Nuclear medicine for photodynamic therapy in cancer: Planning, monitoring and nuclear PDT

Research progress of fullerenes and their derivatives in the field of PDT

In contemporary studies, the predominant utilization of C60 derivatives pertains to their role as photosensitizers or agents that scavenge free radicals. The intriguing coexistence of these divergent functionalities has prompted extensive investigation into water-soluble fullerenes. The photodynamic properties of these compounds find practical applications in DNA cleavage, antitumor interventions, and antibacterial endeavors. Consequently, photodynamic therapy is progressively emerging as a pivotal therapeutic modality within the biomedical domain, owing to its notable levels of safety and efficacy. The essential components of photodynamic therapy encompass light of the suitable wavelength, oxygen, and a photosensitizer, wherein the reactive oxygen species generated by the photosensitizer play a pivotal role in the therapeutic mechanism. The remarkable ability of fullerenes to generate singlet oxygen has garnered significant attention from scholars worldwide. Nevertheless, the limited permeability of fullerenes across cell membranes owing to their low water solubility necessitates their modification to enhance their efficacy and utilization. This paper reviews the applications of fullerene derivatives as photosensitizers in antitumor and antibacterial fields for the recent years.

Investigation of Photodynamic Therapy Promoted by Cherenkov Light Activated Photosensitizers-New Aspects and Revelations

This work investigates the proposed enhanced efficacy of photodynamic therapy (PDT) by activating photosensitizers (PSs) with Cherenkov light (CL). The approaches of Yoon et al. to test the effect of CL with external radiation were taken up and refined. The results were used to transfer the applied scheme from external radiation therapy to radionuclide therapy in nuclear medicine. Here, the CL for the activation of the PSs (psoralen and trioxsalen) is generated by the ionizing radiation from rhenium-188 (a high-energy beta-emitter, Re-188). In vitro cell survival studies were performed on FaDu, B16 and 4T1 cells. A characterization of the PSs (absorbance measurement and gel electrophoresis) and the CL produced by Re-188 (luminescence measurement) was performed as well as a comparison of clonogenic assays with and without PSs. The methods of Yoon et al. were reproduced with a beam line at our facility to validate their results. In our studies with different concentrations of PS and considering the negative controls without PS, the statements of Yoon et al. regarding the positive effect of CL could not be confirmed. There are slight differences in survival fractions, but they are not significant when considering the differences in the controls. Gel electrophoresis showed a dominance of trioxsalen over psoralen in conclusion of single and double strand breaks in plasmid DNA, suggesting a superiority of trioxsalen as a PS (when irradiated with UVA). In addition, absorption measurements showed that these PSs do not need to be shielded from ambient light during the experiment. An observational test setup for a PDT nuclear medicine approach was found. The CL spectrum of Re-188 was measured. Fluctuating inconclusive results from clonogenic assays were found.

Radiometal-Labeled Photoactivatable Pt(IV) Anticancer Complex for Theranostic Phototherapy

A novel photoactivatable Pt(IV) diazido anticancer agent, Pt-succ-DFO, bearing a pendant deferoxamine (DFO) siderophore for radiometal chelation, has been synthesized for the study of its in vivo behavior with radionuclide imaging. Pt-succ-DFO complexation of Fe(III) and Ga(III) ions yielded new heterobimetallic complexes that maintain the photoactivation properties and photocytotoxicity of the parent Pt complex in human cancer cell lines. Radiolabeled Pt-succ-DFO-68Ga (t1/2 = 68 min, positron emitter) was readily prepared under mild conditions and was stable in the dark upon incubation with human serum. PET imaging of Pt-succ-DFO-68Ga in healthy mice revealed a promising biodistribution profile with rapid renal excretion and limited organ accumulation, implying that little off-target uptake is expected for this class of agents. Overall, this research provides the first in vivo imaging study of the whole-body distribution of a photoactivatable Pt(IV) azido anticancer complex and illustrates the potential of radionuclide imaging as a tool for the preclinical development of novel light-activated agents.

