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Jeph S, Gupta S, Yedururi S, Daoud TE, Stanietzky N, Morani AC. Liver Imaging in Gastroenteropancreatic Neuroendocrine Neoplasms. J Comput Assist Tomogr 2024; 48:577-587. [PMID: 38438332 DOI: 10.1097/rct.0000000000001576] [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: 03/06/2024]
Abstract
ABSTRACT The incidence of neuroendocrine neoplasms (NENs) has gradually increased over the past few decades with the majority of patients presenting with metastases on initial presentation. The liver is the most common site of initial metastatic disease, and the presence of liver metastasis is an independent prognostic factor associated with a negative outcome. Because NENs are heterogenous neoplasms with variable differentiation, grading, and risk of grade transformation over time, accurate diagnosis and management of neuroendocrine liver lesions are both important and challenging. This is particularly so with the multiple liver-directed treatment options available. In this review article, we discuss the diagnosis, treatment, and response evaluation of NEN liver metastases.
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Affiliation(s)
- Sunil Jeph
- From the Department of Radiology, Penn State University, Hershey, PA
| | - Shiva Gupta
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sireesha Yedururi
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Taher E Daoud
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nir Stanietzky
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ajaykumar C Morani
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Sunny SS, Hephzibah J, Chacko RT, Kodiatte TA. Therapeutic Response to PRRNT in a Rare Case of Metastatic Renal Neuroendocrine Carcinoma. World J Nucl Med 2024; 23:141-146. [PMID: 38933067 PMCID: PMC11199026 DOI: 10.1055/s-0044-1785461] [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] [Indexed: 06/28/2024] Open
Abstract
Neuroendocrine tumors (NETs) are a rare spectrum of neoplasms that are characterized by neuroendocrine and neural differentiation. The treatment can be challenging in view of the heterogeneity in differentiation and behavior. Primary renal origin NETs are rare and only a few cases have been reported in the literature. There is limited knowledge on their presentation and response to various lines of treatment. We report a case of a patient with a metastatic renal NET from a rare histological subtype of large cell neuroendocrine carcinoma, known to cause aggressive disease with poor prognosis. A multimodality treatment approach was followed. In spite of surgical management and second-line chemotherapy, the disease progressed. The patient subsequently received peptide receptor radionuclide therapy (PRRNT) using lutetium-177 DOTATATE, following which the patient demonstrated a remarkable clinical and radiological response and is stable to date. In a rare tumor with poor prognosis, the relevance of theranostics and the efficacy of targeted therapies like PRRNT are noteworthy.
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Affiliation(s)
- Saumya Sara Sunny
- Department of Nuclear Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Julie Hephzibah
- Department of Medical Oncology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Raju Titus Chacko
- Department of Medical Oncology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Thomas Alex Kodiatte
- Department of Pathology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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AghaAmiri S, Ghosh SC, Hernandez Vargas S, Halperin DM, Azhdarinia A. Somatostatin Receptor Subtype-2 Targeting System for Specific Delivery of Temozolomide. J Med Chem 2024; 67:2425-2437. [PMID: 38346097 PMCID: PMC10896214 DOI: 10.1021/acs.jmedchem.3c00223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 12/04/2023] [Accepted: 12/12/2023] [Indexed: 02/23/2024]
Abstract
Temozolomide (TMZ) is a DNA alkylating agent that produces objective responses in patients with neuroendocrine tumors (NETs) when the DNA repair enzyme O6-methylguanine-DNA methyltransferase (MGMT) is inactivated. At high doses, TMZ therapy exhausts MGMT activity but also produces dose-limiting toxicities. To reduce off-target effects, we converted the clinically approved radiotracer 68Ga-DOTA-TOC into a peptide-drug conjugate (PDC) for targeted delivery of TMZ to somatostatin receptor subtype-2 (SSTR2)-positive tumor cells. We used an integrated radiolabeling strategy for direct quantitative assessment of receptor binding, pharmacokinetics, and tissue biodistribution. In vitro studies revealed selective binding to SSTR2-positive cells with high affinity (5.98 ± 0.96 nmol/L), internalization, receptor-dependent DNA damage, cytotoxicity, and MGMT depletion. Imaging and biodistribution analysis showed preferential accumulation of the PDC in receptor-positive tumors and high renal clearance. This study identified a trackable SSTR2-targeting system for TMZ delivery and utilizes a modular design that could be broadly applied in PDC development.
