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K Nazar A, Basu S. Radiolabeled Somatostatin Analogs for Cancer Imaging. Semin Nucl Med 2024:S0001-2998(24)00058-8. [PMID: 39122608 DOI: 10.1053/j.semnuclmed.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 07/01/2024] [Indexed: 08/12/2024]
Abstract
Somatostatin receptors (SSTR) are expressed by many tumours especially those related to neuro-endocrine origin and molecular functional imaging of SSTR expression using radiolabelled somatostatin analogs have revolutionized imaging of patients with these group of malignancies. Coming a long way from the first radiolabelled somatostatin analog 123I-Tyr-3-octreotide, there has been significant developments in terms of radionuclides used, the ligands and somatostatin derivatives. 111In-Pentetreotide extensively employed for imaging NETs at the beginning has now been replaced by 68Ga-SSA based PET-CT. SSA-PET/CT performs superior to conventional imaging modalities and has evolved in the mainframe for NET imaging. The advantages were multiple: (i) superior spatial resolution of PET versus SPECT, (ii) quantitative capabilities of PET aiding in disease activity and treatment response monitoring with better precision, (iii) shorter scan time and (iv) less patient exposure to radiation. The modality is indicated for staging, detecting the primary in CUP-NETs, restaging, treatment planning (along with FDG: the concept of dual-tracer PET-CT) as well as treatment response evaluation and follow-up of NETs. SSA PET/CT has also been incorporated in the guidelines for imaging of Pheochromocytoma-Paraganglioma, Medullary carcinoma thyroid, Meningioma and Tumor induced osteomalacia. At present, there is rising interest on (a) 18F-labelled SSA, (b) 64Cu-labelled SSA, and (c) somatostatin antagonists. 18F offers excellent imaging properties, 64Cu makes delayed imaging feasible which has implications in dosimetry and SSTR antagonists bind with the SST receptors with high affinity and specificity, providing high contrast images with less background, which can be translated to theranostics effectively. SSTR have been demonstrated in non-neuroendocrine tumours as well in the peer-reviewed literature, with studies demonstrating the potential of SSA PET/CT in Neuroblastoma, Nasopharyngeal carcinoma, carcinoma prostate (neuroendocrine differentiation) and lymphoma. This review will focus on the currently available SSAs and their history, different SPECT/PET agents, SSTR antagonists, comparison between the various imaging tracers, and their utility in both neuroendocrine and non-neuroendocrine tumors.
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Affiliation(s)
- Aamir K Nazar
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Mumbai; Homi Bhabha National Institute, Mumbai
| | - Sandip Basu
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Mumbai; Homi Bhabha National Institute, Mumbai.
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Akaike T, Jabbour AJ, Goff PH, Park SY, Bhatia S, Nghiem P. Merkel cell carcinoma refractory to anti-PD(L)1: utility of adding ipilimumab for salvage therapy. J Immunother Cancer 2024; 12:e009396. [PMID: 39053946 DOI: 10.1136/jitc-2024-009396] [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] [Accepted: 06/30/2024] [Indexed: 07/27/2024] Open
Abstract
Merkel cell carcinoma (MCC) incidence has risen to approximately 3,000 cases annually in the USA. Although anti-programmed cell death (ligand) 1 (PD-(L)1) agents are now the first-line treatment for advanced MCC, approximately 50% of such patients do not persistently benefit. In PD-(L)1-refractory cases, ipilimumab (anti-cytotoxic T lymphocyte antigen-4) is often added; however, the extent of the clinical benefit of this combination is controversial. We identified one prospective study, three retrospective studies, and three case reports regarding this combination in refractory MCC. The aggregate response rate from retrospective studies was 32% (13 of 41 patients) with 4 complete responses (CR) and 9 partial responses (PR). In the prospective study, the response rate was very similar at 31% (8 of 26 patients; 4 CR, 4 PR). Response durability was highly variable (range 2 to >43 months), with patients achieving CR having greater durability. Immune-related adverse events (irAEs) were ≥grade III in 29% (retrospective cohort, N=41) and 36% (prospective cohort, N=50). While these aggregate data indicate adding ipilimumab should be considered in this setting, many patients with refractory MCC are ineligible due to comorbidities/irAEs, and approximately 70% will not benefit from this regimen. There is thus a significant unmet need in PD-(L)1-refractory MCC and clinical trials in this setting should be encouraged.
