International Journal of
Molecular Sciences
Article
Mathematical Model for Evaluation of Tumor Response in
Targeted Radionuclide Therapy with 211At Using Implanted
Mouse Tumor
Yoshiharu Yonekura 1,2, * , Hiroshi Toki 2,3 , Tadashi Watabe 1,4 , Kazuko Kaneda-Nakashima 1 ,
Yoshifumi Shirakami 1 , Kazuhiro Ooe 1 , Atsushi Toyoshima 1 , Hiroo Nakajima 1 , Noriyuki Tomiyama 1,5
and Masako Bando 6
Citation: Yonekura, Y.; Toki, H.;
Watabe, T.; Kaneda-Nakashima, K.;
Shirakami, Y.; Ooe, K.; Toyoshima, A.;
Nakajima, H.; Tomiyama, N.; Bando,
M. Mathematical Model for Evaluation
of Tumor Response in Targeted
Radionuclide Therapy with 211 At
Using Implanted Mouse Tumor. Int. J.
Mol. Sci. 2022, 23, 15966. https://
doi.org/10.3390/ijms232415966
Academic Editor:
Ekaterina Dadachova
Received: 1 November 2022
Accepted: 6 December 2022
Published: 15 December 2022
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
published maps and institutional affil-
iations.
Copyright: © 2022 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Int. J. Mol. Sci. 2022, 23, 15966. https://doi.org/10.3390/ijms232415966
1 Institute for Radiation Sciences, Osaka University, Suita 565-0871, Japan
2 Research Center for Nuclear Physics, Osaka University, Suita 565-0047, Japan
3 Health Care Division, Health and Counseling Center, Osaka University, Toyonaka 560-0043, Japan
4 Department of Nuclear Medicine and Tracer Kinetics, Osaka University Graduate School of Medicine,
Suita 565-0871, Japan
5 Department of Radiology, Osaka University Graduate School of Medicine, Suita 565-0871, Japan
6 Yukawa Institute for Theoretical Physics, Kyoto University, Kyoto 606-8502, Japan
* Correspondence: yonekura@irs.osaka-u.ac.jp
Abstract: Recent introduction of alpha-emitting radionuclides in targeted radionuclide therapy has
stimulated the development of new radiopharmaceuticals. Preclinical evaluation using an animal
experiment with an implanted tumor model is frequently used to examine the efficiency of the
treatment method and to predict the treatment response before clinical trials. Here, we propose a
mathematical model for evaluation of the tumor response in an implanted tumor model and apply
it to the data obtained from the previous experiment of 211 At treatment in a thyroid cancer mouse
model. The proposed model is based on the set of differential equations, describing the kinetics of
radiopharmaceuticals, the tumor growth, and the treatment response. First, the tumor growth rate
was estimated from the control data without injection of 211 At. The kinetic behavior of the injected
radionuclide was used to estimate the radiation dose profile to the target tumor, which can suppress
the tumor growth in a dose-dependent manner. An additional two factors, including the time delay
for the reduction of tumor volume and the impaired recovery of tumor regrowth after the treatment,
were needed to simulate the temporal changes of tumor size after treatment. Finally, the parameters
obtained from the simulated tumor growth curve were able to predict the tumor response in other
experimental settings. The model can provide valuable information for planning the administration
dose of radiopharmaceuticals in clinical trials, especially to determine the starting dose at which
efficacy can be expected with a sufficient safety margin.
Keywords: targeted radionuclide therapy; mathematical model; alpha therapy; 211 At
1. Introduction
Targeted radionuclide therapy (TRT) is an attractive approach to cure patients with
intractable cancer. Recent introduction of alpha-emitting radionuclides in TRT has en-
couraged the medical community to develop new treatment methods with a variety of
radioactive compounds [1,2]. To examine the efficacy and the safety of the treatment
method, an animal experiment with an implanted tumor model is frequently used as
a preclinical evaluation. The successful treatment can suppress tumor growth, and the
information obtained from the multiple experiments with various doses of the adminis-
tered drug is used for the planning of the clinical trial. The experimental design of the
radionuclide treatment is usually determined by the expected radiation doses in the tumor
and the normal tissues after the administration of the radiolabeled compound that is to
be examined.
https://www.mdpi.com/journal/ijms
 information obtained from the multiple experiments with various doses of the adminis-
tered drug is used for the planning of the clinical trial. The experimental design of the
radionuclide treatment is usually determined by the expected radiation doses in the tu-
Int. J. Mol. Sci. 2022, 23, 15966 mor and the normal tissues after the administration of the radiolabeled compound that is
2 of 10
to be examined.
The biological effects of radiation have been studied extensively for external beam
radiotherapy
The biological[3–6]. effects
Treatment protocols
of radiation have
have been
been established
studied based for
extensively on the precise
external beamdo-
simetry and the predicted response in tumors and surrounding healthy
radiotherapy [3–6]. Treatment protocols have been established based on the precise dosime- tissues. In radio-
nuclide
try and thetherapy,
predictedhowever, such
response in an approach
tumors has not beenhealthy
and surrounding possible, and the
tissues. treatment is
In radionuclide
therapy, however, such an approach has not been possible, and the treatment isan
often repeated until complete recovery is reached. As TRT is expected to play im-
often
portant role in curing the patient, a more quantitative approach is
repeated until complete recovery is reached. As TRT is expected to play an important rolenecessary for treatment
planning
in curing theandpatient,
also fora the assessment
more quantitativeof treatment
approach is response.
necessary for treatment planning and
For this purpose, we propose
also for the assessment of treatment response. a mathematical model for evaluation of tumor response
in TRT,
For this purpose, we propose a mathematical model fortumor
considering the kinetics of radiopharmaceuticals, evaluationgrowth, and treatment
of tumor response
response. As these factors involve temporal changes, the
in TRT, considering the kinetics of radiopharmaceuticals, tumor growth, and use of differential equations
treatmentis a
response. As these factors involve temporal changes, the use of differential equations isthe
unique approach to describe the behavior of each process. We applied the model to a
data obtained
unique approach from the previous
to describe animal experiment
the behavior withWe
of each process. 211At treatment in a thyroid can-
applied the model to the data
cer mousefrom
obtained model previous animal experiment with 211 At treatment in a thyroid cancer
the[7].
mouse model [7].
2. Results
2. Results
2.1. Modeling of the Drug Delivery
2.1. Modeling of the Drug Delivery
To simulate the tumor response by TRT, we first estimated the temporal changes in
To simulate
radioactivity thetumor
in the tumorafter
response by TRT, weinjection
the intravenous first estimated
of 211At.the temporalthe
Regarding changes
deliveryin
radioactivity in the tumor after the intravenous injection of 211 At. Regarding the delivery
of 211At in mice, we considered a model consisting of four boxes, as shown in Figure 1:
of 211 At in mice, we considered a model consisting of four boxes, as shown in Figure 1:
blood, tumor, body organs, and excretion. We expressed the drug delivery model in the
blood,
coupled tumor, body organs,
differential andwhere
equations, excretion. We expressed
the temporal changesthe ofdrug
R’s delivery model in
were calculated the
using
coupled differential equations, where the temporal
the parameters 𝛼’s (see details in Materials and Methods). changes of R’s were calculated using
the parameters α’s (see details in Materials and Methods).

