2014年6月13日,美国FDA批准Lymphoseek(锝99m tilmanocept)注射剂一种新用途,这款药物是一种放射性诊断影像剂,帮助医生确定鳞状细胞癌已扩散至人体头部及颈部的程度。
Radiolabeling a. Inspect the Tilmanocept Powder vial for any damage. Do not use if vial integrity appears compromised. Do not vent the Tilmanocept Powder vial prior to or during radiolabeling. b. Use Technetium Tc 99m pertechnetate, sodium injection solution from a technetium Tc 99m generator within 8 hours of its elution. c. Using a sterile syringe, aseptically draw approximately 92.5 MBq (2.5 mCi) of Technetium Tc 99m pertechnetate sodium injection solution in either about 0.35 mL volume (for 0.5 mL Reconstituted Vial Volume) or about 0.7 mL volume (for 2.5 mL or 5 mL Reconstituted Vial Volume). Assay the syringe for technetium Tc 99m activity in a dose calibrator. d. Write the radioactivity amount, the Reconstituted Vial Volume, date and time, expiration time and lot number in the space provided on the radioactive product vial label and affix it to the Tilmanocept Powder vial. Place the vial in a radiation shield and sanitize the septum with alcohol wipe. e. Aseptically add Technetium Tc 99m pertechnetate, sodium injection solution to the Tilmanocept Powder vial. Without withdrawing the needle, remove an equal volume of headspace gas. Do not vent. f. Remove the needle, gently shake the vial to mix the contents, and then let it stand at room temperature for at least 15 minutes. Reconstitution g. Aseptically add the supplied DILUENT for Lymphoseek to the radiolabeled product in the Tilmanocept Powder vial to bring the volume to the Reconstituted Vial Volume of 0.5 mL, 2.5 mL, or 5 mL prior to filling the patient dose in syringe(s). To normalize pressure, withdraw an equal volume of headspace gas. h. Each Lymphoseek vial, once radiolabeled and reconstituted, would contain sufficient amount to provide doses for up to four patients when prepared according to the instructions. Quality Control of Radiolabeled Solution i. Assay the reconstituted vial for total radioactivity using a dose calibrator. Write the technetium Tc 99m activity concentration, total volume, assay time and date, expiration time, and lot number on the shield label supplied with the Kit. Affix the label to the shield. j. Determine the radiochemical purity of the radiolabeled product [see Dosage and Administration (2.4)]. Do not use if the radiochemical purity is less than 90%. k. Withdraw the required volume of the radiolabeled product into the required number of syringes. Assay the syringe(s) in a dose calibrator. Write the radioactivity amount, date and time of assay, volume, and expiration time (this is not to exceed 6 hours from preparation time) on the supplied syringe label and affix it to the syringe(s). Duration of Use and Storage of Radiolabeled Solution l. Store the radiolabeled Lymphoseek in radiation shielding at room temperature. m. Use the radiolabeled Lymphoseek within 6 hours of preparation. Discard the unused radiolabeled Lymphoseek. 2.4 Determination of Radiochemical Purity of Radiolabeled Lymphoseek Determine radiochemical purity of the reconstituted radiolabeled Lymphoseek by Instant Thin Layer Chromatography (ITLC) using either Whatman Grade 1, 3MM, 31ET Chr or Biodex 150-001 Red Strips (cellulose chromatography paper) using the following method: a.Mark the chromatographic strip for origin, mid and solvent front lines with a pencil as shown below:
Lymphoseek is intended to supplement palpation, visual inspection, and other procedures important to lymph node mapping and sentinel node biopsy. Intraoperative lymphatic mapping and sentinel node biopsy using gamma detection of Lymphoseek within lymph nodes should be initiated no sooner than 15 minutes following injection. In clinical studies of breast cancer and melanoma, patients also received a concomitant blue dye tracer for comparative detection of lymph nodes. While most lymph nodes were detected with Lymphoseek, some were detected only with the blue dye tracer or only with palpation [see Clinical Studies (14)]. 2.6 Radiation Dosimetry The radiation doses to organs and tissues of a patient weighing 70 kg given 18.5 MBq (0.5 mCi) of Lymphoseek are shown in Table 3. Table 3. Estimated Absorbed Radiation Dose from 18.5 MBq (0.5 mCi) Lymphoseek in Patients with Breast Cancer and Melanoma
