Tracking cellular and immune therapies in cancer

Direct and Indirect Chimeric Antigen Receptor T-Cell Imaging with PET/MRI in a Tumor Xenograft Model

Background Chimeric antigen receptor (CAR) T cells are a promising cancer therapy; however, reliable and repeatable methods for tracking and monitoring CAR T cells in vivo remain underexplored. Purpose To investigate direct and indirect imaging strategies for tracking the biodistribution of CAR T cells and monitoring their therapeutic effect in target tumors. Materials and Methods CAR T cells co-expressing a tumor-targeting gene (anti-CD19 CAR) and a human somatostatin receptor subtype 2 (hSSTr2) reporter gene were generated from human peripheral blood mononuclear cells. After direct labeling with zirconium 89 (89Zr)-p-isothiocyanatobenzyl-desferrioxamine (DFO), CAR T cells were intravenously injected into immunodeficient mice with a CD19-positive and CD19-negative human tumor xenograft on the left and right flank, respectively. PET/MRI was used for direct in vivo imaging of 89Zr-DFO-labeled CAR T cells on days 0, 1, 3, and 7 and for indirect cell imaging with the radiolabeled somatostatin receptor-targeted ligand gallium 68 (68Ga)-DOTA-Tyr3-octreotide (DOTATOC) on days 6, 9, and 13. On day 13, mice were euthanized, and tissues and tumors were excised. Results The 89Zr-DFO-labeled CAR T cells were observed on PET/MRI scans in the liver and lungs of mice (n = 4) at all time points assessed. However, they were not visualized in CD19-positive or CD19-negative tumors, even on day 7. Serial 68Ga-DOTATOC PET/MRI showed CAR T cell accumulation in CD19-positive tumors but not in CD19-negative tumors from days 6 to 13. Notably, 68Ga-DOTATOC accumulation in CD19-positive tumors was highest on day 9 (mean percentage injected dose [%ID], 3.7% ± 1.0 [SD]) and decreased on day 13 (mean %ID, 2.6% ± 0.7) in parallel with a decrease in tumor volume (day 9: mean, 195 mm3 ± 27; day 13: mean, 127 mm3 ± 43) in the group with tumor growth inhibition. Enhanced immunohistochemistry staining of cluster of differentiation 3 (CD3) and hSSTr2 was also observed in excised CD19-positive tumor tissues. Conclusion Direct and indirect cell imaging with PET/MRI enabled in vivo tracking and monitoring of CAR T cells in an animal model. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Bulte in this issue.

Direct Cell Radiolabeling for in Vivo Cell Tracking with PET and SPECT Imaging

The arrival of cell-based therapies is a revolution in medicine. However, its safe clinical application in a rational manner depends on reliable, clinically applicable methods for determining the fate and trafficking of therapeutic cells in vivo using medical imaging techniques─known as in vivo cell tracking. Radionuclide imaging using single photon emission computed tomography (SPECT) or positron emission tomography (PET) has several advantages over other imaging modalities for cell tracking because of its high sensitivity (requiring low amounts of probe per cell for imaging) and whole-body quantitative imaging capability using clinically available scanners. For cell tracking with radionuclides, ex vivo direct cell radiolabeling, that is, radiolabeling cells before their administration, is the simplest and most robust method, allowing labeling of any cell type without the need for genetic modification. This Review covers the development and application of direct cell radiolabeling probes utilizing a variety of chemical approaches: organic and inorganic/coordination (radio)chemistry, nanomaterials, and biochemistry. We describe the key early developments and the most recent advances in the field, identifying advantages and disadvantages of the different approaches and informing future development and choice of methods for clinical and preclinical application.

