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The Effectiveness of Therapeutic Radionuclides (Lutetium-177) for Prostate Cancer

The Effectiveness of Therapeutic Radionuclides (Lutetium-177) for Prostate Cancer

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One of the reports at the final meeting of the reputable Society of Nuclear Medicine and Molecular Imaging (SNMMI) in 2019 was completely devoted to the use of...

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One of the reports at the final meeting of the reputable Society of Nuclear Medicine and Molecular Imaging (SNMMI) [1] in 2019 was completely devoted to the use of Lutetium-177 PSMA targeted therapy for prostate cancer. For the last 10 years, the number of clinical trials concerning the effectiveness and safety of this technique has increased 6-fold – from 17 trials in 2010 to more than 110 ones in 2019. Nowadays, peptide receptor radionuclide therapy (PRRT) is part of the protocol for the high-tech treatment of advanced prostate cancer and it is applied in leading medical facilities in the world. According to statistics obtained during the relevant international VISION and LuPSMA trials, the use of Lutetium-177 leads to a significant improvement in the results of laboratory tests and PET-CT (more than 57% of patients), and also improves quality (more than 70% of patients) and expectancy of life (more than 45% of patients).

 

Lutetium-177
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Indications for Lutetium-177 PSMA therapy

According to modern protocols for prostate cancer treatment, Lutetium-177 PSMA therapy is used as the second-line therapy, when the surgical and medical options have already exhausted themselves. This is due to the unique mechanism of action of this technique. Radioactive Lutetium is delivered to the tumor cells by a special PSMA-617 molecule carrier, developed by specialists from the University Hospital Heidelberg and the German Cancer Research Center. Many oncologists prescribe Lutetium-177 PSMA therapy in the following clinical cases:

  1. Metastatic prostate cancer, including bone and lymph node lesions
  2. Prostate cancer recurrence after surgical treatment and / or chemotherapy
  3. Tumor resistance to chemotherapy drugs when applying several treatment regimens
  4. Tumor resistance to hormone therapy (castrate-resistant cancer)
  5. The presence of absolute contraindications for surgery or pharmacotherapy (the general health condition of a man does not allow him to undergo surgery or take aggressive pharmacological drugs)

One of the important conditions for achieving high treatment efficacy is good expression of PSMA receptors by tumor cells. The high density of PSMA receptors on the surface of cells of the primary tumor and metastases is a guarantee that they will accumulate radioactive Lutetium during the procedure and subsequently receive a high dose of radiation. Unfortunately, in the case of development of certain mutations, cancer cells lose their membrane receptor for PSMA. In such cases, peptide receptor radionuclide therapy cannot be carried out.

To assess the expression of the necessary receptors, the patient undergoes PSMA PET/CT with radioactive isotope prior to his treatment. The radionuclide firmly binds to atypical cells, thereby making them visible on the tomogram. PSMA PET/CT can be used for the clarifying and differential diagnostics of prostate cancer, the detection of distant metastases and the selection of treatment tactics. In addition, radioactive isotope disintegrates very quickly, so the patient can leave the hospital just upon the procedure completion, without mandatory isolation in a specialized department.

Helios Hospital Berlin-Buch specializes in conducting preliminary diagnostic examinations and PSMA therapy with Lutetium-177. The hospital has the Oncology Center Berlin-Buch that is certified according to the strict standards of the German Cancer Society. The center's specialists demonstrate high rates of success in radionuclide therapy for advanced prostate cancer, in particular, thanks to active interdisciplinary collaboration.

Comparison of the effectiveness of Lutetium-177 PSMA therapy and other treatment methods (VISION trial)

Lutetium-177 is selected as the main radionuclide for targeted therapy of prostate cancer because of its properties, such as high affinity and firm binding to PSMA, prolonged accumulation in the tumor and metastases, high rate of excretion through the kidneys (high renal clearance). In the nearest future, the 3rd phase of extensive international clinical trial VISION [2] will be completed. This is a prospective, multicenter, randomized trial of the use of Lutetium-177 PSMA in the treatment of patients with metastatic castration-resistant prostate cancer. The researchers set themselves the goal of comparing the duration and quality of life of men with prostate cancer during the treatment by means of Lutetium-177 PSMA and in the case of standard treatment (including surgery, radiation therapy, chemotherapy and the use of hormonal drugs).

