[Radioimmunodetection of colorectal cancer, using anti-CEA monoclonal antibody CEA102: experience of 20 cases]

The monoclonal antibody CEA 102 against carcinoembryonic antigen was produced by immunization with purified CEA, and used as a radiotracer for the imaging of colorectal cancer. CEA102 was labeled with 131I by the chloramine-T or the Iodogen method, and administered i.v. to 20 patients with liver metastases, local recurrences, and/or primary tumors. Planar scintigraphy was performed during 5 or 6 postinfusion days. Hypersensitivity reactions such as fever and chill occurred in 4 patients, but no side effects were noted after endotoxin was excluded. Overall sensitivity was 71.4% (primary tumor 4/4, liver metastasis 5/6, lymph node metastasis 1/1, local recurrence 5/10), and no false positive was observed. In the cases of local recurrences, this method was useful to distinguish postoperative fibrosis from local recurrence. These results revealed that radiolabeled CEA102 has a great potential in qualitative diagnosis of colorectal cancer.

High resolution pinhole SPECT for tumor imaging

High-resolution, non-invasive, 3D-imaging techniques would greatly benefit the investigation of the localization properties of tumor-specific radiopharmaceuticals in laboratory animals. The present study reports how pinhole SPECT can be applied to tumor localization studies in small laboratory animals to provide high resolution SPECT images in vivo. Pinhole SPECT was performed using a rotating scintillation camera, equipped with a pinhole collimator. The sensitivity of a 2 mm diameter collimator at 45 mm from the source is 90 cps/MBq for 99mTc. The planar spatial resolution at a 45 mm distance is 2.2 mm. The transaxial spatial resolution, with a distance of 45 mm between the collimator aperture and the axis of rotation, is 3.1 mm. For SPECT imaging, spatial linearity is preserved across the usable field-of-view. The major advantage of the high resolution properties of pinhole tomography is demonstrated by the enhanced lesion-to-normal-brain uptake ratio achieved on tomographic slices as compared to planar images. For example, 201Tl tumor-to-normal-brain uptake ratios of 1.1 to 1.3 observed on planar images, corresponded to ratios ranging from 3.2 to 3.7 on the SPECT slices. Examples of the activity distributions of two radiopharmaceuticals in tumor and in normal brain for sagittal and coronal images are given. In all cases, tumors are clearly delineated on the pinhole SPECT slices. The present study shows that pinhole SPECT performed with standard SPECT instrumentation can give high spatial resolution images, with a FWHM approximately 3 mm and a sensitivity approximately 100 cps/MBq for 99mTc.

Radioimmunoscintigraphy using [111In]antimyosin Fab fragments for the diagnosis and follow-up of rhabdomyosarcoma

Between 1987 and 1992, 39 radioimmunoscintigraphic studies using 111In-labelled antimyosin Fab fragments were performed in 27 patients with rhabdomyosarcoma (RMS), 2 patients with leiomyosarcoma (LMS) and 1 with alveolar soft tissue sarcoma. 21 patients were children aged 3-14 years. These patients, who had histologically proven myosarcoma, were examined scintigraphically to search for local recurrences or metastases and to determine the response to treatment. The results of immunoscintigraphy were compared with histopathological parameters and other imaging modalities. The sensitivity of antimyosin scintigraphy in this series was 82% and the specificity was 73%. Although the technique appears to be not highly specific for RMS, it was found to be useful for the early detection of local recurrence and metastases, as well as for the evaluation of the response to therapy.

Improving radioimmonotargeting of tumors. Variation in the amount of L6 MAb administered, combined with an immunoadsorption system (ECIA)

Extracorporeal immunoadsorption (ECIA) is a new method for the selective removal of circulating radiolabeled monoclonal antibodies (MAb) from plasma to increase the uptake in tumor versus normal tissues (T/N-ratio). To ascertain whether the amount of MAb affects T/N ratios immediately and 24 h after ECIA, we used a rat model with two tumor sites--one intramuscular (im) and one below the subrenal capsule (SR). Extracorporeal immunoadsorption was done with an avidin-agarose column after injection of 125I-labeled biotinylated L6 MAb. The animals received 10, 50 or 250 micrograms of L6 only (controls), or followed by ECIA. The efficacy of the procedure in removing plasma activity was 80-95%. For both tumor sites, the highest T/N-ratios were obtained with 10 micrograms L6. All T/N-ratios significantly improved for SR tumors by a factor ranging from 3.2 (lung) to 12.6 (bone marrow). The T/N-ratios were still elevated 24 h after ECIA. Injection of larger amounts of MAb, probably causing a higher degree of tumor saturation, will not necessarily improve the T/N ratio after ECIA.

Variables influencing cell binding assays for antibody binding kinetics

Owing to growing interest in the use of cell binding assays for quality testing of radiolabelled antibodies in radioimmunoscintigraphy, factors in the assay which might affect final outcome were evaluated in order to accumulate information for effective and reliable assay design. For unmodified antibody, magnitude of binding at certain antibody concentrations changed with alteration in number of target cells attached to the microtitre plate. The level of signal detection could either be enhanced or suppressed by changing the dilution of the enzyme-linked tester antibody as in the case of the enzyme-linked immunosorbent assay (ELISA). Accordingly, changes in either assay factor resulted in a shift in the slope of the binding curve even when the immunoreactivity of the antibody remained unchanged. A conventional technique of single cell preparation by trypsin-EDTA was investigated for the trypsin action on tumour cell antigenicity. No adverse effects could be observed if dissociated cells were incubated for 24 hours before the assay. Variation in number of target cells seemed to be a key factor in determining the power of the assay to reveal changes in the quality of the radiolabelled antibody. Our findings suggested the need to standardize factors such as the size of the seed, determination of plating efficiency and the time for culture in order to assure interassay reproducibility.