Detection and viability of murine NK cells in vivo in a lymphoma model using fluorine-19 MRI

Natural killer (NK) cell therapies are being increasingly used as an adoptive cell therapy for cancer because they can recognize tumor cells in an antigen-independent manner. While promising, the understanding of NK cell persistence, particularly within a harsh tumor microenvironment, is limited. Fluorine-19 (¹⁹ F) MRI is a noninvasive imaging modality that has shown promise in longitudinally tracking cell populations in vivo; however, it has not been studied on murine NK cells. In this study, the impact of ¹⁹ F labeling on murine NK cell viability and function was assessed in vitro and then used to quantify NK cell persistence in vivo. While there was no noticeable impact on viability, labeling NK cells with ¹⁹ F did attenuate cytotoxicity against lymphoma cells in vitro. Fluorescent microscopy verified ¹⁹ F labeling in both the cytoplasm and nucleus of NK cells. Lymphoma-bearing mice were given intratumoral injections of ¹⁹ F-labeled NK cells in which signal was detectable across the 6 day observation period via ¹⁹ F MRI. Quantification from the composite images detected 78-94% of the initially injected NK cells across 6 days, with a significant decrease between Days 3 and 6. Postmortem flow cytometry demonstrated retention of ¹⁹ F intracellularly within adoptively transferred NK cells with less than 1% of ¹⁹ F-containing cells identified as tumor-associated macrophages that presumably ingested nonviable NK cells. This work demonstrates that ¹⁹ F MRI offers a specific imaging platform to track and quantify murine NK cells within tumors noninvasively.

Non-invasive cell-tracking methods for adoptive T cell therapies

Adoptive T cell therapies (ACT) have demonstrated groundbreaking results in blood cancers and melanoma. Nevertheless, their significant cost, the occurrence of severe adverse events, and their poor performance in solid tumors are important hurdles hampering more widespread applicability. In vivo cell tracking allows instantaneous and non-invasive monitoring of the distribution, tumor homing, persistence, and redistribution to other organs of infused T cells in patients. Furthermore, cell tracking could aid in the clinical management of patients, allowing the detection of non-responders or severe adverse events at an early stage. This review provides a concise overview of the main principles and potential of cell tracking, followed by a discussion of the clinically relevant labeling strategies and their application in ACT.

The Unmet Needs of the Diagnosis, Staging, and Treatment of Gastrointestinal Tumors

New scientific insights in cancer biology and immunobiology have changed the clinical practice of medical oncology in recent years. The molecular stratification of solid tumors has led to improved clinical outcomes and is a key part in the diagnostic workup. Beyond mutational spectra (like Rat sarcoma [RAS] mutations or tumor mutational burden), the investigation of the immunological microenvironment has attracted more efforts. Especially as immunotherapies have changed the standard treatment for some solid tumors dramatically and have become an important part of routine oncology, also for gastrointestinal tumors. Still only a subgroup of patients benefits from immunotherapy in gastrointestinal tumors with prominent examples from colorectal, pancreatic or gastric cancer. Not only microsatellite instability as a marker for response to immunotherapy has shown its utility, there plenty of other approaches currently being investigated to better stratify and understand the microenvironment. But these insights have not translated into clinical utility. Reasons for this are limited technical capabilities for stratification and for coping with heterogeneity of tumor cells and the microenvironment as such. So the situation for gastrointestinal tumors has shown mainly progress for a subgroup of immunotherapy-receptive tumors (eg, microsatellite instability), but advances for the remaining majority have been in the area of stratification and combinatorial therapies, including approaches without chemotherapy. Molecular stratification (eg, B-Rapidly Accelerated Fibrosarcoma [BRAF] V600E mutation in colorectal cancer or NRG1 fusions in Kirsten-rat sarcoma (KRAS) Wild-Type Pancreatic Cancer) has clearly improved the possibilities for directed therapies, but there is a plethora of clinical situations where further developments are needed to improve patient care. Finding these areas and identifying the technical approach to unravel the complexities is the next decisive step. Here the recent advances are summarized and an outlook on possible diagnostic and treatment options in areas of unmet need is given with the context of new molecular imaging possibilities and cutting edge advances in nuclear medicine.

High resolution tracking of macrophage cells in deep organs and lymphatics using fluorescent polymer dots

Fluorescent polymer dots for tracking macrophage cells in deep organs using probe-based confocal laser endomicroscopy (pCLE).

