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Resch S, Ziegler SI, Sheikh G, Unterrainer LM, Zacherl MJ, Bartenstein P, Böning G, Brosch-Lenz J, Delker A. Impact of the Reference Multiple-Time-Point Dosimetry Protocol on the Validity of Single-Time-Point Dosimetry for [ 177Lu]Lu-PSMA-I&T Therapy. J Nucl Med 2024; 65:1272-1278. [PMID: 38936975 PMCID: PMC11294067 DOI: 10.2967/jnumed.123.266871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/22/2024] [Indexed: 06/29/2024] Open
Abstract
Internal dosimetry supports safe and effective patient management during radionuclide therapy. Yet, it is associated with high clinical workload, costs, and patient burden, as patient scans at multiple time points (MTPs) must be acquired. Dosimetry based on imaging at a single time point (STP) has continuously gained popularity. However, MTP protocols, used as a reference to judge the validity of STP dosimetry, differ depending on local requirements and deviate from the unknown patient-specific ground truth pharmacokinetics. The aim of this study was to compare the error and optimum time point for different STP approaches using different reference MTP protocols. Methods: Whole-body SPECT/CT scans of 7 patients (7.4-8.9 GBq of [177Lu]Lu-PSMA-I&T) were scheduled at 24, 48, 72, and 168 h after injection. Sixty lesions, 14 kidneys, and 10 submandibular glands were delineated in the SPECT/CT data. Two curve models, that is, a mono- and a biexponential model, were fitted to the MTP data, in accordance with goodness-of-fit analysis (coefficients of variation, sum of squared errors). Three population-based STP approaches were compared: one method published by Hänscheid et al., one by Jackson et al., and one using population-based effective half-lives in the mono- or biexponential curve models. Percentage differences between STP and MTP dosimetry were evaluated. Results: Goodness-of-fit parameters show that a monoexponential function and a biexponential function with shared population-based parameters and physical tail are reasonable reference models. When comparing both reference models, we observed maximum differences of -44%, -19%, and -28% in the estimated absorbed doses for lesions, kidneys, and salivary glands, respectively. STP dosimetry with an average deviation of less than 10% from MTP dosimetry may be feasible; however, this deviation and the optimum imaging time point showed a dependence on the chosen reference protocol. Conclusion: STP dosimetry for [177Lu]Lu-PSMA therapy is promising to boost the integration of dosimetry into clinical routine. According to our patient cohort, 48 h after injection may be regarded as a compromise for STP dosimetry for lesions and at-risk organs. The results from this analysis show that a common gold standard for dosimetry is desirable to allow for reliable and comparable STP dosimetry.
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Affiliation(s)
- Sandra Resch
- Department of Nuclear Medicine, LMU University Hospital, LMU, Munich, Germany;
| | - Sibylle I Ziegler
- Department of Nuclear Medicine, LMU University Hospital, LMU, Munich, Germany
| | - Gabriel Sheikh
- Department of Nuclear Medicine, LMU University Hospital, LMU, Munich, Germany
| | - Lena M Unterrainer
- Department of Nuclear Medicine, LMU University Hospital, LMU, Munich, Germany
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, UCLA, Los Angeles, California; and
| | - Mathias J Zacherl
- Department of Nuclear Medicine, LMU University Hospital, LMU, Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, LMU University Hospital, LMU, Munich, Germany
| | - Guido Böning
- Department of Nuclear Medicine, LMU University Hospital, LMU, Munich, Germany
| | - Julia Brosch-Lenz
- Department of Nuclear Medicine, Technical University of Munich, Munich, Germany
| | - Astrid Delker
- Department of Nuclear Medicine, LMU University Hospital, LMU, Munich, Germany
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Yazdani E, Asadi M, Geramifar P, Karamzade-Ziarati N, Vosoughi H, Kazemi-Jahromi M, Sadeghi M. A step toward simplified dosimetry of radiopharmaceutical therapy via SPECT frame duration reduction. Appl Radiat Isot 2024; 210:111378. [PMID: 38820867 DOI: 10.1016/j.apradiso.2024.111378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 05/09/2024] [Accepted: 05/26/2024] [Indexed: 06/02/2024]
Abstract
Despite being time-consuming, SPECT/CT data is necessary for accurate dosimetry in patient-specific radiopharmaceutical therapy. We investigated how reducing the frame duration (FD) during SPECT acquisition can simplify the dosimetry workflow for [177Lu]Lu-PSMA radioligand therapy (RLT). We aimed to determine the impact of shortened acquisition times on dosimetric precision. Three SPECT scans with FD of 20, 10, and 5 second/frame (sec/fr) were obtained 48 h post-RLT from one metastatic castration-resistant prostate cancer (mCRPC) patient's pelvis. Planar images at 4, 48, and 72 h post-therapy were used to calculate time-integrated activities (TIAs). Using accurate activity calibrations and GATE Monte Carlo (MC) dosimetry, absorbed doses in tumor lesions and kidneys were estimated. Dosimetry precision was assessed by comparing shorter FD results to the 20 sec/fr reference using relative percentage difference (RPD). We observed consistent calibration factors (CFs) across different FDs. Using the same CF, we obtained marginal RPD deviations less than 4% for the right kidney and tumor lesions and less than 7% for the left kidney. By reducing FD, simulation time was slightly decreased. This study shows we can shorten SPECT acquisition time in RLT dosimetry by reducing FD without sacrificing dosimetry accuracy. These findings pave the way for streamlined personalized internal dosimetry workflows.
