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results were not optimal as the study reported no signicant differences in P2X7 receptor binding between the two groups; consequently, it was not tested anymore in AD patients [80]. In the eld of monoamine oxidases (MAO), developing radio­tracers with afnity for only B isoform has proven challenging. [11C]L-deprenyl, the radiolabelled L-deprenyl (selegiline)—a MAO-B inhibitor— was rst used in human clinical applications [81]. Nevertheless, because of the irreversible nature of the binding that limits quantitative stud­ies, a deuterium analogue, [11C]L-deprenyl-D2, with more favourable pharmacokinetics, has been developed and it is now considered the bet­ter MAO-B radioligand [82, 83]. As a part of the inammation mechanisms, arachidonic acid (AA) has been tested as a target for invivo PET studies using the radiolabelled AA itself,[11C] AA.However, the involvement in several func­tions does not make its altered bindings easily interpretable [84–86]. The only applied PET radioligand for COX is [11C]ketoprofen and its methyl ester, which binds selectively to COX-1 [87]. In a study, the authors concluded that it can­not be useful as a potential diagnostic biomarker for MCI/AD [87]. Regardingcox-2, none of the tested radiotracers has been considered to be use­ful for the study of neuroinammation [88, 89].
Acknowledgements We thank Prof. Daniela Perani from Vita-Salute University of Milan and her research group for the remarkable work on the knowledge of neurodegen­erative diseases, for mentoring so many nuclear medicine physicians and for advising us on how to dene clinical case research for this chapter.
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Hypoxia Pathway: 18F-FAZA
https://t.me/med1917
PierpaoloAlongi, PaolaMapelli, ViolaVultaggio, AnnachiaraArnone, andMariaPicchio
20
20.1 Introduction
Hypoxia plays a crucial role in various cellular events, including proliferation, survival, angio­genesis, immuno-surveillance, metabolism, as well as in tumour invasion and metastasis [1, 2]. In the eld of the tumorigenesis, the rapid growth exceeding the vascular supply and the need for oxygen as an energy substrate determine a poorly vascularized microenvironment in which hypoxia and acidosis, as well as the lack of nutri­ents, take place [3, 4]. Tumours react to this hos­tile system through a series of compensatory mechanisms: turning to a glycolytic metabolism, expressing various growth factors (e.g. EGF, insulin, IGF-1, IGF-2, and PDGF, known to pro­mote cell proliferation), producing a number of angiogenic factors that promote blood vessel formation (e.g. VEGF, IL-8, angiogenin, FGF, and PDGF), secreting various immunosuppres-
P. Alongi (*) · V. Vultaggio Nuclear Medicine Unit, A.R.N.A.S.Ospedale Civico Di Cristina Benfratelli, Palermo, Italy
P. Mapelli · M. Picchio Vita-Salute San Raffaele University, Milan, Italy
Nuclear Medicine Department, IRCCS San Raffaele Scientic Institute, Milan, Italy
picchio.maria@hsr.it
e-mail: A. Arnone
Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Florence, Italy
sive factors by hypoxia-inducible factor (HIF)­dependent or -independent pathways aiming to escape immune surveillance [5–9]. In the role of one of the most pervasive microenvironmental stresses that can impact the cancer progression, hypoxia can be recognized in almost every solid tumour and be widely considered as a potential reason of treatment failure and poor outcome for a variety of malignancies and consequently needs to be taken into account during the evalu­ation of prognostic and therapeutic options for cancer patients [10–12].
This chapter will describe the current knowl­edge on technical procedures of radiosynthesis, features of biodistribution, and current research on potential clinical application of 18F-FAZA PET as a radiopharmaceutical agent able to assess the hypoxia expression in neoplastic cells.
20.2 Synthesis
The overall radiosynthesis time of 18F-FAZA is about 70 min. After, quality controls are per­formed to determine the chemical, radiochemi­cal, and radionuclidic purity of the nal product [13].
