Polyclonal 90Yttrium labeled antiferritin for refractory Hodgkin's disease

Monte Carlo simulation of PET and SPECT imaging of 90Y

PURPOSE

Yittrium-90 ((90)Y) is traditionally thought of as a pure beta emitter, and is used in targeted radionuclide therapy, with imaging performed using bremsstrahlung single-photon emission computed tomography (SPECT). However, because (90)Y also emits positrons through internal pair production with a very small branching ratio, positron emission tomography (PET) imaging is also available. Because of the insufficient image quality of (90)Y bremsstrahlung SPECT, PET imaging has been suggested as an alternative. In this paper, the authors present the Monte Carlo-based simulation-reconstruction framework for (90)Y to comprehensively analyze the PET and SPECT imaging techniques and to quantitatively consider the disadvantages associated with them.

METHODS

Our PET and SPECT simulation modules were developed using Monte Carlo simulation of Electrons and Photons (MCEP), developed by Dr. S. Uehara. PET code (MCEP-PET) generates a sinogram, and reconstructs the tomography image using a time-of-flight ordered subset expectation maximization (TOF-OSEM) algorithm with attenuation compensation. To evaluate MCEP-PET, simulated results of (18)F PET imaging were compared with the experimental results. The results confirmed that MCEP-PET can simulate the experimental results very well. The SPECT code (MCEP-SPECT) models the collimator and NaI detector system, and generates the projection images and projection data. To save the computational time, the authors adopt the prerecorded (90)Y bremsstrahlung photon data calculated by MCEP. The projection data are also reconstructed using the OSEM algorithm. The authors simulated PET and SPECT images of a water phantom containing six hot spheres filled with different concentrations of (90)Y without background activity. The amount of activity was 163 MBq, with an acquisition time of 40 min.

RESULTS

The simulated (90)Y-PET image accurately simulated the experimental results. PET image is visually superior to SPECT image because of the low background noise. The simulation reveals that the detected photon number in SPECT is comparable to that of PET, but the large fraction (approximately 75%) of scattered and penetration photons contaminates SPECT image. The lower limit of (90)Y detection in SPECT image was approximately 200 kBq/ml, while that in PET image was approximately 100 kBq/ml.

CONCLUSIONS

By comparing the background noise level and the image concentration profile of both the techniques, PET image quality was determined to be superior to that of bremsstrahlung SPECT. The developed simulation codes will be very useful in the future investigations of PET and bremsstrahlung SPECT imaging of (90)Y.

Improved conditioning regimens for autologous transplantation using targeted radiotherapy

Most patients undergoing autologous hematopoietic stem cell transplantation for malignant diseases suffer recurrences of their neoplasms and die due to the inability of conventional high-dose conditioning regimens to eradicate their malignancies. As a result, intensive efforts to develop more effective conditioning regimens are currently under way at many institutions. Encouraging results have been obtained using targeted radiotherapy with radiolabeled antibodies or bone-seeking isotopes as components of novel conditioning regimens for autologous transplantation of patients with lymphomas, multiple myeloma and bone metastases. Results with radiolabeled antibodies targeting epithelial antigens on solid tumors, however, have been less encouraging. This report reviews the status of clinical studies using myeloablative doses of targeted radiotherapy in patients undergoing autologous stem cell transplantation for hematological malignancies or solid tumors.

Polyclonal antibodies to xenogeneic endothelial cells induce apoptosis and block support of tumor growth in mice

In this study, we demonstrate that vaccination of rabbits with murine endothelial cells yields polyclonal immunoglobulin (IgG) with potent antiangiogenic activity. The mechanism of this response appears to be through apoptosis of endothelial cells in vitro. Induction of polyclonal IgG in a xenogeneic host may be useful in passive immunotherapy of a variety of cancers. In fact, the antibody showed antitumor activity in three mouse tumor models (murine B16F10 melanoma, murine SVR angiosarcoma, and human DLD-1 colorectal adenocarcinoma). The polyclonal antibody generated here demonstrated utility in radioimaging of tumors in vivo, using positron emission tomography (PET) imaging, and suggested an antitumor effect in vivo. The results suggest that the antitumor effect in vivo may be related to antiangiogenic effects. Furthermore, anti-endothelial cell antibodies such as these could be useful reagents in isolating specific targets that comprise and induce the antiangiogenic effect.

