Q J NUCL MED 1999;43:356-66
`
`Therapy of neu ro en do crine tumors
` with radio lab eled som a tos ta tin-ana logues
`
`M. DE JONG, W. A. P. BREE MAN, H. F. BER NARD, P. P. M. KOOIJ, G. D. SLOOT ER*, C. H. J. VAN EIJCK*
`D. J. KWEKKE BOOM, R. VAL KE MA, H. R. MÄCKE**, E. P. KREN NING**
`
`Peptide recep tor scin tig ra phy with the radio ac tive som -
`a tos ta tin-ana logue [111In- DTPA0]octre o tide ( DTPA = dieth -
`y len e tri a min e pen taa cet ic acid) is a sen si tive and spe -
`cif ic tech nique to show in vivo the pres ence and abun -
`dance of som a tos ta tin recep tors on var i ous tumors.
`With this tech nique pri mary tumors and metas ta ses of
`neu ro en do crine can cers as well as of many oth er can -
`cer types can be loc al ised. A new appli ca tion is the use
`of pep tide recep tor radio nu clide ther a py, admin is trat -
`ing high dos es of 111In- or 90Y- labeled octre o tide-ana -
`logues.
`Preclinical. We inves ti gat ed the radio ther a peu tic effect
`of 90Y- and 111In- labeled [ DOTA0,Tyr3]octre o tide ( DOTA=
`[111In-
`tet ra az a cy clo dod e can e tet raa cet ic
` acid) or
` DTPA0]octre o tide in Lewis rats bear ing the som a tos ta tin
`recep tor-pos i tive rat pan creat ic tumor CA20948 in A)
`the flank or B) in the liv er.
`Patients. Thirty end- stage patients with most ly neu ro en -
`do crine pro gress ing tumors were treat ed with [111In-
` DTPA0]octre o tide, up to a max i mal cumu la tive patient
` dose of about 74 GBq, in a phase 1 trial.
`Preclinical results. A) Flank mod el: at least two 111MBq
`injec tions of [111In- DOTA0,Tyr3]octre o tide were need ed
`to reach tumor response, in 40% of the ani mals com plete
` tumor remis sion was found after a fol low-up peri od of
`10 months. One or two injec tions of [90Y- DOTA0,Tyr3]
`octre o tide yield ed tran sient stable dis ease.
`B) Liv er mod el: we found that pep tide recep tor radio nu -
`clide ther a py is only effec tive if som a tos ta tin recep tors
`are present on the tumors, and is there fore recep tor-
`medi at ed. High radio ac tive dos es of 370 MBq [111In-
` DTPA0]octre o tide or 93 MBq [90Y- DOTA0,Tyr3]octre o tide
`can inhib it the growth of som a tos ta tin recep tor-pos i -
`tive metas ta ses.
`
`Address reprint requests to: E. P. Krenning, Department of Nuclear
`Medicine, University Hospital Rotterdam, 3015 GD Rotterdam.
`E- mail: kren ning@ nuge.azr.nl
`
`From the Department of Nuclear Medicine
`*Surgery, **Kantonspital Basel, Switzerland
`and ***Internal Medicine III
`University Hospital and Erasmus University
`Rotterdam, The Netherlands
`
`Clinical results. There were no major clin i cal side effects
` after up to 2 years treat ment, except that a tran sient
` decline in plate let counts and lym pho cyte sub sets can
` occur. Promising ben e fi cial effects on clin i cal symp -
`toms, hor mone pro duc tion and tumor pro life ra tion
` were found. Of the 21 patients with pro gres sive dis ease
`at base line and who received a cumu la tive dose of more
` than 20 GBq [111In- DTPA0]octre o tide, 8 patients showed
`sta bil isa tion of dis ease and 6 oth er patients a reduc tion
`in size of tumors. There is a ten den cy towards bet ter
` results in patients whose tumors have a high er accu -
`mu la tion of the radio lig and.
`Conclusion. Radionuclide ther a py with octre o tide-deriv -
`a tives is fea sible, both with 111In and 90Y as radio nu -
`clides.
`KEY WORDS: Neuroendocrine tumors - Somatostatin ana logues
`and der i vates - Radioisotopes, therapeutic use.