Figure1.
Figure 1. The
The drug
drug delivery
deliverymodel
modeldescribing
describingthe behaviorofof211
thebehavior 211At in mouse. The radiating material
At in mouse. The radiating material
211At is delivered to the tumor and other parts of the body through blood and eventually is excreted
211 At is delivered to the tumor and other parts of the body through blood and eventually is excreted
frombody.
from body.

Figure22shows
Figure showsthe thecalculated
calculatedamounts
amountsof of211
211At in the tumor, blood, and body organs.
tumor,
The amount obtained by rigorous calculation considering all all
The amount obtained by rigorous calculation considering parameters
parameters are are denoted
denoted by theby
the solid
solid curves,
curves, and those
and those withoutwithout consideration
consideration of the of the return
return 21 and𝛼α21
paths, αpaths, 31 ,and 𝛼31 , are
are denoted
denoted
by by thecurves
the dashed dashed incurves
the leftinfigure.
the leftItfigure. It is possible
is possible to express to express the solutions
the solutions ana-
analytically
lytically
once the once
returnthe return
paths arepaths are dropped
dropped in the
in the drug drug delivery
delivery model. model. The radiation
The radiation dose indose
the
tumor shows shows
in the tumor a maximum value around
a maximum three hours
value around threeafter theafter
hours injection, as shown
the injection, asby the red
shown by
solid curve, while 211 At is cleared
the red solid curve, while 211At isfrom the blood
cleared from therapidly,
bloodas rapidly,
shown by asthe
shownblackbysolid
thecurve.
black
The
solidcalculated
curve. The results suggest
calculated that suggest
results most of that
the radiation
most of the dose in the tumor
radiation dose inisthe completed
tumor is
within a daywithin
due toa the 211
completed dayshort physical
due to the short half-life
physical(7.21 h) of (7.21
half-life At. h)
The ofeffects
211 of the
At. The return
effects of
terms are calculated
the return terms areby setting α21
calculated by=setting
α31 = 0, which
𝛼21 = 𝛼31are= shown
0, which byarethe shown
red dashedby thecurve
red
and the black
dashed curve dashed
and thecurve. The difference
black dashed is not
curve. The large for is
difference R2not
, since
large theforreturn coefficient
R2, since the re-
21 is coefficient
αturn small in our𝛼parameter
21 is small choice.
in our Hence, for
parameter the estimate
choice. of
Hence, the radiation
for the effect
estimate in
of the
the
following simulation of the cancer treatment, we employed the analytical expression for
cancer therapy.
 Int.J.J.Mol.
Int. Mol.Sci.
Sci.2022,
2022,23,
23,xxFOR
FORPEER
PEERREVIEW
REVIEW 33 ofof 10
10

Int. J. Mol. Sci. 2022, 23, 15966 radiationeffect

radiation effectin
inthe
thefollowing
followingsimulation
simulationof
ofthe
thecancer
cancertreatment,
treatment,we
weemployed
employedthe
the an-
3 of
an-10
alyticalexpression
alytical expressionforforcancer
cancertherapy.
therapy.