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Affiliation(s)
- Elmira Yazdani
- Medical Physics Department, School of Medicine, Iran University of Medical Sciences, Tehran, Iran; Finetech in Medicine Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Asadi
- Research Center for Nuclear Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Parham Geramifar
- Research Center for Nuclear Medicine, Tehran University of Medical Sciences, Tehran, Iran.
| | | | - Habibeh Vosoughi
- Research Center for Nuclear Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahmood Kazemi-Jahromi
- Medical Physics Department, School of Medicine, Iran University of Medical Sciences, Tehran, Iran; Finetech in Medicine Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahdi Sadeghi
- Medical Physics Department, School of Medicine, Iran University of Medical Sciences, Tehran, Iran; Finetech in Medicine Research Center, Iran University of Medical Sciences, Tehran, Iran.
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Vergnaud L, Dewaraja YK, Giraudet AL, Badel JN, Sarrut D. A review of 177Lu dosimetry workflows: how to reduce the imaging workloads? EJNMMI Phys 2024; 11:65. [PMID: 39023648 DOI: 10.1186/s40658-024-00658-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 06/07/2024] [Indexed: 07/20/2024] Open
Abstract
177 Lu radiopharmaceutical therapy is a standardized systemic treatment, with a typical dose of 7.4 GBq per injection, but its response varies from patient to patient. Dosimetry provides the opportunity to personalize treatment, but it requires multiple post-injection images to monitor the radiopharmaceutical's biodistribution over time. This imposes an additional imaging burden on centers with limited resources. This review explores methods to lessen this burden by optimizing acquisition types and minimizing the number and duration of imaging sessions. After summarizing the different steps of dosimetry and providing examples of dosimetric workflows for177 Lu -DOTATATE and177 Lu -PSMA, we examine dosimetric workflows based on a reduced number of acquisitions, or even just one. We provide a non-exhaustive description of simplified methods and their assumptions, as well as their limitations. Next, we detail the specificities of each normal tissue and tumors, before reviewing dose-response relationships in the literature. In conclusion, we will discuss the current limitations of dosimetric workflows and propose avenues for improvement.
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Affiliation(s)
- Laure Vergnaud
- CREATIS; CNRS UMR 5220; INSERM U 1044, Université de Lyon; INSA-Lyon; Université Lyon 1, Lyon, France.
| | - Yuni K Dewaraja
- Department of Radiology, University of Michigan, Ann Arbor, USA
| | | | - Jean-Noël Badel
- CREATIS; CNRS UMR 5220; INSERM U 1044, Université de Lyon; INSA-Lyon; Université Lyon 1, Lyon, France
- Centre de lutte contre le cancer Léon Bérard, Lyon, France
| | - David Sarrut
- CREATIS; CNRS UMR 5220; INSERM U 1044, Université de Lyon; INSA-Lyon; Université Lyon 1, Lyon, France
- Centre de lutte contre le cancer Léon Bérard, Lyon, France
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4
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Karimzadeh A, Schatz L, Sauer M, Apostolova I, Buchert R, Klutmann S, Lehnert W. Organ and tumor dosimetry including method simplification for [ 177Lu]Lu-PSMA-I&T for treatment of metastatic castration resistant prostate cancer. EJNMMI Phys 2024; 11:63. [PMID: 39017988 PMCID: PMC11255161 DOI: 10.1186/s40658-024-00668-6] [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: 02/16/2024] [Accepted: 07/05/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND Internal dosimetry in individual patients is essential for safe and effective radioligand therapy. Multiple time point imaging for accurate dosimetry is time consuming and hence can be demanding for nuclear medicine departments as well as patients. The objectives of this study were (1) to assess absorbed doses to organs at risk and tumor lesions for [177Lu]Lu-PSMA-I&T using whole body SPECT imaging and (2) to investigate possible simplified dosimetry protocols. METHODS This study included 16 patients each treated with 4 cycles of [177Lu]Lu-PSMA-I&T. They underwent quantitative whole body SPECT/CT imaging (3 bed positions) at four time points (TP) comprising 2 h, 24 h, 48 h and 72-168 h post-injection (p.i.). Full 3D dosimetry (reference method) was performed for all patients and dose cycles for organs at risk (kidneys, parotid glands and submandibular glands) and up to ten tumor lesions per patient (resulting in 90 lesions overall). The simplified dosimetry methods (SM) included (1) generating time activity curves for subsequent cycles using a single TP of imaging applying the kinetics of dose cycle 1, and for organs at risk also (2) simple extrapolation from dose cycle 1 and (3) from both, dose cycle 1 and 2. RESULTS Normalized absorbed doses were 0.71 ± 0.32 mGy/MBq, 0.28 ± 0.12 mGy/MBq and 0.22 ± 0.08 mGy/MBq for kidneys, parotid glands and submandibular glands, respectively. Tumor doses decreased from 3.86 ± 3.38 mGy/MBq in dose cycle 1 to 2.01 ± 2.65 mGy/MBq in dose cycle 4. Compared to the full dosimetry approach the SM 1 using single TP imaging at 48 h p.i. resulted in the most accurate and precise results for the organs at risk in terms of absorbed doses per cycle and total cumulated dose. For tumor lesions better results were achieved using the fourth TP (≥ 72 h p.i.). CONCLUSION Simplification of safety dosimetry protocols is possible for [177Lu]Lu-PSMA-I&T therapy. If tumor dosimetry is of interest a later imaging TP (≥ 72 h p.i.) should be used/added to account for the slower kinetics of tumors compared to organs at risk.
