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Barajas RF, Ambady P, Link J, Krohn KA, Raslan A, Mallak N, Woltjer R, Muldoon L, Neuwelt EA. [ 18F]-fluoromisonidazole (FMISO) PET/MRI hypoxic fraction distinguishes neuroinflammatory pseudoprogression from recurrent glioblastoma in patients treated with pembrolizumab. Neurooncol Pract 2022; 9:246-250. [PMID: 35601969 PMCID: PMC9113243 DOI: 10.1093/nop/npac021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Response assessment after immunotherapy remains a major challenge in glioblastoma due to an expected increased incidence of pseudoprogression. Gadolinium-enhanced magnetic resonance imaging (MRI) is the standard for monitoring therapeutic response, however, is markedly limited in characterizing pseudoprogression. Given that hypoxia is an important defining feature of glioblastoma regrowth, we hypothesized that [18F]-fluoromisonidazole (FMISO) positron emission tomography (PET) could provide an additional physiological measure for the diagnosis of immunotherapeutic failure. Six patients with newly diagnosed glioblastoma who had previously received maximal safe resection followed by Stupp protocol CRT concurrent with pembrolizumab immunotherapy were recruited for FMISO PET and Gd-MRI at the time of presumed progression. The hypoxic fraction was defined as the ratio of hypoxic volume to T1-weighted gadolinium-enhancing volume. Four patients diagnosed with pseudoprogression demonstrated a mean hypoxic fraction of 9.8 ± 10%. Two with recurrent tumor demonstrated a mean hypoxic fraction of 131 ± 66%. Our results, supported by histopathology, suggest that the noninvasive assessment of hypoxic fraction by FMISO PET/MRI is clinically feasible and may serve as a biologically specific metric of therapeutic failure.
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Affiliation(s)
- Ramon F Barajas
- Department of Radiology, Neuroradiology Section, Oregon Health & Science University, Portland Oregon, USA
- Knight Cancer Institute Translational Oncology Program, Oregon Health & Science University, Portland, Oregon, USA
| | - Prakash Ambady
- Neuro-Oncology and Blood-Brain Barrier Program, Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jeanne Link
- Center for Radiochemistry Research, Oregon Health & Science University, Portland, Oregon, USA
| | - Kenneth A Krohn
- Center for Radiochemistry Research, Oregon Health & Science University, Portland, Oregon, USA
| | - Ahmed Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Nadine Mallak
- Advanced Imaging Research Center, Oregon Health & Science University, Portland Oregon, USA
| | - Randy Woltjer
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Leslie Muldoon
- Neuro-Oncology and Blood-Brain Barrier Program, Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - Edward A Neuwelt
- Neuro-Oncology and Blood-Brain Barrier Program, Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
- Office of Research and Development, Portland Veterans Affairs Medical Center, Portland, Oregon, USA
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Muzi M, Wolsztynski E, Fink JR, O'Sullivan JN, O'Sullivan F, Krohn KA, Mankoff DA. Assessment of the Prognostic Value of Radiomic Features in 18F-FMISO PET Imaging of Hypoxia in Postsurgery Brain Cancer Patients: Secondary Analysis of Imaging Data from a Single-Center Study and the Multicenter ACRIN 6684 Trial. ACTA ACUST UNITED AC 2021; 6:14-22. [PMID: 32280746 PMCID: PMC7138522 DOI: 10.18383/j.tom.2019.00023] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Hypoxia is associated with resistance to radiotherapy and chemotherapy in malignant gliomas, and it can be imaged by positron emission tomography with 18F-fluoromisonidazole (18F-FMISO). Previous results for patients with brain cancer imaged with 18F-FMISO at a single center before conventional chemoradiotherapy showed that tumor uptake via T/Bmax (tissue SUVmax/blood SUV) and hypoxic volume (HV) was associated with poor survival. However, in a multicenter clinical trial (ACRIN 6684), traditional uptake parameters were not found to be prognostically significant, but tumor SUVpeak did predict survival at 1 year. The present analysis considered both study cohorts to reconcile key differences and examine the potential utility of adding radiomic features as prognostic variables for outcome prediction on the combined cohort of 72 patients with brain cancer (30 University of Washington and 42 ACRIN 6684). We used both 18F-FMISO intensity metrics (T/Bmax, HV, SUV, SUVmax, SUVpeak) and assessed radiomic measures that determined first-order (histogram), second-order, and higher-order radiomic features of 18F-FMISO uptake distributions. A multivariate model was developed that included age, HV, and the intensity of 18F-FMISO uptake. HV and SUVpeak were both independent predictors of outcome for the combined data set (P < .001) and were also found significant in multivariate prognostic models (P < .002 and P < .001, respectively). Further model selection that included radiomic features showed the additional prognostic value for overall survival of specific higher order texture features, leading to an increase in relative risk prediction performance by a further 5%, when added to the multivariate clinical model..
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Affiliation(s)
- Mark Muzi
- Department of Radiology, University of Washington, Seattle, WA
| | - Eric Wolsztynski
- Department of Statistics, University College, Cork, Ireland.,Insight Centre for Data Analytics, Cork, Ireland
| | - James R Fink
- Department of Radiology, University of Washington, Seattle, WA
| | | | | | - Kenneth A Krohn
- Department of Radiology, University of Washington, Seattle, WA
| | - David A Mankoff
- Department of Radiology, University of Pennsylvania, Philadelphia, PA and
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3
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Romine PE, Peterson LM, Kurland BF, Byrd DW, Novakova-Jiresova A, Muzi M, Specht JM, Doot RK, Link JM, Krohn KA, Kinahan PE, Mankoff DA, Linden HM. 18F-fluorodeoxyglucose (FDG) PET or 18F-fluorothymidine (FLT) PET to assess early response to aromatase inhibitors (AI) in women with ER+ operable breast cancer in a window-of-opportunity study. Breast Cancer Res 2021; 23:88. [PMID: 34425871 PMCID: PMC8381552 DOI: 10.1186/s13058-021-01464-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/10/2021] [Indexed: 12/25/2022] Open
Abstract
PURPOSE This study evaluated the ability of 18F-Fluorodeoxyglucose (FDG) and 18F-Fluorothymidine (FLT) imaging with positron emission tomography (PET) to measure early response to endocrine therapy from baseline to just prior to surgical resection in estrogen receptor positive (ER+) breast tumors. METHODS In two separate studies, women with early stage ER+ breast cancer underwent either paired FDG-PET (n = 22) or FLT-PET (n = 27) scans prior to endocrine therapy and again in the pre-operative setting. Tissue samples for Ki-67 were taken for all patients both prior to treatment and at the time of surgery. RESULTS FDG maximum standardized uptake value (SUVmax) declined in 19 of 22 lesions (mean 17% (range -45 to 28%)). FLT SUVmax declined in 24 of 27 lesions (mean 26% (range -77 to 7%)). The Ki-67 index declined in both studies, from pre-therapy (mean 23% (range 1 to 73%)) to surgery [mean 8% (range < 1 to 41%)]. Pre- and post-therapy PET measures showed strong rank-order agreement with Ki-67 percentages for both tracers; however, the percent change in FDG or FLT SUVmax did not demonstrate a strong correlation with Ki-67 index change or Ki-67 at time of surgery. CONCLUSIONS A window-of-opportunity approach using PET imaging to assess early response of breast cancer therapy is feasible. FDG and FLT-PET imaging following a short course of neoadjuvant endocrine therapy demonstrated measurable changes in SUVmax in early stage ER+ positive breast cancers. The percentage change in FDG and FLT-PET uptake did not correlate with changes in Ki-67; post-therapy SUVmax for both tracers was significantly associated with post-therapy Ki-67, an established predictor of endocrine therapy response.
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Affiliation(s)
- Perrin E. Romine
- grid.34477.330000000122986657Division of Medical Oncology, University of Washington/Seattle Cancer Care Alliance, 1144 Eastlake (Mail Stop LG-200), Seattle, WA 98109-1023 USA
| | - Lanell M. Peterson
- grid.34477.330000000122986657Division of Medical Oncology, University of Washington/Seattle Cancer Care Alliance, 1144 Eastlake (Mail Stop LG-200), Seattle, WA 98109-1023 USA
| | - Brenda F. Kurland
- grid.21925.3d0000 0004 1936 9000University of Pittsburgh, Pittsburgh, PA USA
| | - Darrin W. Byrd
- grid.34477.330000000122986657Department of Radiology, University of Washington, Seattle, WA USA
| | - Alena Novakova-Jiresova
- grid.4491.80000 0004 1937 116XDepartment of Oncology, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Mark Muzi
- grid.34477.330000000122986657Department of Radiology, University of Washington, Seattle, WA USA
| | - Jennifer M. Specht
- grid.34477.330000000122986657Division of Medical Oncology, University of Washington/Seattle Cancer Care Alliance, 1144 Eastlake (Mail Stop LG-200), Seattle, WA 98109-1023 USA
| | - Robert K. Doot
- grid.25879.310000 0004 1936 8972Department of Radiology, University of Pennsylvania, Philadelphia, PA USA
| | - Jeanne M. Link
- grid.5288.70000 0000 9758 5690Department of Diagnostic Radiology, Oregon Health and Science University, Portland, OR USA
| | - Kenneth A. Krohn
- grid.5288.70000 0000 9758 5690Department of Diagnostic Radiology, Oregon Health and Science University, Portland, OR USA
| | - Paul E. Kinahan
- grid.34477.330000000122986657Department of Radiology, University of Washington, Seattle, WA USA
| | - David A. Mankoff
- grid.25879.310000 0004 1936 8972Department of Radiology, University of Pennsylvania, Philadelphia, PA USA
| | - Hannah M. Linden
- grid.34477.330000000122986657Division of Medical Oncology, University of Washington/Seattle Cancer Care Alliance, 1144 Eastlake (Mail Stop LG-200), Seattle, WA 98109-1023 USA
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4
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Peterson LM, Kurland BF, Yan F, Jiresova AN, Gadi VK, Specht JM, Gralow JR, Schubert EK, Link JM, Krohn KA, Eary JF, Mankoff DA, Linden HM. 18F-Fluoroestradiol PET Imaging in a Phase II Trial of Vorinostat to Restore Endocrine Sensitivity in ER+/HER2- Metastatic Breast Cancer. J Nucl Med 2020; 62:184-190. [PMID: 32591490 DOI: 10.2967/jnumed.120.244459] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/27/2020] [Indexed: 12/23/2022] Open
Abstract
Histone deacetylase inhibitors (HDACIs) may overcome endocrine resistance in estrogen receptor-positive (ER+) metastatic breast cancer. We tested whether 18F-fluoroestradiol PET imaging would elucidate the pharmacodynamics of combination HDACIs and endocrine therapy. Methods: Patients with ER+/human epidermal growth factor receptor 2 (HER2)-negative metastatic breast cancer with prior clinical benefit from endocrine therapy but later progression on aromatase inhibitor (AI) therapy were given vorinostat (400 mg daily) sequentially or simultaneously with AI. 18F-fluoroestradiol PET and 18F-FDG PET scans were performed at baseline, week 2, and week 8. Results: Eight patients were treated sequentially, and then 15 simultaneously. Eight patients had stable disease at week 8, and 6 of these 8 patients had more than 6 mo of stable disease. Higher baseline 18F-fluoroestradiol uptake was associated with longer progression-free survival. 18F-fluoroestradiol uptake did not systematically increase with vorinostat exposure, indicating no change in regional ER estradiol binding, and 18F-FDG uptake did not show a significant decrease, as would have been expected with tumor regression. Conclusion: Simultaneous HDACIs and AI dosing in patients with cancer resistant to AI alone showed clinical benefit (6 or more months without progression) in 4 of 10 evaluable patients. Higher 18F-fluoroestradiol PET uptake identified patients likely to benefit from combination therapy, but vorinostat did not change ER expression at the level of detection of 18F-fluoroestradiol PET.
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Affiliation(s)
- Lanell M Peterson
- Division of Medical Oncology, University of Washington/Seattle Cancer Care Alliance, Seattle, Washington
| | - Brenda F Kurland
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Fengting Yan
- Division of Medical Oncology, University of Washington/Seattle Cancer Care Alliance, Seattle, Washington
| | - Alena Novakova- Jiresova
- Department of Oncology, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Vijayakrishna K Gadi
- Division of Medical Oncology, University of Washington/Seattle Cancer Care Alliance, Seattle, Washington.,Clinical Research and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jennifer M Specht
- Division of Medical Oncology, University of Washington/Seattle Cancer Care Alliance, Seattle, Washington
| | - Julie R Gralow
- Division of Medical Oncology, University of Washington/Seattle Cancer Care Alliance, Seattle, Washington
| | - Erin K Schubert
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeanne M Link
- Department of Diagnostic Radiology, Oregon Health and Science University, Portland, Oregon; and
| | - Kenneth A Krohn
- Department of Diagnostic Radiology, Oregon Health and Science University, Portland, Oregon; and
| | - Janet F Eary
- Cancer Imaging Program, National Cancer Institute, Bethesda, Maryland
| | - David A Mankoff
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hannah M Linden
- Division of Medical Oncology, University of Washington/Seattle Cancer Care Alliance, Seattle, Washington
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Krohn KA, Vera DR. Concepts for design and analysis of receptor radiopharmaceuticals: The Receptor-Binding Radiotracers series of meetings provided the foundation. Nucl Med Biol 2020; 92:5-23. [PMID: 32331709 DOI: 10.1016/j.nucmedbio.2020.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 03/08/2020] [Indexed: 12/14/2022]
Abstract
A symposium at George Washington University on Receptor-Binding Radiotracers in 1980 and three follow-up meetings held at University of California, San Diego provided a forum for debating the critical concepts involved in the new field of designing and evaluating radiotracers for imaging receptors and transporters. This review is intended to educate young investigators who may be relatively new to receptor radiopharmaceutical development. Our anticipated audience includes researchers in basic pharmacology, radiochemistry, imaging technology and kinetic data analysis and how these disciplines have worked together to build our understanding of the human biology of transporters and receptor signaling in health and disease. We have chosen to focus on radiochemical design of a useful imaging agent and how design is coupled to analysis of data collected from dynamic imaging with that agent. Some pharmacology may be required for designing the imaging agent and some imaging physics may be important in optimizing the quality of data that is collected. However, the key to a successful imaging agent is matching the radiotracer to the target receptor and to analysis of the time-course data that is used to parse delivery from specific binding and subsequent metabolism or degradation. Properly designed imaging agents are providing critical information about human biology in health and disease as well as pharmacodynamic response to drug interventions. The review emphasizes some of the ideas that were controversial at the 1980 conference and chronicles with literature examples how they have resolved over the four decades of using radiotracers to study transporters and receptors in human subjects. These examples show that there are situations where a very small KD, i.e. high affinity, has the potential to yield an image that reflects blood flow more than receptor density. The examples also show that by combining two studies, one with high specific activity and a second with low specific activity injections one can unravel the pseudo-first order rate B'max into the true second-order rate constant, k3, and the unoccupied receptor density. The final section describes how mathematical methods first presented to the receptor-imaging community in 1980 are now being used to provide confidence in the analysis of kinetic biodistribution studies. Our hope is that by bringing these concepts together in a single review, the next generation of scientists developing receptor imaging agents can be much more efficient than their pioneers in developing useful imaging methods.
