Lutathera (lutetium Lu 177 dotatate)

This comprehensive review delves into the current practice, discussing the use of the various Food and Drug Administration-approved SSTR-agonist positron emission tomography tracers and the predictive imaging biomarkers, and elaborating on 177Lu-DOTATATE peptide receptor radionuclide therapy including the evolving areas of posttherapy imaging practices and peptide receptor radionuclide therapy retreatment. SSTR-targeted imaging and therapy can also be used in patients with PPGL; however, this patient population has demonstrated the best outcomes from norepinephrine transporter-targeted therapy with 131I-metaiodobenzylguanidine. Metaiodobenzylguanidine theranostics for PPGL will be discussed, noting that in 2024 it became commercially unavailable in the United States. Therefore, the use and reported success of SSTR theranostics for PPGL will also be explored.

P1/2, N=200, Recruiting, Novartis Pharmaceuticals | N=39 --> 200

P1, N=10, Active, not recruiting, Memorial Sloan Kettering Cancer Center | Recruiting --> Active, not recruiting

P2, N=120, Not yet recruiting, University of Iowa

Therefore, the benefit of treatment with 177Lu-DOTATATE in the current indication is questionable. In the absence of a validated systemic treatment, and considering a few case reports, treatment with 177Lu-PSMA could be investigated as an additional vectorized internal radiotherapy option.

P=N/A, N=80, Not yet recruiting, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

P1/2, N=0, Withdrawn, David Bushnell | N=50 --> 0 | Trial completion date: Oct 2025 --> Apr 2024 | Recruiting --> Withdrawn | Trial primary completion date: Oct 2025 --> Apr 2024

P1, N=10, Recruiting, Memorial Sloan Kettering Cancer Center | Trial completion date: Sep 2024 --> Sep 2025 | Trial primary completion date: Sep 2024 --> Sep 2025

P1, N=36, Not yet recruiting, Novartis Pharmaceuticals

P2, N=18, Recruiting, Weill Medical College of Cornell University | Trial completion date: Feb 2025 --> Sep 2026 | Trial primary completion date: Feb 2024 --> Sep 2026

P=N/A, N=89, Active, not recruiting, Novartis Pharmaceuticals | Recruiting --> Active, not recruiting | N=50 --> 89

P1/2, N=39, Recruiting, Novartis Pharmaceuticals | Phase classification: P1 --> P1/2

In contrast to the more commonly used external beam radiation, we explored the feasibility of combining chimeric antigen receptor (CAR) T cell therapy with targeted radionuclide therapy (TRT), which is achieved by delivering β-emitting 177Lu-DOTATATE to tumor via tumor-infiltrating CAR T cells that express somatostatin receptor 2 (SSTR2)...However, this higher dose led to cell death in both the tumor and CAR T cells. Our study suggests that there may exist an optimum range of TRT dosage that can enhance T cell activity and sensitize tumor cells to T cell killing, which may result in more durable tumor control compared to a higher radiation dose.

This study confirms that the estimated bone marrow dose is significantly lower with the blood-based method than with the image-based method. The blood-based method with a bi-exponential model proved particularly useful, without the need for blood samples after 24h post-injection. Nevertheless, this blood-based method is based on an assumption that needs to be more validated. The important difference between the two methods does not allow to determine the optimal one to estimate the true absorbed dose and further studies are necessary to compare with biological effects.

In this work, we present an updated appraisal of the literature, reviewing the recent advances in the use of established radiotheranostic agents such as radioiodine for differentiated thyroid carcinoma and Iodine-131-labeled meta-iodobenzylguanidine therapy of tumors of the sympathoadrenal axis as well as the recently approved 177Lu-DOTATATE and 177Lu-PSMA for differentiated neuroendocrine tumors and advanced prostate cancer, respectively. We also discuss the radiotheranostic agents that have been comprehensively characterized in preclinical studies and have shown some clinical evidence supporting their safety and efficacy, especially those targeting fibroblast activation protein (FAP) and chemokine receptor 4 (CXCR4) and those still being investigated in preclinical studies such as those targeting poly (ADP-ribose) polymerase (PARP) and epidermal growth factor receptor 2.