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Affiliation(s)
- Amir Karimzadeh
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Linus Schatz
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Markus Sauer
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Ivayla Apostolova
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Ralph Buchert
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Susanne Klutmann
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Wencke Lehnert
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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5
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Zhang-Yin J. Lutetium-177-Prostate-Specific Membrane Antigen Radioligand Therapy: What Is the Value of Post-Therapeutic Imaging? Biomedicines 2024; 12:1512. [PMID: 39062085 PMCID: PMC11274713 DOI: 10.3390/biomedicines12071512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 06/24/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
Lutetium-177 (Lu-177)-labelled radioligand therapies (RLT) targeting prostate-specific membrane antigen (PSMA) present a promising treatment for patients with progressive metastasized castration-resistant prostate cancer (mCRPC). Personalized dosimetry, facilitated by post-therapeutic imaging, offers the potential to enhance treatment efficacy by customizing radiation doses to individual patient needs, thereby maximizing therapeutic benefits while minimizing toxicity to healthy tissues. However, implementing personalized dosimetry is resource-intensive, requiring multiple single-photon emission-computed tomography (SPECT)/CT scans and posing significant logistical challenges for both healthcare facilities and patients. Despite these challenges, personalized dosimetry can lead to optimized radiation delivery, improved safety, and better management of complex cases. Nevertheless, the financial and resource burdens complicate its adoption in routine clinical practice. While the European Association of Nuclear Medicine (EANM) supports personalized dosimetry, standardization is lacking due to these practical constraints. Further research and streamlined methodologies are essential to balance the benefits and feasibility of personalized dosimetry, potentially improving treatment outcomes for mCRPC patients.
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Affiliation(s)
- Jules Zhang-Yin
- Department of Nuclear Medicine, Clinique Sud Luxembourg, Vivalia, B-6700 Arlon, Belgium
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6
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Bryce AH, Crawford ED, Agarwal N, Hussain MH, Beltran H, Cooperberg MR, Petrylak DP, Shore N, Spratt DE, Tagawa ST, Antonarakis ES, Aparicio AM, Armstrong AJ, Boike TP, Calais J, Carducci MA, Chapin BF, Cookson MS, Davis JW, Dorff T, Eggener SE, Feng FY, Gleave M, Higano C, Iagaru A, Morgans AK, Morris M, Murray KS, Poage W, Rettig MB, Sartor O, Scher HI, Sieber P, Small E, Srinivas S, Yu EY, Zhang T, Koo PJ. Expert Perspectives on Controversies in Metastatic Castration-Resistant Prostate Cancer Management: Narrative Review and Report of the First US Prostate Cancer Conference Part 2. JU OPEN PLUS 2024; 2:e00032. [PMID: 38774467 PMCID: PMC11107999 DOI: 10.1097/ju9.0000000000000138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
Background Management strategies for metastatic castration-resistant prostate cancer (mCRPC) have rapidly shifted in recent years. As novel imaging and therapeutic approaches have made their way to the clinic, providers are encountering increasingly challenging clinical scenarios, with limited guidance from the current literature. Materials and Methods The US Prostate Cancer Conference (USPCC) is a multidisciplinary meeting of prostate cancer experts intended to address the many challenges of prostate cancer management. At the first annual USPCC meeting, areas of controversy and consensus were identified during a 2-day meeting that included expert presentations, full-panel discussions, and postdiscussion responses to questions developed by the USPCC cochairs and session moderators. Results This narrative review covers the USPCC expert discussion and perspectives relevant to mCRPC, including neuroendocrine/aggressive-variant prostate cancer (NEPC/AVPC). Areas of broad agreement identified among USPCC experts include the benefits of poly (ADP-ribose) polymerase (PARP) inhibitors for patients with BRCA1/2 mutations, the use of radioligand therapy in patients with prostate-specific membrane antigen (PSMA)-positive mCRPC, and the need for clinical trials that address real-world clinical questions, including the performance of novel therapies when compared with modern standard-of-care treatment. Ongoing areas of controversy and uncertainty included the appropriateness of PARP inhibitors in patients with non-BRCA1/2 mutations, the optimal definition of PSMA positivity, and systemic therapies for patients with NEPC/AVPC after progression on platinum-based therapies. Conclusions The first annual USPCC meeting identified several areas of controversy in the management of mCRPC, highlighting the urgent need for clinical trials designed to facilitate treatment selection and sequencing in this heterogeneous disease state.
