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Translational imaging of the fibroblast activation protein (FAP) using the new ligand [ 68Ga]Ga-OncoFAP-DOTAGA. Eur J Nucl Med Mol Imaging 2021; 49:1822-1832. [PMID: 34957527 PMCID: PMC9016025 DOI: 10.1007/s00259-021-05653-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/06/2021] [Indexed: 01/12/2023]
Abstract
PURPOSE The fibroblast activation protein (FAP) is an emerging target for molecular imaging and therapy in cancer. OncoFAP is a novel small organic ligand for FAP with very high affinity. In this translational study, we establish [68Ga]Ga-OncoFAP-DOTAGA (68Ga-OncoFAP) radiolabeling, benchmark its properties in preclinical imaging, and evaluate its application in clinical PET scanning. METHODS 68Ga-OncoFAP was synthesized in a cassette-based fully automated labeling module. Lipophilicity, affinity, and serum stability of 68Ga-OncoFAP were assessed by determining logD7.4, IC50 values, and radiochemical purity. 68Ga-OncoFAP tumor uptake and imaging properties were assessed in preclinical dynamic PET/MRI in murine subcutaneous tumor models. Finally, biodistribution and uptake in a variety of tumor types were analyzed in 12 patients based on individual clinical indications that received 163 ± 50 MBq 68Ga-OncoFAP combined with PET/CT and PET/MRI. RESULTS 68Ga-OncoFAP radiosynthesis was accomplished with high radiochemical yields. Affinity for FAP, lipophilicity, and stability of 68Ga-OncoFAP measured are ideally suited for PET imaging. PET and gamma counting-based biodistribution demonstrated beneficial tracer kinetics and high uptake in murine FAP-expressing tumor models with high tumor-to-blood ratios of 8.6 ± 5.1 at 1 h and 38.1 ± 33.1 at 3 h p.i. Clinical 68Ga-OncoFAP-PET/CT and PET/MRI demonstrated favorable biodistribution and kinetics with high and reliable uptake in primary cancers (SUVmax 12.3 ± 2.3), lymph nodes (SUVmax 9.7 ± 8.3), and distant metastases (SUVmax up to 20.0). CONCLUSION Favorable radiochemical properties, rapid clearance from organs and soft tissues, and intense tumor uptake validate 68Ga-OncoFAP as a powerful alternative to currently available FAP tracers.
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Hu K, Wang L, Wu H, Huang S, Tian Y, Wang Q, Xiao C, Han Y, Tang G. [ 18F]FAPI-42 PET imaging in cancer patients: optimal acquisition time, biodistribution, and comparison with [ 68Ga]Ga-FAPI-04. Eur J Nucl Med Mol Imaging 2021; 49:2833-2843. [PMID: 34893920 DOI: 10.1007/s00259-021-05646-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/30/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE [18F]FAPI-42 is a new fibroblast activation protein (FAP)-specific tracer used for cancer imaging. Here, we describe the optimal acquisition time and in vivo evaluation of [18F]FAPI-42 and compared intra-individual biodistribution, tumor uptake, and detection ability to [68Ga]Ga-FAPI-04. METHODS A total of 22 patients with various types of cancer received [18F]FAPI-42 whole-body positron emission tomography/computed tomography (PET/CT). Among them, 4 patients underwent PET/CT scans, including an early dynamic 20-min, static 1-h, and static 2-h scans. The in vivo biodistribution in normal organs and tumor uptake were semiquantitatively evaluated using the standardized uptake value (SUV) and tumor-to-background ratio (TBR). Furthermore, both [18F]FAPI-42 and [68Ga]Ga-FAPI-04 PET/CT were performed in 12 patients to compare biodistribution, tumor uptake, and tumor detection ability. RESULTS [18F]FAPI-42 uptake in the tumors was rapid and reached a high level with an average SUVmax of 15.8 at 18 min, which stayed at a similarly high level to 2 h. The optimal image acquisition time for [18F]FAPI-42 was determined to be 1 h postinjection. For tumor detection, [18F]FAPI-42 had a high uptake and could be clearly visualized in the lesions. Compared to [68Ga]Ga-FAPI-04, [18F]FAPI-42 had the same detectability for 144 positive lesions. In addition, [18F]FAPI-42 showed a higher SUVmax in liver and bone lesions (P < 0.05) and higher TBRs in liver, bone, lymph node, pleura, and peritoneal lesions (all P < 0.05). CONCLUSION The present study demonstrates that the optimal image acquisition time of [18F]FAPI-42 is 1 h postinjection and that [18F]FAPI-42 exhibits comparable lesion detectability to [68Ga]Ga-FAPI-04. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR2100045757).
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Affiliation(s)
- Kongzhen Hu
- Department of Nuclear Medicine, The First School of Clinical Medicine, Guangdong Province, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, China
| | - Lijuan Wang
- Department of Nuclear Medicine, The First School of Clinical Medicine, Guangdong Province, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, China
| | - Hubing Wu
- Department of Nuclear Medicine, The First School of Clinical Medicine, Guangdong Province, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, China
| | - Shun Huang
- Department of Nuclear Medicine, The First School of Clinical Medicine, Guangdong Province, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, China
| | - Ying Tian
- Department of Nuclear Medicine, The First School of Clinical Medicine, Guangdong Province, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, China
| | - Qiaoyu Wang
- Department of Nuclear Medicine, The First School of Clinical Medicine, Guangdong Province, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, China
| | - Caixia Xiao
- Department of Nuclear Medicine, The First School of Clinical Medicine, Guangdong Province, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, China
| | - Yanjiang Han
- Department of Nuclear Medicine, The First School of Clinical Medicine, Guangdong Province, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, China.
| | - Ganghua Tang
- Department of Nuclear Medicine, The First School of Clinical Medicine, Guangdong Province, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, China.
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Poels TT, Vuijk FA, de Geus-Oei LF, Vahrmeijer AL, Oprea-Lager DE, Swijnenburg RJ. Molecular Targeted Positron Emission Tomography Imaging and Radionuclide Therapy of Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2021; 13:6164. [PMID: 34944781 PMCID: PMC8699493 DOI: 10.3390/cancers13246164] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/01/2021] [Accepted: 12/05/2021] [Indexed: 12/15/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) has an inauspicious prognosis, mainly due to difficulty in early detection of the disease by the current imaging modalities. The upcoming development of tumour-specific tracers provides an alternative solution for more accurate diagnostic imaging techniques for staging and therapy response monitoring. The future goal to strive for, in a patient with PDAC, should definitely be first to receive a diagnostic dose of an antibody labelled with a radionuclide and to subsequently receive a therapeutic dose of the same labelled antibody with curative intent. In the first part of this paper, we summarise the available evidence on tumour-targeted diagnostic tracers for molecular positron emission tomography (PET) imaging that have been tested in humans, together with their clinical indications. Tracers such as radiolabelled prostate-specific membrane antigen (PSMA)-in particular, 18F-labelled PSMA-already validated and successfully implemented in clinical practice for prostate cancer, also seem promising for PDAC. In the second part, we discuss the theranostic applications of these tumour-specific tracers. Although targeted radionuclide therapy is still in its infancy, lessons can already be learned from early publications focusing on dose fractioning and adding a radiosensitiser, such as gemcitabine.
