Actinium-225-PSMA radioligand therapy of metastatic castration-resistant prostate cancer (WARMTH Act): a multicentre, retrospective study.

BACKGROUND: Actinium-225 (225Ac) prostate-specific membrane antigen (PSMA) radioligand therapy (RLT) is a novel therapy for metastatic castration-resistant prostate cancer (mCRPC). We aimed to report the safety and antitumour activity of 225Ac-PSMA RLT of mCRPC in a large cohort of patients treated at multiple centres across the world. METHODS: This retrospective study included patients treated at seven centres in Australia, India, Germany, and South Africa. We pooled data of consecutive patients of any age and Eastern Cooperative Oncology Group performance status with histopathologically confirmed adenocarcinoma of the prostate who were treated with one or more cycles of 8 MBq 225Ac-PSMA RLT administered intravenously for mCRPC. Previous lines of mCRPC treatment included taxane-based chemotherapy, androgen-receptor-axis inhibitors, lutetium-177 (177Lu) PSMA RLT, and radium-223 dichloride. The primary outcomes were overall survival and progression-free survival. FINDINGS: Between Jan 1, 2016, and May 31, 2023, 488 men with mCRPC received 1174 cycles of 225Ac-PSMA RLT (median two cycles, IQR 2-4). The mean age of the patients was 68·1 years (SD 8·8), and the median baseline prostate-specific antigen was 169·5 ng/mL (IQR 34·6-519·8). Previous lines of treatment were docetaxel in 324 (66%) patients, cabazitaxel in 103 (21%) patients, abiraterone in 191 (39%) patients, enzalutamide in 188 (39%) patients, 177Lu-PSMA RLT in 154 (32%) patients, and radium-223 dichloride in 18 (4%) patients. The median follow-up duration was 9·0 months (IQR 5·0-17·5). The median overall survival was 15·5 months (95% CI 13·4-18·3) and median progression-free survival was 7·9 months (6·8-8·9). In 347 (71%) of 488 patients, information regarding treatment-induced xerostomia was available, and 236 (68%) of the 347 patients reported xerostomia after the first cycle of 225Ac-PSMA RLT. All patients who received more than seven cycles of 225Ac-PSMA RLT reported xerostomia. Grade 3 or higher anaemia occurred in 64 (13%) of 488 patients, leukopenia in 19 (4%), thrombocytopenia in 32 (7%), and renal toxicity in 22 (5%). No serious adverse events or treatment-related deaths were recorded. INTERPRETATION: 225Ac-PSMA RLT shows a substantial antitumour effect in mCRPC and represents a viable therapy option in patients treated with previous lines of approved agents. Xerostomia is a common side-effect. Severe bone marrow and renal toxicity are less common adverse events. FUNDING: None.

Efficacy and Haematologic Toxicity of Palliative Radioligand Therapy of Metastatic Castrate-Resistant Prostate Cancer with Lutetium-177-Labeled Prostate-Specific Membrane Antigen in Heavily Pre-Treated Patients.

BACKGROUND: Metastatic castration-resistant prostate cancer (mCRPC) remains a significant contributor to the global cancer burden. lutetium-177-prostate-specific membrane antigen radioligand therapy (177Lu-PSMA RLT) is an effective salvage treatment. However, studies have highlighted haematologic toxicity as an adverse event of concern. We report our single-centre experience of compassionate access palliative 177Lu-DOTAGA-(I-y)fk(Sub-KuE) (177Lu-PSMA I&T) with respect to efficacy and haematologic safety. METHODS: Patients with mCRPC and adequate bone marrow/liver function were included. All patients included underwent baseline and response assessment by Gallium-68-PSMA-11 positron emission tomography/computed tomography (68Ga-PSMA-11 PET/CT). Prescribed activity of therapy was a median 6.24 GBq per patient per cycle (IQR1.29 GBq), administered in 8-week intervals, up to four cycles. Response was assessed by prostate specific antigen (PSA) and a week-12 PET/CT. Incidence of grade ≥ 3 haematologic toxicity, including association with risk factors (age ≥ 70 years, prior/concurrent therapy, presence of metastases, and number of cycles completed), was analysed. RESULTS: One hundred patients completed one cycle of 177Lu PSMA I&T and underwent response assessment by both PSA and PET/CT. Two patients had an uninterpretable week-12 PET/CT. Median age was 70 (50-89), median number of prior therapies was three (1-6), and median follow up was 12-months. Fifty-four percent achieved a PSA response. Disease control rate (DCR) by PET/CT was 64% (29% SD, 34% PR, and 1% CR). Disease control by PET/CT was associated with an improved one-year overall survival (OS) compared to non-responders, median OS not-reached vs 10-months (p < 0.0001; 95% CI: 0.08-0.44). Regarding haematologic toxicity, 11% experienced a grade ≥ 3 cytopenia (self-limiting). No cases of myelodysplasia/acute leukaemia (MDS/AL) have been recorded. No association with risk factors was demonstrated. CONCLUSION: 177Lu-PSMA I&T is a safe and effective palliative outpatient treatment for mCRPC. 68Ga-PSMA-11 PET/CT response is associated with an improved one-year OS and may be used to adapt therapy.

