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Manea E, Chitoran E, Rotaru V, Ionescu S, Luca D, Cirimbei C, Alecu M, Capsa C, Gafton B, Prutianu I, Serban D, Simion L. Integration of Ultrasound in Image-Guided Adaptive Brachytherapy in Cancer of the Uterine Cervix. Bioengineering (Basel) 2024; 11:506. [PMID: 38790373 PMCID: PMC11117609 DOI: 10.3390/bioengineering11050506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/09/2024] [Accepted: 05/12/2024] [Indexed: 05/26/2024] Open
Abstract
Cervical cancer continues to be a public health concern, as it remains the second most common cancer despite screening programs. It is the third most common cause of cancer-related death for women, and the majority of cases happen in developing nations. The standard treatment for locally advanced cervical cancer involves the use of external beam radiation therapy, along with concurrent chemotherapy, followed by an image-guided adaptive brachytherapy (IGABT) boost. The five-year relative survival rate for European women diagnosed with cervical cancer was 62% between 2000 and 2007. Updated cervical cancer treatment guidelines based on IGABT have been developed by the Gynecological working group, which is composed of the Group Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology. The therapeutic strategy makes use of three-dimensional imaging, which can be tailored to the target volume and at-risk organs through the use of computed tomography or magnetic resonance imaging. Under anaesthesia, the brachytherapy implantation is carried out. Ultrasonography is utilised to assess the depth of the uterine cavity and to facilitate the dilation of the uterine canal during the application insertion. In this study, we examine data from the international literature regarding the application of ultrasound in cervical cancer brachytherapy.
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Affiliation(s)
- Elena Manea
- Department of Radiotherapy, Regional Institute of Oncology, 700483 Iasi, Romania; (E.M.)
- “Gr. T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Elena Chitoran
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (S.I.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Vlad Rotaru
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (S.I.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Sinziana Ionescu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (S.I.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Dan Luca
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (S.I.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Ciprian Cirimbei
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (S.I.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Mihnea Alecu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (S.I.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Cristina Capsa
- Radiology and Medical Imaging Department, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Bogdan Gafton
- Department of Radiotherapy, Regional Institute of Oncology, 700483 Iasi, Romania; (E.M.)
- “Gr. T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Iulian Prutianu
- “Gr. T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Department of Morpho-Functional Sciences I—Histology, University of Medicine and Pharmacy “Gr. T. Popa”, 700483 Iasi, Romania
| | - Dragos Serban
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (S.I.)
- Surgery Department IV, Bucharest Clinical Emergency Hospital, 050098 Bucharest, Romania
| | - Laurentiu Simion
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (S.I.)
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
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Weykamp F, Meixner E, Arians N, Hoegen-Saßmannshausen P, Kim JY, Tawk B, Knoll M, Huber P, König L, Sander A, Mokry T, Meinzer C, Schlemmer HP, Jäkel O, Debus J, Hörner-Rieber J. Daily AI-Based Treatment Adaptation under Weekly Offline MR Guidance in Chemoradiotherapy for Cervical Cancer 1: The AIM-C1 Trial. J Clin Med 2024; 13:957. [PMID: 38398270 PMCID: PMC10889253 DOI: 10.3390/jcm13040957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/13/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
(1) Background: External beam radiotherapy (EBRT) and concurrent chemotherapy, followed by brachytherapy (BT), offer a standard of care for patients with locally advanced cervical carcinoma. Conventionally, large safety margins are required to compensate for organ movement, potentially increasing toxicity. Lately, daily high-quality cone beam CT (CBCT)-guided adaptive radiotherapy, aided by artificial intelligence (AI), became clinically available. Thus, online treatment plans can be adapted to the current position of the tumor and the adjacent organs at risk (OAR), while the patient is lying on the treatment couch. We sought to evaluate the potential of this new technology, including a weekly shuttle-based 3T-MRI scan in various treatment positions for tumor evaluation and for decreasing treatment-related side effects. (2) Methods: This is a prospective one-armed phase-II trial consisting of 40 patients with cervical carcinoma (FIGO IB-IIIC1) with an age ≥ 18 years and a Karnofsky performance score ≥ 70%. EBRT (45-50.4 Gy in 25-28 fractions with 55.0-58.8 Gy simultaneous integrated boosts to lymph node metastases) will be accompanied by weekly shuttle-based MRIs. Concurrent platinum-based chemotherapy will be given, followed by 28 Gy of BT (four fractions). The primary endpoint will be the occurrence of overall early bowel and bladder toxicity CTCAE grade 2 or higher (CTCAE v5.0). Secondary outcomes include clinical feasibility, quality of life, and imaging-based response assessment.
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Affiliation(s)
- Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (J.H.-R.)
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Eva Meixner
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (J.H.-R.)
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Nathalie Arians
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (J.H.-R.)
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Philipp Hoegen-Saßmannshausen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (J.H.-R.)
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Ji-Young Kim
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (J.H.-R.)
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Bouchra Tawk
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (J.H.-R.)
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Maximilian Knoll
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (J.H.-R.)
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Peter Huber
- Clinical Cooperation Unit Molecular Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (J.H.-R.)
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Anja Sander
- Institute of Medical Biometry, University of Heidelberg, 69120 Heidelberg, Germany
| | - Theresa Mokry
- Department of Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Department of Radiology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Clara Meinzer
- Department of Radiology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Heinz-Peter Schlemmer
- Department of Radiology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Oliver Jäkel
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (J.H.-R.)
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site, 69120 Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (J.H.-R.)
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
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3
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Perez RC, Kim D, Maxwell AWP, Camacho JC. Functional Imaging of Hypoxia: PET and MRI. Cancers (Basel) 2023; 15:3336. [PMID: 37444446 DOI: 10.3390/cancers15133336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/22/2023] [Accepted: 06/22/2023] [Indexed: 07/15/2023] Open
Abstract
Molecular and functional imaging have critical roles in cancer care. Existing evidence suggests that noninvasive detection of hypoxia within a particular type of cancer can provide new information regarding the relationship between hypoxia, cancer aggressiveness and altered therapeutic responses. Following the identification of hypoxia inducible factor (HIF), significant progress in understanding the regulation of hypoxia-induced genes has been made. These advances have provided the ability to therapeutically target HIF and tumor-associated hypoxia. Therefore, by utilizing the molecular basis of hypoxia, hypoxia-based theranostic strategies are in the process of being developed which will further personalize care for cancer patients. The aim of this review is to provide an overview of the significance of tumor hypoxia and its relevance in cancer management as well as to lay out the role of imaging in detecting hypoxia within the context of cancer.
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Affiliation(s)
- Ryan C Perez
- Florida State University College of Medicine, Tallahassee, FL 32306, USA
| | - DaeHee Kim
- Department of Diagnostic Imaging, The Warren Alpert Medical School, Brown University, Providence, RI 02903, USA
| | - Aaron W P Maxwell
- Department of Diagnostic Imaging, The Warren Alpert Medical School, Brown University, Providence, RI 02903, USA
| | - Juan C Camacho
- Department of Clinical Sciences, Florida State University College of Medicine, Tallahassee, FL 32306, USA
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4
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Gouel P, Decazes P, Vera P, Gardin I, Thureau S, Bohn P. Advances in PET and MRI imaging of tumor hypoxia. Front Med (Lausanne) 2023; 10:1055062. [PMID: 36844199 PMCID: PMC9947663 DOI: 10.3389/fmed.2023.1055062] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
Tumor hypoxia is a complex and evolving phenomenon both in time and space. Molecular imaging allows to approach these variations, but the tracers used have their own limitations. PET imaging has the disadvantage of low resolution and must take into account molecular biodistribution, but has the advantage of high targeting accuracy. The relationship between the signal in MRI imaging and oxygen is complex but hopefully it would lead to the detection of truly oxygen-depleted tissue. Different ways of imaging hypoxia are discussed in this review, with nuclear medicine tracers such as [18F]-FMISO, [18F]-FAZA, or [64Cu]-ATSM but also with MRI techniques such as perfusion imaging, diffusion MRI or oxygen-enhanced MRI. Hypoxia is a pejorative factor regarding aggressiveness, tumor dissemination and resistance to treatments. Therefore, having accurate tools is particularly important.
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Affiliation(s)
- Pierrick Gouel
- Département d’Imagerie, Centre Henri Becquerel, Rouen, France,QuantIF-LITIS, EA 4108, IRIB, Université de Rouen, Rouen, France
| | - Pierre Decazes
- Département d’Imagerie, Centre Henri Becquerel, Rouen, France,QuantIF-LITIS, EA 4108, IRIB, Université de Rouen, Rouen, France
| | - Pierre Vera
- Département d’Imagerie, Centre Henri Becquerel, Rouen, France,QuantIF-LITIS, EA 4108, IRIB, Université de Rouen, Rouen, France
| | - Isabelle Gardin
- Département d’Imagerie, Centre Henri Becquerel, Rouen, France,QuantIF-LITIS, EA 4108, IRIB, Université de Rouen, Rouen, France
| | - Sébastien Thureau
- QuantIF-LITIS, EA 4108, IRIB, Université de Rouen, Rouen, France,Département de Radiothérapie, Centre Henri Becquerel, Rouen, France
| | - Pierre Bohn
- Département d’Imagerie, Centre Henri Becquerel, Rouen, France,QuantIF-LITIS, EA 4108, IRIB, Université de Rouen, Rouen, France,*Correspondence: Pierre Bohn,
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5
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Vahidfar N, Farzanefar S, Ahmadzadehfar H, Molloy EN, Eppard E. A Review of Nuclear Medicine Approaches in the Diagnosis and the Treatment of Gynecological Malignancies. Cancers (Basel) 2022; 14:1779. [PMID: 35406552 PMCID: PMC8997132 DOI: 10.3390/cancers14071779] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/19/2022] [Accepted: 03/26/2022] [Indexed: 12/15/2022] Open
Abstract
Nuclear medicine is defined as the diagnosis and the treatment of disease using radiolabeled compounds known as radiopharmaceuticals. Single-photon emission computed tomography/computed tomography (SPECT/CT) and positron emission tomography/computer tomography (PET/CT) based radiopharmaceuticals have proven reliable in diagnostic imaging in nuclear medicine and cancer treatment. One of the most critical cancers that also relies on an early diagnosis is gynecological cancer. Given that approximately 25% of all cancers in developing countries are a subset of gynecological cancer, investigating this cancer subtype is of significant clinical worth, particularly in light of its high rate of mortality. With accurate identification of high grade distant abdominal endometrial cancer as well as extra abdominal metastases, 18F-Fluorodeoxyglucose ([18F]FDG) PET/CT imaging is considered a valuable step forward in the investigation of gynecological cancer. Considering these factors, [18F]FDG PET/CT imaging can assist in making management of patient therapy more feasible. In this literature review, we will provide a short overview of the role of nuclear medicine in the diagnosis of obstetric and gynecological cancers.
