Radiobiological effects of the alpha emitter Ra-223 on tumor cells

Unlocking the power of affibody conjugated radioactive metallopharmaceuticals for targeted cancer diagnosis and therapy

Cancer is the second-largest death-causing disease after cardiovascular diseases. Effective research on cancer diagnosis and subsequent elimination plays a vital role in reducing the cancer-related death toll. Radiotherapy is one of the best strategies that could kill masses of solid tumour tissues; however, the efficacy is limited due to the bystander effect. This issue could be solved by the emergence of targeted delivery of radiometallic complexes, enabling clinicians to monitor the tumour regions and effectively destroy the tumour. Affibody® molecules are a class of synthetic peptides known as antibody mimics having the binding sites of an antibody. The specificity of affibodies is found to be greater than that of antibodies due to their small size. This review intends to highlight the recent developments in the field of affibody-targeted radiometallopharmaceuticals. These approaches could be essential for early cancer detection, tumour staging, and monitoring the response to therapy and could produce better therapeutic outcomes. In an attempt to provide ideas and inspiration for the researchers to design affibody-conjugated radiopharmaceuticals that are clinically applicable, we have provided an in-depth exploration of the various types of affibody-conjugated radiopharmaceuticals that are currently in clinical trials and various other pre-clinically tested conjugates in this article. Only a few review reports on affibody-conjugated radiometallopharmaceuticals, typically focusing on a specific molecular target or radionuclides reported. In this review, we provide a comprehensive overview of most radiometals, such as 111In, 68Ga, 64Cu, 55Co, 57Co, 44Sc, 99mTc, 89Zr, 90Y, 211At, 188Re, and 177Lu, choice of chelators, and potential cancer-associated molecular targets such HER2, EGFR or HER1, HER3, IGF-1R, PDGFRβ, VEGFR2, PD-L1, CAIX, PD-L1, neonatal Fc receptor (FcRn) and B7-H3. This approach highlights the advancements made over the past twenty years in affibody conjugates for radio imaging and therapy in oncology.

212Bi-Macroaggregated Albumin Inhibited Mouse Melanoma Growth by Regulating Cell Cycle Checkpoint Markers Without Promoting Living Cell Repopulation

Radiotherapy using an α-particle emitting radionuclide has emerged as a promising candidate for cancer treatment; however, the efficacy of 212Bi for mouse melanoma treatment has not yet been studied. Here, we evaluated the efficacy of 212Bi-labeled macroaggregated albumin (MAA) in delivering radiation to mouse melanoma cells in vitro and in vivo. Methods: The efficacy of 212Bi efficacy in killing melanoma cells was assessed by in vitro clonogenic and cell survival assays. Immunoblot assays were used to investigate downstream pathways, radioresistance, and epithelial-to-mesenchymal markers. We assessed melanoma cells' repopulation using a conditioned medium (CM; 50%) from 212Bi-MAA-irradiated B16F10 cells. 212Bi-MAA was intratumorally injected in B16F10 melanoma-bearing C57BL/6 mice to study the efficacy, stability, and internal organ toxicity of 212Bi-MAA. Results: 212Bi-MAA effectively killed and inhibited the clonogenic capacity of B16F10 cells. Furthermore, 212Bi-MAA induced the expression of DNA damage (γH2AX) and cell death (cleaved caspase-3) markers, which was at maximum at a dose of 3.7 MBq. Cell cycle checkpoint markers (ATR, Chk1, and Wee1) were also elevated after 212Bi treatment; however, these were reduced at 3.7 MBq compared with 0.93- and 1.85-MBq doses. Minimal to no upregulation of radioresistance (Trex1 and STAT1), cancer stemness (Nanog), and epithelial-mesenchymal transition (E-cadherin, N-cadherin, and Vimentin) markers was found after 212Bi-MAA treatment. CM from 212Bi-MAA-irradiated B16F10 cells did not alter the cell proliferation, colony-forming, and migration capacity of living B16F10 cells. CM did not change epithelial-mesenchymal transition and cell proliferation marker expression. Studies in mice showed that 212Bi-MAA was retained in B16F10 tumors and effectively reduced tumor growth in vivo without causing toxicity. Conclusion: These findings suggested that 212Bi-MAA was an effective therapy for mouse melanoma and did not induce factors that aid melanoma repopulation.

Lutetium-177-prostate-specific membrane antigen therapy for prostate cancer: current status and future prospects

PURPOSE OF REVIEW

Lutetium-177-prostate-specific membrane antigen (Lu 177-PSMA) radioligand therapy has emerged as a promising novel strategy for advanced prostate cancer. With its increasing importance alongside with a plethora of exciting results from latest trials, we would like to summarize current evidence and advancements in Lu 177-PSMA therapy across different stages of prostate cancer.

RECENT FINDINGS

In metastatic castration-resistant prostate cancer (mCRPC), early studies like the LuPSMA trial and TheraP trial demonstrated promising PSA response rates. The landmark VISION trial had established the oncological efficacy of Lu 177-PSMA as salvage therapy and demonstrated its benefit on survival outcomes. Explorations into earlier treatment settings have also been encouraging. Studies like that the PSMAfore trial, Enza-P trial and the UpFrontPSMA trial explored an earlier role of Lu 177-PSMA in mCRPC, and showed benefits when used in solitary or in junction with Docetaxel or androgen receptor pathway inhibitor. Finally, the potential use of Lu 177-PSMA as neoadjuvant therapy in localized prostate cancer is also under consideration, whose safety was demonstrated in the recent LuTectomy trial.