Radioimmunodetection of colorectal cancer metastases with 131I-labeled monoclonal antibody B72.3: a pilot study to determine efficacy of detection and pharmacokinetics

We performed radioimmunoscintigraphy (RIS) and/or pharmacokinetic (PCK) studies in 12 patients with primary or metastatic colorectal carcinoma, utilizing an intravenous administration of 1-4 mCi (1 mg) of 131I-B72.3 monoclonal antibody. Metastatic lesions were correctly identified in 4/8 patients by RIS. Two patients with small lesions (> 2 cm diameter) had a false-negative RIS scan. Two patients had a true-negative RIS scan. Optimal images were obtained at 1 week postinjection. PCK studies showed that the plasma clearance of 131I-B72.3 was biexponential with an alpha-phase half-life ranging from 0.5 to 7.1 hr and a beta-phase half-life ranging from 47.5 to 85.3 hr. Systemic and renal clearance data indicated that 131I-B72.3 was cleared very slowly and almost entirely by deiodination. This pilot study was conducted to gain an understanding of the pharmacokinetics of this radiolabeled antibody. On the basis of these data, we are now studying second-generation antibodies as part of our long-range objectives to incorporate them in early detection and treatment protocols.

CEA-immunoscintigraphy with 99m-technetium correlates with tumour cell differentiation in colorectal cancer

The clinical usefulness of immunoscintigraphy with the monoclonal anti-CEA (carcinoembryonic antigen) antibody BW431/26, directly labelled with 99m-Technetium in targeting colorectal carcinomas was investigated in 43 patients. In addition, tumour cell grading and CEA-expression were examined immunohistochemically. Best imaging results were obtained in pelvic tumour lesions (sensitivity 80%). Tumour grading correlated with radioimmunoimaging, well differentiated tumours being detectable at a higher rate (P = 0.09). Immunoscintigraphy preceded the findings of conventional diagnostic methods in 3 patients. In 4 cases immunoscintigraphy was decisive for patients management. Therefore, immunoscintigraphy with 99m-Technetium is valuable in directing patients management if conventional diagnostic methods remain undecisive.

Technetium-99m-labeled antibodies. Stability compared to 125I labeled antibodies

It is essential in any method for radiolabeling antibody with 99mTc that the labeling procedure is rapid and reliable, producing a highly stable 99mTc-antibody complex with minimal effect on the immunoreactivity of the antibody. In the present study, analysis of the stability and homogeneity of radiolabeled (99mTc and 125I) antibodies (HMFG1 and PR1A3) was carried out by fast protein liquid chromatography (FPLC) using superose-6 and S-200 columns, and by polyacrylamide gel electrophoresis (PAGE) followed by autoradiography. Superose 6 and S-200 gel filtration analysis showed the radiolabel (99mTc or 125I) eluting with a retention time identical to that of native antibody. No peaks of relative molecular size (Mr) corresponding to possible antibody fragments were seen in either the UV or the radioactive FPLC elution profiles. PAGE analysis of 99mTc labeled antibody, however, revealed the presence of a number of radiolabeled antibody fragments (Mr < IgG) that were not detected by the same analysis of 125I labeled antibody. The stability of the radiolabeled antibodies in serum in vitro was also studied. FPLC (superose-6) analysis after 45 h incubation in normal serum in vitro revealed 3.3% (HMFG1), and 20% (PR1A3) of the 99mTc on a molecule or aggregate with a Mr greater than that of IgG. There is also the appearance of small amounts of 99mTc-labeled material with a Mr < IgG in the later fractions (2.2% for HMFG1 and 4.9% for PR1A3). Similar results were obtained using radioiodinated antibody, although the small amount of low molecular size material detected as a single peak with a longer retention time than the 99mTc equivalent corresponds to free iodide.

Use of radiolabelled monoclonal antibodies in patients with primary and metastatic large bowel cancer

Accurate assessment of the extent of primary and metastatic large bowel cancer is critical to surgical decision making and to providing reliable prognostic information. This prospective study compared external gamma camera images and an intraoperative hand-held gamma detecting probe for detection of radiolabelled monoclonal antibody (B72.3) in 28 patients with primary and metastatic large bowel cancer. Fourteen patients received 0.2 to 20 mg (2 or 5 mCi) 111indium-labelled monoclonal antibody B72.3 followed by whole body imaging scan with an external gamma detector/camera on two occasions 24 h apart within 7 days after injection. Fourteen patients received 1.0 mg (2.0 mCi) 125iodine-B72.3 followed by intraoperative probe evaluation 2-3 weeks postinjection. Mean patient ages for the two groups were 60 years (range 28-75 years) and 63 years (range 43-77 years), respectively. Disease sites were primary in the large bowel in six patients and primary as well as metastatic in 22 patients. External scanning detected 111indium-B72.3 uptake in 1/5 primary lesions, 1/7 hepatic and 1/3 extrahepatic sites. The intraoperative gamma probe localized disease in 1/3 primary lesions, 7/11 hepatic and 3/3 extrahepatic sites. The intraoperative gamma probe had a sensitivity of 71% for detection of metastases compared with a 20% sensitivity using the external gamma scan method (P = 0.03). 125iodine-labelled B72.3 influenced the extent of the operative procedure in 4/14 (29%) patients; immunolocalization with external gamma detection did not alter the operative procedure in the 14 patients studied.(ABSTRACT TRUNCATED AT 250 WORDS)

Chromatofocusing studies involving a monoclonal Fab'

Isoelectric focusing (IEF) of the Fab' derivative of murine monoclonal antibody ZCE-025 is known to detect at least six bands having isoelectric points (pI) ranging from 5.4 to 7.8. Chromatofocusing was employed to separate these bands. Electrophoresis of the starting materials under nonreducing conditions indicated all of the materials to migrate as Fab'. The electrophoresis of urine samples obtained from Balb/c and nude mice 8 hr after the i.v. injection of the various 125I bands revealed the low pI bands to migrate approximately as a 125I-Fab'. The higher pI band activity was located in lower molecular weight regions. Serum samples taken at 8 hr postinjection from the above mice revealed a series of what appeared to be high molecular weight complexes and some low molecular weight species. Biodistribution studies in comparison Balb/c mice and nude mice revealed that the low pI 125I-Fab' bands gave an organ and tumor uptake at 8 hr very similar to Fab', while the high pI 125I-Fab' bands were rapidly excreted into the urine and feces and did not concentrate in the tumor. The data suggest that the population of molecules making up the Fab' of this antibody is heterogeneous and variably stable. Theoretically, some of the entities observed could be counter productive to successful radioimmunoimaging. It is also possible that some of the labeled molecules are associating in vivo with endogenous proteins that might, in some Mabs, affect the biodistribution of the radiopharmaceutical.

