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Pantel AR, Bae SW, Li EJ, O'Brien SR, Manning HC. PET Imaging of Metabolism, Perfusion, and Hypoxia: FDG and Beyond. Cancer J 2024; 30:159-169. [PMID: 38753750 PMCID: PMC11101148 DOI: 10.1097/ppo.0000000000000716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
ABSTRACT Imaging glucose metabolism with [18F]fluorodeoxyglucose positron emission tomography has transformed the diagnostic and treatment algorithms of numerous malignancies in clinical practice. The cancer phenotype, though, extends beyond dysregulation of this single pathway. Reprogramming of other pathways of metabolism, as well as altered perfusion and hypoxia, also typifies malignancy. These features provide other opportunities for imaging that have been developed and advanced into humans. In this review, we discuss imaging metabolism, perfusion, and hypoxia in cancer, focusing on the underlying biology to provide context. We conclude by highlighting the ability to image multiple facets of biology to better characterize cancer and guide targeted treatment.
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Affiliation(s)
- Austin R Pantel
- From the Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Seong-Woo Bae
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth J Li
- From the Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Sophia R O'Brien
- From the Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - H Charles Manning
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
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Sharkey AR, Koglin N, Mittra ES, Han S, Cook GJR, Witney TH. Clinical [ 18F]FSPG Positron Emission Tomography Imaging Reveals Heterogeneity in Tumor-Associated System x c- Activity. Cancers (Basel) 2024; 16:1437. [PMID: 38611114 PMCID: PMC11011143 DOI: 10.3390/cancers16071437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/31/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND (4S)-4-(3-[18F]fluoropropyl)-L-glutamic acid ([18F]FSPG) positron emission tomography/computed tomography (PET/CT) provides a readout of system xc- transport activity and has been used for cancer detection in clinical studies of different cancer types. As system xc- provides the rate-limiting precursor for glutathione biosynthesis, an abundant antioxidant, [18F]FSPG imaging may additionally provide important prognostic information. Here, we performed an analysis of [18F]FSPG radiotracer distribution between primary tumors, metastases, and normal organs from cancer patients. We further assessed the heterogeneity of [18F]FSPG retention between cancer types, and between and within individuals. METHODS This retrospective analysis of prospectively collected data compared [18F]FSPG PET/CT in subjects with head and neck squamous cell cancer (HNSCC, n = 5) and non-small-cell lung cancer (NSCLC, n = 10), scanned at different institutions. Using semi-automated regions of interest drawn around tumors and metastases, the maximum standardized uptake value (SUVmax), SUVmean, SUV standard deviation and SUVpeak were measured. [18F]FSPG time-activity curves (TACs) for normal organs, primary tumors and metastases were subsequently compared to 18F-2-fluoro-2-deoxy-D-glucose ([18F]FDG) PET/CT at 60 min post injection (p.i.). RESULTS The mean administered activity of [18F]FSPG was 309.3 ± 9.1 MBq in subjects with NSCLC and 285.1 ± 11.3 MBq in those with HNSCC. The biodistribution of [18F]FSPG in both cohorts showed similar TACs in healthy organs from cancer patients. There was no statistically significant overall difference in the average SUVmax of tumor lesions at 60 min p.i. for NSCLC (8.1 ± 7.1) compared to HNSCC (6.0 ± 4.1; p = 0.29) for [18F]FSPG. However, there was heterogeneous retention between and within cancer types; the SUVmax at 60 min p.i. ranged from 1.4 to 23.7 in NSCLC and 3.1-12.1 in HNSCC. CONCLUSION [18F]FSPG PET/CT imaging from both NSCLC and HNSCC cohorts showed the same normal-tissue biodistribution, but marked tumor heterogeneity across subjects and between lesions. Despite rapid elimination through the urinary tract and low normal-background tissue retention, the diagnostic potential of [18F]FSPG was limited by variability in tumor retention. As [18F]FSPG retention is mediated by the tumor's antioxidant capacity and response to oxidative stress, this heterogeneity may provide important insights into an individual tumor's response or resistance to therapy.
