Strontium-89 chloride (Metastron) for palliative treatment of bony metastases. The University of Minnesota experience

Chinese Expert Consensus on the Diagnosis and Treatment of Castration-Resistant Prostate Cancer (2019 Update)

Currently, the basic treatment of advanced prostate cancer is still endocrine therapy, but almost all patients eventually progress to castration-resistant prostate cancer (CRPC). In 2016, the Chinese Expert Consensus on the Diagnosis and Treatment of CRPC which aimed to help Chinese clinicians formulate treatment plans for CRPC was published. In this 2019 update, the 2016 version was updated with the aim of providing a more appropriate reference for clinical practice, standardizing CRPC patient management, and facilitating decision-making. The consensus is evidence-based and reviews the optimal therapeutic recommendations for CRPC management in China by taking into consideration the clinical characteristics of Chinese patients; drug availability, efficacy and safety; and recent advancements and developments in the international medical arena.

Spinal Metastatic Disease: A Review of the Role of the Multidisciplinary Team

Historically, a simple approach centered on palliation was applicable to the majority of patients with metastatic spinal disease. With advances in diagnosis and treatment, a more complicated algorithm has devolved requiring a multidisciplinary approach with institutional commitment and support. We performed a database review including pertinent articles exploring the multidisciplinary management of spinal metastatic disease. The wide variation in clinical presentation and tumor response to treatment necessitates a multidisciplinary approach that integrates the diagnosis and treatment of the cancer, symptom management, and rehabilitation for optimal care of patients with spinal metastases. Advances in the field of radiology have led to earlier and more focused diagnosis of spinal metastasis and acts to guide therapy. Advances in surgical techniques, neurophysiologic monitoring, and anesthetic expertise have allowed surgeons to perform more extensive procedures leading to improved outcomes and reduced morbidity. Radiation oncology input that is essential as external beam radiation therapy can provide significant pain relief. Non-operative measures may include bisphosphonate infusions, management of complications (e.g. hypercalcemia of malignancy), monoclonal antibody infusions, and chemotherapy if indicated in the treatment of the primary malignancy. Input from psychology services is necessary to address the biopsychosocial ramifications of spinal metastasis. Allied health professionals in the form of physiotherapists, social workers, and dieticians also contribute in maximizing patients' quality of life and well-being.

Radiopharmaceuticals for the palliation of painful bone metastases

Metastatic bone pain is prevalent in advanced cancer, and, despite a plethora of available therapies, effective palliation remains a clinical challenge. Bone-seeking radiopharmaceuticals are an often-overlooked but valuable analgesic option for select patients. These agents work by binding to hydroxyapatite at the tumor-bone interface of osteoblastic lesions, delivering therapeutic doses of radiation to closely circumscribed tissue regions. They have been shown to reduce pain and improve quality of life. Their safety, simplicity, convenience of administration, and cost-effectiveness make them suitable for hospice and palliative care settings.

The role of radiation therapy in the treatment of metastatic castrate-resistant prostate cancer

In the setting of castrate-resistant prostate cancer, patients present with a variety of symptoms, including bone metastases, spinal cord compression and advanced pelvic disease. Fortunately, a variety of radiotherapeutic options exist for palliation. This article focuses on these options, including both external beam radiotherapy and radiopharmaceuticals.

Palliative effects and adverse events of strontium-89 for prostate cancer patients with bone metastasis

