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Moraitis A, Jentzen W, Fragoso Costa P, Kersting D, Himmen S, Coelho M, Meckel M, van Echteld CJA, Fendler WP, Herrmann K, Sraieb M. Safety and Efficacy of Para-Aminohippurate Coinfusion for Renal Protection During Peptide Receptor Radiotherapy in Patients with Neuroendocrine Tumors. J Nucl Med 2024; 65:931-937. [PMID: 38637142 DOI: 10.2967/jnumed.123.266619] [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: 09/05/2023] [Revised: 03/04/2024] [Indexed: 04/20/2024] Open
Abstract
Para-aminohippurate, also known as p-aminohippuric acid (PAH), is used clinically to measure effective renal plasma flow. Preclinically, it was shown to reduce 177Lu-DOTATOC uptake in the kidneys while improving bioavailability compared with amino acid (AA) coinfusion. We report the safety and efficacy of PAH coinfusion during peptide receptor radiotherapy in patients with neuroendocrine tumors. Methods: Twelve patients with metastatic or unresectable gastroenteropancreatic neuroendocrine tumors received 177Lu-DOTATOC in 33 treatment cycles. Either 8 g of PAH or a mixture of 25 g of arginine and 25 g of lysine were coinfused. Safety was assessed by monitoring laboratory data, including hematologic and renal data, as well as electrolytes obtained before and 24 h after treatment. For radiation dosimetry, whole-body scans were performed at 1, 24, and 48 h and a SPECT/CT scan was performed at 48 h, along with blood sampling at 5 min and 0.5, 2, 4, 24, and 48 h after administration. Absorbed dose estimations for the kidneys and bone marrow were performed according to the MIRD concept. Results: In 15 treatment cycles, PAH was coinfused. No changes in mean creatinine level, glomerular filtration rate, and serum electrolytes were observed before or 24 h after treatment when using PAH protection (P ≥ 0.20), whereas serum chloride and serum phosphate increased significantly under AA (both P < 0.01). Kidney-absorbed dose coefficients were 0.60 ± 0.14 Gy/GBq with PAH and 0.53 ± 0.16 Gy/GBq with AA. Based on extrapolated cumulative kidney-absorbed doses for 4 cycles, 1 patient with PAH protection and 1 patient with AA protection in our patient group would exceed the 23-Gy conservative threshold. The bone marrow-absorbed dose coefficient was 0.012 ± 0.004 Gy/GBq with PAH and 0.012 ± 0.003 Gy/GBq with AA. Conclusion: PAH is a promising alternative to AA for renal protection during peptide receptor radiotherapy. Further research is required to systematically investigate the safety profile and radiation dosimetry at varying PAH plasma concentrations.
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Affiliation(s)
- Alexandros Moraitis
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany;
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Walter Jentzen
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Pedro Fragoso Costa
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - David Kersting
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Stephan Himmen
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Marta Coelho
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Marian Meckel
- ITM Isotope Technologies Munich SE, Garching/Munich, Germany; and
| | | | - Wolfgang P Fendler
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Miriam Sraieb
- Department of Nuclear Medicine, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
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Hebert K, Santoro L, Monnier M, Castan F, Berkane I, Assénat E, Fersing C, Gélibert P, Pouget JP, Bardiès M, Kotzki PO, Deshayes E. Absorbed Dose-Response Relationship in Patients with Gastroenteropancreatic Neuroendocrine Tumors Treated with [ 177Lu]Lu-DOTATATE: One Step Closer to Personalized Medicine. J Nucl Med 2024; 65:923-930. [PMID: 38637144 PMCID: PMC11149595 DOI: 10.2967/jnumed.123.267023] [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: 11/15/2023] [Revised: 03/04/2024] [Indexed: 04/20/2024] Open
Abstract
[177Lu]Lu-DOTATATE has been approved for progressive and inoperable gastroenteropancreatic neuroendocrine tumors (GEP-NETs) that overexpress somatostatin receptors. The absorbed doses by limiting organs and tumors can be quantified by serial postinfusion scintigraphy measurements of the γ-emissions from 177Lu. The objective of this work was to explore how postinfusion [177Lu]Lu-DOTATATE dosimetry could influence clinical management by predicting treatment efficacy (tumor shrinkage and survival) and toxicity. Methods: Patients with GEP-NETs treated with [177Lu]Lu-DOTATATE between 2016 and 2022 and who underwent dosimetry were included. Absorbed doses were calculated for healthy organs (liver, kidneys, bone marrow, and spleen) and tumors using PLANET Dose and the local energy deposition method based on serial posttreatment SPECT/CT. Up to 5 lesions per site were selected and measured on images collected at baseline and 3 mo after treatment end (measurement masked to the somatostatin receptor imaging uptake). For toxicity assessment, laboratory parameters were regularly monitored. Clinical data, including time to death or progression, were collected from the patients' health records. Correlations between absorbed doses by organs and toxicity and between absorbed doses by lesions and tumor volume variation were studied using regression models. Results: In total, 35 dosimetric studies were performed in patients with mostly grade 2 (77%) tumors and metastases in liver (89%), lymph nodes (77%), and bone (34%), and 146 lesions were analyzed: 1-9 lesions per patient, mostly liver metastases (65%) and lymph nodes (25%). The median total absorbed dose by tumors was 94.4 Gy. The absorbed doses by tumors significantly decreased between cycles. The absorbed dose by tumors was significantly associated with tumor volume variation (P < 0.001) 3 mo after treatment end, and it was a significant prognostic factor for survival. Toxicity analysis showed a correlation between the decrease of hematologic parameters such as lymphocytes or platelet concentrations and the absorbed doses by the spleen or bone marrow. The mean absorbed dose by the kidneys was not correlated with nephrotoxicity during the studied period. Conclusion: In patients treated with [177Lu]Lu-DOTATATE for GEP-NETs, tumor and healthy organ dosimetry can predict survival and toxicities, thus influencing clinical management.
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Affiliation(s)
- Kévin Hebert
- Department of Nuclear Medicine, Institut du Cancer de Montpellier, Université de Montpellier, Montpellier, France
| | - Lore Santoro
- Department of Nuclear Medicine, Institut du Cancer de Montpellier, Université de Montpellier, Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Université de Montpellier, Montpellier, France
| | - Maeva Monnier
- Biometry Unit, Institut du Cancer de Montpellier, Université de Montpellier, Montpellier, France
| | - Florence Castan
- Biometry Unit, Institut du Cancer de Montpellier, Université de Montpellier, Montpellier, France
| | - Ikrame Berkane
- Department of Nuclear Medicine, Institut du Cancer de Montpellier, Université de Montpellier, Montpellier, France
| | - Eric Assénat
- Department of Medical Oncology, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Cyril Fersing
- Department of Nuclear Medicine, Institut du Cancer de Montpellier, Université de Montpellier, Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Université de Montpellier, Montpellier, France
- Biometry Unit, Institut du Cancer de Montpellier, Université de Montpellier, Montpellier, France
- Department of Medical Oncology, CHU de Montpellier, Université de Montpellier, Montpellier, France
- IBMM, Université de Montpellier, CNRS, ENSCM, Montpellier, France; and
| | | | - Jean-Pierre Pouget
- Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Université de Montpellier, Montpellier, France
| | - Manuel Bardiès
- Department of Nuclear Medicine, Institut du Cancer de Montpellier, Université de Montpellier, Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Université de Montpellier, Montpellier, France
| | - Pierre-Olivier Kotzki
- Department of Nuclear Medicine, Institut du Cancer de Montpellier, Université de Montpellier, Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Université de Montpellier, Montpellier, France
| | - Emmanuel Deshayes
- Department of Nuclear Medicine, Institut du Cancer de Montpellier, Université de Montpellier, Montpellier, France;
- Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Université de Montpellier, Montpellier, France
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Dubois J, Tosato G, Garrigue P, Taieb D, Guillet B, Nail V. Short-Term Biological Toxicity Prediction of [ 177Lu]Lutetium-Oxodotreotide: An Original Retrospective Analysis. Cancer Biother Radiopharm 2024. [PMID: 38655905 DOI: 10.1089/cbr.2023.0195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Introduction: [177Lu]Lutetium (Lu)-oxodotreotide is a radiopharmaceutical drug used as peptide receptor radionuclide therapy (PRRT) for somatostatin receptor-expressing neuroendocrine neoplasms. It provides an additional effective alternative treatment for these rare cancers. Although well tolerated, its safety profile must continue to be characterized to support its use as a first-line treatment or for additional cycles. This study aims to evaluate factors associated with the occurrence of [177Lu]Lu-oxodotreotide induced short-term toxicity. Materials and Methods: A retrospective observational monocentric study was carried out from July 2013 to October 2021. Inclusion criteria were defined as follows: patients who received at least four cycles of [177Lu]Lu-oxodotreotide and were followed up for 6 months after the last injection. Graduated toxicity was defined using the National Cancer Institute Common Terminology Criteria for Adverse Events 5.0. Cox regression was used in the analysis. Results: Forty patients were included. The most frequent toxicities occurred during the first cycle and were graded as G1 or G2. As expected, toxicities were predominantly hematological and hepatic, with incomplete reversibility after each cycle. The following factors were significantly related to the occurrence of hematological or hepatic toxicity during PRRT: gastrointestinal primary tumor diagnosis, bone metastases, peritoneal metastases, pancreatic metastases or pulmonary metastases, and high tumor grade. Conclusion: Knowledge and consideration of these factors in adjusting [177Lu]Lu-oxodotreotide treatment regimen could help prevent or reduce the severity of these toxicities. Further studies are still warranted to refine these results and improve treatment management.
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Affiliation(s)
- Julien Dubois
- Department of Radiopharmacy, La Timone University Hospital, CERIMED, Aix-Marseille University, Marseille, France
- Department of Radiopharmacy, Montpellier University Hospital, Montpellier University, Montpellier, France
- Cancer Research Institute of Montpellier (IRCM), University of Montpellier, Montpellier, France
| | - Guillaume Tosato
- Montpellier University Hospital, Montpellier University, Montpellier, France
| | - Philippe Garrigue
- Department of Radiopharmacy, La Timone University Hospital, CERIMED, Aix-Marseille University, Marseille, France
| | - David Taieb
- Department of Nuclear Medicine, La Timone University Hospital, CERIMED, Aix-Marseille University, Marseille, France
| | - Benjamin Guillet
- Department of Radiopharmacy, La Timone University Hospital, CERIMED, Aix-Marseille University, Marseille, France
| | - Vincent Nail
- Department of Radiopharmacy, La Timone University Hospital, CERIMED, Aix-Marseille University, Marseille, France
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Vallot D, Brillouet S, Pondard S, Vija L, Texier JS, Dierickx L, Courbon F. Impact of different models based on blood samples and images for bone marrow dosimetry after 177Lu-labeled somatostatin-receptor therapy. EJNMMI Phys 2024; 11:32. [PMID: 38564043 PMCID: PMC10987460 DOI: 10.1186/s40658-024-00615-5] [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: 04/28/2023] [Accepted: 01/15/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Peptide receptor radionuclide therapy with 177Lu-DOTATATE is a recognized option for treating neuroendocrine tumors and has few toxicities, except for the kidneys and bone marrow. The bone marrow dose is generally derived from a SPECT/CT image-based method with four timepoints or from a blood-based method with up to 9 timepoints, but there is still no reference method. This retrospective single-center study on the same cohort of patients compared the calculated bone marrow dose administered with both methods using mono, bi- or tri-exponential models. For the image-based method, the dose was estimated using Planetdose© software. Pearson correlation coefficients were calculated. We also studied the impact of late timepoints for both methods. RESULTS The bone marrow dose was calculated for 131 treatments with the blood-based method and for 17 with the image-based method. In the former, the median absorbed dose was 15.3, 20.5 and 28.3 mGy/GBq with the mono-, bi- and tri-exponential model, respectively. With the image-based method, the median absorbed dose was 63.9, 41.9 and 60.8 with the mono-, bi- and tri-exponential model, respectively. Blood samples after 24h post-injection did not evidence any change in the absorbed bone marrow dose with the bi-exponential model. On the contrary, the 6-day post-injection timepoint was more informative with the image-based model. CONCLUSION This study confirms that the estimated bone marrow dose is significantly lower with the blood-based method than with the image-based method. The blood-based method with a bi-exponential model proved particularly useful, without the need for blood samples after 24h post-injection. Nevertheless, this blood-based method is based on an assumption that needs to be more validated. The important difference between the two methods does not allow to determine the optimal one to estimate the true absorbed dose and further studies are necessary to compare with biological effects.
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Santo G, Di Santo G, Virgolini I. Peptide Receptor Radionuclide Therapy of Neuroendocrine Tumors: Agonist, Antagonist and Alternatives. Semin Nucl Med 2024:S0001-2998(24)00013-8. [PMID: 38490913 DOI: 10.1053/j.semnuclmed.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/14/2024] [Accepted: 02/14/2024] [Indexed: 03/17/2024]
Abstract
Peptide receptor radionuclide therapy (PRRT) today is a well-established treatment strategy for patients with neuroendocrine tumors (NET). First performed already more than 30 years ago, PRRT was incorporated only in recent years into the major oncology guidelines, based on its proven efficacy and safety in clinical trials. Following the phase 3 NETTER-1 trial, which led to the final registration of the radiopharmaceutical Luthatera® for G1/G2 NET patients in 2017, the long-term results of the phase 3 NETTER-2 trial may pave the way for a new treatment option also for advanced G2/G3 patients as first-line therapy. The growing knowledge about the synergistic effect of combined therapies could also allow alternative (re)treatment options for NET patients, in order to create a tailored treatment strategy. The evolving thera(g)nostic concept could be applied for the identification of patients who might benefit from different image-guided treatment strategies. In this scenario, the use of dual tracer PET/CT in NET patients, using both [18F]F-FDG/[68Ga]Ga-DOTA-somatostatin analog (SSA) for diagnosis and follow-up, is under discussion and could also result in a powerful prognostic tool. In addition, alternative strategies based on different metabolic pathways, radioisotopes, or combinations of different medical approaches could be applied. A number of different promising "doors" could thus open in the near future for the treatment of NET patients - and the "key" will be thera(g)nostic!
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Affiliation(s)
- Giulia Santo
- Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria; Department of Experimental and Clinical Medicine, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Gianpaolo Di Santo
- Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Irene Virgolini
- Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria.
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6
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Kiess AP, O'Donoghue J, Uribe C, Bodei L, Hobbs RF, Hesterman J, Kesner AL, Sgouros G. How Can Radiopharmaceutical Therapies Reach Their Full Potential? Improving Dose Reporting and Phase I Clinical Trial Design. J Clin Oncol 2024:JCO2301241. [PMID: 38484205 DOI: 10.1200/jco.23.01241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 11/02/2023] [Accepted: 12/12/2023] [Indexed: 03/22/2024] Open
Affiliation(s)
- Ana P Kiess
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph O'Donoghue
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Carlos Uribe
- Functional Imaging, BC Cancer, Vancouver, BC, Canada
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Lisa Bodei
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert F Hobbs
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Adam L Kesner
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - George Sgouros
- Department of Radiology, Johns Hopkins Medical Institutes, Baltimore, MD
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Strosberg J, Hofman MS, Al-Toubah T, Hope TA. Rethinking Dosimetry: The Perils of Extrapolated External-Beam Radiotherapy Constraints to Radionuclide Therapy. J Nucl Med 2024; 65:362-364. [PMID: 38212065 DOI: 10.2967/jnumed.123.267167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/08/2023] [Accepted: 12/08/2023] [Indexed: 01/13/2024] Open
Affiliation(s)
- Jonathan Strosberg
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida;
| | - Michael S Hofman
- Prostate Cancer Theranostics and Imaging Centre of Excellence, Molecular Imaging and Therapeutic Nuclear Medicine, Cancer Imaging, Peter MacCallum Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia; and
| | - Taymeyah Al-Toubah
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
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Dieudonné A, Bailly C, Cachin F, Edet-Sanson A, Kraeber-Bodéré F, Hapdey S, Merlin C, Robin P, Salaun PY, Schwartz P, Tonnelet D, Vera P, Courbon F, Carlier T. Dosimetry for targeted radionuclide therapy in routine clinical practice: experts advice vs. clinical evidence. Eur J Nucl Med Mol Imaging 2024; 51:947-950. [PMID: 38110711 PMCID: PMC10881593 DOI: 10.1007/s00259-023-06568-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Affiliation(s)
- Arnaud Dieudonné
- Department of Nuclear Medicine, Henri Becquerel Cancer Center, Rouen, France.
