Recommandations de Swiss Memory Clinics pour le diagnostic des démences

Résumé. Le diagnostic précoce des atteintes cognitives, ressenties subjectivement ou rapportées par un tiers, est essentiel pour détecter des maladies neurodégénératives ou exclure des causes traitables telles que des pathologies de médecine interne, neurologiques ou psychiatriques. C’est la seule façon de garantir un traitement anticipé. Dans le cadre du projet 3.1 de la stratégie nationale en matière de démences 2014–2019 («Mise en place et extension d’un réseau de centres de compétences régionaux pour le diagnostic»), l’association Swiss Memory Clinics (SMC) s’est fixé pour objectif d’améliorer les normes de qualité en matière de diagnostic des démences et de soins de proximité dans ce domaine. Ces recommandations contiennent des directives d’ordre général sur le diagnostic et les différentes possibilités d’examens, et proposent des normes pour les procédures à appliquer. Elles expliquent en détail les différents éléments du diagnostic standard, tels que l’anamnèse, l’examen clinique, l’analyse de laboratoire, les tests neuropsychologiques et les procédures neuroradiologiques, et présentent des examens complémentaires pouvant alimenter les réflexions sur le diagnostic différentiel. Les principaux objectifs des recommandations SMC pour le diagnostic des démences sont les suivants: assurer l’accès à un diagnostic de haute qualité à un maximum de personnes atteintes, améliorer le diagnostic précoce de la démence, ainsi que proposer aux médecins de premier recours et aux collaborateurs de Memory Clinics un outil d’investigations diagnostiques utile.

Die Empfehlungen der Swiss Memory Clinics für die Diagnostik der Demenzerkrankungen

Zusammenfassung. Die Frühdiagnostik subjektiv wahrgenommener oder fremdanamnestisch beobachteter kognitiver Beeinträchtigungen ist essenziell, um neurodegenerative Erkrankungen nachzuweisen oder behandelbare Ursachen wie internistische, neurologische oder psychiatrische Störungen auszuschliessen. Nur dadurch wird eine frühzeitige Behandlung ermöglicht. Im Rahmen des Projekts 3.1 der Nationalen Demenzstrategie 2014–2019 («Auf- und Ausbau regionaler und vernetzter Kompetenzzentren für die Diagnostik») hat sich der Verein Swiss Memory Clinics (SMC) zum Ziel gesetzt, Qualitätsstandards für die Demenzabklärung zu entwickeln und die wohnortsnahe Versorgung in diesem Bereich zu verbessern. In den vorliegenden Empfehlungen werden allgemeine Richtlinien der Diagnostik und einzelne Untersuchungsmöglichkeiten vorgestellt, sowie Standards für die diesbezüglichen Abläufe vorgeschlagen. Einzelne Bereiche wie Anamneseerhebung, klinische Untersuchung, Laborparameter, neuropsychologische Testung und neuroradiologische Verfahren werden als Teil der Standarddiagnostik ausführlich diskutiert, ergänzende Untersuchungsmethoden für differenzialdiagnostische Überlegungen abgebildet. Die wichtigsten Ziele der SMC-Empfehlungen zur Diagnostik der Demenzerkrankungen sind, möglichst allen Betroffenen Zugang zu einer qualitativ hochstehenden Diagnostik zu ermöglichen, die Frühdiagnostik der Demenz zu verbessern und den Grundversorgern sowie den Mitarbeitenden der Memory Clinics ein nützliches Instrument für die Abklärung anzubieten.

Effects of antifolate drugs on the cellular uptake of radiofolates in vitro and in vivo

Targeting the folate receptor (alpha-FR) with radiolabeled folates for the noninvasive diagnosis and therapy of alpha-FR-overexpressing neoplastic tissue is of great interest. However, the tumor uptake of folate-based radiotracers was shown to be low compared with the high renal retention of radioactivity attributable to alpha-FR expression in the proximal tubule cells. In order to increase the tumor uptake of radiofolates, we wanted to stimulate alpha-FR expression or transport through coapplication of the antifolates methotrexate (MTX), raltitrexed (RTX), and pemetrexed (PMX).

METHODS

(99m)Tc-picolylamine monoacetic acid folate ((99m)Tc-PAMA-folate) was used for these studies. The in vitro experiments with antifolates were performed with alpha-FR-positive KB cancer cells. In vivo experiments were performed with KB tumor-bearing athymic nude mice. In vivo images were acquired with a small-animal SPECT/CT scanner.