The aim of the present study was to evaluate the palliative effects and adverse events of strontium-89 (Sr-89) in patients with bone metastasis from prostate cancer. A total of 18 patients with prostate cancer and painful bone metastases, as diagnosed on bone scintigraphy, who were treated with Sr-89 at the National Kyushu Cancer Center between February, 2008 and April, 2014 were reviewed. Of the 18 subjects, 13 (72.2%) achieved a pain response, whereas 5 were classified as pain non-responders (27.8%). According to a logistic regression analysis, the pre-administration characteristics, including age, prostate-specific antigen (PSA), alkaline phosphatase (ALP), history of bone-modifying agent administration, opioid use or palliative radiation therapy, time after the combined androgen blockade nadir and time since the pain onset, were not found to be significant predictors of the pain response. Similarly, the post-administration characteristics, including pain flares and the PSA and ALP response, were not found to be significant predictors of the pain response. Although no patients exhibited leukocyte toxicities, 2 patients experienced myelosuppression, involving anemia and thrombocytopenia, requiring transfusion of red cell or platelet concentrate following Sr-89 treatment. Of the 18 patients, 5 (27.8%) reported pain flares, all of whom were successfully treated with rescue drugs alone. According to the logistic regression analysis, of the pre-administration characteristics, only ALP was identified as a significant predictor of bone marrow suppression in the univariate and multivariate analyses (P=0.006). Therefore, Sr-89 treatment was found to be effective in ameliorating bone pain associated with metastasis from prostate cancer. Although it is difficult to identify the patients who will receive pain relief prior to Sr-89 administration, this drug should be administered during the early stages due to the potential for bone marrow suppression in patients with high ALP levels.

Effective use of strontium-89 in osseous metastases

Bone is one of the organs to which cancer metastasizes most frequently. However, it is not a vital organ, therefore, survival after the occurrence of osseous metastasis is relatively favorable. Improvements of medical treatment bring prolonged survival to patients with osseous metastases. But this makes us to recognize the importance of quality of life (QOL) due to several factors, including pain. It is important for oncologists to know how to deal with such painful osseous metastases, as pain relief may enable patients to live their remaining lives to the fullest. Strontium-89 (89Sr) has been used worldwide as in Japan, while being reported to have positive effects on pain relief and QOL improvement in patients with osseous metastases. This review paper is aimed to present not only the history, roles, and medical characters of 89Sr, but also new aspects, such as how to use bone turnover markers, which location of osseous metastases is suitable for effective use of 89Sr.

Continuing pursuit for ideal systemic anticancer radiotherapeutics

Cancer is one of the major causes of death for non-transmissible chronic diseases worldwide. Conventional treatments including surgery, chemotherapy and external beam radiotherapy are generally far from curative. Complementary therapies are attempted for achieving more successful treatment response. Systemic targeted radiotherapy (STR) is a radiotherapeutic modality based on systemic administration of radioactive agents for selectively delivering high doses of energy to destroy cancer cells. For this purpose, diverse tumour-target specific agents including monoclonal antibodies (MoAb), MoAb fragments and peptides have been tested and some of them have already got FDA approval for clinical use. However, MoAbs and their tailored analogues have shown non-homogeneous tumour distribution, limited diffusion, insufficient intratumoral accumulation and retention, unwanted uptake in normal tissues and scarcity of identified cancer antigens for generating new MoAbs. Similarly, peptides have also exhibited retention in normal organs, lacks of favourable membrane permeability or drug cell internalization and short-term residence in cancer cells. Recently, a new category of target-specific agent with strong affinity for necrosis has emerged as an excellent option for developing targeted radiotherapeutic agents to be used after necrosis-inducing treatments (NITs). The combination of their high, specific and long-term accumulation and retention at necrotic sites with the crossfire effect of ionizing particle-emitters allows irradiating adjacent residual viable tumour cells during a prolonged period of time. It may considerably enhance the therapeutic response and open a new horizon for improved cancer treatability or curability.

Palliation and survival after repeated (188)Re-HEDP therapy of hormone-refractory bone metastases of prostate cancer: a retrospective analysis

This retrospective study compared the effects of single and multiple administrations of (186)Re-hydroxyethylidenediphosphonate ((186)Re-HEDP) on palliation and survival of prostate cancer patients presenting with more than 5 skeletal metastases.

METHODS

A total of 60 patients were divided into 3 groups. Group A (n = 19) consisted of patients who had received a single injection; group B (n = 19), patients who had 2 injections; and group C (n = 22), patients who had 3 or more successive injections. The (188)Re-HEDP was prepared using non-carrier-added (188)Re obtained from an in-house (188)W/(188)Re generator after dilution with carrier perrhenate. Patients' data available from the referring physicians-including prostate-specific antigen levels-were entered into a Windows-based matrix and analyzed using a statistical program. The Gleason scores were similar for all 3 groups.

