Treatment of Non-Hodgkin’s Lymphoma (NHL) With Radiolabeled Antibodies (mAbs)

Radioimmunotherapy of Non-Hodgkin B-cell Lymphoma: An update

Systemic radioimmunotherapy (RIT) is arguably the most effective and least toxic anticancer treatment for non-Hodgkin lymphoma (NHL). In treatment-naïve patients with indolent NHL, the efficacy of a single injection of RIT compares with that of multiple cycles of combination chemotherapy. However, 20 years following the approval of the first CD20-targeting radioimmunoconjugates ⁹⁰Y-Ibritumomab-tiuxetan (Zevalin) and ¹³¹I-tositumomab (Bexxar), the number of patients referred for RIT in western countries has dramatically decreased. Notwithstanding this, the development of RIT has continued. Therapeutic targets other than CD20 have been identified, new vector molecules have been produced allowing for faster delivery of RIT to the target, and innovative radionuclides with favorable physical characteristics such as alpha emitters have been more widely available. In this article, we reviewed the current status of RIT in NHL, with particular focus on recent clinical and preclinical developments.

Does the Number of Bifunctional Chelators Conjugated to a mAb Affect the Biological Activity of Its Radio-Labeled Counterpart? Discussion Using the Example of mAb against CD-20 Labeled with 90Y or 177Lu

There has been considerable interest in developing a monoclonal antibody (mAb) against-CD-20 (for example, Rituximab) modified by bifunctional chelating agents (BCA) for non-Hodgkin's lymphoma radioimmunotherapy. Therefore, many researchers have modified this monoclonal antibody by attaching different BCA moieties and evaluated their biological activities in terms of in vitro study and in vivo study in healthy and tumor xenografted rodents. This mini-perspective reviews the in vitro studies, the immunoreactivity and physiological distribution studies: organ-to-blood and the tumor-to-organ ratio of conjugates with different numbers of chelators per mAb. We set up a null hypothesis that states there is no statistical significance between the biological activity of monoclonal antibody (Rituximab) and the number of conjugated bifunctional chelators. Overall, we have concluded that there is no strong evidence for this hypothesis. However, the literature data should be questioned due to the potential lack of uniform study methodology.

Impact of DOTA-Chelators on the Antitumor Activity of 177Lu-DOTA-Rituximab Preparations in Lymphoma Tumor-Bearing Mice

Background: This work aimed to evaluate the influence of two chelators: DOTA(SCN) and DOTA(NHS) on radioimmunotherapy using ¹⁷⁷Lu-DOTA-Rituximab preparations in murine lymphoma xenograft models. Subsequently, based on animal data, the organ radiation-absorbed doses were extrapolated to humans (adult male). Materials and Methods: Therapeutic efficacy of ¹⁷⁷Lu-DOTA-Rituximab was evaluated in male nude mice bearing either Raji (B lymphocyte, CD20⁺) and Jurkat (T lymphocyte, CD20) xenografts, utilizing an anti-CD20 antibody-Rituximab conjugate with either DOTA(SCN) or DOTA(NHS). The DOTA-Rituximab conjugates were prepared in the form of freeze-dried kits. Results: All radioimmunoconjugates were obtained with high radiolabeling yield (radiochemical purity, RCP > 95%) and specific activity of ca. 0.5 GBq/mg. Therapeutic effects of ¹⁷⁷Lu-DOTA-Rituximab were observed in animals regardless whether DOTA(SCN) or DOTA(NHS) were used for conjugation. Importantly, therapy involving ¹⁷⁷Lu-DOTA-Rituximab was more effective than use of Rituximab alone. Conclusions: The degree of antitumor efficacy was dependent on the type of applied bifunctional chelators conjugated to mAb. However, this difference was not statistically significant. Dosimetry calculations showed that the absorbed radiation doses extrapolated to humans were very low for osteogenic cells regardless of the conjugates. Organs like the liver and spleen, treated with ¹⁷⁷Lu-DOTA(SCN)-Rituximab, showed similar radiation absorbed doses when compared with ¹⁷⁷Lu-DOTA(NHS)-Rituximab.