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Affiliation(s)
- Nasim Vahidfar
- Department of Nuclear Medicine, Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran 1419733133, Iran; (N.V.); (S.F.)
| | - Saeed Farzanefar
- Department of Nuclear Medicine, Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran 1419733133, Iran; (N.V.); (S.F.)
| | | | - Eóin N. Molloy
- University Clinic for Radiology and Nuclear Medicine, Faculty of Medicine, Otto von Guericke University (OvGU), 39120 Magdeburg, Germany;
- German Center for Neurodegenerative Diseases (DZNE), 39120 Magdeburg, Germany
| | - Elisabeth Eppard
- University Clinic for Radiology and Nuclear Medicine, Faculty of Medicine, Otto von Guericke University (OvGU), 39120 Magdeburg, Germany;
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6
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PET imaging of hypoxia and apoptosis. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00205-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Datta A, West C, O'Connor JPB, Choudhury A, Hoskin P. Impact of hypoxia on cervical cancer outcomes. Int J Gynecol Cancer 2021; 31:1459-1470. [PMID: 34593564 DOI: 10.1136/ijgc-2021-002806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/14/2021] [Indexed: 01/22/2023] Open
Abstract
The annual global incidence of cervical cancer is approximately 604 000 cases/342 000 deaths, making it the fourth most common cancer in women. Cervical cancer is a major healthcare problem in low and middle income countries where 85% of new cases and deaths occur. Secondary prevention measures have reduced incidence and mortality in developed countries over the past 30 years, but cervical cancer remains a major cause of cancer deaths in women. For women who present with Fédération Internationale de Gynécologie et d'Obstétrique (FIGO 2018) stages IB3 or upwards, chemoradiation is the established treatment. Despite high rates of local control, overall survival is less than 50%, largely due to distant relapse. Reducing the health burden of cervical cancer requires greater individualization of treatment, identifying those at risk of relapse and progression for modified or intensified treatment. Hypoxia is a well known feature of solid tumors and an established therapeutic target. Low tumorous oxygenation increases the risk of local invasion, metastasis and treatment failure. While meta-analyses show benefit, many individual trials targeting hypoxia failed in part due to not selecting patients most likely to benefit. This review summarizes the available hypoxia-targeted strategies and identifies further research and new treatment paradigms needed to improve patient outcomes. The applications and limitations of hypoxia biomarkers for treatment selection and response monitoring are discussed. Finally, areas of greatest unmet clinical need are identified to measure and target hypoxia and therefore improve cervical cancer outcomes.
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Affiliation(s)
- Anubhav Datta
- Division of Cancer Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
- Clinical Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Catharine West
- Division of Cancer Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
| | - James P B O'Connor
- Division of Cancer Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, UK
| | - Ananya Choudhury
- Division of Cancer Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
- Clinical Oncology, The Christie Hospital NHS Trust, Manchester, UK
| | - Peter Hoskin
- Division of Cancer Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
- Clinical Oncology, Mount Vernon Cancer Centre, Northwood, Middlesex, UK
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8
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Huang Y, Fan J, Li Y, Fu S, Chen Y, Wu J. Imaging of Tumor Hypoxia With Radionuclide-Labeled Tracers for PET. Front Oncol 2021; 11:731503. [PMID: 34557414 PMCID: PMC8454408 DOI: 10.3389/fonc.2021.731503] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 08/19/2021] [Indexed: 01/27/2023] Open
Abstract
The hypoxic state in a solid tumor refers to the internal hypoxic environment that appears as the tumor volume increases (the maximum radius exceeds 180-200 microns). This state can promote angiogenesis, destroy the balance of the cell’s internal environment, and lead to resistance to radiotherapy and chemotherapy, as well as poor prognostic factors such as metastasis and recurrence. Therefore, accurate quantification, mapping, and monitoring of hypoxia, targeted therapy, and improvement of tumor hypoxia are of great significance for tumor treatment and improving patient survival. Despite many years of development, PET-based hypoxia imaging is still the most widely used evaluation method. This article provides a comprehensive overview of tumor hypoxia imaging using radionuclide-labeled PET tracers. We introduced the mechanism of tumor hypoxia and the reasons leading to the poor prognosis, and more comprehensively included the past, recent and ongoing studies of PET radiotracers for tumor hypoxia imaging. At the same time, the advantages and disadvantages of mainstream methods for detecting tumor hypoxia are summarized.
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Affiliation(s)
- Yuan Huang
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Junying Fan
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yi Li
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shaozhi Fu
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Oncology, Academician (Expert) Workstation of Sichuan Province, Luzhou, China
| | - Yue Chen
- Department of Oncology, Academician (Expert) Workstation of Sichuan Province, Luzhou, China.,Nuclear Medicine and Molecular Imaging key Laboratory of Sichuan Province, Department of Nuclear Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jingbo Wu
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Oncology, Academician (Expert) Workstation of Sichuan Province, Luzhou, China
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9
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[ 18F]-FDG-PET/CT and [ 18F]-FAZA-PET/CT Hypoxia Imaging of Metastatic Thyroid Cancer: Association with Short-Term Progression After Radioiodine Therapy. Mol Imaging Biol 2021; 22:1609-1620. [PMID: 32651718 DOI: 10.1007/s11307-020-01516-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE To examine the relationships between 2-deoxy-2-[18F]fluoro-D-glucose ([18F]-FDG) and hypoxia tracer [18F]fluoro-azomycinarabinofuranoside ([18F]-FAZA) and between 131I and [18F]-FAZA uptake in patients with metastatic thyroid cancer and to evaluate imaging features associated with short-term progression after 131I therapy. PROCEDURES The study population was 20 patients (17 women and 3 men; mean age, 67 years) with metastatic thyroid cancer who underwent both [18F]-FDG- and [18F]-FAZA-positron emission tomography (PET)/X-ray computed tomography (CT) examinations before 131I therapy. Short-term response to radioiodine was assessed (mean follow-up, 19 months ± 9). PET parameters including [18F]-FDG-SUVmax, [18F]-FAZA-SUVmax, and [18F]-FAZA-tumor-to-muscle [T/M] were obtained. Mann-Whitney U, Wilcoxon signed-rank, or χ2 tests were used to assess differences between two quantitative variables or compare categorical data. Predictive factors for short-term progression were investigated with logistic regression analysis. RESULTS Eleven lymph node metastatic lesions were identified in 9 patients and 46 distant metastatic lesions (lung, 19; bone, 17; and liver, 10) in 14 patients. A total of 24 131I-positive and 33 131I-negative lesions were detected. SUVmax was significantly lower with [18F]-FAZA-PET/CT (1.3 ± 0.6) than with [18F]-FDG-PET/CT (6.4 ± 5.9, p < 0.001). No significant correlation was observed between [18F]-FAZA-PET/CT and 131I imaging concerning visibility (p = 0.36). After 131I therapy, 31 of 57 metastatic lesions displayed short-term progression. Multivariate logistic regression revealed that [18F]-FDG-SUVmax (p = 0.022) and [18F]-FAZA-T/M (p = 0.002) showed significant associations with short-term progression. CONCLUSIONS Although [18F]-FAZA uptake was low in metastatic thyroid cancers, not only glucose metabolism but also hypoxic conditions may be associated with progression after 131I therapy in patients with metastatic thyroid cancer.
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10
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Ventura M, Bernards N, De Souza R, Fricke IB, Hendriks BS, Fitzgerald JB, Lee H, Klinz SG, Zheng J. Longitudinal PET Imaging to Monitor Treatment Efficacy by Liposomal Irinotecan in Orthotopic Patient-Derived Pancreatic Tumor Models of High and Low Hypoxia. Mol Imaging Biol 2021; 22:653-664. [PMID: 31482415 PMCID: PMC7782415 DOI: 10.1007/s11307-019-01374-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Purpose Hypoxia is linked to aggressiveness, resistance to therapy, and poor prognosis of pancreatic tumors. Liposomal irinotecan (nal-IRI, ONIVYDE®) has shown potential in reducing hypoxia in the HT29 colorectal cancer model, and here, we investigate its therapeutic activity and ability to modulate hypoxia in patient-derived orthotopic tumor models of pancreatic cancer. Procedures Mice were randomized into nal-IRI treated and untreated controls. Magnetic resonance imaging was used for monitoring treatment efficacy, positron emission tomography (PET) imaging with F-18-labelled fluoroazomycinarabinoside ([18F]FAZA) for tumor hypoxia quantification, and F-18-labelled fluorothymidine ([18F]FLT) for tumor cell proliferation. Results The highly hypoxic OCIP51 tumors showed significant response following nal-IRI treatment compared with the less hypoxic OCIP19 tumors. [18F]FAZA-PET detected significant hypoxia reduction in treated OCIP51 tumors, 8 days before significant changes in tumor volume. OCIP19 tumors also responded to therapy, although tumor volume control was not accompanied by any reduction in [18F]FAZA uptake. In both models, no differences were observable in [18F]FLT uptake in treated tumors compared with control mice. Conclusions Hypoxia modulation may play a role in nal-IRI’s mechanism of action. Nal-IRI demonstrated greater anti-tumor activity in the more aggressive and hypoxic tumor model. Furthermore, hypoxia imaging provided early prediction of treatment response. Electronic supplementary material The online version of this article (10.1007/s11307-019-01374-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Manuela Ventura
- TECHNA Institute for the Advancement of Technology for Health, University Health Network, Toronto, Ontario, Canada
| | - Nicholas Bernards
- TECHNA Institute for the Advancement of Technology for Health, University Health Network, Toronto, Ontario, Canada
| | - Raquel De Souza
- TECHNA Institute for the Advancement of Technology for Health, University Health Network, Toronto, Ontario, Canada
| | - Inga B Fricke
- TECHNA Institute for the Advancement of Technology for Health, University Health Network, Toronto, Ontario, Canada
| | | | | | - Helen Lee
- Merrimack Pharmaceuticals, Inc., Cambridge, MA, USA
| | - Stephan G Klinz
- Merrimack Pharmaceuticals, Inc., Cambridge, MA, USA
- Ipsen Bioscience, Cambridge, MA, USA
| | - Jinzi Zheng
- TECHNA Institute for the Advancement of Technology for Health, University Health Network, Toronto, Ontario, Canada.
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada.
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11
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Abstract
Over the last few years, cancer immunotherapy experienced tremendous developments and it is nowadays considered a promising strategy against many types of cancer. However, the exclusion of lymphocytes from the tumor nest is a common phenomenon that limits the efficiency of immunotherapy in solid tumors. Despite several mechanisms proposed during the years to explain the immune excluded phenotype, at present, there is no integrated understanding about the role played by different models of immune exclusion in human cancers. Hypoxia is a hallmark of most solid tumors and, being a multifaceted and complex condition, shapes in a unique way the tumor microenvironment, affecting gene transcription and chromatin remodeling. In this review, we speculate about an upstream role for hypoxia as a common biological determinant of immune exclusion in solid tumors. We also discuss the current state of ex vivo and in vivo imaging of hypoxic determinants in relation to T cell distribution that could mechanisms of immune exclusion and discover functional-morphological tumor features that could support clinical monitoring.