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Affiliation(s)
- Tomoko Akaike
- Department of Dermatology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Austin J Jabbour
- Department of Dermatology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Peter H Goff
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington, USA
- Radiation Oncology Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Division of Radiation Oncology, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Song Y Park
- Department of Dermatology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Shailender Bhatia
- Department of Medicine, Division of Medical Oncology, University of Washington School of Medicine, Seattle, Washington, USA
- Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Paul Nghiem
- Department of Dermatology, University of Washington School of Medicine, Seattle, Washington, USA
- Fred Hutchinson Cancer Center, Seattle, Washington, USA
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Becker JC, Stang A, Schrama D, Ugurel S. Merkel Cell Carcinoma: Integrating Epidemiology, Immunology, and Therapeutic Updates. Am J Clin Dermatol 2024; 25:541-557. [PMID: 38649621 PMCID: PMC11193695 DOI: 10.1007/s40257-024-00858-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 04/25/2024]
Abstract
Merkel cell carcinoma (MCC) is a rare skin cancer characterized by neuroendocrine differentiation. Its carcinogenesis is based either on the integration of the Merkel cell polyomavirus or on ultraviolet (UV) mutagenesis, both of which lead to high immunogenicity either through the expression of viral proteins or neoantigens. Despite this immunogenicity resulting from viral or UV-associated carcinogenesis, it exhibits highly aggressive behavior. However, owing to the rarity of MCC and the lack of epidemiologic registries with detailed clinical data, there is some uncertainty regarding the spontaneous course of the disease. Historically, advanced MCC patients were treated with conventional cytotoxic chemotherapy yielding a median response duration of only 3 months. Starting in 2017, four programmed cell death protein 1 (PD-1)/programmed cell death-ligand 1 (PD-L1) immune checkpoint inhibitors-avelumab, pembrolizumab, nivolumab (utilized in both neoadjuvant and adjuvant settings), and retifanlimab-have demonstrated efficacy in treating patients with disseminated MCC on the basis of prospective clinical trials. However, generating clinical evidence for rare cancers, such as MCC, is challenging owing to difficulties in conducting large-scale trials, resulting in small sample sizes and therefore lacking statistical power. Thus, to comprehensively understand the available clinical evidence on various immunotherapy approaches for MCC, we also delve into the epidemiology and immune biology of this cancer. Nevertheless, while randomized studies directly comparing immune checkpoint inhibitors and chemotherapy in MCC are lacking, immunotherapy shows response rates comparable to those previously reported with chemotherapy but with more enduring responses. Notably, adjuvant nivolumab has proven superiority to the standard-of-care therapy (observation) in the adjuvant setting.
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Affiliation(s)
- Jürgen C Becker
- Department of Translational Skin Cancer Research (TSCR), German Cancer Consortium (DKTK), partner site Essen, University Duisburg-Essen, Universitätsstrasse 1, 45141, Essen, Germany.
- Department of Dermatology, University Medicine Essen, Essen, Germany.
- German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Andreas Stang
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
- Cancer Registry of North Rhine-Westphalia, Bochum, Germany
| | - David Schrama
- Department of Dermatology, University Hospital Würzburg, Würzburg, Germany
| | - Selma Ugurel
- Department of Dermatology, University Medicine Essen, Essen, Germany
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Uchihara M, Tanabe A, Kojima Y, Shimoi T, Maeshima AM, Umamoto K, Shimomura A, Shimizu C, Yamazaki Y, Nakamura E, Matsui Y, Takemura N, Miyazaki H, Sudo K, Yonemori K, Kajio H. Immunohistochemical Profiling of SSTR2 and HIF-2α with the Tumor Microenvironment in Pheochromocytoma and Paraganglioma. Cancers (Basel) 2024; 16:2191. [PMID: 38927897 PMCID: PMC11201597 DOI: 10.3390/cancers16122191] [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: 05/02/2024] [Revised: 06/03/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024] Open
Abstract
Metastatic pheochromocytomas and paragangliomas (PPGLs) are rare endocrine malignancies with limited effective treatment options. The association between the tumor microenvironment (TME) with somatostatin receptor 2 (SSTR2) and hypoxia-induced factor-2α (HIF-2α) in PPGLs, critical for optimizing combination therapeutic strategies with immunotherapy, remains largely unexplored. To evaluate the association of SSTR2 and HIF-2α immunoreactivity with the TME in patients with PPGLs, we analyzed the expression of SSTR2A, HIF-2α, and TME components, including tumor-infiltrating lymphocytes (CD4 and CD8), tumor-associated macrophages (CD68 and CD163), and PD-L1, using immunohistochemistry in patients with PPGLs. The primary outcome was to determine the association of the immune profiles with SSTR2A and HIF-2α expression. Among 45 patients with PPGLs, SSTR2A and HIF2α were positively expressed in 21 (46.7%) and 14 (31.1%) patients, respectively. The median PD-L1 immunohistochemical score (IHS) was 2.0 (interquartile range: 0-30.0). Positive correlations were observed between CD4, CD8, CD68, and CD163 levels. A negative correlation was found between the CD163/CD68 ratio (an indicator of M2 polarization) and SSTR2A expression (r = -0.385, p = 0.006). HIF-2α expression showed a positive correlation with PD-L1 IHS (r = 0.348, p = 0.013). The co-expression of PD-L1 (HIS > 10) and HIF-2α was found in seven patients (15.6%). No associations were observed between SDHB staining results and the CD163/CD68 ratio, PD-L1, or SSTR2A expression. Our data suggest the potential of combination therapy with immunotherapy and peptide receptor radionuclide therapy or HIF-2α inhibitors as a treatment option in selected PPGL populations.
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Affiliation(s)
- Masaki Uchihara
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Toyama 1-21-1, Shinjuku-ku City, Tokyo 162-8655, Japan; (M.U.)
- Course of Advanced and Specialized Medicine, Juntendo University Graduate School of Medicine, 3-1-3 Hongoh, Bunkyo-ku, Tokyo 113-0033, Japan (C.S.)
- Department of General Internal Medicine, Oncological Endocrinology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo 104-0045, Japan
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Toyama 1-21-1, Shinjuku-ku City, Tokyo 162-8655, Japan; (M.U.)
| | - Yuki Kojima
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo 104-0045, Japan (T.S.)
| | - Tatsunori Shimoi
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo 104-0045, Japan (T.S.)
| | - Akiko Miyagi Maeshima
- Department of Diagnostic Pathology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo 104-0045, Japan
| | - Kotaro Umamoto
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Toyama 1-21-1, Shinjuku-ku City, Tokyo 162-8655, Japan; (M.U.)