(a)
(a) (b)
(b)
Figure2.
Figure
Figure 2.The
2. Thecalculated
The calculatedresults
calculated resultsof
results ofradioactivity
of radioactivityin
radioactivity ineach
in eachbox.
each box.(a)
box. (a)The
(a) Theamounts
The amountsof
amounts ofradiating
of radiatingmaterials
radiating materials
materials
inin blood (R 1),tumor
tumor (R 2),body
body (R 3),and
and total activity (R ) for the case where the
in blood (R1 ), tumor (R2 ), body (R3 ), and total activity (RT ) for the case where the initial amountisis
blood (R 1 ), (R 2 ), (R 3 ), total activity (R T)
T for the case where the initial
initial amount
amount isset
set
set
totoRR1 1==1.1.The
Thesolidsolidcurves
curvesare arecalculated
calculatedrigorously,
rigorously,including
includingthe thereturn
returnpaths,
paths,while
whilethe
thedashed
dashed
to R1 = 1. The solid curves are calculated rigorously, including the return paths, while the dashed
curvesare
curves arethose
thoseof ofthe
theanalytical
analyticalexpressions
expressionswithout
withoutconsidering
consideringthe thereturn
returnpaths.
paths.(b)
(b)The
Theamount
amount
curves are those of the analytical expressions without considering the return paths. (b) The amount
ofofthe
theradiating
radiatingmaterial
materialin inthe
thetumor
tumorconsidering
consideringthe thedecay
decayraterateyyisisshown
shownasasaafunction
functionofoftime.
time.
of the radiating material in the tumor considering the decay rate y is shown as a function of time.
Shown inthe
Shown the rightof of Figure22isisthe
the ratioof
of theradiating
radiating materialin in thetumor
tumor and
Shown inin the right
right of Figure
Figure 2 is the ratio
ratio of the
the radiating material
material in the
the tumor andand
the decay
the decay curve
curve of
of 211
211At, which is usually provided as the renormalized amount of the
the decay curve of At, which is usually provided as the renormalized amount of
211At, which is usually provided as the renormalized amount of the
the
radiating material.The
radiating The renormalizedamount amount iscompared
compared wellwith with thedata
data obtainedby by
radiating material.
material. Therenormalized
renormalized amount is is compared wellwell with the
the data obtained
obtained by
previous
previous work [7]: 23% at three hours and 12% at 24 h after the administration of 211At.
previous work
work [7]:
[7]: 23%
23% atat three
three hours
hours and
and 12%
12% at
at 24
24 hh after
after the
the administration
administration ofof 211At.
211
At.
2.2.The
2.2.
2.2. TheEffects
The Effectsof
Effects ofRadiation
of Radiationon
Radiation onTumor
on TumorVolume
Tumor Volume
Theexperimental
The
The experimentaldata
experimental data
dataofof tumor
oftumor
tumor size
size after
after
size the
the
after treatment
treatment
the treatment with
with 211At
211
with 211
At are
are plotted
At plotted
are inFig-
in
plotted Fig-
in
ure3.3.The
ure
Figure The largelarge
3. large
The variation
variation shown
shown
variation hereisis
here
shown dueis
due
here todue
to theindividual
the individual
to variability
variability
the individual oftumor
of tumor
variability growth
ofgrowth
tumor
in each
in eachin
growth mouse,
mouse, in addition
in
each mouse, addition to the
to
in addition thetomeasurement
measurement
the measurement error.
error. Following
Following
error. the the
the
Following administration
administration
administration of
of
211 At,
211At, most ofthe
the tumors showed
of
211 At, mostmost
of of the tumors
tumors showed
showed aagradual
gradual
a gradual decrease
decrease
decrease involume
in volume
in volume but
but butregrowth
regrowth
regrowth started
started
started inin
in aa
later
a later phase,
phase, except
except in one mouse which received 1 MBq of 211
211 At.
later phase, except inin
oneone mouse
mouse which
which received
received 1 MBq
1 MBq ofof At.At.
211

0.1MBq
0.1 MBq
control
control 0.4MBq
0.4 MBq

11MBq
MBq

Figure3.
Figure
Figure 3.Experimental
3. Experimentaldata
Experimental dataof
data oftumor
tumorvolume
volumein ineach
eachmouse
mouseobtained
obtainedfrom
fromthe previousexperiment
theprevious
previous experiment
experiment
with
with 211At treatment [7]. Each polygonal line represents the measured tumor volume in each mouse
211
with At treatment [7]. Each polygonal line represents the measured tumor volume in each mouse
211At treatment [7]. Each polygonal line represents the measured tumor volume in each mouse
classifiedinto
classified
classified into444groups
into groupsaccording
groups accordingto
according tothe
to theadministered
the administereddose:
administered dose:control
dose: control(green),
control (green),0.1
(green), 0.1MBq
0.1 MBq(red),
MBq (red),0.4
(red), 0.4MBq
0.4 MBq
MBq
(blue)and
(blue) and11MBqMBq(brown).
(brown).
(blue) and 1 MBq (brown).

Wefirst
We
We firstestimated
first estimatedthe
estimated thetumor
the tumorgrowth
tumor growthrate,
growth rate,λ,
rate, λ,from
λ, fromthe
from thecontrol
the controlmice
control micedata
mice dataup
data upto
up to10
to 10 days.
10days.
days.
Table
Table 1 shows
Table 1 shows
shows the the results
the results
results of of the regression
of the regression analysis
regression analysis
analysis of of the
of the tumor
the tumor growth
tumor growth
growth datadata
data inin control
in control
control
mice.In
mice.
mice. Inspite
In spiteof
spite ofthe
of thelarge
the largevariation
large variationin
variation inthe
in theinitial
initialtumor
tumorvolume,
volume,VV00,0,,the
theproliferation
the proliferationrate
proliferation rate
rate
ofthe
of
of thetumor,
the tumor,λ,
tumor, λ,showed
λ, showedless lessvariation,
variation,andandwe weused
usedthe
thevalue
valueofof0.14/day
0.14/dayas
0.14/day thetumor
as the
the tumor
tumor
growthrate
growth
growth ratefor
rate forthe
for thefollowing
the followinganalysis
following analysisto
analysis toexamine
examinethe
examine theeffects
effectsofofradiation.
radiation.
 Int.J.J.Mol.
Int. Mol.Sci.
Sci.2022,
2022,23,
23,15966
x FOR PEER REVIEW 44 of
of 10
10
Int. J. Mol. Sci. 2022, 23, x FOR PEER REVIEW 4 of 10

Table1.1.Results
Table Resultsofofthe
theregression
regressionanalysis
analysisfor
fortumor
tumorgrowth
growthdata
datainincontrol
controlmice
miceup
uptoto10
10days
dayswith
with
Table
the 1. Results
number of of the
data regression
points (n = 6).analysis for tumor growth data in control mice up to 10 days with
the number
the number ofof data
data points
points (n
(n = 6).
= 6).
Parameter
Parameter Mean
Mean Standard Deviation
Standard Deviation
Deviation
Parameter Mean Standard
λ (/day) 0.14 0.08
λ (/day)3 0.14
0.14 0.08
0.08
VV000(mm
V
(mm33 ))
(mm )
577
577
577
372
372
372
Figure 4 illustrates the number of tumor cells with211 211At treatment, which decreases
Figure 4 illustrates the number of tumor
tumor cells
cells with
with 211At treatment, which decreases
quickly after receiving the radiation but gradually recovers in the later period. It is seen
quickly after receiving the radiation but gradually recovers in the later period. It is seen
that the recovery is delayed in the high-dose curve, but the slope in the regrowth phase is
that the
the recovery
recovery isisdelayed
delayedininthe
thehigh-dose
high-dosecurve,
curve,butbutthe
theslope in the
slope regrowth phase is
exactly same as for control data. The data show that the number ofin the regrowth
survived cells isphase
deter-
exactly same
is exactly as for
same control
as for data.
control The The
data. data data
showshow
that the
thatnumber of survived
the number cells iscells
of survived deter-
is
mined by radiation dose, and these cells go back to the proliferation phase thereafter.
mined by radiation
determined dose,dose,
by radiation and these cells go
and these back
cells to thetoproliferation
go back phase
the proliferation thereafter.
phase thereafter.