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Cao X, Allu SR, Jiang S, Gunn Bs JR, Yao PhD C, Xin PhD J, Bruza PhD P, Gladstone ScD DJ, Jarvis Md PhD LA, Tian PhD J, Swartz Md Msph PhD HM, Vinogradov PhD SA, Pogue PhD BW. High-Resolution pO 2 Imaging Improves Quantification of the Hypoxic Fraction in Tumors During Radiation Therapy. Int J Radiat Oncol Biol Phys 2020; 109:603-613. [PMID: 33002542 DOI: 10.1016/j.ijrobp.2020.09.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE The extreme microscopic heterogeneity of tumors makes it difficult to characterize tumor hypoxia. We evaluated how changes in the spatial resolution of oxygen imaging could alter measures of tumor hypoxia and their correlation to radiation therapy response. METHODS AND MATERIALS Cherenkov-Excited Luminescence Imaging in combination with an oxygen probe, Oxyphor PtG4 was used to directly image tumor pO2 distributions with 0.2 mm spatial resolution at the time of radiation delivery. These pO2 images were analyzed with variations of reduced spatial resolution from 0.2 mm to 5 mm, to investigate the influence of how reduced imaging spatial resolution would affect the observed tumor hypoxia. As an in vivo validation test, mice bearing tumor xenografts were imaged for hypoxic fraction and median pO2 to examine the predictive link with tumor response to radiation therapy, while accounting for spatial resolution. RESULTS In transitioning from voxel sizes of 200 μm to 3 mm, the median pO2 values increased by a few mm Hg, and the hypoxic fraction decreased by more than 50%. When looking at radiation-responsive tumors, the median pO2 values changed just a few mm Hg as a result of treatment, and the hypoxic fractions changed by as much as 50%. This latter change, however, could only be seen when sampling was performed with high spatial resolution. Median pO2 or similar quantities obtained from low resolution measurements are commonly used in clinical practice, however these parameters are much less sensitive to changes in the tumor microenvironment than the tumor hypoxic fraction obtained from high-resolution oxygen images. CONCLUSIONS This study supports the hypothesis that for adequate measurements of the tumor response to radiation therapy, oxygen imaging with high spatial resolution is required to accurately characterize the hypoxic fraction.
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Affiliation(s)
- Xu Cao
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire; Xidian University, Engineering Research Center of Molecular & Neuroimaging, Ministry of Education, School of Life Science and Technology, Xi'an, Shaanxi, China
| | - Srinivasa Rao Allu
- Department of Biochemistry and Biophysics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Chemistry, School or Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shudong Jiang
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jason R Gunn Bs
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire
| | - Cuiping Yao PhD
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire; Xi'an Jiaotong University, Institute of Biomedical Analytical Technology and Instrumentation, School of Life Science and Technology, Key Laboratory of Biomedical Information Engineering of Ministry of Education, Xi'an, Shaanxi, China
| | - Jing Xin PhD
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire; Xi'an Jiaotong University, Institute of Biomedical Analytical Technology and Instrumentation, School of Life Science and Technology, Key Laboratory of Biomedical Information Engineering of Ministry of Education, Xi'an, Shaanxi, China
| | - Petr Bruza PhD
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire
| | - David J Gladstone ScD
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Lesley A Jarvis Md PhD
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Jie Tian PhD
- Xidian University, Engineering Research Center of Molecular & Neuroimaging, Ministry of Education, School of Life Science and Technology, Xi'an, Shaanxi, China; CAS Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | | | - Sergei A Vinogradov PhD
- Department of Biochemistry and Biophysics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Chemistry, School or Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian W Pogue PhD
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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Waller J, Onderdonk B, Flood A, Swartz H, Shah J, Shah A, Aydogan B, Halpern H, Hasan Y. The clinical utility of imaging methods used to measure hypoxia in cervical cancer. Br J Radiol 2020; 93:20190640. [PMID: 32286849 PMCID: PMC7336054 DOI: 10.1259/bjr.20190640] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 03/18/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022] Open
Abstract
While it is well-established that hypoxia is a major factor that affects clinical outcomes in cervical cancer, widespread usage of clinically available methods to detect and evaluate hypoxia during the course of treatment have not been established. This review compares these methods, summarizes their strengths and weaknesses, and assesses the pathways for their useful employment to alter clinical practice. We conducted a search on PubMed for literature pertaining to imaging hypoxic cervical cancer, and implemented keywords related to oxygen measurement tools to improve the relevance of the search results.Oxygenation level-dependent applications of MRI have demonstrated hypoxia-induced radioresistance, and changes in cervix tumor oxygenation from hyperoxic therapy.The hypoxic areas within tumors can be indirectly identified in dynamic contrast-enhanced images, where they generally display low signal enhancement, and diffusion-weighted images, which demonstrates areas of restricted diffusion (which correlates with hypoxia). Positron emmision tomography, used independently and with other imaging modalities, has demonstrated utility in imaging hypoxia through tracers specific for low oxygen levels, like Cu-ATSM tracers and nitroimidazoles. Detecting hypoxia in the tumors of patients diagnosed with cervical cancer via medical imaging and non-imaging tools like electron paramagnetic resonance oximetry can be utilized clinically, such as for guiding radiation and post-treatment surveillance, for a more personalized approach to treatment. The merits of these methods warrant further investigation via comparative effectiveness research and large clinical trials into their clinical applications.
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Affiliation(s)
- Joseph Waller
- Drexel College of Medicine, 2900 W Queen Ln, PA 19129, United States
| | - Benjamin Onderdonk
- Department of Radiation and Cellular Oncology, The University of Chicago, 5758 S Maryland Ave, IL 60637, United States
| | - Ann Flood
- Department of Radiology, Dartmouth Geisel School of Medicine, 1 Rope Ferry Rd, NH 03755, United States
| | - Harold Swartz
- Department of Radiology, Dartmouth Geisel School of Medicine, 1 Rope Ferry Rd, NH 03755, United States
| | - Jaffer Shah
- Drexel College of Medicine, 2900 W Queen Ln, PA 19129, United States
| | - Asghar Shah
- Brown University, Providence, RI 02912, United States
| | - Bulent Aydogan
- Department of Radiation and Cellular Oncology, The University of Chicago, 5758 S Maryland Ave, IL 60637, United States
| | - Howard Halpern
- Department of Radiation and Cellular Oncology, The University of Chicago, 5758 S Maryland Ave, IL 60637, United States
| | - Yasmin Hasan
- Department of Radiation and Cellular Oncology, The University of Chicago, 5758 S Maryland Ave, IL 60637, United States
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Gammon ST, Pisaneschi F, Bandi ML, Smith MG, Sun Y, Rao Y, Muller F, Wong F, De Groot J, Ackroyd J, Mawlawi O, Davies MA, Vashisht Gopal Y, Di Francesco ME, Marszalek JR, Dewhirst M, Piwnica-Worms D. Mechanism-Specific Pharmacodynamics of a Novel Complex-I Inhibitor Quantified by Imaging Reversal of Consumptive Hypoxia with [ 18F]FAZA PET In Vivo. Cells 2019; 8:cells8121487. [PMID: 31766580 PMCID: PMC6952969 DOI: 10.3390/cells8121487] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 12/15/2022] Open
Abstract
Tumors lack a well-regulated vascular supply of O2 and often fail to balance O2 supply and demand. Net O2 tension within many tumors may not only depend on O2 delivery but also depend strongly on O2 demand. Thus, tumor O2 consumption rates may influence tumor hypoxia up to true anoxia. Recent reports have shown that many human tumors in vivo depend primarily on oxidative phosphorylation (OxPhos), not glycolysis, for energy generation, providing a driver for consumptive hypoxia and an exploitable vulnerability. In this regard, IACS-010759 is a novel high affinity inhibitor of OxPhos targeting mitochondrial complex-I that has recently completed a Phase-I clinical trial in leukemia. However, in solid tumors, the effective translation of OxPhos inhibitors requires methods to monitor pharmacodynamics in vivo. Herein, 18F-fluoroazomycin arabinoside ([18F]FAZA), a 2-nitroimidazole-based hypoxia PET imaging agent, was combined with a rigorous test-retest imaging method for non-invasive quantification of the reversal of consumptive hypoxia in vivo as a mechanism-specific pharmacodynamic (PD) biomarker of target engagement for IACS-010759. Neither cell death nor loss of perfusion could account for the IACS-010759-induced decrease in [18F]FAZA retention. Notably, in an OxPhos-reliant melanoma tumor, a titration curve using [18F]FAZA PET retention in vivo yielded an IC50 for IACS-010759 (1.4 mg/kg) equivalent to analysis ex vivo. Pilot [18F]FAZA PET scans of a patient with grade IV glioblastoma yielded highly reproducible, high-contrast images of hypoxia in vivo as validated by CA-IX and GLUT-1 IHC ex vivo. Thus, [18F]FAZA PET imaging provided direct evidence for the presence of consumptive hypoxia in vivo, the capacity for targeted reversal of consumptive hypoxia through the inhibition of OxPhos, and a highly-coupled mechanism-specific PD biomarker ready for translation.
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Affiliation(s)
- Seth T. Gammon
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.T.G.); (F.P.); (Y.R.); (F.M.); (J.A.)
| | - Federica Pisaneschi
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.T.G.); (F.P.); (Y.R.); (F.M.); (J.A.)
| | - Madhavi L. Bandi
- Translational Research to Advance Therapeutics and Innovation in Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.L.B.); (M.G.S.); (Y.S.); (J.R.M.)
| | - Melinda G. Smith
- Translational Research to Advance Therapeutics and Innovation in Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.L.B.); (M.G.S.); (Y.S.); (J.R.M.)
| | - Yuting Sun
- Translational Research to Advance Therapeutics and Innovation in Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.L.B.); (M.G.S.); (Y.S.); (J.R.M.)
| | - Yi Rao
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.T.G.); (F.P.); (Y.R.); (F.M.); (J.A.)
| | - Florian Muller
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.T.G.); (F.P.); (Y.R.); (F.M.); (J.A.)
| | - Franklin Wong
- Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - John De Groot
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX,77030, USA;
| | - Jeffrey Ackroyd
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.T.G.); (F.P.); (Y.R.); (F.M.); (J.A.)
| | - Osama Mawlawi
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Michael A. Davies
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.A.D.)
| | - Y.N. Vashisht Gopal
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.A.D.)
| | - M. Emilia Di Francesco
- Institute for Applied Cancer Science, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Joseph R. Marszalek
- Translational Research to Advance Therapeutics and Innovation in Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.L.B.); (M.G.S.); (Y.S.); (J.R.M.)
| | - Mark Dewhirst
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC 27710, USA;
| | - David Piwnica-Worms
- Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.T.G.); (F.P.); (Y.R.); (F.M.); (J.A.)