`
`T he inhib i to ry effect of som a tos ta tin (SS) on hor -
`
`mone secre tion led to the con cept of ben e fi cial
` effects of som a tos ta tin in the treat ment of dis eas es
` based on gland hyper func tion or over pro duc tion of
`hor mones by endo crine- active tumors. The tet ra deca -
`pep tide SS14 itself is unsuit able for treat ment, because
`of its very short half- life of ≈3 min utes in man after
`intra ve nous injec tion and because of its diver sity of
` action, such as low er ing insu lin lev els. Successful
` efforts have been under tak en to syn the sise more
`
`356
`
`THE QUAR TER LY JOUR NAL OF NUCLE AR MED I CINE
`
`December 1999
`
`MIN E R V A M E DIC A
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`or other proprietary information of the Publisher.
`not permitted.It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article.It is not permitted to frame or use framing techniques to enclose any trademark, logo,
`means which may allow access to the Article.The use of all or any part of the Article for any Commercial Use is not permitted.The creation of derivative works from the Article is not permitted.The production of reprints for personal or commercial use is
`(either sporadically or systematically, either printed or electronic) of the Article for any purpose.It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
`This document is protected by international copyright laws.No additional reproduction is authorized.It is permitted for personal use to download and save only one file and print only one copy of this Article.It is not permitted to make additional copies
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`

`

`THERAPY OF NEUROENDOCRINE TUMORS WITH RADIOLABELED SOMATOSTATIN-ANALOGUES
`
`DE JONG
`
`clide-ther a py. The suc cess of the ther a peu tic strat e gy
` relies upon the amount of radio lig and, which can be
`con cen trat ed with in tumor cells and the rates of inter -
`nal isa tion, deg ra da tion and recy cling of both ligand
`and recep tor will among oth er things deter mine this.
`Binding of sev er al pep tide hor mones to spe cif ic sur -
`face recep tors is gen er al ly fol lowed by inter nal isa -
`tion of the ligand recep tor com plex via invag i na tion
`of the plas ma mem brane.9 10 The result ing intra cel lu -
`lar ves i cles, termed endo somes, rap id ly acid i fy, which
`caus es the ligand to dis so ci ate from the recep tor. The
` ligand may be deliv ered to the lyso some 11 and the
`recep tor may recy cle back to the plas ma mem brane.
`The whole pro cess takes approx i mate ly 15-min,9 and
`a sin gle recep tor can deliv er numer ous ligand mole -
`cules to the lyso somes. We have stud ied inter nal isa -
`tion and deg ra da tion of radio lab eled [ DTPA0]octre o -
`tide and we detect ed inter nal isa tion of the radio phar -
`ma ceu ti cal in tumor cells, in accor dance with the find -
`ings of Andersson et al.,12 this pro cess was recep tor-
`spe cif ic and tem per a ture depen dent.13 Receptor-medi -
`at ed inter nal isa tion of [111In- DTPA0]octre o tide will
` most prob ably result in deg ra da tion to 111In- DTPA-D-
`Phe, this metab olite is not capable pass ing the lyso -
`so mal mem brane.11
`Since 111In emits not only gam ma- rays, which are
`visu al ised dur ing scin tig ra phy, but also short- ranged
`Auger-elec trons, an effect on tumor cell pro life ra tion
` could be expect ed, as the radio tox ic ity of Auger-elec -
`trons is very high if the DNA of the cell is with in the
`par ti cle range.14-16 111In emits Auger- and con ver sion-
`elec trons hav ing a tis sue pen e tra tion of 0.02 to 10 μm
`and 200 to 500 μm, respec tive ly, and can there fore be
` used to inves ti gate its anti pro life ra tive effect in can cer.
`We report ed a bio log i cal half- life for 111In of >700
` hours in tumor tis sue.6 Therefore, 111In- labeled [DTPAo]
`octre o tide has an appro pri ate dis tri bu tion pro file in
` humans for scin tig ra phy and radio nu clide ther a py.17
`18 Earlier we report ed 19 that high radio ac tive dos es
` with [111In- DTPA0]octre o tide for radio nu clide-ther a py
` could inhib it the growth of som a tos ta tin recep tor-
`pos i tive liv er metas ta ses in an ani mal mod el, and that
`radio nu clide-ther a py was only effec tive if som a tos -
`ta tin recep tors were present on the tumors. The effect
`of radio nu clide-ther a py with [111In- DTPA0]octre o tide
` could be reduced by pre treat ment with excess unla -
`beled octre o tide, which indi cates that recep tor bind -
`ing is essen tial for radio nu clide-ther a py.
