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Abstract
Theranostics in men with metastatic castration-resistant prostate cancer (mCRPC) has been developed to target bone and the tumor itself. Currently, bone-directed targeted alpha therapy with radium-223 (223Ra) is the only theranostic agent proven to prolong survival in men with mCRPC who have symptomatic bone metastases and no known visceral metastases. The clinical utility and therapeutic success of 223Ra has encouraged the development of other tumor-targeting theranostic agents in mCRPC, primarily targeting prostate-specific membrane antigen (PSMA) with radioligand therapy (RLT). There is increasing evidence of promising response rates and a low toxicity profile with 177Lu-labeled PSMA RLT in patients with mCRPC. A phase III randomized study of 177Lu-labeled PSMA RLT has completed accrual and is awaiting results as to whether the drug improves radiographic progression-free survival and overall survival in men with mCRPC receiving standard of care treatments. Additional early clinical trials are investigating the role of tumor-directed targeted alpha therapy with radiotracers such as 225Ac. In this article, we review the current status of theranostics in prostate cancer, discussing the challenges and opportunities of combination therapies with more conventional agents such as androgen receptor inhibitors, cytotoxic chemotherapy, and immunotherapy.
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2
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Agarwal N, Nussenzveig R, Hahn AW, Hoffman JM, Morton K, Gupta S, Batten J, Thorley J, Hawks J, Santos VS, Nachaegari G, Wang X, Boucher K, Haaland B, Maughan BL. Prospective Evaluation of Bone Metabolic Markers as Surrogate Markers of Response to Radium-223 Therapy in Metastatic Castration-resistant Prostate Cancer. Clin Cancer Res 2020; 26:2104-2110. [PMID: 31937614 DOI: 10.1158/1078-0432.ccr-19-2591] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/25/2019] [Accepted: 01/10/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Radium-223 is approved for metastatic castration-resistant prostate cancer (mCRPC) based on improved overall survival, and delay in skeletal related events. However, it is not associated with PSA or radiographic response, which poses a challenge in real-time assessment of its efficacy. Surrogate markers of treatment outcomes may facilitate tailoring treatment duration with radium-223, by limiting the duration of therapy with radium-223 in these patients. Here, we sought to investigate the utility of bone metabolic markers (BMMs) as surrogate markers of response to radium-223 in mCRPC. PATIENTS AND METHODS A prospective phase II trial of radium-223 plus enzalutamide (RE) versus enzalutamide alone was designed to assess surrogacy of BMMs with respect to response to radium-223. Enzalutamide was used as a comparator in lieu of placebo due to the progressive disease. Co-primary endpoints were relative change in serum BMM N-telopeptide (NTP) levels from baseline to 6 months between the two arms and safety and feasibility of the combination. RESULTS Thirty-nine men were randomized to RE (n = 27) or enzalutamide (n = 12). Combination was safe and feasible. Primary endpoint was met. A statistically significant relative change to NTP ratios between arms (0.64, 95% confidence interval, 0.51-0.81; P = 0.00048) favored RE versus enzalutamide. Overall, BMMs decreased with the RE therapy compared with enzalutamide. Improved PSA response rate in RE versus enzalutamide (P = 0.024), correlated with decline in BMMs. CONCLUSIONS BMMs declined significantly with combination therapy, and were associated with improved outcomes. Upon external validation, BMMs may emerge as surrogate markers to monitor treatment with radium-223 in real-time.
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Affiliation(s)
- Neeraj Agarwal
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.
| | - Roberto Nussenzveig
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Andrew W Hahn
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - John M Hoffman
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah.,Center for Quantitative Cancer Imaging, Huntsman Cancer Center, Salt Lake City, Utah
| | - Kathryn Morton
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah.,Center for Quantitative Cancer Imaging, Huntsman Cancer Center, Salt Lake City, Utah
| | - Sumati Gupta
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Julia Batten
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Jared Thorley
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Josiah Hawks
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | | | - Gayatri Nachaegari
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Xuechen Wang
- Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Kenneth Boucher
- Cancer Biostatistics Center, University of Utah, Salt Lake City, Utah
| | - Benjamin Haaland
- Cancer Biostatistics Center, University of Utah, Salt Lake City, Utah
| | - Benjamin L Maughan
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.
