RADTHYR: an open-label, single-arm, prospective multicenter phase II trial of Radium-223 for the treatment of bone metastases from radioactive iodine refractory differentiated thyroid cancer

Abstract

Purpose: This is the first prospective trial evaluating the efficacy of alpha emitter Radium-223 in patients with bone metastases from radioactive iodine (RAI) refractory (RAIR) differentiated thyroid cancer.

Methods: RADTHYR is a multicenter, single-arm prospective Simon two-stage phase II trial (NCT02390934). The primary objective was to establish the efficacy of three administrations of 55 kBq/kg of Radium-223 by ¹⁸F-FDG PET/CT according to PERCIST criteria. Secondary objectives were to establish the efficacy of six administrations of Radium-223 by ¹⁸F-FDG PET/CT, ^99mTc-HMDP bone scan and ¹⁸FNa PET/CT, clinical benefits, changes in serum bone markers, thyroglobulin levels, and safety.

Results: Ten patients were enrolled between July 2015 and December 2017 (4 M; median age 74 years). Prior to Radium-223 administration, patients received a median RAI cumulative activity of 15 GBq (7.4-35.6), external radiation therapy (n = 9), bone surgery (n = 8), cimentoplasty (n = 5), and cryoablation (n = 2). ¹⁸F-FDG PET/CT showed stable disease (SD) in 4/10 and progressive disease (PD) in 6/10 cases after three administrations and SD in 4/10, PD in 5/10 cases, and 1/10 non-evaluable (NE) case after six administrations. After six injections, ^99mTc-HMDP bone scan showed SD in 9 cases and was NE in 1 case; ¹⁸FNa PET/CT showed SD in 8 cases, partial response (PR) in 1 case, and was NE in 1 case. No significant clinical benefits were reported during the study. A skeletal event occurred in 6 patients (median time without skeletal event of 12.1 months). Seventy-seven adverse events were reported during treatment (7 of grade 3-4). Three patients developed an acute myeloid, a promyelocytic, and a chronic myeloid leukemia after the last Radium-223 administration considered as drug-related.

Conclusion: The trial was stopped after interim analysis for lack of response of bone metastases from RAIR thyroid cancer to Radium-223. Severe hematological toxicity was observed in patients heavily pretreated with RAI and external radiation.

Trial registration number: NCT02390934. Registration date 18.03.2015.

Keywords: Alpha emitters; Bone metastases; Leukemia; Radium-223; Refractory thyroid cancer.

Fig. 1

Consolidated standards of reporting trials (CONSORT) DIAGRAM of the study

Fig. 2

Waterfall plot of total SULpeak variation at 3 months and at 6 months for each included patient according to response criteria used for ¹⁸F-FDG PET/CT. Disease progression (red column) was defined also in case of SULpeak increase less than 30% but increase > 75% of total lesion glycolysis (TLG) or in case of appearance of new lesions

Fig. 3

Baseline, 3 months and 6 months. (A) ¹⁸F-FDG PET/CT. (B) ¹⁸FNa PET/CT. and (C) ⁹⁹mTc-HMDP bone scintigraphy. The patient presented at baseline 4 bone target lesions. Total SULpeak and total TLG at baseline ¹⁸F FDG PET were 39.1 and 335.3, respectively. He was defined as PD for ∆SULpeak of + 33% at 3 and 6 months (∆TLG of + 51% and + 72%, respectively). Total SUVmax at baseline ¹⁸FNa PET/CT was 107.4. He was defined with SD with ∆SUVmax of − 21.5% and − 22% after 3 and 6 administrations of Radium-223, respectively. Disease was considered stable at bone scintigraphy both at 3 and 6 months

Fig. 4

Kaplan-Meier estimation of probability of skeletal event