RESULTS

Mean survival from the start of treatment was 4.50 ± 0.81 mo (95% confidence interval [CI], 2.92-6.08) for group A, 9.98 ± 2.21 mo (95% CI, 5.65-14.31) for group B, and 15.66 ± 3.23 (95% CI, 9.33-22.0) for group C. Although the 3 groups did not differ in Gleason score, the number of lost life-years was significantly lower in group C than in groups A and B. Pain palliation was achieved in 89.5% of group A, 94.7% of group B, and 90.9% of group C.

CONCLUSION

Posttreatment overall survival could be improved from 4.50 to 15.66 mo by multiple-injection bone-targeted therapy with (188)Re-HEDP, when compared with a single injection. Significant pain palliation was common and independent of administration frequency.

Systemic metabolic radiopharmaceutical therapy in the treatment of metastatic bone pain

Bone pain due to skeletal metastases constitutes the most common type of chronic pain among patients with cancer. It significantly decreases the patient's quality of life and is associated with comorbidities, such as hypercalcemia, pathologic fractures and spinal cord compression. Approximately 65% of patients with prostate or breast cancer and 35% of those with advanced lung, thyroid, and kidney cancers will have symptomatic skeletal metastases. The management of bone pain is extremely difficult and involves a multidisciplinary approach, which usually includes analgesics, hormone therapies, bisphosphonates, external beam radiation, and systemic radiopharmaceuticals. In patients with extensive osseous metastases, systemic radiopharmaceuticals should be the preferred adjunctive therapy for pain palliation. In this article, we review the current approved radiopharmaceutical armamentarium for bone pain palliation, focusing on indications, patient selection, efficacy, and different biochemical characteristics and toxicity of strontium-89 chloride, samarium-153 lexidronam, and rhenium-186 etidronate. A brief discussion on the available data on rhenium-188 is presented focusing on its major advantages and disadvantages. We also perform a concise appraisal of the other available treatment options, including pharmacologic and hormonal treatment modalities, external beam radiation, and bisphosphonates. Finally, the available data on combination therapy of radiopharmaceuticals with bisphosphonates or chemotherapy are discussed.

Serum Hemoglobin Levels Predict Response to Strontium-89 and Rhenium-186-HEDP Radionuclide Treatment for Painful Osseous Metastases in Prostate Cancer

OBJECTIVE

Retrospective comparative analysis of strontium-89 chloride (Sr89) and rhenium-186-hydroxyethylidene diphosphonate (Re186-HEDP) radionuclide treatment to find predictors of response in patients with painful metastases from hormone refractory prostate cancer.

PATIENTS AND METHODS

Clinical data from 60 hormone refractory PCA patients (i.e. rising PSA at castrate testosterone serum levels) was obtained. Twenty-nine were treated with Sr89, 31 were treated with Re186-HEDP for painful osseous metastasis. Response was defined as a patient-reported decrease in pain and/or reduction in pain medication with stable pain level. Hematological parameters and serum levels of PSA, alkaline phosphatase, and lactate dehydrogenase were assessed prior to and at 4-week intervals after treatment.

RESULTS

Median survival of all patients was 7 months (95% CI: 6-9 months). Overall, 33/60 (55%) patients reported a decrease in pain after the first radionuclide treatment. This percentage was similar for patients treated with Re168-HEDP and Sr89. Mean duration of reported pain response was 75 days (+/- 68 days) for Sr89 and 61 days (+/- 56 days) for Re186-HEDP, which was not significantly different. A lower blood hemoglobin concentration was associated with a lower pain response rate. In a multivariate Cox regression analysis, pain response to radionuclide treatment predicted longer survival after treatment.

CONCLUSIONS

Pain response was present in 55% of patients. Serum hemoglobin concentration prior to radionuclide treatment predicted pain response for both Re186-HEDP and Sr89. A reduction in pain upon radionuclide treatment was associated with a longer survival after treatment.