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Affiliation(s)
- Kenneth A Krohn
- Center for Radiochemistry Research, Department of Diagnostic Radiology, Mail Code L104, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, United States of America.
| | - David R Vera
- UCSD Moores Cancer Center, Department of Radiology, Mail Code 0819, University of California, San Diego, CA 92037, United States of America
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6
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Barrio JR, Huang SC, Satyamurthy N, Scafoglio CS, Yu AS, Alavi A, Krohn KA. Does 2-FDG PET Accurately Reflect Quantitative In Vivo Glucose Utilization? J Nucl Med 2019; 61:931-937. [PMID: 31676728 DOI: 10.2967/jnumed.119.237446] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 10/22/2019] [Indexed: 12/29/2022] Open
Abstract
2-Deoxy-2-18F-fluoro-d-glucose (2-FDG) with PET is undeniably useful in the clinic, being able, among other uses, to monitor change over time using the 2-FDG SUV metric. This report suggests some potentially serious caveats for this and related roles for 2-FDG PET. Most critical is the assumption that there is an exact proportionality between glucose metabolism and 2-FDG metabolism, called the lumped constant, or LC. This report describes that LC is not constant for a specific tissue and may be variable before and after disease treatment. The purpose of this work is not to deny the clinical value of 2-FDG PET; it is a reminder that when one extends the use of an appropriately qualified imaging method, new observations may arise and further validation would be necessary. The current understanding of glucose-based energetics in vivo is based on the quantification of glucose metabolic rates with 2-FDG PET, a method that permits the noninvasive assessment of various human disorders. However, 2-FDG is a good substrate only for facilitated-glucose transporters (GLUTs), not for sodium-dependent glucose cotransporters (SGLTs), which have recently been shown to be distributed in multiple human tissues. Thus, the GLUT-mediated in vivo glucose utilization measured by 2-FDG PET would be masked to the potentially substantial role of functional SGLTs in glucose transport and use. Therefore, under these circumstances, the 2-FDG LC used to quantify in vivo glucose utilization should not be expected to remain constant. 2-FDG LC variations have been especially significant in tumors, particularly at different stages of cancer development, affecting the accuracy of quantitative glucose measures and potentially limiting the prognostic value of 2-FDG, as well as its accuracy in monitoring treatments. SGLT-mediated glucose transport can be estimated using α-methyl-4-deoxy-4-18F-fluoro-d-glucopyranoside (Me-4FDG). Using both 2-FDG and Me-4FDG should provide a more complete picture of glucose utilization via both GLUT and SGLT transporters in health and disease states. Given the widespread use of 2-FDG PET to infer glucose metabolism, it is relevant to appreciate the potential limitations of 2-FDG as a surrogate for glucose metabolic rate and the potential reasons for variability in LC. Even when the readout for the 2-FDG PET study is only an SUV parameter, variability in LC is important, particularly if it changes over the course of disease progression (e.g., an evolving tumor).
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Affiliation(s)
- Jorge R Barrio
- Department of Molecular and Medical Pharmacology, David Geffen UCLA School of Medicine, Los Angeles, California
| | - Sung-Cheng Huang
- Department of Molecular and Medical Pharmacology, David Geffen UCLA School of Medicine, Los Angeles, California
| | - Nagichettiar Satyamurthy
- Department of Molecular and Medical Pharmacology, David Geffen UCLA School of Medicine, Los Angeles, California
| | - Claudio S Scafoglio
- Department of Medicine, David Geffen UCLA School of Medicine, Los Angeles, California
| | - Amy S Yu
- Department of Molecular and Medical Pharmacology, David Geffen UCLA School of Medicine, Los Angeles, California
| | - Abass Alavi
- University of Pennsylvania, Philadelphia, Pennsylvania; and
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7
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Netto JP, Iliff J, Stanimirovic D, Krohn KA, Hamilton B, Varallyay C, Gahramanov S, Daldrup-Link H, d'Esterre C, Zlokovic B, Sair H, Lee Y, Taheri S, Jain R, Panigrahy A, Reich DS, Drewes LR, Castillo M, Neuwelt EA. Neurovascular Unit: Basic and Clinical Imaging with Emphasis on Advantages of Ferumoxytol. Neurosurgery 2019; 82:770-780. [PMID: 28973554 DOI: 10.1093/neuros/nyx357] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 06/27/2017] [Indexed: 12/11/2022] Open
Abstract
Physiological and pathological processes that increase or decrease the central nervous system's need for nutrients and oxygen via changes in local blood supply act primarily at the level of the neurovascular unit (NVU). The NVU consists of endothelial cells, associated blood-brain barrier tight junctions, basal lamina, pericytes, and parenchymal cells, including astrocytes, neurons, and interneurons. Knowledge of the NVU is essential for interpretation of central nervous system physiology and pathology as revealed by conventional and advanced imaging techniques. This article reviews current strategies for interrogating the NVU, focusing on vascular permeability, blood volume, and functional imaging, as assessed by ferumoxytol an iron oxide nanoparticle.
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Affiliation(s)
- Joao Prola Netto
- Department of Neurology, Oregon Health & Science University, Portland, Oregon.,Department of Neuroradiology, Oregon Health & Science University, Portland, Oregon
| | - Jeffrey Iliff
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Danica Stanimirovic
- Human Health Therapeutics Portfolio, National Research Council of Canada, Ottawa, Ontario, Canada
| | - Kenneth A Krohn
- Department of Radiology, University of Washington, Seattle, Washington.,Department of Radiology, Oregon Health & Science University, Portland, Oregon
| | - Bronwyn Hamilton
- Department of Neuroradiology, Oregon Health & Science University, Portland, Oregon
| | - Csanad Varallyay
- Department of Neurology, Oregon Health & Science University, Portland, Oregon.,Department of Radiology, Oregon Health & Science University, Portland, Oregon
| | - Seymur Gahramanov
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico
| | | | - Christopher d'Esterre
- Department of Radiology, University of Calgary, Foothills Medical Center, Calgary, Alberta, Canada
| | - Berislav Zlokovic
- Zikha Neurogenetic Institute, University of Southern California, Los Angeles, California
| | - Haris Sair
- Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Maryland
| | - Yueh Lee
- Department of Radiology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Saeid Taheri
- Department of Radiology and Radiological Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Rajan Jain
- Department of Radiology and Neurosurgery, New York University School of Medicine, New York, New York
| | - Ashok Panigrahy
- Department of Radiology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel S Reich
- Translational Neuroradiology Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Lester R Drewes
- Department of Biomedical Sciences, University of Minnesota, Duluth, Minnesota
| | - Mauricio Castillo
- Department of Radiology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Edward A Neuwelt
- Department of Neurology, Oregon Health & Science University, Portland, Oregon.,Department of Neurosurgery, Oregon Health & Science University, Portland, Oregon.,Portland Veterans Affairs Medical Center, Portland, Oregon
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8
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Manohar PM, Peterson LM, Wu V, Jenkins IC, Novakova-Jiresova A, Specht JM, Link JM, Krohn KA, Kinahan PE, Mankoff DA, Linden HM. Abstract PD4-10: 18F-fluoroestradiol (FES) and 18F-fluorodeoxyglucose (FDG) PET imaging in staging extent of disease in metastatic lobular breast cancer. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-pd4-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The histology and pattern of spread in lobular breast cancer has presented challenges in estimating extent of disease and identifying treatment options. 18F-FES is an estrogen analogue PET imaging tracer which measures tumor ER expression at multiple tumor sites simultaneously and predicts response to endocrine therapy. We analyzed FES-PET and FDG-PET SUV uptake in patients with metastatic lobular and ductal carcinoma to identify sites of tumor and responsiveness to therapy.
Methods: We retrospectively reviewed FES and FDG SUV uptake between ER+ lobular (n = 36) and ductal (n= 173, including 6 men) metastatic breast cancer patients enrolled in various institutional studies. Up to 3 lesions in each patient were evaluated by FES SUVmax and/or FDG SUVmax for a total of 475 lesions in FES images and 462 lesions in FDG images. Classification into three categories (low FDG, high FDG/high FES, and high FDG/low FES) was generated using recursive portioning with 5-fold internal cross validation. Using a Pearson Chi-squared test, we compared degree of uptake in FES and FDG between lobular and ductal carcinomas. We used linear mixed effects model to assess association of FES SULmean3 (Lean body mass adjusted SUV) and FDG SULmean3 with histology. Overall survival (OS), from time of FES-PET scan to death, and progression free survival (PFS) was evaluated between classification groups in both histologies using Kaplan-Meier curves and Cox model.
Results: In patients with metastatic breast cancer, 72 patients had low FDG, 96 had high FES/high FDG, and 41 with high FES/low FDG. Lobular lesions tended to have a higher proportion of patients in the risk group with lower FDG (42% vs 33%) and a lower proportion in the risk group with high FDG/low FES (11% vs 21%) but the difference was not statistically significant (p = 0.32). Mean (range) FES SULmean3 and FDG SULmax3 respectively for ductal was 1.38 (0.10, 6.7) and 3.17 (0.88, 12.26) and for lobular was 1.42 (0.34, 3.43) and 3.13 (1.04, 13.87). There was no significant difference between in FES SULmean3 and FDG SULmax3 between histologies. Following FES-PET imaging, patients with lobular carcinomas and low FDG demonstrated a higher median survival time (7.7 years) compared to high FDG/low FES (4.3 years) and high FDG/high FES (2.6 years). Similarly, patients with ductal carcinomas and low FDG had an improved median survival time (5.6 years) compared to both high FDG/high FES (2.9 years) and high FDG/low FES (2.5 years). However, the interaction between histology and the FDG/FES classifications was not significant (p = 0.86). Across a variety of tumor sites, lobular histology can be detected by both FES and FDG with no difference between the imaging modalities.
Conclusions: In the metastatic setting, quantitative FES and FDG can be used to discriminate indolent and aggressive phenotypes in both lobular and ductal breast cancer. A greater proportion of lobular carcinoma lesions had higher FES/lower FDG and would be anticipated to be more sensitive to endocrine therapy. Further prospective trials are needed to confirm the utility of FES to stage extent of disease in metastatic breast cancer.
Citation Format: Manohar PM, Peterson LM, Wu V, Jenkins IC, Novakova-Jiresova A, Specht JM, Link JM, Krohn KA, Kinahan PE, Mankoff DA, Linden HM. 18F-fluoroestradiol (FES) and 18F-fluorodeoxyglucose (FDG) PET imaging in staging extent of disease in metastatic lobular breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD4-10.
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Affiliation(s)
- PM Manohar
- University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Fred Hutchinson Cancer Research Institute, Seattle, WA; Oregon Health Sciences University, Portland, OR; University of Pennsylvania, Philadelphia, PA
| | - LM Peterson
- University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Fred Hutchinson Cancer Research Institute, Seattle, WA; Oregon Health Sciences University, Portland, OR; University of Pennsylvania, Philadelphia, PA
| | - V Wu
- University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Fred Hutchinson Cancer Research Institute, Seattle, WA; Oregon Health Sciences University, Portland, OR; University of Pennsylvania, Philadelphia, PA
| | - IC Jenkins
- University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Fred Hutchinson Cancer Research Institute, Seattle, WA; Oregon Health Sciences University, Portland, OR; University of Pennsylvania, Philadelphia, PA
| | - A Novakova-Jiresova
- University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Fred Hutchinson Cancer Research Institute, Seattle, WA; Oregon Health Sciences University, Portland, OR; University of Pennsylvania, Philadelphia, PA
| | - JM Specht
- University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Fred Hutchinson Cancer Research Institute, Seattle, WA; Oregon Health Sciences University, Portland, OR; University of Pennsylvania, Philadelphia, PA
| | - JM Link
- University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Fred Hutchinson Cancer Research Institute, Seattle, WA; Oregon Health Sciences University, Portland, OR; University of Pennsylvania, Philadelphia, PA
| | - KA Krohn
- University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Fred Hutchinson Cancer Research Institute, Seattle, WA; Oregon Health Sciences University, Portland, OR; University of Pennsylvania, Philadelphia, PA
| | - PE Kinahan
- University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Fred Hutchinson Cancer Research Institute, Seattle, WA; Oregon Health Sciences University, Portland, OR; University of Pennsylvania, Philadelphia, PA
| | - DA Mankoff
- University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Fred Hutchinson Cancer Research Institute, Seattle, WA; Oregon Health Sciences University, Portland, OR; University of Pennsylvania, Philadelphia, PA
| | - HM Linden
- University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Fred Hutchinson Cancer Research Institute, Seattle, WA; Oregon Health Sciences University, Portland, OR; University of Pennsylvania, Philadelphia, PA
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9
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Manohar P, Peterson L, Wu V, Jenkins I, Novakova-Jiresova A, Specht JM, Link J, Krohn KA, Kinahan P, Mankoff DA, Linden HM. 18F-Fluoroestradiol (FES) and 18F-Fluorodeoxyglucose (FDG) PET imaging in lobular breast cancer. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.1063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Poorni Manohar
- University of Washington/Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Lanell Peterson
- University of Washington Seattle Cancer Care Alliance, Seattle, WA
| | - Vicky Wu
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Isaac Jenkins
- University of Washington/Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | | | | | | | | | - Hannah M. Linden
- University of Washington Seattle Cancer Care Alliance, Seattle, WA
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10
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Rüdinger V, Ricketts CI, Wilhelm JG, Pratt RP, Stewart BL, Loughborough D, Dillmann HG, Pasler H, Wilhelm JG, Ricketts CI, Rüdinger V, Wilhelm JG, Furrer J, Weinländer W, Neuman WA, Jones JL, Şahin S, Wheeler FJ, Parsons DK, Rushton BL, Nigg DW, Lin C, Dabiri AE, Hagan WK, Swenson DA, Krohn KA, Ma YP, Pei BS, Lin WK, Hsu YY, Hassan YA, Salim P. Authors. NUCL TECHNOL 2017. [DOI: 10.13182/nt90-a34481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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11
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Affiliation(s)
- Ali E. Dabiri
- Science Applications International Corporation, 4161 Campus Point Court, San Diego, California 92121
| | - William K. Hagan
- Science Applications International Corporation, 4161 Campus Point Court, San Diego, California 92121
| | - Donald A. Swenson
- Science Applications International Corporation, 4161 Campus Point Court, San Diego, California 92121
| | - Kenneth A. Krohn
- University of Washington, Department of Radiology, Imaging Research Laboratory, RC-05, Seattle, Washington 98195
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12
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Link JM, Krohn KA, O'Hara MJ. A simple thick target for production of 89Zr using an 11MeV cyclotron. Appl Radiat Isot 2017; 122:211-214. [PMID: 28187357 DOI: 10.1016/j.apradiso.2017.01.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 01/29/2017] [Accepted: 01/29/2017] [Indexed: 11/16/2022]
Abstract
The growing interest but limited availability of 89Zr for PET led us to test targets for the 89Y(p,n) reaction. The goal was an easily constructed target for an 11MeV Siemens cyclotron. Yttrium foils were tested at different thicknesses, angles and currents. A 90° foil tolerated 41µA without damage and produced ~800 MBq/h, >20mCi, an amount adequate for radiochemistry research and human doses in a widely available accelerator. This method should translate to higher energy cyclotrons.