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Affiliation(s)
- Solmaz AghaAmiri
- The Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1881 East Road, 3SCR6.4680, Houston, Texas 77054, United States
| | - Sukhen C Ghosh
- The Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1881 East Road, 3SCR6.4680, Houston, Texas 77054, United States
| | - Servando Hernandez Vargas
- The Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1881 East Road, 3SCR6.4680, Houston, Texas 77054, United States
| | - Daniel M Halperin
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, United States
| | - Ali Azhdarinia
- The Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1881 East Road, 3SCR6.4680, Houston, Texas 77054, United States
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4
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Prosperi D, Gentiloni Silveri G, Panzuto F, Faggiano A, Russo VM, Caruso D, Polici M, Lauri C, Filice A, Laghi A, Signore A. Nuclear Medicine and Radiological Imaging of Pancreatic Neuroendocrine Neoplasms: A Multidisciplinary Update. J Clin Med 2022; 11:jcm11226836. [PMID: 36431313 PMCID: PMC9694730 DOI: 10.3390/jcm11226836] [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: 10/03/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022] Open
Abstract
Pancreatic neuroendocrine neoplasms (panNENs) are part of a large family of tumors arising from the neuroendocrine system. PanNENs show low-intermediate tumor grade and generally high somatostatin receptor (SSTR) expression. Therefore, panNENs benefit from functional imaging with 68Ga-somatostatin analogues (SSA) for diagnosis, staging, and treatment choice in parallel with morphological imaging. This narrative review aims to present conventional imaging techniques and new perspectives in the management of panNENs, providing the clinicians with useful insight for clinical practice. The 68Ga-SSA PET/CT is the most widely used in panNENs, not only fr diagnosis and staging purpose but also to characterize the biology of the tumor and its responsiveness to SSAs. On the contrary, the 18F-Fluordeoxiglucose (FDG) PET/CT is not employed systematically in all panNEN patients, being generally preferred in G2-G3, to predict aggressiveness and progression rate. The combination of 68Ga-SSA PET/CT and 18F-FDG PET/CT can finally suggest the best therapeutic strategy. Other radiopharmaceuticals are 68Ga-exendin-4 in case of insulinomas and 18F-dopamine (DOPA), which can be helpful in SSTR-negative tumors. New promising but still-under-investigation radiopharmaceuticals include radiolabeled SSTR antagonists and 18F-SSAs. Conventional imaging includes contrast enhanced CT and multiparametric MRI. There are now enriched by radiomics, a new non-invasive imaging approach, very promising to early predict tumor response or progression.
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Affiliation(s)
- Daniela Prosperi
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
| | - Guido Gentiloni Silveri
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
| | - Francesco Panzuto
- Digestive Disease Unit, Department of Medical-Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, ENETS Center of Excellence, Sapienza University of Rome, 00189 Roma, Italy
| | - Antongiulio Faggiano
- Endocrinology Unit, Department of Clinical and Molecular Medicine, Sant’Andrea University Hospital, ENETS Center of Excellence, Sapienza University of Rome, 00189 Roma, Italy
| | - Vincenzo Marcello Russo
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
| | - Damiano Caruso
- Radiology Unit, Department of Medical Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
| | - Michela Polici
- Radiology Unit, Department of Medical Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
| | - Chiara Lauri
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
- Correspondence:
| | - Angelina Filice
- Nucler Medicine Unit, AUSL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Andrea Laghi
- Radiology Unit, Department of Medical Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
| | - Alberto Signore
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, 00189 Roma, Italy
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Fortunati E, Argalia G, Zanoni L, Fanti S, Ambrosini V. New PET Radiotracers for the Imaging of Neuroendocrine Neoplasms. Curr Treat Options Oncol 2022; 23:703-720. [PMID: 35325412 PMCID: PMC9001579 DOI: 10.1007/s11864-022-00967-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 12/18/2022]
Abstract
