Purpose

Molecular radiotherapy is a treatment modality that is highly suitable for targeting micrometastases and [¹⁷⁷Lu]Lu-DOTATATE is currently being explored as a potential novel treatment option for high-risk neuroblastoma. p53 is a key player in the proapoptotic signalling in response to radiation-induced DNA damage and is therefore a potential target for radiosensitisation.

Methods

This study investigated the use of the p53 stabilising peptide VIP116 and [¹⁷⁷Lu]Lu-DOTATATE, either alone or in combination, for treatment of neuroblastoma tumour xenografts in mice. Initially, the uptake of [¹⁷⁷Lu]Lu-DOTATATE in the tumours was confirmed, and the efficacy of VIP116 as a monotherapy was evaluated. Subsequently, mice with neuroblastoma tumour xenografts were treated with placebo, VIP116, [¹⁷⁷Lu]Lu-DOTATATE or a combination of both agents.

Results

The results demonstrated that monotherapy with either VIP116 or [¹⁷⁷Lu]Lu-DOTATATE significantly prolonged median survival compared to the placebo group (90 and 96.5 days vs. 50.5 days, respectively). Notably, the combination treatment further improved median survival to over 120 days. Furthermore, the combination group exhibited the highest percentage of complete remission, corresponding to a twofold increase compared to the placebo group. Importantly, none of the treatments induced significant nephrotoxicity. Additionally, the therapies affected various molecular targets involved in critical processes such as apoptosis, hypoxia and angiogenesis.

Conclusion

In conclusion, the combination of VIP116 and [¹⁷⁷Lu]Lu-DOTATATE presents a promising novel treatment approach for neuroblastoma. These findings hold potential to advance research efforts towards a potential cure for this vulnerable patient population.

Photodynamic therapy (PDT) has been used as an alternative or as a complement of conventional approaches for cancer treatment. In PDT, the reactive oxygen species (ROS) produced from the interaction between the photosensitizer (PS), visible light and molecular oxygen, kill malignant cells by triggering a cascade of cytotoxic reactions. In this process, the PS plays an extremely important role in the effectiveness of the therapy. In the present work, a new photoimmunoconjugate (PIC), based on cetuximab and the known third generation PS-glycophthalocyanine ZnPcGal_4, was synthesized via reductive amination. The rationale behind this was the simultaneous cancer-associated specific targeting of PIC and photosensitization of targeted receptor positive cells. Varied reaction parameters and photodynamic conditions, such as PS concentrations and both type and intensities of light, were optimized. ZnPcGal₄ showed significant photoactivity against EGFR expressing A431, EGFR-transfected HCT116 and HT29 cells when irradiated with white light of stronger intensity (38 mW/cm²). Similarly, the synthesized PICs-T1 and T2 also demonstrated photoactivity with high intensity white light. The best optimized PIC: sample 28 showed no precipitation and aggregation when inspected visually and analyzed through SE-HPLC. Fluorescence excitation of sample 28 and ¹²⁵I-sample 28 radioconjugate (¹²⁵I-PIC, ¹²⁵I-radiolabeling yield ≥95%, determined with ITLC) at 660 nm showed presence of appended ZnPcGal₄. In addition, simultaneous fluorescence and radioactivity detection of the ¹²⁵I-PIC in serum and PBS (pH 7.4) for the longest incubated time point of 72 h, respectively, and superimposed signals thereof demonstrated ≥99% of loading and/or labeling yield, assuring overall stability of the PIC and corresponding PIC-radioconjugate w.r.t. both the appended ZnPcGal₄ and bound-¹²⁵I. Moreover, real-time binding analyses on EGFR-transfected HCT116 cells showed specific binding of ¹²⁵I-PIC, suggesting no alternation in the binding kinetics of the mAb after appending it with ZnPcGal₄. These results suggest dual potential applications of synthesized PICs both for PDT and radio-immunotherapy of cancer.

