PSMA-directed Radionuclide Therapy (PSMA PRLT) Lu17 & Ac225

PSMA-directed Radionuclide Therapy (PSMA PRLT) Lu17 & Ac225

Nieprzeczytany postautor: zosia bluszcz » 25 cze 2019, 16:05

Leczenie mCRPC przy pomocy Actinium-225 and Lutetium-177 w Centrum Radioterapii Molekularnej, Departament Medycyny Nuklearnej Uniwersytetu Saarland w Homburgu (DE)




PSMA-directed Radionuclide Therapy (PSMA-PRRT, PRLT) incl Actinium-225 and Lutetium-177

Prostate cancer is the most common malignant tumor affecting men in Germany. After local therapy (surgery and/or radiation) with the intention of curing advanced (metastatic) prostate cancer, a supplementary anti-hormone therapy is often initiated. After prolonged anti-hormone therapy (androgen-deprivation therapy, ADT), the tumor cells often become resistant, so that other chemotherapeutic treatment options are used as the tumor disease progresses. The uro-oncologists use the entire range of therapies for advanced prostate carcinoma.
PSMA-directed radionuclide therapy, also known as PSMA-directed peptide receptor radionuclide therapy (PSMA-PRRT or PRLT), is a new targeted therapy for patients with advanced prostate carcinoma. PSMA (prostate-specific membrane antigen) is a protein receptor that is richly present on the cell surface of prostate carcinoma cells. This is used for diagnostic and therapeutic procedures in Nuclear Medicine particularily for this tumor entity by means of theranostics, a radioactive nuclide coupled to a substance that binds to PSMA, which emits either detectable radiation for diagnostic purposes or (therapeutically) short-range harmful radiation (e.g. Lu177). During PSMA-directed radionuclide therapy, the radioactive radiation (ß-radiation) exerts its therapeutic effect directly on the tumor cells exposing minimal radiation on the surrounding healthy tissues.


Case Report I PSMA-Therapy

61y old male prostate carcinoma patient with bone metastases. Patient had progressive disease under ADT and abiraterone plus prednisolon. Three treatment cycles of PSMA-directed radioligand therapy (PRLT) using Lutetium-177 PSMA-617 resulted in a dramatic decline of PSA level. Follow-up therapy monitoring by 68Ga-PSMA-11 PET imaging showed only minor residual disease.


Indications for PSMA-directed radionuclide therapy (PSMA-PRRT, PRLT) with 177Lu (Lutetium) and/or 225Ac (Actinium)

Initially, the prostate carcinoma is usually surgically removed or irradiated with curative intent. Although the therapy is optimal, recurrence often occurs during the further course. If inoperable, this can usually be controlled for an extended period of time with anti-hormonal therapy (ADT, directed against prostate carcinoma-stimulating androgens). The tumor cells finally become insensitive (resistant) to these agents and continue to grow unhindered.
Solely bone involvement often offers the possibility of bone-directed radionuclide therapy (Alpharadin, Xofigo).
If this therapy is out of question or no longer effective, many patients will have to undergo chemotherapy. Although this can lead to side effects for the patient, it often leads to tumor control for some time. When the tumor cells finally become resistant to this treatment, PSMA-PRRT (PRLT) often still works because it provides targeted intense radiation of the tumor from the inside, sparing the healthy surrounding tissue because of the milimeter or submilimeter range of radiation. This is a new treatment method for patients for whom no satisfactory therapeutic alternatives are left. For an effective treatment, the metastases or tumor lesions should have the ability to accumulate PSMA in sufficient intensity. To determine this, a 68Ga PSMA PET/CT examination is performed as part of the theranostic concept prior to therapy. This PET-CT study is also offered by our department.



Homburg Concept of Tandem 225Ac (Actinium) and 177Lu (Lutetium) PSMA Radioligand Therapy (Alpha/beta Tandem PRLT)

We were able to show, that patients developing Lutetium (177Lu) refractory mCRPC disease, i.e. metastatic prostate cancer with insufficient response to 177Lu PRLT, may respond well to 225Ac-augmented 177Lu-PRLT. With our approach we use a low amount of activity of 225Ac together with standard 177Lu activities achieving superior remission rates with less toxicity as the standard 225Ac PRLT (mono Actinium PRLT) approach.


Case Report II PSMA-Therapy

A 77y old male prostate carcinoma patient showed progressive disease after enzalutamide and chemotherapy. Near complete remission after a single treatment of PSMA-directed radioligand therapy using Lutetium-177 PSMA-617. Therapy monitoring was performed by 68Ga-PSMA-11 PET imaging.