Targeted Radionuclide Therapy of Melanoma

An estimated 60,000 individuals in the United States and 132,000 worldwide are yearly diagnosed with melanoma. Until recently, treatment options for patients with stages III-IV metastatic disease were limited and offered marginal, if any, improvement in overall survival. The situation changed with the introduction of B-RAF inhibitors and anti-cytotoxic T-lymphocyte antigen 4 and anti-programmed cell death protein 1 immunotherapies into the clinical practice. With only some patients responding well to the immune therapies and with very serious side effects and high costs of immunotherapy, there is still room for other approaches for the treatment of metastatic melanoma. Targeted radionuclide therapy of melanoma could be divided into the domains of radioimmunotherapy (RIT), radiolabeled peptides, and radiolabeled small molecules. RIT of melanoma is currently experiencing a renaissance with the clinical trials of alpha-emitter (213)Bi-labeled and beta-emitter (188)Rhenium-labeled monoclonal antibodies in patients with metastatic melanoma producing encouraging results. The investigation of the mechanism of efficacy of melanoma RIT points at killing of melanoma stem cells by RIT and involvement of immune system such as complement-dependent cytotoxicity. The domain of radiolabeled peptides for targeted melanoma therapy has been preclinical so far, with work concentrated on radiolabeled peptide analogues of melanocyte-stimulating hormone receptor and on melanin-binding peptides. The field of radiolabeled small molecule produced radioiodinated benzamides that cross the cellular membrane and bind to the intracellular melanin. The recent clinical trial demonstrated measurable antitumor effects and no acute or midterm toxicities. We are hopeful that the targeted radionuclide therapy of metastatic melanoma would become a clinical reality as a stand-alone therapy or in combination with the immunotherapies such as anti-PD1 programmed cell death protein 1 monoclonal antibodies within the next few years.

Lymphoma: current status of clinical and preclinical imaging with radiolabeled antibodies

Lymphoma is a complex disease that arises from cells of the immune system with an intricate pathology. While lymphoma may be classified as Hodgkin or non-Hodgkin, each type of tumor is genetically and phenotypically different and highly invasive tissue biopsies are the only method to investigate these differences. Noninvasive imaging strategies, such as immunoPET, can provide a vital insight into disease staging, monitoring treatment response in patients, and dose planning in radioimmunotherapy. ImmunoPET imaging with radiolabeled antibody-based tracers may also assist physicians in optimizing treatment strategies and enhancing patient stratification. Currently, there are two common biomarkers for molecular imaging of lymphoma, CD20 and CD30, both of which have been considered for investigation in preclinical imaging studies. In this review, we examine the current status of both preclinical and clinical imaging of lymphoma using radiolabeled antibodies. Additionally, we briefly investigate the role of radiolabeled antibodies in lymphoma therapy. As radiolabeled antibodies play critical roles in both imaging and therapy of lymphoma, the development of novel antibodies and the discovery of new biomarkers may greatly affect lymphoma imaging and therapy in the future.

Radioactive antibodies: a historical review of selective targeting and treatment of cancer

Radioactive antibodies have served as imaging and therapeutic agents for several decades, but recent developments raise enthusiasm that a new generation of cancer therapeutics and diverse molecular imaging agents for various cancers are more likely than ever before. This article traces the development of tumor-targeting antibodies labeled with diagnostic or therapeutic radionuclides, and describes the problems encountered and the clinical advances made. We also emphasize recent attempts to improve both molecular imaging and radioimmunotherapy with multistep pretargeting methods that separate the delivery of the tumor-binding, bispecific antibody given in the first step from the radionuclide carrier, which, in the second step, will localize to the "anti-carrier" binding arm of the pretargeted bispecific antibody.

Patient dosimetry in nuclear medicine

In diagnostic nuclear medicine, the biokinetics of the radiopharmaceutical (actually of the radionuclide) is determined for a number of representative patients. At therapy, it is essential to determine the patient's individual biokinetics of the radiopharmaceutical in order to calculate the absorbed doses to critical normal organs/tissues and to the target volume(s) with high accuracy. For the diagnostic situations, there is still a lack of quantitative determinations of the organ/tissue contents of radiopharmaceuticals and their variation with time. Planar gamma camera imaging using the conjugate view technique combined with a limited number of SPECT/CT images is the main method for such studies. In a similar way, PET/CT is used for 3D image-based internal dosimetry for PET substances. The transition from stylised reference phantoms to voxel phantoms will lead to improved dose estimates for diagnostic procedures. Examples of dose coefficients and effective doses for diagnostic substances are given. For the therapeutic situation, a pre-therapeutic low activity administration is used for quantitative measurements of organ/tissue distribution data by a gamma camera or a SPECT- or PET-unit. Together with CT and/or MR images this will be the base for individual dose calculations using Monte Carlo technique. Treatments based on administered activity should only be used if biological variations between patients are small or if a pre-therapeutic activity administration is impossible.

