Analysis of 76Br-BrdU in DNA of brain tumors after a PET study does not support its use as a proliferation marker

Prediction of Meningioma WHO Grade Using PET Findings: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

World Health Organization (WHO) grading of meningiomas reflects recurrence rate and prognosis. Positron emission tomography (PET) investigates metabolic activity, allowing for distinction between low- and high-grade tumors. As preoperative suspicion for malignant meningioma will influence surgical strategy in terms of timing, extent of resection, and risks taken to achieve a total resection, we systematically reviewed the literature on PET-imaging in meningiomas and relate these findings to histopathological analysis.

METHODS

Searches in PubMed, EMBASE, and The Cochrane Library, from inception to September 2019, included studies of patients who had undergone surgery for a histologically verified intracranial meningioma, with a PET-scan prior to surgery and description of (semi)quantitative PET values for meningiomas from two different WHO groups. Studies comparing more than 1 patient per WHO group were included in the meta-analysis.

RESULTS

Twenty-two studies (432 patients) were included. 18fluor-fluorodesoxyglucose (18F-FDG) PET was mostly described to differentiate benign from malignant meningiomas. Pooled data showed differences in mean (95% CI) Standardized Uptake Value (SUV) for WHO II/III compared to WHO I of 2.51 (1.36, 3.66), and in tumor-to-normal (T/N) ratio (T/N ratio) for WHO II/III versus WHO I of .42 (.12, .73).

CONCLUSIONS

We found that SUV and T/N ratio in 18F-FDG PET may be useful to noninvasively differentiate benign from malignant meningiomas. T/N ratio seems to have a high specificity for the detection of high-grade meningiomas. Other PET tracers were studied too infrequently to draw definitive conclusions. Before treatment strategies can be adapted based on 18F-FDG PET, prospective studies in larger cohorts are warranted to validate the optimal T/N ratio cutoff point.

Development of a Widely Usable Amino Acid Tracer: ⁷⁶Br-α-Methyl-Phenylalanine for Tumor PET Imaging

Radiolabeled amino acids are superior PET tracers for the imaging of malignant tumors, and amino acids labeled with (76)Br, an attractive positron emitter because of its relatively long half-life (16.2 h), could potentially be a widely usable tumor imaging tracer. In this study, in consideration of its stability and tumor specificity, we designed two (76)Br-labeled amino acid derivatives, 2-(76)Br-bromo-α-methyl-l-phenylalanine (2-(76)Br-BAMP) and 4-(76)Br-bromo-α-methyl-l-phenylalanine (4-(76)Br-BAMP), and investigated their potential as tumor imaging agents.

METHODS

Both (76)Br- and (77)Br-labeled amino acid derivatives were prepared. We performed in vitro and in vivo stability studies and cellular uptake studies using the LS180 colon adenocarcinoma cell line. Biodistribution studies in normal mice and in LS180 tumor-bearing mice were performed, and the tumors were imaged with a small-animal PET scanner.

RESULTS

Both (77)Br-BAMPs were stable in the plasma and in the murine body. Although both (77)Br-BAMPs were taken up by LS180 cells and the uptake was inhibited by L-type amino acid transporter 1 inhibitors, 2-(77)Br-BAMP exhibited higher uptake than 4-(77)Br-BAMP. In the biodistribution studies, 2-(77)Br-BAMP showed more rapid blood clearance and lower renal accumulation than 4-(77)Br-BAMP. More than 90% of the injected radioactivity was excreted in the urine by 6 h after the injection of 2-(77)Br-BAMP. High tumor accumulation of 2-(77)Br-BAMP was observed in tumor-bearing mice, and PET imaging with 2-(76)Br-BAMP enabled clear visualization of the tumors.

CONCLUSION

2-(77)Br-BAMP exhibited preferred pharmacokinetics and high LS180 tumor accumulation, and 2-(76)Br-BAMP enabled clear visualization of the tumors by PET imaging. These findings suggest that 2-(76)Br-BAMP could constitute a potential new PET tracer for tumor imaging and may eventually enable the wider use of amino acid tracers.