SUMMARY

Lu 177-PSMA therapy represents a significant advancement in prostate cancer treatment, offering selective and targeted delivery of radiation to prostate cancer cells in patients across various disease stages. Ongoing research and collaborative efforts are essential to overcome existing challenges, optimize patient selection and integrate this therapy into standard clinical practice, ultimately improving outcomes for patients with advanced prostate cancer.

The therapeutic use of 177 Lu-PSMA-617 radioligand therapy in prostate cancer treatment: a review of literature and ongoing trials

Radioligand therapy is a targeted cancer treatment modality in which radioisotopes are utilized in the delivery of radiation at targeted cancer cells, with the goal of sparing normal cells. Prostate cancer is a well-known radiosensitive disease, historically treated with radioisotopes such as Strontium-89, Samarium-153, and Radium-223 for palliation of bone metastases. Recently, prostate specific membrane antigen (PSMA) has recently been employed as a radioligand target due to its unique properties of high expression on the surface of prostate cancer cells, limited expression in normal tissue, function as an internalizing cell surface receptor, and increased expression with androgen deprivation therapy. In 2015, 177Lu-PSMA-617 was first introduced as a promising treatment option for castration-resistant prostate cancer, and 7 years later the results of the phase III VISION trial led to 177Lu-PSMA-617 gaining FDA approval for the treatment of progressive castration-resistant prostate cancer. These results in combination with the inherent properties of 177Lu-PSMA-617 have led to its current exploration as a promising treatment modality beyond progressive metastatic castration-resistant prostate cancer, and into the earlier phases of prostate cancer. This review paper aims to highlight the key phase III randomized controlled trials related to 177Lu-PSMA-617 in all stages of prostate cancer, as well as bring attention to ongoing, earlier phase I/II trials incorporating 177Lu-PSMA-617.

Enhancing Effects of Olaparib by Alpha- and Beta-Emitting Radionuclides, X-Rays, and Ultraviolet A Light in Combination with Ortho-IodoHoechst in a Prostate Cancer Cell Model

Background: New therapeutic strategies for metastatic castration-resistant prostate cancer (mCRPC) have been developed in the past to achieve the best response rates. Most recently, the use of combination therapies has been explored to optimize patient outcomes. Poly(ADP-ribose) polymerase inhibitors (PARPi) may help to treat mCRPC more effectively. Objectives: This study aimed to determine whether the combination of a PARPi with different radiation qualities results in different levels of radiosensitization of PC-3 cells. Methods: The radiosensitizing potential of Olaparib in combination with 177Lu, 223Ra, X-rays and photodynamic therapy (PDT) using the UVA light-activated photosensitizer ortho-iodoHoechst33258 (oIH) was evaluated by determining the clonogenic survival, DNA damage and cell cycle analysis. Results: Here, we show that this combination strategy differentially sensitized PC-3 cells to different radiation qualities. The combination of 177Lu with Olaparib increased the numbers of persistent double-strand breaks (DSBs) by a factor of 3.3 and cell death in PC-3 cells. Overall, the β-emitter 177Lu indicated a higher radiosensitization efficacy compared to 223Ra, with X-rays corresponding to dose modification factors (DMF) of 1.77, 1.17 and 1.16 respectively. Even in the case of the α-emitter 223Ra, the effects were much less pronounced than for 177Lu. PARPi also showed a slight potentiation of the cytotoxic effects both in co-treatment with X-rays and with PDT. Conclusions: The results of our study indicate a potential role for Olaparib in further optimizing the PSMA radioligand therapy (PRLT) outcomes. However, further evaluation of the combination of PARPi with PRLT is needed to gain more insights into improving the benefit to patients suffering from mCRPC.

Aspects and prospects of preclinical theranostic radiopharmaceutical development

This article provides an overview of preclinical theranostic radiopharmaceutical development, highlighting aspects of the preclinical development stages that can lead towards a clinical trial. The key stages of theranostic radiopharmaceutical development are outlined, including target selection, tracer development, radiopharmaceutical synthesis, automation and quality control, in vitro radiopharmaceutical analysis, selecting a suitable in vivo model, preclinical imaging and pharmacokinetic analysis, preclinical therapeutic analysis, dosimetry, toxicity, and preparing for clinical translation. Each stage is described and augmented with examples from the literature. Finally, an outlook on the prospects for the radiopharmaceutical theranostics field is provided.

Radiopharmaceuticals for Pancreatic Cancer: A Review of Current Approaches and Future Directions

The poor prognosis of pancreatic cancer requires novel treatment options. This review examines the evolution of radiopharmaceuticals in the treatment of pancreatic cancer. Established strategies such as peptide receptor radionuclide therapy (PRRT) offer targeted and effective treatment, compared to conventional treatments. However, there are currently no radiopharmaceuticals approved for the treatment of pancreatic cancer in Europe, which requires further research and novel approaches. New radiopharmaceuticals including radiolabeled antibodies, peptides, and nanotechnological approaches are promising in addressing the challenges of pancreatic cancer therapy. These new agents may offer more specific targeting and potentially improve efficacy compared to traditional therapies. Further research is needed to optimize efficacy, address limitations, and explore the overall potential of these new strategies in the treatment of this aggressive and harmful pathology.