Stem cell transplantation for Hodgkin's disease: a review of the literature

High-dose chemotherapy followed by autologous peripheral-blood stem cell transplantation has resulted in long-term disease-free survival of 30%-60% in selected patients with refractory and relapsed Hodgkin's disease. In addition, a significant reduction in early transplant-related mortality in more recent studies has led to the widespread acceptance of autografting. Comparatively few studies of allografting for Hodgkin's disease have been performed. Although no prospective randomized trials have been performed, historical results show a significantly lower relapse rate when allografting results are compared to autografting results. These results suggest that a graft-versus-Hodgkin's disease effect may exist. Unfortunately, the lower relapse rate following allografting is offset by higher transplant-related mortality. The use of low-intensity nonmyeloablative regimens for allografting may harness a graft-versus-Hodgkin's disease effect with less morbidity and mortality than that observed following conventional allografting.

Intrapatient consistency of imaging biodistributions and their application to predicting therapeutic doses in a phase I clinical study of 90Y-based radioimmunotherapy

Intrapatient variation in the biodistribution of the chimeric monoclonal antibody cT84.66 was assessed in 19 patients having a variety of carcinoembryonic antigen (CEA) positive tumors. The two studies, including whole-body imaging and blood and urine specimen collections, were conducted within 14 days of each other using (111)In-cT84.66 at a fixed total protein dose of 5 mg per patient per study. An initial pretherapy infusion of (111)In-cT84.66 was administered followed by a therapy coinfusion of (111)In-ct84.66 and 90Y-cT84.66 A closed five-compartment model was used to integrate source organ activity curves as residence time inputs into the MIRDOSE3 program. Normal organ absorbed doses were estimated for 90Y-cT84.66, the corresponding radiotherapeutic agent. For the two (111)In-cT84.66 biodistributions, all data were modeled with a R2 value of between 0.72 and 1.00 with the exception of the urine data taken during therapy. This was due to the need of diethylenetriaminepentaacetic acid during the therapy phase because of the possibility that yttrium might escape from the chelator attached to the antibody. With the assurance that the biodistributions were reproducible, we were able to estimate the 90Y-cT84.66 absorbed doses on a per-patient basis. Concordance coefficients showing the agreement between the imaging and therapy phase dose estimates were between the 0.60 and 0.99 levels for liver, spleen, red marrow, total body, and other organ systems. Median results were: 27, 17, and 2.7 rad/mCi of 90Y-cT84.66 for liver, spleen, and red marrow, respectively. Because of decreases in platelets and white cells as the amount of 90Y was increased, dose-limiting toxicity was found at 22 mCi/m2. We conclude that patient biodistributions were consistent over time to 14 days so as to allow absorbed dose estimation in a radioimmunotherapy trial involving the cT84.66 anti-CEA antibody.

The current status of targeted radiotherapy in clinical practice

Biologically targeted radiotherapy in clinical practice requires a molecule which has a relative specificity for tumour tissue--the missile--coupled to a radionuclide with appropriate physical characteristics--the warhead. When administered to a patient this combination should result in selective irradiation of the target tumour cells with relative sparing of normal tissues. Simple ions and small molecules which follow physiological pathways as either the natural substrates or analogues form the best examples of biological targeting. Clinically valuable results are seen with, for instance, iodine uptake by normal and malignant thyroid cells, incorporation of the calci-mimetic element strontium in areas of increased bone metabolism and accumulation of the catecholamine analogue meta-iodobenzylguanidine in neuroblastoma. The use of monoclonal antibodies as targeting vehicles has not proved to be a panacea, yet some patients with lymphoma, hepatoma and ovarian carcinoma have obtained benefit. Current clinical studies in targeted radiotherapy focus on the integration of radionuclide treatment with conventional treatments, and the optimization of such combined approaches. The development of modifications to offset the limitations inherent in the use of crude antibodies also offers an opportunity for improved clinical outcomes.