`For radio ther a peu tic appli ca tions, oth er radio nu -
`clides have also been pro posed and inves ti gat ed for
`
`Fig. 1.—Structures of octre o tide, [Tyr3]octre o tide, DTPA and DOTA.
`
` stable som a tos ta tin-ana logues, result ing in octre o tide
`(Fig. 1).
`Somatostatin recep tors are inte gral mem brane gly -
`cop ro teins. Five dif fer ent human som a tos ta tin recep -
`tor types have been cloned. All sub types bind SS14
` with high affin ity, while the affin ity of numer ous som -
`a tos ta tin-ana logues dif fer con sid er ably.1-3 Octreotide
` binds with high affin ity to the som a tos ta tin recep tor
`sub type 2 (sst2), while this ana logue has a low er affin -
`ity for sst3 and sst5 and shows no bind ing to sst1 and
`sst4.1-4 Octreotide scin tig ra phy is, there fore, based on
`the vis u al isa tion of (an) octre o tide-bind ing som a tos -
`ta tin recep tor(s), most prob ably the sst2.
`Peptide recep tor scin tig ra phy with the radio ac tive
`som a tos ta tin-ana logue, [111In- DTPA0]octre o tide (Fig.
`1), is a sen si tive and spe cif ic tech nique to show in vivo
`the pres ence and abun dance of som a tos ta tin recep tors
`on var i ous tumors. In gen er al, map ping of the pres -
`ence of var i ous pep tide recep tors on the cell mem -
`brane by pep tide recep tor scin tig ra phy may become
`an attrac tive, non-inva sive, harm less, easy-to-per form
` tool for an indi vid u al ther a peu tic approach of the
`can cer patient.5-8 A new and fas ci nat ing appli ca tion is
`the use of radio lab eled pep tides for pep tide recep tor
`radio nu clide-ther a py, fur ther referred to as radio nu -
`
`Vol. 43 - No. 4
`
`THE QUAR TER LY JOUR NAL OF NUCLE AR MED I CINE
`
`357
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`MIN E R V A M E DIC A
`C O P Y RIG H T ®
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`or other proprietary information of the Publisher.
`not permitted.It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article.It is not permitted to frame or use framing techniques to enclose any trademark, logo,
`means which may allow access to the Article.The use of all or any part of the Article for any Commercial Use is not permitted.The creation of derivative works from the Article is not permitted.The production of reprints for personal or commercial use is
`(either sporadically or systematically, either printed or electronic) of the Article for any purpose.It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
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`

`DE JONG
`
`THERAPY OF NEUROENDOCRINE TUMORS WITH RADIOLABELED SOMATOSTATIN-ANALOGUES
`
` coupling to octre o tide-ana logues. 90Y is a β-par ti cle
`emit ter, the max i mum ener gy of the elec trons is 2.3
`MeV, their mean range is a few millimeters in tis sue.
`90Y shows dis so ci a tion from DTPA-con ju gat ed pep tides
`in ser um, result ing in hemat o poiet ic tox ic ity in vivo,
`there fore, Tyr3-octre o tide (Fig. 1), which has a higher
`bind ing affin ity for sst2 than octre o tide itself, has been
`deriv a tized with the che la tor DOTA ena bling stable
`radio lab el ing with both 90Y and 111In. Preclinical and
`clin i cal stud ies with [ DOTA0,Tyr3]octre o tide showed
`favour able bio dis trib u tion and tumor uptake char ac -
`ter is tics.20 21
`In this paper pre clin i cal and clin i cal stud ies on the
`radio ther a peu tic effect of radio lab eled octre o tide-
`deriv a tives are described:
`Preclinical stud ies.—A) Flank mod el: experi ments
` using 90Y- and 111In- labeled [ DOTA0,Tyr3]octre o tide
`in Lewis rats bear ing the som a tos ta tin recep tor-pos i -
`tive rat pan creat ic tumor CA20948 in their flank.
`B) Liver mod el: tim ing and dos age char ac ter is tics of
`radio nu clide ther a py using [111In- DTPA0]octre o tide
`and [90Y- DOTA0,Tyr3]octre o tide in rats inoc u lat ed with
`CA20948 tumor cells in the por tal vein of the liv er.