- Department of General Internal Medicine, Oncological Endocrinology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo 104-0045, Japan
| | - Akihiko Shimomura
- Course of Advanced and Specialized Medicine, Juntendo University Graduate School of Medicine, 3-1-3 Hongoh, Bunkyo-ku, Tokyo 113-0033, Japan (C.S.)
- Department of Breast and Medical Oncology, National Center for Global Health and Medicine, Toyama 1-21-1, Shinjuku-ku City, Tokyo 162-8655, Japan
| | - Chikako Shimizu
- Course of Advanced and Specialized Medicine, Juntendo University Graduate School of Medicine, 3-1-3 Hongoh, Bunkyo-ku, Tokyo 113-0033, Japan (C.S.)
- Department of Breast and Medical Oncology, National Center for Global Health and Medicine, Toyama 1-21-1, Shinjuku-ku City, Tokyo 162-8655, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Seiryo-machi 2-1, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Eijiro Nakamura
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo 104-0045, Japan (T.S.)
- Department of Urology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo 104-0045, Japan
| | - Yoshiyuki Matsui
- Department of Urology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo 104-0045, Japan
| | - Nobuyuki Takemura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, Toyama 1-21-1, Shinjuku-ku City, Tokyo 162-8655, Japan
| | - Hideyo Miyazaki
- Department of Urology, National Center for Global Health and Medicine, Toyama 1-21-1, Shinjuku-ku City, Tokyo 162-8655, Japan
| | - Kazuki Sudo
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo 104-0045, Japan (T.S.)
| | - Kan Yonemori
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo 104-0045, Japan (T.S.)
| | - Hiroshi Kajio
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Toyama 1-21-1, Shinjuku-ku City, Tokyo 162-8655, Japan; (M.U.)
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Baum RP, Fan X, Jakobsson V, Schuchardt C, Chen X, Yu F, Zhang J. Extended peptide receptor radionuclide therapy: evaluating nephrotoxicity and therapeutic effectiveness in neuroendocrine tumor patients receiving more than four treatment cycles. Eur J Nucl Med Mol Imaging 2024; 51:1136-1146. [PMID: 38040931 DOI: 10.1007/s00259-023-06544-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/22/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE Currently, the most used peptide receptor radionuclide therapy (PRRT) regimen for neuroendocrine tumors comprises 4 treatment cycles, and there is not enough large-scale data to support the safety of more individualized extended PRRT. This study aims to evaluate the therapeutic effectiveness and potential nephrotoxicity related to PRRT using more than four treatment cycles. METHODS In this retrospective analysis, we included patients who had received at least four PRRT cycles and had available follow-up data. We analyzed renal function indicators before and after multiple treatments, comparing nephrotoxicity in patients receiving four cycles ("standard") with those receiving more than four ("extended treatment"). Nephrotoxicity was assessed via creatinine levels and CTCAE creatinine grades. Treatment effectiveness was gauged using Kaplan-Meier survival analysis, focusing on overall survival and disease-specific survival (DSS). Statistical analyses were performed using SPSS version 26 (IBM), R 4.2.3, and GraphPad Prism 9.0.0. Statistical significance was defined as a P-value of less than 0.05. RESULTS Our study cohort consisted of 281 patients in the standard group and 356 in the extended treatment group. No significant differences in baseline characteristics or renal function were noted between the two groups pre-treatment. Mean post-treatment creatinine levels did not significantly differ between the standard (89.30 ± 51.19 μmol/L) and extended treatment groups (93.20 ± 55.98 μmol/L; P = 0.364). Similarly, there was no statistical significance between the CTCAE creatinine grades of the two groups (P = 0.448). Adverse renal events were observed in 0.4% of patients in the standard group and 1.1% in the extended treatment group. After a median follow-up time of 88.3 months, we found that median overall survival was significantly higher in the extended treatment group (72.8 months) compared to the standard treatment group (52.8 months). A Cox regression analysis further supported these findings, indicating a better prognosis for the extended treatment group in terms of overall survival (HR: 0.580, P < 0.001) and DSS (HR: 0.599, P < 0.001). CONCLUSION Our findings suggest that extending PRRT treatment beyond the standard four cycles may be a safe and effective therapeutic strategy for NET patients. This approach could be particularly beneficial for patients experiencing disease recurrence or progression following standard treatment.
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Affiliation(s)
- Richard P Baum
- Center for Advanced Radiomolecular Precision Oncology, CURANOSTICUM Wiesbaden-Frankfurt, Wiesbaden, Germany
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Xin Fan
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, 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
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, China
| | - Vivianne Jakobsson
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, 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
- Nanomedicine Translational Research Program, NUS Center for Nanomedicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Christiane Schuchardt
- Theranostics Center for Molecular Radiotherapy and Precision Oncology, ENETS Center of Excellence, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Xiaoyuan Chen
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, 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
- Nanomedicine Translational Research Program, NUS Center for Nanomedicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine and College of Design and Engineering, National University of Singapore, Singapore, Singapore
- Department of Chemical and Biomolecular Engineering, Yong Loo Lin School of Medicine and College of Design and Engineering, National University of Singapore, Singapore, Singapore
- Department of Biomedical Engineering, Yong Loo Lin School of Medicine and College of Design and Engineering, National University of Singapore, Singapore, Singapore
- Institute of Molecular and Cell Biology, Agency for Science, Technology, and Research (A*STAR), 61 Biopolis Drive, Proteos, Singapore, 138673, Singapore
| | - Fei Yu
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, China.
| | - Jingjing Zhang
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, 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.
