You are on page 1of 9

reviews

research focus

PSTT Vol. 3, No. 3 March 2000

Advances in the use of monoclonal


antibodies in cancer radiotherapy
Serengulam V. Govindan, David M. Goldenberg, Hans J. Hansen
and Gary L. Griffiths
The use of monoclonal antibodies (MAbs) as radiation carriers in
argeted radiotherapy of cancers has produced striking clinical responses in hematologic diseases, such as non-Hodgkins lymphoma.
Novel strategies are currently being examined in an effort to improve
efficacy in solid tumor therapies. Two of these strategies involve minimizing the systemic toxicity of a circulating radionuclide via pretargeting, and the sensitization of tumors to radiation by combination
therapy with radiosensitizing drugs. Advances made in radiolabeling
chemistries and in the use of alpha-particle emitters can also improve utility. Clinical evidence suggests that radioimmunotherapy
may be best applied in minimal-disease and adjuvant settings in
combination with other cancer therapy modalities.

Serengulam V. Govindan*
Hans J. Hansen
and Gary L. Griffiths
Immunomedics, Inc.
Corporate Headquarters
300 American Road
Morris Plains
NJ 07950
USA
*tel: 11 973 605 8200
fax: 11 973 605 1103
e-mail: sgovindan@
immunomedics.com
David M. Goldenberg
Garden State Cancer Center
520 Belleville Avenue
Belleville
NJ 07109
USA

90

Targeted radiotherapy of cancer using mono-

clonal antibodies (MAbs), referred to as radioimmunotherapy (RAIT), is an area of extensive


investigation at both the experimental and the
clinical levels1. The inherent appeal of this therapy modality is its potential to specifically irradiate tumors while sparing healthy organs. With
fractionated external beam irradiation (XRT),
precise focusing of the beam specifically to a
tumor, especially metastatic cancers, without affecting proximal healthy organs, is impractical.
RAIT involves continuous, low-dose irradiation
from tumor-targeted radionuclides. Biological
effect is facilitated through energy absorption
from the radionuclides emissions. The tissue
range of the nuclides emissions, which are several millimeters when using b-particle emitters,
can have a crossfire effect, in that even antigennegative cells in a tumor can be treated.
The clinical potential of this modality is beginning to be realized in the treatment of hemato-

logic malignancies, particularly non-Hodgkins


lymphoma (NHL). Remarkable clinical responses
have been observed in patients with relapsed,
chemotherapy-resistant, NHL. For the latter, various radiolabeled MAbs are in Phase I/II/III clinical trials.
Radiolabeled MAbs for therapeutic applications
have two components: a tumor-targeting vector,
MAb, and the radiolabel.The science of MAbs, including humanized and human MAbs, radiolabeling aspects, preclinical RAIT, and models for
absorbed-dose calculations have been reviewed in
detail1,2. Most therapeutic applications of radiolabeled MAbs have involved intact antibodies to
maximize uptake and retention in the tumor.
Tumor response depends on several factors,
which include cumulative radiation dose, dose
rate and tumor radiosensitivity. At an accretion in
the range of 0.0010.01% of the injected dose of
the radiolabeled MAb per gram of tumor, a cumulative tumor dose of less than 1500 centiGray
(cGy) is usually delivered; a dose of 5000 cGy or
more is considered necessary for therapeutic response, based on XRT of adenocarcinomas3. Even
this modest level of delivered dose has been
shown to produce antitumor response in radiosensitive lymphomas. However, for radioresistant
solid tumors, measures to increase the delivered
radiation dose using methods that permit increased injectable radioactivity, and/or measures
that increase the radiosensitivity of the tumors,
are needed. In RAIT, the maximum tolerated dose
(MTD) is determined by the dose-limiting radiation (~300 cGy) to bone marrow.
Recent efforts to enhance the utility of RAIT
have pertained to the development of improved
methods for labeling MAbs with two commonly
used b-emitters, a renewed interest in the use of
a-emitters, pretargeting approaches to reduce

1461-5347/00/$ see front matter 2000 Elsevier Science Ltd. All rights reserved. PII: S1461-5347(00)00241-8

Therapeutic radionuclides
Non-penetrating emissions from radionuclides are relevant for
therapy. Aside from the quality of radiation, such as low or
high linear energy transfer (LET) emission, the suitability of
any specific radionuclide for RAIT depends on the nuclides
radiophysical properties, the target tumor morphology and
physiology, the MAbs targeting kinetics, the fate of the nuclide
after antibody metabolism in vivo, the nuclides ready availability (preferably in a carrier-free form), and finally the development of simple and efficient clinical-scale radiolabeling methods. There are several potentially useful radionuclides4,
although those of practical utility comprise a short-list of a few
b-particle emitters and even fewer a-particle emitters (Table 1).
The question of whether low-energy, high-LET, Auger emitters
which require translocation of the antibody-bound
radionuclide to the vicinity of the cell nucleus for cytotoxicity
can be clinically efficacious remains unresolved5.

b-Particle emitters
131I and 90Y are now the two most widely used b-particle emitters. A large number of clinical RAIT trials have utilized 131I because of its ready availability, low cost, its imageable gamma
emissions (albeit of high energy), an advantageous eight-day
half-life, and a simple protein radiolabeling chemistry. In the
Table 1. Radionuclides of value in MAb-based cancer
radiotherapy
Half-life Emission Maximum Maximum
(h)
(for
energy
particle
therapy) (keV)
range (mm)

