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Vergnaud L, Dewaraja YK, Giraudet AL, Badel JN, Sarrut D. A review of 177Lu dosimetry workflows: how to reduce the imaging workloads? EJNMMI Phys 2024; 11:65. [PMID: 39023648 DOI: 10.1186/s40658-024-00658-8] [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: 01/25/2024] [Accepted: 06/07/2024] [Indexed: 07/20/2024] Open
Abstract
177 Lu radiopharmaceutical therapy is a standardized systemic treatment, with a typical dose of 7.4 GBq per injection, but its response varies from patient to patient. Dosimetry provides the opportunity to personalize treatment, but it requires multiple post-injection images to monitor the radiopharmaceutical's biodistribution over time. This imposes an additional imaging burden on centers with limited resources. This review explores methods to lessen this burden by optimizing acquisition types and minimizing the number and duration of imaging sessions. After summarizing the different steps of dosimetry and providing examples of dosimetric workflows for177 Lu -DOTATATE and177 Lu -PSMA, we examine dosimetric workflows based on a reduced number of acquisitions, or even just one. We provide a non-exhaustive description of simplified methods and their assumptions, as well as their limitations. Next, we detail the specificities of each normal tissue and tumors, before reviewing dose-response relationships in the literature. In conclusion, we will discuss the current limitations of dosimetric workflows and propose avenues for improvement.
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Affiliation(s)
- Laure Vergnaud
- CREATIS; CNRS UMR 5220; INSERM U 1044, Université de Lyon; INSA-Lyon; Université Lyon 1, Lyon, France.
| | - Yuni K Dewaraja
- Department of Radiology, University of Michigan, Ann Arbor, USA
| | | | - Jean-Noël Badel
- CREATIS; CNRS UMR 5220; INSERM U 1044, Université de Lyon; INSA-Lyon; Université Lyon 1, Lyon, France
- Centre de lutte contre le cancer Léon Bérard, Lyon, France
| | - David Sarrut
- CREATIS; CNRS UMR 5220; INSERM U 1044, Université de Lyon; INSA-Lyon; Université Lyon 1, Lyon, France
- Centre de lutte contre le cancer Léon Bérard, Lyon, France
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2
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Ytterbrink C, Shubbar E, Parris TZ, Langen B, Druid M, Schüler E, Strand SE, Åkerström B, Gram M, Helou K, Forssell-Aronsson E. Effects of Recombinant α 1-Microglobulin on Early Proteomic Response in Risk Organs after Exposure to 177Lu-Octreotate. Int J Mol Sci 2024; 25:7480. [PMID: 39000587 PMCID: PMC11242497 DOI: 10.3390/ijms25137480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/02/2024] [Accepted: 07/05/2024] [Indexed: 07/16/2024] Open
Abstract
Recombinant α1-microglobulin (A1M) is proposed as a protector during 177Lu-octreotate treatment of neuroendocrine tumors, which is currently limited by bone marrow and renal toxicity. Co-administration of 177Lu-octreotate and A1M could result in a more effective treatment by protecting healthy tissue, but the radioprotective action of A1M is not fully understood. The aim of this study was to examine the proteomic response of kidneys and bone marrow early after 177Lu-octreotate and/or A1M administration. Mice were injected with 177Lu-octreotate and/or A1M, while control mice received saline or A1M vehicle solution. Bone marrow, kidney medulla, and kidney cortex were sampled after 24 h or 7 d. The differential protein expression was analyzed with tandem mass spectrometry. The dosimetric estimation was based on 177Lu activity in the kidney. PHLDA3 was the most prominent radiation-responsive protein in kidney tissue. In general, no statistically significant difference in the expression of radiation-related proteins was observed between the irradiated groups. Most canonical pathways were identified in bone marrow from the 177Lu-octreotate+A1M group. Altogether, a tissue-dependent proteomic response followed exposure to 177Lu-octreotate alone or together with A1M. Combining 177Lu-octreotate with A1M did not inhibit the radiation-induced protein expression early after exposure, and late effects should be further studied.
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Affiliation(s)
- Charlotte Ytterbrink
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden; (C.Y.); (E.S.); (M.D.)
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (T.Z.P.); (K.H.)
| | - Emman Shubbar
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden; (C.Y.); (E.S.); (M.D.)
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (T.Z.P.); (K.H.)
| | - Toshima Z. Parris
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (T.Z.P.); (K.H.)
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Britta Langen
- Section of Molecular Radiation Biology, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA;
| | - Malin Druid
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden; (C.Y.); (E.S.); (M.D.)
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (T.Z.P.); (K.H.)
| | - Emil Schüler
- Department of Radiation Physics, Division of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA;
| | - Sven-Erik Strand
- Department of Clinical Sciences Lund, Oncology, Lund University, 221 00 Lund, Sweden;
| | - Bo Åkerström
- Department of Clinical Sciences Lund, Infection Medicine, Lund University, 221 00 Lund, Sweden;
| | - Magnus Gram
- Department of Clinical Sciences Lund, Pediatrics, Lund University, 221 00 Lund, Sweden;
- Department of Neonatology, Skåne University Hospital, 222 42 Lund, Sweden
- Biofilms—Research Center for Biointerfaces, Department of Biomedical Science, Faculty of Health and Society, Malmö University, 205 06 Malmö, Sweden
| | - Khalil Helou
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (T.Z.P.); (K.H.)
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Eva Forssell-Aronsson
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden; (C.Y.); (E.S.); (M.D.)
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (T.Z.P.); (K.H.)
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
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3
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George SC, Samuel EJJ. Developments in 177Lu-based radiopharmaceutical therapy and dosimetry. Front Chem 2023; 11:1218670. [PMID: 37583569 PMCID: PMC10424930 DOI: 10.3389/fchem.2023.1218670] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 06/27/2023] [Indexed: 08/17/2023] Open
Abstract
177Lu is a radioisotope that has become increasingly popular as a therapeutic agent for treating various conditions, including neuroendocrine tumors and metastatic prostate cancer. 177Lu-tagged radioligands are molecules precisely designed to target and bind to specific receptors or proteins characteristic of targeted cancer. This review paper will present an overview of the available 177Lu-labelled radioligands currently used to treat patients. Based on recurring, active, and completed clinical trials and other available literature, we evaluate current status, interests, and developments in assessing patient-specific dosimetry, which will define the future of this particular treatment modality. In addition, we will discuss the challenges and opportunities of the existing dosimetry standards to measure and calculate the radiation dose delivered to patients, which is essential for ensuring treatments' safety and efficacy. Finally, this article intends to provide an overview of the current state of 177Lu- tagged radioligand therapy and highlight the areas where further research can improve patient treatment outcomes.
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Affiliation(s)
- Siju C. George
- Radiation Oncology Department, Miami Cancer Institute, Baptist Health, Miami, FL, United States
- Department of Physics, School of Advanced Sciences, Vellore Institute of Technology, Vellore, India
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Peterson AB, Mirando DM, Dewaraja YK. Accuracy and uncertainty analysis of reduced time point imaging effect on time-integrated activity for 177Lu-DOTATATE PRRT in patients and clinically realistic simulations. EJNMMI Res 2023; 13:57. [PMID: 37306783 DOI: 10.1186/s13550-023-01007-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/01/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Dosimetry promises many advantages for radiopharmaceutical therapies but repeat post-therapy imaging for dosimetry can burden both patients and clinics. Recent applications of reduced time point imaging for time-integrated activity (TIA) determination for internal dosimetry following 177Lu-DOTATATE peptide receptor radionuclide therapy have shown promising results that allow for the simplification of patient-specific dosimetry. However, factors such as scheduling can lead to sub-optimal imaging time points, but the resulting impact on dosimetry accuracy is still under investigation. We use four-time point 177Lu SPECT/CT data for a cohort of patients treated at our clinic to perform a comprehensive analysis of the error and variability in time-integrated activity when reduced time point methods with various combinations of sampling points are employed. METHODS The study includes 28 patients with gastroenteropancreatic neuroendocrine tumors who underwent post-therapy SPECT/CT imaging at approximately 4, 24, 96, and 168 h post-therapy (p.t.) following the first cycle of 177Lu-DOTATATE. The healthy liver, left/right kidney, spleen and up to 5 index tumors were delineated for each patient. Time-activity curves were fit with either monoexponential or biexponential functions for each structure, based on the Akaike information criterion. This fitting was performed using all 4 time points as a reference and various combinations of 2 and 3 time points to determine optimal imaging schedules and associated errors. 2 commonly used methods of single time point (STP) TIA estimation are also evaluated. A simulation study was also performed with data generated by sampling curve fit parameters from log-normal distributions derived from the clinical data and adding realistic measurement noise to sampled activities. For both clinical and simulation studies, error and variability in TIA estimates were estimated with various sampling schedules. RESULTS The optimal post-therapy imaging time period for STP estimates of TIA was found to be 3-5 days (71-126 h) p.t. for tumor and organs, with one exception of 6-8 days (144-194 h) p.t. for spleen with one STP approach. At the optimal time point, STP estimates give mean percent errors (MPE) within ± 5% and SD < 9% across all structures with largest magnitude error for kidney TIA (MPE = - 4.1%) and highest variability also for kidney TIA (SD = 8.4%). The optimal sampling schedule for 2TP estimates of TIA is 1-2 days (21-52 h) p.t. followed by 3-5 days (71-126 h) p.t. for kidney, tumor, and spleen. Using the optimal sampling schedule, the largest magnitude MPE for 2TP estimates is 1.2% for spleen and highest variability is in tumor with SD = 5.8%. The optimal sampling schedule for 3TP estimates of TIA is 1-2 days (21-52 h) p.t. followed by 3-5 days (71-126 h) p.t. and 6-8 days (144-194 h) p.t. for all structures. Using the optimal sampling schedule, the largest magnitude MPE for 3TP estimates is 2.5% for spleen and highest variability is in tumor with SD = 2.1%. Simulated patient results corroborate these findings with similar optimal sampling schedules and errors. Many sub-optimal reduced time point sampling schedules also exhibit low error and variability. CONCLUSIONS We show that reduced time point methods can be used to achieve acceptable average TIA errors over a wide range of imaging time points and sampling schedules while maintaining low uncertainty. This information can improve the feasibility of dosimetry for 177Lu-DOTATATE and elucidate the uncertainty associated with non-ideal conditions.
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Affiliation(s)
- Avery B Peterson
- Department of Radiology, University of Michigan, 1301 Catherine, 2276 Medical Science I/5610, Ann Arbor, MI, 48109, USA.
- Department of Radiation Oncology, Wayne State University, Detroit, MI, USA.
| | | | - Yuni K Dewaraja
- Department of Radiology, University of Michigan, 1301 Catherine, 2276 Medical Science I/5610, Ann Arbor, MI, 48109, USA
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Rassol N, Andersson C, Pettersson D, Al-Awar A, Shubbar E, Kovács A, Åkerström B, Gram M, Helou K, Forssell-Aronsson E. Co-administration with A1M does not influence apoptotic response of 177Lu-octreotate in GOT1 neuroendocrine tumors. Sci Rep 2023; 13:6417. [PMID: 37076494 PMCID: PMC10115890 DOI: 10.1038/s41598-023-32091-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 03/22/2023] [Indexed: 04/21/2023] Open
Abstract
Recombinant α1-microglobulin (A1M) is a proposed radioprotector during 177Lu-octreotate therapy of neuroendocrine tumors (NETs). To ensure a maintained therapeutic effect, we previously demonstrated that A1M does not affect the 177Lu-octreotate induced decrease in GOT1 tumor volume. However, the underlying biological events of these findings are still unknown. The aim of this work was to examine the regulation of apoptosis-related genes in GOT1 tumors short-time after i.v. administration of 177Lu-octreotate with and without A1M or A1M alone. Human GOT1 tumor-bearing mice received 30 MBq 177Lu-octreotate or 5 mg/kg A1M or co-treatment with both. Animals were sacrificed after 1 or 7 days. Gene expression analysis of apoptosis-related genes in GOT1 tissue was performed with RT-PCR. In general, similar expression patterns of pro- and anti-apoptotic genes were found after 177Lu-octreotate exposure with or without co-administration of A1M. The highest regulated genes in both irradiated groups compared to untreated controls were FAS and TNFSFRS10B. Administration of A1M alone only resulted in significantly regulated genes after 7 days. Co-administration of A1M did not negatively affect the transcriptional apoptotic response of 177Lu-octreotate in GOT1 tumors.
