In vivo imaging of apoptosis in oncology: an update

Preclinical PET Imaging of Tumor Cell Death following Therapy Using Gallium-68-Labeled C2Am

There is an unmet clinical need for imaging agents capable of detecting early evidence of tumor cell death, since the timing, extent, and distribution of cell death in tumors following treatment can give an indication of treatment outcome. We describe here 68Ga-labeled C2Am, which is a phosphatidylserine-binding protein, for imaging tumor cell death in vivo using positron emission tomography (PET). A one-pot synthesis of 68Ga-C2Am (20 min, 25 °C, >95% radiochemical purity) has been developed, using a NODAGA-maleimide chelator. The binding of 68Ga-C2Am to apoptotic and necrotic tumor cells was assessed in vitro using human breast and colorectal cancer cell lines, and in vivo, using dynamic PET measurements in mice implanted subcutaneously with the colorectal tumor cells and treated with a TRAIL-R2 agonist. 68Ga-C2Am showed predominantly renal clearance and low retention in the liver, spleen, small intestine, and bone and generated a tumor-to-muscle (T/m) ratio of 2.3 ± 0.4, at 2 h post probe administration and at 24 h following treatment. 68Ga-C2Am has the potential to be used in the clinic as a PET tracer for assessing early treatment response in tumors.

Shortwave-infrared (SWIR) emitting annexin V for high-contrast fluorescence molecular imaging of tumor apoptosis in living mice

Recently, shortwave infrared (SWIR) fluorescence imaging over 1000 nm has attracted much attention for in vivo optical imaging because of the higher signal to background ratios in the SWIR region. For the application of SWIR fluorescence imaging to biomedical fields, the development of SWIR fluorescent molecular probes with high biocompatibility is crucial. Although many researchers have designed a variety of SWIR emitting probes based on organic dyes, the synthesis of biocompatible SWIR fluorescent molecular imaging probes is still challenging. In this work we synthesized indocyanine green (ICG) and π-conjugation extended ICG (ICG-C11) labelled annexin V as SWIR fluorescent probes for tumor apoptosis. Annexin V is an endogenous protein with binding ability to phosphatidylserine (PS) which appears on the outer monolayer of apoptotic cell membranes. Although there are many types of visible and NIR fluorescent annexin V, there are no SWIR emitting fluorescent probes that can be used for high contrast fluorescence imaging of apoptosis in vivo. Herein, we report the synthesis and application of ICG and ICG-C11 conjugated annexin V for SWIR fluorescence imaging of tumor apoptosis. The presented fluorescent annexin V is the first SWIR emitting probe for in vivo optical imaging of tumor apoptosis. We demonstrate that SWIR emitting ICG- and ICG-C11 conjugated annexin V enable high-contrast fluorescence imaging of tumor apoptosis in living mice. We further demonstrate that ICG-C11-annexin V can be used for long-term (ca. two weeks) SWIR fluorescence imaging of tumor apoptosis. The SWIR fluorescent annexin V will greatly contribute not only to the study of tumor-apoptosis induced by anti-cancer drugs, but also to the study of apoptosis-related diseases in a living system.

The labelling of annexin V with indocyanine green (ICG) and π-conjugation extended ICG (ICG-C11) resulted in SWIR emitting probes that enable high-contrast molecular imaging of tumor apoptosis in living mice.

Aumento de Captação Cardíaca de 18F-FDG Induzida por Quimioterapia em Pacientes com Linfoma: Um Marcador Precoce de Cardiotoxicidade?

Fundamento

Ainda não está estabelecido se a captação de fluorodesoxiglicose no miocárdio ocorre exclusivamente por características fisiológicas ou se representa um desarranjo metabólico causado pela quimioterapia.

Objetivo

Investigar os efeitos da quimioterapia no coração dos pacientes com linfoma por tomografia por emissão de pósitrons associada a tomografia computadorizada (PET/CT) com 2-[18F]-fluoro-2-desoxi-D-glicose (¹⁸F-FDG PET/CT) antes, durante e/ou após a quimioterapia.

