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Besso MJ, Bitto V, Koi L, Wijaya Hadiwikarta W, Conde-Lopez C, Euler-Lange R, Bonrouhi M, Schneider K, Linge A, Krause M, Baumann M, Kurth I. Transcriptomic and epigenetic landscape of nimorazole-enhanced radiochemotherapy in head and neck cancer. Radiother Oncol 2024; 199:110348. [PMID: 38823583 DOI: 10.1016/j.radonc.2024.110348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/27/2024] [Accepted: 05/20/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Hypoxia remains a challenge for the therapeutic management of head and neck squamous cell carcinoma (HNSCC). The combination of radiotherapy with nimorazole has shown treatment benefit in HNSCC, but the precise underlying molecular mechanisms remain unclear. PURPOSE To assess and to characterize the transcriptomic/epigenetic landscape of HNSCC tumor models showing differential therapeutic response to fractionated radiochemotherapy (RCTx) combined with nimorazole. MATERIALS/METHODS Bulk RNA-sequencing and DNA methylation experiments were conducted using untreated and treated HNSCC xenografts after 10 fractions of RCTx with and without nimorazole. These tumor models (FaDu, SAS, Cal33, SAT and UT-SCC-45) previously showed a heterogeneous response to RCTx with nimorazole. The prognostic impact of candidate genes was assessed using clinical and gene expression data from HNSCC patients treated with primary RCTx within the DKTK-ROG. RESULTS Nimorazole responder and non-responder tumor models showed no differences in hypoxia gene signatures However, non-responder models showed upregulation of metabolic pathways. From that, a subset of 15 differentially expressed genes stratified HNSCC patients into low and high-risk groups with distinct outcome. CONCLUSION In the present study, we found that nimorazole non-responder models were characterized by upregulation of genes involved in Retinol metabolism and xenobiotic metabolic process pathways, which might contribute to identify mechanisms of resistance to nitroimidazole compounds and potentially expand the repertoire of therapeutic options to treat HNSCC.
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Affiliation(s)
- María José Besso
- German Cancer Research Center (DKFZ) Heidelberg, Division of Radiooncology Radiobiology, Germany.
| | - Verena Bitto
- German Cancer Research Center (DKFZ) Heidelberg, Division of Radiooncology Radiobiology, Germany; German Cancer Research Center (DKFZ) Heidelberg, Division of Applied Bioinformatics, Germany; Faculty for Mathematics and Computer Science, Heidelberg University, Germany; HIDSS4Health - Helmholtz Information and Data Science School for Health, Karlsruhe/Heidelberg, Germany
| | - Lydia Koi
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Wahyu Wijaya Hadiwikarta
- German Cancer Research Center (DKFZ) Heidelberg, Division of Radiooncology Radiobiology, Germany; National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Cristina Conde-Lopez
- German Cancer Research Center (DKFZ) Heidelberg, Division of Radiooncology Radiobiology, Germany
| | - Rosemarie Euler-Lange
- German Cancer Research Center (DKFZ) Heidelberg, Division of Radiooncology Radiobiology, Germany
| | - Mahnaz Bonrouhi
- German Cancer Research Center (DKFZ) Heidelberg, Division of Radiooncology Radiobiology, Germany
| | - Karolin Schneider
- German Cancer Research Center (DKFZ) Heidelberg, Division of Radiooncology Radiobiology, Germany
| | - Annett Linge
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; German Cancer Research Center (DKFZ), and German Cancer Consortium (DKTK), Partner Site Dresden, Heidelberg, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, and Helmholtz Association / Helmholtz-Zentrum Dresden Rossendorf (HZDR), Dresden, Germany
| | - Mechthild Krause
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; German Cancer Research Center (DKFZ), and German Cancer Consortium (DKTK), Partner Site Dresden, Heidelberg, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, and Helmholtz Association / Helmholtz-Zentrum Dresden Rossendorf (HZDR), Dresden, Germany
| | - Michael Baumann
- German Cancer Research Center (DKFZ) Heidelberg, Division of Radiooncology Radiobiology, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany; German Cancer Research Center (DKFZ), and German Cancer Consortium (DKTK), Core Center Heidelberg, Heidelberg, Germany; National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Ina Kurth
- German Cancer Research Center (DKFZ) Heidelberg, Division of Radiooncology Radiobiology, Germany; German Cancer Research Center (DKFZ), and German Cancer Consortium (DKTK), Core Center Heidelberg, Heidelberg, Germany; National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
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Godet I, Doctorman S, Wu F, Gilkes DM. Detection of Hypoxia in Cancer Models: Significance, Challenges, and Advances. Cells 2022; 11:686. [PMID: 35203334 PMCID: PMC8869817 DOI: 10.3390/cells11040686] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 02/06/2023] Open
Abstract
The rapid proliferation of cancer cells combined with deficient vessels cause regions of nutrient and O2 deprivation in solid tumors. Some cancer cells can adapt to these extreme hypoxic conditions and persist to promote cancer progression. Intratumoral hypoxia has been consistently associated with a worse patient prognosis. In vitro, 3D models of spheroids or organoids can recapitulate spontaneous O2 gradients in solid tumors. Likewise, in vivo murine models of cancer reproduce the physiological levels of hypoxia that have been measured in human tumors. Given the potential clinical importance of hypoxia in cancer progression, there is an increasing need to design methods to measure O2 concentrations. O2 levels can be directly measured with needle-type probes, both optical and electrochemical. Alternatively, indirect, noninvasive approaches have been optimized, and include immunolabeling endogenous or exogenous markers. Fluorescent, phosphorescent, and luminescent reporters have also been employed experimentally to provide dynamic measurements of O2 in live cells or tumors. In medical imaging, modalities such as MRI and PET are often the method of choice. This review provides a comparative overview of the main methods utilized to detect hypoxia in cell culture and preclinical models of cancer.