c-erbB2 protein overexpression in breast cancer as a target for PET using iodine-124-labeled monoclonal antibodies

ICR 12, one of a panel of rat monoclonal antibodies recognizing the external domain of the human c-erb B2 proto-oncogene product, (Styles, 1990) was chosen as a candidate for radiolabeling with 124I for positron emission tomography of selected patients with breast cancer. By using N-bromosuccinimide (NBS), optimal labeling conditions were established using 125I. The labeling efficiency was determined using instant thin-layer chromatography (ITLC) and gel filtration (HPLC). The antibody was then labeled with the positron emitter 124I, and a labeling efficiency of 96% and immunoreactivity of 80%-90% was obtained. The product was stable, with less than 5% of the radiolabel being eluted after six days storage in plasma at 37 degrees C. Immunolocalization studies were performed in athymic mice bearing human breast carcinoma xenografts overexpressing the c-erb B2 gene product using as controls 125I labeled isotype-matched rat antibody, and antigen-negative tumors. Good uptake of 124I-labeled ICR12 was obtained in c-erb B2 expressing tumors (up to 12% injected dose per gram at intervals up to 120 hr), with localization indices of 3.4-6.2. Tumor xenografts of 6 mm diameter were successfully imaged with high resolution at 24, 48 and 120 hr using the RMH/ICR MUP-PET camera. We suggest that 124I-labeled ICR12 is a suitable agent to image and quantify immunolocalization in patients whose tumors overexpress the c-erb B2 proto-oncogene product.

Detection of locally recurrent colorectal cancer with radiolabeled monoclonal antibody H-15

H-15 (HT-29-15) is an IgG1 mouse monoclonal antibody (mAb) to a cell surface antigen (molecular mass, 200,000 daltons) present on virtually all colorectal cancers and also in normal pancreatic ducts and bile ducts, but not in other normal tissues. The biological distribution and imaging characteristics of iodine-131 (131I)-labeled mAb H-15 were studied in 5 primary colorectal cancer patients and 9 patients with local recurrence of colorectal cancer. H-15 mAb labeled with 0.5-10 mCi of 131I was administered 7 to 8 days before surgery at 4 dose levels, ranging from 0.2 to 6 mg. Selective mAb H-15 localization to tumor tissues was demonstrated in 6 of 12 patients with antigen-positive tumors: in two patients, recurrent tumors were negative to H-15 mAb, although the primary tumors were positive. In six patients with positive radioimaging, tumor:normal tissue ratios ranged from 2.05 to 5.35 and tumor:serum ratios from 1.18 to 2.73. The clarity of images seems to correlate well with the latter ratios. Technetium-99 (99mTc)-albumin blood pool studies in selected cases showed that local recurrence of colorectal cancers was hypovascular, emphasizing the selective localization of mAb H-15 despite poor blood flow distribution in the tumors. The results altogether demonstrated that radioimmunodetection with 131I mAb H-15 is valuable for differentiating recurrent colorectal cancer from granuloma formation after surgery.

Correlative imaging study in the diagnosis of ovarian cancer recurrences. The INSERM Research Network (Nantes, Rennes, Reims, Villejuif, Saclay), France

A correlative imaging study was carried out in 61 female patients previously treated for ovarian carcinoma. Upon suspicion of recurrence, abdominopelvic immunoscintigraphy (IS) using F(ab')2 fragments of indium-111-labelled OC 125 monoclonal antibody was performed in all patients, Ultrasonography (US) and computed tomography (CT) were performed 53 and 37 times, respectively. The diagnostic accuracy of the different imaging techniques was studied per site (abdomen and pelvis) and per patient. The diagnostic accuracy of planar scintigraphy (PS) was slightly lower than that of emission computed tomography (ECT): 66% vs 73% for abdomen, 65% vs 72% for pelvis, and 78% vs 84% in analysis per patient. The accuracy of IS (PS and ECT combined) was markedly better than that of US and CT for abdomen (IS = 73%; US = 30%; CT = 47%), pelvis (IS = 73%; US = 37%; CT = 52%) and analysis per patient (IS = 85%; US = 43%; CT = 59%). The results of IS and morphological imaging techniques (MIT: US and/or CT) were correlatively analysed with the frequency of recurrence. When IS and MIT were both negative, the frequency of non-recurrence was 14/23 for abdomen, 7/12 for pelvis and 8/13 in analysis per patient. On the other hand, when both IS and MIT were positive, the frequency of recurrence was high (9/9 for abdomen, 17/21 for pelvis and 24/26 for analysis per patient). It was also found that a positive IS associated with a negative MIT was still highly suggestive of recurrence (17/21 for abdomen, 16/22 for pelvis and 17/19 for analysis per patient).(ABSTRACT TRUNCATED AT 250 WORDS)

Immunoscintigraphy in the detection of tuberculosis with radiolabelled antibody fragment against Mycobacterium bovis bacillus Calmette-Guérin: a preliminary study in a rabbit model

Immunoscintigraphy with radiolabelled monoclonal antibodies is widely used to detect solid tumours, but only a few trials have been carried out concerning the specific in vivo localization of an inflammatory process. The purpose of this study was to investigate the detectability of tuberculous foci utilizing this method with radiolabelled bacillus Calmette-Guérin (BCG)-specific F(ab')2 in rabbits. All of the tuberculous lesions (n = 8) were clearly visualized on serial scintigraphy for up to 48 h after injection of the antibody. Immunohistochemical and Ziel-Neelson staining of the tuberculous lesions confirmed the presence of the tuberculous antigens and bacilli. It failed to demonstrate any sustained retention of the BCG-specific antibody fragment in the control group with syphilitic orchitis (n = 2). Therefore, the specific in vivo localization of tuberculosis is feasible by immunoscintigraphy.