Figure 4. Simulation curves of the number of tumor cells after treatment with211 211At with doses from
Figure 4. Simulation curves of the number of tumor cells after
after treatment
treatment with
with At with
211At with doses from
1 Gy to 20 Gy. We used λ = 0.14/day, N0 = 2 × 109, and Nm = 4 × 10 .10
9 10
Gy. We
1 Gy to 20 Gy. used λλ == 0.14/day, N00 == 2 ××10
We used 109, and
, andNN mm== × 1010. .
4 ×4 10
Comparison of these simulation curves with the experimental data of the tumor vol-
Comparison of
Comparison ofthese
thesesimulation
simulationcurves
curves with
with thethe experimental
experimental datadata
of theof tumor
the tumor
vol-
ume
volume
shown
shown
in in
Figure
Figure
3 suggested
3 suggested
that it is
that it
necessary
is necessary
toto
include
include
additional
additional
parameters
parameters
to
ume shown in Figure 3 suggested that it is necessary to include additional parameters to
reproduce
to reproduce the experimental data. Two important factors should be considered: (i) the
reproduce thethe experimental
experimental data.
data. TwoTwo important
important factors
factors should
should be considered:
be considered: (i)
(i) the
gradual
the gradual decrease in
decrease tumor
in tumor volume
volumeafter the radiation treatment and (ii) a slower slope
gradual decrease in tumor volume after after the radiation
the radiation treatment
treatment and
and (ii) (ii) a slower
a slower slope
during
slope the recovery
during phase after after
the recovery the treatment, particularly for high radiation doses. Con-
during the recovery phasephase the treatment,
after the treatment, particularly
particularly for highforradiation
high radiation
doses.doses.
Con-
sidering these
Considering factors,
these we propose
factors, we a model
propose a modelto simulate
to the volume
simulate the change
volume of tumor
change of cells
tumor
sidering these factors, we propose a model to simulate the volume change of tumor cells
by radiation,
cells as
by radiation, shown in
as shown Figure 5.
in Figure
by radiation, as shown in Figure 5. 5.

Figure5.5.The
The schematic
schematic view
view of the proposed model. We assume that the cancer volume consists of
Figure
Figure 5. The
the viable schematic
tumor view ofof
cell volume,
theproposed
Vthe
proposedmodel.
model.We Weassume
assume that
that thethe cancer
cancer volume
volume
L, and the damaged cell volume, VD, which are related with the cor-
consists
consists of
of the
the viable
viable tumor
tumor cellcell volume,L, V
volume, L , and
the the damagedcell cell volume, VD , which are related
withwith the
responding numbers, N andVN and damaged volume, VD, which are related
D. The tumor cells proliferate with the growth rate, λ, modified
the cor-
corresponding
responding numbers,
numbers, N and
NDN . The tumor cellsproliferate
proliferatewithwiththethe growthrate,
rate, λ, modified
slightly by the damageNofand cancer .tissue
The
D tumor
due to cells
radiation. The cell damagegrowth
is caused by λ,the radiation
slightly by the damage of cancer
with the radiation dose, d(t). tissue due to radiation. The cell damage is caused by the radiation
with the radiation dose, d(t).
Int. J. Mol. Sci. 2022, 23, x FOR PEER REVIEW 5 of 10
Int. J. Mol. Sci. 2022, 23, 15966 5 of 10

Another problem is the recovery of tumor growth after the treatment. The experi-
mental data inproblem
Another Figure 3isshow that theofslope
the recovery tumor of growth
tumor regrowth is slower, The
after the treatment. particularly
experimen-in
the case in
tal data of Figure
high-dose
3 showtreatment,
that the than
slopein of the control
tumor mice,issuggesting
regrowth an effect in
slower, particularly onthe
tumor
case
growth rate after
of high-dose radiation.
treatment, thanWe assumed
in the controlthat tumor
mice, growthan
suggesting is effect
impaired by thegrowth
on tumor total dose
rate
received by that We
after radiation. time and introduced
assumed that tumor λmodgrowth
as a factor to modify
is impaired by the
the tumor growth
total dose rate by
received by
radiation.
that time and introduced λmod as a factor to modify the tumor growth rate by radiation.
Considering
Consideringthese theseparameters,
parameters,the theresults
resultsofof the
the estimated
estimatedtumor
tumorvolume
volumecurves
curvesare
are
shownas
shown as dashed
dashed lines
lines in
in Figure
Figure 6.6. AA slower
slower recovery
recovery slope
slope after
after receiving
receiving the
the high-dose
high-dose
radiation isis well
radiation well reproduced
reproduced in in this
this figure.
figure. InIn this
this final
final process,
process, we we used
used the
the estimated
estimated
radiation dose in
radiation in the
thetumor,
tumor,9.7 9.7Gy,
Gy,from
fromthethe
previous
previous work [7] for
work [7] administration
for administrationof 1 MBq
of 1
211 At. In spite of aoflarge variation ininthe
MBq 211At. In spite a large variation theexperimental
experimentaldata, data,the
the simulated curves can
simulated curves can
reproduce the
reproduce the data.
data.