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Affiliation(s)
- Nishte Rassol
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Charlotte Andersson
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniella Pettersson
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Amin Al-Awar
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Emman Shubbar
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anikó Kovács
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bo Åkerström
- Department of Clinical Sciences, Infection Medicine, Lund University, Lund, Sweden
| | - Magnus Gram
- Neonatology Unit, Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden
| | - Khalil Helou
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Forssell-Aronsson
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
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Ramonaheng K, van Staden JA, du Raan H. Accuracy of two dosimetry software programs for 177Lu radiopharmaceutical therapy using voxel-based patient-specific phantoms. Heliyon 2022; 8:e09830. [PMID: 35865988 PMCID: PMC9293745 DOI: 10.1016/j.heliyon.2022.e09830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 02/18/2022] [Accepted: 06/24/2022] [Indexed: 12/01/2022] Open
Abstract
Purpose Virtual dosimetry using voxel-based patient-specific phantoms and Monte Carlo (MC) simulations offer the advantage of having a gold standard against which absorbed doses may be benchmarked to establish the dosimetry accuracy. Furthermore, these reference values assist in investigating the accuracy of the absorbed dose methodologies from different software programs. Therefore, this study aimed to compare the accuracy of the absorbed doses computed using LundADose and OLINDA/EXM 1.0. Methods The accuracy was based on 177Lu-DOTATATE distributions of three voxel-based phantoms. SPECT projection images were simulated for 1, 24, 96, and 168 h post-administration and reconstructed with LundADose using 3D OS-EM reconstruction. Mono-exponential curves were fitted to the bio-kinetic data for the kidneys, liver, spleen, and tumours resulting in SPECT time-integrated activity (SPECT-TIA). The SPECT-TIA were used to compute mean absorbed doses using LundADose (LND-DSPECT) and OLINDA (OLINDA-DSPECT) for the organs. Pre-defined true activity images, were used to obtain TRUE-TIA and, together with full MC simulations, computed the true doses (MC-DTrue). The dosimetry accuracy was assessed by comparing LND-DSPECT and OLINDA-DSPECT to MC-DTrue. Results Overall, the results presented an overestimation of the mean absorbed dose by LND-DSPECT compared to the MC-DTrue with a dosimetry accuracy ≤6.6%. This was attributed to spill-out activity from the reconstructed LND-DSPECT, resulting in a higher dose contribution than the MC-DTrue. There was a general underestimation (<8.1%) of OLINDA-DSPECT compared to MC-DTrue attributed to the geometrical difference in shape between the voxel-based phantoms and the OLINDA models. Furthermore, OLINDA-DSPECT considers self-doses while MC-DTrue reflects self-doses plus cross-doses. Conclusion The better than 10% accuracy suggests that the mean dose values obtained with LND-DSPECT and OLINDA-DSPECT approximate the true values. The mean absorbed doses of the two software programs, and the gold standard were comparable. This work shall be of use for optimising 177Lu dosimetry for clinical applications.
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Affiliation(s)
- Keamogetswe Ramonaheng
- Department of Medical Physics, Faculty of Health Sciences, University of the Free State, P.O. Box 339, Bloemfontein, 9300, South Africa
| | - Johannes A van Staden
- Department of Medical Physics, Faculty of Health Sciences, University of the Free State, P.O. Box 339, Bloemfontein, 9300, South Africa
| | - Hanlie du Raan
- Department of Medical Physics, Faculty of Health Sciences, University of the Free State, P.O. Box 339, Bloemfontein, 9300, South Africa
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EANM dosimetry committee recommendations for dosimetry of 177Lu-labelled somatostatin-receptor- and PSMA-targeting ligands. Eur J Nucl Med Mol Imaging 2022; 49:1778-1809. [PMID: 35284969 PMCID: PMC9015994 DOI: 10.1007/s00259-022-05727-7] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/13/2022] [Indexed: 12/25/2022]
Abstract
The purpose of the EANM Dosimetry Committee is to provide recommendations and guidance to scientists and clinicians on patient-specific dosimetry. Radiopharmaceuticals labelled with lutetium-177 (177Lu) are increasingly used for therapeutic applications, in particular for the treatment of metastatic neuroendocrine tumours using ligands for somatostatin receptors and prostate adenocarcinoma with small-molecule PSMA-targeting ligands. This paper provides an overview of reported dosimetry data for these therapies and summarises current knowledge about radiation-induced side effects on normal tissues and dose-effect relationships for tumours. Dosimetry methods and data are summarised for kidneys, bone marrow, salivary glands, lacrimal glands, pituitary glands, tumours, and the skin in case of radiopharmaceutical extravasation. Where applicable, taking into account the present status of the field and recent evidence in the literature, guidance is provided. The purpose of these recommendations is to encourage the practice of patient-specific dosimetry in therapy with 177Lu-labelled compounds. The proposed methods should be within the scope of centres offering therapy with 177Lu-labelled ligands for somatostatin receptors or small-molecule PSMA.
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Elvborn M, Shubbar E, Forssell-Aronsson E. Hyperfractionated Treatment with 177Lu-Octreotate Increases Tumor Response in Human Small-Intestine Neuroendocrine GOT1 Tumor Model. Cancers (Basel) 2022; 14:cancers14010235. [PMID: 35008397 PMCID: PMC8750112 DOI: 10.3390/cancers14010235] [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: 11/10/2021] [Revised: 12/29/2021] [Accepted: 12/29/2021] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Neuroendocrine tumors are slow growing and initially associated with vague symptoms and, therefore, often spread in the patient’s body at diagnosis, leading to a poor prognosis without means of curation through surgery. Although tumor-targeting treatments exist and are used in clinics, they are not fully optimized. The aim of this study was to test different dosages and time intervals of the radioactive pharmaceutical 177Lu-octreotate. We found that dividing a dosage into several portions and administering it at short time intervals resulted in a stronger tumor reduction and/or prolonged time for regrowth in mice than if given as a single dose. The biggest differences were seen in the lower dosage levels of the study. The findings indicate that there is clear room for improvements in the treatment of neuroendocrine tumors with 177Lu-octreotate. Abstract Radionuclide treatment of patients with neuroendocrine tumors has advanced in the last decades with favorable results using 177Lu-octreotate. However, the gap between the high cure rate in animal studies vs. patient studies indicates a potential to increase the curation of patients. The aim of this study was to investigate the tumor response for different fractionation schemes with 177Lu-octreotate. BALB/c mice bearing a human small-intestine neuroendocrine GOT1 tumor were either mock treated with saline or injected intravenously with a total of 30–120 MBq of 177Lu-octreotate: 1 × 30, 2 × 15, 1 × 60, 2 × 30, 1 × 120, 2 × 60, or 3 × 40 MBq. The tumor volume was measured twice per week until the end of the experiment. The mean tumor volume for mice that received 2 × 15 = 30 and 1 × 30 MBq 177Lu-octreotate was reduced by 61% and 52%, respectively. The mean tumor volume was reduced by 91% and 44% for mice that received 2 × 30 = 60 and 1 × 60 MBq 177Lu-octreotate, respectively. After 120 MBq 177Lu-octreotate, given as 1–3 fractions, the mean tumor volume was reduced by 91–97%. Multiple fractions resulted in delayed regrowth and prolonged overall survival by 20–25% for the 120 MBq groups and by 45% for lower total activities, relative to one fraction. The results indicate that fractionation and hyperfractionation of 177Lu-octreotate are beneficial for tumor reduction and prolongs the time to regrowth.
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Affiliation(s)
- Mikael Elvborn
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SE-413 45 Gothenburg, Sweden; (E.S.); (E.F.-A.)
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, SE-413 45 Gothenburg, Sweden
- Correspondence: ; Tel.: +46-(0)-31-342-95-99
| | - Emman Shubbar
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SE-413 45 Gothenburg, Sweden; (E.S.); (E.F.-A.)
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, SE-413 45 Gothenburg, Sweden
| | - Eva Forssell-Aronsson
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SE-413 45 Gothenburg, Sweden; (E.S.); (E.F.-A.)
- Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, SE-413 45 Gothenburg, Sweden
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
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Nautiyal A, Mondal T, Mitra D, Goel A, Dey SK, Kaushik A. A SIMPLE AND NOVEL APPROACH TO STUDY KINETICS AND ESTIMATE RADIATION DOSES FROM INTERNALLY ADMINISTERED RADIOPHARMACEUTICALS USING AN EXTERNAL DOSE MEASUREMENT SYSTEM. RADIATION PROTECTION DOSIMETRY 2021; 196:141-152. [PMID: 34585244 DOI: 10.1093/rpd/ncab141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/28/2021] [Accepted: 09/03/2021] [Indexed: 06/13/2023]
Abstract
Various methods have been reported to study radiotracer kinetics and make internal dosimetry feasible in the routine clinical nuclear medicine practice. The aim of the present study was to quantify cumulative activity and organ doses using an indigenously designed and fabricated external dose measurement system. The measurement was demonstrated on patients undergoing whole-body (WB) 18F-FDG (Fluorine-18-fluorodeoxyglucose) direct positron emission tomography/computed tomography investigations. An external dose measurement system comprising of an ionisation chamber-survey meter and the movable focussing collimator was used to quantify the uptake of 18F-FDG in liver and brain. Cumulative activity and normalised cumulative activity in these organs were calculated. The results were validated by performing measurements on a phantom uniformly filled with known activity of 18F-FDG.The difference in the absorbed dose estimated with and without collimator was statistically significant (p < 0.05). The external dose measurement technique is relatively novel, convenient and reliable for the assessment of internal absorbed dose of organs.