Nanoscale Radiotheranostics for Cancer Treatment: From Bench to Bedside

In recent years, the application of radionuclides-containing nanomaterials in cancer treatment has garnered widespread attention. The diversity of nanomaterials allows researchers to selectively combine them with appropriate radionuclides for biomedical purposes, addressing challenges faced by peptides, small molecules, or antibodies used for radionuclide labeling. However, with advantages come challenges, and nanoradionuclides still encounter significant issues during clinical translation. This review summarized the recent progress of nanosized radionuclides for cancer treatment or diagnosis. The discussion began with representative radionuclides and the methods of incorporating them into nanomaterial structures. Subsequently, new combinations of nanomaterials and radionuclides, along with their applications, were introduced to demonstrate their future trends. The benefits of nanoradionuclides included optimized pharmacokinetic properties, enhanced disease-targeting efficacy, and synergistic application with other treatment techniques. Besides, the basic rule of this section was to summarize how these nanoradionuclides can truly impact the diagnosis and therapy of various cancer types. In the last part, the focus was devoted to the nanoradionuclides currently applicable in clinics and how to address the existing issues and problems based on our knowledge.

Synergistic Activity of DNA Damage Response Inhibitors in Combination with Radium-223 in Prostate Cancer

Radium-223 (223Ra) and Lutetium-177-labelled-PSMA-617 (177Lu-PSMA) are currently the only radiopharmaceutical treatments to prolong survival for patients with metastatic-castration-resistant prostate cancer (mCRPC); however, mCRPC remains an aggressive disease. Recent clinical evidence suggests patients with mutations in DNA repair genes associated with homologous recombination have a greater clinical benefit from 223Ra. In this study, we aimed to determine the utility of combining DNA damage response (DDR) inhibitors to increase the therapeutic efficacy of X-rays, or 223Ra. Radiobiological responses were characterised by in vitro assessment of clonogenic survival, repair of double strand breaks, cell cycle distribution, and apoptosis via PARP-1 cleavage. Here, we show that DDR inhibitors increase the therapeutic efficacy of both radiation qualities examined, which is associated with greater levels of residual DNA damage. Co-treatment of ATM or PARP inhibition with 223Ra increased cell cycle arrest in the G2/M phase. In comparison, combined ATR inhibition and radiation qualities caused G2/M checkpoint abrogation. Additionally, greater levels of apoptosis were observed after the combination of DDR inhibitors with 223Ra. This study identified the ATR inhibitor as the most synergistic inhibitor for both radiation qualities, supporting further pre-clinical evaluation of DDR inhibitors in combination with 223Ra for the treatment of prostate cancer.

Alpha-Emitter Radium-223 Induces STING-Dependent Pyroptosis to Trigger Robust Antitumor Immunity

Radium-223 (223 Ra) is the first-in-class alpha-emitter to mediate tumor eradication, which is commonly thought to kill tumor cells by directly cleaving double-strand DNA. However, the immunogenic characteristics and cell death modalities triggered by 223 Ra remain unclear. Here, it is reported that the 223 Ra irradiation induces the pro-inflammatory damage-associated molecular patterns including calreticulin, HMGB1, and HSP70, hallmarks of tumor immunogenicity. Moreover, therapeutic 223 Ra retards tumor progression by triggering pyroptosis, an immunogenic cell death. Mechanically, 223 Ra-induced DNA damage leads to the activation of stimulator of interferon genes (STING)-mediated DNA sensing pathway, which is critical for NLRP3 inflammasome-dependent pyroptosis and subsequent DCs maturation as well as T cell activation. These findings establish an essential role of STING in mediating alpha-emitter 223 Ra-induced antitumor immunity, which provides the basis for the development of novel cancer therapeutic strategies and combinatory therapy.

Theranostic Imaging Surrogates for Targeted Alpha Therapy: Progress in Production, Purification, and Applications

This article highlights recent developments of SPECT and PET diagnostic imaging surrogates for targeted alpha particle therapy (TAT) radiopharmaceuticals. It outlines the rationale for using imaging surrogates to improve diagnostic-scan accuracy and facilitate research, and the properties an imaging-surrogate candidate should possess. It evaluates the strengths and limitations of each potential imaging surrogate. Thirteen surrogates for TAT are explored: 133La, 132La, 134Ce/134La, and 226Ac for 225Ac TAT; 203Pb for 212Pb TAT; 131Ba for 223Ra and 224Ra TAT; 123I, 124I, 131I and 209At for 211At TAT; 134Ce/134La for 227Th TAT; and 155Tb and 152Tb for 149Tb TAT.

Monte Carlo simulation of SPECT characterization for 223 Ra post-injection scintigraphy

OBJECTIVES

223 Ra is a promising α-emitting radionuclide for prostate cancer metastasis palliative treatment. Post-injection scintigraphy is of major importance to verify the concentration of the radiopharmaceutical in the targeted sites. Given the low activity administered to patients, the choice of acquisition parameters, including the collimator type, the energy window's width and the photopeak energy to be used, is primordial for the image quality. The purpose of our work was to select the SPECT configuration suitable for 223 Ra post-injection scintigraphy.

METHODS

We conducted simulation studies with a Symbia T6 Siemens SPECT-CT, available in our department. 223 Ra photons energy spectra were assessed for low energy high resolution (LEHR), medium energy (ME) and high energy (HE) collimators. Then, depending on the energy window, we calculated the scatter fraction, the sensitivity and the spatial resolution.

RESULTS

Scatter fraction was low for all collimators; however, the contribution of photons that scattered more than twice under the low energy photopeaks was important in the case of LEHR. Sensitivity's best values were obtained in the case of the LEHR collimator; nevertheless, the spatial resolution was very low for this collimator. The latter was best for ME and HE collimators.

CONCLUSION

A combination between a good sensitivity, a high spatial resolution and a low scatter fraction has been determined in the case of the ME collimator, followed by HE collimator as an alternative. To increase the image acquisition statistics with ME collimator, we recommend to use simultaneous energy windows: 20% centered at 82 keV, 20% centered at 154 keV and 20% centered at 270 keV.

