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It is the reply to the Letter to the Editor by Chen and Lui regarding "Radiotherapy enhances uptake and efficacy of 90 Y-cetuximab: A preclinical trial" by A Dietrich et al. Abstract: Background and purpose: Systemic molecular radiotherapy utilizes internal irradiation by radionuclide-labeled tumor-targeting agents with the potential to destroy (micro-)metastases. However, doses that are applicable in solid tumors do not reach the levels nessecary for tumor control. Thus, the combination of molecular and external radiotherapy is a promising treatment strategy, as enhanced tumor doses can be delivered with and without minor overlapping toxicities. Here, we combined a 90Y-labeled anti-EGFR antibody (Cetuximab) with clinically relevant fractionated radiotherapy in a preclinical trial using head and neck squamous cell carcinoma xenograft tumors.

Background and purpose Systemic molecular radiotherapy utilizes internal irradiation by radionuclide-labeled tumor-targeting agents with the potential to destroy (micro-)metastases. However, doses that are applicable in solid tumors do not reach the levels nessecary for tumor control. Thus, the combination of molecular and external radiotherapy is a promising treatment strategy, as enhanced tumor doses can be delivered with and without minor overlapping toxicities. Here, we combined a 90Y-labeled anti-EGFR antibody (Cetuximab) with clinically relevant fractionated radiotherapy in a preclinical trial using head and neck squamous cell carcinoma xenograft tumors. Materials and methods To model 90Y-Cetuximab uptake for treatment schedule optimization, FaDu-bearing mice were injected with near-infrared-labeled-Cetuximab at different time points during radiotherapy with differing doses. Cetuximab uptake was longitudinally followed by in vivo-optical imaging. Tumor control probability experiments with fractionated radiotherapy (30 fx, 6 weeks, 8 dose groups/ arm) in combination with 90Y-Cetuximab were performed to test the curative potential. Results Imaging of near-infrared-labeled-Cetuximab uptake revealed that low to moderate external beam doses can enhance antibody uptake. Using the optimized schedule, combination of molecular and external radiotherapy using 90Y-Cetuximab at a dose that did not result in permanent tumor inactivation in previous experiments, led to substantially increased tumor control compared to radiotherapy alone. Conclusion Our results indicate that combination of radiolabeled therapeutics with clinically relevant fractionated radiotherapy has a remarkable potential to improve curative treatment outcome. Application of some radiation dose prior to injection may improve drug uptake and enable patient stratification and treatment personalization via a corresponding PET-tracer during therapy.

Die Therapie von Tumorerkrankungen gründet sich stadienabhängig auf die drei Säulen Chirurgie, Strahlen- und Chemotherapie. Grundprinzip der Strahlentherapie ist die gezielte Einwirkung von ionisierender Strahlung auf erkranktes Gewebe, um die Zerstörung maligner Tumorzellen zu erreichen. Neben der klassischen externen Strahlentherapie unter Verwendung von Photonen hat sich die Endoradionuklidtherapie durch Entwicklung geeigneter Targetingvektoren in den letzten Jahren zu einer zunehmend angewandten Therapieform entwickelt. Insbesondere die Radioimmuntherapie hat das Potential, auch (Mikro-) Metastasen zu zerstören. Die Kombination von externer und interner Strahlentherapie ist eine vielversprechende Behandlungsstrategie, da sie unter Schonung gesunden Gewebes potenziell die Vorteile beider Modalitäten kombiniert. Ziel dieses Projektes war es, im Tiermodell zu überprüfen, ob eine interne Bestrahlung mit Hilfe des anti-EGFR-gerichteten, 90Y-markierten Antikörpers Cetuximab (C225) eine lokale Tumorkontrolle nach vorhergehender externer Bestrahlung bei verringerter Dosis ermöglicht. Cetuximab wurde mit dem bifunktionellen Chelator p-SCN-Bn-CHX-A‘‘-DTPA funktionalisiert und nach 90Y-Markierung in einem Kopf-Hals-Plattenepithelkarzinom-Xenograftmodell (FaDu) eingesetzt. Die externe Bestrahlung erfolgte nach klinisch relevanten Protokollen mit 30 Bestrahlungsfraktionen (fx) verteilt über 6 Wochen. Nach 10 Fraktionen wurden jeweils 2,3 MBq des 90Y-markierten Cetuximab-Konjugats injiziert. Die kombinierte Anwendung von externer und interner Bestrahlung erhöhte massiv die Wahrscheinlichtkeit einer lokalen Tumorkontrolle im Vergleich zur externen Bestrahlung allein oder in Kombination mit unmarkiertem Cetuximab. In der Gruppe mit der niedrigsten externen Strahlendosis (1 Gy/Fraktion, Gesamtdosis = 30 Gy,) plus 90Y-Cetuximab wurden alle Tumore noch permanent kontrolliert (Beobachtungszeitraum = 120 d). Im Gegensatz dazu betrug die gesamte externe Strahlendosis, die notwendig i

Solid tumors can be precisely targeted with external beam radiotherapy (EBRT) but dose is limited by the surrounding tissue. The combination with radioimmunotherapy (= combination of internal and external radiotherapy - CIERT) mediates additional internal irradiation with the potential to strike also distant metastases but affecting different organs at risk. Furthermore, patient stratification is possible using corresponding PET-tracers [1]. We showed the effectiveness of CIERT using 90Y-labelled Cetuximab ([90Y]Y-Cet) and single dose EBRT in a head and neck squamous cell carcinoma xenograft model (FaDu, [2]). The presented project aimed to investigate CIERT using clinical relevant fractionated EBRT with 30 fractions (fx) over 6 weeks. However, the timing of [90Y]Y-Cet is crucial in such settings and was first optimized by modeling [90Y]Y-Cet uptake with near-infrared-labeled Cetuximab (NIR-Cet). The tracer was injected in FaDu-bearing mice at different time points during fxEBRT with differing doses. NIR-Cet uptake was longitudinally followed by in vivo optical imaging to find the optimal schedule for tumor control probability experiments to test the curative potential of CIERT. NIR-Cet uptake was enhanced after applying low to moderate doses of fxEBRT. Thus, [90Y]Y-Cet was injected after 10 fx of EBRT in CIERT efficacy experiments. CIERT massively increased local control probability compared to EBRT alone or in combination with unlabeled Cetuximab. In the group with the lowest external dose (1 Gy/fx, total dose = 30 Gy) plus [90Y]Y-Cet all tumors were still permanently controlled (observation period = 120 d). In contrast, the total EBRT dose to cure 50% of the tumors without additional [90Y]Y-Cet injection was 63.9 Gy [58.7, 73.9]. Our results indicate a remarkably potential to improve treatment outcome if radiolabeled therapeutics are combined with fractionated external radiotherapy in a clinical relevant setting. Tumor uptake may be improved by application of som