Absence of somatostatin SST2 receptor internalization in vivo after intravenous SOM230 application in the AR42J animal tumor model

Bis(Disulfide)-Bridged Somatostatin-14 Analogs and Their [111In]In-Radioligands: Synthesis and Preclinical Profile

The overexpression of one or more somatostatin receptors (SST1-5R) in human tumors has provided an opportunity for diagnosis and therapy with somatostatin-like radionuclide carriers. The application of "pansomatostatin" analogs is expected to broaden the clinical indications and upgrade the diagnostic/therapeutic efficacy of currently applied SST2R-prefering radioligands. In pursuit of this goal, we now introduce two bicyclic somatostatin-14 (SS14) analogs, AT5S (DOTA-Ala1-Gly2-c[Cys3-Lys4-Asn5-c[Cys6-Phe7-DTrp8-Lys9-Thr10-Cys11]-Thr12-Ser13-Cys14]) and AT6S (DOTA-Ala1-Gly2-c[Cys3-Lys4-c[Cys5-Phe6-Phe7-DTrp8-Lys9-Thr10-Phe11-Cys12]-Ser13-Cys14]), suitable for labeling with trivalent radiometals and designed to sustain in vivo degradation. Both AT5S and AT6S and the respective [111In]In-AT5S and [111In]In-AT6S were evaluated in a series of in vitro assays, while radioligand stability and biodistribution were studied in mice. The 8/12-mer bicyclic AT6S showed expanded affinity for all SST1-5R and agonistic properties at the SST2R, whereas AT5S lost all affinity to SST1-5R. Both [111In]In-AT5S and [111In]In-AT6S remained stable in the peripheral blood of mice, while [111In]In-AT6S displayed low, but specific uptake in AR4-2J tumors and higher uptake in HEK293-SST3R tumors in mice. In summary, high radioligand stability was acquired by the two disulfide bridges introduced into the SS14 motif, but only the 8/12-mer ring AT6S retained a pansomatostatin profile. In consequence, [111In]In-AT6S targeted SST2R-/SST3R-positive xenografts in mice. These results call for further research on pansomatostatin-like radioligands for cancer theranostics.

Prolactin and Growth Hormone Signaling and Interlink Focused on the Mammosomatotroph Paradigm: A Comprehensive Review of the Literature

Prolactin (PRL) and growth hormone (GH) are peptide hormones that bind to the class 1 cytokine receptor superfamily, a highly conserved cell surface class of receptors. Both hormones control their own secretion via a negative autocrine loop in their own mammosomatotroph, lactotroph or somatotroph. In this regard, GH and PRL are regulated by similar signaling pathways involving cell growth and hormone secretion. Thus, GH and PRL dysregulation and pituitary neuroendocrine tumor (PitNET) development may have common pathogenic pathways. Based on cell linage, lactotroph and somatotroph PitNETs come from pituitary-specific POU-class homeodomain transcription factor (Pit-1). Mammosomatotroph and plurihormonal PitNETs are a unique subtype of PitNETs that arise from a single-cell population of Pit-1 lineage. In contrast, mixed somatotroph-lactotroph PitNETs are composed of two distinct cell populations: somatotrophs and lactotrophs. Morphologic features that distinguish indolent PitNETs from locally aggressive ones are still unidentified, and no single prognostic parameter can predict tumor aggressiveness or treatment response. In this review, we aim to explore the latest research on lactotroph and somatotroph PitNETs, the molecular mechanisms involved in PRL and GH axis regulation and the signaling pathways involved in their aggressiveness, particularly focused on mammosomatotroph and mixed subtypes. Finally, we summarize epidemiological, clinical, and radiological features of these exceptional tumors. We aim to shed light, from basic to clinical settings, on new perspectives and scientific gaps in this field.

Second line treatment of acromegaly: Pasireotide or Pegvisomant?

Acromegaly is a chronic disease with an increased mortality in case of persistently active disease. The treatment of acromegaly is mainly based on the surgical resection of the GH secreting pituitary tumor and, in cases with persistent disease, on the medical therapy with first generation somatostatin analogues (first gen-SSAs). Data from national registries, meta-analysis and epidemiology studies showed that 24%-65% of acromegaly patients treated with first gen-SSA did not reach the control of disease, requiring second line therapies, as the second gen-SSAs and the GH receptor antagonist. According to the high efficacy of these treatments and their molecular mechanisms of action, the choice of second line therapies should be personalized. In this review, we summarize the evidence on clinical, molecular and morphological aspects that may predict the response to second line therapies, in order to integrate and translate in the clinical practice for a patient-tailored therapeutic approach.

