Prostate-Specific Membrane Antigen-Targeted Radiohalogenated PET and Therapeutic Agents for Prostate Cancer

Targeted Therapy for Prostate Cancer by Prostate-Specific Membrane Antigen-Targeted Small-Molecule Drug Conjugates

In the aging global population, prostate cancer is a worldwide health problem because the incidence rate of this disease increases at advanced ages. Although early-stage prostate cancer can be treated by total prostatectomy, the surgery causes side effects, such as incontinence and dysuria, that lower QOL. Once the disease progresses to metastatic castration-resistant prostate cancer (mCRPC), there are no effective chemotherapeutic agents without systematic side effects. Therefore, targeted therapies for mCPRC are urgently needed. Traditional antibody-drug conjugate treatments for prostate cancer have been tested in clinical trials and several side effects have been observed. Meanwhile, small-molecule drug conjugates (SMDCs) have certain advantages over antibody drug conjugates in terms of non-immunogenicity, reproducibility, and permeability. In this review, prostate-specific membrane antigen-targeted SMDCs for treating prostate cancer are summarized.

ACR Appropriateness Criteria® Post-Treatment Follow-up of Prostate Cancer: 2022 Update

Prostate cancer has a wide spectrum ranging between low-grade localized disease and castrate-resistant metastatic disease. Although whole gland and systematic therapies result in cure in the majority of patients, recurrent and metastatic prostate cancer can still occur. Imaging approaches including anatomic, functional, and molecular modalities are continuously expanding. Currently, recurrent and metastatic prostate cancer is grouped in three major categories: 1) Clinical concern for residual or recurrent disease after radical prostatectomy, 2) Clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments, and 3) Metastatic prostate cancer treated by systemic therapy (androgen deprivation therapy, chemotherapy, immunotherapy). This document is a review of the current literature regarding imaging in these settings and the resulting recommendations for imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Modular Smart Molecules for PSMA-Targeted Chemotherapy

New targeted chemotherapeutics are urgently needed to minimize off-target toxicity and reduce the high-mortality rate associated with metastatic prostate cancer. Herein, we report on the modular synthesis, pharmacokinetics, and efficacy of two small-molecule-drug conjugates (SMDC) targeted to prostate-specific membrane antigen (PSMA) incorporating either: (i) a cathepsin-B-cleavable valine-citrulline (Val-Cit), or (ii) an acid-cleavable phosphoramidate linker. Crucial components used in the design of the conjugates include: (i) CTT1298, a nanomolar affinity ligand that binds irreversibly to PSMA and has proven in past studies to rapidly internalize and shuttle payloads into PSMA-expressing prostate cancer cells, (ii) MMAE, a known potent cytotoxic payload, and (iii) an albumin-binder, proven to improve residence time of drug conjugates. At dose of 0.8 mg/kg (∼250 nmol/kg), the two SMDCs showed significant efficacy in a PSMA(+) PC3-PIP mouse model of human prostate cancer compared with controls, without inducing systemic toxicity. Though localization of the SMDCs was observed in tissues apart from the tumor, release of MMAE was observed predominantly in tumor tissue, at levels that were 2-3 orders of magnitude higher than non-target tissues. Furthermore, SMDC2, which incorporated a novel pH-responsive phosporamidate linker, demonstrated significantly improved efficacy over SMDC1 that has a Val-Cit linker, with a 100% survival over 90 days and 4 out of 8 mice showing complete tumor growth inhibition after 6 weekly doses of 0.8 mg/kg (244 nmol/kg). Our findings demonstrate the potential of irreversible PSMA inhibitors combined with pH-responsive linkers as a way to specifically deliver chemotherapeutic drugs to prostate cancer tumors with minimal toxicity.

Positron emission tomography imaging of lung cancer: An overview of alternative positron emission tomography tracers beyond F18 fluorodeoxyglucose

Lung cancer has been the leading cause of cancer-related mortality in China in recent decades. Positron emission tomography-computer tomography (PET/CT) has been established in the diagnosis of lung cancer. ¹⁸F-FDG is the most widely used PET tracer in foci diagnosis, tumor staging, treatment planning, and prognosis assessment by monitoring abnormally exuberant glucose metabolism in tumors. However, with the increasing knowledge on tumor heterogeneity and biological characteristics in lung cancer, a variety of novel radiotracers beyond ¹⁸F-FDG for PET imaging have been developed. For example, PET tracers that target cellular proliferation, amino acid metabolism and transportation, tumor hypoxia, angiogenesis, pulmonary NETs and other targets, such as tyrosine kinases and cancer-associated fibroblasts, have been reported, evaluated in animal models or under clinical investigations in recent years and play increasing roles in lung cancer diagnosis. Thus, we perform a comprehensive literature review of the radiopharmaceuticals and recent progress in PET tracers for the study of lung cancer biological characteristics beyond glucose metabolism.

177Lu-PSMA-I&T Radioligand Therapy for Treating Metastatic Castration-Resistant Prostate Cancer: A Single-Centre Study in East Asians

Purpose

There is increasing evidence for convincing efficacy and safety of ¹⁷⁷Lu-labled prostate-specific membrane antigen (PSMA)-targeted radioligand therapy (PRLT) for metastatic castration-resistant prostate cancer (mCRPC). However, data are not available regarding the feasibility of ¹⁷⁷Lu-labled PSMA-targeted RLT in East Asians. The present study summarized the first experience with ¹⁷⁷Lu-PSMA-I&T therapy for mCRPC in China.