Radioimmunotherapy of solid cancers: A review

Depending on radionuclide characteristics, radioimmunotherapy (RIT) relies on radioactivity to destroy cells distant from immunotargeted cells. Therefore, even heterogeneous tumors (for antigen recognition) can be treated, because not all cells have to be targeted. Substantial complete response rates have been reported in patients with non-Hodgkin's lymphoma. Much more modest results have been reported for patients with bulky solid tumors, e.g. adenocarcinomas. The radiation doses delivered by targeting antibodies are generally too low to achieve major therapeutic responses. Dose escalation is limited by myelotoxicity, and higher doses need to be delivered to neoplasms less radiosensitive than lymphomas. Various trials for both systemic and regional RIT have been reported on. Intraperitoneal administration has been applied for colorectal and ovarian carcinomas. Our own results indicate that, e.g., intraperitoneal pseudomyxoma can be treated with RIT. Myelotoxicity can be reduced by anti-antibody-enhancement, 2- and 3-step strategies, bispecific monoclonal antibodies (MAbs), and extracorporeal immunoadsorption. The radionuclide has to be selected properly for each purpose; it can be a beta-emitter, e.g. I-131, Y-90, Re-188, Re-186, Lu-177 or Sm-153, an alpha-emitter At-211 or Bi-212 or an Auger-emitter, e.g. I-125, I-123. One major problem with RIT, besides slow penetration rate into tumor tissue and low tumor-to-normal tissue ratio, is the HAMA response, which can be partly avoided by the use of humanized MAbs and immunosuppression. However, RIT will be, because of all the recent developments, an important form of cancer management.

Cancer therapy with radiolabeled antibodies. An overview

Considerable progress has been achieved during the last two decades in the use of radiolabeled tumor-selective monoclonal antibodies in the diagnosis and therapy of cancer. The concept of localizing the cytotoxic radionuclide to the cancer cell is an important supplement to conventional forms of radiotherapy. In theory the intimate contract between a radioactive antibody conjugate and a target cell enables the absorbed radiation dose to be concentrated at the site of abnormality with minimal injury to the normal surrounding cells and tissues. A variety of approaches and combinations of this strategy are now being pursued. This synopsis attempts to summarize the theoretical and biological basis for radio-immuno-therapy (RIT), and to review present efforts to further develop this treatment. Some of the critical issues in RIT are highlighted, and novel ways of improving the therapeutic indices of these radiopharmaceuticals are outlined. The attention is focused on the results obtained in clinical trials employing RIT. Encouraging complete response rates have recently been reported in patients with non-Hodgkin's lymphoma resistant to combination chemotherapy. More modest results have been obtained in patients with solid cancers. The promises and hurdles in creating tumor-selective radiolabeled antibodies for cancer therapy are discussed, and prospects for further improvements are presented.

90Y-labeled antibody uptake by human tumor xenografts and the effect of systemic administration of EDTA

PURPOSE

A human tumor xenograft model was used to compare the tumor and normal tissue uptake of a tumor-associated monoclonal antibody radiolabeled with 125I or 90Y.

METHODS AND MATERIALS

Nude mice bearing SC xenografts of the human colon adenocarcinoma, HT29, were injected with a mixture of 125I- and 90Y-DTPA-labeled AUA1 monoclonal antibody, which recognizes an antigen expressed on the surface of the tumor cells. In addition, the effect of systemic ethylenediaminetetraacetic acid (EDTA) administration on 90Y-labeled antibody clearance, tumor uptake of antibody and bone accumulation of 90Y was studied in a nude mouse model of intraperitoneal cancer.

RESULTS

Both the absolute amount (%id.g-1) and the tumor:normal tissue ratios were superior for the 90Y-labeled antibody, compared with the iodinated antibody, with the notable exception of bone. These results suggest that 90Y is a preferable isotope to iodine for radioimmunotherapy of solid masses, but that myelotoxicity, due to bone uptake of released 90Y, will limit the radiation dose which can be given when DTPA is used to chelate the 90Y. The 90Y-labeled antibody showed similar serum stability in vitro in the presence or absence of EDTA after incubation for up to 48 h. In vivo, urine excretion of 90Y was significantly enhanced in mice receiving daily injections of 20 mg EDTA for 3 days, commencing 2 h after intraperitoneal antibody administration, compared with control mice. There was no significant difference in the tumor uptake of 90Y-labeled antibody in EDTA-treated and control mice at any time-point up to 9 days postinjection. However, the bone levels of 90Y were significantly reduced in EDTA-treated mice at all times from 1 to 9 days.

CONCLUSION

Based on these results, it should be possible to increase the amount of 90Y-labeled antibody administered, by chelating the released 90Y with systemic EDTA to facilitate its excretion, without compromising tumor uptake of radiolabeled antibody.

Comparative toxicity studies of yttrium-90 MX-DTPA and 2-IT-BAD conjugated monoclonal antibody (BrE-3)

BACKGROUND

BrE-3 is monoclonal antibody that has promise for imaging and therapy of human adenocarcinoma. Because of observations in therapeutic trials of yttrium-90 (90Y) escape from radioimmunoconjugates and uptake by the skeleton with resultant bone marrow toxicity, the authors attempted to evaluate the importance of this factor by a comparison of the LD50 in healthy mice treated with 90Y that had been chelated with either of two high affinity chelators, methylbenzyldiethylene-triaminepentaacetic acid (MX-DTPA) or bromoacetamidobenzyl-1,4,7,10-tetraazocyclododecane- N,N',N'',N'''-tetraacetic acid (BAD).