Figure 6.
Figure Estimated dose-response
6. Estimated dose-response curves
curves to reproduce the experimental data of 211
to reproduce Attreatment
211At treatmentinin
xenograft
xenograft model
model mice.
mice. Dashed
Dashedcurve
curvelines
linesdemonstrate
demonstratethe
thetumor
tumorgrowth
growthcurves
curvesby
byadministration
administration
of
of0.1
0.1MBq
MBq(Q (Q==0.1),
0.1),0.4
0.4MBq
MBq(Q(Q==0.4),
0.4),and
and11MBq
MBq(Q(Q==1)1)inincomparison
comparisonwith
withcontrol
controlmice
mice(Q
(Q==0).
0).

3. Discussion
3. Discussion
The animal
The animal experiment
experimentisis thethe most
most important
important preclinical
preclinical process
process before
before thethe clinical
clinical
trials of
trials of TRT.
TRT. The
The obtained
obtained results
results areare directly
directly linked
linked toto the
the design
designof ofthe
theclinical
clinicaltrials.
trials.
Mathematical models can provide important information to overcome
Mathematical models can provide important information to overcome the limited animal the limited animal
data. In
data. Inthis
thisstudy,
study, we
we proposed
proposed aa modelmodel toto simulate
simulate thethe volume
volume changes
changes of of implanted
implanted
tumors after the administration of 211 At, but it can be applied to any animal experiment
tumors after the administration of At, but it can be applied to any animal experiment of
211
of TRT.
TRT. ThisThis model
model is based
is based on on three
three keykey parameters:
parameters: (i) the
(i) the tumor
tumor growth
growth raterate without
without ra-
radiation, (ii) the effect of radiation to decrease the tumor volume, and
diation, (ii) the effect of radiation to decrease the tumor volume, and (iii) the factor to(iii) the factor to
modify the tumor regrowth rate after radiation. In order to estimate these
modify the tumor regrowth rate after radiation. In order to estimate these parameters, we parameters, we
needed the data sets of temporal changes of tumor volume with or without radiation and
needed the data sets of temporal changes of tumor volume with or without radiation and
the radiation profile in the tumor following the administration of radiopharmaceuticals.
the radiation profile in the tumor following the administration of radiopharmaceuticals.
One of the great advantages of the mathematical model is to reproduce the animal
One of the great advantages of the mathematical model is to reproduce the animal
experiment with different treatment protocols. The data of the experiment are often limited
experiment with different treatment protocols. The data of the experiment are often lim-
due to the complicated experimental setup and limited resources. For example, Figure 7
ited due to the complicated experimental setup and limited resources. For211 example, Figure
shows the simulation curves calculated for the administration doses of At beyond the
7 shows the simulation curves calculated for the administration doses of 211At beyond the
range of the experimental data. The model can provide valuable information for planning
range of the experimental data. The model can provide valuable information for planning
the administration dose of radiopharmaceuticals in clinical trials, especially to determine
the administration dose of radiopharmaceuticals in clinical trials, especially to determine
the starting dose at which efficacy can be expected with a sufficient safety margin.
the starting dose at which efficacy can be expected with a sufficient safety margin.
TRT usually requires multiple treatment doses to cure a patient with intractable
malignant tumors. The treatment protocols are often based on the previous experience.
The EU has required the individual treatment planning for all radiotherapeutic procedures,
including radionuclide therapy [8]. ICRP also recommended improving the dosimetry for
the individual dose estimate in radionuclide therapy [9]. This is particularly important for
the use of alpha-emitting radionuclides with high linear energy transfer (LET) radiation.
High LET radiation, including alpha particles, induces double-strand breaks (DSBs) in
DNA and can provide an effective treatment of tumors. However, it may also cause
severe damage to the healthy tissue cells, which should be considered in clinical treatment
planning. The proposed model can be used to estimate the effects of repeated administration
Int. J. Mol. Sci. 2022, 23, 15966 6 of 10

of radiopharmaceuticals, assuming a similar radiation profile to the first treatment or a

modified dose in the subsequent repeated treatment. This treatment approach with multiple
low-dose administrations is beneficial to the patient, as it minimizes the damage to the
Int. J. Mol. Sci. 2022, 23, x FOR PEER REVIEW 6 of 10
healthy tissues, but needs to be optimized in the treatment protocol, considering the control
of tumor regrowth.

Figure 7.
Figure Calculated dose-response
7. Calculated dose-response curves
curves to predict the tumor response to 211
to predict At treatment.
211At treatment. Two
Two
conditions, 0.02
conditions, 0.02 MBq
MBq (Q (Q ==0.02)
0.02)ininyellow
yellow and
and 22MBq
MBq(Q(Q==2)2)ininpurple,
purple,are
areshown
shownasasadditional
additionalcurve
curve
lines
lines for
for the
the results
results in
in Figure
Figure 6.
6.