`Clinical study.—The side- effects and anti pro life ra -
`tive effect of high, mul ti ple radio ther a peu tic dos es of
`[111In- DTPA0] were inves ti gat ed in a phase 1 study.
`We includ ed end- stage patients with main ly a high
` tumor load of pro gress ing som a tos ta tin recep tor-pos -
`i tive neu ro en do crine tumors.
`
`Materials and meth ods
`
`Labeled pep tides
`[ DTPA0]octre o tide ( DTPA = dieth y len e tri a min e pen ta-
`a cet ic acid) and 111InCl3 (DRN 4901, 370 MBq/ml in
`HCl, pH = 1.5 - 1.9) were obtained from Mallinckrodt
`Medical BV (Petten, The Netherlands). [ DTPA0]octre o -
`tide was labeled with 111InCl3 as has been described pre -
`vi ous ly.22 [ DOTA0,Tyr3]octre o tide ( DOTA= tet ra az a cy clo -
`dod e can e tet raa cet ic acid) was syn the sised by Prof. H.
`Mäcke (Basel, Switzerland). 90Y- and 111In-label ing of
` [DOTA0,Tyr3]octre o tide was per formed as described.20
`
`Preclinical in vivo radio nu clide ther a py experi ments
` using radio lab eled som a tos ta tin-ana logues
`A) Flank mod el.—The CA20948 pan creat ic tumors
` were grown at the flank of Lewis rats. Male Lewis rat
`
`(Harlan, The Netherlands; 250-300 g) were inject ed
`sub cu ta ne ous ly into both flanks, each with 500 μl of
`a cell sus pen sion of the CA20948 tumor, pre pared
` from 5 g crude tumor tis sue in 100 ml saline. At the
` start of ther a py, rats were anaesthet ised, and the pep -
`tides were inject ed into the dor sal vein of the penis.
`Five groups of 6 rats were formed. The four ther a peu -
`tic groups received either a sin gle injec tion or two
`injec tions (one week apart) of either 111 MBq [111In-
` DOTA0,Tyr3]octre o tide or 111 MBq [90Y- DOTA0,Tyr3]
`octre o tide. Specific activ ity of the pep tides was 37
`MBq/1.2 μg pep tide. The con trol group received a
`con cor dant amount of unla beled [ DOTA0,Tyr3]octre -
`o tide (3.6 μg).
`In an ear li er study we inves ti gat ed the effects of
`vari a tion in inject ed pep tide amount on tumor uptake
`in CA20948 pan creat ic tumor-bear ing rats for 111In-
` labeled [ DOTA0,Tyr3]octre o tide, in order to find the
`pep tide amount at which the high est uptake in the tar -
`get was achieved. We found that uptake in the tumor
`as a func tion of inject ed amount pep tide showed a bell
` shape with the high est uptake at 0.5 μg pep tide. At
`high er pep tide amounts tumor uptake of radio ac tiv -
`ity was decreased to about 50% of the max i mum
` tumor uptake after injec tion of 4 μg pep tide [Eur J
`Nucl Med, July 1999:26(7):693-8]. In the present study
`we had to inject 3.6 μg pep tide, this was admin is -
`tered in 2 injec tions of 1.8 μg each, 1 hour apart.
`The tumors were meas ured on the day of radio lig -
`and admin is tra tion and eve ry 3-4 days there af ter.
`Tumor growth, ani mal con di tion and body weight
` were deter mined inde pen dent ly by two inves ti ga tors.
`At pro gressed stage of the CA20948 tumor necro sis
`may occur. Besides loss of more than 10% of orig i nal
` body weight, tumor necro sis was an indi ca tion to sac -
`ri fice the rats.
`B) Liver mod el.—The tumor was trans plant ed and
`main tained in the liv er after direct injec tion of tumor
` cells into the vena por ta to pro duce arti fi cial liv er
`metas ta ses. Therefore, tumors were excised from
` donor liv ers, cleaned from nor mal liv er tis sue and
` pressed through sieves with decreas ing mess size.
`The sus pen sion was washed twice in phos phate-buf -
`fered saline. Viability was meas ured with try pan- blue
`exclu sion. A sus pen sion of 2.5×106 liv ing cells/mL
`was used for injec tion into the vena por ta. All rats
` were sac ri ficed 20-21 days after inoc u la tion of tumor.
