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McNeal KC, Reeves KM, Song PN, Lapi SE, Sorace AG, Larimer BM. [ 18F]FMISO-PET imaging reveals the role of hypoxia severity in checkpoint blockade response. Nucl Med Biol 2024; 134-135:108918. [PMID: 38772123 DOI: 10.1016/j.nucmedbio.2024.108918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/09/2024] [Accepted: 05/07/2024] [Indexed: 05/23/2024]
Abstract
CONTEXT Hypoxia within the tumor microenvironment is a critical factor influencing the efficacy of immunotherapy, including immune checkpoint inhibition. Insufficient oxygen supply, characteristic of hypoxia, has been recognized as a central determinant in the progression of various cancers. The reemergence of evofosfamide, a hypoxia-activated prodrug, as a potential treatment strategy has sparked interest in addressing the role of hypoxia in immunotherapy response. This investigation sought to understand the kinetics and heterogeneity of tumor hypoxia and their implications in affecting responses to immunotherapeutic interventions with and without evofosfamide. PURPOSE This study aimed to investigate the influence of hypoxia on immune checkpoint inhibition, evofosfamide monotherapy, and their combination on colorectal cancer (CRC). Employing positron emission tomography (PET) imaging, we developed novel analytical methods to quantify and characterize tumor hypoxia severity and distribution. PROCEDURES Murine CRC models were longitudinally imaged with [18F]-fluoromisonidazole (FMISO)-PET to quantify tumor hypoxia during checkpoint blockade (anti-CTLA-4 + and anti-PD1 +/- evofosfamide). Metrics including maximum tumor [18F]FMISO uptake (FMISOmax) and mean tumor [18F]FMISO uptake (FMISOmean) were quantified and compared with normal muscle tissue (average muscle FMISO uptake (mAvg) and muscle standard deviation (mSD)). Histogram distributions were used to evaluate heterogeneity of tumor hypoxia. FINDINGS Severe hypoxia significantly impeded immunotherapy effectiveness consistent with an immunosuppressive microenvironment. Hypoxia-specific PET imaging revealed a striking degree of spatial heterogeneity in tumor hypoxia, with some regions exhibiting significantly more severe hypoxia than others. The study identified FMISOmax as a robust predictor of immunotherapy response, emphasizing the impact of localized severe hypoxia on tumor volume control during therapy. Interestingly, evofosfamide did not directly reduce hypoxia but markedly improved the response to immunotherapy, uncovering an alternative mechanism for its efficacy. CONCLUSIONS These results enhance our comprehension of the interplay between hypoxia and immune checkpoint inhibition within the tumor microenvironment, offering crucial insights for the development of personalized cancer treatment strategies. Non-invasive hypoxia quantification through molecular imaging evaluating hypoxia severity may be an effective tool in guiding treatment planning, predicting therapy response, and ultimately improving patient outcomes across diverse cancer types and tumor microenvironments. It sets the stage for the translation of these findings into clinical practice, facilitating the optimization of immunotherapy regimens by addressing tumor hypoxia and thereby enhancing the efficacy of cancer treatments.
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Affiliation(s)
- Kaytlyn C McNeal
- Department of Radiology, The University of Alabama at Birmingham, Birmingham, AL, United States of America; O'Neal Comprehensive Cancer Center, The University of Alabama at Birmingham, Birmingham, AL, United States of America; Graduate Biomedical Science Program, The University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Kirsten M Reeves
- Department of Radiology, The University of Alabama at Birmingham, Birmingham, AL, United States of America; O'Neal Comprehensive Cancer Center, The University of Alabama at Birmingham, Birmingham, AL, United States of America; Graduate Biomedical Science Program, The University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Patrick N Song
- Department of Radiology, The University of Alabama at Birmingham, Birmingham, AL, United States of America; Graduate Biomedical Science Program, The University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Suzanne E Lapi
- Department of Radiology, The University of Alabama at Birmingham, Birmingham, AL, United States of America; O'Neal Comprehensive Cancer Center, The University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Anna G Sorace
- Department of Radiology, The University of Alabama at Birmingham, Birmingham, AL, United States of America; O'Neal Comprehensive Cancer Center, The University of Alabama at Birmingham, Birmingham, AL, United States of America; Department of Biomedical Engineering, The University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Benjamin M Larimer
- Department of Radiology, The University of Alabama at Birmingham, Birmingham, AL, United States of America; O'Neal Comprehensive Cancer Center, The University of Alabama at Birmingham, Birmingham, AL, United States of America.
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Gouw ZAR, Jeong J, Rimner A, Lee NY, Jackson A, Fu A, Sonke JJ, Deasy JO. "Primer shot" fractionation with an early treatment break is theoretically superior to consecutive weekday fractionation schemes for early-stage non-small cell lung cancer. Radiother Oncol 2024; 190:110006. [PMID: 37972733 DOI: 10.1016/j.radonc.2023.110006] [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: 07/18/2023] [Revised: 10/14/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Radiotherapy is traditionally given in equally spaced weekday fractions. We hypothesize that heterogeneous interfraction intervals can increase radiosensitivity via reoxygenation. Through modeling, we investigate whether this minimizes local failures and toxicity for early-stage non-small cell lung cancer (NSCLC). METHODS Previously, a tumor dose-response model based on resource competition and cell-cycle-dependent radiosensitivity accurately predicted local failure rates for early-stage NSCLC cohorts. Here, the model mathematically determined non-uniform inter-fraction intervals minimizing local failures at similar normal tissue toxicity risk, i.e., iso-BED3 (iso-NTCP) for fractionation schemes 18Gyx3, 12Gyx4, 10Gyx5, 7.5Gyx8, 5Gyx12, 4Gyx15. Next, we used these optimized schedules to reduce toxicity risk (BED3) while maintaining stable local failures (TCP). RESULTS Optimal schedules consistently favored a "primer shot" fraction followed by a 2-week break, allowing tumor reoxygenation. Increasing or decreasing the assumed baseline hypoxia extended or shortened this optimal break by up to one week. Fraction sizes of 7.5 Gy and up required a single primer shot, while smaller fractions needed one or two extra fractions for full reoxygenation. The optimized schedules, versus consecutive weekday fractionation, predicted absolute LF reductions of 4.6%-7.4%, except for the already optimal LF rate seen for 18Gyx3. Primer shot schedules could also reduce BED3 at iso-TCP with the biggest improvements for the shortest schedules (94.6Gy reduction for 18Gyx3). CONCLUSION A validated simulation model clearly supports non-standard "primer shot" fractionation, reducing the impact of hypoxia-induced radioresistance. A limitation of this study is that primer-shot fractionation is outside prior clinical experience and therefore will require clinical studies for definitive testing.
