Imaging-guided targeted radionuclide tumor therapy: From concept to clinical translation

Since the first introduction of sodium iodide I-131 for use with thyroid patients almost 80 years ago, more than 50 radiopharmaceuticals have reached the markets for a wide range of diseases, especially cancers. The nuclear medicine paradigm also shifts from solely molecular imaging or radionuclide therapy to imaging-guided radionuclide therapy, which is deemed a vital component of precision cancer therapy and an emerging medical modality for personalized medicine. The imaging-guided radionuclide therapy highlights the systematic integration of targeted nuclear diagnostics and radionuclide therapeutics. Regarding this, nuclear imaging serves to "visualize" the lesions and guide the therapeutic strategy, followed by administration of a precise patient specific dose of radiotherapeutics for treatment according to the absorbed dose to different organs and tumors calculated by dosimetry tools, and finally repeated imaging to predict the prognosis. This strategy leads to significantly enhanced therapeutic efficacy, improved patient outcomes, and manageable adverse events. In this review, we provide an overview of imaging-guided targeted radionuclide therapy for different tumors such as advanced prostate cancer and neuroendocrine tumors, with a focus on development of new radioligands and their preclinical and clinical results, and further discuss about challenges and future perspectives.

Application of therapeutic linear accelerators for the production of radioisotopes used in nuclear medicine

This review paper summarizes the possibilities of the use of therapeutic linear electron accelerators for the production of radioisotopes for nuclear medicine. This work is based on our published results and the thematically similar papers by other authors, directly related to five medical radioisotopes as 99Mo/99mTc, 198Au, 186Re, 188Re, 117mSn, produced using therapeutic linacs. Our unpublished data relating to the issues discussed have also been used here. In the experiments, two types of radiation were included in the analysis of the radioisotope production process, i.e. the therapeutic twenty-megavolt (20 MV) X-rays generated by Varian linacs and neutron radiation contaminating the therapeutic beam. Thus, the debated radioisotopes are produced in the photonuclear reactions and in the neutron ones. Linear therapeutic accelerators do not allow the production of radioisotopes with high specific activities, but the massive targets can be used instead. Thus, the amount of the produced radioisotopes may be increased. Apart from linear accelerators, more and more often, the production of radioisotopes is carried out in small medical cyclotrons. More such cyclotrons are developed, built, and sold commercially than for scientific research. The radioisotopes produced with the use of therapeutic linacs or cyclotrons can be successfully applied in various laboratory tests and in research.

Rhenium Radioisotopes for Medicine, a Focus on Production and Applications

In recent decades, the use of alpha; pure beta; or beta/gamma emitters in oncology, endocrinology, and interventional cardiology rheumatology, has proved to be an important alternative to the most common therapeutic regimens. Among radionuclides used for therapy in nuclear medicine, two rhenium radioisotopes are of particular relevance: rhenium-186 and rhenium-188. The first is routinely produced in nuclear reactors by direct neutron activation of rhenium-186 via 185Re(n,γ)186Re nuclear reaction. Rhenium-188 is produced by the decay of the parent tungsten-188. Separation of rhenium-188 is mainly performed using a chromatographic 188W/188Re generator in which tungsten-188 is adsorbed on the alumina column, similar to the 99Mo/99mTc generator system, and the radionuclide eluted in saline solution. The application of rhenium-186 and rhenium-188 depends on their specific activity. Rhenium-186 is produced in low specific activity and is mainly used for labeling particles or diphosphonates for bone pain palliation. Whereas, rhenium-188 of high specific activity can be used for labeling peptides or bioactive molecules. One of the advantages of rhenium is its chemical similarity with technetium. So, diagnostic technetium analogs labeled with radiorhenium can be developed for therapeutic applications. Clinical trials promoting the use of 186/188Re-radiopharmaceuticals is, in particular, are discussed.