USA, the Nuclear Regulatory Commissions new guideline regarding release criteria for patients undergoing 131I radionuclide therapy now enables many lower dose RAIT regimens to
be performed on an outpatient basis.
The use of 131I with internalizing MAbs is less attractive,
however. Lysosomal processing of internalized MAbs and the
subsequent release of the [131I]iodotyrosine catabolite from the
tumor cell reduces the residence time of 131I in the tumor, and
thus diminishes the achievable tumor dose6. One approach to
overcoming the loss of radioiodine from internalizing MAbs is
labeling with radioiodinated entities which are intracellularly
trapped or residualized. Residualization of radioiodine labels
based on radioiodinated derivatives of non-metabolizable carbohydrates, pyridine, and peptides containing unnatural Damino acids7 have been described. Figure 1 provides an illustration of a clear advantage of a residualized versus a
conventional radioiodine label on an internalizing MAb, as observed in a preclinical RAIT study8.
90Y is a pure beta-emitter. Its high energy and long particle
range makes it suitable for the irradiation of large tumor
masses. 90Y and similar metallic radionuclides are residualizing
labels. A key requirement is highly stable attachment of the
radiometal to MAbs, because unbound radioyttrium ion accretes
in bone. Thanks to novel chemistries developed during the last
decade9, chelating agents that form stable 90Y complexes are

Mean tumor volumes (cm3)

whole-body radiation exposure and to increase dose to tumor,


and the use of radiosensitizing chemotherapeutic drugs in
combination with RAIT.These emerging themes and a brief account of the clinical results obtained with radiolabeled MAbs
are the focus of this minireview.

Isotope

reviews

research focus

PSTT Vol. 3, No. 3 March 2000

3.0
2.5
2.0
1.5
1.0
0.5
0.0

Iodine-131

(131I)

193

beta

610

2.0

64

beta

2280

12.0

161

beta

496

1.5

62

beta

577

1.8

Rhenium-186 (186Re) 91
Rhenium-188 (188Re) 17

beta
beta

1080
2120

5.0
11.0

Bismuth-212 (212Bi)
Bismuth-213 (213Bi)

1
0.77

alpha
alpha

8780
.6000

0.09
,0.1

Astatine-211 (211At)

7.2

alpha

7450

0.08

Yttrium-90 (90Y)
Lutetium-177

(177Lu)

Copper-67 (67Cu)

10

15
Weeks

20

25

Pharmaceutical Science & Technology Today

Figure 1. Preclinical therapy of non-small cell lung carcinoma


xenografts in nude mice using maximum-tolerated doses of
radiolabeled anti-epithelial glycoprotein antibody, RS7, compared with
untreated controls (diamond). 131I Radiolabel, introduced by a
conventional chloramine-T method (star), is no more efficient in
controlling tumor growth than a 131I-labeled non-specific antibody
control (triangle), while RS7 radiolabeled with a residualizing form of
131I (square), using the published procedure7, leads to significant
growth control up to 25 weeks post-therapy8.

91

reviews

research focus

now available as bifunctional reagents (Fig. 2).The macrocyclic


chelator 1,4,7,10-tetraazacyclododecane-N,N9,N99,N999-tetraacetic
acid (DOTA) is known to form exceptionally stable metal
chelates, even when one of its side-chain carboxyl groups is
tied up as an amide bond, which is in contrast to the
monoamide derivative for diethylenetriaminepentaacetic acid
(DTPA).This formed the basis for the development of an innovative method for preparing proteinDOTA conjugates using in
situ-generated monoactivated DOTA (Fig. 3)10. This, coupled
with the discovery of more efficient, higher-temperature 90Y-labeling, has greatly simplified the preparation of 90Y-DOTA
protein conjugates in high yields10.
In our work with this approach, optimizations of both
MAbconjugate preparation and 90Y-labeling steps have led to a
facile method for the production of very stable 90Y-labeled humanized MAbs in near-quantitative yields11. Radiolabeling simply involves syringing out the solution of MAbDOTA into a
90Y-shipment vial, and heating at 458C for five minutes. A
clinically relevant, five-minute-458C, high-yield, 90Y-labeling
of MAbDOTA is described in Fig. 4. Slow DOTA chelation
kinetics, which had been a long-standing stumbling block in
the practical preparation of 90YDOTAMAb, is now solved11,12.
The availability of high-purity 90Y, optimum labeling pH, and
higher temperature radiolabelings are factors involved in facile
90Y labelings.
Metallic radiolabels, being residualizing labels, are also retained to some degree in the processing organs, such as liver or
kidney. Enzymatically cleavable peptide spacers, placed between
the radiolabel and the MAb, have been designed to reduce such
normal organ uptake of radioactivity13,14.The reduction of more
severe kidney uptake of radiometal-labeled MAb fragments by
inhibition of tubular reabsorption by lysine infusion has been
documented in extensive preclinical investigations15.
The metallic b-particle-emitters 177Lu and 67Cu are an
alternative to 131I and 90Y, although the consistent production
of high specific activity 67Cu is reported to be problematic16.
177Lu is similar to 90Y in chemistry, but resembles 131I in halflife and possible dosimetric advantage. Rhenium radioisotopes
186Re and 188Re are also useful for RAIT17.

