Production, quality control and pharmacokinetic studies of Ho-EDTMP for therapeutic applications

Advances in Radionuclides and Radiolabelled Peptides for Cancer Therapeutics

Radiopharmaceutical therapy, which can detect and treat tumours simultaneously, was introduced more than 80 years ago, and it has changed medical strategies with respect to cancer. Many radioactive radionuclides have been developed, and functional, molecularly modified radiolabelled peptides have been used to produce biomolecules and therapeutics that are vastly utilised in the field of radio medicine. Since the 1990s, they have smoothly transitioned into clinical application, and as of today, a wide variety of radiolabelled radionuclide derivatives have been examined and evaluated in various studies. Advanced technologies, such as conjugation of functional peptides or incorporation of radionuclides into chelating ligands, have been developed for advanced radiopharmaceutical cancer therapy. New radiolabelled conjugates for targeted radiotherapy have been designed to deliver radiation directly to cancer cells with improved specificity and minimal damage to the surrounding normal tissue. The development of new theragnostic radionuclides, which can be used for both imaging and therapy purposes, allows for more precise targeting and monitoring of the treatment response. The increased use of peptide receptor radionuclide therapy (PRRT) is also important in the targeting of specific receptors which are overexpressed in cancer cells. In this review, we provide insights into the development of radionuclides and functional radiolabelled peptides, give a brief background, and describe their transition into clinical application.

Cutting edge rare earth radiometals: prospects for cancer theranostics

Background

With recent advances in novel approaches to cancer therapy and imaging, the application of theranostic techniques in personalised medicine has emerged as a very promising avenue of research inquiry in recent years. Interest has been directed towards the theranostic potential of Rare Earth radiometals due to their closely related chemical properties which allow for their facile and interchangeable incorporation into identical bifunctional chelators or targeting biomolecules for use in a diverse range of cancer imaging and therapeutic applications without additional modification, i.e. a “one-size-fits-all” approach. This review will focus on recent progress and innovations in the area of Rare Earth radionuclides for theranostic applications by providing a detailed snapshot of their current state of production by means of nuclear reactions, subsequent promising theranostic capabilities in the clinic, as well as a discussion of factors that have impacted upon their progress through the theranostic drug development pipeline.

Main body

In light of this interest, a great deal of research has also been focussed towards certain under-utilised Rare Earth radionuclides with diverse and favourable decay characteristics which span the broad spectrum of most cancer imaging and therapeutic applications, with potential nuclides suitable for α-therapy (¹⁴⁹Tb), β⁻-therapy (⁴⁷Sc, ¹⁶¹Tb, ¹⁶⁶Ho, ¹⁵³Sm, ¹⁶⁹Er, ¹⁴⁹Pm, ¹⁴³Pr, ¹⁷⁰Tm), Auger electron (AE) therapy (¹⁶¹Tb, ¹³⁵La, ¹⁶⁵Er), positron emission tomography (⁴³Sc, ⁴⁴Sc, ¹⁴⁹Tb, ¹⁵²Tb, ¹³²La, ¹³³La), and single photon emission computed tomography (⁴⁷Sc, ¹⁵⁵Tb, ¹⁵²Tb, ¹⁶¹Tb, ¹⁶⁶Ho, ¹⁵³Sm, ¹⁴⁹Pm, ¹⁷⁰Tm). For a number of the aforementioned radionuclides, their progression from ‘bench to bedside’ has been hamstrung by lack of availability due to production and purification methods requiring further optimisation.

Conclusions

In order to exploit the potential of these radionuclides, reliable and economical production and purification methods that provide the desired radionuclides in high yield and purity are required. With more reactors around the world being decommissioned in future, solutions to radionuclide production issues will likely be found in a greater focus on linear accelerator and cyclotron infrastructure and production methods, as well as mass separation methods. Recent progress towards the optimisation of these and other radionuclide production and purification methods has increased the feasibility of utilising Rare Earth radiometals in both preclinical and clinical settings, thereby placing them at the forefront of radiometals research for cancer theranostics.