The Immunoimaging Toolbox

The recent clinical success of cancer immunotherapy has renewed interest in the development of tools to image the immune system. In general, immunotherapies attempt to enable the body's own immune cells to seek out and destroy malignant disease. Molecular imaging of the cells and molecules that regulate immunity could provide unique insight into the mechanisms of action, and failure, of immunotherapies. In this article, we will provide a comprehensive overview of the current state-of-the-art immunoimaging toolbox with a focus on imaging strategies and their applications toward immunotherapy.

Development of Novel ImmunoPET Tracers to Image Human PD-1 Checkpoint Expression on Tumor-Infiltrating Lymphocytes in a Humanized Mouse Model

PURPOSE

It is well known that cancers exploit immune checkpoints (programmed death 1 receptor (PD-1) and its ligand (PD-L1)) to evade anti-tumor immune responses. Although immune checkpoint (IC) blockade is a promising approach, not all patients respond. Hence, imaging of tumor-infiltrating lymphocytes (TILs) is of high specific interest, as they are known to express PD-1 during activation and subsequent exhaustion in the tumor microenvironment and are thought to be potentially predictive of therapeutic responses to IC blockade.

PROCEDURES

We developed immune-tracers for positron emission tomography (PET) to image hPD-1 status of human peripheral blood mononuclear cells (hPBMCs) adoptively transferred to NOD-scid IL-2Rγ^null (NSG) mice (hNSG) bearing A375 human skin melanoma tumors. The anti-PD-1 human antibody (IgG; keytruda) was labeled with either Zr-89 or Cu-64 radiometals to image PD-1-expressing human TILs in vivo.

RESULTS

[⁸⁹Zr] Keytruda (groups = 2; NSG-ctl (control) and hNSG-nblk (non-blocking), n = 3-5, 3.2 ± 0.4 MBq/15-16 μg/200 μl) and [⁶⁴Cu] Keytruda (groups = 3; NSG-ctl, NSG-blk (blocking), and hNSG-nblk; n = 4, 7.4 ± 0.4 MBq /20-25 μg/200 μl) were administered in mice. PET-CT scans were performed over 1-144 h ([⁸⁹Zr] Keytruda) and 1-48 h ([⁶⁴Cu] Keytruda) on mice. hNSG mice exhibited a high tracer uptake in the spleen, lymphoid organs and tumors. At 24 h, human TILs homing into melanoma of hNSG-nblk mice exhibited high signal (mean %ID/g ± SD) of 3.8 ± 0.4 ([⁸⁹Zr] Keytruda), and 6.4 ± 0.7 ([⁶⁴Cu] Keytruda), which was 1.5- and 3-fold higher uptake compared to NSG-ctl mice (p = 0.01), respectively. Biodistribution measurements of hNSG-nblk mice performed at 144 h ([⁸⁹Zr] Keytruda) and 48 h ([⁶⁴Cu] Keytruda) p.i. revealed tumor to muscle ratios as high as 45- and 12-fold, respectively.

CONCLUSIONS

Our immunoPET study clearly demonstrates specific imaging of human PD-1-expressing TILs within the tumor and lymphoid tissues. This suggests these anti-human-PD-1 tracers could be clinically translatable to monitor cancer treatment response to IC blockade therapy.

Paramagnetic nanoemulsions with unified signals for sensitive 19F MRI cell tracking

As a promising cell tracking technology, 19F MRI suffers from low sensitivity. Here, fluorinated nanoemulsions with a unified 19F signal and paramagnetic relaxation enhancement were developed as 19F MRI cellular tracers with high stability, size controllability, biocompatibility, cellular uptake, and dual-modality for sensitive in vivo RAW264.7 cell tracking.