PSTT Vol. 3, No. 3 March 2000

N
N

N
CO2H
CO2H CO2H

SCN

92

N
N
CO2H
CO2H CO2H
N

SCN

CO2H
CO2H

ii: R = H
iii: R = Me

HOOC

COOH
N

HOOC

NCS
COOH

iv

SCN

(CONHCH2)3CONHCHCOOH

HOOC
N

N
COOH

HOOC

O
HOOC

C
N

HOOC

a-Particle-emitting radionuclides
Recent renewed interest in alpha particle therapy18,19 stems
from the availability, albeit limited, of bismuth nuclides 212Bi
and 213Bi as eluates from 224Ra and 225Ac generators, respectively, and of the cyclotron-produced radiohalogen, 211At.
a-Emissions have energies in the several MeV range. These
emissions are characterized by high LET, ~100 keV mm21,
compared with LETmean of 0.2 keV mm21 for b-emissions from
90Y. High LET radiations have a high probability of producing
lethal DNA double-strand breaks. The short range of an

CO2H
CO2H

SO3Na+

N
O

COOH

vi

Figure 2. Structures of commonly used bifunctional chelators for 90Y:


(i) 2-(p-isothiocyanatobenzyl)cyclohexyl DTPA (Ref. 9); (ii) 2-(pisothiocyanatobenzyl)DTPA (Ref. 9); (iii) 2-(p-isothiocyanatobenzyl)-6methyl DTPA (Ref. 9); (iv) 2-(p-isothiocyanatobenzyl)DOTA (Ref. 9);
(v) DOTA-glycylglycylglycyl-L-p-isothiocyanatophenylalanine13;
(vi) sulfosuccinimidyl DOTA (Ref. 10). In these, DTPA is
diethylenetriaminepentraacetic acid, and DOTA is 1,4,7,10tetraazacyclododecane-N,N9,N99,N999-tetraacetic acid.

research focus

PSTT Vol. 3, No. 3 March 2000

O
HOOC

COOH
N

HOOC

HOOC

COOH

C
N

HOOC

N
O

COOH

SO3Na+

reviews

Figure 3. A simplified preparation of antibody-DOTA


conjugates, wherein DOTA is 1,4,7,10tetraazacyclododecane-N,N9,N99,N999-tetraacetic
acid. Commercially available DOTA is monoactivated
with N-hydroxysulfosuccinimide, and directly
reacted with antibodies10.

Monoactivated DOTA

DOTA

O
HOOC

HOOC

C
N

NH

COOH
Antibody-DOTA conjugate

a-emitter prevents damage to nontargeted regions, but the


same characteristic necessitates a more homogeneous tumor
targeting of the carrier MAb, as little, if any, bystander effect on
antigen-negative cells can be expected. a-Particle RAIT may be
best applied to readily accessible circulating tumors such as
leukemias, locoregionally, and in pretargeting formats.
The very short half-lives of these nuclides require fast MAb
labeling procedures. 213Bi was chelated to a cyclohexylbenzyl
DTPA (CHXDTPA) conjugate of anti-CD33 MAb, HuM-195,
at up to 30 mCi mg21 in an overall process time of 24 minutes20. 213Bi-HuM195 targeted tumor sites in vivo rapidly, while
in vitro results showed cell-kill in a dose and specific activitydependent manner20. With 212Bi, an additional option is to use
its 10.6-h half-life precursor 212Pb as an in vivo 212Bi-generator9, although the change from 212Pb-DOTA to 212Bi-DOTA results in the release of 36% of free 212Bi, which then localizes in
kidney21.
Radiolabeling with 211At, at specific activities of 4 mCi
mg21, was achieved by a two-step procedure of first synthesizing N-succinimidyl 3-[211At]astatobenzoate, followed by coupling to MAb in an overall process time of 1.5 h. A preclinical
therapy experiment using single intrathecal doses of 418 mCi
of 211At-labeled anti-tenascin MAb 81C6, in an athymic rat
model of neoplastic meningitis, resulted in a significant increase in median survival rate22.
Current radionuclide choice is not a limitation
The need for the ready availability of a variety of other radionuclides cannot be overstated, but the few that are found
practical for clinical therapy offer a spectrum of maximal energies, tissue ranges and half-lives. With efficient methods for attaching these nuclides to MAbs in-place, factors pertinent to
the delivery of therapeutic doses of radioactivity now appear

to be only minimally radionuclide-related. It has been suggested that combinations of radionuclides of different energies
may prove more beneficial in producing therapeutic response
than single radionuclides23. For example, a MAbDOTA conjugate could be labeled with both 90Y and 177Lu; 90Y with a
higher energy and longer tissue range could irradiate large
tumor masses, while medium energy-short range emissions
from 177Lu would be suitable for micrometastases.
Pretargeting strategies enhance therapeutic index
A pretargeting strategy temporally separates the in vivo tumor
localization of the antibody from that of the radionuclide,
thereby greatly minimizing systemic radiation toxicity caused
by a long-circulating radioactive nuclide24,25. In this approach,
a MAb containing a secondary recognition site, which recognizes both a tumor antigen and a radiolabeled small molecular
mass entity (hapten), is administered. At a time approximating maximal tumor uptake and circulatory clearance of the
MAb, the relevant hapten, labeled at a high specific activity, is
injected. The radiolabeled hapten binds to the second recognition site attached to the tumor-localized antibody, while unbound hapten is rapidly cleared. Higher tumor-to-blood dose
ratios, desirable for both diagnosis and therapy, are achieved in
these systems, compared with directly radiolabeled MAbs. In
these approaches, optimal dosing and timing schedules of
multiple reagents are important25,26.
Pretargeting using streptavidin (or avidin)-biotin approach
The extraordinary noncovalent interaction between streptavidin (sAv) or avidin (Av) and biotin (Ka 5 1015 M21) is taken
advantage of first in targeting the tumor with nonradioactive
MAb-sAv(Av), followed by the administration of radiolabeled
biotin. Depending on whether MAb-sAv is targeted directly, or
93

research focus

PSTT Vol. 3, No. 3 March 2000

9.500

reviews

400

100

14.383

200
8.451

Cpm

300

0
5

10
Time (Min)

15

Pharmaceutical Science & Technology Today

Figure 4. Size-exclusion high performance liquid chromatography


analysis of the labeling of 12 mg of a DOTA conjugate of an anti
B-cell-lymphoma MAb, hLL2, with 58.7 mCi of 90Y acetate at 458C
for five minutes11. High radiolabeling yield (92.3%) in this clinically
relevant-scale of 90Y labeling obviates a need for postlabeling
purification. The monomeric conjugate (90Y-DOTA-hLL2) elutes at
9.5 min. The minor peaks are caused by aggregate eluting at 8.5 min
(4.0%) and unbound 90Y, analysed as 90Y-DTPA, at 14.4 min (3.8%).

