How We Do It: A Multidisciplinary Approach to ¹⁷⁷Lu DOTATATE Peptide Receptor Radionuclide Therapy

Abstract

Lutetium 177 (177 Lu) DOTA-0-Tyr3-Octreotate (DOTATATE) peptide receptor radionuclide therapy (PRRT) is an effective treatment for advanced gastroenteropancreatic neuroendocrine tumors. This review presents a clinical practice workflow that has been successful since 177 Lu DOTATATE PRRT was approved by the U.S. Food and Drug Administration. The workflow relies heavily on the input of a multidisciplinary team and involves a nuclear medicine consultation service, tumor board, and specific preparations in advance of therapy and day-of-therapy procedures. A systematic checklist designed to ensure appropriate selection of treatment candidates and identification of any concerns to address to safely administer PRRT is provided. All patients were evaluated with gallium 68 DOTATATE PET/CT, and in cases of high-grade tumors, they were also evaluated with fluorine 18 fluorodeoxyglucose PET/CT, with imaging findings reviewed as part of the systematic checklist before PRRT. Adverse effects are discussed and imaging follow-up regimens are reviewed, including alternative diagnostic contrast materials. Approaches to multiple challenging patient scenarios are illustrated through case examples. Finally, alternative theranostic radionuclides and treatment strategies are discussed.

High-Contrast Detection of Somatostatin Receptor Subtype-2 for Fluorescence-Guided Surgery

“…To further examine the translational value, we generated an orthotopic tumor model by injecting BON–SSTR2 cells into the pancreas of athymic nude mice . Eight weeks after implantation, we implemented a proposed clinical workflow modeled after the theranostic paradigm that uses 68 Ga-DOTA-TOC (or 68 Ga-DOTA-TATE) as a patient selection tool for patients who may benefit from peptide-receptor radionuclide therapy (Figure A). , We performed PET/CT imaging with 68 Ga-DOTA-TOC to represent preoperative identification of SSTR2+ disease that would potentially benefit from intraoperative imaging with MMC­(FNIR-Tag)-TOC. Abnormal uptake was observed in the abdomen of 4 out of 5 mice (representative mouse shown in Figure B) and suggested tumor development in the pancreas.…”

Preliminary experience with a new institutional tumor board dedicated to patients with neuroendocrine neoplasms

“…The location constraints can be minimized with the use of audiovisual equipment, a necessity turned to reality with the COVID-19 pandemic, without major impact on the function of the TB. Last but not least, additional positive outcomes, such as the quick adoption/standardization of new treatments (in this case PRRT, as seen in other institutions [ 16 ]) or the formation of a common interdepartmental interest group and generation of disease specific publications, presentations and grant submissions cannot be easily calculated and thus are not reportable. However, they are vital for the advancement of knowledge and the evolution of a rare tumor clinic.…”

Molecular imaging in oncology: Current impact and future directions

“…177 Lu‐DOTATATE has rapidly become the targeted radiopharmaceutical therapy archetype whose routine use is forcing nuclear medicine groups in the United States to adopt a more patient‐centered focus, or they risk irrelevance in the current theranostics revolution 114 . With PSMA‐based imaging and therapies on the horizon of regulatory approval (see PSMA‐Targeted Imaging and Therapy, below), the model in which nuclear medicine physicians play a central role in the multidisciplinary care of patients with metastatic cancer 115 is a priority for the field.…”

“…Specifically, we detail techniques in optical and near‐infrared (NIR) imaging, magnetic resonance imaging (MRI), and nuclear medicine techniques, including single‐photon emission computed tomography (SPECT) and positron emission tomography (PET) (Table 1). 4‐119 We also provide specific examples from translational science and cancer clinical care of the utilization of molecular imaging, with a particular focus on the use of these methods to guide and improve patient management. Finally, we delineate the challenges faced by the field and the potential benefits of overcoming them.…”