Zoledronic Acid Prevents Bone Resorption Caused by the Combination of Radium-223, Abiraterone Acetate, and Prednisone in an Intratibial Prostate Cancer Mouse Model

An increased risk of non-pathological fractures in patients with prostate cancer and bone metastases has been associated with combination treatment with radium-223, abiraterone, and prednisone/prednisolone in the absence of bone-protecting agents. Here, we investigated possible mechanisms leading to this outcome using an intratibial LNCaP model mimicking prostate cancer bone metastases. Male NOD.scid mice were inoculated intratibially with LNCaP prostate cancer cells and treated with vehicle, radium-223, abiraterone, prednisone, zoledronic acid, or their combinations for 28 days. Serum TRACP 5b and PSA levels were measured. Bone structure, quality, and formation rate of non-tumor-bearing and tumor-bearing tibiae were analyzed by microCT, 3-point bending assay, and dynamic histomorphometry, respectively. Radium-223 incorporation into bone was also measured. Radium-223/abiraterone/prednisone combination treatment induced a transient increase in bone resorption indicated by elevated TRACP 5b levels, which was inhibited by concurrent treatment with zoledronic acid. Furthermore, radium-223/abiraterone/prednisone combination reduced periosteal and trabecular new bone formation and the number of osteoblasts, but bone structure or biomechanical quality were not affected. The abiraterone/prednisone treatment decreased radium-223 incorporation into tumor-bearing bone, possibly explaining the lack of additional antitumor efficacy. In conclusion, radium-223/abiraterone/prednisone combination increased bone resorption, which may have been one of the mechanisms leading to an increased fracture risk in patients with mCRPC.

Synthesis and Evaluation of 177Lu-DOTA-PD-L1-i and 225Ac-HEHA-PD-L1-i as Potential Radiopharmaceuticals for Tumor Microenvironment-Targeted Radiotherapy

Current cancer therapies focus on reducing immunosuppression and remodeling the tumor microenvironment to inhibit metastasis, cancer progression, and therapeutic resistance. Programmed death receptor 1 (PD-1) is expressed on immune T cells and is one of the so-called checkpoint proteins that can suppress or stop the immune response. To evade the immune system, cancer cells overexpress a PD-1 inhibitor protein (PD-L1), which binds to the surface of T cells to activate signaling pathways that induce immune suppression. This research aimed to synthesize PD-L1 inhibitory peptides (PD-L1-i) labeled with lutetium-177 (177Lu-DOTA-PD-L1-i) and actinium-225 (225Ac-HEHA-PD-L1-i) and to preclinically evaluate their potential as radiopharmaceuticals for targeted radiotherapy at the tumor microenvironment level. Using PD-L1-i peptide as starting material, conjugation with HEHA-benzene-SCN and DOTA-benzene-SCN was performed to yield DOTA-PD-L1-i and HEHA-PD-L1-I, which were characterized by FT-IR, UV-vis spectroscopy, and HPLC. After labeling the conjugates with 225Ac and 177Lu, cellular uptake in HCC827 cancer cells (PD-L1 positive), conjugate specificity evaluation by immunofluorescence, radiotracer effect on cell viability, biodistribution, biokinetics, and assessment of radiation absorbed dose in mice with in duced lung micrometastases were performed. 225Ac-HEHA-PD-L1-i and 177Lu-DOTA-PD-L1-i, obtained with radiochemical purities of 95 ± 3% and 98.5 ± 0.5%, respectively, showed in vitro and in vivo specific recognition for the PD-L1 protein in lung cancer cells and high uptake in HCC287 lung micrometastases (>30% ID). The biokinetic profiles of 177Lu-DOTA-PD-L1-i and 225Ac-DOTA-PD-L1-i showed rapid blood clearance with renal and hepatobiliary elimination and no accumulation in normal tissues. 225Ac-DOTA-PD-L1-i produced a radiation dose of 5.15 mGy/MBq to lung micrometastases. In the case of 177Lu-DOTA-PD-L1-i, the radiation dose delivered to the lung micrometastases was ten times (43 mGy/MBq) that delivered to the kidneys (4.20 mGy/MBq) and fifty times that delivered to the liver (0.85 mGy/MBq). Therefore, the radiotherapeutic PD-L1-i ligands of 225Ac and 177Lu developed in this research could be combined with immunotherapy to enhance the therapeutic effect in various types of cancer.

A Review of Theranostics: Perspectives on Emerging Approaches and Clinical Advancements

Theranostics is the combination of two approaches-diagnostics and therapeutics-applied for decades in cancer imaging using radiopharmaceuticals or paired radiopharmaceuticals to image and selectively treat various cancers. The clinical use of theranostics has increased in recent years, with U.S. Food and Drug Administration (FDA) approval of lutetium 177 (177Lu) tetraazacyclododecane tetraacetic acid octreotate (DOTATATE) and 177Lu-prostate-specific membrane antigen vector-based radionuclide therapies. The field of theranostics has imminent potential for emerging clinical applications. This article reviews critical areas of active clinical advancement in theranostics, including forthcoming clinical trials advancing FDA-approved and emerging radiopharmaceuticals, approaches to dosimetry calculations, imaging of different radionuclide therapies, expanded indications for currently used theranostic agents to treat a broader array of cancers, and emerging ideas in the field. Keywords: Molecular Imaging, Molecular Imaging-Cancer, Molecular Imaging-Clinical Translation, Molecular Imaging-Target Development, PET/CT, SPECT/CT, Radionuclide Therapy, Dosimetry, Oncology, Radiobiology © RSNA, 2023.

