physics and radiobiology, as well as a literature update on the use of Radium-223, are provided along with case presentations, aiming at a better appreciation of research data as well as the assimilation of research data into clinical practice.
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42
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Prostate cancer perspectives after chaarted: Optimizing treatment sequence. Crit Rev Oncol Hematol 2016; 107:119-127. [PMID: 27823639 DOI: 10.1016/j.critrevonc.2016.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 06/29/2016] [Accepted: 08/18/2016] [Indexed: 11/21/2022] Open
Abstract
Prostate cancer is the most frequent cancer amongst men. Until recently, only two therapeutic options, initial androgen-deprivation therapy in patients without castration-resistant prostate cancer, with addition of docetaxel when the disease becomes castration-resistant, were considered as standard. In the last years, new drugs (abiraterone, enzalutamide, Ra-223, Sipuleucel) have been developed for prostate cancer treatment with important advantages in safety and efficacy. Results from the recent Chaarted study, in patients that received docetaxel for the hormone sensitive disease, have contributed to change the initial treatment approach in metastatic prostate cancer, in order to adapt the best sequence for each patient. Those results have been supported by the Stampede trial. Stampede survival data showed not only a benefit in overall survival of adding docetaxel initially, but also a prolonged time to first skeletal related event. Now it is discussed in which setting the available drugs should be administered. This review article summarizes the treatment options for patients treated with docetaxel initially for hormone sensitive prostate cancer after developing progressive disease, and offers an algorithm proposal for treatment.
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Lutz S, Balboni T, Jones J, Lo S, Petit J, Rich SE, Wong R, Hahn C. Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline. Pract Radiat Oncol 2016; 7:4-12. [PMID: 27663933 DOI: 10.1016/j.prro.2016.08.001] [Citation(s) in RCA: 287] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/15/2016] [Accepted: 08/03/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE The purpose is to provide an update the Bone Metastases Guideline published in 2011 based on evidence complemented by expert opinion. The update will discuss new high-quality literature for the 8 key questions from the original guideline and implications for practice. METHODS AND MATERIALS A systematic PubMed search from the last date included in the original Guideline yielded 414 relevant articles. Ultimately, 20 randomized controlled trials, 32 prospective nonrandomized studies, and 4 meta-analyses/pooled analyses were selected and abstracted into evidence tables. The authors synthesized the evidence and reached consensus on the included recommendations. RESULTS Available literature continues to support pain relief equivalency between single and multiple fraction regimens for bone metastases. High-quality data confirm single fraction radiation therapy may be delivered to spine lesions with acceptable late toxicity. One prospective, randomized trial confirms both peripheral and spine-based painful metastases can be successfully and safely palliated with retreatment for recurrence pain with adherence to published dosing constraints. Advanced radiation therapy techniques such as stereotactic body radiation therapy lack high-quality data, leading the panel to favor its use on a clinical trial or when results will be collected in a registry. The panel's conclusion remains that surgery, radionuclides, bisphosphonates, and kyphoplasty/vertebroplasty do not obviate the need for external beam radiation therapy. CONCLUSION Updated data analysis confirms that radiation therapy provides excellent palliation for painful bone metastases and that retreatment is safe and effective. Although adherence to evidence-based medicine is critical, thorough expert radiation oncology physician judgment and discretion regarding number of fractions and advanced techniques are also essential to optimize outcomes when considering the patient's overall health, life expectancy, comorbidities, tumor biology, anatomy, previous treatment including prior radiation at or near current site of treatment, tumor and normal tissue response history to local and systemic therapies, and other factors related to the patient, tumor characteristics, or treatment.
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Affiliation(s)
- Stephen Lutz
- Department of Radiation Oncology, Eastern Woods Radiation Oncology, 15990 Medical Drive South, Findlay, Ohio 45840.
