Nephrotoxicity after radionuclide therapies

Radioligand therapies have opened new treatment avenues for cancer patients. They offer precise tumor targeting with a favorable efficacy-to-toxicity profile. Specifically, the kidneys, once regarded as the critical organ for radiation toxicity, also show excellent tolerance to radiation doses as high as 50–60 Gy in selected cases. However, the number of nephrons that form the structural and functional units of the kidney is determined before birth and is fixed. Thus, loss of nephrons secondary to any injury may lead to an irreversible decline in renal function over time. Our primary understanding of radiation-induced nephropathy is derived from the effects of external beam radiation on the renal tissue. With the growing adoption of radionuclide therapies, considerable evidence has been gained with regard to the occurrence of renal toxicity and its associated risk factors. In this review, we discuss the radionuclide therapies associated with the risk of nephrotoxicity, the present understanding of the factors and mechanisms that contribute to renal injury, and the current and potential methods for preventing, identifying, and managing nephrotoxicity, specifically acute onset nephropathies.     

Radiation induces apoptosis primarily through the intrinsic pathway in mammalian cells

Radiation-induced tumor cells death is the theoretical basis of tumor radiotherapy. Death signaling disorder is the most important factor for radioresistance. However, the signaling pathway(s) leading to radiation-triggered cell death is (are) still not completely known. To better understand the cell death signaling induced by radiation, the immortalized mouse embryonic fibroblast (MEF) deficient in “initiator” caspases, “effector” caspases or different Bcl-2 family proteins together with human colon carcinoma cell HCT116 were used. Our data indicated that radiation selectively induced the activation of caspase-9 and caspase-3/7 but not caspase-8 by triggering mitochondrial outer membrane permeabilization (MOMP). Importantly, the role of radiation in MOMP is independent of the activation of both “initiator” and “effector” caspases. Furthermore, both proapoptotic and antiapoptotic Bcl-2 family proteins were involved in radiation-induced apoptotic signaling. Overall, our study indicated that radiation specifically triggered the intrinsic apoptotic signaling pathway through Bcl-2 family protein-dependent mitochondrial permeabilization, which indicates targeting mitochondria is a promising strategy for cancer radiotherapy.     

Synthesis and biological evaluation of PSMA-targeting paclitaxel conjugates

Prostate cancer (PC) is the second most commonly occurring cancer in men. Conventional chemotherapy has wide variety of disadvantages such as high systemic toxicity and low selectivity. Targeted drug delivery is a promising approach to decrease side effects of therapy. Prostate specific membrane antigen (PSMA) is overexpressed in prostate cancer cells while low level of expression is observed in normal cells. In this study we describe the development of Glu-urea-Lys based PSMA-targeting conjugates with paclitaxel. A series of new PSMA targeting conjugates with paclitaxel was designed and synthesized. The cytotoxicity of conjugates was evaluated against prostate (LNCaP, 22Rv1 and PC-3) and non-prostate (Hek293T, VA13, A549 and MCF-7) cell lines. The most promising conjugate 21 was examined in vivo using 22Rv1 xenograft mice model. It demonstrated good efficiency comparable with paclitaxel, while reduced toxicity. 3D molecular docking study was also performed to understand underlying mechanism of binding and further optimization of the linker substructure and conjugates structure for improving the target affinity. These conjugates may be useful for further design of novel PSMA targeting delivery systems for PC.     

Optimum combination of targeted 131I therapy and total-body irradiation for treatment of disseminated tumors of differing radiosensitivity.

