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Al-Ibraheem A, Abdlkadir AS, Sweedat DA, Maus S, Al-Rasheed U, Salah S, Khriesh F, Juaidi D, Abu Dayek D, Istatieh F, Anwar F, Asrawi A, Abufara A, Al-Rwashdeh M, Abu-Hijlih R, Sharaf B, Ghanem R, Abdel-Razeq H, Mansour A. From Despair to Hope: First Arabic Experience of 177Lu-PSMA and 161Tb-PSMA Therapy for Metastatic Castration-Resistant Prostate Cancer. Cancers (Basel) 2024; 16:1974. [PMID: 38893095 PMCID: PMC11171070 DOI: 10.3390/cancers16111974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/18/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
The objective of this retrospective study is to assess the effectiveness and safety of two beta-emitting prostate-specific membrane antigen (PSMA) radioligands, [177Lu]Lu and [161Tb]Tb, in heavily treated patients with metastatic castration-resistant prostate cancer (mCRPC). A total of 148 cycles of beta-emitting PSMA radioligand therapy were given to 53 patients at a specialized cancer care center in Amman, Jordan. This treatment was offered following the exhaustion of all prior treatment modalities. Approximately half of the cases (n = 26) demonstrated an initial partial response to PSMA radioligand therapy. Moreover, roughly one-fourth of the patients (n = 13) exhibited a sustained satisfactory biochemical response, which qualified them to receive a total of six PSMA radioligand therapy cycles and maintain continued follow-up for additional treatment cycles. This was reflected by an adequate prostate-specific antigen (PSA) decline and a concomitant partial response evident on [68Ga]Ga-PSMA positron emission tomography/computed tomography imaging. A minority of patients (n= 18; 34%) experienced side effects. Generally, these were low-grade and self-limiting toxicities. This study endorses previous research evidence about PSMA radioligand therapy's safety and efficacy. It also provides the first clinical insight from patients of Arab ethnicity. This should facilitate and promote further evidence, both regionally and internationally.
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Affiliation(s)
- Akram Al-Ibraheem
- Department of Nuclear Medicine, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan; (A.S.A.); (D.A.S.); (U.A.-R.); (D.J.); (D.A.D.); (F.I.)
- School of Medicine, University of Jordan, Al-Jubeiha, Amman 11942, Jordan
| | - Ahmed Saad Abdlkadir
- Department of Nuclear Medicine, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan; (A.S.A.); (D.A.S.); (U.A.-R.); (D.J.); (D.A.D.); (F.I.)
| | - Deya’ Aldeen Sweedat
- Department of Nuclear Medicine, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan; (A.S.A.); (D.A.S.); (U.A.-R.); (D.J.); (D.A.D.); (F.I.)
| | - Stephan Maus
- Department of Nuclear Medicine, Saarland University Medical Center, D-66421 Homburg, Germany;
| | - Ula Al-Rasheed
- Department of Nuclear Medicine, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan; (A.S.A.); (D.A.S.); (U.A.-R.); (D.J.); (D.A.D.); (F.I.)
| | - Samer Salah
- Department of Medicine, King Hussein Cancer Center (KHCC), Amman 11941, Jordan; (S.S.); (A.A.); (M.A.-R.); (B.S.); (H.A.-R.)
| | - Fadi Khriesh
- Department of Nuclear Medicine, Klinikum Fulda, Pacelliallee 4, 36039 Fulda, Germany;
| | - Diyaa Juaidi
- Department of Nuclear Medicine, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan; (A.S.A.); (D.A.S.); (U.A.-R.); (D.J.); (D.A.D.); (F.I.)
| | - Dina Abu Dayek
- Department of Nuclear Medicine, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan; (A.S.A.); (D.A.S.); (U.A.-R.); (D.J.); (D.A.D.); (F.I.)
| | - Feras Istatieh
- Department of Nuclear Medicine, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan; (A.S.A.); (D.A.S.); (U.A.-R.); (D.J.); (D.A.D.); (F.I.)
| | - Farah Anwar
- Department of Nuclear Medicine, Warith International Cancer Institute, Karbala 56001, Iraq;
| | - Aisha Asrawi
- Department of Nursing, King Hussein Cancer Center (KHCC), Amman 11941, Jordan;
| | - Alaa Abufara
- Department of Medicine, King Hussein Cancer Center (KHCC), Amman 11941, Jordan; (S.S.); (A.A.); (M.A.-R.); (B.S.); (H.A.-R.)
| | - Mohammad Al-Rwashdeh
- Department of Medicine, King Hussein Cancer Center (KHCC), Amman 11941, Jordan; (S.S.); (A.A.); (M.A.-R.); (B.S.); (H.A.-R.)
| | - Ramiz Abu-Hijlih
- Department of Radiation Oncology, King Hussein Cancer Center (KHCC), Amman 11941, Jordan;
| | - Baha’ Sharaf
- Department of Medicine, King Hussein Cancer Center (KHCC), Amman 11941, Jordan; (S.S.); (A.A.); (M.A.-R.); (B.S.); (H.A.-R.)