| | - Tracy Balboni
- Department of Radiation Oncology, and Department of Psychosocial Oncology and Palliative Care Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joshua Jones
- Department of Radiation Oncology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Simon Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Joshua Petit
- Department of Radiation Oncology, University of Colorado Health, Fort Collins, Colorado
| | - Shayna E Rich
- Hospice and Palliative Medicine, Mayo Clinic College of Medicine, Jacksonville, Florida
| | - Rebecca Wong
- Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Carol Hahn
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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Disassembly of old radium sources and conversion of radium sulfate into radium carbonate for subsequent dissolution in acid. J Radioanal Nucl Chem 2016. [DOI: 10.1007/s10967-016-4927-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Cabrera ME, Rey PM, Carrió I, Montes A, López DA. Response to 223Ra-dichloride in castration-resistant prostate cancer with bone metastasis: A case report. Oncol Lett 2016; 12:1323-1328. [PMID: 27446432 PMCID: PMC4950721 DOI: 10.3892/ol.2016.4762] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 04/29/2016] [Indexed: 11/14/2022] Open
Abstract
Painful bone metastases are common in prostate cancer, with current treatments including non-steroidal analgesics and opiates, surgery, external beam radiotherapy and bone-targeting β-emitting radiopharmaceuticals. The α-emitting isotope 223Ra-dichloride (Ra-223) has been associated with improved overall survival and increased time to first skeletal-related events in patients with castration-resistant prostate cancer (CRPC) presenting with symptomatic bone metastases. The current study reports the case of a 70-year-old male patient, who was diagnosed with prostate cancer in 1999 upon presentation with increased prostate-specific antigen (PSA) levels and painful bone metastases in the context of CRPC. In November 2010, subsequent to undergoing hormonal blockage, the patient was treated with ketoconazole (200 mg/8 h) followed by 10 cycles of docetaxel (75 mg/m2 every 3 weeks). Following disease progression, the patient received 6 doses of Ra-223 (50 kBq/kg; 1 dose/4 weeks). During this treatment period, an improvement in the patient's symptoms, and levels of bone alkaline phosphatase (BAP) and PSA were noted. Furthermore, Ra-223 was well-tolerated without any relevant bone marrow toxicity. However, 2 months after the administration of the final dose of Ra-223, PSA and BAP levels increased again, and bone pain deteriorated. A bone scan showed stable disease in the previously observed metastatic lesions; however, new lesions simultaneously appeared in different locations, indicating progressive disease.
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Affiliation(s)
- Montserrat Estorch Cabrera
- Department of Nuclear Medicine, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, 08025 Barcelona, Spain
| | - Pablo Maroto Rey
- Department of Medical Oncology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, 08025 Barcelona, Spain
| | - Ignasi Carrió
- Department of Nuclear Medicine, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, 08025 Barcelona, Spain
| | - Alberto Montes
- Department of Nuclear Medicine, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, 08025 Barcelona, Spain
| | - Diego Alonso López
- Department of Nuclear Medicine, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, 08025 Barcelona, Spain
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Radium-223 dichloride in clinical practice: a review. Eur J Nucl Med Mol Imaging 2016; 43:1896-909. [DOI: 10.1007/s00259-016-3386-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 03/29/2016] [Indexed: 02/06/2023]
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Liepe K, Shinto A. From palliative therapy to prolongation of survival: (223)RaCl2 in the treatment of bone metastases. Ther Adv Med Oncol 2016; 8:294-304. [PMID: 27482288 DOI: 10.1177/1758834016640494] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patients with hormone-refractory prostate cancer often have multiple bone metastases. The resulting bone pain is associated with reduced life quality, increased cost of therapy and impairment of overall survival. Trials with bone-targeting β-emitters have mostly showed an effect on alleviation of bone pain along with prolongation in survival, documented in only a limited number of patients. A randomized phase III trial (ALSYMPCA) using the α-emitter (223)RaCl2 (Xofigo®) showed for the first time, a longer overall survival of 3.6 months in treated patients as a sign of an antitumor effect. The time to first skeletal-related events was also significantly longer in the therapy group compared with placebo. Because of the short range of α-emitter, the bone marrow toxicity of radium therapy is low, and so this radionuclide could also be a candidate for combination with chemotherapy. The elimination of (223)RaCl2 is mainly through the gastrointestinal tract and side effects are mainly in this area. The procedure is similar to treatment with other bone-seeking agents and consists of six administrations of 50 kBq/kg bodyweight Xofigo®, repeated every 4 weeks. At present Xofigo® is only approved for hormone-refractory prostate cancer.