Neuroendocrine neoplasms (NEN) are a heterogeneous group of tumours derived from cells of neuroendocrine origin and can potentially arise everywhere in the human body. The diagnostic assessment of NEN can be performed using a variety of PET radiopharmaceuticals. Well-differentiated NEN (NET) present a high expression of SSTR (somatostatin receptors) and can therefore be studied with 68Ga-DOTA-peptides ([68Ga]Ga-DOTANOC, [68Ga]Ga-DOTATOC, [68Ga]Ga-DOTATATE). Current guidelines recommend the use of SSTR imaging to assess disease extension at staging/restaging, follow-up, assessment of response to therapy and selection of patients who may benefit from radionuclide therapy (PRRT). [18F]F-FDG is used for the assessment of high-grade tumours (high-grade G2, G3 and NEC) and in every case, there is one or more mismatched lesions between diagnostic CT (positive) and SSTR-PET/CT (negative). [18F]F-DOPA is currently used for the assessment of medullary thyroid carcinoma, neuroblastoma, primary pheochromocytoma and abdominal paraganglioma. In recent years, however, several new tracers were designed exploiting the many potential targets of the neuroendocrine cell and were employed in clinical trials for both imaging and therapy. Currently, the real-life clinical impact of these tracers is still mostly not known; however, the favourable biodistribution (e.g. [68Ga]Ga-FAPI, SSTR antagonists) and the possibility to use new theranostic pairs may provide novel diagnostic as well as therapeutic options (e.g. [68Ga]Ga-PSMA, [64Cu]Cu-SARTATE, [68Ga]Ga-CXCR4) for NEN patients.
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Affiliation(s)
- Emilia Fortunati
- Nuclear Medicine, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.
| | - Giulia Argalia
- Nuclear Medicine, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Lucia Zanoni
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Stefano Fanti
- Nuclear Medicine, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.,Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Valentina Ambrosini
- Nuclear Medicine, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.,Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
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6
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Barca C, Griessinger CM, Faust A, Depke D, Essler M, Windhorst AD, Devoogdt N, Brindle KM, Schäfers M, Zinnhardt B, Jacobs AH. Expanding Theranostic Radiopharmaceuticals for Tumor Diagnosis and Therapy. Pharmaceuticals (Basel) 2021; 15:13. [PMID: 35056071 PMCID: PMC8780589 DOI: 10.3390/ph15010013] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 02/06/2023] Open
Abstract
Radioligand theranostics (RT) in oncology use cancer-type specific biomarkers and molecular imaging (MI), including positron emission tomography (PET), single-photon emission computed tomography (SPECT) and planar scintigraphy, for patient diagnosis, therapy, and personalized management. While the definition of theranostics was initially restricted to a single compound allowing visualization and therapy simultaneously, the concept has been widened with the development of theranostic pairs and the combination of nuclear medicine with different types of cancer therapies. Here, we review the clinical applications of different theranostic radiopharmaceuticals in managing different tumor types (differentiated thyroid, neuroendocrine prostate, and breast cancer) that support the combination of innovative oncological therapies such as gene and cell-based therapies with RT.
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Affiliation(s)
- Cristina Barca
- European Institute for Molecular Imaging, University of Münster, D-48149 Münster, Germany; (A.F.); (D.D.); (M.S.); (B.Z.)
| | - Christoph M. Griessinger
- Roche Innovation Center, Early Clinical Development Oncology, Roche Pharmaceutical Research and Early Development, CH-4070 Basel, Switzerland;
| | - Andreas Faust
- European Institute for Molecular Imaging, University of Münster, D-48149 Münster, Germany; (A.F.); (D.D.); (M.S.); (B.Z.)
- Department of Nuclear Medicine, University Hospital Münster, D-48149 Münster, Germany
| | - Dominic Depke
- European Institute for Molecular Imaging, University of Münster, D-48149 Münster, Germany; (A.F.); (D.D.); (M.S.); (B.Z.)
| | - Markus Essler
- Department of Nuclear Medicine, University Hospital Bonn, D-53127 Bonn, Germany;
| | - Albert D. Windhorst
- Department Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands;
| | - Nick Devoogdt
- In Vivo Cellular and Molecular Imaging Laboratory, Vrije Universiteit Brussel, B-1090 Brussel, Belgium;
| | - Kevin M. Brindle
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge CB2 ORE, UK;
| | - Michael Schäfers
- European Institute for Molecular Imaging, University of Münster, D-48149 Münster, Germany; (A.F.); (D.D.); (M.S.); (B.Z.)
