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Funke SKI, Factor C, Rasschaert M, Robert P, van Dijk NWM, Hußock M, Sperling M, Karst U. Elemental Imaging of Long-term Gadolinium Retention in Rodent Femur. Radiology 2023; 306:e213107. [PMID: 36194115 DOI: 10.1148/radiol.213107] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background The use of gadolinium-based contrast agents (GBCAs) is linked to gadolinium retention in the skeleton of healthy individuals. The mechanism of gadolinium incorporation into bone tissue is not fully understood and requires spatially resolved analysis to locate the gadolinium. Purpose To compare the quantitative distribution of gadolinium retained over time in rodent femur following the administration of gadodiamide and gadobutrol at three different time points. Materials and Methods In this animal study conducted between May 2018 and April 2020, 108 9-week-old healthy rats were repeatedly injected with either gadodiamide, gadobutrol, or saline solution and were killed 1, 3, or 12 months after the last injection. The femurs of six female and six male rats per each group and time point were collected. Quantitative elemental imaging of gadolinium in longitudinal thin sections was performed on one sample per sex with use of laser ablation inductively coupled plasma mass spectrometry (ICP-MS). Gadolinium concentration was determined with use of ICP-MS on the samples of all animals (six per group). Mann-Whitney U tests were applied on pairwise comparisons to determine potential sex effect and GBCA effect on gadolinium concentrations. Results The highest gadolinium retention was observed in the gadodiamide group (concentration, 97-200 nmol · g-1), exceeding the mean concentration in the gadobutrol group (6.5-17 nmol · g-1). However, the gadolinium distribution pattern was similar for both contrast agents, showing prominent gadolinium retention at endosteal surfaces, in the bone marrow, and in small tissue pores. Gadolinium distribution in cortical bone changed over time, initially showing a thin rim of higher concentration close to the periosteum, which appeared to grow wider and move toward the interior of the femur over 1 year. Conclusion For both gadolinium-based contrast agents, gadolinium retention in rat bone was initially located close to the periosteum and bone cavities and changed with bone remodeling processes. The relevance to long-term storage of gadolinium in humans remains to be determined. © RSNA, 2022 Online supplemental material is available for this article.
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Affiliation(s)
- Sabrina K I Funke
- From the Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstrasse 48, 48149 Münster, Germany (S.K.I.F., M.H., M.S., U.K.); Department of Research and Innovation, Guerbet Group, Roissy, France (C.F., M.R., P.R.); and Department of Dentistry, Dental Research Laboratory, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (N.W.M.v.D.)
| | - Cécile Factor
- From the Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstrasse 48, 48149 Münster, Germany (S.K.I.F., M.H., M.S., U.K.); Department of Research and Innovation, Guerbet Group, Roissy, France (C.F., M.R., P.R.); and Department of Dentistry, Dental Research Laboratory, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (N.W.M.v.D.)
| | - Marlène Rasschaert
- From the Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstrasse 48, 48149 Münster, Germany (S.K.I.F., M.H., M.S., U.K.); Department of Research and Innovation, Guerbet Group, Roissy, France (C.F., M.R., P.R.); and Department of Dentistry, Dental Research Laboratory, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (N.W.M.v.D.)
| | - Philippe Robert
- From the Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstrasse 48, 48149 Münster, Germany (S.K.I.F., M.H., M.S., U.K.); Department of Research and Innovation, Guerbet Group, Roissy, France (C.F., M.R., P.R.); and Department of Dentistry, Dental Research Laboratory, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (N.W.M.v.D.)
| | - Natasja W M van Dijk
- From the Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstrasse 48, 48149 Münster, Germany (S.K.I.F., M.H., M.S., U.K.); Department of Research and Innovation, Guerbet Group, Roissy, France (C.F., M.R., P.R.); and Department of Dentistry, Dental Research Laboratory, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (N.W.M.v.D.)
| | - Michelle Hußock
- From the Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstrasse 48, 48149 Münster, Germany (S.K.I.F., M.H., M.S., U.K.); Department of Research and Innovation, Guerbet Group, Roissy, France (C.F., M.R., P.R.); and Department of Dentistry, Dental Research Laboratory, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (N.W.M.v.D.)