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Affiliation(s)
- Amit Nautiyal
- Institute of Nuclear Medicine & Molecular Imaging, AMRI Hospitals, Dhakuria, Kolkata, India
- Amity Institute of Nuclear Science & Technology, Amity University Uttar Pradesh, Noida, India
| | - Tanmoy Mondal
- Department of Biotechnology, Maulana Abul Kalam Azad University of Technology, Salt Lake, Kolkata, India
| | - Deepanjan Mitra
- Institute of Nuclear Medicine & Molecular Imaging, AMRI Hospitals, Dhakuria, Kolkata, India
| | - Alpana Goel
- Amity Institute of Nuclear Science & Technology, Amity University Uttar Pradesh, Noida, India
| | - Subrata Kumar Dey
- Department of Biotechnology, Maulana Abul Kalam Azad University of Technology, Salt Lake, Kolkata, India
| | - Aruna Kaushik
- Institute of Nuclear Medicine & Allied Sciences, Brig. S.K. Mazumdar Marg, Timarpur, Delhi, India
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Mix M, Renaud T, Kind F, Nemer U, Yousetzadeh-Nowsha E, Moalosi TCG, Omrane MA, Meyer PT, Ruf J. Kidney doses in 177Lu-based radioligand therapy in prostate cancer: Is dose estimation based on reduced dosimetry measurements feasible? J Nucl Med 2021; 63:253-258. [PMID: 34088773 DOI: 10.2967/jnumed.121.262245] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/05/2022] [Indexed: 11/16/2022] Open
Abstract
The radiation dose to the kidneys should be monitored in prostate cancer patients treated with radioligand therapy (RLT) targeting the prostate-specific membrane antigen (PSMA). We analyzed whether pretherapeutic kidney function is predictive of subsequent kidney dose and to what extend the cumulative kidney dose after multiple therapy cycles at the end of treatment can be predicted from a dosimetry based on the first cycle. Methods: Data of 59 patients treated with at least 2 cycles of 177Lu-PSMA-617 (PSMA-RLT) were analyzed. Treatment (median: 6 GBq/cycle) was performed at 6-8 week intervals, accompanied by voxel-based 3D-dosimetry (measured kidney dose) with SPECT/CT on each of days 0-3 and once during days 6-9. Pretherapeutic kidney function (eGFR, MAG3-clearance) was correlated to the kidney doses. Cumulative kidney doses at the end of treatment were compared to a dose estimation based on the population-based mean kidney dose, individual first cycle kidney dose and mean kidney doses of cycles 1, 3 and 5 per administered activity. Results: A total of 176 PSMA-RLT cycles were performed with a median of 3 cycles per patient. The average kidney dose per administered activity of all 176 cycles was 0.67 ± 0.24 Gy/GBq (range 0.21 - 1.60). MAG3-clearance and eGFR were no reliable predictors of subsequent absorbed kidney dose and showed only small effect sizes (R2 = 0.080 and 0.014, P = 0.039 and 0.375). All simplified estimations of cumulative kidney dose correlated significantly (P < 0.001) with measured kidney doses: Estimations based on the individual first-cycle dose were more accurate than the use of the population-based average kidney dose (R2 = 0.853 vs. R2 = 0.560). Dose estimation was best when the doses of cycles 3 and 5 were included as well (R2 = 0.960). Conclusion: Pretherapeutic renal function was not predictive for subsequent kidney dose during therapy. Extrapolation of individual data from dosimetry of the first cycle was highly predictive for the cumulative kidney dose at the end of treatment. This is further improved by the integration of dose information from every other cycle. In any case, because of a high interindividual variance, an individual dosimetry is advisable.
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Affiliation(s)
- Michael Mix
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Tobias Renaud
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Felix Kind
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Ursula Nemer
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Elham Yousetzadeh-Nowsha
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Tumelo C G Moalosi
- Department of Medical Imaging and Clinical Oncology, Nuclear Medicine Division, Faculty of Medicine and Health Science, Stellenbosch University, South Africa
| | - Mohamed Aymen Omrane
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Philipp T Meyer
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Juri Ruf
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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Rosar F, Schön N, Bohnenberger H, Bartholomä M, Stemler T, Maus S, Khreish F, Ezziddin S, Schaefer-Schuler A. Comparison of different methods for post-therapeutic dosimetry in [ 177Lu]Lu-PSMA-617 radioligand therapy. EJNMMI Phys 2021; 8:40. [PMID: 33950333 PMCID: PMC8099965 DOI: 10.1186/s40658-021-00385-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/23/2021] [Indexed: 12/24/2022] Open
Abstract
Background Dosimetry is of high importance for optimization of patient-individual PSMA-targeted radioligand therapy (PSMA-RLT). The aim of our study was to evaluate and compare the feasibility of different approaches of image-based absorbed dose estimation in terms of accuracy and effort in clinical routine. Methods Whole-body planar images and SPECT/CT images were acquired from 24 patients and 65 cycles at 24h, 48h, and ≥96h after administration of a mean activity of 6.4 GBq [177Lu]Lu-PSMA-617 (range 3–10.9 GBq). Dosimetry was performed by use of the following approaches: 2D planar-based dosimetry, 3D SPECT/CT-based dosimetry, and hybrid dosimetry combining 2D and 3D data. Absorbed doses were calculated according to IDAC 2.1 for the kidneys, the liver, the salivary glands, and bone metastases. Results Mean absorbed doses estimated by 3D dosimetry (the reference method) were 0.54 ± 0.28 Gy/GBq for the kidneys, 0.10 ± 0.05 Gy/GBq for the liver, 0.81 ± 0.34 Gy/GBq for the parotid gland, 0.72 ± 0.39 Gy/GBq for the submandibular gland, and 1.68 ± 1.32 Gy/GBq for bone metastases. Absorbed doses of normal organs estimated by hybrid dosimetry showed small, non-significant differences (median up to 4.0%) to the results of 3D dosimetry. Using 2D dosimetry, in contrast, significant differences (median up to 10.9%) were observed. Regarding bone metastases, small, but significant differences (median up to 7.0%) of absorbed dose were found for both, 2D dosimetry and hybrid dosimetry. Bland-Altman analysis revealed high agreement between hybrid dosimetry and 3D dosimetry for normal organs and bone metastases, but substantial differences between 2D dosimetry and 3D dosimetry. Conclusion Hybrid dosimetry provides high accuracy in estimation of absorbed dose in comparison to 3D dosimetry for all important organs and is therefore feasible for use in individualized PSMA-RLT.
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Affiliation(s)
- Florian Rosar
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. Geb. 50, D-66421, Homburg, Germany
| | - Niklas Schön
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. Geb. 50, D-66421, Homburg, Germany
| | - Hendrik Bohnenberger
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. Geb. 50, D-66421, Homburg, Germany
| | - Mark Bartholomä
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. Geb. 50, D-66421, Homburg, Germany
| | - Tobias Stemler
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. Geb. 50, D-66421, Homburg, Germany
| | - Stephan Maus
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. Geb. 50, D-66421, Homburg, Germany
| | - Fadi Khreish
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. Geb. 50, D-66421, Homburg, Germany
| | - Samer Ezziddin
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. Geb. 50, D-66421, Homburg, Germany
| | - Andrea Schaefer-Schuler
- Department of Nuclear Medicine, Saarland University-Medical Center, Kirrberger Str. Geb. 50, D-66421, Homburg, Germany.
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12
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Peptide Receptor Radionuclide Therapy of Pulmonary Neuroendocrine Neoplasms: a Single-Centre Experience. Nucl Med Mol Imaging 2021; 55:38-45. [PMID: 33643488 DOI: 10.1007/s13139-020-00679-y] [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: 07/21/2020] [Revised: 11/25/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022] Open
Abstract
Purpose Peptide receptor radionuclide therapy represents a therapeutic option for neuroendocrine neoplasms; to date, experiences with peptide receptor radionuclide therapy of pulmonary neuroendocrine neoplasms are still limited. We report our experience with peptide receptor radionuclide therapy of pulmonary neuroendocrine neoplasm patients. Materials and Methods Clinical records of 14 pulmonary neuroendocrine neoplasm patients (7 female and 7 male) who received at least 2 cycles of peptide receptor radionuclide therapy were retrospectively reviewed. Tumoural uptake of somatostatin analogues at pre-treatment imaging was graded as 2 to 3 in all patients. RECIST criteria were used to evaluate response. Results No treated patient had significant toxicity. Partial response was found in 3 (21.4%) patients, stable disease in 7 (50%), and progressive disease in 4 (28.6%). A statistically significant difference between disease state at enrolment and after peptide receptor radionuclide therapy was found. Conclusions Our data furtherly support peptide receptor radionuclide therapy as a safe and effective treatment of patients affected by pulmonary neuroendocrine neoplasms allowing disease control in about 71% of patients without showing significant toxicity. Other studies are needed to confirm our results.
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13
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Ali WM, Sulieman A, Salah H, Almohammed H, Alkhorayef M, Bradley D. Short-term retention of 99mTc activity in bone scintigraphy. Radiat Phys Chem Oxf Engl 1993 2021. [DOI: 10.1016/j.radphyschem.2020.108907] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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14
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Zhao W, Esquinas PL, Frezza A, Hou X, Beauregard JM, Celler A. Accuracy of kidney dosimetry performed using simplified time activity curve modelling methods: a 177Lu-DOTATATE patient study. Phys Med Biol 2019; 64:175006. [PMID: 31287093 DOI: 10.1088/1361-6560/ab3039] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
177Lu-DOTATATE therapy has been shown to produce encouraging results in treatment of neuroendocrine tumours (NETs). Unfortunately, since dosimetry for radionuclide therapy is considered to be challenging, typically similar amount of radiopharmaceutical is administered to every patient. There is growing evidence that the efficacy of this therapy can be significantly improved by employing personalized protocols, based on the organ-at-risk dosimetry. The aim of this study is to propose a practical and accurate dosimetry protocol based on the simplified acquisition schedules. Data from fifty-three therapy cycles in thirty-nine NET patients were analyzed. Three SPECT/CT scans, acquired at 4 h (D0), 23 h (D1) and 70 h (D3) after injection, were performed. The kidney volume was determined using CT and the activity was determined from quantitative SPECT using an iterative thresholding method. For each dataset, four methods were used to model the time-activity-curves (TAC): M1-two trapezoid segments (0 to D0 and D0 to D1), followed by monoexponential fit to D1 + D3 data; M2-monoexponential fit to D0 + D1 + D3 data; M3 and M4-monoexponential fit to D0 + D3 and D1 + D3 data, respectively. Additionally, kidney doses obtained from single time point method using a monoexponential curve with the population mean effective half-life, normalized to activities at D0 or D1 or D3 points, were calculated. The accuracy of simplified dosimetry methods was assessed as the percentage difference relative to doses calculated from M1. The major contribution to the absorbed dose estimate comes from the area under the late time portion of the TAC (D1 to infinity). Therefore, information from the late scan (D3) is crucial for the determination of kidney absorbed doses. Single time point method using monoexponential TAC, with the population mean effective half-life normalized to the late data point (48-72 h for kidneys) produces <10% deviation in the absorbed dose estimation, thus is recommended for clinical use.
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Affiliation(s)
- Wei Zhao
- Department of Physics and Astronomy, University of British Columbia, Vancouver, BC, Canada. Medical Imaging Research Group, Department of Radiology, University of British Columbia, Vancouver, BC, Canada. Author to whom any correspondence should be addressed
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15
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Chicheportiche A, Grozinsky-Glasberg S, Gross DJ, Krausz Y, Salmon A, Meirovitz A, Freedman N, Godefroy J. Predictive power of the post-treatment scans after the initial or first two courses of [ 177Lu]-DOTA-TATE. EJNMMI Phys 2018; 5:36. [PMID: 30535780 PMCID: PMC6286905 DOI: 10.1186/s40658-018-0234-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/20/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate the predictive power of the absorbed dose to kidneys after the first course of treatment with [177Lu]-DOTA-TATE for neuroendocrine tumors (NETs) on the cumulative kidney absorbed dose after 3 or 4 cycles of treatment. Post-treatment scans (PTS) are acquired after each cycle of peptide receptor radionuclide therapy (PRRT) with [177Lu]-DOTA-TATE for personalized radiation dosimetry in order to ensure a cumulative absorbed dose to kidneys under a safety threshold of 25 Gy. One hundred eighty-seven patients who completed treatment with [177Lu]-DOTA-TATE and underwent PTS for dosimetry calculation were included in this retrospective study. The correlation between the cumulative absorbed dose to kidneys after the completion of treatment and the absorbed dose after the first cycle(s) was studied. Multilinear regression analysis was done to predict the cumulative absorbed dose to the kidneys of the subsequent cycles, and an algorithm for the follow up of kidney absorbed dose is proposed. RESULTS Patients whose absorbed dose to kidneys after the first cycle of treatment is below 5.6 Gy can receive four cycles of treatment with a cumulative dose less than 25 Gy (p < 0.1). For the other patients, the cumulative absorbed dose after 3 or 4 cycles of treatment can be predicted after the second cycle of treatment to allow for an early decision regarding the number of cycles that may be given. CONCLUSIONS The follow up of kidney absorbed dose after PRRT can be simplified with the algorithm presented in this study, reducing by one-third the number of post-treatment scans and reducing hospitalization time for more than half of the treatment cycles.