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Affiliation(s)
- Alan H. Bryce
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, Arizona
| | - E. David Crawford
- Department of Urology, University of California San Diego, La Jolla, California
| | - Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Maha H. Hussain
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Evanston, Illinois
| | - Himisha Beltran
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Matthew R. Cooperberg
- Department of Urology, University of California at San Francisco, San Francisco, California
| | | | - Neal Shore
- Carolina Urologic Research Center/Genesis Care, Myrtle Beach, South Carolina
| | | | - Scott T. Tagawa
- Division of Hematology & Medical Oncology, Weill Cornell Medicine, New York, New York
| | | | - Ana M. Aparicio
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew J. Armstrong
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, North Carolina
| | | | - Jeremie Calais
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, University of California Los Angeles, Los Angeles, California
| | | | - Brian F. Chapin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael S. Cookson
- Department of Urology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - John W. Davis
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tanya Dorff
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Scott E. Eggener
- Departments of Surgery (Urology), University of Chicago Medical Center, Chicago, Illinois
| | - Felix Y. Feng
- Departments of Radiation Oncology, Urology, and Medicine, University of California San Francisco, San Francisco, California
| | - Martin Gleave
- Urological Sciences, Vancouver Prostate Centre, University of British Columbia, Vancouver, Canada
| | - Celestia Higano
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrei Iagaru
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Stanford University, Stanford, California
| | - Alicia K. Morgans
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Michael Morris
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katie S. Murray
- Department of Urology, NYU Langone Health, New York, New York
| | - Wendy Poage
- Prostate Conditions Education Council, Centennial, Colorado
| | - Matthew B. Rettig
- Department of Medicine, Division of Hematology-Oncology, VA Greater Los Angeles, Los Angeles, California
- Departments of Medicine and Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Howard I. Scher
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul Sieber
- Keystone Urology Specialists, Lancaster, Pennsylvania
| | - Eric Small
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Sandy Srinivas
- Division of Medical Oncology, Stanford University Medical Center, Stanford, California
| | - Evan Y. Yu
- Department of Medicine, Division of Hematology & Oncology, University of Washington and Fred Hutchinson Cancer Center, Seattle, Washington
| | - Tian Zhang
- Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
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Herrmann K, Rahbar K, Eiber M, Sparks R, Baca N, Krause BJ, Lassmann M, Jentzen W, Tang J, Chicco D, Klein P, Blumenstein L, Basque JR, Kurth J. Renal and Multiorgan Safety of 177Lu-PSMA-617 in Patients with Metastatic Castration-Resistant Prostate Cancer in the VISION Dosimetry Substudy. J Nucl Med 2024; 65:71-78. [PMID: 38050121 PMCID: PMC10755516 DOI: 10.2967/jnumed.123.265448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 10/10/2023] [Indexed: 12/06/2023] Open
Abstract
In the VISION trial, [177Lu]Lu-PSMA-617 (177Lu-PSMA-617) plus protocol-permitted standard of care significantly improved overall survival and radiographic progression-free survival compared with standard of care alone in patients with prostate-specific membrane antigen-positive metastatic castration-resistant prostate cancer. This VISION dosimetry substudy quantified absorbed doses of 177Lu-PSMA-617 in the kidneys and other organs. Methods: Participants were a separate cohort of 30 nonrandomized patients receiving standard of care plus 177Lu-PSMA-617 at 7.4 GBq per cycle for up to 6 cycles. Blood samples, whole-body conjugate planar image scintigraphy, and abdominal SPECT/CT images were collected. SPECT/CT images were collected at 2, 24, 48, and 168 h after administration in cycle 1 and at a single time point 48 h after administration in cycles 2-6. Outcomes were absorbed dose per unit activity per cycle and cumulative absorbed dose over all cycles. Cumulative absorbed doses were predicted by extrapolation from cycle 1, and calculation of observed values was based on measurements of cycle 1 and cycles 2-6. Safety was also assessed. Results: Mean (±SD) absorbed doses per cycle in the kidneys were 0.43 ± 0.16 Gy/GBq in cycle 1 and 0.44 ± 0.21 Gy/GBq in cycles 2-6. The observed and predicted 6-cycle cumulative absorbed doses in the kidneys were 15 ± 6 and 19 ± 7 Gy, respectively. Observed and predicted cumulative absorbed doses were similar in other at-risk organs. Safety findings were consistent with those in the VISION study; no patients experienced renal treatment-emergent adverse events of a grade higher than 3. Conclusion: The renal cumulative absorbed 177Lu-PSMA-617 dose was below the established limit. 177Lu-PSMA-617 had a good overall safety profile, and low renal radiotoxicity was not a safety concern. Cumulative absorbed doses in at-risk organs over multiple cycles can be predicted by extrapolation from cycle 1 data in patients with metastatic castration-resistant prostate cancer receiving 177Lu-PSMA-617.