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Affiliation(s)
- Thomas T. Poels
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
| | - Floris A. Vuijk
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (F.A.V.); (A.L.V.)
| | - Lioe-Fee de Geus-Oei
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands;
| | - Alexander L. Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (F.A.V.); (A.L.V.)
| | - Daniela E. Oprea-Lager
- Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
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van Dam MA, Vuijk FA, Stibbe JA, Houvast RD, Luelmo SAC, Crobach S, Shahbazi Feshtali S, de Geus-Oei LF, Bonsing BA, Sier CFM, Kuppen PJK, Swijnenburg RJ, Windhorst AD, Burggraaf J, Vahrmeijer AL, Mieog JSD. Overview and Future Perspectives on Tumor-Targeted Positron Emission Tomography and Fluorescence Imaging of Pancreatic Cancer in the Era of Neoadjuvant Therapy. Cancers (Basel) 2021; 13:6088. [PMID: 34885196 PMCID: PMC8656821 DOI: 10.3390/cancers13236088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/25/2021] [Accepted: 11/28/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Despite recent advances in the multimodal treatment of pancreatic ductal adenocarcinoma (PDAC), overall survival remains poor with a 5-year cumulative survival of approximately 10%. Neoadjuvant (chemo- and/or radio-) therapy is increasingly incorporated in treatment strategies for patients with (borderline) resectable and locally advanced disease. Neoadjuvant therapy aims to improve radical resection rates by reducing tumor mass and (partial) encasement of important vascular structures, as well as eradicating occult micrometastases. Results from recent multicenter clinical trials evaluating this approach demonstrate prolonged survival and increased complete surgical resection rates (R0). Currently, tumor response to neoadjuvant therapy is monitored using computed tomography (CT) following the RECIST 1.1 criteria. Accurate assessment of neoadjuvant treatment response and tumor resectability is considered a major challenge, as current conventional imaging modalities provide limited accuracy and specificity for discrimination between necrosis, fibrosis, and remaining vital tumor tissue. As a consequence, resections with tumor-positive margins and subsequent early locoregional tumor recurrences are observed in a substantial number of patients following surgical resection with curative intent. Of these patients, up to 80% are diagnosed with recurrent disease after a median disease-free interval of merely 8 months. These numbers underline the urgent need to improve imaging modalities for more accurate assessment of therapy response and subsequent re-staging of disease, thereby aiming to optimize individual patient's treatment strategy. In cases of curative intent resection, additional intra-operative real-time guidance could aid surgeons during complex procedures and potentially reduce the rate of incomplete resections and early (locoregional) tumor recurrences. In recent years intraoperative imaging in cancer has made a shift towards tumor-specific molecular targeting. Several important molecular targets have been identified that show overexpression in PDAC, for example: CA19.9, CEA, EGFR, VEGFR/VEGF-A, uPA/uPAR, and various integrins. Tumor-targeted PET/CT combined with intraoperative fluorescence imaging, could provide valuable information for tumor detection and staging, therapy response evaluation with re-staging of disease and intraoperative guidance during surgical resection of PDAC. METHODS A literature search in the PubMed database and (inter)national trial registers was conducted, focusing on studies published over the last 15 years. Data and information of eligible articles regarding PET/CT as well as fluorescence imaging in PDAC were reviewed. Areas covered: This review covers the current strategies, obstacles, challenges, and developments in targeted tumor imaging, focusing on the feasibility and value of PET/CT and fluorescence imaging for integration in the work-up and treatment of PDAC. An overview is given of identified targets and their characteristics, as well as the available literature of conducted and ongoing clinical and preclinical trials evaluating PDAC-targeted nuclear and fluorescent tracers.
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Affiliation(s)
- Martijn A. van Dam
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Floris A. Vuijk
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Judith A. Stibbe
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Ruben D. Houvast
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Saskia A. C. Luelmo
- Department of Medical Oncology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Stijn Crobach
- Department of Pathology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | | | - Lioe-Fee de Geus-Oei
- Department of Radiology, Section of Nuclear Medicine, University Medical Center Leiden, 2333 ZA Leiden, The Netherlands;
- Biomedical Photonic Imaging Group, University of Twente, 7522 NB Enschede, The Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Cornelis F. M. Sier
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
- Percuros B.V., 2333 CL Leiden, The Netherlands
| | - Peter J. K. Kuppen
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | | | - Albert D. Windhorst
- Department of Radiology, Section of Nuclear Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands;
| | - Jacobus Burggraaf
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
- Centre for Human Drug Research, 2333 CL Leiden, The Netherlands
| | - Alexander L. Vahrmeijer
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
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Kuyumcu S, Sanli Y, Subramaniam RM. Fibroblast-Activated Protein Inhibitor PET/CT: Cancer Diagnosis and Management. Front Oncol 2021; 11:758958. [PMID: 34858834 PMCID: PMC8632139 DOI: 10.3389/fonc.2021.758958] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 10/18/2021] [Indexed: 01/13/2023] Open
Abstract
Fibroblast activation protein (FAP), overexpressed on cancer-associated fibroblasts (CAFs), is a novel target for molecular imaging of various tumors. Recently, the development of several small-molecule FAP inhibitors for radiolabeling with 68Ga has resulted in the emergence of studies evaluating its clinical role in cancer imaging. Preliminary findings have demonstrated that, in contrast to radiotracers taking advantage of cancer-specific targets such as PSMA and DOTATATE, FAPs as a target are the most promising that can compete with 18FDG in terms of widespread indications. They also have the potential to overcome the shortcomings of 18FDG, particularly false-positive uptake due to inflammatory or infectious processes, low sensitivity in certain cancer types, and radiotherapy planning. In addition, the attractive theranostic properties may facilitate the treatment of many refractory cancers. This review summarizes the current FAP variants and related clinical studies, focusing on radiopharmacy, dosimetry, and diagnostic and theranostic applications.