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Affiliation(s)
- Z A R Gouw
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA; The Netherlands Cancer Institute, Amsterdam, Department of Radiation Oncology, the Netherlands.
| | - J Jeong
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA
| | - A Rimner
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
| | - N Y Lee
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
| | - A Jackson
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA
| | - A Fu
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA
| | - J-J Sonke
- The Netherlands Cancer Institute, Amsterdam, Department of Radiation Oncology, the Netherlands
| | - J O Deasy
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA
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Hirata K, Watanabe S, Kitagawa Y, Kudo K. A Review of Hypoxia Imaging Using 18F-Fluoromisonidazole Positron Emission Tomography. Methods Mol Biol 2024; 2755:133-140. [PMID: 38319574 DOI: 10.1007/978-1-0716-3633-6_9] [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] [Indexed: 02/07/2024]
Abstract
Tumor hypoxia is an essential factor related to malignancy, prognosis, and resistance to treatment. Positron emission tomography (PET) is a modality that visualizes the distribution of radiopharmaceuticals administered into the body. PET imaging with [18F]fluoromisonidazole ([18F]FMISO) identifies hypoxic tissues. Unlike [18F]fluorodeoxyglucose ([18F]FDG)-PET, fasting is not necessary for [18F]FMISO-PET, but the waiting time from injection to image acquisition needs to be relatively long (e.g., 2-4 h). [18F]FMISO-PET images can be displayed on an ordinary commercial viewer on a personal computer (PC). While visual assessment is fundamental, various quantitative indices such as tumor-to-muscle ratio have also been proposed. Several novel hypoxia tracers have been invented to compensate for the limitations of [18F]FMISO.
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Affiliation(s)
- Kenji Hirata
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
- Department of Nuclear Medicine, Hokkaido University Hospital, Sapporo, Japan.
- Global Center for Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Japan.
| | - Shiro Watanabe
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
- Department of Nuclear Medicine, Hokkaido University Hospital, Sapporo, Japan
- Global Center for Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Yoshimasa Kitagawa
- Oral Diagnosis and Medicine, Department of Oral Pathobiological Science, Graduate School of Dental Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Kohsuke Kudo
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
- Department of Nuclear Medicine, Hokkaido University Hospital, Sapporo, Japan
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Japan
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Liu T, Dahle MA, Lystad MH, Marignol L, Karlsen M, Redalen KR. In vitro and in vivo characterization of [ 64Cu][Cu(elesclomol)] as a novel theranostic agent for hypoxic solid tumors. Eur J Nucl Med Mol Imaging 2023; 50:3576-3588. [PMID: 37382663 PMCID: PMC10547809 DOI: 10.1007/s00259-023-06310-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/17/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE Hypoxic tumors are associated with therapy resistance and poor cancer prognosis, but methods to detect and counter tumor hypoxia remain insufficient. Our purpose was to investigate 64Cu(II)-elesclomol ([64Cu][Cu(ES)]) as a novel theranostic agent for hypoxic tumors, by implementing an improved production method and assessing its therapeutic and diagnostic potential compared to the established Cu-64 radiopharmaceuticals [64Cu]CuCl2 and [diacetyl-bis(N4-methylthiosemicarbazone) [64Cu][Cu(ATSM)]. METHODS Cu-64 was produced using a biomedical cyclotron at 12 MeV with the reaction 64Ni(p,n)64Cu, followed by synthesis of [64Cu]CuCl2, [64Cu][Cu(ATSM)], and [64Cu][Cu(ES)]. In vitro therapeutic effects were assessed in both normoxic and hypoxic cells (22Rv1 and PC3 prostate cancer cells, and U-87MG glioblastoma cells) using the clonogenic assay and analyzing cellular uptake and internalization. In vivo therapeutic effects were assessed in 22Rv1 xenografts in BALB/cAnN-Foxn1nu/nu/Rj mice receiving a single or multiple doses of radiopharmaceutical, before their feasibility to detect tumor hypoxia was assessed by positron emission tomography (PET) in 22Rv1 and U-87MG xenografts. RESULTS In vitro and in vivo studies demonstrated that [64Cu][Cu(ES)] reduced cell survival and inhibited tumor growth more effectively than [64Cu][Cu(ATSM)] and [64Cu]CuCl2. Hypoxia increased the cellular uptake and internalization of [64Cu][Cu(ES)] and [64Cu][Cu(ATSM)]. [64Cu][Cu(ES)]-PET tumor hypoxia detection was feasible and also revealed an unexpected finding of uptake in the brain. CONCLUSION To the best of our knowledge, this is the first time that ES is radiolabeled with [64Cu]CuCl2 to [64Cu][Cu(ES)]. We demonstrated superior therapeutic effects of [64Cu][Cu(ES)] compared to [64Cu][Cu(ATSM)] and [64Cu]CuCl2 and that [64Cu][Cu(ES)]-PET is feasible. [64Cu][Cu(ES)] is a promising theranostic agent for hypoxic solid tumors.
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Affiliation(s)
- Tengzhi Liu
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Radiology and Nuclear Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Maria Aanesland Dahle
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Mathilde Hirsum Lystad
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Laure Marignol
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity St. James's Cancer Institute, Trinity College, Dublin, Ireland
| | - Morten Karlsen
- Department of Radiology and Nuclear Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Kathrine Røe Redalen
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway.
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Patil N, Howe O, Cahill P, Byrne HJ. Monitoring and modelling the dynamics of the cellular glycolysis pathway: A review and future perspectives. Mol Metab 2022; 66:101635. [PMID: 36379354 PMCID: PMC9703637 DOI: 10.1016/j.molmet.2022.101635] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/28/2022] [Accepted: 11/06/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The dynamics of the cellular glycolysis pathway underpin cellular function and dysfunction, and therefore ultimately health, disease, diagnostic and therapeutic strategies. Evolving our understanding of this fundamental process and its dynamics remains critical. SCOPE OF REVIEW This paper reviews the medical relevance of glycolytic pathway in depth and explores the current state of the art for monitoring and modelling the dynamics of the process. The future perspectives of label free, vibrational microspectroscopic techniques to overcome the limitations of the current approaches are considered. MAJOR CONCLUSIONS Vibrational microspectroscopic techniques can potentially operate in the niche area of limitations of other omics technologies for non-destructive, real-time, in vivo label-free monitoring of glycolysis dynamics at a cellular and subcellular level.
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Affiliation(s)
- Nitin Patil
- FOCAS Research Institute, Technological University Dublin, City Campus, Camden Row, Dublin 8, Ireland; School of Physics and Optometric & Clinical Sciences, Technological University Dublin, City Campus, Grangegorman, Dublin 7, Ireland.