Cherenkov Radiation induced photodynamic therapy - repurposing older photosensitizers, and radionuclides

CONTEXT

Old-generation photosensitizers are minimally used in current photodynamic therapy (PDT) because they absorb in the UV/blue/green region of the spectrum where biological tissues are generally highly absorbing. The UV/blue light of Cherenkov Radiation (CR) from nuclear disintegration of beta-emitter radionuclides shows promise as an internal light source to activate these photosensitizers within tissue. Outline of the study: 1) radionuclide choice and Cherenkov Radiation, 2) Photosensitizer choice, synthesis and radiolabeling, 3) CR-induced fluorescence, 4) Verification of ROS formation, 5) CR-induced PDT with either free eosine and free CR emitter, or with radiolabelled eosin.

RESULTS

Cherenkov Radiation Energy Transfer (CRET) from therapeutic radionuclides (90Y) and PET imaging radionuclides (18F, 68Ga) to eosin was shown by spectrofluorimetry and in vitro, and was shown to result in a PDT process. The feasibility of CR-induced PDT (CR-PDT) was demonstrated in vitro on B16F10 murine melanoma cells mixing free eosin (λabs = 524 nm, ΦΔ 0.67) with free CR-emitter [18F]-FDG under their respective intrinsic toxicity levels (0.5 mM/8 MBq) and by trapping singlet oxygen with diphenylisobenzofuran (DPBF). An eosin-DOTAGA-chelate conjugate 1 was synthesized and radiometallated with CR-emitter [68Ga] allowed to reach 25 % cell toxicity at 0.125 mM/2 MBq, i.e. below the toxicity threshold of each component measured on controls. Incubation time was carefully examined, especially for CR emitters, in light of its toxicity, and its CR-emitting yield expected to be 3 times as much for 68Ga than 18F (considering their β particle energy) per radionuclide decay, while its half-life is about twice as small.

PERSPECTIVE

This study showed that in complete darkness, as it is at depth in tissues, PDT could proceed relying on CR emission from radionuclides only. Interestingly, this study also repurposed PET imaging radionuclides, such as 68Ga, to trigger a therapeutic event (PDT), albeit in a modest extent. Moreover, although it remains modest, such a PDT approach may be used to achieve additional tumoricidal effect to RIT treatment, where radionuclides, such as 90Y, are strong CR emitters, i.e. very potent light source for photosensitizer activation.

Photodynamic therapy in brain cancer: mechanisms, clinical and preclinical studies and therapeutic challenges

Cancer is a main cause of death and preferred methods of therapy depend on the type of tumor and its location. Gliomas are the most common primary intracranial tumor, accounting for 81% of malignant brain tumors. Although relatively rare, they cause significant mortality. Traditional methods include surgery, radiotherapy and chemotherapy; they also have significant associated side effects that cause difficulties related to tumor excision and recurrence. Photodynamic therapy has potentially fewer side effects, less toxicity, and is a more selective treatment, and is thus attracting increasing interest as an advanced therapeutic strategy. Photodynamic treatment of malignant glioma is considered to be a promising additional therapeutic option that is currently being extensively investigated in vitro and in vivo. This review describes the application of photodynamic therapy for treatment of brain cancer. The mechanism of photodynamic action is also described in this work as it applies to treatment of brain cancers such as glioblastoma multiforme. The pros and cons of photodynamic therapy for brain cancer are also discussed.

Carbon network-hosted porphyrin as a highly biocompatible nanophotosensitizer for enhanced photodynamic therapy

Photodynamic therapy (PDT) has the characteristics of being simple and non-invasive, and with on-demand light control. However, most photosensitizers exhibit strong hydrophobicity, low quantum yields in water and low tumor selectivity. In this study, carbon network-hosted porphyrins (CPs) with high biocompatibility and efficient singlet oxygen (1O2) generation were developed to reduce the biotoxicity of photosensitizers and avoid quenching caused by hydrophobic aggregation for enhanced PDT. The CPs were prepared by a simple solid-phase synthesis method using porphyrin, green non-toxic citric acid and urea as the raw materials. The CPs exhibited excellent water solubility and high biocompatibility. Even when the concentration reached 1.5 mg mL-1, cells still had good biological activity. By separately fixing the porphyrins in the carbon network, the CPs avoided aggregation-induced inactivation and had high generation efficiency of 1O2. Furthermore, in order to improve the PDT effect, the CPs were modified with the upper nuclear targeting peptide TAT (T-CPs), which was used to target the nucleus and generate 1O2in situ to directly destroy genetic material. The proposed strategy provides a simple and green path to prepare nanophotosensitizers with high biocompatibility and efficient 1O2 generation for PDT.