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Affiliation(s)
- Serkan Kuyumcu
- Department of Nuclear Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yasemin Sanli
- Department of Nuclear Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Rathan M. Subramaniam
- Otago Medical School, University of Otago, Dunedin, New Zealand
- Department of Radiology, Duke University, Durham, NC, United States
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Tatekawa S, Ofusa K, Chijimatsu R, Vecchione A, Tamari K, Ogawa K, Ishii H. Methylosystem for Cancer Sieging Strategy. Cancers (Basel) 2021; 13:5088. [PMID: 34680237 PMCID: PMC8534198 DOI: 10.3390/cancers13205088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 10/02/2021] [Accepted: 10/07/2021] [Indexed: 12/14/2022] Open
Abstract
As cancer is a genetic disease, methylation defines a biologically malignant phenotype of cancer in the association of one-carbon metabolism-dependent S-adenosylmethionine (SAM) as a methyl donor in each cell. Methylated substances are involved in intracellular metabolism, but via intercellular communication, some of these can also be secreted to affect other substances. Although metabolic analysis at the single-cell level remains challenging, studying the "methylosystem" (i.e., the intercellular and intracellular communications of upstream regulatory factors and/or downstream effectors that affect the epigenetic mechanism involving the transfer of a methyl group from SAM onto the specific positions of nucleotides or other metabolites in the tumor microenvironment) and tracking these metabolic products are important research tasks for understanding spatial heterogeneity. Here, we discuss and highlight the involvement of RNA and nicotinamide, recently emerged targets, in SAM-producing one-carbon metabolism in cancer cells, cancer-associated fibroblasts, and immune cells. Their significance and implications will contribute to the discovery of efficient methods for the diagnosis of and therapeutic approaches to human cancer.
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Affiliation(s)
- Shotaro Tatekawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Yamadaoka 2-2, Osaka 565-0871, Japan; (S.T.); (K.T.)
| | - Ken Ofusa
- Department of Medical Data Science, Center of Medical Innovation and Translational Research, Osaka University Graduate School of Medicine, Suita, Yamadaoka 2-2, Osaka 565-0871, Japan; (K.O.); (R.C.)
- Food and Life-Science Laboratory, Prophoenix Division, Idea Consultants, Inc., Osaka 559-8519, Japan
| | - Ryota Chijimatsu
- Department of Medical Data Science, Center of Medical Innovation and Translational Research, Osaka University Graduate School of Medicine, Suita, Yamadaoka 2-2, Osaka 565-0871, Japan; (K.O.); (R.C.)
| | - Andrea Vecchione
- Department of Clinical and Molecular Medicine, University of Rome “Sapienza”, Santo Andrea Hospital, Via di Grottarossa, 1035-00189 Rome, Italy;
| | - Keisuke Tamari
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Yamadaoka 2-2, Osaka 565-0871, Japan; (S.T.); (K.T.)
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Yamadaoka 2-2, Osaka 565-0871, Japan; (S.T.); (K.T.)
| | - Hideshi Ishii
- Department of Medical Data Science, Center of Medical Innovation and Translational Research, Osaka University Graduate School of Medicine, Suita, Yamadaoka 2-2, Osaka 565-0871, Japan; (K.O.); (R.C.)
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Kessler L, Ferdinandus J, Hirmas N, Zarrad F, Nader M, Kersting D, Weber M, Kazek S, Sraieb M, Hamacher R, Lueckerath K, Umutlu L, Fendler WP, Rischpler C. Pitfalls and common findings in 68Ga-FAPI-PET - A pictorial analysis. J Nucl Med 2021; 63:890-896. [PMID: 34620730 DOI: 10.2967/jnumed.121.262808] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/20/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Fibroblast activation protein inhibitor positron emission tomography (FAPI-PET) is a new tool in the diagnostic workup of cancer. With growing volume of applications pitfalls and common findings need to be considered for Ga-68-FAPI-PET image interpretation. The aim of this study was to summarize common findings and report pitfalls in Ga-68-FAPI-PET. Methods and materials: 91 patients underwent whole-body PET/CT with either FAPI-04 (N = 25) or FAPI-46 (N = 66). Findings were rated in a consensus session of two experienced readers. Pitfalls and common findings were defined as focal or localized uptake above background and categorized as unspecific / non-malignant and grouped into degenerative, muscular, scarring / wound-healing, uterine, mammary glands and head-and-neck findings. Frequency of findings was reported on a per-patient and per-group basis and SUVmax, SUVmean and SUVpeak was measured. Results: Non-tumor specific tracer uptake was found in 81.3 % of patients. The most frequent finding was tracer uptake in degenerative lesions (51.6%) with mean SUVmax 7.7 ± 2.9 and head-and-neck (45.1%) findings. Except for salivary glands, the uptake values did not differ between 10 and 60 min p.i. in most findings. Uterine uptake was found in most women (66.7%) with mean SUVmax 12.2 ± 7.3 and uptake correlated negatively with age (SUVmax r = -0.6, p<0.01; SUVpeak r = -0.57, p<0.01; SUVmean r = -0.58, p<0.01). Conclusion: Pitfalls include non-tumor specific Ga-68-FAPI uptake in degenerative lesions, muscle, head-and-neck, scarring, mammary glands or uterus. Here we summarize findings to inform readers at centers introducing Ga-68-FAPI-PET to avoid common mistakes.
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Affiliation(s)
- Lukas Kessler
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Justin Ferdinandus
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Nader Hirmas
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Fadi Zarrad
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Michael Nader
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Germany
| | - David Kersting
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Manuel Weber
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Sandra Kazek
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Miriam Sraieb
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Rainer Hamacher
- Department of Medical Oncology, University Hospital Essen, University of Duisburg-Essen
| | - Katharina Lueckerath
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Lale Umutlu
- Institute of Diagnostic and Interventional Radiology, University of Duisburg-Essen
| | - Wolfgang P Fendler
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Christoph Rischpler
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Germany
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Imlimthan S, Moon ES, Rathke H, Afshar-Oromieh A, Rösch F, Rominger A, Gourni E. New Frontiers in Cancer Imaging and Therapy Based on Radiolabeled Fibroblast Activation Protein Inhibitors: A Rational Review and Current Progress. Pharmaceuticals (Basel) 2021; 14:1023. [PMID: 34681246 PMCID: PMC8540221 DOI: 10.3390/ph14101023] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 09/29/2021] [Accepted: 09/29/2021] [Indexed: 12/13/2022] Open
Abstract
Over the past decade, the tumor microenvironment (TME) has become a new paradigm of cancer diagnosis and therapy due to its unique biological features, mainly the interconnection between cancer and stromal cells. Within the TME, cancer-associated fibroblasts (CAFs) demonstrate as one of the most critical stromal cells that regulate tumor cell growth, progression, immunosuppression, and metastasis. CAFs are identified by various biomarkers that are expressed on their surfaces, such as fibroblast activation protein (FAP), which could be utilized as a useful target for diagnostic imaging and treatment. One of the advantages of targeting FAP-expressing CAFs is the absence of FAP expression in quiescent fibroblasts, leading to a controlled targetability of diagnostic and therapeutic compounds to the malignant tumor stromal area using radiolabeled FAP-based ligands. FAP-based radiopharmaceuticals have been investigated strenuously for the visualization of malignancies and delivery of theranostic radiopharmaceuticals to the TME. This review provides an overview of the state of the art in TME compositions, particularly CAFs and FAP, and their roles in cancer biology. Moreover, relevant reports on radiolabeled FAP inhibitors until the year 2021 are highlighted-as well as the current limitations, challenges, and requirements for those radiolabeled FAP inhibitors in clinical translation.