| | - Orla Howe
- School of Biological and Health Sciences, Technological University Dublin, City Campus, Grangegorman, Dublin 7, Ireland
| | - Paul Cahill
- School of Biotechnology, Dublin City University, Glasnevin, Dublin 9, Ireland
| | - Hugh J Byrne
- FOCAS Research Institute, Technological University Dublin, City Campus, Camden Row, Dublin 8, Ireland
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Gertsenshteyn I, Epel B, Ahluwalia A, Kim H, Fan X, Barth E, Zamora M, Markiewicz E, Tsai HM, Sundramoorthy S, Leoni L, Lukens J, Bhuiyan M, Freifelder R, Kucharski A, Giurcanu M, Roman BB, Karczmar G, Kao CM, Halpern H, Chen CT. The optimal 18F-fluoromisonidazole PET threshold to define tumor hypoxia in preclinical squamous cell carcinomas using pO 2 electron paramagnetic resonance imaging as reference truth. Eur J Nucl Med Mol Imaging 2022; 49:4014-4024. [PMID: 35792927 PMCID: PMC9529789 DOI: 10.1007/s00259-022-05889-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/19/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE To identify the optimal threshold in 18F-fluoromisonidazole (FMISO) PET images to accurately locate tumor hypoxia by using electron paramagnetic resonance imaging (pO2 EPRI) as ground truth for hypoxia, defined by pO2 [Formula: see text] 10 mmHg. METHODS Tumor hypoxia images in mouse models of SCCVII squamous cell carcinoma (n = 16) were acquired in a hybrid PET/EPRI imaging system 2 h post-injection of FMISO. T2-weighted MRI was used to delineate tumor and muscle tissue. Dynamic contrast enhanced (DCE) MRI parametric images of Ktrans and ve were generated to model tumor vascular properties. Images from PET/EPR/MRI were co-registered and resampled to isotropic 0.5 mm voxel resolution for analysis. PET images were converted to standardized uptake value (SUV) and tumor-to-muscle ratio (TMR) units. FMISO uptake thresholds were evaluated using receiver operating characteristic (ROC) curve analysis to find the optimal FMISO threshold and unit with maximum overall hypoxia similarity (OHS) with pO2 EPRI, where OHS = 1 shows perfect overlap and OHS = 0 shows no overlap. The means of dice similarity coefficient, normalized Hausdorff distance, and accuracy were used to define the OHS. Monotonic relationships between EPRI/PET/DCE-MRI were evaluated with the Spearman correlation coefficient ([Formula: see text]) to quantify association of vasculature on hypoxia imaged with both FMISO PET and pO2 EPRI. RESULTS FMISO PET thresholds to define hypoxia with maximum OHS (both OHS = 0.728 [Formula: see text] 0.2) were SUV [Formula: see text] 1.4 [Formula: see text] SUVmean and SUV [Formula: see text] 0.6 [Formula: see text] SUVmax. Weak-to-moderate correlations (|[Formula: see text]|< 0.70) were observed between PET/EPRI hypoxia images with vascular permeability (Ktrans) or fractional extracellular-extravascular space (ve) from DCE-MRI. CONCLUSION This is the first in vivo comparison of FMISO uptake with pO2 EPRI to identify the optimal FMISO threshold to define tumor hypoxia, which may successfully direct hypoxic tumor boosts in patients, thereby enhancing tumor control.
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Affiliation(s)
- Inna Gertsenshteyn
- Department of Radiology, The University of Chicago, Chicago, IL, USA
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL, USA
- Center for EPR Imaging In Vivo Physiology, The University of Chicago, Chicago, IL, USA
| | - Boris Epel
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL, USA
- Center for EPR Imaging In Vivo Physiology, The University of Chicago, Chicago, IL, USA
| | | | - Heejong Kim
- Department of Radiology, The University of Chicago, Chicago, IL, USA
| | - Xiaobing Fan
- Department of Radiology, The University of Chicago, Chicago, IL, USA
- Integrated Small Animal Imaging Research Resource, OSRF, The University of Chicago, Chicago, IL, USA
| | - Eugene Barth
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL, USA
- Center for EPR Imaging In Vivo Physiology, The University of Chicago, Chicago, IL, USA
| | - Marta Zamora
- Department of Radiology, The University of Chicago, Chicago, IL, USA
- Integrated Small Animal Imaging Research Resource, OSRF, The University of Chicago, Chicago, IL, USA
| | - Erica Markiewicz
- Integrated Small Animal Imaging Research Resource, OSRF, The University of Chicago, Chicago, IL, USA
| | - Hsiu-Ming Tsai
- Integrated Small Animal Imaging Research Resource, OSRF, The University of Chicago, Chicago, IL, USA
| | - Subramanian Sundramoorthy
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL, USA
- Center for EPR Imaging In Vivo Physiology, The University of Chicago, Chicago, IL, USA
| | - Lara Leoni
- Integrated Small Animal Imaging Research Resource, OSRF, The University of Chicago, Chicago, IL, USA
| | - John Lukens
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL, USA
- Center for EPR Imaging In Vivo Physiology, The University of Chicago, Chicago, IL, USA
| | - Mohammed Bhuiyan
- Department of Radiology, The University of Chicago, Chicago, IL, USA
| | | | - Anna Kucharski
- Department of Radiology, The University of Chicago, Chicago, IL, USA
| | - Mihai Giurcanu
- Department of Public Health Sciences, The University of Chicago, Chicago, IL, USA
| | - Brian B Roman
- Department of Radiology, The University of Chicago, Chicago, IL, USA
- Integrated Small Animal Imaging Research Resource, OSRF, The University of Chicago, Chicago, IL, USA
| | - Gregory Karczmar
- Department of Radiology, The University of Chicago, Chicago, IL, USA
- Integrated Small Animal Imaging Research Resource, OSRF, The University of Chicago, Chicago, IL, USA
| | - Chien-Min Kao
- Department of Radiology, The University of Chicago, Chicago, IL, USA
- Integrated Small Animal Imaging Research Resource, OSRF, The University of Chicago, Chicago, IL, USA
| | - Howard Halpern
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL, USA
- Center for EPR Imaging In Vivo Physiology, The University of Chicago, Chicago, IL, USA
| | - Chin-Tu Chen
- Department of Radiology, The University of Chicago, Chicago, IL, USA.
- Integrated Small Animal Imaging Research Resource, OSRF, The University of Chicago, Chicago, IL, USA.
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Abdo RA, Lamare F, Fernandez P, Bentourkia M. Quantification of Hypoxia in Human Glioblastoma using PET with 18F-FMISO. Nucl Med Mol Imaging 2021; 55:107-115. [PMID: 34109007 DOI: 10.1007/s13139-021-00693-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/16/2021] [Accepted: 03/12/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose This study aimed to investigate the results of compartmental modeling (CM) and spectral analysis (SA) generated with dynamic 18F-FMISO tumor images. Besides, the regular tissue-to-blood ratio (TBR) images were derived and compared with the dynamic models. Methods Nine subjects with glioblastoma underwent PET/CT imaging with the 18F-FMISO tracer. The protocol for PET imaging began with 15 min in dynamic mode and two 10-min duration static images at 120 min and 180 min post-injection. We used the two-tissue compartmental model for CM at the voxel basis, and we conducted SA to estimate the 18F-FMISO accumulation within each voxel. We also investigated the usual tumor-to-blood ratio (TBR) for comparison. Results The images of the tumor showed different patterns of hypoxia and necrosis as a function of PET scanning times, while CM and SA methods based on dynamic PET imaging equally located tumor hypoxia. The mean correlation of Ki images of all subjects between CM and SA was 0.63 ± 0.19 (0.24-0.86). CM produced less noisy K i images than SA, and, in the contrary, SA produced accumulation component images more clear than with CM. CM-K i and SA-K i images were correlated with TBR images (r = 0.72 ± 0.20 and 0.56 ± 0.26, respectively). In the only subject having a continuously increasing tumor time-activity curve, the k 3 image showed a high uptake in the necrosis region which was not apparent in TBR or K i images. Conclusion Based on these results, the combination of CM and SA approaches was found more appropriate in generating voxel-based hypoxia images.