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Affiliation(s)
- Ken Herrmann
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium, University Hospital Essen, Essen, Germany;
| | - Kambiz Rahbar
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
| | | | | | | | - Bernd J Krause
- Department of Nuclear Medicine, Rostock University Medical Center, Rostock, Germany
| | - Michael Lassmann
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Walter Jentzen
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium, University Hospital Essen, Essen, Germany
| | - Jun Tang
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Daniela Chicco
- Advanced Accelerator Applications, a Novartis Company, Turin, Italy
| | - Patrick Klein
- Novartis Institutes for BioMedical Research, East Hanover, New Jersey
| | - Lars Blumenstein
- Novartis Institutes for BioMedical Research, Basel, Switzerland; and
| | | | - Jens Kurth
- Department of Nuclear Medicine, Rostock University Medical Center, Rostock, Germany
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8
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Hohberg M, Reifegerst M, Drzezga A, Wild M, Schmidt M. Prediction of Response to 177Lu-PSMA Therapy Based on Tumor-to-Kidney Ratio on Pretherapeutic PSMA PET/CT and Posttherapeutic Tumor-Dose Evaluation in mCRPC. J Nucl Med 2023; 64:1758-1764. [PMID: 37652546 DOI: 10.2967/jnumed.122.264953] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 07/25/2023] [Indexed: 09/02/2023] Open
Abstract
The aim of this study was to analyze the absorbed dose of 177Lu-PSMA in osseous versus lymphatic metastases in patients with metastatic castration-resistant prostate cancer across therapy cycles and to relate those data to therapeutic success. In addition, pretherapeutic prostate-specific membrane antigen (PSMA) PET/CT was evaluated for its ability to predict response behavior. Methods: The study comprised 30 patients with metastatic castration-resistant prostate cancer, each receiving at least 3 cycles of 177Lu-PSMA therapy. Prostate-specific antigen (PSA) values between baseline and 6 wk after the third therapy cycle were used to classify the patients as responders (PSA decline ≥ 50%) or nonresponders (unchanged or increasing PSA level). Quantitative SPECT/CT images were acquired 24, 48, and 168 h after application of 177Lu-PSMA. The absorbed dose for tumor lesions was calculated with dosimetry software. From the pretherapeutic PET/CT scan, the tumor-to-kidney uptake ratio was determined for different SUVs. Results: Regardless of patient response, the kidneys received a mean dose of 0.55 ± 0.20 Gy/GBq per cycle. In the first therapy cycle, the lymph node lesions received a mean dose of 3.73 ± 1.65 Gy/GBq in responders and 1.86 ± 1.25 Gy/GBq in nonresponders (P < 0.01). For bone lesions, the respective mean doses were 3.47 ± 2.00 Gy/GBq and 1.48 ± 0.95 Gy/GBq (P < 0.01). When successive therapy cycles were compared, the mean dose was found to have been reduced from the first to the second cycle by 27% for lymph nodes and by 33% for bone lesions. A significant difference (P < 0.01) in the ratio of lymph node and bone lesion uptake to kidney uptake between responders and nonresponders could be deduced from the pretherapeutic PET/CT scan. Conclusion: Significantly higher doses were achieved for lymph node and bone lesions in responders. The highest absorbed dose, for both lymphatic and osseous lesions, was achieved in the first cycle, decreasing in the second therapy cycle thereafter despite unchanged therapy activities. It may be possible to estimate the response to therapy from the ratio of tumor uptake to kidney uptake obtained from the pretherapeutic PSMA PET/CT scans.