Preparation and radiolabeling of a lyophilized (kit) formulation of DOTA-rituximab with ⁹⁰Y and ¹¹¹In for domestic radioimmunotherapy and radioscintigraphy of non-Hodgkin's lymphoma

Background

On the basis of results of our previous investigations on ⁹⁰Y-DTPA-rituximab and in order to fulfil national demands to radioimmunoconjugates for radioscintigraphy and radioimmunotherapy of Non-Hodgkin’s Lymphoma (NHL), preparation and radiolabeling of a lyophilized formulation (kit) of DOTA-rituximab with ¹¹¹In and ⁹⁰Y was investigated.

Methods

¹¹¹In and ⁹⁰Y with high radiochemical and radionuclide purity were prepared by ¹¹²Cd (p,2n)¹¹¹In nuclear reaction and a locally developed ⁹⁰Sr/⁹⁰Y generator, respectively. DOTA-rituximab immunoconjugates were prepared by the reaction of solutions of p-SCN-Bz-DOTA and rituximab in carbonate buffer (pH = 9.5) and the number of DOTA per molecule of conjugates were determined by transchelation reaction between DOTA and arsenaso yttrium(III) complex. DOTA-rituximab immunoconjugates were labeled with ¹¹¹In and ⁹⁰Y and radioimmunoconjugates were checked for radiochemical purity by chromatography methods and for immunoreactivity by cell-binding assay using Raji cell line. The stability of radiolabeled conjugate with the approximate number of 7 DOTA molecules per one rituximab molecule which was prepared in moderate yield and showed moderate immunoreactivity, compared to two other prepared radioimmunoconjugates, was determined at different time intervals and against EDTA and human serum by chromatography methods and reducing SDS-polyacrylamide gel electrophoresis, respectively. The biodistribution of the selected radioimmunoconjugate in rats was determined by measurement of the radioactivity of different organs after sacrificing the animals by ether asphyxiation.

Results

The radioimmunoconjugate with approximate DOTA/rituximab molar ratio of 7 showed stability after 24 h at room temperature, after 96 h at 4°C, as the lyophilized formulation after six months storage and against EDTA and human serum. This radioimmunoconjugate had a biodistribution profile similar to that of ⁹⁰Y-ibritumomab, which is approved by FDA for radioimmunotherapy of NHL, and showed low brain and lung uptakes and low yttrium deposition into bone.

Conclusion

Findings of this study suggest that further investigations may result in a lyophilized (kit) formulation of DOTA-rituximab which could be easily radiolabeled with ⁹⁰Y and ¹¹¹In in order to be used for radioimmunotherapy and radioscintigraphy of B-cell lymphoma in Iran.

The status of radioimmunotherapy in CD20+ non-Hodgkin's lymphoma

Rituximab, the CD20-directed antibody, has become a standard component of treatment regimens for patients with B cell non-Hodgkin's lymphoma (NHL). The use of rituximab has resulted in greatly improved response and survival rates with less toxicity relative to standard chemotherapeutic regimes. However, relapse and recurrence is common, particularly in indolent varieties which remain incurable, requiring alternate therapeutic options. The subsequent coupling of β-emitting isotopes such as (131)I and (90)Y to anti-CD20 monoclonal antibodies (mAbs), including rituximab, has been steadily growing over the last decade and demonstrates even greater therapeutic efficacy with more durable responses. (177)Lutetium-labelled rituximab offers a number of convenient advantages over (131)I and (90)Y anti-CD20 mAbs for treatment of NHL, and a number of alpha-emitting isotopes lie at the frontier of consolidation therapy for residual, micrometastatic disease.