b Calculated from data of 18 patients with melanoma who received four intradermal injections of 20 mcg, 100 mcg, and 200 mcg doses of Lymphoseek. Due to the differences in injection sites among patients with melanoma, the injection site was assumed to be the breast for the purposes of this calculation, as it represents the nearest anatomical construct for the skin from the anatomical sites appropriately included in the estimates. 3 DOSAGE FORMS AND STRENGTHS The Kit for preparation of Lymphoseek (technetium Tc 99m tilmanocept) injection is supplied as five Tilmanocept Powder vials each containing 250 mcg tilmanocept and five DILUENT for Lymphoseek vials each containing 4.5 mL of sterile buffered saline. After radiolabeling with technetium Tc 99m, Lymphoseek contains approximately 92.5 MBq (2.5 mCi) and 250 mcg technetium Tc 99m tilmanocept in 0.5 mL to 5 mL total volume. 4 CONTRAINDICATIONS None. 5 WARNINGS AND PRECAUTIONS 5.1 Hypersensitivity Reactions Lymphoseek may pose a risk of hypersensitivity reactions due to its chemical similarity to dextran [see Description (11)]. Serious hypersensitivity reactions have been associated with dextran and modified forms of dextran (such as iron dextran drugs). Before administering Lymphoseek, ask patients about prior hypersensitivity reactions to drugs, especially to dextran and modified forms of dextran. Have resuscitation equipment and trained personnel immediately available at the time of Lymphoseek administration. 5.2 Radiation Risks Any radiation-emitting product may increase the risk for cancer, especially in pediatric patients. Adhere to the dose recommendations and ensure safe handling to minimize the risk for excessive radiation exposure to either patients or health care workers. 6 ADVERSE REACTIONS 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. In open label, single arm clinical trials, 553 patients with either breast cancer, malanoma, or squamous cell carcinoma of the oral cavity, skin, and lip received Lymphoseek. No patients experienced serious adverse reactions. Injection site irritation (4 patients; 0.7%) and pain (1 patient; 0.2%) were reported. 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Pregnancy Category C There are no adequate or well-controlled studies of Lymphoseek in pregnant women. Additionally, animal reproduction studies have not been conducted with technetium Tc 99m tilmanocept. However, all radiopharmaceuticals, including Lymphoseek, have a potential to cause fetal harm. Lymphoseek should be given to a pregnant woman only if the potential benefit justifies the potential risk to the fetus. 8.3 Nursing Mothers It is not known whether technetium Tc 99m tilmanocept is present in human milk. Based on the half-life of technetium Tc 99m, a nursing woman should pump and discard milk for at least 60 hours (ten half-lives) after administration of Lymphoseek. 8.4 Pediatric Use Safety and effectiveness of Lymphoseek in patients less than 18 years of age have not been established. 8.5 Geriatric Use Of the 553 patients enrolled in clinical studies of breast cancer, melanoma, and squamous cell carcinoma (SCC) of oral cavity, skin, and lip, 179 (32%) were aged 65 or older. Review of the clinical data, including evaluation of the frequency of adverse reactions, has not identified differences in safety or efficacy between elderly patients (65 to 90 years of age) and younger patients (18 to 65 years of age). 11 DESCRIPTION Chemical Characteristics The active ingredient in Lymphoseek, a radioactive diagnostic agent, is technetium Tc 99m tilmanocept. Technetium Tc 99m binds to the diethylenetriaminepentaacetic acid (DTPA) moieties of the tilmanocept molecule. Chemically, technetium Tc 99m tilmanocept consists of technetium Tc 99m, dextran 3-[(2-aminoethyl)thio]propyl 17-carboxy-10,13,16-tris(carboxymethyl)-8-oxo-4-thia-7,10,13,16-tetraazaheptadec-1-yl 3-[[2-[[1-imino-2-(D-mannopyranosylthio)ethyl]amino]ethyl]thio]propyl ether complexes. The molecular formula of technetium Tc 99m tilmanocept is [C6H10O5]n.(C19H28N4O9S99mTc)b.(C13H24N2O5S2)c.(C5H11NS)a. It contains 3-8 conjugated DTPA (diethylenetriaminepentaacetic acid) molecules (b); 12-20 conjugated mannose molecules (c) with 0-17 amine side chains (a) remaining free. The calculated average molecular weight of tilmanocept ranges from 15,281 to 23,454 g/mol. Technetium Tc 99m tilmanocept has the following structural formula:
External Radiation The linear mass energy absorption attenuation coefficient for Tc 99m is 18.9 cm-1. The first half-value layer is 0.037 cm of lead (Pb). The use of a 0.25 cm thick standard radiation lead shield will attenuate the radiation emitted by millicurie amounts of technetium Tc 99m by a factor of about 100. A range of values for the relative attenuation of the radiation of technetium Tc 99m that results with various thicknesses of lead shielding are displayed in Table 5. Table 5. Radiation Attenuation by Lead Shielding
Table 6. Physical Decay Chart; Tc 99m, Half-Life of approximately 6 Hours