Neutron-activated theranostic radionuclides for nuclear medicine

Theranostics in nuclear medicine refers to personalized patient management that involves targeted therapy and diagnostic imaging using a single or combination of radionuclide (s). The radionuclides emit both alpha (α) or beta (β^-) particles and gamma (γ) rays which possess therapeutic and diagnostic capabilities, respectively. However, the production of these radionuclides often faces difficulties due to high cost, complexity of preparation methods and that the products are often sourced far from the healthcare facilities, hence losing activity due to radioactive decay during transportation. Subject to the availability of a nuclear reactor within an accessible distance from healthcare facilities, neutron activation is the most practical and cost-effective route to produce radionuclides suitable for theranostic purposes. Holmium-166 (¹⁶⁶Ho), Lutetium-177 (¹⁷⁷Lu), Rhenium-186 (¹⁸⁶Re), Rhenium-188 (¹⁸⁸Re) and Samarium-153 (¹⁵³Sm) are some of the most promising neutron-activated radionuclides that are currently in clinical practice and undergoing clinical research for theranostic applications. The aim of this paper is to review the physical characteristics, current clinical applications and future prospects of these neutron activated radionuclides in theranostics. The production, physical properties, validated clinical applications and clinical studies for each neutron-activated radionuclide suitable for theranostic use in nuclear medicine are reviewed in this paper.

The various therapeutic applications of the medical isotope holmium-166: a narrative review

Over the years, a broad spectrum of applications of the radionuclide holmium-166 as a medical isotope has been established. The isotope holmium-166 is attractive as it emits high-energy beta radiation which can be used for a therapeutic effect and gamma radiation which can be used for nuclear imaging purposes. Furthermore, holmium-165 can be visualized by MRI because of its paramagnetic properties and by CT because of its high density. Since holmium-165 has a natural abundance of 100%, the only by-product is metastable holmium-166 and no costly chemical purification steps are necessary for production of nuclear reactor derived holmium-166. Several compounds labelled with holmium-166 are now used in patients, such Ho¹⁶⁶-labelled microspheres for liver malignancies, Ho¹⁶⁶-labelled chitosan for hepatocellular carcinoma (HCC) and [¹⁶⁶Ho]Ho DOTMP for bone metastases. The outcomes in patients are very promising, making this isotope more and more interesting for applications in interventional oncology. Both drugs as well as medical devices labelled with radioactive holmium are used for internal radiotherapy. One of the treatment possibilities is direct intratumoural treatment, in which the radioactive compound is injected with a needle directly into the tumour. Numerous other applications have been developed, like patches for treatment of skin cancer and holmium labelled antibodies and peptides. The second major application that is currently clinically applied is selective internal radiation therapy (SIRT, also called radioembolization), a novel treatment option for liver malignancies. This review discusses medical drugs and medical devices based on the therapeutic radionuclide holmium-166.

Targeted Radionuclide Therapy of Painful Bone Metastases: Past Developments, Current Status, Recent Advances and Future Directions

Bone pain arising from secondary skeletal malignancy constitutes one of the most common types of chronic pain among patients with cancer which can lead to rapid deterioration of the quality of life. Radionuclide therapy using bone-seeking radiopharmaceuticals based on the concept of localization of the agent at bone metastases sites to deliver focal cytotoxic levels of radiation emerged as an effective treatment modality for the palliation of symptomatic bone metastases. Bone-seeking radiopharmaceuticals not only provide palliative benefit but also improve clinical outcomes in terms of overall and progression-free survival. There is a steadily expanding list of therapeutic radionuclides which are used or can potentially be used in either ionic form or in combination with carrier molecules for the management of bone metastases. This article offers a narrative review of the armamentarium of bone-targeting radiopharmaceuticals based on currently approved investigational and potentially useful radionuclides and examines their efficacy for the treatment of painful skeletal metastases. In addition, the article also highlights the processes, opportunities, and challenges involved in the development of bone-seeking radiopharmaceuticals. Radium-223 is the first agent in this class to show an overall survival advantage in Castration-Resistant Prostate Cancer (CRPC) patients with bone metastases. This review summarizes recent advances, current clinical practice using radiopharmaceuticals for bone pain palliation, and the expected future prospects in this field.

