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Aggarwal P, Satapathy S, Sood A, Singh H, Mittal BR, Lal S, Gupta R, Das CK, Yadav TD, Walia R. Safety and Efficacy of 177 Lu-DOTATATE in Children and Young Adult Population : A Single-Center Experience. Clin Nucl Med 2024; 49:e312-e318. [PMID: 38769655 DOI: 10.1097/rlu.0000000000005233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
PURPOSE This single-center retrospective study explores the safety and efficacy of 177 Lu-DOTATATE in children and young adult population with metastatic/inoperable neuroendocrine tumors (NETs). PATIENTS AND METHODS This study is a retrospective analysis of all children and young adult patients (≤29 years) with advanced inoperable/metastatic epithelial or nonepithelial NETs who were administered a median of 4 cycles of 177 Lu-DOTATATE therapy and low-dose oral capecitabine as a radiosensitizer every 8-12 weeks, except 2 patients who received CAPTEM chemotherapy. The radiological response was assessed using RECIST 1.1 on interim and end-of-treatment 68 Ga-DOTANOC PET/CT. The primary endpoint was objective response rate, whereas disease control rate, toxicity profile, progression-free survival, and overall survival were secondary endpoints. RESULTS Nineteen biopsy-proven NET patients (median age, 22 ± 10 years) with 8 of them adolescents (10-18 years) and the remaining young adults (19-29 years) were included. Fourteen patients had gastroenteropancreatic neuroendocrine tumor (pancreas being most common primary site), whereas the rest had non-gastroenteropancreatic neuroendocrine tumor. A total of 65 cycles of 177 Lu-DOTATATE (range, 1-6 cycles) were administered with a median cumulative activity of 600 mCi (range, 100-1000 mCi). The objective response rate and disease control rate were 41% and 94%, respectively. Grade 1 and 2 adverse events were observed in 14 (74%) and 5 (26%) of 19 patients, respectively. In a total of 8 events (42%), 4 events each of disease progression and death occurred during a median follow-up of 80.1 months with an estimated 5-year progression-free survival and overall survival of 54% (95% confidence interval, 30-78) and 63% (95% confidence interval, 39-87), respectively. CONCLUSIONS 177 Lu-DOTATATE appears safe and effective in children and young adults with metastatic/inoperable NETs. Large prospective trials are required to validate these results.
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Affiliation(s)
| | | | | | | | | | - Sadhna Lal
- Gastroenterology (Division of Pediatric Gastroenterology)
| | | | | | | | - Rama Walia
- Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Mileva M, Van Bogaert C, Marin G, Danieli R, Artigas C, Levillain H, Ameye L, Taraji-Schiltz L, Stathopoulos K, Wimana Z, Hendlisz A, Flamen P, Karfis I. 177Lu-DOTATATE PRRT Safety and Organ-at-Risk Dosimetry in Patients With Gastroenteropancreatic Neuroendocrine Tumors: Data From the Prospective Phase 2 LUMEN Study. Clin Nucl Med 2024:00003072-990000000-01175. [PMID: 38914016 DOI: 10.1097/rlu.0000000000005330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
PURPOSE The aim of this study was to assess the association among toxicity, dosimetry of organs-at-risk, and disease progression in patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs) treated with 177Lu-DOTATATE. PATIENTS AND METHODS Thirty-seven patients with GEP-NETs underwent 177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT) in a single-arm, prospective, phase 2 study, where patients were followed up with blood tests, isotopic glomerular filtration rate (iGFR), and imaging examinations (CT/MRI and PET) every 6 months until disease progression. Adverse events (AEs) graded per CTCAEv4.03 and occurring during treatment were collected and followed up until resolution. Dosimetry, including biologically effective doses (BEDs) to kidneys, BED to bone marrow, and absorbed dose (AD) to spleen, was performed after each PRRT cycle. Statistical analyses explored associations among dosimetry, toxicity, and patient progression free-survival. RESULTS The most common AEs were anemia and lymphopenia (65%), followed by thrombocytopenia and fatigue (each 51%), alopecia (46%), and nausea (41%). The most common grade ≥3 AE was lymphopenia (43%). There was no grade ≥3 nephrotoxicity. The median iGFR % decrease was 11% (P < 0.001), at a median follow-up of 23 months. iGFR %decrease and renal BED did not correlate (Spearman ρ = -0.09). Similarly, no significant association was found between bone marrow BED or spleen AD and the grades of hematological toxicities. We observed no association between progression free-survival and either the decline of renal function or the occurrence of hematological toxicities during PRRT. CONCLUSIONS This study confirms the safety profile of 177Lu-DOTATATE PRRT in patients with GEP-NETs irrespective of the dosimetry of organs at risk. Kidney, bone marrow, and spleen dosimetry measures were not associated with renal or hematological toxicity.
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Affiliation(s)
| | | | | | | | - Carlos Artigas
- From the Nuclear Medicine Department, Institut Jules Bordet
| | | | | | | | | | | | - Alain Hendlisz
- Medical Oncology Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Patrick Flamen
- From the Nuclear Medicine Department, Institut Jules Bordet
| | - Ioannis Karfis
- From the Nuclear Medicine Department, Institut Jules Bordet
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Moraitis A, Jentzen W, Fragoso Costa P, Kersting D, Himmen S, Coelho M, Meckel M, van Echteld CJA, Fendler WP, Herrmann K, Sraieb M. Safety and Efficacy of Para-Aminohippurate Coinfusion for Renal Protection During Peptide Receptor Radiotherapy in Patients with Neuroendocrine Tumors. J Nucl Med 2024; 65:931-937. [PMID: 38637142 DOI: 10.2967/jnumed.123.266619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 03/04/2024] [Indexed: 04/20/2024] Open
Abstract
Para-aminohippurate, also known as p-aminohippuric acid (PAH), is used clinically to measure effective renal plasma flow. Preclinically, it was shown to reduce 177Lu-DOTATOC uptake in the kidneys while improving bioavailability compared with amino acid (AA) coinfusion. We report the safety and efficacy of PAH coinfusion during peptide receptor radiotherapy in patients with neuroendocrine tumors. Methods: Twelve patients with metastatic or unresectable gastroenteropancreatic neuroendocrine tumors received 177Lu-DOTATOC in 33 treatment cycles. Either 8 g of PAH or a mixture of 25 g of arginine and 25 g of lysine were coinfused. Safety was assessed by monitoring laboratory data, including hematologic and renal data, as well as electrolytes obtained before and 24 h after treatment. For radiation dosimetry, whole-body scans were performed at 1, 24, and 48 h and a SPECT/CT scan was performed at 48 h, along with blood sampling at 5 min and 0.5, 2, 4, 24, and 48 h after administration. Absorbed dose estimations for the kidneys and bone marrow were performed according to the MIRD concept. Results: In 15 treatment cycles, PAH was coinfused. No changes in mean creatinine level, glomerular filtration rate, and serum electrolytes were observed before or 24 h after treatment when using PAH protection (P ≥ 0.20), whereas serum chloride and serum phosphate increased significantly under AA (both P < 0.01). Kidney-absorbed dose coefficients were 0.60 ± 0.14 Gy/GBq with PAH and 0.53 ± 0.16 Gy/GBq with AA. Based on extrapolated cumulative kidney-absorbed doses for 4 cycles, 1 patient with PAH protection and 1 patient with AA protection in our patient group would exceed the 23-Gy conservative threshold. The bone marrow-absorbed dose coefficient was 0.012 ± 0.004 Gy/GBq with PAH and 0.012 ± 0.003 Gy/GBq with AA. Conclusion: PAH is a promising alternative to AA for renal protection during peptide receptor radiotherapy. Further research is required to systematically investigate the safety profile and radiation dosimetry at varying PAH plasma concentrations.
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Affiliation(s)
- Alexandros Moraitis
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany;
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Walter Jentzen
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Pedro Fragoso Costa
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - David Kersting
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Stephan Himmen
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Marta Coelho
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Marian Meckel
- ITM Isotope Technologies Munich SE, Garching/Munich, Germany; and
| | | | - Wolfgang P Fendler
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Miriam Sraieb
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
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Grewal US, Loeffler BT, Paschke A, Dillon JS, Chandrasekharan C. Repeat Peptide Receptor Radionuclide Therapy in Neuroendocrine Tumors: A NET Center of Excellence Experience. J Gastrointest Cancer 2024:10.1007/s12029-024-01065-z. [PMID: 38780680 DOI: 10.1007/s12029-024-01065-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION The available data for the safety and efficacy of repeat peptide receptor radionuclide therapy (PRRT) are almost exclusively from European centers. We present an updated experience with repeat PRRT in a cohort of US patients with neuroendocrine tumors (NETs) at our NET center of excellence. METHODS We used our single-center longitudinal NET registry to identify patients who had been previously treated with at least one dose of PRRT (PRRT 1, either 177Lu DOTATATE or 90Y DOTATOC) and following radiographic disease progression were re-treated with a second course of PRRT (PRRT 2). We reviewed patient, tumor and treatment characteristics, objective response rates, and toxicities after PRRT 1 and PRRT 2. RESULTS A total of 11 patients were included in the analysis. 45.5% (5/11) of patients received 177Lu DOTATATE PRRT only, both for PRRT1 and PRRT 2, while 54.5% (6/11) of patients received 90Y DOTATOC PRRT for PRRT1. At first restaging scan after PRRT2 (3-6 months), 18.2% (2/11), 36.4% (4/11), and 27.3% (3/11) of patients had PR, SD, and PD, respectively; 2/11 patients (18.2%) died before the first restaging scan. Therefore, 5/11 (45.5%) patients were noted to have disease progression. Median PFS for PRRT1 was 25.4 months and median PFS for PRRT2 was 13.1 months (p = 0.0001). We did not find a statistically significant difference between the occurrence of short and long-term hematological toxicities as well as renal toxicity after PRRT1 and PRRT2. CONCLUSION We show that repeat PRRT may benefit select patients and have an acceptable safety profile. In our cohort, PFS was significantly lower after PRRT2 as compared to PRRT1.
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Affiliation(s)
- Udhayvir S Grewal
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- University of Iowa Holden Comprehensive Cancer Center, Iowa City, IA, USA
| | - Bradley T Loeffler
- University of Iowa Holden Comprehensive Cancer Center, Iowa City, IA, USA
| | - Alexander Paschke
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Joseph S Dillon
- University of Iowa Holden Comprehensive Cancer Center, Iowa City, IA, USA
- Division of Endocrinology and Metabolism, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, ENETS Center of Excellence, Iowa City, IA, USA
| | - Chandrikha Chandrasekharan
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
- University of Iowa Holden Comprehensive Cancer Center, Iowa City, IA, USA.
- Holden Comprehensive Cancer Center, ENETS Center of Excellence, Iowa City, IA, USA.
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Blakkisrud J, Peterson AB, Wildermann SJ, Kingkiner G, Wong KK, Wang C, Frey KA, Stokke C, Dewaraja YK. SPECT/CT Image-Derived Absorbed Dose to Red Marrow Correlates with Hematologic Toxicity in Patients Treated with [ 177Lu]Lu-DOTATATE. J Nucl Med 2024; 65:753-760. [PMID: 38548350 PMCID: PMC11064826 DOI: 10.2967/jnumed.123.266843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/21/2024] [Indexed: 05/03/2024] Open
Abstract
Hematologic toxicity, although often transient, is the most common limiting adverse effect during somatostatin peptide receptor radionuclide therapy. This study investigated the association between Monte Carlo-derived absorbed dose to the red marrow (RM) and hematologic toxicity in patients being treated for their neuroendocrine tumors. Methods: Twenty patients each receiving 4 treatment cycles of [177Lu]Lu-DOTATATE were included. Multiple-time-point 177Lu SPECT/CT imaging-based RM dosimetry was performed using an artificial intelligence-driven workflow to segment vertebral spongiosa within the field of view (FOV). This workflow was coupled with an in-house macroscale/microscale Monte Carlo code that incorporates a spongiosa microstructure model. Absorbed dose estimates to RM in lumbar and thoracic vertebrae within the FOV, considered as representations of the whole-body RM absorbed dose, were correlated with hematologic toxicity markers at about 8 wk after each cycle and at 3- and 6-mo follow-up after completion of all cycles. Results: The median of absorbed dose to RM in lumbar and thoracic vertebrae within the FOV (D median,vertebrae) ranged from 0.019 to 0.11 Gy/GBq. The median of cumulative absorbed dose across all 4 cycles was 1.3 Gy (range, 0.6-2.5 Gy). Hematologic toxicity was generally mild, with no grade 2 or higher toxicity for platelets, neutrophils, or hemoglobin. However, there was a decline in blood counts over time, with a fractional value relative to baseline at 6 mo of 74%, 97%, 57%, and 97%, for platelets, neutrophils, lymphocytes, and hemoglobin, respectively. Statistically significant correlations were found between a subset of hematologic toxicity markers and RM absorbed doses, both during treatment and at 3- and 6-mo follow-up. This included a correlation between the platelet count relative to baseline at 6-mo follow up: D median,vertebrae (r = -0.64, P = 0.015), D median,lumbar (r = -0.72, P = 0.0038), D median,thoracic (r = -0.58, P = 0.029), and D average,vertebrae (r = -0.66, P = 0.010), where D median,lumbar and D median,thoracic are median absorbed dose to the RM in the lumbar and thoracic vertebrae, respectively, within the FOV and D average,vertebrae is the mass-weighted average absorbed dose of all vertebrae. Conclusion: This study found a significant correlation between image-derived absorbed dose to the RM and hematologic toxicity, including a relative reduction of platelets at 6-mo follow up. These findings indicate that absorbed dose to the RM can potentially be used to understand and manage hematologic toxicity in peptide receptor radionuclide therapy.
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Affiliation(s)
- Johan Blakkisrud
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan;
- Department of Physics and Computational Radiology, Oslo University Hospital, Oslo, Norway
| | - Avery B Peterson
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan
- Department of Radiation Oncology, Wayne State University, Detroit, Michigan
| | - Scott J Wildermann
- Department of Nuclear Engineering and Radiologic Science, University of Michigan, Ann Arbor, Michigan
| | - Griffen Kingkiner
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Ka Kit Wong
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Chang Wang
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan; and
| | - Kirk A Frey
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Caroline Stokke
- Department of Physics and Computational Radiology, Oslo University Hospital, Oslo, Norway
- Department of Physics, University of Oslo, Oslo, Norway
| | - Yuni K Dewaraja
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan
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Vallot D, Brillouet S, Pondard S, Vija L, Texier JS, Dierickx L, Courbon F. Impact of different models based on blood samples and images for bone marrow dosimetry after 177Lu-labeled somatostatin-receptor therapy. EJNMMI Phys 2024; 11:32. [PMID: 38564043 PMCID: PMC10987460 DOI: 10.1186/s40658-024-00615-5] [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: 04/28/2023] [Accepted: 01/15/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Peptide receptor radionuclide therapy with 177Lu-DOTATATE is a recognized option for treating neuroendocrine tumors and has few toxicities, except for the kidneys and bone marrow. The bone marrow dose is generally derived from a SPECT/CT image-based method with four timepoints or from a blood-based method with up to 9 timepoints, but there is still no reference method. This retrospective single-center study on the same cohort of patients compared the calculated bone marrow dose administered with both methods using mono, bi- or tri-exponential models. For the image-based method, the dose was estimated using Planetdose© software. Pearson correlation coefficients were calculated. We also studied the impact of late timepoints for both methods. RESULTS The bone marrow dose was calculated for 131 treatments with the blood-based method and for 17 with the image-based method. In the former, the median absorbed dose was 15.3, 20.5 and 28.3 mGy/GBq with the mono-, bi- and tri-exponential model, respectively. With the image-based method, the median absorbed dose was 63.9, 41.9 and 60.8 with the mono-, bi- and tri-exponential model, respectively. Blood samples after 24h post-injection did not evidence any change in the absorbed bone marrow dose with the bi-exponential model. On the contrary, the 6-day post-injection timepoint was more informative with the image-based model. CONCLUSION This study confirms that the estimated bone marrow dose is significantly lower with the blood-based method than with the image-based method. The blood-based method with a bi-exponential model proved particularly useful, without the need for blood samples after 24h post-injection. Nevertheless, this blood-based method is based on an assumption that needs to be more validated. The important difference between the two methods does not allow to determine the optimal one to estimate the true absorbed dose and further studies are necessary to compare with biological effects.