- Department of Nuclear Medicine, University Hospital Münster, D-48149 Münster, Germany
| | - Bastian Zinnhardt
- European Institute for Molecular Imaging, University of Münster, D-48149 Münster, Germany; (A.F.); (D.D.); (M.S.); (B.Z.)
- Department of Nuclear Medicine, University Hospital Münster, D-48149 Münster, Germany
- Biomarkers and Translational Technologies, Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., CH-4070 Basel, Switzerland
| | - Andreas H. Jacobs
- European Institute for Molecular Imaging, University of Münster, D-48149 Münster, Germany; (A.F.); (D.D.); (M.S.); (B.Z.)
- Department of Geriatrics and Neurology, Johanniter Hospital, D-53113 Bonn, Germany
- Centre of Integrated Oncology, University Hospital Bonn, D-53127 Bonn, Germany
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7
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Baum RP, Zhang J, Schuchardt C, Müller D, Mäcke H. First-in-Humans Study of the SSTR Antagonist 177Lu-DOTA-LM3 for Peptide Receptor Radionuclide Therapy in Patients with Metastatic Neuroendocrine Neoplasms: Dosimetry, Safety, and Efficacy. J Nucl Med 2021; 62:1571-1581. [PMID: 33674401 PMCID: PMC8612334 DOI: 10.2967/jnumed.120.258889] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/16/2020] [Indexed: 12/24/2022] Open
Abstract
The objective of this study was to assess the safety, dosimetry, and efficacy of the 177Lu-labeled somatostatin receptor (SSTR) antagonist DOTA-p-Cl-Phe-cyclo(d-Cys-Tyr-d-4-amino-Phe(carbamoyl)-Lys-Thr-Cys)d-Tyr-NH2 (177Lu-DOTA-LM3) in patients with metastatic neuroendocrine neoplasms (NENs). Methods: Fifty-one patients (aged 27-76 y; mean, 51.6 ± 13.9 y) with metastatic NENs underwent peptide receptor radionuclide therapy (PRRT) with 177Lu-DOTA-LM3 between August 2017 and December 2019. The median administered activity per cycle was 6.1 ± 0.88 GBq (range, 2.8-7.4 GBq). 68Ga-NODAGA-LM3 PET/CT was used for patient selection and follow-up after 177Lu-DOTA-LM3 PRRT. Morphologic and molecular responses were evaluated in accordance with RECIST 1.1 and the criteria of the European Organisation for Research and Treatment of Cancer (EORTC). Treatment-related adverse events were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 5.0. Dosimetry was performed on 11 patients and compared with the SSTR agonist 177Lu-DOTATOC in 247 patients undergoing PRRT on the same dosimetry protocol. Results: Higher uptake and a longer effective half-life were found for 177Lu-DOTA-LM3 than for the agonist 177Lu-DOTATOC in the whole body and in the kidneys, spleen, and metastases, resulting in higher mean absorbed organ and tumor doses. All patients tolerated therapy without any serious acute adverse effects. Mild nausea without vomiting was observed in 5 (9.8%) patients; no other symptoms were reported. The most severe delayed adverse event was Common Terminology Criteria (CTC)-3 thrombocytopenia in 3 (5.9%) patients. Neither CTC-4 thrombocytopenia nor CTC-3-4 anemia or leukopenia was observed after treatment. No significant decline in renal function was observed, nor was hepatotoxicity. According to RECIST 1.1, disease control could be reached in 40 patients (disease control rate, 85.1%) of the 47 patients monitored after 177Lu-DOTA-LM3 PRRT, with a partial response in 17 (36.2%) and stable disease in 23 (48.9%), whereas 7 patients (14.9%) had progressive disease, and by EORTC criteria, there was complete remission in 2 patients (4.3%), partial remission in 21 (44.7%), stable disease in 18 (38.3%), and progressive disease in 6 (12.8%). Conclusion: The antagonist PRRT with 177Lu-DOTA-LM3 could be administered without severe adverse effects and was well tolerated by most patients, with thrombocytopenia occurring in only a few. No other severe adverse effects were observed; in particular, there was no nephrotoxicity. The SSTR antagonist 177Lu-DOTA-LM3 appears to be promising for PRRT, provides a favorable biodistribution and higher tumor radiation doses than SSTR agonists, and was effective in treating advanced metastatic NENs, especially in patients with low or no SSTR agonist binding, even achieving complete remission in some patients.
