Simplified quantification and whole-body distribution of [18F]FE-PE2I in nonhuman primates: prediction for human studies

Simplified quantification of [18F]FE-PE2I PET in Parkinson's disease: Discriminative power, test-retest reliability and longitudinal validity during early peak and late pseudo-equilibrium

Quantification of dopamine transporter (DAT) availability with [¹⁸F]FE-PE2I PET enables the detection of presynaptic dopamine deficiency and provides a potential progression marker for Parkinson`s disease (PD). Simplified quantification is feasible, but the time window of short acquisition protocols may have a substantial impact on the reliability of striatal binding estimates. Dynamic [¹⁸F]FE-PE2I PET data of cross-sectional (33 PD patients, 24 controls), test-retest (9 patients), and longitudinal (12 patients) cohorts were used to assess the variability and reliability of specific binding ratios (SBR) measured during early peak and late pseudo-equilibrium. Receiver operating characteristics area under the curve (PD vs. controls) was high for early (0.996) and late (0.991) SBR. Early SBR provided more favourable effect size, absolute variability, and standard error of measurement than late SBR (caudate: 1.29 vs. 1.23; 6.9% vs. 9.8%; 0.09 vs. 0.20; putamen: 1.75 vs. 1.67; 7.7% vs. 14.0%; 0.08 vs. 0.17). The annual percentage change was comparable for both time windows (-7.2%-8.5%), but decline was significant only for early SBR. Whereas early and late [¹⁸F]FE-PE2I PET acquisitions have similar discriminative power to separate PD patients and controls, the early peak equilibrium acquisition can be recommended if [¹⁸F]FE-PE2I is used to measure longitudinal changes of DAT availability.

Reliability of dopamine transporter PET measurements with [18F]FE-PE2I in patients with Parkinson's disease

Background

Reliable quantification of dopamine transporter (DAT), a biomarker for Parkinson’s disease (PD), is essential for diagnostic purposes as well as for evaluation of potential disease-modifying treatment. Due to degeneration of dopaminergic neurons and thus lower expected radioligand binding to DAT, higher measurement variability in PD patients might be expected than earlier reproducibility results in healthy controls. Therefore, we aimed to examine the test-retest properties of [¹⁸F]FE-PE2I-PET in PD patients.

Methods

Nine patients with PD (Hoehn and Yahr stage < 3) were included (men/women 6/3; mean age 65.2 ± 6.8 years). Each patient underwent two [¹⁸F]FE-PE2I-PET measurements within 7–28 days. The outcome measure was non-displaceable binding potential generated using wavelet-aided parametric imaging with cerebellum as reference region. We assessed test-retest performance using estimates of reliability and repeatability. Regions for primary analysis were caudate, putamen, ventral striatum, and substantia nigra. Exploratory analysis was performed for functional subdivisions of the striatum. We also compared the more vs. less affected side.

Results

[¹⁸F]FE-PE2I showed absolute variability estimates of 5.3–7.6% in striatal regions and 11% in substantia nigra and ICCs of 0.74–0.97 (median 0.91). The absolute variability for functional striatal subdivisions was 6.0–9.6% and ICCs of 0.76–0.91 (median 0.91). The less affected substantia nigra exhibited greater consistency than the more affected side. According to power calculations based on the current sample size, DAT changes of 5–11% in the striatum and 28% in the substantia nigra can be detected with a power of 0.8 (p < 0.0125).

Conclusion

DAT-PET measurements with [¹⁸F]FE-PE2I in PD patients showed good repeatability and reliability. The slightly lower reliability in the substantia nigra in patients may be explained by lower DAT density and smaller anatomical size. Power calculations suggest that [¹⁸F]FE-PE2I PET is a suitable marker for longitudinal DAT decline in PD.

Trial registration

EudraCT 2017-003327-29

EANM practice guideline/SNMMI procedure standard for dopaminergic imaging in Parkinsonian syndromes 1.0

Purpose

This joint practice guideline or procedure standard was developed collaboratively by the European Association of Nuclear Medicine (EANM) and the Society of Nuclear Medicine and Molecular Imaging (SNMMI). The goal of this guideline is to assist nuclear medicine practitioners in recommending, performing, interpreting, and reporting the results of dopaminergic imaging in parkinsonian syndromes.

Methods

Currently nuclear medicine investigations can assess both presynaptic and postsynaptic function of dopaminergic synapses. To date both EANM and SNMMI have published procedural guidelines for dopamine transporter imaging with single photon emission computed tomography (SPECT) (in 2009 and 2011, respectively). An EANM guideline for D2 SPECT imaging is also available (2009). Since the publication of these previous guidelines, new lines of evidence have been made available on semiquantification, harmonization, comparison with normal datasets, and longitudinal analyses of dopamine transporter imaging with SPECT. Similarly, details on acquisition protocols and simplified quantification methods are now available for dopamine transporter imaging with PET, including recently developed fluorinated tracers. Finally, [¹⁸F]fluorodopa PET is now used in some centers for the differential diagnosis of parkinsonism, although procedural guidelines aiming to define standard procedures for [¹⁸F]fluorodopa imaging in this setting are still lacking.

