Neoplasms

Urinary Tract, Sexual Organs, and Pregnancy Conditions

All Conditions

Prostatic Neoplasms

Carcinoma

Genital Neoplasms, Male

Urogenital Neoplasms

Genital Diseases

Genital Diseases, Male

Urogenital Diseases

Prostatic Diseases

Male Urogenital Diseases

Bone Density Conservation Agents

All Drugs and Chemicals

Antineoplastic Agents

Diphosphonates

Methylene diphosphonate

Radium Ra 223 dichloride

Technetium Tc 99m Medronate

Radiopharmaceuticals

Patients undergo NaF PET/CT or MDP scan within 45 days prior to cycle 1 day 1. Patients then receive standard of care Ra-223 IV on day 1 of each cycle. Treatment repeats every 28 days for 6 cycles in the absence of disease progression or unacceptable toxicity. Patients then undergo PSMA PET/CT over 45-60 minutes between 30-60 days after the last dose of Ra-223. Patients also undergo collection of blood samples during screening, on day 1 of every Ra-223 cycle, and at 30 days after the last dose of Ra-223. Patients may also undergo NaF PET/CT or MDP scans during Ra-223 treatment as clinically indicated, and/or CT scans during screening and Ra-223 treatment as clinically indicated.

Radium-223

PSMA Positron Emission Tomography (PET) Scan

Technetium Tc 99M Medronate

Maya Aslam

Thomas A Hope, MD

This phase II trial studies how well prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scans (in combination with bone scans) work in selecting patients for Ra-223 radiation therapy that have castration-resistant prostate cancer that has spread from where it first started (primary site) to the bones (bone metastasis). Ra-223 is a type of therapy that emits radiation. Radiation gives off energy which can kill tumor cells and other cells that may support the tumor cells. Ra-223 is given by infusion into the veins, where it is absorbed by the bones. PSMA PET is a type of scan used to detect prostate cancer tumors. PSMA is a radioactive tracer that binds to a specific protein that is found on prostate tumor cells. The PSMA tracer shows the areas on the PET scan where tumor cells are active. A PET scan uses a special camera to detect the energy given off from radioactive tracers (such as PSMA) to make detailed pictures of areas where the tracer accumulates in the body. The PET scan is often combined with a magnetic resonance imaging (MRI) or computed tomography (CT) scan, which helps to map the locations where PSMA has accumulated. PSMA PET scans may be able to select patients that will benefit the most from Ra-223 treatment.

PRIMARY OBJECTIVE:

I. To determine the PSA50 response rate of participants treated with radium Ra 223 dichloride (Ra-223).

SECONDARY OBJECTIVES:

I. To determine the median overall survival (mOS) of participants treated with Ra-223.

II. To determine the PSA30 response rate of partoicipants treated with Ra-223. III. To determine the time to the first skeletal symptomatic event. IV. To characterize the safety profile of Ra-223 treatment. V. To compare the lesion based PSMA PET response based on sodium fluoride (NaF) PET/technetium Tc-99m medronate (MDP) single photon emission computed tomography (SPECT) uptake.

EXPLORATORY OBJECTIVES; I. To compare the PSA response stratified by PSMA PET tumor volume. II. To determine the location of progression by location. III. Safety on subsequent treatment with PSMA radioligand therapy (RLT).

OUTLINE:

Participants undergo NaF PET/CT or MDP scan within 45 days prior to standard of care (SOC) Ra-223 intravenously (IV). Treatment repeats every 28 days for 6 cycles in the absence of disease progression or unacceptable toxicity. Participants then undergo a PSMA PET/CT between 30-60 days after the last dose of Ra-223. Participants also undergo collection of blood samples during screening, on the first day of every Ra-223 cycle, and at 30 days after the last dose. Participants may also undergo a NaF PET/CT or MDP scan during treatment as clinically indicated, and/or CT scans during screening and treatment as clinically indicated.

After completion of Ra-223 treatment, participants are followed up at 30 days, and then every 3-6 months.

Efficacy of Ra-223 in PSMA PET Optimally Selected Patients

The proportion of patients who achieve a greater than 50% decline from baseline prostate specific antigen (PSA) (PSA50) drawn prior to C1D1, at any point in the treatment course, will be descriptively reported along with 95% binomial confidence interval. It will be compared with the historical control by binomial test. A confirmation repeat PSA will be drawn after the initial PSA50 response to confirm the result. A PSA50 will only be counted if two PSA showing a 50% decline are measured.

The proportion of patients who achieve a greater than 30% decline from baseline PSA (PSA30) drawn prior to cycle 1 day 1 (C1D1), at any point in the treatment course, will be descriptively reported along with 95% binomial confidence interval. It will be compared with the historical control by binomial test.

