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Prasad YR, Anakha J, Pande AH. Treating liver cancer through arginine depletion. Drug Discov Today 2024; 29:103940. [PMID: 38452923 DOI: 10.1016/j.drudis.2024.103940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/16/2024] [Accepted: 02/29/2024] [Indexed: 03/09/2024]
Abstract
Liver cancer, the sixth most common cancer globally and the second-leading cause of cancer-related deaths, presents a critical public health threat. Diagnosis often occurs in advanced stages of the disease, aligning incidence with fatality rates. Given that established treatments, such as stereotactic body radiation therapy and transarterial radioembolization, face accessibility and affordability challenges, the emerging focus on cancer cell metabolism, particularly arginine (Arg) depletion, offers a promising research avenue. Arg-depleting enzymes show efficacy against Arg-auxotrophic cancers, including hepatocellular carcinoma (HCC). Thus, in this review, we explore the limitations of current therapies and highlight the potential of Arg depletion, emphasizing various Arg-hydrolyzing enzymes in clinical development.
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Affiliation(s)
- Yenisetti Rajendra Prasad
- Department of Biotechnology, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S.A.S. Nagar, Mohali 160062, Punjab, India
| | - J Anakha
- Department of Biotechnology, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S.A.S. Nagar, Mohali 160062, Punjab, India
| | - Abhay H Pande
- Department of Biotechnology, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S.A.S. Nagar, Mohali 160062, Punjab, India.
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Yen TYC, Abbasi AZ, He C, Lip HY, Park E, Amini MA, Adissu HA, Foltz W, Rauth AM, Henderson J, Wu XY. Biocompatible and bioactivable terpolymer-lipid-MnO 2 Nanoparticle-based MRI contrast agent for improving tumor detection and delineation. Mater Today Bio 2024; 25:100954. [PMID: 38304342 PMCID: PMC10832465 DOI: 10.1016/j.mtbio.2024.100954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/22/2023] [Accepted: 01/13/2024] [Indexed: 02/03/2024] Open
Abstract
Early and precise detection of solid tumor cancers is critical for improving therapeutic outcomes. In this regard, magnetic resonance imaging (MRI) has become a useful tool for tumor diagnosis and image-guided therapy. However, its effectiveness is limited by the shortcomings of clinically available gadolinium-based contrast agents (GBCAs), i.e. poor tumor penetration and retention, and safety concerns. Thus, we have developed a novel nanoparticulate contrast agent using a biocompatible terpolymer and lipids to encapsulate manganese dioxide nanoparticles (TPL-MDNP). The TPL-MDNP accumulated in tumor tissue and produced paramagnetic Mn2+ ions, enhancing T1-weight MRI contrast via the reaction with H2O2 rich in the acidic tumor microenvironment. Compared to the clinically used GBCA, Gadovist®1.0, TPL-MDNP generated stronger T1-weighted MR signals by over 2.0-fold at 30 % less of the recommended clinical dose with well-defined tumor delineation in preclinical orthotopic tumor models of brain, breast, prostate, and pancreas. Importantly, the MRI signals were retained for 60 min by TPL-MDNP, much longer than Gadovist®1.0. Biocompatibility of TPL-MDNP was evaluated and found to be safe up to 4-fold of the dose used for MRI. A robust large-scale manufacturing process was developed with batch-to-batch consistency. A lyophilization formulation was designed to maintain the nanostructure and storage stability of the new contrast agent.