Conclusion

All these emerging issues are addressed in the present procedural guidelines for dopaminergic imaging in parkinsonian syndromes.

Performance Evaluation of a High-Resolution Nonhuman Primate PET/CT System

The LFER 150 PET/CT device (large-field-of-view extreme-resolution portable research imager) is a system for nonhuman primate (NHP) imaging. The objective of this study was to evaluate the performance of the system using the National Electrical Manufacturers Association NU 4-2008 standard protocol. As a preliminary in vivo evaluation of the system, a PET measurement in an NHP was also performed. Methods: Resolution, sensitivity, image quality, and noise-equivalent count rate (NECR) were measured. NECR measurement was performed with a ratlike phantom and a monkeylike phantom. A Derenzo phantom experiment was performed to test the resolution using 3-dimensional ordered-subset expectation maximization reconstruction. One cynomolgus monkey (4.5 kg, intravenous ketamine/xylazine anesthesia) was examined with the dopamine transporter radioligand ¹⁸F-FE-PE2I (94 MBq) to evaluate the in vivo performance of the system. List-mode PET data acquired for 93 min were reconstructed into 38 frames with the Tera-Tomo 3-dimensional engine. Binding potential for caudate nucleus, putamen, and substantia nigra was evaluated using the simplified reference tissue model. Results: Radial full-width half-maximum resolution using Fourier rebinning and a 2-dimensional filtered backprojection algorithm was less than 2.2 mm and less than 3.2 mm in the central 60-mm-diameter and 140-mm-diameter regions, respectively. Maximum sensitivity in the 400- to 600-keV and 250- to 750-keV energy windows was 30.03 cps/kBq (3.3%) and 49.11 cps/kBq (5.4%), respectively. The uniformity in the image-quality phantom was 3.3%, and the spillover ratio for air and water was 0.1. The peak of the NECR curve was 430 kcps (at 115 MBq) with the ratlike phantom and 78 kcps (at 139 MBq) with the monkeylike phantom. Rods of the Derenzo phantom with 1-mm diameter could be distinguished by eye. In the NHP experiment, binding potentials in the caudate, putamen, and substantia nigra (4.9, 4.9, and 1, respectively) were similar to those previously reported using the same radioligand and a high-resolution research tomograph. Conclusion: The results obtained from phantom experiments and 1 representative PET measurement in an NHP confirm that the LFER 150 is a high-resolution PET/CT system with suitable performance for brain imaging in NHPs.

Whole-Body Biodistribution and Dosimetry of the Dopamine Transporter Radioligand 18F-FE-PE2I in Human Subjects

¹⁸F-(E)-N-(3-iodoprop-2-enyl)-2β-carbofluoroethoxy-3β-(4'-methyl-phenyl) nortropane (¹⁸F-FE-PE2I) was recently developed and has shown adequate affinity and high selectivity for the dopamine transporter (DAT). Previous studies have shown promising results for ¹⁸F-FE-PE2I as a suitable radioligand for DAT imaging. In this study, we investigated the whole-body biodistribution and dosimetry of ¹⁸F-FE-PE2I in healthy volunteers to support its utility as a suitable PET imaging agent for the DAT. Methods: Five healthy volunteers were given a mean activity of 2.5 MBq/kg, and 3 PET scans, head to thigh, were performed immediately after injection followed by 4 whole-body PET/CT scans between 0.5 and 6 h after injection. Blood samples were drawn in connection with the whole-body scans, and all urine was collected until 6 h after injection. Volumes of interest were delineated around 17 organs on all images, and the areas under the time-activity curves were calculated to obtain the total number of decays in the organs. The absorbed doses to organs and the effective dose were calculated using the software IDAC. Results: The highest activity concentration was observed in the liver (0.9%-1.2% injected activity/100 g) up to 30 min after injection. At later time points, the highest concentration was seen in the gallbladder (1.1%-0.1% injected activity/100 g). The activity excreted with urine ranged between 23% and 34%, with a mean of 28%. The urinary bladder received the highest absorbed dose (119 μGy/MBq), followed by the liver (46 μGy/MBq). The effective dose was 23 μSv/MBq (range, 19-28 μSv/MBq), resulting in an effective dose of 4.6 mSv for an administered activity of 200 MBq. Conclusion: The effective dose is within the same order of magnitude as other commonly used PET imaging agents as well as DAT agents. The reasonable effective dose, together with the previously reported favorable characteristics for DAT imaging and quantification, indicates that ¹⁸F-FE-PE2I is a suitable radioligand for DAT imaging.