Overall survival The time to event will be defined by the duration from the first date of study therapy to date of death from any cause. We will estimate the survival function using the Kaplan-Meier method, and obtain its 95% confidence bands over the survival times. The median overall survival time and 95% confidence interval of it will be derived from the estimated survival functions.

The time to the first skeletal symptomatic event will measure the time to the first new symptomatic pathological bone fracture, spinal cord compression, tumor-related orthopedic surgical intervention, or requirement for radiation therapy to relieve bone pain, whichever occurs first. We will also estimate the survival function using the Kaplan-Meier method, and obtain its 95% confidence bands over the survival times. The median survival time and 95% confidence interval of it will be derived from the estimated survival functions.

The incidence and severity of adverse events related to study treatment will be descriptively reported using CTCAE v5.0.

Up to five lesions per patient will be measured by a board certified nuclear medicine physician. For each lesion the maximum SUV (SUVmax) will be measured on PSMA PET and NaF PET. Additionally, the SUVmax on the end of study PSMA PET will also be measured. As there is an underestimation of uptake on MDP bone scan compared to PET, we will multiply the uptake measured on MDP SPECT by 2.3 to correct for the differences in recovery coefficients between the two imaging technologies based on prior comparisons. The percent change in the PSMA PET uptake between baseline and end of study will be measured. A Spearman's rank correlation will be used to compare the baseline NaF uptake for each lesion with the percent change of PSMA PET SUVmax.

Bayer Healthcare Pharmaceuticals, Inc./Bayer Schering Pharma

University of California, San Francisco

Anti-Infective Agents

Fluorodeoxyglucose F18

Gallium 68 PSMA-11

Formaldehyde

Patients will undergo 18F-FDG and whole-body PET/CT (vertex to thighs, or to feet if known lower-limb metastases).

The patient will be measured and weighed before the exam in order to calculate a personalized dose. An intravenous catheter will be put in place in peripheral vein to allow injection of the tracer.

FDG Positron emission tomography (PET) scan

Patients will sequentially undergo 68Ga-PSMA and whole-body PET/CT (vertex to thighs, or to feet if known lower-limb metastases).

PSMA Positron emission tomography (PET) scan

In the case a patient would present at least one PSMA-negative/FDG-positive lesion, he will be referred to undertake a whole-body 68Ga-OCTREOTATE PET/CT within 10 days of the first PET/CT. The delay between this third PET scan and the last one should be minimal (not least than 18 hours, not more than 10 days).

Images and data will be reviewed centrally within 4 days by the Imaging Corelab, which will produce a final report confirming patient's eligibility to Radioligand therapy (RLT).

OCTREOTATE Positron emission tomography (PET) scan

Patients presenting FDG-positive/PSMA-negative or Octreotate-positive lesions on imaging will be asked to undergo a biopsy of these lesions (optional) for research purposes. Bone or soft-tissue biopsies will be collected by an interventional radiologist according to site's standard-of-care procedure and sent to the local pathology department for preparation (formalin-fixed and paraffin-embedded); the blocks being sent to the Pathology Corelab.

Optional Bone or soft-tissue biopsies

Brigitte Guérin, Ph.D

Prostate cancer (PCa) is the most common solid organ cancer in North American men. Patients becoming refractory to loco-regional therapy receive androgen deprivation therapy, but their disease will inevitably progress to metastatic castration-resistant prostate cancer (mCRPC). Treatment failure and poor progression-free survival could be explained by the fact that PCa metastases in the same patient may be polyclonal, showing opposite responses to systemic therapies.

This project aims to recruit 100 patients with mCRPC in order to determine the prevalence of intrapatient intermetastasis polyclonality and NED using PET/CT triple-tracer PSMA/FDG/OCTREOTATE imaging and eligibility for either PSMA or OCTREOTATE radioligand therapy (RLT).

Introduction: Prostate cancer (PCa) is the most common solid organ cancer in North American men. Patients becoming refractory to loco-regional therapy receive androgen deprivation therapy, but their disease will inevitably progress to metastatic castration-resistant prostate cancer (mCRPC). Of the five treatments approved for mCRPC patients, none has been shown to increase median overall survival beyond 4.8 months. Treatment failure and poor progression-free survival could be explained by the fact that PCa metastases in the same patient may be polyclonal, showing opposite responses to systemic therapies. Indeed, neuroendocrine differentiation from adenocarcinoma is often reported in metastatic PCa, which is associated with increased disease aggressiveness. Currently, no molecular tools are available to follow non-invasively mCRPC transdifferentiation and diagnose patients with neuroendocrine and/or polyclonal PCa. Positron emission tomography (PET) is a promising type of imaging using radio-labeled tracers to specifically identify tumour cells.

