Tolerability of a novel bone-seeking radionuclide, the alpha emitter radium-223, in patients with skeletal metastases from breast and prostate cancer

S. Nilsson1, L.Balteskard2, S. D. Fosså3, J.E. Westlin4, K. W. Borch5, R. H. Larsen5, Ø. S. Bruland3

1Karolinska Hospital, Stockholm, Sweden, 2The University Hospital of Tromsø, Norway, 3The Norwegian Radium Hospital, Oslo, Norway, 4Mälarsjukhuset, Eskilstuna, Sweden, 5Algeta AS, Oslo, Norway.

Background: Pre-clinical dosimetry and experimental therapeutic studies of the alpha emitter radium-223 (t1/2 = 11.4 days) indicate a significant therapeutic potential against skeletal

metastases (Ref. 1).Patients and methods: 31 patients (10 breast cancer and 21 prostate cancer patients) have been enrolled in an ongoing phase I trial. In the first part of the study 25 patients were given a single intravenous injection of radium-223 as part of a cohort dose escalating design. Cohorts of 5 patients were followed weekly for 8 weeks. Initial dose level was 37 kBq kg-1 b.w. increasing to 74, 130, 170 and 200 kBq kg-1 b.w. In the second part of the study, 2 of the patients were given a second injection, resulting in a total dose of 200 kBq kg-1 b.w. The tolerability of repeated dosing (100 kBq kg-1 b.w. X 2, six weeks interval, or 40 kBq kg-1 b.w. X 5, three weeks interval) were studied in 6 prostate cancer patients. The primary objective was to evaluate the safety and tolerance of the drug. Toxicity was monitored using NCI common toxicity criteria and quality of life was assessed (EORTC QLQ-C 30) for all patients. Blood clearance of radium-223 was studied in the initial 25 patients.

Results: Dose-limiting haemotoxicity was not observed in the dose escalating part of the study. Reversible myelosuppression occurred, with nadir 2-3 weeks after injection and recovery during the follow-up period. Neutropenia of maximum grade 3 occurred in 2 of the 25 patients. For thrombocytes, even at the two highest dose levels only grade 1 toxicity was observed. See detailed results in Table 1 and Figure 3. Few adverse events were reported, with nausea as the most frequent event (4 of 5 patients) at the highest dose level. Reversible diarrhoea, grades 1 and 2, responding well to medication, were occasionally observed in all dose groups. Several patients reported pain palliation. Radium-223 was rapidly cleared from blood; after 24 hours the blood activity level was below 1 % of the initial level for all dose groups (Figure 1). For all patients a decline in serum-ALP values was observed Figure 2). To date, no trends towards increased myelosuppression upon repeated dosing have been observed. In patients were gamma-camera scintigraphy was performed, accumulation of 223Ra in skeletal lesions in accordance with 99mTc-MDP was seen (Figure 4).

Conclusions: Radium-223 was well tolerated by patients with skeletal metastases. Surprisingly low haematological toxicity was observed at potentially therapeutic doses. These results justify further studies to explore the efficacy of radium-223 as a novel targeted internal radioisotope treatment.

Figure 1. Blood clearance of radium-223

Table 1. Myelotoxicity

ECCO12 Poster No. 543

Figure 4. Scintigraphic images demonstrating accumulation of 223Ra in skeletal lesions in accordance with 99mTc-MDP uptake . (Image quality is dependent on dose administered: 750 MBq 99mTc-MDP vs. 12 MBq 223Ra)

99mTc-MDP

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Anterior Posterior

Reference 1: Henriksen, Breistøl, Bruland, Fodstad and Larsen, Cancer Res. 62, 3120-3125, 2002

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Figure 2. Reduction in serum-ALP levels in patients given a single injection of radium-223 (all dose levels combined)

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Platelets, Single doseDosegroup I: 37 kBq/kgDosegroup II: 70 kBq/kgDosegroup III: 130 kBq/kgDosegroup IV: 170 kBq/kgDosegroup V: 200 kBq/kg

Toxicity Re-

CTC Grade 37 kBq/kg 74 kBq/kg 130 kBq/kg 170 kBq/kg 200 kBq/kg treatment 40 kBq/kg 100 kBq/kg

n=5 n=5 n=5 n=5 n=5 n=2 n=3 n=3

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Serum-ALP change after intravenous administration of radium-223