For the participation in the VISION trial, the patients must meet the following requirements:

  • Age over 18 years
  • Histological or cytological verification of diagnosis
  • Laboratory (high PSA level) or imaging (ultrasound, tomography, skeletal scintigraphy) confirmation of cancer progression, the presence of at least 1 metastatic focus
  • High density of PSMA receptors according to the results of PSMA PET/CT
  • Assessment according to ECOG scale from 0 to 2 (the scale comprehensively assesses the general condition of the cancer patient)
  • Life expectancy of more than 6 months

Each patient underwent from 1 to 6 treatment procedures using Lutetium-177 PSMA, with a 6-week interval between treatment courses. The average total dose of Lutetium-177 was 7.4 GBq (200 mCi). Upon the treatment course completion, the researchers compared patients from the group, which received Lutetium-177 therapy, with patients from the standard treatment group. The comparison was carried out according to the following criteria:

  • Biochemical response to treatment (PSA, alkaline phosphatase, lactate dehydrogenase levels)
  • Radiological response to treatment (scintigraphy, radiography, CT scan)
  • Quality of life
  • Life expectancy without disease progression
  • Safety and tolerability of treatment
  • Cost-effective treatment

The trial involves more than 750 patients from 9 countries (USA, Canada, Sweden, Germany, Israel, Belgium and others). According to the design of the trial [3], its final results will be published in May 2021. Nevertheless, the intermediate results demonstrate that Lutetium-177 PSMA therapy leads to a significant improvement in biochemical and radiological parameters, improves the quality and general life expectancy of patients with metastatic prostate cancer. Radionuclide therapy is also more cost-effective as it reduces the total cost of treatment and the duration of hospital stay.

 

Lutetium-177 PSMA therapy
(c) depositphotos

 

Case report

Patient Igor Buravkin, 51 years old, Russia. A prostate tumor was diagnosed during an examination for pain in the pelvic bones and spine. At the time of diagnostics, the man had more than 10 bone metastases and they caused pathological spinal compression fracture in the lumbar spine. After laboratory diagnostics (PSA levels reached 17 ng/ml) and a puncture biopsy of the prostate at 6 loci, the diagnosis was confirmed. The combined treatment regimen by means of antiandrogens, 5-α-reductase inhibitors and bisphosphonates according to the approved standards did not bring the desired result – the vertebrae continued to deteriorate due to the growth of metastases. Taking into account the high risk of recurrent fractures and the general health condition, the patient was recommended the targeted radionuclide therapy with Lutetium-177. The technical base of the hospitals in his country did not allow the doctors to carry out the procedure at the required level, so the patient turned to foreign hospitals, namely, Charite University Hospital Berlin (Germany) and University Hospital Carl Gustav Carus Dresden (Germany). A man underwent the full course of Lutetium-177 PSMA therapy (3 procedures with a 6-week interval) and currently he is being prepared for a minimally invasive intervention on the spine for the restoration of vertebral bodies, which were destroyed by the disease. According to the results of follow-up imaging examinations (PSMA PET/CT), the growth of metastatic lesions stopped. The mineral density of bone tissue also increased significantly, which minimized the risk of recurrent pathological vertebral fractures.

 

The use of Lutetium-177 in resistance to hormones and chemotherapy (LuPSMA trial)

Another clinical trial called LuPSMA [4] studied the effectiveness of Lutetium-177 PSMA therapy. It was carried out in patients who did not have positive dynamics from the use of anti-hormonal agents and chemotherapy. The LuPSMA intervention trial lasted 3 years and was carried out in accordance with the requirements of ANZCTR (Australian New Zealand Clinical Trials Registry). It was carried out in patients who met the following requirements:

  • Age over 18 years
  • Life expectancy of more than 12 weeks
  • Histologically confirmed prostate adenocarcinoma by biopsy or examination of material, which was removed during surgical intervention
  • Ineffectiveness of treatment by means of chemotherapy drugs from the taxane group and hormonal anticancer drugs
  • Significant progression of the disease over the past 12 months according to the results of PET-CT (occurrence of 2 or more new metastatic foci in the bones) or the progression of pain syndrome
  • ECOG (Eastern Cooperative Oncology Group) scale score is less than 2 points

During LuPSMA trial, all men underwent four Lutetium-177 therapy procedures. To better assess the response to treatment, the procedures were carried out with 6-week interval. The total radiation dose was determined depending on the weight of the patient, the activity of the tumor process and renal function; on average, it was 4-8 GBq. After each administration of the drug, the patients underwent quantitative SPECT / CT, according to the results, the specialists determined the degree of irradiation of the tumor and healthy tissues. The laboratory tests were also carried out – the PSA levels were assessed in dynamics, kidney and liver function was monitored. In order to carefully monitor changes in the condition of each patient, the researchers carried out about 14 follow-up visits over 18 months of monitoring.

