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CHAPTER THIRTEEN
Image-guided cancer immunotherapy
Thomas S.C. Ng
a
Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
b
Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
a,b
and Miles A. Miller
a,b
Contents
1. Introduction 427
2. Clinically relevant imaging modalities to assess anatomic and functional tumor response 428
3. Imaging approaches to probe the immune system 430
3.1 Labeling of immune cells for imaging 430
3.2 Imaging metabolic pathways 432
4. Imaging targets for immunotherapy 432
4.1 Immune checkpoint inhibition 432
5. Imaging of other immune targets 442
6. Imaging immune cellular subsets 442
6.1 Dendritic cells 443
6.2 Monocytes/macrophages 444
6.3 Natural killer cells 447
6.4 B-cells 448
6.5 T-cells 448
6.6 Adoptively transferred T-cell imaging 451
7. Imaging to guide bispecific T-cell engager therapy (BiTE) 454
8. Image-guided interventional immunotherapies 454
9. Summary and future directions 456
References 456
1. Introduction
Multiple promising cancer immunotherapy modalities are being used for patient
care [1] and many more are in clinical development [2, 3]. Effective clinical implementation of these therapies requires methods to evaluate their longitudinal tumor treatment
response in patients. Furthermore, questions remain regarding mechanistic details of the
different cancer immunotherapies in humans, including: Where and when do cell-based
immunotherapies traffic? Are they activated to act at the desired target site? How do we
best assess and predict treatment efficacy in patients? What is the optimal therapy regimen
to maximize the tumor immune response?
Engineering Technologies and Clinical Translation Copyright © 2022 Elsevier Inc.
All rights reserved.https://doi.org/10.1016/B978-0-323-90949-5.00013-9
427
428 Thomas S.C. Ng and Miles A. Miller
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Clinically relevant imaging modalities have and will continue to play a vital role in
addressing these questions [4]. Here, we outline imaging approaches used to evaluate
the different classes of cancer immunotherapies currently in the clinic and development
[5]. While optical molecular imaging approaches are widely used in basic and preclinical
studies to assess immunotherapies, we focus on imaging modalities that likely will have
direct translational potential for clinical use [6]. We first describe the imaging modalities
commonly adopted for therapeutic assessment and outline general approaches for
immune cell detection. We then describe progress made in developing tools to image
specific aspects of the innate and adaptive immune system. Finally, we review interventional image-guided approaches that may be useful for the directed delivery of specific
immunotherapies.
2. Clinically relevant imaging modalities to assess anatomic
and functional tumor response
Tumor size response assessment is the mainstay for determining cancer therapy efficacy [7, 8]. Changes in tumor size, as depicted by X-ray computed tomography (CT) and
magnetic resonance imaging (MRI), are essential in routine cancer treatment monitoring
(Table 1). CT is the current workhorse in clinical radiology, provides anatomic detail,
and can be performed quickly in a relatively cost-effective manner. Additional functional
and metabolic details can be obtained using intravenous contrast [9] and dual-energy
detection [10]. MRI complements CT by providing superior soft-tissue contrast [11].
Table 1 Imaging modalities for cancer immunotherapies.
Current
Ionizing
Modality
Computed tomography
(CT)
Magnetic resonance
imaging (MRI)
Positron emission
tomography (PET)
Cerenkov imaging Yes + No Yes +
Single photon emission
computed
tomography
(SPECT)
Optical imaging No +++++ Yes Yes +
Bioluminescence No ++ No Yes +
radiation?
Yes ++++ Yes Yes, enabled with
No +++ Yes Yes, enabled with
Yes + No Yes +++
Yes + No Yes +++
Spatial
resolution
Anatomical
information? Functional information?
contrast agents
contrast agents,
hyperpolarized
agents
clinical
use
+++
+++
Different imaging sequences can be applied to accentuate different types of imaging contrast, for example using fat suppression to characterize the fat content of lesions [12] or
diffusion MRI to evaluate tumor cellularity [13]. Different types of intravenous contrast
can also be combined with appropriately timed imaging sequences to characterize lesions
[14]. For example, since gadoxetic acid is taken up and excreted in delayed phases via the
normal hepatobiliary pathway, it is routinely used clinically to evaluate hepatic metastases, which do not retain the contrast agent [15]. However, although whole-body MRI
screening protocols are being explored, given the relative complexity of MRI imaging
sequences, longer imaging time required (especially given its low sensitivity), and its relatively high cost, most MRI imaging applications remain tailored for specific imaging
applications. Developments in compressed sensing [16] and hyperpolarized MRI tech-
nologies [17] may offset these limitations but are not yet implemented for routine
clinical use.