Methods

Forty consecutive patients with mCRPC were enrolled from December 2019 to September 2021. Eligible patients received ¹⁷⁷Lu-PSMA-I&T RLT at intervals of 8-12 weeks. Toxicity was assessed based on standardized physicians’ reports and the Common Toxicity Criteria for Adverse Events criteria. Response to PRLT was evaluated according to the changes of prostate specific antigen (PSA) response and imaging response. Quality of life (QOL), Karnofsky performance status (KPS) and pain (visual analogue scale, VAS) were also evaluated. The impacts of baseline parameters on the therapeutic effects were explored by univariate and multivariate logistic regression analyses.

Results

All patients underwent a total of 86 cycles of ¹⁷⁷Lu-PSMA-I&T (range: 1-5 cycles) with dosages of 3.70-14.43GBq per cycle, with a median of 8 months followed up. Six patients (15%) developed mild reversible xerostomia during follow-up, and 28 patients (70%) experienced grade 1-4 bone marrow dysfunction. Changes in PSA were assessed after therapy, accompanied by the partial response (PR) in 25 patients (62.5%), the stable disease (SD) in 5 patients (12.5%), and the progressive disease (PD) in 10 patients (25%), respectively. QOL, KPS (%) and VAS scores were improved significantly due to treatment (P<0.05). Overweight and elevated AST, ALP, and LDH were associated with poor outcomes.

Conclusions

¹⁷⁷Lu-PSMA-I&T achieves the favourable response and well tolerance in mCRPC, which associates with not only PSA decline but also with tumor remission including lymphadenopathy and bone metastasis. We also find that patients with overweight and high AST, ALP, and LDH should be cautious to undergo the PRLT. Large-cohort studies are warranted to confirm the initial findings and elucidate the survival benefit of the treatment.

A Series of PSMA-Targeted Near-Infrared Fluorescent Imaging Agents

We have synthesized a series of 10 new, PSMA-targeted, near-infrared imaging agents intended for use in vivo for fluorescence-guided surgery (FGS). Compounds were synthesized from the commercially available amine-reactive active NHS ester of DyLight800. We altered the linker between the PSMA-targeting urea moiety and the fluorophore with a view to improve the pharmacokinetics. Chemical yields for the conjugates ranged from 51% to 86%. The K_i values ranged from 0.10 to 2.19 nM. Inclusion of an N-bromobenzyl substituent at the ε-amino group of lysine enhanced PSMA⁺ PIP tumor uptake, as did hydrophilic substituents within the linker. The presence of a polyethylene glycol chain within the linker markedly decreased renal uptake. In particular, DyLight800-10 demonstrated high specific uptake relative to background signal within kidney, confirmed by immunohistochemistry. These compounds may be useful for FGS in prostate, renal or other PSMA-expressing cancers.

Automatic radiosynthesis and preclinical evaluation of 18F-AlF-PSMA-NF as a potential PET probe for prostate cancer imaging

Facile automatic production is important for the application of prostate-specific membrane antigen (PSMA) tracers in clinical practice. We developed a new ¹⁸F-AlF-labelled PSMA probe-¹⁸F-AlF-PSMA-NF-and explore its automated production method and potential value in clinical settings. ¹⁸F-AlF-PSMA-NF was prepared using an automated method with dimethylformamide (DMF) as the solvent in a positron emission tomography (PET)-MF-2 V-IT-I synthesizer. Tracer characteristics were examined both in vitro and in vivo. Micro-PET/computed tomography (CT) was performed to investigate the utility of ¹⁸F-AlF-PSMA-NF for imaging PSMA-positive tumours in vivo. ¹⁸F-AlF-PSMA-NF was prepared automatically within 35 min with a non-attenuation correction yield of 37.9 ± 11.2%. The tracer was hydrophilic, had a high affinity for PSMA (Kd = 2.58 ± 0.81 nM), and showed stability in both in vitro and in vivo conditions. In the cellular experiments, ¹⁸F-AlF-PSMA-NF uptake in PSMA-positive LNCaP cells was significantly higher than that in PSMA-negative PC-3 cells (P < 0.001), and could be blocked by excess ZJ-43-a PSMA inhibitor (P < 0.001). LNCaP tumours were clearly visualized by ¹⁸F-AlF-PSMA-NF on micro-PET/CT, with a high level of uptake (13.72 ± 2.01 percent injected dose per gram of tissue [%ID/g]) and high tumour/muscle ratio (close to 50:1). The PSMA-positive LNCaP tumours had a significantly higher uptake than PSMA-negative PC-3 tumours (13.72 ± 2.01%ID/g vs. 1.07 ± 0.48%ID/g, t = 10.382, P < 0.001), and could be blocked by ZJ-43 (13.72 ± 2.01%ID/g vs. 2.77 ± 1.44%ID/g, t = 8.14, P < 0.001). A new ¹⁸F-AlF-labelled PSMA probe-¹⁸F-AlF-PSMA-NF-was successfully developed and can be prepared automatically. It has the biological characteristics resembling that of a PSMA-based probe and can potentially be used in clinical settings.