METHODS AND RESULTS

Bone marrow hematopoietic toxicity was dose-limiting and the source of death for both chelators. The LD50 for 90Y-BrE-3-MX-DTPA was 220.9 microCi, and that for 90Y-BrE-3-2IT-BAD and was 307.8 microCi. Whole-body autoradiography revealed substantially greater uptake of 90Y in the skeleton when MX-DTPA was used as the chelator.

CONCLUSIONS

These observations suggest that 90Y escape to bone is a significant factor in the maximum tolerated dose of radioimmunoconjugate that can be used in therapeutic trials. These results probably underestimate the importance of 90Y escape since 90Y in the skeleton of patients is likely to be more significant than in mice because more of the 90Y energy is absorbed in the marrow of larger species.

Preclinical evaluation of intravenously administered 111In- and 90Y-labeled B72.3 immunoconjugate (GYK-DTPA) in beagle dogs

B72.3, a monoclonal antibody with reactivity against human adenocarcinomas was obtained from the Cytogen Corporation in the form of an immunoconjugate coupled with linker-chelator GYK-DTPA by using proprietary carbohydrate directed site specific chemistry. The immunoconjugate was radiolabeled with indium-111 or yttrium-90. A preclinical analysis was performed in 10 normal beagle dogs. The pharmacokinetics of intravenously administered indium- and yttrium-labeled immunoconjugates were compared serially in blood, bone marrow and urine samples. Compared to 90Y less of the 111In label ended up in urine and more was found in blood and bone marrow. Indium-labeled B72.3 GYK-DTPA had relatively higher uptake in most glandular tissues than 111In-labeled antiferritin immunoconjugate. Bone marrow toxicity was the dose limiting side effect after intravenous infusion of 90Y-labeled B72.3 GYK-DTPA. Toxicity was also observed in the liver but not in other organ systems. Recently other investigators obtained similar results with these immunoconjugates in human patients. A preclinical pharmacokinetic analysis of radioimmunoconjugates in beagle dogs provided useful information regarding bone marrow toxicity, liver toxicity and in vivo instability of the immunoconjugate. Data suggest that for future trials in human patients, a more stable chelated immunoconjugate for yttrium is needed to achieve less liver uptake and a better correlation with the 111In-labeled product than the 90Y-labeled B72.3 GYK-DTPA used in this investigation.

Gallium-67 radiotoxicity in human U937 lymphoma cells

Promising clinical results have been obtained with radiolabeled antibodies in lymphoma patients. The higher uptake by lymphomas of 67Gallium (67Ga) compared with monoclonal antibodies makes selective radiotherapy by the widely available 67Ga appealing. However, the gamma radiation of 67Ga used in scintigraphy is considered to be almost non-toxic to lymphoma cells. However, in addition to photon radiation 67Ga emits low energy Auger electrons and 80-90 keV conversion electrons which could be cytotoxic. The objective of the present study was the assessment of radiotoxicity of 67Ga on a lymphoid cell line: U937. Proliferation (MTT-assay) and clonogenic capacity (CFU-assay) were measured after 3 and 6 days incubation with 10, 20 and 40 microCi ml-1 67Ga. Growth inhibition was 36% after 3 days incubation and 63% after 6 days incubation with 40 microCi 67Ga ml-1. Clonogenic capacity was reduced by 51% after 3 days and 72% after 6 days incubation with 40 microCi ml-1 67Ga. A survival curve showed an initial shoulder and became steeper beyond 200-250 pCi cell-1 (low linear energy transfer type). Iso-effect doses of 67Ga and 90Yttrium (90Y) were determined. The iso-effect dose of 40 microCi 67Ga ml-1 (cumulative dose of conversion electrons 306 cGy) was 2.5 microCi 90Y ml-1 (cumulative dose 494 cGy) and the iso-effect dose of 80 microCi 67Ga ml-1 was 5.0 microCi 90Y/ml. The main cytotoxic effect of 67Ga seems to be induced by the 80 keV conversion electrons. We conclude that the conversion electrons of 67Ga have a cytotoxic effect on U937 cells and that in our experiments a 16-fold higher microCi-dose of 67Ga than of 90Y was needed for the same cytotoxic effect. We believe that 67Ga holds promise for therapeutic use.

