Radioiodine therapy for hyperthyroidism
Radioiodine therapy for thyroid cancer
Therapy of metastatic prostate cancer with 177Lu-PSMAI&T
Therapy with 177Lu-PSMAI&T is a therapy procedure for patients with castration resistant prostate cancer, which can be performed as an individual treatment attempt in certain situations. Normally patients, who are making progress under standard chemotherapy e.g. with docetaxal or cabazitaxel, or for whom they cannot be administered for medical reasons, can be treated. An exclusive osseous metastasis should not exist since in such situations a therapy with Xofigo® is indicated.
Basis is the strong expression of PSMA protein on the cell surface of prostate cancer cells. This PSMA protein can be assayed with a substance, which is marked with a radioactive emitter with very short range (around 0.3mm), the 177Lu-PSMAI&T. 177Lu-PSMAI&T thus binds to the tumour cells, leading to a high radiation dose in all tumour foci. According to published studies, a response to treatment can be anticipated in more than half of all patients.
Relevant side effects affect above all the salivary glands - permanent dry mouth can occur - and haematosis - can lead to anaemia or a fall in white blood cells or platelets. Damage to the renal function can also occur. Although in previously published studies clinically relevant side effects were not observed.
Course of therapy
Before therapy the positive receptor status of all tumour manifestations is demonstrated by means of 68Ga-PSMAHBED PET. On the day of admission a renal scintigraphy is performed to rule out renal function disorder and a salivary gland scintigraphy. Relevant values (above all kidney, liver and inflammation values and blood count) are examined by taking a blood sample. Therapy with 177Lu-PSMAI&T is only performed as an inpatient. Normally 3 therapy cycles are performed at 4 weekly intervals. During the first therapy cycle a 7-day hospital stay is necessary, since daily recordings are taken in order to determine the exact radiation load of the salivary glands and kidneys. This is necessary to adjust the therapy to the requirements of the individual patients. In the subsequent therapy cycles the stay is reduced, since only a few recordings have to be taken.
Therapy of bone metastasis with Ra-223 (Xofigo)
Therapy of neuro endocrine tumours with 177Lu-DOTATATE
Neuro endocrine tumours (NET) are rare tumours, which in principle can develop in the entire body. Most commonly, though, they develop in the pancreas or small intestine. Sometimes NET hormones form, which can trigger severe diarrhoea or paroxysmal sweating. Mostly however they do not cause any specific complaints. Often at the time of their diagnosis NET are therefore already metastased, that is to say they have formed metastases or metastases develop after a certain while, following surgical removal of the primary tumour. As a result NET often can no longer be completely surgically removed and according to the current state of research are no longer treatable. A special feature of NET is their diversity. Depending on the site of origin of NET and the speed at which it grows (this is in general determined using the so-called Ki-67) both prognosis and therapy can differ significantly.
A special feature of NET is the very strong expression of so-called somatostatin receptors. These receptors are of great significance therapeutically since there are medicines (sadostatin and somauline) which bind to it and inhibit both the distribution of hormones (and consequently can improve the symptoms) and can inhibit growth too. In order to reinforce the effect of these medicines, it seemed obvious to change medicines (DOTATATE) and to mark with a radioactive emitter (Lutetium-177). 177Lu-DOTATATE is applied in the bloodstream and finds its own way to NET. Since the somatostatin receptors of NET are very strongly expressed, although significantly less on healthy tissue, it results in target-oriented radiation of all metastases of NET with extensive protection of the healthy tissue.
Condition for therapy with 177Lu-DOTATATE
t must first of all be ensured that NET can no longer be surgically treated and expresses somatostatin receptors. This is generally proven with a so-called PET/CT with 68Ga-DOTANOC. Furthermore there must be a sufficiently good renal function and the haematosis may not be significantly restricted. If these conditions exist the respective case is discussed on the interdisciplinary tumour board with the participation of all physicians specialising in NET in order to establish the best possible treatment for the individual case. If according to this decision therapy with 177Lu-DOTATATE is the optimal therapy, the next course of action, therapy preparation and the admission date as an inpatient are established in a personal consultation.