Targeted molecular imaging of head and neck squamous cell carcinoma: a window into precision medicine

Tumor biomarkers play important roles in tumor growth, invasion, and metastasis. Imaging of specific biomarkers will help to understand different biological activities, thereby achieving precise medicine for each head and neck squamous cell carcinoma (HNSCC) patient. Here, we describe various molecular targets and molecular imaging modalities for HNSCC imaging. An extensive search was undertaken in the PubMed database with the keywords including “HNSCC,” “molecular imaging,” “biomarker,” and “multimodal imaging.” Imaging targets in HNSCC consist of the epidermal growth factor receptor, cluster of differentiation 44 variant 6 (CD44v6), and mesenchymal-epithelial transition factor and integrins. Targeted molecular imaging modalities in HNSCC include optical imaging, ultrasound, magnetic resonance imaging, positron emission tomography, and single-photon emission computed tomography. Making the most of each single imaging method, targeted multimodal imaging has a great potential in the accurate diagnosis and therapy of HNSCC. By visualizing tumor biomarkers at cellular and molecular levels in vivo, targeted molecular imaging can be used to identify specific genetic and metabolic aberrations, thereby accelerating personalized treatment development for HNSCC patients.

A prostate-specific membrane antigen (PSMA)-targeted prodrug with a favorable in vivo toxicity profile

Prostate-specific membrane antigen (PSMA) is a promising target for the treatment of advanced prostate cancer (PC) and various solid tumors. Although PSMA-targeted radiopharmaceutical therapy (RPT) has enabled significant imaging and prostate-specific antigen (PSA) responses, accumulating clinical data are beginning to reveal certain limitations, including a subgroup of non-responders, relapse, radiation-induced toxicity, and the need for specialized facilities for its administration. To date non-radioactive attempts to leverage PSMA to treat PC with antibodies, nanomedicines or cell-based therapies have met with modest success. We developed a non-radioactive prodrug, SBPD-1, composed of a small-molecule PSMA-targeting moiety, a cancer-selective cleavable linker, and the microtubule inhibitor monomethyl auristatin E (MMAE). SBPD-1 demonstrated high binding affinity to PSMA (K_i = 8.84 nM) and selective cytotoxicity to PSMA-expressing PC cell lines (IC₅₀ = 3.90 nM). SBPD-1 demonstrated a significant survival benefit in two murine models of human PC relative to controls. The highest dose tested did not induce toxicity in immunocompetent mice. The high specific targeting ability of SBPD-1 to PSMA-expressing tumors and its favorable toxicity profile warrant its further development.

Synthesis and preliminary evaluation of 211At-labeled inhibitors of prostate-specific membrane antigen for targeted alpha particle therapy of prostate cancer

INTRODUCTION

The high potency and short tissue range of α-particles are attractive features for targeted radionuclide therapy, particularly for cancers with micro-metastases. In the current study, we describe the synthesis of a series of 211At-labeled prostate-specific membrane antigen (PSMA) inhibitors and their preliminary evaluation as potential agents for metastatic prostate cancer treatment.

METHODS

Four novel Glu-urea based PSMA ligands containing a trialkyl stannyl group were synthesized and labeled with 211At, and for comparative purposes, 131I, via halodestannylation reactions with N-chlorosuccinimide as the oxidant. A PSMA inhibitory assay was performed to evaluate PSMA binding of the unlabeled, iodinated compounds. A series of paired-label biodistribution experiments were performed to compare each 211At-labeled PSMA ligand to its 131I-labeled counterpart in mice bearing subcutaneous PC3 PSMA+ PIP xenografts.

RESULTS

Radiochemical yields ranged from 32% to 65% for the 211At-labeled PSMA inhibitors and were consistently lower than those obtained with the corresponding 131I-labeled analogue. Good localization in PC3 PSMA+ PIP but not control xenografts was observed for all labeled molecules studied, which exhibited a variable degree of in vivo dehalogenation as reflected by thyroid and stomach activity levels. Normal tissue uptake and in vivo stability for several of the compounds was markedly improved compared with the previously evaluated compounds, [211At]DCABzL and [*I]DCIBzL.

CONCLUSIONS AND IMPLICATIONS FOR PATIENT CARE

Compared with the first generation compound [211At]DCABzL, several of the novel 211At-labeled PSMA ligands exhibited markedly improved stability in vivo and higher tumor-to-normal tissue ratios. [211At]GV-620 has the most promising characteristics and warrants further evaluation as a targeted radiotherapeutic for prostate cancer.

A simple strategy to reduce the salivary gland and kidney uptake of PSMA-targeting small molecule radiopharmaceuticals

PURPOSE

Peptide-based prostate-specific membrane antigen (PSMA) targeted radionuclide therapy (TRT) agent [¹⁷⁷Lu]-PSMA-617 has emerged as leading TRT candidate for treatment of castration-resistant prostate cancer (mCRPC). [¹⁷⁷Lu]-PSMA-617 and other small molecule-based PSMA ligands have shown efficacy in reducing the tumor burden in mCRPC patients but irradiation to the salivary gland and kidneys is a concern and dose-limiting factor. Therefore, methods to reduce non-target organ toxicity are needed to safely treat patients and preserve their quality of life. Herein, we report that addition of cold PSMA ligand PSMA-11 can aid in reducing the uptake of [¹⁷⁷Lu]-PSMA-617 in the salivary glands and kidneys.

METHODS

Groups of athymic nude mice (n = 4) bearing PC3-PIP (PSMA+) tumor xenografts were administered with [¹⁷⁷Lu]-PSMA-617 along with 0, 5, 100, 500, 1000, and 2000 pmoles of PSMA-11 and biodistribution studies were performed at 1 h.