The nucleophilic substitution reaction of no­carrier- added 18F-uoride with 1-(2,3-di-O-
acetyl-5-O-tosyl-d-arabinofuranosyl)-2­nitroimidazole as precursor has to be performed
[14]. 18F-uoride has to be produced using a
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cyclotron for irradiation of approximately 2mL of enriched 18O water through the 18O(p,n) 18F nuclear reaction. The radiosynthesis of 18F-FAZA is automatically performed with a synthesis mod­ule. In the rst step of the synthesis, 18F-uoride is separated from 18O water using an anion exchange cartridge. To elute the 18F-uoride absorbed on the resin, a mixture of 0.5mL of a solution of K2CO3 in water (6mg/mL) and 1mL of Kryptox 222 (20mg/mL; Merck) in CH3CN was used. The solution in the reactor is then dried under vacuum at 60 °C for 5 min and then at 120°C for another 5min. Labelling is carried out using 5mg of the precursor dissolved in 1mL of anhydrous dimethyl sulfoxide under stirring at 100°C for 5min. To remove acetyl groups, basic hydrolysis is achieved with 1mL of 0.1N NaOH at 35°C in about 2 min. Neutralization is per­formed by adding 0.5 mL of 0.5 N aqueous NaH2PO4. The reaction mixture has to be com­bined with 2 mL of high-performance liquid chromatography eluent (H2O:EtOH 98:2 [v/v]) and then passed through an Al2O3 cartridge (Waters), where unreacted uorine was adsorbed. Then, the mixture is injected into a semiprepara­tive high-performance liquid chromatography column to separate the reaction product from other impurities. At a ow rate of 4mL/min, the product has a retention time of about 34 min, detected with an ultraviolet detector in series with a Geiger–Müller radiodetector. The col­lected radiopharmaceutical has to be ltered using a 0.22-μm sterile lter and then diluted with 0.9% NaCl in order to have 12mL.
18
F-FAZA is obtained with an overall radiochemical yield of 20–25% (not decay-corrected), radiochemical purity of more than 99%, and specic activity of more than 37GBq/μmol [14].
sumption (steady state) and (2) modelling of tracer diffusion and retention depending on its specic diffusion and clearance properties as well as the previously simulated oxygen distribu­tions [15].
Oxygen distribution is described as the steady state of oxygen diffusion and consumption, as each pixel on the vessel map was regarded as a separate oxygen source of a size of approxi­mately 2.5×2.5μm2 and thus much smaller than the distance of hypoxic regions from the vessels, this was judged to be a valid approximation. Therefore, if the initial pO2 distribution is known, pure diffusion at any point in time can be deter­mined by convolving the initial oxygen distribu­tion with the diffusion kernel. The parameters considered are clearance rate, tracer retention in viable hypoxic tissue areas, in fact variations in the vascularization patterns of tissue sections with the same median pO2 can affect overall tracer retention in that section. Tracer uptake in hypoxic cell culture suggests nitroreductase afnity for FAZA; however, overall activity is lower for FAZA than for other hypoxia PET trac­ers in pre-clinical studies, indicating that mecha­nisms other than enzyme activity, such as tracer clearance and diffusion, are responsible for this observation.
Pharmacokinetic analysis of 18F-FAZA dynamic PET imaging acquisitions have also been used to discriminate different tumour pro­les through visual imaging and quantication of blood and tumour time–activity curves, as evi­denced by Provost etal. In this work, the interval between injection and image acquisition nor­mally ranges from 2 to 4h, considered the best time to capture images and a compromise between radiopharmaceutical accumulation in hypoxic cells and clearance from the blood [
16].
20.3 Pharmacokinetics
Dedicated hypoxia PET tracers are bound to cells depending on the local oxygen concentration. Therefore, to simulate hypoxia PET signals, a two-step process can be used: (1) Simulation of the diffusive oxygen supply from blood vessels that is in equilibrium with cellular oxygen con-
20.4 Physiological Distribution
Preliminary biodistribution data are indicative of the potential utility of FAZA for studies of hypoxia in oncology and other pathologies. Its lower lipophilicity may produce higher tissue perfusion and more rapid clearance from blood,
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thereby providing higher hypoxia (tissue):blood differentials at short time intervals after injection that are more compatible with the relatively short half-life of 18F (109 min). Blood clearance is characterized by a rapid distribution followed by rst-order elimination [13].
The highest uptake is in muscle and liver and the critical organ, with the highest absorbed radi­ation doses, is the urinary bladder wall, because radioactivity is excreted through the kidneys, with a fast clearance and hepatic metabolism, so clearance is therefore also dependent on patient kidney function and may hence affect the suit­ability or patients treated with (concurrent) neph­rotoxic systemic agents. This adds variability to the total rate at which the tracer is cleared from the system, resulting in larger absolute ranges of clearance rates [15].