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Affiliation(s)
- Inês Godet
- The Sidney Kimmel Comprehensive Cancer Center, Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA;
- Department of Chemical and Biomolecular Engineering, The Johns Hopkins University, Baltimore, MD 21218, USA; (S.D.); (F.W.)
- Johns Hopkins Institute for NanoBioTechnology, The Johns Hopkins University, Baltimore, MD 21218, USA
| | - Steven Doctorman
- Department of Chemical and Biomolecular Engineering, The Johns Hopkins University, Baltimore, MD 21218, USA; (S.D.); (F.W.)
| | - Fan Wu
- Department of Chemical and Biomolecular Engineering, The Johns Hopkins University, Baltimore, MD 21218, USA; (S.D.); (F.W.)
| | - Daniele M. Gilkes
- The Sidney Kimmel Comprehensive Cancer Center, Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA;
- Department of Chemical and Biomolecular Engineering, The Johns Hopkins University, Baltimore, MD 21218, USA; (S.D.); (F.W.)
- Johns Hopkins Institute for NanoBioTechnology, The Johns Hopkins University, Baltimore, MD 21218, USA
- Cellular and Molecular Medicine Program, The Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
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Suzuki M, Katayama T, Suzuki C, Nakajima K, Magata Y, Ogawa M. Uptake of nicotinic acetylcholine receptor imaging agent is reduced in the pro-inflammatory macrophage. Nucl Med Biol 2021; 102-103:45-55. [PMID: 34619460 DOI: 10.1016/j.nucmedbio.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/11/2021] [Accepted: 09/22/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Macrophages play a vital role in the development of atherosclerotic cardiovascular disease. Macrophages are functionally and phenotypically heterogeneous immune cells and commonly exist in two distinct or polarized subsets: pro-inflammatory M1 and anti-inflammatory M2 phenotypes. Previous reports suggest that stimulation of α7 or α4β2 nicotinic acetylcholine receptors (nAChRs) in macrophages leads to an anti-inflammatory response. However, the biological link between nAChR expression on macrophages and the polarization state is unknown. Therefore, we evaluated the relationship between nAChRs and polarized macrophages in peritoneal macrophages and atherosclerotic plaques of apolipoprotein E knockout (ApoE-/-) mice. METHODS Peritoneal macrophages isolated from mice were polarized into M1 and M2 macrophages, and the uptake of the nAChR-imaging agents, (R)-2-[11C]methylamino-benzoic acid 1-aza-bicyclo[2.2.2]oct-3-yl ester ([11C]MeQAA) or 2-[18F]fluoro-3-(2(S)-azetidinylmethoxy) pyridine ([18F]2FA), and 2-deoxy-2-[18F]fluoro-D-glucose ([18F]FDG) was assessed. We also evaluated the accumulation of imaging agents in atherosclerotic plaques of ApoE-/- mice by autoradiography. After an autoradiogram was obtained, the same aortic tissue was used for immunohistochemical staining of CD68, inducible nitric oxide synthase (iNOS), and arginine-1. RESULTS In an in vitro assay, the uptake of [11C]MeQAA or [18F]2FA was lower in M1 than in M0 and M2 macrophages. In comparison, the uptake of [18F]FDG was higher in M1 macrophages. Ex vivo autoradiography showed that [11C]MeQAA was localized to the extensive plaque area. By contrast, the accumulation of [18F]2FA and [18F]FDG was heterogeneous and found only in some plaques. Moreover, the expression of CD68 and iNOS was higher in [18F]2FA non-uptake than [18F]2FA uptake plaques. CONCLUSION Macrophage polarization was related to nAChR expression, and α4β2 nAChR expression was suppressed in the M1 macrophage. These findings suggest that nAChR imaging has the potential to identify the inflammatory status of atherosclerotic plaque.