- Correspondence: ; Tel.: +1-713-745-0850; Fax: +1-713-745-7540
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Hrinivich WT, Morcos M, Viswanathan A, Lee J. Automatic tandem and ring reconstruction using MRI for cervical cancer brachytherapy. Med Phys 2019; 46:4324-4332. [PMID: 31329302 DOI: 10.1002/mp.13730] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/19/2019] [Accepted: 07/06/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The MRI-guided cervical cancer brachytherapy provides unparalleled soft-tissue contrast for target and normal tissue contouring, but eliminates the ability to use conventional metallic fiducials for radiation source path reconstruction as required for treatment planning. Instead, the source path is reconstructed by manually aligning a library model to the signal void produced by the applicator, which takes time intraoperatively and precludes fully automated treatment planning. The purpose of this study is to present and validate an algorithm to automatically reconstruct tandem and ring applicators using MRI for cervical cancer brachytherapy treatment planning. METHODS Applicators were reconstructed using T2-weighted MR images acquired at 1.5 T from 33 brachytherapy fractions including 10 patients using a model-to-image registration algorithm. The algorithm involves (a) image filtering and maximum intensity projection to highlight the applicator, (b) ring center identification using the circular Hough transform, and (c) three-dimensional surface model registration, optimized by maximizing the image intensity gradient normal to the model surface. Two independent observers manually reconstructed all applicators, enabling the calculation of interobserver variability and establishing a ground truth. Algorithm variability was calculated by comparing algorithm results to each individual observer, and algorithm accuracy was calculated by comparing algorithm results to the ground truth. The algorithm variability and accuracy were compared to the interobserver variability using paired t-tests. RESULTS Mean ± SD interobserver variability was 0.83 ± 0.31 mm and 0.78 ± 0.29 mm for the ring and tandem, respectively. The algorithm had mean ± SD variability and accuracy of 0.72 ± 0.32 mm (P = 0.02) and 0.60 ± 0.24 mm (P = 0.0005) for the ring, and 0.70 ± 0.29 mm (P = 0.11) and 0.58 ± 0.24 mm (P = 0.004) for the tandem, respectively. CONCLUSIONS The algorithm variability and accuracy were within the interobserver variability measured in this study. The algorithm accuracy and mean execution time of 10.0 s are sufficient for clinical tandem and ring reconstruction, and are a step toward fully automated tandem and ring brachytherapy treatment planning.
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Affiliation(s)
- William T Hrinivich
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - Marc Morcos
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - Akila Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - Junghoon Lee
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD, 21287, USA
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Changes in Tumor Biology During Chemoradiation of Cervix Cancer Assessed by Multiparametric MRI and Hypoxia PET. Mol Imaging Biol 2018; 20:160-169. [PMID: 28540524 PMCID: PMC5775363 DOI: 10.1007/s11307-017-1087-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Imaging biomarkers assessed with magnetic resonance imaging (MRI) and/or positron emission tomography (PET) enable non-invasive tumor characterization in cervix cancer patients. We investigated the spatio-temporal stability of hypoxia, perfusion, and the cell density of tumors over time by repetitive imaging prior to, during, and after radio-chemotherapy. PROCEDURES Thirteen patients were included in this prospective study. The imaging protocol included the following: [18F]fluoromisonidazole ([18F]FMISO)-PET/x-ray computed tomography (CT) and multiparametric (mp)-MRI at four time-points (TP): baseline (BL); and weeks 2 (TP1), 5 (TP2), and 19 after treatment start (follow-up FU). Complete datasets for six patients could be assessed for tumor volume, enhancement kinetics, diffusivity, and [18F]FMISO-avidity (P1-P6). In addition, two patients completed all PET/CT examinations (P7-P8) but not all MR scans; however, one of them had no hypoxia (P8). Descriptive statistics, correlations, and voxel-by-voxel analysis were performed. For various, independent reasons, five patients could not complete the study according to the protocol with all imaging sequences. RESULTS Median tumor ADCs (in ×10-3 mm2/s) were 0.99 ± 0.10 at BL, 1.20 ± 0.12 at TP1, 1.33 ± 0.14 at TP2, and 1.38 ± 0.21 at FU. The median TBRpeak (tumor-to-background) was 2.7 ± 0.8 at BL, 1.6 ± 0.2 at TP1, 1.8 ± 0.3 at TP2, and 1.7 ± 0.3 at FU. The voxel-by-voxel analysis of the [18F]FMISO uptake at BL and TP1 showed no correlation. Between TP2 and TP1 and FU and TP2, weak correlations were found for two patients. CONCLUSIONS Longitudinal mp-MR and PET imaging enables the in vivo tumor characterization over time. While perfusion and cell density decreased, there was a non-uniform change of hypoxia observed during radiotherapy. To assess the potential impact with regard to more personalized treatment approaches, hypoxia imaging-based dose painting for cervix cancer requires further research.
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Han K, Shek T, Vines D, Driscoll B, Fyles A, Jaffray D, Keller H, Metser U, Pintilie M, Xie J, Yeung I, Milosevic M. Measurement of Tumor Hypoxia in Patients With Locally Advanced Cervical Cancer Using Positron Emission Tomography with 18F-Fluoroazomyin Arabinoside. Int J Radiat Oncol Biol Phys 2018; 102:1202-1209. [PMID: 29680257 DOI: 10.1016/j.ijrobp.2018.02.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 02/11/2018] [Accepted: 02/20/2018] [Indexed: 01/25/2023]
Abstract
PURPOSE To assess cervical tumor hypoxia using the hypoxia tracer 18F-fluoroazomycin arabinoside (18F-FAZA) and compare different reference tissues and thresholds for quantifying tumor hypoxia. METHODS AND MATERIALS Twenty-seven patients with cervical cancer were studied prospectively by positron emission tomography (PET) imaging with 18F-FAZA before starting standard chemoradiation. The hypoxic volume was defined as all voxels within a tumor (T) with standardized uptake values (SUVs) greater than 3 standard deviations from the mean gluteus maximus muscle SUV value (M) or SUVs greater than 1 to 1.4 times the mean SUV value of the left ventricle, a blood (B) surrogate. The hypoxic fraction was defined as the ratio of the number of hypoxic voxels to the total number of tumor voxels. RESULTS A 18F-FAZA-PET hypoxic volume could be identified in the majority of cervical tumors (89% when using T/M or T/B > 1.2 as threshold) on the 2-hour static scan. The hypoxic fraction ranged from 0% to 99% (median 31%) when defined using the T/M threshold and from 0% to 78% (median 32%) with the T/B > 1.2 threshold. Hypoxic volumes derived from the different thresholds were highly correlated (Spearman's correlation coefficient ρ between T/M and T/B > 1-1.4 were 0.82-0.91), as were hypoxic fractions (0.75-0.85). Compartmental analysis of the dynamic scans showed k3, the FAZA accumulation constant, to be strongly correlated with hypoxic fraction defined using the T/M (Spearman's ρ=0.72) and T/B > 1.2 thresholds (0.76). CONCLUSIONS Hypoxia was detected in the majority of cervical tumors on 18F-FAZA-PET imaging. The extent of hypoxia varied markedly between tumors but not significantly with different reference tissues/thresholds.
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Affiliation(s)
- Kathy Han
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
| | - Tina Shek
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Quantitative Imaging for Personalized Cancer Medicine, Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Douglass Vines
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Quantitative Imaging for Personalized Cancer Medicine, Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Brandon Driscoll
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Quantitative Imaging for Personalized Cancer Medicine, Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Anthony Fyles
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - David Jaffray
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Quantitative Imaging for Personalized Cancer Medicine, Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Harald Keller
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Quantitative Imaging for Personalized Cancer Medicine, Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Ur Metser
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Melania Pintilie
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Jason Xie
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Ivan Yeung
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Quantitative Imaging for Personalized Cancer Medicine, Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Michael Milosevic
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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Bonnitcha P, Grieve S, Figtree G. Clinical imaging of hypoxia: Current status and future directions. Free Radic Biol Med 2018; 126:296-312. [PMID: 30130569 DOI: 10.1016/j.freeradbiomed.2018.08.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/30/2018] [Accepted: 08/14/2018] [Indexed: 12/20/2022]
Abstract
Tissue hypoxia is a key feature of many important causes of morbidity and mortality. In pathologies such as stroke, peripheral vascular disease and ischaemic heart disease, hypoxia is largely a consequence of low blood flow induced ischaemia, hence perfusion imaging is often used as a surrogate for hypoxia to guide clinical diagnosis and treatment. Importantly, ischaemia and hypoxia are not synonymous conditions as it is not universally true that well perfused tissues are normoxic or that poorly perfused tissues are hypoxic. In pathologies such as cancer, for instance, perfusion imaging and oxygen concentration are less well correlated, and oxygen concentration is independently correlated to radiotherapy response and overall treatment outcomes. In addition, the progression of many diseases is intricately related to maladaptive responses to the hypoxia itself. Thus there is potentially great clinical and scientific utility in direct measurements of tissue oxygenation. Despite this, imaging assessment of hypoxia in patients is rarely performed in clinical settings. This review summarises some of the current methods used to clinically evaluate hypoxia, the barriers to the routine use of these methods and the newer agents and techniques being explored for the assessment of hypoxia in pathological processes.
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Affiliation(s)
- Paul Bonnitcha
- Northern and Central Clinical Schools, Faculty of Medicine, Sydney University, Sydney, NSW 2006, Australia; Chemical Pathology Department, NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia; Kolling Institute of Medical Research, University of Sydney, St Leonards, New South Wales 2065, Australia.
| | - Stuart Grieve
- Sydney Translational Imaging Laboratory, Heart Research Institute, Charles Perkins Centre and Sydney Medical School, University of Sydney, NSW 2050, Australia
| | - Gemma Figtree
- Kolling Institute of Medical Research, University of Sydney, St Leonards, New South Wales 2065, Australia; Cardiology Department, Royal North Shore Hospital, St Leonards, New South Wales 2065, Australia
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Stieb S, Eleftheriou A, Warnock G, Guckenberger M, Riesterer O. Longitudinal PET imaging of tumor hypoxia during the course of radiotherapy. Eur J Nucl Med Mol Imaging 2018; 45:2201-2217. [PMID: 30128659 DOI: 10.1007/s00259-018-4116-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/30/2018] [Indexed: 12/11/2022]
Abstract
Hypoxia results from an imbalance between oxygen supply and consumption. It is a common phenomenon in solid malignant tumors such as head and neck cancer. As hypoxic cells are more resistant to therapy, tumor hypoxia is an indicator for poor prognosis. Several techniques have been developed to measure tissue oxygenation. These are the Eppendorf O2 polarographic needle electrode, immunohistochemical analysis of endogenous (e.g., hypoxia-inducible factor-1α (HIF-1a)) and exogenous markers (e.g., pimonidazole) as well as imaging methods such as functional magnetic resonance imaging (e.g., blood oxygen level dependent (BOLD) imaging, T1-weighted imaging) and hypoxia positron emission tomography (PET). Among the imaging modalities, only PET is sufficiently validated to detect hypoxia for clinical use. Hypoxia PET tracers include 18F-fluoromisonidazole (FMISO), the most commonly used hypoxic marker, 18F-flouroazomycin arabinoside (FAZA), 18Ffluoroerythronitroimidazole (FETNIM), 18F-2-nitroimidazolpentafluoropropylacetamide (EF5) and 18F-flortanidazole (HX4). As technical development provides the opportunity to increase the radiation dose to subregions of the tumor, such as hypoxic areas, it has to be ensured that these regions are stable not only from imaging to treatment but also through the course of radiotherapy. The aim of this review is therefore to characterize the behavior of tumor hypoxia during radiotherapy for the whole tumor and for subregions by using hypoxia PET tracers, with focus on head and neck cancer patients.