Automated radiosynthesis and in vivo evaluation of 18F-labeled analog of the photosensitizer ADPM06 for planning photodynamic therapy

BACKGROUND

A family of BF₂-chelated tetraaryl-azadipyrromethenes was developed as non-porphyrin photosensitizers for photodynamic therapy. Among the developed photosensitizers, ADPM06 exhibited excellent photochemical and photophysical properties. Molecular imaging is a useful tool for photodynamic therapy planning and monitoring. Radiolabeled photosensitizers can efficiently address photosensitizer biodistribution, providing helpful information for photodynamic therapy planning. To evaluate the biodistribution of ADPM06 and predict its pharmacokinetics on photodynamic therapy with light irradiation immediately after administration, we synthesized [¹⁸F]ADPM06 and evaluated its in vivo properties.

RESULTS

[¹⁸F]ADPM06 was automatically synthesized by Lewis acid-assisted isotopic ¹⁸F-¹⁹F exchange using ADPM06 and tin (IV) chloride at room temperature for 10 min. Radiolabeling was carried out using 0.4 μmol of ADPM06 and 200 μmol of tin (IV) chloride. The radiosynthesis time was approximately 60 min, and the radiochemical purity was > 95% at the end of the synthesis. The decay-corrected radiochemical yield from [¹⁸F]F^- at the start of synthesis was 13 ± 2.7% (n = 5). In the biodistribution study of male ddY mice, radioactivity levels in the heart, lungs, liver, pancreas, spleen, kidney, small intestine, muscle, and brain gradually decreased over 120 min after the initial uptake. The mean radioactivity level in the thighbone was the highest among all organs investigated and increased for 120 min after injection. Upon co-injection with ADPM06, the radioactivity levels in the blood and brain significantly increased, whereas those in the heart, lung, liver, pancreas, kidney, small intestine, muscle, and thighbone of male ddY mice were not affected. In the metabolite analysis of the plasma at 30 min post-injection in female BALB/c-nu/nu mice, the percentage of radioactivity corresponding to [¹⁸F]ADPM06 was 76.3 ± 1.6% (n = 3). In a positron emission tomography study using MDA-MB-231-HTB-26 tumor-bearing mice (female BALB/c-nu/nu), radioactivity accumulated in the bone at a relatively high level and in the tumor at a moderate level for 60 min after injection.

CONCLUSIONS

We synthesized [¹⁸F]ADPM06 using an automated ¹⁸F-labeling synthesizer and evaluated the initial uptake and pharmacokinetics of ADPM06 using biodistribution of [¹⁸F]ADPM06 in mice to guide photodynamic therapy with light irradiation.

Psoralen as a Photosensitizers for Photodynamic Therapy by Means of In Vitro Cherenkov Light

Possible enhancements of DNA damage with light of different wavelengths and ionizing radiation (Rhenium-188-a high energy beta emitter (Re-188)) on plasmid DNA and FaDu cells via psoralen were investigated. The biophysical experimental setup could also be used to investigate additional DNA damage due to photodynamic effects, resulting from Cherenkov light. Conformational changes of plasmid DNA due to DNA damage were detected and quantified by gel electrophoresis and fluorescent staining. The clonogene survival of the FaDu cells was analyzed with colony formation assays. Dimethyl sulfoxide was chosen as a chemical modulator, and Re-188 was used to evaluate the radiotoxicity and light (UVC: λ = 254 nm and UVA: λ = 366 nm) to determine the phototoxicity. Psoralen did not show chemotoxic effects on the plasmid DNA or FaDu cells. After additional treatment with light (only 366 nm-not seen with 254 nm), a concentration-dependent increase in single strand breaks (SSBs) was visible, resulting in a decrease in the survival fraction due to the photochemical activation of psoralen. Whilst UVC light was phototoxic, UVA light did not conclude in DNA strand breaks. Re-188 showed typical radiotoxic effects with SSBs, double strand breaks, and an overall reduced cell survival for both the plasmid DNA and FaDu cells. While psoralen and UVA light showed an increased toxicity on plasmid DNA and human cancer cells, Re-188, in combination with psoralen, did not provoke additional DNA damage via Cherenkov light.