12.1 Mechanism of Action Lymphoseek (technetium Tc 99m tilmanocept) is a radioactive diagnostic agent. It accumulates in lymphatic tissue and selectively binds to mannose binding receptors (CD206) located on the surface of macrophages and dendritic cells. Technetium Tc 99m tilmanocept is a macromolecule consisting of multiple units of diethylenetriaminepentaacetic acid (DTPA) and mannose, each covalently attached to a 10 kDa dextran backbone. The mannose acts as a ligand for the receptor, and the DTPA serves as a chelating agent for labeling with technetium Tc 99m. 12.2 Pharmacodynamics In in vitro studies, technetium Tc 99m tilmanocept exhibited binding to human mannose binding receptors with a primary binding site affinity of Kd = 2.76 x 10-11 M. In clinical studies, technetium Tc 99m tilmanocept has been detectable in lymph nodes within 10 minutes and up to 30 hours after injection. 12.3 Pharmacokinetics In dose-ranging clinical studies, injection site clearance rates were similar across all Lymphoseek doses (4 to 200 mcg) with a mean elimination rate constant in the range of 0.222 to 0.396/hr, resulting in a drug half-life at the injection site of 1.8 to 3.1 hours. The amount of the accumulated radioactive dose in the liver, kidney, and bladder reached a maximum 1 hour post administration of Lymphoseek and was approximately 1% to 2% of the injected dose in each tissue. 13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Studies to assess the carcinogenicity potential of tilmanocept have not been conducted. Tilmanocept was not mutagenic in vitro in the Ames bacterial mutation assay and in the in vitro mouse lymphoma test, and was negative in the in vivo micronucleus test in mice. Studies on reproductive fertility have not been conducted. 14 CLINICAL STUDIES 14.1 Overview of Clinical Studies The efficacy and safety of Lymphoseek were assessed in three open-label, multicenter, single arm trials of patients with melanoma, breast cancer, or squamous cell carcinoma (SCC) of the oral cavity, skin, and lip (Studies 1, 2, and 3). Prior to the lymph node mapping and sentinel lymph node biopsy procedures, patients had no known regional nodal or metastatic disease by standard clinical staging criteria. In Studies 1 and 2, Lymphoseek was evaluated in patients with breast cancer and melanoma. Diagnostic efficacy for lymphatic mapping was determined by the number of histology-confirmed lymph nodes detected by Lymphoseek and/or the blue dye comparator. Lymphoseek was injected into patients at least 15 minutes prior to initiating lymphatic mapping procedures, and preoperative scintigraphic imaging was performed in 91% of patients. Separately, blue dye was injected shortly prior to initiation of the surgery. Lymphatic mapping was performed intraoperatively using a handheld gamma detection probe followed by excision of lymph nodes identified by Lymphoseek, blue dye, or the surgeon’s visual and palpation examination. The resected lymph nodes were evaluated by histopathology. Lymphoseek localization rate in pathology-positive lymph nodes was also determined. In Study 1, of 179 patients who received Lymphoseek, 94 (53%) had known or suspected breast cancer and 85 (47%) had known or suspected melanoma. The median age was 59 years (range 20 to 90 years) and most (72%) were women. In Study 2, of 153 patients who received Lymphoseek, 77 (50%) had known or suspected breast cancer and 76 (50%) had known or suspected melanoma. The median age was 61 years (range 26 to 88 years) and most (68%) were women. In Study 3, Lymphoseek was evaluated primarily in patients with SCC of the oral cavity (T1-T4a, N0, M0). Diagnostic efficacy was determined by the patient level false negative rate of sentinel lymph node detection by Lymphoseek as confirmed by pathologic assessment of all lymph nodes removed during a planned elective neck dissection (END). Lymphoseek was administered at least 15 minutes prior to the scheduled surgery and preoperative scintigraphic imaging was performed in all patients. Lymphatic mapping was performed intraoperatively using a handheld gamma counter followed by excision of sentinel lymph nodes identified by Lymphoseek. Additional lymph nodes were removed during the END based upon tumor location and surgical practice. All resected lymph nodes (sentinel and non-sentinel) were evaluated for histopathology at the local site. Lymphoseek-identified nodes determined negative for cancer were further evaluated by a central pathology laboratory using additional step sectioning and cytokeratin staining. Of the 85 patients who received Lymphoseek, 79 (93%) had intraoral SCC and 6 (7%) had cutaneous SCC. The median age was 59 years (range 23 to 87 years) and most (75%) were men. 14.2 Lymphoscintigraphy An analysis of the three studies was performed to evaluate the agreement in location of lymph nodes identified by scintigraphic imaging and the handheld gamma counter. At least one scintigraphic “hot spot” was identified in 95% of patients imaged; the percentages were similar across tumor types. Overall, there was 84% agreement on a nodal level (when considering all missing observations as disagreement, as worst case scenario) between the location of preoperative scintigraphic imaging hot spots and the intraoperative lymph node findings (Table 7). Missing observations took the following form: 43 hot spots without corresponding hot nodes and 31 hot nodes without corresponding hot spots. Table 7. Location Agreement between Scintigraphic Imaging and Gamma Counter Findings
Denominator equals total number of hot spots and/or hot nodes. Numerator equals the numbers where hot spots and hot nodes agreed in location.