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Affiliation(s)
- Redha-Alla Abdo
- Department of Nuclear Medicine and Radiobiology, University of Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC J1H 5N4 Canada
| | - Frédéric Lamare
- Service de Médecine Nucléaire, Université de Bordeaux-II, EPHE, Avenue du Haut-Lévêque, 33604 Pessac cedex, Bordeaux, France
| | - Philippe Fernandez
- Service de Médecine Nucléaire, Université de Bordeaux-II, EPHE, Avenue du Haut-Lévêque, 33604 Pessac cedex, Bordeaux, France
| | - M'hamed Bentourkia
- Department of Nuclear Medicine and Radiobiology, University of Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC J1H 5N4 Canada
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Cao X, Allu SR, Jiang S, Gunn Bs JR, Yao PhD C, Xin PhD J, Bruza PhD P, Gladstone ScD DJ, Jarvis Md PhD LA, Tian PhD J, Swartz Md Msph PhD HM, Vinogradov PhD SA, Pogue PhD BW. High-Resolution pO 2 Imaging Improves Quantification of the Hypoxic Fraction in Tumors During Radiation Therapy. Int J Radiat Oncol Biol Phys 2020; 109:603-613. [PMID: 33002542 DOI: 10.1016/j.ijrobp.2020.09.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE The extreme microscopic heterogeneity of tumors makes it difficult to characterize tumor hypoxia. We evaluated how changes in the spatial resolution of oxygen imaging could alter measures of tumor hypoxia and their correlation to radiation therapy response. METHODS AND MATERIALS Cherenkov-Excited Luminescence Imaging in combination with an oxygen probe, Oxyphor PtG4 was used to directly image tumor pO2 distributions with 0.2 mm spatial resolution at the time of radiation delivery. These pO2 images were analyzed with variations of reduced spatial resolution from 0.2 mm to 5 mm, to investigate the influence of how reduced imaging spatial resolution would affect the observed tumor hypoxia. As an in vivo validation test, mice bearing tumor xenografts were imaged for hypoxic fraction and median pO2 to examine the predictive link with tumor response to radiation therapy, while accounting for spatial resolution. RESULTS In transitioning from voxel sizes of 200 μm to 3 mm, the median pO2 values increased by a few mm Hg, and the hypoxic fraction decreased by more than 50%. When looking at radiation-responsive tumors, the median pO2 values changed just a few mm Hg as a result of treatment, and the hypoxic fractions changed by as much as 50%. This latter change, however, could only be seen when sampling was performed with high spatial resolution. Median pO2 or similar quantities obtained from low resolution measurements are commonly used in clinical practice, however these parameters are much less sensitive to changes in the tumor microenvironment than the tumor hypoxic fraction obtained from high-resolution oxygen images. CONCLUSIONS This study supports the hypothesis that for adequate measurements of the tumor response to radiation therapy, oxygen imaging with high spatial resolution is required to accurately characterize the hypoxic fraction.
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Affiliation(s)
- Xu Cao
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire; Xidian University, Engineering Research Center of Molecular & Neuroimaging, Ministry of Education, School of Life Science and Technology, Xi'an, Shaanxi, China
| | - Srinivasa Rao Allu
- Department of Biochemistry and Biophysics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Chemistry, School or Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shudong Jiang
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jason R Gunn Bs
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire
| | - Cuiping Yao PhD
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire; Xi'an Jiaotong University, Institute of Biomedical Analytical Technology and Instrumentation, School of Life Science and Technology, Key Laboratory of Biomedical Information Engineering of Ministry of Education, Xi'an, Shaanxi, China
| | - Jing Xin PhD
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire; Xi'an Jiaotong University, Institute of Biomedical Analytical Technology and Instrumentation, School of Life Science and Technology, Key Laboratory of Biomedical Information Engineering of Ministry of Education, Xi'an, Shaanxi, China
| | - Petr Bruza PhD
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire
| | - David J Gladstone ScD
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Lesley A Jarvis Md PhD
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Jie Tian PhD
- Xidian University, Engineering Research Center of Molecular & Neuroimaging, Ministry of Education, School of Life Science and Technology, Xi'an, Shaanxi, China; CAS Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | | | - Sergei A Vinogradov PhD
- Department of Biochemistry and Biophysics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Chemistry, School or Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian W Pogue PhD
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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Busk M, Overgaard J, Horsman MR. Imaging of Tumor Hypoxia for Radiotherapy: Current Status and Future Directions. Semin Nucl Med 2020; 50:562-583. [PMID: 33059825 DOI: 10.1053/j.semnuclmed.2020.05.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Tumor regions that are transiently or chronically undersupplied with oxygen (hypoxia) and nutrients, and enriched with acidic waste products, are common due to an abnormal and inefficient tumor vasculature, and a deviant highly glycolytic energy metabolism. There is compelling evidence that tumor hypoxia is strongly linked to poor prognosis since oxygen-deprived cells are highly resistant to therapy including radio- and chemotherapy, and survival of such cells is a primary cause of disease relapse. Despite a general improvement in cancer survival rates, hypoxia remains a formidable challenge. Recent progress in radiation delivery systems with improved spatial accuracy that allows dose escalation to hypoxic tumors or even tumor subvolumes, and the development of hypoxia-selective drugs, including bioreductive prodrugs, holds great promise for overcoming this obstacle. However, apart from one notable exception, translation of promising preclinical therapies to the clinic have largely been disappointing. A major obstacle in clinical trials on hypoxia-targeting strategies has been the lack of reliable information on tumor hypoxia, which is crucial for patient stratification into groups of those that are likely to benefit from intervention and those who are not. Further, in many newer trials on hypoxia-selective drugs the choice of cancer disease and combination therapy has not always been ideal, especially not for clinical proof of principle trials. Clearly, there is a pending need for clinical applicable methodologies that may allow us to quantify, map and monitor hypoxia. Molecular imaging may provide the information required for narrowing the gap between potential and actual patient benefit of hypoxia-targeting strategies. The grand majority of preclinical and clinical work has focused on the usefulness of PET-based assessment of hypoxia-selective tracers. Since hypoxia PET has profound inherent weaknesses, the use of other methodologies, including more indirect methods that quantifies blood flow or oxygenation-dependent flux changes through ATP-generating pathways (eg, anaerobic glycolysis) is being extensively studied. In this review, we briefly discuss established and emerging hypoxia-targeting strategies, followed by a more thorough evaluation of strengths and weaknesses of clinical applicable imaging methodologies that may guide timely treatment intensification to overcome hypoxia-driven resistance. Historically, most evidence for the linkage between hypoxia and poor outcome is based on work in the field of radiotherapy. Therefore, main emphasis in this review is on targeting and imaging of hypoxia for improved radiotherapy.