RESULTS

Biodistribution studies at 1 h post-administration revealed that [¹⁷⁷Lu]-PSMA-617 uptake in PC3-PIP tumors was 21.71 ± 6.13, 18.7 ± 2.03, 26.44 ± 2.94, 16.21 ± 3.5, 13.52 ± 3.68, and 12.03 ± 1.96 %ID/g when 0, 5, 100, 500, 1000, and 2000 pmoles of PSMA-11 were added, respectively. Corresponding uptake values in kidney were 123.14 ± 52.52, 132.31 ± 47.4, 84.29 ± 78.25, 2.12 ± 1.88, 1.16 ± 0.36, and 0.64 ± 0.23 %ID/g, respectively. Corresponding salivary gland uptake values were 0.48 ± 0.11, 0.45 ± 0.15, 0.38 ± 0.3, 0.08 ± 0.03, 0.09 ± 0.07, and 0.05 ± 0.02 % ID/g, respectively.

CONCLUSION

The uptake of [¹⁷⁷Lu]-PSMA-617 in the salivary gland and kidney can be substantially reduced without significantly impacting tumor uptake by adding cold PSMA-11.

Development of 5D3-DM1: A Novel Anti-Prostate-Specific Membrane Antigen Antibody-Drug Conjugate for PSMA-Positive Prostate Cancer Therapy

Prostate cancer (PC) is a potentially high-risk disease and the most common cancer in American men. It is a leading cause of cancer-related deaths in men in the US, second only to lung and bronchus cancer. Advanced and metastatic PC is initially treated with androgen deprivation therapy (ADT), but nearly all cases eventually progress to castrate-resistant prostate cancer (CRPC). CRPC is incurable in the metastatic stage but can be slowed by some conventional chemotherapeutics and second-generation ADT, such as enzalutamide and abiraterone. Therefore, novel therapeutic strategies are urgently needed. Prostate-specific membrane antigen (PSMA) is overexpressed in almost all aggressive PCs. PSMA is widely used as a target for PC imaging and drug delivery. Anti-PSMA monoclonal antibodies (mAbs) have been developed as bioligands for diagnostic imaging and targeted PC therapy. However, these mAbs are successfully used in PC imaging and only a few have gone beyond phase-I for targeted therapy. The 5D3 mAb is a novel, high-affinity, and fast-internalizing anti-PSMA antibody. Importantly, 5D3 mAb demonstrates a unique pattern of cellular localization to the centrosome after internalization in PSMA(+) PC3-PIP cells. These characteristics make 5D3 mAb an ideal bioligand to deliver tubulin inhibitors, such as mertansine, to the cell centrosome, leading to mitotic arrest and elimination of dividing PC cells. We have successfully developed a 5D3 mAb- and mertansine (DM1)-based antibody-drug conjugate (ADC) and evaluated it in vitro for binding affinity, internalization, and cytotoxicity. The in vivo therapeutic efficacy of 5D3-DM1 ADC was evaluated in PSMA(+) PC3-PIP and PSMA(-) PC3-Flu mouse models of human PC. This therapeutic study has revealed that this new anti-PSMA ADC can successfully control the growth of PSMA(+) tumors without inducing systemic toxicity.

Molecular imaging of prostate cancer: Review of imaging agents, modalities, and current status

INTRODUCTION

The clinical course of Prostate cancer (PCa) are markedly diverse, ranging from indolent to highly aggressive disseminated disease. Molecular imaging techniques are playing an increasing role in early PCa detection, staging and disease recurrence. There are some molecular imaging modalities, radiotracers agents and its performance are important in current clinical practice PCa.

OBJECTIVE

This review summarizes the latest information regarding molecular imaging of PCa and is designed to assist urologists with ordering and interpreting these modalities and different radiotracers for different patients.

EVIDENCE ACQUISITION

A PubMed-based literature search was conducted up to September 2019. We selected the most recent and relevant original articles, metanalysis and reviews that have provided relevant information to guide molecular imaging modalities and radiotracers use.

EVIDENCE SYNTHESIS

In this review, we discuss 3 main molecular imaging modalities and 7 radiotracer technologies available.

CONCLUSIONS

The use molecular imaging modalities and radiotracers has a unique role in biochemical recurrence and diagnosis of ganglionar and bone progression of PCa. In the present time, no one of these molecular imaging modalities can be recommended over the classical work-up of abdominopelvic CT scan and bone scan, and large-scale and multi-institutional studies are required to validate the efficacy and cost utility of these new technologies.

Comparison of Dual-Tracer PET and CT Features to Conventional Risk Categories in Assessing Response to 177Lu-PSMA-617 Therapy for Metastatic Prostate Adenocarcinoma with Urinary Bladder Involvement

The present communication details the imaging characteristics, peculiarities, and response to ¹⁷⁷Lu-labeled prostate-specific membrane antigen (PSMA)-617-targeted radioligand therapy (PRLT) in accordance with Gleason score and use of dual-tracer PET (⁶⁸Ga-PSMA-11 and ¹⁸F-FDG) in patients with urinary bladder invasion or metastasis by prostate cancer, including the prognostic value of ¹⁸F-FDG PET in predicting response to treatment. The CT attenuation units (Hounsfield units) correlated with the prostate primary in the case of direct tumor extension from the prostate, whereas in hematogenous metastatic seeding the Hounsfield units were lower than in the primary prostatic tumor. A favorable outcome to ¹⁷⁷Lu-PSMA-617 PRLT was observed in patients with low or no baseline ¹⁸F-FDG uptake despite a high Gleason score and a high-risk National Comprehensive Cancer Network prognostic category and did not correlate with the latter alone, whereas a high SUV_max on ¹⁸F-FDG PET/CT was associated with an adverse outcome. These findings suggest a promising role for ¹⁸F-FDG PET/CT in predicting therapeutic outcomes more confidently, and hence the concept of dual-tracer PET appears to hold good in prostate adenocarcinoma theranostics.