Preparation and biological evaluation of 3-[(76)Br]bromo-α-methyl-L-tyrosine, a novel tyrosine analog for positron emission tomography imaging of tumors

INTRODUCTION

3-[(18)F]fluoro-α-methyl-l-tyrosine ([(18)F]FAMT) is a useful amino acid tracer for positron emission tomography (PET) imaging of malignant tumors. FAMT analogs labeled with (76)Br, a positron emitter with a long half-life (t(1/2)=16.1 h), could potentially be widely used as amino acid tracers for tumor imaging. In this study, 3-[(76)Br]bromo-α-methyl-l-tyrosine ([(76)Br]BAMT) was designed, and its usefulness was evaluated as a novel PET tracer for imaging malignant tumors.

METHODS

In this study, both [(76)Br]BAMT and [(77)Br]BAMT were prepared. The in vitro and in vivo stability of [(77)Br]BAMT was evaluated by HPLC analysis. Cellular uptake and retention of [(77)Br]BAMT and [(18)F]FAMT were evaluated using LS180 colon adenocarcinoma cells. Biodistribution studies were performed in normal mice and in LS180 tumor-bearing mice, and the tumors were imaged with a small-animal PET scanner.

RESULTS

[(77)Br]BAMT was stable in vitro but was catabolized after administration in mice. Cellular accumulation and retention of [(77)Br]BAMT were significantly higher than those of [(18)F]FAMT. In biodistribution studies, the tumor accumulation of [(77)Br]BAMT was higher than that of [(18)F]FAMT. However, some level of debromination was seen, which caused more retention of radioactivity in the blood and organs than was seen with [(18)F]FAMT. PET imaging with [(76)Br]BAMT enabled clear visualization of the tumor, and the whole-body image using [(76)Br]BAMT was similar to that using [(18)F]FAMT.

CONCLUSIONS

[(77)Br]BAMT showed high levels of tumor accumulation, and [(76)Br]BAMT enabled clear visualization of the tumor by PET imaging. Although an improvement in stability is still needed, (76)Br-labeled FAMT analogs could potentially serve as PET tracers for the imaging of malignant tumors.

PET imaging of norepinephrine transporter-expressing tumors using 76Br-meta-bromobenzylguanidine

Meta-iodobenzylguanidine (MIBG) labeled with (123)I or (131)I has been widely used for the diagnosis and radiotherapy of norepinephrine transporter (NET)-expressing tumors. However, (123)I/(131)I-MIBG has limitations for detecting small lesions because of its lower spatial resolution than PET tracers. In this study, meta-bromobenzylguanidine (MBBG) labeled with (76)Br (half-life, 16.1 h), an attractive positron emitter, was prepared and evaluated as a potential PET tracer for imaging NET-expressing tumors.

METHODS

(76)Br-MBBG was prepared by a halogen-exchange reaction between the (76)Br and iodine of nonradioactive MIBG. The stability of MBBG was evaluated in vitro and in vivo by high-performance liquid chromatography analysis. Cellular uptake studies with or without NET inhibitors were performed in NET-positive PC-12 cell lines. Biodistribution studies were performed in PC-12 tumor-bearing nude mice by administration of a mixed solution of MBBG, MIBG, and (18)F-FDG. The tumor was imaged using (76)Br-MBBG and (18)F-FDG with a small-animal PET scanner.

RESULTS

MBBG was stable in vitro, but some time-dependent dehalogenation was observed after administration in mice. MBBG showed high uptake in PC-12 tumor cells that was significantly decreased by the addition of NET inhibitors. In biodistribution studies, MBBG showed high tumor accumulation (32.0 +/- 18.6 percentage injected dose per gram at 3 h after administration), and the tumor-to-blood ratio reached as high as 54.4 +/- 31.9 at 3 h after administration. The tumor uptake of MBBG correlated well with that of MIBG (r = 0.997) but not with that of (18)F-FDG. (76)Br-MBBG PET showed a clear image of the transplanted tumor, with high sensitivity, which was different from the lesion shown by (18)F-FDG PET.