- Nanomedicine Translational Research Program, NUS Center for Nanomedicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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Pouget JP, Chan TA, Galluzzi L, Constanzo J. Radiopharmaceuticals as combinatorial partners for immune checkpoint inhibitors. Trends Cancer 2023; 9:968-981. [PMID: 37612188 PMCID: PMC11311210 DOI: 10.1016/j.trecan.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/25/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of multiple cancer types. However, only a fraction of patients with cancer responds to ICIs employed as stand-alone therapeutics, calling for the development of safe and effective combinatorial regimens to extend the benefits of ICIs to a larger patient population. In addition to exhibiting a good safety and efficacy profile, targeted radionuclide therapy (TRT) with radiopharmaceuticals that specifically accumulate in the tumor microenvironment has been associated with promising immunostimulatory effects that (at least in preclinical cancer models) provide a robust platform for the development of TRT/ICI combinations. We discuss preclinical and clinical findings suggesting that TRT stands out as a promising partner for the development of safe and efficient combinatorial regimens involving ICIs.
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Affiliation(s)
- Jean-Pierre Pouget
- Institut de Recherche en Cancérologie de Montpellier (IRCM), Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 1194, Université de Montpellier, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France.
| | - Timothy A Chan
- Center for Immunotherapy and Precision Immuno-Oncology, Cleveland Clinic, Cleveland, OH, USA; National Center for Regenerative Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Lorenzo Galluzzi
- Department of Radiation Oncology, Weill Cornell Medical College, New York, NY, USA; Sandra and Edward Meyer Cancer Centre, New York, NY, USA; Caryl and Israel Englander Institute for Precision Medicine, New York, NY, USA.
| | - Julie Constanzo
- Institut de Recherche en Cancérologie de Montpellier (IRCM), Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 1194, Université de Montpellier, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
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Singh N, McClure EM, Akaike T, Park SY, Huynh ET, Goff PH, Nghiem P. The Evolving Treatment Landscape of Merkel Cell Carcinoma. Curr Treat Options Oncol 2023; 24:1231-1258. [PMID: 37403007 PMCID: PMC11260505 DOI: 10.1007/s11864-023-01118-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 07/06/2023]
Abstract
OPINION STATEMENT Merkel cell carcinoma (MCC) has a high risk of recurrence and requires unique treatment relative to other skin cancers. The patient population is generally older, with comorbidities. Multidisciplinary and personalized care is therefore paramount, based on patient preferences regarding risks and benefits. Positron emission tomography and computed tomography (PET-CT) is the most sensitive staging modality and reveals clinically occult disease in ~ 16% of patients. Discovery of occult disease spread markedly alters management. Newly diagnosed, localized disease is often managed with sentinel lymph node biopsy (SLNB), local excision, primary wound closure, and post-operative radiation therapy (PORT). In contrast, metastatic disease is usually treated systemically with an immune checkpoint inhibitor (ICI). However, one or more of these approaches may not be indicated. Criteria for such exceptions and alternative approaches will be discussed. Because MCC recurs in 40% of patients and early detection/treatment of advanced disease is advantageous, close surveillance is recommended. Given that over 90% of initial recurrences arise within 3 years, surveillance frequency can be rapidly decreased after this high-risk period. Patient-specific assessment of risk is important because recurrence risk varies widely (15 to > 80%: Merkelcell.org/recur) depending on baseline patient characteristics and time since treatment. Blood-based surveillance tests are now available (Merkel cell polyomavirus (MCPyV) antibodies and circulating tumor DNA (ctDNA)) with excellent sensitivity that can spare patients from contrast dye, radioactivity, and travel to a cancer imaging facility. If recurrent disease is locoregional, management with surgery and/or RT is typically indicated. ICIs are now the first line for systemic/advanced MCC, with objective response rates (ORRs) exceeding 50%. Cytotoxic chemotherapy is sometimes used for debulking disease or in patients who cannot tolerate ICI. ICI-refractory disease is the major problem faced by this field. Fortunately, numerous promising therapies are on the horizon to address this clinical need.
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Affiliation(s)
- Neha Singh
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Erin M McClure
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Tomoko Akaike
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
| | - Song Y Park
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
| | - Emily T Huynh
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
| | - Peter H Goff
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Paul Nghiem
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA.