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Affiliation(s)
- Morten Busk
- Experimental Clinical Oncology, Department of Oncology, Aarhus University Hospital (AUH), Aarhus, Denmark; Danish Centre for Particle Therapy, (AUH), Aarhus, Denmark.
| | - Jens Overgaard
- Experimental Clinical Oncology, Department of Oncology, Aarhus University Hospital (AUH), Aarhus, Denmark
| | - Michael R Horsman
- Experimental Clinical Oncology, Department of Oncology, Aarhus University Hospital (AUH), Aarhus, Denmark
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Paredes-Cisneros I, Karger CP, Caprile P, Nolte D, Espinoza I, Gago-Arias A. Simulation of hypoxia PET-tracer uptake in tumours: Dependence of clinical uptake-values on transport parameters and arterial input function. Phys Med 2020; 70:109-117. [PMID: 32006939 DOI: 10.1016/j.ejmp.2020.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/10/2020] [Accepted: 01/11/2020] [Indexed: 11/27/2022] Open
Abstract
Poor radiotherapy outcome is in many cases related to hypoxia, due to the increased radioresistance of hypoxic tumour cells. Positron emission tomography may be used to non-invasively assess the oxygenation status of the tumour using hypoxia-specific radiotracers. Quantification and interpretation of these images remains challenging, since radiotracer binding and oxygen tension are not uniquely related. Computer simulation is a useful tool to improve the understanding of tracer dynamics and its relation to clinical uptake parameters currently used to quantify hypoxia. In this study, a model for simulating oxygen and radiotracer distribution in tumours was implemented to analyse the impact of physiological transport parameters and of the arterial input function (AIF) on: oxygenation histograms, time-activity curves, tracer binding and clinical uptake-values (tissue-to-blood ratio, TBR, and a composed hypoxia-perfusion metric, FHP). Results were obtained for parallel and orthogonal vessel architectures and for vascular fractions (VFs) of 1% and 3%. The most sensitive parameters were the AIF and the maximum binding rate (Kmax). TBR allowed discriminating VF for different AIF, and FHP for different Kmax, but neither TBR nor FHP were unbiased in all cases. Biases may especially occur in the comparison of TBR- or FHP-values between different tumours, where the relation between measured and actual AIF may vary. Thus, these parameters represent only surrogates rather than absolute measurements of hypoxia in tumours.
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Affiliation(s)
- Isabela Paredes-Cisneros
- German Cancer Research Center (DKFZ), Department of Medical Physics in Radiation Oncology, Heidelberg, Germany; Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany; Heidelberg University, Faculty of Physics and Astronomy, Heidelberg, Germany.
| | - Christian P Karger
- German Cancer Research Center (DKFZ), Department of Medical Physics in Radiation Oncology, Heidelberg, Germany; Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany
| | - Paola Caprile
- Pontificia Universidad Católica de Chile, Institute of Physics, Santiago, Chile
| | - David Nolte
- Universidad de Chile, Center for Mathematical Modeling, Santiago, Chile; University of Groningen, Johann Bernoulli Institute, Groningen, The Netherlands
| | - Ignacio Espinoza
- Pontificia Universidad Católica de Chile, Institute of Physics, Santiago, Chile
| | - Araceli Gago-Arias
- Pontificia Universidad Católica de Chile, Institute of Physics, Santiago, Chile; Instituto de Investigación Sanitaria de Santiago (IDIS), Group of Medical Physics and Biomathematics, Santiago de Compostela, Spain
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11
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Kobayashi K, Manabe O, Hirata K, Yamaguchi S, Kobayashi H, Terasaka S, Toyonaga T, Furuya S, Magota K, Kuge Y, Kudo K, Shiga T, Tamaki N. Influence of the scan time point when assessing hypoxia in 18F-fluoromisonidazole PET: 2 vs. 4 h. Eur J Nucl Med Mol Imaging 2019; 47:1833-1842. [PMID: 31781832 DOI: 10.1007/s00259-019-04626-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/18/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE 18F-fluoromisonidazole (18F-FMISO) is the most widely used positron emission tomography (PET) tracer for imaging tumor hypoxia. Previous reports suggested that the time from injection to the scan may affect the assessment of 18F-FMISO uptake. Herein, we directly compared the images at 2 h and 4 h after a single injection of 18F-FMISO. METHODS Twenty-three patients with or suspected of having a brain tumor were scanned twice at 2 and 4 h following an intravenous injection of 18F-FMISO. We estimated the mean standardized uptake value (SUV) of the gray matter and white matter and the gray-to-white matter ratio in the background brain tissue from the two scans. We also performed a semi-quantitative analysis using the SUVmax and maximum tumor-to-normal ratio (TNR) for the tumor. RESULTS At 2 h, the SUVmean of gray matter was significantly higher than that of white matter (median 1.23, interquartile range (IQR) 1.10-1.32 vs. 1.04, IQR 0.95-1.16, p < 0.0001), whereas at 4 h, it significantly decreased to approach that of the white matter (1.10, IQR 1.00-1.23 vs. 1.02, IQR 0.93-1.13, p = NS). The gray-to-white matter ratio thus significantly declined from 1.17 (IQR 1.14-1.19) to 1.09 (IQR 1.07-1.10) (p < 0.0001). All 7 patients with glioblastoma showed significant increases in the SUVmax (2.20, IQR 1.67-3.32 at 2 h vs. 2.65, IQR 1.74-4.41 at 4 h, p = 0.016) and the TNR (1.75, IQR 1.40-2.38 at 2 h vs. 2.34, IQR 1.67-3.60 at 4 h, p = 0.016). CONCLUSION In the assessment of hypoxic tumors, 18F-FMISO PET for hypoxia imaging should be obtained at 4 h rather than 2 h after the injection.
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Affiliation(s)
- Kentaro Kobayashi
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Hokkaido, 060-8638, Japan
| | - Osamu Manabe
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Hokkaido, 060-8638, Japan
| | - Kenji Hirata
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Hokkaido, 060-8638, Japan.
| | - Shigeru Yamaguchi
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | | | | | - Takuya Toyonaga
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Sho Furuya
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Hokkaido, 060-8638, Japan
| | - Keiichi Magota
- Division of Medical Imaging and Technology, Hokkaido University Hospital, Sapporo, Japan
| | - Yuji Kuge
- Central Institute of Isotope Science, Hokkaido University, Sapporo, Japan
| | - Kohsuke Kudo
- Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education, Hokkaido University, Sapporo, Japan
| | - Tohru Shiga
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Hokkaido, 060-8638, Japan
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University, Kyoto, Japan
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Busk M, Horsman MR, Overgaard J, Jakobsen S. Dual-tracer PET of viable tumor volume and hypoxia for identification of necrosis-containing radio-resistant Sub-volumes. Acta Oncol 2019; 58:1476-1482. [PMID: 31432722 DOI: 10.1080/0284186x.2019.1648864] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Positron emission tomography (PET) using hypoxia-selective tracers like FAZA may guide radiation dose-escalation approaches. However, poor resolution combined with slow tracer retention in relatively inaccessible target cells and slow clearance of unbound tracer results in low-contrast images, and areas where viable hypoxic tracer retaining cells and necrosis (no tracer) are intermixed may pass unnoticed during image thresholding. Here we hypothesized that a clinical feasible one-day dual tracer approach that combines a short-lived (e.g., 11C labeled) metabolic tracer that provides voxel-wise information on viable tissue volume (preferably independently of tumor microenvironment) and a hypoxia marker, may limit threshold-based errors. Material and methods: 11C-acetate and 11C-methionine uptake was quantified in tumor cell lines under tumor microenvironment-mimicking conditions of high/low O2 (21%/0%) and pH (7.4/6.7). Next, tumor-bearing mice were administered FAZA and sacrificed 1 h (mimics a clinical low-contrast image scenario) or 4 h (high contrast) later. In addition, all mice were administered pimonidazole (hypoxia) and 14C-methionine 1 h prior to sacrifice. Tumor tissue sections were analyzed using dual-tracer autoradiography. Finally, FAZA, or FAZA normalized to 14C-methionine retention (to adjust for differences in viable tissue volume) was compared to hypoxic fraction (deduced from immune-histological analysis of pimonidazole; ground truth) in PET-mimicking macroscopic pixels with variable extent of necrosis/hypoxia. Results/conclusions: Low pH stimulated 11C-acetate retention in many cell lines, and uptake was further modified by anoxia, compromising its usefulness as a universal marker of viable tumor volume. In contrast, 11C-methionine was largely unaffected by the in vitro microenvironment and was further tested in mice. Necrosis increased the risk of missing hypoxia-containing pixels during thresholding and hypoxic fraction and FAZA signal correlated poorly in the low contrast-scenario. Voxel-based normalization to 14C-methionine increased the likelihood of detecting voxels harboring hypoxic cells profoundly, but did not consistently improve the correlation between the density of hypoxic cells and tracer signal.