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Affiliation(s)
- Richard P Baum
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany
- CURANOSTICUM Wiesbaden-Frankfurt, Center for Advanced Radiomolecular Precision Oncology, Wiesbaden, Germany
| | - Jingjing Zhang
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany;
- Departments of Diagnostic Radiology, Surgery, Chemical and Biomolecular Engineering, and Biomedical Engineering, Yong Loo Lin School of Medicine and Faculty of Engineering, National University of Singapore, Singapore, Singapore
- Clinical Imaging Research Centre, Centre for Translational Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; and
| | - Christiane Schuchardt
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Dirk Müller
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Helmut Mäcke
- Department of Nuclear Medicine, Medical Center, University Hospital of Freiburg, Freiburg, Germany
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Abstract
Peptide receptor radionuclide therapy (PRRT) is an effective form of treatment of patients with metastatic neuroendocrine tumors, delivering modest objective tumor response rates but notable survival and symptomatic benefits. The first PRRT approved by the US Food and Drug Administration was lutetium 177-DOTATATE and is for use in adults with somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors. The treatment paradigm typically leads to significant improvement in symptomology coupled with an extended period of progression-free survival. Side effects are limited, with a small fraction of individuals experiencing clinically significant long-term renal or hematologic toxicity.
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Di Stasio GD, Buonomano P, Travaini LL, Grana CM, Mansi L. From the Magic Bullet to Theragnostics: Certitudes and Hypotheses, Trying to Optimize the Somatostatin Model. Cancers (Basel) 2021; 13:cancers13143474. [PMID: 34298688 PMCID: PMC8305798 DOI: 10.3390/cancers13143474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 01/21/2023] Open
Abstract
Simple Summary In oncology, the hypothetical “perfect magic bullet” should have a specific target on tumor cells which allows one to target only the tumor, in the absence of uptake in normal and/or non-neoplastic cells. Theragnostics is a strategy that strictly combines diagnosis and therapy, which creates the conditions for an “a priori” definition of an effective therapeutic effect. The most complete theragnostic and “magic bullet” experiences in clinical practice are those associated with radioiodine and somatostatin model. In this paper, we analyze whether it could be possible to improve present clinical results, further extending the survival of a wider number of patients, expanding the recruitment criteria to other types of pathology, and improving the quality of life. The ultimate goal is to transform the theragnostic strategy based on the somatostatin model into a curative therapy in the highest possible number of patients. Abstract The first “theragnostic model”, that of radioiodine, was first applied both in diagnosis and therapy in the 1940s. Since then, many other theragnostic models have been introduced into clinical practice. To bring about the closest pharmacokinetic connection, the radiocompound used for diagnosis and therapy should be the same, although at present this is rarely applicable. Today, a widely applied and effective model is also the “DOTA-Ga-68/Lu-177”, used with success in neuroendocrine tumors (NET). In this paper, we analyze the necessary steps from the in vitro evaluation of a target to the choice of radionuclide and chelate for therapy up to in vivo transition and clinical application of most employed radiocompounds used for theragnostic purposes. Possible future applications and strategies of theragnostic models are also highlighted.
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Affiliation(s)
| | - Pasqualina Buonomano
- Nuclear Medicine Service, Ios and Coleman Medicina Futura Medical Center, 80011 Acerra, Italy;
| | - Laura Lavinia Travaini
- Nuclear Medicine Division, European Institute of Oncology—IRCCS, 20141 Milano, Italy; (L.L.T.); (C.M.G.)
| | - Chiara Maria Grana
- Nuclear Medicine Division, European Institute of Oncology—IRCCS, 20141 Milano, Italy; (L.L.T.); (C.M.G.)