Clinical evaluation of radioimmunoimaging with 131I-C0C183B2 monoclonal antibody against ovarian carcinoma by intraperitoneal injection

Forty-eight cases subjected to radioimmunoimaging (RII) by intraperitoneal injection with 131I-C0C183B2 monoclonal antibody (MAb) prepared in our laboratory were studied. Thirteen of 14 cases of proved primary ovarian carcinoma were positive. In 11 follow-up cases of ovarian carcinoma after initial surgery and chemotherapy, 5 recurrences were positive and 6 cases without recurrence were negative; all were confirmed histopathologically after a second operation. One false negative was ovarian mucinous adenocarcinoma, which also negatively stained with C0C183B2 by the peroxidase anti-peroxidase method. Twenty of 23 cases of nonepithelial or metastatic carcinoma of the ovary, benign tumors, and benign diseases were negative. The sensitivity and specificity were 94.7 and 89.7%, respectively. If patients had complications with ascites, the MAb which positively stained with the cancer cells in the ascites was chosen for RII. For follow-up cases PAP staining with the tumor tissue from the initial surgery and the MAb should be done before RII. These are the principal factors that increase the positive rate and accuracy of RII. The intraperitoneal route seems to be a valuable method for clinical staging and tumor localization as well as for follow-up use.

Immunoscintigraphic detection of primary and metastatic spontaneous canine osteosarcoma with F(ab')2 fragments of osteosarcoma-associated monoclonal antibody TP-1

Monoclonal antibody TP-1 has been shown to bind selectively to human and canine osteosarcoma cells in vitro using immunohistochemical stains. This report describes the in vivo administration of radioiodinated F(ab')2 fragments of monoclonal antibody TP-1 in dogs with primary and/or metastatic spontaneous osteosarcoma. Two dogs were injected with 131labeled F(ab')2 TP-1 and two dogs were injected with 123labeled antibody fragments. Immunoscintigraphy successfully demonstrated the radiolabeled antibody fragments in 6/6 known primary or metastatic lesions and in addition detected 4 metastatic lesions not diagnosed by conventional radiographs. Concurrent imaging of 99mTc labeled autologous erythrocytes in two dogs confirmed that the accumulation of radiolabeled antibody fragments was independent of the blood pool. There was no immunoscintigraphic evidence of localization of radioiodine to normal organs or tissues other than those expected to accumulate free iodine. The present study has demonstrated the potential of monoclonal antibody TP-1 F(ab')2 fragments for early detection of metastatic spread of spontaneous osteosarcoma.

Pretargeted immunoscintigraphy: effect of hapten valency on murine tumor uptake

A method of radioimmunoscintigraphy using bivalent "Janus" haptens with an apparent enhanced affinity ("avidity") for the antibody is described. Janus with 50 micrograms pretargeted Mab WC3A11 resulted in significantly higher murine tumor concentrations (approximately 7%/g) compared to monovalent haptens (approximately 1.4%/g, p < 0.001), and the same high tumor-to-background ratios (approximately 3/1). Janus was synthesized by coupling two molecules of BABE together with a 1,4 butanedithiol linker. Janus itself was rapidly excreted (T1/2b = 42 min) by the kidneys and did not concentrate in any other organs or tissues. Three-step pretargeted immunoscintigraphy (binder, chaser, tracer) with 111In- or 67Ga-Co(III) Janus produced excellent mouse tumor images in 3 hr with high tumor-to-background ratios. The use of short-lived tracers, such as 99mTc and 68Ga, with a T1/2p of hours to image antibodies that localize slowly over several days in vivo is accessible with this new technology.

Targeting of [111In]biocytin to cultured ovarian adenocarcinoma cells using covalent monoclonal antibody-streptavidin conjugates

Three monoclonal antibodies (mAb) directed against the human ovarian adenocarcinoma cell line HEY, were substituted with maleimide and covalently bonded to thiolated streptavidin. The conjugates were separated from unreacted reagents by successive affinity chromatography on protein A-Sepharose and iminobiotin columns. Purified conjugates consisted of an immunoglobulin (Ig) monomer bound to a streptavidin tetramer through a covalent bond between the Ig molecule and one of the streptavidin subunits. The conjugates were able to specifically target [111In]biocytin to HEY cells in vitro in the presence of human serum and ascitic fluid from ovarian cancer patients.

99mTc-IMMU-4 monoclonal antibody scan in colorectal cancer. A prospective study

A blinded prospective study of 34 patients with colorectal adenocarcinoma using the Fab' fragment of the anticarcinoembryonic antigen monoclonal antibody type IMMU-4 labeled with technetium 99m was conducted to compare, on a lesion-by-lesion basis, the findings of radioimmunoscintigraphy, preoperative computed tomography, and exploratory celiotomy. Of 115 lesions detected at surgery, 113 were adenocarcinoma. Radioimmunoscintigraphy detected 59 lesions and computed tomography detected 62; both studies combined detected 72. Twenty-nine (54%) lesions missed by radioimmunoscintigraphy and 24 (45%) missed by computed tomography were 1 cm or smaller. When both studies were combined, the sensitivities were 90%, 24%, and 42%, and the specificities were 52%, 86%, and 61% for hepatic, extrahepatic intra-abdominal, and pelvic lesions, respectively. In 10 patients, additional information obtained with the radioimmunoscintigram could have altered the treatment of these patients. In this study, radioimmunodetection scan was complementary to computed tomographic scan in the examination of patients with colorectal carcinoma.

Localization of infection using streptavidin and biotin: an alternative to nonspecific polyclonal immunoglobulin

Since favorable images of infection are obtained with radio-labeled nonspecific IgG, streptavidin has been considered as an alternative protein in this investigation. The advantage of streptavidin is that once localized it may be targeted with radiolabeled biotin. Studies were conducted in a mouse model with an Escherichia coli infection in one thigh. Indium-111-labeled streptavidin showed equivalent localization to the infection as that obtained with 111In-labeled polyclonal nonspecific IgG, however blood levels with streptavidin were lower at all time points; consequently, target-to-blood ratios were improved. Pretargeting with unlabeled streptavidin followed 3 hr later with 111In-labeled biotin showed equivalent localization in the target and reduced activity in all organs sampled. As such, infected thigh-to-normal thigh ratios were improved 3-fold for pretargeting versus either labeled IgG or streptavidin. Improvements in infected thigh-to-liver and blood ratios were greater than 8-fold. Only in the case of kidneys was the ratio unimproved. In conclusion, we have shown that by preadministration of unlabeled streptavidin followed by labeled biotin, infectious lesions in a mouse model may be imaged earlier with lower background levels relative to the administration of labeled nonspecific IgG.