Therapy procedure

Following the preparing examinations (blood tests, quantitative assesment of organ functions, e.g. renal function, salivary gland function), the radionuclide substance is infused through the arm vein at a dose based on the tumor load and the test results. Prophylactic cooling maneuvers of the salivary glands (cooling of the parotid glands from outside) are performed, assuming appropriate for the patient's benefit. Also the infusion of fluids is provided for sufficient hydration (rinsing) .
During the inpatient stay, the radiation dose reached in tumor and the sensitive organs (especially kidney) is calculated. This is achieved by serial whole-body and SPECT-CT examinations, which allow quantification of the gamma radiation emitted out from the respective tissue. These measurements also involve blood sampling. The duration of the inpatient stay ranges from 2-4 days.


Side effects

In most cases the therapy is very well tolerated. Most patients do not report any noticed side effects. Occasionally there are adverse effects such as minor nausea or reduced appetite for days, taste disturbances or dry mouth (transient or permanent) as well as fatigue. The PSMA-binding radiopharmaceutical is excreted by the kidneys, liver and gallbladder. A normal intestinal activity is therefore required, otherwise stimulation of bowel movements may be considered. A minimum intake of liquids is necessary to ensure this. Liver and kidney values are checked further after therapy.
The organs susceptible to radiation-induced injury during this therapy are mainly the salivary and lacrimal glands, which are also rich in PSMA. Cooling of the salivary glands can possibly decrease the severity of radiation damage by means of decreased blood flow in these tissues. Nevertheless, the risk of permanent damage with loss of function (dry mouth) appears to be low with Lu-177 PSMA-PRRT unlike with other radionuclide therapies involving the salivary glands. However, the long-term side effect of dry mouth and/or dry eye cannot be entirely excluded. In addition, this treatment may lead to temporary changes in blood counts.


Case Report III PSMA-Therapy

84y old male prostate carcinoma patient with liver and bone metastases (mCRPC). Patient had progressive disease after androgen deprivation therapy (ADT), abiraterone/prednisolon, and radiation therapy. Full biochemical response (complete remission) was achieved by 3 treatment cycles of PSMA-directed radioligand therapy (PRLT) using Lutetium-177 PSMA-617. Therapy monitoring was performed by 68Ga-PSMA-11 PET imaging.


Expertise in Homburg; Centre of Molecular Radiotherapy, Dep. of Nuclear Medicine, Saarland University

The Department of Nuclear Medicine in Homburg with its Centre of Molecular Radiotherapy focuses on innovative theranostic treatment approaches in oncology. Prof. Ezziddin is a well recognized international expert in targeted radionuclide therapy and has developed various concepts for individualized cancer therapy, which is the main focus of his clinical and scientific efforts. His commitment is to optimize the treatment of advanced metastatic or otherwise difficult-to-treat cancer disease. After the introduction of Lu-177 based therapy in 2004, he pursued and published new concepts for increasing the effect, including intra-arterial and augmentation approaches. In order to optimize PSMA-directed radionuclide therapy, the Homburg group strives to take into account the individual binding properties and receptor capacity, the tumor load, as well as the patient's organ functions and excretion kinetics for therapy planning and decision making.

In Homburg, the Ezziddin working group established a standardized dosing scheme for individualized PSMA-directed (PRLT) and Somatostatin receptor-mediated PRRT. This allows for dose-escalation in difficult or highly advanced metastatic disease. Also, augmentation approaches with different anti-tumor substances and alpha-emitters (Ac225) for tandem PRLT have been succcessfully applied as one of the first centres worldwide.

It is important to emphasize that PSMA-PRRT is still an experimental new therapy for which long-term data are scarce. However, the initial results are so promising that this form of therapy cannot be withheld from patients in need. A temporary tumor mass reduction and tumor control is likely in the setting of good tumoral theranostic uptake and accumulation, however, after repeated treatment courses, this procedure may eventually be no longer able to stop tumor progression, as with all other procedures in the (incurable) metastasized stage of prostate cancer.


saarland.de/de/einrichtungen/kliniken_institute/radiologie/nuklearmedizin/patient_information_in_english/psma_directed_radionuclide_therapy_psma_prlt/
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Re: PSMA-directed Radionuclide Therapy (PSMA PRLT) Lu17 & Ac

Nieprzeczytany postautor: jesien 2015 » 12 sty 2020, 15:23

Ośrodki w Niemczech leczące za pomocą Lutetium 177 PSMA

Szukałam jako " Lutetium 177 PSMA therapy in Germany."
Na poniższej stronie sa ośrodki uniwersyteckie i ceny.