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Affiliation(s)
- Knut Liepe
- Department of Nuclear Medicine, GH Hospital Frankfurt (Oder), Müllroser Chaussee 7, 15236 Frankfurt (Oder), Germany
| | - Ajit Shinto
- Department of Nuclear Medicine, Kovai Medical Centre and Hospital, Coimbatore, India
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Palliative treatment of metastatic bone pain with radiopharmaceuticals: A perspective beyond Strontium-89 and Samarium-153. Appl Radiat Isot 2016; 110:87-99. [DOI: 10.1016/j.apradiso.2016.01.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 12/04/2015] [Accepted: 01/04/2016] [Indexed: 11/22/2022]
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El-Amm J, Aragon-Ching JB. Targeting Bone Metastases in Metastatic Castration-Resistant Prostate Cancer. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2016; 10:11-9. [PMID: 27042152 PMCID: PMC4807885 DOI: 10.4137/cmo.s30751] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/25/2016] [Accepted: 01/27/2016] [Indexed: 12/01/2022]
Abstract
Skeletal involvement in metastatic castrate-resistant prostate cancer (mCRPC) is common and results in significant morbidity and mortality. The interaction of prostate cancer with the bone microenvironment contributes to progression of cancer in the bone leading to skeletal-related events (SREs). Studies aimed at targeting the bone have been carried out over the recent years. Bisphosphonates are synthetic pyrophosphate analogs first investigated for their role in SRE prevention with zoledronic acid as the main bisphosphonate that is approved by the US Food and Drug Administration for retardation of skeletal events in men with metastatic prostate cancer. Denosumab is another bone-targeted agent against uncontrolled osteolysis and serves as a RANK ligand inhibitor, superior to zoledronic acid in delaying SREs. Radiopharmaceuticals have played a role in targeting the bone microenvironment mainly in pain palliation in mCRPC utilizing strontium or samarium in the remote past, but only radium-223 is the first radiopharmaceutical that has yielded improvement in overall survival. The combination and sequencing strategies of these agents is the subject of multiple ongoing trials to guide the best use of these emerging agents.
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Affiliation(s)
- Joelle El-Amm
- The Lebanese American University, Department of Hematology and Oncology, Division of Internal Medicine, Beirut, Lebanon
| | - Jeanny B Aragon-Ching
- Clinical Program Director of Genitourinary Cancers, Inova Dwight and Martha Schar Cancer Institute, Fairfax, VA, USA
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Modi D, Hwang C, Mamdani H, Kim S, Gayar H, Vaishampayan U, Joyrich R, Heath EI. Radium-223 in Heavily Pretreated Metastatic Castrate-Resistant Prostate Cancer. Clin Genitourin Cancer 2016; 14:373-380.e2. [PMID: 27053499 DOI: 10.1016/j.clgc.2016.03.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/21/2016] [Accepted: 03/02/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Radium-223 is a bone-targeting radiopharmaceutical that extends survival in mCRPC. Postapproval data are limited, and the value of biochemical and radiologic monitoring during radium therapy is unknown. PATIENTS AND METHODS We conducted a retrospective study of 29 patients with mCRPC who received radium-223 at 1 of 3 participating institutions between August 2013 and December 2014. Trend of PSA, radiographic changes, and association of biochemical and clinical variables with PSA trend were measured. RESULTS The median age of patients was 70 years, 79% of patients (N = 23) were European Americans, and 17% of patients (N = 5) were African Americans. Twenty patients (69%) had received at least 3 lines of prior therapies. Some 38% of patients (N = 11) received all 6 cycles of radium-223. Twenty patients (69%) had an increase in PSA during radium therapy, and 4 patients (14%) had a decline in PSA levels. Five patients had visceral metastases on computed tomography imaging performed during the course of radium-223. CONCLUSIONS Radium therapy in mCRPC was associated with an increase in PSA in the majority of these heavily pretreated patients. The development of visceral disease was not uncommon, suggesting a need for follow-up computed tomography monitoring during radium-223 therapy. The significance of early increases in PSA and pain with radium-223 is still uncertain. Although pain and PSA flare have been reported in patients who subsequently have a dramatic response to therapy, we observed that a PSA increase or pain flare correlates to an improvement in bone scans only in a minority of patients.
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Affiliation(s)
- Dipenkumar Modi
- Department of Internal Medicine, University Health Center, Wayne State University/Detroit Medical Center, Detroit, MI
| | - Clara Hwang
- Department of Hematology-Oncology, Henry Ford Health System, Detroit, MI
| | - Hirva Mamdani
- Department of Hematology-Oncology, Indiana University, Indianapolis, IN
| | - Seongho Kim
- Biostatistics Core, Department of Oncology, Karmanos Cancer Institute, School of Medicine, Wayne State University, Detroit, MI
| | - Hesham Gayar
- Department of Radiation Oncology, McLaren Cancer Institute, Flint, MI
| | - Ulka Vaishampayan
- Department of Hematology-Oncology, Karmanos Cancer Institute/Wayne State University, Detroit, MI
| | - Richard Joyrich
- Department of Nuclear Medicine, Wayne State University, Detroit, MI
| | - Elisabeth I Heath
- Department of Hematology-Oncology, Karmanos Cancer Institute/Wayne State University, Detroit, MI.
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