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8
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Esfahani SA, De Aguiar Ferreira C, Summer P, Mahmood U, Heidari P. Addition of Peptide Receptor Radiotherapy to Immune Checkpoint Inhibition Therapy Improves Outcomes in Neuroendocrine Tumors. J Nucl Med 2023; 64:1056-1061. [PMID: 37024303 DOI: 10.2967/jnumed.123.265391] [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: 01/02/2023] [Revised: 03/01/2023] [Accepted: 03/01/2023] [Indexed: 04/08/2023] Open
Abstract
Neuroendocrine tumors (NETs) are often diagnosed in advanced stages. Despite the advances in treatment approaches, including somatostatin analogs and peptide receptor radionuclide therapy (PRRT), these patients have no curative treatment option. Moreover, immunotherapy often yields modest results in NETs. We investigated whether combining PRRT using [177Lu]DOTATATE and immune checkpoint inhibition therapy improves treatment response in NETs. Methods: A gastroenteropancreatic NET model was generated by subcutaneous implantation of human QGP-1 cells in immune-reconstituted NOD.Cg-Prkdcscid Il2rgtm1Wjl /SzJ mice engrafted with human peripheral blood mononuclear cells (n = 96). Mice were randomly assigned to receive pembrolizumab (anti-PD1), [177Lu]DOTATATE (PRRT), simultaneous anti-PD1 and PRRT (S-PRRT), anti-PD1 on day 0 followed by PRRT on day 3 (delayed PRRT [D-PRRT]), PRRT on day 0 followed by anti-PD1 (early PRRT [E-PRRT]), or vehicle as control (n = 12/group). Human granzyme-B-specific [68Ga]NOTA-hGZP PET/MRI was performed before and 6 d after treatment initiation, as an indicator of T-cell activation. Response to treatment was based on tumor growth over 21 d and on histologic analyses of extracted tissues on flow cytometry for T cells, hematoxylin and eosin staining, and immunohistochemical staining. Results: [68Ga]NOTA-hGZP PET/MRI showed significantly increased uptake in tumors treated with E-PRRT, S-PRRT, and anti-PD1 on day 6 compared with baseline (SUVmax: 3.36 ± 0.42 vs. 0.73 ± 0.23; 2.36 ± 0.45 vs. 0.76 ± 0.30; 2.20 ± 0.20 vs. 0.72 ± 0.28, respectively; P < 0.001), whereas no significant change was seen in PET parameters in the D-PRRT, PRRT, or vehicle groups (P > 0.05). Ex vivo analyses confirmed the PET results showing the highest granzyme-B levels and T cells (specifically CD8-positive effector T cells) in the E-PRRT group, followed by the S-PRRT and anti-PD1 groups. Tumor growth follow-up showed the most significant tumor size reduction in the E-PRRT group (baseline to day 21, 205.00 ± 30.70 mm3 vs. 78.00 ± 11.75 mm3; P = 0.0074). Tumors showed less growth reduction in the PRRT, D-PRRT, and S-PRRT groups than in the E-PRRT group (P < 0.0001). The vehicle- and anti-PD-1-treated tumors showed continued growth. Conclusion: Combination of PRRT and anti-PD1 shows the most robust inflammatory response to NETs and a better overall outcome than immune checkpoint inhibition or PRRT alone. The most effective regimen is PRRT preceding anti-PD1 administration by several days.
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Affiliation(s)
- Shadi A Esfahani
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts
- Institute for Innovation in Imaging, Massachusetts General Hospital, Boston, Massachusetts; and
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Carolina De Aguiar Ferreira
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Priska Summer
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Umar Mahmood
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Pedram Heidari
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts;
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
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9
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Constanzo J, Bouden Y, Godry L, Kotzki PO, Deshayes E, Pouget JP. Immunomodulatory effects of targeted radionuclide therapy. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2023; 378:105-136. [PMID: 37438015 DOI: 10.1016/bs.ircmb.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
It is now clear that conventional radiation therapy can reinstate cell death immunogenicity. Recent preclinical data indicate that targeted radionuclide therapy that irradiate tumors at continuous low dose rate also can elicit immunostimulatory effects and represents a promising strategy to circumvent immune checkpoint inhibitor resistance. In this perspective, we discuss the accumulating preclinical and clinical data suggesting that activation of the immune system through the cGAS-STING axis and the release of extracellular vesicles by irradiated cells, participate to this antitumor immunity. This should need to be considered for adapting clinical practices to state of the art of the radiobiology and to increase targeted radionuclide therapy effectiveness.
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Affiliation(s)
- J Constanzo
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Université de Montpellier, Nuclear Medicine Department, Institut régional du Cancer de Montpellier (ICM), Montpellier, France.
| | - Y Bouden
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Université de Montpellier, Nuclear Medicine Department, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - L Godry
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Université de Montpellier, Nuclear Medicine Department, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - P-O Kotzki
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Université de Montpellier, Nuclear Medicine Department, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - E Deshayes
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Université de Montpellier, Nuclear Medicine Department, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - J-P Pouget
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Université de Montpellier, Nuclear Medicine Department, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
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10
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Becker JC, Beer AJ, DeTemple VK, Eigentler T, Flaig MJ, Gambichler T, Grabbe S, Höller U, Klumpp B, Lang S, Pföhler C, Posch C, Prasad V, Schlattmann P, Schneider-Burrus S, Ter-Nedden J, Terheyden P, Thoms K, Vordermark D, Ugurel S. S2k-Leitlinie - Merkelzellkarzinom - Update 2022. J Dtsch Dermatol Ges 2023; 21:305-317. [PMID: 36929546 DOI: 10.1111/ddg.14930_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/09/2022] [Indexed: 03/18/2023]