| | - Rami Ghanem
- Department of Surgery, King Hussein Cancer Center (KHCC), Amman 11941, Jordan;
| | - Hikmat Abdel-Razeq
- Department of Medicine, King Hussein Cancer Center (KHCC), Amman 11941, Jordan; (S.S.); (A.A.); (M.A.-R.); (B.S.); (H.A.-R.)
| | - Asem Mansour
- Department of Diagnostic Radiology, King Hussein Cancer Center (KHCC), Amman 11941, Jordan;
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Burgard C, Engler J, Blickle A, Bartholomä M, Maus S, Schaefer-Schuler A, Khreish F, Ezziddin S, Rosar F. Change of glucometabolic activity per PSMA expression predicts survival in mCRPC patients non-responding to PSMA radioligand therapy: introducing a novel dual imaging biomarker. Front Med (Lausanne) 2024; 10:1339160. [PMID: 38298510 PMCID: PMC10827880 DOI: 10.3389/fmed.2023.1339160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 12/30/2023] [Indexed: 02/02/2024] Open
Abstract
Purpose The value of [18F]fluorodeoxyglucose ([18F]FDG) PET/CT in monitoring prostate-specific membrane antigen (PSMA) targeted radioligand therapy (RLT) is still unclear. The aim of this study was to identify appropriate prognostic dynamic parameters derived from baseline and follow-up [18F]FDG and dual [18F]FDG/[68Ga]Ga-PSMA-11 PET/CT for monitoring early non-responding mCRPC patients undergoing PSMA-RLT. Methods Twenty-three mCRPC patients of a prospective registry (NCT04833517), who were treated with [177Lu]Lu-PSMA-617 RLT and classified as early non-responders were included in this study. All patients received dual PET/CT imaging with [18F]FDG and [68Ga]Ga-PSMA-11 at baseline and after median two cycles of RLT. We tested potential biomarkers representing the "change of glucometabolic activity (cGA)" and "change of glucometabolic activity in relation to PSMA expression (cGAP)" composed of established parameters on [18F]FDG PET/CT as SUVmax, cumulative SUV of five lesions (SUV5), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) and its corresponding parameters on [68Ga]Ga-PSMA-11 PET/CT, respectively, for association with overall survival (OS). Results Kaplan-Meier analyses showed no significant association with OS for each tested cGA (cGASUVmaxp = 0.904, cGASUV5, p = 0.747 cGAMTVp = 0.682 and cGATLGp = 0.700), likewise the dual imaging biomarkers cGAPSUVmax (p = 0.136), cGAPSUV5 (p = 0.097), and cGAPTV (p = 0.113) failed significance. In contrast, cGAPTL, which is based on TLG and total lesion PSMA (TLP) showed a significant association with OS (p = 0.004). Low cGAPTL (cut-off 0.7) was associated with significant longer survival (17.6 vs. 12.9 months). Conclusion The novel biomarker cGAPTL, which represents the temporal change of whole-body TLG normalized by TLP, predicts overall survival in the challenging cohort of patients non-responding to PSMA-RLT.
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Affiliation(s)
- Caroline Burgard
- Department of Nuclear Medicine, Saarland University—Medical Center, Homburg, Germany
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Fernández R, Soza-Ried C, Iagaru A, Stephens A, Müller A, Schieferstein H, Sandoval C, Amaral H, Kramer V. Imaging GRPr Expression in Metastatic Castration-Resistant Prostate Cancer with [ 68Ga]Ga-RM2-A Head-to-Head Pilot Comparison with [ 68Ga]Ga-PSMA-11. Cancers (Basel) 2023; 16:173. [PMID: 38201600 PMCID: PMC10778208 DOI: 10.3390/cancers16010173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/18/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND The gastrin-releasing peptide receptor (GRPr) is highly overexpressed in several solid tumors, including treatment-naïve and recurrent prostate cancer. [68Ga]Ga-RM2 is a well-established radiotracer for PET imaging of GRPr, and [177Lu]Lu-RM2 has been proposed as a therapeutic alternative for patients with heterogeneous and/or low expression of PSMA. In this study, we aimed to evaluate the expression of GRPr and PSMA in a group of patients diagnosed with castration-resistant prostate cancer (mCRPC) by means of PET imaging. METHODS Seventeen mCRPC patients referred for radio-ligand therapy (RLT) were enrolled and underwent [68Ga]Ga-PSMA-11 and [68Ga]Ga-RM2 PET/CT imaging, 8.8 ± 8.6 days apart, to compare the biodistribution of each tracer. Uptake in healthy organs and tumor lesions was assessed by SUV values, and tumor-to-background ratios were analyzed. RESULTS [68Ga]Ga-PSMA-11 showed significantly higher uptake in tumor lesions in bone, lymph nodes, prostate, and soft tissues and detected 23% more lesions compared to [68Ga]Ga-RM2. In 4/17 patients (23.5%), the biodistribution of both tracers was comparable. CONCLUSIONS Our results show that in our cohort of mCRPC patients, PSMA expression was higher compared to GRPr. Nevertheless, RLT with [177Lu]Lu-RM2 may be an alternative treatment option for selected patients or patients in earlier disease stages, such as biochemical recurrence.