Small Molecule PET Tracers in Drug Discovery

The process of discovering and developing a new pharmaceutical is a long, difficult, and risky process that requires numerous resources. Molecular imaging techniques such as PET have recently become a useful tool for making decisions along a drug candidate's development timeline. PET is a translational, noninvasive imaging technique that provides quantitative information about a potential drug candidate and its target at the molecular level. Using this technique provides decisional information to ensure that the right drug candidate is being chosen, for the right target, at the right dose within the right patient population. This review will focus on small molecule PET tracers and how they are used within the drug discovery process. PET provides key information about a drug candidate's pharmacokinetic and pharmacodynamic properties in both preclinical and clinical studies. PET is being used in all phases of the drug discovery and development process, and the goal of these studies are to accelerate the process in which drugs are developed.

Noninvasive PET Imaging of T cells

The rapidly evolving field of cancer immunotherapy recently saw the approval of several new therapeutic antibodies. Several cell therapies, for example, chimeric antigen receptor-expressing T cells (CAR-T), are currently in clinical trials for a variety of cancers and other diseases. However, approaches to monitor changes in the immune status of tumors or to predict therapeutic responses are limited. Monitoring lymphocytes from whole blood or biopsies does not provide dynamic and spatial information about T cells in heterogeneous tumors. Positron emission tomography (PET) imaging using probes specific for T cells can noninvasively monitor systemic and intratumoral immune alterations during experimental therapies and may have an important and expanding value in the clinic.

Reporter gene imaging of targeted T cell immunotherapy in recurrent glioma

High-grade gliomas are aggressive cancers that often become rapidly fatal. Immunotherapy using CD8⁺ cytotoxic T lymphocytes (CTLs), engineered to express both herpes simplex virus type 1 thymidine kinase (HSV1-TK) and interleukin-13 (IL-13) zetakine chimeric antigen receptor (CAR), is a treatment strategy with considerable potential. To optimize this and related immunotherapies, it would be helpful to monitor CTL viability and trafficking to glioma cells. We show that noninvasive positron emission tomography (PET) imaging with 9-[4-[¹⁸F]fluoro-3-(hydroxymethyl)butyl]guanine ([¹⁸F]FHBG) can track HSV1-tk reporter gene expression present in CAR-engineered CTLs. [¹⁸F]FHBG imaging was safe and enabled the longitudinal imaging of T cells stably transfected with a PET reporter gene in patients. Further optimization of this imaging approach for monitoring in vivo cell trafficking should greatly benefit various cell-based therapies for cancer.

Optical spectroscopic imaging for cell therapy and tissue engineering

Cell-based therapies hold great potential to treat a wide range of human diseases, yet the mechanisms responsible for cell migration and homing are not fully understood. Emerging molecular imaging technology enables in vivo tracking of transplanted cells and their therapeutic efficacy, which together will improve the clinical outcome of cell-based therapy. Particularly, optical imaging provides highly sensitive, safe (non-radioactive), cost-effective, and fast solutions for real-time cellular trafficking compared to other conventional molecular imaging modalities. This review provides a comprehensive overview of current advances in optical imaging for cell-based therapy and tissue engineering. We discuss different types of fluorescent probes and their labeling methods with a special focus on cardiovascular disease, cancer immunotherapy, and tissue regeneration. In addition, advantages and limitations of optical imaging-based cell tracking strategies along with the future perspectives to translate this imaging technique for a clinical realm are discussed.

Enhancing the treatment effect on melanoma by heat shock protein 70-peptide complexes purified from human melanoma cell lines