indirectly via MAb-biotin and later-administered sAv, the formats are formally referred to as two-step and three-step pretargetings, respectively. The question of endogenous biotin,
particularly when using the two-step method26,27, and the
immunogenicity of sAv28 are aspects to consider when using
sAv-biotin-based methods.
In a two-step approach, the sAv conjugate of a pancarcinoma
MAb, NR-LU-10, was targeted to human tumor xenograft
models of breast and small cell lung cancers in nude mice. The
circulating MabsAv conjugate was cleared, 2472 h later,
using a galactosehuman serum albumin (HSA)biotin conjugate.This was followed, a short time later, by the administration
of radiolabeled biotin-DOTA (radiolabeled with 111In, 90Y or
177Lu). This approach gave .20% of injected dose of radioactivity per gram of tumor, and durable and complete tumor regressions with no sign of toxicity, when tumors (of .200 mm3)
in a xenograft model were treated with 200800 mCi of 90Y
(Ref. 29). Rapid in vivo tumor-targeting of radiobiotin also enabled the use of 212Bi as the radiolabel, with 212Pb-DOTA-biotin
employed as an in vivo 212Bi-DOTA-biotin generator30. Biodistributions up to 24 h after radiobiotin administration showed
persistently .25% ID g21 of 212Pb and 212Bi in tumor through
24 h. Interestingly, the calculated kidney dose from free 212Bi
was reported to be small30.
A Phase I clinical dose-escalation study found that nonmyeloablative doses of .200 mCi of 90Y could be administered, with radioactivity uptake in the tumor rivaling that seen
with conventional RAIT31, although further dose escalation ap94

peared to be contraindicated by unexpected intestinal toxicity.


In a preliminary seven-patient study of low-grade nonHodgkins lymphoma, using up to 50 mCi/m2 of 90Y-DOTA-biotin, a mean tumor-to-whole body dose ratio of 49:1 and an
objective tumor regression were reportedly achieved32.
The three-step method makes use of biotinylated MAb in
the first step, followed by the administration of sAv or Av to
clear circulating MAb and also to couple to biotinylated MAb
prelocalized at the tumor sites, and finally radiolabeled biotin25.
Reagent preparations are simpler in this mode. In a Phase I/II
clinical trial of high-grade glioma28, 48 patients with residual
disease or recurrence were intravenously administered
35 mg/m2 of biotinylated anti-tenascin MAb BC4.This was followed, after 36 h, by Av (30 mg) and sAv (50 mg). After a further 1824 h, biotin-HSA, used as sAv chase, followed by 90Ylabeled DOTA-biotin (6080 mCi/m2), were injected. Some
treated patients received two additional cycles of the therapy.
The study showed an objective response in 25% and stable disease in 52% of patients. Mean absorbed dose to tumor, at the
MTD, was 1200 cGy per cycle, and the tumor-to-marrow dose
ratio was 15. Remarkably, in some patients, with life expectancy
of less than six months when entering therapy, the duration of
response was more than a year.
Bispecific antibody approach
A novel approach to pretargeting, termed affinity enhancement system (AES), targets tumors with a bispecific antibody
(bsAb), chemically constructed from monovalent fragments
of an anti-carcinoembryonic antigen (CEA) MAb and a MAb
that recognizes a DTPA-indium chelate33. After the localization
phase, a bivalent hapten, which is a peptide incorporating two
DTPA-indium units as well as a tyrosine moiety (diDTPA),
carrying a diagnostic or a therapeutic radionuclide, is administered. The bivalent hapten is thought to form a stable complex with two molecules of pretargeted bsAb at the tumor site,
while forming only a loose complex with circulating antibody. Through the use of this method, excellent tumor visualizations were obtained in several immunoscintigraphy trials33,
and also in a fascinating example in a preclinical model of
renal carcinoma which utilized a different bispecific antibody34. In a colon carcinoma model in nude mice, therapy
using a single injection of 2.6 mCi of 131I-bivalent hapten
20 h after the administration of bsAb led to significant tumor
growth control and a 33% cure rate over eight months, with
similar results obtained in the medullary thyroid carcinoma
model33. Phase I/II clinical trials in patients with medullary
thyroid or small cell lung carcinomas tested 131I-diDTPA hapten given four days after bsAb administration; the trials
showed MTDs to be in the 100140 mCi range and that the
treatments were well-tolerated33.