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Affiliation(s)
- Surachet Imlimthan
- Department of Nuclear Medicine, the Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland; (S.I.); (H.R.); (A.A.-O.); (A.R.)
| | - Euy Sung Moon
- Department of Chemistry—TRIGA Site, Johannes Gutenberg—University Mainz, 55128 Mainz, Germany; (E.S.M.); (F.R.)
| | - Hendrik Rathke
- Department of Nuclear Medicine, the Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland; (S.I.); (H.R.); (A.A.-O.); (A.R.)
| | - Ali Afshar-Oromieh
- Department of Nuclear Medicine, the Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland; (S.I.); (H.R.); (A.A.-O.); (A.R.)
| | - Frank Rösch
- Department of Chemistry—TRIGA Site, Johannes Gutenberg—University Mainz, 55128 Mainz, Germany; (E.S.M.); (F.R.)
| | - Axel Rominger
- Department of Nuclear Medicine, the Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland; (S.I.); (H.R.); (A.A.-O.); (A.R.)
| | - Eleni Gourni
- Department of Nuclear Medicine, the Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland; (S.I.); (H.R.); (A.A.-O.); (A.R.)
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Ghidini M, Vuozzo M, Galassi B, Mapelli P, Ceccarossi V, Caccamo L, Picchio M, Dondossola D. The Role of Positron Emission Tomography/Computed Tomography (PET/CT) for Staging and Disease Response Assessment in Localized and Locally Advanced Pancreatic Cancer. Cancers (Basel) 2021; 13:4155. [PMID: 34439307 PMCID: PMC8394552 DOI: 10.3390/cancers13164155] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/03/2021] [Accepted: 08/16/2021] [Indexed: 11/25/2022] Open
Abstract
Pancreatic Cancer (PC) has a poor prognosis, with a 5-year survival rate of only 9%. Even after radical surgical procedures, PC patients have poor survival rates, with a high chance of relapse (70-80%). Imaging is involved in all aspects of the clinical management of PC, including detection and characterization of primary tumors and their resectability, assessment of vascular, perineural and lymphatic invasion and detection of distant metastases. The role of Positron Emission Tomography/Computed Tomography (PET/CT) in detecting PC is still controversial, with the international guidelines not recommending its routine use. However, in resectable PC, PET/CT may play a role in assessing PC stage and grade and potential resectability after neoadjuvant treatment. Quantitative image analysis (radiomics) and new PET/CT radiotracers account for future developments in metabolic imaging and may further improve the relevance of this technique in several aspects of PC. In the present review, the current state of the art and future directions of PET/CT in resectable PC are presented.
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Affiliation(s)
- Michele Ghidini
- Operative Unit of Oncology, Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Marta Vuozzo
- Werner Siemens Imaging Center, Department of Preclinical Imaging and Radiopharmacy, Eberhard Karls Universität Tübingen, 72076 Tübingen, Germany;
- University Medical Center, Eberhard Karls University Tübingen, 72074 Tübingen, Germany
| | - Barbara Galassi
- Operative Unit of Oncology, Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Paola Mapelli
- Vita-Salute San Raffaele University, 20132 Milan, Italy; (P.M.); (M.P.)
- Nuclear Medicine Department, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Virginia Ceccarossi
- Dipartimento di Chirurgia Generale e dei Trapianti di Fegato, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (V.C.); (L.C.); (D.D.)
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, 20122 Milan, Italy
| | - Lucio Caccamo
- Dipartimento di Chirurgia Generale e dei Trapianti di Fegato, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (V.C.); (L.C.); (D.D.)
| | - Maria Picchio
- Vita-Salute San Raffaele University, 20132 Milan, Italy; (P.M.); (M.P.)
- Nuclear Medicine Department, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Daniele Dondossola
- Dipartimento di Chirurgia Generale e dei Trapianti di Fegato, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (V.C.); (L.C.); (D.D.)
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, 20122 Milan, Italy
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Safi SA, Rehders A, Haeberle L, Fung S, Lehwald N, Esposito I, Ziayee F, Krieg A, Knoefel WT, Fluegen G. Para-aortic lymph nodes and ductal adenocarcinoma of the pancreas: Distant neighbors? Surgery 2021; 170:1807-1814. [PMID: 34392977 DOI: 10.1016/j.surg.2021.06.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/07/2021] [Accepted: 06/24/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Para-aortic lymph nodes in the ductal adenocarcinoma of the pancreatic head are regarded as distant metastases. Chemotherapy is considered the only treatment option if para-aortic lymph nodes metastases are detected preoperatively or intraoperatively. The role of standardized para-aortic lymph node lymphadenectomy during pancreaticoduodenectomy remains controversial. The aim of this study was to evaluate complication profiles and survival. METHODS All cases of ductal adenocarcinoma of the pancreatic head were evaluated from a prospectively maintained database (n = 289). Para-aortic lymph node lymphadenectomy was routinely performed in all patients with suspected ductal adenocarcinoma of the pancreatic head. Subgroup analysis was performed between patients with histologically positive (+) and negative (-) para-aortic lymph nodes. Patients receiving pancreaticoduodenectomy without para-aortic lymph node lymphadenectomy for other causes served as a control group. RESULTS A total of 192 patients received para-aortic lymph node lymphadenectomy, of which 41 were positive for para-aortic lymph node metastases. In 97 patients with ductal adenocarcinoma of the pancreatic head, no para-aortic lymph node lymphadenectomy was performed owing to postoperative pancreatic ductal adenocarcinoma diagnosis. Clinicopathologic data were homogenously distributed. Hospital stay and postoperative morbidity demonstrated no significant difference between the 3 subgroups. The median overall survival of 19.63 months (95% confidence interval: 14.57-24.79 months) in para-aortic lymph node- patients was not statistically different when compared with the median overall survival of 18.22 months (95% confidence interval: 12.68-23.75 months) in para-aortic lymph node + patients (log-rank test P = .223). Preoperative computed tomography was a poor predictor for para-aortic lymph node status (sensitivity = 10.3%, specificity = 97.8%). CONCLUSION This study represents the largest cohort receiving routine para-aortic lymph node lymphadenectomy. Extended lymphadenectomy can be performed safely and, although disease-free survival of para-aortic lymph node+ patients was significantly shorter, overall survival and postrelapse survival were on par with that of para-aortic lymph node- patients. Preoperative computed tomography indicating para-aortic lymph node metastasis should not preclude curative resection.