Dose intensified molecular targeted radiotherapy for cancer-lymphoma as a paradigm

Although most patients with locoregional cancer are cured by surgery, radiotherapy, chemotherapy, and combinations thereof, those with distant metastases are not despite systemic chemotherapy. These patients respond to local radiotherapy but generally need systemic therapy. Non-Hodgkin's lymphoma (NHL) provides a paradigm for the role of molecular targeted radiotherapy (MTRT) because these patients have multifocal disease in most cases. Although patients with NHL achieve remissions after multiple cycles of chemotherapy, less than one half of those with aggressive NHL are cured and almost none of those with low grade NHL. Furthermore, NHL, like other cancers, becomes chemoresistant, yet remains responsive to radiotherapy. MTRT, radiation targeted by molecules, is a good strategy for the treatment of multifocal and radiosensitive cancers. Radioimmunotherapy (RIT) is an MTRT approach using MAbs, or parts thereof, to target the radionuclide that delivers radiation. Two anti-CD20 monoclonal antibodies (MAbs), one labeled with (111)In for imaging or (90)Y for therapy and a second labeled with (131)I for imaging and therapy, have proven effective and safe for MTRT for NHL patients. The importance of the radiation is demonstrated in the data from the randomized pivotal trial of (90)Y-ibritumomab; response rates were distinctly better in the (90)Y-ibritumomab arm than in the rituximab arm. Furthermore, the efficacy of (131)I-tositumomab was greater than that of the same MAb alone in another pivotal trial. Although hematologic toxicity is dose limiting for MTRT, febrile neutropenia is uncommon. MTRT is also not associated with mucositis, hair loss, or persistent nausea or vomiting, unlike chemotherapy. Randomized trials of MTRT in different strategies have not been conducted, but there is evidence of better outcomes, particularly for strategies that provide dose intensification, such as pretargeted MTRT, multiple dosing ("fractionation"), and MTRT with stem cell transplantation (SCT). Pretargeted RIT separates delivery of the targeting molecule from radionuclide delivery, provides dose escalation, and is more effective than direct one-step RIT, although more complicated to implement. Improved drugs and strategies for MTRT have documented potential for better patient outcomes. Smaller radionuclide carriers, such as those used for pretargeted MTRT, should be incorporated into the management of patients with NHL and other cancers soon after the patients have proven incurable. Expected improvements using better drugs, strategies, and combinations with other drugs seem likely to make MTRT integral in the management of many patients with cancer and likely to lead to cures of NHL.

CD20-directed small modular immunopharmaceutical, TRU-015, depletes normal and malignant B cells

PURPOSE

CD20-directed therapy with rituximab is effective in many patients with malignant lymphoma or follicular lymphoma. However, relapse frequently occurs within 1 year, and patients become increasingly refractory to retreatment. Our purpose was to produce a compact, single-chain CD20-targeting immunotherapeutic that could offer therapeutic advantages in the treatment of B-cell lymphoma.

EXPERIMENTAL DESIGN

Rituximab is a chimeric antibody containing two heavy chains and two light chains. Here, we describe the properties of TRU-015, a small modular immunopharmaceutical specific for CD20, encoded by a single-chain construct containing a single-chain Fv specific for CD20 linked to human IgG1 hinge, CH2, and CH3 domains but devoid of CH1 and CL domains.

RESULTS

TRU-015 mediates potent direct signaling and antibody-dependent cellular cytotoxicity but has reduced size and complement-mediated cytotoxicity activity compared with rituximab. TRU-015 is a compact dimer of 104 kDa that comigrates with albumin in size exclusion chromatography and retains a long half-life in vivo. TRU-015 induced growth arrest in multiple B lymphoma cell lines in vitro and showed effective antitumor activity against large, established subcutaneous Ramos or Daudi xenograft tumors in nude mice. TRU-015 also showed rapid, dose-dependent, and durable depletion of peripheral blood B cells following single-dose administration to nonhuman primates.

CONCLUSION

These results indicate that TRU-015 may improve CD20-directed therapy by effectively depleting embedded malignant B cells and nonmalignant pathogenic B cells and do so with reduced complement activation.

Imaging and pharmacokinetics of (64)Cu-DOTA-HB22.7 administered by intravenous, intraperitoneal, or subcutaneous injection to mice bearing non-Hodgkin's lymphoma xenografts

PURPOSE

The aim of the study is to compare the tumor-specific targeting, pharmacokinetics, and biodistribution of (64)Cu-DOTA-HB22.7 when administered to xenograft-bearing mice intravenously (IV), intraperitoneally (IP), and subcutaneously (SQ).