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Morris MJ, Corey E, Guise TA, Gulley JL, Kevin Kelly W, Quinn DI, Scholz A, Sgouros G. Radium-223 mechanism of action: implications for use in treatment combinations. Nat Rev Urol 2019; 16:745-756. [PMID: 31712765 PMCID: PMC7515774 DOI: 10.1038/s41585-019-0251-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2019] [Indexed: 12/16/2022]
Abstract
The targeted alpha therapy radium-223 (223Ra) can prolong survival in men with castration-resistant prostate cancer (CRPC) who have symptomatic bone metastases and no known visceral metastases. Preclinical studies demonstrate that 223Ra preferentially incorporates into newly formed bone matrix within osteoblastic metastatic lesions. The emitted high-energy alpha particles induce DNA double-strand breaks that might be irreparable and lead to cell death in nearby exposed tumour cells, osteoblasts and osteoclasts. Consequently, tumour growth and abnormal bone formation are inhibited by these direct effects and by the disruption of positive-feedback loops between tumour cells and the bone microenvironment. 223Ra might also modulate immune responses within the bone. The clinical utility of 223Ra has encouraged the development of other anticancer targeted alpha therapies. A thorough understanding of the mechanism of action could inform the design of new combinatorial treatment strategies that might be more efficacious than monotherapy. On the basis of the current mechanistic knowledge and potential clinical benefits, combination therapies of 223Ra with microtubule-stabilizing cytotoxic drugs and agents targeting the androgen receptor axis, immune checkpoint receptors or DNA damage response proteins are being explored in patients with CRPC and metastatic bone disease.
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Affiliation(s)
- Michael J Morris
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine, New York, NY, USA.
| | - Eva Corey
- Department of Urology, University of Washington, School of Medicine, Seattle, WA, USA
| | - Theresa A Guise
- Indiana University, School of Medicine, Indianapolis, IN, USA
| | - James L Gulley
- Genitourinary Malignancies Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - William Kevin Kelly
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - David I Quinn
- Norris Comprehensive Cancer Center, Los Angeles, CA, USA
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Arne Scholz
- Bayer AG, Drug Discovery, Pharmaceuticals, Berlin, Germany
| | - George Sgouros
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Walz S, Maas M, Stenzl A, Todenhöfer T. Bone Health Issues in Patients with Prostate Cancer: An Evidence-Based Review. World J Mens Health 2019; 38:151-163. [PMID: 31081297 PMCID: PMC7076314 DOI: 10.5534/wjmh.190044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 03/23/2019] [Indexed: 01/13/2023] Open
Abstract
Bone health in prostate cancer patients represents a prerequisite for acceptable quality of life and optimal outcome of this disease. The major threat for bone health in prostate cancer displays cancer treatment induced bone loss as well as the development of bone metastases. In recent years, several new pharmaceuticals targeting bone metabolism such as denosumab or androgen pathway targeting drugs (abiraterone acetate and enzalutamide) have been approved for the treatment of progressive disease aiming to interrupt the vicious circle of bone metastasis and aberrant bone resorption. This development raised the awareness of the pivotal role of bone health in prostate cancer and introduced (symptomatic) skeletal related events as an important end point in recent clinical trials. Bone targeted drugs have become standard of care in patients with metastatic castration resistant prostate cancer, their role in metastatic hormone sensitive prostate cancer has been discussed controversely. In oligometastatic prostate cancer patients several promising approaches in metastasis directed therapy, including conventional surgery, stereotactic ablative radiation and image-guided single-fraction robotic stereotactic radiosurgery (CyberKnife®) were launched but are not in routine clinical use until now caused by sparse clinical evidence.
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Affiliation(s)
- Simon Walz
- Department of Urology, Eberhard Karls University, Tuebingen, Germany
| | - Moritz Maas
- Department of Urology, Eberhard Karls University, Tuebingen, Germany
| | - Arnulf Stenzl
- Department of Urology, Eberhard Karls University, Tuebingen, Germany
| | - Tilman Todenhöfer
- Department of Urology, Eberhard Karls University, Tuebingen, Germany.
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Bouman-Wammes EW, de Klerk JMH, Bloemendal HJ, Van Dodewaard-de Jong JM, Lange R, Ter Heine R, Verheul HMW, Van den Eertwegh AJM. Bone-Targeting Radiopharmaceuticals as Monotherapy or Combined With Chemotherapy in Patients With Castration-Resistant Prostate Cancer Metastatic to Bone. Clin Genitourin Cancer 2018; 17:e281-e292. [PMID: 30555024 DOI: 10.1016/j.clgc.2018.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 07/04/2018] [Accepted: 11/14/2018] [Indexed: 11/25/2022]
Abstract
In patients with metastatic castration-resistant prostate cancer, bone is the most common site for metastases. Because of their osteoblastic character, these lesions are very suitable for treatment with bone-seeking radiopharmaceuticals (RPs). Nowadays, radium-223-chloride is the only RP with a proven benefit in overall survival, whereas the β-emitting RPs are used for pain palliation. In the past, many trials that investigated RPs alone, or in combination with chemotherapy have been performed. Because of different designs, characteristics of included patients, and chemotherapeutical and RP regimens, interpretation of the promising data and positioning of RPs in the treatment of metastatic prostate cancer has become difficult. In this review, we provide an overview of the existing data per RP with a focus on the different RPs in combination with chemotherapy. Furthermore, we aim to clarify the benefits on pain response and quality of life. Finally, we focus on the optimal timing and use of biomarkers in the treatment of patients with castration-resistant prostate cancer with RPs.