- Service de Médecine Nucléaire, Centre Henri Becquerel, 76000, Rouen, France.
| | - Clément Bailly
- Department of Nuclear Medicine, University Hospital, Nantes, France
| | - Florent Cachin
- Department of Nuclear Medicine, Jean Perrin Cancer Center, Clermont-Ferrand, France
| | - Agathe Edet-Sanson
- Department of Nuclear Medicine, Henri Becquerel Cancer Center, Rouen, France
| | | | - Sébastien Hapdey
- Department of Nuclear Medicine, Henri Becquerel Cancer Center, Rouen, France
| | - Charles Merlin
- Department of Nuclear Medicine, Jean Perrin Cancer Center, Clermont-Ferrand, France
| | - Philippe Robin
- Department of Nuclear Medicine, University Hospital, Brest, France
| | | | - Paul Schwartz
- Department of Nuclear Medicine, University Hospital, Bordeaux, France
| | - David Tonnelet
- Department of Nuclear Medicine, Henri Becquerel Cancer Center, Rouen, France
| | - Pierre Vera
- Department of Nuclear Medicine, Henri Becquerel Cancer Center, Rouen, France
| | - Frédéric Courbon
- Department of Medical Imaging, Institut Universitaire du Cancer Toulouse - Oncopole, Toulouse, France
| | - Thomas Carlier
- Department of Nuclear Medicine, University Hospital, Nantes, France
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Yadav S, Lawhn-Heath C, Paciorek A, Lindsay S, Mirro R, Bergsland EK, Hope TA. The Impact of Posttreatment Imaging in Peptide Receptor Radionuclide Therapy. J Nucl Med 2024; 65:409-415. [PMID: 38428966 DOI: 10.2967/jnumed.123.266614] [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: 09/05/2023] [Accepted: 12/20/2023] [Indexed: 03/03/2024] Open
Abstract
Posttreatment imaging of γ-emissions after peptide receptor radionuclide therapy (PRRT) can be used to perform quantitative dosimetry as well as assessment response using qualitative measures. We aimed to assess the impact of qualitative posttreatment imaging on the management of patients undergoing PRRT. Methods: In this retrospective study, we evaluated 100 patients with advanced well-differentiated neuroendocrine tumors undergoing PRRT, who had posttreatment SPECT/CT imaging at 24 h. First, we evaluated the qualitative assessment of response at each cycle. Then using a chart review, we determined the impact on management from the posttreatment imaging. The changes in management were categorized as major or minor, and the cycles at which these changes occurred were noted. Additionally, tumor grade was also evaluated. Results: Of the 100 sequential patients reviewed, most (80% after cycle 2, 79% after cycle 3, and 73% after cycle 4) showed qualitatively stable disease during PRRT. Management changes were observed in 27% (n = 27) of patients; 78% of those (n = 21) were major, and 30% (n = 9) were minor. Most treatment changes occurred after cycle 2 (33% major, 67% minor) and cycle 3 (62% major, 33% minor). Higher tumor grade correlated with increased rate of changes in management (P = 0.006). Conclusion: In this retrospective study, qualitative analysis of posttreatment SPECT/CT imaging informed changes in management in 27% of patients. Patients with higher-grade tumors had a higher rate of change in management, and most of the management changes occurred after cycles 2 and 3. Incorporating posttreatment imaging into standard PRRT workflows could potentially enhance patient management.
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Affiliation(s)
- Surekha Yadav
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Courtney Lawhn-Heath
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Alan Paciorek
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Sheila Lindsay
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
- Department of Medicine, Division of Medical Oncology, University of California San Francisco, San Francisco, California
| | - Rebecca Mirro
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Emily K Bergsland
- Department of Medicine, Division of Medical Oncology, University of California San Francisco, San Francisco, California
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California; and
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California;
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California; and
- Department of Radiology, San Francisco VA Medical Center, San Francisco, California
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10
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Salvadori J, Allegrini O, Opsommer T, Carullo J, Sarrut D, Porot C, Ritzenthaler F, Meyer P, Namer IJ. Anatomy-based correction of kidney PVE on [Formula: see text] SPECT images. EJNMMI Phys 2024; 11:15. [PMID: 38316677 DOI: 10.1186/s40658-024-00612-8] [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: 10/02/2023] [Accepted: 01/15/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND In peptide receptor radionuclide therapy (PRRT), accurate quantification of kidney activity on post-treatment SPECT images paves the way for patient-specific treatment. Due to the limited spatial resolution of SPECT images, the partial volume effect (PVE) is a significant source of quantitative bias. In this study, we aimed to evaluate the performance and robustness of anatomy-based partial volume correction (PVC) algorithms to recover the accurate activity concentration of realistic kidney geometries on [Formula: see text]Lu SPECT images recorded under clinical conditions. METHODS Based on the CT scan data from patients, three sets of fillable kidneys with surface-to-volume (S:V) ratios ranging from 1.5 to 2.8 cm-1, were 3D printed and attached in a IEC phantom. Quantitative [Formula: see text]Lu SPECT/CT acquisitions were performed on a GE Discovery NM CT 870 DR camera for the three modified IEC phantoms and for 6 different Target-To-Background ratios (TBRs: 2, 4, 6, 8, 10, 12). Two region-based (GTM and Labbé) and five voxel-based (GTM + MTC, Labbé + MTC, GTM + RBV, Labbé + RBV and IY) methods were evaluated with this data set. Additionally, the robustness of PVC methods to Point Spread Function (PSF) discrepancies, registration mismatches and background heterogeneity was evaluated. RESULTS Without PVC, the average kidney RCs across all TBRs ranged from 0.66 ± 0.05 (smallest kidney) to 0.80 ± 0.03 (largest kidney). For a TBR of 12, all anatomy-based method were able to recover the kidneys activity concentration with an error < 6%. All methods result in a comparable decline in RC restoration with decreasing TBR. The Labbé method was the most robust against PSF and registration mismatches but was also the most sensitive to background heterogeneity. Among the voxel-based methods, MTC images were less uniform than RBV and IY images at the outer edge of high uptake areas (kidneys and spheres). CONCLUSION Anatomy-based PVE correction allows for accurate SPECT quantification of the [Formula: see text]Lu activity concentration with realistic kidney geometries. Combined with recent progress in deep-learning algorithms for automatic anatomic segmentation of whole-body CT, these methods could be of particular interest for a fully automated OAR dosimetry pipeline with PVE correction.
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Affiliation(s)
- Julien Salvadori
- Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France.
| | - Oreste Allegrini
- Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Thomas Opsommer
- Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Josefina Carullo
- Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - David Sarrut
- Université de Lyon, CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, Université Lyon 1, Centre Léon Bérard, Lyon, France
| | - Clemence Porot
- Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | | | - Philippe Meyer
- Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
- ICUBE, CNRS UMR-7357, University of Strasbourg, Strasbourg, France
| | - Izzie-Jacques Namer
- Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
- ICUBE, CNRS UMR-7357, University of Strasbourg, Strasbourg, France
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11
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Mileva M, Marin G, Levillain H, Artigas C, Van Bogaert C, Marin C, Danieli R, Deleporte A, Picchia S, Stathopoulos K, Jungels C, Vanderlinden B, Paesmans M, Ameye L, Critchi G, Taraji-Schiltz L, Velghe C, Wimana Z, Bali M, Hendlisz A, Flamen P, Karfis I. Prediction of 177Lu-DOTATATE PRRT Outcome Using Multimodality Imaging in Patients with Gastroenteropancreatic Neuroendocrine Tumors: Results from a Prospective Phase II LUMEN Study. J Nucl Med 2024; 65:236-244. [PMID: 38164576 DOI: 10.2967/jnumed.123.265987] [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: 05/09/2023] [Revised: 10/25/2023] [Indexed: 01/03/2024] Open
Abstract
Our objective was to predict the outcome of peptide receptor radionuclide therapy (PRRT) using multimodality imaging and tumor dosimetry on gastroenteropancreatic neuroendocrine tumor (GEP-NET) lesions and patients. Methods: This prospective study included patients with progressive GEP-NETs. Treatment consisted of 4 cycles of 7.4 GBq of 177Lu-DOTATATE. Imaging parameters were measured on 68Ga-DOTATATE PET/CT (SUVmax/mean, somatostatin receptor [SSTR] tumor volume [TV], total lesion SSTR expression, and tumor-to-blood and tumor-to-spleen ratios), 18F-FDG PET/CT (SUVmax/mean, metabolically active TV, and total lesion glycolysis), and diffusion-weighted MRI (apparent diffusion coefficient) in a maximum of 5 target lesions per patient at approximately 10 wk after each injection. Tumor dosimetry was performed using SPECT/CT at 3 time points for every cycle. Baseline imaging parameters, their relative changes after PRRT cycle 1 (C1), and the tumor-absorbed dose at C1 were correlated with lesion morphologic outcome. The average values of the imaging parameters and the minimal, maximal, and mean C1 tumor-absorbed dose in each patient were tested for association with progression-free survival (PFS) and best objective response (RECIST 1.1). Results: In the 37 patients, the median PFS was 28 mo. Eleven of the 37 (30%) achieved a partial response (RECIST 1.1). After a median follow-up of 57 mo, the median time to lesion progression had not been reached in 84 morphologically evaluable lesions, with only 12 (14%) progressing (size increase ≥ 20% from baseline). Patients receiving a minimal C1 dose of 35 Gy in all target lesions exhibited a significantly longer PFS (48.1 vs. 26.2 mo; hazard ratio, 0.37; 95% CI, 0.17-0.82; P = 0.02). Volumetric 68Ga-DOTATATE PET parameters correlated with lesion and patient outcome: patients with an SSTR TV decrease of more than 10% after C1 had a longer PFS (51.3 vs. 22.8 mo; hazard ratio, 0.35; 95% CI, 0.16-0.75; P = 0.003). There was no statistical evidence of an association between other dosimetric or imaging parameters and the lesion or patient outcome. Conclusion: Minimal tumor-absorbed dose at C1 is predictive of outcome in patients with GEP-NETs treated with PRRT, providing a basis for personalized dosimetry-guided treatment strategies. An SSTR TV decrease after C1 could be used for early therapy response assessment as a predictor of PRRT outcome.
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Affiliation(s)
- Magdalena Mileva
- Nuclear Medicine Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Gwennaëlle Marin
- Medical Physics Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Hugo Levillain
- Medical Physics Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Carlos Artigas
- Nuclear Medicine Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Camille Van Bogaert
- Nuclear Medicine Department, CUB-Hôpital Erasme, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Clémentine Marin
- Medical Physics Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Rachele Danieli
- Medical Physics Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Amelie Deleporte
- Medical Oncology Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Simona Picchia
- Radiology Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Konstantinos Stathopoulos
- Radiology Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Christiane Jungels
- Medical Oncology Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Bruno Vanderlinden
- Medical Physics Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Marianne Paesmans
- Data Center, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium; and
| | - Lieveke Ameye
- Data Center, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium; and
| | - Gabriela Critchi
- Nuclear Medicine Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Loubna Taraji-Schiltz
- Nuclear Medicine Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Chloe Velghe
- Data Center, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium; and
| | - Zéna Wimana
- Nuclear Medicine Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
- Radiopharmacy Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Maria Bali
- Radiology Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Alain Hendlisz
- Medical Oncology Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Patrick Flamen
- Nuclear Medicine Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Ioannis Karfis
- Nuclear Medicine Department, Institut Jules Bordet, ENETS Centre of Excellence, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium;
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12
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Has Simsek D, Guzel Y, Denizmen D, Sanli Y, Buyukkaya F, Kovan B, Komek H, Isik EG, Ozkan ZG, Kuyumcu S. The inferior performance of [ 68Ga]Ga-FAPI-04 PET/CT as a diagnostic and theranostic biomarker in [ 177Lu]Lu-DOTATATE refractory well-differentiated neuroendocrine tumors. Eur J Nucl Med Mol Imaging 2024; 51:828-840. [PMID: 37947850 DOI: 10.1007/s00259-023-06497-6] [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: 08/04/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE We aimed to investigate the potential of [68Ga]Ga-FAPI-04 PET/CT as an alternative diagnostic and theranostic tool in well-differentiated NETs refractory to [177Lu]Lu-DOTATATE therapy. METHODS Patients who received at least two cycles of [177Lu]Lu-DOTATATE therapy for metastatic NETs and progressed under treatment were included. All patients had performed [68Ga]Ga-DOTATATE and [68Ga]Ga-FAPI-04 PET/CT within 3 weeks. The number of PET-positive lesions related to NETs and tumor sites was documented. Mann-Whitney U and chi-square tests were used to compare SUVmax levels of tracers and the number of detected metastases. RESULTS Twelve patients (7 male, 5 female) who met the eligibility criteria were included in the study. Ten patients had grade 1-2 NET of various origins, and two had paraganglioma and pheochromocytoma. One hundred ninety-eight of 230 lesions (86%) were SSTR positive with a median SUVmax of 16.6 (2.2-76.5), and 88 of 230 lesions (38.2%) were [68Ga]Ga-FAPI-04 positive with a median SUVmax of 5.1 (2.3-21). Median SUVmax level and detected number of tumors were significantly higher in [68Ga]Ga-DOTATATE PET/CT (p=<0.001). [68Ga]Ga-FAPI-04 PET/CT was completely (n:2) or almost completely (n:3) negative in 5 (42%) patients. Two (17%) patients had flip-flop SSTR/FAPI uptake in tumors. In four patients (33%), tumor uptake or the number of PET-positive lesions was inferior in [68Ga]Ga-FAPI-04 PET/CT. In only one patient (8%), tumor uptakes were higher in [68Ga]Ga-FAPI-04 PET/CT. Low-dose [177Lu]Lu-FAPI-46 dosimetry was performed on the FAPI-dominant patient; absorbed radiation doses per GBq were 1.26 Gy, 0.36 Gy, 0.32 Gy, and 0.2 Gy for kidneys, liver, spleen, and total body, respectively. The mean absorbed dose per GBq was 0.33 Gy for liver mass and 0.41 Gy for metastatic lymph nodes. CONCLUSION Our preliminary results demonstrated that [68Ga]Ga-FAPI-04 PET/CT mainly failed in well-differentiated NETs refractory to [177Lu]Lu-DOTATATE therapy and had a limited role as an alternative diagnostic or theranostic agent. Further investigations with a larger patient population are required to determine the impact of [68Ga]Ga-FAPI-04 PET/CT on NETs.
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Affiliation(s)
- Duygu Has Simsek
- Istanbul Faculty of Medicine, Department of Nuclear Medicine, Istanbul University, 34093 Fatih, Istanbul, Turkey.
| | - Yunus Guzel
- Gazi Yasargil Training and Research Hospital, Department of Nuclear Medicine, Saglik Bilimleri University, 21070 Kayapinar, Diyarbakir, Turkey
| | - Dilara Denizmen
- Istanbul Faculty of Medicine, Department of Nuclear Medicine, Istanbul University, 34093 Fatih, Istanbul, Turkey
| | - Yasemin Sanli
- Istanbul Faculty of Medicine, Department of Nuclear Medicine, Istanbul University, 34093 Fatih, Istanbul, Turkey
| | - Fikret Buyukkaya
- Istanbul Faculty of Medicine, Department of Nuclear Medicine, Istanbul University, 34093 Fatih, Istanbul, Turkey
| | - Bilal Kovan
- Istanbul Faculty of Medicine, Department of Nuclear Medicine, Istanbul University, 34093 Fatih, Istanbul, Turkey
| | - Halil Komek
- Gazi Yasargil Training and Research Hospital, Department of Nuclear Medicine, Saglik Bilimleri University, 21070 Kayapinar, Diyarbakir, Turkey
| | - Emine Goknur Isik
- Istanbul Faculty of Medicine, Department of Nuclear Medicine, Istanbul University, 34093 Fatih, Istanbul, Turkey
| | - Zeynep Gozde Ozkan
- Istanbul Faculty of Medicine, Department of Nuclear Medicine, Istanbul University, 34093 Fatih, Istanbul, Turkey
| | - Serkan Kuyumcu
- Istanbul Faculty of Medicine, Department of Nuclear Medicine, Istanbul University, 34093 Fatih, Istanbul, Turkey
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13
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Siebinga H, Hendrikx JJMA, de Vries-Huizing DMV, Huitema ADR, de Wit-van der Veen BJ. The cycle effect quantified: reduced tumour uptake in subsequent cycles of [ 177Lu]Lu-HA-DOTATATE during peptide receptor radionuclide therapy. Eur J Nucl Med Mol Imaging 2024; 51:820-827. [PMID: 37843598 DOI: 10.1007/s00259-023-06463-2] [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: 06/01/2023] [Accepted: 10/01/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Clear evidence regarding the effect of reduced tumour accumulation in later peptide receptor radionuclide therapy (PRRT) cycles is lacking. Therefore, we aimed to quantify potential cycle effects for patients treated with [177Lu]Lu-HA-DOTATATE using a population pharmacokinetic (PK) modelling approach. METHODS A population PK model was developed using imaging data from 48 patients who received multiple cycles of [177Lu]Lu-HA-DOTATATE. The five-compartment model included a central, kidney, spleen, tumour and lumped rest compartment. Tumour volume and continued use of long-acting somatostatin analogues (SSAs) were tested as covariates in the model. In addition, the presence of a cycle effect was evaluated by relating the uptake rate in a specific cycle as a fraction of the (tumour or organ) uptake rate in the first cycle. RESULTS The final PK model adequately captured observed radioactivity accumulation in kidney, spleen and tumour. A higher tumour volume was identified to increase the tumour uptake rate, where a twofold increase in tumour volume resulted in a 2.3-fold higher uptake rate. Also, continued use of long-acting SSAs significantly reduced the spleen uptake rate (68.4% uptake compared to SSA withdrawal (10.5% RSE)). Lastly, a cycle effect was significantly identified, where tumour uptake rate decreased to 86.9% (5.3% RSE) in the second cycle and even further to 79.7% (5.6% RSE) and 77.6% (6.2% RSE) in the third and fourth cycle, respectively, compared to cycle one. CONCLUSIONS Using a population PK modelling approach, the cycle effect of reduced tumour uptake in subsequent PRRT cycles was quantified. Our findings implied that downregulation of target receptors is probably not the major cause of the cycle effect, due to a plateau in the decrease of tumour uptake in the fourth cycle.