20.5 PET/CT Acquisition Protocols
andImage Interpretation
The acquisition protocol of 18F-FAZA PET/CT scans usually starts 120min after the injection of approximately 370 MBq of radiotracer and includes the acquisition of PET images in 3D mode and CT images used for attenuation correc­tion [17]. Regarding scan acquisition time, some authors investigated the possibility to acquire images at different time points. Available data suggest that the image quality that is gained at 120min is almost the same as for later acquisi­tions and it is higher compared to images acquired less than 120min [ differences between the biodistribution at 1, 2, and 4h after injection are reported.
PET/CT images performed to assess hypoxia usually rely on the measurement of tumour-to­background (T/B) or tumour-to-muscle (T/M) ratio in order to dene the hypoxic fraction within a tumour. In particular, the majority of published literature use a threshold varying between 1.2 and 1.4 to dene hypoxic fraction, regardless of the adopted radiotracer or the types of investi­gated tumour [18, 19, 21–23]. Few data are cur­rently available regarding the different approaches used to evaluate hypoxic fraction. However, it
14, 18–20]. In Fig.20.1, the
has been reported that the T/M uptake ratio might be used as reliable alternative to T/B ratio in those situations where no great vessels (e.g. aorta) or the heart itself is included in the eld of view [17].
20.6 Clinical Indications
18
F-FAZA have shown very promising results in
different oncological clinical settings.
A potential application of hypoxia tracers with possible relevant impact on treatment decisions is related to the radiotherapy eld. In this scenario, Grosu et al. outlined the gross tumour volume (GTV) on 18F-FAZA PET in 17 patients with head and neck cancers [24]. The delineated GTV was obtained by applying a threshold of 50% with regard to background, leading to the inclu­sion of PET-positive areas with a T/M ratio≥1.5. Interestingly, in all cases GTV-FAZA was inside the GTV outlined on CT images, thus suggesting the feasibility of a dose-painting approach based on 18F-FAZA PET images.
Later on, Mortensen etal. investigated the role of 18F-FAZA PET in 40 head and neck cancer before and during radiotherapy [24]. In 63% of patients, PET showed a hypoxic volume with a median T/M of 1.5, having prognostic signi­cance; in fact, at a median follow-up of 19months patients with non-hypoxic tumours had a disease­free survival of 93%, compared to 60% observed in patients presenting hypoxic tumours [
An extremely interesting oncological clinical scenario of possible application of 18F-FAZA PET/CT is represented by gliomas. Several stud­ies have investigated the potentiality of this imag­ing technique in the assessment of hypoxic fraction within this aggressive brain tumours.
One of the largest cohorts investigating the role of 18F-FAZA for hypoxia assessment has been reported by Postema etal. who rstly evalu­ated the safety and general biodistribution of this radiotracer [18]. In a cohort of 50 patients with different types of cancers, including head and neck squamous cell carcinoma, small cell lung cancer (SCLC), non-SCLC, malignant lym­phoma, and high-grade gliomas, the authors
25].
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One-hour post injection
Two-hours post injection
Fig. 20.1 Biodistribution of 18F-FAZA at 1, 2, and 4h post-injection
reported a high uptake of 18F-FAZA in gliomas, with variable uptake in the remaining tumours.
Correlations between 18F FAZA and histologi­cal parameters assessing hypoxia have been recently reported. In a series of 17 patients with high-grade glioma, Mapelli et al. reported an inverse correlation between tumour vascularization, SUVmax, and SUVmean, thus suggesting that highly vascularized tumours might present more oxygen supply than hypoxia [17].
The same group reported the potentiality of
18
F-FAZA PET/CT in guiding tailored radiother­apy treatment in high-grade glioma. The possibil­ity to use an additional boost on the more hypoxic
regions by using 18F-FAZA PET images in a sim­ulated radiotherapy scheme has been reported, along with the possible use of this molecular imaging technique to assess tumour response after radiotherapy, with promising implications for clinical practice [26]. The authors also reported the ability of 18F-FAZA in guiding ste­reotactic biopsy by identifying the tumour areas with the highest aggressive potential, as dened by the higher degree of hypoxia. In this report, a co-registration between MRI and 18F-FAZA PET/ CT images has been performed and the areas with high-perfusion MRI markers and high
18
F-FAZA uptake have been identied to be most
representative regions to be sampled [21].