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Affiliation(s)
- René Fernández
- Nuclear Medicine and PET/CT Center PositronMed, Providencia, Santiago 7501068, Chile; (C.S.-R.); (H.A.); (V.K.)
| | - Cristian Soza-Ried
- Nuclear Medicine and PET/CT Center PositronMed, Providencia, Santiago 7501068, Chile; (C.S.-R.); (H.A.); (V.K.)
- Positronpharma SA, Providencia, Santiago 7501068, Chile
| | - Andrei Iagaru
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Stanford University, Stanford, CA 94305, USA;
| | - Andrew Stephens
- Life Molecular Imaging GmbH, 13353 Berlin, Germany; (A.S.); (A.M.)
| | - Andre Müller
- Life Molecular Imaging GmbH, 13353 Berlin, Germany; (A.S.); (A.M.)
| | - Hanno Schieferstein
- Formerly Piramal Imaging GmbH, 13353 Berlin, Germany;
- Merck Healthcare KGaA, 64293 Darmstadt, Germany
| | - Camilo Sandoval
- Fundación Arturo López Pérez, Providencia, Santiago 750069, Chile;
| | - Horacio Amaral
- Nuclear Medicine and PET/CT Center PositronMed, Providencia, Santiago 7501068, Chile; (C.S.-R.); (H.A.); (V.K.)
- Positronpharma SA, Providencia, Santiago 7501068, Chile
| | - Vasko Kramer
- Nuclear Medicine and PET/CT Center PositronMed, Providencia, Santiago 7501068, Chile; (C.S.-R.); (H.A.); (V.K.)
- Positronpharma SA, Providencia, Santiago 7501068, Chile
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Luna-Gutiérrez M, Hernández-Ramírez R, Soto-Abundiz A, García-Pérez O, Ancira-Cortez A, López-Buenrostro S, Gibbens-Bandala B, Soldevilla-Gallardo I, Lara-Almazán N, Rojas-Pérez M, Ocampo-García B, Azorín-Vega E, Santos-Cuevas C, Ferro-Flores G. Improving Overall Survival and Quality of Life in Patients with Prostate Cancer and Neuroendocrine Tumors Using 177Lu-iPSMA and 177Lu-DOTATOC: Experience after 905 Treatment Doses. Pharmaceutics 2023; 15:1988. [PMID: 37514174 PMCID: PMC10386094 DOI: 10.3390/pharmaceutics15071988] [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: 06/06/2023] [Revised: 07/03/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
177Lu-iPSMA is a novel radioligand developed at ININ-Mexico with a high affinity for the PSMA protein heavily expressed in cancer cells of approximately 95% of patients with metastatic castration-resistant prostate cancer (mCRPC). 177Lu-DOTATOC is a patent-free radioligand, molecularly recognized by somatostatin receptors (SSTR-2) overexpressed in cancer cells of about 80% of patients with metastatic gastroenteropancreatic neuroendocrine tumors (GEP-NET). This translational research aimed to determine the efficacy and safety of 177Lu-iPSMA and 177Lu-DOTATOC developed as GMP pharmaceutical formulations for treating progressive and advanced mCRPC and NET. One hundred and forty-five patients with mCRPC and one hundred and eighty-seven subjects with progressive NET (83% GEP-NET and 17% other NET), treated with 177Lu-iPSMA and 177Lu-DOTATOC, respectively, were evaluated. Patients received a mean dose of 7.4 GBq per administration of 177Lu-iPSMA (range 1-5 administrations; 394 treatment doses) or 177Lu-DOTATOC (range 2-8 administrations; 511 treatment doses) at intervals of 1.5-2.5 months. Efficacy was assessed by SPECT/CT or PET/CT. Results were stratified by primary tumor origin and number of doses administered. Patients with mCRPC showed overall survival (OS) of 21.7 months with decreased radiotracer tumor uptake (SUV) and PSA level in 80% and 73% of patients, respectively. In addition, a significant reduction in pain (numerical scale from 10-7 to 3-1) was observed in 88% of patients with bone metastases between one and two weeks after the second injection. In the GEP-NET population, the median progression-free survival was 34.7 months, with an OS of >44.2 months. The treatments were well tolerated. Only ten patients experienced grade ≥ 3 myelosuppression (3% of all patients). The observed safety profiles and favorable therapeutic responses demonstrated the potential of 177Lu-iPSMA and 177Lu-DOTATOC to improve overall survival and quality of life in patients with progressive and advanced mCRPC and NET.