Métodos

Setenta pacientes com linfoma submetidos a ¹⁸F-FDG PET/CT foram retrospectivamente analisados. O nível de significância foi de 5%. A captação de ¹⁸F-FDG foi avaliada por três medidas: captação máxima no ventrículo esquerdo ( standardized uptake value , SUV max), razão SUV cardíaco / aorta e SUV cardíaco / SUV no fígado. Também foram comparados peso corporal, glicemia de jejum, tempo pós-injeção e dose administrada de ¹⁸F-FDG entre os exames.

Resultados

A idade média foi de 50,4 ± 20,1 anos e 50% dos pacientes eram mulheres. A análise foi realizada em dois grupos – PET/CT basal vs. intermediário e PET/CT basal vs pós-terapia. Não houve diferença significativa entre as variáveis clínicas e do protocolo dos exames entre os diferentes momentos avaliados. Nós observamos um aumento na SUV máxima no ventrículo esquerdo de 3,5±1,9 (basal) para 5,6±4,0 (intermediário), p=0,01, e de 4,0±2,2 (basal) para 6,1±4,2 (pós-terapia), p<0,001. Uma porcentagem de aumento ≥30% na SUV máxima no ventrículo esquerdo ocorreu em mais da metade da amostra. O aumento da SUV cardíaca foi acompanhado por um aumento na razão SUV máxima no ventrículo esquerdo / SUV máxima na aorta e SUV média no ventrículo esquerdo /SUV média no fígado.

Conclusão

O estudo mostrou um aumento evidente na captação cardíaca de ¹⁸F-FDG em pacientes com linfoma, durante e após quimioterapia. A literatura corrobora com esses achados e sugere que a ¹⁸F-FDG PET/CT pode ser um exame de imagem sensível e confiável para detectar sinais metabólicos precoces de cardiotoxicidade.

In Vitro and In Vivo Fluorescence Imaging of Antibody-Drug Conjugate-Induced Tumor Apoptosis Using Annexin V-EGFP Conjugated Quantum Dots

Antibody-drug conjugates (ADCs) are conjugates of a monoclonal antibody and a cytotoxic drug that induce tumor apoptosis. The evaluation of ADC-induced tumor apoptosis is crucial for the development of ADCs for cancer therapy. To evaluate the efficacy of ADCs, we present in vitro and in vivo fluorescence imaging techniques for ADC-induced tumor apoptosis using annexin V-EGFP (EGFP: enhanced green fluorescent protein) conjugated quantum dots (annexin V-EGFP-QDs). This probe emits visible (VIS) and near-infrared (NIR) dual fluorescence at 515 nm (EGFP emission) and 850 nm (QD emission), which can be used for the detection of tumor apoptosis at the cellular and whole-body levels. By using annexin V-EGFP-QDs, we achieved VIS and NIR fluorescence imaging of human epidermal growth factor receptor 2-positive breast tumor apoptosis induced by an ADC, Kadcyla (trastuzumab emtansine). The results show that the in vitro and in vivo fluorescence imaging of ADC-induced tumor apoptosis using annexin V-EGFP-QDs is a useful tool to evaluate the efficacy of ADCs for cancer therapy.

Dual-colour (near-infrared/visible) emitting annexin V for fluorescence imaging of tumour cell apoptosis in vitro and in vivo

Indocyanine green (ICG) labelled recombinant annexin V proteins (ICG-EGFP-Annexin V and ICG-mPlum-Annexin V) were synthesized for dual-colour fluorescence imaging of tumour cell apoptosis in vitro and in vivo. The ICG-labelled fluorescent annexin V proteins showed dual (near-infrared and visible) fluorescence emissions with binding ability to phosphatidylserines on the plasma membranes of apoptotic cells. Although several types of fluorescence labelled annexin V (e.g. FITC-annexin V, Cy3- and Cy5-annexin V) have been reported, there are no dual-colour (near-infrared/visible) emitting apoptosis-detection probes which can be used in vitro and in vivo. In this paper, the utilities of the dual-colour fluorescent annexin V are demonstrated for in vitro and in vivo fluorescence imaging of the apoptosis of human breast tumour cells induced by an antibody-drug conjugate, Kadcyla. The results suggest that the present annexin V probes will be useful to visualize the action of anti-cancer drugs against tumours both at the cellular and whole-body level.