Cancer, a complex disease marked by uncontrolled cell growth, is typically treated with surgery, chemotherapy, radiation therapy and immunotherapy, which can induce significant side effects by affecting healthy tissues. Targeted radionuclide therapy (TRT), where cancer-targeting molecules are equipped with radionuclides to enable cancer-specific radiotherapy, shows promise for treating advanced cancers by addressing both metastatic relapse and heterogeneous tumors. Combining TRT with targeted therapies offers a promising shift towards more effective and less toxic treatments. This thesis focuses on synergistically enhancing the therapeutic efficacy of TRT or chemotherapy through combination strategies with novel drugs that modulate DNA damage and/or interact with the immune system.

In Paper I, we investigated the combination treatment of the chemotherapy drug cisplatin with the heat shock protein 90 (HSP90) inhibitor onalespib in vitro, using ovarian and head and neck cancer cells. Our findings demonstrated that onalespib enhances the therapeutic effects of cisplatin, reducing colony formation and migration, increasing apoptosis, and decreasing DNA damage response (DDR). Key proteins such as ATM, DNA-PKcs, and γH2AX were shown to play crucial roles in the therapeutic efficacy of the combination treatments.

In Papers II and III, we characterized the synergy between the novel radioconjugate, ¹⁷⁷Lu-DOTA-M5A, and onalespib in gastrointestinal cancer models in vitro and in vivo. While ¹⁷⁷Lu-DOTA-M5A exhibited significant cellular uptake and therapeutic efficacy as monotherapy in 3D tumor spheroids and xenografts. The combination exhibited the most pronounced synergistic growth inhibitory effects in both settings with no adverse effects observed in vivo. PARP1 was identified as playing a pivotal role in the therapeutic outcomes.

In Paper IV, we explored combining ¹⁷⁷Lu-DOTA-M5A with PD-1 immune checkpoint blockade in an immunocompetent transgenic mouse model. The radioconjugate demonstrated high tumor uptake and potent therapeutic effects as monotherapy without depleting immune cells within the tumor microenvironment, while PD-1 blockade further enhanced its efficacy by prolonging survival and suppressing tumor growth. CD8⁺ T cells and pro-inflammatory macrophages (M1) were critical for these therapeutic effects and no myelotoxicity was observed with any treatments.

In conclusion, we have investigated various combination treatment approaches aimed at enhancing therapeutic efficacy while mitigating side effects and drug resistance. We have evaluated the feasibility, toxicity, and benefits of these combinations in preclinical settings with promising results, underscoring the potential of integrating TRT into combination therapy.

Further investigation is warranted as an increasing number of TRT and combination therapies are entering clinical trials.

Radioimmunotherapy (RIT) is emerging as an effective treatment for metastatic solid tumors by coupling radionuclides with tumor-targeting molecules, precisely directing radiation to cancer cells while sparing healthy tissue. Carcinoembryonic antigen (CEA) is a promising target for RIT in CEA-expressing cancers, including colorectal cancers (CRCs). Recent studies highlight radiotherapy's role in enhancing the immune response against cancer. Combining RIT with immune checkpoint inhibitors, such as anti-PD-1 antibodies, may further enhance anti-tumor immunity and improve outcomes. This study aimed to investigate, for the first time, the in vivo effects of CEA-targeted RIT using the novel humanized anti-CEA antibody hT84.66-M5A labeled with ¹⁷⁷Lu (¹⁷⁷Lu-DOTA-M5A), combined with PD-1 blockade. Radioconjugate uptake and therapeutic effects were first assessed in vitro using the CRC spheroid model MC38-CEA1. The therapeutic effects of ¹⁷⁷Lu-DOTA-M5A and PD-1 blockade were then evaluated alone or in combination in CEA-transgenic mice bearing CEA-transduced CRC xenografts, with radioconjugate uptake validated in biodistribution studies and visualized via SPECT/CT imaging. Dose-dependent therapeutic effects of ¹⁷⁷Lu-DOTA-M5A were demonstrated in the 3D spheroid model. In vivo studies showed that both ¹⁷⁷Lu-DOTA-M5A and PD-1 antibody monotherapies effectively reduced tumor growth rates compared to the control group, but the combination therapy had the most significant impact. Combination therapy resulted in a dramatic tumor growth inhibition rate of -6% average daily, compared to +7%, +7.9%, and +13.5% in the PD-1 blockade, ¹⁷⁷Lu-DOTA-M5A (2.5 MBq), and control groups, respectively. Median survival increased by 31% in the PD-1 blockade group and by 52% in the ¹⁷⁷Lu-DOTA-M5A (2.5 MBq) group compared to the control group, while median survival was not reached in the corresponding combination group. Radioconjugate monotherapies and combination therapies did not introduce any bone marrow toxicity. ¹⁷⁷Lu-DOTA-M5A slightly altered the immune cell profile in the tumor microenvironment, increasing cytotoxic and helper T cells. Notably, pro-inflammatory macrophages became dominant over tumor-promoting ones in the tumor microenvironment of combination-treated mice. These findings highlight the promise of ¹⁷⁷Lu-DOTA-M5A as a CRC therapeutic agent and its enhanced efficacy when combined with an immune checkpoint inhibitor. Further in vivo studies are needed to fully validate these findings and explore the treatment’s potential for clinical use.