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George SC, Tolakanahalli R, Aguirre S, Kim TP, Samuel EJJ, Mishra V. A single-institution experience with 177Lu RPT workflow improvements and qualifying the SPECT/CT imaging for dosimetry. Front Oncol 2024; 14:1331266. [PMID: 38469241 PMCID: PMC10925616 DOI: 10.3389/fonc.2024.1331266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/22/2024] [Indexed: 03/13/2024] Open
Abstract
Background and purpose Implementing any radiopharmaceutical therapy (RPT) program requires a comprehensive review of system readiness, appropriate workflows, and training to ensure safe and efficient treatment delivery. A quantitative assessment of the dose delivered to targets and organs at risk (OAR) using RPT is possible by correlating the absorbed doses with the delivered radioactivity. Integrating dosimetry into an established RPT program demands a thorough analysis of the necessary components and system fine-tuning. This study aims to report an optimized workflow for molecular radiation therapy using 177Lu with a primary focus on integrating patient-specific dosimetry into an established radiopharmaceutical program in a radiation oncology setting. Materials and methods We comprehensively reviewed using the Plan-Do-Check-Act (PDCA) cycle, including efficacy and accuracy of delivery and all aspects of radiation safety of the RPT program. The GE Discovery SPECT/CT 670DR™ system was calibrated per MIM protocol for dose calculation on MIM SurePlan™ MRT software. Jaszcak Phantom with 15-20 mCi of 177Lu DOTATATE with 2.5 µM EDTA solution was used, with the main energy window defined as 208 keV ±10% (187.6 to 229.2 keV); the upper scatter energy window was set to 240 keV ±5% (228 to 252 keV), while the lower scatter energy window was 177.8 keV ±5% (168.9 to 186.7 keV). Volumetric quality control tests and adjustments were performed to ensure the correct alignment of the table, NM, and CT gantry on SPECT/CT. A comprehensive end-to-end (E2E) test was performed to ensure workflow, functionality, and quantitative dose accuracy. Results Workflow improvements and checklists are presented after systematically analyzing over 400 administrations of 177Lu-based RPT. Injected activity to each sphere in the NEMA Phantom scan was quantified, and the MIM Sureplan MRT reconstruction images calculated activities within ±12% of the injected activity. Image alignment tests on the SPECT/CT showed a discrepancy of more than the maximum tolerance of 2.2 mm on any individual axis. As a result of servicing the machine and updating the VQC and COR corrections, the hybrid imaging system was adjusted to achieve an accuracy of <1 mm in all directions. Conclusion Workflows and checklists, after analysis of system readiness and adequate training for staff and patients, are presented. Hardware and software components for patient-specific dosimetry are presented with a focus on hybrid image registration and correcting any errors that affect dosimetric quantification calculation. Moreover, this manuscript briefly overviews the necessary quality assurance requirements for converting diagnostic images into dosimetry measurement tools and integrating dosimetry for RPT based on 177Lu.
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Affiliation(s)
- Siju C. George
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health, Miami, FL, United States
- Department of Physics, School of Advanced Sciences, Vellore Institute of Technology, Vellore, India
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health, Miami, FL, United States
| | - Santiago Aguirre
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health, Miami, FL, United States
| | - Taehyung Peter Kim
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health, Miami, FL, United States
| | | | - Vivek Mishra
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health, Miami, FL, United States
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Persson M, Hindorf C, Ardenfors O, Larsson M, Nilsson JN. Risk of treatment-altering haematological toxicity and its dependence on bone marrow doses in peptide receptor radionuclide therapy. EJNMMI Res 2024; 14:13. [PMID: 38319478 PMCID: PMC10847080 DOI: 10.1186/s13550-024-01077-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/25/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Peptide receptor radionuclide therapy is effective in treating neuroendocrine tumours, but treatment may be limited by kidney and bone marrow toxicity. In this work, the absorbed dose burden to the bone marrow was estimated using image-based dosimetry and its potential use for predicting treatment-altering toxicity was studied. Peripheral blood samples taken before and after 229 treatments with 177Lu-DOTATATE in 59 patients were studied. In connection to the treatments, a total of 940 blood sample occasions provided data on white blood cell, neutrophil granulocyte, platelet, erythrocyte and haemoglobin concentrations. SPECT/CT image data were collected at two or three time points after each treatment. Absorbed doses to bone marrow were calculated from the activity concentration in a metastasis-free lumbar vertebra. The rate of delayed and aborted treatments was analysed based on medical records. RESULTS The average absorbed dose to the bone marrow was 0.42 Gy (median 0.33 Gy, SD 0.27 Gy) per treatment. Dose-response relationships between white blood cells, neutrophil granulocytes and haemoglobin concentrations were observed, most prominently at 31-45 days after each treatment. The correlations were stronger in patients with skeletal metastases. The rates of haematological toxicity-related delays and aborted treatments were 6% and 12%, respectively. None of the studied bone marrow dosimetric parameters could clearly predict treatment-related toxicity. However, patients with skeletal metastases had higher risk of treatment-altering toxicity (odds ratio = 6.0). CONCLUSIONS Treatment-altering haematological toxicity in peptide receptor radionuclide therapy is relatively rare and appears difficult to fully predict from post-therapeutic image-based dosimetry. However, for patients with skeletal metastases, the haematological dose-response relationships are stronger. Future studies may focus on this patient group, to further investigate the usefulness of dosimetry in predicting decreases in blood values.
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Affiliation(s)
- Märta Persson
- Medicinsk Fysik och Teknik, Mälarsjukhuset, Eskilstuna, Sweden
| | - Cecilia Hindorf
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176, Stockholm, Sweden
| | - Oscar Ardenfors
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Martin Larsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Joachim N Nilsson
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176, Stockholm, Sweden.
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Plachouris D, Eleftheriadis V, Nanos T, Papathanasiou N, Sarrut D, Papadimitroulas P, Savvidis G, Vergnaud L, Salvadori J, Imperiale A, Visvikis D, Hazle JD, Kagadis GC. A radiomic- and dosiomic-based machine learning regression model for pretreatment planning in 177 Lu-DOTATATE therapy. Med Phys 2023; 50:7222-7235. [PMID: 37722718 DOI: 10.1002/mp.16746] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 09/01/2023] [Accepted: 09/07/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Standardized patient-specific pretreatment dosimetry planning is mandatory in the modern era of nuclear molecular radiotherapy, which may eventually lead to improvements in the final therapeutic outcome. Only a comprehensive definition of a dosage therapeutic window encompassing the range of absorbed doses, that is, helpful without being detrimental can lead to therapy individualization and improved outcomes. As a result, setting absorbed dose safety limits for organs at risk (OARs) requires knowledge of the absorbed dose-effect relationship. Data sets of consistent and reliable inter-center dosimetry findings are required to characterize this relationship. PURPOSE We developed and standardized a new pretreatment planning model consisting of a predictive dosimetry procedure for OARs in patients with neuroendocrine tumors (NETs) treated with 177 Lu-DOTATATE (Lutathera). In the retrospective study described herein, we used machine learning (ML) regression algorithms to predict absorbed doses in OARs by exploiting a combination of radiomic and dosiomic features extracted from patients' imaging data. METHODS Pretreatment and posttreatment data for 20 patients with NETs treated with 177 Lu-DOTATATE were collected from two clinical centers. A total of 3412 radiomic and dosiomic features were extracted from the patients' computed tomography (CT) scans and dose maps, respectively. All dose maps were generated using Monte Carlo simulations. An ML regression model was designed based on ML algorithms for predicting the absorbed dose in every OAR (liver, left kidney, right kidney, and spleen) before and after the therapy and between each therapy session, thus predicting any possible radiotoxic effects. RESULTS We evaluated nine ML regression algorithms. Our predictive model achieved a mean absolute dose error (MAE, in Gy) of 0.61 for the liver, 1.58 for the spleen, 1.30 for the left kidney, and 1.35 for the right kidney between pretherapy 68 Ga-DOTATOC positron emission tomography (PET)/CT and posttherapy 177 Lu-DOTATATE single photon emission (SPECT)/CT scans. Τhe best predictive performance observed was based on the gradient boost for the liver, the left kidney and the right kidney, and on the extra tree regressor for the spleen. Evaluation of the model's performance according to its ability to predict the absorbed dose in each OAR in every possible combination of pretherapy 68 Ga-DOTATOC PET/CT and any posttherapy 177 Lu-DOTATATE treatment cycle SPECT/CT scans as well as any 177 Lu-DOTATATE SPECT/CT treatment cycle and the consequent 177 Lu-DOTATATE SPECT/CT treatment cycle revealed mean absorbed dose differences ranges from -0.55 to 0.68 Gy. Incorporating radiodosiomics features from the 68 Ga-DOTATOC PET/CT and first 177 Lu-DOTATATE SPECT/CT treatment cycle scans further improved the precision and minimized the standard deviation of the predictions in nine out of 12 instances. An average improvement of 57.34% was observed (range: 17.53%-96.12%). However, it's important to note that in three instances (i.e., Ga,C.1 → C3 in spleen and left kidney, and Ga,C.1 → C2 in right kidney) we did not observe an improvement (absolute differences of 0.17, 0.08, and 0.05 Gy, respectively). Wavelet-based features proved to have high correlated predictive value, whereas non-linear-based ML regression algorithms proved to be more capable than the linear-based of producing precise prediction in our case. CONCLUSIONS The combination of radiomics and dosiomics has potential utility for personalized molecular radiotherapy (PMR) response evaluation and OAR dose prediction. These radiodosiomic features can potentially provide information on any possible disease recurrence and may be highly useful in clinical decision-making, especially regarding dose escalation issues.
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Affiliation(s)
- Dimitris Plachouris
- 3DMI Research Group, Department of Medical Physics, School of Medicine, University of Patras, Rion, Greece
| | | | - Thomas Nanos
- 3DMI Research Group, Department of Medical Physics, School of Medicine, University of Patras, Rion, Greece
| | | | | | | | | | | | | | | | | | - John D Hazle
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - George C Kagadis
- 3DMI Research Group, Department of Medical Physics, School of Medicine, University of Patras, Rion, Greece
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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10
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Silva MM, Canha M, Salazar D, Neves JS, Ferreira G, Carvalho D, Duarte H. Efficacy, Toxicity, and Prognostic Factors of Re-treatment With [177Lu]Lu-DOTA-TATE in Patients With Progressing Neuroendocrine Tumors: The Experience of a Single Center. Cureus 2023; 15:e47506. [PMID: 38021538 PMCID: PMC10663964 DOI: 10.7759/cureus.47506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 12/01/2023] Open
Abstract
PURPOSE Peptide receptor radionuclide therapy (PRRT) is an effective and safe treatment of unresectable or metastatic, progressive neuroendocrine tumours (NETs). However, if progression occurs after the initial PRRT, treatment options remain limited. Our aim was to evaluate the efficacy and safety of a repeat 177Lutetium-[DOTA°,Tyr3]octreotate ([177Lu]Lu-DOTA-TATE) PRRT course in patients with progressive NET after the first [177Lu]Lu-DOTA-TATE PRRT (peptide receptor radionuclide therapy first treatment (PRRT1)). METHODS This is a nine-year retrospective observational study of 20 patients who were re-treated with PRRT (peptide receptor radionuclide therapy retreatment (PRRTR)) after PRRT1. RESULTS The median progression-free survival (PFS) following PRRT1 was 32 months (interquartile range (IQR): 16.5-44.5). After PRRT1, all 20 patients progressed. Of the 20 patients included, two were lost during follow-up. The median PFS after PRRTR was 17.5 months (IQR: 7-39). At the time of analysis, 15/18 patients progressed, and 3/18 had stable disease after PRRTR. Among those patients who progressed, the median time to progression was nine months (IQR: 0-17). The median overall survival from the time of the first cycle of PRRT1 was 66 months (IQR: 65-90). No significant renal or liver toxicity was reported, nor was there a drop in haemoglobin. The decrease in platelet count after PRRTR was statistically significant (p=0.03). Two cycles at PRRTR (vs. 1) were associated with a longer PFS (p=0.014) and the presence of metastases pre-PRRTR was associated with a shorter time to progression following PRRTR (p=0.04). Conclusion: Patients who progressed after PRRT1 can achieve good PFS and minor toxicity. Our study reinforces the efficacy and safety of PRRTR and provides an analysis of factors associated with better outcomes, which can aid clinicians in clinical decision-making.
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Affiliation(s)
- Maria Manuel Silva
- Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Marta Canha
- Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Daniela Salazar
- Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, PRT
| | - João Sergio Neves
- Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Gonçalo Ferreira
- Nuclear Medicine, Instituto Português de Oncologia Porto, Porto, PRT
| | - Davide Carvalho
- Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Hugo Duarte
- Nuclear Medicine, Instituto Português de Oncologia Porto, Porto, PRT
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11
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Hemmingsson J, Svensson J, Hallqvist A, Smits K, Johanson V, Bernhardt P. Specific Uptake in the Bone Marrow Causes High Absorbed Red Marrow Doses During [ 177Lu]Lu-DOTATATE Treatment. J Nucl Med 2023; 64:1456-1462. [PMID: 37290797 PMCID: PMC10478826 DOI: 10.2967/jnumed.123.265484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/03/2023] [Indexed: 06/10/2023] Open
Abstract
Bone marrow suppression is a common side effect after [177Lu]Lu-DOTATATE treatment of neuroendocrine neoplasms. Neuroendocrine neoplasms share expression of somatostatin receptor type 2 with CD34-positive hematopoietic progenitor cells, potentially leading to active uptake in the radiosensitive red marrow region where these cells are located. This study aimed to identify and quantify specific red marrow uptake using SPECT/CT images collected after the first treatment cycle. Methods: Seventeen patients diagnosed with neuroendocrine neoplasms were treated with [177Lu]Lu-DOTATATE. Seven of them had confirmed bone metastases. After the first treatment cycle, each patient went through 4 SPECT/CT imaging sessions 4, 24, 48, and 168 h after administration. Monte Carlo-based reconstructions were used to quantify activity concentrations in tumors and multiple skeletal sites presumed to house red marrow: the T9-L5 vertebrae and the ilium portion of the hip bones. The activity concentration from the descending aorta was used as input in a compartment model intended to establish a pure red marrow biodistribution by separating the nonspecific blood-based contribution from the specific activity concentration in red marrow. The biodistributions from the compartment model were used to perform red marrow dosimetry at each skeletal site. Results: Increased uptake of [177Lu]Lu-DOTATATE was observed in the T9-L5 vertebrae and hip bones in all 17 patients compared with activity concentrations in the aorta. The mean specific red marrow uptake was 49% (range, 0%-93%) higher than the nonspecific uptake. The median (±SD) total absorbed dose to the red marrow was 0.056 ± 0.023 Gy/GBq and 0.043 ± 0.022 Gy/GBq for the mean of all vertebrae and hip bones, respectively. The patients with bone metastases had an absorbed dose of 0.085 ± 0.046 Gy/GBq and 0.069 ± 0.033 Gy/GBq for the vertebrae and hip bones, respectively. The red marrow elimination phase was statistically slower in patients with fast tumor elimination, which is in line with transferrin transport of 177Lu back to the red marrow. Conclusion: Our results suggest that specific red marrow uptake of [177Lu]Lu-DOTATATE is in line with observations of somatostatin receptor type 2-expressing hematopoietic progenitor cells within the bone marrow. Blood-based dosimetry methods fail to account for the prolonged elimination of specific uptake and underestimate the absorbed dose to red marrow.