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Affiliation(s)
- Melanie Hohberg
- Department of Nuclear Medicine and Cancer Center Cologne, University Hospital of Cologne, Cologne, Germany
| | - Manuel Reifegerst
- Department of Nuclear Medicine and Cancer Center Cologne, University Hospital of Cologne, Cologne, Germany
| | - Alexander Drzezga
- Department of Nuclear Medicine and Cancer Center Cologne, University Hospital of Cologne, Cologne, Germany
| | - Markus Wild
- Department of Nuclear Medicine and Cancer Center Cologne, University Hospital of Cologne, Cologne, Germany
| | - Matthias Schmidt
- Department of Nuclear Medicine and Cancer Center Cologne, University Hospital of Cologne, Cologne, Germany
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9
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Pretze M, Kotzerke J, Freudenberg R, Brogsitter C. Potential of 188Re as an Alternative to 177Lu and Dosimetric Consequences. J Nucl Med 2023; 64:1663. [PMID: 37536739 PMCID: PMC10586487 DOI: 10.2967/jnumed.123.265782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/14/2023] [Indexed: 08/05/2023] Open
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10
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Kratochwil C, Fendler WP, Eiber M, Hofman MS, Emmett L, Calais J, Osborne JR, Iravani A, Koo P, Lindenberg L, Baum RP, Bozkurt MF, Delgado Bolton RC, Ezziddin S, Forrer F, Hicks RJ, Hope TA, Kabasakal L, Konijnenberg M, Kopka K, Lassmann M, Mottaghy FM, Oyen WJG, Rahbar K, Schoder H, Virgolini I, Bodei L, Fanti S, Haberkorn U, Hermann K. Joint EANM/SNMMI procedure guideline for the use of 177Lu-labeled PSMA-targeted radioligand-therapy ( 177Lu-PSMA-RLT). Eur J Nucl Med Mol Imaging 2023; 50:2830-2845. [PMID: 37246997 PMCID: PMC10317889 DOI: 10.1007/s00259-023-06255-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/25/2023] [Indexed: 05/30/2023]
Abstract
Prostate-specific membrane antigen (PSMA) is expressed by the majority of clinically significant prostate adenocarcinomas, and patients with target-positive disease can easily be identified by PSMA PET imaging. Promising results with PSMA-targeted radiopharmaceutical therapy have already been obtained in early-phase studies using various combinations of targeting molecules and radiolabels. Definitive evidence of the safety and efficacy of [177Lu]Lu-PSMA-617 in combination with standard-of-care has been demonstrated in patients with metastatic castration-resistant prostate cancer, whose disease had progressed after or during at least one taxane regimen and at least one novel androgen-axis drug. Preliminary data suggest that 177Lu-PSMA-radioligand therapy (RLT) also has high potential in additional clinical situations. Hence, the radiopharmaceuticals [177Lu]Lu-PSMA-617 and [177Lu]Lu-PSMA-I&T are currently being evaluated in ongoing phase 3 trials. The purpose of this guideline is to assist nuclear medicine personnel, to select patients with highest potential to benefit from 177Lu-PSMA-RLT, to perform the procedure in accordance with current best practice, and to prepare for possible side effects and their clinical management. We also provide expert advice, to identify those clinical situations which may justify the off-label use of [177Lu]Lu-PSMA-617 or other emerging ligands on an individual patient basis.
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Affiliation(s)
- Clemens Kratochwil
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany.
| | - Wolfgang P Fendler
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, 45147, Essen, Germany
| | - Matthias Eiber
- Department of Nuclear Medicine, Klinikum Rechts Der Isar, Technical University Munich (TUM), 81675, Munich, Germany
| | - Michael S Hofman
- Prostate Cancer Theranostics and Imaging Centre of Excellence, Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Oncology, Sir Peter MacCallum, University of Melbourne, Melbourne, VIC, Australia
| | - Louise Emmett
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital Sydney, Darlinghurst, Australia
| | - Jeremie Calais
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph R Osborne
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10021, USA
| | - Amir Iravani
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
| | - Phillip Koo
- Division of Diagnostic Imaging, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - Liza Lindenberg
- Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
- F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Richard P Baum
- Curanosticum Wiesbaden-Frankfurt, Center for Advanced Radiomolecular Precision Oncology, Wiesbaden, Germany
| | - Murat Fani Bozkurt
- Hacettepe University Faculty of Medicine, Department of Nuclear Medicine, Ankara, Turkey
| | - Roberto C Delgado Bolton
- Department of Diagnostic Imaging (Radiology) and Nuclear Medicine, University Hospital San Pedro and Centre for Biomedical Research of La Rioja (CIBIR), Logroño (La Rioja), Spain
| | - Samer Ezziddin
- Department of Nuclear Medicine, Saarland University Medical Center, Homburg, Germany
| | - Flavio Forrer
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Rodney J Hicks
- The University of Melbourne Department of Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging / Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Levent Kabasakal
- Department of Nuclear Medicine, Cerrahpasa Medical Faculty, Istanbul University- Cerrahpasa, Istanbul, Turkey
| | - Mark Konijnenberg
- Radiology & Nuclear Medicine Department, Erasmus MC, Rotterdam, The Netherlands
| | - Klaus Kopka
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
- Technical University Dresden, School of Science, Faculty of Chemistry and Food Chemistry; German Cancer Consortium (DKTK), Partner Site Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT) Dresden, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Michael Lassmann
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Felix M Mottaghy
- Department of Nuclear Medicine, RWTH Aachen University Medical Faculty, Aachen, Germany
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Wim J G Oyen
- Department of Biomedical Sciences, Humanitas University, and Humanitas Clinical and Research Centre, Department of Nuclear Medicine, Milan, Italy
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, the Netherlands
- Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Kambiz Rahbar
- Department of Nuclear Medicine, University Hospital Muenster, Muenster, Germany
| | - Heiko Schoder