[The demonstration and staging of bladder carcinoma. A comparative study between magnetic resonance tomography, computed tomography and radioimmunoscintigraphy]

The purpose of the present study was to compare the effectiveness of MRI, CT and radioimmunoscintigraphy in the staging and detection of bladder cancers in 28 patients. We distinguish two groups: Group I included the tumour stages CIS-T3A and the second group the deep infiltrative tumours T3B-T4. MRI was slightly superior to CT in respect of tumour staging (75% correct results as compared to 63%). No understaging occurred with MRI, whereas in 22% of the cases the stage of the tumour was underestimated using CT diagnostics. Overstaging occurred in 25% of the MRI and 15% of the CT-diagnostics, respectively. RIS cannot distinguish the tumour groups, and hence this method is useful only for the detection of the primary tumour and metastases. In 77% of cases the tumour was detected and in 15% the tumour could be safely excluded.

Radioimmunoguided surgery challenges traditional decision making in patients with primary colorectal cancer

BACKGROUND

Initial experience with the radioimmunoguided surgery system (RIGS) has been found to impact on decision making in patients with recurrent colorectal cancers. Reported here is experience with RIGS-influenced therapeutic decisions in patients with primary colorectal cancer.

METHODS

Thirty-six evaluable patients with primary cancers were injected with the second-generation anti-tumor-associated glycoprotein antibody CC49 labeled with 1 to 2 mCi iodine 125. Pharmacokinetic determination and precordial counts were obtained after injection and weekly until levels were less than 20 counts/2 sec. At surgery abdominal and pelvic explorations were performed, first traditionally by inspection and palpation and then with the hand-held, gamma-detecting probe. RIGS-positive tissue was considered cancerous and removed if possible.

RESULTS

Thirty patients (83%) had positive antibody localization at surgery. Of those patients with localization, in 24 (80%) additional information was obtained at the time of surgery. In 11 patients (34%) staging changes were made as a result of RIGS exploration. New findings resulted in operative changes in nine patients (25%). Eleven (30%) of the original 36 patients became eligible for adjuvant chemotherapy based on current recommendations because of RIGS findings.

CONCLUSIONS

In conclusion, the RIGS system provides immediate staging information that impacts on therapeutic interventions, challenging the adequacy of traditional procedures alone for primary colorectal cancer exploration.

[Radioimmunoscintigraphy: fundamentals (1)]

Radioimmunoscintigraphy (scintigraphy of benign and malignant diseases with radioactively labelled monoclonal antibodies) is being performed via clinically controlled studies in Germany since 1985. In this review the immunological fundamentals and diagnostic possibilities of this new diagnostic approach are given described.

Immunoscintigraphy in Hodgkin's disease and anaplastic large cell lymphomas: results in 18 patients using the iodine radiolabeled monoclonal antibody HRS-3

Immunoscintigraphy (IS) using the HRS-3 Hodgkin associated monoclonal antibody (MoAb) was performed in 18 patients with Hodgkin's Disease (HD) at staging or restaging. Either F(ab')2 fragments (14 patients) or whole HRS-3 (4 patients) labeled with 77-260 Mbq 131-I were used. Whole body images, including anterior and posterior views, were taken from a digital gamma camera, within 4 to 8 hours after injection and then daily for 5 days. In one patient IS was discontinued due to iodine intolerance. Seventeen patients were evaluable: 14 showed a true positive result including 2 cases which were reviewed as anaplastic large cell lymphoma (ALCL). Nodal, splenic, bone marrow and muscle involvements were imaged, many of these sites were previously unsuspected. In 7 patients with true positive findings the Pressman Specificity Index, as measured from biopsied material, ranged from 1.5-3 in 4 patients and from 5 to greater than 100 in 3 patients. Imaging was equivocal or failed in 1 patient (lymph nodes). In 2 patients, IS imaging was truly negative due to the absence of active HD, and a false negative result occurred once (inguinal node). In none of the patients a false positive image was observed. In order to rule out non-specific iodine uptake a control, anti-ACE MoAb, labeled with 125-Iodine was injected simultaneously in 10 patients. The evaluation of the study gave a sensitivity of 87% and a good specificity. IS using radioiodine labeled MoAbs is feasible and represents a reliable non-invasive diagnostic method for the staging and follow-up of HD and ALCL.

Fluorine-18-labeled monoclonal antibody fragments: a potential approach for combining radioimmunoscintigraphy and positron emission tomography

Monoclonal antibody fragments labeled with 18F could be useful for PET if selective tumor uptake could be achieved within a few half-lives of this nuclide. To evaluate this possibility, the F(ab')2 fragment of Mel-14, an antibody reactive with gliomas and other tumors, was labeled by reaction with N-succinimidyl-4-[18F]fluorobenzoate. The in-vitro binding properties of 18F-labeled Mel-14 F(ab')2 were nearly identical to those observed when this F(ab')2 was labeled by reaction with N-succinimidyl-4-[125I]iodobenzoate (18F, affinity constant = (6.7 +/- 1.1) x 10(8) M-1; 125I, affinity constant = (8.8 +/- 0.6) x 10(8) M-1). The tissue distribution of the two labeled fragments was compared in paired-label studies performed in athymic mice with subcutaneous D-54 MG human glioma xenografts. Uptake of both nuclides in tumor was rapid with levels as high as 18.7% +/- 1.1% injected dose/g for 18F and 19.4% +/- 1.0% injected dose/g for 125I observed by 4 hr after injection. Tumor-to-normal tissue ratios for 18F-labeled Mel-14 F(ab')2 at 4 hr ranged between 0.8:1 for kidneys to 40:1 for brain. These results suggest that it may be feasible to use 18F-labeled antibody fragments for imaging tumors with PET.