PSTT Vol. 3, No. 3 March 2000

Pretargeting approach holds promise


Clinical studies of pretargeted RAIT, performed mainly in the
Phase I context, show that low marrow toxicity allows higher
levels of radioactivity to be administered. Although delivered
tumor doses per mCi are not expected to be significantly better
than those with conventional RAIT, the relative safety and the
rapid tumor targeting of a radiolabel may permit repeat therapy cycles28,33. Use of conjugates derived from humanized
MAbs, applications in minimal-disease, and combination with
other treatment modalities are strategies that are expected to
further improve efficacy33.
Combination of RAIT with chemotherapy shows
synergistic effect in animal models
Rationale
An underlying cause of the striking response of lymphomas to
low dose and low dose-rate radiation from RAIT is the inherent
radiosensitivity of the tumors. In an interesting in vitro study, it
was shown that many lymphoma cell lines exhibited programmed cell-death (apoptosis) upon exposure to radiation,
and that these cell lines could be further sensitized to radiation35. Chemotherapeutics, such as paclitaxel, camptothecin,
doxorubicin, and 5-fluorouracil (5-FU), are radiosensitizers3640. Synergistic effects of combination therapy involving
RAIT and a radiosensitizing chemotherapeutic, without additive toxicities, have been documented in several preclinical solid
tumor models, as detailed below. These findings bode well for
expectations of similar synergistic effects in clinical settings.
The timings of the radiolabeled MAb and the drug administrations must take into account the different in vivo pharmacokinetics of the two agents, so that radiosensitization is concentrated at the tumor region. This is usually achieved through the
administration of chemotherapy after RAIT.
Examples
In nude mice bearing HBT 3477 human breast carcinoma
xenografts, a single dose of 300 or 600 mg of paclitaxel administered intraperitoneally at 6 or 24 h after RAIT with
260 mCi of 90Y-chL6 produced a 100% response rate and an
48% tumor disappearance rate with no re-growth (cure rate)
in an 84-day study; this was in contrast to a 79% response rate
and no cures with RAIT alone, and no responses at all with the
drug given alone36. Paclitaxel, a drug used for the treatment of
breast and ovarian cancers, triggers several cellular signals, including cell accumulation in the radiosensitive phase of the
cell-cycle which is advantageous for RAIT.
In a 60-day study of rats bearing hepatoma ascites tumors,
six out of seven (86%) animals were cured following dosing at
5 mg kg21 camptothecin and 200 mCi of 131I-RH1 every week
for four weeks; this was significantly more effective than the

research focus

reviews

same dose regimen of drug and RAIT monotherapies


(P ,0.005 and P ,0.025, respectively), and combination therapy involving a control 131I-MAb and the drug was not better
than treatment with the drug alone (P .0.25) (Ref. 37). Synergism was hypothesized to involve the interaction of a drugstabilized topoisomerase IDNA complex with the replication
machinery involved in the repair of radiation-induced damage.
In the RAIT of radioresistant medullary thyroid cancer
xenografts with a 90Y-MAb, the addition of a chemotherapy
component and the use of paclitaxel or doxorubicin showed
improved antitumor effects and synergism38,39.
In a human colon carcinoma model, an additive effect for
tumor growth control was found for the combination of
chemotherapy (5-FU at 30 mg kg21 per day for five days or
75 mg kg21 on days one and five) and RAIT (specific MAb
131I-A33 given at 20% of MTD) (Ref. 40). A synergistic effect
was operative if long-term disease-free survival was used as the
end point, because 38% of mice treated with 5-FU and RAIT
were disease-free at 276 days post-treatment, compared with
none from groups treated with single agents.
Clinical results with radiolabeled MAbs
Hematologic tumors
Significant clinical responses obtained with hematologic cancers have been reviewed4144.The strategy for NHL, which is of
B-cell origin, has involved targeting antigenic markers such as
idiotypic IgGs, CD-20, CD-21, CD-22 and CD-37 antigens, and
human leukocyte antigen (HLA-DR). A rate of 62% progression-free survival and 93% overall survival [16 of 21 complete
responses (CRs)] were recorded at two-year follow-up, in patients with refractive low grade NHL, who had been given custom-calculated high doses of 131I-B1 (anti-CD20 MAb;
345785 mCi) with autologous bone marrow transplantation
(ABMT)45. A lower-dose 131I-B1 (Bexxar, Coulter
Pharmaceutical, South San Francisco, CA, USA) trial in a 28patient study, without ABMT, produced a 79% response rate,
with 14 CRs and eight partial responses (PRs) and 1631
months of complete remission in six patients46.
A Phase I/II dose escalation study in 18 patients with relapsed low or intermediate grade NHL, using 13.550 mCi of
murine 90Y-2B8 (anti-CD20 MAb; IDEC-Y2B8, IDEC Pharmaceuticals Corporation, San Diego, CA, USA) activity, resulted in
an overall response rate of 72%, including 33% CR (Ref. 47). In
a Phase I clinical trial with 131I-labeled LL2 MAbs (anti-CD22
MAb), of 17 assessable advanced-disease NHL patients given
nonmyeloablative doses of 131I-LL2 [IgG or divalent fragment],
six patients had responses, including one patient who experienced CR to three diagnostic doses of the intact 131I-MAb48. In
the ongoing trials of low and intermediate-grade NHL using
90Y-humanized LL2, two out of seven patients had PRs lasting
95

reviews

research focus

three months (Fig. 5) and .18 months49, while myeloablative


RAIT of aggressive forms of NHL, combined with peripheral
blood-stem cell rescue, led to one CR and two PRs in a fivepatient study50. Finally, using 131I-Lym-1 (anti-HLA-DR MAb),
a 54% overall response rate in 24 patients (eight CR and five
PR) was observed51.
Several observations have been made from the various clinical trials of NHL.

Therapeutic response is observed even at low tumor doses


The incidence of human anti-mouse antibody reaction is
generally low because of immune suppression
The use of unlabeled MAb, which blocks circulating antigen, often improves biodistributions of labeled MAbs
High-dose therapy with ABMT gives higher overall response, with better long-term prognosis for progressionfree survival
Patients with low involvement of the disease in bone marrow, low tumor burden and without enlarged spleen respond more favorably
Radiometalated MAbs give better tumor dosimetry compared with 131I-MAbs, although 131I-B1 has produced a high
therapeutic response rate.

Figure 5. Computed tomography (CT) scans of the pelvis obtained four


weeks before (b), and four weeks after (c) radioimmunotherapy with
13.1 mCi of 90Y-humanized LL2 in a patient with mantle cell
lymphoma, showing a marked regression of the adenopathy. This
patient had a partial remission for three months. (a) Single photon
emission computed tomography images obtained with 111In-humanized
LL2, displaying excellent targeting of the pelvic lesion49. Reproduced,
with permission, from Ref. 49.