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Irene Virgolini
- Department of Nuclear Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Lisa Bodei
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stefano Fanti
- Division of Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Uwe Haberkorn
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Ken Hermann
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, 45147, Essen, Germany
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11
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Delker A, Schleske M, Liubchenko G, Berg I, Zacherl MJ, Brendel M, Gildehaus FJ, Rumiantcev M, Resch S, Hürkamp K, Wenter V, Unterrainer LM, Bartenstein P, Ziegler SI, Beyer L, Böning G. Biodistribution and dosimetry for combined [ 177Lu]Lu-PSMA-I&T/[ 225Ac]Ac-PSMA-I&T therapy using multi-isotope quantitative SPECT imaging. Eur J Nucl Med Mol Imaging 2023; 50:1280-1290. [PMID: 36629878 PMCID: PMC10027798 DOI: 10.1007/s00259-022-06092-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/22/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE Quantitative SPECT for patient-specific dosimetry is a valuable tool in the scope of radionuclide therapy, although its clinical application for 225Ac-based treatments may be limited due to low therapeutic activities. Therefore, the aim of this study was to demonstrate the feasibility of clinical quantitative low-count SPECT imaging during [177Lu]Lu-PSMA-I&T/[225Ac]Ac-PSMA-I&T treatment. METHODS Eight prostate cancer patients (1000 MBq/8 MBq [177Lu]Lu-PSMA-I&T/[225Ac]Ac-PSMA-I&T) received a single-bed quantitative 177Lu/225Ac SPECT/CT acquisition (1 h) at 24 h post treatment (high-energy collimator, 16 projections p. head à 3.5 min, 128 × 128 pixel). The gamma peak at 440 keV (width: 10%) of the progeny 213Bi was imaged along with the peak at 208 keV (width: 15%) of 177Lu. Quantification included CT-based attenuation and window-based scatter correction plus resolution modelling. Gaussian post-filtering with a full-width-half-maximum of 30 mm and 40-45 mm was employed to match the signal-to-noise ratio of 225Ac and 177Lu, respectively. RESULTS Kidney (r = 0.96, p < 0.01) and lesion (r = 0.94, p < 0.01) SUV for [177Lu]Lu-PSMA-I&T and [225Ac]Ac-PSMA-I&T showed a strong and significant correlation. Kidney SUV were significantly higher (p < 0.01) for [225Ac]Ac-PSMA-I&T (2.5 ± 0.8 vs. 2.1 ± 0.9), while for [177Lu]Lu-PSMA-I&T lesion SUV were significantly higher (p = 0.03; 1.8 ± 1.1 vs. 2.1 ± 1.5). For absorbed dose estimates, significant differences regarding the kidneys remained, while no significant differences for lesion dosimetry were found. CONCLUSION Quantitative low-count SPECT imaging of the peak at 440 keV during [225Ac]Ac-PSMA-I&T therapy is feasible. Multi-isotope imaging for [177Lu]Lu-PSMA-I&T/[225Ac]Ac-PSMA-I&T therapy indicates accumulation of free 213Bi in the kidneys.
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Affiliation(s)
- Astrid Delker
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany.
| | - Mirjam Schleske
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Grigory Liubchenko
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Isabella Berg
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | | | - Matthias Brendel
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
- SyNergy, University of Munich, Munich, Germany
- DZNE - German Center for Neurodegenerative Diseases, Munich, Germany
| | | | - Mikhail Rumiantcev
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Sandra Resch
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Kerstin Hürkamp
- Institute of Radiation Medicine, Helmholtz Zentrum München, German Research Center for Environmental Health GmbH, 85764, Neuherberg, Germany
| | - Vera Wenter
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Lena M Unterrainer
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Sibylle I Ziegler
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Leonie Beyer
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Guido Böning
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
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12
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Peters SMB, Mink MCT, Privé BM, de Bakker M, de Lange F, Muselaers CHJ, Mehra N, Witjes JA, Gotthardt M, Nagarajah J, Konijnenberg MW. Optimization of the radiation dosimetry protocol in Lutetium-177-PSMA therapy: toward clinical implementation. EJNMMI Res 2023; 13:6. [PMID: 36692682 PMCID: PMC9873880 DOI: 10.1186/s13550-023-00952-z] [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: 07/25/2022] [Accepted: 01/11/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Dosimetry in [177Lu]Lu-PSMA therapy is a valuable tool to assess treatment efficacy and toxicity. This study aims to develop a clinically implementable protocol to determine the absorbed dose in organs and tumor lesions after [177Lu]Lu-PSMA-617 therapy, by reducing the imaging time points and utilizing population-based kinetics with a single scan, with evaluation of its influence on the uncertainty in absorbed dose. METHODS Ten patients with metastatic hormone-sensitive prostate cancer received two cycles of [177Lu]Lu-PSMA-617. Post-treatment imaging was performed at 1 h, 24 h, 48 h, 72 h and 168 h, consisting of three-bed positions SPECT/CT and a whole-body planar scan. Five-time point SPECT dosimetry was performed for lesions and organs with physiological uptake (kidneys, liver and salivary glands) and used as the reference standard. Absorbed dose values for various simplified protocols were compared to the reference standard. RESULTS Accurate lesion dosimetry is possible using one-time point SPECT imaging at 168 h, with an increase in uncertainty (20% vs. 14% for the reference standard). By including a second time point, uncertainty was comparable to the reference standard (13%). Organ dosimetry can be performed using a single SPECT at 24 h or 48 h. Dosimetry based on planar scans did not provide accurate dose estimations. CONCLUSION Accurate lesion dosimetry in [177Lu]Lu-PSMA therapy can be performed using a one- or two-time point protocol, making dosimetry assessments more suitable for routine clinical implementation, although dosimetry based om multiple time points is more accurate. Clinical trial registration This study was approved by the Medical Review Ethics Committee Region Arnhem-Nijmegen on January 23, 2018 and was registered on clinicaltrials.gov (NCT03828838).
