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Di Franco M, Zanoni L, Fortunati E, Fanti S, Ambrosini V. Radionuclide Theranostics in Neuroendocrine Neoplasms: An Update. Curr Oncol Rep 2024; 26:538-550. [PMID: 38581469 PMCID: PMC11063107 DOI: 10.1007/s11912-024-01526-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE OF REVIEW This paper aims to address the latest findings in neuroendocrine tumor (NET) theranostics, focusing on new evidence and future directions of combined diagnosis with positron emission tomography (PET) and treatment with peptide receptor radionuclide therapy (PRRT). RECENT FINDINGS Following NETTER-1 trial, PRRT with [177Lu]Lu-DOTATATE was approved by FDA and EMA and is routinely employed in advanced G1 and G2 SST (somatostatin receptor)-expressing NET. Different approaches have been proposed so far to improve the PRRT therapeutic index, encompassing re-treatment protocols, combinations with other therapies and novel indications. Molecular imaging holds a potential added value in characterizing disease biology and heterogeneity using different radiopharmaceuticals (e.g., SST and FDG) and may provide predictive and prognostic parameters. Response assessment criteria are still an unmet need and new theranostic pairs showed preliminary encouraging results. PRRT for NET has become a paradigm of modern theranostics. PRRT holds a favorable toxicity profile, and it is associated with a prolonged time to progression, reduction of symptoms, and improved patients' quality of life. In light of further optimization, different new strategies have been investigated, along with the development of new radiopharmaceuticals.
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Affiliation(s)
- Martina Di Franco
- Nuclear Medicine, Alma Mater Studiorum, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
| | - Lucia Zanoni
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Emilia Fortunati
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Stefano Fanti
- Nuclear Medicine, Alma Mater Studiorum, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Valentina Ambrosini
- Nuclear Medicine, Alma Mater Studiorum, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Nuclear Medicine, IRCCS, Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
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Ambrosini V, Fortunati E, Fanti S, Ursprung S, Asmundo L, O'Shea A, Kako B, Lee S, Furtado FS, Blake M, Goiffon RJ, Najmi Z, Hesami M, Murakami T, Domachevsky L, Catalano OA. State-of-the-Art Hybrid Imaging of Neuroendocrine Neoplasms. J Comput Assist Tomogr 2024:00004728-990000000-00299. [PMID: 38518197 DOI: 10.1097/rct.0000000000001594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
ABSTRACT Neuroendocrine neoplasms (NENs) may be challenging to diagnose due to their small size and diverse anatomical locations. Hybrid imaging techniques, specifically positron emission tomography/computed tomography (PET/CT) and positron emission tomography/magnetic resonance imaging (PET/MRI), represent the current state-of-the-art for evaluating NENs. The preferred radiopharmaceuticals for NEN PET imaging are gallium-68 (68Ga) DOTA-peptides, which target somatostatin receptors (SSTR) overexpressed on NEN cells. Clinical applications of [68Ga]Ga-DOTA-peptides PET/CT include diagnosis, staging, prognosis assessment, treatment selection, and response evaluation. Fluorodeoxyglucose-18 (18F-FDG) PET/CT aids in detecting low-SSTR-expressing lesions and helps in patient stratification and treatment planning, particularly in grade 3 neuroendocrine tumors (NETs). New radiopharmaceuticals such as fluorine-labeled SSTR agonists and SSTR antagonists are emerging as alternatives to 68Ga-labeled peptides, offering improved detection rates and favorable biodistribution. The maturing of PET/MRI brings advantages to NEN imaging, including simultaneous acquisition of PET and MRI images, superior soft tissue contrast resolution, and motion correction capabilities. The PET/MRI with [68Ga]Ga-DOTA-peptides has demonstrated higher lesion detection rates and more accurate lesion classification compared to PET/CT. Overall, hybrid imaging offers valuable insights in the diagnosis, staging, and treatment planning of NENs. Further research is needed to refine response assessment criteria and standardize reporting guidelines.
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Affiliation(s)
| | - Emilia Fortunati
- From the Nuclear Medicine, Alma Mater Studiorum, University of Bologna
| | | | | | | | - Aileen O'Shea
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Bashar Kako
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Susanna Lee
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Felipe S Furtado
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael Blake
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Reece J Goiffon
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Zahra Najmi
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mina Hesami
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Takaaki Murakami
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Hospital, Kyoto, Japan
| | - Liran Domachevsky
- Department of Nuclear Medicine, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Onofrio A Catalano
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Marcus C, Muzahir S, Subramaniam RM. Quarter Century PET/Computed Tomography Transformation of Oncology: Neuroendocrine Tumors. PET Clin 2024; 19:187-196. [PMID: 38160070 DOI: 10.1016/j.cpet.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Significant improvement in molecular imaging and theranostics in the management of neuroendocrine tumors (NETs) has been made in the last few decades. Somatostatin receptor-targeted PET imaging outperforms conventional, planar, and single-photon emission computed tomography imaging and is indicated in the evaluation of these patients when available, resulting in a significant impact on staging, treatment response assessment, and restaging of these patients. Radionuclide therapy can have an impact on patient outcome in metastatic disease when not many treatment options are available.