96

PSTT Vol. 3, No. 3 March 2000

In a clinical trial of adult T-cell leukemia and lymphoma


using 90Y-anti-Tac MAb, a 12% CR and a 53% PR were obtained
with 17 patients, with 716 months of response duration52. In
heavily pretreated patients with relapsed Hodgkins disease,
single-agent application of 90Y-labeled rabbit polyclonal antiferritin MAb produced a response rate of .60% for an
average duration of six months53.
Used in conjunction with cyclophosphamide, external radiation and ABMT, 131I-labeled anti-CD33 MAb M195 and antiCD45 MAb BC8 have led to high CR rates, as well as durable
responses in patients with acute myelogenous leukemia
(AML)54,55. The potential of 213Bi to sterilize single leukemia
cells while sparing normal marrow progenitors was tested in a
nine-patient trial of AML using 213Bi-HuM195 (humanized
M195); in the dose range of 0.280.56 mCi kg21, a target-towhole body ratio 1000-fold greater than that obtained with
131I or 90Y RAIT was achieved, and five of the nine patients had
decreases in the percentage of leukemia blasts in the bone
marrow56.
Solid tumors: a case for therapy in residual-disease and
adjuvant settings
Results from the various clinical RAIT trials of solid tumors
have been reviewed43,44. The best results have been obtained
through locoregional administrations of radiolabeled MAbs. In
a clinical trial of malignant glioma involving 105 patients
whose tumor burden was minimized by surgery and radiation,
RAIT with a mean dose of 54 mCi of 131I-labeled anti-tenascin
MAbs BC-2 and BC-4, administered intralesionally via a
catheter, resulted in an overall response rate of 51.6% in assessable patients and significantly improved median survival57.
After intraperitoneal RAIT of ovarian cancers in a 12-patient
Phase I trial using 1030 mCi/m2 of 177Lu-CC49, one of eight
patients with gross disease had .50% tumor reduction and
three of four with occult disease were disease-free for at least
18 months after therapy58.
A detailed study involving 119 tumors in 93 patients with
CEA-expressing cancers has revealed that favorable conditions
for the systemic delivery of high tumor doses, calculated to be
.100 cGy mCi21, may be obtained in small lesions of colorectal and medullary thyroid cancers using 131I-labeled anti-CEA
MAbs NP-4, MN-14 and humanized MN-14, as well as anticolon-specific antigen-p MAb, Mu-9 (Ref. 59). Moreover, it was
demonstrated, using a liver phantom, that millimeter-sized
metastases could easily escape detection60. In ovarian cancer patients, intraperitoneal 90Y RAIT, given as an adjuvant after complete remission with standard therapy, led to a significantly prolonged duration of cure: an 80% survival rate at five years
compared with a 55% rate for chemotherapy controls without
RAIT (p 5 0.0035), and a projected 10-year survival rate of

research focus

PSTT Vol. 3, No. 3 March 2000

70% versus a 32% rate for the same controls (p 5 0.003)61.


These and other findings62 strongly support the view that the
addition of RAIT as a first-line therapy of minimal disease, or as
an adjuvant, in combination with other modalities, would
prove to be of value62,63.

optimized pH to achieve high specific activity and high chelate stability


in radiolabeled conjugates. Bioconj. Chem. 5, 565576
11

Griffiths, G.L. et al. (1999) Quantitative 5-minute radiolabeling of


DOTAHMAB conjugates with Y-90 for cancer radioimmunotherapy.
J. Nucl. Med. 40, 150P (abstract number 603)

12

Conclusion
Our understanding of the many complex aspects of MAb-based
radiotherapy of cancer has significantly expanded in the last
two decades, while expectations have evolved concurrently.
RAIT is a relatively safe treatment. Its efficacy will continue to
be demonstrated in the therapy of radiosensitive and readily
accessible neoplasms, particularly non-Hodgkins lymphoma.
For solid tumors, it appears that RAIT will most likely be used
as an adjuvant and in minimal-disease situations. Here, the
combination of RAIT and chemotherapy appears set to prove
superior to chemotherapy alone in several disease indications.
It is also to be hoped that further developments in areas such
as pretargeting and a-particle therapy will further advance
RAITs prospects for contributing to a more successful cancer
management.

reviews

Kukis, D.L. et al. (1998) Optimized conditions for chelation of yttrium90-DOTA immunoconjugates. J. Nucl. Med. 39, 21052110

13

Li, M. and Meares, C.F. (1993) Synthesis, metal-chelate stability studies,


and enzyme digestion of a peptide-linked DOTA derivative and its
corresponding radiolabeled immunoconjugates. Bioconj. Chem. 4,
275283

14

Arano,Y. et al. (1999) Chemical design of radiolabeled antibody

15

Behr, T.M. et al. (1997) Overcoming the nephrotoxicity of radiometal-

fragments for low renal radioactivity levels. Cancer Res. 59, 128134
labeled immunoconjugates. Cancer (Suppl.) 80, 25912610
16

Srivastava, S.C. et al. (1999) Scandium-47: a replacement for Cu-67 as a

17

Griffiths, G.L. (1995) Antibody radiolabeling with isotopes of rhenium.

b2/g therapeutic radiolabel. J. Nucl. Med. 40, 121P (abstract number 489)
In Cancer Therapy with Radiolabeled Antibodies (Goldenberg, D.M., ed.),
pp. 7786, CRC Press, Boca Raton, FL, USA
18