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Affiliation(s)
- Jeanne M Link
- Molecular Imaging Research, Box356004, Department of Radiology, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195-6004, USA.
| | - Kenneth A Krohn
- Molecular Imaging Research, Box356004, Department of Radiology, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195-6004, USA.
| | - Matthew J O'Hara
- Radiochemical Science & Engineering Energy & Environment Directorate, Pacific Northwest National Laboratory, 902 Battelle Boulevard, Richland, WA 99352, USA.
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13
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Barajas RF, Krohn KA, Link JM, Hawkins RA, Clarke JL, Pampaloni MH, Cha S. Glioma FMISO PET/MR Imaging Concurrent with Antiangiogenic Therapy: Molecular Imaging as a Clinical Tool in the Burgeoning Era of Personalized Medicine. Biomedicines 2016; 4:biomedicines4040024. [PMID: 28536391 PMCID: PMC5344267 DOI: 10.3390/biomedicines4040024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 10/27/2016] [Accepted: 10/29/2016] [Indexed: 01/17/2023] Open
Abstract
The purpose of this article is to provide a focused overview of the current use of positron emission tomography (PET) molecular imaging in the burgeoning era of personalized medicine in the treatment of patients with glioma. Specifically, we demonstrate the utility of PET imaging as a tool for personalized diagnosis and therapy by highlighting a case series of four patients with recurrent high grade glioma who underwent 18F-fluoromisonidazole (FMISO) PET/MR (magnetic resonance) imaging through the course of antiangiogenic therapy. Three distinct features were observed from this small cohort of patients. First, the presence of pseudoprogression was retrospectively associated with the absence of hypoxia. Second, a subgroup of patients with recurrent high grade glioma undergoing bevacizumab therapy demonstrated disease progression characterized by an enlarging nonenhancing mass with newly developed reduced diffusion, lack of hypoxia, and preserved cerebral blood volume. Finally, a reduction in hypoxic volume was observed concurrent with therapy in all patients with recurrent tumor, and markedly so in two patients that developed a nonenhancing reduced diffusion mass. This case series demonstrates how medical imaging has the potential to influence personalized medicine in several key aspects, especially involving molecular PET imaging for personalized diagnosis, patient specific disease prognosis, and therapeutic monitoring.
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Affiliation(s)
- Ramon F Barajas
- Department of Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
- Advanced Imaging Research Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
| | - Kenneth A Krohn
- Department of Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
- Radiochemistry Research Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
| | - Jeanne M Link
- Department of Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
- Radiochemistry Research Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
| | - Randall A Hawkins
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, M-391, San Francisco, CA 94143-0628, USA.
| | - Jennifer L Clarke
- Neurological Surgery, University of California, San Francisco, 505 Parnassus Ave., Room 779 M, San Francisco, CA 94143-0112, USA.
| | - Miguel H Pampaloni
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, M-391, San Francisco, CA 94143-0628, USA.
| | - Soonmee Cha
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, M-391, San Francisco, CA 94143-0628, USA.
- Neurological Surgery, University of California, San Francisco, 505 Parnassus Ave., Room 779 M, San Francisco, CA 94143-0112, USA.
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14
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Kurland BF, Peterson LM, Lee JH, Schubert EK, Currin ER, Link JM, Krohn KA, Mankoff DA, Linden HM. Estrogen Receptor Binding (18F-FES PET) and Glycolytic Activity (18F-FDG PET) Predict Progression-Free Survival on Endocrine Therapy in Patients with ER+ Breast Cancer. Clin Cancer Res 2016; 23:407-415. [PMID: 27342400 DOI: 10.1158/1078-0432.ccr-16-0362] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/05/2016] [Accepted: 06/07/2016] [Indexed: 01/13/2023]
Abstract
PURPOSE 18F-fluoroestradiol (FES) PET scans measure regional estrogen binding, and 18F-fluorodeoxyglucose (FDG) PET measures tumor glycolytic activity. We examined quantitative and qualitative imaging biomarkers of progression-free survival (PFS) in breast cancer patients receiving endocrine therapy. EXPERIMENTAL DESIGN Ninety patients with breast cancer from an estrogen receptor-positive (ER+), HER2- primary tumor underwent FES PET and FDG PET scans prior to endocrine therapy (63% aromatase inhibitor, 22% aromatase inhibitor and fulvestrant, 15% other). Eighty-four had evaluable data for PFS prediction. RESULTS Recursive partitioning with 5-fold internal cross-validation used both FES PET and FDG PET measures to classify patients into three distinct response groups. FDG PET identified 24 patients (29%) with low FDG uptake, suggesting indolent tumors. These patients had a median PFS of 26.1 months (95% confidence interval, 11.2-49.7). Of patients with more FDG-avid tumors, 50 (59%) had high average FES uptake, and 10 (12%) had low average FES uptake. These groups had median PFS of 7.9 (5.6-11.8) and 3.3 months (1.4-not evaluable), respectively. Patient and tumor features did not replace or improve the PET measures' prediction of PFS. Prespecified endocrine resistance classifiers identified in smaller cohorts did not individually predict PFS. CONCLUSIONS A wide range of therapy regimens are available for treatment of ER+ metastatic breast cancer, but no guidelines are established for sequencing these therapies. FDG PET and FES PET may help guide the timing of endocrine therapy and selection of targeted and/or cytotoxic chemotherapy. A multicenter trial is ongoing for external validation. Clin Cancer Res; 23(2); 407-15. ©2016 AACR.
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Affiliation(s)
- Brenda F Kurland
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Lanell M Peterson
- Department of Radiology, University of Washington, Seattle, Washington
| | - Jean H Lee
- Department of Radiology, University of Washington, Seattle, Washington
| | - Erin K Schubert
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erin R Currin
- Division of Medical Oncology, University of Washington, Seattle, Washington
| | - Jeanne M Link
- Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Oregon
| | - Kenneth A Krohn
- Department of Radiology, University of Washington, Seattle, Washington
| | - David A Mankoff
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hannah M Linden
- Division of Medical Oncology, University of Washington, Seattle, Washington
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15
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Roberts TK, Peterson L, Kurland B, Novakova A, Shields A, Doot RK, Schubert EK, Gadi VK, Specht JM, Gralow J, Eary JF, Muzi M, Link J, Krohn KA, Mankoff DA, Linden HM. Use of serial 18F-Fluorothymidine (FLT) PET and Ki-67 to predict response to aromatase inhibitors (AI) in women with ER+ breast cancer. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.e12039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | - Robert K Doot
- Department of Radiology, University of Washington, Seattle, WA
| | | | | | | | - Julie Gralow
- University of Washington/Seattle Cancer Care Alliance, Seattle, WA
| | | | - Mark Muzi
- University of Washington, Seattle, WA
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16
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Rockne RC, Trister AD, Jacobs J, Hawkins-Daarud AJ, Neal ML, Hendrickson K, Mrugala MM, Rockhill JK, Kinahan P, Krohn KA, Swanson KR. Addendum to 'A patient-specific computational model of hypoxia-modulated radiation resistance in glioblastoma using 18F-FMISO-PET'. J R Soc Interface 2016; 12:rsif.2015.0927. [PMID: 26577597 DOI: 10.1098/rsif.2015.0927] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Russell C Rockne
- Department of Neurological Surgery, Northwestern University and Feinberg School of Medicine, 676 N Saint Clair Street, Suite 1300, Chicago, IL 60611, USA Northwestern Brain Tumor Institute, Northwestern University, 675 N Saint Clair Street, Suite 2100, Chicago, IL 60611, USA
| | - Andrew D Trister
- Department of Radiation Oncology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Joshua Jacobs
- Department of Neurological Surgery, Northwestern University and Feinberg School of Medicine, 676 N Saint Clair Street, Suite 1300, Chicago, IL 60611, USA Northwestern Brain Tumor Institute, Northwestern University, 675 N Saint Clair Street, Suite 2100, Chicago, IL 60611, USA
| | - Andrea J Hawkins-Daarud
- Department of Neurological Surgery, Northwestern University and Feinberg School of Medicine, 676 N Saint Clair Street, Suite 1300, Chicago, IL 60611, USA Northwestern Brain Tumor Institute, Northwestern University, 675 N Saint Clair Street, Suite 2100, Chicago, IL 60611, USA
| | - Maxwell L Neal
- Department of Pathology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Kristi Hendrickson
- Department of Radiation Oncology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Maciej M Mrugala
- Department of Neurology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Jason K Rockhill
- Department of Radiation Oncology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Paul Kinahan
- Department of Radiology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Kenneth A Krohn
- Department of Radiation Oncology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA Department of Radiology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Kristin R Swanson
- Department of Neurological Surgery, Northwestern University and Feinberg School of Medicine, 676 N Saint Clair Street, Suite 1300, Chicago, IL 60611, USA Northwestern Brain Tumor Institute, Northwestern University, 675 N Saint Clair Street, Suite 2100, Chicago, IL 60611, USA
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17
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Muzi M, Krohn KA. Imaging Hypoxia with ¹⁸F-Fluoromisonidazole: Challenges in Moving to a More Complicated Analysis. J Nucl Med 2016; 57:497-8. [PMID: 26912434 DOI: 10.2967/jnumed.115.171694] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 01/19/2016] [Indexed: 11/16/2022] Open
Affiliation(s)
- Mark Muzi
- Department of Radiology, University of Washington, Seattle, Washington
| | - Kenneth A Krohn
- Department of Radiology, University of Washington, Seattle, Washington
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18
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Currin E, Peterson LM, Schubert EK, Link JM, Krohn KA, Livingston RB, Mankoff DA, Linden HM. Temporal Heterogeneity of Estrogen Receptor Expression in Bone-Dominant Breast Cancer:18F-Fluoroestradiol PET Imaging Shows Return of ER Expression. J Natl Compr Canc Netw 2016; 14:144-7. [DOI: 10.6004/jnccn.2016.0017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
Hypoxia in solid tumors is one of the seminal mechanisms for developing aggressive trait and treatment resistance in solid tumors. This evolutionarily conserved biological mechanism along with derepression of cellular functions in cancer, although resulting in many challenges, provide us with opportunities to use these adversities to our advantage. Our ability to use molecular imaging to characterize therapeutic targets such as hypoxia and apply this information for therapeutic interventions is growing rapidly. Evaluation of hypoxia and its biological ramifications to effectively plan appropriate therapy that can overcome the cure-limiting effects of hypoxia provides an objective means for treatment selection and planning. Fluoromisonidazole (FMISO) continues to be the lead radiopharmaceutical in PET imaging for the evaluation, prognostication, and quantification of tumor hypoxia, one of the key elements of the tumor microenvironment. FMISO is less confounded by blood flow, and although the images have less contrast than FDG-PET, its uptake after 2 hours is an accurate reflection of inadequate regional oxygen partial pressure at the time of radiopharmaceutical administration. By virtue of extensive clinical utilization, FMISO remains the lead candidate for imaging and quantifying hypoxia. The past decade has seen significant technological advances in investigating hypoxia imaging in radiation treatment planning and in providing us with the ability to individualize radiation delivery and target volume coverage. The presence of widespread hypoxia in the tumor can be effectively targeted with a systemic hypoxic cell cytotoxin or other agents that are more effective with diminished oxygen partial pressure, either alone or in combination. Molecular imaging in general and hypoxia imaging in particular will likely become an important in vivo imaging biomarker of the future, complementing the traditional direct tissue sampling methods by providing a snap shot of a primary tumor and metastatic disease and in following treatment response and will serve as adjuncts to personalized therapy.
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Affiliation(s)
- Joseph G Rajendran
- Department of Radiology, University of Washington, Seattle, WA; Department of Radiation Oncology, University of Washington, Seattle, WA.
| | - Kenneth A Krohn
- Department of Radiology, University of Washington, Seattle, WA; Department of Radiation Oncology, University of Washington, Seattle, WA
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20
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Fink JR, Muzi M, Peck M, Krohn KA. Multimodality Brain Tumor Imaging: MR Imaging, PET, and PET/MR Imaging. J Nucl Med 2015; 56:1554-61. [PMID: 26294301 DOI: 10.2967/jnumed.113.131516] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 08/18/2015] [Indexed: 01/16/2023] Open
Abstract
Standard MR imaging and CT are routinely used for anatomic diagnosis in brain tumors. Pretherapy planning and posttreatment response assessments rely heavily on gadolinium-enhanced MR imaging. Advanced MR imaging techniques and PET imaging offer physiologic, metabolic, or functional information about tumor biology that goes beyond the diagnostic yield of standard anatomic imaging. With the advent of combined PET/MR imaging scanners, we are entering an era wherein the relationships among different elements of tumor metabolism can be simultaneously explored through multimodality MR imaging and PET imaging. The purpose of this review is to provide a practical and clinically relevant overview of current anatomic and physiologic imaging of brain tumors as a foundation for further investigations, with a primary focus on MR imaging and PET techniques that have demonstrated utility in the current care of brain tumor patients.
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Affiliation(s)
- James R Fink
- Department of Radiology, University of Washington, Seattle, Washington
| | - Mark Muzi
- Department of Radiology, University of Washington, Seattle, Washington
| | - Melinda Peck
- Department of Radiology, University of Washington, Seattle, Washington
| | - Kenneth A Krohn
- Department of Radiology, University of Washington, Seattle, Washington
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21
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Rockne RC, Trister AD, Jacobs J, Hawkins-Daarud AJ, Neal ML, Hendrickson K, Mrugala MM, Rockhill JK, Kinahan P, Krohn KA, Swanson KR. A patient-specific computational model of hypoxia-modulated radiation resistance in glioblastoma using 18F-FMISO-PET. J R Soc Interface 2015; 12:rsif.2014.1174. [PMID: 25540239 PMCID: PMC4305419 DOI: 10.1098/rsif.2014.1174] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Glioblastoma multiforme (GBM) is a highly invasive primary brain tumour that has poor prognosis despite aggressive treatment. A hallmark of these tumours is diffuse invasion into the surrounding brain, necessitating a multi-modal treatment approach, including surgery, radiation and chemotherapy. We have previously demonstrated the ability of our model to predict radiographic response immediately following radiation therapy in individual GBM patients using a simplified geometry of the brain and theoretical radiation dose. Using only two pre-treatment magnetic resonance imaging scans, we calculate net rates of proliferation and invasion as well as radiation sensitivity for a patient's disease. Here, we present the application of our clinically targeted modelling approach to a single glioblastoma patient as a demonstration of our method. We apply our model in the full three-dimensional architecture of the brain to quantify the effects of regional resistance to radiation owing to hypoxia in vivo determined by [(18)F]-fluoromisonidazole positron emission tomography (FMISO-PET) and the patient-specific three-dimensional radiation treatment plan. Incorporation of hypoxia into our model with FMISO-PET increases the model-data agreement by an order of magnitude. This improvement was robust to our definition of hypoxia or the degree of radiation resistance quantified with the FMISO-PET image and our computational model, respectively. This work demonstrates a useful application of patient-specific modelling in personalized medicine and how mathematical modelling has the potential to unify multi-modality imaging and radiation treatment planning.