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Affiliation(s)
- Charles Marcus
- Division of Nuclear Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road Northeast, E163, Atlanta, GA 30322, USA.
| | - Saima Muzahir
- Division of Nuclear Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road Northeast, E163, Atlanta, GA 30322, USA
| | - Rathan M Subramaniam
- Faculty of Medicine, Nursing, Midwifery and Health Sciences, The University of Notre Dame Australia, 160 Oxford Street, Darlinghurst, New South Wales 2010, Australia; Department of Radiology, Duke University, Durham, NC, USA; Department of Medicine, Otago Medical School, The University of Otago, New Zealand
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Lee H, Kipnis ST, Niman R, O’Brien SR, Eads JR, Katona BW, Pryma DA. Prediction of 177Lu-DOTATATE Therapy Outcomes in Neuroendocrine Tumor Patients Using Semi-Automatic Tumor Delineation on 68Ga-DOTATATE PET/CT. Cancers (Basel) 2023; 16:200. [PMID: 38201627 PMCID: PMC10778298 DOI: 10.3390/cancers16010200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 12/28/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Treatment of metastatic neuroendocrine tumors (NET) with 177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT) results in favorable response only in a subset of patients. We investigated the prognostic value of quantitative pre-treatment semi-automatic 68Ga-DOTATATE PET/CT analysis in NET patients treated with PRRT. METHODS The medical records of 94 NET patients who received at least one cycle of PRRT at a single institution were retrospectively reviewed. On each pre-treatment 68Ga-DOTATATE PET/CT, the total tumor volume (TTV), maximum tumor standardized uptake value for the patient (SUVmax), and average uptake in the lesion with the lowest radiotracer uptake (SUVmin) were determined with a semi-automatic tumor delineation method. Progression-free survival (PFS) and overall survival (OS) among the patients were compared based on optimal cutoff values for the imaging parameters. RESULTS On Kaplan-Meier analysis and univariate Cox regression, significantly shorter PFS was observed in patients with lower SUVmax, lower SUVmin, and higher TTV. On multivariate Cox regression, lower SUVmin and higher TTV remained predictive of shorter PFS. Only higher TTV was found to be predictive of shorter OS on Kaplan-Meier and Cox regression analyses. In a post hoc Kaplan-Meier analysis, patients with at least one high-risk feature (low SUVmin or high TTV) showed shorter PFS and OS, which may be the most convenient parameter to measure in clinical practice. CONCLUSIONS The tumor volume and lowest lesion uptake on 68Ga-DOTATATE PET/CT can predict disease progression following PRRT in NET patients, with the former also predictive of overall survival. NET patients at risk for poor outcomes following PRRT can be identified with semi-automated quantitative analysis of 68Ga-DOTATATE PET/CT.
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Affiliation(s)
- Hwan Lee
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Sarit T. Kipnis
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
- Department of Medicine, Georgetown University, Washington, DC 20007, USA
| | - Remy Niman
- MIM Software Inc., Cleveland, OH 44122, USA
| | - Sophia R. O’Brien
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Jennifer R. Eads
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Bryson W. Katona
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Daniel A. Pryma
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19104, USA
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Zhang C, Niu W, Xu Y, Lu Y, Huang L, Li S, Jiang X, Wu J. Multivisceral resection of nonfunctional pancreatic neuroendocrine neoplasm with nearby organ invasion: a case report. Front Endocrinol (Lausanne) 2023; 14:1236685. [PMID: 37822595 PMCID: PMC10562619 DOI: 10.3389/fendo.2023.1236685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/08/2023] [Indexed: 10/13/2023] Open
Abstract
Pancreatic neuroendocrine neoplasms (pNENs) are relatively rare epithelial malignancies originating from pancreatic neuroendocrine cells, pathologically classified into well-differentiated pancreatic neuroendocrine tumors (pNETs) and poorly-differentiated pancreatic neuroendocrine carcinoma (pNECs). Although they also fall under the category of pNENs, the almost entirely distinct biological characteristics and survival prognosis have caused debate among surgeons when it comes to the development of surgical intervention options, particularly for locally advanced G3 pNETs and pNECs. We present a case of 66-year-old male with nonfunctional G3 pNET, invasion of five nearby pancreatic organs and type II liver metastases. The patient achieved good outcomes after undergoing multivisceral resection and postoperative adjuvant chemotherapy. This finding helps surgeons better understand locally advanced pNENs, formulate treatment decisions systematically and confidently, and balance patient benefits and risks of surgery.