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Affiliation(s)
- Motofumi Suzuki
- Laboratory of Bioanalysis and Molecular Imaging, Graduate School of Pharmaceutical Sciences, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Tatsuki Katayama
- Laboratory of Bioanalysis and Molecular Imaging, Graduate School of Pharmaceutical Sciences, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Chie Suzuki
- Department of Molecular Imaging, Institute for Medical Photonics Research, Preeminent Medical Photonics Education & Research Center, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Kohei Nakajima
- Laboratory of Bioanalysis and Molecular Imaging, Graduate School of Pharmaceutical Sciences, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Yasuhiro Magata
- Department of Molecular Imaging, Institute for Medical Photonics Research, Preeminent Medical Photonics Education & Research Center, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Mikako Ogawa
- Laboratory of Bioanalysis and Molecular Imaging, Graduate School of Pharmaceutical Sciences, Hokkaido University, Sapporo, Hokkaido, Japan.
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Shimizu Y, Nakai Y, Watanabe H, Iikuni S, Ono M, Saji H, Kuge Y, Saga T, Nakamoto Y. Increased [ 18F]FMISO accumulation under hypoxia by multidrug-resistant protein 1 inhibitors. EJNMMI Res 2021; 11:9. [PMID: 33492449 PMCID: PMC7835267 DOI: 10.1186/s13550-021-00752-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/11/2021] [Indexed: 11/30/2022] Open
Abstract
Background [18F]Fluoromisonidazole ([18F]FMISO) is a PET imaging probe widely used for the detection of hypoxia. We previously reported that [18F]FMISO is metabolized to the glutathione conjugate of the reduced form in hypoxic cells. In addition, we found that the [18F]FMISO uptake level varied depending on the cellular glutathione conjugation and excretion ability such as enzyme activity of glutathione-S-transferase and expression levels of multidrug resistance-associated protein 1 (MRP1, an efflux transporter), in addition to the cellular hypoxic state. In this study, we evaluated whether MRP1 activity affected [18F]FMISO PET imaging. Methods FaDu human pharyngeal squamous cell carcinoma cells were pretreated with MRP1 inhibitors (cyclosporine A, lapatinib, or MK-571) for 1 h, incubated with [18F]FMISO for 4 h under hypoxia, and their radioactivity was then measured. FaDu tumor-bearing mice were intravenously injected with [18F]FMISO, and PET/CT images were acquired at 4 h post-injection (1st PET scan). Two days later, the same mice were pretreated with MRP1 inhibitors (cyclosporine A, lapatinib, or MK-571) for 1 h, and PET/CT images were acquired (2nd PET scan). Results FaDu cells pretreated with MRP1 inhibitors exhibited significantly higher radioactivity than those without inhibitor treatment (cyclosporine A: 6.91 ± 0.27, lapatinib: 10.03 ± 0.47, MK-571: 10.15 ± 0.44%dose/mg protein, p < 0.01). In the in vivo PET study, the SUVmean ratio in tumors [calculated as after treatment (2nd PET scan)/before treatment of MRP1 inhibitors (1st PET scan)] of the mice treated with MRP1 inhibitors was significantly higher than those of control mice (cyclosporine A: 2.6 ± 0.7, lapatinib: 2.2 ± 0.7, MK-571: 2.2 ± 0.7, control: 1.2 ± 0.2, p < 0.05). Conclusion In this study, we revealed that MRP1 inhibitors increase [18F]FMISO accumulation in hypoxic cells. This suggests that [18F]FMISO-PET imaging is affected by MRP1 inhibitors independent of the hypoxic state.
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Affiliation(s)
- Yoichi Shimizu
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoinkawahara-cho, Sakyo-Ku, Kyoto, 606-8507, Japan. .,Department of Patho-Functional Bioanalysis, Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, 606-8501, Japan.