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Affiliation(s)
- Jens Hemmingsson
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden;
| | - Johanna Svensson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Hallqvist
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Katja Smits
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
| | - Viktor Johanson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden; and
| | - Peter Bernhardt
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Medical Physics and Medical Bioengineering, Sahlgrenska University Hospital, Gothenburg, Sweden
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12
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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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13
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Chandra P, Kumar K. Screening for Clonal Hematopoiesis for Mitigating the Risk of Hematopoietic Neoplasms after PRRT. World J Nucl Med 2023; 22:150-151. [PMID: 37223622 PMCID: PMC10202583 DOI: 10.1055/s-0043-1764308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Affiliation(s)
- Piyush Chandra
- Department of Nuclear Medicine, Zydus Hospitals, Vadodara, Gujarat, India
| | - Kishore Kumar
- Department of Hematology, MIOT International, Chennai, Tamil Nadu, India
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14
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Barakat A, Santoro L, Vivien M, Kotzki PO, Deshayes E, Khier S. Clinical Pharmacokinetics of Radiopharmaceuticals from SPECT/CT Image Acquisition by Contouring in Patients with Gastroenteropancreatic Neuroendocrine Tumors: Lu-177 DOTATATE (Lutathera ®) Case. Eur J Drug Metab Pharmacokinet 2023:10.1007/s13318-023-00829-5. [PMID: 37184824 DOI: 10.1007/s13318-023-00829-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND AND OBJECTIVE Lu-177 DOTATATE (Lutathera®) is a radiolabeled analog of somatostatin administered intravenously in patients with somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors. Biodistribution of Lu-177 DOTATATE in tumor and healthy tissues can be monitored by serial post-injection scintigraphy imaging. Patient exposure to the drug is variable with the recommended fixed dosage, and hence there is a variable response to treatment. The aim of this work was to study the pharmacokinetics of Lu-177 DOTATATE by a population modeling approach, based on single-photon emission computed tomography (SPECT)/computed tomography (CT) images used as surrogate of plasma concentrations to study the interindividual variability and finally optimize an individual dosage. METHODS From a retrospective study, SPECT/CT images were acquired at 4 h, 24 h, 72 h, and 192 h postadministration. From these images, volumic activities were calculated in blood and bone marrow. An individual non-compartmental pharmacokinetic analysis was performed, and the mean pharmacokinetic parameters of each tissue were compared together and with reference data. Blood volumic activities were then used to perform a population pharmacokinetic analysis (NONMEM). RESULTS The pharmacokinetic parameters (non-compartmental analysis) obtained from blood (clearance [CL] = 2.65 L/h, volume of distribution at steady state [Vss] = 309 L, elimination half-life [t1/2] = 86.3 h) and bone marrow (CL =1.68 L/h, Vss = 233 L, t1/2 = 98.8 h) were statistically different from each other and from reference values (CL = 4.50 L/h, Vss = 460 L, t1/2 = 71.0 h) published in the literature. SPECT/CT blood images were used as a surrogate of plasma concentrations to develop a population pharmacokinetic model. Weight was identified as covariate on volume of the central compartment, reducing the interindividual variability of all population pharmacokinetic parameters. CONCLUSION This study is a proof of concept that obtaining pharmacokinetic parameters with image-based blood concentration is possible. Obtaining observed concentrations from SPECT/CT images, without the need for blood sampling, is a real advantage for the patient and the drug monitoring. Pharmacokinetic modeling could be combined with a deep learning model for automatic contouring and allow precise patient-specific dose adjustment in a non-invasive manner.
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Affiliation(s)
- Anissa Barakat
- Pharmacokinetics and Pharmacometrics Department, School of Pharmacy, UFR Pharmacie, Montpellier University, 15 Avenue Charles Flahault, 34000, Montpellier, France
- Probabilities and Statistics Department, Institut Montpelliérain Alexander Grothendieck (IMAG), CNRS, UMR 5149, Inria, Montpellier University, Montpellier, France
- Nuclear Medicine Department, Montpellier Cancer Institute, Montpellier University, Montpellier, France
| | - Lore Santoro
- Nuclear Medicine Department, Montpellier Cancer Institute, Montpellier University, Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier University, Montpellier, France
| | - Myrtille Vivien
- Biostatistics, Informatics and pharmaceutical physic Laboratory, School of Pharmacy, UFR Pharmacie, Montpellier University, 15 Av. Ch. Flahault, 34000, Montpellier, France
- Institute of Functional Genomic (IGF)- UMR 5203, INSERM U1191, Montpellier, France
| | - Pierre-Olivier Kotzki
- Nuclear Medicine Department, Montpellier Cancer Institute, Montpellier University, Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier University, Montpellier, France
| | - Emmanuel Deshayes
- Nuclear Medicine Department, Montpellier Cancer Institute, Montpellier University, Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier University, Montpellier, France
| | - Sonia Khier
- Pharmacokinetics and Pharmacometrics Department, School of Pharmacy, UFR Pharmacie, Montpellier University, 15 Avenue Charles Flahault, 34000, Montpellier, France.
- Probabilities and Statistics Department, Institut Montpelliérain Alexander Grothendieck (IMAG), CNRS, UMR 5149, Inria, Montpellier University, Montpellier, France.
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15
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O'Shea A, Iravani A, Saboury B, Jadvar H, Catalano O, Mahmood U, Heidari P. Integrating Theranostics Into Patient Care Pathways: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2023; 220:619-629. [PMID: 36321986 PMCID: PMC10133840 DOI: 10.2214/ajr.22.28237] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Theranostics describes the coupling of a diagnostic biomarker and a therapeutic agent (i.e., a theranostic pair) that have a common target in tumor cells or their microenvironment. The term is increasingly associated with in vivo nuclear medicine oncologic applications that couple diagnostic imaging by means of gamma radiation with concomitant localized high-energy particulate radiation to a tissue expressing the common target. Several theranostic pairs have been translated into clinical practice in the United States and are poised to become a mainstay of cancer treatment. The purposes of this article are to review experience with theranostics for solid-organ malignancies and to address the practical integration into care pathways of β-emitting therapies that include somatostatin analogue radioligands for neuroendocrine tumors, PSMA-directed therapy for prostate cancer, and 131I-MIBG therapy for tumors of neural crest origin. Toxicities related to theranostics administration and indications for cessation of therapy in patients who experience adverse events are also discussed. A multidisciplinary team-based approach for identifying patients most likely to respond to these agents, determining the optimal time for therapy delivery, and managing patient care throughout the therapeutic course is critical to the success of a radiotheranostic program.
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Affiliation(s)
- Aileen O'Shea
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Massachusetts General Hospital, 55 Fruit St, White 427, Boston, MA 02115
| | | | - Babak Saboury
- Department of Radiology and Imaging Sciences, Clinical Center, NIH, Bethesda, MD
- Department of Computer Science and Electrical Engineering, University of Maryland, Baltimore County, Baltimore, MD
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Hossein Jadvar
- Division of Nuclear Medicine and Molecular Imaging Center, Keck School of Medicine and Viterbi School of Engineering, University of Southern California, Los Angeles, CA
| | - Onofrio Catalano
- Division of Abdominal Imaging, Massachusetts General Hospital, Boston, MA
| | - Umar Mahmood
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Massachusetts General Hospital, 55 Fruit St, White 427, Boston, MA 02115
| | - Pedram Heidari
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Massachusetts General Hospital, 55 Fruit St, White 427, Boston, MA 02115
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16
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Neuroendocrine Tumor Therapy Response Assessment. PET Clin 2023; 18:267-286. [PMID: 36858748 DOI: 10.1016/j.cpet.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Peptide receptor radionuclide therapy has become an integral part of management of neuroendocrine neoplasms. Gallium-68- and lutetium-177-labeled somatostatin receptor analogues have replaced yttrium-90- and 111-indium-based tracers. Several newer targeted therapies are also being used in clinical and research settings. It is imperative to accurately evaluate the response to these agents. The characteristics of NENs and the response patterns of the targeted therapies make response assessment in this group challenging. This article provides an overview of the strengths and weaknesses of the various biomarkers available for response assessment.
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17
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Minczeles NS, de Herder WW, Feelders RA, Verburg FA, Hofland J, Brabander T. Long-Term Outcomes of Submaximal Activities of Peptide Receptor Radionuclide Therapy with 177Lu-DOTATATE in Neuroendocrine Tumor Patients. J Nucl Med 2023; 64:40-46. [PMID: 35680417 DOI: 10.2967/jnumed.122.263856] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 01/13/2023] Open
Abstract
In the literature, up to 45% of neuroendocrine tumor (NET) patients who are treated with 177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT) do not receive the intended cumulative activity of 29.6 GBq (800 mCi). The aim of this study was to analyze the efficacy of submaximal activities of PRRT in patients who discontinued treatment for non-disease-related reasons. Methods: We retrospectively included patients with well-differentiated and advanced NETs who underwent PRRT from 2000 until 2019 and did not receive 29.6 GBq of 177Lu-DOTATATE. For comparison, we selected control NET patients who received the intended cumulative activity of 29.6 GBq of 177Lu-DOTATATE between 2000 and 2012. Primary outcomes were progression-free survival (PFS) and tumor response, and the secondary outcome was overall survival (OS). Results: In total, 243 patients received 3.7-27.8 GBq. In 130 patients, the submaximal activity was unrelated to disease (e.g., bone marrow and renal toxicity in 48% and maximal renal absorbed dose in 23%), and they were included. Patients receiving a reduced activity had more bone metastases, a lower body mass index and albumin level, a higher alkaline phosphatase level, and fewer grade 1 tumors than the 350 patients included in the control group. The disease control rate in the reduced-activity group was 85%, compared with 93% for the control group (P = 0.011). The median PFS (95% CI) was 23 mo (range, 21-26 mo) for the reduced-activity group and 31 mo (range, 27-35 mo) for the control group (P = 0.001), and the median OS (95% CI) was 34 mo (range, 28-40 mo) and 60 mo (range, 53-67 mo), respectively (P < 0.0001). With adjustment for relevant confounders in the multivariable Cox regression analyses, cumulative activity was an independent predictor of both PFS and OS. Conclusion: In NET patients treated with a cumulative activity of less than 29.6 GBq of 177Lu-DOTATATE, PRRT was less efficacious in tumor response and survival than in patients who received 29.6 GBq.
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Affiliation(s)
- Noémie S Minczeles
- Section of Endocrinology, Department of Internal Medicine, ENETS Centre of Excellence Rotterdam, Erasmus MC and Erasmus MC Cancer Centre, Rotterdam, The Netherlands; and .,Department of Radiology and Nuclear Medicine, ENETS Centre of Excellence Rotterdam, Erasmus MC and Erasmus MC Cancer Centre, Rotterdam, The Netherlands
| | - Wouter W de Herder
- Section of Endocrinology, Department of Internal Medicine, ENETS Centre of Excellence Rotterdam, Erasmus MC and Erasmus MC Cancer Centre, Rotterdam, The Netherlands; and
| | - Richard A Feelders
- Section of Endocrinology, Department of Internal Medicine, ENETS Centre of Excellence Rotterdam, Erasmus MC and Erasmus MC Cancer Centre, Rotterdam, The Netherlands; and
| | - Frederik A Verburg
- Department of Radiology and Nuclear Medicine, ENETS Centre of Excellence Rotterdam, Erasmus MC and Erasmus MC Cancer Centre, Rotterdam, The Netherlands
| | - Johannes Hofland
- Section of Endocrinology, Department of Internal Medicine, ENETS Centre of Excellence Rotterdam, Erasmus MC and Erasmus MC Cancer Centre, Rotterdam, The Netherlands; and
| | - Tessa Brabander
- Department of Radiology and Nuclear Medicine, ENETS Centre of Excellence Rotterdam, Erasmus MC and Erasmus MC Cancer Centre, Rotterdam, The Netherlands
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Hemmingsson J, Svensson J, van der Meulen NP, Müller C, Bernhardt P. Active bone marrow S-values for the low-energy electron emitter terbium-161 compared to S-values for lutetium-177 and yttrium-90. EJNMMI Phys 2022; 9:65. [PMID: 36153386 PMCID: PMC9509518 DOI: 10.1186/s40658-022-00495-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Based on theoretical and preclinical results, terbium-161 may be a valid alternative to lutetium-177 and yttrium-90 in radionuclide therapies. The large low-energy electron emission from terbium-161 is a favorable feature in the treatment of disseminated disease, but its impact on the radiosensitive bone marrow needs to be evaluated. Using voxel-based skeletal dosimetry models in which active bone marrow is defined as regions containing stem cells and progenitor cells of the hematopoietic lineage, we generated S-values (absorbed dose per decay) for terbium-161 and evaluated its distribution-dependence in bone marrow cavities.
Methods
S-values in the active bone marrow were calculated for terbium-161, lutetium-177, and yttrium-90 irradiation using two (male/female) image-based bone marrow dosimetry models. The radionuclides were distributed to one of the three structures that define the spongiosa bone region in the skeletal models: (i) active bone marrow, (ii) inactive bone marrow, or (iii) surface or whole volume of the trabecular bone. Decay data from ICRP 107 were combined with specific absorbed fractions to calculate S-values for 13 skeletal sites. To increase the utility, the skeletal site-specific S-values were averaged to produce whole-body average S-values and spongiosa average S-values.
Results
For yttrium-90, the high-energy β particles irradiate the active marrow regardless of the source compartment, consistently generating the highest S-values (65–90% higher). Between terbium-161 and lutetium-177, the largest differences in S-values were with an active marrow source (50%), such as self-irradiation, due to the contribution of the short-ranged conversion and Auger electrons from terbium-161. Their influence decreased as the source moved to inactive marrow or the surface or volume of the trabecular bone, reducing the S-values and the differences between terbium-161 and lutetium-177 (15–35%).
Conclusion
The S-values of terbium-161 for active bone marrow and, consequently, the bone marrow toxicity profile were more dependent on the radionuclide distribution within the bone marrow cavity than the S-values of lutetium-177 and yttrium-90. This effect was attributed to the considerable low-energy electron emission of terbium-161. Therefore, it will be critical to investigate the bone marrow distribution of a particular radiopharmaceutical for accurate estimation of the active bone marrow dose.