Cancer imaging with CEA antibodies: historical and current perspectives

This article reviews the history and status of cancer imaging with radiolabeled antibodies against carcinoembryonic antigen (CEA). Although CEA and many other cancer-associated antigens are not distinct for neoplasia, the quantitative increase of these markers in malignant tissues provides a sufficient differential for selective antibody targeting. Animal studies with xenografted human tumors provided the first evidence of the prospects of this technology, followed by initial clinical success with purified goat whole IgG antibodies to CEA, labeled with 131I and with the use of dual-isotope subtraction methods. Subsequently, improved and earlier imaging could be accomplished with monoclonal antibody fragments, which then would permit the use of shorter-lived radionuclides, such as 111In, 123I, and 99mTc. The preferred use of a monoclonal anti-CEA IgG Fab' fragment, labeled with 99mTc by a recently developed, simple and rapid kit, has enabled the detection of small lesions, including those in the liver, within 4 h of injection. By means of SPECT imaging, a high sensitivity and specificity for RAID could be achieved.

[The clinical relevance of anti-CEA immunoscintigraphy with the 99mTc-labelled monoclonal antibody BW 431/26. A critical assessment after 119 studies]

The results of 119 radioimmunoscintigraphies (RIS) in 113 patients with the 99mTc-labeled monoclonal anti-CEA-antibody BW 431/26 (Behring) have been analysed. The aim of our study was the estimation of the method's sensitivity and specificity under different aspects to find out for which indications and questions the 99mTc-RIS is useful. Colorectal primary tumours in 19 patients were scintigraphically detected with a sensitivity of 83% and a specificity of 100%; 3 out of 7 other tumour sites were localised correctly. 55 patients were examined during the follow-up of colorectal cancer. There were 17 out of 22 true positive findings of local recurrences (sensitivity 77%, specificity 88%). Liver metastases were imaged as hot lesions with only 41% sensitivity and 86% specificity. The detection of extrahepatic tumour sites is difficult because of the persistently high blood-pool activity of the monoclonal antibody and, in the pelvic area, the unspecific bowel activity. Skeletal metastases were recognised in 7 out of 9 cases. In 14 patients with other non-colorectal carcinomas, RIS was successful in single cases. It is not helpful, however, when searching for tumours of unknown origin or for the screening of patients with elevated CEA levels without tumour history. The high technical, methodological and time effort required by RIS is justified in the follow-up of cancer patients when conventional diagnostic procedures are inconclusive or the status of morphological findings remains unclear. The use of RIS as an unspecific screening tool in tumour diagnosis must be rejected because of the not completely explored risks of the examination. Repeated applications of monoclonal antibodies require controls of the patients' HAMA titers before performing RIS.

Visualization of myocardial infarction 6 h after injection of 111In-antimyosin antibodies using a blood pool subtraction technique

111In-antimyosin antibodies are capable of visualizing myocardial infarction (MI). Because of slow blood clearance, images are usually recorded 24 or 48 h postinjection. In this pilot study, a blood pool subtraction technique, which makes it possible to visualize MI 6 h postinjection, is validated. Twenty-five patients with proven MI (16 anterior, 9 inferior) were imaged a few minutes, 6 and 24 h after an injection of 111 MBq 111In-labelled antimyosin antibodies. Three planar views are obtained each time. Using software which performs the geometric registration, the grey level normalization and the subtraction of images, the blood pool image (obtained a few minutes postinjection) is subtracted from the 6 h image. The resulting image is the blood pool corrected 6 h image. The 24 h images and the blood pool corrected 6 h images were interpreted blindly and the number of correct, incorrect and impossible MI localizations was counted. The number of correct localizations is 19/25 for the standard 24 h images and 22/25 for the blood pool corrected 6 h images. Then, with this blood pool subtraction method, it is possible to visualize MI 6 h postinjection. This has to be taken into account when discussing the role of antimyosin scintigraphy in the management of patients with MI.

Clinical radioimmunoscintigraphy

In summary, radioimmunoscintigraphy has emerged into clinical practice, has many advantages and relatively few side effects. Its use in the routine practice is not going to be limited to the areas of oncology, but will also be used in other disease states such as infections, thrombus detection and infarcts.

Radioiodinated anti-hepatocellular carcinoma (HCC) ferritin. Targeting therapy, tumor imaging and anti-antibody response in HCC patients with hepatic arterial infusion

Radioimmunoimaging and radioimmunotherapy with radioiodinated anti-(hepatocellular carcinoma ferritin) antibody (131I- or 125I-FtAb) have been applied in patients with primary liver cancer. A total of 41 patients with surgically unresectable hepatocellular carcinoma (HCC) and receiving hepatic artery ligation and cannulation during exploratory laparotomy were treated with this regimen by intrahepatic arterial infusion. Compared with the control group, a decline of serum alpha-fetoprotein (65.7% versus 42.9%) and shrinkage of tumor (68.3% versus 33.9%) were observed in the treated group, and a higher second-look resection rate (31.7% versus 5.1%) and longer survival (1-year: 61.0% versus 37.3%, 3-year: 25.0% versus 6.9%) resulted. The administration of antibody through a hepatic arterial catheter (n = 16) was compared with intravenous injection (n = 17) in terms of the tumor-imaging sensitivity in 33 patients with liver cancer. The results indicated that hepatic arterial infusion was superior to intravenous injection. The sensitivity 7 days after the administration was 100% in the i.a. group and 76.5% in the i.v. group, the uptake ratio of tumor to liver being 1.74 +/- 0.57 in the former and 1.34 +/- 0.29 in the latter. Furthermore, intrahepatic arterial infusion revealed a lower anti-antibody detection rate than intravenous injection (0/14 versus 4/11).