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Affiliation(s)
- H Siebinga
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - J J M A Hendrikx
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - D M V de Vries-Huizing
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - A D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - B J de Wit-van der Veen
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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14
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Fele-Paranj A, Saboury B, Uribe C, Rahmim A. Physiologically based radiopharmacokinetic (PBRPK) modeling to simulate and analyze radiopharmaceutical therapies: studies of non-linearities, multi-bolus injections, and albumin binding. EJNMMI Radiopharm Chem 2024; 9:6. [PMID: 38252191 PMCID: PMC10803696 DOI: 10.1186/s41181-023-00236-w] [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: 11/01/2023] [Accepted: 12/22/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND We aimed to develop a publicly shared computational physiologically based pharmacokinetic (PBPK) model to reliably simulate and analyze radiopharmaceutical therapies (RPTs), including probing of hot-cold ligand competitions as well as alternative injection scenarios and drug designs, towards optimal therapies. RESULTS To handle the complexity of PBPK models (over 150 differential equations), a scalable modeling notation called the "reaction graph" is introduced, enabling easy inclusion of various interactions. We refer to this as physiologically based radiopharmacokinetic (PBRPK) modeling, fine-tuned specifically for radiopharmaceuticals. As three important applications, we used our PBRPK model to (1) study the effect of competition between hot and cold species on delivered doses to tumors and organs at risk. In addition, (2) we evaluated an alternative paradigm of utilizing multi-bolus injections in RPTs instead of prevalent single injections. Finally, (3) we used PBRPK modeling to study the impact of varying albumin-binding affinities by ligands, and the implications for RPTs. We found that competition between labeled and unlabeled ligands can lead to non-linear relations between injected activity and the delivered dose to a particular organ, in the sense that doubling the injected activity does not necessarily result in a doubled dose delivered to a particular organ (a false intuition from external beam radiotherapy). In addition, we observed that fractionating injections can lead to a higher payload of dose delivery to organs, though not a differential dose delivery to the tumor. By contrast, we found out that increased albumin-binding affinities of the injected ligands can lead to such a differential effect in delivering more doses to tumors, and this can be attributed to several factors that PBRPK modeling allows us to probe. CONCLUSIONS Advanced computational PBRPK modeling enables simulation and analysis of a variety of intervention and drug design scenarios, towards more optimal delivery of RPTs.
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Affiliation(s)
- Ali Fele-Paranj
- School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
- Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada
| | - Babak Saboury
- Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland, US
| | - Carlos Uribe
- Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada
- Department of Functional Imaging, BC Cancer, Vancouver, BC, Canada
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Arman Rahmim
- School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada.
- Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada.
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada.
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15
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Cicone F, Sjögreen Gleisner K, Sarnelli A, Indovina L, Gear J, Gnesin S, Kraeber-Bodéré F, Bischof Delaloye A, Valentini V, Cremonesi M. The contest between internal and external-beam dosimetry: The Zeno's paradox of Achilles and the tortoise. Phys Med 2024; 117:103188. [PMID: 38042710 DOI: 10.1016/j.ejmp.2023.103188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/06/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023] Open
Abstract
Radionuclide therapy, also called molecular radiotherapy (MRT), has come of age, with several novel radiopharmaceuticals being approved for clinical use or under development in the last decade. External beam radiotherapy (EBRT) is a well-established treatment modality, with about half of all oncologic patients expected to receive at least one external radiation treatment over their disease course. The efficacy and the toxicity of both types of treatment rely on the interaction of radiation with biological tissues. Dosimetry played a fundamental role in the scientific and technological evolution of EBRT, and absorbed doses to the target and to the organs at risk are calculated on a routine basis. In contrast, in MRT the usefulness of internal dosimetry has long been questioned, and a structured path to include absorbed dose calculation is missing. However, following a similar route of development as EBRT, MRT treatments could probably be optimized in a significant proportion of patients, likely based on dosimetry and radiobiology. In the present paper we describe the differences and the similarities between internal and external-beam dosimetry in the context of radiation treatments, and we retrace the main stages of their development over the last decades.
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Affiliation(s)
- Francesco Cicone
- Department of Experimental and Clinical Medicine, "Magna Graecia" University of Catanzaro, Catanzaro, Italy; Nuclear Medicine Unit, "Mater Domini" University Hospital, Catanzaro, Italy.
| | | | - Anna Sarnelli
- Medical Physics Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Luca Indovina
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Jonathan Gear
- Joint Department of Physics, Royal Marsden NHSFT & Institute of Cancer Research, Sutton, UK
| | - Silvano Gnesin
- Institute of Radiation Physics, Lausanne University Hospital, Lausanne, Switzerland; University of Lausanne, Lausanne, Switzerland
| | - Françoise Kraeber-Bodéré
- Nantes Université, Université Angers, CHU Nantes, INSERM, CNRS, CRCI2NA, Médecine Nucléaire, F-44000 Nantes, France
| | | | - Vincenzo Valentini
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marta Cremonesi
- Unit of Radiation Research, IEO, European Institute of Oncology IRCCS, Milan, Italy
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16
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Sjögreen-Gleisner K, Flux G, Bacher K, Chiesa C, de Nijs R, Kagadis GC, Lima T, Georgosopoulou ML, Gabiña PM, Nekolla S, Peters S, Santos J, Sattler B, Stokke C, Tran-Gia J, Gilligan P, Bardiès M. EFOMP policy statement NO. 19: Dosimetry in nuclear medicine therapy - Molecular radiotherapy. Phys Med 2023; 116:103166. [PMID: 37926641 DOI: 10.1016/j.ejmp.2023.103166] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 10/22/2023] [Indexed: 11/07/2023] Open
Abstract
The European Council Directive 2013/59/Euratom (BSS Directive) includes optimisation of treatment with radiotherapeutic procedures based on patient dosimetry and verification of the absorbed doses delivered. The present policy statement summarises aspects of three directives relating to the therapeutic use of radiopharmaceuticals and medical devices, and outlines the steps needed for implementation of patient dosimetry for radioactive drugs. To support the transition from administrations of fixed activities to personalised treatments based on patient-specific dosimetry, EFOMP presents a number of recommendations including: increased networking between centres and disciplines to support data collection and development of codes-of-practice; resourcing to support an infrastructure that permits routine patient dosimetry; research funding to support investigation into individualised treatments; inter-disciplinary training and education programmes; and support for investigator led clinical trials. Close collaborations between the medical physicist and responsible practitioner are encouraged to develop a similar pathway as is routine for external beam radiotherapy and brachytherapy. EFOMP's policy is to promote the roles and responsibilities of medical physics throughout Europe in the development of molecular radiotherapy to ensure patient benefit. As the BSS directive is adopted throughout Europe, unprecedented opportunities arise to develop informed treatments that will mitigate the risks of under- or over-treatments.
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Affiliation(s)
| | - Glenn Flux
- Joint Department of Physics, Royal Marsden Hospital and Institute of Cancer Research, Sutton, Surrey, UK
| | - Klaus Bacher
- Medical Physics, Ghent University, Ghent, Belgium
| | - Carlo Chiesa
- Nuclear Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Robin de Nijs
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - George C Kagadis
- 3DMI Research Group, Department of Medical Physics, University of Patras, Rion, Greece
| | - Thiago Lima
- Department of Radiology and Nuclear Medicine, Luzerner Kantonsspital, Lucerne, Switzerland/Faculty of Health Sciences and Medicine, University of Lucerne, Switzerland
| | | | - Pablo Minguez Gabiña
- Department of Medical Physics and Radiation Protection, Gurutzeta-Cruces University Hospital /Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | - Stephan Nekolla
- School of Medicine and Health, Department of Nuclear Medicine, Technical University Munich, Munich, Germany
| | - Steffie Peters
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joao Santos
- Medical Physics, Radiobiology and Radiation Protection Group, IPO Porto Research Center, Portuguese Oncology Institute of Porto/Porto Comprehensive Cancer Center & Health Research Network, Porto, Portugal
| | - Bernhard Sattler
- Department of Nuclear Medicine, University of Leipzig Medical Centre, Leipzig, Germany
| | - Caroline Stokke
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway & Department of Physics, University of Oslo, Oslo, Norway
| | - Johannes Tran-Gia
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Paddy Gilligan
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Manuel Bardiès
- IRCM, UMR 1194 INSERM, Université de Montpellier and Institut Régional du Cancer de Montpellier (ICM), France & Département de Médecine Nucléaire, Institut Régional du Cancer de Montpellier (ICM), France
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17
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Al-Toubah T, Strosberg J, Hallanger-Johnson J, El-Haddad G. Targeted radionuclide therapy in endocrine-related cancers: advances in the last decade. Front Endocrinol (Lausanne) 2023; 14:1187870. [PMID: 38053729 PMCID: PMC10694449 DOI: 10.3389/fendo.2023.1187870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 10/26/2023] [Indexed: 12/07/2023] Open
Abstract
Targeted radionuclide therapy plays an increasingly important role in managing endocrine-related tumors and significantly advances the therapeutic landscape for patients with these diseases. With increasing FDA-approved therapies and advances in the field, come an increased knowledge of the potential for long-term toxicities associated with these therapies and the field must develop new strategies to increase potency and efficacy while individualizing the selection of patients to those most likely to respond to treatment. Novel agents and modalities of therapy are also being explored. This review will discuss the current landscape and describe the avenues for growth in the field currently being explored.
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Affiliation(s)
- Taymeyah Al-Toubah
- Department of GI Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Jonathan Strosberg
- Department of GI Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Julie Hallanger-Johnson
- Department of Head and Neck - Endocrine Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Ghassan El-Haddad
- Department of Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
- Department of Nuclear Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
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18
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Danieli R, Stella M, Leube J, Tran-Gia J, Marin C, Uribe CF, Vanderlinden B, Reynaert N, Flamen P, Levillain H. Quantitative 177Lu SPECT/CT imaging for personalized dosimetry using a ring-shaped CZT-based camera. EJNMMI Phys 2023; 10:64. [PMID: 37853247 PMCID: PMC10584798 DOI: 10.1186/s40658-023-00586-z] [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: 08/07/2023] [Accepted: 10/12/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Dosimetry after radiopharmaceutical therapy with 177Lu (177Lu-RPT) relies on quantitative SPECT/CT imaging, for which suitable reconstruction protocols are required. In this study, we characterized for the first time the quantitative performance of a ring-shaped CZT-based camera using two different reconstruction algorithms: an ordered subset expectation maximization (OSEM) and a block sequential regularized expectation maximization (BSREM) combined with noise reduction regularization. This study lays the foundations for the definition of a reconstruction protocol enabling accurate dosimetry for patients treated with 177Lu-RPT. METHODS A series of 177Lu-filled phantoms were acquired on a StarGuide™ (GE HealthCare), with energy and scatter windows centred at 208 (± 6%) keV and 185 (± 5%) keV, respectively. Images were reconstructed with the manufacturer implementations of OSEM (GE-OSEM) and BSREM (Q.Clear) algorithms, and various combinations of iterations and subsets. Additionally, the manufacturer-recommended Q.Clear-based reconstruction protocol was evaluated. Quantification accuracy, measured as the difference between the SPECT-based and the radionuclide calibrator-based activity, and noise were evaluated in a large cylinder. Recovery coefficients (RCs) and spatial resolution were assessed in a NEMA IEC phantom with sphere inserts. The reconstruction protocols considered suitable for clinical applications were tested on a cohort of patients treated with [177Lu]Lu-PSMA-I&T. RESULTS The accuracy of the activity from the cylinder, although affected by septal penetration, was < 10% for all reconstructions. Both algorithms featured improved spatial resolution and higher RCs with increasing updates at the cost of noise build-up, but Q.Clear outperformed GE-OSEM in reducing noise accumulation. When the reconstruction parameters were carefully selected, similar values for noise (~0.15), spatial resolution (~1 cm) and RCs were found, irrespective of the reconstruction algorithm. Analogue results were found in patients. CONCLUSIONS Accurate activity quantification is possible when imaging 177Lu with StarGuide™. However, the impact of septal penetration requires further investigations. GE-OSEM is a valid alternative to the recommended Q.Clear reconstruction algorithm, featuring comparable performances assessed on phantoms and patients.
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Affiliation(s)
- Rachele Danieli
- Department of Medical Physics, Institut Jules Bordet, Hôpital Universitaire de Bruxelles (H.U.B), Université Libre de Bruxelles (ULB), Brussels, Belgium.
- Radiophysics and MRI Physics Laboratory, Université Libre de Bruxelles (ULB), Brussels, Belgium.
| | - Martina Stella
- Radiophysics and MRI Physics Laboratory, Université Libre de Bruxelles (ULB), Brussels, Belgium
- GE HealthCare, Diegem, Belgium
| | - Julian Leube
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Johannes Tran-Gia
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Clementine Marin
- Department of Medical Physics, Institut Jules Bordet, Hôpital Universitaire de Bruxelles (H.U.B), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Bruno Vanderlinden
- Department of Medical Physics, Institut Jules Bordet, Hôpital Universitaire de Bruxelles (H.U.B), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Radiophysics and MRI Physics Laboratory, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Nick Reynaert
- Department of Medical Physics, Institut Jules Bordet, Hôpital Universitaire de Bruxelles (H.U.B), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Radiophysics and MRI Physics Laboratory, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Patrick Flamen
- Department of Nuclear Medicine, Institut Jules Bordet, Hôpital Universitaire de Bruxelles (H.U.B), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Hugo Levillain
- Department of Medical Physics, Institut Jules Bordet, Hôpital Universitaire de Bruxelles (H.U.B), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Radiophysics and MRI Physics Laboratory, Université Libre de Bruxelles (ULB), Brussels, Belgium
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19
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Chicheportiche A, Sason M, Zidan M, Godefroy J, Krausz Y, Gross DJ, Grozinsky-Glasberg S, Ben-Haim S. Impact of Single-Time-Point Estimates of 177Lu-PRRT Absorbed Doses on Patient Management: Validation of a Trained Multiple-Linear-Regression Model in 159 Patients and 477 Therapy Cycles. J Nucl Med 2023; 64:1610-1616. [PMID: 37500259 DOI: 10.2967/jnumed.122.264923] [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: 10/23/2022] [Revised: 05/31/2023] [Indexed: 07/29/2023] Open
Abstract
Dosimetry after 177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT) enables estimation of radiation doses absorbed by normal organs and target lesions. This process is time-consuming and requires multiple posttreatment studies on several subsequent days. In a previous study, we described a newly developed multiple-linear-regression model to predict absorbed doses (ADs) from a single-time-point (STP) posttreatment study acquired 168 h after the first infusion and 24 h after the following ones, with similar results to the standard multiple-time-point (MTP) protocol. The present study aimed to validate this model in a large patient cohort and to assess whether STP dosimetry affects patient management decisions compared with our MTP protocol. Methods: Quantitative 177Lu-DOTATATE SPECT/CT post-PRRT data from 159 consecutive patients (172 therapies, 477 therapy cycles) were retrospectively analyzed. ADs obtained from an STP model were compared with those obtained using an MTP model. We evaluated the impact of the STP model on the decision on whether PRRT should be stopped because of an expected kidney AD exceeding the safety threshold. We hypothesized that patient management based on the STP model does not differ from that based on the MTP model in at least 90% of the cases. Results: There was no difference in management decisions between the MTP and STP models in 170 of 172 therapies (98.8%). A Fisher χ2 test for combined probabilities produced a composite P value of 0.0003. Mean cumulative AD relative differences between the STP and MTP models were 0.8% ± 8.0%, -7.7% ± 4.8%, 0.0% ± 11.4%, -2.8% ± 6.3%, and -2.1% ± 18.4% for kidneys, bone marrow, liver, spleen, and tumors, respectively (Pearson r = 0.99 for all), for patients who underwent 4 therapy cycles. Similar results were obtained with fewer therapy cycles. Conclusion: Estimated radiation ADs and patient management decisions were similar with the STP and MTP models. The STP model can simplify the dosimetry process while also reducing scanner and staff time and improving patient comfort.
