Will 177Lu-DOTATATE Treatment Become More Effective in Salvage Meningioma Patients, When Boosting Somatostatin Receptor Saturation? A Promising Case on Intra-arterial Administration
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Somatostatin receptor subtype 2 upregulation is very common in meningiomas, and the use of peptide receptor radionuclide therapy (PRRT) is recognized in recent European guidelines, with long-term stable disease and a long overall survival. Treatment efficacy of radionuclide treatments is correlated with tumour radiation absorbed dose. Meningioma patients with low tumour uptake might benefit less from treatment. Thus, a method to increase tumour uptake in these patients is needed. We describe a case treated with both intravenous and intra-arterial PRRT. Tumour uptake after intravenous PRRT was disappointing, and after intra-arterial administration significantly increased tumour uptake was seen. Patient had a partial response on imaging and reduction in tumour-related complaints. Potentially, intra-arterial administration of PRRT could increase treatment efficacy in meningioma patients.
Level of Evidence 5 (case report).
KeywordsPRRT Lu-177-HA-DOTATATE Meningioma Neuro-oncology
Somatostatin receptor subtype 2 (SSTR2) upregulation is very common in meningiomas. The potential of peptide receptor radionuclide therapy (PRRT) was recognized in recent European guidelines on meningioma . The only currently available phase 2 prospective trial describing 34 patients showed long-term stable disease in 65.6% and a mean overall survival (OS) of 8.6 years. Looking at pre-treatment SSTR2 expression on imaging with indium-111-pentetreotide, the authors mentioned that on pre-treatment imaging, patients with high tumour uptake did better than those with low or intermediate uptake . More recently, a case series study in 20 salvage meningioma patients found similar results . Stable disease in 50% and median OS was not reached at a median follow-up period of 20 months. WHO I and II patients did better than WHO III patients, with stable disease after treatment in 100%, 57% and 13%, respectively. Notably, SSTR2 expression on gallium-68-DOTATOC PET imaging was significantly lower in WHO III meningiomas compared to WHO I/II meningiomas . According to these two studies, treatment efficacy is related to SSTR2a expression. Logically, increased tumour uptake of the radiopharmaceutical results in a higher radiation absorbed dose. As expression of the somatostatin receptor in tumours cannot be increased, can we increase tumour uptake via other means and thereby increase treatment efficacy? Significantly increased uptake and objective response rates have been described in intra-arterial administration of PRRT in the hepatic artery of patient with neuroendocrine tumour as compared to intravenous administration . We hypothesized that intra-arterial administration could be feasible in meningiomas as well, with increased efficacy compared to the intravenous route.
Based on this experience, intra-arterial PRRT might be a promising new treatment for meningioma patients’ refractory to conventional treatments. Similar to the initial findings on hepatic infusion of PRRT in neuroendocrine tumours, increasing the tumour absorbed dose via a selective intra-arterial injection may be possible. Additionally, as in this case, complaints/epileptic seizures caused by the tumour could be palliated effectively, increasing the patients’ quality of life. The short- and long-term toxicity profile of this treatment is expected to be similar as PRRT for neuroendocrine tumours (temporary bone marrow suppression, nausea and fatigue), as the radiopharmaceutical is a targeted agent . Available literature on PRRT in meningioma is sparse, but promising. A combination of both stereotactic external radiation therapy and PRRT (combining high and low dose rate irradiation) seems to be safe and effective as well . Future prospective studies on intra-arterial administration of PRRT (and potentially the combination with external radiation therapy) are needed to determine the safety and the long-term efficacy of this therapeutic modality in meningioma.
Intra-arterial administration of PRRT might be a promising new treatment for meningioma patients’ refractory to conventional treatments.
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Conflict of interest
The authors declare that they have no conflict of interest.
Informed consent was obtained from the patient for the treatments described in the manuscript.
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Consent for publication was obtained from the patient described in the manuscript.
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