Current issues in the management of differentiated thyroid cancer

Tyrosine Kinase Inhibitors for Radioactive Iodine Refractory Differentiated Thyroid Cancer

Patients with differentiated thyroid cancer usually present with early-stage disease and undergo surgery followed by adjuvant radioactive iodine ablation, resulting in excellent clinical outcomes and prognosis. However, a minority of patients relapse with metastatic disease, and eventually develop radioactive iodine refractory disease (RAIR). In the past there were limited and ineffective options for systemic therapy for RAIR, but over the last ten to fifteen years the emergence of tyrosine kinase inhibitors (TKIs) has provided important new avenues of treatment for these patients, that are the focus of this review. Currently, Lenvatinib and Sorafenib, multitargeted TKIs, represent the standard first-line systemic treatment options for RAIR thyroid carcinoma, while Cabozantinib is the standard second-line treatment option. Furthermore, targeted therapies for patients with specific targetable molecular abnormalities include Latrectinib or Entrectinib for patients with NTRK gene fusions and Selpercatinib or Pralsetinib for patients with RET gene fusions. Dabrafenib plus Trametinib currently only have tumor agnostic approval in the USA for patients with BRAF V600E mutations, including thyroid cancer. Redifferentiation therapy is an area of active research, with promising initial results, while immunotherapy studies with checkpoint inhibitors in combination with tyrosine kinase inhibitors are underway.

Human sodium iodide transporter gene-mediated imaging and therapy of mouse glioma, comparison between 188Re and 131I

Novel treatment options are urgently required for patients with glioma who are not effectively treated through standard therapy. Human sodium iodide symporter (hNIS) is a molecular target of certain tumors types. Compared with ¹³¹I, ¹⁸⁸Re possesses a higher energy and shorter half-life; therefore, the effects of ¹⁸⁸Re and ¹³¹I were compared in hNIS-mediated gene imaging and therapy in the present study. Recombinant human brain glioma cell line U87 was transfected with a recombinant lentiviral vector containing hNIS (U87-hNIS). U87-0 cell line transfected with blank lentivirus was prepared as a control. In vitro, the ¹⁸⁸Re and ¹³¹I uptake of U87-hNIS cells were 21.3-times and 25.9-times that of the control groups, however the excretion rate of the two nuclides was very rapid, and the half-life was only ~4 min. Sodium perchlorate inhibited hNIS-mediated ¹⁸⁸Re and ¹³¹I uptake to levels observed in the control groups. ¹⁸⁸Re and ¹³¹I were able to kill U87-hNIS cells selectively, with a survival of only 21.6 and 36.2%, respectively. U87-hNIS nude mice appeared to accumulate ¹⁸⁸Re, with a ratio of radioactivity counts between tumor and non-tumor sites of ~13.5 compared with 10.3 of ¹³¹I 1 h after radionuclide injection. In contrast with in vitro studies, U87-hNIS cells demonstrated a notable increase in ¹⁸⁸Re retention in vivo, even 24 h after ¹⁸⁸Re injection. U87-hNIS cells also exhibited increased ¹³¹I retention in vivo; however, as the time increased, ¹³¹I was rapidly released with the tumor no longer able to be imaged 24 h after ¹³¹I injection. Following treatment, U87-hNIS tumors experienced a volume reduction of 24.1%, whereas U87-0 cells demonstrated an increase of 28.8%. ¹⁸⁸Re and ¹³¹I were revealed to be effective at decreasing tumor volume compared with the control. However, ¹⁸⁸Re was significantly more potent compared with ¹³¹I (P<0.01). The present study indicated that the U87-hNIS cell line is sufficient to induce specific ¹⁸⁸Re and ¹³¹I uptake, which may kill cells in vitro and in vivo. ¹⁸⁸Re exhibited an increased retention time in vivo compared with ¹³¹I, which facilitates the imaging and therapy of U87-hNIS tumors.

Theranostic studies of human sodium iodide symporter imaging and therapy using 188Re: a human glioma study in mice

Objective

To investigate the role of ¹⁸⁸Re in human sodium iodide symporter (hNIS) theranostic gene-mediated human glioma imaging and therapy in model mice.