CONCLUSION

(76)Br-MBBG showed high tumor accumulation, which correlated well with that of MIBG, and provided a clear PET image. These results indicated that (76)Br-MBBG would be a potential PET tracer for imaging NET-expressing neuroendocrine tumors and could provide useful information for determining the indications for (131)I-MIBG therapy.

The role of DNA synthesis imaging in cancer in the era of targeted therapeutics

Non-specific targets such as DNA and microtubules have been the mainstay of cancer therapeutics and the most effective clinical agents until a decade ago. Advances in genetics, molecular and cellular biology over the past decade led to the development of a new generation of agents that are far more specific and effective. In contrast to progress seen with therapeutic agents, general monitoring targets such as proliferation imaging are just gaining momentum and targeted imaging is still in its infancy. In these paradoxical times, this review assesses the role of proliferation imaging in monitoring the efficacy of targeted therapeutics.

Imaging of cell proliferation: status and prospects

Increased cellular proliferation is an integral part of the cancer phenotype. Several in vitro assays have been developed to measure the rate of tumor growth, but these require biopsies, which are particularly difficult to obtain over time and in different areas of the body in patients with multiple metastatic lesions. Most of the effort to develop imaging methods to noninvasively measure the rate of tumor cell proliferation has focused on the use of PET in conjunction with tracers for the thymidine salvage pathway of DNA synthesis, because thymidine contains the only pyrimidine or purine base that is unique to DNA. Imaging with 11C-thymidine has been tested for detecting tumors and tracking their response to therapy in animals and patients. Its major limitations are the short half-life of 11C and the rapid catabolism of thymidine after injection. These limitations led to the development of analogs that are resistant to degradation and can be labeled with radionuclides more conducive to routine clinical use, such as 18F. At this point, the thymidine analogs that have been studied the most are 3'-deoxy-3'-fluorothymidine (FLT) and 1-(2'-deoxy-2'-fluoro-1-beta-d-arabinofuranosyl)-thymine (FMAU). Both are resistant to degradation and track the DNA synthesis pathway. FLT is phosphorylated by thymidine kinase 1, thus being retained in proliferating cells. It is incorporated by the normal proliferating marrow and is glucuronidated in the liver. FMAU can be incorporated into DNA after phosphorylation but shows less marrow uptake. It shows high uptake in the normal heart, kidneys, and liver, in part because of the role of mitochondrial thymidine kinase 2. Early clinical data for 18F-FLT demonstrated that its uptake correlates well with in vitro measures of proliferation. Although 18F-FLT can be used to detect tumors, its tumor-to-normal tissue contrast is generally lower than that of 18F-FDG in most cancers outside the brain. The most promising use for thymidine and its analogs is in monitoring tumor treatment response, as demonstrated in animal studies and pilot human trials. Further work is needed to determine the optimal tracer(s) and timing of imaging after treatment.

Metabolic functional imaging for tumor radiosensitivity monitoring

Assessing tumor radiosensitivity before and during radiation therapy can be a crucial element in decision-making with regard to treatment. However, no known non-invasive test is available at present, which allows for a reliable evaluation of the radiosensitivity of a tissue subjected to radiotherapy. Among tests being evaluated, positron emission tomography (PET) is considered to be a promising method. The purpose of this review is to identify the tests and research paths that have recently been explored for the evaluation of tumor response to treatment after isotopic labeling revealed by nuclear imaging. The majority of the explored methodologies are based on the indirect evaluation of the radiosensitivity by cell proliferation or apoptosis, tissue oxygenation or hypoxia, intrinsic radiosensitivity of clonogenic cells, tumor metabolism and angiogenesis. The development of such methods would permit the adoption of a therapeutic regimen with respect to a given radiosensitivity of a tissue. Therefore, a given therapeutic strategy could be readjusted (by associating, for instance, a radiosensitizer of hypoxic cells) or even modified if it proved to be inadequate or when it presents an unfavorable cost-effectiveness ratio. We present here a critical review of the radiotracers revealed by nuclear imaging that are developed for radiosensitivity monitoring.