131I is the radionuclide most commonly used in biologically targeted radiotherapy at the present time. Microdosimetric analysis has shown that microtumors whose diameters are less than the beta-particle maximum range absorb radiation energy inefficiently from targeted radionuclides. Micrometastases of diameters < 1 mm are likely to be spared if targeted 131I is used as a single modality. Because of this, combined modality therapy incorporating targeted 131I, external beam total-body irradiation (TBI), and bone marrow rescue has been proposed. In this study, the minimum necessary TBI component is shown to depend on the radiosensitivity of the tumor cells. The analysis shows that the TBI component, to achieve radiocurability, increases directly with tumor radioresistance. For the most radiosensitive tumors, a whole-body TBI treatment dose 2 x 2 Gy is calculated to be obligatory, whereas practical arguments exist in favor of higher doses. For more radioresistant tumors, the analysis implies that a TBI treatment delivery of 5 x 2 Gy is obligatory. In all situations, external beam TBI appears to be an essential factor in providing reasonable probability of cure of disseminated malignant disease. Reasonable prospects of tumor cure by combination strategies incorporating 131I exist for the more radiosensitive tumor types (e.g., neuroblastoma, lymphoma, leukemia, myeloma, seminoma), but more resistant tumors are unlikely to be curable at present. Superior targeting agents, and the possible use of panels of different radionuclides, may be necessary to achieve high cure probabilities for less radiosensitive tumor types.     

Genome-wide CRISPR/Cas9 screening identifies CARHSP1 responsible for radiation resistance in glioblastoma

Glioblastomas (GBM) is the most common primary malignant brain tumor, and radiotherapy plays a critical role in its therapeutic management. Unfortunately, the development of radioresistance is universal. Here, we identified calcium-regulated heat-stable protein 1 (CARHSP1) as a critical driver for radioresistance utilizing genome-wide CRISPR activation screening. This is a protein with a cold-shock domain (CSD)-containing that is highly similar to cold-shock proteins. CARHSP1 mRNA level was upregulated in irradiation-resistant GBM cells and knockdown of CARHSP1 sensitized GBM cells to radiotherapy. The high expression of CARHSP1 upon radiation might mediate radioresistance by activating the inflammatory signaling pathway. More importantly, patients with high levels of CARHSP1 had poorer survival when treated with radiotherapy. Collectively, our findings suggested that targeting the CARHSP1/TNF-α inflammatory signaling activation induced by radiotherapy might directly affect radioresistance and present an attractive therapeutic target for GBM, particularly for patients with high levels of CARHSP1.Subject terms: Tumour biomarkers, Glial biology     

Intérêt des traceurs de l’hypoxie en radiothérapie

Tumor hypoxia is a major parameter of radioresistance. Hypoxia PET imaging using several radiotracers (F-Miso, FAZA, Cu-ATSM, EF5…) may help predict response to radiotherapy. Hypoxic area evaluation may also help select patients for hypoxia-targeting drugs, and thus reinforcing radiotherapy effects. Hypoxia imaging may also be fused with radiotherapy planning CT to define radioresistance areas that may be boosted by dose-painting radiotherapy. Despite several difficulties (patient positioning, organ and tumor motion, image definition…), targeting hypoxic regions within tumors is one of the most promising research strategies of modern radiotherapy.     

The Use of Liposomes as Carriers of Lipophilic Anthracycline Antibiotics

Abstract

Tumor drug resistance and lack of tumor selectivity are the two main limitations of current systemic anticancer therapy. Liposomes have been shown to decrease certain doxorubicin (Dox)-related toxicities. By modifying liposome size and composition, the tumor localization of liposome entrapped drugs can be greatly enhanced. Through extensive structure-activity studies aimed at identifying anthracycline antibiotics which combine an enhanced affinity for lipid membranes and an ability to overcome multidrug resistance (MDR), we have identified Annamycin (Ann), which is ideally suited for entrapment in liposomes of different size and composition and has shown remarkable in vivo antitumor activity in different tumor models that display natural or acquired resistance to Dox. The unprecedented liposome formulation flexibility offered by Ann is expected to facilitate current efforts aimed at developing pharmaceutically acceptable liposomal-Ann formulations with optimal tumor targeting properties.     