Radioimmunoscintigraphy of colorectal carcinoma with a 99Tcm-labelled anti-CEA monoclonal antibody (BW 431/26)

Radioimmunoscintigraphy (RIS) with BW 431/26 monoclonal antibody (MoAb) labelled with 99Tcm (962 MBq) has been performed in 64 patients with colorectal carcinoma, one of them with two independent tumours. The group consisted of 46 primary lesions, 15 pelvic recurrences and four suspected recurrences which were shown to be liver metastases. Imaging of liver was obtained in all patients, but surgical liver examination was performed in only 56 of them. Planar scans were obtained at 4 and 24 h postinjection. Tomographic images were also performed in five patients. The final diagnosis was confirmed in all patients by their clinical course and by findings at surgery and pathology. A comparative study between the RIS results and the final diagnosis gave a global sensitivity in primary tumours and pelvic recurrences of 59.7% with an accuracy of 59.0%. When rectal tumours were excluded, the results were 81.1 and 84.9%, respectively. In liver metastases the sensitivity was 50%, with an accuracy of 85.7% and a specificity of 100%. No correlation has been found between CEA serum levels and lesion detection. In conclusion, RIS is a useful technique for the study and localization of colorectal tumours, being also indicated in patients with normal carcinoembryonic antigen (CEA) serum levels and clinical suspicion of illness.

Autoradiographic analysis of radiolabeled anti-carcinoembryonic antigen monoclonal antibody CEA102 in colorectal cancer using computed radiography

Anti-carcinoembryonic antigen monoclonal antibody (MAb) CEA102 was produced by immunization with purified CEA and the specific accumulation of radiolabeled CEA102 in colorectal cancers was investigated by autoradiography of surgical specimens using Fuji Computed Radiography (FCR). Five patients with colorectal cancer were injected intravenously with 131I-labeled intact CEA102 or its F(ab')2. Primary tumor and liver metastases were successfully detected by external scanning with a gamma camera in 4 cases. Autoradiographic study of the surgical specimens using FCR showed predominant localization of 131I-labeled CEA102 in primary tumors and liver metastases in all cases. Even a small liver metastasis (0.5 cm) was clearly visualized in the autoradiogram by FCR. The pixel distribution curves of the density of the respective tissues in the autoradiograms by FCR showed the heterogeneity of the distribution of administered radiolabeled MAb in individual tumors, but the density of the tumors was higher than that of the normal tissues. In the quantitative distribution analysis of CEA102, the uptake of the primary tumor (mean 1.10%ID/kg) was ten-fold greater than that of the normal colon mucosa (mean 0.10%ID/kg). These results revealed that the application of MAb has great potential in radioimmunodetection as well as in antibody-directed therapy.

Indium-111 monoclonal antibody B72.3 scintigraphy in colorectal cancer. Correlation with computed tomography, surgery, histopathology, immunohistology, and human immune response

As part of an open-labeled nonrandomized multi-institutional Phase III study, the authors compared the results of In-111 (In-111) B72.3 glycyl-tyrosyl-n-diethylenetriaminepentaacetic acid lysine (GYK-DTPA) monoclonal antibody scintigraphy with computed tomography (CT), surgery, histopathology, immunohistology, and human antibody response in 23 patients with primary colorectal carcinoma. There were no significant adverse reactions to 1 mg of In-111-labeled antibody. Planar imaging identified 16 of 23 primary colon lesions, whereas single photon emission computer tomography (SPECT) imaging identified 21. SPECT also correctly identified lymphatic involvement in four patients. (There were two false-positive results.) Liver metastases were identified with SPECT imaging. Twenty-six percent of patients developed human anti-mouse antibody (HAMA). These preliminary results demonstrate that In-111 B72.3 GYK-DTPA is a safe monoclonal antibody conjugate that has a high sensitivity for identifying primary colorectal cancer. Regional lymphatic and distant liver metastases also can be imaged, but false-positive results can occur.

Radioimmunoscintigraphy of metastatic breast carcinoma

Seventeen patients with breast cancer underwent preoperative radioimmunoscintigraphy (RIS). Planar and tomographic imaging techniques (single photon emission computerised tomography--SPECT) were studied using Indium-111-labelled anti-epithelial membrane antigen (EMA) antibodies for tumour localisation. Overall imaging sensitivities were reasonable with correct identification of around 90% of primary lesions and 50% of secondary lesions. Planar imaging was more sensitive than SPECT for identification of superficial lesions such as the primary lesions (88% vs 56%) and axillary metastases (59% vs 53%). SPECT was necessary, however, for detection of deeper lesions such as internal mammary chain metastases and often served as an adjunct rather than an alternative to planar imaging. RIS, therefore, may contribute to more accurate staging of breast cancer, although further technical advances in RIS would enhance this contribution.

Radioimmunolocalization of neuroblastoma xenografts with chimeric antibody chCE7

This study was performed to evaluate the tumor targeting ability of chCE7 with a view to clinical applications in neuroblastoma imaging and therapy. A chimeric (mouse/human) monoclonal antibody (chCE7) of gamma 1/kappa isotype directed against a neuroblastoma-associated cell-surface glycoprotein is described. In vitro chCE7 binds with high affinity (KD approximately 1 x 10(-10) M) to SKN-AS human neuroblastoma cells. Binding studies with 125I-labeled chCE7 show temperature-dependent modulation of antigen binding and indicate that a proportion of the bound antibody is internalized due to rapid antigen turnover. In vivo biodistribution of radioiodinated chCE7 in nude mice bearing SKN-AS tumors shows optimal tumor uptake after 24 hr with about 30% of the injected dose per g. Optimal tumor/blood ratios (3.4:1) are reached after 4-5 days. Uptake in other organs including the reticuloendothelial system is low with tumor/organ ratios of 10 and more. Tumor uptake of chCE7 and the parent murine CE7 are found to be similar. Stability of chCE7 during and after radiolabeling is good with no loss of immunoreactivity in preparations labeled with 123I up to 100 mCi/mg and 80% immunoreactivity after labeling with 13 mCi/mg of 131I. Neuroblastoma xenografts can be imaged by radioimmunoscintigraphy with 123I- and and 131I-labeled chCE7.