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Affiliation(s)
- Alexandre Chicheportiche
- Department of Nuclear Medicine & Biophysics, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel.
| | - Simona Grozinsky-Glasberg
- Neuroendocrine Tumor Unit, Endocrinology and Metabolism Department, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - David J Gross
- Neuroendocrine Tumor Unit, Endocrinology and Metabolism Department, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Yodphat Krausz
- Department of Nuclear Medicine & Biophysics, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Asher Salmon
- Oncology Department and Radiation Therapy Unit, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Amichay Meirovitz
- Oncology Department and Radiation Therapy Unit, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Nanette Freedman
- Department of Nuclear Medicine & Biophysics, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Jeremy Godefroy
- Department of Nuclear Medicine & Biophysics, Hadassah-Hebrew University Medical Center, 91120, Jerusalem, Israel
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16
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Santoro L, Mora-Ramirez E, Trauchessec D, Chouaf S, Eustache P, Pouget JP, Kotzki PO, Bardiès M, Deshayes E. Implementation of patient dosimetry in the clinical practice after targeted radiotherapy using [ 177Lu-[DOTA0, Tyr3]-octreotate. EJNMMI Res 2018; 8:103. [PMID: 30498938 PMCID: PMC6265360 DOI: 10.1186/s13550-018-0459-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 11/20/2018] [Indexed: 01/01/2023] Open
Abstract
Background This study’s aim was to develop our dosimetric methodology using a commercial workstation for the routine evaluation of the organs at risk during peptide receptor radionuclide therapy (PRRT) with 177Lu. Methods First, planar and SPECT sensitivity factors were determined on phantoms. The reconstruction parameters were optimized by SPECT/CT image acquisition using a NEMA IEC phantom containing a 500 ml bottle of 177Lu, to simulate a kidney. The recovery coefficients were determined on various phantoms. For the red marrow, this was calculated using a NEMA IEC phantom that contained a centrally placed bottle of 80 ml of 177Lu (to model the L2-L4 red marrow) flanked by two 200 ml bottles with 177Lu to simulate the kidneys. Then, SPECT/CT images were acquired at 4, 24, 72, and 192 h after injection in 12 patients with neuroendocrine tumors who underwent PRRT with 177Lu-DOTATATE. SPECT data were reconstructed using the iterative ordered subset expectation maximization (OSEM) method, with six iterations and ten subsets, attenuation, scatter, recovery resolution corrections, and a Gaussian post-filter of 0.11 cm. The liver, spleen, kidneys, and red marrow dose per administered activity (AD/A admin) values were calculated with the Medical Internal Radiation Dose (MIRD) formalism and the residence times (Dosimetry toolkit® application) using standard and CT imaging-based organ masses (OLINDA/EXM® V1.0 software). Results Sensitivity factors of 6.11 ± 0.01 and 5.67 ± 0.08 counts/s/MBq were obtained with planar and SPECT/CT acquisitions, respectively. A recovery coefficient of 0.78 was obtained for the modeled L2–L4 red marrow. The mean AD/A admin values were 0.43 ± 0.13 mGy/MBq [0.27–0.91] for kidneys, 0.54 ± 0.58 mGy/MBq [0.12–2.26] for liver, 0.61 ± 0.13 mGy/MBq [0.42–0.89] for spleen, and 0.04 ± 0.02 mGy/MBq [0.01–0.09] for red marrow. The AD/A admin values varied when calculated using the personalized and standard organ mass, particularly for kidneys (p = 1 × 10−7), spleen (p = 0.0069), and red marrow (p = 0.0027). Intra-patient differences were observed especially in organs close to or including tumor cells or metastases. Conclusions The obtained AD/A admin values were in agreement with the literature data. This study shows the technical feasibility of patient dosimetry in clinical practice and the need to obtain patient-specific information.
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Affiliation(s)
- Lore Santoro
- Nuclear Medicine Department, Montpellier Cancer Institute (ICM), University of Montpellier, 208 Avenue des Apothicaires, 34298, Montpellier Cedex5, France.
| | - Erick Mora-Ramirez
- Centre de Recherche en Cancérologie de Toulouse, Toulouse, France.,INSERM, UMR 1037, Toulouse III Paul Sabatier University, Toulouse, France.,University of Costa Rica, Physics School, CICANUM, San Jose, Costa Rica
| | - Dorian Trauchessec
- Nuclear Medicine Department, Montpellier Cancer Institute (ICM), University of Montpellier, 208 Avenue des Apothicaires, 34298, Montpellier Cedex5, France
| | - Soufiane Chouaf
- Nuclear Medicine Department, Montpellier Cancer Institute (ICM), University of Montpellier, 208 Avenue des Apothicaires, 34298, Montpellier Cedex5, France
| | - Pierre Eustache
- Nuclear Medicine Department, Montpellier Cancer Institute (ICM), University of Montpellier, 208 Avenue des Apothicaires, 34298, Montpellier Cedex5, France
| | - Jean-Pierre Pouget
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Université de Montpellier, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Pierre-Olivier Kotzki
- Nuclear Medicine Department, Montpellier Cancer Institute (ICM), University of Montpellier, 208 Avenue des Apothicaires, 34298, Montpellier Cedex5, France.,Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Université de Montpellier, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Manuel Bardiès
- Centre de Recherche en Cancérologie de Toulouse, Toulouse, France.,INSERM, UMR 1037, Toulouse III Paul Sabatier University, Toulouse, France
| | - Emmanuel Deshayes
- Nuclear Medicine Department, Montpellier Cancer Institute (ICM), University of Montpellier, 208 Avenue des Apothicaires, 34298, Montpellier Cedex5, France.,Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Université de Montpellier, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
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17
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Marin G, Vanderlinden B, Karfis I, Guiot T, Wimana Z, Reynaert N, Vandenberghe S, Flamen P. A dosimetry procedure for organs-at-risk in 177Lu peptide receptor radionuclide therapy of patients with neuroendocrine tumours. Phys Med 2018; 56:41-49. [PMID: 30527088 DOI: 10.1016/j.ejmp.2018.11.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/05/2018] [Accepted: 11/02/2018] [Indexed: 01/25/2023] Open
Abstract
PURPOSE Peptide receptor radionuclide therapy with 177Lu-DOTATATE has become a standard treatment modality in neuroendocrine tumours (NETs). No consensus has yet been reached however regarding the absorbed dose threshold for lesion response, the absorbed dose limit to organs-at-risk, and the optimal fractionation and activity to be administered. This is partly due to a lack of uniform and comparable dosimetry protocols. The present article details the development of an organ-at-risk dosimetry procedure, which could be implemented and used routinely in a clinical context. METHODS Forty-seven patients with NETs underwent 177Lu-DOTATATE therapy. Three SPECT/CT images were acquired at 4, 24 and 144-192 h post-injection. Three blood samples were obtained together with the SPECT/CT acquisitions and 2 additional samples were obtained around 30 min and 1 h post-injection. A bi-exponential fit was used to compute the source organ time-integrated activity coefficients. Coefficients were introduced into OLINDA/EXM software to compute organ-at-risk absorbed doses. Median values for all patients were computed for absorbed dose coefficient D/A0 and for late effective half-life T1/2eff for kidneys, spleen and red marrow. RESULTS Dosimetry resulted in a median[interquartile range] of 0.78[0.35], 1.07[0.58] and 0.028[0.010] Gy/GBq for D/A0 and of 55[9], 71[9] and 52[18] h for T1/2eff for kidneys, spleen and red marrow respectively. CONCLUSIONS A dosimetry procedure for organs-at-risk in 177Lu-DOTATATE therapy based on serial SPECT/CT images and blood samples can be implemented routinely in a clinical context with limited patient burden. The results obtained were in accordance with those of other centres.
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Affiliation(s)
- Gwennaëlle Marin
- Department of Medical Physics, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 121 boulevard de Waterloo, 1000 Brussels, Belgium; Medical Imaging and Signal Processing (MEDISIP), Department of Electronics and Information Systems (ELIS), Faculty of Engineering and Architecture (FEA), Ghent University (UGent), 185 De Pintelaan, 9000 Gent, Belgium.
| | - Bruno Vanderlinden
- Department of Medical Physics, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 121 boulevard de Waterloo, 1000 Brussels, Belgium.
| | - Ioannis Karfis
- Department of Nuclear Medicine, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 121 boulevard de Waterloo, 1000 Brussels, Belgium.
| | - Thomas Guiot
- Department of Medical Physics, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 121 boulevard de Waterloo, 1000 Brussels, Belgium.
| | - Zena Wimana
- Department of Nuclear Medicine, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 121 boulevard de Waterloo, 1000 Brussels, Belgium.
| | - Nick Reynaert
- Department of Medical Physics, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 121 boulevard de Waterloo, 1000 Brussels, Belgium.
| | - Stefaan Vandenberghe
- Medical Imaging and Signal Processing (MEDISIP), Department of Electronics and Information Systems (ELIS), Faculty of Engineering and Architecture (FEA), Ghent University (UGent), 185 De Pintelaan, 9000 Gent, Belgium.
| | - Patrick Flamen
- Department of Nuclear Medicine, Institut Jules Bordet-Université Libre de Bruxelles (ULB), 121 boulevard de Waterloo, 1000 Brussels, Belgium.
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Peptide receptor radionuclide therapy with 177Lu-DOTA-octreotate: dosimetry, nephrotoxicity, and the effect of hematological toxicity on survival. Nucl Med Commun 2018; 39:236-246. [PMID: 29315138 DOI: 10.1097/mnm.0000000000000795] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Peptide receptor radionuclide therapy (PRRT) with lutetium-177 (Lu)-DOTATATE is regarded as a safe treatment option with promising results for patients with neuroendocrine neoplasia (NEN). We aimed to study the absorbed organ and tumor doses, the renal and hematological toxicity as well as their mutual interaction. Another aim was the identification of adverse effects as possible predictors which may affect survival. METHODS A total of 30 (14 female and 16 male) patients with inoperable/metastatic NEN were treated with 7.4 GBq of Lu-DOTATATE. Occurrence of renal and hematological toxicity wasretrospectively studied. Morever, we examined the effects of hematological toxicity on survival after Lu-DOTATATE-PRRT. RESULTS In 49 treatment cycles, the mean absorbed dose to the kidneys was 5.13±2.12, 4.49±2.49 Gy to the liver, and 14.44±8.97 Gy to the spleen, whereas tumor lesions absorbed a mean dose of 31.43±36.86 Gy. Comparing different localizations of metastases, no significant differences in absorbed dose were observed. Clinical response status revealed regressive disease in 47.6%, stable disease in 38.1%, and progressive disease in 14.3% of cases (n=21). Biochemically, 81.3% of patients showed reduced serotonin values (n=16; P<0.05) following Lu-DOTATATE-PRRT. No severe subacute renal or hematological toxicity occurred (one Common Terminology Criteria for Adverse Events-grade 3 for thrombocytopenia and another one for leukocytopenia). No statistically significant relation between baseline kidney function and post-therapeutic hematological changes was identified. CONCLUSION The findings indicate that Lu-DOTATATE-PRRT is a safe and effective treatment method for patients with NEN. Moreover, these data strongly suggest that hematological parameters may affect survival so a further re-evaluation in prospective studies is warranted.