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Affiliation(s)
- Morten Busk
- Department of Experimental Clinical Oncology, Aarhus University Hospital (AUH), Aarhus, Denmark
| | - Michael R. Horsman
- Department of Experimental Clinical Oncology, Aarhus University Hospital (AUH), Aarhus, Denmark
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital (AUH), Aarhus, Denmark
| | - Steen Jakobsen
- Department of Nuclear Medicine and PET Centre, AUH, Aarhus, Denmark
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Analysis of hypoxia in human glioblastoma tumors with dynamic 18F-FMISO PET imaging. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2019; 42:981-993. [PMID: 31520369 DOI: 10.1007/s13246-019-00797-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/27/2019] [Accepted: 08/31/2019] [Indexed: 02/07/2023]
Abstract
Gliomas are the most common type of primary brain tumors and are classified as grade IV. Necrosis and hypoxia are essential diagnostic features which result in poor prognosis of gliomas. The aim of this study was to report quantitative temporal analyses aiming at determining the hypoxic regions in glioblastoma multiforme and to suggest an optimal time for the clinical single scan of hypoxia. Nine subjects were imaged with PET and 18F-FMISO in dynamic mode for 15 min followed with static scans at 2, 3 and 4 h post-injection. Spectral analysis, tumor-to-blood ratio (TBR) and tumor-to-normal tissue ratio (TNR) were used to delimit perfused and hypoxic tumor regions. TBR and TNR images were further scaled by thresholding at 1.2, 1.4, 2 and 2.5 levels. The images showed a varying tumor volume with time. TBR produced broader images of the tumor than TNR considering the same thresholds on intensity. Spectral analysis reliably determined hypoxia with different degrees of perfusion. By comparing TBR and TNR with spectral analysis images, weak to moderate correlation coefficients were found for most thresholding values and imaging times (range: 0 to 0.69). Hypoxic volume (HV) estimated from the net uptake rate (Ki) were changing among imaging times. The minimum HV changes were found between 3 h and 4 h, confirming that after 3 h, there was a very low exchange of 81F-FMISO between blood and tumor. On the other hand, hypoxia started to dominate the perfused tissue at 90 min, suggesting this time is suitable for a single scan acquisition irrespective of tumor status being highly hypoxic or perfused. At this time, TBR and TNR were respectively found in the nine subjects as 1.72 ± 0.22 and 1.74 ± 0.19.
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Ibrahim A, Vallières M, Woodruff H, Primakov S, Beheshti M, Keek S, Refaee T, Sanduleanu S, Walsh S, Morin O, Lambin P, Hustinx R, Mottaghy FM. Radiomics Analysis for Clinical Decision Support in Nuclear Medicine. Semin Nucl Med 2019; 49:438-449. [DOI: 10.1053/j.semnuclmed.2019.06.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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15
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The Roles of Hypoxia Imaging Using 18F-Fluoromisonidazole Positron Emission Tomography in Glioma Treatment. J Clin Med 2019; 8:jcm8081088. [PMID: 31344848 PMCID: PMC6723061 DOI: 10.3390/jcm8081088] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 07/16/2019] [Accepted: 07/22/2019] [Indexed: 12/14/2022] Open
Abstract
Glioma is the most common malignant brain tumor. Hypoxia is closely related to the malignancy of gliomas, and positron emission tomography (PET) can noninvasively visualize the degree and the expansion of hypoxia. Currently, 18F-fluoromisonidazole (FMISO) is the most common radiotracer for hypoxia imaging. The clinical usefulness of FMISO PET has been established; it can distinguish glioblastomas from lower-grade gliomas and can predict the microenvironment of a tumor, including necrosis, vascularization, and permeability. FMISO PET provides prognostic information, including survival and treatment response information. Because hypoxia decreases a tumor’s sensitivity to radiation therapy, dose escalation to an FMISO-positive volume is an attractive strategy. Although this idea is not new, an insufficient amount of evidence has been obtained regarding this concept. New tracers for hypoxia imaging such as 18F-DiFA are being tested. In the future, hypoxia imaging will play an important role in glioma management.
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Watanabe S, Shiga T, Hirata K, Magota K, Okamoto S, Toyonaga T, Higashikawa K, Yasui H, Kobayashi J, Nishijima KI, Iseki K, Matsumoto H, Kuge Y, Tamaki N. Biodistribution and radiation dosimetry of the novel hypoxia PET probe [ 18F]DiFA and comparison with [ 18F]FMISO. EJNMMI Res 2019; 9:60. [PMID: 31278504 PMCID: PMC6611855 DOI: 10.1186/s13550-019-0525-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/05/2019] [Indexed: 02/03/2023] Open
Abstract
Background To facilitate hypoxia imaging in a clinical setting, we developed 1-(2,2-dihydroxymethyl-3-[18F]-fluoropropyl)-2-nitroimidazole ([18F]DiFA) as a new tracer that targets tumor hypoxia with its lower lipophilicity and efficient radiosynthesis. Here, we evaluated the radiation dosage, biodistribution, human safety, tolerability, and early elimination after the injection of [18F]DiFA in healthy subjects, and we performed a preliminary clinical study of patients with malignant tumors in a comparison with [18F]fluoromisonidazole ([18F]FMISO). Results The single administration of [18F]DiFA in 8 healthy male adults caused neither adverse events nor abnormal clinical findings. Dynamic and sequential whole-body scans showed that [18F]DiFA was rapidly cleared from all of the organs via the hepatobiliary and urinary systems. The whole-body mean effective dose of [18F]DiFA estimated by using the medical internal radiation dose (MIRD) schema with organ level internal dose assessment/exponential modeling (OLINDA/EXM) computer software 1.1 was 14.4 ± 0.7 μSv/MBq. Among the organs, the urinary bladder received the largest absorbed dose (94.7 ± 13.6 μSv/MBq). The mean absorbed doses of the other organs were equal to or less than those from other hypoxia tracers. The excretion of radioactivity via the urinary system was very rapid, reaching 86.4 ± 7.1% of the administered dose. For the preliminary clinical study, seven patients were subjected to [18F]FMISO and [18F]DiFA positron emission tomography (PET) at 48-h intervals to compare the two tracers’ diagnostic ability for tumor hypoxia. The results of the tumor hypoxia evaluation by [18F]DiFA PET at 1 h and 2 h were not significantly different from those obtained with [18F]FMISO PET at 4 h ([18F]DiFA at 1 h, p = 0.32; [18F]DiFA at 2 h, p = 0.08). Moreover, [18F]DiFA PET at both 1 h (k = 0.68) and 2 h (k = 1.00) showed better inter-observer reproducibility than [18F]FMISO PET at 4 h (k = 0.59). Conclusion [18F]DiFA is well tolerated, and its radiation dose is comparable to those of other hypoxia tracers. [18F]DiFA is very rapidly cleared via the urinary system. [18F]DiFA PET generated comparable images to [18F]FMISO PET in hypoxia imaging with shorter waiting time, demonstrating the promising potential of [18F]DiFA PET for hypoxia imaging and for a multicenter trial. Electronic supplementary material The online version of this article (10.1186/s13550-019-0525-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shiro Watanabe
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Tohru Shiga
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Kenji Hirata
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Keiichi Magota
- Division of Medical Imaging and Technology, Hokkaido University Hospital, Kita-14, Nishi-5, Kita-ku, Sapporo, 060-8648, Japan
| | - Shozo Okamoto
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.,Department of Radiology, Obihiro Kosei Hospital, West 14 South 10-1, Obihiro, 080-0024, Japan
| | - Takuya Toyonaga
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Kei Higashikawa