Personalized Medical Treatment in Patients with Acromegaly: A Review

Acromegaly is associated with significant morbidity and mortality if not appropriately treated. In addition to insulin-like growth factor 1 (IGF-1) and growth hormone (GH) normalization, and tumor shrinkage, treatment goals include symptom relief, managing complications and improving quality of life. Surgical resection is a first-line treatment in most patients, with few being pretreated pre-operatively with medications. Somatostatin receptor ligands (SRLs), injectable and more recently oral capsules, have been the cornerstone of first-line medical therapy for persistent disease. However, several factors, including sparsely granulated adenomas, absent/low somatostatin receptor (SSTR2) status, imaging T2-hyperintensity, young age and aryl hydrocarbon receptor interacting protein mutations could predict first-generation SRL resistance. Patients with these characteristics may be better candidates for the GH receptor antagonist, pegvisomant, or in cases of large tumors the second-generation SRL, pasireotide. Combination therapy should be further pursued in patients who remain biochemically uncontrolled or have high remnant tumor after monotherapy. An efficacious and cost-effective pegvisomant dose-sparing effect of SRLs when used in combination has been demonstrated. With such a wide array of medical treatment options, it is increasingly important to tailor treatment to patients' unique characteristics as well as preferences, with a goal of personalizing management to achieve high quality outcomes.

Pasireotide in the Personalized Treatment of Acromegaly

The delay in controlling the disease in patients who do not respond to first-line treatment with first generation somatostatin receptor ligands (first-generation SRLs) can be quantified in years, as every modification in the medical therapy requires some months to be fully evaluated. Considering this, acromegaly treatment should benefit from personalized medicine therapeutic approach by using biomarkers identifying drug response. Pasireotide has been positioned mostly as a compound to be used in first-generation SRLs resistant patients and after surgical failure, but sufficient data are now available to indicate it is a first line therapy for patients with certain characteristics. Pasireotide has been proved to be useful in patients in which hyperintensity T2 MRI signal is shown and in those depicting low SST2 and high expression of SST5, low or mutated AIP condition and sparsely granulated immunohistochemical pattern. This combination of clinical and pathological characteristics is unique for certain patients and seems to cluster in the same cases, strongly suggesting an etiopathogenic link. Thus, in this paper we propose to include this clinico-pathologic phenotype in the therapeutic algorithm, which would allow us to use as first line medical treatment those compounds with the highest potential for achieving the fastest control of GH hypersecretion as well as a positive effect upon tumor shrinkage, therefore accelerating the implementation of precision medicine for acromegaly. Moreover, we suggest the development, validation and clinical use of a pasireotide acute test, able to identify patients responsive to pasireotide LAR as the acute octreotide test is able to do for SRLs.

Neodymium-140 DOTA-LM3: Evaluation of an In Vivo Generator for PET with a Non-Internalizing Vector

¹⁴⁰Nd (t_1/2 = 3.4 days), owing to its short-lived positron emitting daughter ¹⁴⁰Pr (t_1/2 = 3.4 min), has promise as an in vivo generator for positron emission tomography (PET). However, the electron capture decay of ¹⁴⁰Nd is chemically disruptive to macrocycle-based radiolabeling, meaning that an in vivo redistribution of the daughter ¹⁴⁰Pr is expected before positron emission. The purpose of this study was to determine how the delayed positron from the de-labeled ¹⁴⁰Pr affects preclinical imaging with ¹⁴⁰Nd. To explore the effect, ¹⁴⁰Nd was produced at CERN-ISOLDE, reacted with the somatostatin analogue, DOTA-LM3 (1,4,7,10- tetraazacyclododecane, 1,4,7- tri acetic acid, 10- acetamide N - p-Cl-Phecyclo(d-Cys-Tyr-d-4-amino-Phe(carbamoyl)-Lys-Thr-Cys)d-Tyr-NH2) and injected into H727 xenograft bearing mice. Comparative pre- and post-mortem PET imaging at 16 h postinjection was used to quantify the in vivo redistribution of ¹⁴⁰Pr following ¹⁴⁰Nd decay. The somatostatin receptor-positive pancreas exhibited the highest tissue accumulation of ¹⁴⁰Nd-DOTA-LM3 (13% ID/g at 16 h) coupled with the largest observed redistribution rate, where 56 ± 7% (n = 4, mean ± SD) of the in situ produced ¹⁴⁰Pr washed out of the pancreas before decay. Contrastingly, the liver, spleen, and lungs acted as strong sink organs for free ¹⁴⁰Pr³⁺. Based upon these results, we conclude that ¹⁴⁰Nd imaging with a non-internalizing vector convolutes the biodistribution of the tracer with the accumulation pattern of free ¹⁴⁰Pr. This redistribution phenomenon may show promise as a probe of the cellular interaction with the vector, such as in determining tissue dependent internalization behavior.