| | - Michael Sperling
- From the Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstrasse 48, 48149 Münster, Germany (S.K.I.F., M.H., M.S., U.K.); Department of Research and Innovation, Guerbet Group, Roissy, France (C.F., M.R., P.R.); and Department of Dentistry, Dental Research Laboratory, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (N.W.M.v.D.)
| | - Uwe Karst
- From the Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstrasse 48, 48149 Münster, Germany (S.K.I.F., M.H., M.S., U.K.); Department of Research and Innovation, Guerbet Group, Roissy, France (C.F., M.R., P.R.); and Department of Dentistry, Dental Research Laboratory, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (N.W.M.v.D.)
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Fingerhut S, Buchholz R, Bücker P, Clasen W, Sperling M, Müller KM, Rehkämper J, Radbruch A, Richter H, Jeibmann A, Karst U. Gadolinium retention in the tunica media of arterial walls - a complementary study using elemental bioimaging and immunogold staining. Metallomics 2022; 14:6575571. [PMID: 35482657 DOI: 10.1093/mtomcs/mfac029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/08/2022] [Indexed: 11/14/2022]
Abstract
Gadolinium (Gd) deposition has been found in both animal and human tissues after serial injections of gadolinium-based contrast agents (GBCAs). Without the knowledge of which tissues are most affected, it is difficult to determine whether Gd accumulation could lead to any pathological changes. The current study aims at investigating histological sections of three patients who were exposed to GBCAs during their lifetime, and identify areas of Gd accumulation. Tissue sections of three autopsy cases were investigated by laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) to assess the distribution of Gd, and the deposition within tissue sections was quantified. Additional application of laser ablation-inductively coupled plasma-optical emission spectroscopy (LA-ICP-OES) enabled a sensitive detection of calcium (Ca) in the vessel walls, which is usually impeded in LA-ICP-MS due to the isobaric interference with argon. Complementary LA-ICP-MS and LA-ICP-OES analysis revealed that Gd was co-localized with zinc and calcium, in the area where smooth muscle actin was present. Notably, high levels of Gd were found in the tunica media of arterial walls, which requires further research into potential Gd-related toxicity in this specific location.
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Affiliation(s)
- Stefanie Fingerhut
- Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstraße 28/30, 48149 Münster, Germany
| | - Rebecca Buchholz
- Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstraße 28/30, 48149 Münster, Germany
| | - Patrick Bücker
- Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstraße 28/30, 48149 Münster, Germany
| | - Wolfgang Clasen
- Clinic for Internal Medicine, Herz-Jesu-Krankenhaus Hiltrup GmbH, Westfalenstraße 109, 48165 Münster-Hiltrup, Germany
| | - Michael Sperling
- Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstraße 28/30, 48149 Münster, Germany
| | - Klaus-Michael Müller
- Gerhard-Domagk-Institute for Pathology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Jan Rehkämper
- Gerhard-Domagk-Institute for Pathology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.,Department of Pathology, University Hospital Köln, Kerpener Straße 62, 50937 Köln, Germany
| | - Alexander Radbruch
- Clinic for Neuroradiology, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany.,Clinical Neuroimaging, German Center for Neurodegenerative Diseases, Venusberg Campus 1, 53127 Bonn, Germany
| | - Henning Richter
- Clinical Neuroimaging, German Center for Neurodegenerative Diseases, Venusberg Campus 1, 53127 Bonn, Germany.,Diagnostic Imaging Research Unit (DIRU), Clinic for Diagnostic Imaging, Department of Clinical Diagnostics and Services, Vetsuisse Faculty, University of Zurich, Winterthurerstrasse 258c, 8057 Zurich, Switzerland
| | - Astrid Jeibmann
- Institute of Neuropathology, University Hospital Münster, Pottkamp 2, 48149 Münster Germany
| | - Uwe Karst
- Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstraße 28/30, 48149 Münster, Germany
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Bücker P, Funke SKI, Factor C, Rasschaert M, Robert P, Sperling M, Karst U. Combined speciation analysis and elemental bioimaging provides new insight into gadolinium retention in kidney. Metallomics 2022; 14:6527577. [PMID: 35150284 DOI: 10.1093/mtomcs/mfac004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/31/2022] [Indexed: 11/14/2022]