Carcinoembryonic antigen (CEA) is an antigen that is highly expressed in colorectal cancers and widely used as a tumor marker. I-131 and Y-90-radiolabeled anti-CEA monoclonal antibodies (mAbs) have previously been assessed for radioimmunotherapy in early clinical trials with promising results. Moreover, the heat shock protein 90 inhibitor onalespib has previously demonstrated radiotherapy potentiation effects in vivo. In the present study, a Lu-177-radiolabeled anti-CEA hT84.66-M5A mAb (M5A) conjugate was developed and the potential therapeutic effects of Lu-177-DOTA-M5A and/or onalespib were investigated. The Lu-177 radiolabeling of M5A was first optimized and characterized. Binding specificity and affinity of the conjugate were then evaluated in a panel of gastrointestinal cancer cell lines. The effects on spheroid growth and cell viability, as well as molecular effects from treatments, were then assessed in several three-dimensional (3D) multicellular colorectal cancer spheroid models. Stable and reproducible radiolabeling was obtained, with labeling yields above 92%, and stability was retained at least 48 h post-radiolabeling. Antigen-specific binding of the radiolabeled conjugate was demonstrated on all CEA-positive cell lines. Dose-dependent therapeutic effects of both Lu-177-DOTA-M5A and onalespib were demonstrated in the spheroid models. Moreover, effects were potentiated in several dose combinations, where spheroid sizes and viabilities were significantly decreased compared to the corresponding monotherapies. For example, the combination treatment with 350 nM onalespib and 20 kBq Lu-177-DOTA-M5A resulted in 2.5 and 2.3 times smaller spheroids at the experimental endpoint than the corresponding monotreatments in the SNU1544 spheroid model. Synergistic effects were demonstrated in several of the more effective combinations. Molecular assessments validated the therapy results and displayed increased apoptosis in several combination treatments. In conclusion, the combination therapy of anti-CEA Lu-177-DOTA-M5A and onalespib showed enhanced therapeutic effects over the individual monotherapies for the potential treatment of colorectal cancer. Further in vitro and in vivo studies are warranted to confirm the current study findings.