Potential for improvement in clinical decision-making: tumor imaging with in-111 labeled liposomes results of a phase ii-iii study

Abstract

Liposome scanning using In- 111 labeled VS102 liposomes (VesCan^R) has previously been shown to image a wide variety of common human tumors, probably related to tumor neovascular capIIIary fenestrations and binding of liposomes to tumor cells. We further tested In-III VS102 liposomes in a Phase II trial (27 patients) and a Phase III trial (38 patients). The sensitivity for detecting tumors in primary sites was 82% and in metastatic sites was 65% at the recommended lipid dose of 100 mg. There was 1 false positive scan (specificity 98%). Tumors which have been imaged include carcinomas of the breast, lung, head-neck, prostate, colon, ovary, cervix, thyroid, kidney, testes, melanoma, sarcoma and lymphoma. Sites imaged have included soft tissue, breast, mediastinum, bone, lung, lymph node, liver and pelvis. We also describe five patients in whom a In-111 liposome scan was performed in addition to standard tests, and in whom therapy plans were changed by use of liposome scan results. In two instances, no therapy would have been given without In-III liposome scan, but chemotherapy or radiotherapy were used based on liposome scan results and confirmatory tests. In one patient, surgery would have been used in the absence of In-III liposome scans, versus radiotherapy with In-III liposome scan results. In two other patients, palliative radiotherapy or chemotherapy would have been given without In-111 liposome scan. One of the patients would have required further therapy and the other needed curative surgery after liposome scan evaluation. These results suggest In-111 liposome scans may be useful to complement standard diagnostic tests in cancer patient management.     

Antiangiogenic and radiotherapy for cancer treatment

Tumor growth and progression depends on tumor angiogenesis, the growth of tumor blood vessels, therefore, targeting tumor angiogenesis is a very promising approach for controlling tumor growth and/or causing regression. Tumor blood vessels have been recognized as a critical component of radiation response to the point of being independent of tumor oxygenation during radiation. An anti-angiogenic approach has been considered less likely to develop drug resistance. But recent findings suggest that anti-angiogenesis causes hypoxia that selects tumor cells (due to genetic instability) that are less dependent on blood supply and leads to drug resistance. The approach of combination of anti-angiogenesis with ionizing radiation by targeting both endothelial and tumor cells should minimize this possibility. The combination may produce a synergistic anti-tumor effect.     

Radiomodulatory effect of liposome encapsulated AK-2123 on tumor in mice exposed to hepatocarcinogen

An attempt was made to evaluate the whole body -radiation effect on tumor in the presence of free and liposome encapsulated AK-2123, a hypoxic cell radiosensitizer that has widely been used in combination with a number of cancer therapies such as thermotherapy, chemotherapy and radiotherapy. Entrapment efficiency of AK-2123 into liposome was determined by LASER Raman spectroscopy. Cancer induction in mice was carried out by repeated exposure of N-nitrosodiethylamine (DEN) in combination with partial hepatectomy. Parameters such as marker enzymes activities (GGT and AChE), rates of nucleic acid synthesis, viability modification factor and the histology of liver tissues monitored, supported the induction of cancer in liver. In addition, the effect of free as well as liposome encapsulated AK-2123 on haemopoietic parameters were also studied. It was observed that AK-2123 after incorporation into liposome afforded more efficient radiomodulatory effects than that of free AK-2123 as determined by the above-mentioned parameters. Neither free AK-2123 nor liposome encapsulated AK-2123 showed any detectable toxic effects on the mice. Thus, it is seen that treatment of cancer with a combination of radiation, a radiomodifier and a drug delivery system, opens a wide scope for exploitation for the improvement of existing cancer therapies. (Mol Cell Biochem 271: 139–150, 2005)     

Controlled Administration of Penicillamine Reduces Radiation Exposure in Critical Organs during 64Cu-ATSM Internal Radiotherapy: A Novel Strategy for Liver Protection

Purpose

⁶⁴Cu-diacetyl-bis (N ⁴-methylthiosemicarbazone) (⁶⁴Cu-ATSM) is a promising theranostic agent that targets hypoxic regions in tumors related to malignant characteristics. Its diagnostic usefulness has been recognized in clinical studies. Internal radiotherapy (IRT) with ⁶⁴Cu-ATSM is reportedly effective in preclinical studies; however, for clinical applications, improvements to reduce radiation exposure in non-target organs, particularly the liver, are required. We developed a strategy to reduce radiation doses to critical organs while preserving tumor radiation doses by controlled administration of copper chelator penicillamine during ⁶⁴Cu-ATSM IRT.