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Affiliation(s)
- Myrna Luna-Gutiérrez
- Department of Radioactive Materials, Instituto Nacional de Investigaciones Nucleares (ININ), Ocoyoacac 52750, Mexico
| | | | - Airam Soto-Abundiz
- Department of Radioactive Materials, Instituto Nacional de Investigaciones Nucleares (ININ), Ocoyoacac 52750, Mexico
| | - Osvaldo García-Pérez
- Department of Nuclear Medicine, Instituto Nacional de Cancerología, Mexico City 14000, Mexico
| | - Alejandra Ancira-Cortez
- Department of Radioactive Materials, Instituto Nacional de Investigaciones Nucleares (ININ), Ocoyoacac 52750, Mexico
| | | | - Brenda Gibbens-Bandala
- Department of Radioactive Materials, Instituto Nacional de Investigaciones Nucleares (ININ), Ocoyoacac 52750, Mexico
| | - Irma Soldevilla-Gallardo
- Department of Nuclear Medicine, Centro Médico ABC Campus Observatorio, Mexico City 01120, Mexico
| | - Nancy Lara-Almazán
- Department of Radioactive Materials, Instituto Nacional de Investigaciones Nucleares (ININ), Ocoyoacac 52750, Mexico
| | - Melissa Rojas-Pérez
- Department of Radioactive Materials, Instituto Nacional de Investigaciones Nucleares (ININ), Ocoyoacac 52750, Mexico
| | - Blanca Ocampo-García
- Department of Radioactive Materials, Instituto Nacional de Investigaciones Nucleares (ININ), Ocoyoacac 52750, Mexico
| | - Erika Azorín-Vega
- Department of Radioactive Materials, Instituto Nacional de Investigaciones Nucleares (ININ), Ocoyoacac 52750, Mexico
| | - Clara Santos-Cuevas
- Department of Radioactive Materials, Instituto Nacional de Investigaciones Nucleares (ININ), Ocoyoacac 52750, Mexico
| | - Guillermina Ferro-Flores
- Department of Radioactive Materials, Instituto Nacional de Investigaciones Nucleares (ININ), Ocoyoacac 52750, Mexico
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Singh B, Sahani G, Prasad V, Watts A, Kumar R. India's Growing Nuclear Medicine Infrastructure and Emergence of Radiotheranostics in Cancer Care: Associated Challenges and the Opportunities to Collaborate. Indian J Nucl Med 2023; 38:201-207. [PMID: 38046962 PMCID: PMC10693374 DOI: 10.4103/ijnm.ijnm_77_23] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 08/09/2023] [Indexed: 12/05/2023] Open
Affiliation(s)
- Baljinder Singh
- Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ghanshyam Sahani
- Division of Radiological Safety, Medical Applications Section, Atomic Energy Regulatory Board, Mumbai, Maharashtra, India
| | - Vikas Prasad
- Division of Nuclear Medicine, Mallinckrodt Institute of Radiology, WUSTL, St. Louis, MO, USA
| | - Ankit Watts
- Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kumar
- Department of Nuclear Medicine, AIIMS, All India Institute of Medical Sciences, New Delhi, India
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Kratochwil C, Fendler WP, Eiber M, Hofman MS, Emmett L, Calais J, Osborne JR, Iravani A, Koo P, Lindenberg L, Baum RP, Bozkurt MF, Delgado Bolton RC, Ezziddin S, Forrer F, Hicks RJ, Hope TA, Kabasakal L, Konijnenberg M, Kopka K, Lassmann M, Mottaghy FM, Oyen WJG, Rahbar K, Schoder H, Virgolini I, Bodei L, Fanti S, Haberkorn U, Hermann K. Joint EANM/SNMMI procedure guideline for the use of 177Lu-labeled PSMA-targeted radioligand-therapy ( 177Lu-PSMA-RLT). Eur J Nucl Med Mol Imaging 2023; 50:2830-2845. [PMID: 37246997 PMCID: PMC10317889 DOI: 10.1007/s00259-023-06255-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/25/2023] [Indexed: 05/30/2023]
Abstract
Prostate-specific membrane antigen (PSMA) is expressed by the majority of clinically significant prostate adenocarcinomas, and patients with target-positive disease can easily be identified by PSMA PET imaging. Promising results with PSMA-targeted radiopharmaceutical therapy have already been obtained in early-phase studies using various combinations of targeting molecules and radiolabels. Definitive evidence of the safety and efficacy of [177Lu]Lu-PSMA-617 in combination with standard-of-care has been demonstrated in patients with metastatic castration-resistant prostate cancer, whose disease had progressed after or during at least one taxane regimen and at least one novel androgen-axis drug. Preliminary data suggest that 177Lu-PSMA-radioligand therapy (RLT) also has high potential in additional clinical situations. Hence, the radiopharmaceuticals [177Lu]Lu-PSMA-617 and [177Lu]Lu-PSMA-I&T are currently being evaluated in ongoing phase 3 trials. The purpose of this guideline is to assist nuclear medicine personnel, to select patients with highest potential to benefit from 177Lu-PSMA-RLT, to perform the procedure in accordance with current best practice, and to prepare for possible side effects and their clinical management. We also provide expert advice, to identify those clinical situations which may justify the off-label use of [177Lu]Lu-PSMA-617 or other emerging ligands on an individual patient basis.