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Park R, Amin M, Trikalinos NA. Temozolomide duration and secondary hematological neoplasms: A literature review and implications for patients with neuroendocrine neoplasms. J Neuroendocrinol 2022; 34:e13178. [PMID: 35854663 DOI: 10.1111/jne.13178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/25/2022] [Accepted: 06/16/2022] [Indexed: 11/30/2022]
Abstract
Evidence-based recommendations for the optimal duration and sequencing of temozolomide-based treatments in advanced neuroendocrine neoplasms are lacking. Here, we conducted a systematic review of the literature for a descriptive analysis of temozolomide-associated myelodysplasias and leukemias to guide treatment planning. A database search of PubMed and Embase was conducted to identify case reports and/or case series reporting secondary myelodysplasias or leukemias in the setting of temozolomide therapy. Key data items extracted from the studies were the temozolomide dose and duration, latency to hematological disorder, type of secondary malignancy and cytogenetics. Reported cases were summarized graphically. A total of 16 studies with 27 patient cases of therapy-related hematologic neoplasms were identified, all of which were case reports or case series. The median treatment duration and cumulative dose were 19 months and 18,000 mg/m2 , respectively. Most patients (21/27) were diagnosed on, or after, 12 months, while only one patient was diagnosed before 6 months of treatment. Most of the patients were diagnosed, while still on treatment with temozolomide. Graphically, cases clustered around a cumulative dose of 10,000 to 30,000 mg/m2 and a latency period of 10 to 40 months which translates to an approximate treatment duration of 12.5 to 37.5 months. Taken together, most reported treatment-related hematological neoplasms appear to develop on or beyond the 12-month mark, while patients are still on treatment with temozolomide. For patients with neuroendocrine neoplasms, where sequencing of multiple therapies is important, we suggest an approach to optimizing treatment duration by establishing disease response at 6 months before continuing further treatment and restricting treatment to or establishing closer vigilance beyond 12 months.
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Affiliation(s)
- Robin Park
- Department of Medicine, MetroWest Medical Center/Tufts University School of Medicine, Framingham, Massachusetts, USA
| | - Manik Amin
- Department of Medicine, Division of Oncology, Dartmouth- Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Nikolaos A Trikalinos
- Department of Medicine, Division of Oncology, Washington University Medical School, St. Louis, Missouri, USA
- Siteman Cancer Center, St Louis, Missouri, USA
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Naveed Ahmad JA, Schroeder BB, Ruhoy SM, Kennecke HF, Lin BS. Severe Thrombocytopenia in Patients With Advanced Neuroendocrine Tumor Treated With Peptide Receptor Radioligand Therapy. Clin Nucl Med 2022; 47:409-413. [PMID: 35307721 PMCID: PMC8983945 DOI: 10.1097/rlu.0000000000004130] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/02/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Peptide receptor radioligand therapy (PRRT) was Food and Drug Administration approved in 2018 for the treatment of unresectable somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (NETs) and provides an important option for patients with advanced disease. A known adverse effect of this treatment is hematologic toxicity, although usually transient. We present 3 patients with metastatic gastroenteropancreatic NETs treated with PRRT who were evaluated for severe persistent thrombocytopenia. METHODS Three patients who commenced therapy with PRRT were known to proceed to a bone marrow (BM) biopsy for persistent severe thrombocytopenia and were included in this study. These patients were identified retrospectively and evaluated for their tumor properties, including immunohistochemical markers, treatment modalities, and clinical outcomes. RESULTS All 3 patients had metastatic NETs that progressed on prior lines of therapy and were treated with 1 to 4 doses of 177Lu-DOTATATE 7.4 GBq (200 mCi) before developing grade 3 (25,000 to 50,000/μL) refractory thrombocytopenia. All patients had concurrent bone metastases, and 2 of the 3 had baseline grade 1 thrombocytopenia. In all 3 cases, BM biopsy documented widespread tumor infiltration. CONCLUSIONS Severe refractory thrombocytopenia after PRRT is rare and may result from numerous known causes, including radiation-induced myelotoxicity, myelodysplastic syndrome, and tumor BM infiltration. We present 3 cases of thrombocytopenia related to persistent or progressive BM metastasis. Although known bone metastasis is not a contraindication to PRRT, thrombocytopenia may be a manifestation of tumor progression and should be considered when making decisions about continuation of therapy.
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Affiliation(s)
| | - Brett B. Schroeder
- From the Cancer Institute, Virginia Mason Medical Center, Seattle, WA
- National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Steven M. Ruhoy
- Anatomic and Clinical Pathology, Virginia Mason Medical Center, Seattle, WA
| | | | - Bruce S. Lin
- From the Cancer Institute, Virginia Mason Medical Center, Seattle, WA
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Khatami A, Sistani G, Sutherland DEK, DeBrabandere S, Reid RH, Laidley DT. Toxicity and Tolerability of 177Lu-DOTA-TATE PRRT with a Modified Administered Activity Protocol in NETs of Variable Origin - A Phase 2 Registry Study. Curr Radiopharm 2022; 15:123-133. [PMID: 35135467 PMCID: PMC9900697 DOI: 10.2174/1874471014666210810100435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Peptide receptor radionuclide therapy (PRRT) has been recently approved for advanced, metastatic, or progressive neuroendocrine tumors (NETs). OBJECTIVE This study reports the adverse events (AEs) observed with patient-tailored administered activity. METHODS Fifty-two PRRT naive patients were treated with 177Lu-DOTATATE. The administered activity ranges between 2.78 and 5.55 GBq/cycle using the patient's unique characteristics (age, symptoms, blood work, and biomarkers). RESULTS The protocol was well tolerated with the overwhelming majority of participants being forty- six (88%), completing all 4 induction therapy cycles. The median cumulative administered activity was 19.6 GBq (ranged 3.8-22.3 GBq). A total of 42/52 (81%) reported at least one symptom, and 43/52 (83%) had evidence of biochemical abnormality at enrollment that would meet grade 1 or 2 criteria for AEs. These symptoms only slightly increase with treatment to 50/52 (96%) and 51/52 (98%), respectively. The most common symptoms were mild fatigue (62%), shortness of breath (50%), nausea (44%), abdominal pain (38%), and musculoskeletal pain (37%). The most common biomarker abnormalities were mild anemia (81%), reduced estimated glomerular filtration rate (eGFR) (58%), increased alkaline phosphatase (ALP) (50%), and leukopenia (37%). Of critical importance, no 177Lu-DOTATATE related grade 3 or 4 AEs were observed. CONCLUSION Tailoring the administered activity of 177Lu-DOTATATE to the individual patient with a variety of NETs is both safe and well-tolerated. No patient developed severe grade 3 or 4 AEs. Most patients exhibit symptoms or biochemical abnormality before treatment and this only slightly worsens following induction therapy.
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Affiliation(s)
- Alireza Khatami
- Division of Nuclear Medicine, Department of Medical Imaging, Western University, London, ON N645C1, Canada; ,Address correspondence to this author at the Division of Nuclear Medicine, Department of Medical Imaging, Western University, London, ON N645C1, Canada; E-mail:
| | - Golmehr Sistani
- Division of Nuclear Medicine, Department of Medical Imaging, Western University, London, ON N645C1, Canada; ,Division of Radiology, Department of Medical Imaging, Western University, London, ON, Canada
| | - Duncan E. K. Sutherland
- Division of Nuclear Medicine, Department of Medical Imaging, Western University, London, ON N645C1, Canada;
| | - Sarah DeBrabandere
- Division of Nuclear Medicine, Department of Medical Imaging, Western University, London, ON N645C1, Canada;
| | - Robert H. Reid
- Division of Nuclear Medicine, Department of Medical Imaging, Western University, London, ON N645C1, Canada;
| | - David T. Laidley
- Division of Nuclear Medicine, Department of Medical Imaging, Western University, London, ON N645C1, Canada;
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22
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Dose-Limiting Bone Marrow Toxicities After Peptide Receptor Radionuclide Therapy Are More Prevalent in Women Than in Men. Clin Nucl Med 2022; 47:599-605. [DOI: 10.1097/rlu.0000000000004203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Efficacy and safety of 177Lu‑DOTATATE in patients with advanced pancreatic neuroendocrine tumours: data from the NETTER-R international, retrospective study. Eur J Nucl Med Mol Imaging 2022; 49:3529-3537. [PMID: 35389069 PMCID: PMC9308585 DOI: 10.1007/s00259-022-05771-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/20/2022] [Indexed: 11/16/2022]
Abstract
Purpose NETTER-R aimed to determine the efficacy, safety and tolerability of 177Lu-DOTATATE in patients with progressive, advanced pancreatic neuroendocrine tumours (panNETs) using retrospective real-world data from multiple sites. Methods This international study retrospectively included patients with panNETs treated with 177Lu-DOTATATE. The primary endpoint was progression-free survival (PFS) by Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST v1.1). Secondary endpoints included overall survival (OS), safety and tumour response. Results In total, 110 patients with panNETs were studied; 65.5% received a cumulative dose of 177Lu-DOTATATE 29.6 GBq ± 10% (median: 7.4 GBq). In 62 patients with available RECIST v1.1 tumour response, the median PFS was 24.8 months (95% confidence interval [CI]: 17.5–34.5), and the objective response rate was 40.3% (95% CI: 28.1–53.6); all responses were partial. With a median follow up of 24.5 months (range: 2.0–123.4 months) after the first cycle of 177Lu-DOTATATE, the median OS in the full analysis set (n = 110) was 41.4 months (95% CI: 28.6–50.2). PFS (hazard ratio [HR]: 3.672; p = 0.0009) and OS (HR: 3.360; p < 0.0001) were longer in patients who received no chemotherapy prior to 177Lu-DOTATATE than those who did. No treatment-emergent adverse events (TEAEs) led to treatment discontinuation. Grade 3 anaemia, lymphopenia and thrombocytopenia occurred in 0.9%, 5.4% and 0.9% of patients, respectively. No acute leukaemia or myelodysplastic syndrome was reported. Six patients (5.5%) had renal TEAEs. All renal grade ≥ 3 events were transient and did not lead to treatment modification. Conclusions These results reinforce the role of 177Lu-DOTATATE for the treatment of patients with advanced, somatostatin receptor-positive panNETs. Supplementary Information The online version contains supplementary material available at 10.1007/s00259-022-05771-3.
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Navalkissoor S, Toumpanakis C, Caplin M, Gnanasegaran G. Treatment of neuroendocrine tumours with 177 Lu-peptide receptor radionuclide therapy: Challenging clinical scenarios and their management. J Neuroendocrinol 2022; 34:e13088. [PMID: 35078265 DOI: 10.1111/jne.13088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 12/09/2021] [Accepted: 12/31/2021] [Indexed: 11/28/2022]
Abstract
Peptide receptor radionuclide therapy (PRRT) for the treatment of patients with neuroendocrine tumours is usually well tolerated, with selection based on existing guidelines. However, there are various scenarios where the risk-benefit analysis of PRRT needs to be evaluated to limit any complications associated with PRRT. This review looks at 11 key scenarios where the risk-benefit of PRRT needs to be closely evaluated.
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Affiliation(s)
- Shaunak Navalkissoor
- Department of Nuclear Medicine, Royal Free London NHS Foundation Trust, London, UK
| | | | - Martyn Caplin
- Neuroendocrine Unit, Royal Free London NHS Foundation Trust, London, UK
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Alkassis S, Ali M, Awadelkarim AM, Saad E, Halboni A, Alhusain R, Kamatham S, Idris I. Lutetium-177 Dotatate-Induced Hemolytic Anemia and Myelodysplastic Syndrome. Cureus 2022; 14:e22392. [PMID: 35371754 PMCID: PMC8938243 DOI: 10.7759/cureus.22392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2022] [Indexed: 11/24/2022] Open
Abstract
Lutetium-177 (177Lu) dotatate is a type of peptide receptor radioligand therapy (PRRT) using radiolabeled somatostatin for patients with progressive somatostatin receptor-positive gastrointestinal neuroendocrine tumors. While cases of therapy-related myeloid neoplasms (t-MN) have been described as a consequence of 177 Lu dotatate, there are no reports of hemolytic anemia associated with therapy. We present a case of a 68-year-old woman with metastatic low-grade neuroendocrine tumor who presented four weeks after the second dose of 177Lu dotatate with progressive fatigue and dyspnea. Laboratory workup was remarkable for hemolytic anemia. Lutetium-177 dotatate-induced hemolysis was suspected after ruling out other causes. Corticosteroid treatment was initiated with improvement in hemoglobin, and dose-reduced PRRT was planned upon discharge. Six months into the treatment course of 177Lu dotatate, macrocytic anemia was noticed on routine follow-up with normal vitamin B12 and folic acid levels. A bone marrow biopsy was done, revealing myelodysplastic syndrome (MDS) features. Given the temporal relationship between drug introduction and the objective findings, early-onset 177Lu dotatate-induced MDS was diagnosed with a plan for close hematologic follow-up. Myelodysplastic syndrome should be suspected when megaloblastic anemia develops in patients with previous 177Lu dotatate therapy. The latency period between initial treatment and MDS diagnosis reported in the literature ranges between 15 months to seven years. Apart from the unusually early onset of MDS, what is unique about our case is the development of hemolytic anemia after administration of PRRT. The clinical course and the brisk response to steroid therapy, suggest other mechanisms of PRRT toxicity besides DNA breaks, genetic mutations, and myelosuppression by an immune-mediated component that likely plays a role in 177Lu dotatate toxicity. Further investigation and monitoring are needed to identify the frequency of such adverse events and the pathophysiology of their occurrence.
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26
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Early Complications of Radioisotope Therapy with Lutetium-177 and Yttrium-90 in Patients with Neuroendocrine Neoplasms-A Preliminary Study. J Clin Med 2022; 11:jcm11040919. [PMID: 35207193 PMCID: PMC8874379 DOI: 10.3390/jcm11040919] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/06/2022] [Accepted: 02/07/2022] [Indexed: 12/12/2022] Open
Abstract
Neuroendocrine neoplasms (NENs) constitute a heterogenous group of tumors originating from neuroendocrine cells scattered throughout the body. Peptide Receptor Radionuclide Therapy (PRRT) is a treatment of choice of unresectable metastasized progressive and well-differentiated NENs. The aim of the study was to assess early bone marrow and kidney injury after administration of Lutetium-177 or Lutetium-177 combined with Yttrium-90. Thirty-one patients received treatment with [177Lu]Lu-DOTATATE with the activity of 7.4 GBq. Eleven patients received tandem treatment with [90Y]Y-DOTATATE with the activity of 1.85 GBq + [177Lu]Lu-DOTATATE with the activity of 1.85 GBq. After PRRT a significant decrease in leukocyte, neutrophil, and lymphocyte counts was noted. Tandem treatment demonstrated a more marked decrease in white blood cell count compared to Lutetium-177 therapy only. Conversely, no significant influence on glomerular filtration was found in this assessment. However, PRRT triggered acute renal tubule dysfunction, regardless of the treatment type. Regarding the acute complications, PRRT appeared to be a safe modality in the treatment of patients with NEN.