After a comprehensive analysis of the information obtained, the Australian Nuclear Science and Technology Organisation (ANSTO) provided the results of the trial at the meeting of the Society of Nuclear Medicine and Molecular Imaging (SNMMI). Within the first 12 weeks of monitoring, the PSA levels decreased by more than 50% in half of the patients, while in 27% of men, the PSA levels decreased to 80% or more. According to the results of PET-CT and scintigraphy, the radiological improvement of more than 50% occurred in 57% of patients, and in 43% of them this indicator reached 80% or more. The size of metastases in the bones and soft tissues decreased, the pain syndrome became less severe.

Currently, at least 8 clinical trials of Lutetium-177 PSMA therapy are being carried out at the major clinics in Italy, Germany, Australia, the Netherlands and the USA. They are in the first (testing of methodology on healthy volunteers) and in the second phases (testing of methodology on patients with prostate cancer), therefore they are open to the inclusion of new patients. Thanks to this, men with prostate cancer can be treated in specialized centers of the leading countries of the world, without extra fee, at the expense of the organizers of the trials. For this purpose, you need to contact the clinic which carries out the trial, and undergo an examination there for compliance with its criteria. It is also important to prepare a package of documents and translate them into the official language of the country. The patients can do this on their own or with the help of the specialist in medical tourism.

 

Case report

Patient Oliver Davis, 47 years old, USA. Prostate cancer was diagnosed at the advanced stage, when the primary tumor had already spread metastasize to the spine, regional and distant lymph nodes. A multifocal biopsy confirmed prostate adenocarcinoma, with a Gleason score of 9 points (high grade). Taking into account the spread of the tumor, the board of an oncologist, urologist and surgeon decided to perform Flare blockade and medical castration as hormone therapy. Chemotherapy from a group of taxanes (for example, Docetaxelum) was considered as the second-line therapy or additional therapy. The patient was regularly treated according to the recommended scheme, however, follow-up scintigraphy and CT showed the growth of metastatic lesions and an increase in their number. Despite the young age of the man, life expectancy decreased to 6-8 months. This served as an indication for high-tech treatment – Lutetium-177 PSMA therapy. The results of preliminary PSMA-PET/CT assumed an excellent result from the use of Lutetium-177, as the tumor and metastases actively accumulated the drug. Despite the urgency of the situation, the number of patients on the "waiting list" for radionuclide therapy allowed him to undergo the first procedure not earlier than in 1.5 months. To speed up this process, the patient signed up for treatment at a foreign medical facility – Helios Hospital Berlin-Buch, in Germany. The treatment began after 12 days. According to the results of the follow-up PSMA PET/CT, small metastases in the bones disappeared after the first procedure, while large ones significantly decreased in size. The second procedure was planned after 4 weeks, with a mandatory follow-up examination. Currently, the life expectancy of the man is more than 18 months.

 

Specificities of Lutetium-177 PSMA therapy

Lutetium-177 PSMA therapy is not complex – this is the standard intravenous infusion of the drug, which, as a rule, is not accompanied by serious undesirable symptoms. The infusion takes no more than 30-60 seconds, after which the drug is actively distributed throughout the circulatory system and precisely accumulates in the tumor cells.

The technical complexity of peptide receptor radionuclide therapy is associated with the individual manufacturing of the drug for each patient and compliance with radiation protection protocols. Prior to the treatment, imaging dosimetry (quantitative SPECT/CT) is carried out for the assessment of the accumulation of the radiopharmaceutical in the tumor, metastases, kidneys, salivary and lacrimal glands. According to the SPECT/CT results, the doctor determines the necessary therapeutic dose of Lutetium-177.

According to the radiation protection protocol, the patient stays in a special room for up to 48 hours from the moment of intravenous drug injection. Considering the rapid excretion of the drug by the kidneys, during the first 2-4 hours, medical staff regularly assesses the level of radiation in the room and notes the dynamics of its decline. The patient can take personal items with him, including clothes, a mobile phone or tablet, books, notebook. After discharge from the hospital, the patient takes his belongings with him, since they do not require special cleaning and are not a source of radiation.

 

PSMA PET/CT
(c) depositphotos

Follow-up monitoring upon Lutetium-177 PSMA therapy completion

The first follow-up examination is carried out before the patient is discharged from the hospital. This includes a general examination, assessment of kidney and liver function according to the biochemical blood test, as well as the diagnostic CT scan. Tomography allows the doctor to assess the distribution of the radionuclide in the body and the activity of its accumulation in the target areas – bone metastases, metastases in soft tissues and lymph nodes, and the primary tumor. Additionally, radiologists determine the absorbed dose of radiation. This helps to assess the response to treatment and plan further therapy. In the case of good overall health and satisfactory examination results, the patient is discharged from the hospital for further outpatient monitoring.