Therapy with 125I-labelled internalized and non-internalized monoclonal antibodies in nude mice with human colon carcinoma xenografts

The therapeutic effects of 125I-labelled (18-97 MBq) monoclonal antibodies (MAb) C-242, C-215 and S-S.1 were studied in nude mice with human colorectal adenocarcinoma tumours. The antibodies were administered 2 or 10-16 days after implantation of the tumour cells. The monoclonal antibody C-242 was internalized into the tumour cells, C-215 was internalized to a lower degree while S-S.1 (unspecific MAb) was not internalized at all. No enhanced therapeutic effect of 125I-C-242 was observed, as a result of Auger electrons, compared with 125I-C-215 and 125I-S-S.1.

Imaging and dosimetry determinations using radiolabeled antibodies

Numerous studies using radiolabeled antibodies for imaging and therapy of lymphoma have been reported (Table 4). The targeting of lymphoma associated antigens with MoAb appears to be more favorable than the targeting of antigens on epithelial tumor. Antigen abundance may not be the overriding factor in this favorable targeting, since the number of antigenic sites per cell are often in the same range or lower than those targeted in epithelial tumors. This improved targeting is likely related to the greater access of antibody to the target antigen in lymph nodes, bone marrow, circulation, and other sites. With certain antibodies, trafficking of the cells targeted with the radiolabeled antibody may also result in favorable localization [19]. While the most frequently used isotope for imaging and therapy has been 131I, certain limitations have been observed, including its high-energy gamma rays and resulting lower resolution, and the frequent occurrence of dehalogenation [21,25,98]. Many of the antigens expressed by lymphomas undergo antigenic modulation. Antigens that undergo modulation may be targeted successfully, but once modulation occurs the antibody is broken down and the iodine is rapidly excreted from the cells. While this rapid release from normal organs is an advantage, it is an undesirable event at the tumor site. In contrast to the case of 131I MoAb, modulation may be an advantage for targeting with 111In labeled antibodies, since the radioactive metals are retained for longer periods at the tumor sites; even if the antibody is broken down, the 111In is not easily excreted from the cells [52]. Among the most consistent and favorable targeting observed to date is that seen with 111In T101 in CTCL. These studies have shown concentration of 111In in tumor of 10-100 times that seen in other tumor systems using iodinated antibodies. Unfortunately no studies have followed this lead and performed the necessary comparisons between 111In and 131I MoAb to determine if this is a consistent finding. The use of 99mTc labeled MoAb for imaging lymphomas is in its infancy, although preliminary reports appear promising [71]. While in epithelial tumors preferential tumor targeting may take more than 48 hours in lymphomas, targeting is usually seen within the first 24 hours, which is within the window of imaging time for 99mTc. Therefore, further evaluation of 99mTc antibodies should be performed. Determination of the optimum dose of antibody for imaging has been attempted. Studies using various anti-lymphoma directed antibodies have shown widely varying biodistribution and variable dose-response curves.(ABSTRACT TRUNCATED AT 400 WORDS)

Effects of hyperthermia and iodine-131-labeled anticarcinoembryonic antigen monoclonal antibody on human tumor xenografts in nude mice

BACKGROUND

Many studies have demonstrated synergistic interaction between hyperthermia and radiation. This study was undertaken to determine whether hyperthermia could enhance the effect of radioimmunotherapy (RIT) in the treatment of human colon adenocarcinoma xenografts in nude mice.

METHODS

The experiments were conducted in two parts. During the first part of the study, preliminary information was obtained regarding the effect of various temperatures (41 degrees C, 42 degrees C, and 43 degrees C for 45 minutes) and iodine-131-labeled anticarcinoembryonic antigen (CEA) monoclonal antibodies (RMoAb) with administered activity ranging from 130 +/- 19 microCi to 546 +/- 19 microCi on tumor regrowth delay (TRD) and volume doubling time. This information was used in Part 2 of the study, which included four groups of mice: (1) a control group, (2) a group treated with hyperthermia, (3) a group treated with RMoAb, and (4) a group treated with a combination of RMoAb and hyperthermia.

RESULTS

Maximum and significantly increased TRD was observed in the group treated with RMoAb and hyperthermia (slope, 0.057) compared with the control group (slope, 0.322), the hyperthermia-treated group (slope, 0.302), and the group treated with RMoAb alone (slope, 0.098). The ratio of the slopes between the groups treated with RMoAb and those treated with RMoAb and hyperthermia was 1.72. No correlation was detected between the percent of antibody uptake in the tumor and tumor regression in the groups treated with heat and RMoAb and those treated with RMoAb alone.