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Affiliation(s)
- Clemens Kratochwil
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany.
| | - Wolfgang P Fendler
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, 45147, Essen, Germany
| | - Matthias Eiber
- Department of Nuclear Medicine, Klinikum Rechts Der Isar, Technical University Munich (TUM), 81675, Munich, Germany
| | - Michael S Hofman
- Prostate Cancer Theranostics and Imaging Centre of Excellence, Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Oncology, Sir Peter MacCallum, University of Melbourne, Melbourne, VIC, Australia
| | - Louise Emmett
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital Sydney, Darlinghurst, Australia
| | - Jeremie Calais
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph R Osborne
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10021, USA
| | - Amir Iravani
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
| | - Phillip Koo
- Division of Diagnostic Imaging, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - Liza Lindenberg
- Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
- F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Richard P Baum
- Curanosticum Wiesbaden-Frankfurt, Center for Advanced Radiomolecular Precision Oncology, Wiesbaden, Germany
| | - Murat Fani Bozkurt
- Hacettepe University Faculty of Medicine, Department of Nuclear Medicine, Ankara, Turkey
| | - Roberto C Delgado Bolton
- Department of Diagnostic Imaging (Radiology) and Nuclear Medicine, University Hospital San Pedro and Centre for Biomedical Research of La Rioja (CIBIR), Logroño (La Rioja), Spain
| | - Samer Ezziddin
- Department of Nuclear Medicine, Saarland University Medical Center, Homburg, Germany
| | - Flavio Forrer
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Rodney J Hicks
- The University of Melbourne Department of Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging / Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Levent Kabasakal
- Department of Nuclear Medicine, Cerrahpasa Medical Faculty, Istanbul University- Cerrahpasa, Istanbul, Turkey
| | - Mark Konijnenberg
- Radiology & Nuclear Medicine Department, Erasmus MC, Rotterdam, The Netherlands
| | - Klaus Kopka
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
- Technical University Dresden, School of Science, Faculty of Chemistry and Food Chemistry; German Cancer Consortium (DKTK), Partner Site Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT) Dresden, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Michael Lassmann
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Felix M Mottaghy
- Department of Nuclear Medicine, RWTH Aachen University Medical Faculty, Aachen, Germany
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Wim J G Oyen
- Department of Biomedical Sciences, Humanitas University, and Humanitas Clinical and Research Centre, Department of Nuclear Medicine, Milan, Italy
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, the Netherlands
- Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Kambiz Rahbar
- Department of Nuclear Medicine, University Hospital Muenster, Muenster, Germany
| | - Heiko Schoder
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Irene Virgolini
- Department of Nuclear Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Lisa Bodei
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stefano Fanti
- Division of Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Uwe Haberkorn
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Ken Hermann
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, 45147, Essen, Germany
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Patell K, Kurian M, Garcia JA, Mendiratta P, Barata PC, Jia AY, Spratt DE, Brown JR. Lutetium-177 PSMA for the treatment of metastatic castrate resistant prostate cancer: a systematic review. Expert Rev Anticancer Ther 2023; 23:731-744. [PMID: 37194261 DOI: 10.1080/14737140.2023.2213892] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/10/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION Metastatic castrate resistant prostate cancer (mCPRC) remains an aggressive form of prostate cancer that no longer responds to traditional hormonal treatment alone. Despite the advent of novel anti-androgen medications, many patients continue to progress, and as a result, there is a growing need for additional treatment options. AREAS COVERED Lutetium-177 (177Lu) - PSMA-617 has become one of the new frontline treatment options for refractory metastatic castrate resistant prostate cancer after the failure of novel anti-androgen therapy and chemotherapy. Lu-177 has been used in real-world prospective trials and is now becoming utilized in newer phase III clinical trials. Here, we present a comprehensive overview of the current literature, covering retrospective studies, prospective studies, and clinical trials that established Lutetium-177-PSMA-617 (177Lu-PSMA-617) for the treatment of mCRPC. EXPERT OPINION 177Lu - PSMA-617 has been approved for treatment of mCRPC based on positive phase III studies. While this treatment is tolerable and effective, biomarkers are necessary to determine which patients will benefit. In the future, radioligand treatments will likely be utilized in earlier lines of therapy and potentially in combination with other prostate cancer treatments.