Nuclear data for light charged particle induced production of emerging medical radionuclides

Whatever the radionuclide to be used in nuclear medicine, it is essential to know the expected yield during the production process, but also of all the possible radionuclidic impurities coproduced, that can have an impact on the product final quality, as well as in the related waste management. The availability of the majority of emerging radioisotopes, including the theranostic ones or pairs, is mainly limited by the fact that, for most of them, the optimal production route still needs to be strengthened if not defined in some cases. The aim of this work is to present a review on the charged particle induced nuclear cross sections to produce some emerging radionuclides for medical applications to show that all types of projectiles should be considered in the quest of producing medical radionuclides. An accurate analysis of the production routes is presented for some radionuclides (67Cu, 47Sc, 89Zr, 103Pd, 186gRe, 97Ru, 211At) chosen as examples to highlight (i) how the quality of the final product strongly depends on the chosen target/projectile/energy parameters set, (ii) how deuteron production routes may sometimes be more effective than the proton ones or lead to a different impurity profile and (iii) how α-particle beams may allow to bypass the limitations occurring when using Z = 1 beams. An overview of possible advantages and drawbacks of the cited production routes and of potential cross sections that still need to be measured, is also reported.

Bifunctional chelators for radiorhenium: past, present and future outlook

Targeted radionuclide therapy (TRNT) is an ever-expanding field of nuclear medicine that provides a personalised approach to cancer treatment while limiting toxicity to normal tissues. It involves the radiolabelling of a biological targeting vector with an appropriate therapeutic radionuclide, often facilitated by the use of a bifunctional chelator (BFC) to stably link the two entities. The radioisotopes of rhenium, 186Re (t 1/2 = 90 h, 1.07 MeV β-, 137 keV γ (9%)) and 188Re (t 1/2 = 16.9 h, 2.12 MeV β-, 155 keV γ (15%)), are particularly attractive for radiotherapy because of their convenient and high-abundance β--particle emissions as well as their imageable γ-emissions and chemical similarity to technetium. As a transition metal element with multiple oxidation states and coordination numbers accessible for complexation, there is great opportunity available when it comes to developing novel BFCs for rhenium. The purpose of this review is to provide a recap on some of the past successes and failings, as well as show some more current efforts in the design of BFCs for 186/188Re. Future use of these radionuclides for radiotherapy depends on their cost-effective availability and this will also be discussed. Finally, bioconjugation strategies for radiolabelling biomolecules with 186/188Re will be touched upon.

Translating Research for the Radiotheranostics of Nanotargeted 188Re-Liposome

Nanoliposomes are one of the leading potential nano drug delivery systems capable of targeting chemotherapeutics to tumor sites because of their passive nano-targeting capability through the enhanced permeability and retention (EPR) effect for cancer patients. Recent advances in nano-delivery systems have inspired the development of a wide range of nanotargeted materials and strategies for applications in preclinical and clinical usage in the cancer field. Nanotargeted ¹⁸⁸Re-liposome is a unique internal passive radiotheranostic agent for nuclear imaging and radiotherapeutic applications in various types of cancer. This article reviews and summarizes our multi-institute, multidiscipline, and multi-functional studied results and achievements in the research and development of nanotargeted ¹⁸⁸Re-liposome from preclinical cells and animal models to translational clinical investigations, including radionuclide nanoliposome formulation, targeted nuclear imaging, biodistribution, pharmacokinetics, radiation dosimetry, radiation tumor killing effects in animal models, nanotargeted radionuclide and radio/chemo-combination therapeutic effects, and acute toxicity in various tumor animal models. The systemic preclinical and clinical studied results suggest ¹⁸⁸Re-liposome is feasible and promising for in vivo passive nanotargeted radionuclide theranostics in future cancer care applications.