Évaluation de la radiosensibilité tumorale par l'imagerie fonctionnelle et métabolique : de la recherche à l'application clinique. Revue de la littérature

During the last half of century considerable research on radiosensitivity biomarkers has been published. However, to date there is no non-invasive marker of cellular radiosensitivity identified for clinical routinely use. In this review, the main functional and metabolic imaging isotopic techniques for tumor radiosensitivity that have been explored over the last years are being described. This indirect evaluation fall into 3 topics associated with tumor proliferation rate or apoptosis, tumor hypoxic fraction, neoangiogenesis and the intrinsic radiosensitivity of clonogenic tumor cells. The final objective of the radiosensitivity monitoring during radiotherapy would be to adapt treatment strategy for overcoming the identified radioresistance mechanism such as hypoxia by the addition of radiosensitisers for example. This would allow better tumor control rather than continue inefficient and costly treatment delivery, which in addition could compromise outcome.

Positron Emission Tomography Imaging of Cell Proliferation in Oncology

Tumour-cell proliferation is a hallmark of the malignant phenotype. Positron emission tomography (PET) offers a unique method of imaging biological and biochemical changes in vivo. Radiolabelled thymidine and thymidine analogues are currently in development as PET tracers. By studying the uptake and kinetics of such compounds using PET, a measure of DNA synthesis and hence cell proliferation can be obtained. Molecular imaging of cellular proliferation with PET is now possible, and has the potential to play an important role in the evaluation of efficacy of new anti-cancer agents.

In vivo comparison of IVDU and IVFRU in HSV1-TK gene expressing tumor bearing rats

(E)-5-(2-Iodovinyl)-2'-deoxyuridine (IVDU) and (E)-5-(2-iodovinyl)-2'-fluoro-2'-deoxyuridine (IVFRU) are potential substrates of Herpes Simplex Virus type 1 thymidine kinase (HSV-TK). In the present study, cellular uptake of radioiodinated substrates was found to be low in wild type MCA cells, but high in HSV-TK gene expressing cells. The carrier-free substrates, in particular, showed higher cellular uptake than carrier-added compounds. Biodistribution showed that the %ID/g of the MCA-TK/MCA tumor ratio of IVDU injected at 1, 4, and 24h were 1.1, 0.9 and 1.3, and those of IVFRU were 1.7, 1.7 and 1.8 respectively. Therefore, both IVDU and IVFRU could possibly be used as radiopharmaceuticals to evaluate reporter gene expression. However, IVFRU was more specific and stable than IVDU for selective non-invasive imaging of HSV-TK expression.

Nuclear medicine imaging to predict response to radiotherapy: a review

PURPOSE

To review available literature on positron emission tomography (PET) and single photon emission computerized tomography (SPECT) for the measurement of tumor metabolism, hypoxia, growth factor receptor expression, and apoptosis as predictors of response to radiotherapy.

METHODS AND MATERIALS

Medical literature databases (Pubmed, Medline) were screened for available literature and critically analyzed as to their scientific relevance.

RESULTS

Studies on 18F-fluorodeoxyglucose PET as a predictor of response to radiotherapy in head-and-neck carcinoma are promising but need confirmation in larger series. 18F-fluorothymine is stable in human plasma, and preliminary clinical data obtained with this marker of tumor cell proliferation are promising. For imaging tumor hypoxia, novel, more widely available radiopharmaceuticals with faster pharmacokinetics are mandatory. Imaging of ongoing apoptosis and growth factor expression is at a very early stage, but results obtained in other domains with radiolabeled peptides appear promising. Finally, for most of the tracers discussed, validation against a gold standard is needed.

CONCLUSION

Optimization of the pharmacokinetics of relevant radiopharmaceuticals as well as validation against gold-standard tests in large patient series are mandatory if PET and SPECT are to be implemented in routine clinical practice for the purpose of predicting response to radiotherapy.