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Affiliation(s)
- Kanchi Patell
- Deparment of Internal Medicine, Division of Medical Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Matthew Kurian
- Deparment of Internal Medicine, Division of Medical Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Jorge A Garcia
- Deparment of Internal Medicine, Division of Medical Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Prateek Mendiratta
- Deparment of Internal Medicine, Division of Medical Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Pedro C Barata
- Deparment of Internal Medicine, Division of Medical Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Angela Y Jia
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Jason R Brown
- Deparment of Internal Medicine, Division of Medical Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Cleveland, OH, USA
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Satapathy S, Sahoo RK, Bal C. [ 177Lu]Lu-PSMA-Radioligand Therapy Efficacy Outcomes in Taxane-Naïve Versus Taxane-Treated Patients with Metastatic Castration-Resistant Prostate Cancer: A Systematic Review and Metaanalysis. J Nucl Med 2023:jnumed.123.265414. [PMID: 37169534 DOI: 10.2967/jnumed.123.265414] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/10/2023] [Indexed: 05/13/2023] Open
Abstract
Radioligand therapy (RLT) with 177Lu-prostate-specific membrane antigen (PSMA) inhibitors ([177Lu]Lu-PSMA) is currently approved for patients with metastatic castration-resistant prostate cancer (mCRPC) after progression with at least 1 taxane and 1 androgen-receptor-pathway inhibitor. However, the impact of prior chemotherapy on [177Lu]Lu-PSMA-RLT outcomes is debatable, with various studies showing inconsistent results. This study was conducted to precisely evaluate the impact of prior taxane chemotherapy on response and survival outcomes in mCRPC patients after [177Lu]Lu-PSMA-RLT. Methods: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches in PubMed, Scopus, and Embase were made using relevant key words, and articles up to December 2022 were included. The endpoints included prostate-specific antigen (PSA) response rate (RR), progression-free survival, and overall survival (OS). Individual patient data were pooled when feasible. Univariate odds ratios (ORs) and hazard ratios (HRs) were extracted from the individual articles, and pooled estimates and 95% CIs were generated using metaanalysis. Results: Thirteen articles comprising 2,068 patients were included. In 6 articles (553 patients), taxane-naïve patients had significantly better odds of biochemical response after [177Lu]Lu-PSMA-RLT (pooled OR, 1.82; 95% CI, 1.21-2.71). Individual patient data metaanalysis for PSA RRs in 3 articles revealed a significantly higher PSA RR in the taxane-naïve versus taxane-treated patients (57.1% vs. 39.5%; difference, 17.6%; 95% CI, 5.6%-28.9%). Further, taxane-naïve status was also a predictor of significantly better progression-free survival (5 articles; 1,027 patients; pooled HR, 0.60; 95% CI, 0.51-0.69) and OS (8 articles; 1,594 patients; pooled HR, 0.54; 95% CI, 0.43-0.68) after [177Lu]Lu-PSMA-RLT. There was no evidence of publication bias. Conclusion: mCRPC patients with no prior taxanes had significantly better outcomes after [177Lu]Lu-PSMA-RLT than did taxane-treated patients. Further trials evaluating [177Lu]Lu-PSMA-RLT in the taxane-naïve setting are now required.
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Affiliation(s)
- Swayamjeet Satapathy
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India; and
| | - Ranjit K Sahoo
- Department of Medical Oncology, B.R. Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Chandrasekhar Bal
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India; and
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Bauder-Wüst U, Schäfer M, Winter R, Remde Y, Roscher M, Breyl H, Poethko T, Tömböly C, Benešová-Schäfer M. Synthesis of tritium-labeled Lu-PSMA-617: Alternative tool for biological evaluation of radiometal-based pharmaceuticals. Appl Radiat Isot 2023; 197:110819. [PMID: 37119703 DOI: 10.1016/j.apradiso.2023.110819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/24/2023] [Accepted: 04/11/2023] [Indexed: 05/01/2023]
Abstract
This project focuses on the generation and evaluation of functional alternatives to radiometal-based pharmaceuticals supporting basic research and the in vitro developmental phase. Employing robust tritium chemistry and non-radioactive metal surrogates in two synthetic and labeling strategies resulted in ([ring-3H]Nal)PSMA-617 and ([α,ß-3H]Nal)PSMA-617. In particular, ([α,ß-3H]Nal)Lu-PSMA-617 exhibited high radiolytic as well as metal-complex stability and was compared to the clinically-established radiopharmaceutical [177Lu]Lu-PSMA-617. The cell-based assays confirmed the applicability of ([α,ß-3H]Nal)Lu-PSMA-617 as a substitute of [177Lu]Lu-PSMA-617 in pre-clinical biological settings.
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Affiliation(s)
- Ulrike Bauder-Wüst
- Research Group Molecular Biology of Systemic Radiotherapy, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
| | - Martin Schäfer
- Service Unit for Radiopharmaceuticals and Preclinical Trials, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
| | - Ruth Winter
- Research Group Molecular Biology of Systemic Radiotherapy, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
| | - Yvonne Remde
- Service Unit for Radiopharmaceuticals and Preclinical Trials, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
| | - Mareike Roscher
- Service Unit for Radiopharmaceuticals and Preclinical Trials, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
| | - Heinz Breyl
- Executive Department for Radiation Protection and Dosimetry, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
| | - Thorsten Poethko
- Bayer AG, Research & Development, Pharmaceuticals, DMPK, Apratherweg 18a, 42096, Wuppertal, Germany.
| | - Csaba Tömböly
- Institute of Biochemistry, Biological Research Center, Temesvári körút 62, 6726, Szeged, Hungary.