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Affiliation(s)
- Amy R. Sharkey
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK; (A.R.S.); (G.J.R.C.)
| | | | - Erik S. Mittra
- Division of Molecular Imaging and Therapy, Oregon Health & Science University, Portland, OR 97239, USA;
| | - Sangwon Han
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea;
| | - Gary J. R. Cook
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK; (A.R.S.); (G.J.R.C.)
- King’s College London and Guy’s and St. Thomas’ PET Center, St. Thomas’ Hospital, London SE1 7EH, UK
| | - Timothy H. Witney
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK; (A.R.S.); (G.J.R.C.)
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Sharkey AR, Witney TH, Cook GJR. Is System x c- a Suitable Target for Tumour Detection and Response Assessment with Imaging? Cancers (Basel) 2023; 15:5573. [PMID: 38067277 PMCID: PMC10705217 DOI: 10.3390/cancers15235573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 02/12/2024] Open
Abstract
System xc- is upregulated in cancer cells and can be imaged using novel radiotracers, most commonly with (4S)-4-(3-[18F]fluoropropyl)-L-glutamic acid (18F-FSPG). The aim of this review was to summarise the use of 18F-FSPG in humans, explore the benefits and limitations of 18F-FSPG, and assess the potential for further use of 18F-FSPG in cancer patients. To date, ten papers have described the use of 18F-FSPG in human cancers. These studies involved small numbers of patients (range 1-26) and assessed the use of 18F-FSPG as a general oncological diagnostic agent across different cancer types. These clinical trials were contrasting in their findings, limiting the scope of 18F-FSPG PET/CT as a purely diagnostic agent, primarily due to heterogeneity of 18F-FSPG retention both between cancer types and patients. Despite these limitations, a potential further application for 18F-FSPG is in the assessment of early treatment response and prediction of treatment resistance. Animal models of cancer have shown that changes in 18F-FSPG retention following effective therapy precede glycolytic changes, as indicated by 18F-FDG, and changes in tumour volume, as measured by CT. If these results could be replicated in human clinical trials, imaging with 18F-FSPG PET/CT would offer an exciting route towards addressing the currently unmet clinical needs of treatment resistance prediction and early imaging assessment of therapy response.
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Affiliation(s)
- Amy R. Sharkey
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St. Thomas’ Hospital, London SE1 7EH, UK
| | - Timothy H. Witney
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St. Thomas’ Hospital, London SE1 7EH, UK
| | - Gary J. R. Cook
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St. Thomas’ Hospital, London SE1 7EH, UK
- King’s College London and Guy’s and St. Thomas’ PET Centre, St. Thomas’ Hospital, London SE1 7EH, UK
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Lin M, Ta RT, Manning HC. Simplified and highly-reliable automated production of [ 18F]FSPG for clinical studies. EJNMMI Radiopharm Chem 2023; 8:15. [PMID: 37486582 PMCID: PMC10366059 DOI: 10.1186/s41181-023-00200-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 07/13/2023] [Indexed: 07/25/2023] Open
Abstract
BACKGROUND (S)-4-(3-18F-Fluoropropyl)-L-Glutamic Acid ([18F]FSPG) is a positron emission tomography (PET) tracer that specifically targets the cystine/glutamate antiporter (xc-), which is frequently overexpressed in cancer and several neurological disorders. Pilot studies examining the dosimetry and biodistribution of [18F]FSPG in healthy volunteers and tumor detection in patients with non-small cell lung cancer, hepatocellular carcinoma, and brain tumors showed promising results. In particular, low background uptake in the brain, lung, liver, and bowel was observed that further leads to excellent imaging contrasts of [18F]FSPG PET. However, reliable production-scale cGMP-compliant automated procedures for [18F]FSPG production are still lacking to further increase the utility and clinical adoption of this radiotracer. Herein, we report the optimized automated approaches to produce [18F]FSPG through two commercially available radiosynthesizers capable of supporting centralized and large-scale production for clinical use. RESULTS Starting with activity levels of 60-85 GBq, the fully-automated process to produce [18F]FSPG took less than 45 min with average radiochemical yields of 22.56 ± 0.97% and 30.82 ± 1.60% (non-decay corrected) using TRACERlab™ FXFN and FASTlab™, respectively. The radiochemical purities were > 95% and the formulated [18F]FSPG solution was determined to be sterile and colorless with the pH of 6.5-7.5. No radiolysis of the product was observed up to 8 h after final batch formulation. CONCLUSIONS In summary, cGMP-compliant radiosyntheses and quality control of [18F]FSPG have been established on two commercially available synthesizers leveraging high activity concentration and radiochemical purity. While the clinical trials using [18F]FSPG PET are currently underway, the automated approaches reported herein will accelerate the clinical adoption of this radiotracer and warrant centralized and large-scale production of [18F]FSPG.