RESULTS

KB cells incubated with solutions (10 micro mol/L) of MTX, RTX, or PMX for 24 h displayed twice as much (99m)Tc-PAMA-folate uptake as untreated cells. In contrast, KB tumor-bearing mice that received MTX intravenously 24 h before (99m)Tc-PAMA-folate showed significantly lower uptake of the radiofolate in tumors (1.35 +/- 0.33 percentage injected dose per gram of tissue [%ID/g] [mean +/- SD]) and the alpha-FR-positive kidneys (9.35 +/- 1.73 %ID/g) than did control mice (2.33 +/- 0.36 and 18.48 +/- 0.72 %ID/g, respectively, at 4 h after injection). When the antifolate PMX and (99m)Tc-PAMA-folate were injected 1 h apart, the tumor uptake of the radiotracer was unaffected (2.21 +/- 0.34 %ID/g at 4 h after injection), whereas radioactivity in the kidneys was significantly decreased (1.14 +/- 0.18 %ID/g at 4 h after injection). In vivo SPECT/CT studies demonstrated the specific accumulation of (99m)Tc-PAMA-folate in tumors and almost a complete absence of radioactivity in the renal tissue of mice preinjected with PMX.

CONCLUSION

Our data suggest that the preadministration of antifolates improves tumor-to-kidney ratios of radiofolates and opens a "therapeutic window" for folates radiolabeled with particle-emitting nuclides, which could otherwise be nephrotoxic.

Synthesis and preclinical evaluation of a folic acid derivative labeled with 18F for PET imaging of folate receptor-positive tumors

Folic acid was linked regioselectively through its alpha- and gamma-carboxyl groups to 4-fluorobenzylamine (FBA), and the alpha- and gamma-FBA-folate regioisomers were evaluated for their ability to bind to folate receptor-positive cells. The 18F-labeled alpha/gamma-FBA-folate counterpart was examined for in vivo tumor targeting efficiency in nude mice bearing folate receptor-positive tumor cells.

METHODS

18F-alpha/gamma-FBA-folate was prepared in a 4-step reaction sequence starting from folic acid. The relative binding affinities of the alpha- and gamma-FBA-folates to the folate receptor with respect to parent folic acid were determined in cultured KB-31 cells (nasopharyngeal epidermal carcinoma cell line) overexpressing the folate receptor using 3H-folic acid. Tumor accumulation of the 18F-labeled alpha/gamma-FBA-folate and 18F-FDG was analyzed in vivo by high-resolution PET. Biodistribution and PET studies were performed under baseline and blockage conditions.

RESULTS

The radiochemical yield of the coupling step ranged from 15% to 44%, and the maximum specific radioactivity was 24 GBq/micromol. The in vitro binding affinities of the alpha- and gamma-isomers and folic acid were 71, 62, and 41 nmol/L, respectively. PET revealed heterogeneous uptake of the radioligand, with the highest activity concentrations found in the tumor rim. In contrast, 18F-FDG uptake in a nude mouse bearing KB-31 folate receptor-positive tumors was negligible. Radioligand uptake in tumors at 125 min after injection amounted to 6.56% of the injected dose per gram of tissue (%ID/g) in control animals, whereas radioactivity accumulation in the tumors of folic acid-treated animals was significantly reduced by more than 80%-to 1.07 %ID/g (P = 0.001).

CONCLUSION

This new 18F-labeled folic acid derivative is a promising tool for PET imaging of folate receptor-positive tumors.

Dynamic imaging of striatal D2 receptors in mice using quad-HIDAC PET

The novel, dedicated small animal PET tomograph, quad-HIDAC, offers submillimeter resolution in instrumental characterization experiments. The aim of this study was to establish the tomograph's utility in a biologic application and to demonstrate the feasibility of rapid dynamic neuroreceptor imaging in mice.

METHODS

We used the well-established, high-affinity dopamine D(2) receptor PET ligand (18)F-fallypride for imaging striatal D(2) receptors in NMRI mice. Dynamic PET data were acquired using the quad-HIDAC tomograph and subject to 2 different kinetic modeling approaches. The cerebellum, a brain region devoid of D(2) receptors, was chosen as a reference region for kinetic modeling.

RESULTS

The resolution of the quad-HIDAC camera allowed clear visualization of the left and right mouse striatum with high target-to-nontarget signal ratios. The sensitivity of the tomograph permitted the generation of time-activity curves with initial time frames of 120 s. PET experiments acquiring data for 150 min demonstrated that the binding potential of (18)F-fallypride could be fitted robustly with both reference tissue models for scan durations of >or=40 min. Voxel-wise modeling resulted in parametric maps of high quality. The values for the binding potential in the striatum reached approximately 14, consistent with striatum-to-cerebellum ratios extracted from regional time-activity curves. Comparison of in vivo PET imaging results with ex vivo postmortem tissue sampling analyses indicated discrepancies in signal intensity, possibly resulting from scatter and random background in the cerebellum region of interest and leading to an overestimation of cerebellar activity concentrations and degradation of striatum-to-cerebellum ratios in PET experiments. Intraperitoneal injection of the unlabeled D(2) receptor antagonist haloperidol 30 min before intravenous injection of (18)F-fallypride blocked tracer accumulation in the striatum by >95%.