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Affiliation(s)
- Russell C Rockne
- Department of Neurological Surgery, Northwestern University and Feinberg School of Medicine, 676 N Saint Clair Street, Suite 1300, Chicago, IL 60611, USA Northwestern Brain Tumor Institute, Northwestern University, 675 N Saint Clair Street, Suite 2100, Chicago, IL 60611, USA,
| | - Andrew D Trister
- Department of Radiation Oncology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Joshua Jacobs
- Department of Neurological Surgery, Northwestern University and Feinberg School of Medicine, 676 N Saint Clair Street, Suite 1300, Chicago, IL 60611, USA Northwestern Brain Tumor Institute, Northwestern University, 675 N Saint Clair Street, Suite 2100, Chicago, IL 60611, USA
| | - Andrea J Hawkins-Daarud
- Department of Neurological Surgery, Northwestern University and Feinberg School of Medicine, 676 N Saint Clair Street, Suite 1300, Chicago, IL 60611, USA Northwestern Brain Tumor Institute, Northwestern University, 675 N Saint Clair Street, Suite 2100, Chicago, IL 60611, USA
| | - Maxwell L Neal
- Department of Pathology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Kristi Hendrickson
- Department of Radiation Oncology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Maciej M Mrugala
- Department of Neurology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Jason K Rockhill
- Department of Radiation Oncology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Paul Kinahan
- Department of Radiology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Kenneth A Krohn
- Department of Radiation Oncology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA Department of Radiology, University of Washington, School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Kristin R Swanson
- Department of Neurological Surgery, Northwestern University and Feinberg School of Medicine, 676 N Saint Clair Street, Suite 1300, Chicago, IL 60611, USA Northwestern Brain Tumor Institute, Northwestern University, 675 N Saint Clair Street, Suite 2100, Chicago, IL 60611, USA
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22
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Muzi M, Peterson LM, O'Sullivan JN, Fink JR, Rajendran JG, McLaughlin LJ, Muzi JP, Mankoff DA, Krohn KA. 18F-Fluoromisonidazole Quantification of Hypoxia in Human Cancer Patients Using Image-Derived Blood Surrogate Tissue Reference Regions. J Nucl Med 2015; 56:1223-8. [PMID: 26112020 DOI: 10.2967/jnumed.115.158717] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 06/15/2015] [Indexed: 12/17/2022] Open
Abstract
UNLABELLED (18)F-fluoromisonidazole ((18)F-FMISO) is the most widely used PET agent for imaging hypoxia, a condition associated with resistance to tumor therapy. (18)F-FMISO equilibrates in normoxic tissues but is retained under hypoxic conditions because of reduction and binding to macromolecules. A simple tissue-to-blood (TB) ratio is suitable for quantifying hypoxia. A TB ratio threshold of 1.2 or greater is useful in discriminating the hypoxic volume (HV) of tissue; TBmax is the maximum intensity of the hypoxic region and does not invoke a threshold. Because elimination of blood sampling would simplify clinical use, we tested the validity of using imaging regions as a surrogate for blood sampling. METHODS Patients underwent 20-min (18)F-FMISO scanning during the 90- to 140-min interval after injection with venous blood sampling. Two hundred twenty-three (18)F-FMISO patient studies had detectable surrogate blood regions in the field of view. Quantitative parameters of hypoxia (TBmax, HV) derived from blood samples were compared with values using surrogate blood regions derived from the heart, aorta, or cerebellum. In a subset of brain cancer patients, parameters from blood samples and from the cerebellum were compared for their ability to independently predict outcome. RESULTS Vascular regions of heart showed the highest correlation to measured blood activity (R(2) = 0.84). For brain studies, cerebellar activity was similarly correlated to blood samples. In brain cancer patients, Kaplan-Meier analysis showed that image-derived reference regions had predictive power nearly identical to parameters derived from blood, thus obviating the need for venous sampling in these patients. CONCLUSION Simple static analysis of (18)F-FMISO PET captures both the intensity (TBmax) and the spatial extent (HV) of tumor hypoxia. An image-derived region to assess blood activity can be used as a surrogate for blood sampling in quantification of hypoxia.
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Affiliation(s)
- Mark Muzi
- Department of Radiology, University of Washington, Seattle, Washington
| | - Lanell M Peterson
- Department of Radiology, University of Washington, Seattle, Washington
| | - Janet N O'Sullivan
- School of Mathematics, Department of Statistics, University College Cork, Cork, Ireland
| | - James R Fink
- Department of Radiology, University of Washington, Seattle, Washington
| | | | - Lena J McLaughlin
- Department of Radiology, University of Washington, Seattle, Washington
| | - John P Muzi
- Department of Radiology, University of Washington, Seattle, Washington
| | - David A Mankoff
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kenneth A Krohn
- Department of Radiology, University of Washington, Seattle, Washington
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23
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Peck M, Pollack HA, Friesen A, Muzi M, Shoner SC, Shankland EG, Fink JR, Armstrong JO, Link JM, Krohn KA. Applications of PET imaging with the proliferation marker [18F]-FLT. Q J Nucl Med Mol Imaging 2015; 59:95-104. [PMID: 25737423 PMCID: PMC4415691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
[18F]-3'-fluoro-3'-deoxythymidine (FLT) is a nucleoside-analog imaging agent for quantifying cellular proliferation that was first reported in 1998. It accumulates during the S-phase of the cell cycle through the action of cytosolic thymidine kinase, TK1. Since TK1 is primarily expressed in dividing cells, FLT uptake is essentially limited to dividing cells. Thus FLT is an effective measure of cell proliferation. FLT uptake has been shown to correlate with the more classic proliferation marker, the monoclonal antibody to Ki-67. Increased cellular proliferation is known to correlate with worse outcome in many cancers. However, the Ki-67 binding assay is performed on a sampled preparation, ex vivo, whereas FLT can be quantitatively measured in vivo using positron emission tomography (PET). FLT is an effective and quantitative marker of cell proliferation, and therefore a useful prognostic predictor in the setting of neoplastic disease. This review summarizes clinical studies from 2011 forward that used FLT-PET to assess tumor response to therapy. The paper focuses on our recommendations for a standardized clinical trial protocol and components of a report so multi center studies can be effectively conducted, and different studies can be compared. For example, since FLT is glucuronidated by the liver, and the metabolite is not transported into the cell, the plasma fraction of FLT can be significantly changed by treatment with particular drugs that deplete this enzyme, including some chemotherapy agents and pain medications. Therefore, the plasma level of metabolites should be measured to assure FLT uptake kinetics can be accurately calculated. This is important because the flux constant (KFLT) is a more accurate measure of proliferation and, by inference, a better discriminator of tumor recurrence than standardized uptake value (SUVFLT). This will allow FLT imaging to be a specific and clinically relevant prognostic predictor in the treatment of neoplastic disease.
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Affiliation(s)
- M Peck
- Stanford University, Stanford, CA, USA -
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Plotnik DA, Wu S, Linn GR, Yip FCT, Comandante NL, Krohn KA, Toyohara J, Schwartz JL. In vitro analysis of transport and metabolism of 4'-thiothymidine in human tumor cells. Nucl Med Biol 2014; 42:470-474. [PMID: 25659855 PMCID: PMC4387014 DOI: 10.1016/j.nucmedbio.2014.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 11/19/2014] [Accepted: 12/01/2014] [Indexed: 01/11/2023]
Abstract
Introduction The use of thymidine (TdR) and thymidine analogs such as 3′-fluoro-3′-deoxythymidine (FLT) as positron emission tomography (PET)-based proliferation markers can provide information on tumor response to treatment. Studies on another TdR analog, 4'-thiothymidine (4DST), suggest that it might be a better PET-based proliferation tracer than either TdR or FLT. 4DST is resistant to the catabolism that complicates analysis of TdR in PET studies, but unlike FLT, 4DST is incorporated into DNA. Methods To further evaluate 4DST, the kinetics of 4DST transport and metabolism were determined and compared to FLT and TdR. Transport and metabolism of FLT, TdR and 4DST were examined in the human adenocarcinoma cell line A549 under exponential-growth conditions. Single cell suspensions were incubated in buffer supplemented with radiolabeled tracer in the presence or absence of nitrobenzylmercaptopurine ribonucleoside (NBMPR), an inhibitor of equilibrative nucleoside transporters (ENT). Kinetics of tracer uptake was determined in whole cells and tracer metabolism measured by high performance liquid chromatography of cell lysates. Results TdR and 4DST were qualitatively similar in terms of ENT-dependent transport, shapes of uptake curves, and relative levels of DNA incorporation. FLT did not incorporate into DNA, showed a significant temperature effect for uptake, and its transport had a significant NBMPR-resistant component. Overall 4DST metabolism was significantly slower than either TdR or FLT. Conclusions 4DST provides a good alternative for TdR in PET and has advantages over FLT in proliferation measurement. However, slow 4DST metabolism and the short half-life of the 11C label might limit widespread use in PET.
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Affiliation(s)
- David A Plotnik
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Stephen Wu
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Geoffrey R Linn
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | | | | | - Kenneth A Krohn
- Department of Radiation Oncology, University of Washington, Seattle, WA; Department of Radiology, University of Washington, Seattle, WA
| | - Jun Toyohara
- Research Team for Neuroimaging, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Jeffrey L Schwartz
- Department of Radiation Oncology, University of Washington, Seattle, WA.
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O'Sullivan F, Muzi M, Mankoff DA, Eary JF, Spence AM, Krohn KA. VOXEL-LEVEL MAPPING OF TRACER KINETICS IN PET STUDIES: A STATISTICAL APPROACH EMPHASIZING TISSUE LIFE TABLES. Ann Appl Stat 2014; 8:1065-1094. [PMID: 25392718 PMCID: PMC4225726 DOI: 10.1214/14-aoas732] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Most radiotracers used in dynamic positron emission tomography (PET) scanning act in a linear time-invariant fashion so that the measured time-course data are a convolution between the time course of the tracer in the arterial supply and the local tissue impulse response, known as the tissue residue function. In statistical terms the residue is a life table for the transit time of injected radiotracer atoms. The residue provides a description of the tracer kinetic information measurable by a dynamic PET scan. Decomposition of the residue function allows separation of rapid vascular kinetics from slower blood-tissue exchanges and tissue retention. For voxel-level analysis, we propose that residues be modeled by mixtures of nonparametrically derived basis residues obtained by segmentation of the full data volume. Spatial and temporal aspects of diagnostics associated with voxel-level model fitting are emphasized. Illustrative examples, some involving cancer imaging studies, are presented. Data from cerebral PET scanning with 18F fluoro-deoxyglucose (FDG) and 15O water (H2O) in normal subjects is used to evaluate the approach. Cross-validation is used to make regional comparisons between residues estimated using adaptive mixture models with more conventional compartmental modeling techniques. Simulations studies are used to theoretically examine mean square error performance and to explore the benefit of voxel-level analysis when the primary interest is a statistical summary of regional kinetics. The work highlights the contribution that multivariate analysis tools and life-table concepts can make in the recovery of local metabolic information from dynamic PET studies, particularly ones in which the assumptions of compartmental-like models, with residues that are sums of exponentials, might not be certain.
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Linden HM, Kurland BF, Link J, Novakova A, Chai X, Specht JM, Gadi VK, Gralow J, Schubert EK, Peterson L, Eary JF, Shields A, Mankoff DA, Krohn KA. A phase II clinical trial of HDACi (vorinostat) and AI therapy in breast cancer with molecular imaging correlates. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Brenda F. Kurland
- Biostatistics, University of Pittsburgh Cancer Institute, Pittsburgh, PA
| | | | | | - Xiaoyu Chai
- Fred Hutchinson Cancer Research Center, Seattle, WA
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Linden HM, Kurland BF, Link JM, Novakova A, Chai X, Specht JM, Gadi VK, Gralow JR, Schubert EK, Peterson LM, Eary J, Shields A, Mankoff DA, Krohn KA. Abstract P4-01-03: HDACi (vorinostat) in metastatic breast cancer to restore sensitivity to ER-directed (AI) therapy: A phase II clinical trial with FES imaging correlates. Cancer Res 2013. [DOI: 10.1158/0008-5472.sabcs13-p4-01-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Histone deacetylase inhibitors (HDACi) have shown pre-clinical promise in estrogen receptor(ER)-modulation and restoring sensitivity to endocrine manipulation, suggesting potential clinical benefit (Sabnis 2011) (Huang 2000) in ER+ breast cancer. Vorinostat is an FDA-approved HDACi for CTCL, and could have a beneficial role in restoring ER-signaling in endocrine-resistant tumors (Munster 2011) (Yardley 2011). [F-18]fluoroestradiol (FES) PET imaging may be used to monitor regional tumor ER expression in patients with breast cancer (Linden 2011).
Methods: Patients with metastatic breast cancer with prior clinical benefit from endocrine manipulation who progressed on an AI therapy are eligible for this ongoing trial. In part A, patients were given vorinostat for 2 weeks, then resumed AI for 6 W. In part B (reflecting results of prior HDACi trials) patients are given vorinostat 400mg po daily 5/7 days 3/4 weeks while AI is given continuously. Paired FES and FDG PET are performed at baseline, week 2 and 8; clinical/radiologic assessment of disease is also performed at week 8. Patients with clinical benefit (response or stable disease) may continue on treatment until progressive disease or study withdrawal. Lesion-level analysis of the association between baseline FES uptake (logged) and FES/FDG ratio used generalized estimating equations (GEE) with small-sample adjustments to standard errors.
Results: 12/ 20 planned patients have accrued, and the treatment is well tolerated. Enrolled women were postmenopausal, the majority with primary infiltrating ductal tumors, bone/soft tissue dominant with longstanding metastatic disease, exposed to multiple endocrine and chemotherapy regimens. Five patients have had clinical benefit (2/4 on part B with greater HDACi exposure). One patient withdrew from the study due to toxicity. FES and FDG uptake was analyzed in 42 lesions in 11 patients. Average FES uptake was 2.0 (SULmean) for patients with clinical benefit, and 1.2 in patients with progressive disease by 8 weeks (p = 0.09). FES/FDG ratio at baseline was also associated with response (p = 0.04).
Conclusions: HDACi therapy is promising in relapsed ER+ breast cancer. Imaging of metabolic pathways in parallel with clinical trials may accelerate understanding of the underlying tumor biology and refine treatment selection.
Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-01-03.