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Affiliation(s)
- Tin-Yo C. Yen
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Azhar Z. Abbasi
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Chungsheng He
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Ho-Yin Lip
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Elliya Park
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Mohammad A. Amini
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | | | - Warren Foltz
- STTARR Innovation Centre, Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Ontario, M5G 2M9, Canada
| | - Andrew M. Rauth
- Departments of Medical Biophysics and Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey Henderson
- Departments of Medical Biophysics and Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Xiao Yu Wu
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
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Xue Y, Xiao B, Xia Z, Dai L, Xia Q, Zhong L, Zhu C, Zhu J. A New OATP-Mediated Hepatobiliary-Specific Mn(II)-Based MRI Contrast Agent for Hepatocellular Carcinoma in Mice: A Comparison With Gd-EOB-DTPA. J Magn Reson Imaging 2023; 58:926-933. [PMID: 36609994 DOI: 10.1002/jmri.28590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/27/2022] [Accepted: 12/27/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Growing concerns about the safety of gadolinium (Gd)-based contrast agents have reinforced the need for the development of Gd-free MRI contrast agents (CAs) that are effective in imaging liver tumors. PURPOSE To evaluate the ability of Mn-BnO-TyEDTA MRI CA to detect hepatocellular carcinoma in a mouse model of implanted liver tumor. STUDY TYPE Prospective. ANIMAL MODEL Thirteen orthotopically implanted liver tumor mice. FIELD STRENGTH/SEQUENCE 3.0 T/precontrast and postcontrast T1-weighted fast spoiled gradient recalled echo and T2-weighted fast recovery fast spin-echo imaging with fat suppression. ASSESSMENT The relative enhancement ratio was calculated and statistically compared. Lesion detection in postcontrast images was analyzed by calculations of area under the curve (AUC, the increases in liver-to-tumor contrast-to-noise ratio [∆CNR] vs. time curve). Mn or Gd levels were measured in the liver and tumoral tissues by inductively coupled plasma-mass spectrometry. Tumor specimens were stained with hematoxylin and eosin (H&E) and the expression of organic anion transfer peptide (OATP)1B1 was evaluated by immunofluorescence (IF) staining and mean fluorescence intensity (MFI) was calculated. STATISTICAL TESTS Unpaired t-test and two-tailed paired t-test. P < 0.05 was considered statistical significance. RESULTS Mn-BnO-TyEDTA and Gd-EOB-DTPA demonstrated nearly identical enhancement patterns in the liver, tumor, and psoas muscle and no difference in lesion detection (AUC10-30, Mn = 851 ∆CR·min, AUC10-30, Gd = 823 ∆CR·min). A Significant higher concentration of metal (Mn or Gd) was found in the liver compared to the tumor ([Mn]liver = 0.88 ± 0.07 μmmol/g, [Mn]tumor = 0.49 ± 0.05 μmmol/g, [Gd]liver = 0.65 ± 0.07 μmmol/g, [Gd]tumor = 0.27 ± 0.04 μmmol/g). IF staining showed significantly decreased expression of OATP1B1 in the tumor core compared to the liver (MFItumor = 5.28 ± 1.54, MFIliver = 25.49 ± 3.41). DATA CONCLUSION Mn-BnO-TyEDTA can provide comparable hepatobiliary tumor contrast enhancement to Gd-EOB-DTPA. EVIDENCE LEVEL 1 TECHNICAL EFFICACY: Stage 1.