Methods

Biodistribution was evaluated in HT-29 tumor-bearing mice injected with ⁶⁴Cu-ATSM (185 kBq) with or without oral penicillamine administration. The appropriate injection interval between ⁶⁴Cu-ATSM and penicillamine was determined. Then, the optimal penicillamine administration schedule was selected from single (100, 300, and 500 mg/kg) and fractionated doses (100 mg/kg×3 at 1- or 2-h intervals from 1 h after ⁶⁴Cu-ATSM injection). PET imaging was performed to confirm the effect of penicillamine with a therapeutic ⁶⁴Cu-ATSM dose (37 MBq). Dosimetry analysis was performed to estimate human absorbed doses.

Results

Penicillamine reduced ⁶⁴Cu accumulation in the liver and small intestine. Tumor uptake was not affected by penicillamine administration at 1 h after ⁶⁴Cu-ATSM injection, when radioactivity was almost cleared from the blood and tumor uptake had plateaued. Of the single doses, 300 mg/kg was most effective. Fractionated administration at 2-h intervals further decreased liver accumulation at later time points. PET indicated that penicillamine acts similarly with the therapeutic ⁶⁴Cu-ATSM dose. Dosimetry demonstrated that appropriately scheduled penicillamine administration reduced radiation doses to critical organs (liver, ovaries, and red marrow) below tolerance levels. Laxatives reduced radiation doses to the large intestine.

Conclusions

We developed a novel strategy to reduce radiation exposure in critical organs during ⁶⁴Cu-ATSM IRT, thus promoting its clinical applications. This method could be beneficial for other ⁶⁴Cu-labeled compounds.     

Normal tissue complication probability models for severe acute radiological lung injury after radiotherapy for lung cancer

PurposeTo derive Normal Tissue Complication Probability (NTCP) models for severe patterns of early radiological radiation-induced lung injury (RRLI) in patients treated with radiotherapy (RT) for lung tumors. Second, derive threshold doses and optimal doses for prediction of RRLI to be used in differential diagnosis of tumor recurrence from RRLI during follow-up.Methods and materialsLyman-EUD (LEUD), Logit-EUD (LogEUD), relative seriality (RS) and critical volume (CV) NTCP models, with DVH corrected for fraction size, were used to model the presence of severe early RRLI in follow-up CTs. The models parameters, including α/β, were determined by fitting data from forty-five patients treated with IMRT for lung cancer. Models were assessed using Akaike information criterion (AIC) and area under receiver operating characteristic curve (AUC). Threshold doses for risk of RRLI and doses corresponding to the optimal point of the receiver operating characteristic (ROC) curve were determined.ResultsThe α/βs obtained with different models were 2.7–3.2 Gy. The thresholds and optimal doses curves were EUDs of 3.2–7.8 Gy and 15.2–18.1 Gy with LEUD, LogEUD and RS models, and μ_d of 0.013 and 0.071 with the CV model. NTCP models had AUCs significantly higher than 0.5. Occurrence and severity of RRLI were correlated with patients’ values of EUD and μ_d.ConclusionsThe models and dose levels derived can be used in differential diagnosis of tumor recurrence from RRLI in patients treated with RT. Cross validation is needed to prove prediction performance of the model outside the dataset from which it was derived.     

Advancing role of radiolabeled antibodies in the therapy of cancer

This review focuses on the use of radiolabeled antibodies in the therapy of cancer, termed radioimmunotherapy (RAIT). Basic problems concerned with the choice of antibody, radionuclide, and physiology of the tumor and host are discussed, followed by a review of the pertinent clinical publications of various radioantibody constructs in the treatment of hematopoietic and solid tumors of diverse histopathology, grade, and stage, and in different clinical settings. Factors such as dose rate delivered, tumor size, and radiosensitivity play a major role in determining therapeutic response, while target-to-nontarget ratios and, particularly, circulating radioactivity to the bone marrow determine the principal dose-limiting toxicities. RAIT appears to be gaining a place in the therapy of hematopoietic neoplasms, such as non-Hodgkin's lymphoma: several agents are advancing in clinical trials toward registration, and one has recently been approved by the FDA. Although RAIT of solid tumors has shown less progress, use of pretargeting strategies, such as an affinity-enhancement system consisting of bispecific antibodies separating targeting from delivery of the radiotherapeutic, appears to enhance tumor-to-nontumor ratios, and may increase radiation doses to tumors more selectively than directly labeled antibodies.     