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Affiliation(s)
- HM Linden
- University of Washington, Seattle, WA; Fred Hutchison Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - BF Kurland
- University of Washington, Seattle, WA; Fred Hutchison Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - JM Link
- University of Washington, Seattle, WA; Fred Hutchison Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - A Novakova
- University of Washington, Seattle, WA; Fred Hutchison Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - X Chai
- University of Washington, Seattle, WA; Fred Hutchison Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - JM Specht
- University of Washington, Seattle, WA; Fred Hutchison Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - VK Gadi
- University of Washington, Seattle, WA; Fred Hutchison Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - JR Gralow
- University of Washington, Seattle, WA; Fred Hutchison Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - EK Schubert
- University of Washington, Seattle, WA; Fred Hutchison Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - LM Peterson
- University of Washington, Seattle, WA; Fred Hutchison Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - J Eary
- University of Washington, Seattle, WA; Fred Hutchison Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - A Shields
- University of Washington, Seattle, WA; Fred Hutchison Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - DA Mankoff
- University of Washington, Seattle, WA; Fred Hutchison Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - KA Krohn
- University of Washington, Seattle, WA; Fred Hutchison Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
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Linden HM, Kurland BF, Link JM, Novakova A, Chai X, Gadi VK, Specht JM, Hills D, Gralow JR, Schubert EK, Korde L, Peterson LM, Doot R, Eary J, Shields A, Krohn KA, Mankoff DA. Abstract P4-01-02: The role of FLT PET early assessment of response to endocrine therapy for early stage breast cancer. Cancer Res 2013. [DOI: 10.1158/0008-5472.sabcs13-p4-01-02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: In estrogen receptor positive (ER+) tumors, a low proliferative index (Ki-67) two weeks into endocrine therapy predicts response. FLT PET non-invasively measures tumor proliferation in vivo. The pre-operative window is an opportunity to assess impact of systemic therapies. We tested associations between FLT PET qualitative and quantitative measures and Ki-67 following two weeks of aromatase inhibitor (AI) therapy.
Methods: Women with clinical stage I-II ER+ HER2– breast cancer underwent “run-in” of AI monotherapy prior to definitive surgery. Premenopausal women were given GNRH agonist treatment 2 W prior to AI therapy. FLT PET was performed before AI therapy, and 1-7 days before surgery. Ki-67 was measured in baseline core biopsy and surgical specimens.
Results: Fourteen patients (8 postmenopausal, 6 premenopausal) have been enrolled. All have undergone baseline FLT PET imaging; 11 have completed imaging and surgery, including one premenopausal patient with no residual invasive carcinoma following 26 days of AI therapy. The majority harbored ductal carcinomas (n = 9, 5 with lobular histology) with the majority histologic grade ≥ 2 (n = 11). The median number of days exposed to AI was 19 (range, 9-42). Baseline SUVmax ranged from 1.2 to 3.9 (median 2.2), and post run-in SUV (6-64 days later) ranged from 1.2 to 2.8 (median 1.8). Baseline Ki-67 ranged from 6-26.2, median 11.6; surgical Ki-67 post AI therapy ranged from 0- 20.3 median 3.7, with seven below 5%. SUV and flux declined in most patients, as did Ki-67.
Quantitative FLT flux correlated with tumor response assessed by proliferative index (Ki-67) before the “run-in” period, with a stronger correlation at surgery, Pearson correlation coefficients = 0.41 and 0.82, respectively. FLT SUV and qualitative changes were not strongly associated with Ki-67.
Conclusions: Both pre and postmenopausal women with early stage breast cancer showed imaging and tissue response to endocrine therapy. Quantitative, but not qualitative FLT is a promising tool to assess tumor proliferation and response to therapy. Accrual is ongoing and updated results will be reported.
Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-01-02.
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Affiliation(s)
- HM Linden
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - BF Kurland
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - JM Link
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - A Novakova
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - X Chai
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - VK Gadi
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - JM Specht
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - D Hills
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - JR Gralow
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - EK Schubert
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - L Korde
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - LM Peterson
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - R Doot
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - J Eary
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - A Shields
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - KA Krohn
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
| | - DA Mankoff
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; University of Pennsylvania, Philadelphia, PA; University of Pittsburgh, Pittsburgh, PA
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Eary JF, Link JM, Muzi M, O'Sullivan F, Rockhill JK, Fink JR, Linden HM, Krohn KA. Abstract B147: Tumor response imaging with [F-18] fluorothymidine (FLT). Mol Cancer Ther 2013. [DOI: 10.1158/1535-7163.targ-13-b147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Current cancer treatments have different mechanisms and variable responses in most histologic groups. The ability to determine treatment response at the molecular level by measuring tumor thymidine kinase 1 activity is being evaluated with FLT PET in groups of patients with different tumor histology.
Methods: Under FDA IND approved protocols, patients treated on standard clinical and clinical trial protocols for glioblastoma, carcinoma brain metastases, breast cancer, and AML underwent quantitative PET imaging with FLT at baseline, mid-therapy, and post therapy. Dynamic acquisitions of the sites of known tumor were acquired for 60 minutes, followed by a whole-body static image survey. All images were reconstructed with CT attenuation correction. Regions of interest for the tumor, liver, and surrounding tissues were analyzed for uptake at each data time. Regional tissue FLT uptake was described as the tissue standard uptake variable (SUV), and FLT transport (K1) and flux using a compartmental model analysis. The tumor K1 values were generated to quantify FLT delivery to tumor. Comparisons were made between FLT-PET obtained at sequential times in individual patients and with clinical response.
Results: At this time, 19 patients with primary brain tumors, 3 patients with brain metastases, 9 breast cancer patients, and 7 AML patients have been enrolled; at least one post-therapy image has been completed in all but 2 patients. The results have been analyzed semi-quantitatively as SUV and quantitatively by compartmental modeling to determine K1 and flux values for tumor baseline and post therapy comparisons. In most tumors, uptake by either SUV or flux declined in response to treatment but trends in tumor SUV values were not consistent with FLT flux values. In several cases, the FLT K1 and flux values were divergent, emphasizing the requirement to account for FLT delivery changes in observed tumor activity in response to therapy. This effect was most prominent in brain tumors and AML patients. Tumor blood flow/delivery is likely an independent response parameter that can be estimated from analysis of dynamic FLT PET. The poster will show evaluation of the predictive ability of baseline FLT studies as well as the role of pre/post comparisons.
Conclusions: FLT PET imaging shows increased tumor uptake across several histologic types. This uptake decreases significantly with therapy, however the flow/delivery parameters and flux values from imaging are important uptake parameters to consider individually to understand changes in response to therapy.
Supported by NIH/NCI P01 CA042045-23 and S10 RR017229.
Citation Information: Mol Cancer Ther 2013;12(11 Suppl):B147.
Citation Format: Janet F. Eary, Jeanne M. Link, Mark Muzi, Finbarr O'Sullivan, Jason K. Rockhill, James R. Fink, Hannah M. Linden, Kenneth A. Krohn. Tumor response imaging with [F-18] fluorothymidine (FLT). [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr B147.
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Affiliation(s)
| | | | - Mark Muzi
- 1University Of Washington, Seattle, WA
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Muzi M, O'Sullivan J, Eary JF, Krohn KA. Abstract B149: Quantitative FMISO imaging to assess regional tumor hypoxia as a predictor of response to therapy. Mol Cancer Ther 2013. [DOI: 10.1158/1535-7163.targ-13-b149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Hypoxia is associated with resistance to RT and chemotherapy in malignant tumors, where the burden of hypoxic tumor present before as well as after RT influences treatment outcome. Due to the low retention in normal oxygenated tissue, FMISO is an effective quantitative imaging agent for tumor hypoxia. Because FMISO has a partition coefficient near one, the concentrations in oxygenated tissue and blood rapidly equilibrate and are essentially identical. Normalizing the FMISO uptake data to blood activity, has permitted the generation of a threshold value, above which indicates tissue hypoxia. Through our earlier work using FMISO in tumor cells in culture, animal tumor models and human patient studies, we have determined empirically that blood-normalized tissue uptake (T/B) above a threshold can reliably be used to indicate tissue hypoxia and predict outcome [reviewed in Krohn et al. J Nucl Med 49(suppl 2):129S-148S, 2008]. Over the time course of FMISO uptake after injection, vascularized normoxic tissues tend to equilibrate with blood activity and the ratio of tissue-to-blood tends toward a mean of slightly less than 1. In the collection of FMISO regional tissue activity from normoxic tissue types (muscle, cerebellum, breast, lung; n > 400), the T/B values were consistently (> 90%) less than 1. In the examination of various hypoxic thresholds from normoxic brain tissue, a value of 1.1 results in 10% hypoxia, which is unrealistic for normal functioning brain tissue; a value of 1.2 results in ∼2.5% hypoxia and 0% for T/B=1.3. Thus a FMISO T/B ratio threshold of 1.2 adequately characterizes normoxic tissue; a FMISO T/B value >1.2 indicates hypoxia. Applying a hypoxic threshold T/B value for FMISO permits the determination of hypoxic volume (HV, mL) of a tissue region that can be determined as the volume of pixels within the tissue VOI above the hypoxic threshold. This simple static image analysis is one of the strengths of FMISO-PET; it captures both the intensity and spatial distribution of tumor hypoxia. In this imaging procedure, a static scan of 20 min duration is acquired 2 hrs after tracer injection during which three venous blood samples are acquired. The quantitative parameters from FMISO imaging that describe tissue hypoxia are the maximum value (T/Bmax) determined from the pixel within the tumor that has the highest uptake, and HV. HV depicts the extent of tumor that has crossed the threshold for hypoxia and T/Bmax depicts the severity of the hypoxia. In general HV and T/Bmax are correlated within an individual patient. Quantitative FMISO imaging can be used to select patients with hypoxic tumors and to identify regions of hypoxia that might be subjected to more intense therapy. Kaplan-Meier survival analysis and multivariate Cox regressions were used to show that T/Bmax or HV are independent predictors of TTP and survival, where progression was defined by clinical criteria. Serial FMISO studies can also be used to follow the reoxygenation response after radiation or chemotherapies such as anti-VEGF treatments.
Supported by NIH Grant P01 CA042045-23.
Citation Information: Mol Cancer Ther 2013;12(11 Suppl):B149.
Citation Format: Mark Muzi, Janet O'Sullivan, Janet F. Eary, Kenneth A. Krohn. Quantitative FMISO imaging to assess regional tumor hypoxia as a predictor of response to therapy. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr B149.
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Affiliation(s)
- Mark Muzi
- 1University Of Washington, Seattle, WA
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Eary JF, Krohn KA. Standards for Reporting PET Clinical Trials. J Nucl Med 2013; 54:1516-7. [DOI: 10.2967/jnumed.113.127845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hawkins-Daarud A, Rockne R, Kinahan P, Muzi M, Alessio A, Krohn KA, Swanson K. Quantifying the impact of antiangiogenic therapy on hypoxia and implications for radiation therapy in glioblastoma multiforme with a biomathematical model. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.e13028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e13028 Background: Glioblastoma multiforme (GBM) is the most aggressive form of primary brain tumor. As angiogenesis is a major hallmark of GBM, it can be inferred that hypoxia plays a prominent role in the progression of the disease. However, due to difficulty in assessing hypoxia, the development and evolution of hypoxia has not been well studied for GBM. 18F-Fluoromisonidazole (FMISO) PET indirectly measures hypoxia. It is known that hypoxia reduces the efficacy of radiation therapy, and one current strategy being explored is to combine anti-angiogenic therapy and radiation therapy. However, it is unclear whether anti-angiogenic therapy is ultimately reducing or increasing hypoxia nor is it clear how long the effects last. Methods: We have developed a spatio-temporal biomathematical model for glioma proliferation and invasion that incorporates the angiogenic cascade. In this context, we can simulate the action of anti-angiogenic treatment, such as bevacizumab, by modifying the availability of angiogenic factors. By applying a pharmacokinetic model for the uptake of FMISO to the simulation results, we can generate the corresponding FMISO-PET images during and after anti-angiogenic therapy to compare with what would be seen in the clinic. Results: Simulation results for a wide range of tumor kinetics demonstrated that hypoxia in general decreased during anti-angiogenic therapy. However, the rates at which it decreased and the time for the hypoxia to return to pre-treatment levels were not uniform. Conclusions: Dynamic understanding of anti-angiogenic therapy effects on vascular normalization and hypoxia suggest that optimal timing of radiation therapy and anti-angiogenic therapies would vary by patient. This biomathematical model can be tuned to individual patients’ tumors and provide similar information as a FMISO-PET image and also give insight into the dynamics of the hypoxia over time. Such insight could be invaluable to patient-specific treatment planning for combining radiation with antiangiogenics.
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Affiliation(s)
| | | | | | - Mark Muzi
- University of Washington, Seattle, WA
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Choudhury KR, Yagle KJ, Swanson PE, Krohn KA, Rajendran JG. A robust automated measure of average antibody staining in immunohistochemistry images. J Histochem Cytochem 2013; 58:95-107. [PMID: 19687472 DOI: 10.1369/jhc.2009.953554] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 08/03/2009] [Indexed: 02/02/2023] Open
Abstract
Identifying and scoring cancer markers plays a key role in oncology, helping to characterize the tumor and predict the clinical course of the disease. The current method for scoring immunohistochemistry (IHC) slides is labor intensive and has inherent issues of quantitation. Although multiple attempts have been made to automate IHC scoring in the past decade, a major limitation in these efforts has been the setting of the threshold for positive staining. In this report, we propose the use of an averaged threshold measure (ATM) score that allows for automatic threshold setting. The ATM is a single multiplicative measure that includes both the proportion and intensity scores. It can be readily automated to allow for large-scale processing, and it is applicable in situations in which individual cells are hard to distinguish. The ATM scoring method was validated by applying it to simulated images, to a sequence of images from the same tumor, and to tumors from different patient biopsies that showed a broad range of staining patterns. Comparison between the ATM score and manual scoring by an expert pathologist showed that both methods resulted in essentially identical scores when applied to these patient biopsies. This manuscript contains online supplemental material at http://www.jhc.org. Please visit this article online to view these materials.
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Linden HM, Kurland BF, Specht JM, Vijayakrishn GK, Gralow JR, Peterson LM, Schubert EK, Link JM, David MA, Eary JF, Krohn KA. Abstract P6-04-03: Changes in breast tumor metabolism and estradiol binding as measured by FES PET in patients treated with the histone deacetylace inhibitor vorinostat and aromatase inhibitor therapy. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p6-04-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Some estrogen receptor-positive (ER+) metastatic breast cancers are bone and soft tissue dominant, indolent, and controlled by endocrine therapy. However, these tumors eventually become refractory to endocrine therapy and need a mechanism to reset the “estrogen-dependence” to allow continued benefit upon progression. Histone deacetylase inhibitors (HDACi) act as modulators of gene expression that are promising therapeutic agents for this group of tumors (Huang 2000, Sabnis 2011). Preclinical and clinical data demonstrate in ER-poor tumors and cell lines ER up-regulation and consequently enhanced lethality to endocrine agents. The optimal dose and schedule are not known, but two promising phase II studies show benefit in a continuous schedule (Yardley 2011, Munster 2011). FES PET is a promising imaging agent used as a biomarker to determine which patients will benefit from endocrine therapy, and to monitor estradiol binding during therapy (Mortimer 2001, Linden 2011).
Methods: Patients with ER+ HER2− metastatic breast cancer with prior aromatase inhibitor (AI) exposure and clinical benefit of endocrine therapy were eligible for a phase II study of HDACi therapy to restore sensitivity to AI therapy. Following baseline FDG PET, FES PET and standard imaging (CT, MRI, ultrasound and/or bone scan as indicated by tumor location), patients received 2 weeks of vorinostat therapy (400 mg po daily). FES PET was performed at 2 weeks while on HDACi therapy. Patients then received 6 weeks of AI monotherapy. FDG PET, FES PET and response assessment were performed at 8 weeks. Patients with clinical benefit (stable disease or response) continued on the regimen, 2 weeks of vorinostat followed by 6 weeks of AI.