https://bookinghealth.com/disease/lutet ... ma-therapy

Finski Docrates tez leczy mCRPC przy użyciu Lutetium177.
Maz rocznik 1952. Cukrzyca typ2. Niewielkie objawy powiększenia prostaty od końca września 2015
2015: X: PSA 20, XI: Biopsja: Gleason 7 (3+4), bez przejścia poza torebkę. W płacie prawym nie stwierdzono cech złośliwości. mpMRi, PET/CT: PiRDAS 5, bez przejścia poza torebkę, naciek wzdłuż wiązki nerwowej, w prawym bez nacieku, węzły chłonne nie są powieszone, pojedyncze ognisko w okolicy iliac crest podejrzane o meta do kości.
2.XII rozpoczęto 16 dni Bicalutamide 50 mg 1 dziennie oraz jednocześnie Triptorelin (pamorelin) w zastrzyku co 6 miesięcy. Wznowienie metforminy. UniKalk ( Ca, wit D, wit K2). 19/12 Bicalutamide stop.
2016.02.09 Nanoknife. Po 14 dniach wyjecie cewnika, 100% trzymania moczu.
2016.03.05 Trzy miesiące od rozpoczęcia hormonoterapii: PSA 0,08 µg/L. Testosteron < 0,1nmol/L. Wit D 73 nmol/L ( norma >50 nmol/L)
2016.06.09 T 0,3 nmol/L, PSA < 0,06 µg/L Przerwa w HT na 4 miesiące.
2016.07.20 T 1,2 nmol/l, PSA nieoznaczalne. Nadal przerwa w HT.
2016.10.11 T 3,7 nmol/L, PSA nieoznaczalne. Nadal przerwa w HT.
2017.03.27 PSA nieoznaczalne, bez HT od 9 miesiecy
2017.09.27 PSA nieoznaczalne 2 lata od diagnozy, 20 miesiecy od IRE.
2018.10.05 PSA nieoznaczalne 3 lata od diagnozy, 2 lata i 8 miesiecy od IRE
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" By kiedy przyjdzie pora na nie –
Na strach prawdziwy, gniew i rozpacz
Ujrzeć, że nie jesteśmy w stanie
Wielkim wyznaniom sprostać." Jacek Kaczmarski
jesien 2015
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Re: PSMA-directed Radionuclide Therapy (PSMA PRLT) Lu17 & Ac

Nieprzeczytany postautor: leonardo556 » 07 mar 2021, 00:35

W czasie konsultacji u dr IS zapytałem o leczenie Sipuleucel-T. Doktor niespecjalnie chciała temat rozwijać, ale nadmieniła, że jej zdaniem aktualnie najbardziej obiecującą metodą leczenia zaawansowanego raka prostaty jest Lutet 177.

Na forum mamy wielu kolegów z rakiem hormonoopornym. Wydaje się, że Ramzej, Zbyszko i wielu innych powinno się bliżej zainteresować się tą metodą leczenia. W Niemczech terapia Lu 177 kosztuje kilkanaście tys EUR. Jeżeli ktoś uważa, że to drogo proponuję zastosować metodę "na koszt spadkobierców". :)

Wszelkie informacje o Lu 177 mile widziane.

Leonardo
ur. 1956 PSA 5,2 Gleason 7 (3+4) sierpień 2013
RP Da Vinci 9 październik 2013 , pT3a pN0 (0/13) R0, Gleason: 4(75%) + 3(25%) = 7
PSA - 0,003 - 28.11.2013, 28.11.2014
PSA - 0.008, 0.012, 0.018 odpowiednio styczeń, lipiec, październik 2015
PSA - 0.044 22 luty, 0,038 13 lipiec 2016, 0,103 23 listopad 2016, 0,476 14 lipiec 2017, 0,55 październik 2017
wycięcie 50 węzłów Da Vinci , UICC: pT3a pN1 (1/63) R0, PSA 0,31 październik 2017, PSA 0,7 marzec 2018
IMRT TrueBeam, 22x2,6 Gy = 57,2 Gy, maj 2018 + bikalutamid 50 mg (kwiecień ,maj, czerwiec)
PSA - 0,341 - 0,310 - 0,234 - 0,212 - 0,188 - 0,154 (15.03.2019) - 0,142 (31.07.2019) - 0,148 (19.12.2019)
0,248 (19.02.2020) - 0,337 (21.04.2020) - 0,466 (03.07.2020) - 0,518 (27.07.2020) - 0,947 (10.11.2020)
IMRT Truebem 3x5=15 Gy - naświetlanie prewencyjne ginekomastii - 12.11.2020, monoterapia bikalutamidem 50 mg
PSA - 1,04 (10.12.20), 0,127 (13.04.21)
leonardo556
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Re: PSMA-directed Radionuclide Therapy (PSMA PRLT) Lu17 & Ac