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Affiliation(s)
- Alexandre Chicheportiche
- Department of Nuclear Medicine and Biophysics, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel;
| | - Moshe Sason
- Department of Nuclear Medicine and Biophysics, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Mahmoud Zidan
- Department of Nuclear Medicine and Biophysics, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jeremy Godefroy
- Department of Nuclear Medicine and Biophysics, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yodphat Krausz
- Department of Nuclear Medicine and Biophysics, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David J Gross
- Neuroendocrine Tumor Unit, ENETS Center of Excellence, Hebrew University of Jerusalem, Jerusalem, Israel; and
| | - Simona Grozinsky-Glasberg
- Neuroendocrine Tumor Unit, ENETS Center of Excellence, Hebrew University of Jerusalem, Jerusalem, Israel; and
| | - Simona Ben-Haim
- Department of Nuclear Medicine and Biophysics, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- University College London, London, United Kingdom
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20
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Mader N, Schoeler C, Pezeshkpour N, Klimek K, Groener D, Happel C, Tselis N, Mandel P, Grünwald F, Sabet A. Intermittent Radioligand Therapy with 177Lu-PSMA-617 for Oligometastatic Castration-Resistant Prostate Cancer. Cancers (Basel) 2023; 15:4605. [PMID: 37760574 PMCID: PMC10527374 DOI: 10.3390/cancers15184605] [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: 08/17/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
177Lu-PSMA-617 radioligand therapy (177Lu-PSMA-RLT) in patients with metastatic castration-resistant prostate cancer (mCRPC) currently consists of 4-6 cycles of 6.0-7.4 GBq of 177Lu-PSMA-617 each every 6-8 weeks. While safety and efficacy could be demonstrated in larger prospective trials irrespective of the tumor burden at 177Lu-PSMA RLT initiation, increased renal absorbed doses due to a reduced tumor sink effect in early responding, oligometastatic mCRPC patients pose difficulties. Response-adapted, dose distributing, intermittent treatment with up to six cycles has not been routinely performed, due to concerns about the potential loss of disease control. Treatment was discontinued in 19 early-responding patients with oligometastatic tumor burden after two (IQR 2-3) cycles of 177Lu-PSMA-RLT and 6.5 ± 0.7 GBq per cycle and resumed upon 68Ga-PSMA-11-PET/CT-based progression (according to the PCWG3 criteria). Subsequent treatment breaks were imposed if a PSMA-based imaging response could be achieved. A total of five (IQR 3-6) cycles reaching a cumulative activity of 32 ± 11 GBq were applied. A routine blood work-up including blood counts and liver and renal function was measured throughout the 177Lu-PSMA-RLT and follow-up to grade toxicity according to CTCAE v5.0 criteria. Survival outcome was calculated based on the Kaplan-Meier method. In total, treatment-free periods of 9 (IQR 6-17) cumulative months and the application of 177Lu-PSMA-RLT cycles over 16 (IQR 9-22) months could be achieved. Fifteen (84%) patients responded to subsequent cycles after the first treatment break and in 7/19 (37%) patients, intermittent 177Lu-PSMA-RLT consisted of ≥2 treatment breaks. The median PFS was 27 months (95% CI: 23-31) and overall survival was 45 months (95% CI: 28-62). No grade ≥3 hematological or renal toxicities could be observed during the 45 ± 21 months of follow-up. The cumulative mean renal absorbed dose was 16.7 ± 8.3 Gy and 0.53 ± 0.21 Gy/GBq. Intermittent radioligand therapy with 177Lu-PSMA-617 is feasible in early-responding patients with oligometastatic disease. A late onset of progression after subsequent cycles and the absence of significant toxicity warrants further investigation of the concept of intermittent treatment in selected patients.
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Affiliation(s)
- Nicolai Mader
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; (N.M.); (C.S.); (N.P.); (K.K.); (D.G.); (C.H.); (F.G.)
| | - Christina Schoeler
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; (N.M.); (C.S.); (N.P.); (K.K.); (D.G.); (C.H.); (F.G.)
| | - Niloufar Pezeshkpour
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; (N.M.); (C.S.); (N.P.); (K.K.); (D.G.); (C.H.); (F.G.)
| | - Konrad Klimek
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; (N.M.); (C.S.); (N.P.); (K.K.); (D.G.); (C.H.); (F.G.)
| | - Daniel Groener
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; (N.M.); (C.S.); (N.P.); (K.K.); (D.G.); (C.H.); (F.G.)
| | - Christian Happel
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; (N.M.); (C.S.); (N.P.); (K.K.); (D.G.); (C.H.); (F.G.)
| | - Nikolaos Tselis
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany;
| | - Philipp Mandel
- Department of Urology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany;
| | - Frank Grünwald
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; (N.M.); (C.S.); (N.P.); (K.K.); (D.G.); (C.H.); (F.G.)
| | - Amir Sabet
- Department of Nuclear Medicine, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; (N.M.); (C.S.); (N.P.); (K.K.); (D.G.); (C.H.); (F.G.)
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21
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Singh S, Hope TA, Bergsland EB, Bodei L, Bushnell DL, Chan JA, Chasen BR, Chauhan A, Das S, Dasari A, Del Rivero J, El-Haddad G, Goodman KA, Halperin DM, Lewis MA, Lindwasser OW, Myrehaug S, Raj NP, Reidy-Lagunes DL, Soares HP, Strosberg JR, Kohn EC, Kunz PL. Consensus report of the 2021 National Cancer Institute neuroendocrine tumor clinical trials planning meeting. J Natl Cancer Inst 2023; 115:1001-1010. [PMID: 37255328 PMCID: PMC10483264 DOI: 10.1093/jnci/djad096] [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] [Received: 10/24/2022] [Revised: 05/01/2023] [Accepted: 05/11/2023] [Indexed: 06/01/2023] Open
Abstract
Important progress has been made over the last decade in the classification, imaging, and treatment of neuroendocrine neoplasm (NENs), with several new agents approved for use. Although the treatment options available for patients with well-differentiated neuroendocrine tumors (NETs) have greatly expanded, the rapidly changing landscape has presented several unanswered questions about how best to optimize, sequence, and individualize therapy. Perhaps the most important development over the last decade has been the approval of 177Lu-DOTATATE for treatment of gastroenteropancreatic-NETs, raising questions around optimal sequencing of peptide receptor radionuclide therapy (PRRT) relative to other therapeutic options, the role of re-treatment with PRRT, and whether PRRT can be further optimized through use of dosimetry among other approaches. The NET Task Force of the National Cancer Institute GI Steering Committee convened a clinical trial planning meeting in 2021 with multidisciplinary experts from academia, the federal government, industry, and patient advocates to develop NET clinical trials in the era of PRRT. Key clinical trial recommendations for development included 1) PRRT re-treatment, 2) PRRT and immunotherapy combinations, 3) PRRT and DNA damage repair inhibitor combinations, 4) treatment for liver-dominant disease, 5) treatment for PRRT-resistant disease, and 6) dosimetry-modified PRRT.
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Affiliation(s)
- Simron Singh
- Department of Medicine, Sunnybrook Health Sciences Centre, Odette Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Emily B Bergsland
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Lisa Bodei
- Department of Radiology, Memorial Sloan Kettering Cancer Center, Molecular Imaging and Therapy Service, New York, NY, USA
| | | | - Jennifer A Chan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Beth R Chasen
- Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aman Chauhan
- Department of Medicine, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Satya Das
- Late-Stage Development, Oncology R&D AstraZeneca, Gaithersburg, MD, USA
| | - Arvind Dasari
- Department of GI Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaydira Del Rivero
- Developmental Therapeutics Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ghassan El-Haddad
- Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Daniel M Halperin
- Department of GI Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark A Lewis
- Department of Medicine, Intermountain Health, Salt Lake City, UT, USA
| | - O Wolf Lindwasser
- Coordinating Center for Clinical Trials, National Cancer Institute, Bethesda, MD, USA
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Center, Toronto, ON, Canada
| | - Nitya P Raj
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Heloisa P Soares
- Department of Medicine, Huntsman Cancer Institute at University of Utah, Salt Lake City, UT, USA
| | | | | | - Pamela L Kunz
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
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22
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Hemmingsson J, Svensson J, Hallqvist A, Smits K, Johanson V, Bernhardt P. Specific Uptake in the Bone Marrow Causes High Absorbed Red Marrow Doses During [ 177Lu]Lu-DOTATATE Treatment. J Nucl Med 2023; 64:1456-1462. [PMID: 37290797 PMCID: PMC10478826 DOI: 10.2967/jnumed.123.265484] [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: 01/18/2023] [Revised: 05/03/2023] [Indexed: 06/10/2023] Open
Abstract
Bone marrow suppression is a common side effect after [177Lu]Lu-DOTATATE treatment of neuroendocrine neoplasms. Neuroendocrine neoplasms share expression of somatostatin receptor type 2 with CD34-positive hematopoietic progenitor cells, potentially leading to active uptake in the radiosensitive red marrow region where these cells are located. This study aimed to identify and quantify specific red marrow uptake using SPECT/CT images collected after the first treatment cycle. Methods: Seventeen patients diagnosed with neuroendocrine neoplasms were treated with [177Lu]Lu-DOTATATE. Seven of them had confirmed bone metastases. After the first treatment cycle, each patient went through 4 SPECT/CT imaging sessions 4, 24, 48, and 168 h after administration. Monte Carlo-based reconstructions were used to quantify activity concentrations in tumors and multiple skeletal sites presumed to house red marrow: the T9-L5 vertebrae and the ilium portion of the hip bones. The activity concentration from the descending aorta was used as input in a compartment model intended to establish a pure red marrow biodistribution by separating the nonspecific blood-based contribution from the specific activity concentration in red marrow. The biodistributions from the compartment model were used to perform red marrow dosimetry at each skeletal site. Results: Increased uptake of [177Lu]Lu-DOTATATE was observed in the T9-L5 vertebrae and hip bones in all 17 patients compared with activity concentrations in the aorta. The mean specific red marrow uptake was 49% (range, 0%-93%) higher than the nonspecific uptake. The median (±SD) total absorbed dose to the red marrow was 0.056 ± 0.023 Gy/GBq and 0.043 ± 0.022 Gy/GBq for the mean of all vertebrae and hip bones, respectively. The patients with bone metastases had an absorbed dose of 0.085 ± 0.046 Gy/GBq and 0.069 ± 0.033 Gy/GBq for the vertebrae and hip bones, respectively. The red marrow elimination phase was statistically slower in patients with fast tumor elimination, which is in line with transferrin transport of 177Lu back to the red marrow. Conclusion: Our results suggest that specific red marrow uptake of [177Lu]Lu-DOTATATE is in line with observations of somatostatin receptor type 2-expressing hematopoietic progenitor cells within the bone marrow. Blood-based dosimetry methods fail to account for the prolonged elimination of specific uptake and underestimate the absorbed dose to red marrow.
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Affiliation(s)
- Jens Hemmingsson
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden;
| | - Johanna Svensson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Hallqvist
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Katja Smits
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
| | - Viktor Johanson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden; and
| | - Peter Bernhardt
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Medical Physics and Medical Bioengineering, Sahlgrenska University Hospital, Gothenburg, Sweden
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23
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Siebinga H, de Wit-van der Veen BJ, Beijnen JH, Stokkel MPM, Dorlo TPC, Huitema ADR, Hendrikx JJMA. Predicting [ 177Lu]Lu-HA-DOTATATE kidney and tumor accumulation based on [ 68Ga]Ga-HA-DOTATATE diagnostic imaging using semi-physiological population pharmacokinetic modeling. EJNMMI Phys 2023; 10:48. [PMID: 37615812 PMCID: PMC10449733 DOI: 10.1186/s40658-023-00565-4] [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: 03/20/2023] [Accepted: 07/24/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Prediction of [177Lu]Lu-HA-DOTATATE kidney and tumor uptake based on diagnostic [68Ga]Ga-HA-DOTATATE imaging would be a crucial step for precision dosing of [177Lu]Lu-HA-DOTATATE. In this study, the population pharmacokinetic (PK) differences between [177Lu]Lu-HA-DOTATATE and [68Ga]Ga-HA-DOTATATE were assessed and subsequently [177Lu]Lu-HA-DOTATATE was predicted based on [68Ga]Ga-HA-DOTATATE imaging. METHODS A semi-physiological nonlinear mixed-effects model was developed for [68Ga]Ga-HA-DOTATATE and [177Lu]Lu-HA-DOTATATE, including six compartments (representing blood, spleen, kidney, tumor lesions, other somatostatin receptor expressing organs and a lumped rest compartment). Model parameters were fixed based on a previously developed physiologically based pharmacokinetic model for [68Ga]Ga-HA-DOTATATE. For [177Lu]Lu-HA-DOTATATE, PK parameters were based on literature values or estimated based on scan data (four time points post-injection) from nine patients. Finally, individual [177Lu]Lu-HA-DOTATATE uptake into tumors and kidneys was predicted based on individual [68Ga]Ga-HA-DOTATATE scan data using Bayesian estimates. Predictions were evaluated compared to observed data using a relative prediction error (RPE) for both area under the curve (AUC) and absorbed dose. Lastly, to assess the predictive value of diagnostic imaging to predict therapeutic exposure, individual prediction RPEs (using Bayesian estimation) were compared to those from population predictions (using the population model). RESULTS Population uptake rate parameters for spleen, kidney and tumors differed by a 0.29-fold (15% relative standard error (RSE)), 0.49-fold (15% RSE) and 1.43-fold (14% RSE), respectively, for [177Lu]Lu-HA-DOTATATE compared to [68Ga]Ga-HA-DOTATATE. Model predictions adequately described observed data in kidney and tumors for both peptides (based on visual inspection of goodness-of-fit plots). Individual predictions of tumor uptake were better (RPE AUC -40 to 28%) compared to kidney predictions (RPE AUC -53 to 41%). Absorbed dose predictions were less predictive for both tumor and kidneys (RPE tumor and kidney -51 to 44% and -58 to 82%, respectively). For most patients, [177Lu]Lu-HA-DOTATATE tumor accumulation predictions based on individual PK parameters estimated from diagnostic imaging outperformed predictions based on population parameters. CONCLUSION Our semi-physiological PK model indicated clear differences in PK parameters for [68Ga]Ga-HA-DOTATATE and [177Lu]Lu-HA-DOTATATE. Diagnostic images provided additional information to individually predict [177Lu]Lu-HA-DOTATATE tumor uptake compared to using a population approach. In addition, individual predictions indicated that many aspects, apart from PK differences, play a part in predicting [177Lu]Lu-HA-DOTATATE distribution.
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Affiliation(s)
- Hinke Siebinga
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
- Graduate School of Life Sciences, Utrecht University, Utrecht, The Netherlands.
| | | | - Jos H Beijnen
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Marcel P M Stokkel
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas P C Dorlo
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Jeroen J M A Hendrikx
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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24
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Alipour R, Jackson P, Bressel M, Hogg A, Callahan J, Hicks RJ, Kong G. The relationship between tumour dosimetry, response, and overall survival in patients with unresectable Neuroendocrine Neoplasms (NEN) treated with 177Lu DOTATATE (LuTate). Eur J Nucl Med Mol Imaging 2023; 50:2997-3010. [PMID: 37184682 PMCID: PMC10382388 DOI: 10.1007/s00259-023-06257-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 04/30/2023] [Indexed: 05/16/2023]
Abstract
Peptide Receptor Radionuclide Therapy (PRRT) delivers targeted radiation to Somatostatin Receptor (SSR) expressing Neuroendocrine Neoplasms (NEN). We sought to assess the predictive and prognostic implications of tumour dosimetry with respect to response by 68 Ga DOTATATE (GaTate) PET/CT molecular imaging tumour volume of SSR (MITVSSR) change and RECIST 1.1, and overall survival (OS). METHODS Patients with gastro-entero-pancreatic (GEP) NEN who received LuTate followed by quantitative SPECT/CT (Q-SPECT/CT) the next day (Jul 2010 to Jan 2019) were retrospectively reviewed. Single time-point (STP) lesional dosimetry was performed for each cycle using population-based pharmacokinetic modelling. MITVSSR and RECIST 1.1 were measured at 3-months post PRRT. RESULTS Median of 4 PRRT cycles were administered to 90 patients (range 2-5 cycles; mean 27.4 GBq cumulative activity; mean 7.6 GBq per cycle). 68% received at least one cycle with radiosensitising chemotherapy (RSC). RECIST 1.1 partial response was 24%, with 70% stable and 7% progressive disease. Cycle 1 radiation dose in measurable lesions was associated with local response (odds ratio 1.5 per 50 Gy [95% CI: 1.1-2.0], p = 0.002) when adjusted by tumour grade and RSC. Median change in MITVSSR was -63% (interquartile range -84 to -29), with no correlation with radiation dose to the most avid lesion on univariable or multivariant analyses (5.6 per 10 Gy [95% CI: -1.6, 12.8], p = 0.133). OS at 5-years was 68% (95% CI: 56-78%). Neither baseline MITVSSR (hazard ratio 1.1 [95% CI: 1.0, 1.2], p = 0.128) nor change in baseline MITVSSR (hazard ratio 1.0 [95% CI: 1.0, 1.1], p = 0.223) were associated with OS when adjusted by tumour grade and RSC but RSC was (95% CI: 0.2, 0.8, p = 0.012). CONCLUSION Radiation dose to tumour during PRRT was predictive of radiologic response but not survival. Survival outcomes may relate to other biological factors. There was no evidence that MITVSSR change was associated with OS, but a larger study is needed.