McDewitt, M.R. et al. (1998) Radioimmunotherapy with alpha-emitting


nuclides. Eur. J. Nucl. Med. 25, 13411351

References
1

19

Zalutsky, M.R. and Bigner, D.D. (1996) Radioimmunotherapy with alpha

20

Nikula, T.K. et al. (1999) Alpha-emitting bismuth cyclohexylbenzyl DTPA

(1995) Cancer Therapy with Radiolabeled Antibodies (Goldenberg, D.M., ed.),


CRC Press, Boca Raton, FL, USA

particle-emitting radioimmunoconjugates. Acta Oncol. 35, 373379

Goldenberg, D.M. (1993) Monoclonal antibodies in cancer detection and

constructs of recombinant humanized anti-CD33 antibodies:

therapy. Am. J. Med. 94, 297312

pharmacokinetics, bioactivity, toxicity and chemistry. J. Nucl. Med. 40,

Rosler, H. et al. (1986) Endoarterial radionuclide embolizing tumor


therapy. In Radionuclides for Therapy (Schubiger, P.A. and Hasler, P.H., eds),

166176
21

Schubiger, P.A. et al. (1996) Vehicles, chelators, and radionuclides:

22

radioimmunoconjugate. Bioconj. Chem. 7, 165179


Welt, S. et al. (1996) Phase I/II study of iodine-125-labeled monoclonal

Cancer Res. 54, 47194725


23

antibody A33 in patients with advanced colon cancer. J. Clin. Oncol. 14,
Geissler, F. et al. (1992) Intracellular catabolism of radiolabeled anti-m

radionuclides. J. Nucl. Med. 36, 19021909


24

antibodies by malignant B-cells. Cancer Res. 52, 29072915


7

Govindan, S.V. et al. (1999) Labeling of monoclonal antibodies with

25

Sharkey, R.M. et al. (1997) Development of a streptavidin-anti-

Stein, R. et al. Therapy of a human lung cancer xenograft using MAb RS7

carcinoembryonic antigen antibody, radiolabeled biotin pretargeting

labeled with residualizing iodine. Cancer Biother. Radiopharm.15 (abstract),

method for radioimmunotherapy of colorectal cancer. Studies in a

Gansow, O.A. and Wu, C. (1995) Advanced methods for radiolabeling

human colon cancer xenograft model. Bioconj. Chem. 8, 595604


27

monoclonal antibodies with therapeutic radionuclides. In Cancer Therapy


with Radiolabeled Antibodies (Goldenberg, D.M., ed.), pp. 6376, CRC Press,
Lewis, M.R. et al. (1994) A facile, water-soluble method for the
modification of proteins with DOTA. Use of elevated temperature and

Hnatowich, D.J. (1994) The in vivo uses of streptavidin and biotin: a short
progress report. Nucl. Med. Commun. 15, 575577

28

Paganelli, G. et al. (1999) Antibody-guided three-step therapy for high

29

Axworthy, D.B. et al. (1994) Preclinical evaluation of an anti-tumor

Boca Raton, FL, USA


10

Stoldt, H.S. et al. (1997) Pretargeting strategies for radio-immunoguided


tumour localisation and therapy. Eur. J. Cancer 33, 186192

26

(in press)
9

Goodwin, D.A. (1991) Strategies for antibody targeting. Antibody


Immunoconjug. Radiopharm. 4, 427434

diethylenetriaminepentaacetic acid-appended radioiodinated peptides


containing D-amino acids. Bioconj. Chem. 10, 231240

ODonoghue, J.A. et al. (1995) Relationships between tumor size and


curability for uniformly targeted therapy with beta-emitting

17871797
6

Zalutsky, M.R. et al. (1994) Radioimmunotherapy of neoplastic


meningitis in rats using an a-particle-emitting immunoconjugate.

choosing the building blocks of an effective therapeutic


5

Mirzadeh, S. et al. (1993) The chemical fate of 212Bi-DOTA formed by


beta2 decay of 212Pb(DOTA)22. Radiochim.Acta 60, 110

pp. 227244, Hoffmann-LaRoche, Basel, Switzerland

grade glioma with yttrium-90 biotin. Eur. J. Nucl. Med. 26, 348357
monoclonal antibody/streptavidin conjugate for pretargeted 90Y

97

reviews

research focus

radioimmunotherapy in a mouse xenograft model. J. Immunother. 16, 158

PSTT Vol. 3, No. 3 March 2000

48

(abstract number 44)


30

31

radiolabeled murine, chimeric, or humanized LL2, an anti-CD22

Su, F-M. et al. (1998) Pretargeted radioimmunotherapy in tumored mice


using an in vivo Pb-212/Bi-212 generator. J. Nucl. Med. 39, 91P (abstract

monoclonal antibody. Cancer Res. (Suppl.) 55, 58995907


49

therapeutic results with 131I- and 111In-/90Y-labeled humanized LL2 anti-

Abrams, P. et al. (1995) Phase I clinical evaluation of pretargeted 90Y

CD22 monoclonal antibody in patients with relapsed, refractory non-

radioimmunotherapy. Proc.Am. Soc. Clin. Oncol. 14, 423 (abstract number

33

Hodgkins lymphoma. Clin. Cancer Res. (Suppl.) 5, 3292s3303s


50

supported radioimmunotherapy (RAIT) with humanized 90Y-LL2 (90Y-

treatment of non-Hodgkins lymphoma (NHL): preliminary results.