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Affiliation(s)
- Yuan Xue
- Medical Imaging Key Laboratory of Sichuan Province, Department of Oncology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
- School of Basic Medical Sciences and Forensic Medicine, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Bin Xiao
- Medical Imaging Key Laboratory of Sichuan Province, Department of Oncology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Zhiyang Xia
- Medical Imaging Key Laboratory of Sichuan Province, Department of Oncology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
- School of Basic Medical Sciences and Forensic Medicine, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Lixiong Dai
- Wenzhou Key Laboratory of Biophysics, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang, China
| | - Qian Xia
- Medical Imaging Key Laboratory of Sichuan Province, Department of Oncology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Lei Zhong
- Medical Imaging Key Laboratory of Sichuan Province, Department of Oncology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Chunrong Zhu
- Medical Imaging Key Laboratory of Sichuan Province, Department of Oncology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
- School of Basic Medical Sciences and Forensic Medicine, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Jiang Zhu
- Medical Imaging Key Laboratory of Sichuan Province, Department of Oncology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
- School of Pharmacy, North Sichuan Medical College, Nanchong, Sichuan, China
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Werner A, Freesmeyer M, Kühnel C, Drescher R, Greiser J. Liver PET Reloaded: Automated Synthesis of [68Ga]Ga-BP-IDA for Positron Imaging of the Hepatobiliary Function and First Clinical Experience. Diagnostics (Basel) 2023; 13:diagnostics13061144. [PMID: 36980451 PMCID: PMC10047126 DOI: 10.3390/diagnostics13061144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/12/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
Hepatobiliary scintigraphy is a well-established nuclear imaging method for evaluating liver function and displaying the biliary system, but the spatial and temporal resolution is limited, and, there is still no established PET equivalent. Adapted from the work of Schuhmacher et al. in 1983, the production of a 68Gallium-labeled substitute, tetrabromophthalein ([68Ga]Ga-BP-IDA), was undertaken according to current Good Manufacturing Practice (GMP) standards and proved feasible and reproducible. PET/CT with the radiotracer was performed in two complex patients with hepatocellular carcinoma in preparation for transarterial radioembolization. Due to its high spatial and temporal resolution, localization of areas with impaired liver function and visualization of the biliary system were possible. We could demonstrate that this 68Gallium-labeled, IDA-based PET tracer is feasible and could advance hepatic and biliary function PET imaging.
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Automated GMP Production and Preclinical Evaluation of [ 68Ga]Ga-TEoS-DAZA and [ 68Ga]Ga-TMoS-DAZA. Pharmaceutics 2022; 14:pharmaceutics14122695. [PMID: 36559188 PMCID: PMC9783202 DOI: 10.3390/pharmaceutics14122695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/04/2022] Open
Abstract
[68Ga]Ga-TEoS-DAZA and [68Ga]Ga-TMoS-DAZA are two novel radiotracers suitable for functional PET liver imaging. Due to their specific liver uptake and biliary excretion, the tracers may be applied for segmental liver function quantification, gall tree imaging and the differential diagnosis of liver nodules. The purpose of this study was to investigate problems that occurred initially during the development of the GMP compliant synthesis procedure and to evaluate the tracers in a preclinical model. After low radiolabeling yields were attributed to precursor instability at high temperatures, an optimized radiolabeling procedure was established. Quality controls were in accordance with Ph. Eur. requirements and gave compliant results, although the method for the determination of the 68Ga colloid is partially inhibited due to the presence of a radioactive by-product. The determination of logP revealed [68Ga]Ga-TEoS-DAZA (ethoxy bearing) to be more lipophilic than [68Ga]Ga-TMoS-DAZA (methoxy bearing). Accordingly, biodistribution studies in an in ovo model showed a higher liver uptake for [68Ga]Ga-TEoS-DAZA. In dynamic in ovo PET imaging, rapid tracer accumulation in the liver was observed. Similarly, the activity in the intestines rose steadily within the first hour p.i., indicating biliary excretion. As [68Ga]Ga-TEoS-DAZA and [68Ga]Ga-TMoS-DAZA can be prepared according to GMP guidelines, transition into the early clinical phase is now possible.
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Subramanian S, Mallia MB, Shinto AS, Mathew AS. Clinical Management of Liver Cancer in India and Other Developing Nations: A Focus on Radiation Based Strategies. Oncol Ther 2021; 9:273-295. [PMID: 34046873 PMCID: PMC8593115 DOI: 10.1007/s40487-021-00154-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/12/2021] [Indexed: 11/28/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is a global killer with preponderance in Asian and African countries. It poses a challenge for successful management in less affluent or developing nations like India, with large populations and limited infrastructures. This review aims to assess the available options and future directions for management of HCC applicable to such countries. While summarizing current and emerging clinical strategies for detection, staging and therapy of the disease, it highlights radioisotope- and radioactivity-based strategies as part of an overall program. Using the widely accepted Barcelona Clinic Liver Cancer (BCLC) staging system as a base, it evaluates the applicability of different therapeutic approaches and their synergistic combination(s) in the context of a patient-specific dynamic results-based strategy. It distills the conclusions of multiple HCC management-focused consensus recommendations to provide a picture of clinical strategies, especially radiation-related approaches. Additionally, it discusses the logistical and economic feasibility of these approaches in the context of the limitations of the burdened public health infrastructure in India (and like nations) and highlights possible strategies both at the clinical level and in terms of an administrative health policy on HCC to provide the maximum possible benefit to the widest swathe of the affected population.