Methods

The human glioma cell line U87 was transfected with recombinant lentivirus encoding the hNIS gene under the control of cytomegalovirus promoter (U87-hNIS). The uptake and efflux of ¹⁸⁸Re were determined after incubating the cells with ¹⁸⁸Re. ¹⁸⁸Re uptake experiments in the presence of various concentrations of sodium perchlorate were carried out. In vitro cell killing tests with ¹⁸⁸Re were performed. U87-hNIS mediated ¹⁸⁸Re distribution, imaging and therapy in nude mice were also tested.

Results

U87-hNIS cell line was successfully established. The uptake of ¹⁸⁸Re in U87-hNIS cells increased up to 26-fold compared to control cells, but was released rapidly with a half-life of approximately 4 minutes. Sodium perchlorate reduced hNIS-mediated ¹⁸⁸Re uptake to levels of control cell lines. U87-hNIS cells were selectively killed following exposure to ¹⁸⁸Re, with a survival of 21.4%, while control cells had a survival of 92.1%. Unlike in vitro studies, U87-hNIS tumor showed a markedly increased ¹⁸⁸Re retention even 48 hours after ¹⁸⁸Re injection. In the therapy study, there was a significant difference in tumor size between U87-hNIS mice (317±67 mm³) and control mice (861±153 mm³) treated with ¹⁸⁸Re for 4 weeks (P<0.01).

Conclusion

The results indicate that inserting the hNIS gene into U87 cells is sufficient to induce specific ¹⁸⁸Re uptake, which has a cell killing effect both in vitro and in vivo. Moreover, our study, based on the function of hNIS as a theranostic gene allowing noninvasive imaging of hNIS expression by ¹⁸⁸Re scintigraphy, provides detailed characterization of in vivo vector biodistribution and level, localization, essential prerequisites for precise planning and monitoring of clinical gene therapy that aims to individualize gene therapy concept.

Sodium butyrate enhances the expression of baculovirus-mediated sodium/iodide symporter gene in A549 lung adenocarcinoma cells

OBJECTIVE

Increased expression of sodium/iodide symporter (NIS) is required for reporter gene imaging and effective radioiodine treatment of tumor. We investigated whether increased accumulation of iodine can be induced by sodium butyrate through a newly developed baculoviral transfer of the human NIS (hNIS) gene in A549 human lung adenocarcinoma.

METHODS

A recombinant baculovirus [Bac-cytomegalovirus (CMV)-hNIS] encoding hNIS gene under the control of the CMV promoter was constructed. After A549 cells were transfected with Bac-CMV-hNIS in the presence of sodium butyrate, the expression of hNIS protein was detected by immunofluorescence and western blot analysis. The uptake and efflux of iodine were determined after the incubation of the transfected cells with I-iodide in the presence or absence of sodium butyrate.

RESULTS

Immunocytochemical staining and western blot analysis showed increased hNIS protein expression in A549 cells transfected with Bac-CMV-hNIS after sodium butyrate treatment. Bac-CMV-hNIS transfected A549 cells accumulated up to about nine times more I than nontransfected cells; the amount of I uptake increased in a sodium butyrate in dose-dependent manner (P<0.001). However, rapid efflux of radioactivity was observed, with 50% lost during the first 2 min after I-containing medium had been replaced by a nonradioactive medium.

CONCLUSION

Our results indicated that an improved efficiency of baculovirus-mediated hNIS reporter gene imaging in lung adenocarcinoma is possible with treatment with sodium butyrate. However, additional conditions need to be defined to reduce the rapid efflux of radioiodine for the purpose of radionuclide therapy.

Update on recent developments in the therapy of differentiated thyroid cancer

In the past decade, the management of differentiated thyroid carcinoma changed significantly and thus contributed to the improvement of the already favorable prognosis of this malignant disease. Surgical treatment techniques improved and the extent of initial surgery is more individualized. Radioiodine therapy is an essential part of therapeutic regimens in almost all cases, and the use of recombinant human thyroid-stimulating hormone has established for ablation of remnant tissue, treatment of iodine-positive cancer, and sensitive thyroglobulin measurement during follow-up. Risk stratification has become more important to plan treatment and follow-up individually, particularly to evaluate the need for thyroid-stimulating hormone suppression therapy. Especially for inoperable and radioiodine-negative thyroid carcinomas, novel treatment options such as tyrosine kinase inhibitor therapy have emerged. This article deals with the current options of optimal therapy regimens in differentiated thyroid carcinoma.