Salvage Radiopeptide Therapy of Advanced Castrate-Resistant Prostate Cancer with Lutetium-177-Labeled Prostate-Specific Membrane Antigen: Efficacy and Safety in Routine Practice.

BACKGROUND: Prostate-specific membrane antigen (PSMA)-based radiopeptide/radioligand therapy represents a rapidly expanding field in the management of metastatic castrate-resistant prostate cancer (mCRPC). However, there remains concern for the development of significant toxicities in heavily pretreated patients. In this study, the authors present their local experience, with respect to efficacy and toxicity, of 22 consecutive patients treated with lutetium-177-DOTAGA-(I-y)fk(Sub-KuE) or 177Lu-PSMA I&T radioimmunotherapy for progressive mCRPC, followed up over 1 year. MATERIALS AND METHODS: All patients had progressive mCRPC, an European Cooperative Oncology Group (ECOG) ≤2 with adequate bone marrow and liver function. 177Lu-PSMA I&T therapy was administered at 8-week intervals with a mean prescribed activity of 5.5 GBq (gigabecquerel) per patient. RESULTS: Twenty patients had evaluable results, median age of 71 years, and median duration of follow-up of 17 months. Three patients (15%) experienced a G1/2 myelotoxicity and four (20%) G3/4. No incidences of myelodysplasia/acute leukemia have been identified. All toxicities were self-limiting. Baseline cytopenia was predictive of the development of subsequent G3/4 myelotoxicity (p = 0.0035). Eight patients (40%) experienced an objective PSA response, with a median time to response of 15 weeks. The median time to PSA progression was not reached. Patients receiving three cycles of therapy were statistically more likely to experience a disease response when compared to those treated with one, two, or four cycles (p < 0.0001). CONCLUSIONS: 177Lu-PSMA I&T radioimmunotherapy of progressive mCRPC is safe and effective with three cycles being the potential optimal number for determining long-term disease response.

The effect of counterion/ligand interplay on the activity and stereoselectivity of palladium(II)-diimine catalysts for CO/p-methylstyrene copolymerization.

The catalytic activity and stereoselectivity of complexes [Pd(eta(1),eta(2)-C(8)H(12)OMe)(Ar--N==C(R')--C(R')==N--Ar)]X in the copolymerization of CO and p-methylstyrene have been correlated with their interionic structure in solution and in the solid state, as determined by (19)F,(1)H-HOESY NMR spectroscopy and X-ray diffraction studies, respectively. The highest productivity is obtained with unhindered diimine ligands bearing electron-donating substituents and with the least coordinating counterion. Copolymers with a microstructure ranging from atactic to predominantly isotactic are obtained. The degree of isotacticity increases as the steric hindrance in the apical positions and the coordinating ability of the counterion increase. The counterion is located close to the diimine in both solution and the solid state but it moves toward the palladium as the steric hindrance in the apical positions decreases. When the latter is small the counterion competes with the substrate for apical coordination, and consequently it affects the productivity. In the case of ortho-dimethyl-substituted ligands the counterion is confined in the back, above the N==C(R')--C(R')==N moiety, and does not affect the productivity. However, it contributes to increasing the stereoregularity of the copolymer by making the aryl moieties more rigid. With R'=Me and Ar=o-Me(2)C(6)H(3) an ll of 81 % and 72 % was obtained with X(-)=CF(3)SO(3) (-) or BArF(-), respectively. The isotacticity of the copolymers produced by ortho-monosubstituted catalysts depends greatly on the counterion and ranges from 30 % to 59 % with X(-)=BArF(-) and X(-)=CF(3)SO(3) (-), respectively, with Ar=o-EtC(6)H(4) and R'=Me. Based on the interionic structural results, this effect can be explained by a greater reduction of the copolymerization rate of C(s)-symmetric isomers with respect to their C(2)-symmetric counterparts.

Aggregation tendency and reactivity toward AgX of cationic half-sandwich ruthenium(II) complexes bearing neutral N,O-ligands.