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Affiliation(s)
- Suresh Subramanian
- Radiopharmaceuticals Division, RLG Building, Bhabha Atomic Research Centre, Trombay, Mumbai, Maharashtra, 400085, India.
| | - Madhava B Mallia
- Radiopharmaceuticals Division, RLG Building, Bhabha Atomic Research Centre, Trombay, Mumbai, Maharashtra, 400085, India
| | - Ajit S Shinto
- Apollo Proton Cancer Centre, Chennai, 600096, Tamil Nadu, India
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Chen K, Li P, Zhu C, Xia Z, Xia Q, Zhong L, Xiao B, Cheng T, Wu C, Shen C, Zhang X, Zhu J. Mn(II) Complex of Lipophilic Group-Modified Ethylenediaminetetraacetic Acid (EDTA) as a New Hepatobiliary MRI Contrast Agent. J Med Chem 2021; 64:9182-9192. [PMID: 34152137 DOI: 10.1021/acs.jmedchem.1c00393] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Liver-specific contrast agents (CAs) can improve the Magnetic resonance imaging (MRI) detection of focal and diffuse liver lesions by increasing the lesion-to-liver contrast. A novel Mn(II) complex, Mn-BnO-TyrEDTA, with a lipophilic group-modified ethylenediaminetetraacetic acid (EDTA) structure as a ligand to regulate its behavior in vivo, is superior to Gd-EOB-DTPA in terms of a liver-specific MRI contrast agent. An MRI study on mice demonstrated that Mn-BnO-TyrEDTA can be rapidly taken up by hepatocytes with a combination of hepatobiliary and renal clearance pathways. Bromosulfophthalein (BSP) inhibition imaging, biodistribution, and cellular uptake studies confirmed that the mechanism of hepatic targeting of Mn-BnO-TyrEDTA is the hepatic uptake of the amphiphilic anion contrast agent mediated by organic anion transporting polypeptides (OATPs) expressed by functional hepatocytes.
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Affiliation(s)
| | - Pan Li
- Department of Radiotherapy, Sichuan Cancer Hospital & Institute, Chengdu 610041, China
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Freesmeyer M, Greiser J, Winkens T, Gühne F, Kühnel C, Rauchfuß F, Tautenhahn HM, Drescher R. Dynamic PET/CT with the Hepatobiliary Tracer [68Ga]Ga-Tmos-DAZA for Characterization of a Hepatic Tumor. Diagnostics (Basel) 2021; 11:diagnostics11040660. [PMID: 33917643 PMCID: PMC8067586 DOI: 10.3390/diagnostics11040660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 11/23/2022] Open
Abstract
Established imaging modalities for the characterization of liver tumors are computed tomography (CT), magnetical resonance (MR) imaging, sonography, and hepatobiliary scintigraphy. In some cases, their results may be inconclusive or certain examinations not possible due to contraindications. Positron emission tomography (PET)/CT has the capability of dynamic imaging with high temporal resolution. With radiolabeled tri-alkoxysalicyl-1,4-diazepan-6-amine (TAoS-DAZA) tracers, imaging of liver perfusion and hepatobiliary function is possible in a single examination. In the presented case, the PET/CT was performed in a patient with suspected hepatocellular carcinoma and atypical CT findings. PET imaging characteristics were consistent with a hepatocellular carcinoma (HCC). PET with DAZA ligands may be a supplemental method for liver tumor characterization in difficult cases.
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Affiliation(s)
- Martin Freesmeyer
- Clinic of Nuclear Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany; (J.G.); (T.W.); (F.G.); (C.K.); (R.D.)