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Affiliation(s)
- Sami A Safi
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Alexander Rehders
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Lena Haeberle
- Institute of Pathology, Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Stephen Fung
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Nadja Lehwald
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Irene Esposito
- Institute of Pathology, Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Farid Ziayee
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Andreas Krieg
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Wolfram T Knoefel
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany.
| | - Georg Fluegen
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
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Pu Y, Wang C, Zhao S, Xie R, Zhao L, Li K, Yang C, Zhang R, Tian Y, Tan L, Li J, Li S, Chen L, Sun H. The clinical application of 18F-FDG PET/CT in pancreatic cancer: a narrative review. Transl Cancer Res 2021; 10:3560-3575. [PMID: 35116659 PMCID: PMC8799156 DOI: 10.21037/tcr-21-169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/20/2021] [Indexed: 12/13/2022]
Abstract
Pancreatic cancer is one of the worst prognoses of all malignant tumors, with an annual incidence near its annual mortality rate. To improve the prognosis of patients with pancreatic cancer, it is essential to diagnose and evaluate pancreatic cancer early. Imaging examinations play an essential role in tumor detection, staging, and surgical resection assessment and can provide reliable evidence for the diagnosis and treatment of pancreatic cancer. Currently, imaging techniques commonly used for pancreatic cancer include endoscopic ultrasound (EUS), conventional ultrasound, magnetic resonance imaging (MRI), multidetector spiral computed tomography (MDCT), positron emission tomography/computed tomography (PET/CT), and others PET/CT is a new imaging device composed of PET and CT. 18F-Fluorodeoxyglucose (18F-FDG) is a commonly used tracer in the clinic. Cancer cells are more robust than other ordinary cells in that they can ingest glucose, and the structure of glucose is similar to the structure of 18F-FDG. Therefore, after the injection of 18F-FDG, 18F-FDG in tumor cells appears very thick during PET scanning. Therefore, PET/CT can determine the metabolic capacity and anatomical position of pancreatic tumor cells in the body accurately diagnose the patient's condition and tumor location. It plays a vital role in early diagnosis and accurate staging, predicts survival, and monitors therapeutic effectiveness and pancreatic cancer recurrence. Although 18F-FDG PET/CT has limitations in identifying inflammatory diseases and tumors, it still has good development potential. This article reviews the clinical application of 18F-FDG PET/CT in pancreatic cancer.
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Affiliation(s)
- Yongzhu Pu
- Department of PET/CT Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Cancer Center of Yunnan Province, Kunming, China
| | - Chun Wang
- Department of PET/CT Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Cancer Center of Yunnan Province, Kunming, China
| | - Sheng Zhao
- Department of PET/CT Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Cancer Center of Yunnan Province, Kunming, China
| | - Ran Xie
- Department of PET/CT Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Cancer Center of Yunnan Province, Kunming, China
| | - Lei Zhao
- Department of PET/CT Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Cancer Center of Yunnan Province, Kunming, China
| | - Kun Li
- Department of Radiology, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Cancer Center of Yunnan Province, Kunming, China
| | - Conghui Yang
- Department of PET/CT Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Cancer Center of Yunnan Province, Kunming, China
| | - Rui Zhang
- Department of PET/CT Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Cancer Center of Yunnan Province, Kunming, China
| | - Yadong Tian
- Department of PET/CT Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Cancer Center of Yunnan Province, Kunming, China
| | - Lixian Tan
- Department of PET/CT Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Cancer Center of Yunnan Province, Kunming, China
| | - Jindan Li
- Department of PET/CT Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Cancer Center of Yunnan Province, Kunming, China
| | - Shujuan Li
- Department of PET/CT Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Cancer Center of Yunnan Province, Kunming, China
| | - Long Chen
- Department of PET/CT Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Cancer Center of Yunnan Province, Kunming, China
| | - Hua Sun
- Department of PET/CT Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Cancer Center of Yunnan Province, Kunming, China
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68Ga-FAPI-PET/CT improves diagnostic staging and radiotherapy planning of adenoid cystic carcinomas - Imaging analysis and histological validation. Radiother Oncol 2021; 160:192-201. [PMID: 33940087 PMCID: PMC9913884 DOI: 10.1016/j.radonc.2021.04.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/19/2021] [Accepted: 04/23/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Adenoid cystic carcinomas (ACCs) are rare epithelial tumors mostly situated in the head and neck region and characterized by infiltrative growth. The tumor stroma of ACCs includes cancer-associated fibroblasts (CAFs) expressing Fibroblast Activation Protein (FAP), a new target for positron emission tomography (PET) imaging. Here we describe the value of PET/ computed tomography (PET/CT) imaging using 68Ga-labelled FAP-Inhibitors (68Ga-FAPI-PET/CT) and their clinical potential for staging and radiotherapy planning in 12 ACC patients (7 primary, 5 recurrent). PATIENTS AND METHODS Patients underwent contrast enhanced staging CT (ceCT) and magnetic resonance imaging (ceMRI) before 68Ga-FAPI - PET/CT. PET-scans were acquired 10, 60 and 180 minutes after administration of 150-250 MBq of 68Ga-labelled FAPI tracers. SUVmax and SUVmean values of ACCs and healthy organs were obtained using a 60% of maximum iso-contour. FAP and alpha smooth muscle actin (α-SMA) immunohistochemistry was performed in 13 cases (3 with and 10 without 68Ga FAPI-PET/CT). Staging and radiotherapy planning based on 68Ga-FAPI-PET/CT versus ceCT/MRI alone were compared. RESULTS We observed elevated tracer uptake in all ACCs. Immunohistochemistry showed FAP-expressing CAFs in the tumor. Compared to conventional staging, 68Ga-FAPI-PET/CT led to upstaging in 2/12 patients and to detection of additional metastases in 3 patients, thus in total 42% of patients had their staging altered. Moreover, 68Ga-FAPI PET improved the accuracy of target volume delineation for radiotherapy, as compared to CT and MRI. CONCLUSION 68Ga-FAPI-PET/CT is a promising imaging modality for ACC, increasing the accuracy of staging exams and radiotherapy planning volumes, as compared conventional to CT and MRI.