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Affiliation(s)
- R Alipour
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia.
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.
| | - P Jackson
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - M Bressel
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - A Hogg
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - J Callahan
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - R J Hicks
- Department of Medicine, St Vincent's Medical School, The University of Melbourne, Melbourne, Australia
| | - G Kong
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
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Akhavanallaf A, Peterson AB, Fitzpatrick K, Roseland M, Wong KK, El-Naqa I, Zaidi H, Dewaraja YK. The predictive value of pretherapy [ 68Ga]Ga-DOTA-TATE PET and biomarkers in [ 177Lu]Lu-PRRT tumor dosimetry. Eur J Nucl Med Mol Imaging 2023; 50:2984-2996. [PMID: 37171633 PMCID: PMC10981963 DOI: 10.1007/s00259-023-06252-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/24/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE Metastatic neuroendocrine tumors (NETs) overexpressing type 2 somatostatin receptors are the target for peptide receptor radionuclide therapy (PRRT) through the theragnostic pair of 68Ga/177Lu-DOTATATE. The main purpose of this study was to develop machine learning models to predict therapeutic tumor dose using pre therapy 68Ga -PET and clinicopathological biomarkers. METHODS We retrospectively analyzed 90 segmented metastatic NETs from 25 patients (M14/F11, age 63.7 ± 9.5, range 38-76) treated by 177Lu-DOTATATE at our institute. Patients underwent both pretherapy [68Ga]Ga-DOTA-TATE PET/CT and four timepoints SPECT/CT at ~ 4, 24, 96, and 168 h post-177Lu-DOTATATE infusion. Tumors were segmented by a radiologist on baseline CT or MRI and transferred to co-registered PET/CT and SPECT/CT, and normal organs were segmented by deep learning-based method on CT of the PET and SPECT. The SUV metrics and tumor-to-normal tissue SUV ratios (SUV_TNRs) were calculated from 68Ga -PET at the contour-level. Posttherapy dosimetry was performed based on the co-registration of SPECT/CTs to generate time-integrated-activity, followed by an in-house Monte Carlo-based absorbed dose estimation. The correlation between delivered 177Lu Tumor absorbed dose and PET-derived metrics along with baseline clinicopathological biomarkers (such as Creatinine, Chromogranin A and prior therapies) were evaluated. Multiple interpretable machine-learning algorithms were developed to predict tumor dose using these pretherapy information. Model performance on a nested tenfold cross-validation was evaluated in terms of coefficient of determination (R2), mean-absolute-error (MAE), and mean-relative-absolute-error (MRAE). RESULTS SUVmean showed a significant correlation (q-value < 0.05) with absorbed dose (Spearman ρ = 0.64), followed by TLSUVmean (SUVmean of total-lesion-burden) and SUVpeak (ρ = 0.45 and 0.41, respectively). The predictive value of PET-SUVmean in estimation of posttherapy absorbed dose was stronger compared to PET-SUVpeak, and SUV_TNRs in terms of univariate analysis (R2 = 0.28 vs. R2 ≤ 0.12). An optimal trivariate random forest model composed of SUVmean, TLSUVmean, and total liver SUVmean (normal and tumoral liver) provided the best performance in tumor dose prediction with R2 = 0.64, MAE = 0.73 Gy/GBq, and MRAE = 0.2. CONCLUSION Our preliminary results demonstrate the feasibility of using baseline PET images for prediction of absorbed dose prior to 177Lu-PRRT. Machine learning models combining multiple PET-based metrics performed better than using a single SUV value and using other investigated clinicopathological biomarkers. Developing such quantitative models forms the groundwork for the role of 68Ga -PET not only for the implementation of personalized treatment planning but also for patient stratification in the era of precision medicine.
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Affiliation(s)
- Azadeh Akhavanallaf
- Department of Radiology, University of Michigan, 1301 Catherine, 2276 Medical Science I/5610, Ann Arbor, MI, 48109, USA.
- Division of Nuclear Medicine and Molecular Imaging, Geneva University Hospital, CH-1211, Geneva, Switzerland.
| | - Avery B Peterson
- Department of Radiology, University of Michigan, 1301 Catherine, 2276 Medical Science I/5610, Ann Arbor, MI, 48109, USA
| | - Kellen Fitzpatrick
- Department of Radiology, University of Michigan, 1301 Catherine, 2276 Medical Science I/5610, Ann Arbor, MI, 48109, USA
| | - Molly Roseland
- Department of Radiology, University of Michigan, 1301 Catherine, 2276 Medical Science I/5610, Ann Arbor, MI, 48109, USA
| | - Ka Kit Wong
- Department of Radiology, University of Michigan, 1301 Catherine, 2276 Medical Science I/5610, Ann Arbor, MI, 48109, USA
| | - Issam El-Naqa
- Department of Machine Learning, Moffitt Cancer Center, Tampa, FL, USA
| | - Habib Zaidi
- Division of Nuclear Medicine and Molecular Imaging, Geneva University Hospital, CH-1211, Geneva, Switzerland
- Geneva University Neurocenter, Geneva University, CH-1205, Geneva, Switzerland
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, 9700 RB, Groningen, Netherlands
- Department of Nuclear Medicine, University of Southern Denmark, DK-500, Odense, Denmark
| | - Yuni K Dewaraja
- Department of Radiology, University of Michigan, 1301 Catherine, 2276 Medical Science I/5610, Ann Arbor, MI, 48109, USA
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26
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Bednarz B. Theranostics and Patient-Specific Dosimetry. Semin Radiat Oncol 2023; 33:317-326. [PMID: 37331786 PMCID: PMC10414757 DOI: 10.1016/j.semradonc.2023.03.011] [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] [Indexed: 06/20/2023]
Abstract
Radiopharmaceutical therapy (RPT) is an invigorated form of cancer therapy that systemically delivers targeted radioactive drugs to cancer cells. Theranostics is a type of RPT that utilizes imaging, either of the RPT drug directly or a companion diagnostic, to inform whether a patient will benefit from the treatment. Given the ability to image the drug onboard theranostic treatments also lends itself readily to patient-specific dosimetry, which is a physics-based process that determines the overall absorbed dose burden to healthy organs and tissues and tumors in patients. While companion diagnostics identify who will benefit from RPT treatments, dosimetry determines how much activity these beneficiaries can receive to maximize therapeutic efficacy. Clinical data is starting to accrue suggesting tremendous benefits when dosimetry is performed for RPT patients. RPT dosimetry, which was once performed by florid and often inaccurate workflows, can now be performed more efficiently and accurately with FDA-cleared dosimetry software. Therefore, there is no better time for the field of oncology to adopt this form of personalize medicine to improve outcomes for cancer patients.
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Affiliation(s)
- Bryan Bednarz
- Department of Medical Physics, University of Wisconsin - Madison, Madison, WI.
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27
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Staanum PF. Tumor dosimetry using 177Lu: influence of background activity, measurement method and reconstruction algorithm. EJNMMI Phys 2023; 10:39. [PMID: 37341930 DOI: 10.1186/s40658-023-00561-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/13/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Image-based tumor dosimetry after radionuclide therapy, using the isotope 177Lu, finds application e.g., for tumor-to-organ dose comparison and for dose response evaluation. When the tumor extent is not much larger than the image resolution, and when 177Lu is found in nearby organs or other tumors, an accurate determination of tumor dose is particularly challenging. Here a quantitative evaluation of three different methods for determining the 177Lu activity concentration in a phantom is performed, and the dependence on a variety of parameters is described. The phantom (NEMA IEC body phantom) has spheres of different size in a background volume, and sphere-to-background 177Lu activity concentration ratios of infinity, 9.5, 5.0 and 2.7 are applied. The methods are simple to implement and well-known from the literature. They are based on (1) a large VOI encompassing the whole sphere, without background activity and with volume information from other sources, (2) a small VOI located in the sphere center, and (3) a VOI consisting of voxels with voxel value above a certain percentage of the maximum voxel value. RESULTS The determined activity concentration varies significantly with sphere size, sphere-to-background ratio, SPECT reconstruction method and method for determining the concentration. Based on the phantom study, criteria are identified under which the activity concentration can be determined with a maximal error of 40% even in the presence of background activity. CONCLUSIONS Tumor dosimetry is feasible in the presence of background activity using the above-mentioned methods, provided appropriate SPECT reconstructions are applied and tumors are selected for dosimetry analysis according to the following criteria for the three methods: (1) solitary tumor with diameter > 15 mm, (2) tumor diameter > 30 mm and tumor-to-background ratio > 2, and (3) tumor diameter > 30 mm and tumor-to-background ratio > 3.
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Affiliation(s)
- Peter Frøhlich Staanum
- Department of Nuclear Medicine and PET-Centre, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N, Denmark.
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28
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Gear J, Stokke C, Terwinghe C, Gnesin S, Sandström M, Tran-Gia J, Cremonesi M, Cicone F, Verburg F, Hustinx R, Giovanella L, Herrmann K, Gabiña PM. EANM enabling guide: how to improve the accessibility of clinical dosimetry. Eur J Nucl Med Mol Imaging 2023; 50:1861-1868. [PMID: 37086275 PMCID: PMC10287783 DOI: 10.1007/s00259-023-06226-z] [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: 02/11/2023] [Accepted: 04/04/2023] [Indexed: 04/23/2023]
Abstract
Dosimetry can be a useful tool for personalization of molecular radiotherapy (MRT) procedures, enabling the continuous development of theranostic concepts. However, the additional resource requirements are often seen as a barrier to implementation. This guide discusses the requirements for dosimetry and demonstrates how a dosimetry regimen can be tailored to the available facilities of a centre. The aim is to help centres wishing to initiate a dosimetry service but may not have the experience or resources of some of the more established therapy and dosimetry centres. The multidisciplinary approach and different personnel requirements are discussed and key equipment reviewed example protocols demonstrating these factors are given in the supplementary material for the main therapies carried out in nuclear medicine, including [131I]-NaI for benign thyroid disorders, [177Lu]-DOTATATE and 131I-mIBG for neuroendocrine tumours and [90Y]-microspheres for unresectable hepatic carcinoma.
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Affiliation(s)
- Jonathan Gear
- Joint Department of Physics, Royal Marsden NHSFT & Institute of Cancer Research, Sutton, UK.
| | - Caroline Stokke
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Department of Physics, University of Oslo, Oslo, Norway
| | - Christelle Terwinghe
- Department of Nuclear Medicine, Universitair Ziekenhuis Leuven, Louvain, Belgium
| | - Silvano Gnesin
- Institute of Radiation Physics, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Mattias Sandström
- Section of Nuclear Medicine and PET, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Sweden & Section of Medical Physics, Department of Immunology, Genetics and Pathology, Uppsala University, 751 85, Uppsala, Sweden
| | - Johannes Tran-Gia
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Marta Cremonesi
- Radiation Research Unit, Department of Medical Imaging and Radiation Sciences, Istituto Europeo Di Oncologia, IRCCS, Milan, Italy
| | - Francesco Cicone
- Department of Experimental and Clinical Medicine, Neuroscience Research Centre, PET/RM Unit, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
- Nuclear Medicine Unit, University Hospital "Mater Domini, Catanzaro, Italy
| | - Fredrik Verburg
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Roland Hustinx
- Division of Nuclear Medicine and Oncological Imaging, University Hospital of Liège, Liège, Belgium
- GIGA-CRC in Vivo Imaging, University of Liège, Liège, Belgium
| | - Luca Giovanella
- Clinic for Nuclear Medicine and Molecular Imaging, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Ken Herrmann
- Department of Nuclear Medicine, University of Duisburg-Essen, Duisburg, Germany
- German Cancer Consortium (DKTK)-University Hospital Essen, Essen, Germany
| | - Pablo Minguez Gabiña
- Department of Medical Physics and Radiation Protection, Gurutzeta-Cruces University Hospital/Biocruces Health Research Institute, Barakaldo, Spain
- Department of Applied Physics, Faculty of Engineering, UPV/EHU, Bilbao, Spain
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Privé BM, Boussihmad MA, Timmermans B, van Gemert WA, Peters SMB, Derks YHW, van Lith SAM, Mehra N, Nagarajah J, Heskamp S, Westdorp H. Fibroblast activation protein-targeted radionuclide therapy: background, opportunities, and challenges of first (pre)clinical studies. Eur J Nucl Med Mol Imaging 2023; 50:1906-1918. [PMID: 36813980 PMCID: PMC10199876 DOI: 10.1007/s00259-023-06144-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Fibroblast activation protein (FAP) is highly overexpressed in stromal tissue of various cancers. While FAP has been recognized as a potential diagnostic or therapeutic cancer target for decades, the surge of radiolabeled FAP-targeting molecules has the potential to revolutionize its perspective. It is presently hypothesized that FAP targeted radioligand therapy (TRT) may become a novel treatment for various types of cancer. To date, several preclinical and case series have been reported on FAP TRT using varying compounds and showing effective and tolerant results in advanced cancer patients. Here, we review the current (pre)clinical data on FAP TRT and discuss its perspective towards broader clinical implementation. METHODS: A PubMed search was performed to identify all FAP tracers used for TRT. Both preclinical and clinical studies were included if they reported on dosimetry, treatment response or adverse events. The last search was performed on July 22 2022. In addition, a database search was performed on clinical trial registries (date 15th of July 2022) to search for prospective trials on FAP TRT. RESULTS In total, 35 papers were identified that were related to FAP TRT. This resulted in the inclusion of the following tracers for review: FAPI-04, FAPI-46, FAP-2286, SA.FAP, ND-bisFAPI, PNT6555, TEFAPI-06/07, FAPI-C12/C16, and FSDD. CONCLUSION To date, data was reported on more than 100 patients that were treated with different FAP targeted radionuclide therapies such as [177Lu]Lu-FAPI-04, [90Y]Y-FAPI-46, [177Lu]Lu-FAP-2286, [177Lu]Lu-DOTA.SA.FAPI and [177Lu]Lu-DOTAGA.(SA.FAPi)2. In these studies, FAP targeted radionuclide therapy has resulted in objective responses in difficult to treat end stage cancer patients with manageable adverse events. Although no prospective data is yet available, these early data encourages further research.
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Affiliation(s)
- Bastiaan M Privé
- Department of Radiology and Nuclear Medicine, PO Box 9101, Radboudumc, 6500 HB, Nijmegen, The Netherlands.