Affiliation(s)
- Jürgen C Becker
- Translational Skin Cancer Research (TSCR), Deutsches Konsortium für translationale Krebsforschung (DKTK), Partnerstandort Essen, Klinik für Dermatologie, Universitätsmedizin Essen, Deutsches Krebsforschungszentrum, Heidelberg
| | | | - Viola K DeTemple
- Universitätsklinik für Dermatologie, Venerologie, Allergologie und Phlebologie, Johannes Wesling Klinikum Minden
| | - Thomas Eigentler
- Klinik für Dermatologie, Venerologie und Allergologie, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin
| | - Michael J Flaig
- Klinik und Poliklinik für Dermatologie und Allergologie, Klinikum der Universität München, LMU München
| | - Thilo Gambichler
- Klinik für Dermatologie, Venerologie und Allergologie, Ruhr-Universität Bochum
| | | | | | | | - Stephan Lang
- Hals-Nasen-Ohren-Klinik am Universitätsklinikum Essen
| | - Claudia Pföhler
- Klinik für Dermatologie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Christian Posch
- Hautklinik Campus Biederstein, Technische Universität München
| | - Vikas Prasad
- Klinik für Nuklearmedizin, Universitätsklinikum Ulm
| | | | | | | | - Patrick Terheyden
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck
| | - Kai Thoms
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Göttingen, Göttingen
| | - Dirk Vordermark
- Universitätsklinik und Poliklinik für Strahlentherapie, Halle
| | - Selma Ugurel
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Essen
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11
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Askari E, Moghadam SZ, Wild D, Delpassand E, Baldari S, Nilica B, Hartrampf PE, Kong G, Grana CM, Alexander Walter M, Capoccetti F, Kasi PM, Strosberg J. Peptide Receptor Radionuclide Therapy in Merkel Cell Carcinoma: A Comprehensive Review. J Nucl Med Technol 2023; 51:22-25. [PMID: 36195446 DOI: 10.2967/jnmt.122.264904] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/14/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Merkel cell carcinoma is a rare, aggressive skin malignancy, also known as neuroendocrine carcinoma of the skin, with high rates of recurrence and distant metastasis. In refractory metastatic Merkel cell carcinoma (mMCC), besides immunotherapy, chemotherapy, and radiation, peptide receptor radionuclide therapy (PRRT) may be a viable option since this type of tumor can express somatostatin receptors. Methods: We performed a comprehensive review of the literature to evaluate the efficacy of PRRT in mMCC patients. Results: Thirty-seven patients with mMCC received PRRT (1-5 cycles) with 177Lu- or 90Y-labeled somatostatin analogs (cumulative activity, 1.5-30 GBq). Radiographic response was available for 19 of 28 patients who received PRRT alone. Six (31.6%) of 19 patients showed objective responses, from partial to complete, and no severe adverse events were reported. Conclusion: Our analysis supports the use of PRRT in mMCC with sufficient somatostatin receptor uptake, although the quality of the available evidence is low. Prospective clinical trials are already in development and have started accruing in some parts of the world.
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Affiliation(s)
- Emran Askari
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Damian Wild
- ENETS Center of Excellence, Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Ebrahim Delpassand
- Department of Clinical Nuclear Medicine, Excel Diagnostics Imaging Clinic, Houston, Texas
| | - Sergio Baldari
- Nuclear Medicine Unit, Department of Biomedical and Dental Sciences and of Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Bernhard Nilica
- Department of Nuclear Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Philipp E Hartrampf
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Grace Kong
- Sir Peter MacCallum Department of Oncology and Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Chiara Maria Grana
- Division of Nuclear Medicine, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Francesca Capoccetti
- UOC Nuclear Medicine-PET Center-Single Regional Center for Radiometabolic Therapy, Department of Radiological Diagnosis and Services, ASUR Marche Area Vasta 3, Macerata, Italy
| | - Pashtoon Murtaza Kasi
- Meyer Cancer Center and Englander Institute of Precision Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York; and
| | - Jonathan Strosberg
- Neuroendocrine Tumor Division, Gastrointestinal Department, Moffitt Cancer Center, Tampa, Florida
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12
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Becker JC, Beer AJ, DeTemple VK, Eigentler T, Flaig M, Gambichler T, Grabbe S, Höller U, Klumpp B, Lang S, Pföhler C, Posch C, Prasad V, Schlattmann P, Schneider-Burrus S, Ter-Nedden J, Terheyden P, Thoms K, Vordermark D, Ugurel S. S2k Guideline - Merkel cell carcinoma (MCC, neuroendocrine carcinoma of the skin) - Update 2022. J Dtsch Dermatol Ges 2023; 21:305-320. [PMID: 36929552 DOI: 10.1111/ddg.14930] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/09/2022] [Indexed: 03/18/2023]
Abstract
Merkel cell carcinoma (MCC, ICD-O M8247/3) is a rare, malignant, primary skin tumor with epithelial and neuroendocrine differentiation. The tumor cells share many morphologic, immunohistochemical, and ultrastructural features with cutaneous Merkel cells. Nevertheless, the cell of origin of MCC is unclear. MCC appears clinically as a reddish to purple spherical tumor with a smooth, shiny surface and a soft to turgid, elastic consistency, usually showing rapid growth. Spontaneous and often complete regressions of the tumor are observed. These likely immunologically-mediated regressions explain the cases in which only lymph node or distant metastases are found at the time of initial diagnosis and why the tumor responds very well to immunomodulatory therapies even at advanced stages. Due to its aggressiveness, the usually given indication for sentinel lymph node biopsy, the indication of adjuvant therapies to be evaluated, as well as the complexity of the necessary diagnostics, clinical management should already be determined by an interdisciplinary tumor board at the time of initial diagnosis.
