Clinical Translation of Bone Pain

Palliation Radiopharmaceuticals

Tapas Das
Radiopharmaceuticals Division
Bhabha Atomic Research Centre
Trombay, Mumbai - 400 085, INDIA
tdas@barc.gov.in
 Organic Chemistry Isotope Production

Inorganic Chemistry Radiochemistry

Biology Pharmaceutical Chemistry

Radiopharmaceuticals

Pre-Clinical Evaluation

Marketing
Regulatory Clearance Authorization

Clinical Evaluation in
Patients Approved
Phase 0/I/II/III Radiopharmaceuticals
 Translation from Laboratory to Clinics

 Radiochemical formulation at the laboratory scale

 Optimization of the radiolabeling parameters
 Purification of the radiolabeled product, if required
 Characterization of the radiolabeled product (Appearance, Color, pH, RC Purity, RN Purity etc.)

 Biological evaluation of the radiolabeled product

 In appropriate cancer cell-line(s)
 In small animal models (Biodistribution, Pharmacokinetics, Scintigraphy)
 In higher animal models

 Formulation of Patient dose

 Scale-up the preparation to one or multiple patient dose equivalent
 Physicochemical quality control tests (Appearance, Color, pH, RC Purity, RN Purity etc.)
 Biological quality control tests (Sterility, BET, Toxicity)
 Biological studies in small animal model (Biodistribution, Pharmacokinetics, Scintigraphy)
 Biological studies in higher animal model (Administration of human-dose equivalent)
 Translation from Laboratory to Clinics

 Experiments required for obtaining regulatory approval

 Formulation of several batches of patient-dose equivalent radiopharmaceuticals
 Physicochemical quality control tests for all the batches
 Biological quality control tests for all the batches

 Clinical investigation

Phase I Phase II Phase III Phase IV

Pharmacokinetics and Evaluate effectiveness and Evaluate more about Monitoring efficacy
biological distribution. short-term side-effects in efficacy and long-term and safety in large
Dosimetry studies in specific population side effects in population
limited patients to demographically diverse (Uncontrolled uses)
determine MTD sample
 Production of 177Lu

 Direct neutron activation of natural /enriched Lu2O3

176Lu (n,) 177Lu  = 2100 b
(abundance 2.6%)

 Indirect neutron activation

-
176Yb (n,) 177Yb  177Lu  = 2.4 b
(abundance 12.7%) 1.9 h
 Production of 177Lu by Direct Neutron Activation

 Irradiation
 Target: Isotopically enriched (82%+ in 176Lu) or natural Lu2O3
Spectroscopic grade , >99.99% chemically pure,
 Irradiation for 3-4 weeks at high flux positions

 Chemical processing
 Dissolution of target in supra-pure HCl to obtain LuCl3 solution
 Evaporation to near dryness
 Reconstitution in the required volume in HPLC water
 Repetition of evaporation and reconstitution multiple times
 177LuCl3 solution at pH ~4: Ready for preperation of radiopharmaceuticals

 Radioactivity assay and Radionuclidic purity determination

 By Isotope dose calibrator or pre-calibrated ionization chamber
 By  ray spectrometry using HPGe-MCA
 Determination of Radionuclidic purity of 177Lu

 Radionuclidic purity of 177Lu obtained is ~99.98%

 Average level of 177mLu in 177Lu : 7.4 kBq of 177mLu / 37 MBq of 177Lu (200 nCi / 1 mCi) at EOB
208 keV ( Lu)
113 keV ( Lu)

177

140000

208 keV ( Lu)

177

177
120000
72 keV( Lu)

Lu)
177

177m
113 keV ( Lu &
250 keV( Lu)
321 keV( Lu)

100000
10000
177

177
177

80000

228 keV ( Lu)

Net counts (log scale)

CPS
1000

177m
60000

128 keV ( Lu)

177m

174 keV ( Lu)

177m
100

378 keV ( Lu)

328 keV ( Lu)

418 keV ( Lu)

40000

282 keV ( Lu)