Mechanochemically synthesized mesoporous alumina: a smart new-generation sorbent for preparation of chromatographic 188W/188Re generator

Abstract

In an effort towards affordable availability of chromatographic 188W/188Re generators for widespread clinical use, we report the mechanochemical synthesis of mesoporous alumina as an advanced sorbent material for preparation of the generator. The synthesized material exhibits remarkably high sorption capacity (550 ± 12 mg W/g), which is adequate for preparation of clinical-scale generators using low specific activity (LSA) 188W produced in medium flux research reactors. Sorption of 188W in mesoporous alumina follows Freundlich adsorption isotherm and pseudo second order kinetics, indicating that the process is chemisorption. A clinical-scale (~ 14.0 GBq) 188W/188Re generator was developed and its performance was evaluated over a period of 6 months. Rhenium-188 could be consistently obtained from the generator with high yield (> 80%) and it met all the requirements for clinical use. The present strategy is expected to increase the scope of separation chemistry for availing clinical-grade 188Re for the benefit of millions of cancer patients world over.

Graphic abstract

Standardisation of Rhenium-188 and determination of calibration factors for secondary standard and radionuclide calibrator

The use of Rhenium-188 for various therapeutic applications in the field of nuclear medicine has increased in recent years due to its favourable properties like decay scheme, cost effective availability and easy chemistry. Two independent measuring setups were used to standardise ¹⁸⁸Re radioactive solution. The modus operandi of standardisation was 4πβ-γ coincidence technique where the beta detection was done by proportional counting and liquid scintillation counting and the gamma detection was done by using NaI(Tl) detectors. The secondary standard, high pressure ionisation chamber type Centronic IG12, 20A was calibrated with the standardised ¹⁸⁸Re solution and the sensitivity coefficient (pA MBq^-1) was determined. To enhance the accuracy of the commercial radionuclide calibrator and to ensure that patients receive optimum dose of these radiopharmaceuticals, calibration number of the Capintec CRC-15β radionuclide calibrator was also verified. This paper presents the standardisation of ¹⁸⁸Re radioactive solution by primary methods and calibration of BARC secondary standard ionisation chamber system and a Capintec CRC-15β radionuclide calibrator.

Therapeutic Radiometals: Worldwide Scientific Literature Trend Analysis (2008⁻2018)

Academic journals have published a large number of papers in the therapeutic nuclear medicine (NM) research field in the last 10 years. Despite this, a literature analysis has never before been made to point out the research interest in therapeutic radionuclides (RNs). For this reason, the present study aims specifically to analyze the research output on therapeutic radiometals from 2008 to 2018, with intent to quantify and identify global trends in scientific literature and emphasize the interdisciplinary nature of this research field. The data search targeted conventional (¹³¹I, ⁹⁰Y, ¹⁷⁷Lu, ¹⁸⁸Re, ¹⁸⁶Re, ¹⁵³Sm, ⁸⁹Sr, ¹⁸⁶Er) and emergent (⁶⁷Cu, ⁴⁷Sc, ²²³Ra, ¹⁶⁶Ho, ¹⁶¹Tb, ¹⁴⁹Tb, ²¹²Pb/²¹²Bi, ²²⁵Ac, ²¹³Bi, ²¹¹At, ^117mSn) RNs. Starting from this time frame, authors have analyzed and interpreted this scientific trend quantitatively first, and qualitatively after.

Radioactive Transition Metals for Imaging and Therapy

Nuclear medicine is composed of two complementary areas, imaging and therapy. Positron emission tomography (PET) and single-photon imaging, including single-photon emission computed tomography (SPECT), comprise the imaging component of nuclear medicine. These areas are distinct in that they exploit different nuclear decay processes and also different imaging technologies. In PET, images are created from the 511 keV photons produced when the positron emitted by a radionuclide encounters an electron and is annihilated. In contrast, in single-photon imaging, images are created from the γ rays (and occasionally X-rays) directly emitted by the nucleus. Therapeutic nuclear medicine uses particulate radiation such as Auger or conversion electrons or β^- or α particles. All three of these technologies are linked by the requirement that the radionuclide must be attached to a suitable vector that can deliver it to its target. It is imperative that the radionuclide remain attached to the vector before it is delivered to its target as well as after it reaches its target or else the resulting image (or therapeutic outcome) will not reflect the biological process of interest. Radiochemistry is at the core of this process, and radiometals offer radiopharmaceutical chemists a tremendous range of options with which to accomplish these goals. They also offer a wide range of options in terms of radionuclide half-lives and emission properties, providing the ability to carefully match the decay properties with the desired outcome. This Review provides an overview of some of the ways this can be accomplished as well as several historical examples of some of the limitations of earlier metalloradiopharmaceuticals and the ways that new technologies, primarily related to radionuclide production, have provided solutions to these problems.