Radiolabeled Peptides for Molecular Imaging of Apoptosis

Apoptosis is a regulated cell death induced by extrinsic and intrinsic stimulants. Tracking of apoptosis provides an opportunity for the assessment of cardiovascular and neurodegenerative diseases as well as monitoring of cancer therapy at early stages. There are some key mediators in apoptosis cascade, which could be considered as specific targets for delivering imaging or therapeutic agents. The targeted radioisotope-based imaging agents are able to sensitively detect the physiological signal pathways which make them suitable for apoptosis imaging at a single-cell level. Radiopeptides take advantage of both the high sensitivity of nuclear imaging modalities and favorable features of peptide scaffolds. The aim of this study is to review the characteristics of those radiopeptides targeting apoptosis with different mechanisms.

23 Na-MRI as a Noninvasive Biomarker for Cancer Diagnosis and Prognosis

The influx of sodium (Na⁺) ions into a resting cell is regulated by Na⁺ channels and by Na⁺/H⁺ and Na⁺/Ca²⁺ exchangers, whereas Na⁺ ion efflux is mediated by the activity of Na⁺/K⁺‐ATPase to maintain a high transmembrane Na⁺ ion gradient. Dysfunction of this system leads to changes in the intracellular sodium concentration that promotes cancer metastasis by mediating invasion and migration. In addition, the accumulation of extracellular Na⁺ ions in cancer due to inflammation contributes to tumor immunogenicity. Thus, alterations in the Na⁺ ion concentration may potentially be used as a biomarker for malignant tumor diagnosis and prognosis. However, current limitations in detection technology and a complex tumor microenvironment present significant challenges for the in vivo assessment of Na⁺ concentration in tumor. ²³Na‐magnetic resonance imaging (²³Na‐MRI) offers a unique opportunity to study the effects of Na⁺ ion concentration changes in cancer. Although challenged by a low signal‐to‐noise ratio, the development of ultrahigh magnetic field scanners and specialized sodium acquisition sequences has significantly advanced ²³Na‐MRI. ²³Na‐MRI provides biochemical information that reflects cell viability, structural integrity, and energy metabolism, and has been shown to reveal rapid treatment response at the molecular level before morphological changes occur. Here we review the basis of ²³Na‐MRI technology and discuss its potential as a direct noninvasive in vivo diagnostic and prognostic biomarker for cancer therapy, particularly in cancer immunotherapy. We propose that ²³Na‐MRI is a promising method with a wide range of applications in the tumor immuno‐microenvironment research field and in cancer immunotherapy monitoring.

Level of Evidence

2

Technical Efficacy

Stage 2

Optical and Optoacoustic Imaging

The spatiotemporal determination of molecular events and cells is important for understanding disease processes, especially in oncology, and thus for the development of novel treatments. Equally important is the knowledge of the biodistribution, localization, and targeted accumulation of novel therapies as well as monitoring of tumor growth and therapeutic response. Optical imaging provides an ideal versatile platform for imaging of all these problems and questions.

Preclinical SPECT and SPECT-CT in Oncology

Molecular imaging enables both spatial and temporal understanding of the complex biologic systems underlying carcinogenesis and malignant spread. Single-photon emission tomography (SPECT) is a versatile nuclear imaging-based technique with ideal properties to study these processes in vivo in small animal models, as well as to identify potential drug candidates and characterize their antitumor action and potential adverse effects. Small animal SPECT and SPECT-CT (single-photon emission tomography combined with computer tomography) systems continue to evolve, as do the numerous SPECT radiopharmaceutical agents, allowing unprecedented sensitivity and quantitative molecular imaging capabilities. Several of these advances, their specific applications in oncology as well as new areas of exploration are highlighted in this chapter.

