²¹³Bi-DOTATOC receptor-targeted alpha-radionuclide therapy induces remission in neuroendocrine tumours refractory to beta radiation: a first-in-human experience

Purpose

Radiopeptide therapy using a somatostatin analogue labelled with a beta emitter such as ⁹⁰Y/¹⁷⁷Lu-DOTATOC is a new therapeutic option in neuroendocrine cancer. Alternative treatments for patients with refractory disease are rare. Here we report the first-in-human experience with ²¹³Bi-DOTATOC targeted alpha therapy (TAT) in patients pretreated with beta emitters.

Methods

Seven patients with progressive advanced neuroendocrine liver metastases refractory to treatment with ⁹⁰Y/¹⁷⁷Lu-DOTATOC were treated with an intraarterial infusion of ²¹³Bi-DOTATOC, and one patient with bone marrow carcinosis was treated with a systemic infusion of ²¹³Bi-DOTATOC. Haematological, kidney and endocrine toxicities were assessed according to CTCAE criteria. Radiological response was assessed with contrast-enhanced MRI and ⁶⁸Ga-DOTATOC-PET/CT. More than 2 years of follow-up were available in seven patients.

Results

The biodistribution of ²¹³Bi-DOTATOC was evaluable with 440 keV gamma emission scans, and demonstrated specific tumour binding. Enduring responses were observed in all treated patients. Chronic kidney toxicity was moderate. Acute haematotoxicity was even less pronounced than with the preceding beta therapies.

Conclusion

TAT can induce remission of tumours refractory to beta radiation with favourable acute and mid-term toxicity at therapeutic effective doses.

Electronic supplementary material

The online version of this article (doi:10.1007/s00259-014-2857-9) contains supplementary material, which is available to authorized users.

Production of Ac-225 from Th-229 for targeted alpha therapy

This work describes a method for the separation and purification of Ac-225 from a Th-229 source. The procedure is based on the combination of ion exchange and extraction chromatographic methods in nitric acid media and allows the preparation of carrier-free, clinical grade Ac-225 with an overall yield exceeding 95%. Quality control of the product is performed using radiometric (alpha, gamma spectrometry) and mass spectrometric methods. The Ac-225 product can be loaded on a radionuclide generator for the preparation of Bi-213 for preclinical and clinical studies of targeted alpha therapy of cancer and infectious diseases.

Cyclotron production of Ac-225 for targeted alpha therapy

The feasibility of producing Ac-225 by proton irradiation of Ra-226 in a cyclotron through the reaction Ra-226(p,2n)Ac-225 has been experimentally demonstrated for the first time. Proton energies were varied from 8.8 to 24.8 MeV and cross-sections were determined by radiochemical analysis of reaction yields. Maximum yields were reached at incident proton energies of 16.8 MeV. Radiochemical separation of Ac-225 from the irradiated target yielded a product suitable for targeted alpha therapy of cancer.

Determination of the age of highly enriched uranium

This paper describes the analytical methods (thermal ionization mass spectrometry, inductively coupled plasma mass spectrometry, and alpha spectrometry) that have been developed for determination of the age of uranium and discusses their advantages and limitations. With regard to potential application of the methods (e.g. Fissile Material Cut-off Treaty), the discussion focuses on highly enriched uranium, because this seems to be of highest strategic relevance. The different analytical methods were tested and validated by use of uranium reference materials of different (235)U isotope abundance and of known ages. The results show that thermal ionization mass spectrometry and alpha spectrometry are both very accurate and precise techniques for this application. Inductively coupled plasma mass spectrometry, on the other hand, although less precise, because of the different approach to the analytical problem, is still sufficiently accurate to be used as a rapid screening method.

Age determination of highly enriched uranium: separation and analysis of 231Pa

An analytical procedure has been developed for the age determination of highly enriched uranium samples exploiting the mother/daughter pair 235U/231Pa. Protactinium is separated from bulk uranium through highly selective sorption to silica gel and is subsequently quantified using alpha-spectrometry. The method has been validated using uranium standard reference materials of known ages. It affords decontamination factors exceeding 2.5 x 10(7), overall recoveries in the range of 80-85%, and a combined uncertainty below 5%.