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Affiliation(s)
- Sonja Stieb
- Department of Radiation Oncology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland. .,Institute of Diagnostic and Interventional Radiology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Afroditi Eleftheriou
- Department of Pharmacology and Toxicology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland
| | - Geoffrey Warnock
- Department of Pharmacology and Toxicology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland.,Department of Nuclear Medicine, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Oliver Riesterer
- Department of Radiation Oncology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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Marcu LG, Moghaddasi L, Bezak E. Imaging of Tumor Characteristics and Molecular Pathways With PET: Developments Over the Last Decade Toward Personalized Cancer Therapy. Int J Radiat Oncol Biol Phys 2018; 102:1165-1182. [PMID: 29907486 DOI: 10.1016/j.ijrobp.2018.04.055] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 04/09/2018] [Accepted: 04/19/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE Improvements in personalized therapy are made possible by the advances in molecular biology that led to developments in molecular imaging, allowing highly specific in vivo imaging of biological processes. Positron emission tomography (PET) is the most specific and sensitive imaging technique for in vivo molecular targets and pathways, offering quantification and evaluation of functional properties of the targeted anatomy. MATERIALS AND METHODS This work is an integrative research review that summarizes and evaluates the accumulated current status of knowledge of recent advances in PET imaging for cancer diagnosis and treatment, concentrating on novel radiotracers and evaluating their advantages and disadvantages in cancer characterization. Medline search was conducted, limited to English publications from 2007 onward. Identified manuscripts were evaluated for most recent developments in PET imaging of cancer hypoxia, angiogenesis, proliferation, and clonogenic cancer stem cells (CSC). RESULTS There is an expansion observed from purely metabolic-based PET imaging toward antibody-based PET to achieve more information on cancer characteristics to identify hypoxia, proangiogenic factors, CSC, and others. 64Cu-ATSM, for example, can be used both as a hypoxia and a CSC marker. CONCLUSIONS Progress in the field of functional imaging will possibly lead to more specific tumor targeting and personalized treatment, increasing tumor control and improving quality of life.
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Affiliation(s)
- Loredana Gabriela Marcu
- Faculty of Science, University of Oradea, Oradea, Romania; Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide SA, Australia
| | - Leyla Moghaddasi
- GenesisCare, Tennyson Centre, Adelaide SA, Australia; Department of Physics, University of Adelaide, Adelaide SA, Australia
| | - Eva Bezak
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide SA, Australia; Department of Physics, University of Adelaide, Adelaide SA, Australia.
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Kalshetty A, Basu S. Non- 18F-2-Fluoro-2-Deoxy-d-Glucose PET/Computed Tomography in Gynecologic Oncology: An Overview of Current Status and Future Potential. PET Clin 2018; 13:239-248. [PMID: 29482752 DOI: 10.1016/j.cpet.2017.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The current status and future potential targets of non-18F-2-fluoro-2-deoxy-d-glucose (FDG) PET/computed tomography (CT) in 3 major gynecologic malignancies are discussed. Estrogen receptor-based 16alpha-18F-fluoro-17beta-estradiol (18F-FES) PET/CT has been investigated in (a) Uterine malignancies (both endometrial and myometrial pathologies) and (b) ovarian carcinoma. For uterine tumors, FDG/FES standardized uptake value and/or uptake ratio showed a positive correlation with malignant transformation (ie, endometrial carcinoma and uterine sarcoma) and higher malignant grades, whereas higher 18F-FES uptake was documented in benign pathologies (ie, endometrial hyperplasia and leiomyoma). For epithelial ovarian carcinomas, 18F-FES PET/CT can predict the response to antiestrogen therapy in platinum-resistant cases.
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Affiliation(s)
- Ashwini Kalshetty
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe Building, Jerbai Wadia Road, Parel, Mumbai 400 012, India; Homi Bhabha National Institute, Mumbai, India
| | - Sandip Basu
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe Building, Jerbai Wadia Road, Parel, Mumbai 400 012, India; Homi Bhabha National Institute, Mumbai, India.
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Mirabello V, Cortezon-Tamarit F, Pascu SI. Oxygen Sensing, Hypoxia Tracing and in Vivo Imaging with Functional Metalloprobes for the Early Detection of Non-communicable Diseases. Front Chem 2018; 6:27. [PMID: 29527524 PMCID: PMC5829448 DOI: 10.3389/fchem.2018.00027] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 02/02/2018] [Indexed: 01/10/2023] Open
Abstract
Hypoxia has been identified as one of the hallmarks of tumor environments and a prognosis factor in many cancers. The development of ideal chemical probes for imaging and sensing of hypoxia remains elusive. Crucial characteristics would include a measurable response to subtle variations of pO2 in living systems and an ability to accumulate only in the areas of interest (e.g., targeting hypoxia tissues) whilst exhibiting kinetic stabilities in vitro and in vivo. A sensitive probe would comprise platforms for applications in imaging and therapy for non-communicable diseases (NCDs) relying on sensitive detection of pO2. Just a handful of probes for the in vivo imaging of hypoxia [mainly using positron emission tomography (PET)] have reached the clinical research stage. Many chemical compounds, whilst presenting promising in vitro results as oxygen-sensing probes, are facing considerable disadvantages regarding their general application in vivo. The mechanisms of action of many hypoxia tracers have not been entirely rationalized, especially in the case of metallo-probes. An insight into the hypoxia selectivity mechanisms can allow an optimization of current imaging probes candidates and this will be explored hereby. The mechanistic understanding of the modes of action of coordination compounds under oxygen concentration gradients in living cells allows an expansion of the scope of compounds toward in vivo applications which, in turn, would help translate these into clinical applications. We summarize hereby some of the recent research efforts made toward the discovery of new oxygen sensing molecules having a metal-ligand core. We discuss their applications in vitro and/or in vivo, with an appreciation of a plethora of molecular imaging techniques (mainly reliant on nuclear medicine techniques) currently applied in the detection and tracing of hypoxia in the preclinical and clinical setups. The design of imaging/sensing probe for early-stage diagnosis would longer term avoid invasive procedures providing platforms for therapy monitoring in a variety of NCDs and, particularly, in cancers.
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Mahantshetty U, Teni T, Naga P, Hotwani C, Umesh S, Kannan S, Hande V, Pawar S, Engineer R, Chopra S, Deodhar K, Maheshwari A, Gurram L, Gupta S, Shrivastava SK. Impact of HPV 16/18 infection on clinical outcomes in locally advanced cervical cancers treated with radical radio (chemo) therapy - A prospective observational study. Gynecol Oncol 2018; 148:299-304. [DOI: 10.1016/j.ygyno.2017.11.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/21/2017] [Accepted: 11/24/2017] [Indexed: 10/18/2022]
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Khan SR, Arshad M, Wallitt K, Stewart V, Bharwani N, Barwick TD. What’s New in Imaging for Gynecologic Cancer? Curr Oncol Rep 2017; 19:85. [DOI: 10.1007/s11912-017-0640-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Ohliger MA, Hope TA, Chapman JS, Chen LM, Behr SC, Poder L. PET/MR Imaging in Gynecologic Oncology. Magn Reson Imaging Clin N Am 2017; 25:667-684. [DOI: 10.1016/j.mric.2017.03.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Challapalli A, Carroll L, Aboagye EO. Molecular mechanisms of hypoxia in cancer. Clin Transl Imaging 2017; 5:225-253. [PMID: 28596947 PMCID: PMC5437135 DOI: 10.1007/s40336-017-0231-1] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 04/21/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Hypoxia is a condition of insufficient oxygen to support metabolism which occurs when the vascular supply is interrupted, or when a tumour outgrows its vascular supply. It is a negative prognostic factor due to its association with an aggressive tumour phenotype and therapeutic resistance. This review provides an overview of hypoxia imaging with Positron emission tomography (PET), with an emphasis on the biological relevance, mechanism of action, highlighting advantages, and limitations of the currently available hypoxia radiotracers. METHODS A comprehensive PubMed literature search was performed, identifying articles relating to biological significance and measurement of hypoxia, MRI methods, and PET imaging of hypoxia in preclinical and clinical settings, up to December 2016. RESULTS A variety of approaches have been explored over the years for detecting and monitoring changes in tumour hypoxia, including regional measurements with oxygen electrodes placed under CT guidance, MRI methods that measure either oxygenation or lactate production consequent to hypoxia, different nuclear medicine approaches that utilise imaging agents the accumulation of which is inversely related to oxygen tension, and optical methods. The advantages and disadvantages of these approaches are reviewed, along with individual strategies for validating different imaging methods. PET is the preferred method for imaging tumour hypoxia due to its high specificity and sensitivity to probe physiological processes in vivo, as well as the ability to provide information about intracellular oxygenation levels. CONCLUSION Even though hypoxia could have significant prognostic and predictive value in the clinic, the best method for hypoxia assessment has in our opinion not been realised.