An Overview of In Vitro Assays of 64Cu-, 68Ga-, 125I-, and 99mTc-Labelled Radiopharmaceuticals Using Radiometric Counters in the Era of Radiotheranostics

Radionuclides are unstable isotopes that mainly emit alpha (α), beta (β) or gamma (γ) radiation through radiation decay. Therefore, they are used in the biomedical field to label biomolecules or drugs for diagnostic imaging applications, such as positron emission tomography (PET) and/or single-photon emission computed tomography (SPECT). A growing field of research is the development of new radiopharmaceuticals for use in cancer treatments. Preclinical studies are the gold standard for translational research. Specifically, in vitro radiopharmaceutical studies are based on the use of radiopharmaceuticals directly on cells. To date, radiometric β- and γ-counters are the only tools able to assess a preclinical in vitro assay with the aim of estimating uptake, retention, and release parameters, including time- and dose-dependent cytotoxicity and kinetic parameters. This review has been designed for researchers, such as biologists and biotechnologists, who would like to approach the radiobiology field and conduct in vitro assays for cellular radioactivity evaluations using radiometric counters. To demonstrate the importance of in vitro radiopharmaceutical assays using radiometric counters with a view to radiogenomics, many studies based on ⁶⁴Cu-, ⁶⁸Ga-, ¹²⁵I-, and ^99mTc-labeled radiopharmaceuticals have been revised and summarized in this manuscript.

Radium-223 dichloride treatment in metastatic castration-resistant prostate cancer in Finland: A real-world evidence multicenter study

BACKGROUND

Radium-233 dichloride is an alpha emitter that specifically targets bone metastases in prostate cancer. Results of a previously reported phase III randomized trial showed survival benefit for radium-223 compared to best supportive care in castration-resistant prostate cancer (CRPC) with bone metastases. However, real-world data are also needed with wider inclusion criteria.

METHODS

We report results of a retrospective multicenter study including all patients with metastatic CRPC treated with radium-223 in all five university hospitals in Finland since the introduction of the treatment. We identified 160 patients who had received radium-223 in Finland in 2014-2019.

RESULTS

The median overall survival (OS) was 13.8 months (range 0.5-57 months), and the median real-world progression-free survival (rwPFS) was 4.9 months (range 0.5-29.8 months). Alkaline phosphatase (ALP) values within the normal range before and during the radium-223 treatment or the reduction of elevated ALP to normal range during treatment were associated with better OS when compared to elevated ALP values before and during treatment (p < 0.0001). High prostate-specific antigen (PSA) level (≥100 μg/L) before radium-223 treatment was associated with poor OS compared to low PSA level (<20 μg/L) (p = 0.0001). Most patients (57%) experienced pain relief. Pain relief indicated better OS (p = 0.002). Radium-223 treatment was well tolerated. Toxicity was mostly low grade. Only 12.5% of the patients had grade III-IV adverse events, most commonly anemia, neutropenia, leucopenia, and thrombocytopenia.

CONCLUSION

Radium-223 was well tolerated in routine clinical practice, and most patients achieved pain relief. Pain relief, ALP normalization, lower baseline PSA, and PSA decrease during radium-223 treatment were prognostic for better survival. The efficacy of radium-223 in mCRPC as estimated using OS was comparable to earlier randomized trial in this retrospective real-world study. Our results support using radium-223 for mCRPC patients with symptomatic bone metastases even in the era of new-generation androgen receptor-targeted agents.

Radiopharmaceuticals heat anti-tumor immunity

Radiopharmaceutical therapy (RPT) has proven to be an effective cancer treatment with minimal toxicity. With several RPT agents approved by FDA, the remarkable potential of this therapy is now being recognized, and the anti-tumor immunity induced by RPT is beginning to be noticed. This review evaluates the potential of RPT for immune activation, including promoting the release of danger associated-molecular pattern molecules that recruit inflammatory cells into the tumor microenvironment, and activating antigen-presenting cells and cytotoxic T cells. We also discuss the progress of combining RPT with immunotherapy to increase efficacy.

Differential Recruitment of DNA Repair Proteins KU70/80 and RAD51 upon Microbeam Irradiation with α-Particles

In addition to representing a significant part of the natural background radiation exposure, α-particles are thought to be a powerful tool for targeted radiotherapy treatments. Understanding the molecular mechanisms of recognition, signaling, and repair of α-particle-induced DNA damage is not only important in assessing the risk associated with human exposure, but can also potentially help in identifying ways of improving the efficacy of radiation treatment. α-particles (He2+ ions), as well as other types of ionizing radiation, and can cause a wide variety of DNA lesions, including DNA double-strand breaks (DSBs). In mammalian cells, DNA DSBs can be repaired by two major pathways: non-homologous end-joining (NHEJ) and homologous recombination (HR). Here, we investigated their dynamics in mouse NIH-3T3 cells through the recruitment of key proteins, such as the KU heterodimer for NHEJ and RAD51 for HR upon localized α-particle irradiation. To deliver α-particles, we used the MIRCOM microbeam, which allows targeting of subnuclear structures with submicron accuracy. Using mouse NIH-3T3 cells, we found that the KU heterodimer is recruited much earlier at DNA damage sites marked by H2AX phosphorylation than RAD51. We also observed that the difference in the response of the KU complex and RAD51 is not only in terms of time, but also in function of the chromatin nature. The use of a microbeam such as MIRCOM, represents a powerful tool to study more precisely the cellular response to ionizing irradiation in a spatiotemporal fashion at the molecular level.