Secure transplantation by tissue purging using photodynamic therapy to eradicate malignant cells

The field of photodynamic therapy (PDT) for treating various malignant neoplasms has been given researchers' attention due to its ability to be a selective and minimally invasive cancer therapy strategy. The possibility of tumor cell infection and hence high recurrence rates in cancer patients tends to restrict autologous transplantation. So, the photodynamic tissue purging process, which consists of selective photoinactivation of the malignant cells in the graft, is defined as a compromising strategy to purify contaminated tissues before transplantation. In this strategy, the direct malignant cells' death results from the reactive oxygen species (ROS) generation through the activation of a photosensitizer (PS) by light exposure in the presence of oxygen. Since new PS generations can effectively penetrate the tissue, PDT could be an ideal ex vivo tissue purging protocol that eradicates cancer cells derived from various malignancies. The challenge is that the applied pharmacologic ex vivo tissue purging should efficiently induce tumor cells with minor influence on normal tissue cells. This review aims to provide an overview of the current status of the most effective PDT strategies and PS development concerning their potential application in ex vivo purging before hematopoietic stem cell or ovarian tissue transplantation.

Recent Advances in Photosensitizers as Multifunctional Theranostic Agents for Imaging-Guided Photodynamic Therapy of Cancer

In recent years tremendous effort has been invested in the field of cancer diagnosis and treatment with an overall goal of improving cancer management, therapeutic outcome, patient survival, and quality of life. Photodynamic Therapy (PDT), which works on the principle of light-induced activation of photosensitizers (PS) leading to Reactive Oxygen Species (ROS) mediated cancer cell killing has received increased attention as a promising alternative to overcome several limitations of conventional cancer therapies. Compared to conventional therapies, PDT offers the advantages of selectivity, minimal invasiveness, localized treatment, and spatio-temporal control which minimizes the overall therapeutic side effects and can be repeated as needed without interfering with other treatments and inducing treatment resistance. Overall PDT efficacy requires proper planning of various parameters like localization and concentration of PS at the tumor site, light dose, oxygen concentration and heterogeneity of the tumor microenvironment, which can be achieved with advanced imaging techniques. Consequently, there has been tremendous interest in the rationale design of PS formulations to exploit their theranostic potential to unleash the imperative contribution of medical imaging in the context of successful PDT outcomes. Further, recent advances in PS formulations as activatable phototheranostic agents have shown promising potential for finely controlled imaging-guided PDT due to their propensity to specifically turning on diagnostic signals simultaneously with photodynamic effects in response to the tumor-specific stimuli. In this review, we have summarized the recent progress in the development of PS-based multifunctional theranostic agents for biomedical applications in multimodal imaging combined with PDT. We also present the role of different imaging modalities; magnetic resonance, optical, nuclear, acoustic, and photoacoustic in improving the pre-and post-PDT effects. We anticipate that the information presented in this review will encourage future development and design of PSs for improved image-guided PDT for cancer treatment.

Aptamer-Targeted Photodynamic Platforms for Tumor Therapy

Achieving controlled and accurate delivery of photosensitizers (PSs) into tumor sites is a major challenge in conventional photodynamic therapy (PDT). Aptamer is a short oligonucleotide sequence (DNA or RNA) with a folded three-dimensional structure, which can selectively bind to specific small molecules, proteins, or the whole cells. Aptamers could act as ligands and be modified onto PSs or nanocarriers, enabling specific recognition and binding to tumor cells or their membrane proteins. The resultant aptamer-modified PSs or PSs-containing nanocarriers generate amounts of reactive oxygen species with light irradiation and obtain superior photodynamic therapeutic efficiency in tumors. Herein, we overview the recent progress in the designs and applications of aptamer-targeted photodynamic platforms for tumor therapy. First, we focus on the progress on the rational selection of aptamers and summarize the applications of aptamers which have been applied for targeted tumor diagnosis and therapy. Then, aptamer-targeted photodynamic therapies including various aptamer-PSs, aptamer-nanocarriers containing PSs, and aptamer-nano-photosensitizers are highlighted. The aptamer-targeted synergistically therapeutic platforms including PDT, photothermal therapy, and chemotherapy, as well as the imaging-guided theranostics, are also discussed. Finally, we offer an insight into the development trends and future perspectives of aptamer-targeted photodynamic platforms for tumor therapy.