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Affiliation(s)
- Amarnath Challapalli
- Department of Clinical Oncology, Bristol Cancer Institute, Horfield Road, Bristol, United Kingdom
| | - Laurence Carroll
- Department of Surgery and Cancer, Imperial College, GN1, Commonwealth Building, Hammersmith Hospital, Du Cane Road, London, W120NN United Kingdom
| | - Eric O. Aboagye
- Department of Surgery and Cancer, Imperial College, GN1, Commonwealth Building, Hammersmith Hospital, Du Cane Road, London, W120NN United Kingdom
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Lyng H, Malinen E. Hypoxia in cervical cancer: from biology to imaging. Clin Transl Imaging 2017; 5:373-388. [PMID: 28804704 PMCID: PMC5532411 DOI: 10.1007/s40336-017-0238-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 06/24/2017] [Indexed: 12/14/2022]
Abstract
PURPOSE Hypoxia imaging may improve identification of cervical cancer patients at risk of treatment failure and be utilized in treatment planning and monitoring, but its clinical potential is far from fully realized. Here, we briefly describe the biology of hypoxia in cervix tumors of relevance for imaging, and evaluate positron emission tomography (PET) and magnetic resonance imaging (MRI) techniques that have shown promise for assessing hypoxia in a clinical setting. We further discuss emerging imaging approaches, and how imaging can play a role in future treatment strategies to target hypoxia. METHODS We performed a PubMed literature search, using keywords related to imaging and hypoxia in cervical cancer, with a particular emphasis on studies correlating imaging with other hypoxia measures and treatment outcome. RESULTS Only a few and rather small studies have utilized PET with tracers specific for hypoxia, and no firm conclusions regarding preferred tracer or clinical potential can be drawn so far. Most studies address indirect hypoxia imaging with dynamic contrast-enhanced techniques. Strong evidences for a role of these techniques in hypoxia imaging have been presented. Pre-treatment images have shown significant association to outcome in several studies, and images acquired during fractionated radiotherapy may further improve risk stratification. Multiparametric MRI and multimodality PET/MRI enable combined imaging of factors of relevance for tumor hypoxia and warrant further investigation. CONCLUSIONS Several imaging approaches have shown promise for hypoxia imaging in cervical cancer. Evaluation in large clinical trials is required to decide upon the optimal modality and approach.
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Affiliation(s)
- Heidi Lyng
- Department of Radiation Biology, Institute for Cancer Research, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Eirik Malinen
- Department of Medical Physics, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
- Department of Physics, University of Oslo, Oslo, Norway
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Lindblom E, Dasu A, Beskow C, Toma-Dasu I. High brachytherapy doses can counteract hypoxia in cervical cancer—a modelling study. Phys Med Biol 2016; 62:560-572. [DOI: 10.1088/1361-6560/aa520f] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Tanderup K, Lindegaard JC, Kirisits C, Haie-Meder C, Kirchheiner K, de Leeuw A, Jürgenliemk-Schulz I, Van Limbergen E, Pötter R. Image Guided Adaptive Brachytherapy in cervix cancer: A new paradigm changing clinical practice and outcome. Radiother Oncol 2016; 120:365-369. [PMID: 27555228 DOI: 10.1016/j.radonc.2016.08.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/03/2016] [Accepted: 08/03/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Kari Tanderup
- Aarhus University Hospital, Department of Oncology, Denmark
| | | | - Christian Kirisits
- Medical University of Vienna, Comprehensive Cancer Center, Department of Radiation Oncology, Austria
| | - Christine Haie-Meder
- Gustave Roussy Cancer Campus Grand Paris, Department of Radiation Oncology, Villejuif, France
| | - Kathrin Kirchheiner
- Medical University of Vienna, Comprehensive Cancer Center, Department of Radiation Oncology, Austria
| | - Astrid de Leeuw
- University Medical Center Utrecht, Department of Radiotherapy, The Netherlands
| | | | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Richard Pötter
- Medical University of Vienna, Comprehensive Cancer Center, Department of Radiation Oncology, Austria.
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Multiparametric [18F]Fluorodeoxyglucose/ [18F]Fluoromisonidazole Positron Emission Tomography/ Magnetic Resonance Imaging of Locally Advanced Cervical Cancer for the Non-Invasive Detection of Tumor Heterogeneity: A Pilot Study. PLoS One 2016; 11:e0155333. [PMID: 27167829 PMCID: PMC4864307 DOI: 10.1371/journal.pone.0155333] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 04/27/2016] [Indexed: 01/09/2023] Open
Abstract
Objectives To investigate fused multiparametric positron emission tomography/magnetic resonance imaging (MP PET/MRI) at 3T in patients with locally advanced cervical cancer, using high-resolution T2-weighted, contrast-enhanced MRI (CE-MRI), diffusion-weighted imaging (DWI), and the radiotracers [18F]fluorodeoxyglucose ([18F]FDG) and [18F]fluoromisonidazol ([18F]FMISO) for the non-invasive detection of tumor heterogeneity for an improved planning of chemo-radiation therapy (CRT). Materials and Methods Sixteen patients with locally advanced cervix were enrolled in this IRB approved and were examined with fused MP [18F]FDG/ [18F]FMISO PET/MRI and in eleven patients complete data sets were acquired. MP PET/MRI was assessed for tumor volume, enhancement (EH)-kinetics, diffusivity, and [18F]FDG/ [18F]FMISO-avidity. Descriptive statistics and voxel-by-voxel analysis of MRI and PET parameters were performed. Correlations were assessed using multiple correlation analysis. Results All tumors displayed imaging parameters concordant with cervix cancer, i.e. type II/III EH-kinetics, restricted diffusivity (median ADC 0.80x10-3mm2/sec), [18F]FDG- (median SUVmax16.2) and [18F]FMISO-avidity (median SUVmax3.1). In all patients, [18F]FMISO PET identified the hypoxic tumor subvolume, which was independent of tumor volume. A voxel-by-voxel analysis revealed only weak correlations between the MRI and PET parameters (0.05–0.22), indicating that each individual parameter yields independent information and the presence of tumor heterogeneity. Conclusion MP [18F]FDG/ [18F]FMISO PET/MRI in patients with cervical cancer facilitates the acquisition of independent predictive and prognostic imaging parameters. MP [18F]FDG/ [18F]FMISO PET/MRI enables insights into tumor biology on multiple levels and provides information on tumor heterogeneity, which has the potential to improve the planning of CRT.
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Abstract
Tumor hypoxia is a clinically relevant cause of radiation resistance. Direct measurements of tumor oxygenation have been performed predominantly with the Eppendorf histograph and these have defined the reduced prognosis after radiotherapy in poorly oxygenated tumors, especially head-and-neck cancer, cervix cancer and sarcoma. Exogenous markers have been used for immunohistochemical detection of hypoxic tumor areas (pimonidazole) or for positron-emission tomography (PET) imaging (misonidazole). Overexpression of hypoxia-related proteins such as hypoxia-inducible factor-1α (HIF-1α) has also been linked to poor prognosis after radiotherapy and such proteins are considered as potential endogenous hypoxia markers.
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Affiliation(s)
- Dirk Vordermark
- Universitätsklinik und Poliklinik für Strahlentherapie, Martin-Luther-Universität Halle-Wittenberg, Halle/Saale, Germany.
| | - Michael R Horsman
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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Assessment of Parametrial Response by Growth Pattern in Patients With International Federation of Gynecology and Obstetrics Stage IIB and IIIB Cervical Cancer: Analysis of Patients From a Prospective, Multicenter Trial (EMBRACE). Int J Radiat Oncol Biol Phys 2015; 93:788-96. [DOI: 10.1016/j.ijrobp.2015.08.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 08/03/2015] [Accepted: 08/04/2015] [Indexed: 11/19/2022]
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Zheng J, Klinz SG, De Souza R, Fitzgerald J, Jaffray DA. Longitudinal tumor hypoxia imaging with [(18)F]FAZA-PET provides early prediction of nanoliposomal irinotecan (nal-IRI) treatment activity. EJNMMI Res 2015; 5:57. [PMID: 26481012 PMCID: PMC4610963 DOI: 10.1186/s13550-015-0135-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/09/2015] [Indexed: 02/05/2023] Open
Abstract
Background Non-invasive measurement of tumor hypoxia has demonstrated potential for the evaluation of disease progression, as well as prediction and assessment of treatment outcome. [18F]fluoroazomycin arabinoside (FAZA) positron emission tomography (PET) has been identified as a robust method for quantification of hypoxia both preclinically and clinically. The goal of this investigation was to evaluate the feasibility and value of repeated FAZA-PET imaging to quantify hypoxia in tumors that received multi-dose chemotherapy. Methods FAZA-PET imaging was conducted over a 21-day period in a mouse xenograft model of HT-29 human colorectal carcinoma, following multi-dose chemotherapy treatment with irinotecan (CPT-11) or nanoliposomal irinotecan (nal-IRI, MM-398). Results Tumors treated with 10 mg/kg nal-IRI maintained significantly lower levels of hypoxia and smaller hypoxic fractions compared to tumors that received 50 mg/kg CPT-11. Specifically, differences in FAZA uptake were detectable 9 days before any significant differences in tumor volume were observed between the treatment groups. Conclusions These findings highlight the potential use of FAZA-PET as an early marker of treatment response following multi-dose chemotherapy. Electronic supplementary material The online version of this article (doi:10.1186/s13550-015-0135-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jinzi Zheng
- TECHNA Institute for the Advancement of Technology for Health, University Health Network, 101 College Street, Rm 7-302, Toronto, Ontario, M5G 1L7, Canada. .,Department of Radiation Physics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada. .,Institute of Biomaterials & Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada.
| | | | - Raquel De Souza
- Department of Radiation Physics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | | | - David A Jaffray
- TECHNA Institute for the Advancement of Technology for Health, University Health Network, 101 College Street, Rm 7-302, Toronto, Ontario, M5G 1L7, Canada.,Department of Radiation Physics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Institute of Biomaterials & Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada.,Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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Fleming IN, Manavaki R, Blower PJ, West C, Williams KJ, Harris AL, Domarkas J, Lord S, Baldry C, Gilbert FJ. Imaging tumour hypoxia with positron emission tomography. Br J Cancer 2015; 112:238-50. [PMID: 25514380 PMCID: PMC4453462 DOI: 10.1038/bjc.2014.610] [Citation(s) in RCA: 234] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 09/30/2014] [Accepted: 11/10/2014] [Indexed: 01/02/2023] Open
Abstract
Hypoxia, a hallmark of most solid tumours, is a negative prognostic factor due to its association with an aggressive tumour phenotype and therapeutic resistance. Given its prominent role in oncology, accurate detection of hypoxia is important, as it impacts on prognosis and could influence treatment planning. A variety of approaches have been explored over the years for detecting and monitoring changes in hypoxia in tumours, including biological markers and noninvasive imaging techniques. Positron emission tomography (PET) is the preferred method for imaging tumour hypoxia due to its high specificity and sensitivity to probe physiological processes in vivo, as well as the ability to provide information about intracellular oxygenation levels. This review provides an overview of imaging hypoxia with PET, with an emphasis on the advantages and limitations of the currently available hypoxia radiotracers.