Dendritic cell (DC) vaccines are currently one of the most effective approaches to treat melanoma. The immunogenicity of antigens loaded into DCs determines the treatment effects. Patients treated with autologous antigen-loaded DC vaccines achieve the best therapeutic effects. In China, most melanoma patients cannot access their autologous antigens because of formalin treatment of tumor tissue after surgery. In the present study, we purified heat shock protein 70 (HSP70)-peptide complexes (PCs) from human melanoma cell lines A375, A875, M21, M14, WM‑35, and SK‑HEL‑1. We named the purified product as M‑HSP70‑PCs, and determined its immunological activities. Autologous HSP70‑PCs purified from primary tumor cells of melanoma patients (nine cases) were used as controls. These two kinds of tumor antigenic complexes loaded into DCs were used to stimulate an antitumor response against tumor cells in the corresponding patients. Mature DCs pulsed with M‑HSP70‑PCs stimulated autologous T cells to secrete the same levels of type I cytokines compared with the autologous HSP70‑PCs. Moreover, DCs pulsed with M‑HSP70‑PCs induced CD8+ T cells with an equal ability to kill melanoma cells from patients compared with autologous HSP70‑PCs. Next, we used these PC‑pulsed autologous DCs and induced autologous specific CD8+ T cells to treat one patient with melanoma of the nasal skin and lung metastasis. The treatment achieved a good effect after six cycles. These findings provide a new direction for DC-based immunotherapy for melanoma patients who cannot access autologous antigens.

CCL20-CCR6 Cytokine Network Facilitate Treg Activity in Advanced Grades and Metastatic Variants of Hepatocellular Carcinoma

Tumour immunity regulates tumour restriction to the site of occurrence. Failure of this balance facilitates tumour spread beyond the primary organ of origin. Tregs are known to be recruited in infections, including viral infections like hepatitis B and hepatitis C. Thus, they form a continuum of initial viral infection, an environment of immune suppression by recruitment of Tregs, intrinsic viral-mediated nuclear transformation and carcinogenesis, and thereafter worsening of progress, including metastasis due to the Tregs suppressing the cell-mediated destruction of tumour cells. In this study, we obtained advanced grades of hepatocellular carcinoma (HCC) and examined the cytokines that is potentially known to recruit Tregs. We examined the expression of CCL20, the cytokine that recruits Tregs. We isolated Tregs from HCC samples and examined expression of CCR6, the receptor for CCL20 and compared expression in control tissues obtained mainly from subjects with cirrhosis, but no evidence of cancer. The findings of this study indicate that mRNA expression of CCL20 is significantly enhanced, along with expression of mRNA for the cytokines IL17 and IL6. Furthermore, tissue expression of Gamma-interferon was reduced in HCC. When Tregs were isolated from the liver cancer samples, the expression of CCR6, the only and specific receptor for CCL20, was upregulated in the cancer tissue derived Tregs . Furthermore, STAT3 levels were significantly increased in these tumour-derived Tregs. This study demonstrates that immune evasion mechanisms are operant in hepatocellular carcinoma through a transcriptional network of CCL20-IL17-IL6 cytokines that facilitate immune suppression-mediated cancer cell elimination and metastasis.

In Vivo Tracking of Phagocytic Immune Cells Using a Dual Imaging Probe with Gadolinium-Enhanced MRI and Near-Infrared Fluorescence

A novel dual imaging probe for in vivo magnetic resonance imaging (MRI) and optical imaging was developed by combining gadolinium (Gd)-chelating MR probe and a near-infrared (NIR) fluorophore, aza-BODIPY (AB; BODIPY = boron-dipyrromethene). This aza-BODIPY-based bimodal contrast agent (AB-BCA) showed a significant fluorescence emission around the NIR range and an enhanced longitudinal relaxivity in MR modality. The probe was easily delivered to phagocytic cells of the innate immune system, together with macrophages and dendritic cells (DCs), and presented high-performance fluorescence and MR imaging without obvious cytotoxicity. For in vivo visualization of AB-BCA using MRI and optical imaging, bone marrow-derived DCs were labeled and injected into the footpad of mice, and labeled DCs were tracked in vivo. We observed the migration of AB-BCA-labeled DCs into the lymph nodes via lymphatic vessels using NIR fluorescence and T1-weighted MR images. This dual-modality imaging probe was used for noninvasive monitoring of DC migration into lymph nodes and could be useful for investigating advanced cellular immunotherapy.