`Tumor growth was deter mined by two inves ti ga tors
`
`358
`
`THE QUAR TER LY JOUR NAL OF NUCLE AR MED I CINE
`
`December 1999
`
`MIN E R V A M E DIC A
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`or other proprietary information of the Publisher.
`not permitted.It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article.It is not permitted to frame or use framing techniques to enclose any trademark, logo,
`means which may allow access to the Article.The use of all or any part of the Article for any Commercial Use is not permitted.The creation of derivative works from the Article is not permitted.The production of reprints for personal or commercial use is
`(either sporadically or systematically, either printed or electronic) of the Article for any purpose.It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
`This document is protected by international copyright laws.No additional reproduction is authorized.It is permitted for personal use to download and save only one file and print only one copy of this Article.It is not permitted to make additional copies
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`

`

`THERAPY OF NEUROENDOCRINE TUMORS WITH RADIOLABELED SOMATOSTATIN-ANALOGUES
`
`DE JONG
`
`count ing and rank ing the num ber of metas ta ses (from
`0 to 5+), while blind ed for treat ment modal ity.
`Experiment 1 was designed to deter mine the min i mal
`effec tive dos age of radio nu clide-ther a py: the rats
` were inject ed with 3.7, or 37 or 370 MBq (0.5 μg)
`[111In- DTPA0]octre o tide on day 1. In experi ment 2
` rats were treat ed with 370 MBq (0.5 μg) [111In-
` DTPA0]octre o tide on day 6 or 12. In experi ment 3
` rats received radio nu clide-ther a py on day 7 or 14.
`In experi ment 4 the rats were inject ed at day 1 with
` saline (A), or with vehi cle (2 μg [ DOTA0,Tyr3]octre o -
`tide) (B), or with 93 MBq (2 μg) [90Y- DOTA0,
`Tyr3]octre o tide (C). Experi-ments 1-4 were per formed
` twice. Rats were weighed 3 times/ week, and their
` body weight was expressed as the per cent age of
` their body weight at day 3.
`
`Statistical anal y sis
`Statistical anal y sis was per formed using Mann-
`Whitney “U”- test on categ or ised out comes, Fisher's
` exact test on pro por tions and anal y sis of var i ance.
`Statistical sig nif i cance was defined as p<0.05.
`
`Clinical in vivo radio nu clide ther a py experi ments
` using radio lab eled som a tos ta tin-ana logues
`The typ i cal dose per admin is tra tion is 6000-7000
`MBq 111In incor po rat ed in 40-50 μg [ DTPA0]octre o tide.
`Doses were giv en with at least 2 week inter vals
` between admin is tra tions and a total of 8 admin is -
`tra tions is aimed at with exten sions in a few patients
`to about 20 admin is tra tions. Radionuclide ther a py
` with [111In- DTPA0]octre o tide was applied after wit -
`nessed informed con sent by the patient and approv -
`al by the med i cal eth ics com mit tee of our hos pi tal.
`The fol low ing meas ure ments, car ried out prior to
`and between all admin is tra tions, served as param e -
`ters of pos sible side- effects: the usu al hae mat o log i -
`cal and chem i cal anal y ses of bone-mar row, liv er,
`kid ney and endo crine pan creat ic (glu cose or Hb A1c)
`func tion. Pituitary func tion (Free T4, post-men o pau -
`sal wom en: LH and FSH, men: tes tos te rone) was
` assessed prior to and 4 weeks after the 4th and 8th
`admin is tra tion of [111In- DTPA0]octre o tide; also pos -
`sible effects on: 1) the endo crine activ ity of the
` tumors and/or their pro duc tion of spe cif ic ser um
`mark ers, and 2) tumor- size (CT or MRI) were inves -
`ti gat ed. Pituitary-adren al- axis func tion test ing (mety -
`ra pone test) prior to and after 8 admin is tra tions as
`
` well as long- term fol low up with 3-4 month inter vals
`was inves ti gat ed if fea sible.
`
`Dosimetry of [111In- DTPA0]octre o tide in humans
`Scoring of tumor radio ac tiv ity uptake in patients
` prior to the start of treat ment with [111In- DTPA0]octre -
`o tide was done vis u al ly by using scin ti grams obtained
`24 hr after injec tion of a diag nos tic dose (220 MBq)
`of [111In- DTPA0]octre o tide. The scor ing grades used
` were: 4 = intense, 3 = clear (high er than liv er uptake),
`2 = clear but faint (low er than or equal to liv er
` uptake), 1 = equiv ocal and 0 = no accu mu la tion.