| | - Martina Benešová-Schäfer
- Research Group Molecular Biology of Systemic Radiotherapy, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
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10
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Determination of pharmacokinetics and tissue distribution of a novel lutetium-labeled PSMA-targeted ligand, 177Lu-DOTA-PSMA-GUL, in rats by using LC–MS/MS. Sci Rep 2022; 12:15452. [PMID: 36104447 PMCID: PMC9474474 DOI: 10.1038/s41598-022-19700-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 09/02/2022] [Indexed: 11/15/2022] Open
Abstract
Prostate specific membrane antigen (PSMA) is known to be overexpressed in prostate cancer cells, providing as a diagnostic and therapeutic target for prostate cancer. A lutetium-labeled PSMA targeted ligand, 177Lu-DOTA-PSMA-GUL is a novel radiopharmaceutical, which has been developed for the treatment of prostate cancer. While the GUL domain of 177Lu-DOTA-PSMA-GUL binds to the antigen, the beta-emitting radioisotope, 177Lu-labeled DOTA, interacts with prostate cancer cells. However, the in vivo pharmacokinetics of intact 177Lu-DOTA-PSMA-GUL has never been characterized. This study aimed to evaluate the pharmacokinetics and tissue distribution of the radiopharmaceutical in rats by using its stable isotope-labeled analog, 175Lu-DOTA-PSMA-GUL. A sensitive liquid chromatography-tandem mass spectrometry (LC–MS/MS) analysis of 175Lu-DOTA-PSMA-GUL was developed and validated. Following intravenous injection, the plasma concentration–time profiles of 175Lu-DOTA-PSMA-GUL showed a multi-exponential decline with the average elimination half-life of 0.30 to 0.33 h. Systemic exposure increased with the dose and renal excretion is the major elimination route. Tissue distribution of 175Lu-DOTA-PSMA-GUL was most substantial in kidneys, followed by the prostate. The developed LC–MS/MS assay and the in vivo pharmacokinetic data of 175Lu-DOTA-PSMA-GUL would provide helpful information for further clinical studies to be developed as a novel therapeutic agent for prostate cancer.
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11
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Jeitner TM, Babich JW, Kelly JM. Advances in PSMA theranostics. Transl Oncol 2022; 22:101450. [PMID: 35597190 PMCID: PMC9123266 DOI: 10.1016/j.tranon.2022.101450] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/04/2022] [Accepted: 05/08/2022] [Indexed: 12/15/2022] Open
Abstract
PSMA is an appealing target for theranostic because it is a transmembrane protein with a known substrate that is overexpessed on prostate cancer cells and internalizes upon ligand binding. There are a number of PSMA theranostic ligands in clinical evaluation, clinical trial, or clinically approved. PSMA theranostic ligands increase progression-free survival, overall survival, and pain in patients with metastatic castration resistant prostate cancer. A major obstacle to PSMA-targeted radioligand therapy is off-target toxicity in salivary glands.
The validation of prostate specific membrane antigen (PSMA) as a molecular target in metastatic castration-resistant prostate cancer has stimulated the development of multiple classes of theranostic ligands that specifically target PSMA. Theranostic ligands are used to image disease or selectively deliver cytotoxic radioactivity to cells expressing PSMA according to the radioisotope conjugated to the ligand. PSMA theranostics is a rapidly advancing field that is now integrating into clinical management of prostate cancer patients. In this review we summarize published research describing the biological role(s) and activity of PSMA, highlight the most clinically advanced PSMA targeting molecules and biomacromolecules, and identify next generation PSMA ligands that aim to further improve treatment efficacy. The goal of this review is to provide a comprehensive assessment of the current state-of-play and a roadmap to achieving further advances in PSMA theranostics.
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Affiliation(s)
- Thomas M Jeitner
- Molecular Imaging Innovations Institute, Department of Radiology, Weill Cornell Medicine, Belfer Research Building, 413 East 69th Street, Room BB-1604, New York, NY 10021, USA
| | - John W Babich
- Molecular Imaging Innovations Institute, Department of Radiology, Weill Cornell Medicine, Belfer Research Building, 413 East 69th Street, Room BB-1604, New York, NY 10021, USA; Weill Cornell Medicine, Sandra and Edward Meyer Cancer Center, New York, NY 10021, USA; Weill Cornell Medicine, Citigroup Biomedical Imaging Center, New York, NY 10021, USA
| | - James M Kelly
- Molecular Imaging Innovations Institute, Department of Radiology, Weill Cornell Medicine, Belfer Research Building, 413 East 69th Street, Room BB-1604, New York, NY 10021, USA; Weill Cornell Medicine, Citigroup Biomedical Imaging Center, New York, NY 10021, USA.
