Whole-Body Biodistribution and Dosimetry of the Dopamine Transporter Radioligand 18F-FE-PE2I in Human Subjects

Pilot study on 11C-CFT dynamic imaging using total-body PET/CT: biodistribution and radiation dosimetry in Parkinson's disease

Objective

Total-body PET/CT equipment, uEXPLORER, is a newly developed imaging technology with a superior resolution, high sensitivity, and high signal-to-noise ratio, providing unique application advantages in the pharmacokinetic evaluation of positron tracers. While ¹¹C-CFT PET/CT has been widely utilized in the early diagnosis of Parkinson's disease (PD), it is limited by the short half-life of the radionuclide and an incomplete understanding of its biological distribution in humans. This study aimed to use a total-body PET/CT dynamic scan with ¹¹C-CFT imaging to describe the real-time internal biodistribution in PD patients and to obtain accurate radiation dosimetry.

Methods

Six male subjects with suspected PD underwent dynamic ¹¹C-CFT total-body PET/CT. Following a bedside intravenous bolus injection of 373.3 ± 71.56 MBq of ¹¹C-CFT, PET acquisition was performed synchronously for 75 min with a maximum axial field of view (AFOV) of 194 cm. Time-activity curves (TACs) were generated by delineating volumes of interest (VOIs) of the sourced organs using PMOD software. Tracer kinetics and cumulative organ activities were calculated, and absorbed doses were calculated and estimated using the OLINDA/EXM software.

Results

In the systemic TAC analysis of ¹¹C-CFT, several unique types of distribution patterns were obtained among several major organs, including a "Fast-in Fast-out" pattern in the kidneys, lungs, spleen, and thyroid, a "Fast-in Slow-out" curve in the heart wall, a "Slow-in Slow-out" mode in the liver, a "Low-level extending" pattern in the whole brain and muscle, and a "Slow-in to plateau" trend in the striatum and bone. The effective dose of ¹¹C-CFT was calculated to be 2.83E-03 mSv/MBq, which is only one-third of the literature value measured by the conventional method. Moreover, this dose is much lower compared to all other doses of DAT radioligands used in PET imaging.

Conclusion

This study is a pioneering application of total-body PET/CT to ¹¹C-CFT dynamic imaging. Our results confirmed that ¹¹C-CFT has a favorable total body biodistribution, an extremely low internal radiation dose, and high imaging quality, making it suitable for reasonable PD diagnosis in patients requiring multiple follow-up examinations.

Reliability and validity of visual analysis of [ 18 F]FE-PE2I PET/CT in early Parkinsonian disease

OBJECTIVE

[ 18 F]FE-PE2I (FE-PE2I) is a new radiotracer for dopamine transporter (DAT) imaging with PET. The aim of this study was to evaluate the visual interpretation of FE-PE2I images for the diagnosis of idiopathic Parkinsonian syndrome (IPS). The inter-rater variability, sensitivity, specificity, and diagnostic accuracy for visual interpretation of striatal FE-PE2I compared to [ 123 I]FP-CIT (FP-CIT) single-photon emission computed tomography (SPECT) was evaluated.

METHODS

Thirty patients with newly onset parkinsonism and 32 healthy controls with both an FE-PE2I and FP-CIT were included in the study. Four patients had normal DAT imaging, of which three did not fulfil the IPS criteria at the clinical reassessment after 2 years. Six raters evaluated the DAT images blinded to the clinical diagnosis, interpreting the image as being 'normal' or 'pathological', and assessed the degree of DAT-reduction in the caudate and putamen. The inter-rater agreement was assessed with intra-class correlation and Cronbach's α . For calculation of sensitivity and specificity, DAT images were defined as correctly classified if categorized as normal or pathological by ≥4/6 raters.

RESULTS

The overall agreement in visual evaluation of the FE-PE2I- and FP-CIT images was high for the IPS patients ( α  = 0.960 and 0.898, respectively), but lower in healthy controls (FE-PE2I: α  = 0.693, FP-CIT: α  = 0.657). Visual interpretation gave high sensitivity (both 0.96) but lower specificity (FE-PE2I: 0.86, FP-CIT: 0.63) with an accuracy of 90% for FE-PE2I and 77% for FP-CIT.