| | - Luigi Mansi
- Section Health and Development, Interuniversity Research Center for Sustainability (CIRPS), 00038 Rome, Italy
- Correspondence: ; Tel.: +39-3280024554
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10
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Calabrò D, Argalia G, Ambrosini V. Role of PET/CT and Therapy Management of Pancreatic Neuroendocrine Tumors. Diagnostics (Basel) 2020; 10:E1059. [PMID: 33297381 PMCID: PMC7762240 DOI: 10.3390/diagnostics10121059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 12/12/2022] Open
Abstract
Pancreatic neuroendocrine neoplasms (panNENs) are heterogeneous neoplasms with neuroendocrine differentiation that show peculiar clinical and histomorphological features, with variable prognosis. In recent years, advances in knowledge regarding the pathophysiology and heterogeneous clinical presentation, as well as the availability of different diagnostic procedures for panNEN diagnosis and novel therapeutic options for patient clinical management, has led to the recognition of the need for an active multidisciplinary discussion for optimal patient care. Molecular imaging with positron emission tomography/computed tomography (PET/CT) has become indispensable for the management of panNENs. Several PET radiopharmaceuticals can be used to characterize either panNEN receptor expression or metabolism. The aim of this review is to offer an overview of all the currently used radiopharmaceuticals and of the new upcoming tracers for pancreatic neuroendocrine tumors (panNETs), and their clinical impact on therapy management. [68Ga]Ga-DOTA-peptide PET/CT (SSA-PET/CT) has high sensitivity, specificity, and accuracy and is recommended for the staging and restaging of any non-insulinoma well-differentiated panNEN cases to carry out detection of unknown primary tumor sites or early relapse and for evaluation of in vivo somatostatin receptors expression (SRE) to select patient candidates for peptide receptor radiometabolic treatment (PRRT) with 90Y or 177Lu and/or cold analogs. SSA-PET/CT also has a strong impact on clinical management, leading to a change in treatment in approximately a third of the cases. Its role for treatment response assessment is still under debate due to the lack of standardized criteria, even though some semiquantitative parameters seem to be able to predict response. [18F]FDG PET/CT generally shows low sensitivity in small growing and well-differentiated neuroendocrine tumors (NET; G1 and G2), while it is of utmost importance in the evaluation and management of high-grade NENs and also provides important prognostic information. When positive, [18F]FDG PET/CT impacts therapeutical management, indicating the need for a more aggressive treatment regime. Although FDG positivity does not exclude the patient from PRRT, several studies have demonstrated that it is certainly useful to predict response, even in this setting. The role of [18F]FDOPA for the study of panNET is limited by physiological uptake in the pancreas and is therefore not recommended. Moreover, it provides no information on SRE that has crucial clinical management relevance. Early acquisition of the abdomen and premedication with carbidopa may be useful to increase the accuracy, but further studies are needed to clarify its utility. GLP-1R agonists, such as exendin-4, are particularly useful for benign insulinoma detection, but their accuracy decreases in the case of malignant insulinomas. Being a whole-body imaging technique, exendin-PET/CT gives important preoperative information on tumor size and localization, which is fundamental for surgical planning as resection (enucleation of the lesion or partial pancreatic resection) is the only curative treatment. New upcoming tracers are under study, such as promising SSTR antagonists, which show a favorable biodistribution and higher tumor-to-background ratio that increases tumor detection, especially in the liver. [68Ga]pentixafor, an in vivo marker of CXCR4 expression associated with the behavior of more aggressive tumors, seems to only play a limited role in detecting well-differentiated NET since there is an inverse expression of SSTR2 and CXCR4 in G1 to G3 NETs with an elevation in CXCR4 and a decrease in SSTR2 expression with increasing grade. Other tracers, such as [68Ga]Ga-PSMA, [68Ga]Ga-DATA-TOC, [18F]SiTATE, and [18F]AlF-OC, are also under investigation.
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Affiliation(s)
- Diletta Calabrò
- Department of Nuclear Medicine, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy; (G.A.); (V.A.)
- Department of Nuclear Medicine, DIMES University of Bologna, 40138 Bologna, Italy
| | - Giulia Argalia
- Department of Nuclear Medicine, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy; (G.A.); (V.A.)
- Department of Nuclear Medicine, DIMES University of Bologna, 40138 Bologna, Italy
| | - Valentina Ambrosini
- Department of Nuclear Medicine, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy; (G.A.); (V.A.)