CONCLUSIONS

The results of these experiments show that hyperthermia increased the effectiveness of iodine-131-labeled anti-CEA monoclonal antibodies against human colon carcinoma xenografts in nude mice. This study offers a rationale for combining hyperthermia and low-dose radiation produced from RIT in clinical practice.

Radioimmunotherapy: clinical results and dosimetric considerations

Radiolabeled antibodies for cancer therapy are being investigated in clinical trials in more than 30 centers. 131Iodine-labeled antibody (Ab) therapy of solid tumors has produced few responses when given alone. When given in conjunction with chemotherapy and external beam therapy in hepatoma patients, objective responses have occurred. Because of the short range of 131I, 90Y and 186Re are being studied and objective responses have occurred in patients without the addition of other therapies. 131I-labeled Ab therapy of lymphoma, a radioresponsive tumor, has produced a much higher objective response rate than in other solid tumors. Regional RIT has not been shown to offer a definite advantage over the intravenous route. Tumor doses have generally been less than 2000 cGy per treatment with some tumors receiving higher doses. The bone marrow is the dose-limiting organ for RIT and marrow cryopreservation with subsequent reinfusion may prove useful.

Selection of reagents for human radioimmunotherapy

Promising response rates are noted in patients with refractory Hodgkin's disease after radioimmunoglobulin therapy (RIT) with Yttrium-90 labeled polyclonal antiferritin. To explore the most efficacious selection of RIT reagents for use in humans, experimental animal data are reviewed for radiolabeled antiferritin and B72.3. Nude mice with subcutaneously implanted human malignancies provide an excellent primary screen for radiolabeled antibodies under consideration for use in humans. They provide information on the potential of a new reagent to target a human malignancy in vivo. The other determinant of the therapeutic ratio of RIT reagents--normal tissue toxicity--is best analyzed in large animals, such as dogs. Hematologic toxicity is dose limiting in all species and best predicted by a prescription of radiolabeled antibodies in mCi per kilogram body weight and the presence or absence of bone marrow targeting. Per cGy, RIT is more effective in causing BM damage in dogs than in rats. In dogs, bone marrow transplantation with autologous cryopreserved bone marrow cells or G-CSF treatment can accelerate hemopoietic recovery and granulopoiesis, respectively, after RIT. When dose escalation beyond bone marrow toxicity is performed, the liver (dog) or the intestinal tract (rat) become the next dose limiting tissue in dose escalation studies. Significant improvement in RIT results will be achieved when the normal liver uptake of chelated monoclonal antibody in dogs and in human patients can be prevented. The described animal models and continued investigations of RIT in patients with endstage Hodgkin's disease will allow for further improvement in the therapeutic ratio of RIT and the applicability of RIT in humans.

Optimal scheduling of biologically targeted radiotherapy and total body irradiation with bone marrow rescue for the treatment of systemic malignant disease

A mathematical model analysis is used to address the question of optimal scheduling of combined treatments consisting of biologically targeted radiotherapy (BTR), total body irradiation (TBI), and bone marrow rescue. Radiation effects on normal tissue are described using an extension of the LQ model. Tumor effects are described using a simple model that allows for radiation-induced sterilization and exponential proliferation of tumor cells, a proportion of which completely escapes the effects of targeted radiotherapy. The effect on a tumor cell population of a set of treatment schedules, composed partly of targeted radiotherapy and partly of fractionated external beam irradiation, are calculated. Treatment schedules are chosen to be biologically equivalent, for a "late responding" organ, to a fractionated TBI schedule of 7 fractions of 2 Gy. The tumor effects of the treatment schedules depend on the specificity of targeting, represented by the ratio of initial dose-rate for the tumor cells to that in the dose-limiting organ, and the heterogeneity of targeting, represented by the proportion of tumor cells that escape irradiation by targeted radiotherapy. The main mechanism determining optimal combinations is an overkill of effectively targeted tumor cells. Treatment regiments consisting of targeted radiotherapy alone fail, due to the unimpeded growth of those tumor cells that escape targeted irradiation. Optimal schedules almost invariably consist of elements of both BTR and TBI. Although it is recognized that the model is simplistic in a number of respects, these findings provide support for the clinical use of integrated BTR, TBI, and bone marrow rescue for the treatment of systemic malignant disease.