- Central Institute of Isotope Science, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hironobu Yasui
- Central Institute of Isotope Science, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Jun Kobayashi
- Department of Pharmacy, Hokkaido University Hospital, Kita-14, Nishi-5, Kita-ku, Sapporo, 060-8648, Japan
| | - Ken-Ichi Nishijima
- Central Institute of Isotope Science, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.,Advanced Clinical Research Center, Fukushima Global Medical Science Center, Fukushima Medical University, 1 Hikariga-oka, Fukushima, 960-1295, Japan
| | - Ken Iseki
- Department of Pharmacy, Hokkaido University Hospital, Kita-14, Nishi-5, Kita-ku, Sapporo, 060-8648, Japan.,Faculty of Pharmaceutical Sciences, Kita-14, Nishi-5, Kita-ku, Sapporo, 060-8648, Japan
| | - Hiroki Matsumoto
- Research Centre, Nihon Medi-Physics Co., Ltd., 3-1 Kitasode, Sodegaura, 299-0266, Japan
| | - Yuji Kuge
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.,Central Institute of Isotope Science, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Nagara Tamaki
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.,Department of Radiology, Kyoto Prefectural University of Medicine, Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
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Thorwarth D, Welz S, Mönnich D, Pfannenberg C, Nikolaou K, Reimold M, La Fougère C, Reischl G, Mauz PS, Paulsen F, Alber M, Belka C, Zips D. Prospective Evaluation of a Tumor Control Probability Model Based on Dynamic 18F-FMISO PET for Head and Neck Cancer Radiotherapy. J Nucl Med 2019; 60:1698-1704. [PMID: 31076504 DOI: 10.2967/jnumed.119.227744] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/02/2019] [Indexed: 12/23/2022] Open
Abstract
Our purpose was to evaluate an imaging parameter-response relationship between the extent of tumor hypoxia quantified by dynamic 18F-fluoromisonidazole (18F-FMISO) PET/CT and the risk of relapse after radiotherapy in patients with head and neck cancer. Methods: Before a prospective cohort of 25 head and neck cancer patients started radiotherapy, they were examined with dynamic 18F-FMISO PET/CT 0-240 min after tracer injection. 18F-FMISO image parameters, including a hypoxia metric, M FMISO , derived from pharmacokinetic modeling of dynamic 18F-FMISO and maximum tumor-to-muscle ratio (TMRmax) at 4 h after injection, gross tumor volume (GTV), relative hypoxic volume based on M FMISO , and a logistic regression model combining GTV and TMRmax, were assessed and compared with a previous training cohort (n = 15). Dynamic 18F-FMISO was used to validate a tumor control probability model based on M FMISO The prognostic potential with respect to local control of all potential parameters was validated using the concordance index for univariate Cox regression models determined from the training cohort, in addition to Kaplan-Meier analysis including the log-rank test. Results: The tumor control probability model was confirmed, indicating that dynamic 18F-FMISO allows stratification of patients into different risk groups according to radiotherapy outcome. In this study, M FMISO was the only parameter that was confirmed as prognostic in the independent validation cohort (concordance index, 0.71; P = 0.004). All other investigated parameters, such as TMRmax, GTV, relative hypoxic volume, and the combination of GTV and TMRmax, were not able to stratify patient groups according to outcome in this validation cohort (P = not statistically significant). Conclusion: In this study, the relationship between M FMISO and the risk of relapse was prospectively validated. The data support further evaluation and external validation of dynamic 18F-FMISO PET/CT as a promising method for patient stratification and hypoxia-based radiotherapy personalization, including dose painting.
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Affiliation(s)
- Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Tübingen, Germany .,German Cancer Consortium, Tübingen, Germany, and German Cancer Research Center, Heidelberg, Germany
| | - Stefan Welz
- Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
| | - David Mönnich
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
| | - Christina Pfannenberg
- Diagnostic and Interventional Radiology, Department of Radiology, University of Tübingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Diagnostic and Interventional Radiology, Department of Radiology, University of Tübingen, Tübingen, Germany
| | - Matthias Reimold
- Department of Nuclear Medicine, University of Tübingen, Tübingen, Germany
| | | | - Gerald Reischl
- Department of Preclinical Imaging and Radiopharmacy, University of Tübingen, Tübingen, Germany
| | - Paul-Stefan Mauz
- Department of Otorhinolaryngology, University of Tübingen, Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
| | - Markus Alber
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Tübingen, Germany.,Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany; and
| | - Claus Belka
- German Cancer Consortium, Tübingen, Germany, and German Cancer Research Center, Heidelberg, Germany.,Department of Radiation Oncology, LMU Munich, München, Germany
| | - Daniel Zips
- German Cancer Consortium, Tübingen, Germany, and German Cancer Research Center, Heidelberg, Germany.,Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
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18
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Bandurska-Luque A, Löck S, Haase R, Richter C, Zöphel K, Perrin R, Appold S, Krause M, Steinbach J, Kotzerke J, Hofheinz F, Zips D, Baumann M, Troost EG. Correlation between FMISO-PET based hypoxia in the primary tumour and in lymph node metastases in locally advanced HNSCC patients. Clin Transl Radiat Oncol 2019; 15:108-112. [PMID: 30834349 PMCID: PMC6384311 DOI: 10.1016/j.ctro.2019.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/13/2019] [Accepted: 02/14/2019] [Indexed: 02/07/2023] Open
Abstract
We investigated correlation between hypoxia in the primary tumour and LN before and during RCTx. The Correlation between primary tumour and LN hypoxia is stronger in patients with large LN compared to the entire cohort. We advise to perform a comprehensive evaluation of hypoxia in the primary tumour and LN.
Purpose This secondary analysis of the prospective study on repeat [18F]fluoromisonidazole (FMISO)-PET in patients with locally advanced head and neck squamous cell carcinoma (HNSCC) assessed the correlation of hypoxia in the primary tumour and lymph node metastases (LN) prior to and during primary radiochemotherapy. Methods This analysis included forty-five LN-positive HNSCC patients having undergone FMISO-PET/CTs at baseline, and at week 1, 2 and 5 of radiochemotherapy. The quantitative FMISO-PET/CT parameters maximum standardised uptake value (SUVmax, corrected for partial volume effect) and peak tumour-to-background ratio (TBRpeak) were estimated in the primary tumour as well as in index and large LN, respectively. Statistical analysis was performed using the Spearman correlation coefficient ρ. Results In 15 patients with large LN (FDG-PET positive volume >5 ml), there was a significant correlation between the hypoxia measured in the primary tumour and the large LN at three out of four time-points using the TBRpeak (baseline: ρ = 0.57, p = 0.006; week 2: ρ = 0.64, p = 0.003 and week 5: ρ = 0.68, p = 0.001). For the entire cohort (N = 45) only assessed prior to the treatment, there was a statistically significant, though weak correlation between FMISO-SUVmax of the primary tumour and the index LN (ρ = 0.36, p = 0.015). Conclusions We observed a significant correlation between FMISO-based hypoxia in the primary tumour and large lymph node(s) in advanced stage HNSCC patients. However, since most patients only had relatively small hypoxic lymph node metastases, a comprehensive assessment of the primary tumour and lymph node hypoxia is essential.