- Department of Nuclear Medicine, DIMES University of Bologna, 40138 Bologna, Italy
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11
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Impacto clínico del PET/TC Ga68-DOTATOC en tumores de origen neuroendocrino. Experiencia preliminar. ENDOCRINOL DIAB NUTR 2020; 67:636-642. [DOI: 10.1016/j.endinu.2019.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 12/12/2019] [Accepted: 12/23/2019] [Indexed: 12/28/2022]
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12
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Cives M, Pelle’ E, Strosberg J. Emerging Treatment Options for Gastroenteropancreatic Neuroendocrine Tumors. J Clin Med 2020; 9:E3655. [PMID: 33202931 PMCID: PMC7696369 DOI: 10.3390/jcm9113655] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 02/06/2023] Open
Abstract
Treatment options for neuroendocrine tumors (NETs) and carcinomas (NECs) are expanding. Early-phase studies have shown preliminary evidence of the antitumor activity of alpha-emitting peptide receptor radionuclide therapy (PRRT), and novel radiopeptides incorporating somatostatin receptor antagonists (rather than agonists) have been developed. Several tyrosine kinase inhibitors (TKIs) with antiangiogenic potential have been evaluated in patients with NETs, including lenvatinib, axitinib, cabozantinib and pazopanib. Recently, two phase 3 clinical trials have demonstrated the efficacy and safety of surufatinib, an inhibitor of vascular endothelial growth factor receptor (VEGFR)-1, -2, -3, fibroblast growth factor receptor (FGFR)-1 and colony stimulating factor-1 receptor (CSF-1R), in patients with pancreatic and extra-pancreatic NETs. Multiple clinical trials of combination immunotherapy have been recently completed, but interpretation of the results is hampered by small samples sizes and discordant outcomes. This review summarizes recent data on emerging treatments for neuroendocrine neoplasms.
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Affiliation(s)
- Mauro Cives
- Department of Biomedical Sciences and Human Oncology, University of Bari, 70124 Bari, Italy; (M.C.); (E.P.)
- IRCCS Istituto Tumori Giovanni Paolo II, 70124 Bari, Italy
| | - Eleonora Pelle’
- Department of Biomedical Sciences and Human Oncology, University of Bari, 70124 Bari, Italy; (M.C.); (E.P.)
| | - Jonathan Strosberg
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
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13
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Langbein T, Weber WA, Eiber M. Future of Theranostics: An Outlook on Precision Oncology in Nuclear Medicine. J Nucl Med 2020; 60:13S-19S. [PMID: 31481583 DOI: 10.2967/jnumed.118.220566] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 06/24/2019] [Indexed: 01/13/2023] Open
Abstract
Molecular alterations in malignant disease result in the expression or upregulations of various targets that can be used for imaging and treatment with radiopharmaceuticals. This theranostic principle has acquired greater importance in personalized medicine in recent years, particularly in oncology, where advanced tumors can be treated effectively with low side effects. Since the pioneering use of 131I in differentiated thyroid cancer in the 1940s, remarkable achievements in nuclear medicine endoradiotherapy have been demonstrated, mainly in the treatment of neuroendocrine neoplasms by using 177Lu-labeled somatostatin analogs or in the treatment of advanced prostate cancer using prostate-specific membrane antigen-directed radionuclide therapy. Besides that, this review focuses on promising novel radiopharmaceuticals and describes their preclinical and clinical status. Radiolabeled antibodies, such as 131I-omburtamab directed against the B7-H3 protein on the surface of neuroblastoma cells; HuMab-5B1, a 89Zr/177Lu-labeled antibody for the treatment of CA19-9-expressing malignancies; and 177Lu-lilotomab, a CD37 antibody for the treatment of B-cell lymphomas, are being highlighted. The neurotensin receptor ligand 111In/177Lu-3B-227 has demonstrated high potential in imaging and therapy for several malignancies (e.g., pancreatic adenocarcinomas). Targeting of the fibroblast activation protein is currently being explored for different tumor entities using PET imaging with the fibroblast activation protein inhibitor (FAPI) 68Ga-FAPI-04, and the first therapeutic applications of 90Y-FAPI-04 have been applied. After 2 decades of rapid development in theranostics, a variety of new targets are available for further clinical investigation.