Differential responses to 223Ra and Alpha-particles exposure in prostate cancer driven by mitotic catastrophe

Introduction

Radium-223 (223Ra) has been shown to have an overall survival benefit in metastatic castration-resistant prostate cancer (mCRPC) involving bone. Despite its increased clinical usage, relatively little is known regarding the mechanism of action of 223Ra at the cellular level.

Methods

We evaluated the effects of 223Ra irradiation in a panel of cell lines and then compared them with standard X-ray and external alpha-particle irradiation, with a particular focus on cell survival and DNA damage repair kinetics.

Results

223Ra exposures had very high, cell-type-dependent RBE50% ranging from 7 to 15. This was significantly greater than external alpha irradiations (RBE50% from 1.4 to 2.1). These differences were shown to be partially related to the volume of 223Ra solution added, independent of the alpha-particle dose rate, suggesting a radiation-independent mechanism of effect. Both external alpha particles and 223Ra exposure were associated with delayed DNA repair, with similar kinetics. Additionally, the greater treatment efficacy of 223Ra was associated with increased levels of residual DNA damage and cell death by mitotic catastrophe.

Conclusions

These results suggest that 223Ra exposure may be associated with greater biological effects than would be expected by direct comparison with a similar dose of external alpha particles, highlighting important challenges for future therapeutic optimization.

Alpha emitting nuclides in nuclear medicine theranostics

Theranostic applications with radio-isotopes currently are rapidly progressing and expand nuclear medicine application in clinical routine. Alpha emitting isotopes, in particular, have long been hypothesized to achieve relevant advances for the treatment of malignancies. Here, an overview of their properties and the knowledge of radiobiology is reviewed in view of clinical translation. Clinical evidence of radiopharmaceuticals based on alpha emitters is summarized with a focus on recent developments for treatment of metastasized castration resistant prostate cancer.

225Ac-rHDL Nanoparticles: A Potential Agent for Targeted Alpha-Particle Therapy of Tumors Overexpressing SR-BI Proteins

Actinium-225 and other alpha-particle-emitting radionuclides have shown high potential for cancer treatment. Reconstituted high-density lipoproteins (rHDL) specifically recognize the scavenger receptor B type I (SR-BI) overexpressed in several types of cancer cells. Furthermore, after rHDL-SR-BI recognition, the rHDL content is injected into the cell cytoplasm. This research aimed to prepare a targeted ²²⁵Ac-delivering nanosystem by encapsulating the radionuclide into rHDL nanoparticles. The synthesis of rHDL was performed in two steps using the microfluidic synthesis method for the subsequent encapsulation of ²²⁵Ac, previously complexed to a lipophilic molecule (²²⁵Ac-DOTA-benzene-p-SCN, CLog P = 3.42). The nanosystem (13 nm particle size) showed a radiochemical purity higher than 99% and stability in human serum. In vitro studies in HEP-G2 and PC-3 cancer cells (SR-BI positive) demonstrated that ²²⁵Ac was successfully internalized into the cytoplasm of cells, delivering high radiation doses to cell nuclei (107 Gy to PC-3 and 161 Gy to HEP-G2 nuclei at 24 h), resulting in a significant decrease in cell viability down to 3.22 ± 0.72% for the PC-3 and to 1.79 ± 0.23% for HEP-G2 at 192 h after ²²⁵Ac-rHDL treatment. After intratumoral ²²⁵Ac-rHDL administration in mice bearing HEP-G2 tumors, the biokinetic profile showed significant retention of radioactivity in the tumor masses (90.16 ± 2.52% of the injected activity), which generated ablative radiation doses (649 Gy/MBq). The results demonstrated adequate properties of rHDL as a stable carrier for selective deposition of ²²⁵Ac within cancer cells overexpressing SR-BI. The results obtained in this research justify further preclinical studies, designed to evaluate the therapeutic efficacy of the ²²⁵Ac-rHDL system for targeted alpha-particle therapy of tumors that overexpress the SR-BI receptor.

Alpha Before Beta: Exceptional Response to First-Line 225Ac-DOTATATE in a Patient of Metastatic Neuroendocrine Tumor With Extensive Skeletal Involvement

ABSTRACT

The utility of β-emitter 177Lu-DOTATATE in patients of neuroendocrine tumors (NETs) with widespread skeletal metastases is limited by its relatively modest response rates and a significant concern for hematotoxicity. In such situations, targeted α therapy with 225Ac-DOTATATE can be potentially beneficial. In this report, a 46-year-old man with rectal NET and extensive skeletal metastases was treated upfront with 6 cycles of 225Ac-DOTATATE at 8 weeks' intervals. The patient showed excellent symptomatic, biochemical, and radiological response with no grade 3/4 adverse events. The first-line use of 225Ac-DOTATATE, therefore, presents a novel strategy for metastatic NETs with high skeletal disease burden.

Dose estimation after a mixed field exposure: Radium-223 and intensity modulated radiotherapy

INTRODUCTION

Radium-223 dichloride ([²²³Ra]RaCl₂), a radiopharmaceutical that delivers α-particles to regions of bone metastatic disease, has been proven to improve overall survival of men with metastatic castration resistant prostate cancer (mCRPC). mCRPC patients enrolled on the ADRRAD clinical trial are treated with a mixed field exposure comprising radium-223 (²²³Ra) and intensity modulated radiotherapy (IMRT). While absorbed dose estimation is an important step in the characterisation of wider systemic radiation risks in nuclear medicine, uncertainties remain for novel radiopharmaceuticals such as ²²³Ra.