PROCEDURES

Mice bearing human non-Hodgkin's lymphoma (NHL) xenografts were injected IV, IP, or SQ with (64)Cu-DOTA-HB22.7. Xenograft targeting was evaluated by micro positron emission tomography (microPET) and confirmed by organ biodistribution studies. Blood measurements of (64)Cu were performed to determine the pharmacokinetics and clearance of (64)Cu-DOTA-HB22.7.

RESULTS

(64)Cu-DOTA-HB22.7 demonstrated equivalent tumor targeting within 24-48 h, regardless of the route of administration. Organ biodistribution confirmed tumor-specific targeting. Blood pharmacokinetics demonstrated that (64)Cu-DOTA-HB22.7 accessed the bloodstream after IP and SQ administration to a similar degree as IV administration, albeit at a slower rate.

CONCLUSIONS

These findings establish (64)Cu-DOTA-HB22.7 as a potential radioimmunotherapeutic and/or NHL-specific imaging agent. These findings provide evidence that IP and SQ administration can achieve results equivalent to IV administration and may lead to more efficient, reproducible treatment plans for antibody-based therapeutics.

A33 antigen displays persistent surface expression

The A33 antigen is a cell surface glycoprotein of the small intestine and colonic epithelium with homology to tight junction-associated proteins of the immunoglobulin superfamily, including CAR and JAM. Its restricted tissue localization and high level of expression have led to its use as a target in colon cancer immunotherapy. Although the antigen is also present in normal intestine, radiolabeled antibodies against A33 are selectively retained by tumors in the gut as well as in metastatic lesions for as long as 6 weeks. Accordingly, we have studied the trafficking and kinetic properties of the antigen to determine its promise in two-step, pretargeted therapies. The localization, mobility, and persistence of the antigen were investigated, and this work has demonstrated that the antigen is both highly immobile and extremely persistent-retaining its surface localization for a turnover halflife of greater than 2 days. In order to explain these unusual properties, we explored the possibility that A33 is a component of the tight junction. The simple property of surface persistence, described here, may contribute to the prolonged retention of the clinically administered antibodies, and their uncommon ability to penetrate solid tumors.

Hypersensitivity reactions to biological drugs

OBJECTIVES

To review the current evidence regarding hypersensitivity reactions related to the administration of biological drugs in the management of cancer, and to provide the nurse with appropriate interventions related to the management of hypersensitivity reactions.

DATA SOURCES

Review articles and research studies from the medical and nursing literature.

CONCLUSION

Current evidence is available regarding the types of reactions that are associated with the administration of biological drugs in the management of cancer. Medical and nursing studies that review the most effective management of hypersensitivity reactions related to the administration of biological drugs. A review of "best practice" is offered in this article regarding the management of hypersensitivity reactions related to the administration of biological drugs.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a key role in the early identification of hypersensitivity reactions. Management of hypersensitivity reactions must be rapid for optimal patient outcomes.

Selective High-Affinity Ligand Antibody Mimics for Cancer Diagnosis and Therapy: Initial Application to Lymphoma/Leukemia

PURPOSE

More than two decades of research and clinical trials have shown radioimmunotherapy to be a promising approach for treating various forms of cancer. Lym-1 antibody, which binds selectively to HLA-DR10 on malignant B-cell lymphocytes, has proved to be effective in delivering radionuclides to non-Hodgkin's lymphoma and leukemia. Using a new approach to create small synthetic molecules that mimic the targeting properties of the Lym-1 antibody, a prototype, selective high-affinity ligand (SHAL), has been developed to bind to a unique region located within the Lym-1 epitope on HLA-DR10.

EXPERIMENTAL DESIGN

Computer docking methods were used to predict two sets of small molecules that bind to neighboring cavities on the beta subunit of HLA-DR10 surrounding a critical amino acid in the epitope, and the ligands were confirmed to bind to the protein by nuclear magnetic resonance spectroscopy. Pairs of these molecules were then chemically linked together to produce a series of bidentate and bisbidentate SHALs.

RESULTS

These SHALs bind with nanomolar to picomolar K(d)'s only to cell lines expressing HLA-DR10. Analyses of biopsy sections obtained from patients also confirmed that SHAL bound to both small and large cell non-Hodgkin's lymphomas mimicking the selectivity of Lym-1.