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Sundlöv A, Gustafsson J, Brolin G, Mortensen N, Hermann R, Bernhardt P, Svensson J, Ljungberg M, Tennvall J, Sjögreen Gleisner K. Feasibility of simplifying renal dosimetry in 177Lu peptide receptor radionuclide therapy. EJNMMI Phys 2018; 5:12. [PMID: 29974391 PMCID: PMC6031553 DOI: 10.1186/s40658-018-0210-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Accepted: 03/21/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Recently, 177Lu-dotatate therapy for neuroendocrine tumours has received regulatory approval. Dosimetry can be used to optimize treatment on an individual basis, but there is no international consensus as to how it should be done. The aim of this study is to determine a feasible and accurate dosimetry method to guide individualized peptide receptor radionuclide therapy (PRRT) for patients with neuroendocrine tumours. As part of a clinical trial on 177Lu-dotatate therapy, renal dosimetry was performed for all patients in each treatment cycle, using a hybrid planar-SPECT/CT method. In the present study, we use the image data acquired from 22 patients and 119 cycles and define a set of alternative treatment planning strategies, each representing a simplification in terms of image acquisition and dosimetric calculations. The results from the simplified strategies are compared to the results from the protocol-prescribed hybrid planar-SPECT/CT-based method by analysing differences both in per-cycle and total cumulative absorbed dose (AD) analyses. RESULTS In general, the SPECT-based methods gave results that were largely consistent with the protocol-specified hybrid method, both in the per-cycle and cumulative AD analyses. Notably, performing one SPECT/CT per cycle at 96 h yielded ADs that were very similar to the protocol method. The methods using planar dosimetry resulted in larger variations, as expected, while giving 4 cycles to all patients resulted in the largest inter-individual differences in cumulative AD. CONCLUSIONS Performing one SPECT/CT at 96 h in every treatment cycle gives sufficiently reliable dosimetric results to base individualized treatment planning on, with a reasonable demand on resources.
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Affiliation(s)
- Anna Sundlöv
- Oncology and Pathology, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden.
- Department of Oncology, Skåne University Hospital, SE-221 85, Lund, Sweden.
| | - Johan Gustafsson
- Department of Medical Radiation Physics, Lund University, Lund, Sweden
| | - Gustav Brolin
- Department of Medical Radiation Physics, Lund University, Lund, Sweden
| | - Nadja Mortensen
- Oncology and Pathology, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Rebecca Hermann
- Department of Radiation Physics, University of Gothenburg, Gothenburg, Sweden
| | - Peter Bernhardt
- Department of Radiation Physics, University of Gothenburg, Gothenburg, Sweden
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johanna Svensson
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Michael Ljungberg
- Department of Medical Radiation Physics, Lund University, Lund, Sweden
| | - Jan Tennvall
- Oncology and Pathology, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
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Correlation of dose with toxicity and tumour response to 90Y- and 177Lu-PRRT provides the basis for optimization through individualized treatment planning. Eur J Nucl Med Mol Imaging 2018; 45:2426-2441. [PMID: 29785514 DOI: 10.1007/s00259-018-4044-x] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 04/27/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE Peptide receptor radionuclide therapy (PRRT) with 90Y-labelled and 177Lu-labelled peptides is an effective strategy for the treatment of metastatic/nonresectable neuroendocrine tumours (NETs). Dosimetry provides important information useful for optimizing PRRT with individualized regimens to reduce toxicity and increase tumour responses. However, this strategy is not applied in routine clinical practice, despite the fact that several dosimetric studies have demonstrated significant dose-effect correlations for normal organ toxicity and tumour response that can better guide therapy planning. The present study reviews the key relationships and the radiobiological models available in the literature with the aim of providing evidence that optimization of PRRT is feasible through the implementation of dosimetry. METHODS The MEDLINE database was searched combining specific keywords. Original studies published in the English language reporting dose-effect outcomes in patients treated with PRRT were chosen. RESULTS Nine of 126 studies were selected from PubMed, and a further five were added manually, reporting on 590 patients. The studies were analysed and are discussed in terms of weak and strong elements of correlations. CONCLUSION Several studies provided evidence of clinical benefit from the implementation of dosimetry in PRRT, indicating the potential contribution of this approach to reducing severe toxicity and/or reducing undertreatment that commonly occurs. Prospective trials, possibly multicentre, with larger numbers of patients undergoing quantitative dosimetry and with standardized methodologies should be carried out to definitively provide robust predictive paradigms to establish effective tailored PRRT.
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Abstract
BACKGROUND The kidneys are the dose-limiting organ in lutetium-177 DOTATATE therapy. Therefore, it is advisable to perform critical organ dosimetry focussed on renal dose in treated patients. A key uncertainty in such dose estimates is the use of standard phantoms to represent the individual patient. The primary aim of this study was to investigate the accuracy of methods for estimating kidney size, and hence absorbed kidney dose, by comparison with individual measurements from computed tomography (CT) imaging. MATERIALS AND METHODS Kidney volume was measured using diagnostic CT images for 57 patients who underwent lutetium-177 DOTATATE therapy. Kidney mass was also estimated in two ways: using the standard adult phantoms, as well as through the application of a weight scaling factor to these phantoms and their organs. Dose calculations were performed for each of the three methods using OLINDA/EXM software. RESULTS Scaling of the phantom by patient weight gave a more accurate result when compared with the CT gold standard than the standard phantom. The dose difference from the CT method had mean values of 1.4% (SD=22.6%) and 8.4% (SD=21.5%) for scaled and unscaled, respectively. Patient weight was not found to be a good predictor of kidney mass in these patients (r of 0.12 from linear regression analysis). CONCLUSION The most accurate method of organ volume estimation would be individual measurements from CT imaging; however, where this is not possible, scaling of organ masses by weight ratio is more accurate than the use of the standard phantom.
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Garske-Román U, Sandström M, Fröss Baron K, Lundin L, Hellman P, Welin S, Johansson S, Khan T, Lundqvist H, Eriksson B, Sundin A, Granberg D. Prospective observational study of 177Lu-DOTA-octreotate therapy in 200 patients with advanced metastasized neuroendocrine tumours (NETs): feasibility and impact of a dosimetry-guided study protocol on outcome and toxicity. Eur J Nucl Med Mol Imaging 2018; 45:970-988. [PMID: 29497803 PMCID: PMC5915504 DOI: 10.1007/s00259-018-3945-z] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/11/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Peptide receptor radionuclide therapy in patients with neuroendocrine tumours has yielded promising results. This prospective study investigated the feasibility of dosimetry of the kidneys and bone marrow during therapy and its impact on efficacy and outcome. METHODS The study group comprised 200 consecutive patients with metastasized somatostatin receptor-positive neuroendocrine tumours progressing on standard therapy or not suitable for other therapeutic options. A treatment cycle consisted of 7.4 GBq 177Lu-DOTA-octreotate with co-infusion of a mixed amino acid solution, and cycles were repeated until the absorbed dose to the kidneys reached 23 Gy or there were other reasons for stopping therapy. The Ki-67 index was ≤2% in 47 patients (23.5%), 3-20% in 121 (60.5%) and >20% in 16 (8%). RESULTS In 123 patients (61.5%) the absorbed dose to the kidneys reached 23 Gy with three to nine cycles during first-line therapy; in no patient was a dose to the bone marrow of 2 Gy reached. The best responses (according to RECIST 1.1) were a complete response (CR) in 1 patient (0.5%), a partial response (PR) in 47 (23.5%), stable disease (SD) in 135 (67.5%) and progressive disease (PD) in 7 (3.5%). Median progression-free survival was 27 months (95% CI 22-30 months) in all patients, 33 months in those in whom the absorbed dose to the kidneys reached 23 Gy and 15 months in those in whom it did not. Median overall survival (OS) was 43 months (95% CI 39-53 months) in all patients, 54 months in those in whom the absorbed dose to the kidneys reached 23 Gy and 25 months in those in whom it did not. Median OS was 60 months in patients with a best response of PR or CR, 42 months in those with SD and 16 months in those with PD. Three patients (1.5%) developed acute leukaemia, 1 patient (0.5%) chronic leukaemia (unconfirmed) and 30 patients (15%) grade 3 or 4 bone marrow toxicity. Eight patients (4%) developed grade 2 kidney toxicity and one patient (0.5%) grade 4 kidney toxicity. CONCLUSIONS Dosimetry-based therapy with 177Lu-DOTA-octreotate is feasible. Patients in whom the absorbed dose to the kidneys reached 23 Gy had a longer OS than those in whom it did not. Patients with CR/PR had a longer OS than those with SD. Bone marrow dosimetry did not predict toxicity.
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Affiliation(s)
- Ulrike Garske-Román
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden. .,Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
| | - Mattias Sandström
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Lars Lundin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Per Hellman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Staffan Welin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Silvia Johansson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Tanweera Khan
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Hans Lundqvist
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Barbro Eriksson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Sundin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Dan Granberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Kupitz D, Wetz C, Wissel H, Wedel F, Apostolova I, Wallbaum T, Ricke J, Amthauer H, Grosser OS. Software-assisted dosimetry in peptide receptor radionuclide therapy with 177Lutetium-DOTATATE for various imaging scenarios. PLoS One 2017; 12:e0187570. [PMID: 29107992 PMCID: PMC5673218 DOI: 10.1371/journal.pone.0187570] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 10/23/2017] [Indexed: 12/12/2022] Open
Abstract
In peptide receptor radionuclide therapy (PRRT) of patients with neuroendocrine neoplasias (NENs), intratherapeutic dosimetry is mandatory for organs at risk (e.g. kidneys) and tumours. We evaluated commercial dosimetry software (Dosimetry Toolkit) using varying imaging scenarios, based on planar and/or tomographic data, regarding the differences in calculated organ/tumour doses and the use for clinical routines. A total of 16 consecutive patients with NENs treated by PRRT with 177Lu-DOTATATE were retrospectively analysed. Single-photon emission computed tomography (SPECT)/low-dose computed tomography (CT) of the thorax and abdomen and whole body (WB) scintigraphy were acquired up to 7 days p.i. (at a maximum of five imaging time points). Different dosimetric scenarios were evaluated: (1) a multi-SPECT-CT scenario using SPECT/CT only; (2) a planar scenario using WB scintigraphy only; and (3) a hybrid scenario using WB scintigraphy in combination with a single SPECT/low-dose CT. Absorbed doses for the kidneys, liver, spleen, lungs, bladder wall and tumours were calculated and compared for the three different scenarios. The mean absorbed dose for the kidneys estimated by the multi-SPECT-CT, the planar and the hybrid scenario was 0.5 ± 0.2 Sv GBq-1, 0.8 ± 0.4 Sv GBq-1 and 0.6 ± 0.3 Sv GBq-1, respectively. The absorbed dose for the residual organs was estimated higher by the planar scenario compared to the multi-SPECT-CT or hybrid scenario. The mean absorbed tumour doses were 2.6 ± 1.5 Gy GBq-1 for the multi-SPECT-CT, 3.1 ± 2.2 Gy GBq-1 for the hybrid scenario and 5.3 ± 6.3 Gy GBq-1 for the planar scenario. SPECT-based dosimetry methods determined significantly lower kidney doses than the WB scintigraphy-based method. Dosimetry based completely on SPECT data is time-consuming and tedious. Approaches combining SPECT/CT and WB scintigraphy have the potential to ensure compromise between accuracy and user-friendliness.