Monoclonal Antibodies Radiolabeling with Rhenium-188 for Radioimmunotherapy

Rhenium-188, obtained from an alumina-based tungsten-188/rhenium-188 generator, is actually considered a useful candidate for labeling biomolecules such as antibodies, antibody fragments, peptides, and DNAs for radiotherapy. There is a widespread interest in the availability of labeling procedures that allow obtaining ¹⁸⁸Re-labeled radiopharmaceuticals for various therapeutic applications, in particular for the rhenium attachment to tumor-specific monoclonal antibodies (Mo)Abs for immunotherapy. Different approaches have been developed in order to obtain ¹⁸⁸Re-radioimmunoconjugates in high radiochemical purity starting from the generator eluted [¹⁸⁸Re]ReO₄⁻. The aim of this paper is to provide a short overview on ¹⁸⁸Re-labeled (Mo)Abs, focusing in particular on the radiolabeling methods, quality control of radioimmunoconjugates, and their in vitro stability for radioimmunotherapy (RIT), with particular reference to the most important contributions published in literature in this topic.

Recent achievements in Tc-99m radiopharmaceutical direct production by medical cyclotrons

^99mTc is the most commonly used radionuclide in the field of diagnostic imaging, a noninvasive method intended to diagnose a disease, assess the disease state and monitor the effects of treatments. Annually, the use of ^99mTc, covers about 85% of nuclear medicine applications. This isotope releases gamma rays at about the same wavelength as conventional X-ray diagnostic equipment, and owing to its short half-life (t_½ = 6 h) is ideal for diagnostic nuclear imaging. A patient can be injected with a small amount of ^99mTc and within 24 h almost 94% of the injected radionuclide would have decayed and left the body, limiting the patient's radiation exposure. ^99mTc is usually supplied to hospitals through a ⁹⁹Mo/^99mTc radionuclide generator system where it is produced from the β decay of the parent nuclide ⁹⁹Mo (t_½ = 66 h), which is produced in nuclear reactors via neutron fission. Recently, the interruption of the global supply chain of reactor-produced ⁹⁹Mo, has forced the scientific community to investigate alternative production routes for ^99mTc. One solution was to consider cyclotron-based methods as potential replacement of reactor-based technology and the nuclear reaction ¹⁰⁰Mo(p,2n)^99mTc emerged as the most worthwhile approach. This review reports some achievements about ^99mTc produced by medical cyclotrons. In particular, the available technologies for target design, the most efficient extraction and separation procedure developed for the purification of ^99mTc from the irradiated targets, the preparation of high purity ^99mTc radiopharmaceuticals and the first clinical studies carried out with cyclotron produced ^99mTc are described.

188Re(V) Nitrido Radiopharmaceuticals for Radionuclide Therapy

The favorable nuclear properties of rhenium-188 for therapeutic application are described, together with new methods for the preparation of high yield and stable ¹⁸⁸Re radiopharmaceuticals characterized by the presence of the nitride rhenium core in their final chemical structure. ¹⁸⁸Re is readily available from an ¹⁸⁸W/¹⁸⁸Re generator system and a parallelism between the general synthetic procedures applied for the preparation of nitride technetium-99m and rhenium-188 theranostics radiopharmaceuticals is reported. Although some differences between the chemical characteristics of the two metallic nitrido fragments are highlighted, it is apparent that the same general procedures developed for the labelling of biologically active molecules with technetium-99m can be applied to rhenium-188 with minor modification. The availability of these chemical strategies, that allow the obtainment, in very high yield and in physiological condition, of ¹⁸⁸Re radiopharmaceuticals, gives a new attractive prospective to employ this radionuclide for therapeutic applications.