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Abstract
Fibroblast activation protein inhibitor emerges as a novel and highly promising agent for diagnostic and possibly theranostic application in various malignant and non-malignant diseases. FAPI impresses with its selective expression in several pathologies, ligand induced internalization, and presence in a large variety of malignancies. Current studies indicate that FAPI is equal or even superior to the current standard oncological tracer fluorodeoxyglucose in several oncological diseases. It seems to present lower background activity, stronger uptake in tumorous lesions and thus sharper contrasts. For improved comprehension of fibroblast activation, protein expression and clinicopathologic conditions, further studies are of essence.
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Sollini M, Kirienko M, Gelardi F, Fiz F, Gozzi N, Chiti A. State-of-the-art of FAPI-PET imaging: a systematic review and meta-analysis. Eur J Nucl Med Mol Imaging 2021; 48:4396-4414. [PMID: 34173007 DOI: 10.1007/s00259-021-05475-0] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/17/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Fibroblast activation protein-α (FAPα) is overexpressed on cancer-associated fibroblasts in approximately 90% of epithelial neoplasms, representing an appealing target for therapeutic and molecular imaging applications. [68 Ga]Ga-labelled radiopharmaceuticals-FAP-inhibitors (FAPI)-have been developed for PET. We systematically reviewed and meta-analysed published literature to provide an overview of its clinical role. MATERIALS AND METHODS The search, limited to January 1st, 2018-March 31st, 2021, was performed on MedLine and Embase databases using all the possible combinations of terms "FAP", "FAPI", "PET/CT", "positron emission tomography", "fibroblast", "cancer-associated fibroblasts", "CAF", "molecular imaging", and "fibroblast imaging". Study quality was assessed using the QUADAS-2 criteria. Patient-based and lesion-based pooled sensitivities/specificities of FAPI PET were computed using a random-effects model directly from the STATA "metaprop" command. Between-study statistical heterogeneity was tested (I2-statistics). RESULTS Twenty-three studies were selected for systematic review. Investigations on staging or restaging head and neck cancer (n = 2, 29 patients), abdominal malignancies (n = 6, 171 patients), various cancers (n = 2, 143 patients), and radiation treatment planning (n = 4, 56 patients) were included in the meta-analysis. On patient-based analysis, pooled sensitivity was 0.99 (95% CI 0.97-1.00) with negligible heterogeneity; pooled specificity was 0.87 (95% CI 0.62-1.00), with negligible heterogeneity. On lesion-based analysis, sensitivity and specificity had high heterogeneity (I2 = 88.56% and I2 = 97.20%, respectively). Pooled sensitivity for the primary tumour was 1.00 (95% CI 0.98-1.00) with negligible heterogeneity. Pooled sensitivity/specificity of nodal metastases had high heterogeneity (I2 = 89.18% and I2 = 95.74%, respectively). Pooled sensitivity in distant metastases was good (0.93 with 95% CI 0.88-0.97) with negligible heterogeneity. CONCLUSIONS FAPI-PET appears promising, especially in imaging cancers unsuitable for [18F]FDG imaging, particularly primary lesions and distant metastases. However, high-level evidence is needed to define its role, specifically to identify cancer types, non-oncological diseases, and clinical settings for its applications.
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Affiliation(s)
- Martina Sollini
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4Pieve Emanuele, 20090, Milan, Italy.,IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Margarita Kirienko
- Fondazione IRCCS Istituto Nazionale Tumori, Via G. Venezian 1, 20133, Milan, Italy
| | - Fabrizia Gelardi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4Pieve Emanuele, 20090, Milan, Italy. .,IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Francesco Fiz
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Noemi Gozzi
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Arturo Chiti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4Pieve Emanuele, 20090, Milan, Italy.,IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
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Shou Y, Xue Q, Yuan J, Zhao J. 68Ga-FAPI-04 PET/MR is helpful in differential diagnosis of pancreatitis from pancreatic malignancy compared to 18F-FDG PET/CT: a case report. Eur J Hybrid Imaging 2021; 5:12. [PMID: 34181149 PMCID: PMC8218089 DOI: 10.1186/s41824-021-00106-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/16/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction 68Ga-fibroblast activation protein-specific enzyme inhibitor 04 (FAPI-04) is a radiolabelled molecular agent targeting the inhibitor of fibroblast activation protein (FAP), which is often present in tumor stroma and inflammatory tissue with prominent fibroblast proliferation. FAPI-04 is a promising PET tracer for tumor imaging as well as IgG4-related disease (IgG4-RD). Case description We herein present a case where 68Ga-FAPI PET/MR helped to diagnose IgG4-RD that involved pancreas and bile duct. A 62-year-old patient suffered from diffusive discomfort at middle upper abdomen and presented brown urine. Blood test revealed abnormal liver function and elevated IgG4 (4.830g/L↑). 18F-FDG PET showed enlarged uncinate process and dilated bile duct tree. Mild increase of FDG uptake in uncinate process and head of pancreas indicated possible pancreatic malignancy, but the clinical evidence was not sufficient and histology examination was negative. 68Ga-FAPI PET revealed prominent increased radioactivity distribution in the entire pancreas and bile duct, suggesting IgG4-RD. Conclusion FAPI-04 is not only a good PET imaging tracer for tumors, but also for prominent fibroblast-mediated inflammation. FAPI imaging should be considered when the diagnosis using 18F-FDG imaging is ambiguous. The presented case illustrates that 68Ga-FAPI-04 PET is helpful in improving the differential diagnosis of pancreatitis and pancreatic cancer.
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Affiliation(s)
- Yi Shou
- Department of Nuclear Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qiaoyi Xue
- Central Research Institute, UIH Group, Shanghai, China
| | - Jianmin Yuan
- Central Research Institute, UIH Group, Shanghai, China
| | - Jun Zhao
- Department of Nuclear Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China.