Scintigraphic imaging using ionizing radiation provides a highly sensitive assay for
in vivo imaging. Radioisotopes can be linked to physiologic probes of interest, including
small molecule drugs and antibodies, and imaged using single-photon electronic computed tomography (SPECT) or positron emission tomography (PET). Given the high
sensitivity of these modalities, tracer amounts (nanomolar) of the agents are needed
for imaging and do not significantly interfere with the probed physiological processes.
18F-fluorodeoxyglucose (FDG) PET is widely used in clinical oncologic imaging to
measure metabolically active tumor burden [18]. While very sensitive for metabolically
active disease, high uptake can also be seen in active inflammation, including demonstrating the presence of metabolically active immune cells, thus reducing its specificity. This
issue has prompted the development of more specific targeting agents [19], as outlined
below. Combinations of SPECT and PET with CT [20] and/or MRI [21] are now routinely used to provide functional and quantitative information within the context of a
patient’s anatomy. The advent of highly sensitive total body PET/CT systems will allow
further improved sensitivity to lower radioactivity doses, potentially allowing for monitoring immune cells and processes for longer timepoints than is currently possible [22].
At present, optical and bioluminescence imaging are primarily used for preclinical and
basic science inquiry, but some clinical applications are being explored [23]. For example,
Cerenkov luminescence systems are being developed to exploit Cerenkov radiation
emitted from many commonly used radioisotopes [24] and may have clinical potential,
especially in the intraoperative setting [25–27]. Surface-enhanced Raman spectroscopy
(SERS) using SERS-activated nanomaterials have been tested for multiplexed in vitro and
in vivo monitoring of immune signatures and cellular subsets [28]. Optically labeled agents
are also being explored for use in endoscopic and intraoperative applications [29] or
assessment of immune populations in blood samples or tissue biopsies [30]. Magnetic particle imaging may also be a promising approach for cell tracking [31] but remains currently in the preclinical stage.
429Image-guided cancer immunotherapy
430 Thomas S.C. Ng and Miles A. Miller
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3. Imaging approaches to probe the immune system
3.1 Labeling of immune cells for imaging
Understanding the spatial-temporal dynamics of immune cells remains a challenge, especially in patients. Imaging can address this aim by labeling immune cell populations and
monitoring them in vivo (Fig. 1) [32–34]. Imageable probes can be taken up by immune
cells and allow direct monitoring of cellular populations. Many of these probes rely on the
phagocytic or endocytic properties of immune cells. Agents in this class have been developed for optical imaging, Cerenkov luminescence imaging, MRI, and nuclear imaging.
While this approach is relatively straightforward, dilution of the signal from parental cell
division, or loss of specificity resulting from phagocytosis from native macrophages or
other cell populations, may preclude long-term immune cell monitoring. Reporter gene
technologies may be a solution to these issues and have also been explored for cell tracking
[35]. Several studies demonstrate its potential in humans [36]. With this approach, a gene
expressing a protein that is not naturally present in the cell or tissue of interest is expressed,
such as a fluorescent protein or iron-binding protein, in which case direct optical or MRI
imaging of the cells can be performed, respectively. Precise delivery and expression of these
constructs are enhanced with new molecular biology techniques such as CRISPR-Cas
[37]. Companion imaging probes labeled with radioisotopes targeting the expressed
protein or activated by the cell-expressed enzyme (in the case of luciferin for bioluminescence) can then be applied for specific imaging. One recent approach was reported by
Shapiro et al., which over-expressed aquaporin receptors in the cells of interest, allowing
their image localization using diffusion MRI imaging without a companion probe [38].
Compared to other approaches, the imageable signal from gene reporters ostensibly does
not dilute over time. However, the immunogenicity and transduction efficacy of the gene
reporter needs to be considered when translating to patients.
An alternative approach to imaging the immune system involves targeting specific
endogenous receptor expression of immune cell subsets [39]. Probes based on antibodies,
antibody fragments (including minibodies and nanobodies), surface coated nanoparticles
[40], and tumor-targeting peptides [41] can be developed with excellent specificity for
cell-specific receptors [19]. Much work has been done to tune the pharmacokinetics
of these agents for optimal blood circulation and excretion times, allowing their pairing
with radioisotopes with commensurate radioactive half-lives. However, translation of
these probes may be limited by the extensive work required to develop a highly specific
probe for the target of interest, and binding properties (of both intended and unintended
targets) of these agents may preclude appropriate labeling of all the cells of interest for
imaging. For example, using intravital imaging, Arlauckas et al. observed that antiPD1 antibody binding on PD1+ T-cell targets could be relatively short (hours) before
being transferred to tumor-associated macrophages (TAM) [42]. This process was found
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