Production and Clinical Applications of Radiopharmaceuticals and Medical Radioisotopes in Iran

During past 3 decades, nuclear medicine has flourished as vibrant and independent medical specialty in Iran. Since that time, more than 200 nuclear physicians have been trained and now practicing in nearly 158 centers throughout the country. In the same period, Tc-99m generators and variety of cold kits for conventional nuclear medicine were locally produced for the first time. Local production has continued to mature in robust manner while fulfilling international standards. To meet the ever-growing demand at the national level and with international achievements in mind, work for production of other Tc-99m-based peptides such as ubiquicidin, bombesin, octreotide, and more recently a kit formulation for Tc-99m TRODAT-1 for clinical use was introduced. Other than the Tehran Research Reactor, the oldest facility active in production of medical radioisotopes, there is one commercial and three hospital-based cyclotrons currently operational in the country. I-131 has been one of the oldest radioisotope produced in Iran and traditionally used for treatment of thyrotoxicosis and differentiated thyroid carcinoma. Since 2009, (131)I-meta-iodobenzylguanidine has been locally available for diagnostic applications. Gallium-67 citrate, thallium-201 thallous chloride, and Indium-111 in the form of DTPA and Oxine are among the early cyclotron-produced tracers available in Iran for about 2 decades. Rb-81/Kr-81m generator has been available for pulmonary ventilation studies since 1996. Experimental production of PET radiopharmaceuticals began in 1998. This work has culminated with development and optimization of the high-scale production line of (18)F-FDG shortly after installation of PET/CT scanner in 2012. In the field of therapy, other than the use of old timers such as I-131 and different forms of P-32, there has been quite a significant advancement in production and application of therapeutic radiopharmaceuticals in recent years. Application of (131)I-meta-iodobenzylguanidine for treatment of neuroblastoma, pheochromocytoma, and other neuroendocrine tumors has been steadily increasing in major academic university hospitals. Also (153)Sm-EDTMP, (177)Lu-EDTMP, (90)Y-citrate, (90)Y-hydroxyapatite colloid, (188/186)Re-sulfur colloid, and (188/186)Re-HEDP have been locally developed and now routinely available for bone pain palliation and radiosynovectomy. Cu-64 has been available to the nuclear medicine community for some time. With recent reports in diagnostic and therapeutic applications of this agent especially in the field of oncology, we anticipate an expansion in production and availability. The initiation of the production line for gallium-68 generator is one of the latest exciting developments. We are proud that Iran would be joining the club of few nations with production lines for this type of generator. There are also quite a number of SPECT and PET tracers at research and preclinical stage of development preliminarily introduced for possible future clinical applications. Availability of fluorine-18 tracers and gallium-68 generators would no doubt allow rapid dissemination of PET/CT practices in various parts of our large country even far from a cyclotron facility. Also, local production and availability of therapeutic radiopharmaceuticals are going to open exciting horizons in the field of nuclear medicine therapy. Given the available manpower, local infrastructure of SPECT imaging, and rapidly growing population, the production of Tc-99m generators and cold kit would continue to flourish in Iran.

Pharmaceutical and clinical development of phosphonate-based radiopharmaceuticals for the targeted treatment of bone metastases

Therapeutic phosphonate-based radiopharmaceuticals radiolabeled with beta, alpha and conversion electron emitting radioisotopes have been investigated for the targeted treatment of painful bone metastases for >35years. We performed a systematic literature search and focused on the pharmaceutical development, preclinical research and early human studies of these radiopharmaceuticals. The characteristics of an ideal bone-targeting therapeutic radiopharmaceutical are presented and compliance with these criteria by the compounds discussed is verified. The importance of both composition and preparation conditions for the stability and biodistribution of several agents is discussed. Very few studies have described the characterization of these products, although knowledge on the molecular structure is important with respect to in vivo behavior. This review discusses a total of 91 phosphonate-based therapeutic radiopharmaceuticals, of which only six agents have progressed to clinical use. Extensive clinical studies have only been described for (186)Re-HEDP, (188)Re-HEDP and (153)Sm-EDTMP. Of these, (153)Sm-EDTMP represents the only compound with worldwide marketing authorization. (177)Lu-EDTMP has recently received approval for clinical use in India. This review illustrates that a thorough understanding of the radiochemistry of these agents is required to design simple and robust preparation and quality control methods, which are needed to fully exploit the potential benefits of these theranostic radiopharmaceuticals. Extensive biodistribution and dosimetry studies are indispensable to provide the portfolios that are required for assessment before human administration is possible. Use of the existing knowledge collected in this review should guide future research efforts and may lead to the approval of new promising agents.