`Patients were also scanned 3 and 7 days after each
`admin is tra tion of the radio ther a peu tic dose. Percen-
`tage uptake of the admin is tered dose in total body
`and in the most prom i nent tumor was cal cu lat ed ( data
`not shown). Uptakes decreased slow ly or remained
`the same if the inter val between the suc ces sive admin -
`is tra tions was less than one month. In patients who
`had 6 or more admin is tra tions of 6000 to 7000 MBq
`of [111In- DTPA0]octre o tide with inter vals of max i mal -
`ly one- month between admin is tra tions, uptake in the
` tumor was still clear ly vis ible after the last admin is tra -
`tion. Typical radi a tion dos es to tis sues with dos es of
`6000-7000 MBq [111In- DTPA0]octre o tide are: kid neys
`300-1400 (depend ing on the rel a tive bio log i cal effec -
`tive ness [RBE: 1- 20] for Auger elec trons) cGy, spleen
`200 cGy, liv er 50 cGy, bone mar row 13 cGy (tar get
` organ for gam ma pho tons), thy roid gland 25 cGy
`and pitui tary 70 cGy, the crit i cal organs are kid neys
`and spleen. With these dos es the esti mat ed tumor
`radi a tion dos es for a 10 g tumor (assump tions: 1%
` uptake; effec tive half- life is the phys i cal half- life)
`1700 and 6700 cGy (RBE for Auger elec trons 1 and 20,
`respec tive ly) and for a 100 gram tumor (1 % uptake)
`250 and 750 cGy, respec tive ly.
`
`Results and dis cus sion
`
`Preclinical in vivo radio nu clide ther a py experi ments
` using radio lab eled som a tos ta tin-ana logues
`A) Flank mod el.—Figure 2 shows that the tumors of
`the rats in the con trol group grew exces sive ly. Those
` rats had to be sac ri ficed on aver age 12 days post unla -
`beled pep tide injec tion. The treat ment with a sin gle
` dose of 111 MBq [111In- DOTA0,Tyr3]octre o tide did not
` induce tumor response, where as two injec tions of
`
`Vol. 43 - No. 4
`
`THE QUAR TER LY JOUR NAL OF NUCLE AR MED I CINE
`
`359
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`MIN E R V A M E DIC A
`C O P Y RIG H T ®
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`or other proprietary information of the Publisher.
`not permitted.It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article.It is not permitted to frame or use framing techniques to enclose any trademark, logo,
`means which may allow access to the Article.The use of all or any part of the Article for any Commercial Use is not permitted.The creation of derivative works from the Article is not permitted.The production of reprints for personal or commercial use is
`(either sporadically or systematically, either printed or electronic) of the Article for any purpose.It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
`This document is protected by international copyright laws.No additional reproduction is authorized.It is permitted for personal use to download and save only one file and print only one copy of this Article.It is not permitted to make additional copies
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`West-Ward Pharm.
`Exhibit 1010
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`
`

`

`DE JONG
`
`THERAPY OF NEUROENDOCRINE TUMORS WITH RADIOLABELED SOMATOSTATIN-ANALOGUES
`
`TABLE I.—Effects of therapy with [111In-DTPA0]octreotide on count
`of tumor colonies in liver.
`
`Exp 1
`
`3.7 MBq
`37 MBq
`370 MBq
`Control
`
`Tumor colonies count
`
`0
`
`1+
`
`2+
`
`3+
`
`4+
`
`5+
`
`Rats (n)
`
`5
`4
`
`2
`
`4
`
`4
`
`1
`4
`
`4
`
`8
`8
`8*, **, §, ¶, ¶¶
`4
`
`*: p<0.05 versus Control, **: p<0.05 versus 37 MBq, §: p<0.05 versus 3.7
`MBq, ¶: p<0.05 versus 37 MBq, based on liver weight, ¶¶: p<0.05 versus 3.7
`MBq, based on liver weight.
`
`111 MBq result ed in at least par tial tumor remis sion.