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12
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Sadaghiani MS, Sheikhbahaei S, Werner RA, Pienta KJ, Pomper MG, Gorin MA, Solnes LB, Rowe SP. 177 Lu-PSMA radioligand therapy effectiveness in metastatic castration-resistant prostate cancer: An updated systematic review and meta-analysis. Prostate 2022; 82:826-835. [PMID: 35286735 PMCID: PMC9311733 DOI: 10.1002/pros.24325] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/14/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND An updated systematic review and meta-analysis of relevant studies to evaluate the effectiveness of prostate-specific membrane antigen (PSMA)-targeted endoradiotherapy/radioligand therapy (PRLT) in castration resistant prostate cancer (CRPC). METHODS A systematic search was performed in July 2020 using PubMed/Medline database to update our prior systematic review. The search was limited to papers published from 2019 to June 2020. A total of 472 papers were reviewed. The studied parameters included pooled proportion of patients showing any or ≥50% prostate-specific antigen (PSA) decline after PRLT. Survival effects of PRLT were assessed based on pooled hazard ratios (HRs) of the overall survival (OS) according to any PSA as well as ≥50% PSA decline after PRLT. Response to therapy based on ≥50% PSA decrease after PRLT versus controls was evaluated using Mantel-Haenszel random effect meta-analysis. All p values < 0.05 were considered as statistically significant. RESULTS A total of 45 publications were added to the prior 24 studies. 69 papers with total of 4157 patients were included for meta-analysis. Meta-analysis of the two recent randomized controlled trials showed that patients treated with 177 Lu-PSMA 617 had a significantly higher response to therapy compared to controls based on ≥50% PSA decrease. Meta-analysis of the HRs of OS according to any PSA decline and ≥50% PSA decline showed survival prolongation after PRLT. CONCLUSIONS PRLT results in higher proportion of patients responding to therapy based on ≥50% PSA decline compared to controls. Any PSA decline and ≥50% PSA decline showed survival prolongation after PRLT. ADVANCES IN KNOWLEDGE This is the first meta-analysis to aggregate the recent randomized controlled trials of PRLT which shows CRPC patients had a higher response to therapy after PRLT compared to controls.
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Affiliation(s)
- Mohammad S. Sadaghiani
- The Russell H. Morgan Department of Radiology and Radiological ScienceJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Sara Sheikhbahaei
- The Russell H. Morgan Department of Radiology and Radiological ScienceJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Rudolf A. Werner
- Department of Nuclear MedicineUniversity Hospital WürzburgWürzburgGermany
| | - Kenneth J. Pienta
- Department of Urology, The James Buchanan Brady Urological InstituteJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Martin G. Pomper
- The Russell H. Morgan Department of Radiology and Radiological ScienceJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of Urology, The James Buchanan Brady Urological InstituteJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Michael A. Gorin
- Urology Associates and UPMC Western MarylandCumberlandMarylandUSA
- Department of UrologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Lilja B. Solnes
- The Russell H. Morgan Department of Radiology and Radiological ScienceJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Steven P. Rowe
- The Russell H. Morgan Department of Radiology and Radiological ScienceJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of Urology, The James Buchanan Brady Urological InstituteJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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13
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Nautiyal A, Jha AK, Mithun S, Rangarajan V. Dosimetry in Lu-177-PSMA-617 prostate-specific membrane antigen targeted radioligand therapy: a systematic review. Nucl Med Commun 2022; 43:369-377. [PMID: 35045551 DOI: 10.1097/mnm.0000000000001535] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND 177Lu-prostate-specific membrane antigen (PSMA) gained popularity as a choice of agent in the treatment of patients with advanced prostate cancer or metastatic castration-resistant stage of prostate carcinoma (mCRPC) diseases. However, this treatment may cause fatal effects, probably due to unintended irradiation of normal organs. We performed an extensive systematic review to assess the organs at risk and the absorbed dose received by tumor lesions in 177Lu-PSMA therapy. DESIGN In this review, published peer-reviewed articles that cover clinical dosimetry in patients following peptide radionuclide ligand therapy using 177Lu-PSMA have been included. Two senior researchers independently checked the articles for inclusion. A systematic search in the database was made using PubMed, Publons and DOAJ. All selected articles were categorized into three groups: (1) clinical studies with the technical description of dosimetry in 177Lu-PSMA therapy (2) organ dosimetry in 177Lu-PSMA therapy or (3) tumor dosimetry in 177Lu-PSMA therapy. RESULT In total, 182 citations were identified on PSMA therapy and 17 original articles on 177Lu-PSMA dosimetry were recognized as eligible for review. The median absorbed dose per unit of administered activity for kidneys, salivary, liver, spleen, lacrimal and bone marrow was 0.55, 0.81, 0.1, 0.1, 2.26 and 0.03 Gy/GBq, respectively. The median absorbed dose per unit of activity for tumor lesions was found in a range of 2.71-10.94 Gy/GBq. CONCLUSION 177Lu-PSMA systemic radiation therapy (SRT) is a well-tolerated and reliable treatment option against the management of the mCRPC stage of prostate carcinoma. Lacrimal glands and salivary glands are the major critical organs in 177Lu-PSMA SRT. Besides, tumors receive 3-6 times higher absorbed doses compared to organs at risk.
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Affiliation(s)
- Amit Nautiyal
- Department of Nuclear Medicine and Molecular Imaging, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Kharghar, Navi Mumbai
- Homi Bhabha National Institute
| | - Ashish K Jha
- Homi Bhabha National Institute
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Sneha Mithun
- Homi Bhabha National Institute
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Venkatesh Rangarajan
- Homi Bhabha National Institute
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
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