Estimation of human absorbed dose for (166)Ho-PAM: comparison with (166)Ho-DOTMP and (166)Ho-TTHMP

OBJECTIVE

In this study, the human absorbed dose of holmium-166 ((166)Ho)-pamidronate (PAM) as a potential agent for the management of multiple myeloma was estimated.

METHODS

(166)Ho-PAM complex was prepared at optimized conditions and injected into the rats. The equivalent and effective absorbed doses to human organs after injection of the complex were estimated by radiation-absorbed dose assessment resource and methods proposed by Sparks et al based on rat data. The red marrow to other organ absorbed dose ratios were compared with these data for (166)Ho-DOTMP, as the only clinically used (166)Ho bone marrow ablative agent, and (166)Ho-TTHMP.

RESULTS

The highest absorbed dose amounts are observed in the bone surface and bone marrow with 1.11 and 0.903 mGy MBq(-1), respectively. Most other organs would receive approximately insignificant absorbed dose. While (166)Ho-PAM demonstrated a higher red marrow to total body absorbed dose ratio than (166)Ho-1,4,7,10-tetraazacyclo dodecane-1,4,7,10 tetra ethylene phosphonic acid (DOTMP) and (166)Ho-triethylene tetramine hexa (methylene phosphonic acid) (TTHMP), the red marrow to most organ absorbed dose ratios for (166)Ho-TTHMP and (166)Ho-PAM are much higher than the ratios for (166)Ho-DOTMP.

CONCLUSION

The result showed that (166)Ho-PAM has significant characteristics than (166)Ho-DOTMP and therefore, this complex can be considered as a good agent for bone marrow ablative therapy.

ADVANCES IN KNOWLEDGE

In this work, two separate points have been investigated: (1) human absorbed dose of (166)Ho-PAM, as a potential bone marrow ablative agent, has been estimated; and (2) the complex has been compared with (166)Ho-DOTMP, as the only clinically used bone marrow ablative radiopharmaceutical, showing significant characteristics.

Study of Bone Surface Absorbed Dose in Treatment of Bone Metastases via Selected Radiopharmaceuticals: Using MCNP4C Code and Available Experimental Data

Bone metastases are major clinical concern that can cause severe problems for patients. Currently, various beta emitters are used for bone pain palliation. This study, describes the process for absorbed dose prediction of selected bone surface and volume-seeking beta emitter radiopharmaceuticals such as (32)P, (89)SrCl2,(90)Y-EDTMP,(153)Sm-EDTMP, (166)Ho-DOTMP, (177)Lu-EDTMP,(186)Re-HEDP, and (188)Re-HEDP in human bone, using MCNP code. Three coaxial sub-cylinders 5 cm in height and 1.2, 2.6, and 7.6 cm in diameter were used for bone marrow, bone, and muscle simulation respectively. The *F8 tally was employed to calculate absorbed dose in the MCNP4C simulations. Results show that with injection of 1 MBq of these radiopharmaceuticals given to a 70 kg adult man, (32)P, (89)SrCl2, and (90)Y-EDTMP radiopharmaceuticals will have the highest amount of bone surface absorbed dose, where beta particles will have the greatest proportion in absorbed dose of bone surface in comparison with gamma radiation. These results demonstrate moderate agreement with available experimental data.

Development of (166)Holmium-1,2 Propylene Di-amino Tetra (Methy1enephosphonicacid) as a Possible Bone Palliation Agent

¹⁶⁶Holmium-1,2-propylene di-amino tetra (methy1enephosphonicacid) (¹⁶⁶ Ho-PDTMP) complex was prepared successfully using an in-house synthesized PDTMP ligand and ¹⁶⁶ HoCl ₃ . Ho-166 chloride was obtained by thermal neutron irradiation (1 × 10 ¹³ n/cm ² /s) of natural Ho (NO ₃ ) ₃ samples (specific activity = 3-5 GBq/mg), dissolved in acidic media. Radiochemical purity of ¹⁶⁶ Ho-PDTMP was checked by instant thin layer chromatography (>99%). Stability studies of the complex in the final preparation and in the presence of human serum were performed up to 72 h. The biodistribution of ¹⁶⁶ Ho-PDTMP and ¹⁶⁶ HoCl ₃ in wild-type rats was checked in animal tissues up to 48 h. The produced ¹⁶⁶ Ho-PDTMP properties suggest a possible new bone palliative therapeutic to overcome the metastatic bone pains.