Radiation Therapy and Radio-nuclides for Palliation of Bone Pain

Bone pain from metastatic prostate cancer can be effectively palliated by a single fraction of 8 Gy with no increase in toxicity, which can occur with more protracted fractionation schemes. Re-treatment, if required, is simple and effective. For multiple painful sites on the same side of the diaphragm, hemi-body radiotherapy is rapidly effective; pre-medication with odanstetron and steroids has markedly improved tolerance. For multiple painful sites on both sides of the diaphragm, radiopharmaceuticals can be considered but will not treat adjacent soft tissue disease or neurologic compromise.

Palliative radiation therapy in oncology

Palliative radiation therapy is considered when the incurable cancer patient has symptoms specifically related to a malignancy that may be relieved by localized treatment of the primary tumor or metastatic lesions. Developing a treatment plan with radiation in the palliative setting may be more difficult than the curative setting, where there are clear guidelines for many situations. Radiation therapy has been used successfully in the management of a variety of pain syndromes. Radiation also has proven effective in the management of other tumor-related symptoms, including bleeding, neurologic compromise, dysphagia, and airway obstruction. Palliative radiation can be delivered using a variety of techniques: external beam radiation therapy, intraluminal brachytherapy (radioactive seed delivery), and systemic radionucleotides.

Radioisotopes for the palliation of metastatic bone cancer: a systematic review

Strontium-89 and samarium-153 are radioisotopes that are approved in the USA and Europe for the palliation of pain from metastatic bone cancer, whereas rhenium-186 and rhenium-188 are investigational. Radioisotopes are effective in providing pain relief with response rates of between 40% and 95%. Pain relief starts 1-4 weeks after the initiation of treatment, continues for up to 18 months, and is associated with a reduction in analgesic use in many patients. Thrombocytopenia and neutropenia are the most common toxic effects, but they are generally mild and reversible. Repeat doses are effective in providing pain relief in many patients. The effectiveness of radioisotopes can be greater when they are combined with chemotherapeutic agents such as cisplatin. Some studies with 89Sr and 153Sm indicate a reduction of hot spots on bone scans in up to 70% of patients, and suggest a possible tumoricidal action. Further studies are needed to address the questions of which isotope to use, what dose and schedule to use, and which patients will respond.

Radiopharmaceuticals for the palliation of painful bone metastases—a systematic review

BACKGROUND AND PURPOSE

The purpose was to develop a systematic review that would address the following question: what is the role of radiopharmaceuticals in the palliation of metastatic bone pain in adults with uncomplicated, multifocal painful bone metastases whose pain is not controlled with conventional analgesic regimens? The outcomes of interest are pain response, analgesic consumption, overall survival, adverse effects and quality of life.

MATERIALS AND METHODS

A systematic review of the English published literature was undertaken to provide evidence relevant to the above outcomes.

RESULTS

Six randomized phase III trials, two randomized phase II trials and one randomized crossover trial of strontium-89 were reviewed. A randomized phase III trial comparing strontium-89 plus cisplatin with strontium-89 plus placebo reported a significantly higher proportion of patients experiencing pain relief for a significantly longer duration with strontium-89 plus cisplatin. A randomized phase III trial comparing adjuvant strontium-89 with placebo following radiotherapy reported a higher proportion of pain-free patients with strontium-89. Patients who received strontium-89 also experienced fewer new sites of bone pain. A second, but underpowered study failed to confirm these results. In one randomized trial of strontium-89 versus radiotherapy (hemibody or local), patients treated with strontium-89 developed fewer new sites of pain. In a second trial comparing strontium-89 versus local radiotherapy, median overall survival was improved with radiotherapy, while pain response and time-to-progression were similar in the two groups. One randomized phase III trial reported no difference in pain relief between strontium-89 and placebo. Three randomized phase III trials and two randomized phase II trials investigating samarium-153 were reviewed. In a randomized phase III trial of three different doses of samarium-153, the pain responses were similar for all three doses. In a randomized phase III trial of two different doses of samarium-153 versus placebo, the complete pain response rate was significantly higher with the higher dose of samarium-153 compared with placebo. In a randomized phase III trial comparing samarium-153 with placebo, significant differences favouring samarium-153 were reported for pain and opiate use. In addition, one randomized phase III trial, two randomized phase II trials, one randomized crossover trial and 13 phase II or phase I trials of rhenium, one phase I trial of tin-117 m and one phase II trial of phosphorus-32 were reviewed. The majority of patients treated in trials of radiopharmaceuticals where histology was specified had metastatic breast cancer (approximately 5-10% of patients reported), metastatic hormone-refractory prostate cancer (80-90% of patients reported) or metastatic lung cancer (5-10% of patients reported). Information on histologic subtype was not available for a significant proportion of patients treated on trials (30-40% of patients reported).