Nieprzeczytany postautor: zosia bluszcz » 09 mar 2021, 11:17

Obiecujące wyniki australijskiego badania klinicznego:



[177Lu]Lu-PSMA-617 vs Cabazitaxel in Patients With Metastatic Castration-Resistant Prostate Cancer
The Lancet


Abstract

BACKGROUND
Lutetium-177 [177Lu]Lu-PSMA-617 is a radiolabelled small molecule that delivers β radiation to cells expressing prostate-specific membrane antigen (PSMA), with activity and safety in patients with metastatic castration-resistant prostate cancer.
We aimed to compare [177Lu]Lu-PSMA-617 with cabazitaxel in patients with metastatic castration-resistant prostate cancer.

METHODS
We did this multicentre, unblinded, randomised phase 2 trial at 11 centres in Australia.
We recruited men with metastatic castration-resistant prostate cancer for whom cabazitaxel was considered the next appropriate standard treatment. Participants were required to have adequate renal, haematological, and liver function, and an Eastern Cooperative Oncology Group performance status of 0-2. Previous treatment with androgen receptor-directed therapy was allowed.
Men underwent gallium-68 [68Ga]Ga-PSMA-11 and 2-flourine-18[18F]fluoro-2-deoxy-D-glucose (FDG) PET-CT scans.
PET eligibility criteria for the trial were PSMA-positive disease, and no sites of metastatic disease with discordant FDG-positive and PSMA-negative findings.
Men were randomly assigned (1:1) to [177Lu]Lu-PSMA-617 (6·0–8·5 GBq intravenously every 6 weeks for up to six cycles) or cabazitaxel (20 mg/m2 intravenously every 3 weeks for up to ten cycles). The primary endpoint was prostate-specific antigen (PSA) response defined by a reduction of at least 50% from baseline.
This trial is registered with ClinicalTrials.gov, NCT03392428.

FINDINGS
Between Feb 6, 2018, and Sept 3, 2019, we screened 291 men, of whom 200 were eligible on PET imaging.
Study treatment was received by 98 (99%) of 99 men randomly assigned to [177Lu]Lu-PSMA-617 versus 85 (84%) of 101 randomly assigned to cabazitaxel.

PSA responses were more frequent among men in the [177Lu]Lu-PSMA-617 group than in the cabazitaxel group (65 vs 37 PSA responses; 66% vs 37% by intention to treat; difference 29% (95% CI 16–42; p<0·0001; and 66% vs 44% by treatment received; difference 23% [9–37]; p=0·0016).
Grade 3–4 adverse events occurred in 32 (33%) of 98 men in the [177Lu]Lu-PSMA-617 group versus 45 (53%) of 85 men in the cabazitaxel group.
No deaths were attributed to [177Lu]Lu-PSMA-617.

INTERPRETATION
[177Lu]Lu-PSMA-617 compared with cabazitaxel in men with metastatic castration-resistant prostate cancer led to a higher PSA response and fewer grade 3 or 4 adverse events. [177Lu]Lu-PSMA-617 is a new effective class of therapy and a potential alternative to cabazitaxel.



Advanced Prostate Cancer
Written by Oliver Sartor MD

This is an important trial; congratulations are due to the authors for executing an important prospective randomized study. This is good work.

The study by Michael Hofman and colleagues in Australia compared cabazitaxel with PSMA-617 lutetium-177 and enrolled patients who were considered to be PSMA-positive and, importantly, excluded patients who had FDG PET–discordant lesions.
A total of 291 people were screened for the trial and 91 patients were excluded either because predominantly they had either PSMA uptake that was insufficient for randomization or because they had FDG-discordant disease.

The patients included in the trial had to have failed a previous abiraterone- or enzalutamide-type novel hormonal agent, and progressive disease at the time of trial entry was required.

What was found was interesting in that, by a variety of endpoints including time to PSA progression and PSA response rate, as well as radiographic progression and time to image-based progression, those patients treated with the PSMA lutetium-177 had better outcomes.
Notably missing, however, was adequate survival information, making this trial quite provocative but not definitive, and it will not lead to regulatory approval as it was a randomized phase II trial.

The VISION trial with PSMA lutetium-177 in a similar setting of post abiraterone/ post docetaxel has now completed accrual, and the investigators anticipate having results later in 2021. This is a definitive phase III trial and could lead to regulatory approval should the results be positive.


https://www.practiceupdate.com/c/113763 ... d=20845155
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