Pasireotide in Acromegaly: An Overview of Current Mechanistic and Clinical Data

BACKGROUND

Acromegaly is an insidious neuroendocrine disorder caused by hypersecretion of growth hormone (GH) by a somatotroph adenoma. Somatostatin receptor ligands (SRLs) are recommended as first-line medical therapy in patients for whom surgery has failed or is contraindicated. There are 5 known somatostatin receptor subtypes (SSTRs), 2 of which, i.e. SSTR2 and SSTR5, are expressed by a majority of somatotroph adenomas. The currently available SRLs, i.e. octreotide and lanreotide, primarily bind to SSTR2. Pasireotide (SOM230) is a new multireceptor-targeted SRL which has a broader binding profile and an increased affinity for SSTR1, 2, 3, and 5.

METHODS

PubMed searches were performed to identify all of the available published English language data on pasireotide with regard to the mechanism of action, in vitro effects, and clinical data.

RESULTS

Preclinical studies have demonstrated that pasireotide has a broader range of functional activity than octreotide. Recently, the efficacy of pasireotide in attenuating GH and insulin-like growth factor 1 (IGF-1) levels in patients with acromegaly has been evaluated in phase III clinical trials. Pasireotide demonstrated superiority over octreotide in achieving biochemical control (i.e. GH ≤2.5 µg/l and age- and sex-matched IGF-1 normalization) in patients with acromegaly, as well as significant efficacy in treating patients who were previously inadequately controlled on the maximum allowed doses of octreotide and lanreotide. Pasireotide-induced hyperglycemia was the most concerning adverse event but was reversible upon discontinuation of pasireotide.

CONCLUSION

The clinical data support pasireotide as a promising new therapy for the treatment of acromegaly, and the long-acting formulation was recently approved in the US and Europe for the treatment of acromegaly.

[DOTA]Somatostatin-14 analogs and their (111)In-radioligands: effects of decreasing ring-size on sst1-5 profile, stability and tumor targeting

Multiple somatostatin receptor (sst)-subtype expression has been manifested in several human tumors. Hence, the availability of radiopeptides retaining the full pansomatostatin profile of the native hormone (SS14) is expected to increase the sensitivity and broaden the clinical indications of currently applied sst2-preferring cyclic octapeptide radioligands, like OctreoScan(®) ([(111)In-DTPA]octreotide). On the other hand, SS14 has been excluded from clinical use due to its rapid in vivo degradation. We herein present a small library of seven novel cyclic SS14-mimics carrying at their N-terminus the universal chelator DOTA (1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid) for stable binding of medically useful radiometals, like (111)In. By decreasing the number of amino acids composing the ring in their structure from 12 up to 6 AA, we induced important changes in key-biological parameters in vitro and in vivo. In particular, we observed unexpected changes and even total loss of sst1-5-affinity (6AA-ring), as well as weaker sst2-internalization efficacy as the ring size decreased. In contrast, in vivo stability increased with decreasing ring size, reaching its maximum in the 6AA-ring analogs. Interestingly, only the 12AA- and 9AA-ring members of this series showed sst2-specific uptake in AR4-2J tumors in mice revealing the prominent role of ring size on the biological response of tested SS14-derived radioligands.