METHODS

24-Colour karyotyping was used to quantify the spectrum of chromosome aberrations in peripheral blood lymphocytes of ADRRAD patients at incremental times during their treatment. Dicentric equivalent frequencies were used in standard models for estimation of absorbed blood dose. To account for the mixed field nature of the treatment, existing models were used to determine the ratio of the component radiation types. Additionally, a new approach (M-FISH_LET), based on the ratio of cells containing damage consistent with high-LET exposure (complex chromosomal exchanges) and low-LET exposure (simple exchanges), was used as a pseudo ratio for ²²³Ra:IMRT dose.

RESULTS

Total IMRT estimated doses delivered to the blood after completion of mixed radiotherapy (after 37 IMRT fractions and two [²²³Ra]RaCl₂ injections) were in the range of 1.167 ± 0.092 and 2.148 ± 0.096 Gy (dose range across all models applied). By the last treatment cycle analysed in this study (four [²²³Ra]RaCl₂ injections), the total absorbed ²²³Ra dose to the blood was estimated to be between 0.024 ± 0.027 and 0.665 ± 0.080 Gy, depending on the model used. Differences between the models were observed, with the observed dose variance coming from inter-model as opposed to inter-patient differences. The M-FISH_LET model potentially overestimates the ²²³Ra absorbed blood dose by accounting for further PBL exposure in the vicinity of metastatic sites.

CONCLUSIONS

The models presented provide initial estimations of cumulative dose received during incremental IMRT fractions and [²²³Ra]RaCl₂ injections, which will enable improved understanding of the doses received by individual patients. While the M-FISH_LET method builds on a well-established technique for external exposures, further consideration is needed to evaluate this method and its use in assessing non-targeted exposure by ²²³Ra after its localization at bone metastatic sites.

DNA repair inhibitors sensitize cells differently to high and low LET radiation

The aim of this study was to investigate effects of high LET α-radiation in combination with inhibitors of DDR (DNA-PK and ATM) and to compare the effect with the radiosensitizing effect of low LET X-ray radiation. The various cell lines were irradiated with α-radiation and with X-ray. Clonogenic survival, the formation of micronuclei and cell cycle distribution were studied after combining of radiation with DDR inhibitors. The inhibitors sensitized different cancer cell lines to radiation. DNA-PKi affected survival rates in combination with α-radiation in selected cell lines. The sensitization enhancement ratios were in the range of 1.6–1.85 in cancer cells. ATMi sensitized H460 cells and significantly increased the micronucleus frequency for both radiation qualities. ATMi in combination with α-radiation reduced survival of HEK293. A significantly elicited cell cycle arrest in G₂/M phase after co-treatment of ATMi with α-radiation and X-ray. The most prominent treatment effect was observed in the HEK293 by combining α-radiation and inhibitions. ATMi preferentially sensitized cancer cells and normal HEK293 cells to α-radiation. DNA-PKi and ATMi can sensitize cancer cells to X-ray, but the effectiveness was dependent on cancer cells itself. α-radiation reduced proliferation in primary fibroblast without G₂/M arrest.

Why bother with alpha particles?

The approval of 223RaCl2 for cancer therapy in 2013 has heralded a resurgence of interest in the development of α-particle emitting radiopharmaceuticals. In the last decade, over a dozen α-emitting radiopharmaceuticals have entered clinical trials, spawned by strong preclinical studies. In this article, we explore the potential role of α-particle therapy in cancer treatment. We begin by providing a background for the basic principles of therapy with α-emitters, and we explore recent breakthroughs in therapy with α-emitting radionuclides, including conjugates with small molecules and antibodies. Finally, we discuss some outstanding challenges to the clinical adoption of α-therapies and potential strategies to address them.

Systematic overview on the most widespread techniques for inducing and visualizing the DNA double-strand breaks

DNA double-strand breaks (DSBs) are one of the most frequent causes of initiating cancerous malformations, therefore, to reduce the risk, cells have developed sophisticated DNA repair mechanisms. These pathways ensure proper cellular function and genome integrity. However, any alteration or malfunction during DNA repair can influence cellular homeostasis, as improper recognition of the DNA damage or dysregulation of the repair process can lead to genome instability. Several powerful methods have been established to extend our current knowledge in the field of DNA repair. For this reason, in this review, we focus on the methods used to study DSB repair, and we summarize the advantages and disadvantages of the most commonly used techniques currently available for the site-specific induction of DSBs and the subsequent tracking of the repair processes in human cells. We highlight methods that are suitable for site-specific DSB induction (by restriction endonucleases, CRISPR-mediated DSB induction and laser microirradiation) as well as approaches [e.g., fluorescence-, confocal- and super-resolution microscopy, chromatin immunoprecipitation (ChIP), DSB-labeling and sequencing techniques] to visualize and follow the kinetics of DSB repair.

TOPAS a tool to evaluate the impact of cell geometry and radionuclide on alpha particle therapy

Due to the increasing clinical application of alpha particles, accurate assessment of their dosimetry at the cellular scale should be strongly advocated. Although observations of the impact of cell and nuclear geometry have been previously reported, this effect has not been fully quantified. Additionally, alpha particle dosimetry presents several challenges and most conventional methodologies have poor resolution and are limited to average parameters across populations of cells. Meaningful dosimetry studies with alpha particles require detailed information on the geometry of the target at a subcellular scale.