A randomized prospective trial comparing full dose chemotherapy to 131I antiferritin: an RTOG study

A previously reported Phase I/II multimodality program for non-resectable hepatocellular cancer began with external beam-radiation and chemotherapy, followed by administration of 131I antiferritin-specific radioimmunoglobulin and led to a 48% remission (7% complete remission and 41% partial remission). Survival and response depended on alpha fetoprotein status. AFP+ patients had a median survival of 5 months; AFP- patients had a median survival of 10.5 months. No acute effects occurred relative to treatment with radiolabeled antibody. A randomized prospective study was designed to compare full dose chemotherapy consisting of 60 mg/m2, doxorubicin and 500 mg/m2 of 5-fluorouracil administered every 3 weeks, to 131I antiferritin administration every 8 weeks and allowed for crossover treatment if tumor progression occurred. Overall, radiolabeled antibody administration and full dose chemotherapy led to equivalent partial remission rates (22-30% vs 23-25%) and survival rates compared to chemotherapy (6 month median; AFP+ 5 months; AFP- 10 months). The most important new observations were the response in AFP- patients who, following chemotherapy failure, achieved remission using 131I radiolabeled antibody (7/11) and a subset of patients (7%) who were treated with radiolabeled antibody and converted from non-resectable to resectable status followed by surgical excision.

Radiobiologic studies comparing Yttrium-90 irradiation and external beam irradiation in vitro

The purpose of this study was to compare the effectiveness of Yttrium-90 (Y-90) labeled antibody irradiation to 60Co external beam irradiation in vitro by colony formation assay. Two human colon carcinoma cell lines, LS174T, a high CEA producer, and WiDr, a low CEA producer, were exposed to specific activities of Y-90 labeled murine monoclonal anti-CEA antibody ranging from 2.5 to 30 microCi/ml for a fixed period of time. This resulted in calculated doses of 2.25 to 27 Gy and initial dose rates of 2.5 to 29 cGy/hr. Results were compared to similar doses of Y-90 labeled non-specific antibody, unlabeled specific and non-specific antibody, and 60Co external beam irradiation. External beam irradiation studies showed that WiDr, compared to LS174T, was more radioresistant with a larger shoulder to the survival curve, indicating a greater capacity for radiation-induced sublethal damage repair. WiDr was also more radioresistant to Y-90 antibody irradiation. When compared to external beam irradiation, Y-90 labeled antibody irradiation resulted in less cell killing by a factor of 2.4 for LS174T and 3.4 for WiDr. Unlabeled antibody had no significant effect on cell survival. Radiation-induced cell cycle delay experiments demonstrated that WiDr had less cell cycle delay (0.9 to 1.0 min/cGy) compared to LS174T (1.2 min/cGy) after single fraction external beam irradiation. Our results indicate that Y-90 low dose-rate irradiation is radiobiologically less effective in vitro than high dose-rate external beam irradiation by a factor of about 2.4 to 3.4. The results also suggest that the magnitude of this difference depends on the cell line's ability to repair sublethal radiation damage and the degree of cell cycle prolongation after irradiation.

A pilot study of monoclonal antibody targeted radiotherapy in the treatment of central nervous system leukaemia in children

A pilot study was performed to investigate the toxicity, pharmacokinetics and therapeutic effect of intrathecally administered radiolabelled monoclonal antibody (MAb) in patients with meningeal acute lymphoblastic leukaemia (ALL). Six children aged 3-16, in second or subsequent central nervous system (CNS) relapse of ALL, received between 629 and 1480 MBq of 131Iodine conjugated to either MAb HD37 (CD19, n = 2) or WCMH15.14 (CD10, n = 4). Conjugate was administered as a single injection either via an Ommaya reservoir (n = 4) or by lumbar puncture (n = 2). Acute toxicity was manifest by headache (n = 4), nausea and vomiting (n = 4) and pyrexia (n = 2). All acute symptoms resolved within 72 h. Transient myelosuppression occurred in three patients. Pharmacokinetic studies included investigation of whole body, blood and CSF clearance of isotope. 131I was seen to clear from the CSF by biexponential kinetics. Five patients responded to therapy. In four, the CSF became clear of blast cells at both 2 and 4 weeks following antibody injection, but evidence of relapse was seen at 6 weeks. The fifth patient, with blast cells present on a cytospin preparation, responded to therapy over an 8-week period but relapsed at 12 weeks. This study demonstrates the potential of targeted radiotherapy in CNS ALL, but further studies are necessary to increase the length of remission.