18F-Labeled, PSMA-Targeted Radiotracers: Leveraging the Advantages of Radiofluorination for Prostate Cancer Molecular Imaging

Prostate-specific membrane antigen (PSMA)-targeted PET imaging for prostate cancer with 68Ga-labeled compounds has rapidly become adopted as part of routine clinical care in many parts of the world. However, recent years have witnessed the start of a shift from 68Ga- to 18F-labeled PSMA-targeted compounds. The latter imaging agents have several key advantages, which may lay the groundwork for an even more widespread adoption into the clinic. First, facilitated delivery from distant suppliers expands the availability of PET radiopharmaceuticals in smaller hospitals operating a PET center but lacking the patient volume to justify an onsite 68Ge/68Ga generator. Thus, such an approach meets the increasing demand for PSMA-targeted PET imaging in areas with lower population density and may even lead to cost-savings compared to in-house production. Moreover, 18F-labeled radiotracers have a higher positron yield and lower positron energy, which in turn decreases image noise, improves contrast resolution, and maximizes the likelihood of detecting subtle lesions. In addition, the longer half-life of 110 min allows for improved delayed imaging protocols and flexibility in study design, which may further increase diagnostic accuracy. Moreover, such compounds can be distributed to sites which are not allowed to produce radiotracers on-site due to regulatory issues or to centers without access to a cyclotron. In light of these advantageous characteristics, 18F-labeled PSMA-targeted PET radiotracers may play an important role in both optimizing this transformative imaging modality and making it widely available. We have aimed to provide a concise overview of emerging 18F-labeled PSMA-targeted radiotracers undergoing active clinical development. Given the wide array of available radiotracers, comparative studies are needed to firmly establish the role of the available 18F-labeled compounds in the field of molecular PCa imaging, preferably in different clinical scenarios.

PRMT5 Cooperates with pICln to Function as a Master Epigenetic Activator of DNA Double-Strand Break Repair Genes

DNA double-strand break (DSB) repair is critical for cell survival and genome integrity. Upon recognition of DSBs, repair proteins are transiently upregulated to facilitate repair through homologous recombination (HR) or non-homologous end joining (NHEJ). We present evidence that PRMT5 cooperates with pICln to function as a master epigenetic activator of DNA damage response (DDR) genes involved in HR, NHEJ, and G₂ arrest (including RAD51, BRCA1, and BRCA2) to upregulate gene expression upon DNA damage. Contrary to the predominant role of PRMT5 as an epigenetic repressor, our results demonstrate that PRMT5 and pICln can activate gene expression, potentially independent of PRMT5's obligate cofactor MEP50. Targeting PRMT5 or pICln hinders repair of DSBs in multiple cancer cell lines, and both PRMT5 and pICln expression positively correlates with DDR genes across 32 clinical cancer datasets. Thus, targeting PRMT5 or pICln may be explored in combination with radiation or chemotherapy for cancer treatment.

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PRMT5 activates transcription of DSB repair genes upon DNA damage

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pICln cooperates with PRMT5 to activate transcription of DSB repair genes

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Targeting PRMT5 is effective to sensitize multiple cancer types to radiation

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PRMT5 expression positively correlates with DSB repair genes in cancer tissues

Integration of PSMA-targeted PET imaging into the armamentarium for detecting clinically significant prostate cancer

PURPOSE OF REVIEW

To explore the current state of using prostate-specific membrane antigen (PSMA)-targeted PET imaging to aid in the diagnosis of clinically significant prostate cancer.

RECENT FINDINGS

Prostate-specific antigen screening remains controversial, as it is associated with the underdetection of clinically significant prostate cancer as well as the overdetection and subsequent overtreatment of clinically insignificant disease. A diagnostic test that can accurately assess the presence of clinically significant prostate cancer and avoid detection of low-risk tumors is needed. Multiparametric magnetic resonance imaging (mpMRI) can aid in the detection of clinically significant prostate cancer and can be used with fusion-based biopsy platforms to target biopsies to specific lesions. However, there are several limitations of mpMRI including a modest negative predictive value for high-grade cancer. PSMA-targeted PET imaging has shown promise as a noninvasive test to aid in the detection of clinically significant prostate cancer while providing anatomical information to guide targeted biopsies. PSMA-targeted PET in combination with mpMRI offers a higher degree of diagnostic accuracy for imaging localized prostate cancer than either modality alone.

SUMMARY

PSMA-targeted PET imaging can aid in the identification of men with clinically significant prostate cancer. Further research is needed to determine the full potential of PSMA-targeted imaging in both the detection and treatment of localized prostate cancer.

Quality control and GMP synthesis of 68Ga-prostate-specific membrane antigen-11 for detection of low- and high-grade prostate cancer

Prostate-specific membrane antigen (PSMA) labeled with ⁶⁸Ga routinely used with higher sensibility and specificity than other radiotracers for detection of low and high grades of prostate cancer using positron emission tomography (PET)-computed tomography. ⁶⁸Ge/⁶⁸Ga generators are generally used with automated modules for the syntheses of ⁶⁸Ga radiopharmaceuticals. The aim of the current study is to describe the procedures for labeling PSMA with radiotracers and their standard QC tests. The automated synthesis method for ⁶⁸Ga-PSMA-11 was taken and set of a quality control based on chromatographic and spectrometric methods used to determine radiochemical and radionuclide purity of the radiolabeled compound. Meanwhile, high-performance liquid chromatography and rainbow trail Lutheran camp are the best choices after stability tests for assessment of radiochemical purity at the optimized conditions. The clinical utility of the synthesized radiopharmaceuticals was ascertained by performing PET scans in human patients.