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Affiliation(s)
- Dennis Kupitz
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg A.ö.R., Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- * E-mail:
| | - Christoph Wetz
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg A.ö.R., Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Heiko Wissel
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg A.ö.R., Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Florian Wedel
- Department of Nuclear Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Ivayla Apostolova
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg A.ö.R., Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- Department of Nuclear Medicine, University Medical Center Hamburg UKE, Hamburg, Germany
| | - Thekla Wallbaum
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg A.ö.R., Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Jens Ricke
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg A.ö.R., Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- Department of Clinical Radiology, Ludwig-Maximilians-University LMU, München, Germany
| | - Holger Amthauer
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg A.ö.R., Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- Department of Nuclear Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver S. Grosser
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg A.ö.R., Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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Eberlein U, Cremonesi M, Lassmann M. Individualized Dosimetry for Theranostics: Necessary, Nice to Have, or Counterproductive? J Nucl Med 2017; 58:97S-103S. [PMID: 28864620 DOI: 10.2967/jnumed.116.186841] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/10/2017] [Indexed: 11/16/2022] Open
Abstract
In 2005, the term theragnostics (theranostics) was introduced for describing the use of imaging for therapy planning in radiation oncology. In nuclear medicine, this expression describes the use of tracers for predicting the absorbed doses in molecular radiotherapy and, thus, the safety and efficacy of a treatment. At present, the most successful groups of isotopes for this purpose are 123I/124I/131I, 68Ga/177Lu, and 111In/86Y/90Y. The purpose of this review is to summarize available data on the dosimetry and dose-response relationships of several theranostic compounds, with a special focus on radioiodine therapy for differentiated thyroid cancer and peptide receptor radionuclide therapy. These are treatment modalities for which dose-response relationships for healthy tissues and tumors have been demonstrated. In addition, available data demonstrate that posttherapeutic dosimetry after a first treatment cycle predicts the absorbed doses in further cycles. Both examples show the applicability of the concept of theranostics in molecular radiotherapies. Nevertheless, unanswered questions need to be addressed in clinical trials incorporating dosimetry-related concepts for determining the amount of therapeutic activity to be administered.
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Affiliation(s)
- Uta Eberlein
- Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Würzburg, Würzburg, Germany; and
| | - Marta Cremonesi
- Radiation Research Unit, Istituto Europeo di Oncologia, Milano, Italy
| | - Michael Lassmann
- Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Würzburg, Würzburg, Germany; and
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Negro A, Rossi GM, Nicoli D, Versari A, Farnetti E, Santi R, De Pietri S. Peptide Receptor Radionuclide Therapy-Induced Gitelman-like Syndrome. Am J Kidney Dis 2017; 70:725-728. [PMID: 28739329 DOI: 10.1053/j.ajkd.2017.05.024] [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: 03/28/2017] [Accepted: 05/18/2017] [Indexed: 11/11/2022]
Abstract
Peptide receptor radionuclide therapy (PRRT) is a molecular-targeted therapy in which a somatostatin analogue (a small peptide) is coupled with a radioligand so that the radiation dose is selectively administered to somatostatin receptor-expressing metastasized neuroendocrine tumors, particularly gastroenteropancreatic. Reported toxicities include myelotoxicity and nephrotoxicity, the latter manifesting as decreased kidney function, often developing months to years after treatment completion. We present a case of PRRT-induced kidney toxicity manifesting as a severe Gitelman-like tubulopathy with preserved kidney function. Because profound hypokalemia and hypocalcemia can lead to life-threatening arrhythmias, we highlight the necessity for careful monitoring of serum and urine electrolytes in patients receiving PRRT.
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Affiliation(s)
- Aurelio Negro
- Internal Medicine and Hypertension Unit, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | | | - Davide Nicoli
- Molecular Biology Laboratory, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Annibale Versari
- Nuclear Medicine Unit, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Enrico Farnetti
- Molecular Biology Laboratory, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Rosaria Santi
- Internal Medicine and Hypertension Unit, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Stefano De Pietri
- Emergency Department, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
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Hänscheid H, Lapa C, Buck AK, Lassmann M, Werner RA. Dose Mapping After Endoradiotherapy with 177Lu-DOTATATE/DOTATOC by a Single Measurement After 4 Days. J Nucl Med 2017; 59:75-81. [DOI: 10.2967/jnumed.117.193706] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/14/2017] [Indexed: 11/16/2022] Open
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Dalmo J, Spetz J, Montelius M, Langen B, Arvidsson Y, Johansson H, Parris TZ, Helou K, Wängberg B, Nilsson O, Ljungberg M, Forssell-Aronsson E. Priming increases the anti-tumor effect and therapeutic window of 177Lu-octreotate in nude mice bearing human small intestine neuroendocrine tumor GOT1. EJNMMI Res 2017; 7:6. [PMID: 28097640 PMCID: PMC5241264 DOI: 10.1186/s13550-016-0247-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 12/05/2016] [Indexed: 12/15/2022] Open
Abstract
Background 177Lu-[DOTA0, Tyr3]-octreotate (177Lu-octreotate) is used for treatment of patients with somatostatin receptor (SSTR) expressing neuroendocrine tumors. However, complete tumor remission is rarely seen, and optimization of treatment protocols is needed. In vitro studies have shown that irradiation can up-regulate the expression of SSTR1, 2 and 5, and increase 177Lu-octreotate uptake. The aim of the present study was to examine the anti-tumor effect of a 177Lu-octreotate priming dose followed 24 h later by a second injection of 177Lu-octreotate compared to a single administration of 177Lu-octreotate, performed on the human small intestine neuroendocrine tumor cell line, GOT1, transplanted to nude mice. Results Priming resulted in a 1.9 times higher mean absorbed dose to the tumor tissue per administered activity, together with a reduced mean absorbed dose for kidneys. Priming gave the best overall anti-tumor effects. Magnetic resonance imaging showed no statistically significant difference in tumor response between treatment with and without priming. Gene expression analysis demonstrated effects on cell cycle regulation. Biological processes associated with apoptotic cell death were highly affected in the biodistribution and dosimetry study, via differential regulation of, e.g., APOE, BAX, CDKN1A, and GADD45A. Conclusions Priming had the best overall anti-tumor effects and also resulted in an increased therapeutic window. Results indicate that potential biomarkers for tumor regrowth may be found in the p53 or JNK signaling pathways. Priming administration is an interesting optimization strategy for 177Lu-octreotate therapy of neuroendocrine tumors, and further studies should be performed to determine the mechanisms responsible for the reported effects. Electronic supplementary material The online version of this article (doi:10.1186/s13550-016-0247-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Johanna Dalmo
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden.
| | - Johan Spetz
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Mikael Montelius
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Britta Langen
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Yvonne Arvidsson
- Department of Pathology, Institute of Biomedicine, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Henrik Johansson
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Toshima Z Parris
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Khalil Helou
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Bo Wängberg
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Ola Nilsson
- Department of Pathology, Institute of Biomedicine, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Maria Ljungberg
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Eva Forssell-Aronsson
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
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Svensson J, Rydén T, Hagmarker L, Hemmingsson J, Wängberg B, Bernhardt P. A novel planar image-based method for bone marrow dosimetry in (177)Lu-DOTATATE treatment correlates with haematological toxicity. EJNMMI Phys 2016; 3:21. [PMID: 27654452 PMCID: PMC5031567 DOI: 10.1186/s40658-016-0157-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 09/09/2016] [Indexed: 11/25/2022] Open
Abstract
Background 177Lu-DOTATATE is a valuable treatment option for patients with advanced neuroendocrine tumours overexpressing somatostatin receptors. Though well tolerated in general, bone marrow toxicity can, besides renal exposure, become dose limiting and affect the ability to sustain future therapies. The aim of this study was to develop a novel planar image-based method for bone marrow dosimetry and evaluate its correlation with haematological toxicity during 177Lu-DOTATATE treatment. In this study, 46 patients with advanced neuroendocrine tumours were treated with 7.2 GBq (3.5–8.3 GBq) of 177Lu-DOTATATE on two to five occasions. Planar gamma camera images were acquired at 2, 24, 48 and 168 h post-injection. Whole-body regions of interest were created in the images, and a threshold-based segmentation algorithm was applied to separate the uptake of 177Lu-DOTATATE into high and low uptake compartments. The conjugate view method was used to quantify the activity, the accumulated activity was calculated and the absorbed dose to the bone marrow was estimated according to the MIRD scheme. Patients were monitored for haematological toxicity based on haemoglobin (Hb), white blood cell (WBC) and platelet (PLT) counts every other week during the treatment period. Results The mean absorbed dose to the bone marrow was estimated to 0.20 Gy (0.11–0.37 Gy) per 7.4 GBq of 177Lu-DOTATATE, and the mean dose per fraction correlated with a decrease in Hb (p = 0.01), WBC (p < 0.01) and PLT (p < 0.01) counts. The total mean absorbed dose to the bone marrow was 0.64 Gy (0.30–1.5 Gy) per 24 GBq (8.2–37 GBq) of 177Lu-DOTATATE and also correlated with a decrease in Hb (p < 0.01), WBC (p = 0.01) and PLT (p < 0.01) counts. Conclusions The planar image-based method developed in this study resulted in similar absorbed doses to the bone marrow as reported in earlier studies with blood-based bone marrow dosimetry. The results correlated with haematological toxicity, making it a promising method for estimating bone marrow doses in 177Lu-DOTATATE treatment without the need for blood and urine sampling.
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Affiliation(s)
- Johanna Svensson
- Department of Oncology, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden.
| | - Tobias Rydén
- Department of Radiation Physics, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Linn Hagmarker
- Department of Radiation Physics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jens Hemmingsson
- Department of Radiation Physics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bo Wängberg
- Department of Surgery, Institute of Clinical Sciences, The Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Peter Bernhardt
- Department of Radiation Physics, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
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Heikkonen J, Mäenpää H, Hippeläinen E, Reijonen V, Tenhunen M. Effect of calculation method on kidney dosimetry in 177Lu-octreotate treatment. Acta Oncol 2016; 55:1069-1076. [PMID: 27219529 DOI: 10.1080/0284186x.2016.1182642] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND 177Lu-octreotate is an effective treatment modality for patients with metastatic neuroendocrine tumors. The kidney is a critical dose-limiting organ in that modality. We investigated the absorbed doses in the kidney and compared whole kidney volume (WKV) and small (4 cm3) volume of the kidney (SV) methods. We also evaluated a new calculation method that was based on two single photon emission computed tomography/computed tomography (SPECT/CT) scans. METHODS Absorbed radiation doses in the kidneys were calculated for 24 patients with neuroendocrine tumors. All patients received four cycles of 177Lu-octreotate given at eight-week intervals with a mean activity of 7.1 GBq (range 3.28-8.79 GBq). Absorbed doses and half-lives were calculated by the WKV and SV methods. Dosimetry was determined for the cortex and medulla in the first treatment cycle. RESULTS The mean absorbed radiation dose was 0.44 ± 0.15 Gy/GBq for the WKV method and, 0.74 ± 0.28 Gy/GBq for the SV method. Three patients had a 20% increase of the absorbed dose over the four treatment cycles for the WKV method compared to eight patients for the SV method. The mean absorbed dose in the medulla was 0.62 ± 0.27 Gy/GBq, whereas the mean absorbed dose in the cortex was 0.41 ± 0.22 Gy/GBq. Both regions had similar half-lives. Patients who received lower activities for medical reasons still had similar absorbed doses to kidneys compared to those who received the full activities. Our study indicates that absorbed doses can be calculated reliably using two SPECT/CT scans, at 24 and 168 hours after each treatment. CONCLUSIONS Absorbed doses in the kidneys from systemic radionuclide therapy that are measured by the WKV method and SV method cannot be directly compared. There were regional differences within kidneys for the uptake of 177Lu-octreotate. Two SPECT/CTs are sufficient for kidney dosimetry based on our new calculation method.