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Affiliation(s)
- Steffie M B Peters
- Department of Medical Imaging, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Maaike C T Mink
- Department of Medical Imaging, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.,Department of Physics and Astronomy, Radboud University, Nijmegen, The Netherlands
| | - Bastiaan M Privé
- Department of Medical Imaging, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Maarten de Bakker
- Department of Medical Imaging, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Frank de Lange
- Department of Medical Imaging, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | | | - Niven Mehra
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Alfred Witjes
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martin Gotthardt
- Department of Medical Imaging, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - James Nagarajah
- Department of Medical Imaging, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Mark W Konijnenberg
- Department of Medical Imaging, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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13
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Pirozzi Palmese V, D'Ambrosio L, Di Gennaro F, Maisto C, de Marino R, Morisco A, Coluccia S, Di Gennaro P, De Lauro F, Raddi M, Gaballo P, Tafuto S, Celentano E, Lastoria S. A comparison of simplified protocols of personalized dosimetry in NEN patients treated by radioligand therapy (RLT) with [ 177Lu]Lu-DOTATATE to favor its use in clinical practice. Eur J Nucl Med Mol Imaging 2023; 50:1753-1764. [PMID: 36688980 PMCID: PMC10119237 DOI: 10.1007/s00259-023-06112-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/05/2023] [Indexed: 01/24/2023]
Abstract
The role of internal dosimetry is usually proposed for investigational purposes in patients treated by RLT, even if its application is not yet the standard method in clinical practice. This limited use is partially justified by several concomitant factors that make calculations a complex process. Therefore, simplified dosimetry protocols are required. METHODS In our study, dosimetric evaluations were performed in thirty patients with NENs who underwent RLT with [177Lu]Lu-DOTATATE. The reference method (M0) calculated the cumulative absorbed dose performing dosimetry after each of the four cycles. Obtained data were employed to assess the feasibility of simplified protocols: defining the dosimetry only after the first cycle (M1) and after the first and last one (M2). RESULTS The mean differences of the cumulative absorbed doses between M1 and M0 were - 10% for kidney, - 5% for spleen, + 34% for liver, + 13% for red marrow, and + 37% for tumor lesions. Conversely, differences lower than ± 10% were measured between M2 and M0. CONCLUSION Cumulative absorbed doses obtained with the M2 protocol resembled the doses calculated by M0, while the M1 protocol overestimated the absorbed doses in all organs at risk, except for the spleen.
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Affiliation(s)
| | - Laura D'Ambrosio
- S.C. Medicina Nucleare E Terapia Radiometabolica, INT IRCCS Fondazione G. Pascale, Naples, Italy
| | - Francesca Di Gennaro
- S.C. Medicina Nucleare E Terapia Radiometabolica, INT IRCCS Fondazione G. Pascale, Naples, Italy
| | - Costantina Maisto
- S.C. Medicina Nucleare E Terapia Radiometabolica, INT IRCCS Fondazione G. Pascale, Naples, Italy
| | - Roberta de Marino
- S.C. Medicina Nucleare E Terapia Radiometabolica, INT IRCCS Fondazione G. Pascale, Naples, Italy
| | - Anna Morisco
- S.C. Medicina Nucleare E Terapia Radiometabolica, INT IRCCS Fondazione G. Pascale, Naples, Italy
| | - Sergio Coluccia
- S.C. Epidemiologia E Biostatistica, INT IRCCS Fondazione G. Pascale, Naples, Italy
| | | | - Francesco De Lauro
- S.C. Medicina Nucleare E Terapia Radiometabolica, INT IRCCS Fondazione G. Pascale, Naples, Italy
| | - Marco Raddi
- S.C. Medicina Nucleare E Terapia Radiometabolica, INT IRCCS Fondazione G. Pascale, Naples, Italy
| | - Paolo Gaballo
- S.C. Medicina Nucleare E Terapia Radiometabolica, INT IRCCS Fondazione G. Pascale, Naples, Italy
| | - Salvatore Tafuto
- S.C. Sarcomi E Tumori Rari, INT IRCCS Fondazione G. Pascale, Naples, Italy
| | - Egidio Celentano
- S.C. Epidemiologia E Biostatistica, INT IRCCS Fondazione G. Pascale, Naples, Italy
| | - Secondo Lastoria
- S.C. Medicina Nucleare E Terapia Radiometabolica, INT IRCCS Fondazione G. Pascale, Naples, Italy.
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