The in vivo fate of 225Ac daughter nuclides using polymersomes as a model carrier

Increasing attention is given to personalized tumour therapy, where α-emitters can potentially play an important role. Alpha particles are ideal for localized cell killing because of their high linear energy transfer and short ranges. However, upon the emission of an α particle the daughter nuclide experiences a recoil energy large enough to ensure decoupling from any chemical bond. These 'free' daughter nuclides are no longer targeted to the tumour and can accumulate in normal tissue. In this paper, we used polymersomes as model carrier to evaluate the retention of recoiling daughters of ²²⁵Ac in vivo, and assessed their suitability as therapeutic agents. Vesicles containing ²²⁵Ac were injected intravenously in healthy mice, and intratumourally in tumour-bearing mice, and the relocation of free ²¹³Bi was assessed in different organs upon the injection [²²⁵Ac]Ac-polymersomes. The therapeutic effect of ²²⁵Ac-containing vesicles was studied upon intratumoural injection, where treatment groups experienced no tumour-related deaths over a 115 day period. While polymersomes containing ²²⁵Ac could be suitable agents for long-term irradiation of tumours without causing significant renal toxicity, there is still a significant re-distribution of daughter nuclides throughout the body, signifying the importance of careful evaluation of the effect of daughter nuclides in targeted alpha therapy.

Single-column extraction chromatographic separation of U, Pu, Np and Am

A rapid, single-column extraction chromatographic method using commercially available UTEVA resin has been developed for the separation of uranium, plutonium, neptunium and americium. The method yields recoveries superior to 90% and allows direct loading of separated fractions on filaments for subsequent analysis by thermal ionization mass spectrometry. The use of reagents compatible with robotized equipment allows automation of the separation process for routine analysis of nuclear materials. The redox reactions between plutonium, neptunium and hydrogen peroxide involved in the separation process were studied by UV/Vis/NIR absorption spectroscopy.

Kinetics of the oxidation of Pu(IV) by manganese dioxide

The kinetics of the oxidation of plutonium(IV) by manganese dioxide were studied in 1.0 M NaCl over the pH range from 2.5 to 8.2 with variable concentrations of manganese dioxide from 0.01 m2/L to 4.97 m2/L at a constant temperature of 19 ± 2 °C. The concentration of plutonium in solution was 6.0(± 1.0) × 10−10M. Fractions of Pu(IV), (V) and (VI) as a function of time were determined by removal of plutonium from the solid phase followed by an ultrafiltration/solvent extraction procedure using TTA and HDEHP as extractants. Appropriate removal conditions were established for Pu(IV), Pu(V) and Pu(VI) using Th(IV), Np(V) and U(VI) as oxidation state analogs.

In the pH range from 2.0 to 3.5, the oxidation of Pu(IV) by manganese dioxide was first order with respect to the concentration of manganese dioxide and −0.21 with respect to the hydrogen ion concentration. Consequently, assuming a first order dependence with respect to the concentration of Pu(IV), the oxidation reaction can be described by the following rate equation:

withk= 3.72(± 0.13) × 10−3(m−2L)(mol−1L)−0.21(min)−1. Using the kinetic data determined in this study, the influence of manganese dioxide on the oxidation state distribution of plutonium under various environmental conditions as well as in waste solutions can be estimated.

Measurement of the 225Ac half-life

The (225)Ac half-life was determined by measuring the activity of (225)Ac sources as a function of time, using various detection techniques: α-particle counting with a planar silicon detector at a defined small solid angle and in a nearly-2π geometry, 4πα+β counting with a windowless CsI sandwich spectrometer and with a pressurised proportional counter, gamma-ray spectrometry with a HPGe detector and with a NaI(Tl) well detector. Depending on the technique, the decay was followed for 59-141 d, which is about 6-14 times the (225)Ac half-life. The six measurement results were in good mutual agreement and their mean value is T(1/2)((225)Ac)=9.920 (3)d. This half-life value is more precise and better documented than the currently recommended value of 10.0 d, based on two old measurements lacking uncertainty evaluations.

Toward developing a universal treatment for fungal disease using radioimmunotherapy targeting common fungal antigens

BACKGROUND

Previously, we demonstrated the ability of radiolabeled antibodies recognizing the cryptococcal polysaccharide capsule to kill Cryptococcus neoformans both in vitro and in infected mice. This approach, known as radioimmunotherapy (RIT), uses the exquisite ability of antibodies to bind antigens to deliver microbicidal radiation. To create RIT reagents which would be efficacious against all major medically important fungi, we have selected monoclonal antibodies (mAbs) to common surface fungal antigens such as heat shock protein 60 (HSP60), which is found on the surface of diverse fungi; beta (1,3)-glucan, which is a major constituent of fungal cell walls; ceramide which is found at the cell surface, and melanin, a polymer present in the fungal cell wall.