`Of the ani mals in this group 40% reached com plete
` tumor remis sion. Mean sur vi val time in the lat ter group
`was 85 days post ther a py (p<0.001 ver sus con trol),
`deter mined 140 days post ther a py. After a sin gle injec -
`tion with [90Y- DOTA0,Tyr3]octre o tide tran sient regres -
`sion of the tumors was found and the rats lived 28 days
` post ther a py (p<0.001 ver sus con trol). Two injec tions
` with 111 MBq [90Y-DO TA0,Tyr3]octre o tide, one week
` apart, result ed in a mean sur vi val of 65 days post
`ther a py (p<0.001 ver sus con trol), no com plete remis -
`sion was reached.
`We and oth ers have also stud ied sev er al param e ters
` like his tol o gy of var i ous organs, blood cell count and
`endo crine param e ters (man u script in prep ar a tion),
`no obvi ous tox i col o gy of the giv en radio ther a py has
` been found so far in rats.
`Liver mod el.—In experi ment 1 we inves ti gat ed
`radio nu clide-ther a py at day 1 after injec tion of 370, 37
`or 3.7 MBq [111In- DTPA0]octre o tide (Table I). Figure 3
` shows exam ples of liv ers from con trol ( left) and 37
`MBq-treat ed ( right) rats. Twenty days after the direct
`injec tion of CA20948 tumor cells into the por tal vein
`the rats were sac ri ficed. In all groups tumor col o nies
` were count ed. The 370 MBq dos age had sig nif i cant -
`ly more effect on tumor score and inhib it ed the
` increase of liv er weight due to tumor growth more
` than the 37 or 3.7 MBq dose. Starting from day 14
` after ther a py we also found a sig nif i cant rela tion
` between the decrease of body weight (100% at day 3)
`and the liv er weight and tumor score at sac ri fice at day
`20 ( data not shown). A sig nif i cant pre dic tive val ue
`for tumor growth was found at a loss of ≥9% of body
` weight ( data not shown).
`Since a dose response was found, we con tin ued our
`stud ies with 370 MBq for experi ments 2 and 3. In
`
`Fig. 2.—Effect of 111In- or 90Y- labeled [ DOTA0,Tyr3]octre o tide (one or
`two injec tions of 111 MBq/rat, indi cat ed by the arrows at the hor i zon -
`tal axis) on tumour growth in Lewis rats bear ing CA20948 tumors in
`the flanks. Control ani mals received unla beled pep tide in the same
` amount as giv en in the radio lab eled admin is tra tions (3.6 μg).
`
`360
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`THE QUAR TER LY JOUR NAL OF NUCLE AR MED I CINE
`
`December 1999
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`MIN E R V A M E DIC A
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`or other proprietary information of the Publisher.
`not permitted.It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article.It is not permitted to frame or use framing techniques to enclose any trademark, logo,
`means which may allow access to the Article.The use of all or any part of the Article for any Commercial Use is not permitted.The creation of derivative works from the Article is not permitted.The production of reprints for personal or commercial use is
`(either sporadically or systematically, either printed or electronic) of the Article for any purpose.It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
`This document is protected by international copyright laws.No additional reproduction is authorized.It is permitted for personal use to download and save only one file and print only one copy of this Article.It is not permitted to make additional copies
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`

`THERAPY OF NEUROENDOCRINE TUMORS WITH RADIOLABELED SOMATOSTATIN-ANALOGUES
`
`DE JONG
`
`Fig. 3.—A) These pho to graphs show exam ples of liv ers from the treat ed and untreat ed group. B) Right liv ers with no vis u al metas ta ses after
`pep tide recep tor radio nu clide ther a py with 370 MBq (0.5 μg) [111In- DTPA0]octre o tide.
`
`experi ment 2 radio nu clide-ther a py on day 6 or day 12
` induced a sig nif i cant decrease in tumor score ver sus the
`con trol group. The liv ers in the con trol group all had
`the high est tumor score (5+). There was sig nif i cant less
` tumor growth and increase in liv er weight in rats treat -
`ed on day 6 or 12 ver sus con trols ( data not shown). In
`experi ment 3 radio nu clide-ther a py on day 7 was also
` able to sig nif i cant ly reduce the tumor score and to
` reduce the liv er weight ver sus con trol, this in con trast
`to radio nu clide-ther a py on day 14 ( data not shown). In
`experi ments 2 and 3 we thus con firmed the find ing
` that tumor growth can be inhib it ed with radio nu clide-
`ther a py,19 even 12 days after inoc u la tion of the som a -
`tos ta tin recep tor-pos i tive tumor in the por tal vein. These
`find ings sug gest that even on estab lished tumors reduc -
`tion of tumor vol ume can be obtained and there by
`sup port the results in case reports that also describe
`
`reduc tion of tumor vol ume.17 Liver weights of rats treat -
`ed on day 12 were sig nif i cant ly low er com pared to
`the liv er weights of rats treat ed on day 6. One hypoth -
`e sis is that the tumor cell has a long lag- phase and
` starts pro life rat ing fast after 1 week and there by may
`
`TABLE II.—Effects of therapy with [90Y-DOTA0, Tyr3]octreotide on
`count of tumor colonies in liver.