The use of metabolically stabilized, radiolabeled somatostatin (SST) analogs ([68Ga]Ga/[177Lu]Lu-DOTA-TATE/TOC/NOC) is well established in nuclear medicine...The involvement of neprilysin (NEP) in the metabolism of [111In]In-XG1 was confirmed by coadministration of Entresto®, a registered antihypertensive drug, in vivo releasing the selective and potent NEP-inhibitor sacubitrilat...To corroborate the imaging data, the tumors and the kidneys were excised and analyzed with a γ-counter. Even if receptor-specific tumor uptake for [111In]In-XG1 could be confirmed (1.61% IA/g), further optimization is required to improve its pharmacokinetic properties for radiotracer development.

P4, N=6, Recruiting, Vanderbilt-Ingram Cancer Center | Not yet recruiting --> Recruiting | Trial completion date: Mar 2026 --> Feb 2028 | Initiation date: Sep 2023 --> Apr 2024 | Trial primary completion date: Mar 2025 --> Feb 2027

P2, N=135, Not yet recruiting, European Organisation for Research and Treatment of Cancer - EORTC

This denies many patients with adequate somatostatin receptor expression and biochemical profiles from the beneficial effects of PRRT on the quality of life, daily function, and overall survival. The 2 cases highlight the favorable response of PRRT in patients with metastatic neuroendocrine tumor having a very poor performance status initially.

This initial study suggests that 225Ac-DOTATATE is a potentially promising option for treating NENs with elevated SSTR expression, with an acceptable toxicity profile and well-tolerated adverse effects.

P1, N=10, Not yet recruiting, University of Wisconsin, Madison | Trial completion date: Oct 2024 --> Mar 2025 | Trial primary completion date: Oct 2024 --> Mar 2025

P=N/A, N=347, Active, not recruiting, Novartis Pharmaceuticals | Recruiting --> Active, not recruiting

P1, N=29, Active, not recruiting, National Cancer Institute (NCI) | Recruiting --> Active, not recruiting

P1, N=29, Active, not recruiting, National Cancer Institute (NCI) | Trial completion date: Jan 2024 --> Jun 2024 | Trial primary completion date: Jan 2024 --> Jun 2024

This rare case highlights the pathological complete response of initially unresectable multiple liver metastases achieved by PRRT and SSAs following PNET resection, suggesting their potential as a multimodality treatment option for unresectable PNET.

P1/2, N=52, Recruiting, University of Chicago | Phase classification: P2 --> P1/2

Oncology nurses provide assessment, education, direct care, and emotional support when caring for patients with GEP-NETs receiving PRRT with 177Lu-DOTATATE. As the treatment landscape evolves, so too will these roles and responsibilities.

P1, N=6, Active, not recruiting, Providence Health & Services | Recruiting --> Active, not recruiting | N=90 --> 6 | Trial completion date: Dec 2031 --> Dec 2026 | Trial primary completion date: Dec 2027 --> Dec 2024

Visual and quantitative analyses of baseline SSTR-PET can yield valuable information to prognosticate outcomes after Lu-DOTATATE PRRT.

P1, N=24, Recruiting, National Cancer Institute (NCI) | Initiation date: Jan 2024 --> Apr 2024

P2, N=11, Active, not recruiting, Advanced Accelerator Applications | Recruiting --> Active, not recruiting

P1, N=29, Recruiting, National Cancer Institute (NCI) | Phase classification: P1b --> P1

Treatment with 177Lu-DOTATATE was well tolerated. The predefined PFS-6 threshold was met in this interim analysis, thereby allowing this multicenter clinical trial to continue enrollment. 68Ga-DOTATATE PET may be a useful imaging biomarker to assess therapeutic outcome in patients with meningioma.

P2, N=100, Recruiting, National Cancer Institute (NCI) | Initiation date: Dec 2023 --> Mar 2024

P2, N=94, Recruiting, National Cancer Institute (NCI) | Initiation date: Dec 2023 --> Aug 2023

P1, N=10, Not yet recruiting, University of Wisconsin, Madison | Initiation date: Nov 2023 --> Feb 2024

P1, N=60, Recruiting, Novartis Pharmaceuticals | Trial completion date: Jun 2025 --> Jul 2026 | Trial primary completion date: May 2024 --> Jul 2025

P2, N=32, Active, not recruiting, Nicholas Fidelman, MD | Trial completion date: Dec 2025 --> May 2026 | Trial primary completion date: Sep 2023 --> May 2024

P1, N=18, Active, not recruiting, Vastra Gotaland Region | Recruiting --> Active, not recruiting | Trial completion date: Jun 2023 --> Jun 2024 | Trial primary completion date: Jun 2022 --> Jun 2024

P2, N=28, Not yet recruiting, Central Hospital, Nancy, France

P1, N=10, Not yet recruiting, University of Wisconsin, Madison