Application of phototherapeutic-based nanoparticles in colorectal cancer

Colorectal cancer (CRC) is the third most commonly diagnosed malignancy and the second leading cause of cancer death, which accounts for approximately 10% of all new cancer cases worldwide. Surgery is the main method for treatment of early-stage CRC. However, it is not effective for most metastatic tumors, and new treatment and diagnosis strategies need to be developed. Photosensitizers (PSs) play an important role in the treatment of CRC. Phototherapy also has a broad prospect in the treatment of CRC because of its low invasiveness and low toxicity. However, most PSs are associated with limitations including poor solubility, poor selectivity and high toxicity. The application of nanomaterials in PSs has added many advantages, including increased solubility, bioavailability, targeting, stability and low toxicity. In this review, based on phototherapy, we discuss the characteristics and development progress of PSs, the targeting of PSs at organ, cell and molecular levels, and the current methods of optimizing PSs, especially the application of nanoparticles as carriers in CRC. We introduce the photosensitizer (PS) targeting process in photodynamic therapy (PDT), the damage mechanism of PDT, and the application of classic PS in CRC. The action process and damage mechanism of photothermal therapy (PTT) and the types of ablation agents. In addition, we present the imaging examination and the application of PDT / PTT in tumor, including (fluorescence imaging, photoacoustic imaging, nuclear magnetic resonance imaging, nuclear imaging) to provide the basis for the early diagnosis of CRC. Notably, single phototherapy has several limitations in vivo, especially for deep tumors. Here, we discuss the advantages of the combination therapy of PDT and PTT compared with the single therapy. At the same time, this review summarizes the clinical application of PS in CRC. Although a variety of nanomaterials are in the research and development stage, few of them are actually on the market, they will show great advantages in the treatment of CRC in the near future.

Conjugated Photosensitizers for Imaging and PDT in Cancer Research

Early cancer detection and perfect understanding of the disease are imperative toward efficient treatments. It is straightforward that, for choosing a specific cancer treatment methodology, diagnostic agents undertake a critical role. Imaging is an extremely intriguing tool since it assumes a follow up to treatments to survey the accomplishment of the treatment and to recognize any conceivable repeating injuries. It also permits analysis of the disease, as well as to pursue treatment and monitor the possible changes that happen on the tumor. Likewise, it allows screening the adequacy of treatment and visualizing the state of the tumor. Additionally, when the treatment is finished, observing the patient is imperative to evaluate the treatment methodology and adjust the treatment if necessary. The goal of this review is to present an overview of conjugated photosensitizers for imaging and therapy.

A chlorin-lipid nanovesicle nucleus drug for amplified therapeutic effects of lung cancer by internal radiotherapy combined with the Cerenkov radiation-induced photodynamic therapy

Traditional photodynamic therapy (PDT) requires external light excitation to produce reactive oxygen species (ROSs) for the treatment of tumors. Due to problems of light penetration, traditional PDT is limited by the location and depth of the tumor. In this study, we rationally designed and constructed a novel strategy to amplify the therapeutic effect of PDT. We prepared a chlorin-lipid nanovesicle based on the conjugates of chlorin e6 (Ce 6) and phospholipids, with the surface conjugating the aptamer for lung cancer targeting, GLT21.T. ¹³¹I-labeled bovine serum albumin (¹³¹I-BSA) was loaded into the chlorin-lipid nanovesicle cavity (¹³¹I-BSA@LCN-Apt). ¹³¹I not only plays a role in radiotherapy, but its Cerenkov radiation (CR), as an internal light source, can also stimulate Ce6 to produce ROSs without external light excitation. The in vitro and in vivo therapeutic effects in subcutaneous lung tumor models and orthotopic lung tumor models indicated that ¹³¹I-BSA@LCN-Apt produced a powerful anti-tumor effect through synergistic radiotherapy and CR-PDT, which almost caused complete tumor growth regression. After treatment, the survival time of the mice was significantly prolonged. During the treatment, no obvious side effects were found by histopathology of important organs, hematology and biochemistry analysis except the decrease of the white blood cell count (WBC). The study provides a major tool for deep-seated tumors to obtain amplified therapeutic effects by synergistic radiotherapy and CR-PDT without the use of any external light source.