Isoeffect relationships for fractionated biologically targeted radiotherapy

This paper describes a method of analysis of the biological effects on normal tissues of fractionated administrations of biologically targeted radiotherapy (BTR). The linear-quadratic (LQ) model as extended by Dale [2] is used to consider the case in which administrations may be separated by time gaps down to the order of a single day. It is assumed that the pharmacokinetics of clearance are linear and that dose-rate profiles in organs are simple exponential decays. The method adopted is to calculate the extrapolated response doses (ERDs) for individual time periods of the treatment between one administration and the next (assuming complete recovery between periods) and additional components which are corrections for incomplete recovery between these time periods. The overall ERD for the course of administrations is given by the sum of these factors. No account is taken of cellular repopulation. As it is likely that fractionated biologically targeted radiotherapy (BTR) will be used in practice, this subject is of clinical relevance. The method is illustrated by a numerical example.

The radiobiology of targeted radiotherapy

Targeted radiotherapy consists of biologically selective irradiation of malignant cells by means of radionuclides attached to tumour-seeking molecules. A variety of clinical strategies for targeted radiotherapy may be used, for which different normal tissues will be critical. A large number of radionuclides exist, emitting nuclear particles with a range of path lengths from nanometres to millimetres. An important feature of normal-tissue radiobiology is the dose-rate effect, which is especially marked for late-responding tissues. Radiobiological calculations imply that tolerance dose for targeted radiotherapy using low-LET emitters will depend strongly on the effective half-life of the radionuclide, which will be affected by pharmacokinetics and may vary between patients. Some strategies designed to improve the therapeutic radio (e.g. accelerated clearance of radionuclide) may have modulating effects on the tolerance dose. Tumour response will be governed by the 'four Rs' (repair, repopulation, reoxygenation, redistribution) as well as by mechanisms peculiar to targeted radiotherapy. Analysis based on the extended linear quadratic model predicts that dose-rate effects will be of major importance for only a minority of tumours. Most of the radiation dose to tumour will usually be delivered over a time-scale of a few days. This might give insufficient time for tumour reoxygenation, making the use of hypoxic sensitizers appropriate. A special feature of targeted radiotherapy is the complex relationship between tumour curability and tumour size for different radionuclides. For long-range beta-emitters, microscopic tumours may be operationally resistant because of inefficient absorption of radionuclide disintegration energy in small volumes. Short-range emitters will be more efficient in sterilization of micrometastases but sterilization of larger tumours may require an unattainable degree of homogeneity of radionuclide distribution. Optimal use of targeted radiotherapy may require it to be combined with external-beam irradiation or chemotherapy. Experimental studies will be necessary to investigate those features of targeted radiotherapy which differ from external-beam irradiation. Future directions may include targeted radiotherapy of minimal numbers of tumour cells detected by use of molecular probes. Such applications call for use of short-range alpha-emitters and Auger emitters whose radiobiology will become increasingly important.

Systemic radiotherapy--the new frontier

The present day use of systemically administered isotopes and conjugated isotopic combinations are reviewed. Administration of 131Iodine in thyroid cancer led to a 97% local control and 50% complete remission of pulmonary metastases. Specificity directed isotopic therapy (metabolic, hormonal, and antibody) is discussed and includes factors such as tumor physiology and isotopic linkage. The clinical results and new knowledge being gained in Hodgkin's disease, non-Hodgkin's, colorectal, hepatoma, intrahepatic biliary and gliomatous cancers are reviewed. The dose response relationship to tumor remission is demonstrated in Hodgkin's treated with 131I antiferritin (40% partial remission) and more recently 90Yttrium antiferritin (50% complete response). Varied routes of administration, the problem of anti-antibody and bone marrow transplantation are discussed. Finally, the challenge to radiobiologists, physicists, chemists, immunologists, nuclear radiologists, and radiation oncologists is emphasized by definition of the new laboratory and clinical approaches being developed in systemic radiation therapy.

The theoretical implications and experimental and clinical results of radiolabeled antiferritin

Ferritin is produced in malignant and normal tissues. It acts both as an immunosuppressant and as an iron storage protein. As a tumor associated protein, it is related to virally induced tumors, and selective tumor targeting by radiolabeled antiferritin antibodies has led to its use in clinical trials. In patients with advanced Hodgkin's disease who have failed conventional therapy, 131I antiferritin produced partial remissions, while 90Y antiferritin led to complete remissions and a demonstrable dose-response relationship. Combining the variable low-dose radiation patterns produced by radiolabeled antibody therapy with chemotherapy in the treatment of hepatocellular cancer has led to enhanced tumor cytotoxicity and, in some cases, the conversion of non-resectable hepatoma to resectable. Further, the potential for clinical and laboratory investigation of radiolabeled antibody therapy is discussed in light of new findings.