Bimodal Fluorescence-Magnetic Resonance Contrast Agent for Apoptosis Imaging

Effective cancer therapy largely depends on inducing apoptosis in cancer cells via chemotherapy and/or radiation. Monitoring apoptosis in real-time provides invaluable information for evaluating cancer therapy response and screening preclinical anticancer drugs. In this work, we describe the design, synthesis, characterization, and in vitro evaluation of caspase probe 1 (CP1), a bimodal fluorescence-magnetic resonance (FL-MR) probe that exhibits simultaneous FL-MR turn-on response to caspase-3/7. Both caspases exist as inactive zymogens in normal cells but are activated during apoptosis and are unique biomarkers for this process. CP1 has three distinct components: a DOTA-Gd(III) chelate that provides the MR signal enhancement, tetraphenylethylene as the aggregation induced emission luminogen (AIEgen), and DEVD peptide which is a substrate for caspase-3/7. In response to caspase-3/7, the water-soluble peptide DEVD is cleaved and the remaining Gd(III)-AIEgen (Gad-AIE) conjugate aggregates leading to increased FL-MR signals. CP1 exhibited sensitive and selective dual FL-MR turn-on response to caspase-3/7 in vitro and was successfully tested by fluorescence imaging of apoptotic cells. Remarkably, we were able to use the FL response of CP1 to quantify the exact concentrations of inactive and active agents and accurately predict the MR signal in vitro. We have demonstrated that the aggregation-driven FL-MR probe design is a unique method for MR signal quantification. This probe design platform can be adapted for a variety of different imaging targets, opening new and exciting avenues for multimodal molecular imaging.

Cardiac molecular pathways influenced by doxorubicin treatment in mice

Doxorubicin (DOX) is a potent chemotherapeutic with distinct cardiotoxic properties. Understanding the underlying cardiotoxic mechanisms on a molecular level would enable the early detection of cardiotoxicity and implementation of prophylactic treatment. Our goal was to map the patterns of different radiopharmaceuticals as surrogate markers of specific metabolic pathways induced by chemotherapy. Therefore, cardiac distribution of ^99mTc-sestamibi, ^99mTc-Annexin V, ^99mTc-glucaric acid and [¹⁸F]FDG and cardiac expression of Bcl-2, caspase-3 and -8, TUNEL, HIF-1α, and p53 were assessed in response to DOX exposure in mice. A total of 80 mice (64 treated, 16 controls) were evaluated. All radiopharmaceuticals showed significantly increased uptake compared to controls, with peak cardiac uptake after one (^99mTc-Annexin V), two (^99mTc-sestamibi), three ([¹⁸F]FDG), or four (^99mTc-glucaric acid) cycles of DOX. Strong correlations (p < 0.01) were observed between ^99mTc-Annexin V, caspase 3 and 8, and TUNEL, and between [¹⁸F]FDG and HIF-1α. This suggests that the cardiac DOX response starts with apoptosis at low exposure levels, as indicated by ^99mTc-Annexin V and histological apoptosis markers. Late process membrane disintegration can possibly be detected by ^99mTc-sestamibi and ^99mTc-glucaric acid. [¹⁸F]FDG signifies an early adaptive response to DOX, which can be further exploited clinically in the near future.

SPECT and PET radiopharmaceuticals for molecular imaging of apoptosis: from bench to clinic

Owing to the central role of apoptosis in many human diseases and the wide-spread application of apoptosis-based therapeutics, molecular imaging of apoptosis in clinical practice is of great interest for clinicians, and holds great promises. Based on the well-defined biochemical changes for apoptosis, a rich assortment of probes and approaches have been developed for molecular imaging of apoptosis with various imaging modalities. Among these imaging techniques, nuclear imaging (including single photon emission computed tomography and positron emission tomography) remains the premier clinical method owing to their high specificity and sensitivity. Therefore, the corresponding radiopharmaceuticals have been a major focus, and some of them like ^99mTc-Annexin V, ¹⁸F-ML-10, ¹⁸F-CP18, and ¹⁸F-ICMT-11 are currently under clinical investigations in Phase I/II or Phase II/III clinical trials on a wide scope of diseases. In this review, we summarize these radiopharmaceuticals that have been widely used in clinical trials and elaborate them in terms of radiosynthesis, pharmacokinetics and dosimetry, and their applications in different clinical stages. We also explore the unique features required to qualify a desirable radiopharmaceutical for imaging apoptosis in clinical practice. Particularly, a perspective of the impact of these clinical efforts, namely, apoptosis imaging as predictive and prognostic markers, early-response indicators and surrogate endpoints, is also the highlight of this review.