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a
Fig. 20.2 18F-FAZA PET/CT and MRI: Tumor Hypoxic evaluation in the suspicion of glioma
a
b
b
c
Fig. 20.3 18F-FAZA PET/CT: Tumor Hypoxic evaluation of lung lesion
20.7 Clinical Cases
Departments, Ospedale San Raffaele, Milan, Italy.
20.7.1 18F-FAZA PET/CT
inGlioblastoma
20.7.2 18F-FAZA inLung Cancer
See Fig.20.2.
Fifty-seven year-old patient who underwent a brain MRI scan for behavioural disorders and headache. A large edematous cystic necrotic enhancing frontal lesion suggestive for high­grade glioma is seen on MRI image (A: T1weighted image). In the suspicion of glioma, the patient underwent 18F-FAZA PET/CT to iden­tify tumour hypoxic regions, showing tracer uptake (hypoxic volume, 16.69) in the left frontal brain lesion (B: PET transaxial image; C: fused PET/CT transaxial image); a central photopenic area, corresponding to necrosis, has been also identied. Glioblastoma was conrmed at histol­ogy. From Database of Nuclear Medicine
See Fig.20.3.
A 76-year-old man underwent CT scan show­ing a pulmonary mass and ipsilateral hilar lymph adenopathy. 18F-FDG PET/CT performed to characterize the lung lesion and to stage the dis­ease showed intense uptake in correspondence of the right pulmonary lesion (A: transaxial PET/ CT). The patient underwent 18F-FAZA PET/CT as part of a clinical research protocol (EudraCT: 2011–002647-98).
18
F-FAZA PET/CT showed moderate hetero­geneous radiotracer uptake in correspondence of the right pulmonary lesion (B: transaxial PET/ CT). The lung mass presented a hypoxic volume
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a
b
Fig. 20.4 18F-FAZA PET/CT and 18F-FDG PET/CT: Tumor Hypoxic of brain metastasis of lung origin
(T/B ratio > 1.2) 115 cc. From Database of Nuclear Medicine Departments, Ospedale San Raffaele, Milan, Italy.
cd
e
(C: major intensity projection; D: transaxial PET/ CT) and of the pathological adenopathy (E: trans­axial PET/CT).
Images from database of Nuclear Medicine
Department, IRCCS San Raffaele Scientic
20.7.3 Cerebral Metastases
18
Identied by
F-FAZA PET/CT
Institute, Milan, Italy.
See Fig.20.4.
A 72-year-old patient presented severe neuro­logical symptoms and underwent a brain MRI scan showing a brain mass in the right parietal lobe, suggestive for high-grade glioma. The patient underwent 18F-FAZA PET/CT as part of a clinical protocol (EudraCT: 2015–000679-28). The scan showed 18F-FAZA with a photopenic area of necrosis (A: transaxial PET; B: transaxial PET/CT). The patient underwent surgical inter­vention; histological examination revealed a met­astatic lesion of a poorly differentiated carcinoma compatible with lung origin and immunohisto­chemical analysis related to hypoxic factors was performed. A CT scan was performed to identify the primary tumour and revealed a left lung mass with ipsilateral adenopathy. Disease staging was completed with 18f-FDG PET/CT scan showing tracer uptake in correspondence of the left lung
20.7.4 18F-FAZA PET/CT asaGuide forTumour Biopsy
Fig. 20.5.
A 77-year-old patient underwent brain MRI was admitted for progressive left leg hyperto­nia. MRI showed an enhancing, edematous lesion in the right basal ganglia and corona radiata on T1-weighted images (A), suggestive for high- grade glioma. The lesion also showed high values of transfer constant (b: yellow arrow). 18F-FAZA PET/CT was performed to assess tumour hypoxia and to identify the tumour regions more likely to be resistant to chemo and/or radiotherapy. 18F-FAZA PET images (C) showed uptake in correspondence of the brain lesion with a central photopenic area. A co-registration of MRI and 18F-FAZA PET/TC images was performed and an area of