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Montemagno C, Cassim S, De Leiris N, Durivault J, Faraggi M, Pagès G. Pancreatic Ductal Adenocarcinoma: The Dawn of the Era of Nuclear Medicine? Int J Mol Sci 2021; 22:6413. [PMID: 34203923 PMCID: PMC8232627 DOI: 10.3390/ijms22126413] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 12/12/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC), accounting for 90-95% of all pancreatic tumors, is a highly devastating disease associated with poor prognosis. The lack of accurate diagnostic tests and failure of conventional therapies contribute to this pejorative issue. Over the last decade, the advent of theranostics in nuclear medicine has opened great opportunities for the diagnosis and treatment of several solid tumors. Several radiotracers dedicated to PDAC imaging or internal vectorized radiotherapy have been developed and some of them are currently under clinical consideration. The functional information provided by Positron Emission Tomography (PET) or Single Photon Emission Computed Tomography (SPECT) could indeed provide an additive diagnostic value and thus help in the selection of patients for targeted therapies. Moreover, the therapeutic potential of β-- and α-emitter-radiolabeled agents could also overcome the resistance to conventional therapies. This review summarizes the current knowledge concerning the recent developments in the nuclear medicine field for the management of PDAC patients.
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Affiliation(s)
- Christopher Montemagno
- Département de Biologie Médicale, Centre Scientifique de Monaco, 98000 Monaco, Monaco; (S.C.); (J.D.); (G.P.)
- Institute for Research on Cancer and Aging of Nice, Centre Antoine Lacassagne, CNRS UMR 7284 and IN-SERM U1081, Université Cote d’Azur, 06200 Nice, France
- LIA ROPSE, Laboratoire International Associé Université Côte d’Azur—Centre Scientifique de Monaco, 98000 Monaco, Monaco
| | - Shamir Cassim
- Département de Biologie Médicale, Centre Scientifique de Monaco, 98000 Monaco, Monaco; (S.C.); (J.D.); (G.P.)
- LIA ROPSE, Laboratoire International Associé Université Côte d’Azur—Centre Scientifique de Monaco, 98000 Monaco, Monaco
| | - Nicolas De Leiris
- Nuclear Medicine Department, Grenoble-Alpes University Hospital, 38000 Grenoble, France;
- Laboratoire Radiopharmaceutiques Biocliniques, Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Jérôme Durivault
- Département de Biologie Médicale, Centre Scientifique de Monaco, 98000 Monaco, Monaco; (S.C.); (J.D.); (G.P.)
- LIA ROPSE, Laboratoire International Associé Université Côte d’Azur—Centre Scientifique de Monaco, 98000 Monaco, Monaco
| | - Marc Faraggi
- Centre Hospitalier Princesse Grace, Nuclear Medicine Department, 98000 Monaco, Monaco;
| | - Gilles Pagès
- Département de Biologie Médicale, Centre Scientifique de Monaco, 98000 Monaco, Monaco; (S.C.); (J.D.); (G.P.)
- Institute for Research on Cancer and Aging of Nice, Centre Antoine Lacassagne, CNRS UMR 7284 and IN-SERM U1081, Université Cote d’Azur, 06200 Nice, France
- LIA ROPSE, Laboratoire International Associé Université Côte d’Azur—Centre Scientifique de Monaco, 98000 Monaco, Monaco
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Hesterberg AB, Rios BL, Wolf EM, Tubbs C, Wong HY, Schaffer KR, Lotan TL, Giannico GA, Gordetsky JB, Hurley PJ. A distinct repertoire of cancer-associated fibroblasts is enriched in cribriform prostate cancer. J Pathol Clin Res 2021; 7:271-286. [PMID: 33600062 PMCID: PMC8073007 DOI: 10.1002/cjp2.205] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/11/2020] [Accepted: 01/13/2021] [Indexed: 12/27/2022]
Abstract
Outcomes for men with localized prostate cancer vary widely, with some men effectively managed without treatment on active surveillance, while other men rapidly progress to metastatic disease despite curative-intent therapies. One of the strongest prognostic indicators of outcome is grade groups based on the Gleason grading system. Gleason grade 4 prostate cancer with cribriform morphology is associated with adverse outcomes and can be utilized clinically to improve risk stratification. The underpinnings of disease aggressiveness associated with cribriform architecture are not fully understood. Most studies have focused on genetic and molecular alterations in cribriform tumor cells; however, less is known about the tumor microenvironment in cribriform prostate cancer. Cancer-associated fibroblasts (CAFs) are a heterogeneous population of fibroblasts in the tumor microenvironment that impact cancer aggressiveness. The overall goal of this study was to determine if cribriform prostate cancers are associated with a unique repertoire of CAFs. Radical prostatectomy whole-tissue sections were analyzed for the expression of fibroblast markers (ASPN in combination with FAP, THY1, ENG, NT5E, TNC, and PDGFRβ) in stroma adjacent to benign glands and in Gleason grade 3, Gleason grade 4 cribriform, and Gleason grade 4 noncribriform prostate cancer by RNAscope®. Halo® Software was used to quantify percent positive stromal cells and expression per positive cell. The fibroblast subtypes enriched in prostate cancer were highly heterogeneous. Both overlapping and distinct populations of low abundant fibroblast subtypes in benign prostate stroma were enriched in Gleason grade 4 prostate cancer with cribriform morphology compared to Gleason grade 4 prostate cancer with noncribriform morphology and Gleason grade 3 prostate cancer. In addition, gene expression was distinctly altered in CAF subtypes adjacent to cribriform prostate cancer. Overall, these studies suggest that cribriform prostate cancer has a unique tumor microenvironment that may distinguish it from other Gleason grade 4 morphologies and lower Gleason grades.
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Affiliation(s)
| | - Brenda L Rios
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | - Elysa M Wolf
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | - Colby Tubbs
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | - Hong Yuen Wong
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | - Kerry R Schaffer
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | - Tamara L Lotan
- Department of PathologyJohns Hopkins School of MedicineBaltimoreMDUSA
| | - Giovanna A Giannico
- Department of PathologyVanderbilt University Medical CenterNashvilleTNUSA
- Department of UrologyVanderbilt University Medical CenterNashvilleTNUSA
| | - Jennifer B Gordetsky
- Department of PathologyVanderbilt University Medical CenterNashvilleTNUSA
- Department of UrologyVanderbilt University Medical CenterNashvilleTNUSA
| | - Paula J Hurley
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
- Department of UrologyVanderbilt University Medical CenterNashvilleTNUSA
- Vanderbilt‐Ingram Cancer CenterVanderbilt University Medical CenterNashvilleTNUSA
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Aime S, Al-Qahtani M, Behe M, Bormans G, Carlucci G, DaSilva JN, Decristoforo C, Duatti A, Elsinga PH, Kopka K, Li XG, Liu Z, Mach RH, Middel O, Passchier J, Patt M, Penuelas I, Rey A, Scott PJH, Todde S, Toyohara J, Vugts D, Yang Z. Highlight selection of radiochemistry and radiopharmacy developments by editorial board. EJNMMI Radiopharm Chem 2021; 6:13. [PMID: 33738618 PMCID: PMC7973323 DOI: 10.1186/s41181-021-00128-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The Editorial Board of EJNMMI Radiopharmacy and Chemistry releases a biyearly highlight commentary to update the readership on trends in the field of radiopharmaceutical development. RESULTS This commentary of highlights has resulted in 23 different topics selected by each member of the Editorial Board addressing a variety of aspects ranging from novel radiochemistry to first in man application of novel radiopharmaceuticals. CONCLUSION Trends in radiochemistry and radiopharmacy are highlighted demonstrating the progress in the research field being the scope of EJNMMI Radiopharmacy and Chemistry.