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Affiliation(s)
- Esther W Bouman-Wammes
- Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands.
| | - John M H de Klerk
- Department of Nuclear Medicine, Meander Medical Center, Amersfoort, The Netherlands
| | - Haiko J Bloemendal
- Department of Medical Oncology, UMC Utrech, Utrech, The Netherlands; Department of Medical Oncology, Meander Medical Center, Amersfoort, The Netherlands
| | | | - Rogier Lange
- Department of Hospital Pharmacy, Meander Medical Center, Amersfoort, The Netherlands
| | - Rob Ter Heine
- Department of Hospital Pharmacy, Radboud UMC, Nijmegen, The Netherlands
| | - Henk M W Verheul
- Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands
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Poty S, Francesconi LC, McDevitt MR, Morris MJ, Lewis JS. α-Emitters for Radiotherapy: From Basic Radiochemistry to Clinical Studies-Part 2. J Nucl Med 2018; 59:1020-1027. [PMID: 29496984 DOI: 10.2967/jnumed.117.204651] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 02/03/2018] [Indexed: 12/30/2022] Open
Abstract
The use of radioactive sources to deliver cytotoxic ionizing radiation to disease sites dates back to the early 20th century, with the discovery of radium and its physiologic effects. α-emitters are of particular interest in the field of clinical oncology for radiotherapy applications. The first part of this review explored the basic radiochemistry, high cell-killing potency, and availability of α-emitting radionuclides, together with hurdles such as radiolabeling methods and daughter redistribution. The second part of this review will give an overview of the most promising and current uses of α-emitters in preclinical and clinical studies.
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Affiliation(s)
- Sophie Poty
- Department of Radiology and Program in Molecular Pharmacology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lynn C Francesconi
- Department of Chemistry, Hunter College, New York, New York.,Graduate Center of City University of New York, New York, New York
| | - Michael R McDevitt
- Department of Radiology and Program in Molecular Pharmacology, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Radiology, Weill Cornell Medical College, New York, New York
| | - Michael J Morris
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Jason S Lewis
- Department of Radiology and Program in Molecular Pharmacology, Memorial Sloan Kettering Cancer Center, New York, New York .,Departments of Radiology and Pharmacology, Weill Cornell Medical College, New York, New York
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Komura K, Sweeney CJ, Inamoto T, Ibuki N, Azuma H, Kantoff PW. Current treatment strategies for advanced prostate cancer. Int J Urol 2018; 25:220-231. [PMID: 29266472 PMCID: PMC6053280 DOI: 10.1111/iju.13512] [Citation(s) in RCA: 153] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 11/09/2017] [Indexed: 12/18/2022]
Abstract
During the past decade, treatment strategies for patients with advanced prostate cancer involving stage IV (T4N0M0, N1M0 or M1) hormone-sensitive prostate cancer and recurrent prostate cancer after treatment with curative intent, as well as castration-resistant prostate cancer, have extensively evolved with the introduction and approval of several new agents including sipuleucel-T, radium-223, abiraterone, enzalutamide and cabazitaxel, all of which have shown significant improvement on overall survival. The appropriate use of these agents and the proper sequencing of these agents are still not optimized. The results of several recently reported randomized controlled trials and retrospective studies could assist in developing a treatment strategy for advanced prostate cancer. In addition, prospective studies and molecular characterization of tumors to address these issues are ongoing.
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Affiliation(s)
- Kazumasa Komura
- Department of Urology, Osaka Medical College, Takatsuki, Osaka, Japan
| | | | - Teruo Inamoto
- Department of Urology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Naokazu Ibuki
- Department of Urology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Haruhito Azuma
- Department of Urology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Philip W. Kantoff
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Luna Pais H, Alho I, Vendrell I, Mansinho A, Costa L. Radionuclides in oncology clinical practice – review of the literature. Dalton Trans 2017; 46:14475-14487. [DOI: 10.1039/c7dt01929g] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Radionuclide therapy is a promising type of targeted therapy for cancer and its use is becoming more common in several types of malignant tumors.
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Affiliation(s)
- Helena Luna Pais
- Medical Oncology Department
- Hospital de Santa Maria
- 1649-035 Lisbon
- Portugal
| | - Irina Alho
- Instituto de Medicina Molecular
- Faculdade de Medicina
- Universidade de Lisboa
- 1649-035 Lisbon
- Portugal
| | - Inês Vendrell
- Medical Oncology Department
- Hospital de Santa Maria
- 1649-035 Lisbon
- Portugal
| | - André Mansinho
- Medical Oncology Department
- Hospital de Santa Maria
- 1649-035 Lisbon
- Portugal
| | - Luís Costa
- Medical Oncology Department
- Hospital de Santa Maria
- 1649-035 Lisbon
- Portugal
- Instituto de Medicina Molecular
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