The synthesis, radiolabeling and first biological evaluation of a new 166Ho-complex for radiotherapy of bone metastases

In this study, the 166Ho-triethylene tetramine hexa (methylene phosphonic acid) (166Ho-TTHMP) complex was prepared as a bone palliation agent. The complex was successfully prepared using an in-house synthesized TTHMP ligand and [166Ho]HoCl3. Ho-166 chloride was obtained by thermal neutron irradiation (1×1013 n cm−2 s−1) of natural Ho(NO3)3 samples, followed by radiolabeling and stability studies. Biodistribution studies were also performed in wild type rats. The complex was prepared with the specific activity of 3–5 GBq/mg and a high radiochemical purity > 99%, (checked by ITLC). The 166Ho-TTHMP complex was stable in the final preparation and in the presence of human serum (> 90%) up to 72 h. The biodistribution of 166Ho-TTHMP in wild-type rats demonstrated significant bone uptake compared to 166HoCl3 up to 48 h. SPECT imaging of the radiolabeled compound was demonstrated to be in complete accordance with the biodistribution data. The major uptake was observed for long bones including thigh bones as well as skull and also knee and vertebrae. Primary properties of 166Ho-TTHMP demonstrate that this new therapeutic agent can be a good choice for metastatic bone pains.

Production, Quality Control and Biological Evaluation of (166)Ho-PDTMP as a Possible Bone Palliation Agent

OBJECTIVE(S)

In this study, (166)Ho-1,2-propylene di-amino tetra(methy1enephosphonicAcid) ((166)Ho-PDTMP) complex was prepared as a bone palliation agent.

MATERIALS AND METHODS

The complex was successfully prepared using an in-house synthesized EDTMP ligand and (166)HoCl3. Ho-166 chloride was obtained by thermal neutron irradiation (1 × 1013 n.cm-2.s-1) of natural Ho(NO3)3 samples followed by radiolabeling and stability studies. Biodistribution in wild type rats was also peformed.

RESULTS

The complex was prepared with the specific activity of 278 GBq/mg and high radiochemical purity (>99%, checked by ITLC). (166)Ho-PDTMP complex was stabilized in the final preparation and in the presence of human serum (>90%) up to 72 hr. The biodistribution of (166)Ho-PDTMP in wild-type rats demonstrated significant bone uptake was up to 48 hr compared to (166)HoCl3.

CONCLUSION

The produced (166)Ho-PDTMP properties suggest a possible new bone palliative therapeutic to overcome the metastatic bone pains.

Synthesis, quality control and biological evaluation of tris[(1,10-phenanthroline)[153Sm]samarium(III)]trithiocyanate complex as a therapeutic agent

Therapeutic radiopharmaceuticals are designed to deliver high doses of radiation to selected target organs or tissues with an aim of minimizing unwanted radiation to surrounding healthy tissue. In this work, [tris(1,10-phenanthroline) [153Sm]samarium(III)]trithiocyanate (153Sm-TPTTC) was developed for possible therapeutic properties. The cold compound, i.e. natSm-TPTTC was prepared and characterized by IR, UV, mass and 1H-NMR spectroscopy. 153Sm-TPTTC was prepared in two steps using [153Sm]SmCl3, obtained by neutron activation of an enriched 152Sm sample. Stability tests, partition coefficient determination, toxicity tests and biodistribution studies of the complex in wild-type and fibrosarcoma-bearing mice were determined. The radiolabeled complex was prepared in high radiochemical purity (> 99% precipitation method) and specific activity of 278 GBq/mmol and demonstrated significant stability at 4, 25 and 37 ºC (in presence of human serum). Initial complex biodistribution data showed significant liver accumulation in wild-type mice and significant tumor accumulation in fibrosarcoma-bearing mice with tumor:blood and tumor:muscle ratios of 3.55 (2 h) and 38.26 (96 h) respectively. 153Sm-TPTTC properties suggest an efficient tumor targeting agent with high tumor-avidity. Further investigation on the therapeutic properties must be conducted.