CONCLUSIONS

These results show that synthetic molecules less than 1/50th the mass of an antibody can be designed to exhibit strong binding to subtle structural features on cell surface proteins similar to those recognized by antibodies. This approach offers great potential for developing small molecule therapeutics that target other types of cancer and disease.

Copper-67 radioimmunotherapy and growth inhibition by anti-L1-cell adhesion molecule monoclonal antibodies in a therapy model of ovarian cancer metastasis

PURPOSE

We examined the tumor-targeting and therapeutic effects of (67)Cu-labeled single amino acid mutant forms of anti-L1 monoclonal antibody chCE7 in nude mice with orthotopically implanted SKOV3ip human ovarian carcinoma cells.

EXPERIMENTAL DESIGN

For radioimmunotherapy, chCE7 antibodies with a mutation of histidine 310 to alanine (chCE7H310A) and a mutation of asparagine 297 to glutamine (chCE7agl) were generated to achieve more rapid blood clearance. Biodistributions of (67)Cu-4-(1,4,8,11-tetraazacyclotetradec-1-yl)-methyl benzoic acid tetrachloride (CPTA)-labeled mutant antibodies were measured in nude mice bearing SKOV3ip human ovarian cancer metastases. The effects of single i.v. injections of (67)Cu-chCE7agl alone on tumor reduction and survival were investigated. In addition, a combination of low-dose (67)Cu-radioimmunotherapy with unlabeled anti-L1 antibody L1-11A on survival was investigated.

RESULTS

(67)Cu-CPTA-chCE7agl showed high (up to 49% ID/g) and persistent (up to 168 h) uptake in SKOV3ip metastases, with low levels in normal tissues. (67)Cu-CPTA-chCE7H310A revealed a shorter half-life in the blood and a lower tumor uptake and retention. A single low dose of 4 MBq of (67)Cu-chCE7agl reduced tumor growth but did not prolong survival significantly, whereas a single 10.5 MBq dose of (67)Cu-chCE7agl reduced tumor growth and prolonged survival significantly. The combination of unlabeled monoclonal antibody L1-11A with a subtherapeutic dose of (67)Cu-radioimmunotherapy also prolonged survival significantly.

CONCLUSION

The results show improved pharmacokinetics and biodistributions as well as the therapeutic effect of the (67)Cu-labeled single amino acid mutant chCE7agl. Therapeutic data indicate, for the first time, the feasibility of combining anti-L1-directed growth inhibition and (67)Cu-radioimmunotherapy, thereby increasing the efficiency of antibody treatment of metastatic ovarian carcinoma.

Radioimmunotherapy for non-Hodgkin's lymphoma

OBJECTIVES

To describe the rationale for radioimmunotherapy as a treatment of non-Hodgkin's lymphoma. To present the similarities and differences in the two radioimmunotherapies and the nursing implications in caring for patients receiving these agents.

DATA SOURCES

Published literature and review of published clinical trials.

CONCLUSION

Radiolabeled monoclonal antibodies bind to specific antigens and provide a means of targeting tumor cells with cytotoxic radioactivity. The infusion of radiolabeled monoclonal antibodies requires an understanding of antibody therapy, radiation therapy, and principles of time, distance, and shielding.

IMPLICATIONS FOR NURSING PRACTICE

As the use of radioimmunotherapy grows, nurses must be aware of the background for, logistics of, and follow-up required for patients receiving this form of radiation treatment.

Evaluation of 177Lu-DOTA-labeled aglycosylated monoclonal anti-L1-CAM antibody chCE7: influence of the number of chelators on the in vitro and in vivo properties

INTRODUCTION

In this study, we optimized the 1,4,7,10-tetraazacyclododecane-N-N'-N"-N"'-tetraacetic acid (DOTA) chelator-to-antibody (c/a) ratio for the aglycosylated variant of the anti-L1-CAM antibody chCE7 (chCE7agl), providing high specific activity and low liver uptake in 177Lu-labeled form.