METHODS

The impact of cellular geometry was evaluated for 3 different scenarios, a spherical cell with a concentric nucleus, a spherical cell with an eccentric nucleus and a model of a cell attached to a flask, consisting of a hemispherical oblate ellipsoid, all exposed to 1,700 211At radionuclide decays. We also evaluated the cross-fire effect of alpha particles as function of distance to a source cell. Finally, a nanodosimetric analysis of absorbed dose to the nucleus of a cell exposed to 1 Gy of different alpha emitting radionuclides was performed.

RESULTS

Simulated data shows the dosimetry of self-absorbed-dose strongly depends on activity localization in the source cell, but that activity localization within the source cell did not significantly affect the cross-fire absorbed dose even when cells are in direct contact with each other. Additionally, nanodosimetric analysis failed to show any significant differences in the energy deposition profile between different alpha particle emitters.

CONCLUSIONS

The collected data allows a better understanding of the dosimetry of alpha particles emitters at the sub-cellular scale. Dosimetric variations between different cellular configurations can generate complications and confounding factors for the translation of dosimetric outcomes into clinical settings, but effects of different radionuclides are generally similar.

α-Particle-induced DNA damage tracks in peripheral blood mononuclear cells of [223Ra]RaCl2-treated prostate cancer patients

PURPOSE

One therapy option for prostate cancer patients with bone metastases is the use of [²²³Ra]RaCl₂. The α-emitter ²²³Ra creates DNA damage tracks along α-particle trajectories (α-tracks) in exposed cells that can be revealed by immunofluorescent staining of γ-H2AX+53BP1 DNA double-strand break markers. We investigated the time- and absorbed dose-dependency of the number of α-tracks in peripheral blood mononuclear cells (PBMCs) of patients undergoing their first therapy with [²²³Ra]RaCl₂.

METHODS

Multiple blood samples from nine prostate cancer patients were collected before and after administration of [²²³Ra]RaCl₂, up to 4 weeks after treatment. γ-H2AX- and 53BP1-positive α-tracks were microscopically quantified in isolated and immuno-stained PBMCs.

RESULTS

The absorbed doses to the blood were less than 6 mGy up to 4 h after administration and maximally 16 mGy in total. Up to 4 h after administration, the α-track frequency was significantly increased relative to baseline and correlated with the absorbed dose to the blood in the dose range < 3 mGy. In most of the late samples (24 h - 4 weeks after administration), the α-track frequency remained elevated.

CONCLUSION

The γ-H2AX+53BP1 assay is a potent method for detection of α-particle-induced DNA damages during treatment with or after accidental incorporation of radionuclides even at low absorbed doses. It may serve as a biomarker discriminating α- from β-emitters based on damage geometry.

The potential of PSMA-targeted alpha therapy in the management of prostate cancer

INTRODUCTION

Alpha emitters present several advantages for cancer therapy. The radiopharmaceutical ²²³Ra-dichloride has been recently introduced for the targeted alpha therapy (TAT) of metastastic castration-resistant prostate cancer (mCRPC). However, since ²²³Ra-dichloride targets only skeletal lesions, its use in clinical practice is recommended only in subjects without visceral metastases. To overcome this, several efforts have been made to develop radiopharmaceuticals suitable for TAT and specifically directed toward the biomarker prostate specific membrane antigen (PSMA), overexpressed by both skeletal and visceral metastases from mCRPC.

AREAS COVERED

The radiobiological principles concerning TAT applications are covered, with particular emphasis on its pros and cons, especially in comparison with beta-emitter radionuclide therapy. Furthermore, the role of PSMA as a theranostic target for imaging and therapy is reviewed. Lastly, the pre-clinical and clinical applications of TAT through 225Actinium (²²⁵AC) and 213Bismuth (²¹³Bi) are discussed.

EXPERT OPINION

PSMA-based TAT holds the promise of becoming a powerful tool for the management of mCRPC. Nevertheless, several issues have still to be addressed, especially concerning TAT toxicity. Furthermore, several efforts have to be made for identifying the more adequate alpha-emitter (²²⁵Ac vs ²¹³Bi) with a view to the patient's tailored therapeutic approach.

Targeted Alpha Therapy: Current Clinical Applications

α-Emitting radionuclides have been approved for cancer treatment since 2013, with increasing degrees of success. Despite this clinical utility, little is known regarding the mechanisms of action of α particles in this setting, and accurate assessments of the dosimetry underpinning their effectiveness are lacking. However, targeted alpha therapy (TAT) is gaining more attention as new targets, synthetic chemistry approaches, and α particle emitters are identified, constructed, developed, and realized. From a radiobiological perspective, α particles are more effective at killing cells compared to low linear energy transfer radiation. Also, from these direct effects, it is now evident from preclinical and clinical data that α emitters are capable of both producing effects in nonirradiated bystander cells and stimulating the immune system, extending the biological effects of TAT beyond the range of α particles. The short range of α particles makes them a potent tool to irradiate single-cell lesions or treat solid tumors by minimizing unwanted irradiation of normal tissue surrounding the cancer cells, assuming a high specificity of the radiopharmaceutical and good stability of its chemical bonds. Clinical approval of ²²³RaCl₂ in 2013 was a major milestone in the widespread application of TAT as a safe and effective strategy for cancer treatment. In addition, ²²⁵Ac-prostate specific membrane antigen treatment benefit in metastatic castrate-resistant prostate cancer patients, refractory to standard therapies, is another game-changing piece in the short history of TAT clinical application. Clinical applications of TAT are growing with different radionuclides and combination therapies, and in different clinical settings. Despite the remarkable advances in TAT dosimetry and imaging, it has not yet been used to its full potential. Labeled ²²⁷Th and ²²⁵Ac appear to be promising candidates and could represent the next generation of agents able to extend patient survival in several clinical scenarios.