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27
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Treatment patterns and oncological outcome of patients with advanced small intestinal neuroendocrine tumors: real-world data from the Medical University of Vienna. Ther Adv Med Oncol 2022; 14:17588359221138389. [DOI: 10.1177/17588359221138389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 10/24/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Different oncological therapies have been approved for small intestinal neuroendocrine tumors (SI-NETs), but relatively little is known about efficacy and long-term outcome outside of phase III trials. Methods: This retrospective analysis assessed patients with well-differentiated, metastatic SI-NETs treated at the Medical University of Vienna, an approved European Neuroendocrine Tumor Society (ENETS) Center of Excellence for neuroendocrine tumors. The primary objective was to assess progression-free survival (PFS) following approved therapies, that is, octreotide, lanreotide, peptide receptor radionuclide therapy (PRRT), and everolimus, in a representative real-world collective. Results: A total of 77 patients receiving systemic treatment for advanced SI-NETs between 2010 and 2021 were included, with a median follow-up time of 82.3 months [95% confidence interval (CI), 57.8–106.8 months]. In the entire collective, the estimated median PFS following first-line therapy was 32.0 months (95% CI, 23.5–40.5 months). Peritoneal carcinomatosis was significantly associated with worse PFS ( p = 0.016). Regarding therapeutic strategies and outcome, 59 patients received somatostatin analogs first line and no significant difference in PFS was observed between lanreotide and octreotide (29.3 versus 35.5 months, p = 0.768). Across all treatment lines, 42 patients underwent PRRT (estimated median PFS: 32.0 months; 95% CI, 25.6–38.3 months) and a small subgroup of 7 patients received everolimus (estimated median PFS: 9.2 months; 95% CI, 1.6–17.0 months). For the total cohort, the estimated median OS following first-line therapy was 100.6 months (95% CI, 82.3–118.8 months), but the high proportion of deaths attributed to NET (77.8%) underlines the lethal nature of the disease. No unexpected toxicities were observed. Conclusions: While peritoneal carcinomatosis emerged as an adverse prognostic factor for PFS in this collective, the long-term outcome of patients treated at a specialized NET center using approved therapies appeared comparable to pivotal studies in SI-NET.
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28
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Forrer F. Side effects of radiopeptide therapy for neuroendocrine tumors. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00157-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Capdevila J, Grande E, García-Carbonero R, Simó M, del Olmo-García MI, Jiménez-Fonseca P, Carmona-Bayonas A, Pubul V. OUP accepted manuscript. Oncologist 2022; 27:e328-e339. [PMID: 35380724 PMCID: PMC8982404 DOI: 10.1093/oncolo/oyab041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/08/2021] [Indexed: 11/25/2022] Open
Abstract
Background The aim of this study was to provide a guidance for the management of neuroendocrine tumors (NETs) in clinical practice. Material and Methods Nominal group and Delphi techniques were used. A steering committee of 8 experts reviewed the current management of NETs, identified controversies and gaps, critically analyzed the available evidence, and formulated several guiding statements for clinicians. Subsequently, a panel of 26 experts, was selected to test agreement with the statements through 2 Delphi rounds. Items were scored on a 4-point Likert scale from 1 = totally agree to 4 = totally disagree. The agreement was considered if ≥75% of answers pertained to Categories 1 and 2 (consensus with the agreement) or Categories 3 and 4 (consensus with the disagreement). Results Overall, 132 statements were proposed, which incorporated the following areas: (1) overarching principles; (2) progression and treatment response criteria; (3) advanced gastro-enteric NETs; (4) advanced pancreatic NETs; (5) advanced NETs in other locations; (6) re-treatment with radioligand therapy (RLT); (7) neoadjuvant therapy. After 2 Delphi rounds, only 4 statements lacked a clear consensus. RLT was not only recommended in the sequencing of different NETs but also as neoadjuvant treatment, while several indications for retreatment with RLT were also established. Conclusion This document sought to pull together the experts’ attitudes when dealing with different clinical scenarios of patients suffering from NETs, with RLT having a specific role where evidence-based data are limited.
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Affiliation(s)
- Jaume Capdevila
- Department of Medical Oncology, Vall Hebron University Hospital, Vall Hebron Institute of Oncology (VHIO), IOB-Quiron-Teknon Barcelona, Barcelona, Spain
- Corresponding author: Jaume Capdevila, Department of Medical Oncology, Vall Hebron University Hospital, Passeig de la Vall d’Hebron, 119, 08035 Barcelona, Spain. Tel: +34 934 89 30 00;
| | - Enrique Grande
- Department of Medical Oncology, MD Anderson Cancer Center, Madrid, Spain
| | | | - Marc Simó
- Department of Nuclear Medicine and Molecular Imaging, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Mª Isabel del Olmo-García
- Department of Endocrinology, Hospital Universitario y Politécnico la Fe de Valencia, Valencia, Spain
| | - Paula Jiménez-Fonseca
- Department of Medical Oncology, Hospital Universitario Central de Asturias, ISPA, Madrid, Spain
| | - Alberto Carmona-Bayonas
- Department of Hematology and Medical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, IMIB, CP13/00126, PI17/0050 (ISCIII & FEDER) and Fundación Séneca (04515/GERM/06), Murcia, Spain
| | - Virginia Pubul
- Department of Nuclear Medicine Department and Molecular Imaging Research Group, University Hospital and Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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Matching-adjusted indirect treatment comparison of [ 177Lu]Lu-DOTA-TATE, everolimus and sunitinib in advanced, unresectable gastroenteropancreatic neuroendocrine tumours: Relative effectiveness of [ 177Lu]Lu-DOTA-TATE in gastroenteropancreatic neuroendocrine tumours. EJC Suppl 2021; 16:5-13. [PMID: 34912478 PMCID: PMC8591206 DOI: 10.1016/j.ejcsup.2021.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 11/24/2022] Open
Abstract
Head-to-head comparisons of the efficacy of treatments for gastroenteropancreatic neuroendocrine tumours (GEP-NETs) have not yet been reported. This study used a series of matching-adjusted indirect comparisons to indirectly compare the effectiveness of [177Lu]Lu-DOTA-TATE to everolimus, sunitinib and best supportive care (BSC) for extending progression-free survival and overall survival in patients with advanced, unresectable gastrointestinal (GI)-NETs and P-NETs. The results of the main analysis suggest that after accounting for differences in key prognostic variables, the hazard of progression was 62% (hazard ratio [HR], 0.38; confidence interval [CI]95 0.25–0.58) and 65% (HR 0.35 CI95 0.21–0.59) lower in patients with GI-NETs treated with [177Lu]Lu-DOTA-TATE than in those treated with everolimus and BSC, respectively. Similarly, the hazard of progression was 64% (HR 0.36 CI95 0.18–0.70), 54% (HR 0.46 CI95 0.30–0.71) and 79–87% (HR 0.21 CI95 0.13–0.32; HR 0.13 CI95 0.08–0.22) lower in patients with P-NET treated with [177Lu]Lu-DOTA-TATE than in those treated with sunitinib, everolimus and BSC, respectively. The hazard of death was 58% (HR 0.42 CI95 0.25–0.72), 47% (HR 0.53 CI95 0.33–0.87) and 44–64% (HR 0.56 CI95 0.36–0.90; HR 0.34 CI95 0.20–0.57) lower in P-patients with NET treated with [177Lu]Lu-DOTA-TATE than in those treated with sunitinib, everolimus and BSC, respectively. While our results must be interpreted with caution given the non-randomised nature of the comparisons and the potential for residual confounding, the magnitude of the effect sizes we observe and their consistency across comparators suggest that [177Lu]Lu-DOTA-TATE may be a more effective treatment option than everolimus, sunitinib and BSC in advanced, unresectable GEP-NETs. The study reports unanchored indirect comparisons of treatments in GI- and P-NETs. 177Lu-DOTATATE was compared with everolimus, sunitinib and supportive care. GI- and P-NETs patients treated with 177Lu-DOTATATE had lower hazard of progression. Patients with P-NET treated with 177Lu-DOTATATE had lower hazard of death. Results must be interpreted with caution given potential for residual confounding.
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Pandit-Taskar N, Iravani A, Lee D, Jacene H, Pryma D, Hope T, Saboury B, Capala J, Wahl RL. Dosimetry in Clinical Radiopharmaceutical Therapy of Cancer: Practicality Versus Perfection in Current Practice. J Nucl Med 2021; 62:60S-72S. [PMID: 34857623 DOI: 10.2967/jnumed.121.262977] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 10/22/2021] [Indexed: 12/25/2022] Open
Abstract
The use of radiopharmaceutical therapies (RPTs) in the treatment of cancers is growing rapidly, with more agents becoming available for clinical use in last few years and many new RPTs being in development. Dosimetry assessment is critical for personalized RPT, insofar as administered activity should be assessed and optimized in order to maximize tumor-absorbed dose while keeping normal organs within defined safe dosages. However, many current clinical RPTs do not require patient-specific dosimetry based on current Food and Drug Administration-labeled approvals, and overall, dosimetry for RPT in clinical practice and trials is highly varied and underutilized. Several factors impede rigorous use of dosimetry, as compared with the more convenient and less resource-intensive practice of empiric dosing. We review various approaches to applying dosimetry for the assessment of activity in RPT and key clinical trials, the extent of dosimetry use, the relative pros and cons of dosimetry-based versus fixed activity, and practical limiting factors pertaining to current clinical practice.
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Affiliation(s)
| | - Amir Iravani
- Washington University School of Medicine, St. Louis, Missouri
| | - Dan Lee
- Ochsner Medical Center, New Orleans, Louisiana
| | | | - Dan Pryma
- Penn Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas Hope
- University of San Francisco, San Francisco, California; and
| | | | - Jacek Capala
- National Institutes of Health, Bethesda, Maryland
| | - Richard L Wahl
- Washington University School of Medicine, St. Louis, Missouri
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Strosberg JR, Caplin ME, Kunz PL, Ruszniewski PB, Bodei L, Hendifar A, Mittra E, Wolin EM, Yao JC, Pavel ME, Grande E, Van Cutsem E, Seregni E, Duarte H, Gericke G, Bartalotta A, Mariani MF, Demange A, Mutevelic S, Krenning EP. 177Lu-Dotatate plus long-acting octreotide versus high‑dose long-acting octreotide in patients with midgut neuroendocrine tumours (NETTER-1): final overall survival and long-term safety results from an open-label, randomised, controlled, phase 3 trial. Lancet Oncol 2021; 22:1752-1763. [PMID: 34793718 DOI: 10.1016/s1470-2045(21)00572-6] [Citation(s) in RCA: 194] [Impact Index Per Article: 64.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The primary analysis of the phase 3 NETTER-1 trial showed significant improvement in progression-free survival with 177Lu-Dotatate plus long-acting octreotide versus high-dose long-acting octreotide alone in patients with advanced midgut neuroendocrine tumours. Here, we report the prespecified final analysis of overall survival and long-term safety results. METHODS This open-label, randomised, phase 3 trial enrolled patients from 41 sites in eight countries across Europe and the USA. Patients were 18 years and older with locally advanced or metastatic, well differentiated, somatostatin receptor-positive midgut neuroendocrine tumours (Karnofsky performance status score ≥60) and disease progression on fixed-dose long-acting octreotide. Patients were randomly assigned (1:1) via an interactive web-based response system to intravenous 177Lu-Dotatate 7·4 GBq (200 mCi) every 8 weeks (four cycles) plus intramuscular long-acting octreotide 30 mg (177Lu-Dotatate group) or high-dose long-acting octreotide 60 mg every 4 weeks (control group). The primary endpoint of progression-free survival has been previously reported; here, we report the key secondary endpoint of overall survival in the intention-to-treat population. Final overall survival analysis was prespecified to occur either after 158 deaths or 5 years after the last patient was randomised, whichever occurred first. During long-term follow-up, adverse events of special interest were reported in the 177Lu-Dotatate group only. This trial is registered with ClinicalTrials.gov, NCT01578239. FINDINGS From Sept 6, 2012, to Jan 14, 2016, 231 patients were enrolled and randomly assigned for treatment. The prespecified final analysis occurred 5 years after the last patient was randomly assigned (when 142 deaths had occurred); median follow-up was 76·3 months (range 0·4-95·0) in the 177Lu-Dotatate group and 76·5 months (0·1-92·3) in the control group. The secondary endpoint of overall survival was not met: median overall survival was 48·0 months (95% CI 37·4-55·2) in the 177Lu-Dotatate group and 36·3 months (25·9-51·7) in the control group (HR 0·84 [95% CI 0·60-1·17]; two-sided p=0·30). During long-term follow-up, treatment-related serious adverse events of grade 3 or worse were recorded in three (3%) of 111 patients in the 177Lu-Dotatate group, but no new treatment-related serious adverse events were reported after the safety analysis cutoff. Two (2%) of 111 patients given 177Lu-Dotatate developed myelodysplastic syndrome, one of whom died 33 months after randomisation (this person was the only the only reported 177Lu-Dotatate treatment-related death). No new cases of myelodysplastic syndrome or acute myeloid leukaemia were reported during long-term follow-up. INTERPRETATION 177Lu-Dotatate treatment did not significantly improve median overall survival versus high-dose long-acting octreotide. Despite final overall survival not reaching statistical significance, the 11·7 month difference in median overall survival with 177Lu-Dotatate treatment versus high-dose long-acting octreotide alone might be considered clinically relevant. No new safety signals were reported during long-term follow-up. FUNDING Advanced Accelerator Applications, a Novartis company.
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Affiliation(s)
| | | | | | - Philippe B Ruszniewski
- Division of Gastroenterology and Pancreatology, Université de Paris and Beaujon Hospital, AP-HP, Clichy, France
| | - Lisa Bodei
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Erik Mittra
- Division of Diagnostic Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Edward M Wolin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James C Yao
- Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marianne E Pavel
- Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | | | - Eric Van Cutsem
- Division of Digestive Oncology, University of Leuven, University Hospital Gasthuisberg, Leuven, Belgium
| | - Ettore Seregni
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Hugo Duarte
- Portuguese Institute of Oncology, Porto, Portugal
| | | | - Amy Bartalotta
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | | | - Eric P Krenning
- Department of Nuclear Medicine, Erasmus Medical Center, Rotterdam, Netherlands
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Opalińska M, Sowa-Staszczak A, Grochowska A, Olearska H, Hubalewska-Dydejczyk A. Value of Peptide Receptor Radionuclide Therapy as Neoadjuvant Treatment in the Management of Primary Inoperable Neuroendocrine Tumors. Front Oncol 2021; 11:687925. [PMID: 34868906 PMCID: PMC8633407 DOI: 10.3389/fonc.2021.687925] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 10/21/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Neuroendocrine neoplasms including neuroendocrine tumors (NETs) are often diagnosed as primary disseminated or inoperable. In those cases, systemic extensive therapy is necessary, but radical treatment is unlikely. As described in the literature, in some selected cases, peptide receptor radionuclide therapy (PRRT) may be used as a first-line/neoadjuvant therapy that allows further successful surgery. Such treatment may enable a reduction of total tumor burden or allow a radical treatment which improves the final outcomes. AIM This study aims to assess whether neoadjuvant PRRT could be a treatment option for patients with initially unresectable NETs. METHODS Among the group of 114 patients treated with PRRT between the years 2005 and 2020, in 32 cases, it was the first-line therapy, mainly due to massive disease burden at the time of diagnosis. Among them, nine patients received PRRT as the first-line treatment due to the primary inoperable tumors with the intention of preoperative reduction of the tumor size in order to allow for a surgical treatment. RESULTS Neoadjuvant PRRT enabled surgery in four out of nine (45%) patients. Finally, in two out of four cases, the goal (radical surgery) has been achieved. CONCLUSION PRRT may be considered not only as a palliative but also as a neoadjuvant therapy in advanced, somatostatin-positive NETs that were initially inoperable.