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Affiliation(s)
- Thomas Langbein
- Department of Nuclear Medicine, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Wolfgang A Weber
- Department of Nuclear Medicine, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Matthias Eiber
- Department of Nuclear Medicine, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Herrera-Martínez AD, Hofland LJ, Gálvez Moreno MA, Castaño JP, de Herder WW, Feelders RA. Neuroendocrine neoplasms: current and potential diagnostic, predictive and prognostic markers. Endocr Relat Cancer 2019; 26:R157-R179. [PMID: 30615596 DOI: 10.1530/erc-18-0354] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/03/2019] [Indexed: 12/13/2022]
Abstract
Some biomarkers for functioning and non-functioning neuroendocrine neoplasms (NENs) are currently available. Despite their application in clinical practice, results should be interpreted cautiously. Considering the variable sensitivity and specificity of these parameters, there is an unmet need for novel biomarkers to improve diagnosis and predict patient outcome. Nowadays, several new biomarkers are being evaluated and may become future tools for the management of NENs. These biomarkers include (1) peptides and growth factors; (2) DNA and RNA markers based on genomics analysis, for example, the so-called NET test, which has been developed for analyzing gene transcripts in circulating blood; (3) circulating tumor/endothelial/progenitor cells or cell-free tumor DNA, which represent minimally invasive methods that would provide additional information for monitoring treatment response and (4) improved imaging techniques with novel radiolabeled somatostatin analogs or peptides. Below we summarize some future directions in the development of novel diagnostic and predictive/prognostic biomarkers in NENs. This review is focused on circulating and selected tissue markers.
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Affiliation(s)
- Aura D Herrera-Martínez
- Division of Endocrinology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC); Reina Sofia University Hospital, Córdoba, Spain
| | - Leo J Hofland
- Division of Endocrinology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - María A Gálvez Moreno
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC); Reina Sofia University Hospital, Córdoba, Spain
| | - Justo P Castaño
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC); Reina Sofia University Hospital, Córdoba, Spain
| | - Wouter W de Herder
- Division of Endocrinology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Richard A Feelders
- Division of Endocrinology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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15
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Turner JH. An introduction to the clinical practice of theranostics in oncology. Br J Radiol 2018; 91:20180440. [PMID: 30179054 DOI: 10.1259/bjr.20180440] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
"Those who cannot remember the past are condemned to repeat it." George Santayana 1905 "If men could learn from history, what lessons it might teach us! But passion and party blind our eyes, and the light which experience gives is a lantern on the stern, which shines only on the waves behind us!" Samuel Taylor Coleridge 1835 The medical speciality of theranostic nuclear oncology has taken three-quarters of a century to move the stern light cast retrospectively by single-centre clinical reports, to the forepeak in the bow of our theranostic craft, where prospective randomised controlled multicentre clinical trials now illuminate the way forward. This recent reorientation of nuclear medicine clinical research practice to align with that of standard medical and radiation oncology protocols, reflects the paradigm shift toward individualised molecular oncology and precision medicine. Theranostics is the epitome of personalised medicine. The specific tumour biomarker is quantitatively imaged on positron emission tomography (PET)/CT or single photon emission computed tomography (SPECT)/CT. If it is clearly demonstrated that a tumoricidal radiation absorbed dose can be delivered, the theranostic beta or alpha-emitting radionuclide pair, coupled to the same targeted molecule, is then administered, to control advanced metastatic cancer in that individual patient. This prior selection of patients who may benefit from theranostic treatment is in direct contrast to the evolving oncological indirect treatments using immune-check point inhibitors, where there is an urgent need to define biomarkers which can reliably predict response, and thus avoid the high cost and toxicity of these agents in patients who are unlikely to benefit. The immune and molecular treatment approaches of oncology are a recent phenomenon and the efficacy and safety of immune-check point blockade and chimeric antigen receptor T-cell therapies are currently under evaluation in multicentre randomised controlled trials. Such objective evaluation is compromised by the inadequacy of conventional response evaluation criteria in solid tumour (RECIST) CT/MR anatomical/functional imaging to define tumour response, in both immune-oncology and theranostic nuclear oncology. This introduction to the clinical practice of theranostics explores ways in which nuclear physicians can learn from the lessons of history, and join with their medical, surgical and radiation oncology colleagues to establish a symbiotic collaboration to realise the potential of personalised molecular medicine to control advanced cancer and actually enhance quality of life whilst prolonging survival.
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Affiliation(s)
- J Harvey Turner
- School of Medicine and Pharmacology, The University of Western Australia , Perth , Australia
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