hLL2) anti-CD22 monoclonal antibody (MAb) in NHL patients who

J. Nucl. Med. 40, 19P (abstract number 75)

failed high-dose chemotherapy. Blood (Suppl.) 94, 174a (abstract number

Barbet, J. et al. (1999) Pretargeting with the affinity enhancement system

757)
51

malignancies with 131I-Lym-1 and 67Cu-2IT-BAT-Lym-1 and

improved tumor targeting with a bivalent chelate. Cancer Res. 59,

opportunities for improvement. In Cancer Therapy with Radiolabeled Antibodies


(Goldenberg, D.M., ed.), pp. 217227, CRC Press, Boca Raton, FL, USA

Macklis, R.M. et al. (1994) Radiobiologic studies of low-dose-rate


90Y-lymphoma

36

52

therapy. Cancer (Suppl.) 73, 966973

DeNardo, S.J. et al. (1997) Synergy of Taxol and radioimmunotherapy

53

(Suppl.) 80, 27212727


54

Jurcic, J.G. et al. (1995) Monoclonal antibody therapy of leukemia and

55

Matthews, D.C. et al. (1995) Development of a marrow transplant

inhibition of topoisomerase I. Cancer Res. 54, 12761285


38

39

Stein, R. et al. (1999) Assessment of combined radioimmunotherapy and

lymphoma. Adv. Pharmacol. 33, 287314

chemotherapy for treatment of medullary thyroid cancer. Clin. Cancer Res.

regimen for accute leukemia using targeted hematopoietic irradiation

5 (Suppl.), 3199s3206s

delivered by 131I-labeled anti-CD45 antibody, combined with

Behr,T.M. et al. (1997) Improved treatment of medullary thyroid cancer


in a nude mouse model by combined radioimmunochemotherapy:

40

cyclophosphamide and total body irradiation. Blood 85, 11221131


56

leukemias: a phase-I trial of bismuth-213-HuM195 (anti-CD33).

antibodies in a radioresistant tumor type. Cancer Res. 57, 53095319

Blood (Suppl.) 90, 504a (abstract number 2245)

Tschmelitsch, J. et al. (1997) Enhanced antitumor activity of combination

57

Jurcic, J.G. and Scheinberg, D.A. (1995) Radioimmunotherapy of

(Suppl.) 80, 27332742


58

Meredith, R.F. et al. (1996) Intraperitoneal radioimmunotherapy of

59

Behr,T.M. et al. (1997) Variables influencing tumor dosimetry in

hematological cancer: problems and progress. Clin. Cancer Res. 1,


14391446

43

ovarian cancer with lutetium-177-CC49. J. Nucl. Med. 37, 14911496

Corcoran, M.C. et al. (1997) Radioimmunotherapy strategies for non-

radioimmunotherapy of CEA-expressing cancers with anti-CEA and

Hodgkins lymphomas. Ann. Oncol. 8 (Suppl. 1), 133138

antimucin monoclonal antibodies. J. Nucl. Med. 38, 409418

Wilder, R.B. et al. (1996) Radioimmunotherapy: recent results and future

60

directions. J. Clin. Oncol. 14, 13831400


44

Meredith, R.F. et al. (1997) Recent progress in radioimmunotherapy for

Gooden, N.S. et al. (1998) Radioimmunotherapy after chemotherapy


compared to chemotherapy alone in the treatment of advanced ovarian

Press, O.W. et al. (1995) Phase II trial of 131I-B1 (anti-CD20) antibody


therapy with autologous stem cell transplantation for relapsed B-cell

Dunn, R.M. et al. (1997) Can occult metastases be treated by


radioimmunotherapy? Cancer (Suppl.) 80, 26562659

61

cancer. Oncology 11, 979987


45

Riva, P. et al. (1997) Local application of radiolabeled monoclonal


antibodies in the treatment of high grade malignant gliomas. Cancer

chemotherapy (fluorouracil). Cancer Res. 57, 21812186

42

Jurcic, J.G. et al. (1997) Targeted alpha-particle therapy for myeloid

doxorubicin potentiates the therapeutic efficacy of radiolabeled

radioimmunotherapy (131I-labeled monoclonal antibody A33) with


41

Vriesendorp, H. et al. (1997) Recurrence of Hodgkins disease after


indium-111 and yttrium-90 labeled antiferretin administration. Cancer

breast cancer xenografts. Proc. Natl.Acad. Sci. U. S.A. 94, 40004004


Roffler, S.R. et al. (1994) Potentiation of radioimmunotherapy by

Waldmann,T.A. (1994) Lymphokine receptors: A target for


immunotherapy of lymphomas. Ann. Oncol. 5, S13S17

with yttrium-90-labeled chimeric L6 antibody: efficacy and toxicity in


37

DeNardo, G.L. and DeNardo, S.J. (1995) Treatment of B-lymphocyte

Boerman, O.C. et al. (1999) Pretargeting of renal cell carcinoma:


44004405

35

Juweid, M. et al. (1999) Conventional and hematopoietic stem-cell-

Breitz, H.B. et al. (1999) Pretargeted radioimmunotherapy (PRITR) for

for radioimmunotherapy. Cancer Biother. Radiopharm. 14, 153166


34

Juweid, M. et al. (1999) Pharmacokinetics, dosimetry, and initial

number 354)

1348)
32

Juweid, M. et al. (1995) Treatment of non-Hodgkins lymphoma with

cancer: a matched analysis. Oncol. Rep. 5, 223226


62

Sharkey, R.M. et al. (1995) Development of cancer radioimmunotherapy

lymphomas. Lancet 346, 336340

and its potential as an adjuvant treatment. In Cancer Therapy with Radiolabeled

46

Kaminski, M.S. et al. (1996) Iodine-131 anti-B1 radioimmunotherapy for

Antibodies (Goldenberg, D.M., ed.), pp. 101114, CRC Press, Boca Raton,

47

Knox, S.J. et al. (1996) Yttrium-90-labeled anti-CD20 monoclonal

B-cell lymphoma. J. Clin. Oncol. 14, 19741981


antibody therapy of recurrent B-cell lymphoma. Clin. Cancer Res. 2, 457470

98

FL, USA
63

Sgouros, G. (1995) Radioimmunotherapy of micrometastases:


sidestepping the solid-tumor hurdle. J. Nucl. Med. 36, 19101912