- Department of Radiation Oncology, Erasmus MC, Rotterdam, The Netherlands.
| | - Mohamed A Boussihmad
- Department of Radiology and Nuclear Medicine, PO Box 9101, Radboudumc, 6500 HB, Nijmegen, The Netherlands
| | - Bart Timmermans
- Department of Radiology and Nuclear Medicine, PO Box 9101, Radboudumc, 6500 HB, Nijmegen, The Netherlands
| | - Willemijn A van Gemert
- Department of Radiology and Nuclear Medicine, PO Box 9101, Radboudumc, 6500 HB, Nijmegen, The Netherlands
| | - Steffie M B Peters
- Department of Radiology and Nuclear Medicine, PO Box 9101, Radboudumc, 6500 HB, Nijmegen, The Netherlands
| | - Yvonne H W Derks
- Department of Radiology and Nuclear Medicine, PO Box 9101, Radboudumc, 6500 HB, Nijmegen, The Netherlands
| | - Sanne A M van Lith
- Department of Radiology and Nuclear Medicine, PO Box 9101, Radboudumc, 6500 HB, Nijmegen, The Netherlands
| | - Niven Mehra
- Department of Medical Oncology, Radboudumc, Nijmegen, The Netherlands
| | - James Nagarajah
- Department of Radiology and Nuclear Medicine, PO Box 9101, Radboudumc, 6500 HB, Nijmegen, The Netherlands
| | - Sandra Heskamp
- Department of Radiology and Nuclear Medicine, PO Box 9101, Radboudumc, 6500 HB, Nijmegen, The Netherlands
| | - Harm Westdorp
- Department of Radiology and Nuclear Medicine, PO Box 9101, Radboudumc, 6500 HB, Nijmegen, The Netherlands
- Department of Medical Oncology, Radboudumc, Nijmegen, The Netherlands
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30
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Barakat A, Santoro L, Vivien M, Kotzki PO, Deshayes E, Khier S. Clinical Pharmacokinetics of Radiopharmaceuticals from SPECT/CT Image Acquisition by Contouring in Patients with Gastroenteropancreatic Neuroendocrine Tumors: Lu-177 DOTATATE (Lutathera ®) Case. Eur J Drug Metab Pharmacokinet 2023:10.1007/s13318-023-00829-5. [PMID: 37184824 DOI: 10.1007/s13318-023-00829-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND AND OBJECTIVE Lu-177 DOTATATE (Lutathera®) is a radiolabeled analog of somatostatin administered intravenously in patients with somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors. Biodistribution of Lu-177 DOTATATE in tumor and healthy tissues can be monitored by serial post-injection scintigraphy imaging. Patient exposure to the drug is variable with the recommended fixed dosage, and hence there is a variable response to treatment. The aim of this work was to study the pharmacokinetics of Lu-177 DOTATATE by a population modeling approach, based on single-photon emission computed tomography (SPECT)/computed tomography (CT) images used as surrogate of plasma concentrations to study the interindividual variability and finally optimize an individual dosage. METHODS From a retrospective study, SPECT/CT images were acquired at 4 h, 24 h, 72 h, and 192 h postadministration. From these images, volumic activities were calculated in blood and bone marrow. An individual non-compartmental pharmacokinetic analysis was performed, and the mean pharmacokinetic parameters of each tissue were compared together and with reference data. Blood volumic activities were then used to perform a population pharmacokinetic analysis (NONMEM). RESULTS The pharmacokinetic parameters (non-compartmental analysis) obtained from blood (clearance [CL] = 2.65 L/h, volume of distribution at steady state [Vss] = 309 L, elimination half-life [t1/2] = 86.3 h) and bone marrow (CL =1.68 L/h, Vss = 233 L, t1/2 = 98.8 h) were statistically different from each other and from reference values (CL = 4.50 L/h, Vss = 460 L, t1/2 = 71.0 h) published in the literature. SPECT/CT blood images were used as a surrogate of plasma concentrations to develop a population pharmacokinetic model. Weight was identified as covariate on volume of the central compartment, reducing the interindividual variability of all population pharmacokinetic parameters. CONCLUSION This study is a proof of concept that obtaining pharmacokinetic parameters with image-based blood concentration is possible. Obtaining observed concentrations from SPECT/CT images, without the need for blood sampling, is a real advantage for the patient and the drug monitoring. Pharmacokinetic modeling could be combined with a deep learning model for automatic contouring and allow precise patient-specific dose adjustment in a non-invasive manner.
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Affiliation(s)
- Anissa Barakat
- Pharmacokinetics and Pharmacometrics Department, School of Pharmacy, UFR Pharmacie, Montpellier University, 15 Avenue Charles Flahault, 34000, Montpellier, France
- Probabilities and Statistics Department, Institut Montpelliérain Alexander Grothendieck (IMAG), CNRS, UMR 5149, Inria, Montpellier University, Montpellier, France
- Nuclear Medicine Department, Montpellier Cancer Institute, Montpellier University, Montpellier, France
| | - Lore Santoro
- Nuclear Medicine Department, Montpellier Cancer Institute, Montpellier University, Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier University, Montpellier, France
| | - Myrtille Vivien
- Biostatistics, Informatics and pharmaceutical physic Laboratory, School of Pharmacy, UFR Pharmacie, Montpellier University, 15 Av. Ch. Flahault, 34000, Montpellier, France
- Institute of Functional Genomic (IGF)- UMR 5203, INSERM U1191, Montpellier, France
| | - Pierre-Olivier Kotzki
- Nuclear Medicine Department, Montpellier Cancer Institute, Montpellier University, Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier University, Montpellier, France
| | - Emmanuel Deshayes
- Nuclear Medicine Department, Montpellier Cancer Institute, Montpellier University, Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier University, Montpellier, France
| | - Sonia Khier
- Pharmacokinetics and Pharmacometrics Department, School of Pharmacy, UFR Pharmacie, Montpellier University, 15 Avenue Charles Flahault, 34000, Montpellier, France.
- Probabilities and Statistics Department, Institut Montpelliérain Alexander Grothendieck (IMAG), CNRS, UMR 5149, Inria, Montpellier University, Montpellier, France.
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Peterson AB, Wang C, Wong KK, Frey KA, Muzik O, Schipper MJ, Dewaraja YK. 177Lu-DOTATATE Theranostics: Predicting Renal Dosimetry From Pretherapy 68Ga-DOTATATE PET and Clinical Biomarkers. Clin Nucl Med 2023; 48:393-399. [PMID: 37010563 PMCID: PMC10353839 DOI: 10.1097/rlu.0000000000004599] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
PURPOSE Pretreatment predictions of absorbed doses can be especially valuable for patient selection and dosimetry-guided individualization of radiopharmaceutical therapy. Our goal was to build regression models using pretherapy 68Ga-DOTATATE PET uptake data and other baseline clinical factors/biomarkers to predict renal absorbed dose delivered by 177Lu-DOTATATE peptide receptor radionuclide therapy (177Lu-PRRT) for neuroendocrine tumors. We explore the combination of biomarkers and 68Ga PET uptake metrics, hypothesizing that they will improve predictive power over univariable regression. PATIENTS AND METHODS Pretherapy 68Ga-DOTATATE PET/CTs were analyzed for 25 patients (50 kidneys) who also underwent quantitative 177Lu SPECT/CT imaging at approximately 4, 24, 96, and 168 hours after cycle 1 of 177Lu-PRRT. Kidneys were contoured on the CT of the PET/CT and SPECT/CT using validated deep learning-based tools. Dosimetry was performed by coupling the multi-time point SPECT/CT images with an in-house Monte Carlo code. Pretherapy renal PET SUV metrics, activity concentration per injected activity (Bq/mL/MBq), and other baseline clinical factors/biomarkers were investigated as predictors of the 177Lu SPECT/CT-derived mean absorbed dose per injected activity to the kidneys using univariable and bivariable models. Leave-one-out cross-validation (LOOCV) was used to estimate model performance using root mean squared error and absolute percent error in predicted renal absorbed dose including mean absolute percent error (MAPE) and associated standard deviation (SD). RESULTS The median therapy-delivered renal dose was 0.5 Gy/GBq (range, 0.2-1.0 Gy/GBq). In LOOCV of univariable models, PET uptake (Bq/mL/MBq) performs best with MAPE of 18.0% (SD = 13.3%), and estimated glomerular filtration rate (eGFR) gives an MAPE of 28.5% (SD = 19.2%). Bivariable regression with both PET uptake and eGFR gives LOOCV MAPE of 17.3% (SD = 11.8%), indicating minimal improvement over univariable models. CONCLUSIONS Pretherapy 68Ga-DOTATATE PET renal uptake can be used to predict post-177Lu-PRRT SPECT-derived mean absorbed dose to the kidneys with accuracy within 18%, on average. Compared with PET uptake alone, including eGFR in the same model to account for patient-specific kinetics did not improve predictive power. Following further validation of these preliminary findings in an independent cohort, predictions using renal PET uptake can be used in the clinic for patient selection and individualization of treatment before initiating the first cycle of PRRT.
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Affiliation(s)
- Avery B. Peterson
- Department of Radiology, University of Michigan, Ann Arbor
- Department of Radiation Oncology, Wayne State University, Detroit
| | - Chang Wang
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Ka Kit Wong
- Department of Radiology, University of Michigan, Ann Arbor
| | - Kirk A. Frey
- Department of Radiology, University of Michigan, Ann Arbor
| | - Otto Muzik
- Department of Pediatrics, Wayne State University, Detroit, MI
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Urso L, Nieri A, Uccelli L, Castello A, Artioli P, Cittanti C, Marzola MC, Florimonte L, Castellani M, Bissoli S, Porto F, Boschi A, Evangelista L, Bartolomei M. Lutathera® Orphans: State of the Art and Future Application of Radioligand Therapy with 177Lu-DOTATATE. Pharmaceutics 2023; 15:pharmaceutics15041110. [PMID: 37111596 PMCID: PMC10142322 DOI: 10.3390/pharmaceutics15041110] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Lutathera® is the first EMA- and FDA-approved radiopharmaceutical for radioligand therapy (RLT). Currently, on the legacy of the NETTER1 trial, only adult patients with progressive unresectable somatostatin receptor (SSTR) positive gastroenteropancreatic (GEP) neuroendocrine neoplasms (NET) can be treated with Lutathera®. Conversely, patients with SSTR-positive disease arising from outside the gastroenteric region do not currently have access to Lutathera® treatment despite several papers in the literature reporting the effectiveness and safety of RLT in these settings. Moreover, patients with well-differentiated G3 GEP-NET are also still “Lutathera orphans”, and retreatment with RLT in patients with disease relapse is currently not approved. The aim of this critical review is to summarize current literature evidence assessing the role of Lutathera® outside the approved indications. Moreover, ongoing clinical trials evaluating new possible applications of Lutathera® will be considered and discussed to provide an updated picture of future investigations.
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Affiliation(s)
- Luca Urso
- Department of Translational Medicine, University of Ferrara, Via Aldo Moro 8, 44124 Ferrara, Italy; (L.U.); (C.C.); (F.P.)
- Department of Nuclear Medicine, PET/CT Centre, S. Maria della Misericordia Hospital, 45100 Rovigo, Italy;
| | - Alberto Nieri
- Nuclear Medicine Unit, Oncological Medical and Specialist Department, University Hospital of Ferrara, 44124 Cona, Italy; (A.N.); (M.B.)
| | - Licia Uccelli
- Department of Translational Medicine, University of Ferrara, Via Aldo Moro 8, 44124 Ferrara, Italy; (L.U.); (C.C.); (F.P.)
- Nuclear Medicine Unit, Oncological Medical and Specialist Department, University Hospital of Ferrara, 44124 Cona, Italy; (A.N.); (M.B.)
- Correspondence: ; Tel.: +39-053-232-6387
| | - Angelo Castello
- Nuclear Medicine Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.C.); (L.F.); (M.C.)
| | - Paolo Artioli
- Nuclear Medicine Unit, AULSS1 Dolomiti, San Martino Hospital, 32100 Belluno, Italy; (P.A.); (S.B.)
| | - Corrado Cittanti
- Department of Translational Medicine, University of Ferrara, Via Aldo Moro 8, 44124 Ferrara, Italy; (L.U.); (C.C.); (F.P.)
- Nuclear Medicine Unit, Oncological Medical and Specialist Department, University Hospital of Ferrara, 44124 Cona, Italy; (A.N.); (M.B.)
| | - Maria Cristina Marzola
- Department of Nuclear Medicine, PET/CT Centre, S. Maria della Misericordia Hospital, 45100 Rovigo, Italy;
| | - Luigia Florimonte
- Nuclear Medicine Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.C.); (L.F.); (M.C.)
| | - Massimo Castellani
- Nuclear Medicine Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.C.); (L.F.); (M.C.)
| | - Sergio Bissoli
- Nuclear Medicine Unit, AULSS1 Dolomiti, San Martino Hospital, 32100 Belluno, Italy; (P.A.); (S.B.)
| | - Francesca Porto
- Department of Translational Medicine, University of Ferrara, Via Aldo Moro 8, 44124 Ferrara, Italy; (L.U.); (C.C.); (F.P.)
| | - Alessandra Boschi
- Department of Chemical, Pharmaceutical and Agricultural Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Laura Evangelista
- Department of Medicine DIMED, University of Padua, 35128 Padua, Italy;
| | - Mirco Bartolomei
- Nuclear Medicine Unit, Oncological Medical and Specialist Department, University Hospital of Ferrara, 44124 Cona, Italy; (A.N.); (M.B.)
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Rubira L, Deshayes E, Santoro L, Kotzki PO, Fersing C. 225Ac-Labeled Somatostatin Analogs in the Management of Neuroendocrine Tumors: From Radiochemistry to Clinic. Pharmaceutics 2023; 15:pharmaceutics15041051. [PMID: 37111537 PMCID: PMC10146019 DOI: 10.3390/pharmaceutics15041051] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/18/2023] [Accepted: 03/22/2023] [Indexed: 04/29/2023] Open
Abstract
The widespread use of peptide receptor radionuclide therapy (PRRT) represents a major therapeutic breakthrough in nuclear medicine, particularly since the introduction of 177Lu-radiolabeled somatostatin analogs. These radiopharmaceuticals have especially improved progression-free survival and quality of life in patients with inoperable metastatic gastroenteropancreatic neuroendocrine tumors expressing somatostatin receptors. In the case of aggressive or resistant disease, the use of somatostatin derivatives radiolabeled with an alpha-emitter could provide a promising alternative. Among the currently available alpha-emitting radioelements, actinium-225 has emerged as the most suitable candidate, especially regarding its physical and radiochemical properties. Nevertheless, preclinical and clinical studies on these radiopharmaceuticals are still few and heterogeneous, despite the growing momentum for their future use on a larger scale. In this context, this report provides a comprehensive and extensive overview of the development of 225Ac-labeled somatostatin analogs; particular emphasis is placed on the challenges associated with the production of 225Ac, its physical and radiochemical properties, as well as the place of 225Ac-DOTATOC and 225Ac-DOTATATE in the management of patients with advanced metastatic neuroendocrine tumors.
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Affiliation(s)
- Léa Rubira
- Nuclear Medicine Department, Institut Régional du Cancer de Montpellier (ICM), University Montpellier, 34090 Montpellier, France
| | - Emmanuel Deshayes
- Nuclear Medicine Department, Institut Régional du Cancer de Montpellier (ICM), University Montpellier, 34090 Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, University Montpellier, Institut Régional du Cancer de Montpellier (ICM), 34298 Montpellier, France
| | - Lore Santoro
- Nuclear Medicine Department, Institut Régional du Cancer de Montpellier (ICM), University Montpellier, 34090 Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, University Montpellier, Institut Régional du Cancer de Montpellier (ICM), 34298 Montpellier, France
| | - Pierre Olivier Kotzki
- Nuclear Medicine Department, Institut Régional du Cancer de Montpellier (ICM), University Montpellier, 34090 Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, University Montpellier, Institut Régional du Cancer de Montpellier (ICM), 34298 Montpellier, France
| | - Cyril Fersing
- Nuclear Medicine Department, Institut Régional du Cancer de Montpellier (ICM), University Montpellier, 34090 Montpellier, France
- IBMM, University Montpellier, CNRS, ENSCM, 34293 Montpellier, France
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Te Beek ET, Burggraaf J, Teunissen JJM, Vriens D. Clinical Pharmacology of Radiotheranostics in Oncology. Clin Pharmacol Ther 2023; 113:260-274. [PMID: 35373336 DOI: 10.1002/cpt.2598] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/23/2022] [Indexed: 01/27/2023]
Abstract
The combined use of diagnostic and therapeutic radioligands with the same molecular target, also known as theranostics, enables accurate patient selection, targeted therapy, and prediction of treatment response. Radioiodine, bone-seeking radioligands and norepinephrine analogs have been used for many years for diagnostic imaging and radioligand therapy of thyroid carcinoma, bone metastases, pheochromocytoma, paraganglioma, and neuroblastoma, respectively. In recent years, radiolabeled somatostatin analogs and prostate-specific membrane antigen ligands have shown clinical efficacy in the treatment of neuroendocrine tumors and prostate cancer, respectively. Several candidate compounds are targeting novel theranostic targets such as fibroblast activation protein, C-X-C chemokine receptor 4, and gastrin-releasing peptide receptor. In addition, several strategies to improve efficacy of radioligand therapy are being evaluated, including dosimetry-based dose optimization, multireceptor targeting, upregulation of target receptors, radiosensitization, pharmacogenomics, and radiation genomics. Design and evaluation of novel radioligands and optimization of dose and dose schedules, within the complex context of individualized multimodal cancer treatment, requires a multidisciplinary approach that includes clinical pharmacology. Significant increases in the use of these radiopharmaceuticals in routine oncological practice can be expected, which will have major impact on patient care as well as (radio)pharmacy utilization.