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Affiliation(s)
| | | | - Martin Behe
- Paul Scherrer Institute, Villigen, Switzerland
| | - Guy Bormans
- Katholieke Universiteit Leuven, Leuven, Belgium
| | - Giuseppe Carlucci
- UCLA Molecular and Medical Pharmacology Department, Los Angeles, USA
| | | | | | | | - Philip H. Elsinga
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Klaus Kopka
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | | | | | | | | | | | | | | | - Ana Rey
- Universidad de la Republica, Montevideo, Uruguay
| | | | | | - Jun Toyohara
- Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | | | - Zhi Yang
- Peking University Cancer Hospital, Beijing, China
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Liermann J, Syed M, Ben-Josef E, Schubert K, Schlampp I, Sprengel SD, Ristau J, Weykamp F, Röhrich M, Koerber SA, Haberkorn U, Debus J, Herfarth K, Giesel FL, Naumann P. Impact of FAPI-PET/CT on Target Volume Definition in Radiation Therapy of Locally Recurrent Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13040796. [PMID: 33672893 PMCID: PMC7918160 DOI: 10.3390/cancers13040796] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/06/2021] [Accepted: 02/11/2021] [Indexed: 12/28/2022] Open
Abstract
Simple Summary We demonstrate how manual target definition based on contrast-enhanced computed tomography is highly unreliable and inconsistent. In a second step, we used a novel positron emission tomography tracer, FAPI (68Ga-labeled fibroblast activation protein inhibitor) for target volume definition. FAPI-PET/CT contains biologic information as it visualizes cancer associated fibroblasts. The pioneering use of FAPI PET/CT in radiation treatment planning improved target definition in locally recurrent pancreatic cancer. Abstract (1) Background: A new radioactive positron emission tomography (PET) tracer uses inhibitors of fibroblast activation protein (FAPI) to visualize FAP-expressing cancer associated fibroblasts. Significant FAPI-uptake has recently been demonstrated in pancreatic cancer patients. Target volume delineation for radiation therapy still relies on often less precise conventional computed tomography (CT) imaging, especially in locally recurrent pancreatic cancer patients. The need for improvement in precise tumor detection and delineation led us to innovatively use the novel FAPI-PET/CT for radiation treatment planning. (2) Methods: Gross tumor volumes (GTVs) of seven locally recurrent pancreatic cancer cases were contoured by six radiation oncologists. In addition, FAPI-PET/CT was used to automatically delineate tumors. The interobserver variability in target definition was analyzed and FAPI-based automatic GTVs were compared to the manually defined GTVs. (3) Results: Target definition differed significantly between different radiation oncologists with mean dice similarity coefficients (DSCs) between 0.55 and 0.65. There was no significant difference between the volumes of automatic FAPI-GTVs based on the threshold of 2.0 and most of the manually contoured GTVs by radiation oncologists. (4) Conclusion: Due to its high tumor to background contrast, FAPI-PET/CT seems to be a superior imaging modality compared to the current gold standard contrast-enhanced CT in pancreatic cancer. For the first time, we demonstrate how FAPI-PET/CT could facilitate target definition and increases consistency in radiation oncology in pancreatic cancer.
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Affiliation(s)
- Jakob Liermann
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.S.); (K.S.); (I.S.); (S.D.S.); (J.R.); (F.W.); (S.A.K.); (J.D.); (K.H.); (P.N.)
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-622-156-8202
| | - Mustafa Syed
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.S.); (K.S.); (I.S.); (S.D.S.); (J.R.); (F.W.); (S.A.K.); (J.D.); (K.H.); (P.N.)
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
| | - Edgar Ben-Josef
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Kai Schubert
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.S.); (K.S.); (I.S.); (S.D.S.); (J.R.); (F.W.); (S.A.K.); (J.D.); (K.H.); (P.N.)
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Ingmar Schlampp
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.S.); (K.S.); (I.S.); (S.D.S.); (J.R.); (F.W.); (S.A.K.); (J.D.); (K.H.); (P.N.)
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
| | - Simon David Sprengel
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.S.); (K.S.); (I.S.); (S.D.S.); (J.R.); (F.W.); (S.A.K.); (J.D.); (K.H.); (P.N.)
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
| | - Jonas Ristau
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.S.); (K.S.); (I.S.); (S.D.S.); (J.R.); (F.W.); (S.A.K.); (J.D.); (K.H.); (P.N.)
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.S.); (K.S.); (I.S.); (S.D.S.); (J.R.); (F.W.); (S.A.K.); (J.D.); (K.H.); (P.N.)
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
| | - Manuel Röhrich
- Department of Nuclear Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.R.); (U.H.); (F.L.G.)
| | - Stefan A. Koerber
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.S.); (K.S.); (I.S.); (S.D.S.); (J.R.); (F.W.); (S.A.K.); (J.D.); (K.H.); (P.N.)
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
| | - Uwe Haberkorn
- Department of Nuclear Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.R.); (U.H.); (F.L.G.)
| | - Juergen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.S.); (K.S.); (I.S.); (S.D.S.); (J.R.); (F.W.); (S.A.K.); (J.D.); (K.H.); (P.N.)
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.S.); (K.S.); (I.S.); (S.D.S.); (J.R.); (F.W.); (S.A.K.); (J.D.); (K.H.); (P.N.)
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Frederik L. Giesel
- Department of Nuclear Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.R.); (U.H.); (F.L.G.)
| | - Patrick Naumann
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.S.); (K.S.); (I.S.); (S.D.S.); (J.R.); (F.W.); (S.A.K.); (J.D.); (K.H.); (P.N.)
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
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