Peripheral ganglia in healthy rats as target structures for the evaluation of PSMA imaging agents

Background

The recent implementation of PET with prostate specific membrane antigen (PSMA)-specific radiotracers into the clinical practice has resulted in the significant improvement of accuracy in the detection of prostate carcinoma (PCa). PSMA-expression in ganglia has been regarded as an important pitfall in prostate carcinoma-PET diagnostics but has not found any practical use for diagnosis or therapy.

Methods

We explored this phenomenon and demonstrated the applicability of peripheral ganglia in healthy rats as surrogates for small PSMA positive lesions for the preclinical evaluation of diagnostic PCa PET probes. Healthy rats were measured with PET/CT using the tracers [¹⁸F]DCFPyL, [Al¹⁸F]PSMA-11 and [⁶⁸Ga]PSMA-11. Sections of ganglia were stained with an anti-PSMA antibody. [¹⁸F]DCFPyL uptake in ganglia was compared to that in LNCaP tumor xenografts in mice.

Results

Whereas [¹⁸F]DCFPyL and [⁶⁸Ga]PSMA-11 were stable in vivo and accumulated in peripheral ganglia, [Al¹⁸F]PSMA-11 suffered from fast in vivo deflourination resulting in high bone uptake. Ganglionic PSMA expression was confirmed by immunohistochemistry. [¹⁸F]DCFPyL uptake and signal-to-noise ratio in the superior cervical ganglion was not significantly different from LNCaP xenografts.

Conclusions

Our results demonstrated the non-inferiority of the novel model compared to conventionally used tumor xenografts in immune compromised rodents with regard to reproducibility and stability of the PSMA signal. Furthermore, the model involves less expense and efforts while it is permanently available and avoids tumor-growth associated animal morbidity and distress. To the best of our knowledge, this is the first tumor-free model suitable for the in vivo evaluation of tumor imaging agents.

Advances in prostate-specific membrane antigen PET of prostate cancer

PURPOSE OF REVIEW

In recent years, a large number of reports have been published on prostate-specific membrane antigen (PSMA)/PET in prostate cancer (PCa). This review highlights advances in PSMA PET in PCa during the past year.

RECENT FINDINGS

PSMA PET/computed tomography (CT) is useful in detection of biochemical recurrence, especially at low prostate-specific antigen (PSA) values. The detection rate of PSMA PET is influenced by PSA level. For primary PCa, PSMA PET/CT shows promise for tumour localization in the prostate, especially in combination with multiparametric MRI (mpMRI). For primary staging, PSMA PET/CT can be used in intermediate and high-risk PCa. Intraoperative PSMA radioligand guidance seems promising for detection of malignant lymph nodes. While the use of PSMA PET/MRI in primary localized disease is limited to high and intermediate-risk patients and localized staging, in the recurrence setting, PET/MRI can be particularly helpful when the lesions are subtle. PSMA PET/CT is superior to choline PET/CT and other conventional imaging modalities.

SUMMARY

Molecular imaging with PSMA PET continues to pave the way for personalized medicine in PCa.However, large prospective clinical studies are still needed to fully evaluate the role of PSMA PET/CT and PET/MRI in the clinical workflow of PCa.

Targeting Prostate-Specific Membrane Antigen (PSMA) with F-18-Labeled Compounds: the Influence of Prosthetic Groups on Tumor Uptake and Clearance Profile

PURPOSE

Prostate-specific membrane antigen (PSMA) is an important biomarker expressed in the majority of prostate cancers. The favorable positron emission tomography (PET) imaging profile of the PSMA imaging agent 2-(3-(1-carboxy-5-[(6-[¹⁸F]fluoro-pyridine-3-carbonyl)-amino]-pentyl)-ureido)-pentane-dioic acid [¹⁸F]DCFPyL in preclinical prostate cancer models and in prostate cancer patients stimulated the development and validation of other fluorine-containing PSMA inhibitors to further enhance pharmacokinetics and simplify production methods. Here, we describe the synthesis and radiopharmacological evaluation of various F-18-labeled PSMA inhibitors which were prepared through different prosthetic group chemistry strategies.

PROCEDURES

Prosthetic groups N-succinimidyl-4-[¹⁸F]fluorobenzoate ([¹⁸F]SFB), 4-[¹⁸F]fluorobenzaldehyde, and 2-deoxy-2-[¹⁸F]fluoro-D-glucose ([¹⁸F]FDG) were used for bioconjugation reactions to PSMA-binding lysine-urea-glutamate scaffold via acylation and oxime formation. All fluorine-containing PSMA inhibitors were tested for their PSMA inhibitory potency in an in vitro competitive binding assay in comparison to an established reference compound [¹²⁵I]TAAG-PSMA. Tumor uptake and clearance profiles of three F-18-labeled PSMA inhibitors ([¹⁸F]4, [¹⁸F]7, and [¹⁸F]8) were studied with dynamic PET imaging using LNCaP tumor-bearing mice.