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Affiliation(s)
- Mai Lin
- Cyclotron Radiochemistry Facility, The University of Texas MD Anderson Cancer Center, Houston, TX, 77054, USA
| | - Robert T Ta
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - H Charles Manning
- Cyclotron Radiochemistry Facility, The University of Texas MD Anderson Cancer Center, Houston, TX, 77054, USA.
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.
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Lin M, Ta RT, Manning HC. Simplified and Highly-reliable automated production of [18F]FSPG for clinical studies. RESEARCH SQUARE 2023:rs.3.rs-3031030. [PMID: 37461634 PMCID: PMC10350228 DOI: 10.21203/rs.3.rs-3031030/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
Background (S)-4-(3- 18 F-Fluoropropyl)-L-Glutamic Acid ([ 18 F]FSPG) is a positron emission tomography (PET) tracer that specifically targets the cystine/glutamate antiporter (xc-), which is frequently overexpressed in cancer and several neurological disorders. Pilot studies examining the dosimetry and biodistribution of ([ 18 F]FSPG in healthy volunteers and tumor detection in patients with non-small cell lung cancer, hepatocellular carcinoma, and brain tumors showed promising results. In particular, low background uptake in the brain, lung, liver, and bowel was observed that further leads to excellent imaging contrasts of [ 18 F]FSPG PET. However, reliable production-scale cGMP-compliant automated procedures for [ 18 F]FSPG production are still lacking to further increase the utility and clinical adoption of this radiotracer. Herein, we report the optimized automated approaches to produce [ 18 F]FSPG through two commercially available radiosynthesizers capable of supporting centralized and large-scale production for clinical use. Results Starting with activity levels of 60-85 GBq, the fully-automated process to produce [ 18 F]FSPG took less than 45 minutes with average radiochemical yields of 22.56 ± 0.97% and 30.82 ± 1.60% (non-decay corrected) using TRACERlab™ FXFN and FASTlab™, respectively. The radiochemical purities were > 95% and the formulated [ 18 F]FSPG solution was determined to be sterile and colorless with the pH of 6.5-7.5. No radiolysis of the product was observed up to 8 hours after final batch formulation. Conclusions In summary, cGMP-compliant radiosyntheses and quality control of [ 18 F]FSPG have been established on two commercially available synthesizers leveraging high activity concentration and radiochemical purity. While the clinical trials using [ 18 F]FSPG PET are currently underway, the automated approaches reported herein will accelerate the clinical adoption of this radiotracer and warrant centralized and large-scale production of [ 18 F]FSPG.
