High-dose indium 111In pentetreotide radiotherapy for metastatic atypical carcinoid tumor.

Indium In 111 pentetreotide imaging of neuroendocrine tumors that overexpress somatostatin receptors has become standard for localization of these tumors. This radioligand is internalized into the cell and can induce receptor-specific cytotoxicity by emission of Auger electrons. We hypothesized that high-dose 111In-pentetreotide could be therapeutic in patients with somatostatin receptor-expressing tumors. Our 35-year-old patient had atypical carcinoid tumor metastatic to cervical, supraclavicular, mediastinal, and mesenteric lymph nodes and to the liver and bone. Chemotherapy had stabilized the disease but with severe gastrointestinal side effects. After a diagnostic 111In-pentetreotide scan, the patient was given eight courses (180 mCi each) of 111In-pentetreotide therapy to selectively target somatostatin receptor-expressing tumor cells. The disease was stable for approximately 14 months. The patient had two additional courses of 111In-pentetreotide therapy (360 mCi each). She died of the disease approximately 18 months after initiation of 111In-pentetreotide therapy.

Experiences with high dose radiopeptide therapy: the health physics perspective.

One of the new, promising areas of nuclear medicine involves radiolabeled low-molecular-weight peptides for the diagnosis and management of cancer. Somatostatin analogous peptides bind to membrane receptors on tumors with high specificity. These analogues, when radiolabeled with 123I, 131I, 99mTc, or (111)In, allow for external scintigraphic imaging or radioguided surgical resection of tumors. Somatostatin analogues with high tumor binding affinity have also been used for high-dose radiotherapy at the Medical Center of Louisiana since 1994. Although we had extensive prior experience with relatively high-dose 131I administration for thyroid ablation, our personnel protection, contamination control, and other safety techniques required significant modification to ensure effective contamination and radiation exposure control. As therapy with radiolabeled peptides becomes more widely utilized, the controls developed at our institution may be implemented by others to maintain exposures ALARA.

Multiply radioiodinated somatostatin analogs induce receptor-specific cytotoxicity.

BACKGROUND: Radiolabeled somatostatin analogs have gained popularity for tumor imaging and have recently been used for the treatment of somatostatin receptor-expressing tumors. We have developed a novel, N-terminally extended, multiply iodinated somatostatin analog, 125I-WOC 4a, that we hypothesize will be a useful tool for the detection of and therapy for somatostatin receptor-positive tumors. To evaluate the therapeutic potential of this agent, we compared the cytotoxicity of 125I-WOC 4a in a somatostatin receptor subtype-2 (sst 2)-expressing human neurobalstoma cell line to its cytotoxicity in a somatostatin receptor-negative human pancreatic carcinoma cell line. METHODS: IMR-32 neuroblastoma cells (sst 2-positive) and PANC-1 human pancreatic cells (sst 2-negative) were incubated with 125I-WOC 4a at doses ranging from 0.1-100 CPM/cell for 48 h and cell viability was assessed by a colorimetric (MTT) cell viability assay. Subsequently, IMR-32 cells were incubated with either control medium, 125I-WOC 4a (1 cpm/cell) alone, 125I-WOC 4a with 10(-6) M octreotide acetate, 125I (1 cpm/cell) alone, 125I with octreotide acetate, or octreotide acetate alone for 48 h, washed, and cryopreserved for 4 weeks. Cells were then thawed, replated, and allowed to acclimate for 48 h. Cell viability was assessed by trypan blue exclusion and a colorimetric assay. RESULTS: Following short-term exposure, 125I-WOC 4a induced dose-dependent cytotoxicity in IMR-32 cells (P < 0.05 by ANOVA), but not in the PANC-1 cells. After exposure to 125I-WOC 4a (1 cpm/cell) for 48 h followed by a 4-week cryopreserved exposure, significant cytotoxicity was induced in IMR-32 cells (P < 0.05 by ANOVA) which was not seen in cells treated with 125I alone or 125I with 10(-6) M octreotide acetate. Simultaneous exposure to 125I-WOC 4a and octreotide acetate was also cytotoxic. CONCLUSION: 125I-WOC 4a induces receptor-specific cytotoxicity following both short- and long-term drug exposures. This radiopharmaceutical may be useful for localizing or treating somatostatin receptor-positive tumors.

In situ radiotherapy with 111In-pentetreotide: initial observations and future directions.

PURPOSE: Somatostatin and its analogues, such as octreotide and lanreotide, are used to treat neuroendocrine malignancies. Somatostatin analogues bind to somatostatin receptors (sst 1-5), which are differentially expressed in a wide variety of neoplasms. Following ligand receptor binding, a fraction of these complexes internalize. Internalization of radiolabeled somatostatin analogues, especially those that emit Auger electrons, may allow treatment of somatostatin-receptor-positive tumors by delivering a radioactive isotope to the cancer cell in a targeted fashion. 111In-pentetreotide, an sst-2-preferring somatostatin analogue, has been used for scintigraphic evaluation and management of neuroendocrine cancer patients. We hypothesized that binding and internalization of 111In-pentetreotide, an Auger electron emitter, may induce receptor-specific cytotoxicity and could be a useful therapeutic agent in somatostatin-receptor-expressing malignancies. METHODS: To test this hypothesis, subjects who had failed conventional therapy and had somatostatin-receptor-positive malignancies, as determined by positive uptake on a 6.0 mCi 111In-pentetreotide scan, were treated with two monthly 180 mCi intravenous injections of 111In-pentetreotide. CT scans were obtained before therapy and within 30 days following the completion of the second 111In-pentetreotide dose. Toxicity was evaluated using standard criteria. RESULTS: Fourteen patients were studied from February 1997 to August 1997. Clinical benefit occurred in six of 10 gastroenteropancreatic tumor patients. Objective partial radiographic responses occurred in two of 14 patients, and significant tumor necrosis (defined by changes in Hounsfield units) developed in six of the 10 gastroenteropancreatic tumor patients. Possible treatment-related toxicity included two patients experiencing grade 3/4 myelosuppression, and two patients had no measurable toxicity. The most common toxicity was grade 1/2 hemoglobin (N = 6). CONCLUSION: One hundred eighty millicurie (180-mCi) doses of 111In-pentetreotide are well tolerated and are an effective therapy in some subjects with somatostatin receptor-expressing tumors. The maximal tolerated dose of 111In-pentetreotide and the optimal dosing schedules remain to be determined.