Targeted α-Emitter Therapy with 212Pb-DOTAMTATE for the Treatment of Metastatic SSTR-Expressing Neuroendocrine Tumors: First-in-Humans Dose-Escalation Clinical Trial

Abstract

Peptide receptor radiotherapy with somatostatin analogs has been successfully used for years as a treatment for somatostatin-overexpressing tumors. Treatment of neuroendocrine tumors (NETs) with the β-particle emitter ¹⁷⁷Lu-DOTATATE is currently considered the standard of care for subjects with gastroenteropancreatic NETs. Despite the success of ¹⁷⁷Lu-DOTATATE, there remains significant room for improvement in terms of both safety and efficacy. Targeted α-emitter therapy with isotopes such as ²¹²Pb has the potential to improve both. Here, we present the preliminary results of the phase 1 first-in-humans dose-escalation trial evaluating ²¹²Pb-DOTAMTATE (a bifunctional metal chelator [DOTAM] and the SSTR-targeting peptide [TATE]) in patients with somatostatin receptor-positive NETs. Methods: Twenty subjects with histologically confirmed NETs, prior positive somatostatin analog scans, and no prior history of ¹⁷⁷Lu/⁹⁰Y/¹¹¹In peptide receptor radiotherapy, with different primary sites of the disease, were enrolled. Treatment began with single ascending doses of ²¹²Pb-DOTAMTATE, with subsequent cohorts receiving an incremental 30% dose increase, which was continued until a tumor response or a dose-limiting toxicity was observed. This was followed by a multiple ascending dose regimen. The recommended phase 2 dose regimen consisted of 4 cycles of 2.50 MBq/kg (67.6 μCi/kg) of ²¹²Pb-DOTAMTATE administered at 8-wk intervals, intravenously. Results: Ten subjects received the highest dose, 2.50 MBq/kg/cycle (67.6 μCi/kg/cycle). Treatment was well tolerated, with the most common treatment-emergent adverse events being nausea, fatigue, and alopecia. No serious treatment-emergent adverse events were related to the study drug, and no subjects required treatment delay or a dose reduction. An objective radiologic response of 80% was observed for the first 10 subjects treated at the recommended phase 2 dose. Conclusion: Targeted α-therapy with ²¹²Pb-DOTAMTATE has been shown to be well tolerated. Preliminary efficacy results are highly promising. If these results are confirmed in a larger, multicenter clinical trial, ²¹²Pb-DOTAMTATE would provide a substantial benefit over currently Food and Drug Administration-approved therapies for patients with metastatic or inoperable SSTR-expressing NETs regardless of the grade and location of the primary tumor.

Keywords: 212Pb-DOTAMTATE; NEN; NET; PRRT; TAT; phase 1.

Graphical abstract

FIGURE 1.

Volume-rendered images of ¹⁸F-FDG PET/CT scans from subject MAD4-03 before (left) and after (right) treatment with 4 cycles of ²¹²Pb-DOTAMTATE.

FIGURE 2.

MRI of liver before (A) and after (B) treatment with 4 cycles of ²¹²Pb-DOTAMTATE in subject MAD4-02. Arrows point to liver metastases. Near-complete resolution of liver metastases is seen in B.

FIGURE 3.

Bone scans of subject MAD4-02 before (left) and after (right) treatment with 4 cycles of ²¹²Pb-DOTAMTATE. Most lesions on initial baseline bone scan (arrows) are completely healed on bone scan after treatment.

FIGURE 4.

Volume-rendered images of ⁶⁸Ga-DOTATATE PET/CT scans from first 10 subjects enrolled in cohort 4 (MAD4) before treatment (left side of each panel) and after treatment (right side of each panel) with 4 cycles of ²¹²Pb-DOTAMTATE at dose of 2.50 MBq/kg (67.6 µCi/kg) for each cycle.