177m
177m
249 keV ( Lu)

177m
177m
177
10 20000

0
1 0 500 1000 1500 2000
0 1000 2000
Channel Number
Channel number

Typical gamma ray spectrum of 177Lu recorded

after radiochemical processing Typical gamma ray spectrum after complete decay of 177Lu
 Synthesis of EDTMP

Direct synthesis of -aminomethyl phosphonic acid : mannich type reactions with o-phosphorus acid.
Moedritzer K, Irani RR.
J. Org. Chem. 31, 1603-1607, 1996
 Characterization of EDTMP

FT-IR Spectrum ( cm-1)

3308, 2633, 2311, 1668, 1436, 1356

1H-NMR Spectrum

Multiplicity Shift ( ppm) No. of protons

>N-CH2-CH2-N< Singlet 3.84 4

-N-[CH2-P(O)(OH)2]2 Doublet, J=12.3 Hz 3.46 8

31P-NMR (1H-decoupled) Spectrum

-N-[CH2-P(O)(OH)2]2 Singlet 8.8

Mass Spectrum

m/z =437
 Laboratory-scale Preparation of 177Lu-EDTMP

EDTMP (5 mg) dissolved in 0.4 mL 0.5 M NaHCO3 solution (pH 9)

+
0.5 mL normal saline
+
0.1 mL of 177LuCl3

Adjust PH to 7 and incubate at RT for 15 minutes

177Lu-EDTMP
 Characterization of 177Lu-EDTMP

177 177
Lu-EDTMP Complex Lu-EDTMP
177 177
LuCl3 LuCl3
100 100

Paper Chromatography
80 80
in NH3: EtOH: H20
% Radioactivity

% Radioactivity
60 60
(1: 10: 20, v/v)
40 or 40

20
in normal saline 20

0 0
0 1 2 3 4 5 6 7 -7 -5 -3 -1 0 1 3 5 7

Migration from the point of spotting (cm) Migration from the point of spotting (cm)
 Biodistribution Pattern of 177Lu-EDTMP in Wistar Rats

5 animals were used at each time point

Figures in the parentheses indicate standard deviations
 Scintigraphic Images of 177Lu-EDTMP in Wistar Rats

1 d post-injection 2 d post-injection 7 d post-injection 14 d post-injection

 Preparation of ready-to-use 177Lu-EDTMP complex suitable for
human administration
EDTMP 0.5 M NaHCO3 Saline
177LuCl
3
(350 mg) solution (pH 9) (9 mL) (1 mL)
(10 mL) 1 Ci

Incubation for 15 min pH = 7

at room temperature

For the preparation of 10 patient doses Addition of 30 mL saline

Passed through Millipore filter

177Lu-EDTMP suitable for human administration

1 Ci (37 GBq) activity, 50 mL volume
Biodistribution Pattern of 177Lu-EDTMP in Swiss Mice
SPECT-CT Images of Wistar Rat Injected with 177Lu-EDTMP

The animal was injected with 40 MBq 177Lu-EDTMP and the images were recorded at
3 h post-administration at the (A) level of midline and (B) right knee joint
Biodistribution Pattern of 177Lu-EDTMP in New Zealand White Rabbits
Time-activity Curves of Blood, Bone and Whole-body during
the First 24 h in Mice and Rabbits
Scintigraphic Images of 177Lu-EDTMP in New Zealand White Rabbits

3 h post-injection

2 d post-injection
Scintigraphic Images of 177Lu-EDTMP in Dogs bearing Osteosarcoma

48 h post-injection
Scintigraphic Images of 177Lu-EDTMP in Dogs bearing Bone Metastases

48 h post-injection
Urinary Excretion in Beagle Dogs Injected with Various Doses
of 177Lu-EDTMP
 Blood Cell Counts of Dogs Injected with Different Doses of
177Lu-EDTMP at Different Post-administration Time Points