CONCLUSION

Visual evaluation of FE-PE2I PET imaging demonstrates high reliability and diagnostic accuracy for IPS.

Longitudinal DAT changes measured with [18F]FE-PE2I PET in patients with Parkinson's disease; a validation study

BACKGROUND

Dopamine transporter (DAT) PET provides higher resolution than DAT SPECT and opportunity for integrated imaging with MRI. The radioligand [¹⁸F]FE-PE2I is highly selective for the DAT, and PET measurements with this radioligand have good reliability and repeatability in patients with non-advanced Parkinson's disease.

OBJECTIVES

To validate [¹⁸F]FE-PE2I PET as measurement tool of longitudinal DAT changes in patients with Parkinson's disease.

METHODS

Thirty-seven subjects with Parkinson's disease (Hoehn and Yahr stage < 3) were included in a longitudinal PET study with [¹⁸F]FE-PE2I. DAT availability (BP_ND) in the caudate nucleus, putamen, sensorimotor striatum, and substantia nigra, was estimated with parametric imaging using Logan graphical analysis and cerebellum as reference region. For comparison with DAT-SPECT literature, sample size calculations for disease intervention studies were made.

RESULTS

Baseline and follow-up PET data (interval: 2.3 ± 0.5 years) were available for 25 patients (9 females, 16 males). Median age was 64.7 years (range 46-76); symptom duration: 3 years (0.25-14); Hoehn and Yahr stage (H&Y): 1 (1-2). Annualized DAT decline and effect size were: -8.5 ± 6.6 % and 1.08 for caudate nucleus; -7.1 ± 6.1 % and 1.02 for putamen; -8.3 ± 8.5 % and 0.99 for sensorimotor striatum; -0.11 ± 9.3 % and 0.11 for substantia nigra. The estimated minimum sample size needed for a treatment trial using [¹⁸F]FE-PE2I PET as imaging marker is 2-3 times lower than is reported in literature on [¹²³I]FP-CIT SPECT.

CONCLUSIONS

Longitudinal [¹⁸F]FE-PE2I PET measurements in non-advanced PD demonstrate a striatal DAT decline consistent with previous SPECT and PET studies. No obvious changes of DAT availability were observed in the substantia nigra, indicating perhaps slower progression or compensatory changes. The effect sizes were numerically larger than reported in the literature for other DAT radioligands, suggesting that [¹⁸F]FE-PE2I might detect smaller DAT changes, and can be well used as progression marker in clinical trials.

Validation of dynamic [18F]FE-PE2I PET for estimation of relative regional cerebral blood flow: a comparison with [15O]H2O PET

BACKGROUND

Dopamine transporter (DAT) imaging is used in the diagnostic work-up in suspected parkinsonian syndromes and dementia with Lewy bodies but cannot differentiate between these syndromes, and an extra brain imaging examination of the regional cerebral blood flow (rCBF) or glucose metabolism is often needed for differential diagnosis. The requirement of two different imaging examinations is resource-consuming and inconvenient for the patients. Therefore, imaging of both cortical blood flow and DAT imaging with the same radiotracer would be more convenient and cost-effective. The aim of this study was to test whether relative regional cerebral blood flow (rCBF_R) can be measured with the DAT-specific positron emission tomography (PET) tracer [¹⁸F]FE-PE2I (FE-PE2I), by validation with cerebral perfusion measured with [¹⁵O]H₂O PET (H₂O).

METHODS

The rCBF_R was quantified by kinetic modeling for FE-PE2I (R1) and H₂O (F). The R1 was calculated using the simplified reference tissue model, and F was calculated with a modified Koopman double-integration method. The linear relationship and intraclass correlation (ICC) between R1 and F were tested in image data derived from 29 patients with recent onset parkinsonism and 30 healthy controls.