Dual Cherenkov Radiation-Induced Near-Infrared Luminescence Imaging and Photodynamic Therapy toward Tumor Resection

Cherenkov radiation (CR), the blue light seen in nuclear reactors, is emitted by some radiopharmaceuticals. This study showed that (1) a portion of CR could be transferred in the region of the optical spectrum, where biological tissues are most transparent: as a result, upon radiance amplification in the near-infrared window, the detection of light could occur twice deeper in tissues than during classical Cherenkov luminescence imaging and (2) Cherenkov-photodynamic therapy (CR-PDT) on cells could be achieved under conditions mimicking unlimited depth using the CR-embarked light source, which is unlike standard PDT, where light penetration depth is limited in biological tissues. Both results are of utmost importance for simultaneous applications in tumor resection and post-resection treatment of remaining unresected margins, thanks to a molecular construct designed to raise its light collection efficiency (i.e., CR energy transfer) by conjugation with multiple CR-absorbing (water-soluble) antenna followed by intramolecular-FRET/TBET energy transfers.

Nanoscale ZnO-based photosensitizers for photodynamic therapy

Due to the ability to induce the generation of reactive oxygen species (ROS) under light irradiation, ZnO nanoparticles show great potential in photodynamic therapy (PDT). Photo-triggered ROS production by ZnO nanoparticles and the resulting phototoxicity are efficient in killing cancer cells. This review highlights the recent exciting progress on the nanoscale ZnO-based photosensitizers (PSs) for PDT. Both the semplice ZnO nanoparticles as the PSs and the various chemicals (organic PS, dopant, metal and chemotherapeutic drugs) modified ZnO nanoparticles as the PSs show good ROS generation efficiency. The productive rate of ROS, the wavelength of exciting lights, and the therapeutic effect can be altered by doping different chemicals into ZnO nanoparticles at will. Additionally, we give some outlook on the design and functionalization of next-generation ZnO nanoparticles for more effective anti-cancer applications.

Overexpression of E74-Like Factor 5 (ELF5) Inhibits Migration and Invasion of Ovarian Cancer Cells

Background

E74-like factor 5 (ELF5) plays a key role in the processes of cell differentiation, apoptosis, and occurrence of tumors. However, the effect of ELF5 on metastasis and invasion in human ovarian cancer remains poorly understood.

Material/Methods

Quantitative real-time polymerase chain reaction (qPCR) was performed to measure the expression of ELF5. The viability of cells was detected by cell counting kit (CCK-8). Cell apoptosis was tested by flow cytometry. Matrigel plug angiogenesis assay was employed to determine angiogenesis rate. The protein expression levels of vascular endothelial growth factor (VEGF), cleaved caspase-3, B-cell lymphoma 2 (Bcl-2), Bcl-2-associated X protein (Bax), E-cadherin, N-cadherin, Snail, phosphoinositide 3 kinase (PI3K), phosphorylated (p)-PI3K, tyrosine kinase B (AKT), and phosphorylated (p)-AKT were determined by Western blot. Wound-healing assay and Transwell were used to determine invasion and migration.

Results

We found that expression of ELF5 was obviously decreased in ovarian cancer cell lines. The cells viability, invasion and metastasis were inhibited by overexpression ELF5. ELF5 suppressed angiogenesis rate and the expression of VEGF. Changes of the expressions of Bcl-2, cleaved caspase-3 and Bax showed that anti-apoptosis ability was improved by ELF5. ELF5 also repressed N-cadherin and Snail and increased E-cadherin. The expressions of p-PI3K and p-AKT were decreased by ELF5. Further study showed that IGF-I reversed the inhibitory effect of ELF5 on growth and metastasis of SKOV3 cells.

Conclusions

Overexpression of ELF5 promoted the apoptosis and reduced the migration and invasion of ovarian cancer cells; therefore, it could provide a new approach to gene treatment of ovarian carcinoma.

Porphyrins as ligands for 64copper: background and trends

Porphyrins and 64Cu have emerged as a novel synergic option for applications in PET molecular imaging. Both the characteristics and photophysical properties of macrocyclic porphyrins and the relatively long half-life of the copper isotope, in addition to the increased tumor-specific uptake of porphyrins compared to normal cells, make this complex an attractive option not only for diagnosis but also for therapeutic applications. Herein, we present an overview of the latest results on the development of PET agents based on porphyrins and 64Cu, including methods used to improve the selectivity of these macrocycles when conjugated with biological units such as monoclonal antibodies, peptides or proteins.