Over the last couple of decades, gallium-68 (68Ga) has gained a formidable interest for PET molecular imaging of various conditions, from cancer to infection, through cardiac pathologies or neuropathies. It has gained routine use, with successful radiopharmaceuticals such as somatostatin analogs ([68Ga]Ga-DOTATOC and [68Ga]GaDOTATATE) for neuroendocrine tumors, and PSMA ligands for prostate cancer. It represents a major clinical impact, particularly in the context of theranostics, coupled with their 177Lu-labeled counterparts. Beside those, a bunch of new 68Ga-labeled molecules are in the preclinical and clinical pipelines, with some of them showing great promise for patient care. Increasing clinical demand and regulatory issues have led to the development of automated procedures for the production of 68Ga radiopharmaceuticals. However, the widespread use of these radiopharmaceuticals may rely on simple and efficient radiolabeling methods, undemanding in terms of equipment and infrastructure. To make them technically and economically accessible to the medical community and its patients, it appears mandatory to develop a procedure similar to the well-established kit-based 99mTc chemistry. Already available commercial kits for the production of 68Ga radiopharmaceuticals have demonstrated the feasibility of using such an approach, thus paving the way for more kit-based 68Ga radiopharmaceuticals to be developed. This article discusses the development of 68Ga cold kit radiopharmacy, including technical issues, and regulatory aspects.

/pdf/cold-kit-labeling-the-future-of-68ga-radiopharmaceuticals-31gl2r0n.pdf

Cold Kit Labeling: The Future of 68Ga Radiopharmaceuticals?

Radiolabelled prostate-specific membrane antigen (PSMA)-based PET–CT has been shown in numerous studies to be superior to conventional imaging in the detection of nodal or distant metastatic lesions. 68Ga-PSMA PET–CT is now recommended by many guidelines for the detection of biochemically relapsed disease after radical local therapy. PSMA radioligands can also function as radiotheranostics, and Lu-PSMA has been shown to be a potential new line of treatment for metastatic castration-resistant prostate cancer. Whole-body (WB) MRI has been shown to have a high diagnostic performance in the detection and monitoring of metastatic bone disease. Prospective, randomized, multicentre studies comparing 68Ga-PSMA PET–CT and WB MRI for pelvic nodal and metastatic disease detection are yet to be performed. Challenges for interpretation of PSMA include tracer trapping in non-target tissues and also urinary excretion of tracers, which confounds image interpretation at the vesicoureteral junction. Additionally, studies have shown how long-term androgen deprivation therapy (ADT) affects PSMA expression and could, therefore, reduce tracer uptake and visibility of PSMA+ lesions. Furthermore, ADT of short duration might increase PSMA expression, leading to the PSMA flare phenomenon, which makes the accurate monitoring of treatment response to ADT with PSMA PET challenging. Scan duration, detection of incidentalomas and presence of metallic implants are some of the major challenges with WB MRI. Emerging data support the wider adoption of PSMA PET and WB MRI for diagnosis, staging, disease burden evaluation and response monitoring, although their relative roles in the standard-of-care management of patients are yet to be fully defined. In this Review, the authors discuss the current evidence for the use of prostate-specific membrane antigen (PSMA) PET and whole-body (WB) MRI, consider the evolving use of PSMA PET-derived and WB MRI-derived quantitative biomarkers and make recommendations for future clinical trials of these modalities. 

/pdf/the-future-of-psma-pet-and-wb-mri-as-next-generation-imaging-1tv655vg.pdf

The future of PSMA PET and WB MRI as next-generation imaging tools in prostate cancer

Accurate primary staging is the cornerstone in all malignancies. Different morphological imaging modalities are employed in the evaluation of prostate cancer (PCa). Regardless of all developments in imaging, invasive histopathologic evaluation is still the standard method for the detection and staging of the primary PCa. Magnetic resonance imaging (MRI) and computed tomography (CT) play crucial roles; however, functional imaging provides additional valuable information, and it is gaining ever-growing acceptance in the management of PCa. Targeted imaging with different radiotracers has remarkably evolved in the past two decades. [111In]In-capromab pendetide scintigraphy was a new approach in the management of PCa. Afterwards, positron emission tomography (PET) tracers such as [11C/18F]choline and [11C]acetate were developed. Nevertheless, none found a role in the primary staging. By introduction of the highly sensitive small molecule prostate-specific membrane antigen (PSMA) PET/CT, as well as recent developments in MRI and hybrid PET/MRI systems, non-invasive staging of PCa is being contemplated. Several studies investigated the role of these sophisticated modalities in the primary staging of PCa, showing promising results. Here, we recapitulate the role of targeted functional imaging. We briefly mention the most popular radiotracers, their diagnostic accuracy in the primary staging of PCa, and impact on patient management.

Molecular Imaging in Primary Staging of Prostate Cancer Patients: Current Aspects and Future Trends.

Despite its prevalence in the environment, the chemistry of the Ti 4+ ion has long been relegated to anhydrous solutions or hydrolyzed TiO 2 polymorphs. A knowledge gap in stabilizing molecular Ti 4+ species in aqueous environments has prevented the use of this ion for various applications such as cancer therapy, radioimaging, design of water-compatible metal-organic frameworks (MOFs), and aqueous-phase molecular catalysis applications. Herein, we demonstrate that a fragment-based screening approach of bidentate chelators with Ti 4+ in aqueous solution, as well as computational and structural analysis reliably predicts that a hexadentate analogues of catechol (benzene-1,2-diol) and deferiprone (3-hydroxy-1,2-dimethyl-4(1H)-pyridone), TREN-CAM and THP Me respectively, form mononuclear Ti 4+ complexes resistant against hydrolysis from pH 4-10. We further validate our findings using radiochemical labeling with the short-lived isotopeTi-45, which demonstrates that the [ 45 Ti]Ti-TREN-CAM complex remains inert against transchelation in vivo.