White blood cells

Platelets
Biochemical Parameters of Dogs Treated with
37 MBq/Kg Body Weight Of 177Lu-EDTMP
 Initiation of Clinical Studies
 Obtaining consent from the ‘Competent Authority’ is mandatory before initiation of any clinical studies
 ‘Competent Authority’ is different in different countries
 Permission must be obtained from ‘Medical Ethics Committee’ before initiation of clinical studies
 Permission may be given for limited number of patients at first
 The procedure, benefits, risks etc. along with the fact that a new investigational drug is being
administered must be clearly explained to the patients/their relatives in their native language
 Written consent must be obtained from the patients before administration of new agents
 It is advisable that consent given process may be video recorded and preserved
 ‘Competent Authority’ may review the initial results before giving permission to continue further studies
 The process needs to be repeated till ‘Marketing Authorization’ is received from ‘Competent Authority’
of the respective country
 Pre-clinical Dosimetry of 177Lu-EDTMP in Human Patients
 Pre-clinical dosimetry studies were carried out in 6 male patients suffering from metastatic
prostate carcinoma for determining the distribution pattern of the agent

 Each patient were administered 148-222 MBq (4-6 mCi) of 177Lu EDTMP intravenously

 Sequential whole-body images were recorded at 30 min (pre-void), 4 h, 8 h, 1 d, 2 d, 4 d, 6 d

or 7 d post-administration

 Images were recorded using both 113 keV and 208 keV gamma photons of 177Lu

 Blood pharmacokinetics of the agent was studied by drawing the blood samples at 10 min, 30
min, 1 h, 4 h, 8 h, 1 d, 2 d and 7 d post-administration

 Renal excretion pattern of the agent was also determined by measuring the radioactivity
associated with the urine samples collected between 0-4 h, 4-8 h, 8-24 h and 24-48 h

 Dose distribution pattern of the agent was calculated using the OLINDA 1.0 software
 Whole-body Images of a Patient Injected with 5 mCi of
177Lu-EDTMP at 30 Min Post-administration

Anterior Posterior
 Dose Escalation Study of 177Lu-EDTMP in human patients
 Dose escalation studies performed to find out the maximum tolerated dose (MTD) of 177Lu-EDTMP
 Patients were first injected with 2-3 mCi (74-111 MBq) of tracer dose to determine the percentage skeletal
uptake, which helped in determining the actual therapy dose to be injected to the patients
 Subsequently different doses of 177Lu-EDTMP preparation, which are corresponding to 75%-150% of
MTD of the agent, were injected to the patients
 For a particular dose of 177Lu-EDTMP, 3 patients were chosen
 Sequential whole-body images were recorded at 30 min (pre-void), 4 h, 8 h, 1 d, 2 d, 4 d, 7 d and 14 d
post-administration using LEHR collimator
 Images were recorded using both 113 keV and 208 keV gamma photons of 177Lu
 Blood pharmacokinetics of the agent was studied by drawing the blood samples at 0 min, 2 min, 4 min, 8
min, 15 min, 30 min, 2 h, 4 h, 8 h, and 1 d post-administration
 Renal excretion pattern of the agent was also determined by measuring the radioactivity associated with
the urine samples collected between 0-4 h, 4-8 h, 8-24 h and 24-48 h
177Lu-EDTMP in Human Patients

99mTc-MDP

177Lu-EDTMP
Marketing Authorization
 Acknowledgements

 My colleagues from Radiopharmaceuticals Division, Bhabha Atomic Research Centre, Mumbai

 Radiation Biology and Health Sciences Division, Bhabha Atomic Research Centre, Mumbai
 ‘Frederic Joliot Curie’ Research Institute for Radiobiology and Radiohygiene, Budapest, Hungary
 All India Institute of Medical Sciences (AIIMS), New Delhi
 Kovai Medical Center and Hospital (KMCH), Coimbatore
 Radiation Medicine Centre, Bhabha Atomic Research Centre, Mumbai
 Board of Radiation and Isotope Technology (BRIT), Mumbai
 International Atomic Energy Agency (IAEA), Vienna, Austria
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