Upon the discharge, men are monitored by an oncologist and / or urologist:

  • PSA blood test. Normally, the PSA levels decrease by more than 90% from the initial levels and remain stably low. PSA blood test is an easy-to-use and informative test, which confirms persistent remission of the disease.
  • PSMA PET/CT is performed for initial assessment of the treatment effectiveness and, subsequently, in suspicion on recurrence. Images, which were obtained using PSMA PET/CT, show the size of the foci in the prostate, bones and lymph nodes. With their help, the doctor can assess the dynamics of regression or tumor growth, as well as its activity.

The results of long-term monitoring show a decrease in PSA levels in more than 50% of men. Moreover, the average duration of the remission after Lutetium-177 PSMA therapy is more than 13 months, and more than 78% of patients overcame the 2-year survival threshold. The achievement of such indicators in men with metastatic cancer is a significant progress in the treatment of the advanced stages of this pathology.

 

Case report

Patient Martin Ulsson, 52 years old, Sweden. A prostate tumor with the size of 1.5 cm was detected during the annual preventive examination. At the time of diagnosis, the patient had no severe complaints about well-being, despite the fact that during the comprehensive examination the doctors detected a metastatic lesion of the sentinel lymph nodes (iliac pelvic lymph nodes on both sides). The PSA level was 18 ng/ml. Taking into account the small size of the primary tumor, a radical prostatectomy was performed using da Vinci Surgical System. Histological examination of the removed tumor confirmed its high grade. After surgery, the patient underwent combination hormone therapy, which included antiandrogen drugs and GnRH agonists. Despite the active postoperative treatment, the disease continued to progress – according to scintigraphy results, the foci of bone lesions were detected, a severe pain syndrome occurred. The necessity of Lutetium-177 PSMA therapy was adopted at the tumor board with the participation of a clinical oncologist, radiologist, urologist and general practitioner. After the first procedure, the PSA levels decreased by 60% (to 7.2 ng/ml). After a repeated procedure, the patient noted a decrease in pain (painkillers were used up to 3 times a week instead of their intake 2-3 times a day prior to the course of radionuclide therapy).

 

Planning of Lutetium-177 PSMA therapy abroad with the Booking Health company

Peptide receptor radionuclide therapy is carried out at the specialized medical facilities, which comply with strict radiation protection protocols and have access to the production of drugs for the treatment using Lutetium-177 PSMA. In addition to selection of the clinic, it is important for the patients to find a competent doctor who will select the necessary dosage of the drug and the duration of the therapy course, and will also carry out regular follow-up examinations.

In the absence of experience in the treatment abroad, it will be more convenient for the patients and their families to use the help of the Booking Health company. Booking Health is a certified medical tourism operator (ISO 9001:2015 certification), which has been organizing the treatment of men with prostate cancer abroad for more than 10 years. The specialists of Booking Health will provide the following benefits for the patient and his family:

  • Selection of the right clinic based on the annual qualification grade
  • Establishment of communication directly with your doctor or team of specialists (oncologist, radiologist, urologist)
  • Preliminary treatment or diagnostic program, which will not repeat previous examinations
  • Сlinic services at the favorable price, without overpricing and additional coefficients for foreign patients (saving up to 50%)
  • Booking the appointment or procedure on the desired date
  • Monitoring of the medical program at all its stages
  • Insurance against an increase in the cost of treatment in the case of complications (coverage of 200,000 euro, the insurance will be valid for 4 years)
  • Buying and, if necessary, forwarding medicines to the home country
  • Сommunication with the clinic upon treatment completion
  • Control of invoices in the clinic
  • Organization of additional examinations, remote consultation of the doctor according to the results of the follow-up examination in the home country
  • Booking a hotel, airline tickets, transfer organization

Please, fill out the "SEND REQUEST" form on the official website of the Booking Health company, and our medical consultant or patient case manager will contact you within 24 hours. You will discuss medical and organizational details with the specialist, choose the best clinic for you, and begin a preparation for a trip to undergo treatment. During the preparation, the personal coordinator will be in touch with you constantly, and during your stay abroad you will have a personal medical translator.

 

Choose treatment abroad and you will for sure get the best results!

 


Author: Dr. Nadezhda Ivanisova

 

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