Therapy is always carried out as an inpatient. Since under therapy seldom does damage to the kidneys on the back of the radiation load to the kidneys, during the first course of therapy, recordings of the distribution of 177Lu-DOTATATE in the body, so-called scintigrams, are taken for 7 days continuously, in order to be able to establish the radiation load of healthy organs individually for each patient and to adjust the therapy where necessary. Therefore you are required to stay in hospital for 8 days for the first course of therapy. For other therapy cycles (generally a total of 4 therapy cycles are performed at 3 monthly intervals), it is necessary stay in hospital for 3 days. Depending on the existing NET the therapy success using 68Ga-DOTANOC PET/CT is checked either between the 2nd and 3rd cycle or approx. 6-12 weeks after the 4th cycle.
Non-specific side effects like tiredness may occur. A temporary reinforcement of hormone-related symptoms such as diarrhoea or flush is also possible. On the day of treatment and the next day nausea and vomiting is possible. Additionally medium-term blood count changes with a reduction in the number of red blood cells (erythrocytes), platelets (thrombocytes) and the white cells (leucocytes) are possible, regular blood count checks are therefore recommended after therapy. In seldom cases (approx. 2-5%) it can result in a permanent restriction of renal function.
Selective internal radiotherapy of liver tumours (SIRT)
SIRT stands for selective internal radiotherapy, also known as radioembolisation. SIRT is a relatively new type of treatment for malignant liver tumours of primary (i.e. emanating from the liver tissue) or secondary (i.e. from tissue outside of the liver = Liver metastases) origin. Treatment with SIRT normally is only considered when the liver tumours present the main tumour load and are not suitable for surgical removal or systematic treatments such as chemotherapies for example have been performed without sustained success. In principle all liver tumours are considered, which have the most experience with HCC, CCC and liver metastasis of colorectal cancer, breast cancer, neuroendocrine tumours and (choroid membrane) melanoma.
The principle of SIRT is based on the strong arterial blood circulation of the most malignant tumours, whereas the healthy liver tissue is mainly treated by the portal vein. During SIRT millions of small particles, which are marked with the radioactive emitter Yttrium-90 are inserted into the liver artery via a venous catheter, which is inserted from the groin into the liver artery. A significantly higher concentration is achieved via the high arterial blood supply of the liver tumours in this than in the healthy liver tissue. The radioactive marked particles remain hidden in the small blood vessels of the liver tumours and stay there. As a result very high radiation doses are possible, through which the liver tumours are treated as selectively as possible.
In order to avoid radiation of other body organs, the expected distribution of particles is investigated through preliminary examinations. In order to rule out an outflow into the lungs, a trial angiography is performed about 1-3 weeks before actual treatment, during which a very weak radioactive emitter (Technetium-99m-Macroalbumin, gamma emitter) is injected into the liver artery and distribution is then measured. Should too high an outflow of the emitter show into the lungs, the treatment may possibly not be performed or only with a reduced dose, since this can cause a radiation-related lung inflammation. Furthermore within the scope of this trial run an outflow of particles into other organs of the upper abdomen such as the stomach or the duodenum is also examined. If this is the case it may be necessary to close the small branch of a vessel branching down from the liver artery using a catheter, in order to avoid radiation-induced inflammation in these organs.
Conditions for a SIRT are:
- Good liver function, i.e. a bilirubin of up to maximum 1.8 mg/dl and a normal value albumin (>35 g/l)
- Regular blood clotting
- No ascites
For the most part treatment is well tolerated. However a few patients may experience short-term (possibly even during treatment) upper abdominal pain, nausea and fever, which generally can be treated efficiently with a dose of medicines, and generally subside again after 1 to 2 days. Often after treatment there is tiredness and loss appetite for several days or weeks.
Very rarely might serious side effects occur, e.g. then, if despite all precautionary measures microspheres should flow into other organs (e.g. stomach, pancreas, lungs). In rare cases the radiation exposure of the normal liver tissue can lead to a temporary or permanent deterioration of the liver function (Radiation hepatitis).<
Radionuclide therapy of malign lymphoma (Zevalin)