Hypothesis: The hypothesis of the 3TMPO clinical study is that the prevalence of intrapatient intermetastasis polyclonality can be diagnosed by combining 18F-FDG to other specific PET tracers that have the ability to non-invasively differentiate CRPC adenocarcinoma (CRPC-Adeno) (68Ga-PSMA) from neuroendocrine CRPC (CRPC-NE) tumours (68Ga-OCTREOTATE).

Objectives: The study objectives are to determine, in mCRPC patients, the prevalence of intrapatient intermetastasis polyclonality and NED using PET/CT triple tracer PSMA/FDG/OCTREOTATE imaging and their eligibility for radioligand therapy (RLT).

Method: This multicentre observational clinical study, for which prevalence of intrapatient intermetastasis polyclonality was set as the primary outcome, will recruit 100 mCRPC patients at 5 different sites across the province of Québec. 68Ga-PSMA and 18F-FDG PET scans will be performed on all enrolled patients, while 68Ga-OCTREOTATE will be performed on those presenting at least one PSMA-negative/FDG-positive lesion. The uptake of each individual lesion will be assessed for each PET tracer and patients with lesions presenting discordant uptake profiles will be considered as having polyclonal disease. OCTREOTATE-positivity will confirm the presence of CRPC-NE. PSMA or OCTREOTATE positivity of all lesions (or at least those with FDG uptake) will determine the eligibility for PSMA and OCTREOTATE RLT, respectively.

Relevance: Paradigm-shifting diagnostic and therapeutic strategies are urgently needed to improve the survival of patients with PCa and to deepen our understanding of mCRPC progression.

Bone or soft-tissues biopsies or blood samples (optional)

3TMPO (Triple-Tracer Strategy Against Metastatic Prostate Cancer

Triple-tracer Molecular Imaging Using 18F-FDG, 68Ga-PSMA and 68Ga-OCTREOTATE to Characterize Metastatic Castration-resistant Prostate Cancer (mCRPC) and Evaluate Eligibility for Radionuclide Therapies

A patient with at least two lesions with discordant FDG/PSMA/OCTREOTATE multi-tracer imaging phenotypes.

Neuroendocrine lesion DEFINITION: A patient with at least one OCTREOTATE-positive lesion or histopathological features of neuroendocrine differentiation

Eligibility for PSMA RLT is defined as : Having (1) at least one lesion that is PSMA-positive, and (2) no lesion that is PSMA-negative and FDG-positive. Eligibility for Octreotate RLT: Having (1) at least one lesion that is Octreotate-positive, and (2) no lesion that is Octreotate-negative and FDG-positive.

POSITIVE LESION: 18F-FDG, 68Ga-PSMA and 68Ga-OCTREOTATE lesion uptake will be defined as positive if greater than that of the liver \[18,19\]. Using quantitative imaging methods, standardized uptake value ratio (SUVR, i.e. the ratio between lesion uptake (SUVpeak) over liver uptake (SUVmean)) will be obtained for each lesion with each tracer. For a given tracer, lesion positivity is defined as a SUVR equal or superior to 1.5.

Using a Brief Pain Index (BPI) questionnaire. The severity can be expressed through 4 aspects: worst, least, average and now. The pain interference with daily activities can be represented with 7 aspects: general activity, walking, work, mood, enjoyment of life, relationships and sleep.

Using EQ5D questionnaire which use a 5-scale and evaluates 5 aspects: mobility, selfcare, activity, pain, anxiety and global self-evaluation.

using FACT-P questionnaire: with subscale specific for wellbeing on physical, social/family, emotional functional and prostate aspects.

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Efficacy of Ra-223 in PSMA PET Optimally Selected Patients	NCT05924672	Castration-Resi... Metastatic Mali... Stage IVB Prost...	Radium-223 PSMA Positron E... Technetium Tc 9...	18 Years -	University of California, San Francisco
Efficacy of Ra-223 in PSMA PET Optimally Selected Patients	NCT05924672	Castration-Resi... Metastatic Mali... Stage IVB Prost...	Radium-223 PSMA Positron E... Technetium Tc 9...	18 Years -	University of California, San Francisco
Efficacy of Ra-223 in PSMA PET Optimally Selected Patients	NCT05924672	Castration-Resi... Metastatic Mali... Stage IVB Prost...	Radium-223 PSMA Positron E... Technetium Tc 9...	18 Years -	University of California, San Francisco
3TMPO (Triple-Tracer Strategy Against Metastatic Prostate Cancer	NCT04000776	Metastatic Cast...	FDG Positron em... PSMA Positron e... OCTREOTATE Posi... Optional Bone o...	18 Years -	Université de Sherbrooke

Spots Global Cancer Trial Database for psma positron emission tomography (pet) scan