- Correspondence: ; Tel.: +49-3641-9329801
| | - Julia Greiser
- Clinic of Nuclear Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany; (J.G.); (T.W.); (F.G.); (C.K.); (R.D.)
| | - Thomas Winkens
- Clinic of Nuclear Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany; (J.G.); (T.W.); (F.G.); (C.K.); (R.D.)
| | - Falk Gühne
- Clinic of Nuclear Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany; (J.G.); (T.W.); (F.G.); (C.K.); (R.D.)
| | - Christian Kühnel
- Clinic of Nuclear Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany; (J.G.); (T.W.); (F.G.); (C.K.); (R.D.)
| | - Falk Rauchfuß
- Clinic of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany; (F.R.); (H.-M.T.)
| | - Hans-Michael Tautenhahn
- Clinic of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany; (F.R.); (H.-M.T.)
| | - Robert Drescher
- Clinic of Nuclear Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany; (J.G.); (T.W.); (F.G.); (C.K.); (R.D.)
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Mat Nawi N, Tagiling N, Mohd Rohani MF, Wan Zainon WMN, Zanial MS, Wong MS, Lee YY. 99mTc-sodium phytate is a valid alternative to the gold-standard 99mTc-sulfur colloid in the measurement of gastric emptying among healthy multi-ethnic Asian population: results of a randomized cross-over trial. BMC Gastroenterol 2020; 20:293. [PMID: 32867699 PMCID: PMC7457507 DOI: 10.1186/s12876-020-01426-5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/13/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND It is unclear if the 99mTc-sodium phytate (99mTc-SP) is as reliable as the gold-standard 99mTc-sulfur colloid (99mTc-SC) for gastric emptying scintigraphy (GES). This study is aimed to compare the emptying rates of both radiotracers in a prospective, randomized cross-over trial and to determine the normative data of a healthy multi-ethnic Asian population. METHODS Out of the 44 healthy individuals screened, 31 (14 females; mean age: 28.4 ± 7.0 years) were enrolled and underwent GES using the standardized egg-white meal. All participants were randomly assigned to either 99mTc-SP or 99mTc-SC on the first GES session before crossed over to the other formulation after 2 weeks. RESULTS Both kits achieved the radiochemical purities of > 95%. The median rate (95th upper normative limit) of gastric emptying, reported as total gastric meal retention between 99mTc-SP and 99mTc-SC, was found to be comparable at all measured time points: 0.5 h [85.0% (96.6%) vs. 82.0% (94.0%)], 1 h [70.0% (86.4%) vs. 65.0% (86.6%)], 2 h [31.0% (55.8%) vs. 25.0% (64.4%)], 3 h [7.0% (26.3%) vs. 5.0% (29.9%)], and 4 h [3.0% (10.3%) vs. 2.0% (9.9%)]; P > 0.05. In addition, both radiotracers correlated well (Kendall's Tau (τ) coefficient = 0.498, P < 0.001) and presented with a good agreement at the 4th-hour time frame based on the Bland-Altman plot analysis. CONCLUSIONS 99mTc-SP is a valid radiotracer alternative to 99mTc-SC for routine GES examination. The normative values for both radiotracers have also been determined for the healthy multi-ethnic Asian population. TRIAL REGISTRATION This trial was registered retrospectively in the Thai Clinical Trials Registry on May 23rd, 2020 (Identifier: TCTR20200526004; http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=6296 ).
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Affiliation(s)
- Norazlina Mat Nawi
- Department of Nuclear Medicine, Radiotherapy and Oncology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
- Hospital USM, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
| | - Nashrulhaq Tagiling
- Department of Nuclear Medicine, Radiotherapy and Oncology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
| | | | - Wan Mohd Nazlee Wan Zainon
- Hospital USM, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
- School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
| | | | - Mung Seong Wong
- Hospital USM, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
| | - Yeong Yeh Lee
- Hospital USM, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia.
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia.
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