The percentages may not add to 100% due to rounding. 95% Confidence Intervals (CI) are based on Exact Binomial and represent the individual estimates In Studies 1 and 2 lymphatic mapping was performed in 328 patients with melanoma or breast cancer. The overall rate of lymph node detection by Lymphoseek at the patient level was 97% (319/328). The average number of lymph nodes detected by Lymphoseek was approximately 2 per patient. In Study 3 lymphatic mapping was performed in 83 patients with SCC of the oral cavity. The rate of lymph node detection by Lymphoseek at the patient level was 98% (81/83) with a 95% confidence interval of 92% to 100%. The average number of lymph nodes identified was 4 per patient. 14.4 Guiding Sentinel Lymph Node Biopsy In Study 3 in patients with SCC of the oral cavity (n=79), skin (n=5), and lip (n=1), pathology findings for Lymphoseek-identified nodes (sentinel lymph nodes) were compared to the pathology findings of all other lymph nodes removed during the scheduled elective node dissection to determine the false negative rate of Lymphoseek. Thirty-nine patients were determined to have pathology-positive regional lymph nodes. In these patients, the Lymphoseek false negative rate for detecting patients with cancer-positive nodes was 2.6% (95% CI: 0.06% to 13.5%). In this study the pathology-positive nodes were all found in patients with SCC of the oral cavity. Supportive analyses were conducted in Studies 1 and 2 in patients with breast cancer or melanoma. The presence or absence of Lymphoseek in nodes resected from patients determined by pathology staging to have lymphatic spread of cancer (n=64) was evaluated. The overall patient level rate for identifying at least one cancer-positive node in these pathology-positive patients (both cancers combined) was 97%. Lymphoseek identified 27 out of 29 node positive breast cancer patients and all of the 35 node positive melanoma patients. 16 HOW SUPPLIED/STORAGE AND HANDLING The Kit for the Preparation of Lymphoseek (technetium Tc 99m tilmanocept) injection includes: Five vials of Tilmanocept Powder, 250 mcg (NDC 52579-1695-1) Five vials of DILUENT for Lymphoseek (NDC 52579-1649-1) Prescribing information Five labels for shields Twenty-five labels for product vials and individual syringes Storage Store Kit for the preparation of Lymphoseek (technetium Tc 99m tilmanocept) injection in the original packaging at USP controlled room temperature 20oC - 25oC (68oF - 77oF), excursions permitted to 15°C to 30°C (59°F to 86°F). Store radiolabeled Lymphoseek in radiation shielding at room temperature. Use radiolabeled Lymphoseek within 6 hours of preparation. Handling This Kit for the preparation of Lymphoseek (technetium Tc 99m tilmanocept) injection is approved for distribution to persons licensed by the U.S. Nuclear Regulatory Commission to use by product material identified in 10 CFR 35.200 or under an equivalent license issued by an Agreement State. 17 PATIENT COUNSELING INFORMATION Advise patients to seek medical attention for reactions following injection of Lymphoseek such as difficulty breathing, skin rash, or other allergy manifestations. Inform nursing women to pump and discard milk for at least 60 hours following administration of Lymphoseek injection [see Use in Specific Populations (8.3)]. Distributed by: Navidea Biopharmaceuticals, Inc., Dublin, OH 43017 Lymphoseek is a registered trademark of Navidea Biopharmaceuticals, Inc. Revision date: 9/2014 |
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LYMPHOSEEK KIT(TECHNETIUM TC-99M TILMANOCEPT)INJECTION简介:
2014年6月13日,美国FDA批准Lymphoseek(锝99m tilmanocept)注射剂一种新用途,这款药物是一种放射性诊断影像剂,帮助医生确定鳞状细胞癌已扩散至人体头部及颈部的程度。2013年,Lymphoseek被批准用来帮 ... 责任编辑:admin
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