Peptide receptor targeting in cancer: the somatostatin paradigm

Peptide receptors involved in pathophysiological processes represent promising therapeutic targets. Neuropeptide somatostatin (SST) is produced by specialized cells in a large number of human organs and tissues. SST primarily acts as inhibitor of endocrine and exocrine secretion via the activation of five G-protein-coupled receptors, named sst1–5, while in central nervous system, SST acts as a neurotransmitter/neuromodulator, regulating locomotory and cognitive functions. Critical points of SST/SST receptor biology, such as signaling pathways of individual receptor subtypes, homo- and heterodimerization, trafficking, and cross-talk with growth factor receptors, have been extensively studied, although functions associated with several pathological conditions, including cancer, are still not completely unraveled. Importantly, SST exerts antiproliferative and antiangiogenic effects on cancer cells in vitro, and on experimental tumors in vivo. Moreover, SST agonists are clinically effective as antitumor agents for pituitary adenomas and gastro-pancreatic neuroendocrine tumors. However, SST receptors being expressed by tumor cells of various tumor histotypes, their pharmacological use is potentially extendible to other cancer types, although to date no significant results have been obtained. In this paper the most recent findings on the expression and functional roles of SST and SST receptors in tumor cells are discussed.

Radionuclide therapy via SSTR: future aspects from experimental animal studies

There is need for better therapeutic options for neuroendocrine tumours. The aim of this review was to summarize results of experimental animal studies and raise ideas for future radionuclide therapy based on high expression of somatostatin (SS) receptors by many neuroendocrine tumours. In summary, one of the major options is individualized treatment for each patient, including choice of SS analogues, radionuclides and treatment schedules. Other options are methods to increase the treatment effect on tumour tissue (increasing tumour uptake and retention by upregulation of receptor expression and avoiding saturation of receptor binding), methods to increase the tumour tissue response (by choice of radionuclides, SS analogues or combined therapies), and methods to reduce side effects (diminished uptake and retention in critical organs and reduced normal tissue response). Furthermore, combination therapy with other radiopharmaceuticals, cytotoxic drugs or radiosensitizers can be considered to enhance the effects of radiolabelled SS analogues.

[111In-DOTA]Somatostatin-14 analogs as potential pansomatostatin-like radiotracers - first results of a preclinical study

Background

In this study, we report on the synthesis, radiolabeling, and biological evaluation of two new somatostatin-14 (SS14) analogs, modified with the universal chelator DOTA. We were interested to investigate if and to what extent such radiotracer prototypes may be useful for targeting sst_1-5-expressing tumors in man but, most importantly, to outline potential drawbacks and benefits associated with their use.

Methods

AT1S and AT2S (DOTA-Ala¹-Gly²-c[Cys³-Lys⁴-Asn⁵-Phe⁶-Phe⁷-Trp⁸/DTrp⁸-Lys⁹-Thr¹⁰-Phe¹¹-Thr¹²-Ser¹³-Cys¹⁴-OH], respectively) were synthesized on the solid support and labeled with ¹¹¹In. The sst_1-5 affinity profile of AT1S/AT2S was determined by receptor autoradiography using [Leu⁸,dTrp²²,¹²⁵I-Tyr²⁵]SS28 as radioligand. The ability of AT2S to stimulate sst₂ or sst₃ internalization was qualitatively analyzed by an immunofluorescence-based internalization assay using hsst₂- or hsst₃-expressing HEK293 cells. Furthermore, the internalization of the radioligands [¹¹¹In]AT1S and [¹¹¹In]AT2S was studied at 37 °C in AR4-2J cells endogenously expressing sst₂. The in vivo stability of [¹¹¹In]AT1S and [¹¹¹In]AT2S was tested by high-performance liquid chromatography analysis of mouse blood collected 5 min after radioligand injection, and biodistribution was studied in normal mice. Selectively for [¹¹¹In]AT2S, biodistribution was further studied in SCID mice bearing AR4-2J, HEK293-hsst_2A⁺, -hsst₃⁺ or -hsst₅⁺ tumors.