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Affiliation(s)
- Erik T Te Beek
- Department of Nuclear Medicine, Reinier de Graaf Hospital, Delft, The Netherlands
| | | | - Jaap J M Teunissen
- Department of Nuclear Medicine, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Dennis Vriens
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Minczeles NS, de Herder WW, Feelders RA, Verburg FA, Hofland J, Brabander T. Long-Term Outcomes of Submaximal Activities of Peptide Receptor Radionuclide Therapy with 177Lu-DOTATATE in Neuroendocrine Tumor Patients. J Nucl Med 2023; 64:40-46. [PMID: 35680417 DOI: 10.2967/jnumed.122.263856] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 01/13/2023] Open
Abstract
In the literature, up to 45% of neuroendocrine tumor (NET) patients who are treated with 177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT) do not receive the intended cumulative activity of 29.6 GBq (800 mCi). The aim of this study was to analyze the efficacy of submaximal activities of PRRT in patients who discontinued treatment for non-disease-related reasons. Methods: We retrospectively included patients with well-differentiated and advanced NETs who underwent PRRT from 2000 until 2019 and did not receive 29.6 GBq of 177Lu-DOTATATE. For comparison, we selected control NET patients who received the intended cumulative activity of 29.6 GBq of 177Lu-DOTATATE between 2000 and 2012. Primary outcomes were progression-free survival (PFS) and tumor response, and the secondary outcome was overall survival (OS). Results: In total, 243 patients received 3.7-27.8 GBq. In 130 patients, the submaximal activity was unrelated to disease (e.g., bone marrow and renal toxicity in 48% and maximal renal absorbed dose in 23%), and they were included. Patients receiving a reduced activity had more bone metastases, a lower body mass index and albumin level, a higher alkaline phosphatase level, and fewer grade 1 tumors than the 350 patients included in the control group. The disease control rate in the reduced-activity group was 85%, compared with 93% for the control group (P = 0.011). The median PFS (95% CI) was 23 mo (range, 21-26 mo) for the reduced-activity group and 31 mo (range, 27-35 mo) for the control group (P = 0.001), and the median OS (95% CI) was 34 mo (range, 28-40 mo) and 60 mo (range, 53-67 mo), respectively (P < 0.0001). With adjustment for relevant confounders in the multivariable Cox regression analyses, cumulative activity was an independent predictor of both PFS and OS. Conclusion: In NET patients treated with a cumulative activity of less than 29.6 GBq of 177Lu-DOTATATE, PRRT was less efficacious in tumor response and survival than in patients who received 29.6 GBq.
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Affiliation(s)
- Noémie S Minczeles
- Section of Endocrinology, Department of Internal Medicine, ENETS Centre of Excellence Rotterdam, Erasmus MC and Erasmus MC Cancer Centre, Rotterdam, The Netherlands; and .,Department of Radiology and Nuclear Medicine, ENETS Centre of Excellence Rotterdam, Erasmus MC and Erasmus MC Cancer Centre, Rotterdam, The Netherlands
| | - Wouter W de Herder
- Section of Endocrinology, Department of Internal Medicine, ENETS Centre of Excellence Rotterdam, Erasmus MC and Erasmus MC Cancer Centre, Rotterdam, The Netherlands; and
| | - Richard A Feelders
- Section of Endocrinology, Department of Internal Medicine, ENETS Centre of Excellence Rotterdam, Erasmus MC and Erasmus MC Cancer Centre, Rotterdam, The Netherlands; and
| | - Frederik A Verburg
- Department of Radiology and Nuclear Medicine, ENETS Centre of Excellence Rotterdam, Erasmus MC and Erasmus MC Cancer Centre, Rotterdam, The Netherlands
| | - Johannes Hofland
- Section of Endocrinology, Department of Internal Medicine, ENETS Centre of Excellence Rotterdam, Erasmus MC and Erasmus MC Cancer Centre, Rotterdam, The Netherlands; and
| | - Tessa Brabander
- Department of Radiology and Nuclear Medicine, ENETS Centre of Excellence Rotterdam, Erasmus MC and Erasmus MC Cancer Centre, Rotterdam, The Netherlands
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The Effects of Radioligand Therapy on Quality of Life and Sexual Function in Patients with Neuroendocrine Neoplasms. Cancers (Basel) 2022; 15:cancers15010115. [PMID: 36612112 PMCID: PMC9817532 DOI: 10.3390/cancers15010115] [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: 07/19/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
Peptide receptor radionuclide therapy (PRRT), also called radioligand therapy, is an effective antitumoral treatment in patients with neuroendocrine neoplasm (NEN). It improves the patient's health-related quality of life (HRQoL), which is evaluated by self-assessment questionnaires. The aim of this narrative review was to report the current knowledge on the changes of HRQoL and sexual function in patients with NEN treated with PRRT. We conducted a literature search of the PubMed, Embase, and APA PsycInfo databases. We selected 15 studies (12 for HRQoL and three for sexual function). After treatment with PRRT, patients with NEN experienced a significant improvement in their global health status, disease-related worries, social and emotional functioning, and cancer-related symptoms such as fatigue and diarrhea. Other symptoms, such as nausea/vomiting, dyspnea, and constipation, as well as the economic impact, were unchanged by radioligand therapy. Data on sexual function were not equally promising; only a few studies investigated this issue by using appropriate questionnaires in patients treated with radioligand therapy. Therefore, additional studies are needed to draw a conclusion about the benefits from PRRT on sexual function.
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37
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Deshayes E, Assenat E, Meignant L, Bardiès M, Santoro L, Gourgou S. A prospective, randomized, phase II study to assess the schemas of retreatment with Lutathera® in patients with new progression of an intestinal, well-differentiated neuroendocrine tumor (ReLUTH). BMC Cancer 2022; 22:1346. [PMID: 36550428 PMCID: PMC9773621 DOI: 10.1186/s12885-022-10443-4] [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: 11/08/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Although neuroendocrine tumors (NET) are classed as rare, they have a high prevalence and their incidence is increasing. Effective treatment with lutetium 17-[177Lu]Lu-oxodotreotide (Lutathera®) is possible in patients with well-differentiated NET, improving progression-free survival (PFS), overall survival (OS), and quality of life (QoL). However, progression does occur. Retreatment with additional Lutathera® cycles is an option to extend PFS and OS. Two retreatment cycles are usually proposed. We aim to compare four versus two Lutathera® retreatment cycles in patients with new progression of a well-differentiated intestinal NET. METHODS This will be a multicenter, randomized, controlled, open-label, phase II study in France (ReLUTH). The aim is to evaluate the efficacy of retreatment with Lutathera® in patients with progressive intestinal NET (determined by somatostatin-receptor positive imaging) after previous treatment with two cycles of Lutathera®. Before randomization, all patients will have already received two Lutathera® retreatment cycles (7.4 GBq infusion each, 8 weeks apart). A total of 146 patients will be randomized (1:1) to two additional cycles of Lutathera® (7.4 GBq infusion each, separated by 8 weeks) or to no treatment (active surveillance). PRIMARY OBJECTIVE efficacy of two additional Lutathera® retreatment cycles compared to active surveillance over 6 months. PRIMARY ENDPOINT disease control rate at 6 months from randomization (defined as Complete Response, Partial Response, and Stable Disease in the Response Evaluation Criteria In Solid Tumours) with an evaluation every 2 months. A secondary objective will be the safety, as well as the PFS, OS, and QoL. It is expected that the efficacy of retreatment will increase after two additional Lutathera® cycles, with no increased safety concerns. DISCUSSION Our prospective, randomized controlled study may lead to new recommendations for the use of Lutathera® in patients with intestinal progressive NET, and should confirm that four cycles will be more effective than two, with limited adverse impact on safety. Four Lutathera® treatment cycles have the potential to prolong life and improve quality of life in patients. TRIAL REGISTRATION ClinicalTrials.gov: NCT04954820.
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Affiliation(s)
- Emmanuel Deshayes
- grid.121334.60000 0001 2097 0141Nuclear Medicine Department, Montpellier Cancer Institute (ICM), University of Montpellier, 208 Avenue des Apothicaires, 34298 Montpellier, France ,grid.488845.d0000 0004 0624 6108Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, University of Montpellier, Montpellier, France
| | - Eric Assenat
- grid.121334.60000 0001 2097 0141Medical Oncology Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France ,grid.121334.60000 0001 2097 0141Medical Oncology Department, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Laetitia Meignant
- grid.121334.60000 0001 2097 0141Clinical Research and Innovation Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Manuel Bardiès
- grid.121334.60000 0001 2097 0141Nuclear Medicine Department, Montpellier Cancer Institute (ICM), University of Montpellier, 208 Avenue des Apothicaires, 34298 Montpellier, France ,grid.488845.d0000 0004 0624 6108Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, University of Montpellier, Montpellier, France
| | - Lore Santoro
- grid.121334.60000 0001 2097 0141Nuclear Medicine Department, Montpellier Cancer Institute (ICM), University of Montpellier, 208 Avenue des Apothicaires, 34298 Montpellier, France ,grid.488845.d0000 0004 0624 6108Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, University of Montpellier, Montpellier, France
| | - Sophie Gourgou
- grid.121334.60000 0001 2097 0141Biometrics Unit, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
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Rahmim A, Brosch-Lenz J, Fele-Paranj A, Yousefirizi F, Soltani M, Uribe C, Saboury B. Theranostic digital twins for personalized radiopharmaceutical therapies: Reimagining theranostics via computational nuclear oncology. Front Oncol 2022; 12:1062592. [PMID: 36591527 PMCID: PMC9797662 DOI: 10.3389/fonc.2022.1062592] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022] Open
Abstract
This work emphasizes that patient data, including images, are not operable (clinically), but that digital twins are. Based on the former, the latter can be created. Subsequently, virtual clinical operations can be performed towards selection of optimal therapies. Digital twins are beginning to emerge in the field of medicine. We suggest that theranostic digital twins (TDTs) are amongst the most natural and feasible flavors of digitals twins. We elaborate on the importance of TDTs in a future where 'one-size-fits-all' therapeutic schemes, as prevalent nowadays, are transcended in radiopharmaceutical therapies (RPTs). Personalized RPTs will be deployed, including optimized intervention parameters. Examples include optimization of injected radioactivities, sites of injection, injection intervals and profiles, and combination therapies. Multi-modal multi-scale images, combined with other data and aided by artificial intelligence (AI) techniques, will be utilized towards routine digital twinning of our patients, and will enable improved deliveries of RPTs and overall healthcare.
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Affiliation(s)
- Arman Rahmim
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada,Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada,School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada,*Correspondence: Arman Rahmim,
| | - Julia Brosch-Lenz
- Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada
| | - Ali Fele-Paranj
- Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada,School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Fereshteh Yousefirizi
- Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada
| | - Madjid Soltani
- Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada,Department of Electrical and Computer Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Carlos Uribe
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada,Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada,Department of Functional Imaging, BC Cancer, Vancouver, BC, Canada
| | - Babak Saboury
- Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada,Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
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Beauregard JM. Use of imaging-based dosimetry for personalising radiopharmaceutical therapy of cancer. Cancer Imaging 2022; 22:67. [PMID: 36494731 PMCID: PMC9733022 DOI: 10.1186/s40644-022-00505-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
Theranostics - i.e., the combination of molecular imaging and radiopharmaceutical therapy of cancer targeting a common biological feature - is a rapidly expanding field owing the recent successes of novel radiopharmaceutical therapies, such as 177Lu-based prostate-specific membrane antigen radioligand therapy of prostate cancer and peptide receptor radionuclide therapy of neuroendocrine tumours. Despite the ongoing technical developments in imaging-based dosimetry, the existence of tumour absorbed dose-efficacy and organ absorbed dose-toxicity relationships, as well as the high interpatient variability in absorbed doses per unit activity, radiopharmaceutical therapies are still mostly administered in a fixed-activity, one-size-fits-all fashion. This is at odds with the principles of radiation oncology, where the absorbed doses to tissues are prescribed and their delivery is carefully planned and controlled for each individual patient to maximise the clinical benefits. There is a growing body of clinical evidence that dosimetry-based radiopharmaceutical therapy allows to safely optimise tumour irradiation, which translates into improved clinical outcomes. In this narrative review, we will present the reported prospective clinical experience to date on the use of imaging-based dosimetry to personalise radiopharmaceutical therapies.
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Affiliation(s)
- Jean-Mathieu Beauregard
- grid.411081.d0000 0000 9471 1794Department of Medical Imaging, and Research Center (Oncology Axis), CHU de Québec – Université Laval, 11 côte du Palais, Quebec City, G1R 2J6 Canada ,grid.23856.3a0000 0004 1936 8390Department of Radiology and Nuclear Medicine, and Cancer Research Center, Université Laval, Quebec City, Canada
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Navalkissoor S, Gnanasegaran G, Grossman A. Optimisation of radioligand therapy in neuroendocrine tumours: Current and evolving evidence. J Neuroendocrinol 2022; 34:e13208. [PMID: 36346690 DOI: 10.1111/jne.13208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/23/2022] [Accepted: 10/02/2022] [Indexed: 11/27/2022]
Abstract
Treatment of neuroendocrine tumours (NETs) with radioligand therapy (RLT) for example, 177 Lu-DOTATATE is generally well-tolerated and prolongs time to progression in most patients. However, approximately 20% of patients are nonresponders. In addition, complete responses are rare (<5% of patients), and durable responses beyond 3-4 years are uncommon. This article will discuss factors which may improve the outcomes of PRRT by using biomarkers to identify patients at high risk to be nonresponders (imaging and liquid biomarkers) and will examine mechanisms to potentially improve/optimise current RLT treatment strategies. These include mechanisms to potentiate the effects of RLT, increase tumour absorbed dose, overcoming radio-resistance and upregulation of somatostatin receptors, although larger studies will be required to demonstrate which techniques are going to be most efficacious in clinical practice.
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Affiliation(s)
- Shaunak Navalkissoor
- Department of Nuclear Medicine, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | - Gopinath Gnanasegaran
- Department of Nuclear Medicine, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
| | - Ashley Grossman
- NET Unit, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, UK
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41
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Estimate of activity discharged into the sewer network in neuroendocrine treatments with 177Lu-DOTA-TATE. Appl Radiat Isot 2022; 190:110459. [DOI: 10.1016/j.apradiso.2022.110459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 11/17/2022]
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Desy A, Bouvet GF, Lafrenière N, Zamanian A, Després P, Beauregard JM. Impact of the dead-time correction method on quantitative 177Lu-SPECT (QSPECT) and dosimetry during radiopharmaceutical therapy. EJNMMI Phys 2022; 9:54. [PMID: 35976503 PMCID: PMC9385894 DOI: 10.1186/s40658-022-00484-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dead-time correction is required for accurate quantitative SPECT-based dosimetry in the context of personalised 177Lu radiopharmaceutical therapy. We aimed to evaluate the impact of applying dead-time correction on the reconstructed SPECT image versus on the acquisition projections before reconstruction. METHODS Data from 16 SPECT/CT acquisitions of a decaying 177Lu-filled phantom (up to 20.75 GBq) and dual-timepoint SPECT/CT in 14 patients treated with personalised 177Lu peptide receptor radionuclide therapy were analysed. Dead time was determined based on the acquisition wide-spectrum count rate for each projection and averaged for the entire acquisition. Three dead-time correction methods (DTCMs) were used: the per-projection correction, where each projection was individually corrected before reconstruction (DTCM1, the standard of reference), and two per-volume methods using the average dead-time correction factor of the acquisition applied to all projections before reconstruction (DTCM2) or to the SPECT image after reconstruction (DTCM3). Relative differences in quantification were assessed for various volumes of interest (VOIs) on the phantom and patient SPECT images. In patients, the resulting dosimetry estimates for tissues of interest were also compared between DTCMs. RESULTS Both per-volume DTCMs (DTCM2 and DTCM3) were found to be equivalent, with VOI count differences not exceeding 0.8%. When comparing the per-volume post-reconstruction DTCM3 versus the per-projection pre-reconstruction DTCM1, differences in VOI counts and absorbed dose estimates did not exceed 2%, with very few exceptions. The largest absorbed dose deviation was observed for a kidney at 3.5%. CONCLUSION While per-projection dead-time correction appears ideal for QSPECT, post-reconstruction correction is an acceptable alternative that is more practical to implement in the clinics, and that results in minimal deviations in quantitative accuracy and dosimetry estimates, as compared to the per-projection correction.
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Affiliation(s)
- Alessandro Desy
- Department of Medical Imaging, and Research Centre (Oncology Axis), CHU de Québec - Université Laval, 11 Côte du Palais, QC, G1R 2J6, Quebec City, Canada.,Department of Radiology and Nuclear Medicine, and Cancer Research Centre, Université Laval, Quebec City, Canada
| | - Guillaume F Bouvet
- Department of Medical Imaging, and Research Centre (Oncology Axis), CHU de Québec - Université Laval, 11 Côte du Palais, QC, G1R 2J6, Quebec City, Canada.,Department of Radiology and Nuclear Medicine, and Cancer Research Centre, Université Laval, Quebec City, Canada
| | - Nancy Lafrenière
- Department of Medical Imaging, and Research Centre (Oncology Axis), CHU de Québec - Université Laval, 11 Côte du Palais, QC, G1R 2J6, Quebec City, Canada
| | - Atefeh Zamanian
- Department of Medical Imaging, and Research Centre (Oncology Axis), CHU de Québec - Université Laval, 11 Côte du Palais, QC, G1R 2J6, Quebec City, Canada.,Department of Radiology and Nuclear Medicine, and Cancer Research Centre, Université Laval, Quebec City, Canada
| | - Philippe Després
- Department of Radiation Oncology, and Research Centre (Oncology Axis), CHU de Québec - Université Laval, Quebec City, Canada.,Department of Physics, Physical Engineering and Optics, and Cancer Research Centre, Université Laval, Quebec City, Canada
| | - Jean-Mathieu Beauregard
- Department of Medical Imaging, and Research Centre (Oncology Axis), CHU de Québec - Université Laval, 11 Côte du Palais, QC, G1R 2J6, Quebec City, Canada. .,Department of Radiology and Nuclear Medicine, and Cancer Research Centre, Université Laval, Quebec City, Canada.