Folate-Targeted Liposomes for Drug Delivery

Abstract

The folate receptor has been identified as a marker for ovarian carcinomas and is also up-regulated in many other types of cancer. Folate-conjugation has been successfully applied in the tumor cell-selective targeting of liposomes. A long polyethyleneglycol (PEG) spacer between the targeting ligand (i.e. folic acid) and the liposome surface is required for receptor recognition. Ligand binding is compatible with the PEG-coating of the liposomes needed for prolonged systemic circulation. Folate-targeted liposomes have been shown to enhance the in vitro cytotoxicity of liposome-entrapped doxorubicin and antisense oligodeoxynucleotides to receptor-bearing tumor cells. Folate, as a targeting ligand, offers unique advantages over immunoliposomes, i.e., easy liposomal incorporation, low cost, high receptor affinity and tumor specificity, extended stability, and potential lack of immunogenicity.     

三维适形放疗与调强放疗对晚期非小细胞肺癌患者血清肿瘤标志物及剂量学参数比较研究

目的:对比晚期非小细胞肺癌患者经三维适形放疗(3D-CRT)与调强放疗(IMRT)后,其血清肿瘤标志物及剂量学参数的变化。方法:选择2015年1月-2016年12月期间我院收治的非小细胞肺癌患者120例,根据放疗方案将其分为IMRT组60例与3D-CRT组60例。比较两组临床疗效、药物毒副反应、1年内的生存率、放射剂量参数,以及治疗前与治疗后血清肿瘤标志物的变化。结果:IMRT组治疗的总有效率与3D-CRT组对比差异无统计学意义(P0.05)。IMRT组血小板减少、Ⅲ度放射性食管炎、Ⅲ度消化道反应、Ⅲ度放射性肺炎、Ⅲ度白细胞减少的发生率均低于3D-CRT组(P0.05)。IMRT组1年内的生存率90.00%,高于3D-CRT组的75.00%(P0.05)。IMRT组CI值与HI值均高于3D-CRT组(P0.05),IMRT组与3D-CRT组平均剂量对比差异无统计学意义(P0.05)。治疗后两组鳞状细胞癌抗原(SCC)、细胞角蛋白19片段抗原21-1(CYFRA21-1)与肿瘤特异性生长因子(TSGF)水平均显著降低,且IMRT组低于3D-CRT组(P0.05)。结论:IMRT与3D-CRT对于晚期非小细胞肺癌患者的临床疗效相当,但IMRT药物毒副反应少、放射剂量低,可能通过控制肿瘤来降低肿瘤标志物水平。     

Site-specific conjugation allows modulation of click reaction stoichiometry for pretargeted SPECT imaging