Abstract
This study uses a leaching approach in combination with elemental bioimaging and speciation analysis to obtain insight into the gadolinium species present in the kidney of rats that were treated with either a linear or a macrocyclic gadolinium-based contrast agent. Fresh frozen thin sections of the harvested kidneys were immersed halfway into water to wash out hydrophilic species and subsequently analyzed by laser ablation-inductively coupled plasma-mass spectrometry. The water-extracted gadolinium species were analyzed by means of hydrophilic interaction liquid chromatography-inductively coupled plasma-mass spectrometry. Information on the water-soluble species could not only be obtained from the full kidney, but also be traced back to its localization in the tissue. On longitudinal kidney sections treated with gadobutrol, it was found that water-insoluble, permanent Gd depositions were mainly located in the renal cortex, while water-soluble species were found in the medulla, which contains the intact contrast agent up to one year after injection. Moreover, kidney samples from gadodiamide-treated rats showed more water-insoluble Gd deposition in both cortex and medulla, while the concentration of intact contrast agent in the water-soluble fraction was below the limit of detection after twelve months. In conclusion, this rapid approach allowed the spatially resolved differentiation between water-soluble and insoluble gadolinium deposition and is therefore capable of generating new insight into the retention and transportation behavior of gadolinium.
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Affiliation(s)
- Patrick Bücker
- Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstrasse 28/30, Münster 48149, Germany
| | - Sabrina K I Funke
- Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstrasse 28/30, Münster 48149, Germany
| | - Cécile Factor
- Department of Research and Innovation, Guerbet, Roissy CDG, France
| | | | - Philippe Robert
- Department of Research and Innovation, Guerbet, Roissy CDG, France
| | - Michael Sperling
- Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstrasse 28/30, Münster 48149, Germany
| | - Uwe Karst
- Institute of Inorganic and Analytical Chemistry, University of Münster, Corrensstrasse 28/30, Münster 48149, Germany
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Laser Ablation ICP-MS Analysis of Chemically Different Regions of Rat Prostate Gland with Implanted Cancer Cells. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12031474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The comparison of tissues analyzed by LA-ICP-MS is challenging in many aspects, both medical and mathematical. The concept of distinguishing regions of interest (ROIs) was proposed in the literature, allowing for data reduction and targeted comparative analysis. ROIs can be drawn before any analysis, by indicating the anatomical parts of tissue, or after the first step of analysis, by using elemental distribution maps and characteristic regions of enrichment in selected elements. A simple method for identifying different regions, without the manual extraction of image fragments, is highly needed in biological experiments, where large groups of individuals (with samples taken from each of them) is very common. In the present study, two ROIs were distinguished: (1) tissue-rich in fat (and tissue-poor in water); and (2) tissue-rich in water (and tissue-poor in fat). ROIs were extracted mathematically, using an algorithm based on the relationship between 13C and 23Na signal intensities. A cut-off point was indicated in the point of the simultaneous decrease in 13C and increase in 23Na signal intensity. Separate analyses of chemically different ROIs allow for targeted comparison, which is a great advantage of laser ablation over liquid introductions to ICP-MS. In the present experiment, tissues were provided from animals with implanted prostate cancer cells as well as supplemented with mineral compounds particularly important both for prostate gland functions (Zn and Se) and neoplastic processes (Ca, Fe, and Cu). One of the goals was to try to determine whether dietary supplementation qualitatively and quantitatively affects the mineral composition of the prostate gland.