The usually
TRT results obtained in this study
requires multiple provide
treatment dosesvarious
to curesuggestions
a patient with for intractable
understanding ma-
tumor growth
lignant tumors.and Thethe effects of
treatment radiation.
protocols areSuppression
often based on of the
the tumor
previous regrowth rate after
experience. The
211
EUAt hastreatment
requiredcan thebeindividual
explained treatment
by alterations to the for
planning characteristics of tumor cells
all radiotherapeutic or tissue
procedures,
environment
including by radiation.
radionuclide It has
therapy [8].been
ICRP shown that rapidly growing
also recommended improving tumor cells are more
the dosimetry for
radiosensitive than slowly growing tumor cells [3]. Therefore, it is
the individual dose estimate in radionuclide therapy [9]. This is particularly important possible that the residual
for
tumor
the usecells, which survived
of alpha-emitting after radiation
radionuclides withtreatment,
high linearmay grow slowly.
energy transferCancer stem cells,
(LET) radiation.
whichLET
High have been reported
radiation, includingto bealpha
radioresistant, may play
particles, induces a role in this breaks
double-strand process(DSBs)
[10]. Wein
should
DNA andalso
canconsider
providethe an possible
effective effects
treatmenton the immuneHowever,
of tumors. system after thealso
it may treatment [11].
cause severe
damage Theto model used intissue
the healthy this study
cells,needs
whichtoshould
be improved by beingin
be considered applied
clinicaltotreatment
other treatment
plan-
protocols and tumor models. The parameters used in this study
ning. The proposed model can be used to estimate the effects of repeated administrationwere adjusted to reproduce
theradiopharmaceuticals,
of previous experiment assuming with [211 At]NaAt
a similartreatment
radiation in K1-NIS
profile to thexenograft model mice.
first treatment or a
In this study, we used the b
modified dose in the subsequent repeated treatment. This treatment approach number
value, which is responsible for decreasing the with mul- of
tumor cells, of 0.3/Gy. A similar simulation study revealed
tiple low-dose administrations is beneficial to the patient, as it minimizes lower values for external
the damage to
beam radiotherapy [12], supporting the efficient treatment effects of 211 At [13–15]. The
the healthy tissues, but211needs to be optimized in the treatment protocol, considering the
therapeutic
control effects
of tumor of At could be predicted by relative biological effectiveness (RBE),
regrowth.
but the evaluation of RBE for radionuclide therapy is complicated and requires careful
The results obtained in this study provide various suggestions for understanding tu-
consideration of the methods used [16]. Therefore, we expect that the use of the proposed
mor growth and the effects of radiation. Suppression of the tumor regrowth rate after 211At
model can be used to estimate the RBE value of radionuclide treatment in vivo.
treatment can be explained by alterations to the characteristics of tumor cells or tissue
In addition to RBE, we may want to consider the effects of dose rate in TRT. The tumor
environment by radiation. It has been shown that rapidly growing tumor cells 211 are more
cells received most of the radiation dose within a day after the administration of At due
radiosensitive than slowly growing tumor cells [3]. Therefore, it is possible that the resid-
to the relatively short physical half-life (7.21 h). It may be interesting to compare the results
ual tumor cells, which survived after radiation treatment, may grow slowly. Cancer stem
with other alpha-emitting radionuclides of a longer physical half-life, such as 225 Ac. It
cells, which have been reported to be radioresistant, may play a role in this process [10].
is conceivable that TRT may require the best treatment protocol, considering the kinetic
We should also consider the possible effects on the immune system after the treatment
behavior, RBE, and dose rate of the radionuclide used, and the present model can be used
[11].
to compare the results of different treatment methods.
The model used in this study needs to be improved by being applied to other treat-
ment protocols
4. Materials andand tumor models. The parameters used in this study were adjusted to
Methods
reproduce
4.1. Animal Experiment experiment with [ At]NaAt treatment in K1-NIS xenograft
the previous 211

model mice. In this study, we used the b value, which is responsible for decreasing the
The data obtained from the previous animal experiment of 211 At treatment in a mouse
number of tumor cells, of 0.3/Gy. A similar simulation study revealed lower values for
xenograft model were reanalyzed in this study [7]. K1 cells (human papillary thyroid
external
carcinoma) beam radiotherapy
expressing the [12], supporting symporter
sodium/iodide the efficient(NIS)
treatment
geneeffects of 211At [13–15].
were subcutaneously
The therapeutic
injected into theeffects of 211At
SCID mice could
(1–2 × 10be predicted
7 cells). The by relative
mice were biological
treated byeffectiveness
intravenous
(RBE), but the evaluation of RBE for radionuclide therapy
administration of 211 At solution (control, 0.1 MBq, 0.4 MBq, 1 MBq) when is complicated andthe requires
tumor
careful consideration of the methods used [16]. Therefore,
size reached approximately 10 mm in diameter (37 days on average). The tumor we expect that the use of size
the
proposed model can be used to estimate the RBE value of radionuclide treatment in vivo.
In addition to RBE, we may want to consider the effects of dose rate in TRT. The
tumor cells received most of the radiation dose within a day after the administration of
211At due to the relatively short physical half-life (7.21 h). It may be interesting to compare

the results with other alpha-emitting radionuclides of a longer physical half-life, such as
Int. J. Mol. Sci. 2022, 23, 15966 7 of 10

was measured by an external caliper, and the tumor volume was calculated using the
assumption of an oblate ellipsoid.

4.2. Estimation of the Drug Delivery

In order to analyze the drug delivery model expressed by the box model shown in
Figure 1, we wrote differential equations for the numbers of radionuclides, R, in these
boxes: R1 for blood, R2 for tumor, R3 for body organs, and R4 for excretion.

dR1 (t)
= −α12 R1 − α13 R1 − α14 R1 + α21 R2 + α31 R3 − yR1 (1)
dt
dR2 (t)
= α12 R1 − α21 R2 − yR2
dt
dR3 (t)
= α13 R1 − α31 R3 − yR3
dt
dR4 (t)
= α14 R1 − yR4
dt
Here, y denotes the decay rate of the radiating material. The coefficients α are fixed so
as to reproduce the experimental behavior. The total number of radionuclides, RT (=R1 +
R2 + R3 + R4 ), decreases with the decay rate, y:

dR T
= −yR T (t), with R T = R1 (t = 0)e−yt (2)
dt
In the case where the coefficients of the return paths are zero, α21 = 0 and α31 = 0, we
can solve the differential equations analytically. The solutions are

R1 = R1 (t = 0)e− At (3)

and
α1i
R i = R1 ( t = 0) (1 − e− Bt )e−yt (4)
B
with i = 2, 3, 4. Here, A = α12 + α13 + α14 + y, and B = α12 + α13 + α14 . This equation
indicates that R2 increases linearly with the slope α12 and has a peak and decreases with
the decay rate y. The amount R2 is determined by the ratio of α12 /B. The initial condition
can be provided as follows: the injected activity, Q, for R1 (t = 0), and 0 for other parameters

R1 (t = 0) = Q, R2 (t = 0) = 0, R3 (t = 0) = 0, R4 (t = 0) = 0. (5)

These equations provide the following numerical results for the radiation dose profile
by taking the parameters:

α12 = 0.33, α13 = 1, α14 = 0.5, α21 = 0.1, α31 = 0.5,

(6)
y = log(2)/7.21 = 0.096.