`
`Exp 1
`
`A
`B
`C
`
`0
`
`1
`
`Tumor colonies count
`
`1+
`
`2+
`
`3+
`
`1
`
`1
`
`2
`2
`3
`
`4+
`
`2
`
`1
`
`5+
`
`4
`5
`
`Rats (n)
`
`8
`7
`7*
`
`A: control rats, B: rats received 2 µg [DOTA0, Tyr3]octreotide, and C: 93 MBq
`(2 µg) [90Y-DOTA0, Tyr3]octreotide, *: p<0.05 vs A and B.
`
`Vol. 43 - No. 4
`
`THE QUAR TER LY JOUR NAL OF NUCLE AR MED I CINE
`
`361
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`MIN E R V A M E DIC A
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`or other proprietary information of the Publisher.
`not permitted.It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article.It is not permitted to frame or use framing techniques to enclose any trademark, logo,
`means which may allow access to the Article.The use of all or any part of the Article for any Commercial Use is not permitted.The creation of derivative works from the Article is not permitted.The production of reprints for personal or commercial use is
`(either sporadically or systematically, either printed or electronic) of the Article for any purpose.It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
`This document is protected by international copyright laws.No additional reproduction is authorized.It is permitted for personal use to download and save only one file and print only one copy of this Article.It is not permitted to make additional copies
`
`West-Ward Pharm.
`Exhibit 1010
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`
`

`

`DE JONG
`
`THERAPY OF NEUROENDOCRINE TUMORS WITH RADIOLABELED SOMATOSTATIN-ANALOGUES
`
`TABLE III.—Characteristics of patients treated with [111In-DTPA-
`D-Phe'1]octreotide.
`
`Grade II
`
`Grade III
`
`Grade IV
`
`1(P)
`1(R)
`
`6(2*, P, 2S, R) 3(2*, S)
`3(2*, P)
`3(P, S, R)
`1(S)
`
`1(R)
`1(R)
`
`1(R)
`
`7(+2*)
`
`86%
`
`Pathology
`
`Carcinoid
`NE Tumour
`Gastrinoma
`Vipoma
`Glucagonoma
`Med. Thyroid Canc.
`Pap. Thyroid Canc.
`Glomus tumour
`Pheochromocytoma
`Leiomyosarcoma
`
`N
`
`10
`7
`1
`1
`1
`4
`2
`1
`2
`1
`
`4(1*, 2P, S)
`2(1*, S)
`
`2(P, S)
`1(1*)
`
`Total
`
`21(+9*) 8(+3*)
`
`6(+4*)
`
`Pos Effect (S+R)
`
`67%
`
`50%
`
`67%
`
`P= progression; S= stable; R= reduction in tumoursize; *= << 20 GBq
`and/or no FU.
`
` become more radio sen si tive. Another hypoth e sis is
` that the tumor treat ed on day 6 had more time to re-
`estab lish and sub se quent ly becomes heavi er.
`Heterogeneity of recep tor-expres sion on the tumor
` will cause incom plete respons es dur ing radio nu clide-
`ther a py with 111In because of the short par ticle range of
`its Auger- and con ver sion-elec trons. Therefore, we also
`inves ti gat ed [90Y- DOTA0,Tyr3]octre o tide in this mod el.
`In experi ment 4 rats receiv ing 93 MBq (2 μg) [90Y-
` DOTA0,Tyr3]octre o tide (C) on day 1 had sig nif i cant
`low er tumor score and low er liv er weight due to less
` tumor growth than the con trol groups (Table II).
`Experiments 1-4 were repeat ed with con cor dant results.
`Our results show radio ther a peu tic effects of b