Fully automated production of the fibroblast activation protein radiotracer [18 F]FAPI-74

Fully Automated Cassette-Based Synthesis of 2-Deoxy-2-[18F]Fluorocellobiose Using Trasis AllInOne Module

Due to the continuous rise in global incidence and severity of invasive fungal infections (IFIs), particularly among immunocompromised and immunodeficient patients, there is an urgent demand for swift and accurate fungal pathogen diagnosis. Therefore, the need for fungal-specific positron emission tomography (PET) imaging agents that can detect the infection in the early stages is increasing. Cellobiose, a disaccharide, is readily metabolized by fungal pathogens such as Aspergillus species. Recently, our group reported fluorine-18 labeled cellobiose, 2-deoxy-2-[18F]fluorocellobiose ([18F]FCB), for specific imaging of Aspergillus infection. The positive imaging findings with very low background signal on delayed imaging make this ligand a promising fungal-specific imaging ligand. Inspired by this result, the decision was made to automate the radiolabeling procedure for better reproducibility and to facilitate clinical translation. A Trasis AllInOne (Trasis AIO) automated module was used for this purpose. The reagent vials contain commercially available 2-deoxy-2-[18F]fluoroglucose ([18F]FDG), glucose-1-phosphate, and enzyme (cellobiose phosphorylase). A Sep-Pak cartridge was used to purify the tracer. The overall radiochemical yield was 50%-70% (n = 6, decay corrected) in 75-min synthesis time with a radiochemical purity of > 98%. This is a highly reliable protocol to produce current good manufacturing practice (cGMP)-compliant [18F]FCB for clinical PET imaging.

Optimization and automation of the radiosynthesis of [18F]Lu-LuFL as a clinically useful PET ligand targeting FAP for tumor imaging

Recently, a novel radiohybrid tracer [18F]Lu-LuFL targeting the fibroblast activation protein (FAP) has been developed for PET imaging of solid tumors. This tracer has shown promising results, prompting us to conduct a first-in-human study to evaluate its efficacy for PET imaging of FAP in human body. In order to facilitate the routine production and clinical application of [18F]Lu-LuFL, a straightforward and efficient automated synthesis is described. The optimum labeling parameters were determined at laboratory scale, and subsequently incorporated into an automated production process. Further studies have demonstrated that clinical doses of [18F]Lu-LuFL can be prepared within 19 min, with excellent radio chemical purity (>99%) and activity yield (23.58% ± 2.20%, non-decay corrected), coupled with solid phase extraction (SPE) purification method. All the quality control results satisfy the required criteria for release. In conclusion, we have successfully synthesized [18F]Lu-LuFL with sufficient radioactivity and superior quality, thereby establishing its potential for further clinical application.

Research progress on the role of fibroblast activation protein in diagnosis and treatment of cancer

Fibroblast activation protein (FAP) is a type II transmembrane protein, which is over-expressed in cancer-associated fibroblasts (CAFs). CAFs are tumor stromal cells that constitute a major component of cancer volume and are reportedly related to tumorigenesis, angiogenesis, metastasis, promotion of drug resistance and induction of tumor immunity. FAP is widely acknowledged as the signature protein of CAFs. At present, FAP inhibitors (FAPI) have achieved ideal results in tumor PET/computed tomography (CT) imaging. Theoretically, FAP-targeted drugs can inhibit tumor progression. Nonetheless, no satisfactory therapeutic effect has been observed so far, which has impeded their implementation in clinical practice. In this review, we describe the characteristics of FAP and its role in the occurrence and development of cancer. We also highlight the potential value of targeting FAP to improve current diagnostic and therapeutic approaches.

FAPI-PET/CT in Cancer Imaging: A Potential Novel Molecule of the Century

Fibroblast activation protein (FAP), a type II transmembrane serine protease, is highly expressed in more than 90% of epithelial tumors and is closely associated with various tumor invasion, metastasis, and prognosis. Using FAP as a target, various FAP inhibitors (FAPIs) have been developed, most of which have nanomolar levels of FAP affinity and high selectivity and are used for positron emission tomography (PET) imaging of different tumors. We have conducted a systematic review of the available data; summarized the biological principles of FAPIs for PET imaging, the synthesis model, and metabolic characteristics of the radiotracer; and compared the respective values of FAPIs and the current mainstream tracer ¹⁸F-Fludeoxyglucose (¹⁸F-FDG) in the clinical management of tumor and non-tumor lesions. Available research evidence indicates that FAPIs are a molecular imaging tool complementary to ¹⁸F-FDG and are expected to be the new molecule of the century with better imaging effects than ¹⁸F-FDG in a variety of cancers, including gastrointestinal tumors, liver tumors, breast tumors, and nasopharyngeal carcinoma.