METHODS

chCE7agl was substituted with increasing molar excess of DOTA-NCS. The number of chelators coupled to the antibody and the binding affinities to target tumor cells (IC50 values) of the resulting immunoconjugates were determined. The different immunoconjugates were labeled with 177Lu; specific activity was measured, and metabolic stability was analyzed in human plasma. The effect of different c/a ratios on blood clearance and liver uptake was tested in nude mice. Changes of the protein backbone structure were analyzed by circular dichroism spectroscopy.

RESULTS

chCE7agl was substituted with 7, 12 or 15 DOTA ligands. The IC50 concentrations displacing radioiodinated chCE7 antibody increased with the number of chelators (1.5-fold with 7 ligands, 2.5-fold with 12 ligands and a 5-fold increase with 15 ligands). The highest specific activity for 177Lu-DOTA-chCE7agl was obtained with a c/a ratio of 12 (106 MBq/mg). Radioimmunoconjugates were stable in human plasma for at least 24 h. Blood clearance and liver uptake were measured after 24 h (c/a ratios of 12 and 15) or 48 h (c/a ratio of 7). The liver-to-blood ratios were 0.35+/-0.14 (7 ligands), 0.77+/-0.19 (12 ligands) and 17.85+/-3.44 (15 ligands).

CONCLUSIONS

DOTA-chCE7agl conjugates with a c/a ratio of 12 combined high specific activity with good in vitro and in vivo properties. The rapid elimination rate from the blood and the high uptake in the liver of chCE7agl substituted with 15 DOTA ligands were found not to be due to conformational changes of the antibody backbone structure.

Recombinant antibodies: from the laboratory to the clinic

The development of recombinant antibodies has facilitated the exploitation of the Ab-Ag interaction specificity for targeted therapies. A fully human antibody, with custom integrated designs, can be obtained in one-third the time, compared to development of antibodies by hybridoma technology. Recombinant antibodies can be tailored for specific applications, "armed" with cytotoxic agents in a controllable fashion, and used for extracellular and intracellular targeting. Multitargeted and combination therapies are rapidly evolving for the treatment of cancer. Antibody therapeutics, costly to develop and produce, have proven beneficial in the clinic.

Update: Renaissance of Targeting Molecules for Melanoma

Malignant melanoma affects approximately 40,000 new patients each year in the United States and an estimated 100,000 people worldwide. There is no satisfactory treatment for patients with metastatic melanoma that have an estimated 5-year survival of 6%. The potential of radioimmunotherapy (RIT) for the treatment of metastatic melanoma was recognized very early by RIT pioneers when murine melanoma was successfully treated by DeNardo, and later when Larson reported a shrinkage of tumor in a patient with metastatic melanoma treated with 131I-labeled Fab' fragments of a mAb against high-molecular-weight melanoma-associated antigen. Despite successes in the 1980s, RIT of melanoma did not develop into a clinical modality. The reasons for this are complex. In recent years, RIT has made an impression, as evidenced by the recent approval of Zevalin and Bexxar (anti-CD20 mAbs labeled with 90Y and 131I, respectively). Now there is a "window of opportunity" for RIT to become an effective therapy for metastatic melanoma. Surface antigen GD3 has been evaluated in patients as a potential target for melanoma RIT; pretargeting the administration of antibodies and intralesional administration of an antibody labeled with potent alpha-emitter 213-Bismuth have shown promise in clinical studies. Melanin, the pigment that gives melanoma its name, has emerged as a novel antigen for delivery of radioactivity to the tumors by antimelanin antibody. Simultaneously, radiolabeled metal-cyclized alpha-MSH peptide analogs and melanin-binding peptides are being developed as targeting molecules for melanoma. Overall, we are hopeful that targeted radionuclide therapy of metastatic melanoma will become a reality within the next few years.

Single-Photon Emission Computed Tomography/Computed Tomography in Lung Cancer and Malignant Lymphoma