RESULTS

F-18-labeled PSMA inhibitors were synthesized in 32-69 % radiochemical yields using (1) acylation reaction at the primary amino group of the lysine residue with [¹⁸F]SFB and (2) oxime formation with 4-[¹⁸F]fluorobenzaldehyde and [¹⁸F]FDG using the respective aminooxy-functionalized lysine residue. Compound 7 displayed an IC₅₀ value of 6 nM reflecting very high affinity for PSMA. Compounds 4 and 8 showed IC₅₀ values of 13 and 62 nM, respectively. The IC₅₀ value of reference compound DCFPyL was 13 nM. Dynamic PET imaging revealed the following SUV_60min for radiotracer uptake in PSMA(+) LNCaP tumors: 0.98 ([¹⁸F]DCFPyL), 2.11 ([¹⁸F]7), 0.40 ([¹⁸F]4), and 0.19 ([¹⁸F]8).

CONCLUSION

The observed tumor uptake and clearance profiles demonstrate the importance of the selected prosthetic group on the pharmacokinetic profile of analyzed PSMA-targeting radiotracers. Radiotracer [¹⁸F]7 displayed the highest uptake and retention in LNCaP tumors, which exceeded uptake values of reference compound [¹⁸F]DCFPyL by more than 100 %. Despite the higher kidney and liver uptake and retention of compound [¹⁸F]7, the simple radiosynthesis and the exceptionally high tumor uptake (SUV_60min 2.11) and retention make radiotracer [¹⁸F]7 an interesting alternative to radiotracer [¹⁸F]DCFPyL for PET imaging of PSMA in prostate cancer.

Radiotheranostics in Cancer Diagnosis and Management

The fundamental foundation for precision medicine is accurate and specific targeting of cancer cells. Advances in the understanding of cancer biology, developments in diagnostic technologies, and expansion of therapeutic options have all contributed to the concept of personalized cancer care. Theranostics is the systematic integration of targeted diagnostics and therapeutics. The theranostic platform includes an imaging component that "sees" the lesions followed by administration of the companion therapy agent that "treats" the same lesions. This strategy leads to enhanced therapy efficacy, manageable adverse events, improved patient outcome, and lower overall costs. Radiotheranostics refers to the use of radionuclides for the paired imaging and therapy agents. Radioiodine is the classic radiotheranostic agent that has been used clinically in management of thyroid diseases for nearly 75 years. More recently there have been major exciting strides in radiotheranostics for neuroendocrine tumors and prostate cancer, among other conditions. Regulatory approval of a number of radiotheranostic pairs is anticipated in the near future. Continued support will be needed in research and development to keep pace with the current momentum in radiotheranostics innovations. Moreover, regulatory and reimbursement agencies need to streamline their requirements for seamless transfer of the radiotheranostic agents from the bench to the bedside. In this review, the concept, history, recent developments, current challenges, and outlook for radiotheranostics in the treatment of patients with cancer will be discussed. ^© RSNA, 2018.

Magnetic Gold Nanoparticle-Labeled Heparanase Monoclonal Antibody and its Subsequent Application for Tumor Magnetic Resonance Imaging

Heparanase (HPA) is ubiquitously expressed in various metastatic malignant tumors; previous studies have demonstrated that HPA was a potential tumor-associated antigen (TAA) for tumor immunotherapy. We sought to evaluate the feasibility of HPA as a common TAA for magnetic resonance imaging (MRI) of tumor metastasis and its potential application in tumor molecular imaging. We prepared a targeted probe based on magnetic gold nanoparticles coupled with an anti-HPA antibody for the specific detection of HPA by MRI. The specificity of the targeted probe was validated in vitro by incubation of the probe with various tumor cells, and the probe was able to selectively detect HPA (+) cells. We found the probes displayed significantly reduced signal intensity in several tumor cells, and the signal intensity decreased significantly after the targeted probe was injected in tumor-bearing nude mice. In the study, we demonstrated that the HPA&GoldMag probe had excellent physical and chemical properties and immune activities and could specifically target many tumor cell tissues both in vitro and in vivo. This may provide an experimental base for molecular imaging of tumor highly expressing heparanase using HPA mAbs.

Molecular imaging of prostate cancer

Prostate cancer is a common malignancy with various treatments from surveillance, surgery, radiation and chemotherapy. The institution of appropriate, effective treatment relies in part on accurate imaging. Molecular imaging techniques offer an opportunity for increased timely detection of prostate cancer, its recurrence, as well as metastatic disease. Advancements within the field of molecular imaging have been complex with some agents targeting receptors and others acting as metabolic intermediaries. In this article, we provide an overview of the most clinically relevant radiotracers to date based on a combination of the five states model and the National Comprehensive Cancer Network Guidelines.

Low levels of PSMA expression limit the utility of 18F-DCFPyL PET/CT for imaging urothelial carcinoma

OBJECTIVE

To explore the clinical utility of PSMA-targeted 18F-DCFPyL PET/CT in patients with metastatic urothelial carcinoma.

METHODS

Three patients with metastatic urothelial carcinoma were imaged with 18F-DCFPyL PET/CT. All lesions with perceptible radiotracer uptake above background were considered positive. Maximum standardized uptake values were recorded for each detected lesion and findings on 18F-DCFPyL PET/CT were compared to those on conventional imaging studies. To further explore PSMA as a molecular target of urothelial carcinoma, RNA-sequencing data from The Cancer Genome Atlas were used to compare the relative expression of PSMA among cases of bladder cancer, prostate cancer, and clear cell renal cell carcinoma. Additionally, immunohistochemical staining for PSMA was performed on a biopsy specimen from one of the imaged patients.

RESULTS

18F-DCFPyL PET/CT allowed for the detection of sites of urothelial carcinoma, albeit with low levels of radiotracer uptake. Analysis of RNA-sequencing data revealed that bladder cancer had significantly lower levels of PSMA expression than both prostate cancer and clear cell renal cell carcinoma. Consistent with this observation, immunohistochemical staining of tissue from one of the imaged patients demonstrated a low level of neovascularization and nearly absent PSMA expression.