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Affiliation(s)
- Jorma Heikkonen
- Nuclear Medicine, Helsinki University Central Hospital, Cancer Center, Helsinki, Finland
| | - Hanna Mäenpää
- Nuclear Medicine, Helsinki University Central Hospital, Cancer Center, Helsinki, Finland
| | - Eero Hippeläinen
- HUS Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Vappu Reijonen
- Nuclear Medicine, Helsinki University Central Hospital, Cancer Center, Helsinki, Finland
| | - Mikko Tenhunen
- Department of Radiotherapy, Helsinki University Central Hospital, Cancer Center, Helsinki, Finland
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Svensson J, Hagmarker L, Magnander T, Wängberg B, Bernhardt P. Radiation exposure of the spleen during (177)Lu-DOTATATE treatment and its correlation with haematological toxicity and spleen volume. EJNMMI Phys 2016; 3:15. [PMID: 27491429 PMCID: PMC4975733 DOI: 10.1186/s40658-016-0153-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/28/2016] [Indexed: 12/29/2022] Open
Abstract
Background Somatostatin analogue-based radionuclide therapy with 177Lu-DOTATATE is an important treatment option for patients with advanced neuroendocrine tumours overexpressing somatostatin receptors. In addition to the kidneys, the bone marrow is a major dose-limiting organ. The correlation between developed haematological toxicity and absorbed dose to the bone marrow is poor, which indicates that other factors affect haematological response. The spleen has an important role in the haematopoetic system, including being a reservoir for blood cells. It is also the organ that receives the highest mean absorbed dose during 177Lu-DOTATATE treatment. The aim of this study was to analyse mean absorbed dose to the spleen and its correlation with haematological toxicity, and to explore changes in splenic volume. The study included 41 patients treated with 7.2 GBq (3.5–8.3 GBq) of 177Lu-DOTATATE on two to five occasions. Following each fraction, planar whole-body scans were acquired at 2, 24, 48, and 168 h, and a SPECT/CT at 24 h post-injection. Mean absorbed spleen dose was calculated utilising planar images for time-activity data and SPECT to adjust activity amounts. Splenic volume information was collected from diagnostic CT scans at baseline and follow-up. Results Median and total absorbed spleen doses were estimated to 4.5 and 15 Gy, respectively. Total absorbed spleen dose correlated with decrease in Hb (p = 0.02), but not WBC (p = 0.31) or PLT (p = 0.65) counts. For patients without bone metastases, mean absorbed spleen dose correlated with decrease in PLT (p = 0.04) but not Hb (p = 0.16) or WBC (p = 0.42) counts. The spleen volume was reduced to 75 % (p < 0.001) of original values (200 vs. 260 ml) at a mean follow-up of 36 months. Conclusions Haematological toxicity according to Hb counts was moderately but significantly correlated with total absorbed spleen dose. This supports the possibility that radiation exposure of the spleen affects overall haematological response during 177Lu-DOTATATE treatment.
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Affiliation(s)
- Johanna Svensson
- Department of Oncology, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden.
| | - Linn Hagmarker
- Department of Radiation Physics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Tobias Magnander
- Department of Radiation Physics, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bo Wängberg
- Department of Surgery, Institute of Clinical Sciences, The Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Peter Bernhardt
- Department of Radiation Physics, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
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Delker A, Ilhan H, Zach C, Brosch J, Gildehaus FJ, Lehner S, Bartenstein P, Böning G. The Influence of Early Measurements Onto the Estimated Kidney Dose in [(177)Lu][DOTA(0),Tyr(3)]Octreotate Peptide Receptor Radiotherapy of Neuroendocrine Tumors. Mol Imaging Biol 2016; 17:726-34. [PMID: 25790773 DOI: 10.1007/s11307-015-0839-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE Multiple measurements have been required to estimate the radiation dose to the kidneys resulting from [(177)Lu]DOTATATE therapy for neuroendocrine tumors. The aim of this study was to investigate the influence of early time-point measurement in the renal dose calculation. PROCEDURES Anterior/posterior whole-body planar scintigraphy images were acquired at approx. 1, 24, 48, and 72 h after administration of [(177)Lu]DOTATATE. Furthermore, we acquired planar 1-bed dynamic recordings in 12 frames (5 min each) during the first hour. We assessed kidney exposure with a three-phase model consisting of a linear increase to the maximum within the initial minutes p.i., followed a bi-exponential decline. This three-phase-model served as reference for evaluating accuracy of dose estimates in 105 kidneys calculated by conventional mono-exponential fitting of the final three and four whole-body images. RESULTS Mean effective half-life times for the reference model were 25.8 ± 12.0 min and 63.9 ± 17.6 h, predicting a mean renal dose of 5.7 ± 2.1 Gy. The effective half-life time was 46.3 ± 15.4 h for the last four and 63.3 ± 17.0 h for the last three data points. The mean start of the first whole-body measurement was 1.2 ± 0.1 h p.i. The ratio of fast to slow phases was 28.1 ± 23.9% at this time point, which caused a mean absolute percentage dose deviation of 12.4% for four data points, compared to 3.1% for three data points. At a mean time of 2.4 h p.i. (max 5.1 h), the ratio of fast to slow phase declined below 5%. CONCLUSIONS Kinetic analysis of renal uptake using dynamic planar scans from the first hour after injection revealed a fast and a slow washout phase. Although the fast phase did not contribute substantially to the estimated renal dose, it could influence planar measurements performed within the first hours. We found that the presence of two clearance phases can hamper accurate dose estimation based on a single-phase model, resulting in approximately 12.4% dose underestimation, thus potentially resulting in overtreatment. In the absence of dynamic initial recordings, the first dosimetry measurements should therefore be obtained later than 3-5 h after [(177)Lu]DOTATATE injection. Omitting the early whole-body image reduced the dose estimation error to 3.1%.
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Affiliation(s)
- Andreas Delker
- Department of Nuclear Medicine, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Harun Ilhan
- Department of Nuclear Medicine, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Christian Zach
- Department of Nuclear Medicine, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julia Brosch
- Department of Nuclear Medicine, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Franz Josef Gildehaus
- Department of Nuclear Medicine, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Sebastian Lehner
- Department of Nuclear Medicine, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Guido Böning
- Department of Nuclear Medicine, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany.
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Magnander T, Svensson J, Båth M, Gjertsson P, Bernhardt P. IMPROVED PLANAR KIDNEY ACTIVITY CONCENTRATION ESTIMATE BY THE POSTERIOR VIEW METHOD IN 177LU-DOTATATE TREATMENTS. RADIATION PROTECTION DOSIMETRY 2016; 169:259-266. [PMID: 27012883 PMCID: PMC4911968 DOI: 10.1093/rpd/ncw046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The aims of this study were to determine how different background regions of interest (ROIs) around the kidney represent true background activity in over- and underlying tissues in (177)Lu-DOTA-octreatate ((177)Lu-DOTATATE) treatments and to determine the influence of the background positions on the kidney activity concentration estimates by the conjugate view (ConjV) and posterior view (PostV) methods. The analysis was performed in single-photon emission computed tomography (SPECT) images of 20 patients, acquired 24 h post injection of a (177)Lu-DOTATATE treatment, by a computer algorithm that created planar images from the SPECT data. The ratio between the activity concentration in the background and the true background varied from 0.36 to 2.08 [coefficient of variation (CV) = 25-181 %] and from 0.44 to 1.52 (CV = 16-70 %) for the right and left kidneys, respectively. The activity concentration estimate in the kidneys was most accurate with the PostV method using a background ROI surrounding the whole kidney, and this combination might be an alternative planar method for improved kidney dosimetry in the (177)Lu-DOTATATE treatments.
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Affiliation(s)
- Tobias Magnander
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SE-413 45 Gothenburg, Sweden Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
| | - Johanna Svensson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SE-413 45 Gothenburg, Sweden
| | - Magnus Båth
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SE-413 45 Gothenburg, Sweden Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
| | - Peter Gjertsson
- Department of Clinical Physiology, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
| | - Peter Bernhardt
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SE-413 45 Gothenburg, Sweden Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
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Gamma camera calibration and validation for quantitative SPECT imaging with 177Lu. Appl Radiat Isot 2016; 112:156-64. [DOI: 10.1016/j.apradiso.2016.03.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 02/09/2016] [Accepted: 03/07/2016] [Indexed: 11/21/2022]
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Sandström M, Ilan E, Karlberg A, Johansson S, Freedman N, Garske-Román U. Method dependence, observer variability and kidney volumes in radiation dosimetry of (177)Lu-DOTATATE therapy in patients with neuroendocrine tumours. EJNMMI Phys 2015; 2:24. [PMID: 26501825 PMCID: PMC4883125 DOI: 10.1186/s40658-015-0127-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/24/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Radionuclide therapy can be individualized by performing dosimetry. To determine absorbed organ doses in (177)Lu-DOTATATE therapy, three methods based on activity concentrations are currently in use: the small volume of interest (sVOI) method, and two methods based on large VOIs either on anatomical CT (aVOI) or on thresholds on functional images (tVOI). The main aim of the present work was to validate the sVOI in comparison to the other two methods regarding agreement and time efficiency. Secondary aims were to investigate inter-observer variability for the sVOI and the change of functional organ volumes following therapy. METHODS Thirty patients diagnosed with neuroendocrine tumours undergoing therapy with (177)Lu-DOTATATE were included. Each patient underwent three SPECT/CT scans at 1, 4 and 7 days after the treatment. Three independent observers calculated absorbed doses to the right and left kidney and the spleen using sVOI and one observer used aVOI. For tVOI, the absorbed doses were calculated based on automatically drawn isocontours around the organs at different thresholds (42, 50, 60 and 70 %). The inter-observer difference between the calculated absorbed doses for sVOI was calculated, and the differences between the three methods were computed. Ratios of organ volumes acquired at days 1, 4 and 7 versus the volume at day 1 were calculated for the tVOI method. RESULTS The differences in results of the absorbed dose calculations using all the sVOI and tVOI were small (<5 %). Absorbed dose calculations using aVOI differed slightly more from these results but were still below 10 %. The differences between the three dose calculation methods varied between <5 and 10 %. The organ volumes derived from the tVOI were independent of time for the spleen while they decreased with time for the kidneys. The fastest analysis was performed with the sVOI method. CONCLUSIONS All three dose calculation methods rendered comparable results with small inter-observer differences for sVOI. Unlike the spleen, the functional volume of the kidneys decreased over time during therapy, which suggests that the absorbed dose calculation for the kidneys on activity concentrations should be performed for each time point. The sVOI is the preferred method for calculating absorbed doses in solid organs.