Real-time imaging of single neuronal cell apoptosis in patients with glaucoma

See Herms and Schön (doi10.1093/brain/awx100) for a scientific commentary on this article.

Assesment of apoptosis induced changes in scattering using optical coherence tomography

The aim of this study is to identify changes in scattering with optical coherence tomography (OCT) and relate these measurements with mitochondrial changes during the initiation of apoptosis. Human retinal pigment epithelial cells were cultured and apoptosis was induced using 10% alcohol. Using the attenuation coefficient and backscattering, changes were measured during cell death in a cell-pellet and monolayer respectively. To confirm apoptosis, fluorescent activated cell sorting was used. Mitochondrial activity during apoptosis was assessed using an oxidative stress assay and fluorescent confocal microscopy. Pelleted apoptotic cells measured with OCT showed a clear rise while untreated cells showed a very small increase in attenuation coefficient. Monolayered apoptotic cells displayed a distinct increase, while untreated cells showed a small increase in the backscattering. Apoptosis was confirmed by FACS experiments. Mitochondrial changes during the onset of apoptosis were also measured. The results demonstrate that apoptotic cell death could be monitored in real-time by OCT. Changes in the scattering after induction of apoptosis are likely to be related to changes in the intracellular morphology. Oxidative stress-induced mitochondrial swelling could be responsible for the initial increase, while cell blebbing and secondary necrosis subsequently for the observed decrease in scattering.

In Vivo Apoptosis Imaging Using Site-Specifically (68)Ga-Labeled Annexin V

Noninvasive molecular imaging, using positron emission tomography (PET), is an important technique to visualize metabolic processes in vivo. It also allows to visualize the process of apoptosis, by using radiolabeled compounds such as Annexin V, that bind to extracellular phosphatidylserine (PS). This chapter describes the radiosynthesis of (68)Ga-labeled Annexin V and how to noninvasively image apoptosis in vivo.

Bench to bedside molecular functional imaging in translational cancer medicine: to image or to imagine?

Ongoing research on malignant and normal cell biology has substantially enhanced the understanding of the biology of cancer and carcinogenesis. This has led to the development of methods to image the evolution of cancer, target specific biological molecules, and study the anti-tumour effects of novel therapeutic agents. At the same time, there has been a paradigm shift in the field of oncological imaging from purely structural or functional imaging to combined multimodal structure-function approaches that enable the assessment of malignancy from all aspects (including molecular and functional level) in a single examination. The evolving molecular functional imaging using specific molecular targets (especially with combined positron-emission tomography [PET] computed tomography [CT] using 2- [(18)F]-fluoro-2-deoxy-D-glucose [FDG] and other novel PET tracers) has great potential in translational research, giving specific quantitative information with regard to tumour activity, and has been of pivotal importance in diagnoses and therapy tailoring. Furthermore, molecular functional imaging has taken a key place in the present era of translational cancer research, producing an important tool to study and evolve newer receptor-targeted therapies, gene therapies, and in cancer stem cell research, which could form the basis to translate these agents into clinical practice, popularly termed "theranostics". Targeted molecular imaging needs to be developed in close association with biotechnology, information technology, and basic translational scientists for its best utility. This article reviews the current role of molecular functional imaging as one of the main pillars of translational research.

Advantages of the phosphatidylserine-recognizing peptide PSP1 for molecular imaging of tumor apoptosis compared with annexin V

A number of peptide-based indicators have been identified and reported as potential apoptosis probes, offering great promise for early assessment of therapeutic efficacy in several types of cancer. Direct comparison of the newly developed probes with previously used ones would be an important step in assessing possible applications. Here, we compared the newly identified peptide-based phosphatidylserine (PS) indicator PSP1 (CLSYYPSYC) with annexin V, a common probe for molecular imaging of apoptotic cells, with respect to PS binding kinetics, apoptotic cell-targeting ability, and the efficacy of homing to apoptotic tumor cells in a mouse model after treatment with the anticancer agent camptothecin. Our results indicate that PSP1 efficiently targeted apoptotic cells and generated apoptosis/tumor-specific signals after cancer treatment in the animal model, whereas a similar dose of annexin V showed weak signals. The formation of a stable complex of PSP1 with PS might be one reason for the efficient in vivo targeting. We suggest that PSP1 has potential advantages for in vivo apoptotic cell imaging and could serve as a platform for the development of de novo peptide-based probes for apoptosis.