A General Design Strategy Enabling the Synthesis of Hydrolysis-Resistant, Water-Stable Titanium(IV) Complexes.

Simple Summary Prostate-specific membrane antigen positron emission tomography (PSMA PET) is a modern imaging modality used in the management of patients with prostate cancer with improved accuracy in detecting lymph nodes and distant disease spread. In this paper, we discuss how the increasing use of PSMA PET is changing clinical management in patients with prostate cancer, specifically those previously treated for localized disease and now presenting with recurrence or low-volume metastatic disease spread. We also discuss how PSMA PET is affecting clinical trial design and interpretation. More clinical trials are needed to investigate whether the use of PSMA PET translates into improved patient survival or quality of life. Abstract Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scans have higher sensitivity and specificity for detecting lymph nodes or metastatic disease relative to conventional imaging in prostate cancer staging. Since its FDA approval and incorporation into treatment guidelines, the use of PSMA PET has increased in patients undergoing initial staging, those with recurrence after initial definitive treatment, and patients with metastatic disease. Although the early detection of metastatic lesions is changing disease management, it is unclear whether this impact on management translates into clinical benefit. This review will summarize evidence pertaining to the change in patient management due to PSMA PET use and will discuss the implications of PSMA PET on treatment decisions in prostate cancer, particularly in the settings of biochemical recurrence and metachronous oligometastatic disease.

/pdf/management-of-patients-with-recurrent-and-metachronous-12ktwgb8.pdf

Management of Patients with Recurrent and Metachronous Oligometastatic Prostate Cancer in the Era of PSMA PET

Objectives: To assess the safety and clinical impact of a novel, kit-based formulation of 68Ga‐THP PSMA positron emission tomography/computed tomography (PET/CT) when used to guide the management of patients with prostate cancer (PCa). 


Methods: Patients were prospectively recruited in to one of:
Group A: high-risk untreated prostate cancer; Gleason score >4+3, or PSA >20 ng/mL or clinical stage >T2c. 
Group B: biochemical recurrence (BCR) and eligible for salvage treatment after radical prostatectomy with two consecutive rises in prostate specific antigen (PSA) with a three month interval in between reads and final PSA >0.1 ng/mL or a PSA level >0.5 ng/mL. 
Group C: BCR with radical curative radiotherapy or brachytherapy at least three months prior to enrolment, and an increase in PSA level >2.0 ng/mL above the nadir level after radiotherapy or brachytherapy. 
Patients underwent evaluation with PET/CT 60 minutes following intravenous administration of 160±30 MBq of 68Ga-THP PSMA. Safety was assessed by means including vital signs, cardiovascular profile, serum haematology, biochemistry, urinalysis, PSA, and Adverse Events (AEs). A change in management was reported when the predefined clinical management of the patient altered as a result of 68Ga-THP PSMA PET/CT findings.


Results: Forty-nine patients were evaluated with PET/CT; 20 in Group A, 21 in Group B and 8 in Group C. No patients experienced serious AEs discontinued the study due to AEs, or died during the study. Two patients had Treatment Emergent AEs attributed to 68Ga-THP-PSMA (pruritus in one patient and intravenous catheter site rash in another). Management change secondary to PET/CT occurred in 42.9% of all patients; 30% in Group A, 42.9% in Group B and 75% in Group C. 


Conclusion:68Ga-THP PSMA was safe to use with no serious AE and no AE resulting in withdrawal from the study. 68Ga-THP PSMA PET/CT changed the management of patients in 42.9% of the study population, comparable to studies using other PSMA tracers. These data form the basis of a planned Phase III study of 68Ga-THP PSMA in patients with prostate cancer.

https://jnm.snmjournals.org/content/jnumed/early/2021/03/19/jnumed.120.257527.full.pdf

A Phase II, Open-label study to assess safety and management change using 68Ga-THP PSMA PET/CT in patients with high risk primary prostate cancer or biochemical recurrence after radical treatment: The PRONOUNCED study.

Surgery is the curative treatment of choice in many types of cancer diagnosed at an early stage when the disease is still localized, and there is no evidence of distant metastases. The success of curative surgery depends on removing the tumor with a margin of healthy tissue around it to ensure that no malignant cells are left behind. However, the recurrence rates after complete surgical resection with curative intent remain high in many types of cancer. Imaging plays an essential role in the assessment of postoperative complications. The chapter will discuss the advantages and limitations of conventional imaging and PET/CT in the postsurgical setting of various cancer types, reviewing several guidelines and recommendations. Besides, the potential pitfalls in the image interpretation will be discussed.

Conventional Radiological Techniques and PET-CT in Treatment Response Evaluation in Postsurgical Setting

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A Phase II, Open-label study to assess safety and management change using 68Ga-THP PSMA PET/CT in patients with high risk primary prostate cancer or biochemical recurrence after radical treatment: The PRONOUNCED study.

Conventional Radiological Techniques and PET-CT in Treatment Response Evaluation in Postsurgical Setting