68Ga and 188Re Starch-Based Microparticles as Theranostic Tool for the Hepatocellular Carcinoma: Radiolabeling and Preliminary In Vivo Rat Studies

Purpose

This work aims to develop, validate and optimize the radiolabeling of Starch-Based Microparticles (SBMP) by ¹⁸⁸Re and ⁶⁸Ga in the form of ready-to-use radiolabeling kits, the ultimate goal being to obtain a unique theranostic vector for the treatment of Hepatocellular Carcinoma.

Methods

Optimal labeling conditions and composition of freeze-dried kits were defined by monitoring the radiochemical purity while varying several parameters. In vitro stability studies were carried out, as well as an in vivo biodistribution as a preliminary approach with the intra-arterial injection of ⁶⁸Ga radiolabeled SBMP into the hepatic artery of DENA-induced rats followed by PET/CT imaging.

Results

Kits were optimized for ¹⁸⁸Re and ⁶⁸Ga with high and stable radiochemical purity (>95% and >98% respectively). The in vivo preliminary study was successful with more than 95% of activity found in the liver and mostly in the tumorous part.

Conclusion

SBMP are a promising theranostic agent for the Selective Internal Radiation Therapy of Hepatocellular carcinoma.

Novel (188)Re multi-functional bone-seeking compounds: Synthesis, biological and radiotoxic effects in metastatic breast cancer cells

INTRODUCTION

Radiolabeled bisphosphonates (BPs) have been used for bone imaging and delivery of β(-) emitting radionuclides for bone pain palliation. As a β(-) emitter, (188)Re has been considered particularly promising for bone metastases therapy. Aimed at finding innovative bone-seeking agents for systemic radiotherapy of bone metastases, we describe herein novel organometallic compounds of the type fac-[(188)Re(CO)3(k(3)-L)], (L=BP-containing chelator), their in vitro and in vivo stability, and their cellular damage in MDAMB231 cells, a metastatic breast cancer cell line.

METHODS

After synthesis and characterization of the novel organometallic compounds of the type fac-[(188)Re(CO)3(k(3)-L)] their radiochemical purity and in vitro stability was assessed by HPLC. In vivo stability and pharmacokinetic profile were evaluated in mice and the radiocytotoxic activity and DNA damage were assessed by MTT assay and by the cytokinesis-block micronucleus (CBMN) assay, respectively.

RESULTS

Among all complexes, (188)Re3 was obtained with high radiochemical purity (>95%) and high specific activity and presented high in vitro and in vivo stability. Biodistribution studies of (188)Re3 in Balb/c mice showed fast blood clearance, high bone uptake (16.1 ± 3.3% IA/g organ, 1h p.i.) and high bone-to-blood and bone-to-muscle radioactivity ratios, indicating that it is able to deliver radiation to bone in a very selective way. The radiocytotoxic effect elicited by (188)Re3 in the MDAMB231 cells was dependent on its concentration, and was higher than that induced by identical concentrations of [(188)ReO4](-). Additionally, (188)Re3 elicited morphological changes in the cells and induced DNA damage by the increased number of MN observed.

CONCLUSION

Altogether, our results demonstrate that (188)Re3 could be considered an attractive candidate for further preclinical evaluation for systemic radionuclide therapy of bone metastases considering its ability to deliver radiation to bone in a very selective way and to induce radiation damage.

Underestimated potential of organometallic rhenium complexes as anticancer agents

In the recent years, organometallic compounds have become recognized as promising anti-cancer drug candidates. While radioactive (186/188)Re compounds are already used in clinics for cancer treatment, cold Re organometallic compounds have mostly been explored as luminescent probes for cell imaging and photosensitizers in photocatalysis. However, a growing number of studies have recently revealed the potential of Re organometallic complexes as anti-cancer agents. Several compounds have displayed cytotoxicity equaling or exceeding that of the well-established anti-cancer drug cisplatin. In this review, we present the currently known Re organometallic complexes that have shown anti-proliferative activity on cancer cell lines. A particular emphasis is placed on their cellular uptake and localization as well as their potential mechanism of action.