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Boyraz B, Saatz J, Pompös IM, Gad M, Dernedde J, Maier AKB, Moscovitz O, Seeberger PH, Traub H, Tauber R. Imaging Keratan Sulfate in Ocular Tissue Sections by Immunofluorescence Microscopy and LA-ICP-MS. ACS APPLIED BIO MATERIALS 2022; 5:853-861. [PMID: 35076201 DOI: 10.1021/acsabm.1c01240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Carbohydrate-specific antibodies can serve as valuable tools to monitor alterations in the extracellular matrix resulting from pathologies. Here, the keratan sulfate-specific monoclonal antibody MZ15 was characterized in more detail by immunofluorescence microscopy as well as laser ablation ICP-MS using tissue cryosections and paraffin-embedded samples. Pretreatment with keratanase II prevented staining of samples and therefore demonstrated efficient enzymatic keratan sulfate degradation. Random fluorescent labeling and site-directed introduction of a metal cage into MZ15 were successful and allowed for a highly sensitive detection of the keratan sulfate landscape in the corneal stroma from rats and human tissue.
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Affiliation(s)
- Burak Boyraz
- Institut für Laboratoriumsmedizin, Klinische Chemie und Pathobiochemie, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, Berlin 13353, Germany.,Freie Universität Berlin, Fachbereich Biologie, Chemie, Pharmazie, Arnimallee 22, Berlin 14195, Germany
| | - Jessica Saatz
- Bundesanstalt für Materialforschung und -prüfung (BAM), Richard-Willstätter-Strasse, 11, Berlin 12489, Germany
| | - Inga-Marie Pompös
- Klinik für Augenheilkunde, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, Berlin 13353, Germany
| | - Michel Gad
- Bundesanstalt für Materialforschung und -prüfung (BAM), Richard-Willstätter-Strasse, 11, Berlin 12489, Germany.,Department Chemie und Biologie, Universität Siegen, Adolf-Reichwein-Strasse 2, Siegen 57076, Germany
| | - Jens Dernedde
- Institut für Laboratoriumsmedizin, Klinische Chemie und Pathobiochemie, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, Berlin 13353, Germany
| | - Anna-Karina B Maier
- Klinik für Augenheilkunde, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, Berlin 13353, Germany
| | - Oren Moscovitz
- Biomolecular Systems Department, Max-Planck-Institute for Colloids and Interfaces, Am Mühlenberg 1, Potsdam 14476, Germany
| | - Peter H Seeberger
- Biomolecular Systems Department, Max-Planck-Institute for Colloids and Interfaces, Am Mühlenberg 1, Potsdam 14476, Germany
| | - Heike Traub
- Bundesanstalt für Materialforschung und -prüfung (BAM), Richard-Willstätter-Strasse, 11, Berlin 12489, Germany
| | - Rudolf Tauber
- Institut für Laboratoriumsmedizin, Klinische Chemie und Pathobiochemie, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, Berlin 13353, Germany
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Funke SKI, Sperling M, Karst U. Weighted Linear Regression Improves Accuracy of Quantitative Elemental Bioimaging by Means of LA-ICP-MS. Anal Chem 2021; 93:15720-15727. [PMID: 34784194 DOI: 10.1021/acs.analchem.1c03630] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The application of ordinary least squares (OLS) linear regression is widely used in order to approximate linear external calibration data. However, the assumption of homoscedasticity is often not considered as a requirement for correct data approximation, which can result in a poor regression fit that is often more prominent in the lower concentration range. Heteroscedasticity in inductively coupled plasma-mass spectrometry (ICP-MS) data has been discussed in literature as an intrinsic problem and was found to be addressed better by the use of weighted least squares (WLS) regression in multiple studies. In this study, the effects of OLS and WLS linear regression models have been investigated for quantitative imaging experiments by means of laser ablation (LA)-ICP-MS using matrix-matched standards. The calibration data produced by this technique was found to be heteroscedastic in all 60 analyzed datasets, which yielded poor regression fits for OLS linear regression. In comparison to conventional ICP-MS analysis, the resulting negative effects were found to become even more visible in imaging LA-ICP-MS due to an inaccurate estimation of the regression line's intercept. Also, the calculation of average concentrations in selected regions of interest (ROIs) yields incorrect quantification results at the lower end of the calibration range. The application of WLS linear regression resulted in an improved goodness of fit (GOF), although the weighting factor should be selected carefully. Besides the reciprocal of the variance of each calibration standard (1/si2), more empirical weighting factors that have been discussed in the literature were also evaluated regarding the GOF.