CONCLUSIONS

Use of single-agent radiopharmaceuticals (strontium-89 and samarium-153) should be considered as a possible option for the palliation of multiple sites of bone pain from metastatic cancer where pain control with conventional analgesic regimens is unsatisfactory and where activity on a bone scan of the painful lesions is demonstrated. Ongoing clinical research should seek to establish the benefit of newer radiopharmaceuticals and radiopharmaceuticals in combination with other systemic therapies.

Supportive Care in Lung Cancer

Lung cancer often is associated with significant morbidity, which has a detrimental effect on quality of life. Supportive care plays a central role in the multimodal treatment of lung cancer. Palliation of symptoms often improves quality of life and compliance with therapy. New developments in supportive care, reviewed here, include management of symptoms of the disease, such as respiratory problems, pain, and cachexia, as well as effects of treatment, including chemotherapy-induced nausea and vomiting, neutropenia, anemia, and mucositis. In the past few years, significant advances have been made in this field; however, palliation of the symptoms of lung cancer remains an area of active investigation.

Phase I dose escalation clinical trial of adenovirus vector carrying osteocalcin promoter-driven herpes simplex virus thymidine kinase in localized and metastatic hormone-refractory prostate cancer

Osteocalcin (OC), a major noncollagenous bone matrix protein, is expressed prevalently in prostate cancer epithelial cells, adjacent fibromuscular stromal cells, and osteoblasts in locally recurrent prostate cancer and prostate cancer bone metastasis [Matsubara, S., Wada, Y., Gardner, T.A., Egawa, M., Park, M.S., Hsieh, C.L., Zhau, H.E., Kao, C., Kamidono, S., Gillenwater, J.Y., and Chung, L.W. (2001). Cancer Res. 61, 6012-6019]. We constructed an adenovirus vector carrying osteocalcin promoter-driven herpes simplex virus thymidine kinase (Ad-OC-hsv-TK) to cotarget prostate cancer cells and their surrounding stromal cells. A phase I dose escalation clinical trial of the intralesional administration of Ad-OC-hsv-TK followed by oral valacyclovir was conducted at the University of Virginia (Charlottesville, VA) in 11 men with localized recurrent and metastatic hormone-refractory prostate cancer (2 local recurrent, 5 osseous metastasis, and 4 lymph node metastasis) in order to determine the usefulness of this vector for the palliation of androgen-independent prostate cancer metastasis. This is the first clinical trial in which therapeutic adenoviruses are injected directly into prostate cancer lymph node and bone metastasis. Results show that (1). all patients tolerated this therapy with no serious adverse events; (2). local cell death was observed in treated lesions in seven patients (63.6%) as assessed by TUNEL assay, and histomorphological change (mediation of fibrosis) was detected in all posttreated specimens; (3). one patient showed stabilization of the treated lesion for 317 days with no alternative therapy. Of the two patients who complained of tumor-associated symptoms before the treatment, one patient with bone pain had resolution of pain, although significant remission of treated lesions was not observed by image examination; (4). CD8-positive T cells were predominant compared with CD4-positive T cells, B cells (L26 positive), and natural killer cells (CD56 positive) in posttreated tissue specimens; (5). levels of HSV TK gene transduction correlated well with coxsackie-adenovirus receptor expression but less well with the titers of adenovirus injected; and (6). intrinsic OC expression and the efficiency of HSV TK gene transduction affected the levels of HSV TK protein expression in clinical specimens. Our data suggest that this form of gene therapy requires further development for the treatment of androgen-independent prostate cancer metastasis although histopathological and immunohistochemical evidence of apoptosis was observed in the specimens treated. Further studies including the development of viral delivery will enhance the efficacy of Ad-OC-hsv-TK.