Translating a radiolabeled imaging agent to the clinic

Molecular Imaging is entering the most fruitful, exciting period in its history with many new agents under development, and several reaching the clinic in recent years. While it is unusual for just one laboratory to take an agent from initial discovery through to full clinical approval the steps along the way are important to understand for all interested participants even if one is not involved in the entire process. Here, we provide an overview of these processes beginning at discovery and preclinical validation of a new molecular imaging agent and using as an exemplar a low molecular weight disease-specific targeted positron emission tomography (PET) agent. Compared to standard drug development requirements, molecular imaging agents may benefit from a regulatory standpoint from their low mass administered doses, they nonetheless still need to go through a series of well-defined steps before they can be considered for Phase 1 human testing. After outlining the discovery and preclinical validation approaches, we will also discuss the nuances of Phase 1, Phase 2 and Phase 3 studies that may culminate in an FDA general use approval. Finally, some post-approval aspects of novel molecular imaging agents are considered.

Automatic Production and Preliminary PET Imaging of a New Imaging Agent [18F]AlF-FAPT

Background

Fibroblast activating protein (FAP) has become an important target for cancer diagnostic imaging and targeted radiotherapy. In particular, [¹⁸F]FAPI-42 has been successfully applied to positron emission tomography (PET) imaging of various tumors. However, it exhibits high hepatobiliary metabolism and is thus not conducive to abdominal tumor imaging. This study reports a novel ¹⁸F-labeled FAP inhibitor, [¹⁸F]AlF-FAPT, a better FAPI imaging agent than [¹⁸F]FAPI-42.

Materials and Methods

The precursor of [¹⁸F]AlF-FAPT (NOTA-FAPT) was designed and synthesized using the standard FMOC solid phase synthesis method. [¹⁸F]AlF-FAPT was subsequently synthesized and radiolabeled with ¹⁸F using the AllInOne synthesis module. Dynamic MicroPET and biodistribution studies of [¹⁸F]AlF-FAPT were then conducted in xenograft tumor mouse models to determine its suitability.

Results

The precursors NOTA-FAPT were obtained with a chemical purity of > 95%. [¹⁸F]AlF-FAPT was synthesized automatically using the cassette-based module AllInOne within 40 min. The non-decay corrected radiochemical yield was 25.0 ± 5.3% (n=3). In vivo imaging and biodistribution studies further demonstrated that compared with [¹⁸F]-FAPI-42, [¹⁸F]AlF-FAPT had a lower hepatobiliary uptake than [¹⁸F]FAPI-42, which was advantageous for imaging abdominal tumors.

Conclusion

[¹⁸F]AlF-FAPT can be synthesized automatically using a one-step method of aluminum fluoride. Collectively, [¹⁸F]AlF-FAPT is a better FAPI imaging agent than [¹⁸F]FAPI-42. This study proves the feasibility of using [¹⁸F]AlF-FAPT as a new radioactive tracer for PET imaging.

18F-labeled tracers targeting fibroblast activation protein

Background

Cancer-associated fibroblasts are found in the stroma of epithelial tumors. They are characterized by overexpression of the fibroblast activation protein (FAP), a serine protease which was already proven as attractive target for chelator-based theranostics. Unfortunately, the value of gallium-68 labeled tracers is limited by their batch size and the short nuclide half-life. To overcome this drawback, radiolabeling with aluminum fluoride complexes and 6-fluoronicotinamide derivatives of the longer-lived nuclide fluorine-18 was established. The novel compounds were tested for their FAP-specific binding affinity. Uptake and binding competition were studied in vitro using FAP expressing HT-1080 cells. HEK cells transfected with the closely related dipeptidyl peptidase-4 (HEK-CD26) were used as negative control. Small animal positron emission tomography imaging and biodistribution experiments were performed in HT-1080-FAP xenografted nude mice. [¹⁸F]AlF-FAPI-74 was selected for PET/CT imaging in a non-small cell lung cancer (NSCLC) patient.

Results

In vitro, ¹⁸F-labeled FAPI-derivatives demonstrated high affinity (EC₅₀ = < 1 nm to 4.2 nm) and binding of up to 80% to the FAP-expressing HT1080 cells while no binding to HEK-CD26 cells was observed. While small animal PET imaging revealed unfavorable biliary excretion of most of the ¹⁸F-labeled compounds, the NOTA bearing compounds [¹⁸F]AlF-FAPI-74 and -75 achieved good tumor-to-background ratios, as a result of their preferred renal excretion. These two compounds showed the highest tumor accumulation in PET imaging. The organ distribution values of [¹⁸F]AlF-FAPI-74 were in accordance with the small animal PET imaging results. Due to its less complex synthesis, fast clearance and low background values, [¹⁸F]AlF-FAPI-74 was chosen for clinical imaging. PET/CT of a patient with metastasized non-small cell lung cancer (NSCLC), enabled visualization of the primary tumor and its metastases at the hepatic portal and in several bones. This was accompanied by a rapid clearance from the blood pool and low background in healthy organs.

Conclusion

[¹⁸F]AlF-labeled FAPI derivatives represent powerful tracers for PET. Owing to an excellent performance in PET imaging, FAPI-74 can be regarded as a promising precursor for [¹⁸F]AlF-based FAP-imaging.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41181-021-00144-x.