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Affiliation(s)
- I N Fleming
- Aberdeen Biomedical Imaging Centre, Lilian Sutton Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - R Manavaki
- Department of Radiology, School of Clinical Medicine, University of Cambridge, Box 218-Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK
| | - P J Blower
- Division of Imaging Sciences and Biomedical Engineering, St Thomas' Hospital, King's College London, 4th Floor, Lambeth Wing, London SE1 7EH, UK
| | - C West
- Manchester Academic Health Science Centre, Institute of Cancer Sciences, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK
| | - K J Williams
- Manchester Pharmacy School, Faculty of Medical and Human Sciences, University Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, UK
- EPSRC and CRUK Cancer Imaging Centre in Cambridge and Manchester, Cambridge, UK
| | - A L Harris
- Molecular Oncology Laboratories, University Department of Medical Oncology, The Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DS, UK
| | - J Domarkas
- Centre for Cardiovascular and Metabolic Research, Respiratory Medicine, Hull-York Medical School, University of Hull, Hull HU16 5JQ, UK
| | - S Lord
- Molecular Oncology Laboratories, University Department of Medical Oncology, The Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DS, UK
| | - C Baldry
- Division of Imaging Sciences and Biomedical Engineering, St Thomas' Hospital, King's College London, 4th Floor, Lambeth Wing, London SE1 7EH, UK
| | - F J Gilbert
- Department of Radiology, School of Clinical Medicine, University of Cambridge, Box 218-Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK
- EPSRC and CRUK Cancer Imaging Centre in Cambridge and Manchester, Cambridge, UK
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Verwer EE, Boellaard R, Veldt AAMVD. Positron emission tomography to assess hypoxia and perfusion in lung cancer. World J Clin Oncol 2014; 5:824-844. [PMID: 25493221 PMCID: PMC4259945 DOI: 10.5306/wjco.v5.i5.824] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 04/29/2014] [Accepted: 07/15/2014] [Indexed: 02/06/2023] Open
Abstract
In lung cancer, tumor hypoxia is a characteristic feature, which is associated with a poor prognosis and resistance to both radiation therapy and chemotherapy. As the development of tumor hypoxia is associated with decreased perfusion, perfusion measurements provide more insight into the relation between hypoxia and perfusion in malignant tumors. Positron emission tomography (PET) is a highly sensitive nuclear imaging technique that is suited for non-invasive in vivo monitoring of dynamic processes including hypoxia and its associated parameter perfusion. The PET technique enables quantitative assessment of hypoxia and perfusion in tumors. To this end, consecutive PET scans can be performed in one scan session. Using different hypoxia tracers, PET imaging may provide insight into the prognostic significance of hypoxia and perfusion in lung cancer. In addition, PET studies may play an important role in various stages of personalized medicine, as these may help to select patients for specific treatments including radiation therapy, hypoxia modifying therapies, and antiangiogenic strategies. In addition, specific PET tracers can be applied for monitoring therapy. The present review provides an overview of the clinical applications of PET to measure hypoxia and perfusion in lung cancer. Available PET tracers and their characteristics as well as the applications of combined hypoxia and perfusion PET imaging are discussed.
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Head and neck tumor hypoxia imaging by 18F-fluoroazomycin-arabinoside (18F-FAZA)-PET: a review. Clin Nucl Med 2014; 39:44-8. [PMID: 24152663 DOI: 10.1097/rlu.0000000000000286] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Tumor hypoxia is known to be associated with poor clinical outcome; therefore, patients with hypoxic tumors might benefit from more intensive treatment approaches. This is particularly true for patients with head and neck cancer. Pretreatment assessment of hypoxia in tumors would be desirable, not only to predict prognosis but also to select patients for more aggressive treatment.As an alternative to the invasive polarographic needle electrode method, there is the possibility of using PET with radiopharmaceuticals visualizing hypoxia. Most hypoxia imaging studies on head and cancer have been performed using F-labeled fluoromisonidazole (F-FMISO). A chemically related molecule, F-fluoroazomycin-arabinoside (F-FAZA), seems to have superior kinetic properties and may therefore be the radiopharmaceutical of choice.This minireview summarizes the published literature on animal and human F-FAZA PET studies. Furthermore, future perspectives on how individualized treatment could be applied in patients with hypoxic head and neck tumors are discussed, for instance, the use of hypoxia sensitizers or special intensity-modulated radiation therapy techniques achieving tumor subvolume dose escalation.
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Kelada OJ, Carlson DJ. Molecular imaging of tumor hypoxia with positron emission tomography. Radiat Res 2014; 181:335-49. [PMID: 24673257 DOI: 10.1667/rr13590.1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The problem of tumor hypoxia has been recognized and studied by the oncology community for over 60 years. From radiation and chemotherapy resistance to the increased risk of metastasis, low oxygen concentrations in tumors have caused patients with many types of tumors to respond poorly to conventional cancer therapies. It is clear that patients with high levels of tumor hypoxia have a poorer overall treatment response and that the magnitude of hypoxia is an important prognostic factor. As a result, the development of methods to measure tumor hypoxia using invasive and noninvasive techniques has become desirable to the clinical oncology community. A variety of imaging modalities have been established to visualize hypoxia in vivo. Positron emission tomography (PET) imaging, in particular, has played a key role for imaging tumor hypoxia because of the development of hypoxia-specific radiolabelled agents. Consequently, this technique is increasingly used in the clinic for a wide variety of cancer types. Following a broad overview of the complexity of tumor hypoxia and measurement techniques to date, this article will focus specifically on the accuracy and reproducibility of PET imaging to quantify tumor hypoxia. Despite numerous advances in the field of PET imaging for hypoxia, we continue to search for the ideal hypoxia tracer to both qualitatively and quantitatively define the tumor hypoxic volume in a clinical setting to optimize treatments and predict response in cancer patients.
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Affiliation(s)
- Olivia J Kelada
- a Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut; and
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Apostolova I, Hofheinz F, Buchert R, Steffen I, Michel R, Rosner C, Prasad V, Köhler C, Derlin T, Brenner W, Marnitz S. Combined measurement of tumor perfusion and glucose metabolism for improved tumor characterization in advanced cervical carcinoma. Strahlenther Onkol 2014; 190:575-81. [DOI: 10.1007/s00066-014-0611-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 11/28/2013] [Indexed: 11/30/2022]
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Recent Trends in PET Image Interpretations Using Volumetric and Texture-based Quantification Methods in Nuclear Oncology. Nucl Med Mol Imaging 2014; 48:1-15. [PMID: 24900133 DOI: 10.1007/s13139-013-0260-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 12/10/2013] [Accepted: 12/12/2013] [Indexed: 12/22/2022] Open
Abstract
Image quantification studies in positron emission tomography/computed tomography (PET/CT) are of immense importance in the diagnosis and follow-up of variety of cancers. In this review we have described the current image quantification methodologies employed in (18)F-fluorodeoxyglucose ((18)F-FDG) PET in major oncological conditions with particular emphasis on tumor heterogeneity studies. We have described various quantitative parameters being used in PET image analysis. The main contemporary methodology is to measure tumor metabolic activity; however, analysis of other image-related parameters is also increasing. Primarily, we have identified the existing role of tumor heterogeneity studies in major cancers using (18)F-FDG PET. We have also described some newer radiopharmaceuticals other than (18)F-FDG being studied/used in the management of these cancers. Tumor heterogeneity studies are being performed in almost all major oncological conditions using (18)F-FDG PET. The role of these studies is very promising in the management of these conditions.
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Schmid MP, Fidarova E, Pötter R, Petric P, Bauer V, Woehs V, Georg P, Kirchheiner K, Berger D, Kirisits C, Dörr W, Dimopoulos JCA. Magnetic resonance imaging for assessment of parametrial tumour spread and regression patterns in adaptive cervix cancer radiotherapy. Acta Oncol 2013; 52:1384-90. [PMID: 23957566 DOI: 10.3109/0284186x.2013.818251] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To investigate the impact of magnetic resonance imaging (MRI)-morphologic differences in parametrial infiltration on tumour response during primary radiochemotherapy in cervical cancer. MATERIAL AND METHODS Eighty-five consecutive cervical cancer patients with FIGO stages IIB (n = 59) and IIIB (n = 26), treated by external beam radiotherapy (± chemotherapy) and image-guided adaptive brachytherapy, underwent T2-weighted MRI at the time of diagnosis and at the time of brachytherapy. MRI patterns of parametrial tumour infiltration at the time of diagnosis were assessed with regard to predominant morphology and maximum extent of parametrial tumour infiltration and were stratified into five tumour groups (TG): 1) expansive with spiculae; 2) expansive with spiculae and infiltrating parts; 3) infiltrative into the inner third of the parametrial space (PM); 4) infiltrative into the middle third of the PM; and 5) infiltrative into the outer third of the PM. MRI at the time of brachytherapy was used for identifying presence (residual vs. no residual disease) and signal intensity (high vs. intermediate) of residual disease within the PM. Left and right PM of each patient were evaluated separately at both time points. The impact of the TG on tumour remission status within the PM was analysed using χ(2)-test and logistic regression analysis. RESULTS In total, 170 PM were analysed. The TG 1, 2, 3, 4, 5 were present in 12%, 11%, 35%, 25% and 12% of the cases, respectively. Five percent of the PM were tumour-free. Residual tumour in the PM was identified in 19%, 68%, 88%, 90% and 85% of the PM for the TG 1, 2, 3, 4, and 5, respectively. The TG 3-5 had significantly higher rates of residual tumour in the PM in comparison to TG 1 + 2 (88% vs. 43%, p < 0.01). CONCLUSION MRI-morphologic features of PM infiltration appear to allow for prediction of tumour response during external beam radiotherapy and chemotherapy. A predominantly infiltrative tumour spread at the time of diagnosis resulted in a significantly higher rate of residual tumour in the PM at the time of brachytherapy in comparison to a predominantly expansive tumour spread.
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Affiliation(s)
- Maximilian P Schmid
- Department of Radiotherapy, Comprehensive Cancer Center, Medical University of Vienna , Vienna , Austria
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Jacobson O, Chen X. Interrogating tumor metabolism and tumor microenvironments using molecular positron emission tomography imaging. Theranostic approaches to improve therapeutics. Pharmacol Rev 2013; 65:1214-56. [PMID: 24064460 DOI: 10.1124/pr.113.007625] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Positron emission tomography (PET) is a noninvasive molecular imaging technology that is becoming increasingly important for the measurement of physiologic, biochemical, and pharmacological functions at cellular and molecular levels in patients with cancer. Formation, development, and aggressiveness of tumor involve a number of molecular pathways, including intrinsic tumor cell mutations and extrinsic interaction between tumor cells and the microenvironment. Currently, evaluation of these processes is mainly through biopsy, which is invasive and limited to the site of biopsy. Ongoing research on specific target molecules of the tumor and its microenvironment for PET imaging is showing great potential. To date, the use of PET for diagnosing local recurrence and metastatic sites of various cancers and evaluation of treatment response is mainly based on [(18)F]fluorodeoxyglucose ([(18)F]FDG), which measures glucose metabolism. However, [(18)F]FDG is not a target-specific PET tracer and does not give enough insight into tumor biology and/or its vulnerability to potential treatments. Hence, there is an increasing need for the development of selective biologic radiotracers that will yield specific biochemical information and allow for noninvasive molecular imaging. The possibility of cancer-associated targets for imaging will provide the opportunity to use PET for diagnosis and therapy response monitoring (theranostics) and thus personalized medicine. This article will focus on the review of non-[(18)F]FDG PET tracers for specific tumor biology processes and their preclinical and clinical applications.