In nuclear oncology, despite the fast-growing diffusion of (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET), single-photon emission computed tomography (SPECT) studies can still play an useful clinical role in several applications. The main limitation of SPECT imaging with tumor-seeking agents is the lack of the structural delineation of the pathologic processes they detect; this drawback sometimes renders SPECT interpretation difficult and can diminish its diagnostic accuracy. Fusion with morphological studies can overcome this limitation by giving an anatomical map to scintigraphic data. In the past, software-based fusion of independently performed SPECT and CT images proved to be time-consuming and impractical for routine use. The recent development of dual-modality integrated imaging systems that provide functional (SPECT) and anatomical (CT) images in the same scanning session, with the acquired images coregistered by means of the hardware, has opened a new era in this field. The first reports indicate that SPECT/CT is very useful in cancer imaging because it is able to provide further information of clinical value in several cases. In SPECT, studies of lung cancer and malignant lymphomas using different radiopharmaceutical, hybrid images are of value in providing the correct localization of tumor sites, with a precise detection of the involved organs, and the definition of their functional status, and in allowing the exclusion of disease in sites of physiologic tracer uptake. Therefore, in lung cancer and lymphomas, hybrid SPECT/CT can play a role in the diagnosis of the primary tumor, in the staging of the disease, in the follow-up, in the monitoring of therapy, in the detection of recurrence, and in dosimetric estimations for target radionuclide therapy.

Multicenter Phase II Clinical Study of Iodine-131–Rituximab Radioimmunotherapy in Relapsed or Refractory Indolent Non-Hodgkin’s Lymphoma

Purpose

To evaluate efficacy and safety of iodine-131 (131I) –rituximab chimeric anti-CD20 antibody radioimmunotherapy in patients with relapsed or refractory indolent non-Hodgkin's lymphoma (NHL).

Patients and Methods

After a standard loading dose of rituximab 375 mg/m2, individualized dosimetry was performed by whole-body gamma imaging of a tracer activity of 131I-rituximab followed by administration of a therapeutic activity of 131I-rituximab to deliver an estimated whole-body radiation absorbed dose of 0.75 Gy.

Results

Ninety-one patients were entered onto the trial: 78 patients (86%) had follicular lymphoma, six patients (7%) had mucosa-associated lymphoid tissue/marginal zone lymphoma, and seven patients (8%) had small lymphocytic lymphoma. The objective overall response rate (ORR) was 76%, with 53% attaining a complete response (CR) or CR unconfirmed (CRu). Median duration of response for patients achieving CR/CRu was 20 v 7 months for those with a partial response (P = .0121). Median progression-free survival for the entire cohort was 13 months, with 14% remaining relapse free beyond 4 years. Median follow-up was 23 months, with a 4-year actuarial survival rate of 59% ± 10%. Toxicity was principally hematologic; grade 4 thrombocytopenia occurred in 4% and neutropenia occurred in 16% of patients, with nadirs at 6 to 7 weeks after treatment.

Conclusion

131I-rituximab radioimmunotherapy of relapsed or refractory indolent NHL achieves high ORR and CR rates with minimal toxicity.

Phase I Single-Dose Study of Intracavitary-Administered Iodine-131-TM-601 in Adults With Recurrent High-Grade Glioma

Purpose

TM-601 binds to malignant brain tumor cells with high affinity and does not seem to bind to normal brain tissue. Preclinical studies suggest that iodine-131 (131I) –TM-601 may be an effective targeted therapy for the treatment of glioma. We evaluated the safety, biodistribution, and dosimetry of intracavitary-administered 131I-TM-601 in patients with recurrent glioma.

Patients and Methods

Eighteen adult patients (17 with glioblastoma multiforme and one with anaplastic astrocytoma) with histologically documented recurrent glioma and a Karnofsky performance status of ≥ 60% who were eligible for cytoreductive craniotomy were enrolled. An intracavitary catheter with subcutaneous reservoir was placed in the tumor cavity during surgery. Two weeks after surgery, patients received a single dose of 131I-TM-601 from one of three dosing panels (0.25, 0.50, or 1.0 mg of TM-601), each labeled with 10 mCi of 131I.

Results

Intracavitary administration was well tolerated, with no dose-limiting toxicities observed. 131I-TM-601 bound to the tumor periphery and demonstrated long-term retention at the tumor with minimal uptake in any other organ system. Nonbound peptide was eliminated from the body within 24 to 48 hours. Only minor adverse events were reported during the 22 days after administration. At day 180, four patients had radiographic stable disease, and one had a partial response. Two of these patients further improved and were without evidence of disease for more than 30 months.

Conclusion

A single dose of 10 mCi 131I-TM-601 was well tolerated for 0.25 to 1.0 mg TM-601 and may have an antitumoral effect. Dosimetry and biodistribution from this first trial suggest that phase II studies of 131I-TM-601 are indicated.