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Affiliation(s)
- Jürgen C Becker
- Translational Skin Cancer Research (TSCR), Deutsches Konsortium für translationale Krebsforschung (DKTK), Partnerstandort Essen, Department of Dermatology, University Hospital Essen, German Cancer Research Center (DKFZ), Heidelberg
| | - Ambros J Beer
- Department of Nuclear Medicine, University Hospital Ulm
| | - Viola K DeTemple
- Department of Dermatology, Venereology, Allergology and Phlebology, Johannes Wesling Klinikum, Minden
| | - Thomas Eigentler
- Department of Dermatology, Venereology and Allergology, University Hospital Berlin
| | - Michael Flaig
- Department and Clinic for Dermatology and Allergology, LMU Klinikum Munich
| | - Thilo Gambichler
- Department of Dermatology, Venereology and Allergology, Ruhr University Bochum
| | | | | | | | - Stephan Lang
- Department of Ear, Nose and Throat Medicine, University Hospital Essen
| | - Claudia Pföhler
- Department of Dermatology, University Hospital Saarland, Homburg/Saar
| | - Christian Posch
- Department of Dermatology Campus Biederstein, Technical University Munich
| | - Vikas Prasad
- Department of Nuclear Medicine, University Hospital Ulm
| | | | | | - Jan Ter-Nedden
- Professional Association of German Dermatologists, Hamburg
| | - Patrick Terheyden
- Department of Dermatology, Venereology and Allergology, University Hospital Schleswig-Holstein, Campus Lübeck
| | - Kai Thoms
- Department of Dermatology, Venereology and Allergology, University Hospital Göttingen, Göttingen
| | | | - Selma Ugurel
- Department of Dermatology, Venereology and Allergology, University Hospital Essen
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13
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Lückerath K, Trajkovic-Arsic M, Mona CE. Fibroblast Activation Protein Inhibitor Theranostics. PET Clin 2023:S1556-8598(23)00019-6. [PMID: 36990945 DOI: 10.1016/j.cpet.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Fibroblast activation protein (FAP)-radioligand therapy might be effective in some patients without being curative. FAP-radioligands deliver ionizing radiation directly to FAP+ cancer-associated fibroblasts and, in some cancers, to FAP+ tumor cells; in addition, they indirectly irradiate FAP- cells in tumor tissue via cross-fire and bystander effects. Here, we discuss the potential to improve FAP-radioligand therapy through interfering with DNA damage repair, immunotherapy, and co-targeting cancer-associated fibroblasts. As the molecular and cellular effects of FAP-radioligands on the tumor and its microenvironment have not been investigated yet, we call for future research to close this gap in knowledge, which prevents the development of more effective FAP-radioligand therapies.
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Affiliation(s)
- Katharina Lückerath
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Marija Trajkovic-Arsic
- Division of Solid Tumor Translational Oncology, DKTK and German Cancer Research Center (DKFZ) Partner Side Essen, Hufelandstrasse 15, 45147, Germany; Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Christine E Mona
- Ahmanson Translational Theranostic Division, Department of Molecular and Medical Pharmacology, University of California Los Angeles, 650 Charles E Young Drive S, Los Angeles, CA 90095, USA.
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14
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Kerr CP, Grudzinski JJ, Nguyen TP, Hernandez R, Weichert JP, Morris ZS. Developments in Combining Targeted Radionuclide Therapies and Immunotherapies for Cancer Treatment. Pharmaceutics 2022; 15:128. [PMID: 36678756 PMCID: PMC9865370 DOI: 10.3390/pharmaceutics15010128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 01/01/2023] Open
Abstract
Targeted radionuclide therapy (TRT) and immunotherapy are rapidly growing classes of cancer treatments. Basic, translational, and clinical research are now investigating therapeutic combinations of these agents. In comparison to external beam radiation therapy (EBRT), TRT has the unique advantage of treating all disease sites following intravenous injection and selective tumor uptake and retention-a particularly beneficial property in metastatic disease settings. The therapeutic value of combining radiation therapy with immune checkpoint blockade to treat metastases has been demonstrated in preclinical studies, whereas results of clinical studies have been mixed. Several clinical trials combining TRT and immune checkpoint blockade have been initiated based on preclinical studies combining these with EBRT and/or TRT. Despite the interest in translation of TRT and immunotherapy combinations, many questions remain surrounding the mechanisms of interaction and the optimal approach to clinical implementation of these combinations. This review highlights the mechanisms of interaction between anti-tumor immunity and radiation therapy and the status of basic and translational research and clinical trials investigating combinations of TRT and immunotherapies.
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Affiliation(s)
- Caroline P. Kerr
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53705, USA
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Joseph J. Grudzinski
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Thanh Phuong Nguyen
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Reinier Hernandez
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Jamey P. Weichert
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Zachary S. Morris
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53705, USA
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15
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Kleinendorst SC, Oosterwijk E, Bussink J, Westdorp H, Konijnenberg MW, Heskamp S. Combining Targeted Radionuclide Therapy and Immune Checkpoint Inhibition for Cancer Treatment. Clin Cancer Res 2022; 28:3652-3657. [PMID: 35471557 PMCID: PMC9433955 DOI: 10.1158/1078-0432.ccr-21-4332] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/03/2022] [Accepted: 04/11/2022] [Indexed: 01/07/2023]
Abstract
The development of immunotherapy, in particular immune checkpoint inhibitors (ICI), has revolutionized cancer treatment in the past decades. However, its efficacy is still limited to subgroups of patients with cancer. Therefore, effective treatment combination strategies are needed. Here, radiotherapy is highly promising, as it can induce immunogenic cell death, triggering the release of pro-inflammatory cytokines, thereby creating an immunogenic phenotype and sensitizing tumors to ICI. Recently, targeted radionuclide therapy (TRT) has attained significant interest for cancer treatment. In this approach, a tumor-targeting radiopharmaceutical is used to specifically deliver a therapeutic radiation dose to all tumor cells, including distant metastatic lesions, while limiting radiation exposure to healthy tissue. However, fundamental differences between TRT and conventional radiotherapy make it impossible to directly extrapolate the biological effects from conventional radiotherapy to TRT. In this review, we present a comprehensive overview of studies investigating the immunomodulatory effects of TRT and the efficacy of combined TRT-ICI treatment. Preclinical studies have evaluated a variety of murine cancer models in which α- or β-emitting radionuclides were directed to a diverse set of targets. In addition, clinical trials are ongoing to assess safety and efficacy of combined TRT-ICI in patients with cancer. Taken together, research indicates that combining TRT and ICI might improve therapeutic response in patients with cancer. Future research has to disclose what the optimal conditions are in terms of dose and treatment schedule to maximize the efficacy of this combined approach.