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Bae SW, Wang J, Georgiou DK, Wen X, Cohen AS, Geng L, Tantawy MN, Manning HC. Feasibility of [ 18F]FSPG PET for Early Response Assessment to Combined Blockade of EGFR and Glutamine Metabolism in Wild-Type KRAS Colorectal Cancer. Tomography 2023; 9:497-508. [PMID: 36961000 PMCID: PMC10037609 DOI: 10.3390/tomography9020041] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 02/26/2023] Open
Abstract
Early response assessment is critical for personalizing cancer therapy. Emerging therapeutic regimens with encouraging results in the wild-type (WT) KRAS colorectal cancer (CRC) setting include inhibitors of epidermal growth factor receptor (EGFR) and glutaminolysis. Towards predicting clinical outcome, this preclinical study evaluated non-invasive positron emission tomography (PET) with (4S)-4-(3-[18F]fluoropropyl)-L-glutamic acid ([18F]FSPG) in treatment-sensitive and treatment-resistant WT KRAS CRC patient-derived xenografts (PDXs). Tumor-bearing mice were imaged with [18F]FSPG PET before and one week following the initiation of treatment with either EGFR-targeted monoclonal antibody (mAb) therapy, glutaminase inhibitor therapy, or the combination. Imaging was correlated with tumor volume and histology. In PDX that responded to therapy, [18F]FSPG PET was significantly decreased from baseline at 1-week post-therapy, prior to changes in tumor volume. In contrast, [18F]FSPG PET was not decreased in non-responding PDX. These data suggest that [18F]FSPG PET may serve as an early metric of response to EGFR and glutaminase inhibition in the WT KRAS CRC setting.
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Affiliation(s)
- Seong-Woo Bae
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
| | - Jianbo Wang
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
| | - Dimitra K. Georgiou
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
| | - Xiaoxia Wen
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
| | - Allison S. Cohen
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
| | - Ling Geng
- Vanderbilt Center for Molecular Probes, Vanderbilt University Medical Center, 1161 21st Avenue South, Medical Center North, AA-1105, Nashville, TN 37232, USA
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, 1161 21st Avenue South, Medical Center North, AA-1105, Nashville, TN 37232, USA
| | - Mohammed Noor Tantawy
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, 1161 21st Avenue South, Medical Center North, AA-1105, Nashville, TN 37232, USA
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, 1161 21st Avenue South, Medical Center North, Nashville, TN 37232, USA
| | - H. Charles Manning
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
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Lin M, Coll RP, Cohen AS, Georgiou DK, Manning HC. PET Oncological Radiopharmaceuticals: Current Status and Perspectives. Molecules 2022; 27:6790. [PMID: 36296381 PMCID: PMC9609795 DOI: 10.3390/molecules27206790] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/03/2022] [Accepted: 10/07/2022] [Indexed: 02/01/2024] Open
Abstract
Molecular imaging is the visual representation of biological processes that take place at the cellular or molecular level in living organisms. To date, molecular imaging plays an important role in the transition from conventional medical practice to precision medicine. Among all imaging modalities, positron emission tomography (PET) has great advantages in sensitivity and the ability to obtain absolute imaging quantification after corrections for photon attenuation and scattering. Due to the ability to label a host of unique molecules of biological interest, including endogenous, naturally occurring substrates and drug-like compounds, the role of PET has been well established in the field of molecular imaging. In this article, we provide an overview of the recent advances in the development of PET radiopharmaceuticals and their clinical applications in oncology.