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Roosen J, Westlund Gotby LEL, Arntz MJ, Fütterer JJ, Janssen MJR, Konijnenberg MW, van Wijk MWM, Overduin CG, Nijsen JFW. Intraprocedural MRI-based dosimetry during transarterial radioembolization of liver tumours with holmium-166 microspheres (EMERITUS-1): a phase I trial towards adaptive, image-controlled treatment delivery. Eur J Nucl Med Mol Imaging 2022; 49:4705-4715. [PMID: 35829749 DOI: 10.1007/s00259-022-05902-w] [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: 03/09/2022] [Accepted: 06/30/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Transarterial radioembolization (TARE) is a treatment for liver tumours based on injection of radioactive microspheres in the hepatic arterial system. It is crucial to achieve a maximum tumour dose for an optimal treatment response, while minimizing healthy liver dose to prevent toxicity. There is, however, no intraprocedural feedback on the dose distribution, as nuclear imaging can only be performed after treatment. As holmium-166 (166Ho) microspheres can be quantified with MRI, we investigate the feasibility and safety of performing 166Ho TARE within an MRI scanner and explore the potential of intraprocedural MRI-based dosimetry. METHODS Six patients were treated with 166Ho TARE in a hybrid operating room. Per injection position, a microcatheter was placed under angiography guidance, after which patients were transported to an adjacent 3-T MRI system. After MRI confirmation of unchanged catheter location, 166Ho microspheres were injected in four fractions, consisting of 10%, 30%, 30% and 30% of the planned activity, alternated with holmium-sensitive MRI acquisition to assess the microsphere distribution. After the procedures, MRI-based dose maps were calculated from each intraprocedural image series using a dedicated dosimetry software package for 166Ho TARE. RESULTS Administration of 166Ho microspheres within the MRI scanner was feasible in 9/11 (82%) injection positions. Intraprocedural holmium-sensitive MRI allowed for tumour dosimetry in 18/19 (95%) of treated tumours. Two CTCAE grade 3-4 toxicities were observed, and no adverse events were attributed to treatment in the MRI. Towards the last fraction, 4/18 tumours exhibited signs of saturation, while in 14/18 tumours, the microsphere uptake patterns did not deviate from the linear trend. CONCLUSION This study demonstrated feasibility and preliminary safety of a first in-human application of TARE within a clinical MRI system. Intraprocedural MRI-based dosimetry enabled dynamic insight in the microsphere distribution during TARE. This proof of concept yields unique possibilities to better understand microsphere distribution in vivo and to potentially optimize treatment efficacy through treatment personalization. REGISTRATION Clinicaltrials.gov, identifier NCT04269499, registered on February 13, 2020 (retrospectively registered).
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Affiliation(s)
- Joey Roosen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Lovisa E L Westlund Gotby
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark J Arntz
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jurgen J Fütterer
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel J R Janssen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark W Konijnenberg
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Meike W M van Wijk
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christiaan G Overduin
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Frank W Nijsen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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44
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Beykan S, Tran-Gia J, Borup Jensen S, Lassmann M. Is a single late SPECT/CT based kidney 177Lu-dosimetry superior to hybrid dosimetry with sequential multiple time-point whole-body planar scans in combination with an early SPECT/CT? Phys Med 2022; 100:39-50. [PMID: 35724608 DOI: 10.1016/j.ejmp.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 05/25/2022] [Accepted: 06/11/2022] [Indexed: 11/18/2022] Open
Abstract
PURPOSE The aim is to assess the impact of different imaging-protocols on image-based kidney dosimetry in 177Lu labelled peptide receptor radiotherapies. METHODS Kidney data of five [177Lu]Lu-OPS201 injected pigs and a 3D printed phantom were used for comparing the absorbed doses and time-integrated activity coefficients calculated based on the following imaging-protocols: A-) multiple time-point SPECT/CTs, B-) multiple time-point planar scans in combination with one SPECT/CT, C-) single time-point SPECT/CT. In addition, the influence of late scan time-points on kidney dosimetry was investigated by sequentially eliminating scan data at > 100 h from the pig/phantom datasets for imaging-protocols A and B. RESULTS Compared to imaging-protocol A, absorbed doses based on imaging-protocols B and C (scans at > 24 h post-injection) were always lower (differences > 34%). The best agreement in absorbed dose was achieved by imaging-protocol C at ∼ 100 h post-injection (difference: 4%). Regarding the phantom/pig experiments, eliminating scan data at > 100 h post-injection increased the time-integrated activity coefficients calculated based on imaging-protocols A and B by up to 83%. CONCLUSION While imaging-protocol A is accurate if scans at >∼100 h are included, it is time-consuming. In addition to being time-consuming, imaging-protocol B shows high differences associated with organ-count overlay, a lack of accuracy concerning the geometric mean based 2D attenuation correction, and 2D background subtraction due to the inhomogeneous and time-varying background contributions. Our findings indicate that dosimetry based on imaging-protocol C, if appropriately performed, provides similar kidney absorbed doses compared to imaging-protocol A, while only a single scan time-point is necessary.
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Affiliation(s)
- Seval Beykan
- Department of Nuclear Medicine, University of Würzburg, Würzburg, Germany.
| | - Johannes Tran-Gia
- Department of Nuclear Medicine, University of Würzburg, Würzburg, Germany
| | - Svend Borup Jensen
- Department of Nuclear Medicine, Aalborg University Hospital, Aalborg, Denmark; Department of Chemistry and Bioscience, Aalborg University, Aalborg, Denmark
| | - Michael Lassmann
- Department of Nuclear Medicine, University of Würzburg, Würzburg, Germany
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45
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Hope TA, Pavel M, Bergsland EK. Neuroendocrine Tumors and Peptide Receptor Radionuclide Therapy: When Is the Right Time? J Clin Oncol 2022; 40:2818-2829. [PMID: 35649195 DOI: 10.1200/jco.22.00176] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Since its approval in 2018 by the US Food and Drug Administration, peptide receptor radionuclide therapy (PRRT) has become a mainstay in the treatment of neuroendocrine tumors. Lutetium-177-DOTATATE, the only approved agent, is indicated for the treatment of gastroenteropancreatic-neuroendocrine tumors. Although patient selection appears straightforward with somatostatin receptor-positron emission tomography, there is considerable complexity when deciding which patients to treat and when to start PRRT. Herein, we review the many factors that affect patient selection, focusing on the optimal patients to treat. Although significant effort has been expended to determine which patients benefit the most from PRRT, a validated predictive biomarker remains elusive. Although PRRT has been used for more than 2 decades in Europe and standards of care exist for safe treatment, there remain numerous questions regarding when PRRT should be used relative to other treatments. It is important to remember that multidisciplinary discussions are essential. Currently, there are a number of ongoing studies looking to assess the efficacy of PRRT compared with other treatment options and to optimize treatment through combination therapy, different dosing strategies, or use of different radionuclides and radioligands.
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Affiliation(s)
- Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA.,Helen Diller Family Comprehensive Cancer Centre, University of California, San Francisco, San Francisco, CA.,Department of Radiology, San Francisco VA Medical Center, San Francisco, CA
| | - Marianne Pavel
- Department of Medicine 1, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Emily K Bergsland
- Helen Diller Family Comprehensive Cancer Centre, University of California, San Francisco, San Francisco, CA.,Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA
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46
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Phase II trial demonstrates the efficacy and safety of individualized, dosimetry-based 177Lu-DOTATATE treatment of NET patients. Eur J Nucl Med Mol Imaging 2022; 49:3830-3840. [PMID: 35451612 PMCID: PMC9399027 DOI: 10.1007/s00259-022-05786-w] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/28/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE Radionuclide therapy with 177Lu-DOTATATE is well established for patients with advanced somatostatin receptor-positive neuroendocrine tumors with a standard schedule of 7.4 GBq at four occasions. However, this approach does not consider individual variability affecting the tumor radiation dose or dose to organs at risk. Therefore, it is important to assess more personalized strategies. The aim of this phase II trial was to evaluate individualized 177Lu-DOTATATE for which the number of cycles varied based on renal dosimetry. METHODS Patients were eligible if they had a progressive, somatostatin receptor-positive neuroendocrine tumor with a Ki 67 labeling index < 20%. They received cycles of 7.4 GBq of 177Lu-DOTATATE at 10 ± 2-week intervals until a predefined radiation dose to the kidneys was reached. The primary endpoint was objective tumor response (RECIST v 1.1). Secondary endpoints included progression-free survival (PFS), overall survival (OS), and toxicity (CTCAE v. 4.0). RESULTS Ninety-six patients who had received a median of 5 cycles (range 1-9) were evaluable for efficacy. The objective tumor response was 16% partial response, 66% stable disease, and 19% progressive disease. The median PFS and OS were 29 months and 47 months, respectively, and were significantly associated with kidney dose, performance status, and Ki 67 levels but not with tumor origin. The overall toxicity was mild, and the most common events were grade 1-2 anemia, thrombocytopenia, fatigue, nausea, and diarrhea. Grade 3-4 toxicity occurred in < 10% of patients and was mostly hematological, with no grade 3-4 renal toxicity. CONCLUSION Individualized treatment with 177Lu-DOTATATE based on renal dosimetry is clearly feasible with low toxicity and promising efficacy, showing the potential to further improve outcome beyond the standard approach, and should be further assessed in randomized trials. TRIAL REGISTRATION EudraCT 2011-000,240-16. NCT01456078. https://clinicaltrials.gov/ct2/show/NCT01456078.
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47
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Dose-Limiting Bone Marrow Toxicities After Peptide Receptor Radionuclide Therapy Are More Prevalent in Women Than in Men. Clin Nucl Med 2022; 47:599-605. [DOI: 10.1097/rlu.0000000000004203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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48
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Navalkissoor S, Toumpanakis C, Caplin M, Gnanasegaran G. Treatment of neuroendocrine tumours with 177 Lu-peptide receptor radionuclide therapy: Challenging clinical scenarios and their management. J Neuroendocrinol 2022; 34:e13088. [PMID: 35078265 DOI: 10.1111/jne.13088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 12/09/2021] [Accepted: 12/31/2021] [Indexed: 11/28/2022]
Abstract
Peptide receptor radionuclide therapy (PRRT) for the treatment of patients with neuroendocrine tumours is usually well tolerated, with selection based on existing guidelines. However, there are various scenarios where the risk-benefit analysis of PRRT needs to be evaluated to limit any complications associated with PRRT. This review looks at 11 key scenarios where the risk-benefit of PRRT needs to be closely evaluated.
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Affiliation(s)
- Shaunak Navalkissoor
- Department of Nuclear Medicine, Royal Free London NHS Foundation Trust, London, UK
| | | | - Martyn Caplin
- Neuroendocrine Unit, Royal Free London NHS Foundation Trust, London, UK
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49
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Malcolm JC, Falzone N, Gains JE, Aldridge MD, Mirando D, Lee BQ, Gaze MN, Vallis KA. Impact of cyclic changes in pharmacokinetics and absorbed dose in pediatric neuroblastoma patients receiving [ 177Lu]Lu-DOTATATE. EJNMMI Phys 2022; 9:24. [PMID: 35347483 PMCID: PMC8960523 DOI: 10.1186/s40658-022-00436-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 01/24/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Recent reports personalizing the administered activity (AA) of each cycle of peptide receptor radionuclide therapy based on the predicted absorbed dose (AD) to the kidneys (dose-limiting organ) have been promising. Assuming identical renal pharmacokinetics for each cycle is pragmatic, however it may lead to over- or under-estimation of the optimal AA. Here, we investigate the influence that earlier cycles of [177Lu]Lu-DOTATATE had on the biokinetics and AD of subsequent cycles in a recent clinical trial that evaluated the safety and activity of [177Lu]Lu-DOTATATE in pediatric neuroblastoma (NBL). We investigated whether predictions based on an assumption of unchanging AD per unit AA (Gy/GBq) prove robust to cyclical changes in biokinetics. METHODS A simulation study, based on dosimetry data from six children with NBL who received four-cycles of [177Lu]Lu-DOTATATE in the LuDO trial (ISRCTN98918118), was performed to explore the effect of variable biokinetics on AD. In the LuDO trial, AA was adapted to the patient's weight and SPECT/CT-based dosimetry was performed for the kidneys and tumour after each cycle. The largest tumour mass was selected for dosimetric analysis in each case. RESULTS The median tumour AD per cycle was found to decrease from 15.6 Gy (range 8.12-26.4) in cycle 1 to 11.4 Gy (range 9.67-28.8), 11.3 Gy (range 2.73-32.9) and 4.3 Gy (range 0.72-20.1) in cycles 2, 3 and 4, respectively. By the fourth cycle, the median of the ratios of the delivered AD (ADD) and the predicted (or "expected") AD (ADE) (which was based on an assumption of stable biokinetics from the first cycle onwards) were 0.16 (range 0.02-0.92, p = 0.013) for the tumour and 1.08 (range 0.84-1.76, p > 0.05) for kidney. None of the patients had an objective response at 1 month follow up. CONCLUSION This study demonstrates variability in Gy/GBq and tumour AD per cycle in children receiving four administrations of [177Lu]Lu-DOTATATE treatment for NBL. NBL is deemed a radiation sensitive tumour; therefore, dose-adaptive treatment planning schemes may be appropriate for some patients to compensate for decreasing tumour uptake as treatment progresses. Trial registration ISRCTN ISRCTN98918118. Registered 20 December 2013 (retrospectively registered).
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Affiliation(s)
- Javian C Malcolm
- Oxford Institute for Radiation Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford, OX3 7DQ, UK
| | - Nadia Falzone
- Oxford Institute for Radiation Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford, OX3 7DQ, UK
| | - Jennifer E Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Matthew D Aldridge
- Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Boon Q Lee
- Oxford Institute for Radiation Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford, OX3 7DQ, UK
| | - Mark N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Katherine A Vallis
- Oxford Institute for Radiation Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford, OX3 7DQ, UK.
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50
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Fortunati E, Argalia G, Zanoni L, Fanti S, Ambrosini V. New PET Radiotracers for the Imaging of Neuroendocrine Neoplasms. Curr Treat Options Oncol 2022; 23:703-720. [PMID: 35325412 PMCID: PMC9001579 DOI: 10.1007/s11864-022-00967-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 12/18/2022]
Abstract
Neuroendocrine neoplasms (NEN) are a heterogeneous group of tumours derived from cells of neuroendocrine origin and can potentially arise everywhere in the human body. The diagnostic assessment of NEN can be performed using a variety of PET radiopharmaceuticals. Well-differentiated NEN (NET) present a high expression of SSTR (somatostatin receptors) and can therefore be studied with 68Ga-DOTA-peptides ([68Ga]Ga-DOTANOC, [68Ga]Ga-DOTATOC, [68Ga]Ga-DOTATATE). Current guidelines recommend the use of SSTR imaging to assess disease extension at staging/restaging, follow-up, assessment of response to therapy and selection of patients who may benefit from radionuclide therapy (PRRT). [18F]F-FDG is used for the assessment of high-grade tumours (high-grade G2, G3 and NEC) and in every case, there is one or more mismatched lesions between diagnostic CT (positive) and SSTR-PET/CT (negative). [18F]F-DOPA is currently used for the assessment of medullary thyroid carcinoma, neuroblastoma, primary pheochromocytoma and abdominal paraganglioma. In recent years, however, several new tracers were designed exploiting the many potential targets of the neuroendocrine cell and were employed in clinical trials for both imaging and therapy. Currently, the real-life clinical impact of these tracers is still mostly not known; however, the favourable biodistribution (e.g. [68Ga]Ga-FAPI, SSTR antagonists) and the possibility to use new theranostic pairs may provide novel diagnostic as well as therapeutic options (e.g. [68Ga]Ga-PSMA, [64Cu]Cu-SARTATE, [68Ga]Ga-CXCR4) for NEN patients.
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Affiliation(s)
- Emilia Fortunati
- Nuclear Medicine, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.
| | - Giulia Argalia
- Nuclear Medicine, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Lucia Zanoni
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Stefano Fanti
- Nuclear Medicine, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.,Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Valentina Ambrosini
- Nuclear Medicine, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.,Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
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