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Affiliation(s)
- Mattias Sandström
- Section of Nuclear Medicine and PET, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden. .,Section of Medical Physics, Department of Immunology, Genetics and Pathology, Uppsala University, 751 85, Uppsala, Sweden.
| | - Ezgi Ilan
- Section of Nuclear Medicine and PET, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,Section of Medical Physics, Department of Immunology, Genetics and Pathology, Uppsala University, 751 85, Uppsala, Sweden
| | - Anna Karlberg
- Section of Medical Physics, Department of Immunology, Genetics and Pathology, Uppsala University, 751 85, Uppsala, Sweden
| | - Silvia Johansson
- Section of Oncology, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Nanette Freedman
- Medical Biophysics and Nuclear Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ulrike Garske-Román
- Section of Nuclear Medicine and PET, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Abstract
Peptide receptor radionuclide therapy with (90)Y-peptides is generally well tolerated. Acute side effects are usually mild; some are related to the coadministration of amino acids and others to the radiopeptide itself. Chronic and permanent effects on target organs, particularly kidneys and bone marrow, are generally mild if necessary precautions are taken. The potential risk to kidney and red marrow limits the amount of radioactivity that may be administered. However, when tumor masses are irradiated with adequate doses, volume reduction may be observed. (90)Y-octreotide has been the most used radiopeptide in the first 8 to 10 years of experience.
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Affiliation(s)
- Lisa Bodei
- Division of Nuclear Medicine, European Institute of Oncology, via Ripamonti 435, 20141 Milan, Italy
| | - Marta Cremonesi
- Division of Medical Physics, European Institute of Oncology, via Ripamonti 435, 20141 Milan, Italy
| | - Giovanni Paganelli
- Division of Nuclear Medicine, European Institute of Oncology, via Ripamonti 435, 20141 Milan, Italy.
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Renal function affects absorbed dose to the kidneys and haematological toxicity during ¹⁷⁷Lu-DOTATATE treatment. Eur J Nucl Med Mol Imaging 2015; 42:947-55. [PMID: 25655484 PMCID: PMC4382534 DOI: 10.1007/s00259-015-3001-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 01/16/2015] [Indexed: 12/25/2022]
Abstract
Purpose Peptide receptor radionuclide therapy (PRRT) has become an important treatment option in the management of advanced neuroendocrine tumours. Long-lasting responses are reported for a majority of treated patients, with good tolerability and a favourable impact on quality of life. The treatment is usually limited by the cumulative absorbed dose to the kidneys, where the radiopharmaceutical is reabsorbed and retained, or by evident haematological toxicity. The aim of this study was to evaluate how renal function affects (1) absorbed dose to the kidneys, and (2) the development of haematological toxicity during PRRT treatment. Methods The study included 51 patients with an advanced neuroendocrine tumour who received 177Lu-DOTATATE treatment during 2006 – 2011 at Sahlgrenska University Hospital in Gothenburg. An average activity of 7.5 GBq (3.5 – 8.2 GBq) was given at intervals of 6 – 8 weeks on one to five occasions. Patient baseline characteristics according to renal and bone marrow function, tumour burden and medical history including prior treatment were recorded. Renal and bone marrow function were then monitored during treatment. Renal dosimetry was performed according to the conjugate view method, and the residence time for the radiopharmaceutical in the whole body was calculated. Results A significant correlation between inferior renal function before treatment and higher received renal absorbed dose per administered activity was found (p < 0.01). Patients with inferior renal function also experienced a higher grade of haematological toxicity during treatment (p = 0.01). The residence time of 177Lu in the whole body (range 0.89 – 3.0 days) was correlated with grade of haematological toxicity (p = 0.04) but not with renal absorbed dose (p = 0.53). Conclusion Patients with inferior renal function were exposed to higher renal absorbed dose per administered activity and developed a higher grade of haematological toxicity during 177Lu-DOTATATE treatment. The study confirms the tolerability of PRRT in patients with an advanced neuroendocrine tumour but indicates that patients with inferior renal function are at risk of being exposed to higher absorbed doses to normal tissue on treatment.
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37
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Dalmo J, Westberg E, Barregard L, Svedbom L, Johansson M, Törnqvist M, Forssell-Aronsson E. Evaluation of retinol binding protein 4 and carbamoylated haemoglobin as potential renal toxicity biomarkers in adult mice treated with (177)Lu-octreotate. EJNMMI Res 2014; 4:59. [PMID: 26116120 PMCID: PMC4452688 DOI: 10.1186/s13550-014-0059-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 10/13/2014] [Indexed: 12/25/2022] Open
Abstract
Background The kidneys are regarded as one of the main dose-limiting organs in the treatment of neuroendocrine tumours with 177Lu-[DOTA0, Tyr3]-octreotate (177Lu-octreotate), despite the successful use of kidney uptake blocking agents such as lysine and arginine. To avoid renal toxicity but still give each patient as high amount of 177Lu-octreotate as possible, there is a need for methods/biomarkers that indicate renal injury in an early stage of the treatment. The aim of this study was to investigate the potential of using urinary retinol binding protein 4 (RBP4) and carbamoylated haemoglobin (Hb) in blood as biomarkers of nephrotoxic effects on adult mice after 177Lu-octreotate treatment. Methods Adult BALB/c nude mice were injected with 60 MBq or 120 MBq of 177Lu-octreotate or with saline (control). Urine was collected before injection and concentrations of urinary RBP4 and creatinine were determined 14 to 90 days after injection Blood samples were collected after 90 days, and carbamoylated N-terminal valine in Hb, formed from urea, was measured as valine hydantoin (VH) after detachment from Hb. Results The RBP4 values increased with administered activity and time. For the 60 and 120 MBq groups, statistically significantly higher RBP4 levels (p <0.05) were found at day 60 and 90 compared to baseline, also at day 30 for 120 MBq group. For VH, the mean values were similar for the 60 MBq and control groups, while a small increase was observed for the 120 MBq group; but there were no statistically significant differences between any of the groups (p >0.05). No morphological changes in the kidney tissue were found. Conclusions Urinary RBP4 is a promising new biomarker for radiation-induced renal toxicity. For the conditions used in this experiment, carbamoylated Hb (from urea) measured as VH may not be a sufficiently sensitive biomarker to be used for renal toxicity. Trial registration ID 326-2008
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Affiliation(s)
- Johanna Dalmo
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Cancer Centre, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, SE-413 45, Sweden,
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Minutoli F, Amato E, Sindoni A, Cardile D, Conti A, Herberg A, Baldari S. Peptide receptor radionuclide therapy in patients with inoperable meningiomas: our experience and review of the literature. Cancer Biother Radiopharm 2014; 29:193-9. [PMID: 24811687 DOI: 10.1089/cbr.2013.1599] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE Few studies describe peptide receptor radionuclide therapy (PRRT) using (90)Y- or (177)Lu-labeled peptides in patients with recurrent meningiomas. No clinical data about (111)In-Pentetreotide in such patients are available. We report on (111)In-Pentetreotide therapy in patients with inoperable meningiomas and review the literature about PRRT of meningiomas. METHODS We reviewed clinical records of 8 patients with meningioma/meningiomatosis showing high (111)In-Pentetreotide uptake on pretherapy scintigraphy who were treated with at least one cycle of (111)In-Pentetreotide. In 2 patients, a cocktail of (111)In-Pentetreotide and beta-emitting radiolabeled peptides had been administered. RESULTS No patient experienced acute toxicity, neurological or renal function impairment. Mild transient bone marrow toxicity was observed in 4 patients. Objective partial response was observed in 2 patients, stable disease in 5 and disease progression in one. There were no statistically significant correlations between objective response and patient age, tumor WHO grade, baseline Karnofsky performance score, (111)In-Pentetreotide tumoral uptake grade, tumor/nontumor ratio, disease state at baseline, and cumulative dose. CONCLUSIONS In consideration of its efficacy and the lack of significant toxicity, PRRT of meningiomas using (111)In-Pentetreotide could be proposed even nowadays when the use of (177)Lu- or (90)Y-labeled peptides seems unsafe, namely in patients with renal impairment/toxicity.
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Affiliation(s)
- Fabio Minutoli
- 1 Department of Biomedical Sciences and Morphological and Functional Images, University of Messina , Messina, Italy
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Schüler E, Rudqvist N, Parris TZ, Langen B, Helou K, Forssell-Aronsson E. Transcriptional response of kidney tissue after 177Lu-octreotate administration in mice. Nucl Med Biol 2013; 41:238-47. [PMID: 24434014 DOI: 10.1016/j.nucmedbio.2013.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 10/29/2013] [Accepted: 12/03/2013] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The kidneys are one of the main dose limiting organs in (177)Lu-octreotate therapy of neuroendocrine tumors. Therefore, biomarkers for radiation damage would be of great importance in this type of therapy. The purpose of this study was to investigate the absorbed dose dependency on early transcriptional changes in the kidneys from (177)Lu-octreotate exposure. METHODS Female Balb/c nude mice were i.v. injected with 1.3, 3.6, 14, 45 or 140 MBq (177)Lu-octreotate. The animals were killed 24 h after injection followed by excision of the kidneys. The absorbed dose to the kidneys ranged between 0.13 and 13 Gy. Total RNA was extracted from separated renal tissue samples, and applied to Illumina MouseRef-8 Whole-Genome Expression Beadchips to identify regulated transcripts after irradiation. Nexus Expression 2.0 and Gene Ontology terms were used for data processing and to determine affected biological processes. RESULTS Distinct transcriptional responses were observed following (177)Lu-octreotate administration. A higher number of differentially expressed transcripts were observed in the kidney medulla (480) compared to cortex (281). In addition, 39 transcripts were regulated at all absorbed dose levels in the medulla, compared to 32 in the cortex. Three biological processes in the cortex and five in the medulla were also shared by all absorbed dose levels. Strong association to metabolism was found among the affected processes in both tissues. Furthermore, an association with cellular and developmental processes was prominent in kidney medulla, while transport and immune response were prominent in kidney cortex. CONCLUSION Specific biological and dose-dependent responses were observed in both tissues. The number of affected transcripts and biological processes revealed distinct response differences between the absorbed doses delivered to the tissues.
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Affiliation(s)
- Emil Schüler
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Nils Rudqvist
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Toshima Z Parris
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Britta Langen
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Khalil Helou
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eva Forssell-Aronsson
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Kidney dosimetry in ¹⁷⁷Lu and ⁹⁰Y peptide receptor radionuclide therapy: influence of image timing, time-activity integration method, and risk factors. BIOMED RESEARCH INTERNATIONAL 2013; 2013:935351. [PMID: 23865075 PMCID: PMC3705840 DOI: 10.1155/2013/935351] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 05/31/2013] [Indexed: 11/17/2022]
Abstract
Kidney dosimetry in 177Lu and 90Y PRRT requires 3 to 6 whole-body/SPECT scans to extrapolate the peptide kinetics, and it is considered time and resource consuming. We investigated the most adequate timing for imaging and time-activity interpolating curve, as well as the performance of a simplified dosimetry, by means of just 1-2 scans. Finally the influence of risk factors and of the peptide (DOTATOC versus DOTATATE) is considered. 28 patients treated at first cycle with 177Lu DOTATATE and 30 with 177Lu DOTATOC underwent SPECT scans at 2 and 6 hours, 1, 2, and 3 days after the radiopharmaceutical injection. Dose was calculated with our simplified method, as well as the ones most used in the clinic, that is, trapezoids, monoexponential, and biexponential functions. The same was done skipping the 6 h and the 3 d points. We found that data should be collected until 100 h for 177Lu therapy and 70 h for 90Y therapy, otherwise the dose calculation is strongly influenced by the curve interpolating the data and should be carefully chosen.
Risk factors (hypertension, diabetes) cause a rather statistically significant 20% increase in dose (t-test, P < 0.10), with DOTATATE affecting an increase of 25% compared to DOTATOC (t-test, P < 0.05).
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