Preclinical assessment of strategies for enhancement of metaiodobenzylguanidine therapy of neuroendocrine tumors.

By virtue of its high affinity for the norepinephrine transporter (NET), [(131)I]metaiodobenzylguanidine ([(131)I]MIBG) has been used for the therapy of tumors of neuroectodermal origin for more than 25 years. Although not yet universally adopted, [(131)I]MIBG targeted radiotherapy remains a highly promising means of management of neuroblastoma, pheochromocytoma, and carcinoids. Appreciation of the mode of conveyance of [(131)I]MIBG into malignant cells and of factors that influence the activity of the uptake mechanism has indicated a variety of means of increasing the effectiveness of this type of treatment. Studies in model systems revealed that radiolabeling of MIBG to high specific activity reduced the amount of cold competitor, thereby increasing tumor dose and minimizing pressor effects. Increased radiotoxicity to targeted tumors might also be achieved by the use of the α-particle emitter [(211)At]astatine rather than (131)I as radiolabel. Recently it has been demonstrated that potent cytotoxic bystander effects were induced by [(131)I]MIBG, [(123)I]MIBG, and [(211)At]meta-astatobenzylguanidine. Discovery of the structure of bystander factors could increase the therapeutic ratio achievable by MIBG targeted radiotherapy. [(131)I]MIBG combined with topotecan produced supra-additive cytotoxicity in vitro and tumor growth delay in vivo. The enhanced antitumor effect was consistent with a failure to repair DNA damage. Initial findings suggest that further enhancement of efficacy might be achieved by triple combination therapy with drugs that disrupt alternative tumor-specific pathways and synergize not only with [(131)I]MIBG abut also with topotecan. With these ploys, it is expected that advances will be made toward the optimization of [(131)I]MIBG therapy of neuroectodermal tumors.

Optimizing MIBG therapy of neuroendocrine tumors: preclinical evidence of dose maximization and synergy.

[(131)I]meta-Iodobenzylguanidine ([(131)I]MIBG) has been used for the therapy of tumors of neuroectodermal origin since the 1980s. Its role in the management of these malignancies remains controversial because of the large variation in response rates. Appreciation of the mode of conveyance of [(131)I]MIBG via the noradrenaline transporter into malignant cells and of factors that influence the activity of the uptake mechanism has indicated various ways in which the effectiveness of this type of targeted radiotherapy may be improved. Experimental observations indicate that radiolabeling of MIBG to high specific activity reduced the amount of cold competitor, thereby increasing tumor dose and minimizing pressor effects. We observed supra-additive tumor cell kill and inhibition of tumor growth following combined topotecan and [(131)I]MIBG treatment. The improved efficacy is related to topotecan's increased disruption of DNA repair. Radiation damage to targeted tumors may also be enhanced by the use of the alpha-particle emitter [(211)At]astatine rather than (131)I as radiolabel. Furthermore, recent experimental findings indicate that [(123)I]MIBG may have therapeutic potential over and above its utility as an imaging agent. It has recently been demonstrated that potent cytotoxic bystander effects were induced by the intracellular concentration of [(131)I]MIBG, [(123)I]MIBG or meta-[(211)At]astatobenzylguanidine. Identification of the nature of bystander factors could be exploited to maximize the specificity and potency of MIBG-targeted radiotherapy. By employing a range of strategies, there are good prospects for the improvement of the [(131)I]MIBG therapy of neuroectodermal tumors.

Feasibility of dosimetry-based high-dose 131I-meta-iodobenzylguanidine with topotecan as a radiosensitizer in children with metastatic neuroblastoma.

INTRODUCTION: (131)I-meta iodobenzylguanidine ((131)I-mIBG) therapy is established palliation for relapsed neuroblastoma. The topoisomerase-1 inhibitor, topotecan, has direct activity against neuroblastoma and acts as a radiation sensitiser. These 2 treatments are synergistic in laboratory studies. Theoretically, the benefit of (131)I-mIBG treatment could be enhanced by dose escalation and combination with topotecan. Haematological support would be necessary to overcome the myelosuppression, which is the dose-limiting toxicity. AIMS: Firstly, one aim of this study was to establish whether in vivo dosimetry could be used to guide the delivery of a precise total whole-body radiation-absorbed dose of 4 Gy accurately from 2 (131)I-mIBG treatments. Secondly, the other aim of this study was to determine whether it is feasible to combine this treatment with the topotecan in children with metastatic neuroblastoma. MATERIAL AND METHODS: An activity of (131)I-mIBG (12 mCi/kg, 444 MBq/kg), estimated to give a whole-body absorbed-radiation dose of approximately 2 Gy, was administered on day 1, with topotecan 0.7 mg/m(2) administered daily from days 1-5. In vivo dosimetry was used to calculate a 2nd activity of (131)I-mIBG, to be given on day 15 which would give a total whole-body dose of 4 Gy. A further 5 doses of topotecan were given from days 15-19. The myeloablative effect of this regimen was circumvented by peripheral blood stem cell or bone marrow support. RESULTS: Eight children with relapsed stage IV neuroblastoma were treated. The treatment was delivered according to protocol in all patients. There were no unanticipated side-effects. Satisfactory haematological reconstitution occurred in all patients. The measured total whole-body radiation-absorbed dose ranged from 3.7 Gy to 4.7 Gy (mean, 4.2 Gy). CONCLUSIONS: In vivo dosimetry allows for a specified total whole-body radiation dose to be delivered accurately. This schedule of intensification of (131)I-mIBG therapy by dose escalation and radiosensitization with topotecan with a haemopoietic autograft is safe and practicable. This approach should now be tested for efficacy in a phase II clinical trial.

Development of a real-time polymerase chain reaction assay for prediction of the uptake of meta-[(131)I]iodobenzylguanidine by neuroblastoma tumors.

PURPOSE: The suitability of neuroblastoma patients for therapy using radiolabeled meta-iodobenzylguanidine (MIBG) is determined by scintigraphy after the administration of a tracer dose of radioiodinated MIBG whose uptake is dependent upon the cellular expression of the noradrenaline transporter (NAT). As a possible alternative to gamma camera imaging, we developed a novel molecular assay of NAT expression. mRNA extracted from neuroblastoma biopsy samples, obtained retrospectively, was reverse transcribed, and NAT-specific cDNA was quantified by real-time PCR, referenced against the expression of the housekeeping gene glyceraldehyde-3-phosphate dehydrogenase. EXPERMENTAL DESIGN: Tumor specimens from 54 neuroblastoma patients were analyzed using real-time PCR, and NAT expression was compared with the corresponding diagnostic scintigrams. RESULTS: Forty-eight of 54 (89%) of tumors showed MIBG uptake by scintigraphy. NAT expression was found to be significantly associated with MIBG uptake (P < 0.0001, Fisher's exact test). None of the samples from the six tumors that failed to concentrate MIBG expressed detectable levels of the NAT (specificity = 1.0). However, of the 48 MIBG uptake-positive tumors, only 43 (90%) expressed NAT (sensitivity = 0.9). The real-time PCR test has a positive predictive value of 1.0 but a negative predictive value of 0.55. CONCLUSIONS: The results indicate that whereas this method has substantial ability to predict the capacity of neuroblastoma tumors to accumulate MIBG, confirmation is required in prospective studies to determine more accurately the predictive strength of the test and its role in the management of patients with neuroblastoma.