Radium-223 Dichloride (Xofigo): Targeted Alpha Therapy for Castration-Resistant Prostate Cancer with Bone Metastases

Radium-223 dichloride (Xofigo) is a targeted alpha therapy employed in the treatment of castration-resistant prostate cancer (CRPC) with bone metastases. The agent specifically targets bone metastases, delivering high-energy alpha particles to tumour cells while minimising damage to surrounding normal tissues. Its unique mechanism of action allows for a dual effect: killing cancer cells and providing palliative relief from bone pain.

Castration-Resistant Prostate Cancer (CRPC) signifies a progressive stage of prostate cancer where the disease continues to grow and spread even when the levels of androgens (male hormones) are reduced to very low levels in the body. This stage of cancer is challenging to manage and generally has a poorer prognosis compared to earlier stages. The term “castration-resistant” reflects the cancer’s resistance to treatments that lower testosterone, such as medical or surgical castration.

The transition to castration-resistance involves various complex molecular and genetic changes within prostate cancer cells. These alterations may include the amplification of androgen receptor (AR) signalling, mutations in the AR, increased expression of AR variants, and other bypass mechanisms that enable the cancer to continue growing despite low levels of androgens.

Management of CRPC involves a multidisciplinary approach. The mainstay of treatment has traditionally been chemotherapy; however, several new agents have emerged that show promise in treating CRPC. Among them are novel hormone therapies, immunotherapies, bone-targeted agents, and radiopharmaceuticals like radium-223 dichloride, which specifically targets bone metastases common in CRPC, providing both an anti-tumour effect and palliative relief from bone pain.

From Reactor to Radiopharmacy: The Comprehensive Journey of Radium-223 Dichloride Production for Therapeutic Use

Radium-223 dichloride is generated from a parent nuclide, thorium-227, through a decay process. This decay process involves the following:

Parent Nuclide Production: Thorium-227, the parent nuclide of radium-223, is produced in a nuclear reactor. Thorium-227 is usually generated by neutron bombardment of radium-226 targets.

Decay Process:

  1. Radium-223 is obtained through the decay of thorium-227.
  2. Thorium-227 decays into radium-223 and radon-219 through beta decay.
  3. The half-life of thorium-227 is about 18.7 days, while the half-life of radium-223 is approximately 11.4 days, which is a suitable half-life for therapeutic purposes.

Separation and Purification:

  1. After the decay process, radium-223 dichloride is separated from its parent nuclide and other decay products.
  2. This can be done through a variety of chemical processes, including column chromatography.


  1. Once purified, radium-223 is formulated as radium-223 dichloride, which is a water-soluble salt.
  2. The radium-223 dichloride solution can be administered intravenously to patients.

Quality Control:

  1. Before it’s used in a clinical setting, radium-223 dichloride goes through rigorous quality control tests to ensure it meets the required standards for medical use.

Radiopharmaceutical Production:

  1. The final radium-223 dichloride product is prepared in a radiopharmacy, where it’s formulated into a sterile solution for intravenous administration.
  2. The preparation must be done in compliance with regulatory standards to ensure the safety and efficacy of the treatment.

The generation of radium-223 dichloride is a complex process that requires a controlled environment and adherence to strict regulatory and safety standards to ensure the production of a high-quality therapeutic agent for the treatment of patients with CRPC with bone metastases.

Therapeutic Strategies in CRPC: Radium-223 Dichloride and the Pursuit of Enhanced Patient Outcomes

The goal of treatment in CRPC is to prolong survival, manage symptoms, and maintain a good quality of life. However, the heterogeneity of the disease often necessitates a tailored approach to treatment, taking into consideration the extent of the disease, the presence of metastases, prior treatments, and the patient’s overall health status and preferences.

Ongoing research in understanding the underlying mechanisms of castration resistance and the development of new therapeutic agents is crucial to improving the outlook for patients with CRPC. Early detection and constant monitoring are essential to manage the disease effectively and enhance the outcomes of individuals affected by CRPC.

Clinical trials have demonstrated the efficacy and safety of radium-223 dichloride in extending overall survival and delaying time to the first symptomatic skeletal event in patients with CRPC. The treatment is generally well-tolerated with a manageable safety profile. Side effects may include nausea, diarrhoea, and thrombocytopenia, among others.

ALSYMPCA Trial Insights: Establishing Radium-223 Dichloride as a Pillar in the Multimodal Management of Metastatic Castration-Resistant Prostate Cancer

The ALSYMPCA (ALpharadin in SYMptomatic Prostate CAncer) trial was a pivotal phase 3 clinical study that assessed the efficacy and safety of radium-223 dichloride in patients with metastatic castration-resistant prostate cancer (mCRPC) who had symptomatic bone metastases. Here are key points about the trial:

Trial Enrollment and Design:

  1. The ALSYMPCA trial enrolled patients with mCRPC, with or without baseline opioid use, to assess the efficacy and safety of radium-223 dichloride versus placebo.

Efficacy and Safety:

  1. The findings of the ALSYMPCA trial showed that radium-223 was well-tolerated during treatment and remained so up to three years after each patient’s first injection.
  2. Radium-223 dichloride selectively targeted bone metastases with alpha particles and was evaluated against a placebo, in addition to the best standard of care, in men with mCRPC and bone metastases.


  1. The trial demonstrated that radium-223 dichloride (marketed as Xofigo®) improved overall survival in men with advanced prostate cancer that had spread to their bones, compared with a placebo.

This trial was crucial in establishing radium-223 dichloride as a therapeutic option for patients with mCRPC and symptomatic bone metastases, demonstrating a favourable balance between efficacy and safety.

Radium-223 dichloride is administered intravenously once a month for up to six months, providing patients with a relatively convenient treatment schedule. The integration of this radiopharmaceutical into the treatment paradigm for CRPC with bone metastases has been a significant advancement, offering a new option for patients with this challenging condition.

The use of radium-223 dichloride can be part of a multimodal approach to managing CRPC, potentially in combination with other systemic therapies. Moreover, ongoing research aims to elucidate further the optimal sequencing and combination of radium-223 with other treatments and to explore its efficacy in earlier stages of prostate cancer or different cancer types.


Radium-223 dichloride is a valuable treatment option for patients with castration-CRPC and bone metastases, offering a positive balance between efficacy and safety. Its role in the broader context of prostate cancer treatment continues to evolve with ongoing research aimed at maximizing patient benefits.

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