Results: To date, 8 patients have been enrolled of whom 6 have completed the first 8 weeks of treatment and all correlative imaging studies. FES biomarker imaging results are mixed, with some patients showing an increase in tumor estradiol concentrating ability by FES PET on HDACi therapy, and decline in metabolic activity by FDG. Two patients continue on treatment with clinical benefit. Results will be updated as accrual continues.
Conclusions: Changes in estradiol binding are measured by serial FES PET in patients on HDACi therapy support preclinical concept of HDACi modulation of ER expression in metastatic breast cancer. Molecular imaging is a promising tool to monitor Estradiol binding pharmacodynamics, and Vorinostat HDACi therapy is a promising novel approach to allow patients to avoid toxicities of traditional chemotherapy once their tumor has progressed on endocrine therapy.
Funding: P01, MKA, Merck
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-04-03.
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Affiliation(s)
- HM Linden
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; University of Pennsylvania, Philadelphia, PA
| | - BF Kurland
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; University of Pennsylvania, Philadelphia, PA
| | - JM Specht
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; University of Pennsylvania, Philadelphia, PA
| | - GK Vijayakrishn
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; University of Pennsylvania, Philadelphia, PA
| | - JR Gralow
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; University of Pennsylvania, Philadelphia, PA
| | - LM Peterson
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; University of Pennsylvania, Philadelphia, PA
| | - EK Schubert
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; University of Pennsylvania, Philadelphia, PA
| | - JM Link
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; University of Pennsylvania, Philadelphia, PA
| | - MA David
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; University of Pennsylvania, Philadelphia, PA
| | - JF Eary
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; University of Pennsylvania, Philadelphia, PA
| | - KA Krohn
- University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA; University of Pennsylvania, Philadelphia, PA
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Krohn KA, Katzenellenbogen JA. Tribute to Professor Michael John Welch (1939–2012). Bioconjug Chem 2012. [DOI: 10.1021/bc300336k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kenneth A. Krohn
- Department of Radiology, University of Illinois,
1959
NE Pacific Street, Box 356004, Seattle, Washington 98195, United States
| | - John A. Katzenellenbogen
- Department of Chemistry, University
of Washington,
600 S. Mathews Avenue, 461 RAL, Box 37-5 Urbana, Illinois 61801, United
States
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Plotnik DA, Asher C, Chu SK, Miyaoka RS, Garwin GG, Johnson BW, Li T, Krohn KA, Schwartz JL. Levels of human equilibrative nucleoside transporter-1 are higher in proliferating regions of A549 tumor cells grown as tumor xenografts in vivo. Nucl Med Biol 2012; 39:1161-6. [PMID: 22985987 DOI: 10.1016/j.nucmedbio.2012.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 07/26/2012] [Indexed: 11/18/2022]
Abstract
UNLABELLED 3'-Fluoro-3'-deoxythymidine (FLT) has been proposed for positron emission tomography (PET)-based identification of tumor chemosensitivity that is mediated by the human equilibrative nucleoside transporter-1 (ENT1). ENT1 facilitates transport of FLT into cells and elevated levels of FLT are associated with both larger FLT-PET signals and increased response to nucleoside-based chemotherapies. FLT-PET is also used as a measure of tumor proliferation. The present study examined the extent to which ENT1 levels vary in a proliferation-dependent manner in tumor cells in vivo. METHODS The human adenocarcinoma cell line A549 was used to establish tumor xenografts in nude mice. FLT uptake was measured in vivo using PET, and further examined ex vivo using autoradiography. FLT uptake patterns were compared to immunohistochemical (IHC) analysis of ENT1 and the proliferation markers Ki67 and BrdU. RESULTS Regional differences in FLT uptake matched differences in IHC proliferation markers. All cells stained for ENT1, but the staining intensity was twice as high for Ki67(+) cells than for Ki67(-) cells. CONCLUSIONS Under in vivo conditions, proliferating regions of tumors show increased FLT uptake and higher ENT1 levels than nonproliferating tumor regions.
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Affiliation(s)
- David A Plotnik
- Department of Radiation Oncology, Box 356069, University of Washington, Seattle, WA 98195 USA
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Plotnik DA, McLaughlin LJ, Krohn KA, Schwartz JL. The effects of 5-fluoruracil treatment on 3'-fluoro-3'-deoxythymidine (FLT) transport and metabolism in proliferating and non-proliferating cultures of human tumor cells. Nucl Med Biol 2012; 39:970-6. [PMID: 22560972 DOI: 10.1016/j.nucmedbio.2012.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Revised: 02/21/2012] [Accepted: 03/20/2012] [Indexed: 01/19/2023]
Abstract
UNLABELLED 3'-Fluoro-3'-deoxythymidine (FLT) positron emission tomography (PET) has been proposed for imaging thymidylate synthase (TS) inhibition. Agents that target TS and shut down de novo synthesis of thymidine monophosphate increase the uptake and retention of FLT in vitro and in vivo because of a compensating increase in the salvage pathway. Increases in both thymidine kinase-1 (TK1) and the equilibrative nucleoside transporter hENT1 have been reported to underlie this effect. We examined whether the effects of one TS inhibitor, 5-fluorouracil (5FU), on FLT uptake require proliferating cells and whether the effects are limited to increasing TK1 activity. METHODS The effects of 5FU on FLT transport and metabolism, TK1 activity, and cell cycle progression were evaluated in the human tumor cell line, A549, maintained as either a proliferating or non-proliferating culture. RESULTS There were dose-dependent increases in FLT uptake that peaked after a 10 μM 5FU exposure and then declined to baseline levels or below at higher doses in both proliferating and non-proliferating cultures. The dose-dependence for FLT uptake was mirrored by changes in TK1 activity. S phase fraction did not correlate with FLT uptake in proliferating cultures. Chemical inhibition of hENT1 reduced overall levels of FLT uptake but did not affect the low dose increase in FLT uptake. CONCLUSIONS 5FU only affects FLT uptake in proliferating A549 cells and increases in FLT uptake are directly related to increased TK1 activity. Our studies did not support a role for hENT1 in the increased uptake of FLT after exposure to 5FU. Our studies with A549 cells support the suggestion that FLT-PET could provide a measure of TS inhibition in vivo.
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Affiliation(s)
- David A Plotnik
- Department of Radiation Oncology, University of Washington, Box 356069 Seattle, WA 98195, USA
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Eary JF, Link JM, Mankoff DA, Muzi M, O'Sullivan F, Fink JR, Rockhill JK, Linden HM, Krohn KA. Abstract SY42-02: Novel PET imaging in the clinic: Selecting patient cohorts and measuring early response. Cancer Res 2012. [DOI: 10.1158/1538-7445.am2012-sy42-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Molecular imaging with PET is most commonly associated with tumor detection and staging, currently with [F-18]-fluorodeoxyglucose (FDG-PET) to measure energy metabolism. However other imaging agents can be used to measure important characteristics of tumors that have the potential to guide in therapy selection or provide an early indication of response to therapy. Even though there are enthusiastic predictions of the role that “omics” biomarkers will play in personalized medicine, imaging biomarkers have some practical advantages over tissue and serum biomarkers. Imaging characterizes the entire tumor burden in the context of its environment and it can be repeated frequently. Several new PET agents are becoming widely available to probe important aspects of the tumor phenotype. The UW NCI-sponsored program project is developing PET to image tumor cancer biology with new agents that examine the tumor phenotype and how it changes in response to therapy.
There are many biological factors that can influence response of an individual patient to cancer therapy. Evaluation of these factors provides the questions and hypotheses posed in the UW PPG. The group focuses on investigations of reasons for poor tumor response to treatment. Hypoxia, cellular proliferation, low abundance of therapeutic targets (e.g. estrogen receptors) and acquired multidrug resistance (MDR/P-gp) are some of the imaging targets. These tumor variables can be quantified by PET imaging with [F-18]-fluoromisonidazole, [F-18]-3′-fluoro-3′-deoxythymidine, [F-18]-16α-fluoroestradiol and [C-11]-verapamil, respectively. Because hypoxia is a common characteristic of tumors but it is heterogeneous within a tumor mass and differs between tumor sites in a patient, imaging has an important role in assessing regional tumor tissue oxygenation. [F-18]-Fluoromisonidazole (FMISO) developed by our group is a PET hypoxia-imaging probe that accumulates at low PO2. Imaging results with this agent have demonstrated tumor hypoxic volume is an independent predictor of overall survival in patients with head and neck cancer, soft tissue sarcoma and primary brain tumors.
PET can also be used to image the response mechanism of a tumor to therapy. Current therapies are cytotoxic or cytostatic, with some combinations that are overlapping or aimed at a particular phosphokinase pathway. Uncontrolled tumor growth results from dysregulation of cellular proliferation and/or deficiencies in programmed cell death. FDG has been advocated for monitoring this net process but there are many contributors to energy metabolism in tumors, thus reducing the specificity of FDG-PET for evaluating tumor response. Thymidine and its analogs can be used to image the salvage pathway of cellular proliferation (DNA synthesis) with better specificity because these nucleosides are accumulated and phosphorylated during cellular S-phase. The UW PET group developed [F-18]-3′-fluoro-3′-deoxythymidine (FLT) for this purpose.
Our recent studies have focused on the challenge of distinguishing whether clinical symptoms and standard imaging appearance after therapy is predominantly a result of tumor progression or radionecrosis/pseudoprogression in patients with primary brain tumors. This application of FLT-PET emphasizes the value of dynamic imaging to separate the blood flow or delivery phase of the imaging agent from its tumor incorporation as a flux through the DNA salvage pathway. Segmentation algorithms and compartmental analyses are being used to generate parametric maps of regional tumor transport and synthetic flux. In several study results, the flux parametric image in recurrent brain tumors shows much higher FLT accumulation (salvage pathway activity) than in tumors with pseudo-progression whereas the transport images overlap between the two groups.
Imaging the P-gp drug resistance mechanism is performed using [C-11]-verapamil, a substrate for the transporter similar to the anthracyclines, which are the mainstay of many chemotherapy regimens. Preliminary work in sarcoma patients has shown that levels of P-gp activity are variable in tumors at presentation and change in response to therapy, usually resulting in an increase in activity. This increase in P-gp activity may confirm clinical suspicion that drug resistance has been induced in an individual as an important contributor to treatment resistance.
In summary, PET imaging provides an important tool for selecting patients with specific mechanisms of resistance to cancer therapy so that new drugs can be used with maximum effectiveness. PET imaging results can also provide useful biomarkers for tumor response to standard and experimental therapy, and will be important contributors towards the goal of personalized medicine for cancer patients. The UW PET group has worked with NCI-CIP to develop INDs for FMISO and FLT that are now used in multicenter trials. The group has also developed methods for analysis of FMISO and FLT images and provides a resource for image analysis in the trials. Both of these imaging agents, and approaches to acquiring and analyzing their images, are widely available to nuclear medicine clinical research groups to contribute toward progress in understanding cancer and its response to therapy.
The research results to be presented were supported by P01 CA042045-22.
Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr SY42-02. doi:1538-7445.AM2012-SY42-02
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Affiliation(s)
- Janet F. Eary
- 1Univ. of Washington/FHCRC Cancer Center Consortium, Seattle, WA
| | - Jeanne M. Link
- 1Univ. of Washington/FHCRC Cancer Center Consortium, Seattle, WA
| | - David A. Mankoff
- 2Univ. of Washington/FHCRC Cancer Center Consortium, Seattle Cancer Care Alliance, Seattle, WA
| | | | | | | | | | - Hannah M. Linden
- 2Univ. of Washington/FHCRC Cancer Center Consortium, Seattle Cancer Care Alliance, Seattle, WA
| | - Kenneth A. Krohn
- 1Univ. of Washington/FHCRC Cancer Center Consortium, Seattle, WA
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Kurland BF, Peterson LM, Lee JH, Linden HM, Schubert EK, Dunnwald LK, Link JM, Krohn KA, Mankoff DA. Between-patient and within-patient (site-to-site) variability in estrogen receptor binding, measured in vivo by 18F-fluoroestradiol PET. J Nucl Med 2011; 52:1541-9. [PMID: 21903739 DOI: 10.2967/jnumed.111.091439] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
UNLABELLED Heterogeneity of estrogen receptor (ER) expression may be an important predictor of breast cancer therapeutic response. (18)F-fluoroestradiol PET produces in vivo quantitative measurements of regional estrogen binding in breast cancer tumors. We describe within-patient (site-to-site) and between-patient heterogeneity of lesions in patients scheduled to receive endocrine therapy. METHODS In 91 patients with a prior ER-positive biopsy, 505 lesions were analyzed for both (18)F-fluoroestradiol and (18)F-FDG uptake and the (18)F-fluoroestradiol/(18)F-FDG uptake ratio. Standardized uptake values (SUVs) were recorded for up to 16 lesions per patient, of 1.5 cm or more and visible on (18)F-FDG PET or conventional staging. Linear mixed-effects regression models examined associations between PET parameters and patient or lesion characteristics and estimated variance components. A reader study of SUV measurements for 9 scans further examined sources of within-patient variability. RESULTS Average (18)F-fluoroestradiol uptake and (18)F-fluoroestradiol/(18)F-FDG ratio varied greatly across these patients, despite a history of ER-positive disease: about 37% had low or absent (18)F-fluoroestradiol uptake even with marked (18)F-FDG uptake. (18)F-fluoroestradiol SUV and (18)F-fluoroestradiol/(18)F-FDG ratio measurements within patients with multiple lesions were clustered around the patient's average value in most cases. Summarizing these findings, the intraclass correlation coefficient (proportion of total variation that is between-patient) was 0.60 (95% confidence interval, 0.50-0.69) for (18)F-fluoroestradiol SUV and 0.65 (95% confidence interval, 0.56-0.73) for the (18)F-fluoroestradiol/(18)F-FDG ratio. Some within-patient variation in PET measures (22%-44%) was attributable to interobserver variability as measured by the reader study. A subset of patients had mixed uptake, with widely disparate (18)F-fluoroestradiol SUV or (18)F-fluoroestradiol/(18)F-FDG ratio for lesions in the same scan. CONCLUSION (18)F-fluoroestradiol uptake and the (18)F-fluoroestradiol/(18)F-FDG ratio varied greatly between patients but were usually consistent across lesions in the same scan. The average (18)F-fluoroestradiol SUV and (18)F-fluoroestradiol/(18)F-FDG ratio for a limited sample of lesions appear to provide a reasonable summary of synchronous ER expression for most patients. However, imaging the entire disease burden remains important to identify the subset of patients with mixed uptake, who may be at a critical point in their disease evolution.
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Affiliation(s)
- Brenda F Kurland
- Department of Clinical Statistics, Fred Hutchinson Cancer Research Center, Seattle Washington 98109, USA.