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Affiliation(s)
- Orit Jacobson
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, MD.
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Tumour hypoxia imaging with 18F-fluoroazomycinarabinofuranoside PET/CT in patients with locally advanced rectal cancer. Nucl Med Commun 2013. [PMID: 23196674 DOI: 10.1097/mnm.0b013e32835bd5bc] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the feasibility of F-fluoroazomycinarabinofuranoside (F-FAZA) positron emission tomography (PET)/computed tomography (CT) in patients with locally advanced rectal cancer. MATERIALS AND METHODS The study included 14 patients with locally advanced rectal cancer. Before chemoradiotherapy, PET/CT with F-FAZA was performed with static 15 min images 2 h after injection of F-FAZA. Attenuation correction was obtained with a low-dose CT, and a contrast-enhanced CT was performed immediately after the PET scan. RESULTS F-FAZA uptake [mean and maximum standardized uptake value (SUVmean) and (SUVmax)] was significantly higher in rectal tumours than in both muscles (P<0.003) and normal intestinal walls (P<5×10). The tumour to muscle (T/M) ratios ranged from 1.19 to 3.05 with a mean of 1.97, whereas the tumour to intestinal wall (T/I) ratios had values of 1.73-5.81 with a mean of 2.83. Intense activity accumulating in the bladder produced obvious scattered activity, which spread into the surrounding tissue. Tumour volumes excluding scatter were therefore determined, in which the SUVmax and SUVmean were also significantly higher than in both muscles (P<0.004) and normal intestinal walls (P<2×10) and had T/M ratios of 1.19-2.72 with a mean of 1.85 and T/I ratios of 1.71-5.40 with a mean of 2.67. The individual SUVmax, SUVmean, T/M and T/I values were significantly higher in the entire tumour volume compared with the tumour volume adjusted for scatter from the urinary bladder (P<0.005), although the absolute differences were small. CONCLUSION F-FAZA PET/CT is feasible for visualization of hypoxia in patients with rectal cancer, but scattered activity from the urinary bladder should be taken into consideration.
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Verwer EE, van Velden FHP, Bahce I, Yaqub M, Schuit RC, Windhorst AD, Raijmakers P, Lammertsma AA, Smit EF, Boellaard R. Pharmacokinetic analysis of [18F]FAZA in non-small cell lung cancer patients. Eur J Nucl Med Mol Imaging 2013; 40:1523-31. [PMID: 23740374 DOI: 10.1007/s00259-013-2462-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 05/09/2013] [Indexed: 12/12/2022]
Abstract
PURPOSE [(18)F]Fluoroazomycin arabinoside (FAZA) is a positron emission tomography (PET) tracer developed to enable identification of hypoxic regions within a tumour. The aims of this study were to determine the optimal kinetic model along with validation of using alternatives to arterial blood sampling for analysing [(18)F]FAZA studies and to assess the validity of simplified analytical methods. METHODS Dynamic 70-min [(18)F]FAZA PET/CT scans were obtained from nine non-small cell lung cancer patients. Continuous arterial blood sampling, together with manual arterial and venous sampling, was performed to derive metabolite-corrected plasma input functions. Volumes of interest (VOIs) were defined for tumour, healthy lung muscle and adipose tissue generating [(18)F]FAZA time-activity curves (TACs). TACs were analysed using one- and two-tissue compartment models using both metabolite-corrected blood sampler plasma input functions (BSIF) and image-derived plasma input functions (IDIF). RESULTS The reversible two-tissue compartment model with blood volume parameter (2T4k+VB) best described kinetics of [(18)F]FAZA in tumours. Volumes of distribution (VT) obtained using IDIF correlated well with those derived using BSIF (R(2) = 0.82). Venous samples yielded the same radioactivity concentrations as arterial samples for times >50 min post-injection (p.i.). In addition, both plasma to whole blood ratios and parent fractions were essentially the same for venous and arterial samples. Both standardised uptake value (SUV), normalised to lean body mass, and tumour to blood ratio correlated well with VT (R(2) = 0.77 and R(2) = 0.87, respectively, at 50-60 min p.i.), although a bias was observed at low VT. CONCLUSION The 2T4k+VB model provided the best fit to the dynamic [(18)F]FAZA data. IDIF with venous blood samples can be used as input function. Further data are needed to validate the use of simplified methods.
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Affiliation(s)
- Eline E Verwer
- Department of Radiology & Nuclear Medicine, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands,
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Abstract
In locally advanced cervical cancer, 18F-fluorodeoxyglucose (FDG) positron emission tomography – computed tomography (PET/CT) has become important in the initial evaluation of disease extent. It is superior to other imaging modalities for lymph node status and distant metastasis. PET-defined cervical tumor volume predicts progression-free and overall survival. Higher FDG uptake in both primary and regional lymph nodes is strongly predictive of worse outcome. FDG-PET is useful for assessing treatment response 3 months after completing concurrent chemo-radiotherapy (CRT) and predicting long-term survival, and in suspected disease recurrence. In the era of image-guided adaptive radiotherapy, accurately defining disease areas is critical to avoid irradiating normal tissue. Based on additional information provided by FDG-PET, radiation treatment volumes can be modified and higher doses to FDG-positive lymph nodes safely delivered. FDG-PET/CT has been used for image-guided brachytherapy of FDG-avid tumor volume, while respecting low doses to bladder and rectum. Despite survival improvements due to CRT in cervical cancer, disease recurrences continue to be a major problem. Biological rationale exists for combining novel non-cytotoxic agents with CRT, and drugs targeting specific molecular pathways are under clinical development. The integration of these targeted therapies in clinical trials, and the need for accurate predictors of radio-curability is essential. New molecular imaging tracers may help identifying more aggressive tumors. 64Cu-labeled diacetyl-di(N(4)-methylthiosemicarbazone) is taken up by hypoxic tissues, which may be valuable for prognostication and radiation treatment planning. PET/CT imaging with novel radiopharmaceuticals could further impact cervical cancer treatment as surrogate markers of drug activity at the tumor microenvironment level. The present article reviews the current and emerging role of PET/CT in the management of cervical cancer.
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Affiliation(s)
- Fernanda G Herrera
- Department of Radiation Oncology, Lausanne University Hospital Lausanne, Switzerland
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Horsman MR, Mortensen LS, Petersen JB, Busk M, Overgaard J. Imaging hypoxia to improve radiotherapy outcome. Nat Rev Clin Oncol 2012; 9:674-87. [DOI: 10.1038/nrclinonc.2012.171] [Citation(s) in RCA: 422] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Mortensen LS, Johansen J, Kallehauge J, Primdahl H, Busk M, Lassen P, Alsner J, Sørensen BS, Toustrup K, Jakobsen S, Petersen J, Petersen H, Theil J, Nordsmark M, Overgaard J. FAZA PET/CT hypoxia imaging in patients with squamous cell carcinoma of the head and neck treated with radiotherapy: results from the DAHANCA 24 trial. Radiother Oncol 2012; 105:14-20. [PMID: 23083497 DOI: 10.1016/j.radonc.2012.09.015] [Citation(s) in RCA: 231] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 09/22/2012] [Accepted: 09/22/2012] [Indexed: 12/12/2022]
Abstract
PURPOSE Hypoxia is a cause of resistance to radiotherapy, especially in patients with head and neck squamous cell carcinoma (HNSCC). The purpose of this study was to evaluate (18)F-fluoroazomycin arabinoside (FAZA) positron emission tomography (PET)/computed tomography (CT) hypoxia imaging as a prognostic factor in HNSCC patients receiving radiotherapy. MATERIAL AND METHODS Forty patients with HNSCC treated with radiotherapy (66-76 Gy) were included. Static FAZA PET/CT imaging 2h post injection was conducted prior to irradiation. The hypoxic volume (HV) was delineated using a tumor-to-muscle value ≥ 1.4. In 13 patients, a repetitive FAZA PET/CT scan was conducted during the radiotherapy treatment. RESULTS A hypoxic volume could be identified in 25 (63%) of the 40 tumors. FAZA PET HV varied considerably with a range from 0.0 to 30.9 (median: 0.3) cm(3). The T(max)/M(med) ranged from 1.1 to 2.9 (median: 1.5). The distribution of hypoxia among the Human Papillomavirus (HPV) positive (12/16) and negative (13/24) tumors was not significant different. In the FAZA PET/CT scans performed during radiotherapy, hypoxia could be detected in six of the 13 patients. For these six patients the location of HV remained stable in location during radiotherapy treatment, though the size of the HV decreased. In 30 patients a positive correlation was detected between maximum FAZA uptake in the primary tumor and the lymph node. During a median follow up of 19 months a significant difference in disease free survival rate with 93% for patients with non hypoxic tumors and 60% for patients with hypoxic tumors could be detected. CONCLUSION This study emphasizes the role of FAZA PET/CT imaging as a suitable assay with prognostic potential for detection of hypoxia in HNSCC.
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Lin A, Hahn SM. Hypoxia Imaging Markers and Applications for Radiation Treatment Planning. Semin Nucl Med 2012; 42:343-52. [DOI: 10.1053/j.semnuclmed.2012.04.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kumar P, Shustov G, Liang H, Khlebnikov V, Zheng W, Yang XH, Cheeseman C, Wiebe LI. Design, synthesis, and preliminary biological evaluation of 6-O-glucose-azomycin adducts for diagnosis and therapy of hypoxic tumors. J Med Chem 2012; 55:6033-46. [PMID: 22708968 DOI: 10.1021/jm2017336] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Several 2-nitroimidazole-based molecules (NIs) are used as clinical hypoxic tumor radiodiagnostics, but they are not effective as radiosensitizers/radiochemotherapeutics. These NIs permeate tumor cells nonselectively via diffusion, and in therapy, where high doses are required, their dose limiting toxicities preclude success. The synthesis and preliminary in vitro evaluations of three glucoazomycins, members of a novel class of C6-O-glucose-linked-azomycin conjugates that are putative substrates of glucose transport proteins (GLUTs) and possess hypoxia-selective radiosensitization features, are now reported. The hypoxia-dependent upregulation of several GLUTs provides a rational basis to develop these glucoazomycins because more selective uptake in hypoxic cells would decrease systemic toxicities at effective doses. Calculated partition coefficients (ClogP, -1.70 to -2.99) predict rapid in vivo clearance for low systemic toxicity. In vitro experimental data show that glucoazomycins are radiosensitizers and that they competitively inhibit glucose uptake.
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Affiliation(s)
- Piyush Kumar
- Department of Oncology, University of Alberta , Edmonton, Alberta T6G 1Z2, Canada.
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