Optimal Acquisition Time Window and Simplified Quantification of Dopamine Transporter Availability Using 18F-FE-PE2I in Healthy Controls and Parkinson Disease Patients

¹⁸F-(E)-N-(3-iodoprop-2-enyl)-2β-carbofluoroethoxy-3β-(4'methylphenyl)nortropane (¹⁸F-FE-PE2I) is a newly developed dopamine transporter (DAT) PET radioligand. Full quantification methods rely on dynamic acquisition of ¹⁸F-FE-PE2I, but in a clinical setting a simplified protocol is preferable. The aims of this study were to identify the optimal acquisition time window for ¹⁸F-FE-PE2I and to validate the specific binding ratio (SBR) as a simplified quantification method.

METHODS

Ten Parkinson disease (PD) patients and 10 controls were included. Ninety-three-min dynamic PET measurements with ¹⁸F-FE-PE2I were conducted using the high-resolution research tomograph (HRRT). The dynamic measurement was also smoothed to the resolution of a clinical PET system (HR). Regions of interest for the caudate, putamen, ventral striatum, substantia nigra (SN), and cerebellum were manually drawn on coregistered MR images. The outcome measure was the SBR, and the gold standard was the binding potential obtained with wavelet-aided parametric imaging (WAPI BP_ND). The cerebellum was used as a reference region. In a preliminary analysis, SBR was computed for 8 time windows (SBR_dyn). Linear regression analysis and Bland-Altman plots were used to select the optimal acquisition time window. An average image from the selected time window was created, from which new SBR values (SBR calculated on the average image on the HRRT and SBR calculated on the average image on the simulated HR images) were calculated and compared with WAPI BP_ND The effect size was calculated.

RESULTS

SBR_dyn values for the time window between 16.5 and 42 min correlated best with WAPI BP_ND (r² = 0.98, P < 0.001). Significant correlations (P < 0.001) were observed between SBR_HR and WAPI-BP_ND (r² = 0.95 in controls and 0.97 in PD patients). In the striatum, SBR_HR values were 37% lower than BP_ND in controls, 29% in PD patients, whereas in the SN the underestimation was 22% in controls and 15% in PD patients. Similar effect sizes for BP_ND and SBR_HR were found in the caudate (0.6), putamen (1.7 and 1.4), ventral striatum (0.7), and SN (0.5 and 0.4).

CONCLUSION

A single ¹⁸F-FE-PE2I acquisition between 16.5 and 42 min provides the best outcome measure for simplified DAT quantification. Despite underestimation of the BP_ND, the SBR can be used in a clinical setting as a valid quantification method for DAT using ¹⁸F-FE-PE2I, because it provides differentiation similar to BP_ND between controls and PD patients.

PET imaging of dopamine transporters with [(18)F]FE-PE2I: Effects of anti-Parkinsonian drugs

PURPOSE

This study aimed to assess the striatal [(18)F]FE-PE2I binding and the immunohistochemical stain of tyrosine hydroxylase (TH) in the striatum, and to evaluate the effects of therapeutic drugs on [(18)F]FE-PE2I binding.

METHODS

Dynamic PET/CT of [(18)F]FE-PE2I was performed in Parkinson's disease (PD) rat models, induced by the unilateral injection of 6-OHDA into the striatum. A simplified reference tissue model method was used to calculate the striatal binding potential (striatal BPND). Each of the four normal rats was pretreated with pramipexole, amantadine, and escitalopram 30 min before [(18)F]FE-PE2I injection. The effect of L-DOPA combined with benserazide was assessed in the normal and PD rats.

RESULTS

The BPND was significantly lower in the lesioned striatum than in the striatum of the normal rats. After the pretreatment with pramipexole, amantadine, and escitalopram, the values of the striatal BPND did not differ from those of the controls. The pretreatment with L-DOPA/benserazide, however, significantly reduced the striatal BPND. The striatal BPND of the PD rats with L-DOPA/benserazide pretreatment was not different from that of the same PD rats with placebo treatment.

CONCLUSION

[(18)F]FE-PE2I may be used as a radioligand for the in-vivo imaging of the DAT. In the normal rats, [(18)F]FE-PE2I binding is unaffected by pramipexole, amantadine, and escitalopram. L-DOPA/benserazide does not affect the striatal [(18)F]FE-PE2I binding in PD rats.

In vivo activity of modafinil on dopamine transporter measured with positron emission tomography and [¹⁸F]FE-PE2I

Modafinil, a wake-promoting drug used to treat narcolepsy, is a dopamine transporter inhibitor and is said to have very low abuse liability; this, however, is still up for debate. We conducted a dopamine transporter (DAT) occupancy study with modafinil (200 or 300 mg) in ten healthy volunteers using positron emission tomography (PET) with [¹⁸F]FE-PE2I, a new PET radioligand with high affinity and selectivity for the dopamine transporter, to characterize its relation to abuse liability. Mean striatal DAT occupancies were 51.4% at 200 mg and 56.9% at 300 mg. There was a significant correlation between occupancy and plasma concentration, indicating dose dependency of DAT inhibition by modafinil in the striatum, and especially in the nucleus accumbens. This study showed that DAT occupancy by modafinil was close to that of methylphenidate, indicating that modafinil may be near the same level as methylphenidate in relation to abuse liability in terms of dopaminergic transmission.