METHODS

MAbs 4E12, an IgG2a to fungal HSP60; 2G8, an IgG2b to beta-(1,3)-glucan; and 6D2, an IgM to melanin, were labeled with the alpha particle emitting radionuclide 213-Bismuth ((213)Bi) using the chelator CHXA". B11, an IgM antibody to glucosylceramide, was labeled with the beta emitter 188-Rhenium ((188)Re). Model organisms Cryptococcus neoformans and Candida albicans were used to assess the cytotoxicity of these compounds after exposure to either radiolabeled mAbs or controls.

RESULTS

(213)Bi-mAbs to HSP60 and to the beta-(1,3)-glucan each reduced the viability of both fungi by 80-100%. The (213)Bi-6D2 mAb to melanin killed 22% of C. neoformans, but did not kill C. albicans. B11 mAb against fungal ceramide was effective against wild-type C. neoformans, but was unable to kill a mutant lacking the ceramide target. Unlabeled mAbs and radiolabeled irrelevant control mAbs caused no killing.

CONCLUSION

Our results suggest that it is feasible to develop RIT against fungal pathogens by targeting common antigens and such an approach could be developed against fungal diseases for which existing therapy is unsatisfactory.

Antibody-guided alpha radiation effectively damages fungal biofilms

The use of indwelling medical devices--pacemakers, prosthetic joints, catheters--is rapidly growing and is often complicated by infections with biofilm-forming microbes that are resistant to antimicrobial agents and host defense mechanisms. We investigated for the first time the use of microbe-specific monoclonal antibodies (MAbs) as delivery vehicles for targeting biofilms with cytocidal radiation. MAb 18B7 (immunoglobulin G1 [IgG1]), which binds to capsular polysaccharides of the human pathogenic fungus Cryptococcus neoformans, penetrated cryptococcal biofilms, as shown by confocal microscopy. When the alpha radiation-emitter 213-Bismuth ((213)Bi) was attached to MAb 18B7 and the radiolabeled MAb was added to C. neoformans biofilms, there was a 50% reduction in biofilm metabolic activity. In contrast, when the IgM MAb 13F1 labeled with (213)Bi was used there was no penetration of the fungal biofilm and no damage. Unlabeled 18B7, (213)Bi-labeled nonspecific MAbs, and gamma and beta types of radiation did not have an effect on biofilms. The lack of efficacy of gamma and beta radiation probably reflects the radioprotective properties of polysaccharide biofilm matrix. Our results indicate that C. neoformans biofilms are susceptible to treatment with antibody-targeted alpha radiation, suggesting a novel option for the prevention or treatment of microbial biofilms on indwelling medical devices.

Improved 225Ac daughter retention in InPO4 containing polymersomes

Alpha-emitting radionuclides like actinium-225 (²²⁵Ac) are ideal candidates for the treatment of small metastasised tumours, where the long half-life of ²²⁵Ac enables it to also reach less accessible tumours. The main challenge lies in retaining the recoiled alpha-emitting daughter nuclides, which are decoupled from targeting agents upon emission of an alpha particle and can subsequently cause unwanted toxicity to healthy tissue. Polymersomes, vesicles composed of amphiphilic block copolymers, are capable of transporting (radio)pharmaceuticals to tumours, and are ideal candidates for the retention of these daughter nuclides. In this study, the Geant4 Monte Carlo simulation package was used to simulate ideal vesicle designs. Vesicles containing an InPO₄ nanoparticle in the core were found to have the highest recoil retention, and were subsequently synthesized in the lab. The recoil retention of two of the daughter nuclides, namely francium-221 (²²¹Fr) and bismuth-213 (²¹³Bi) was determined at different vesicle sizes. Recoil retention was found to have improved significantly, from 37 ± 4% and 22 ± 1% to 57 ± 5% and 40 ± 2% for ²²¹Fr and ²¹³Bi respectively for 100nm polymersomes, as compared to earlier published results by Wang et al. where ²²⁵Ac was encapsulated using a hydrophilic chelate (Wang et al. 2014). To better understand the different parameters influencing daughter retention, simulation data was expanded to include vesicle polydispersity and nanoparticle position within the polymersome. The high retention of the recoiling daughters and the ²²⁵Ac itself makes this vesicle design very suitable for future in vivo verification.