| | - Yukihiro Nakai
- Department of Patho-Functional Bioanalysis, Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, 606-8501, Japan
| | - Hiroyuki Watanabe
- Department of Patho-Functional Bioanalysis, Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, 606-8501, Japan
| | - Shimpei Iikuni
- Department of Patho-Functional Bioanalysis, Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, 606-8501, Japan
| | - Masahiro Ono
- Department of Patho-Functional Bioanalysis, Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, 606-8501, Japan
| | - Hideo Saji
- Department of Patho-Functional Bioanalysis, Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto, 606-8501, Japan
| | - Yuji Kuge
- Central Institute of Isotope Science, Hokkaido University, Sapporo, 060-0815, Japan
| | - Tsuneo Saga
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoinkawahara-cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoinkawahara-cho, Sakyo-Ku, Kyoto, 606-8507, Japan
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Gelardi F, Kirienko M, Sollini M. Climbing the steps of the evidence-based medicine pyramid: highlights from Annals of Nuclear Medicine 2019. Eur J Nucl Med Mol Imaging 2020; 48:1293-1301. [PMID: 33150459 DOI: 10.1007/s00259-020-05073-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 10/12/2020] [Indexed: 12/17/2022]
Abstract
We aimed to provide an overview on research path in nuclear medicine climbing the steps of the Evidence-Based Medicine (EBM) pyramid using review of 14 subjectively selected papers out of 111 published in the Annals of Nuclear Medicine during January-December 2019. Following the structure of the EBM hierarchy, we chose at least one study for each step of the pyramid from the basis (pre-clinical research, expert opinion, case report and case series), to the middle (case-control and cohort studies, randomised controlled trials), towards the top (meta-analyses and systematic reviews). Additionally, we collected information on the promoter of each included study: investigator-initiated trials (IITs) vs industry-sponsored trials (ISTs). We found that pre-clinical studies are primarily focused on the development of novel molecular targets in cancer, with promising results. At the same time, clinical investigations deal with cardiological, neurological, infectious and oncological applications using both SPECT and PET modalities. Additionally, radionuclide therapy gained interest and is experiencing comprehensive clinical implementation. Our overview confirms the current central role of IITs as compared with ISTs. Challenges and future directions in Nuclear Medicine research are discussed.
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Affiliation(s)
- Fabrizia Gelardi
- Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Margarita Kirienko
- Nuclear Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - Martina Sollini
- Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
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Abstract
Most of the acute ischemic events, such as acute coronary syndromes and stroke, are attributed to vulnerable plaques. These lesions have common histological and pathophysiological features, including inflammatory cell infiltration, neo-angiogenesis, remodelling, haemorrhage predisposition, thin fibrous cap, large lipid core, and micro-calcifications. Early detection of the presence of a plaque prone to rupture could be life-saving for the patient; however, vulnerable plaques usually cause non-haemodynamically significant stenosis, and anatomical imaging techniques often underestimate, or may not even detect, these lesions. Although ultrasound techniques are currently considered as the "first-line" examinations for the diagnostic investigation and treatment monitoring in patients with atherosclerotic plaques, positron emission tomography (PET) imaging could open new horizons in the assessment of atherosclerosis, given its ability to visualize metabolic processes and provide molecular-functional evidence regarding vulnerable plaques. Moreover, modern hybrid imaging techniques, combining PET with computed tomography or magnetic resonance imaging, can evaluate simultaneously both functional and morphological parameters of the atherosclerotic plaques, and are expected to significantly expand their clinical role in the future. This review summarizes current research on the PET imaging of the vulnerable atherosclerotic plaques, outlining current and potential applications in the clinical setting.
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Calcagno C, Fayad ZA. Clinical imaging of cardiovascular inflammation. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2020; 64:74-84. [PMID: 32077666 PMCID: PMC7145733 DOI: 10.23736/s1824-4785.20.03228-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cardiovascular disease due to atherosclerosis is the number one cause of morbidity and mortality worldwide. In the past twenty years, compelling preclinical and clinical data have indicated that a maladaptive inflammatory response plays a crucial role in the development of atherosclerosis initiation and progression in the vasculature, all the way to the onset of life-threatening cardiovascular events. Furthermore, inflammation is key to heart and brain damage and healing after myocardial infarction or stroke. Recent evidence indicates that this interplay between the vasculature, organs target of ischemia and the immune system is mediated by the activation of hematopoietic organs (bone marrow and spleen). In this evolving landscape, non-invasive imaging is becoming more and more essential to support either mechanistic preclinical studies to investigate the role of inflammation in cardiovascular disease (CVD), or as a translational tool to quantify inflammation in the cardiovascular system and hematopoietic organs in patients. In this review paper, we will describe the clinical applications of non-invasive imaging to quantify inflammation in the vasculature, infarcted heart and brain, and hematopoietic organs in patients with cardiovascular disease, with specific focus on [18F]FDG PET and other novel inflammation-specific radiotracers. Furthermore, we will briefly describe the most recent clinical applications of other imaging techniques such as MRI, SPECT, CT, CEUS and OCT in this arena.
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Affiliation(s)
- Claudia Calcagno
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zahi A Fayad
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA -
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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