Lung cancer. Palliative care

The majority of patients who acquire lung cancer will have troublesome symptoms at some time during the course of their disease. Some of the symptoms are common to many types of cancers, while others are more often encountered with lung cancer than other primary sites. The most common symptoms are pain, dyspnea, and cough. This document will address the management of these symptoms, and it will also address the palliation of specific problems that are commonly seen in lung cancer: metastases to the brain, spinal cord, and bones; hemoptysis; tracheoesophageal fistula; and obstruction of the superior vena cava.

[Treatment of metastatic bone pain with repeated doses of strontium-89 in patients with prostate neoplasm]

This study has aimed to evaluate the usefulness of repeated treatment with 89Sr in patients with prostate neoplasm and metastatic bone pain. Seventeen patients with partial or complete response after the first dose were retreated with two or more doses (total of 39 doses). The Karnofsky functional status, pain and degree of analgesia were assessed. After the first dose the response was good in 68% of the patients and partial in 32%. After the second dose, the response was good in 62% of the patients, partial in 15% and there was no response in 23% of the cases. The pre-treatment Karnofsky functional status and duration of the effect of 89Sr was lower after the second dose (p = 0.03, p = 0.02), but there were no statistically significant differences in the type of response. In conclusion, re-treatment with 89Sr can be administered safely and with a similar response to that achieved after the first dose.

Synthesis, purification, and in vitro stability of 211At- and 125I-labeled amidobisphosphonates

A method is described for preparing 211At- and radioiodinated amidobisphosphonates. The active esters N-succinimidyl 3-(tri-methylstannyl) benzoate (ATE) and N-succinimidyl 5-(tri-methylstannyl)-3-pyridinecarboxylate (SPC) were used as precursors. The isolated and purified radiolabeled intermediates were coupled to 3-amino-1-hydroxypropylidene-1,1-bisphosphonate (APB) in high yields ranging from 60% to 97%. The lipophilicity of the compounds was found to depend on the nature of the labeled template and the halogen. High in vitro stability in mouse, fetal calf, and human serum was documented by high performance liquid chromatography.

Local and systemic radiation for palliation of metastatic disease

Many radiotherapeutic treatment options are available for the palliation of patients with metastatic prostate cancer. These include local field radiotherapy to symptomatic sites of metastasis and the use of radioisotope therapy either alone or in combination with local field radiotherapy. To date, the majority of patients treated with radioisotope therapy have been treated with 89Sr. Other agents, such as 153Sm-EDTMP are available now, also. Combined radioisotope therapy, cytotoxic chemotherapy, and biphosphonates hold great promise.

Strontium-89 chloride in the treatment of bone metastases from breast cancer

Sixty-four patients with painful metastatic breast cancer in bone were treated with 2 MBq/kg of strontium-89 chloride as a single intravenous injection. Patients were followed with records of medication, hematology parameters, serial bone and Sr-89 bremsstrahlung images and with a point pain score scale (10-0). The response was assessed during a 6-month period of follow-up. Fifty-two of 64 patients (81%) showed at least a moderate improvement. Eighteen out of the 52 responders showed a dramatic decrease in bone pain (35%), 21 (40%) presented a satisfactory response and in 13 cases (25%) the response was moderate. Only 12 patients (19%) from the whole group did not feel any improvement on pain palliation. A statistically significant decrease of pretreatment levels of platelets and leukocyte counts was observed after 4-6 weeks of therapy in 50 (70%) patients. Although most patients showed no change in their bone scans after 3 months of treatment, an obvious improvement was observed in 3 of them. Furthermore no additional painful metastases on their bone scintigraphic images were observed. The selective strontium-89 local uptake in metastatic sites was also confirmed directly by bremsstrahlung scans which were absolutely comparable to the respective 99mTc bone scans. Precautions have been taken against Sr-89 contamination from the patients' blood or excretions.