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Affiliation(s)
- Mai Lin
- Cyclotron Radiochemistry Facility, The University of Texas MD Anderson Cancer Center, Houston, TX 77054, USA
| | - Ryan P. Coll
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Allison S. Cohen
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Dimitra K. Georgiou
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Henry Charles Manning
- Cyclotron Radiochemistry Facility, The University of Texas MD Anderson Cancer Center, Houston, TX 77054, USA
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Yi L, Peng Z, Chen Z, Tao Y, Lin Z, He A, Jin M, Peng Y, Zhong Y, Yan H, Zuo M. Identification of pulmonary adenocarcinoma and benign lesions in isolated solid lung nodules based on a nomogram of intranodal and perinodal CT radiomic features. Front Oncol 2022; 12:924055. [PMID: 36147924 PMCID: PMC9485677 DOI: 10.3389/fonc.2022.924055] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/22/2022] [Indexed: 11/17/2022] Open
Abstract
To develop and validate a predictive model based on clinical radiology and radiomics to enhance the ability to distinguish between benign and malignant solitary solid pulmonary nodules. In this study, we retrospectively collected computed tomography (CT) images and clinical data of 286 patients with isolated solid pulmonary nodules diagnosed by surgical pathology, including 155 peripheral adenocarcinomas and 131 benign nodules. They were randomly divided into a training set and verification set at a 7:3 ratio, and 851 radiomic features were extracted from thin-layer enhanced venous phase CT images by outlining intranodal and perinodal regions of interest. We conducted preprocessing measures of image resampling and eigenvalue normalization. The minimum redundancy maximum relevance (mRMR) and least absolute shrinkage and selection operator (lasso) methods were used to downscale and select features. At the same time, univariate and multifactorial analyses were performed to screen clinical radiology features. Finally, we constructed a nomogram based on clinical radiology, intranodular, and perinodular radiomics features. Model performance was assessed by calculating the area under the receiver operating characteristic curve (AUC), and the clinical decision curve (DCA) was used to evaluate the clinical practicability of the models. Univariate and multivariate analyses showed that the two clinical factors of sex and age were statistically significant. Lasso screened four intranodal and four perinodal radiomic features. The nomogram based on clinical radiology, intranodular, and perinodular radiomics features showed the best predictive performance (AUC=0.95, accuracy=0.89, sensitivity=0.83, specificity=0.96), which was superior to other independent models. A nomogram based on clinical radiology, intranodular, and perinodular radiomics features is helpful to improve the ability to predict benign and malignant solitary pulmonary nodules.
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Krarup MMK, Fischer BM, Christensen TN. New PET Tracers: Current Knowledge and Perspectives in Lung Cancer. Semin Nucl Med 2022; 52:781-796. [PMID: 35752465 DOI: 10.1053/j.semnuclmed.2022.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/04/2022] [Indexed: 11/11/2022]
Abstract
PET/CT with the tracer 2-[18F]fluoro-2-deoxy-D-glucose ([18F]FDG) has improved diagnostic imaging in cancer and is routinely used for diagnosing, staging and treatment planning in lung cancer patients. However, pitfalls of [18F]FDG-PET/CT limit the use in specific settings. Additionally, lung cancer is still the leading cause of cancer associated death and has high risk of recurrence after curative treatment. These circumstances have led to the continuous search for more sensitive and specific PET tracers to optimize lung cancer diagnosis, staging, treatment planning and evaluation. The objective of this review is to present and discuss current knowledge and perspectives of new PET tracers for use in lung cancer. A literature search was performed on PubMed and clinicaltrials.gov, limited to the past decade, excluding case reports, preclinical studies and studies on established tracers such as [18F]FDG and DOTATE. The most relevant papers from the search were evaluated. Several tracers have been developed targeting specific tumor characteristics and hallmarks of cancer. A small number of tracers have been studied extensively and evaluated head-to-head with [18F]FDG-PET/CT, whereas others need further investigation and validation in larger clinical trials. At this moment, none of the tracers can replace [18F]FDG-PET/CT. However, they might serve as supplementary imaging methods to provide more knowledge about biological tumor characteristics and visualize intra- and inter-tumoral heterogeneity.
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Affiliation(s)
- Marie M K Krarup
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet Copehagen University Hospital, Copenhagen, Denmark.
| | - Barbara M Fischer
- Department of Clinical Medicine, Faculty of Health, Univeristy of Copenhagen (UCPH), Copenhagen, Denmark; School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Tine N Christensen
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet Copehagen University Hospital, Copenhagen, Denmark
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