RESULTS

There was a strong linear correlation across all subjects between R1 and F in the frontal, parietal, temporal, cingulate and occipital cortex as well as in the striatum (r  ≥  0.731-0.905, p  < 0.001) with a good-to-excellent ICC, ranging from 0.727 to 0.943 (p < 0.001).

CONCLUSIONS

Our results suggest that FE-PE2I may be used as a proxy for cerebral perfusion, thus potentially serving as a radiotracer for assessment of both DAT availability and rCBF_R in one single dynamic scan. This could be valuable in the differential diagnosis of parkinsonian syndromes.

TRIAL REGISTRATION

EUDRA-CT 2015-003045-26. Registered 23 October 2015 https://www.clinicaltrialsregister.eu/ctr-search/search?query=2015-003045-26.

[18F]FE-PE2I PET is a feasible alternative to [123I]FP-CIT SPECT for dopamine transporter imaging in clinically uncertain parkinsonism

BACKGROUND

Dopamine transporter (DAT) imaging of striatum is clinically used in Parkinson's disease (PD) and neurodegenerative parkinsonian syndromes (PS) especially in the early disease stages. The aim of the present study was to evaluate the diagnostic performance of the recently developed tracer for DAT imaging [¹⁸F]FE-PE2I PET/CT to the reference standard [¹²³I]FP-CIT SPECT.

METHODS

Ninety-eight unselected patients referred for DAT imaging were included prospectively and consecutively and evaluated with [¹⁸F]FE-PE2I PET/CT and [¹²³I]FP-CIT SPECT on two separate days. PET and SPECT scans were categorized independently by two blinded expert readers as either normal, vascular changes, or mixed. Semiquantitative values were obtained for each modality and compared regarding effect size using Glass' delta.

RESULTS

Fifty-six of the [¹²³I]FP-CIT SPECT scans were considered abnormal (52 caused by PS, 4 by infarctions). Using [¹⁸F]FE-PE2I PET/CT, 95 of the 98 patients were categorized identically to SPECT as PS or non-PS with a sensitivity of 0.94 [0.84-0.99] and a specificity of 1.00 [0.92-1.00]. Inter-reader agreement for [¹⁸F]FE-PE2I PET with a kappa of 0.97 [0.89-1.00] was comparable to the agreement for [¹²³I]FP-CIT SPECT of 0.96 [0.76-1.00]. Semiquantitative values for short 10-min reconstructions of [¹⁸F]FE-PE2I PET/CT were comparable to longer reconstructions. The effect size for putamen/caudate nucleus ratio was significantly increased using PET compared to SPECT.

CONCLUSIONS

The high correspondence of [¹⁸F]FE-PE2I PET compared to reference standard [¹²³I]FP-CIT SPECT establishes [¹⁸F]FE-PE2I PET as a feasible PET tracer for clinical use with favourable scan logistics.

Whole-body biodistribution and radiation dosimetry of [18F]PR04.MZ: a new PET radiotracer for clinical management of patients with movement disorders

PURPOSE

[18F]PR04.MZ is a new PET imaging agent for dopamine transporters, providing excellent image quality and allowing for the evaluation of patients with movement disorders such as Parkinson's disease. The objective of this study was to evaluate the biodistribution and radiation dosimetry of [18F]PR04.MZ by serial PET imaging.

METHODS

Six healthy subjects (n = 3 males, n = 3 females) were enrolled in this study. A series of 14 whole-body PET/CT scans were acquired until 5.5 h post-injection of 200 ± 11 MBq of [18F]PR04.MZ. After rigid co-registration, volumes of interest were outlined either on CT or PET images. Time-integrated activity coefficients were calculated for selected source organs. Organ absorbed doses, and the effective dose were calculated using IDAC-Dose 2.1.