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Affiliation(s)
- Marta Opalińska
- Nuclear Medicine Unit, Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Kraków, Poland
| | - Anna Sowa-Staszczak
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland
| | - Anna Grochowska
- Department of Radiology, University Hospital, Kraków, Poland
| | - Helena Olearska
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland
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Sabet A, Mader N, Bittenbring JT, Khreish F, Grünwald F, Biersack HJ, Ezziddin S. Prophylactic Peripheral Blood Stem Cell Collection in Patients with Extensive Bone-Marrow Infiltration of Neuroendocrine Tumours Prior to Peptide Receptor Radionuclide Therapy with 177Lu-DOTATATE. Pharmaceuticals (Basel) 2021; 14:ph14101022. [PMID: 34681247 PMCID: PMC8539404 DOI: 10.3390/ph14101022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022] Open
Abstract
Peptide receptor radionuclide therapy (PRRT) of metastatic neuroendocrine tumors (NET) can be successfully repeated but may eventually be dose-limited. Since 177Lu-DOTATATE dose limitation may come from hematological rather than renal function, hematological peripheral blood stem cell backup might be desirable. Here, we report our initial experience of peripheral blood stem-cell collection (PBSC) in patients with treatment-related cytopenia and therefore high risk of bone-marrow failure. Five patients with diffuse bone-marrow infiltration of NET and relevant myelosuppression (≥grade 2) received PBSC before one PRRT cycle with 177Lu-DOTATATE (7.6 ± 0.8 GBq/cycle). Standard stem-cell mobilization with Granulocyte-colony stimulating factor (G-CSF) was applied, and successful PBSC was defined as a collection of >2 × 106/kg CD34+ cells. In case of initial failure, Plerixafor was administered in addition to G-CSF prior to apheresis. PBSC was successfully performed in all patients with no adverse events. Median cumulative activity was 44.8 GBq (range, 21.3-62.4). Three patients had been previously treated with PRRT, two of which needed the addition of Plerixafor for stem-cell mobilization. Only one of five patients required autologous peripheral blood stem-cell transplantation during the median follow up time of 28 months. PBSC collection seems to be feasible in NET with bone-marrow involvement and might be worth considering as a backup strategy prior to PRRT, in order to overcome dose-limiting bone-marrow toxicity.
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Affiliation(s)
- Amir Sabet
- Department of Nuclear Medicine, University Hospital Frankfurt, 60590 Frankfurt am Main, Germany; (N.M.); (F.G.)
- Correspondence:
| | - Nicolai Mader
- Department of Nuclear Medicine, University Hospital Frankfurt, 60590 Frankfurt am Main, Germany; (N.M.); (F.G.)
| | - Jörg Thomas Bittenbring
- Department of Haematology and Oncology, Caritas Hospital Saarbrücken, 66123 Saarbrücken, Germany;
| | - Fadi Khreish
- Department of Nuclear Medicine, Saarland University Medical Center, 66421 Homburg, Germany; (F.K.); (S.E.)
| | - Frank Grünwald
- Department of Nuclear Medicine, University Hospital Frankfurt, 60590 Frankfurt am Main, Germany; (N.M.); (F.G.)
| | | | - Samer Ezziddin
- Department of Nuclear Medicine, Saarland University Medical Center, 66421 Homburg, Germany; (F.K.); (S.E.)
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Groener D, Baumgarten J, Haefele S, Happel C, Klimek K, Mader N, Nguyen Ngoc C, Tselis N, Chun FKH, Grünwald F, Sabet A. Salvage Radioligand Therapy with Repeated Cycles of 177Lu-PSMA-617 in Metastatic Castration-Resistant Prostate Cancer with Diffuse Bone Marrow Involvement. Cancers (Basel) 2021; 13:cancers13164017. [PMID: 34439172 PMCID: PMC8393804 DOI: 10.3390/cancers13164017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/02/2021] [Accepted: 08/06/2021] [Indexed: 01/09/2023] Open
Abstract
Simple Summary Metastatic castration-resistant prostate cancer (mCRPC) with extensive spread to the bone marrow is an incurable stage of disease associated with a poor prognosis and a high risk of impaired blood cell formation. Therapeutic options prolonging survival are limited and may result in significant bone marrow toxicity. The concept of radioligand therapy (RLT) in mCRPC is marked by the targeted delivery of radionuclides, such as beta particle emitting 177Lutetium (177Lu) to the prostate-specific membrane antigen (PSMA), a transmembrane protein frequently present on prostate cancer cells. RLT has yielded promising anti-tumoral activity and excellent tolerability in patients with mCRPC as shown by multiple retrospective series and a growing number of prospective trials. The presented study aims to investigate the role of RLT in mCRPC patients with metastases diffusely involving the bone marrow. Special emphasis is laid on identifying early indicators for a favorable treatment response and potential risk factors for adverse outcomes. The impact of RLT-specific variables, including administered treatment activity, cumulative activity and whole-body absorbed dose is assessed individually. Abstract Advanced stage metastatic prostate cancer with extensive bone marrow involvement is associated with a high risk of therapy-induced myelotoxicity and unfavorable outcomes. The role of salvage radioligand therapy (RLT) with 177Lu-PSMA-617 in this subset of patients remains to be further elucidated. Forty-five patients with progressive metastatic castration-resistant prostate cancer (mCRPC) and diffuse bone marrow involvement were treated with repeated cycles of RLT after having exhausted standard treatment options. A mean treatment activity of 7.4 ± 1.4 GBq 177Lu-PSMA-617 was administered in a median of four treatment cycles (IQR 2-6) and the mean cumulative activity was 32.6 ± 20.1 GBq. After two RLT cycles, ≥50% PSA decline was observed in 25/45 (56%) patients and imaging-based partial remission (PR) was observed in 18/45 (40%) patients. Median imaging-based progression-free survival (PFS) was 6.4 mo (95% CI, 3.0–9.8) and the median overall survival (OS) was 10.2 months (95% CI, 7.2–12.8). The biochemical response translated into a significantly prolonged PFS (12.9 vs. 2.8 mo, p < 0.001) and OS (13.5 vs. 6.7 mo, p < 0.001). Patients with PR on interim imaging after two cycles had a longer median OS compared to patients with stable or progressive disease (15.5 vs. 7.1 mo, p < 0.001). Previous taxane-based chemotherapy (HR 3.21, 95%CI 1.18–8.70, p = 0.02) and baseline LDH levels (HR 1.001, 95%CI 1.000–1.001, p = 0.04) were inversely associated with OS on a Cox-regression analysis. Grade ≥ 3 hematological decline was observed after 22/201 (11%) cycles with anemia, leukopenia and thrombocytopenia in 15/45 (33%), 6/45 (13%) and 8/45 (18%) patients, respectively. Cumulative treatment activity and absorbed whole-body dose were not correlated with new onset grade ≥ 3 hematotoxicity (p = 0.91, p = 0.69). No event of grade ≥ 3 chronic kidney disease was observed during RLT or the follow-up. Last line RLT with 177Lu-PSMA-617 in mCRPC patients with diffuse bone marrow involvement may thus contribute to prolonged disease control at an acceptable safety profile.
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Affiliation(s)
- Daniel Groener
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany
| | - Justus Baumgarten
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany
| | - Sebastian Haefele
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany
| | - Christian Happel
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany
| | - Konrad Klimek
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany
| | - Nicolai Mader
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany
| | - Christina Nguyen Ngoc
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany
| | - Nikolaos Tselis
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany
| | - Frank Grünwald
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany
| | - Amir Sabet
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany
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Krug S, Damm M, Garbe J, König S, Schmitz RL, Michl P, Schrader J, Rinke A. Finding the Appropriate Therapeutic Strategy in Patients with Neuroendocrine Tumors of the Pancreas: Guideline Recommendations Meet the Clinical Reality. J Clin Med 2021; 10:3023. [PMID: 34300189 PMCID: PMC8304907 DOI: 10.3390/jcm10143023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/28/2021] [Accepted: 07/03/2021] [Indexed: 01/04/2023] Open
Abstract
The systemic treatment of patients with pancreatic neuroendocrine tumors is based on placebo-controlled trials and long-established chemotherapy approaches. In addition, peptide receptor radionuclide therapy (PRRT) was approved as a parallel approach for pancreatic neuroendocrine tumors (NET), in addition to small bowel NET, after the NETTER-1 trial. The current ESMO and NCCN guidelines attempted to describe treatment algorithms for pancreatic NET based on the current data. In our survey, we recorded therapy decisions for the first- until the third-line of therapy in German-speaking countries (Germany, Austria, and Switzerland) using fictional case reports and discussed these in the context of the current ESMO guidelines. Compared with the recommendations of the guidelines, PRRT was used more frequently and earlier. In patients with NET G1/G2 Ki-67 < 10%, the therapy algorithm consisting of somatostatin analogs (SSA)-PRRT-targeted therapy is a relevant approach. In clinical situations where chemotherapy is primarily used (remission pressure, Ki-67 > 10%), second-line PRRT was found acceptance and was often considered prior to targeted therapies. Despite the lack of prospective controlled trials, our study demonstrated the pivotal impact of PRRT. Therefore, further studies should compare PRRT with chemotherapy in pancreatic NETs in different clinical settings in first- and second-line approaches.
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Affiliation(s)
- Sebastian Krug
- Clinic for Internal Medicine I, Martin-Luther University Halle/Wittenberg, Ernst-Grube-Straße 40, D 06120 Halle, Germany; (M.D.); (J.G.); (S.K.); (R.L.S.); (P.M.)
| | - Marko Damm
- Clinic for Internal Medicine I, Martin-Luther University Halle/Wittenberg, Ernst-Grube-Straße 40, D 06120 Halle, Germany; (M.D.); (J.G.); (S.K.); (R.L.S.); (P.M.)
| | - Jakob Garbe
- Clinic for Internal Medicine I, Martin-Luther University Halle/Wittenberg, Ernst-Grube-Straße 40, D 06120 Halle, Germany; (M.D.); (J.G.); (S.K.); (R.L.S.); (P.M.)
| | - Senta König
- Clinic for Internal Medicine I, Martin-Luther University Halle/Wittenberg, Ernst-Grube-Straße 40, D 06120 Halle, Germany; (M.D.); (J.G.); (S.K.); (R.L.S.); (P.M.)
| | - Rosa Lynn Schmitz
- Clinic for Internal Medicine I, Martin-Luther University Halle/Wittenberg, Ernst-Grube-Straße 40, D 06120 Halle, Germany; (M.D.); (J.G.); (S.K.); (R.L.S.); (P.M.)
| | - Patrick Michl
- Clinic for Internal Medicine I, Martin-Luther University Halle/Wittenberg, Ernst-Grube-Straße 40, D 06120 Halle, Germany; (M.D.); (J.G.); (S.K.); (R.L.S.); (P.M.)
| | - Jörg Schrader
- I. Medical Department, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D 20246 Hamburg, Germany;
| | - Anja Rinke
- Department of Gastroenterology and Endocrinology, University Hospital Marburg, Baldinger Strasse, D 35043 Marburg, Germany;
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Groener D, Nguyen CT, Baumgarten J, Bockisch B, Davis K, Happel C, Mader N, Nguyen Ngoc C, Wichert J, Banek S, Mandel P, Chun FKH, Tselis N, Grünwald F, Sabet A. Hematologic safety of 177Lu-PSMA-617 radioligand therapy in patients with metastatic castration-resistant prostate cancer. EJNMMI Res 2021; 11:61. [PMID: 34216290 PMCID: PMC8254689 DOI: 10.1186/s13550-021-00805-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/20/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Myelosuppression is a potential dose-limiting factor in radioligand therapy (RLT). This study aims to investigate occurrence, severity and reversibility of hematotoxic adverse events in patients undergoing RLT with 177Lu-PSMA-617 for metastatic castration-resistant prostate cancer (mCRPC). The contribution of pretreatment risk factors and cumulative treatment activity is taken into account specifically. METHODS RLT was performed in 140 patients receiving a total of 497 cycles. A mean activity of 6.9 [Formula: see text] 1.3 GBq 177Lu-PSMA-617 per cycle was administered, and mean cumulative activity was 24.6 [Formula: see text] 15.9 GBq. Hematological parameters were measured at baseline, prior to each treatment course, 2 to 4 weeks thereafter and throughout follow-up. Toxicity was graded based on Common Terminology Criteria for Adverse Events v5.0. RESULTS Significant (grade ≥ 3) hematologic adverse events occurred in 13 (9.3%) patients, with anemia in 10 (7.1%), leukopenia in 5 (3.6%) and thrombocytopenia in 6 (4.3%). Hematotoxicity was reversible to grade ≤ 2 through a median follow-up of 8 (IQR 9) months in all but two patients who died from disease progression within less than 3 months after RLT. Myelosuppression was significantly more frequent in patients with pre-existing grade 2 cytopenia (OR: 3.50, 95%CI 1.08-11.32, p = 0.04) or high bone tumor burden (disseminated or diffuse based on PROMISE miTNM, OR: 5.08, 95%CI 1.08-23.86, p = 0.04). Previous taxane-based chemotherapy was associated with an increased incidence of significant hematotoxicity (OR: 4.62, 95%CI 1.23-17.28, p = 0.02), while treatment with 223Ra-dichloride, cumulative RLT treatment activity and activity per cycle were not significantly correlated (p = 0.93, 0.33, 0.29). CONCLUSION Hematologic adverse events after RLT have an acceptable overall incidence and are frequently reversible. High bone tumor burden, previous taxane-based chemotherapy and pretreatment grade 2 cytopenia may be considered as risk factors for developing clinically relevant myelosuppression, whereas cumulative RLT activity and previous 223Ra-dichloride treatment show no significant contribution to incidence rates.
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Affiliation(s)
- Daniel Groener
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Cam Tu Nguyen
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Justus Baumgarten
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Benjamin Bockisch
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Karen Davis
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Christian Happel
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Nicolai Mader
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Christina Nguyen Ngoc
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Jennifer Wichert
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Severine Banek
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Philipp Mandel
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Nikolaos Tselis
- Department of Radiation Oncology, University Hospital Frankfurt, Frankfurt, Germany
| | - Frank Grünwald
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Amir Sabet
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor Stern Kai 7, 60590, Frankfurt, Germany.
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Das S, Berlin J, Savona M. Pancytopenia in a Patient With Metastatic Well-Differentiated Neuroendocrine Tumor After Peptide Receptor Radionuclide Therapy. JAMA Oncol 2021; 7:1060-1061. [PMID: 33914019 DOI: 10.1001/jamaoncol.2021.0183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Satya Das
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jordan Berlin
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Savona
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Lu X, Lu C, Yang Y, Shi X, Wang H, Yang N, Yang K, Zhang X. Current Status and Trends in Peptide Receptor Radionuclide Therapy in the Past 20 Years (2000-2019): A Bibliometric Study. Front Pharmacol 2021; 12:624534. [PMID: 33986664 PMCID: PMC8111084 DOI: 10.3389/fphar.2021.624534] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 02/15/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Peptide receptor radionuclide therapy (PRRT) is an emerging therapeutic option for the treatment of neuroendocrine tumors (NETs), and the number of publications in this field has been increasing in recent years. The aim of the present study was to present the research status and summarize the key topics through bibliometric analysis of published PRRT literature. Methods: A literature search for PRRT research from 2000 to 2019 was conducted using the Science Citation Index Expanded of Web of Science Core Collection (limited to SCIE) on August 4, 2020. The VOSviewer, R-bibliometrix, and CiteSpace software were used to conduct the bibliometric analysis. Results: From 2000 to 2019, a total of 681 publications (523 articles and 158 reviews) were retrieved. Annual publication outputs grew from three to 111 records. Germany had the largest number of publications, making the largest contribution to the field (n = 151, 22.17%). Active cooperation between countries/regions was observed. Kwekkeboom from the Erasmus Medical Center is perhaps a key researcher in the field of PRRT. The European Journal of Nuclear Medicine and Molecular Imaging and Journal of Nuclear Medicine ranked first for productive (n = 84, 12.33%) and co-cited (n = 3,438) journals, respectively. Important topics mainly included matters related to the efficacy of PRRT (e.g., 90Y-dotatoc and 177Lu-dotatate), the long-term adverse effects of PRRT (e.g., hematologic and renal toxicities), standardization of NETs and PRRT in practice, the development of medical imaging techniques, and the individual dose optimization of PRRT. Conclusion: Using bibliometric analysis, we gained deep insight into the global status and trends of studies investigating PRRT for the first time. The PRRT field is undergoing a period of rapid development, and our study provides a valuable reference for clinical researchers and practitioners.