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Linden HM, Kurland BF, Peterson LM, Schubert EK, Gralow JR, Specht JM, Ellis GK, Lawton TJ, Livingston RB, Petra PH, Link JM, Krohn KA, Mankoff DA. Fluoroestradiol positron emission tomography reveals differences in pharmacodynamics of aromatase inhibitors, tamoxifen, and fulvestrant in patients with metastatic breast cancer. Clin Cancer Res 2011; 17:4799-805. [PMID: 21750198 PMCID: PMC3139698 DOI: 10.1158/1078-0432.ccr-10-3321] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine, by molecular imaging, how in vivo pharmacodynamics of estrogen-estrogen receptor (ER) binding differ between types of standard endocrine therapy. EXPERIMENTAL DESIGN The ER has been a highly successful target for breast cancer treatment. ER-directed treatments include lowering ligand concentration by using aromatase inhibitors (AI) and blocking the receptor with agents like tamoxifen (TAM) or fulvestrant (FUL). We measured regional estrogen-ER binding by using positron emission tomography with (18)F-fluoroestradiol (FES PET) prior to and during treatment with AI, TAM, or FUL in a series of 30 metastatic breast cancer patients. FES PET measured in vivo estrogen binding at all tumor sites in heavily pretreated women with metastatic bone soft tissue-dominant breast cancer. In patients with uterus (n = 16) changes in uterine FES uptake were also measured. RESULTS As expected, tumor FES uptake declined more markedly on ER blockers (TAM and FUL, average 54% decline) compared with a less than 15% average decline on estrogen-depleting AIs (P < 0.001). The rate of complete tumor blockade [FES standardized uptake value (SUV) ≤1.5] following TAM (5/5 patients) was greater than the blockade rate following FUL (4/11; 2-sided mid P = 0.019). Percent FES SUV change in the uterus showed a strong association with tumoral change (ρ = 0.63, P = 0.01). CONCLUSIONS FES PET can assess the in vivo pharmacodynamics of ER-targeted agents and may give insight into the activity of established therapeutic agents. Imaging revealed significant differences between agents, including differences in the efficacy of blockade by different ER antagonists in current clinical use.
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Affiliation(s)
- Hannah M Linden
- Department of Medicine, University of Washington, Seattle, Washington, USA.
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Gu S, Chakraborty G, Champley K, Alessio AM, Claridge J, Rockne R, Muzi M, Krohn KA, Spence AM, Alvord EC, Anderson ARA, Kinahan PE, Swanson KR. Applying a patient-specific bio-mathematical model of glioma growth to develop virtual [18F]-FMISO-PET images. Math Med Biol 2011; 29:31-48. [PMID: 21562060 DOI: 10.1093/imammb/dqr002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Glioblastoma multiforme (GBM) is a class of primary brain tumours characterized by their ability to rapidly proliferate and diffusely infiltrate surrounding brain tissue. The aggressive growth of GBM leads to the development of regions of low oxygenation (hypoxia), which can be clinically assessed through [18F]-fluoromisonidazole (FMISO) positron emission tomography (PET) imaging. Building upon the success of our previous mathematical modelling efforts, we have expanded our model to include the tumour microenvironment, specifically incorporating hypoxia, necrosis and angiogenesis. A pharmacokinetic model for the FMISO-PET tracer is applied at each spatial location throughout the brain and an analytical simulator for the image acquisition and reconstruction methods is applied to the resultant tracer activity map. The combination of our anatomical model with one for FMISO tracer dynamics and PET image reconstruction is able to produce a patient-specific virtual PET image that reproduces the image characteristics of the clinical PET scan as well as shows no statistical difference in the distribution of hypoxia within the tumour. This work establishes proof of principle for a link between anatomical (magnetic resonance image [MRI]) and molecular (PET) imaging on a patient-specific basis as well as address otherwise untenable questions in molecular imaging, such as determining the effect on tracer activity from cellular density. Although further investigation is necessary to establish the predicitve value of this technique, this unique tool provides a better dynamic understanding of the biological connection between anatomical changes seen on MRI and biochemical activity seen on PET of GBM in vivo.
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Affiliation(s)
- Stanley Gu
- Department of Bioengineering and Pathology, University of Washington, Seattle, WA 98195, USA
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Abstract
UNLABELLED A major goal of molecular imaging in cancer is to evaluate patient tumors for risk of treatment resistance and poor outcome using biologically specific PET agents. This approach was investigated using a multiagent imaging protocol for which patients were imaged in a single session to minimize changes in tumor parameters caused by multiple-day and -setting observation differences. METHODS We present data from a pilot study in 10 soft-tissue sarcoma patients imaged with (11)C-thymidine for cellular proliferation, (18)F-fluoromisonidazole (FMISO) for tissue hypoxia, and (11)C-verapamil for P-glycoprotein activity, in comparison with (15)O-water for blood flow and (11)C-CO(2) for metabolite analysis and (18)F-FDG clinical scans. Several patients underwent repeated imaging after adriamycin-based chemotherapy. RESULTS Quantitative imaging results showed that tumor uptake parameters vary between patients and with respect to each other in individual patients, suggesting that each patient's tumor biologic profile is unique. Specific tumor characteristics such as variable cellular proliferation, hypoxic volume, and upregulated P-glycoprotein activity were identified. CONCLUSION This study shows that multiagent PET is feasible and yields unique and potentially complementary biologic information on individual tumors.
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Affiliation(s)
- Janet F Eary
- Department of Radiology, University of Washington, Seattle, Washington, USA.
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Plotnik DA, Emerick LE, Krohn KA, Unadkat JD, Schwartz JL. Different modes of transport for 3H-thymidine, 3H-FLT, and 3H-FMAU in proliferating and nonproliferating human tumor cells. J Nucl Med 2010; 51:1464-71. [PMID: 20720049 DOI: 10.2967/jnumed.110.076794] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED The basis for the use of nucleoside tracers in PET is that activity of the cell-growth-dependent enzyme thymidine kinase 1 is the rate-limiting factor driving tracer retention in tumors. Recent publications suggest that nucleoside transporters might influence uptake and thereby affect the tracer signal in vivo. Understanding transport mechanisms for different nucleoside PET tracers is important for evaluating clinical results. This study examined the relative role of different nucleoside transport mechanisms in uptake and retention of [methyl-(3)H]-3'-deoxy-3'-fluorothymidine ((3)H-FLT), [methyl-(3)H]-thymidine ((3)H-thymidine), and (3)H-1-(2-deoxy-2-fluoro-beta-D-arabinofuranosyl)-5-methyluracil ((3)H-FMAU). METHODS Transport of (3)H-FLT, (3)H-thymidine, and (3)H-FMAU was examined in a single human adenocarcinoma cell line, A549, under both nongrowth and exponential-growth conditions. RESULTS (3)H-Thymidine transport was dominated by human equilibrative nucleoside transporter 1 (hENT1) under both growth conditions. (3)H-FLT was also transported by hENT1, but passive diffusion dominated its transport. (3)H-FMAU transport was dominated by human equilibrative nucleoside transporter 2. Cell membrane levels of hENT1 increased in cells under exponential growth, and this increase was associated with a more rapid rate of uptake for both (3)H-thymidine and (3)H-FLT. (3)H-FMAU transport was not affected by changes in growth conditions. All 3 tracers concentrated in the plateau phase, nonproliferating cells at levels many-fold greater than their concentration in buffer, in part because of low levels of nucleoside metabolism, which inhibited tracer efflux. CONCLUSION Transport mechanisms are not the same for (3)H-thymidine, (3)H-FLT, and (3)H-FMAU. Levels of hENT1, an important transporter of (3)H-FLT and (3)H-thymidine, increase as proliferating cells enter the cell cycle.
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Affiliation(s)
- David A Plotnik
- Department of Radiation Oncology, University of Washington, Seattle, Washington 98195, USA
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Krohn KA, Eary JF, Linden HM, Link JM, Mankoff DA, Muzi M, O'Sullivan F, Spence AM. Abstract A230: Exploring novel PET agents for support of experimental cancer therapy: Selecting patient cohorts and monitoring response to therapy. Mol Cancer Ther 2009. [DOI: 10.1158/1535-7163.targ-09-a230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
The time course of biodistribution of PET radiopharmaceuticals, when analyzed by appropriate models, can be used to image molecular differences between tumors and normal tissues. Understanding important molecular differences and how they change during treatment should lead to better characterization of tumor biology and ultimately better treatment outcome. Four examples will show the value of PET to image specific aspects of the tumor phenotype.
Proliferation imaging started with [C-11]-thymidine and later with our development of [F-18]-FLT. The salvage pathway provides a robust measure of the growth rate of tumors. As an example, standard therapy for newly diagnosed glioblastoma multiforme is 60 Gy RT plus concurrent temozolomide. Many patients who complete therapy show MRIs consistent with tumor progression but they improve on continued TMZ. This pseudoprogression is an important problem; clinicians armed with MRI alone may wrongly conclude that standard treatment is failing. Misdiagnosing tumor progression could risk entering patients into trials of new agents, leading to falsely positive outcomes. FLT PET may help clarify this dilemma since preliminary studies have shown promise in distinguishing radionecrosis from recurrent disease. In these studies, we assessed FLT flux and transport as well as SUV and MRI and found that only FLT flux was an independent variable to distinguish the two groups.
Anthracycline based therapy continues to be a mainstay for solid cancers but many of these tumors have variable levels of multiple drug resistance. Pglycoprotein is a membrane pump to exclude anthracyclines from intracellular accumulation. We use PET to quantify Pgp activity using a transporter substrate, [C-11]-verapamil. Pilot studies of sarcoma patients showed a range of uptake kinetics in tumors before treatment compared with after exposure to chemotherapy. Our initial data shows that the extent of acquired MDR measured by PET correlates with survival.
Hypoxia is an important resistance factor in treatment. [F-18]-FMISO is an imaging agent that accumulates in hypoxia but not in necrosis. In outcomes studies of patients with brain tumors, FMISO was an independent predictor of outcome. Glioma patients with hypoxic volumes >15 cc had a median survival of ∼4 mo while patients with less hypoxia had a median survival of ∼15 mo compared to 12–14 mo with current standard therapy. These data argue that better treatments directed at hypoxic disease deserve serious attention. We have also imaged recurrent malignant gliomas before and after treatment with bevacizumab plus irinotecan and correlated FMISO changes with survival. Our preliminary results argue that anti-angiogenic therapy may reduce hypoxia and lower resistance to radiotherapy and chemotherapy.
We are imaging estrogen receptors using [F-18]-fluoroestradiol to select breast cancer patients for targeted therapy. FES predicts response to endocrine therapy in metastatic breast cancer. It shows a pharmacodynamic difference between two ER blocking agents, tamoxifen and fulvestrant. We are beginning to explore the value of FES PET in novel therapy intended to re-express ER in breast cancer tumors refractory to endocrine therapy using a HDAC inhibitor.
Citation Information: Mol Cancer Ther 2009;8(12 Suppl):A230.
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Affiliation(s)
- Kenneth A. Krohn
- 1 University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Janet F. Eary
- 1 University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Hannah M. Linden
- 2 University of Washington; Seattle Cancer Care Alliance, Seattle, WA
| | - Jeanne M. Link
- 1 University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA
| | - David A. Mankoff
- 3 Fred Hutchinson Cancer Research Center; Seattle Cancer Care Alliance, Seattle, WA
| | - Mark Muzi
- 4 University of Washington, Seattle, WA
| | | | - Alexander M. Spence
- 1 University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA
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O'Sullivan F, Muzi M, Spence AM, Mankoff DM, O'Sullivan JN, Fitzgerald N, Newman GC, Krohn KA. Nonparametric Residue Analysis of Dynamic PET Data With Application to Cerebral FDG Studies in Normals. J Am Stat Assoc 2009; 104:556-571. [PMID: 19830267 PMCID: PMC2760850 DOI: 10.1198/jasa.2009.0021] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Kinetic analysis is used to extract metabolic information from dynamic positron emission tomography (PET) uptake data. The theory of indicator dilutions, developed in the seminal work of Meier and Zierler (1954), provides a probabilistic framework for representation of PET tracer uptake data in terms of a convolution between an arterial input function and a tissue residue. The residue is a scaled survival function associated with tracer residence in the tissue. Nonparametric inference for the residue, a deconvolution problem, provides a novel approach to kinetic analysis-critically one that is not reliant on specific compartmental modeling assumptions. A practical computational technique based on regularized cubic B-spline approximation of the residence time distribution is proposed. Nonparametric residue analysis allows formal statistical evaluation of specific parametric models to be considered. This analysis needs to properly account for the increased flexibility of the nonparametric estimator. The methodology is illustrated using data from a series of cerebral studies with PET and fluorodeoxyglucose (FDG) in normal subjects. Comparisons are made between key functionals of the residue, tracer flux, flow, etc., resulting from a parametric (the standard two-compartment of Phelps et al. 1979) and a nonparametric analysis. Strong statistical evidence against the compartment model is found. Primarily these differences relate to the representation of the early temporal structure of the tracer residence-largely a function of the vascular supply network. There are convincing physiological arguments against the representations implied by the compartmental approach but this is the first time that a rigorous statistical confirmation using PET data has been reported. The compartmental analysis produces suspect values for flow but, notably, the impact on the metabolic flux, though statistically significant, is limited to deviations on the order of 3%-4%. The general advantage of the nonparametric residue analysis is the ability to provide a valid kinetic quantitation in the context of studies where there may be heterogeneity or other uncertainty about the accuracy of a compartmental model approximation of the tissue residue.