RESULTS

Physiological uptake of [18F]PR04.MZ was mainly observed in the striatum, brain, liver, gall bladder, intestine, red marrow and cortical bone. [18F]PR04.MZ was primarily excreted via hepatobiliary clearance and, to a lower extent, via renal clearance. The normalized absorbed doses were highest in gall bladder wall (32.2 ± 6.4 µGy/MBq), urinary bladder wall (27.2 ± 4.5 µGy/MBq), red marrow (26.5 ± 1.4 µGy/MBq), cortical bone surface (26.3 ± 2.5 µGy/MBq), liver (22.5 ± 1.8 µGy/MBq) and kidneys (21.8 ± 1.1 µGy/MBq). The effective dose according to ICRP 60 and 103 was 16.3 ± 1.1 and 16.6 ± 1.5 µSv/MBq, respectively.

CONCLUSION

[18F]PR04.MZ has a favourable dosimetry profile, comparable to those of other 18F-labelled PET tracers, and is suitable for larger clinical applications. Trial registration CEC SSM Oriente, Santiago, Chile, permit 20140520.

Reliability of dopamine transporter PET measurements with [18F]FE-PE2I in patients with Parkinson's disease

Background

Reliable quantification of dopamine transporter (DAT), a biomarker for Parkinson’s disease (PD), is essential for diagnostic purposes as well as for evaluation of potential disease-modifying treatment. Due to degeneration of dopaminergic neurons and thus lower expected radioligand binding to DAT, higher measurement variability in PD patients might be expected than earlier reproducibility results in healthy controls. Therefore, we aimed to examine the test-retest properties of [¹⁸F]FE-PE2I-PET in PD patients.

Methods

Nine patients with PD (Hoehn and Yahr stage < 3) were included (men/women 6/3; mean age 65.2 ± 6.8 years). Each patient underwent two [¹⁸F]FE-PE2I-PET measurements within 7–28 days. The outcome measure was non-displaceable binding potential generated using wavelet-aided parametric imaging with cerebellum as reference region. We assessed test-retest performance using estimates of reliability and repeatability. Regions for primary analysis were caudate, putamen, ventral striatum, and substantia nigra. Exploratory analysis was performed for functional subdivisions of the striatum. We also compared the more vs. less affected side.

Results

[¹⁸F]FE-PE2I showed absolute variability estimates of 5.3–7.6% in striatal regions and 11% in substantia nigra and ICCs of 0.74–0.97 (median 0.91). The absolute variability for functional striatal subdivisions was 6.0–9.6% and ICCs of 0.76–0.91 (median 0.91). The less affected substantia nigra exhibited greater consistency than the more affected side. According to power calculations based on the current sample size, DAT changes of 5–11% in the striatum and 28% in the substantia nigra can be detected with a power of 0.8 (p < 0.0125).

Conclusion

DAT-PET measurements with [¹⁸F]FE-PE2I in PD patients showed good repeatability and reliability. The slightly lower reliability in the substantia nigra in patients may be explained by lower DAT density and smaller anatomical size. Power calculations suggest that [¹⁸F]FE-PE2I PET is a suitable marker for longitudinal DAT decline in PD.

Trial registration

EudraCT 2017-003327-29

EANM practice guideline/SNMMI procedure standard for dopaminergic imaging in Parkinsonian syndromes 1.0

Purpose

This joint practice guideline or procedure standard was developed collaboratively by the European Association of Nuclear Medicine (EANM) and the Society of Nuclear Medicine and Molecular Imaging (SNMMI). The goal of this guideline is to assist nuclear medicine practitioners in recommending, performing, interpreting, and reporting the results of dopaminergic imaging in parkinsonian syndromes.

Methods

Currently nuclear medicine investigations can assess both presynaptic and postsynaptic function of dopaminergic synapses. To date both EANM and SNMMI have published procedural guidelines for dopamine transporter imaging with single photon emission computed tomography (SPECT) (in 2009 and 2011, respectively). An EANM guideline for D2 SPECT imaging is also available (2009). Since the publication of these previous guidelines, new lines of evidence have been made available on semiquantification, harmonization, comparison with normal datasets, and longitudinal analyses of dopamine transporter imaging with SPECT. Similarly, details on acquisition protocols and simplified quantification methods are now available for dopamine transporter imaging with PET, including recently developed fluorinated tracers. Finally, [¹⁸F]fluorodopa PET is now used in some centers for the differential diagnosis of parkinsonism, although procedural guidelines aiming to define standard procedures for [¹⁸F]fluorodopa imaging in this setting are still lacking.