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Affiliation(s)
- Xiaojing Lu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Cuncun Lu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yongjie Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiangfen Shi
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haibo Wang
- School of Integrated Traditional Chinese and Western Medicine, Gansu University of Chinese Medicine, Lanzhou, China
| | - Nan Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Xiaojian Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Mirian C, Duun-Henriksen AK, Maier A, Pedersen MM, Jensen LR, Bashir A, Graillon T, Hrachova M, Bota D, van Essen M, Spanjol P, Kreis C, Law I, Broholm H, Poulsgaard L, Fugleholm K, Ziebell M, Munch T, Walter MA, Mathiesen T. Somatostatin Receptor-Targeted Radiopeptide Therapy in Treatment-Refractory Meningioma: Individual Patient Data Meta-analysis. J Nucl Med 2021; 62:507-513. [PMID: 32859705 DOI: 10.2967/jnumed.120.249607] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/29/2020] [Indexed: 11/16/2022] Open
Abstract
Somatostatin receptor (SSTR)-targeted peptide receptor radionuclide therapy (PRRT) represents a promising approach for treatment-refractory meningiomas. Methods: We performed an individual patient data meta-analysis, including all published data on meningioma patients treated with SSTR-targeted PRRT. The main outcomes were toxicity, response to treatment, progression-free survival (PFS), and overall survival (OS). We applied the Kaplan-Meier method to estimate survival probabilities and report incidence rates per 100 person-years. We applied Cox proportional hazards models to determine the effect of covariates. Results: We screened 537 papers and identified 6 eligible cohort studies. We included a total of 111 patients who had treatment-refractory meningioma and received SSTR-targeted PRRT. Disease control was achieved in 63% of patients. The 6-mo PFS rates were 94%, 48%, and 0% for World Health Organization grades I, II, and III, respectively. The risk of disease progression decreased by 13% per 1,000-MBq increase in the total applied activity. The 1-y OS rates were 88%, 71%, and 52% for World Health Organization grades I, II, and III, respectively. The risk of death decreased by 17% per 1,000-MBq increase in the total applied activity. The main side effects comprised transient hematotoxicity, such as anemia in 22% of patients, leukopenia in 13%, lymphocytopenia in 24%, and thrombocytopenia in 17%. Conclusion: To our knowledge, this individual patient data meta-analysis represents the most comprehensive analysis of the benefits of and adverse events associated with SSTR-targeted PRRT for treatment-refractory meningioma. The treatment was well tolerated, achieved disease control in most cases, and showed promising results regarding PFS and OS.
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Affiliation(s)
- Christian Mirian
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Nuclear Medicine, University Hospital of Geneva, Geneva, Switzerland
| | | | - Andrea Maier
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Maria Møller Pedersen
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lasse Rehné Jensen
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Asma Bashir
- Department of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Graillon
- APHM, Department of Neurosurgery, La Timone Hospital, Marseille, France
| | - Maya Hrachova
- Department of Neurology, UC Irvine Medical Center, Irvine, California
| | - Daniela Bota
- Department of Neurology, UC Irvine Medical Center, Irvine, California
- Department of Neurosurgery, UC Irvine Medical Center, Irvine, California
| | - Martjin van Essen
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Petar Spanjol
- Department of Nuclear Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Christian Kreis
- Department of Nuclear Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Ian Law
- Department of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Copenhagen, Denmark
| | - Helle Broholm
- Department of Neuropathology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Poulsgaard
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kåre Fugleholm
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten Ziebell
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tina Munch
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark; and
| | - Martin A Walter
- Department of Nuclear Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Tiit Mathiesen
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Massironi S, Campana D, Pusceddu S, Albertelli M, Faggiano A, Panzuto F, Smiroldo V, Andreasi V, Rossi RE, Maggio I, Torchio M, Dotto A, Modica R, Rinzivillo M, Carnaghi C, Partelli S, Fanetti I, Lamberti G, Corti F, Ferone D, Colao A, Annibale B, Invernizzi P, Falconi M. Second primary neoplasms in patients with lung and gastroenteropancreatic neuroendocrine neoplasms: Data from a retrospective multi-centric study. Dig Liver Dis 2021; 53:367-374. [PMID: 33645508 DOI: 10.1016/j.dld.2020.09.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/27/2020] [Accepted: 09/29/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with sporadic neuroendocrine neoplasms may exhibit a higher risk of a second primary tumor than the general population. AIM This study aimed to analyze the occurrence of second primary malignancies. METHODS A retrospective cohort of 2757 patients with sporadic lung and gastro-entero-pancreatic neuroendocrine neoplasms, managed at eight Italian tertiary referral Centers, was included. RESULTS Between 2000 and 2019, a second primary malignancy was observed in 271 (9.8%) neuroendocrine neoplasms patients with 32 developing a third tumor. There were 135 (49.8%) females and the median age was 64 years. The most frequent locations of the second tumors were breast (18.8%), prostate (12.5%), colon (9.6%), blood tumors (8.5%), and lung (7.7%). The second primary tumor was synchronous in 19.2% of cases, metachronous in 43.2%, and previous in 37.6%. As concerned the neuroendocrine neoplasms, the 5- and 10-year survival rates were 87.8% and 74.4%, respectively. PFS for patients with a second primary malignancy was shorter than for patients without a second primary malignancy. Death was mainly related to neuroendocrine neoplasms. CONCLUSION In NEN patients the prevalence of second primary malignancies was not negligible, suggesting a possible neoplastic susceptibility. Overall survival was not affected by the occurrence of a second primary malignancy.
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Affiliation(s)
- S Massironi
- Division Gastroenterology, San Gerardo Hospital, University of Milano - Bicocca School of Medicine, Via Pergolesi 33, 20900 Monza (MB), Italy.
| | - D Campana
- NET Team Bologna, ENETS Center of Excellence, "S. Orsola-Malpighi" University Hospital, "Alma Mater Studiorum" University of Bologna, Bologna, Italy
| | - S Pusceddu
- Department of Medical Oncology, ENETS Center of Excellence, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - M Albertelli
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, and Department of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, University of Genova, Genoa, Italy
| | - A Faggiano
- Department of Experimental Medicine, "Sapienza University of Rome" Rome, Italy
| | - F Panzuto
- Digestive Disease Unit, Sant'Andrea University Hospital, ENETS Center of Excellence, Rome, Italy
| | - V Smiroldo
- UO Oncologia Medica ed Ematologia, Humanitas Cancer Center, ENETS Center of Excellence, Humanitas Research Hospital IRCCS, Rozzano, Italy
| | - V Andreasi
- Pancreatic Surgery Unit, ENETS Center of Excellence, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - R E Rossi
- Gastrointestinal and Hepato-Pancreatic Surgery and Liver Transplantation Unit, ENETS Center of Excellence, Fondazione IRCCS Istituto Nazionale Tumori (INT, National Cancer Institute) and Department of Pathophysiology and Organ Transplant, Università degli Studi di Milano, Milan, Italy
| | - I Maggio
- NET Team Bologna, ENETS Center of Excellence, "S. Orsola-Malpighi" University Hospital, "Alma Mater Studiorum" University of Bologna, Bologna, Italy
| | - M Torchio
- Department of Medical Oncology, ENETS Center of Excellence, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - A Dotto
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, and Department of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, University of Genova, Genoa, Italy
| | - R Modica
- Department of Clinical Medicine and Surgery, ENETS Center of Excellence, Federico II University of Naples, Naples, Italy
| | - M Rinzivillo
- Digestive Disease Unit, Sant'Andrea University Hospital, ENETS Center of Excellence, Rome, Italy
| | - C Carnaghi
- UO Oncologia Medica, Comprensorio Sanitario Bolzano, Bozen, Italy
| | - S Partelli
- Pancreatic Surgery Unit, ENETS Center of Excellence, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - I Fanetti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - G Lamberti
- NET Team Bologna, ENETS Center of Excellence, "S. Orsola-Malpighi" University Hospital, "Alma Mater Studiorum" University of Bologna, Bologna, Italy
| | - F Corti
- Department of Medical Oncology, ENETS Center of Excellence, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - D Ferone
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, and Department of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, University of Genova, Genoa, Italy
| | - A Colao
- Department of Clinical Medicine and Surgery, ENETS Center of Excellence, Federico II University of Naples, Naples, Italy
| | - B Annibale
- Digestive Disease Unit, Sant'Andrea University Hospital, ENETS Center of Excellence, Rome, Italy; Department of Medical-Surgical Sciences and Translational Medicine, "La Sapienza" University of Rome, Rome, Italy
| | - P Invernizzi
- Division Gastroenterology, San Gerardo Hospital, University of Milano - Bicocca School of Medicine, Via Pergolesi 33, 20900 Monza (MB), Italy
| | - M Falconi
- Pancreatic Surgery Unit, ENETS Center of Excellence, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
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Sonbol MB, Halfdanarson TR, Hilal T. Assessment of Therapy-Related Myeloid Neoplasms in Patients With Neuroendocrine Tumors After Peptide Receptor Radionuclide Therapy: A Systematic Review. JAMA Oncol 2021; 6:1086-1092. [PMID: 32297906 DOI: 10.1001/jamaoncol.2020.0078] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance Peptide receptor radionuclide therapy (PRRT) is a tumor-targeted treatment that uses radiation to induce tumor cell death in neuroendocrine tumors (NET) via β particle-emitting radionuclide linked to a somatostatin peptide analog. Therapy-related myeloid neoplasm (t-MN) has been reported as a potential long-term and frequently lethal adverse event after PRRT. However, the incidence, time of diagnosis, and nature of t-MN is unclear. Therefore, a systematic review is helpful to study the incidence and characteristics of t-MN after PRRT in patients with NET. Objective To systematically evaluate the literature and report the incidence, time of diagnosis, and nature of t-MN after PRRT. Evidence Review MEDLINE, Embase, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials for articles and abstracts reporting studies of different designs studying more than 1 patient (randomized clinical trials, prospective phase I or phase II, retrospective studies, and case series) were searched from database inception through April 2019. Studies of interest included patients with NET who were treated with PRRT and reported the incidence of t-MN, if any. The primary outcome was the incidence of t-MN. Findings Twenty-eight articles were identified comprising 7334 patients who were treated with PRRT for NET. The main reason of exclusion was not reporting the t-MN incidence. The incidence of t-MN was variable between studies with mean (SD) incidence of 2.61% (4.38%). Of all 134 cases, cytogenetic abnormalities were reported in 32 patients with the most common abnormality being complex cytogenetics, consistent with myeloid neoplasms following exposure to alkylating agents or irradiation. Conclusions and Relevance The risk of t-MN after PRRT is small but not insignificant given the poor prognosis after t-MN diagnosis. Close monitoring is warranted to identify such patients early in the disease course when hematologic abnormalities persist.
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Affiliation(s)
| | | | - Talal Hilal
- University of Mississippi Medical Center, Jackson
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Abstract
Neuroendocrine tumors (NETs) are a heterogeneous group of tumors that originate in endocrine tissues throughout the body. Peptide receptor radionuclide therapy (PRRT) has emerged as a promising therapeutic option for patients with locally advanced and/or metastatic disease refractory to standard of care treatment. The landmark international phase III NETTER-1 trial led to the approval of 177Lu-DOTATATE (Lutathera) in the treatment of somatostatin receptor-positive gastroenteropancreatic NETs. Similarly, data from the multicenter, phase II Study IB12B led to the approval of meta-[131I]Iodo-Benzyl-Guanidine (I31I-MIBG) for treatment of iobenguane scan-positive, unresectable, locally advanced or metastatic pheochromocytoma or paraganglioma. With the clinical approval of these novel radiopharmaceuticals for managing select patients with NETs, additional studies are needed to refine patient selection, predict and assess therapy response, and optimize radiopharmaceutical delivery and clinical outcomes.
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Affiliation(s)
- Re-I Chin
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Francis S Wu
- Department of Radiology, St. Louis University, St. Louis, MO
| | - Yusuf Menda
- Department of Radiology, University of Iowa, Iowa City, IA
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO.
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Koffas A, Toumpanakis C. Comparative safety review of the current therapies for gastroenteropancreatic neuroendocrine tumors. Expert Opin Drug Saf 2020; 20:321-334. [PMID: 33338383 DOI: 10.1080/14740338.2021.1867097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Neuroendocrine neoplasms (NENs) comprise a heterogeneous group of neoplasms, whose management requires complex and individualized clinical decisions. Over the last decades the advent of novel medications and advanced diagnostic and therapeutic modalities, alongside our deeper understanding of the disease, revolutionized the landscape of their management, significantly improving both prognosis and quality of life of patients.Area covered: Treatment-related adverse events and safety concerns as demonstrated in clinical trials, as well as in real-world clinical practice.Expert opinion: The only true curative option for NENs remains surgery, whereas high-grade advanced neuroendocrine carcinomas should be primarily managed with platinum-based chemotherapy. For the remaining cases, that comprise the vast majority, the current armamentarium includes somatostatin analogs, interferon, telotristat ethyl, molecular targeted therapies, chemotherapy, peptide receptor radionuclide therapy, and locoregional treatment. The use of the aforementioned therapeutic options is associated with several and not uncommonly severe treatment-related adverse events. However, the benefits offered inclusive of improved prognosis, amelioration of symptoms, and better quality of life amidst others, by far outweighs any adverse event.
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Affiliation(s)
- Apostolos Koffas
- Department of Gastroenterology, General University Hospital of Larisa, Mezourlo Larisa, Greece
| | - Christos Toumpanakis
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, UK
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45
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Salvage peptide receptor radionuclide therapy in patients with progressive neuroendocrine tumors: a systematic review and meta-analysis. Nucl Med Commun 2020; 42:451-458. [PMID: 33346603 DOI: 10.1097/mnm.0000000000001350] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Peptide receptor radionuclide therapy (PRRT) is an effective treatment option in patients with metastatic neuroendocrine tumors (NETs). Recently, salvage PRRT has been introduced for progressing NET patients. This systematic review and meta-analysis evaluated the therapeutic efficacy, survival, and toxicity of salvage PRRT in patients with progressive NETs. METHODS A systematic (PubMed, Embase, Cochrane, and Scopus) were performed. To determine therapeutic efficacy, objective response rate (ORR), and disease control rate (DCR) were identified using radiologic response criteria. To determine survival, progression-free survival (PFS), and overall survival (OS) were verified. To determine toxicity, information was collected on serious (grades 3 or 4) hematologic and renal adverse events. RESULTS Nine articles featuring 426 patients were included in this study. Salvage PRRT achieved pooled proportions of ORR in 17.1% [95% confidence interval (CI) 11.6-23.5] and DCR in 76.9% (95% CI 72.3-81.0) of patients. Salvage PRRT demonstrated pooled estimates of PFS of 14.1 months (95% CI 12.2-15.9) and OS of 26.8 months (95% CI 18.8-34.9). Pooled proportions of hematologic and renal toxicities were 10.8% (95% CI 5.9-16.8) and 0.7% (95% CI 0.2-1.8), respectively. A subgroup direct comparison study with initial PRRT revealed that salvage PRRT showed significantly lower therapeutic efficacy (ORR and DCR, all P < 0.001) and shorter PFS (P = 0.03) despite similar hematologic toxicity (P = 0.25) and renal toxicity (P = 0.45). CONCLUSION Salvage PRRT is effective in patients with progressive NETs, and toxicity appeared to be similar to initial PRRT which could be a feasible treatment option.