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Affiliation(s)
| | | | | | | | | | | | - Xinwei Jiang
- Department of Hepatobiliary Surgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Gusu School, Nanjing Medical University, Suzhou, China
| | - Jianwu Wu
- Department of Hepatobiliary Surgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Gusu School, Nanjing Medical University, Suzhou, China
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Stenvall A, Gustafsson J, Larsson E, Roth D, Sundlöv A, Jönsson L, Hindorf C, Ohlsson T, Sjögreen Gleisner K. Relationships between uptake of [ 68Ga]Ga-DOTA-TATE and absorbed dose in [ 177Lu]Lu-DOTA-TATE therapy. EJNMMI Res 2022; 12:75. [PMID: 36534192 PMCID: PMC9763525 DOI: 10.1186/s13550-022-00947-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Somatostatin receptor 68Ga PET imaging is standard for evaluation of a patient's suitability for 177Lu peptide receptor radionuclide therapy of neuroendocrine tumours (NETs). The 68Ga PET serves to ensure sufficient somatostatin receptor expression, commonly evaluated qualitatively. The aim of this study is to investigate the quantitative relationships between uptake in 68Ga PET and absorbed doses in 177Lu therapy. METHOD Eighteen patients underwent [68Ga]Ga-DOTA-TATE PET imaging within 20 weeks prior to their first cycle of [177Lu]Lu-DOTA-TATE. Absorbed doses for therapy were estimated for tumours, kidney, spleen, and normal liver parenchyma using a hybrid SPECT/CT-planar method. Gallium-68 activity concentrations were retrieved from PET images and also used to calculate SUVs and normalized SUVs, using blood and tissue for normalization. The 68Ga activity concentrations per injected activity, SUVs, and normalized SUVs were compared with 177Lu activity concentrations 1 d post-injection and 177Lu absorbed doses. For tumours, for which there was a variable number per patient, both inter- and intra-patient correlations were analysed. Furthermore, the prediction of 177Lu tumour absorbed doses based on a combination of tumour-specific 68Ga activity concentrations and group-based estimates of the effective half-lives for grade 1 and 2 NETs was explored. RESULTS For normal organs, only spleen showed a significant correlation between the 68Ga activity concentration and 177Lu absorbed dose (r = 0.6). For tumours, significant, but moderate, correlations were obtained, with respect to both inter-patient (r = 0.7) and intra-patient (r = 0.45) analyses. The correlations to absorbed doses did not improve when using 68Ga SUVs or normalized SUVs. The relationship between activity uptakes for 68Ga PET and 177Lu SPECT was stronger, with correlation coefficients r = 0.8 for both inter- and intra-patient analyses. The 177Lu absorbed dose to tumour could be predicted from the 68Ga activity concentrations with a 95% coverage interval of - 65% to 248%. CONCLUSIONS On a group level, a high uptake of [68Ga]Ga-DOTA-TATE is associated with high absorbed doses at 177Lu-DOTA-TATE therapy, but the relationship has a limited potential with respect to individual absorbed dose planning. Using SUV or SUV normalized to reference tissues do not improve correlations compared with using activity concentration per injected activity.
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Affiliation(s)
- Anna Stenvall
- grid.4514.40000 0001 0930 2361Medical Radiation Physics, Lund, Lund University, Lund, Sweden ,grid.411843.b0000 0004 0623 9987Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Johan Gustafsson
- grid.4514.40000 0001 0930 2361Medical Radiation Physics, Lund, Lund University, Lund, Sweden
| | - Erik Larsson
- grid.411843.b0000 0004 0623 9987Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Daniel Roth
- grid.4514.40000 0001 0930 2361Medical Radiation Physics, Lund, Lund University, Lund, Sweden
| | - Anna Sundlöv
- grid.4514.40000 0001 0930 2361Division of Oncology, Department of Clinical Sciences, Lund, Lund University, Lund, Sweden
| | - Lena Jönsson
- grid.4514.40000 0001 0930 2361Medical Radiation Physics, Lund, Lund University, Lund, Sweden ,grid.411843.b0000 0004 0623 9987Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Cecilia Hindorf
- grid.4514.40000 0001 0930 2361Medical Radiation Physics, Lund, Lund University, Lund, Sweden ,grid.24381.3c0000 0000 9241 5705Department of Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Ohlsson
- grid.411843.b0000 0004 0623 9987Radiation Physics, Skåne University Hospital, Lund, Sweden
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