Conclusion

All these emerging issues are addressed in the present procedural guidelines for dopaminergic imaging in parkinsonian syndromes.

In Vitro Ligand Binding Kinetics Explains the Pharmacokinetics of [18F]FE-PE2I in Dopamine Transporter PET Imaging

Two of the most popular positron emission tomography (PET) tracers, [¹¹C]PE2I and [¹⁸F]FE-PE2I, used to quantify dopamine transporters (DAT), display dissimilar kinetic behavior in in vivo assays. This difference can be explained by comparing values of kinetic rate constants, which characterize interaction of these tracers with DAT sites in vitro. At the same time, this kinetic analysis showed that the overall binding mechanism is similar for these two tracers and includes a fast step of complex formation followed by a slow isomerization step of this complex. Comparison with previous PE2I data revealed that isomerization of the DAT complex with PE2I occurs three times faster than in the case of FE-PE2I, which leads to the slower onset of peak specific binding of the former tracer in the DAT-rich regions. Therefore, ligands with slower isomerization on-rate, including [¹⁸F]FE-PE2I, seem to be better tracers in vivo, and their properties can be predicted in vitro.

Dopamine transporter imaging with [18F]FE-PE2I PET and [123I]FP-CIT SPECT-a clinical comparison

Background

Dopamine transporter (DAT) imaging may be of diagnostic value in patients with clinically suspected parkinsonian disease. The purpose of this study was to compare the diagnostic performance of DAT imaging with positron emission computed tomography (PET), using the recently developed, highly DAT-selective radiopharmaceutical [¹⁸F]FE-PE2I (FE-PE2I), to the commercially available and frequently used method with [¹²³I]FP-CIT (FP-CIT) single-photon emission computed tomography (SPECT) in early-stage idiopathic parkinsonian syndrome (PS).

Methods

Twenty-two patients with a clinical de novo diagnosis of PS and 28 healthy controls (HC) participating in an on-going clinical trial of FE-PE2I were analyzed in this study. Within the trial protocol, participants are clinically reassessed 2 years after inclusion. A commercially available software was used for automatic calculation of FP-CIT-specific uptake ratio (SUR). MRI-based volumes of interest combined with threshold PET segmentation were used for FE-PE2I binding potential relative to non-displaceable binding (BP_ND) quantification and specific uptake value ratios (SUVR).

Results

PET with FE-PE2I revealed significant differences between patients with a clinical de novo diagnosis of PS and healthy controls in striatal DAT availability (p < 0.001), with excellent accuracy of predicting dopaminergic deficit in early-stage PS. The effect sizes were calculated for FE-PE2I BP_ND (Glass’s Δ = 2.95), FE-PE2I SUVR (Glass’s Δ = 2.57), and FP-CIT SUR (Glass’s Δ = 2.29). The intraclass correlation (ICC) between FE-PE2I BP_ND FP-CIT SUR was high in the caudate (ICC = 0.923), putamen (ICC = 0.922), and striatum (ICC = 0.946), p < 0.001. Five of the 22 patients displayed preserved striatal DAT availability in the striatum with both methods. At follow-up, a non-PS clinical diagnosis was confirmed in three of these, while one was clinically diagnosed with corticobasal syndrome. In these patients, FE-PE2I binding was also normal in the substantia nigra (SN), while significantly reduced in the remaining patients. FE-PE2I measurement of the mean DAT availability in the putamen was strongly correlated with BP_ND in the SN (R = 0.816, p < 0.001). Olfaction and mean putamen DAT availability was correlated using both FE-PE2I BP_ND and FP-CIT SUR (R ≥ 0.616, p < 0.001).

Conclusion

DAT imaging with FE-PE2I PET yields excellent basic diagnostic differentiation in early-stage PS, at least as good as FP-CIT SPECT.