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Burkett BJ, Dundar A, Young JR, Packard AT, Johnson GB, Halfdanarson TR, Eiring RA, Gansen DN, Patton CM, Kendi AT. How We Do It: A Multidisciplinary Approach to 177Lu DOTATATE Peptide Receptor Radionuclide Therapy. Radiology 2020; 298:261-274. [PMID: 33231532 DOI: 10.1148/radiol.2020201745] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Lutetium 177 (177Lu) DOTA-0-Tyr3-Octreotate (DOTATATE) peptide receptor radionuclide therapy (PRRT) is an effective treatment for advanced gastroenteropancreatic neuroendocrine tumors. This review presents a clinical practice workflow that has been successful since 177Lu DOTATATE PRRT was approved by the U.S. Food and Drug Administration. The workflow relies heavily on the input of a multidisciplinary team and involves a nuclear medicine consultation service, tumor board, and specific preparations in advance of therapy and day-of-therapy procedures. A systematic checklist designed to ensure appropriate selection of treatment candidates and identification of any concerns to address to safely administer PRRT is provided. All patients were evaluated with gallium 68 DOTATATE PET/CT, and in cases of high-grade tumors, they were also evaluated with fluorine 18 fluorodeoxyglucose PET/CT, with imaging findings reviewed as part of the systematic checklist before PRRT. Adverse effects are discussed and imaging follow-up regimens are reviewed, including alternative diagnostic contrast materials. Approaches to multiple challenging patient scenarios are illustrated through case examples. Finally, alternative theranostic radionuclides and treatment strategies are discussed.
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Affiliation(s)
- Brian J Burkett
- From the Division of Nuclear Medicine, Department of Radiology (B.J.B., A.D., J.R.Y., A.T.P., G.B.J., D.N.G., C.M.P., A.T.K.), and Department of Medical Oncology (T.R.H., R.A.E.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Ayca Dundar
- From the Division of Nuclear Medicine, Department of Radiology (B.J.B., A.D., J.R.Y., A.T.P., G.B.J., D.N.G., C.M.P., A.T.K.), and Department of Medical Oncology (T.R.H., R.A.E.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Jason R Young
- From the Division of Nuclear Medicine, Department of Radiology (B.J.B., A.D., J.R.Y., A.T.P., G.B.J., D.N.G., C.M.P., A.T.K.), and Department of Medical Oncology (T.R.H., R.A.E.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Annie T Packard
- From the Division of Nuclear Medicine, Department of Radiology (B.J.B., A.D., J.R.Y., A.T.P., G.B.J., D.N.G., C.M.P., A.T.K.), and Department of Medical Oncology (T.R.H., R.A.E.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Geoffrey B Johnson
- From the Division of Nuclear Medicine, Department of Radiology (B.J.B., A.D., J.R.Y., A.T.P., G.B.J., D.N.G., C.M.P., A.T.K.), and Department of Medical Oncology (T.R.H., R.A.E.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Thorvardur R Halfdanarson
- From the Division of Nuclear Medicine, Department of Radiology (B.J.B., A.D., J.R.Y., A.T.P., G.B.J., D.N.G., C.M.P., A.T.K.), and Department of Medical Oncology (T.R.H., R.A.E.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Rachel A Eiring
- From the Division of Nuclear Medicine, Department of Radiology (B.J.B., A.D., J.R.Y., A.T.P., G.B.J., D.N.G., C.M.P., A.T.K.), and Department of Medical Oncology (T.R.H., R.A.E.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Denise N Gansen
- From the Division of Nuclear Medicine, Department of Radiology (B.J.B., A.D., J.R.Y., A.T.P., G.B.J., D.N.G., C.M.P., A.T.K.), and Department of Medical Oncology (T.R.H., R.A.E.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Cynthia M Patton
- From the Division of Nuclear Medicine, Department of Radiology (B.J.B., A.D., J.R.Y., A.T.P., G.B.J., D.N.G., C.M.P., A.T.K.), and Department of Medical Oncology (T.R.H., R.A.E.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - A Tuba Kendi
- From the Division of Nuclear Medicine, Department of Radiology (B.J.B., A.D., J.R.Y., A.T.P., G.B.J., D.N.G., C.M.P., A.T.K.), and Department of Medical Oncology (T.R.H., R.A.E.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
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Liu Q, Zang J, Sui H, Ren J, Guo H, Wang H, Wang R, Jacobson O, Zhang J, Cheng Y, Zhu Z, Chen X. Peptide Receptor Radionuclide Therapy of Late-Stage Neuroendocrine Tumor Patients with Multiple Cycles of 177Lu-DOTA-EB-TATE. J Nucl Med 2020; 62:386-392. [PMID: 32826319 DOI: 10.2967/jnumed.120.248658] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/03/2020] [Indexed: 01/23/2023] Open
Abstract
This study aimed to evaluate the safety and efficacy of multiple cycles of 177Lu-DOTA-Evans blue (EB)-TATE peptide receptor radionuclide therapy (PRRT) at escalating doses in neuroendocrine tumors (NETs). Methods: Thirty-two NET patients were randomly divided into 3 groups and treated with escalating doses. Group A received 1.17 ± 0.09 GBq/cycle; group B, 1.89 ± 0.53 GBq/cycle; and group C, 3.97 ± 0.84 GBq/cycle. The treatment was planned for up to 3 cycles. Treatment-related adverse events were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), version 5.0. Treatment response was evaluated according to the European Organisation for Research and Treatment of Cancer criteria and modified PERCIST. Results: Administration of PRRT was well tolerated, without life-threatening adverse events (CTCAE grade 4). CTCAE grade 3 hematotoxicity was recorded in 1 patient (16.6%) in group B (thrombocytopenia) and 3 patients (21.4%) in group C (thrombocytopenia in 3, anemia in 1). CTCAE grade 3 hepatotoxicity (elevated aspartate aminotransferase) was recorded in 1 patient in group A (8.3%) and 1 patient in group C (7.1%). No nephrotoxicity was observed. According to the criteria of the European Organisation for Research and Treatment of Cancer, the overall disease response rates were similar in groups A, B, and C (50.0%, 50.0%, and 42.9%, respectively), and the overall disease control rates were higher in groups B (83.3%) and C (71.5%) than in group A (66.7%). According to modified PERCIST, a lower disease response rate but a similar disease control rate were found. When a comparable baseline SUVmax ranging from 15 to 40 was selected, the percentage change in SUVmax increased slightly in group A (2.1% ± 40.8%) but decreased significantly in groups B and C (-38.7% ± 10.0% and -14.7% ± 20.0%, respectively) after the first PRRT (P = 0.001) and decreased in all 3 groups after the third PRRT (groups A, B, and C: -6.9% ± 42.3%, -49.2% ± 30.9%, -11.9% ± 37.9%, respectively; P = 0.044). Conclusion: Dose escalations of up to 3.97 GBq/cycle seem to be well tolerated for 177Lu-DOTA-EB-TATE. 177Lu-DOTA-EB-TATE doses of 1.89 and 3.97 GBq/cycle were effective in tumor control and more effective than 1.17 GBq/cycle.
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Affiliation(s)
- Qingxing Liu
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Jie Zang
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Huimin Sui
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Jiakun Ren
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Hua Guo
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Hao Wang
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Rongxi Wang
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Orit Jacobson
- Departments of Diagnostic Radiology, Chemical and Biomolecular Engineering, Biomedical Engineering, Yong Loo Lin School of Medicine and Faculty of Engineering, National University of Singapore, Singapore, Singapore
| | - Jingjing Zhang
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, Zentralklinik Bad Berka, Bad Berka, Germany; and
| | - Yuejuan Cheng
- Division of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhaohui Zhu
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Xiaoyuan Chen
- Departments of Diagnostic Radiology, Chemical and Biomolecular Engineering, Biomedical Engineering, Yong Loo Lin School of Medicine and Faculty of Engineering, National University of Singapore, Singapore, Singapore
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Hope TA, Bodei L, Chan JA, El-Haddad G, Fidelman N, Kunz PL, Mailman J, Menda Y, Metz DC, Mittra ES, Pryma DA, Reidy-Lagunes DL, Singh S, Strosberg JR. NANETS/SNMMI Consensus Statement on Patient Selection and Appropriate Use of 177Lu-DOTATATE Peptide Receptor Radionuclide Therapy. J Nucl Med 2020; 61:222-227. [PMID: 32015164 DOI: 10.2967/jnumed.119.240911] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 12/12/2019] [Indexed: 12/27/2022] Open
Affiliation(s)
- Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California .,Department of Radiology, San Francisco VA Medical Center, San Francisco, California
| | - Lisa Bodei
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jennifer A Chan
- Department of Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Nicholas Fidelman
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Pamela L Kunz
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Yusuf Menda
- Department of Radiology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - David C Metz
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erik S Mittra
- Department of Diagnostic Radiology, Division of Nuclear Medicine & Molecular Imaging, Oregon Health & Science University, Portland, Oregon
| | - Daniel A Pryma
- Division of Nuclear Medicine & Clinical Molecular Imaging, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Simron Singh
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario; and
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Kim C, Liu SV, Subramaniam DS, Torres T, Loda M, Esposito G, Giaccone G. Phase I study of the 177Lu-DOTA 0-Tyr 3-Octreotate (lutathera) in combination with nivolumab in patients with neuroendocrine tumors of the lung. J Immunother Cancer 2020; 8:jitc-2020-000980. [PMID: 32616557 PMCID: PMC7333915 DOI: 10.1136/jitc-2020-000980] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2020] [Indexed: 12/21/2022] Open
Abstract
Background Lutathera is a 177Lutetium-labeled somatostatin analog approved for the treatment of gastroenteropancreatic neuroendocrine tumors (NETs). Somatostatin receptors are expressed in small cell lung cancer (SCLC). Nivolumab, an anti-PD-1 antibody, may act synergistically with lutathera to generate antitumor immunity. We conducted a phase I study of lutathera plus nivolumab in patients with advanced NETs of the lung. Methods Patients with relapsed/refractory extensive-stage SCLC (ES-SCLC), non-progressing ES-SCLC after first-line platinum-based chemotherapy, or advanced grade I-II pulmonary NETs were eligible. The primary objective was to determine the recommended phase 2 dose (RP2D). The phase I portion followed a standard 3+3 design, assessing two dose levels (dose level 1: lutathera 3.7 GBq every 8 weeks for four doses with nivolumab 240 mg every 2 weeks; dose level 2: lutathera 7.4 GBq every 8 weeks for four doses with nivolumab 240 mg every 2 weeks). Results Nine patients were enrolled (six ES-SCLC, two pulmonary atypical carcinoid, one high-grade pulmonary neuroendocrine carcinoma). No dose-limiting toxicities (DLTs) were observed at dose level 1. At dose level 2, one patient with refractory ES-SCLC developed a DLT (grade 3 rash). The most common treatment-related adverse events (TRAEs) were lymphopenia (n=7), thrombocytopenia (n=4), anemia (n=3), and nausea (n=3). The most common grade 3 TRAE was lymphopenia (n=4). Among the seven patients with measurable disease, one patient with ES-SCLC had a partial response. Two patients with pulmonary atypical carcinoid had stable disease lasting 6 months. The RP2D was dose level 2. Conclusions Lutathera plus nivolumab was well tolerated and showed signs of antitumor activity. This combination warrants further exploration. Trial registration number NCT03325816
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Affiliation(s)
- Chul Kim
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, USA
| | - Stephen V Liu
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, USA
| | - Deepa S Subramaniam
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, USA
| | - Tisdrey Torres
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, USA
| | - Massimo Loda
- Department of Pathology, Weill Medical College of Cornell University, New York, NY, United States
| | - Giuseppe Esposito
- Department of Radiology, Georgetown University, Washington, District of Columbia, USA
| | - Giuseppe Giaccone
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, USA .,Division of Hematology and Oncology, Weill Cornell Medical College, New York, New York, USA
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50
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Medaer E, Verslype C, Van Cutsem E, Dekervel J, Clement PM, Nackaerts K, Laenen A, Gheysens O, Goffin K, Jentjens S, Van Laere K, Deroose CM. Influence of pretreatment with everolimus or sunitinib on the subacute hematotoxicity of 177Lu-DOTATATE PRRT. Acta Oncol 2020; 59:644-651. [PMID: 32036716 DOI: 10.1080/0284186x.2020.1723161] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background: Peptide receptor radionuclide therapy (PRRT) is a validated treatment for somatostatin receptor overexpressing neuroendocrine tumors (NETs). The NETTER-1 trial demonstrated a pronounced positive effect on progression-free-survival compared to high dose somatostatin analogs (SSAs), with a strong tendency toward overall survival benefit. Our aim was to investigate the influence of pretreatment with everolimus and/or sunitinib on subacute hematotoxicity of PRRT. To assess the influence of prior treatment with everolimus/sunitinib might be of clinical relevance due to the link between short-term hematotoxicity and increased incidence of late hematotoxicity.Material and methods: Our single-center retrospective study enrolled all patients treated with 177Lu-DOTATATE PRRT (1-4 cycles of 7.4 GBq), between November 2013 and July 2018. Patients were assigned to two groups according to their pretreatment: no targeted agents (N = 41), or targeted agents (everolimus, sunitinib or both; N = 41). The end point was subacute hematotoxicity, defined as the nadir value between the first administration until 3 months after the last administration, using the CTCAE 4.03 classification. The impact of splenectomy was also explored.Results: Eighty percent of patients had a primary gastroenteropancreatic NET. No statistically significant differences in severe subacute hematotoxicity were seen in the pretreated group vs. the naive group for hemoglobin (grade 3/4: 12% vs. 22%), neither for leucocytes (grade 3/4: 10% vs. 7%), neutrophils (grade 3/4: 5% vs. 7%), lymphocytes (grade 3/4: 49% vs. 37%) and platelets (grade 3/4: 15% vs. 15%). Furthermore, we observed significantly lower toxicity for total white blood cells, lymphocytes and platelets in the subgroup that had splenectomy (N = 12). Limitations of this study include the potential bias in lack of use of targeted agents in patients more susceptible to toxicity, and the limited number of patients and events.Conclusions: In a patient cohort with NET pretreated with everolimus and/or sunitinib, we could not demonstrate a significant effect of prior/pretreatment with everolimus and/or sunitinib on the subacute hematotoxicity of 177Lu-DOTATATE PRRT.
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Affiliation(s)
- Eva Medaer
- Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium
- Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Chris Verslype
- Digestive Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Eric Van Cutsem
- Digestive Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Jeroen Dekervel
- Digestive Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Paul M. Clement
- General Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | | | - Annouschka Laenen
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Leuven, Belgium
| | - Olivier Gheysens
- Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium
- Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Karolien Goffin
- Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium
- Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Sander Jentjens
- Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium
- Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Koen Van Laere
- Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium
- Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Christophe M. Deroose
- Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium
- Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
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