Carcinoembryonic antigen (CEA) has emerged as an attractive target for theranostic applications in colorectal cancers (CRCs). In the present study, the humanized anti-CEA antibody hT84.66-M5A (M5A) was labeled with ¹⁷⁷Lu for potential CRC therapy. Moreover, the novel combination of ¹⁷⁷Lu-DOTA-M5A with the heat shock protein 90 inhibitor onalespib, suggested to mediate radiosensitizing properties, was assessed in vivo for the first time. M5A antibody uptake and therapeutic effects, alone or in combination with onalespib, were assessed in human CRC xenografts and visualized using SPECT/CT imaging. Although both ¹⁷⁷Lu-DOTA-M5A and onalespib monotherapies effectively reduced tumor growth rates, the combination therapy demonstrated the most substantial impact, achieving a fourfold reduction in tumor growth compared to the control group. Median survival increased by 33% compared to ¹⁷⁷Lu-DOTA-M5A alone, and tripled compared to control and onalespib groups. Importantly, combination therapy yielded comparable or superior effects to the double dose of ¹⁷⁷Lu-DOTA-M5A monotherapy. ¹⁷⁷Lu-DOTA-M5A increased apoptotic cell levels, indicating its potential to induce tumor cell death. These findings show promise for ¹⁷⁷Lu-DOTA-M5A as a CRC therapeutic agent, and its combination with onalespib could significantly enhance treatment efficacy. Further in vivo studies are warranted to validate these findings fully and explore the treatment’s potential for clinical use.

Simple summary

Cancer treatment is hampered by the limitations of individual therapy modalities and the intricate nature of the disease. The administration of maximal monotherapy doses often leads to undesirable side effects and/or therapy resistance. As a result, there is a growing recognition of the importance of investigating combination therapy to effectively address these obstacles. In the present in vivo study, the therapeutic effects of combination therapy with the heat shock protein 90 inhibitor onalespib, a potential radiosensitizer, and ¹⁷⁷Lu-DOTA-M5A for colorectal cancer (CRC) treatment were explored for the first time. The results demonstrated that the combination treatment was so effective that retained or even superior therapeutic effects could be achieved with only half the dose of administered ¹⁷⁷Lu-DOTA-M5A, showing enhanced tumor growth suppression and increased apoptosis. Consequently, the combination therapy involving ¹⁷⁷Lu-DOTA-M5A and onalespib constitutes a promising approach for treating metastatic CRCs. By enhancing therapeutic effects, minimizing therapy resistance, and reducing side effects, this approach has the potential to expand the patient population that can benefit from targeted treatment.

Rational Cisplatin based cancer therapy is an affordable and effective standard therapy for several solid cancers, including lung, ovarian and head and neck cancers. However, the clinical use of cisplatin is routinely limited by the development of drug resistance and subsequent therapeutic failure. Therefore, methods of circumventing cisplatin resistance have the potential to increase therapeutic efficiency and dramatically increase overall survival. Cisplatin resistance can be mediated by alterations to the DNA damage response, where multiple components of the repair machinery have been described to be client proteins of HSP90. In the present study, we have investigated whether therapy with the novel HSP90 inhibitor onalespib can potentiate the efficacy of cisplatin and potentially reverse cisplatin resistance in ovarian and head and neck cancer cells. Methods Cell viability, cancer cell proliferation and migration capacity were evaluatedin vitroon models of ovarian and head and neck cancer cells. Western blotting was used to assess the downregulation of HSP90 client proteins and alterations in downstream signaling proteins after exposure to cisplatin and/or onalespib. Induction of apoptosis and DNA damage response were evaluated in both monotherapy and combination therapy groups. Results Results demonstrate that onalespib enhances the efficiency of cisplatin in a dose-dependent manner. Tumor cells treated with both drugs displayed lower viability and a decreased migration rate compared to vehicle-control cells and cells treated with individual compounds. An increase of DNA double strand breaks was observed in both cisplatin and onalespib treated cells. The damage was highest and most persistent in the combination group, delaying the DNA repair machinery. Further, the cisplatin and onalespib co-treated cells had greater apoptotic activity compared to controls. Conclusion The results of this study demonstrate that the reduced therapeutic efficacy of cisplatin due to drug-resistance could be overcome by combination treatment with onalespib. We speculate that the increased apoptotic signaling, DNA damage as well as the downregulation of HSP90 client proteins are important mechanisms promoting increased sensitivity to cisplatin treatment.