CONCLUSION

The quad-HIDAC camera represents a powerful tool for future dynamic neuroreceptor PET studies in mice and rats under numerous pharmacologic or pathophysiologic conditions.

PET imaging of dopamine transporters in the human brain using [(11)C]-beta-CPPIT, a cocaine derivative lacking the 2 beta-ester function

The compound 3 beta-(4'-chlorophenyl)-2 beta-(3'-phenylisoxazol-5'-yl)tropane (CPPIT or RTI 177) is a 2beta-heterocyclic substituted cocaine congener with high in vitro selectivity and affinity for the dopamine transporter relative to serotonin and norepinephrine transporters. The aim of the present study was to evaluate the in vivo selectivity of [(11)C]-beta-CPPIT and to determine whether [(11)C]-beta-CPPIT may be a suitable alternative to existing DAT PET radioligands. [(11)C]-beta-CPPIT was prepared by N-alkylation of the free amine with [(11)C]methyl iodide. In mouse brain, the striatal binding of [(11)C]-beta-CPPIT was reduced significantly by preinjecting the dopamine reuptake antagonist GBR 12909 (5 mg/kg). By contrast, radioactivity uptake in the brain was not affected significantly by the preinjection of citalopram (5 mg/kg) and desipramine (5 mg/kg), inhibitors for the serotonin and norepinephrine transporters, respectively. No effect was also observed by pretreatment with ketanserin (2.5 mg/kg) a compound with high affinity for the 5-HT(2A)-receptor and the vesicular monoamine transporter. In a PET study with six healthy volunteers high striatal uptake was observed. The distribution pattern of [(11)C]-beta-CPPIT was similar to the known distribution of the dopamine transporter in the human brain. Compared to (123)I labeled beta-CIT, the rate of metabolic degradation of [(11)C]-beta-CPPIT was almost twofold slower suggesting that bioisosteric heterocyclic substitution of the ester group at the 2 beta-position of the tropane ring does have an influence on the rate of metabolism of [(11)C]-beta-CPPIT. The rank order of the distribution volumes obtained via the one-tissue compartment model is also similar to the reported distribution of DAT. These preliminary results suggest that [(11)C]-beta-CPPIT may be a useful PET radioligand for the visualization and quantification of dopamine transporters in man.

Radiopharmaceuticals for Targeted Tumor Diagnosis and Therapy

Radiopharmaceutical research and development is carried out by the Center for Radiopharmaceutical Science as part of the PSI Life Science Department, the Department of Applied BioSciences at the Swiss Federal Institute of Technology Zürich and the University Hospital Zürich. The common theme is the search for radioactive-labeled tracer molecules, which bind to specific targets in the body. Such radiopharmaceuticals are applied either systemically into the blood stream or locally to patients. Due to their specific molecular binding properties combined with the emitted radiation, they can be used for non-invasive imaging of tumors and the destruction of tumor cells. In this first of two articles, we will present exemplified topics from the research activities of the groups involved with tumor targeting.

[Determination of three body compartments in the chest by scintigraphy]

We adapted a previously described method for the measurement of transthoracic tissue thickness and volumes of blood and interstitial tissue. This non-invasive procedure can be performed safely and by relatively simple means. We used a gamma camera and 99mTc to obtain transmission and emission scintigrams. A computer program written for a personal computer, can recognize the borders of the lung in a fully automatic manner and do the necessary calculations. Clinical studies show significantly higher interstitial volumes of the lung in patients with chronic pulmonary sarcoidosis.

Die szintigraphische Messung dreier Körperkompartimente im Thoraxbereich

Anhand von Literaturhinweisen wurde ein vollautomatisiertes Verfahren zur Messung der Dicken von drei Lungenkompartimenten entsprechend unserer Gerätekonfiguration eingeführt. Es handelt sich um eine nichtinvasive, schnell und mit relativ einfachen Mitteln durchzuführende szintigraphische Methode, die auf einem Personal Computer mit kommerziell erhältlicher Software realisiert werden kann. Als Berechnungsgrundlage der Meßgrößen (totale absorbierende Gewebedicke, Dicke des intravasalen und des interstitiellen Kompartiments) dient eine kombinierte Transmissions/Emissionsszintigraphie der Lunge. Zur Bildauswertung wurde ein Computerprogramm geschrieben, das in der Lage ist, die Lungengrenzen auf dem Transmissionsbild zu erkennen und diese unter Korrektur von allfälligen Positionsänderungen des Patienten auf weitere, während der Untersuchung erstellte Bilder zu übertragen. Klinische Untersuchungen zeigen, daß die Dicken in einzelnen Lungenkompartimenten krankheitsspezifische Abweichungen gegenüber der Norm aufweisen.