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Affiliation(s)
- Simone C. Kleinendorst
- Department of Medical Imaging, Nuclear Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Egbert Oosterwijk
- Department of Urology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Johan Bussink
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Harm Westdorp
- Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands.,Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mark W. Konijnenberg
- Department of Medical Imaging, Nuclear Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Sandra Heskamp
- Department of Medical Imaging, Nuclear Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands.,Corresponding Author: Sandra Heskamp, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands. Phone: 243-614-511; E-mail:
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16
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Short-Interval, Low-Dose Peptide Receptor Radionuclide Therapy in Combination with PD-1 Checkpoint Immunotherapy Induces Remission in Immunocompromised Patients with Metastatic Merkel Cell Carcinoma. Pharmaceutics 2022; 14:pharmaceutics14071466. [PMID: 35890361 PMCID: PMC9323617 DOI: 10.3390/pharmaceutics14071466] [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: 05/29/2022] [Revised: 07/05/2022] [Accepted: 07/11/2022] [Indexed: 11/17/2022] Open
Abstract
Merkel cell carcinoma (MCC) is a neuroendocrine skin cancer of the elderly, with high metastatic potential and poor prognosis. In particular, the primary resistance to immune checkpoint inhibitors (ICI) in metastatic (m)MCC patients represents a challenge not yet met by any efficient treatment modality. Herein, we describe a novel therapeutic concept with short-interval, low-dose 177Lutetium (Lu)-high affinity (HA)-DOTATATE [177Lu]Lu-HA-DOTATATE peptide receptor radionuclide therapy (SILD-PRRT) in combination with PD-1 ICI to induce remission in patients with ICI-resistant mMCC. We report on the initial refractory response of two immunocompromised mMCC patients to the PD-L1 inhibitor avelumab. After confirming the expression of somatostatin receptors (SSTR) on tumor cells by [68Ga]Ga-HA-DOTATATE-PET/CT (PET/CT), we employed low-dose PRRT (up to six treatments, mean activity 3.5 GBq per cycle) at 3–6 weeks intervals in combination with the PD-1 inhibitor pembrolizumab to restore responsiveness to ICI. This combination enabled the synergistic application of PD-1 checkpoint immunotherapy with low-dose PRRT at more frequent intervals, and was very well tolerated by both patients. PET/CTs demonstrated remarkable responses at all metastatic sites (lymph nodes, distant skin, and bones), which were maintained for 3.6 and 4.8 months, respectively. Both patients eventually succumbed with progressive disease after 7.7 and 8 months, respectively, from the start of treatment with SILD-PRRT and pembrolizumab. We demonstrate that SILD-PRRT in combination with pembrolizumab is safe and well-tolerated, even in elderly, immunocompromised mMCC patients. The restoration of clinical responses in ICI-refractory patients as proposed here could potentially be used not only for patients with mMCC, but many other cancer types currently treated with PD-1/PD-L1 inhibitors.
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17
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Iravani A, Parihar AS, Akhurst T, Hicks RJ. Molecular imaging phenotyping for selecting and monitoring radioligand therapy of neuroendocrine neoplasms. Cancer Imaging 2022; 22:25. [PMID: 35659779 PMCID: PMC9164531 DOI: 10.1186/s40644-022-00465-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 05/26/2022] [Indexed: 11/10/2022] Open
Abstract
Neuroendocrine neoplasia (NEN) is an umbrella term that includes a widely heterogeneous disease group including well-differentiated neuroendocrine tumours (NETs), and aggressive neuroendocrine carcinomas (NECs). The site of origin of the NENs is linked to the intrinsic tumour biology and is predictive of the disease course. It is understood that NENs demonstrate significant biologic heterogeneity which ultimately translates to widely varying clinical presentations, disease course and prognosis. Thus, significant emphasis is laid on the pre-therapy evaluation of markers that can help predict tumour behavior and dynamically monitors the response during and after treatment. Most well-differentiated NENs express somatostatin receptors (SSTRs) which make them appropriate for peptide receptor radionuclide therapy (PRRT). However, the treatment outcomes of PRRT depend heavily on the adequacy of patient selection by molecular imaging phenotyping not only utilizing pre-treatment SSTR PET but 18F-Fluorodeoxyglucose (18F-FDG) PET to provide insights into the intra- or inter-tumoural heterogeneity of the metastatic disease. Molecular imaging phenotyping may go beyond patient selection and provide useful information during and post-treatment for monitoring of temporal heterogeneity of the disease and dynamically risk-stratify patients. In addition, advances in the understanding of genomic-phenotypic classifications of pheochromocytomas and paragangliomas led to an archetypical example in precision medicine by utilizing molecular imaging phenotyping to guide radioligand therapy. Novel non-SSTR based peptide receptors have also been explored diagnostically and therapeutically to overcome the tumour heterogeneity. In this paper, we review the current molecular imaging modalities that are being utilized for the characterization of the NENs with special emphasis on their role in patient selection for radioligand therapy.
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