The aggregation tendency of complexes [Ru(eta6-cymene)(N,O)Cl]X [N,O = 2-benzoylpyridine (2-bzpy), 1, and 2-acetylpyridine (2-acpy), 2, X- = BPh4- or PF6-] has been studied by means of PGSE NMR experiments. It was found that complexes with PF6- as counterion are mainly present in CD2Cl2 as ion pairs at low concentration, as a mixture of ion triples and free anions at medium concentration and as ion quadruples at elevated concentration. 19F, 1H-HOESY NMR experiments revealed that in ion triples and ion quadruples two cationic Ru-units pair up. Consistently, in the solid-state structure of 1PF6, determined through X-ray single-crystal investigation, two cationic Ru-units are held together by an intermolecular pi-pi stacking interaction between the pyridyl rings. Complexes having BPh4- as counterion are only present in solution as even aggregates, namely ion pairs at low concentration and ion quadruples at elevated concentration. In such a case a counteranion bridges two cationic Ru-units as observed in the solid-state structure of 1BPh4. The reactivity of complexes 1-2 toward AgX salts has been investigated in different solvents. Bicationic [Ru(eta6-cymene)(N,O)(MeCN)]X2 (N,O = 2-bzpy, 3, and 2-acpy, 4) and [Ru(MeCN)4(N,O)]X2 (N,O = 2-bzpy, 5, and 2-acpy, 6) complexes were obtained by the reaction of 1 and 2 with AgX in the presence of three equivalents of acetonitrile or in acetonitrile, respectively. The reaction of 1 with AgPF6 in acetone afforded complex [Ru(eta6-cymene)(N,O,O)]PF6 (7, where N,O,O = 4-alcoxide-4-phenyl-4-(pyridin-2-yl)butan-2-one) from the C-C coupling of a deprotonated methyl group of the coordinated acetone and the C=O moiety of 2-bzpy ligand.

Randomised phase 2 trial of SIR-Spheres plus fluorouracil/leucovorin chemotherapy versus fluorouracil/leucovorin chemotherapy alone in advanced colorectal cancer.

PURPOSE: Selective internal radiation therapy (SIRT) with SIR-Spheres(R) is a new technique for selectively targeting high doses of radiation to tumours within the liver. The primary objectives of this randomised trial were to compare the response rate, time to progressive disease (PD), and toxicity of a regimen of systemic fluorouracil/leucovorin chemotherapy versus the same chemotherapy plus a single administration of SIR-Spheres in patients with advanced colorectal liver metastases. The trial was designed to presage a larger trial that would have survival as the primary outcome. PATIENTS AND METHODS: Twenty-one patients with previously untreated advanced colorectal liver metastases, with or without extrahepatic metastases, were randomised into the study. RESULTS: Using RECIST criteria, the response rate for 11 patients receiving the combination treatment was significantly greater than for 10 patients receiving chemotherapy alone (First Integrated Response; 10 PR, 1 SD vs. 0 PR, 6 SD, 4 PD, P < 0.001 and Best Confirmed Response; 8 PR, 3 SD vs. 0 PR, 6 SD, 4 PD P < 0.001). The time to PD was greater for patients receiving the combination treatment (18.6 months vs. 3.6 months, P < 0.0005). Median survival was significantly longer for patients receiving the combination treatment (29.4 months vs. 12.8 months, P = 0.02). One patient in the combination arm died from chemotherapy induced neutropenic sepsis after the fourth chemotherapy cycle. There were more Grade 3 and 4 toxicity events in patients receiving the combination treatment. There was no difference in quality-of-life over a 3 month period between the two treatments when rated by patients (P = 0.96) or physicians (P = 0.98). CONCLUSIONS: This small phase 2 randomised trial demonstrated that the addition of a single administration of SIR-Spheres to a regimen of systemic fluorouracil/leucovorin chemotherapy significantly increased both treatment related response, time to PD, and survival with acceptable toxicity. The combination of SIR-Spheres plus systemic chemotherapy is now the subject of ongoing trials to further define patient benefit.

PGSE and NOE NMR evidence for higher order aggregation in some cationic ruthenium complexes in both protic and aprotic solvents.

PGSE and NOE NMR measurements were carried out for complexes [Ru(eta(6)-cymene)((2-R-C(6)H(4))N=C(Me)-C(Me)=N(2-R-C(6)H(4)))Cl]X (X = BF(4) or BPh(4)) in both protic and aprotic solvents with a relative permettivity (epsilon(r)) ranging from 2.27 (benzene-d(6)) to 46.45 (dimethyl sulfoxide-d(6)). PGSE and NOE results indicate that complexes have a tendency to aggregate even in medium-polarity solvents such as ethanol (epsilon(r) = 24.55) and methanol (epsilon(r) = 32.66). In addition, the aggregation process is favored by a decrease of epsilon(r) and, unexpectedly, by protic solvents. NOE measurement investigations, interpreted with the help of theoretical calculations and confirmed by X-ray single crystal studies, suggest different aggregation processes for the two counteranions: two cationic moieties approach each other when X = BF(4) while the anion bridges two cationic moieties when X = BPh(4).