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Affiliation(s)
- Sabrina K I Funke
- Institute of Inorganic and Analytical Chemistry, University of Münster, Münster 48149, Germany
| | - Michael Sperling
- Institute of Inorganic and Analytical Chemistry, University of Münster, Münster 48149, Germany.,European Virtual Institute for Speciation Analysis (EVISA), Münster 48149, Germany
| | - Uwe Karst
- Institute of Inorganic and Analytical Chemistry, University of Münster, Münster 48149, Germany
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Gamov GA, Zavalishin MN. La3+, Ce3+, Eu3+, and Gd3+ Complex Formation with Hydrazones Derived from Pyridoxal 5'-Phosphate in a Neutral Tris–HCl Buffer. RUSS J INORG CHEM+ 2021. [DOI: 10.1134/s0036023621100053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ullmann JM, Erbersdobler A. Gastric lanthanosis (lanthanum deposition) in an immunosuppressed patient that discontinued lanthanum carbonate seven years ago. Clin Case Rep 2021; 9:e05075. [PMID: 34815874 PMCID: PMC8594568 DOI: 10.1002/ccr3.5075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/15/2021] [Accepted: 10/26/2021] [Indexed: 11/14/2022] Open
Abstract
A 72-year-old female patient used the oral phosphate binder lanthanum carbonate for 6 years, before discontinuing it after receiving a pancreas and kidney transplant. Now, 7 years after discontinuation, the patient developed bilious emesis. An upper gastrointestinal endoscopy showed an unspecific gastritis. Biopsies showed subepithelial crystalline deposits consistent with gastric lanthanosis.
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Affiliation(s)
- Joana M. Ullmann
- Institute of PathologyUniversity Medicine RostockStrempelstr. 14Rostock18057Germany
| | - Andreas Erbersdobler
- Institute of PathologyUniversity Medicine RostockStrempelstr. 14Rostock18057Germany
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Doble PA, de Vega RG, Bishop DP, Hare DJ, Clases D. Laser Ablation-Inductively Coupled Plasma-Mass Spectrometry Imaging in Biology. Chem Rev 2021; 121:11769-11822. [PMID: 34019411 DOI: 10.1021/acs.chemrev.0c01219] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Elemental imaging gives insight into the fundamental chemical makeup of living organisms. Every cell on Earth is comprised of a complex and dynamic mixture of the chemical elements that define structure and function. Many disease states feature a disturbance in elemental homeostasis, and understanding how, and most importantly where, has driven the development of laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) as the principal elemental imaging technique for biologists. This review provides an outline of ICP-MS technology, laser ablation cell designs, imaging workflows, and methods of quantification. Detailed examples of imaging applications including analyses of cancers, elemental uptake and accumulation, plant bioimaging, nanomaterials in the environment, and exposure science and neuroscience are presented and discussed. Recent incorporation of immunohistochemical workflows for imaging biomolecules, complementary and multimodal imaging techniques, and image processing methods is also reviewed.
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Affiliation(s)
- Philip A Doble
- Atomic Medicine Initiative, University of Technology Sydney, Broadway, New South Wales 2007, Australia
| | - Raquel Gonzalez de Vega
- Atomic Medicine Initiative, University of Technology Sydney, Broadway, New South Wales 2007, Australia
| | - David P Bishop
- Atomic Medicine Initiative, University of Technology Sydney, Broadway, New South Wales 2007, Australia
| | - Dominic J Hare
- Atomic Medicine Initiative, University of Technology Sydney, Broadway, New South Wales 2007, Australia.,School of BioSciences, University of Melbourne, Parkville, Victoria 3052, Australia
| | - David Clases
- Atomic Medicine Initiative, University of Technology Sydney, Broadway, New South Wales 2007, Australia
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