Molecular imaging of apoptosis: from micro to macro

Apoptosis, or programmed cell death, is involved in numerous human conditions including neurodegenerative diseases, ischemic damage, autoimmune disorders and many types of cancer, and is often confused with other types of cell death. Therefore strategies that enable visualized detection of apoptosis would be of enormous benefit in the clinic for diagnosis, patient management, and development of new therapies. In recent years, improved understanding of the apoptotic machinery and progress in imaging modalities have provided opportunities for researchers to formulate microscopic and macroscopic imaging strategies based on well-defined molecular markers and/or physiological features. Correspondingly, a large collection of apoptosis imaging probes and approaches have been documented in preclinical and clinical studies. In this review, we mainly discuss microscopic imaging assays and macroscopic imaging probes, ranging in complexity from simple attachments of reporter moieties to proteins that interact with apoptotic biomarkers, to rationally designed probes that target biochemical changes. Their clinical translation will also be our focus.

A dual-labeled Annexin A5 is not suited for SPECT imaging of brain cell death in experimental murine stroke

Cell death is one of the pathophysiological hallmarks after stroke. Markers to image cell death pathways in vivo are highly desirable. We previously showed that fluorescently labeled Annexin A5 (AnxA5), which binds specifically to phosphatidylserine (PS) on dead/dying cells, can be used in experimental stroke for monitoring cell death with optical imaging. Here we investigated whether dual-labeled AnxA5 (technetium and fluorescence label) can be used for single-photon emission computed tomography (SPECT) of cell death in the same model. C57Bl6/N mice were subjected to 60-minute middle cerebral artery occlusion (MCAO) and underwent SPECT imaging at 24, 48, and 72 hours afterwards. They were injected intravenously with either PS-binding AnxA5 or the nonfunctional AnxA5 (negative control), labeled with 99mTc and Alexa Fluor 568, respectively. After SPECT imaging, brain sections were cut for autoradiography and fluorescence microscopy. Ethanol-induced cell death in the femur muscle was used as positive control. We detected dual-labeled AnxA5 in the model of ethanol-induced cell death in the femur muscle, but not after MCAO at any time point, either with SPECT or with ex vivo autoradiography or fluorescence microscopy. Dual-labeled AnxA5 appears to be unsuited for visualizing death of brain cells in this MCAO model.

Comparison of different probes based on labeled annexin V for detection of apoptosis

Schematic representation of the different probes based on annexin V for the detection of apoptosis.

The anticancer properties of iron core-gold shell nanoparticles in colorectal cancer cells

Previously, iron core–gold shell nanoparticles (Fe@Au) have been shown to possess cancer-preferential cytotoxicity in oral and colorectal cancer (CRC) cells. However, CRC cell lines are less sensitive to Fe@Au treatment when compared with oral cancer cell lines. In this research, Fe@Au are found to decrease the cell viability of CRC cell lines, including Caco-2, HT-29, and SW480, through growth inhibition rather than the induction of cell death. The cytotoxicity induced by Fe@Au in CRC cells uses different subcellular pathways to the mitochondria-mediated autophagy found in Fe@Au-treated oral cancer cells, OECM1. Interestingly, the Caco-2 cell line shows a similar response to OECM1 cells and is thus more sensitive to Fe@Au treatment than the other CRC cell lines studied. We have investigated the underlying cell resistance mechanisms of Fe@Au-treated CRC cells. The resistance of CRC cells to Fe@Au does not result from the total amount of Fe@Au internalized. Instead, the different amounts of Fe and Au internalized appear to determine the different response to treatment with Fe-only nanoparticles in Fe@Au-resistant CRC cells compared with the Fe@Au-sensitive OECM1 cells. The only moderately cytotoxic effect of Fe@Au nanoparticles on CRC cells, when compared to the highly sensitive OECM1 cells, appears to arise from the CRC cells’ relative insensitivity to Fe, as is demonstrated by our Fe-only treatments. This is a surprising outcome, given that Fe has thus far been considered to be the “active” component of Fe@Au nanoparticles. Instead, we have found that the Au coatings, previously considered only as a passivating coating to protect the Fe cores from oxidation, significantly enhance the cytotoxicity of Fe@Au in certain CRC cells. Therefore, we conclude that both the Fe and Au in these core–shell nanoparticles are essential for the anticancer properties observed in CRC cells.