ABSTRACT

Antibody pretargeting is a promising strategy for improving molecular imaging, wherein the separation in time of antibody targeting and radiolabeling can lead to rapid attainment of high contrast, potentially increased sensitivity, and reduced patient radiation exposure. The inverse electron demand Diels-Alder ‘click’ reaction between trans-cyclooctene (TCO) conjugated antibodies and radiolabeled tetrazines presents an ideal platform for pretargeted imaging due to rapid reaction kinetics, bioorthogonality, and potential for optimization of both slow and fast clearing components. Herein, we evaluated a series of anti-human epidermal growth factor receptor 2 (HER2) pretargeting antibodies containing distinct molar ratios of site-specifically incorporated TCO. The effect of stoichiometry on tissue distribution was assessed for pretargeting TCO-modified antibodies (monitored by ¹²⁵I) and subsequent accumulation of an ¹¹¹In-labeled tetrazine in a therapeutically relevant HER2+tumor-bearing mouse model. Single photon emission computed tomography (SPECT) imaging was also employed to assess tumor imaging at various TCO-to-monoclonal antibody (mAb) ratios. Increasing TCO-to-mAb molar ratios correlated with increased in vivo click reaction efficiency evident by increased tumor distribution and systemic exposure of ¹¹¹In-labeled tetrazines. The pharmacokinetics of TCO-modified antibodies did not vary with stoichiometry. Pretargeted SPECT imaging of HER2-expressing tumors using ¹¹¹In-labeled tetrazine demonstrated robust click reaction with circulating antibody at ~2 hours and good tumor delineation for both the 2 and 6 TCO-to-mAb ratio variants at 24 hours, consistent with a limited cell-surface pool of pretargeted antibody and benefit from further distribution and internalization. To our knowledge, this represents the first reported systematic analysis of how pretargeted imaging is affected solely by variation in click reaction stoichiometry through site-specific conjugation chemistry.     

Recent advances in clinical studies of selenium supplementation in radiotherapy

BackgroundRadiotherapy is one of the most important and common therapies for cancer patients. Selenium has been shown to be capable of reducing the side effects of radiotherapy because selenoproteins have anti-oxidative functions against reactive oxygen species that are induced by the radiation. They also function in DNA-repair and cytokine control.PurposeWe explored the benefits and risks of selenium supplementation in radiotherapy in our previous review to establish guidelines. In the current study, we expanded the search to cover recent advances in clinical studies of selenium supplementation in radiotherapy.MethodsWe conducted an initial screening in the PubMed using the MeSH terms and keywords “selenium”, “radiation”, “therapy”, and “radiotherapy” using the same methodology applied in our previous review. We identified 121 articles published between January 2013 and December 2019. We then identified eight articles (six studies) on selenium and radiotherapy by excluding 113 articles.ResultsIn selenium supplementation studies, selenium doses of 300−500 μg/day with duration of 10 days to 6 months were used. Selenium supplementation improved the selenium nutritional conditions of the patients and reduced the side effects of radiotherapy. Selenium supplementation did not reduce the effectiveness of radiotherapy, and no toxicities were reported.ConclusionThe results of our previous and current reviews showed that selenium supplementation offers specific benefits for several cancer types treated with radiotherapy. Here, we suggest a new guideline for selenium supplementation in radiotherapy. We recommend determining the selenium status of the patients before radiotherapy, and in cases of deficiency (<100 μg/L serum selenium level), selenium supplement can be beneficial.     

Adaptive radiotherapy in patients receiving neoadjuvant radiation for soft tissue sarcoma

AimThe aim of this study is to evaluate tumor volume changes during preoperative radiotherapy and to assess the role of adaptive radiation.BackgroundContemporary neoadjuvant radiotherapy utilizes image guidance for precise treatment delivery. Moreover, it may depict changes in tumor size and shape.Materials and methodsBetween 2016 and 2018, 23 patients aged ≥18 years with soft tissue sarcoma were treated with neoadjuvant radiation followed by surgical resection. The tumor volumes (cc) were measured using the Pinnacle planning system prior to starting radiotherapy and during treatment, the changes in volume and absolute differences were estimated. Moreover, patient's position on the machine was evaluated to assess setup offsets. The triggers for plan adaptation were >1 cm expansion or unacceptable setup offsets.ResultsThe mean tumors volume at presentation was 810 cc (range, 55–4000). At last cone beam CT the tumor volume had changed in 14 patients (61%); it was stable in nine patients (39%). Disease regression was documented in eight patients (35%), with median shrinkage of −20.5% (range, −2 to −29%), while tumor progression was observed in six cases (26%), the median change was 12.5% (range, +10 to +25%).Adaptive radiation was required in four patients (17%). For the remaining 19 cases (83%), the dose distribution was adequate to cover target volumes.ConclusionsChange in soft tissue sarcoma volume during radiation is not uncommon. Image guidance should be used to reduce setup errors and to detect differences in tumor volume. Image guidance and adaptive radiation are paramount to ensure optimal radiation delivery.