Advancing biomedical imaging

Imaging reveals complex structures and dynamic interactive processes, located deep inside the body, that are otherwise difficult to decipher. Numerous imaging modalities harness every last inch of the energy spectrum. Clinical modalities include magnetic resonance imaging (MRI), X-ray computed tomography (CT), ultrasound, and light-based methods [endoscopy and optical coherence tomography (OCT)]. Research modalities include various light microscopy techniques (confocal, multiphoton, total internal reflection, superresolution fluorescence microscopy), electron microscopy, mass spectrometry imaging, fluorescence tomography, bioluminescence, variations of OCT, and optoacoustic imaging, among a few others. Although clinical imaging and research microscopy are often isolated from one another, we argue that their combination and integration is not only informative but also essential to discovering new biology and interpreting clinical datasets in which signals invariably originate from hundreds to thousands of cells per voxel.

Radioactive Nanomaterials for Multimodality Imaging

Nuclear imaging techniques, including primarily positron emission tomography (PET) and single-photon emission computed tomography (SPECT), can provide quantitative information for a biological event in vivo with ultra-high sensitivity, however, the comparatively low spatial resolution is their major limitation in clinical application. By convergence of nuclear imaging with other imaging modalities like computed tomography (CT), magnetic resonance imaging (MRI) and optical imaging, the hybrid imaging platforms can overcome the limitations from each individual imaging technique. Possessing versatile chemical linking ability and good cargo-loading capacity, radioactive nanomaterials can serve as ideal imaging contrast agents. In this review, we provide a brief overview about current state-of-the-art applications of radioactive nanomaterials in the circumstances of multimodality imaging. We present strategies for incorporation of radioisotope(s) into nanomaterials along with applications of radioactive nanomaterials in multimodal imaging. Advantages and limitations of radioactive nanomaterials for multimodal imaging applications are discussed. Finally, a future perspective of possible radioactive nanomaterial utilization is presented for improving diagnosis and patient management in a variety of diseases.

Novel Radiotracer for ImmunoPET Imaging of PD-1 Checkpoint Expression on Tumor Infiltrating Lymphocytes

Immune checkpoint signaling through the programmed death 1 (PD-1) axis to its ligand (PD-L1) significantly dampens anti-tumor immune responses. Cancer patients treated with checkpoint inhibitors that block this suppressive signaling have exhibited objective response rates of 20-40% for advanced solid tumors, lymphomas, and malignant melanomas. This represents a tremendous advance in cancer treatment. Unfortunately, all patients do not respond to immune checkpoint blockade. Recent findings suggest that patients with tumor infiltrating lymphocytes (TILs) expressing PD-1 may be most likely to respond to αPD-1/PD-L1 checkpoint inhibitors. There is a compelling need for diagnostic and prognostic imaging tools to assess the PD-1 status of TILs in vivo. Here we have developed a novel immunoPET tracer to image PD-1 expressing TILs in a transgenic mouse model bearing melanoma. A (64)Cu labeled anti-mouse antibody (IgG) PD-1 immuno positron emission tomography (PET) tracer was developed to detect PD-1 expressing murine TILs. Quality control of the tracer showed >95% purity by HPLC and >70% immunoreactivity in an in vitro cell binding assay. ImmunoPET scans were performed over 1-48 h on Foxp3+.LuciDTR4 mice bearing B16-F10 melanoma tumors. Mice receiving anti-PD-1 tracer (200 ± 10 μCi/10-12 μg/200 μL) revealed high tracer uptake in lymphoid organs and tumors. BLI images of FoxP3(+) CD4(+) Tregs known to express PD-1 confirmed lymphocyte infiltration of tumors at the time of PET imaging. Biodistribution measurements performed at 48 h revealed a high (11×) tumor to muscle uptake ratio of the PET tracer (p < 0.05). PD-1 tumors exhibited 7.4 ± 0.7%ID/g tracer uptake and showed a 2× fold signal decrease when binding was blocked by unlabeled antibody. To the best of our knowledge this data is the first report to image PD-1 expression in living subjects with PET. This radiotracer has the potential to assess the prognostic value of PD-1 in preclinical models of immunotherapy and may ultimately aid in predicting response to therapies targeting immune checkpoints.