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Affiliation(s)
- Finbarr O'Sullivan
- Finbarr O'Sullivan is Professor of Statistics, University College Cork, Ireland and Affiliate Professor of Radiology, University of Washington, Seattle, WA 98195 (E-mail: ). Mark Muzi is Director of Image Analysis, Department of Radiology, University of Washington, Seattle, WA 98195. Alexander M. Spence is Professor of Neurology, University of Washington, Seattle, WA 98195. David M. Mankoff is Professor of Radiology, University of Washington, Seattle, WA 98195. Janet N. O'Sullivan is Research Scientist, University College Cork, Ireland. Niall Fitzgerald is Ph.D. student, University College Cork, Ireland. George C. Newman is Chair of Neurosensory Sciences, Albert Einstein Medical Center, Philadelphia, PA. Kenneth A. Krohn is Professor of Radiology, University of Washington, Seattle, WA 98195
| | - Mark Muzi
- Finbarr O'Sullivan is Professor of Statistics, University College Cork, Ireland and Affiliate Professor of Radiology, University of Washington, Seattle, WA 98195 (E-mail: ). Mark Muzi is Director of Image Analysis, Department of Radiology, University of Washington, Seattle, WA 98195. Alexander M. Spence is Professor of Neurology, University of Washington, Seattle, WA 98195. David M. Mankoff is Professor of Radiology, University of Washington, Seattle, WA 98195. Janet N. O'Sullivan is Research Scientist, University College Cork, Ireland. Niall Fitzgerald is Ph.D. student, University College Cork, Ireland. George C. Newman is Chair of Neurosensory Sciences, Albert Einstein Medical Center, Philadelphia, PA. Kenneth A. Krohn is Professor of Radiology, University of Washington, Seattle, WA 98195
| | - Alexander M. Spence
- Finbarr O'Sullivan is Professor of Statistics, University College Cork, Ireland and Affiliate Professor of Radiology, University of Washington, Seattle, WA 98195 (E-mail: ). Mark Muzi is Director of Image Analysis, Department of Radiology, University of Washington, Seattle, WA 98195. Alexander M. Spence is Professor of Neurology, University of Washington, Seattle, WA 98195. David M. Mankoff is Professor of Radiology, University of Washington, Seattle, WA 98195. Janet N. O'Sullivan is Research Scientist, University College Cork, Ireland. Niall Fitzgerald is Ph.D. student, University College Cork, Ireland. George C. Newman is Chair of Neurosensory Sciences, Albert Einstein Medical Center, Philadelphia, PA. Kenneth A. Krohn is Professor of Radiology, University of Washington, Seattle, WA 98195
| | - David M. Mankoff
- Finbarr O'Sullivan is Professor of Statistics, University College Cork, Ireland and Affiliate Professor of Radiology, University of Washington, Seattle, WA 98195 (E-mail: ). Mark Muzi is Director of Image Analysis, Department of Radiology, University of Washington, Seattle, WA 98195. Alexander M. Spence is Professor of Neurology, University of Washington, Seattle, WA 98195. David M. Mankoff is Professor of Radiology, University of Washington, Seattle, WA 98195. Janet N. O'Sullivan is Research Scientist, University College Cork, Ireland. Niall Fitzgerald is Ph.D. student, University College Cork, Ireland. George C. Newman is Chair of Neurosensory Sciences, Albert Einstein Medical Center, Philadelphia, PA. Kenneth A. Krohn is Professor of Radiology, University of Washington, Seattle, WA 98195
| | - Janet N. O'Sullivan
- Finbarr O'Sullivan is Professor of Statistics, University College Cork, Ireland and Affiliate Professor of Radiology, University of Washington, Seattle, WA 98195 (E-mail: ). Mark Muzi is Director of Image Analysis, Department of Radiology, University of Washington, Seattle, WA 98195. Alexander M. Spence is Professor of Neurology, University of Washington, Seattle, WA 98195. David M. Mankoff is Professor of Radiology, University of Washington, Seattle, WA 98195. Janet N. O'Sullivan is Research Scientist, University College Cork, Ireland. Niall Fitzgerald is Ph.D. student, University College Cork, Ireland. George C. Newman is Chair of Neurosensory Sciences, Albert Einstein Medical Center, Philadelphia, PA. Kenneth A. Krohn is Professor of Radiology, University of Washington, Seattle, WA 98195
| | - Niall Fitzgerald
- Finbarr O'Sullivan is Professor of Statistics, University College Cork, Ireland and Affiliate Professor of Radiology, University of Washington, Seattle, WA 98195 (E-mail: ). Mark Muzi is Director of Image Analysis, Department of Radiology, University of Washington, Seattle, WA 98195. Alexander M. Spence is Professor of Neurology, University of Washington, Seattle, WA 98195. David M. Mankoff is Professor of Radiology, University of Washington, Seattle, WA 98195. Janet N. O'Sullivan is Research Scientist, University College Cork, Ireland. Niall Fitzgerald is Ph.D. student, University College Cork, Ireland. George C. Newman is Chair of Neurosensory Sciences, Albert Einstein Medical Center, Philadelphia, PA. Kenneth A. Krohn is Professor of Radiology, University of Washington, Seattle, WA 98195
| | - George C. Newman
- Finbarr O'Sullivan is Professor of Statistics, University College Cork, Ireland and Affiliate Professor of Radiology, University of Washington, Seattle, WA 98195 (E-mail: ). Mark Muzi is Director of Image Analysis, Department of Radiology, University of Washington, Seattle, WA 98195. Alexander M. Spence is Professor of Neurology, University of Washington, Seattle, WA 98195. David M. Mankoff is Professor of Radiology, University of Washington, Seattle, WA 98195. Janet N. O'Sullivan is Research Scientist, University College Cork, Ireland. Niall Fitzgerald is Ph.D. student, University College Cork, Ireland. George C. Newman is Chair of Neurosensory Sciences, Albert Einstein Medical Center, Philadelphia, PA. Kenneth A. Krohn is Professor of Radiology, University of Washington, Seattle, WA 98195
| | - Kenneth A. Krohn
- Finbarr O'Sullivan is Professor of Statistics, University College Cork, Ireland and Affiliate Professor of Radiology, University of Washington, Seattle, WA 98195 (E-mail: ). Mark Muzi is Director of Image Analysis, Department of Radiology, University of Washington, Seattle, WA 98195. Alexander M. Spence is Professor of Neurology, University of Washington, Seattle, WA 98195. David M. Mankoff is Professor of Radiology, University of Washington, Seattle, WA 98195. Janet N. O'Sullivan is Research Scientist, University College Cork, Ireland. Niall Fitzgerald is Ph.D. student, University College Cork, Ireland. George C. Newman is Chair of Neurosensory Sciences, Albert Einstein Medical Center, Philadelphia, PA. Kenneth A. Krohn is Professor of Radiology, University of Washington, Seattle, WA 98195
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Szeto MD, Chakraborty G, Hadley J, Rockne R, Muzi M, Alvord EC, Krohn KA, Spence AM, Swanson KR. Quantitative metrics of net proliferation and invasion link biological aggressiveness assessed by MRI with hypoxia assessed by FMISO-PET in newly diagnosed glioblastomas. Cancer Res 2009; 69:4502-9. [PMID: 19366800 DOI: 10.1158/0008-5472.can-08-3884] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Glioblastoma multiforme (GBM) are aggressive and uniformly fatal primary brain tumors characterized by their diffuse invasion of the normal-appearing parenchyma peripheral to the clinical imaging abnormality. Hypoxia, a hallmark of aggressive tumor behavior often noted in GBMs, has been associated with resistance to therapy, poorer survival, and more malignant tumor phenotypes. Based on the existence of a set of novel imaging techniques and modeling tools, our objective was to assess a hypothesized quantitative link between tumor growth kinetics [assessed via mathematical models and routine magnetic resonance imaging (MRI)] and the hypoxic burden of the tumor [assessed via positron emission tomography (PET) imaging]. Our biomathematical model for glioma kinetics describes the spatial and temporal evolution of a glioma in terms of concentration of malignant tumor cells. This model has already been proven useful as a novel tool to dynamically quantify the net rates of proliferation (rho) and invasion (D) of the glioma cells in individual patients. Estimates of these kinetic rates can be calculated from routinely available pretreatment MRI in vivo. Eleven adults with GBM were imaged preoperatively with (18)F-fluoromisonidazole (FMISO)-PET and serial gadolinium-enhanced T1- and T2-weighted MRIs to allow the estimation of patient-specific net rates of proliferation (rho) and invasion (D). Hypoxic volumes were quantified from each FMISO-PET scan following standard techniques. To control for tumor size variability, two measures of hypoxic burden were considered: relative hypoxia (RH), defined as the ratio of the hypoxic volume to the T2-defined tumor volume, and the mean intensity on FMISO-PET scaled to the blood activity of the tracer (mean T/B). Pearson correlations between RH and the net rate of cell proliferation (rho) reached significance (P < 0.04). Moreover, highly significant positive correlations were found between biological aggressiveness ratio (rho/D) and both RH (P < 0.00003) and the mean T/B (P < 0.0007).
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Affiliation(s)
- Mindy D Szeto
- Department of Pathology, University of Washington School of Medicine, Seattle, WA 98104, USA
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Spence AM, Muzi M, Link JM, O'Sullivan F, Eary JF, Hoffman JM, Shankar LK, Krohn KA. NCI-sponsored trial for the evaluation of safety and preliminary efficacy of 3'-deoxy-3'-[18F]fluorothymidine (FLT) as a marker of proliferation in patients with recurrent gliomas: preliminary efficacy studies. Mol Imaging Biol 2009; 11:343-55. [PMID: 19326172 DOI: 10.1007/s11307-009-0215-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Revised: 09/30/2008] [Accepted: 10/24/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE 3'-Deoxy-3'-[18F]fluorothymidine ([18F]FLT) is being developed for imaging cellular proliferation. The goals were to explore the capacity of FLT-positron emission tomography (PET) to distinguish between recurrence and radionecrosis in gliomas and compare the results to those obtained with 2-fluoro-2-deoxy-D: -glucose (FDG). PROCEDURES Fifteen patients with tumor recurrence and four with radionecrosis, determined by clinical course and magnetic resonance imaging results, were studied by dynamic [18F]FLT-PET with arterial blood sampling. A two-tissue compartment four-rate constant model was used to determine metabolic flux (K (FLT)), blood to tissue transport (K (1)), and phosphorylation (k (3)). FDG-PET scans were obtained 75-90 min postinjection. RESULTS K (FLT) and k (3), but not K (1) or k (3)/k (2) + k (3), reached significance for separating the recurrence from radionecrosis groups. Standardized uptake value and visual analyses of FLT or FDG images did not reach significance. CONCLUSIONS K (FLT) (flux) appears to distinguish recurrence from radionecrosis better than other parameters, FLT and FDG semiquantitative approaches, or visual analysis of images of either tracer.
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Affiliation(s)
- Alexander M Spence
- Department of Neurology, University of Washington, Mailstop 356465, 1959 NE Pacific Street, Seattle, WA 98195, USA.
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Swanson KR, Chakraborty G, Wang CH, Rockne R, Harpold HLP, Muzi M, Adamsen TCH, Krohn KA, Spence AM. Complementary but distinct roles for MRI and 18F-fluoromisonidazole PET in the assessment of human glioblastomas. J Nucl Med 2008; 50:36-44. [PMID: 19091885 DOI: 10.2967/jnumed.108.055467] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED Glioblastoma multiforme is a primary brain tumor known for its rapid proliferation, diffuse invasion, and prominent neovasculature and necrosis. This study explores the in vivo link between these characteristics and hypoxia by comparing the relative spatial geometry of developing vasculature inferred from gadolinium-enhanced T1-weighted MRI (T1Gd), edematous tumor extent revealed on T2-weighted MRI (T2), and hypoxia assessed by 18F-fluoromisonidazole PET (18F-FMISO). Given the role of hypoxia in upregulating angiogenic factors, we hypothesized that the distribution of hypoxia seen on 18F-FMISO is correlated spatially and quantitatively with the amount of leaky neovasculature seen on T1Gd. METHODS A total of 24 patients with glioblastoma underwent T1Gd, T2, and 18F-FMISO-11 studies preceded surgical resection or biopsy, 7 followed surgery and preceded radiation therapy, and 11 followed radiation therapy. Abnormal regions seen on the MRI scan were segmented, including the necrotic center (T0), the region of abnormal blood-brain barrier associated with disrupted vasculature (T1Gd), and infiltrating tumor cells and edema (T2). The 18F-FMISO images were scaled to the blood 18F-FMISO activity to create tumor-to-blood ratio (T/B) images. The hypoxic volume (HV) was defined as the region with T/Bs greater than 1.2, and the maximum T/B (T/Bmax) was determined by the voxel with the greatest T/B value. RESULTS The HV generally occupied a region straddling the outer edge of the T1Gd abnormality and into the T2. A significant correlation between HV and the volume of the T1Gd abnormality that relied on the existence of a large outlier was observed. However, there was consistent correlation between surface areas of all MRI-defined regions and the surface area of the HV. The T/Bmax, typically located within the T1Gd region, was independent of the MRI-defined tumor size. Univariate survival analysis found the most significant predictors of survival to be HV, surface area of HV, surface area of T1Gd, and T/Bmax. CONCLUSION Hypoxia may drive the peripheral growth of glioblastomas. This conclusion supports the spatial link between the volumes and surface areas of the hypoxic and MRI regions; the magnitude of hypoxia, T/Bmax, remains independent of size.
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Affiliation(s)
- Kristin R Swanson
- Department of Pathology, University of Washington, Seattle, Washington 98195, USA.
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Spence AM, Muzi M, Swanson KR, O'Sullivan F, Rockhill JK, Rajendran JG, Adamsen TCH, Link JM, Swanson PE, Yagle KJ, Rostomily RC, Silbergeld DL, Krohn KA. Regional hypoxia in glioblastoma multiforme quantified with [18F]fluoromisonidazole positron emission tomography before radiotherapy: correlation with time to progression and survival. Clin Cancer Res 2008; 14:2623-30. [PMID: 18451225 DOI: 10.1158/1078-0432.ccr-07-4995] [Citation(s) in RCA: 209] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE Hypoxia is associated with resistance to radiotherapy and chemotherapy and activates transcription factors that support cell survival and migration. We measured the volume of hypoxic tumor and the maximum level of hypoxia in glioblastoma multiforme before radiotherapy with [(18)F]fluoromisonidazole positron emission tomography to assess their impact on time to progression (TTP) or survival. EXPERIMENTAL DESIGN Twenty-two patients were studied before biopsy or between resection and starting radiotherapy. Each had a 20-minute emission scan 2 hours after i.v. injection of 7 mCi of [(18)F]fluoromisonidazole. Venous blood samples taken during imaging were used to create tissue to blood concentration (T/B) ratios. The volume of tumor with T/B values above 1.2 defined the hypoxic volume (HV). Maximum T/B values (T/B(max)) were determined from the pixel with the highest uptake. RESULTS Kaplan-Meier plots showed shorter TTP and survival in patients whose tumors contained HVs or tumor T/B(max) ratios greater than the median (P < or = 0.001). In univariate analyses, greater HV or tumor T/B(max) were associated with shorter TTP or survival (P < 0.002). Multivariate analyses for survival and TTP against the covariates HV (or T/B(max)), magnetic resonance imaging (MRI) T1Gd volume, age, and Karnovsky performance score reached significance only for HV (or T/B(max); P < 0.03). CONCLUSIONS The volume and intensity of hypoxia in glioblastoma multiforme before radiotherapy are strongly associated with poorer TTP and survival. This type of imaging could be integrated into new treatment strategies to target hypoxia more aggressively in glioblastoma multiforme and could be applied to assess the treatment outcomes.
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Affiliation(s)
- Alexander M Spence
- Department of Neurology, University of Washington, Seattle, Washington 98195, USA.
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Abstract
Hypoxia, a condition of insufficient O2 to support metabolism, occurs when the vascular supply is interrupted, as in stroke or myocardial infarction, or when a tumor outgrows its vascular supply. When otherwise healthy tissues lose their O2 supply acutely, the cells usually die, whereas when cells gradually become hypoxic, they adapt by up-regulating the production of numerous proteins that promote their survival. These proteins slow the rate of growth, switch the mitochondria to glycolysis, stimulate growth of new vasculature, inhibit apoptosis, and promote metastatic spread. The consequence of these changes is that patients with hypoxic tumors invariably experience poor outcome to treatment. This has led the molecular imaging community to develop assays for hypoxia in patients, including regional measurements from O2 electrodes placed under CT guidance, several nuclear medicine approaches with imaging agents that accumulate with an inverse relationship to O2, MRI methods that measure either oxygenation directly or lactate production as a consequence of hypoxia, and optical methods with NIR and bioluminescence. The advantages and disadvantages of these approaches are reviewed, along with the individual strategies for validating different imaging methods. Ultimately the proof of value is in the clinical performance to predict outcome, select an appropriate cohort of patients to benefit from a hypoxia-directed treatment, or plan radiation fields that result in better local control. Hypoxia imaging in support of molecular medicine has become an important success story over the last decade and provides a model and some important lessons for development of new molecular imaging probes or techniques.
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Affiliation(s)
- Kenneth A Krohn
- Department of Radiology, University of Washington, Seattle, Washington 98195-6004, USA.
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