99mTc-HYNIC-Annexin A5 in Oncology: Evaluating Efficacy of Anti-Cancer Therapies

Evaluation of efficacy of anti-cancer therapy is currently performed by anatomical imaging (e.g., MRI, CT). Structural changes, if present, become apparent 1-2 months after start of therapy. Cancer patients thus bear the risk to receive an ineffective treatment, whilst clinical trials take a long time to prove therapy response. Both patient and pharmaceutical industry could therefore profit from an early assessment of efficacy of therapy. Diagnostic methods providing information on a functional level, rather than a structural, could present the solution. Recent technological advances in molecular imaging enable in vivo imaging of biological processes. Since most anti-cancer therapies combat tumors by inducing apoptosis, imaging of apoptosis could offer an early assessment of efficacy of therapy. This review focuses on principles of and clinical experience with molecular imaging of apoptosis using Annexin A5, a widely accepted marker for apoptosis detection in vitro and in vivo in animal models. 99mTc-HYNIC-Annexin A5 in combination with SPECT has been probed in clinical studies to assess efficacy of chemo- and radiotherapy within 1-4 days after start of therapy. Annexin A5-based functional imaging of apoptosis shows promise to offer a personalized medicine approach, now primarily used in genome-based medicine, applicable to all cancer patients.

Molecular pathways and molecular imaging in breast cancer: an update

Breast cancer is a heterogenic cancer being characterized by a variability of somatic mutations and in particular by different receptor expressions, such as estrogen, progesterone and human epidermal receptor. These phenotype characteristics play a crucial role in determining tumour response to various chemotherapies and other treatments and in the development of resistance to therapies. Positron emission tomography (PET) as a nuclear medicine technique, has recently demonstrated the advantages in determining the severity of disease and in evaluating the efficacy of treatments in a variety of neoplasm, including breast cancer. Because this procedure is able to pinpoint molecular activity within the body, it offers the potential to identify disease in its earliest stages as well as a patient's immediate response to therapeutic interventions in a non-invasive way. In this paper we performed an extended view about the correlation between molecular factors of breast cancer and PET tracers; in particular, we focalized our attention on their possible advantages in terms of 1) early detection of primary or recurrent cancer; 2) as a guide for target therapies and 3) for the evaluation of response to specific and now-available molecular treatments.

Real-time monitoring of caspase cascade activation in living cells

We introduce a simple, versatile and robust one-step technique that enables real-time imaging of multiple intracellular caspase activities in living cells without the need for complicated synthetic protocols. Conventional fluorogenic probes or recently reported activatable probes have been designed to target various proteases but are limited to extracellular molecules. Only a few have been applied to image intracellular proteases in living cells because most of these probes have limited cell-permeability. Our platform does not need complicated synthetic processes; instead it involves a straightforward peptide synthesis and a simple mixing step with a commercial transfection agent. The transfection agent efficiently delivered the highly quenched fluorogenic probes, comprised of distinctive pairs of dyes and quenchers, to the initiator caspase-8 and the effector caspase-3 in MDA-MB-435 cells, allowing dual-imaging of the activities of both caspases during the apoptotic process induced by TNF-related apoptosis induced ligand (TRAIL). With the combination of multiple fluorogenic probes, this simple platform can be applied to multiplexed imaging of selected intracellular proteases to study apoptotic processes in pathologies or for cell-based high throughput screening systems for drug discovery.