Results

The new SS14-derived analogs were obtained by solid phase peptide synthesis and were easily labeled with ¹¹¹In. Both SS14 conjugates, AT1S, and its DTrp⁸ counterpart, AT2S, showed a pansomatostatin affinity profile with the respective hsst_1-5 IC₅₀ values in the lower nanomolar range. In addition, AT2S behaved as an agonist for sst₂ and sst₃ since it stimulated receptor internalization. The ¹¹¹In radioligands effectively and specifically internalized into rsst_2A-expressing AR4-2J cells with [¹¹¹In]AT2S internalizing faster than [¹¹¹In]AT1S. Ex vivo mouse blood analysis revealed a rapid degradation of both radiopeptides in the bloodstream with the DTrp⁸ analog showing higher stability. Biodistribution results in healthy mice were consistent with these findings with only [¹¹¹In]AT2S showing specific uptake in the sst₂-rich pancreas. Biodistribution of [¹¹¹In]AT2S in tumor-bearing mice revealed receptor-mediated uptake in the AR4-2J (1.82 ± 0.36 %ID/g - block 0.21 ± 0.17 %ID/g at 4 h post injection (pi)), the HEK293-hsst_2A⁺ (1.49 ± 0.2 %ID/g - block 0.27 ± 0.20 %ID/g at 4 h pi), the HEK293-hsst₃⁺ (1.24 ± 0.27 %ID/g - block 0.32 ± 0.06 %ID/g at 4 h pi), and the HEK293-hsst₅⁺ tumors (0.41 ± 0.12 %ID/g - block 0.22 ± 0.006 %ID/g at 4 h pi). Radioactivity washed out from blood and background tissues via the kidneys.

Conclusions

This study has revealed that the native SS14 structure can indeed serve as a motif for the development of promising pansomatostatin-like radiotracers. Further peptide stabilization is required to increase in vivo stability and, consequently, to enhance in vivo delivery and tumor targeting.

Somatostatin receptors as targets for nuclear medicine imaging and radionuclide treatment

Radiolabeled peptides have been an important class of compounds in radiopharmaceutical sciences and nuclear medicine for more than 20 years. Despite strong research efforts, only somatostatin-based radiopeptides have a real impact on patient care, diagnostically and therapeutically. [(111)In-diethylenetriaminepentaacetic acid(0)]octreotide is commercially available for imaging. Imaging was highly improved by the introduction of PET radionuclides such as (68)Ga, (64)Cu, and (18)F. Two peptides are successfully used in targeted radionuclide therapy when bound to DOTA and labeled with (90)Y and (177)Lu.

Ligand-dependent mechanisms of sst2A receptor trafficking: role of site-specific phosphorylation and receptor activation in the actions of biased somatostatin agonists

The somatostatin receptor subtype 2A (sst2A) mediates many of somatostatin's neuroendocrine actions and is the primary therapeutic target for the stable somatostatin analogs used to inhibit hormone secretion by pituitary and gastroenteropancreatic tumors. Two new multireceptor targeting somatostatin analogs currently under clinical investigation, the multisomatostatin receptor agonist cyclo-[diaminoethylcarbamoyl-HydroxyPro-Phenylglycine-D-Trp-Lys-(4-O-benzyl)Tyr-Phe] (SOM230) (Pasireotide) and pan-somatostatin receptor agonist Tyr-cyclo-[D-diaminobutyric acid-Arg-Phe-Phe-D-Trp-Lys-Thr-Phe] (KE108), behave as functionally selective ligands at the sst2A receptor, mimicking some of somatostatin's actions but antagonizing others. Further, SOM230 and KE108 are less able to induce receptor internalization than somatostatin, indicating that they exhibit functional selectivity for receptor regulation as well as signaling. Here, we identify agonist-specific differences in the molecular events regulating sst2A receptor endocytosis. SOM230 and KE108 were less potent and less effective than somatostatin at stimulating sst2A receptor phosphorylation at two pairs of residues, Ser341/343 and Thr353/354. Only the pattern of Thr353/354 phosphorylation correlated with receptor internalization, consistent with the known importance of Thr phosphorylation for sst2A receptor endocytosis. As expected, arrestin recruitment to membrane receptors was reduced with SOM230 and KE108. In addition, both receptor dephosphorylation and receptor recycling occurred more rapidly with SOM230 and KE108 than with somatostatin. Surprisingly, however, SOM230 and KE108 also altered sst2A internalization in a phosphorylation-independent manner, because these analogs were less effective than somatostatin at stimulating the endocytosis of a phosphorylation-negative receptor mutant. These results show that the decreased receptor internalization produced by SOM230 and KE108 compared with somatostatin result from phosphorylation-independent effects as well as reduced site-specific receptor phosphorylation and receptor-arrestin association.