CONCLUSION

The relatively scant expression of PSMA by urothelial carcinoma likely limits the utility of PSMA-targeted PET imaging of this malignancy. Future research efforts should focus on the development of other molecularly targeted imaging agents for urothelial carcinoma.

Multimodality Image Fusion with PSMA PET/CT and High-Intensity Focused Ultrasound Focal Therapy for Primary Diagnosis and Management of Prostate Cancer: A Planned Research Initiative

Recent developments in diagnostic imaging herald a new approach to diagnosis and management of prostate cancer. Multimodality fusion that combines anatomic with functional imaging data has surpassed either of the two alone. This opens up the possibility to "find and fix" malignancy with greater accuracy than ever before. This is particularly important for prostate cancer because it is the most common male cancer in most developed countries. This article describes technical advances under investigation at our institution and others using multimodality image fusion of magnetic resonance imaging (MRI), transrectal ultrasound (TRUS), and PSMA PET/CT (defined as the combination of prostate-specific membrane antigen [PSMA], positron emission tomography [PET], and computed tomography [CT]) for personalized medicine in the diagnosis and focal therapy of prostate cancer with high-intensity focused ultrasound (HiFUS).

Prostate Specific Membrane Antigen Targeted 18F-DCFPyL Positron Emission Tomography/Computerized Tomography for the Preoperative Staging of High Risk Prostate Cancer: Results of a Prospective, Phase II, Single Center Study

PURPOSE

We prospectively evaluated the diagnostic performance of prostate specific membrane antigen targeted ¹⁸F-DCFPyL positron emission tomography/computerized tomography in the preoperative staging of men at high risk for harboring metastatic prostate cancer despite a negative conventional staging evaluation.

MATERIALS AND METHODS

Men with clinically localized high or very high risk prostate cancer were imaged with ¹⁸F-DCFPyL positron emission tomography/computerized tomography before undergoing radical prostatectomy with standardized pelvic lymph node dissection. The scans were interpreted by 2 blinded nuclear medicine readers and assessed for interreader variability as well as diagnostic accuracy for pelvic lymph node staging. Surgical pathology served as the reference standard to which ¹⁸F-DCFPyL scan findings were compared.

RESULTS

A total of 25 men contributed analyzable data to this study. Seven of these patients (28%) were found to have 1 or more positive lymph nodes on surgical pathology. Sites of radiotracer uptake were identified in the prostate of all imaged patients. The 2 readers identified the same number of prostatic lesions in 22 patients (88%), of whom all had at least 1 intraprostatic lesion in common between the 2 reads. Additionally, the readers assigned the same N stage to 46 of 50 individual lymph node packets (92%). Following reconciliation of the relatively few discordant imaging reads, 7 patients (28%) were found to have 1 or more sites of radiotracer uptake in the pelvis consistent with N1 disease, resulting in 71.4% sensitivity (95% CI 29.0-96.3) and 88.9% specificity (95% CI 65.3-98.6). Analysis at the level of individual nodal packets resulted in 66.7% sensitivity (95% CI 29.9-92.5) and 92.7% specificity (95% CI 80.1-98.5). Three men (12%) had evidence of M1a disease.

CONCLUSIONS

¹⁸F-DCFPyL positron emission tomography/computerized tomography allowed for accurate detection of prostate cancer sites in men believed to have clinically localized disease based on conventional imaging. Our results support the need for a larger study to more precisely define the diagnostic accuracy of this novel molecular imaging test.

PSMA Ligands for PET Imaging of Prostate Cancer

Targeting the prostate-specific membrane antigen (PSMA) with ⁶⁸Ga-labeled and ¹⁸F-labeled PET agents has become increasingly important in recent years. Imaging of biochemically recurrent prostate cancer has been established as a widely accepted clinical indication for PSMA ligand PET/CT in many parts of the world because of the results of multiple, primarily retrospective, studies that indicate superior detection efficacy compared with standard-of-care imaging. For high-risk primary prostate cancer, evidence is growing that this modality significantly aids in the detection of otherwise occult nodal and bone metastases. For both clinical indications in recurrent as well as in primary prostate cancer, preliminary data demonstrate a substantial impact on clinical management. Emerging data imply that intraprostatic tumor localization, therapy stratification, and treatment monitoring of advanced disease in specific clinical situations might become future indications. Current criteria for image reporting of PSMA ligand PET are evolving given the expanding body of literature on physiologic and pathologic uptake patterns and pitfalls. This article intends to give an educational overview on the current status of PSMA ligand PET imaging, including imaging procedure and interpretation, clinical indications, diagnostic potential, and impact on treatment planning.

Imaging of Prostate-Specific Membrane Antigen Using [18F]DCFPyL

Prostate-specific membrane antigen (PSMA) has been explored as a target for molecular imaging of prostate cancer and other malignancies that express PSMA in their tumor-associated neovasculature. Although several PSMA-targeted radiotracers labeled with a variety of radionuclides have been reported, positron-emitting radiotracers labeled with ¹⁸F are of particular interest. One such compound, the small molecule PSMA inhibitor [¹⁸F]DCFPyL, has demonstrated initial success. This article reviews the literature on this radiotracer, including radiosynthetic approaches to the molecule, data that are available from preclinical experiments, and evidence to date of the clinical utility of this agent in prostate cancer and clear cell renal cell carcinoma.