Immunoscintigraphy of infections using 123I and 99mTc-labeled monoclonal antibodies. Advanced experiences in 230 patients

Advanced experiences show an extremely high diagnostic potential in immunoscintigraphy of infections using monoclonal antigranulocytes antibodies (Mab). There was no hampering of the biological properties of the granulocytes after in vivo labeling with 123I or 99mTc-tagged Mabs. There were mostly identical findings and an equal functional behavior of the granulocytes observed with the use of different agents. Diagnosis of infections was made mostly within four to six hours p.i. 99mTc labeling is more advantageous than 123I because of better image quality, constant availability, and lower costs. 123I Mab 47 seems to be recommended in some cases of chronic osteomyelitis and spondylitis. No relevant antigenicity was observed in follow-up studies of testing HAMA serum levels. Only a few short-time reactions were seen after repeated administration of 99mTc Mab. There were no side effects and no allergic or adverse reactions. Despite these methodical advantages of the immunoscintigraphic detection of infectious and inflammatory lesions, this method should be further restricted to severe cases or patients in whom other methods would not be practicable or have failed. HAMA controls are continued in all our patients undergoing immunoscintigraphy.

Pharmacokinetic analysis of antibody localization in human colon cancer: comparison with immunoscintigraphy

The biodistribution and imaging characteristics of the 111In-labeled anti CEA monoclonal antibody ZCE-025 were studied in five patients with suspicion of colorectal carcinoma. Evaluation included antibody pharmacokinetics and assessment of antibody distribution in surgical specimen, making a comparison with whole-body imaging with a gamma camera. ZCE-025 localization in tumors was demonstrated by gamma-camera imaging in 4 of the 5 patients, corresponding to surgical findings. Persistent accumulation of 111In in the lymph nodes was observed in one patient, whereas surgical exploration of these lymph nodes showed no gross or microscopic evidence of metastases of colon carcinoma. Analysis of individual plasma by size exclusion HPLC showed two radioactivity peaks, labeled antibody and free DTPA. No transchelation of 111In to circulating transferrin was observed. The blood clearance was fitted to a two-compartment equation and its half-lives were found to be 10.8 +/- 8.7 h and 69.5 +/- 21.8 h for t1/2 alpha and t1/2 beta, respectively. Total urinary excretion averaged 0.3% of the injected dose/h with a small patient to patient variation. At 24 hrs postadministration the predominant radiolabeled species in urine was free DTPA. Thereafter, radioactivity in urine was partly present as a low molecular weight catabolic product. No apparent correlation between CEA content and uptake of 111In-ZCE-025 in tumors resected by surgery could be found. How 111In-labeled antibody is accumulated into tumors as well as into some nontumor tissues needs further study.

Evaluation of the 111In-(Sn)-citrate method to label antibodies for radioimmunotargeting studies

Monoclonal antibody against carcinoembryonic antigen (CEA) was labeled by the 111In-(Sn)-citrate technique and its characteristics were determined from the point of radioimmunotargeting studies. Antibodies of high specific radioactivity could be labeled with a high labeling yield of greater than 90% without any further purification step, and without loss of immunoreactivity. In biodistribution studies using nude mice bearing CEA-producing tumors, an extremely high tumor-to-blood ratio (40 on day 6) was obtained since 111In in the blood cleared very rapidly, but nonspecific 111In localized in the liver and spleen should be seriously considered.

Safety and role of repeated administrations of Indium-111-labeled anti-carcinoembryonic antigen monoclonal antibody ZCE 025 in the postoperative follow-up of colorectal carcinoma patients

The safety and clinical utility of repeated administrations of 111In-ZCE 025 were evaluated in 25 patients who have undergone colorectal carcinoma resection. Fifteen patients were clinically and radiologically free of recurrences and asymptomatic while 10 had rising CEA and/or symptoms. We repeatedly imaged the patients following intravenous administrations of 40 mg ZCE 025, every 4 to 6 mo. Side effects occurred in 16% of patients who received two or more infusions. Sixteen lesions were detected by immunoscintigraphy in 11 patients who were free of disease by CT scans or other imaging modalities. Ten recurrences were surgically confirmed in seven patients. Radiographic and clinical follow-up confirmed the remaining 6 Mab-positive lesions. Elevated human anti-mouse antibody (HAMA) titers were detectable in the sera of 30% and 64% of patients following the 1st and 2nd Mab injection respectively, but did not interfere with successful immunoscintigraphy nor correlated with the occurrence of side effects. This study suggests that a negative Mab scan indicates that a patient will remain free of recurrence; conversely, a positive scan was associated with recurrences of disease.

Evaluation of a technique for the intraoperative detection of a radiolabelled monoclonal antibody against colorectal cancer

Occult tumour deposits may be localised at operation with a radiation detecting probe following the administration of a radiolabelled monoclonal antibody (MoAb) recognising a tumour-associated antigen. We have recently evaluated the clinical usefulness of this technique in detecting primary colorectal tumours targetted with an indium-111 MoAb. In the present study the physical characteristics of the two detector systems used were investigated; a sodium iodide [NaI(Tl)] scintillation detector and a cadmium telluride (CdTe) semiconductor probe. Limitations of the technique in use have been examined by testing the statistical significance of tumour detection using an abdominal phantom based on the currently available clinical biodistribution data for tumour uptake of radiolabelled MoAbs. The effect of tumour volume, antibody uptake, collimation and counting conditions was examined. Results indicate that tumours of 10 ml volume may be detected with the NaI(Tl) probe at the lowest levels of radiolabelled antibody uptake currently reported in the literature but that at higher published levels, lesions as small as 1 ml may be identified with both detector systems. Detector sensitivity and limited antibody specificity restrict the usefulness of the technique, although moderate improvements in tumour uptake may allow the detection of tumour deposits not clinically apparent. The statistical significance criterion used for this study could be an accurate and reliable indicator for tumour detection in vivo.

Radioimmunoimaging of subacute infective endocarditis using a technetium-99m monoclonal granulocyte-specific antibody

Immunoscintigraphy with a technetium-99m murine monoclonal IgG1 antibody directed against non-specific cross-reacting antigen (NCA-95) and carcinoembryonic antigen was performed with 20 patients with suspected subacute infective endocarditis (SIE) and 6 controls with suspected inflammatory/infectious disease elsewhere in the body. Immunoscintigraphy and echocardiography localised SIE in 11 of 15 patients in whom the disease could be confirmed. In 4 patients with validated SIE, the immunoscan was abnormal, and the echocardiogram was normal. In another 4 patients, the result was exactly the opposite. These findings suggest that the combination of immunoscintigraphy and echocardiography improves diagnostic efficacy in patients with suspected SIE.