Next, we wanted to estimate the amount of radiation in the tumor using the analytical
expression for R2 by integrating R2 (t) over time:
Z ∞  
α12 1 1 α
R2 (t) dt = Q − = Q 12 (7)
0 B y A yA

This expression denotes the total amount of radiating material in the tumor, where
one 211 At emits two alpha particles of energy 5.9 and 7.5 MeV. Since the becquerel (Bq) is
the unit for the number of emitting particles per second, we should take an average of the
two energies per one emission. The radiation dose of 1 MBq of 211 At in a tumor with the
weight 1.5 g provides 5.45 Gy per hour, so the total dose in the tumor becomes 9.7 Gy using
the above Equation (7) with the parameters (6), corresponding to the calculated value of
Int. J. Mol. Sci. 2022, 23, 15966 8 of 10

Watabe et al. [7]. Based on this observation, we calculated the radiation dose rate for each
administration dose of 211 At.

4.3. Estimation of Radiation Effects on Tumor Volume

The treatment model for cancer therapy by external radiation using X-rays has been
studied by Bando et al. [12], and we applied a similar concept to TRT. We assume that the
implanted tumor cells grow continuously with a certain limit on the volume. We start with
a simple consideration, where the number of the tumor cells, N, increases with the growth
rate, λ, with the maximum number, Nm , and decreases with the killing rate, b, due to the
radiation with the dose rate, d(t).
 
dN N
= (λ − bd(t)) N 1 − (8)
dt Nm

Here, we can calculate the radiation dose rate, d(t), from the amount of radionuclide
in the tumor, R2 (t), considering the temporal changes in its activity.
In control mice during the growth phase, tumor volume, V, is considered to be parallel
to the number of cells, N, and the tumor growth rate, λ, can be estimated from the early
stage of tumor growth. Here, we assume the volume of a cancer cell as v and V = vN.
 
dV V
= (λ − bd(t))V 1 − (9)
dt Vm

If d(t) = 0, and V is small compared to Vm , we get the following simple equation and
corresponding analytical solution.
dV
= λV (10)
dt
V = V0 exp(λt) (11)
We estimated the tumor growth rate, λ, from the control mice data up to 10 days using
the simple expression (11).
Numerical analysis of Equation (8) provided the simulation curves for the number of
tumor cells after treatment with 211 At by setting the initial conditions of N0 as 2 × 109 and
b as 0.3/Gy.
The tumor volume slowly decreased after receiving the radiation dose, while the
damaged tumor cells quickly lost the ability to proliferate. The gradual decrease in the
cancer volume is attributed to the gradual loss of volume of the damaged cells. To reflect
this relation, we introduced the time-delay effect for the volume change of damaged tumor
cells. Here, we considered two types of tumor cells: those with cancer cell proliferation and
damaged cells without the ability to proliferate. The tumor volume is a sum of the volume
of proliferating cells, VL , and that of damaged cells, VD .

V (t) = VL (t) + VD (t) (12)

Then we get the following equation to convert the number of cells into their volume,
considering the apparent volume size of the tumor cell, v, and VL (t) = vN (t), with the
single cell volume, v.
V (t) = vN (t) + VD (t) (13)
Proliferating tumor cells, N, and damaged cells, ND , can be described by the following
equations, neglecting the saturation volume effect.

dN
= (λ − bd) N (14)
dt
dND
= bdN (15)
dt
Int. J. Mol. Sci. 2022, 23, 15966 9 of 10

The delay effect of tumor volume change of damaged cells can be described as a
function of time.
VD (t) = vND e−c(t−t0 ) (16)
This simple formula is obtained by approximating that the time duration, t0 , (<1 day)
of the radiation effect is much smaller than the time 1/c (~10 days) of the damaged cell
decrease. In the actual calculation, we set t0 = 0 and c = 0.1.
Finally, we introduced λmod as a factor to modify the tumor growth rate by radiation,
assuming that tumor growth is impaired by the total dose, D(t), received by that time.

λ
λmod (t) = (17)
1 + D (t)1/4
Z t
D (t) = d(τ )dτ (18)
0
This modified tumor growth rate, λmod , calculated by Equation (17) was applied to
Equations (8) and (9) for the estimation of tumor growth curves with 211 At treatment.

dN N
= (λmod (t) − bd(t)) N (1 − ) (19)
dt Nm

dV V
= (λmod (t) − bd(t))V (1 − ) (20)
dt Vm

5. Conclusions
The present study demonstrated the value of a mathematical model for the evaluation
of the treatment efficiency of TRT in an implanted mouse tumor model. The model
can be used to predict the treatment response and to plan the administration dose of
radiopharmaceuticals in clinical trials, especially to determine the starting dose at which
efficacy can be expected with a sufficient safety margin.

Author Contributions: Conceptualization, Y.Y., H.T. and M.B.; methodology, H.T. and T.W.; software,
H.T.; validation, H.T.; formal analysis, H.T., T.W., K.K.-N., Y.S., K.O. and A.T.; investigation, H.T.,
T.W., K.K.-N., Y.S. and K.O.; resources, T.W., K.K.-N., Y.S., K.O. and A.T.; data curation, T.W. and
K.K.-N.; writing—original draft preparation, Y.Y. and H.T.; writing—review and editing, Y.S., H.N.
and M.B.; visualization, H.T.; supervision, H.T., T.W., N.T. and M.B.; project administration, Y.Y.,
H.T. and T.W.; funding acquisition, T.W. and H.T. All authors have read and agreed to the published
version of the manuscript.
Funding: This study is supported by the COREnet program of RCNP, Osaka University. The animal
study was funded by the QiSS program of the OPERA (grant number: JPMJOP1721) from the Science
and Technology Agency (JST).
Institutional Review Board Statement: All animal experiments complied with the guidelines of the
Institute of Experimental Animal Sciences. The protocol was approved by the Animal Care and Use
Committee of the Osaka University Graduate School of Medicine (approval number: 30-103-008).
Data Availability Statement: All data are included in this published article.
Acknowledgments: The 211 At was procured from the Research Center for Nuclear Physics at Osaka
University and RIKEN Nishina Center for Accelerator-Based Science via Supply Platform of short-
lived radioisotopes supported by JSPS Grant-in-Aid for Scientific Research on Innovative Areas (grant
number 16H06278).
Conflicts of Interest: The authors declare no conflict of interest.
Int. J. Mol. Sci. 2022, 23, 15966 10 of 10