The therapeutic potential of polymersomes loaded with 225Ac evaluated in 2D and 3D in vitro glioma models

Alpha emitters have great potential in targeted tumour therapy, especially in destroying micrometastases, due to their high linear energy transfer (LET). To prevent toxicity caused by recoiled daughter atoms in healthy tissue, alpha emitters like ²²⁵Ac can be encapsulated in polymeric nanocarriers (polymersomes), which are capable of retaining the daughter atoms to a large degree. In the translation to a (pre-)clinical setting, it is essential to evaluate their therapeutic potential. As multicellular tumour spheroids mimic a tumour microenvironment more closely than a two-dimensional cellular monolayer, this study has focussed on the interaction of the polymersomes with U87 human glioma spheroids. We have found that polymersomes distribute themselves throughout the spheroid after 4 days which, considering the long half-life of ²²⁵Ac (9.9 d) (Vaidyanathan and Zalutsky, 1996), allows for irradiation of the entire spheroid. A decrease in spheroidal growth has been observed upon the addition of only 0.1 kBq ²²⁵Ac, an effect which was more pronounced for the ²²⁵Ac in polymersomes than when only coupled to DTPA. At higher activities (5 kBq), the spheroids have been found to be destroyed completely after two days. We have thus demonstrated that ²²⁵Ac containing polymersomes effectively inhibit tumour spheroid growth, making them very promising candidates for future in vivo testing.

The control of endothelial cell adhesion and migration by shear stress and matrix-substrate anchorage

Endothelial cells constitute the natural inner lining of blood vessels and possess anti-thrombogenic properties. This characteristic is frequently used by seeding endothelial cells on vascular prostheses. As the type of anchorage of adhesion ligands to materials surfaces is known to determine the mechanical balance of adherent cells, we investigated herein the behaviour of endothelial cells under physiological shear stress conditions. The adhesion ligand fibronectin was anchored to polymer surfaces of four physicochemical characteristics exhibiting covalent and non-covalent attachment as well as high and low hydrophobicity. The in situ analysis combined with cell tracking of shear stress-induced effects on cultured isolated cells and monolayers under venous (0.5 dyn/cm(2)) and arterial (12 dyn/cm(2)) shear stress over a time period of 24 h revealed distinct differences in their morphological and migratory features. Most pronounced, unidirectional and bimodal migration patterns of endothelial cells in or against flow direction were found in dependence on the type of substrate-matrix anchorage. Combined by an immunofluorescent analysis of the actin cytoskeleton, cell-cell junctions, cell-matrix adhesions, and matrix reorganization these results revealed a distinct balance of laminar shear stress, cell-cell contacts and substrate-matrix anchorage in affecting endothelial cell fate under flow conditions. This analysis underlines the importance of materials surface parameters as well as primary and secondary adhesion ligand anchorage in the context of artificial blood vessels for future therapeutic devices.

Evidence of extranuclear cell sensitivity to alpha-particle radiation using a microdosimetric model. I. Presentation and validation of a microdosimetric model

A microdosimetric model that makes it possible to consider the numerous biological and physical parameters of cellular alpha-particle irradiation by radiolabeled mAbs was developed. It allows for the calculation of single-hit and multi-hit distributions of specific energy within a cell nucleus or a whole cell in any irradiation configuration. Cells are considered either to be isolated or to be packed in a monolayer or a spheroid. The method of calculating energy deposits is analytical and is based on the continuous-slowing-down approximation. A model of cell survival, calculated from the microdosimetric spectra and the microdosimetric radiosensitivity, z(0), was also developed. The algorithm of calculations was validated by comparison with two general Monte Carlo codes: MCNPX and Geant4. Microdosimetric spectra determined by these three codes showed good agreement for numerous geometrical configurations. The analytical method was far more efficient in terms of calculation time: A gain of more than 1000 was observed when using our model compared with Monte Carlo calculations. Good agreements were also observed with previously published results.

Half-lives of 221Fr, 217At, 213Bi, 213Po and 209Pb from the 225Ac decay series

The half-lives of (221)Fr, (217)At, (213)Bi, (213)Po, and (209)Pb were measured by means of an ion-implanted planar Si detector for alpha and beta particles emitted from weak (225)Ac sources or from recoil sources, which were placed in a quasi-2π counting geometry. Recoil sources were prepared by collecting atoms from an open (225)Ac source onto a glass substrate. The (221)Fr and (213)Bi half-lives were determined by following the alpha particle emission rate of recoil sources as a function of time. Similarly, the (209)Pb half-life was determined from the beta particle count rate. The shorter half-lives of (217)At and (213)Po were deduced from delayed coincidence measurements on weak (225)Ac sources using digital data acquisition in list mode. The resulting values: T1/2((221)Fr)=4.806 (6) min, T1/2((217)At)=32.8 (3)ms, T1/2((213)Bi)=45.62 (6)min, T1/2((213)Po)=3.708 (8) μs, and T1/2((209)Pb)=3.232 (5)h were in agreement only with the best literature data.