References
1. Parker, C.; Nilsson, S.; Heinrich, D.; Helle, S.I.; O’Sullivan, J.M.; Fosså, S.D.; Chodacki, A.; Wiechno, P.; Logue, J.; Seke, M.; et al.
for the ALSYMPCA Investigators. Alpha emitter radium-223 and survival in metastatic prostate cancer. N. Engl. J. Med. 2013, 369,
213–223. [CrossRef] [PubMed]
2. Kratochwil, C.; Bruchertseifer, F.; Giesel, F.L.; Weis, M.; Verburg, F.A.; Mottaghy, F.; Kopka, K.; Apostolidis, C.; Haberkorn, U.;
Morgestern, A. 225 Ac-PSMA-617 for PSMA-targeted α-radiation therapy of metastatic castration-resistant prostate cancer. J. Nucl.
Med. 2016, 57, 1941–1944. [CrossRef] [PubMed]
3. Hall, E.J.; Giaccia, A.J. Radiobiology for the Radiologist, 8th ed.; Wolters Kluwer: Philadelphia, PA, USA, 2019; pp. 398–416.
4. Xu, X.G.; Bednartz, T.; Paganetti, H. A review of dosimetry studies on external-beam radiation treatment with respect to second
cancer induction. Phys. Med. Biol. 2008, 53, R193–R241. [CrossRef] [PubMed]
5. Caudell, J.J.; Torres-Roca, J.F.; Gillies, R.J.; Enderling, H.; Kim, S.; Rishi, A.; Moros, E.G.; Harrison, L.B. The future of personalised
radiotherapy for head and neck cancer. Lancet Oncol. 2017, 18, e266–e273. [CrossRef] [PubMed]
6. Yonekura, Y.; Tsujii, H.; Hopewell, J.W.; Lopez, P.O.; Cosset, J.-M.; Paganetti, H.; Montelius, A.; Schrdt, D.; Jones, B.; Nakamura, T.
Radiological protection in ion beam radiotherapy. ICRP Publication 127. Ann. ICRP 2014, 42, 5–113. [CrossRef] [PubMed]
7. Watabe, T.; Kaneda-Nakashima, K.; Liu, Y.; Shirakami, Y.; Ooe, K.; Toyoshima, A.; Shimosegawa, E.; Fukuda, M.; Shinohara, A.;
Hatazawa, J. Enhancement of 211 At uptake via the sodium iodide symporter by the addition of ascorbic acid in targeted a-therapy
of thyroid cancer. J. Nucl. Med. 2019, 60, 1301–1307. [CrossRef] [PubMed]
8. European Society of Radiology (ESR). Summary of the European Directive 2013/59/Euratom: Essentials for health professionals
in radiology. Insights Imaging 2015, 6, 411–417. [CrossRef] [PubMed]
9. Yonekura, Y.; Mattson, S.; Flux, G.; Bolch, W.E.; Dauer, L.T.; Fisher, D.R.; Palm, S.; Hosono, M.; Doruff, M.; Divgi, C.; et al.
Radiological protection in therapy with radiopharmaceuticals. ICRP Publication 140. Ann. ICRP 2019, 48, 1–332. [CrossRef]
[PubMed]
10. Arnold, C.R.; Mangesius, J.; Skvortsova, I.I.; Ganswindt, U. The role of cancer stem cells in radiation resistance. Front. Oncol.
2020, 10, 164. [CrossRef] [PubMed]
11. Becker, R.A.; Kim, S.; Pilon-Thomas, S.; Enderling, H. Mathematical modeling of radiotherapy and its impact on tumor interactions
with the immune system. Neoplasia 2022, 28, 100796. [CrossRef] [PubMed]
12. Bando, M.; Tsunoyama, Y.; Suzuki, K.; Toki, H. WAM to SeeSaw model for cancer therapy –overcoming LQM difficulties–. Int. J.
Radiat. Biol. 2021, 97, 228–239. [CrossRef] [PubMed]
13. Spetz, J.; Rudqvist, N.; Forssell-Aronsson, E. Biodistribution and dosimetry of free 211 At, 125 I- and 131 I- in rats. Cancer Biother.
Radiopharm. 2013, 28, 657–664. [CrossRef] [PubMed]
14. Watabe, T.; Liu, Y.; Kaneda-Nakashima, K.; Sato, T.; Shirakami, Y.; Ooe, K.; Toyoshima, A.; Shimosegawa, E.; Wang, Y.; Haba, H.;
et al. Comparison of the therapeutic effects of [211 At]NaAt and [131 I]NaI in an NIS-expressing thyroid cancer mouse model. Int. J.
Mol. Sci. 2022, 23, 9434. [CrossRef] [PubMed]
15. Sgouros, G.; Roeske, J.C.; McDevitt, M.R.; Palm, S.; Allen, B.J.; Fisher, D.R.; Brill, A.B.; Song, H.; Howell, R.W.; Akabani, G. MIRD
Pamphlet No. 22 (Abridged): Radiobiology and dosimetry of alpha-particle emitters for targeted radionuclide therapy. J. Nucl.
Med. 2010, 51, 311–328. [CrossRef] [PubMed]
16. Hobbs, R.F.; Howell, R.W.; Song, H.; Baechler, S.; Sgouros, G. Redefining relative biological effectiveness in the context of the
EQDX formalism: Implications for alpha-particle emitter therapy. Radiat. Res. 2014, 181, 90–98. [CrossRef] [PubMed]