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Affiliation(s)
- Anna Bandurska-Luque
- 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
- Corresponding author at: Department of Radiotherapy and Radiation Oncology, University Hospital Carl Gustav Carus Dresden, Fetscherstrasse 74, 01307 Dresden, Germany.
| | - Steffen Löck
- 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 Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Robert Haase
- 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
| | - Christian Richter
- 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 Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
| | - Klaus Zöphel
- 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 Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases, Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz Association / Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Rosalind Perrin
- 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
| | - Steffen Appold
- 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
| | - 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
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
- National Center for Tumor Diseases, Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz Association / Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
- Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Jörg Steinbach
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Rossendorf, Germany
- Faculty of Chemistry and Food Chemistry, Technische Universität Dresden, Dresden, Germany
| | - Jörg Kotzerke
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Frank Hofheinz
- Helmholtz-Zentrum Dresden-Rossendorf, PET Center, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Daniel Zips
- Department of Radiation Oncology, Eberhard Karls Universität Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, Germany
| | - Michael Baumann
- 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 Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases, Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz Association / Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
- Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Esther G.C. Troost
- 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 Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
- National Center for Tumor Diseases, Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz Association / Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
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How to Modulate Tumor Hypoxia for Preclinical In Vivo Imaging Research. CONTRAST MEDIA & MOLECULAR IMAGING 2018; 2018:4608186. [PMID: 30420794 PMCID: PMC6211155 DOI: 10.1155/2018/4608186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/24/2018] [Accepted: 08/13/2018] [Indexed: 01/20/2023]
Abstract
Tumor hypoxia is related with tumor aggressiveness, chemo- and radiotherapy resistance, and thus a poor clinical outcome. Therefore, over the past decades, every effort has been made to develop strategies to battle the negative prognostic influence of tumor hypoxia. For appropriate patient selection and follow-up, noninvasive imaging biomarkers such as positron emission tomography (PET) radiolabeled ligands are unprecedentedly needed. Importantly, before being able to implement these new therapies and potential biomarkers into the clinical setting, preclinical in vivo validation in adequate animal models is indispensable. In this review, we provide an overview of the different attempts that have been made to create differential hypoxic in vivo cancer models with a particular focus on their applicability in PET imaging studies.
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Kelada OJ, Decker RH, Nath SK, Johung KL, Zheng MQ, Huang Y, Gallezot JD, Liu C, Carson RE, Oelfke U, Carlson DJ. High Single Doses of Radiation May Induce Elevated Levels of Hypoxia in Early-Stage Non-Small Cell Lung Cancer Tumors. Int J Radiat Oncol Biol Phys 2018; 102:174-183. [PMID: 30102194 PMCID: PMC6092043 DOI: 10.1016/j.ijrobp.2018.05.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 05/10/2018] [Accepted: 05/13/2018] [Indexed: 01/12/2023]
Abstract
PURPOSE Tumor hypoxia correlates with treatment failure in patients undergoing conventional radiation therapy. However, no published studies have investigated tumor hypoxia in patients undergoing stereotactic body radiation therapy (SBRT). We aimed to noninvasively quantify the tumor hypoxic volume (HV) in non-small cell lung cancer (NSCLC) tumors to elucidate the potential role of tumor vascular response and reoxygenation at high single doses. METHODS AND MATERIALS Six SBRT-eligible patients with NSCLC tumors >1 cm were prospectively enrolled in an institutional review board-approved study. Dynamic positron emission tomography images were acquired at 0 to 120 minutes, 150 to 180 minutes, and 210 to 240 minutes after injection of 18F-fluoromisonidazole. Serial imaging was performed prior to delivery of 18 Gy and at approximately 48 hours and approximately 96 hours after SBRT. Tumor HVs were quantified using the tumor-to-blood ratio (>1.2) and rate of tracer influx (>0.0015 mL·min·cm-3). RESULTS An elevated and in some cases persistent level of tumor hypoxia was observed in 3 of 6 patients. Two patients exhibited no detectable baseline tumor hypoxia, and 1 patient with high baseline hypoxia only completed 1 imaging session. On the basis of the tumor-to-blood ratio, in the remaining 3 patients, tumor HVs increased on day 2 after 18 Gy and then showed variable responses on day 4. In the 3 of 6 patients with detectable hypoxia at baseline, baseline tumor HVs ranged between 17% and 24% (mean, 21%), and HVs on days 2 and 4 ranged between 33% and 45% (mean, 40%) and between 18% and 42% (mean, 28%), respectively. CONCLUSIONS High single doses of radiation delivered as part of SBRT may induce an elevated and in some cases persistent state of tumor hypoxia in NSCLC tumors. Hypoxia imaging with 18F-fluoromisonidazole positron emission tomography should be used in a larger cohort of NSCLC patients to determine whether elevated tumor hypoxia is predictive of treatment failure in SBRT.
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Affiliation(s)
- Olivia J Kelada
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut; Department of Medical Physics in Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Sameer K Nath
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Kimberly L Johung
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Ming-Qiang Zheng
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
| | - Yiyun Huang
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
| | - Jean-Dominique Gallezot
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
| | - Chi Liu
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
| | - Richard E Carson
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
| | - Uwe Oelfke
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - David J Carlson
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut.
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Stieb S, Eleftheriou A, Warnock G, Guckenberger M, Riesterer O. Longitudinal PET imaging of tumor hypoxia during the course of radiotherapy. Eur J Nucl Med Mol Imaging 2018; 45:2201-2217. [PMID: 30128659 DOI: 10.1007/s00259-018-4116-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/30/2018] [Indexed: 12/11/2022]
Abstract
Hypoxia results from an imbalance between oxygen supply and consumption. It is a common phenomenon in solid malignant tumors such as head and neck cancer. As hypoxic cells are more resistant to therapy, tumor hypoxia is an indicator for poor prognosis. Several techniques have been developed to measure tissue oxygenation. These are the Eppendorf O2 polarographic needle electrode, immunohistochemical analysis of endogenous (e.g., hypoxia-inducible factor-1α (HIF-1a)) and exogenous markers (e.g., pimonidazole) as well as imaging methods such as functional magnetic resonance imaging (e.g., blood oxygen level dependent (BOLD) imaging, T1-weighted imaging) and hypoxia positron emission tomography (PET). Among the imaging modalities, only PET is sufficiently validated to detect hypoxia for clinical use. Hypoxia PET tracers include 18F-fluoromisonidazole (FMISO), the most commonly used hypoxic marker, 18F-flouroazomycin arabinoside (FAZA), 18Ffluoroerythronitroimidazole (FETNIM), 18F-2-nitroimidazolpentafluoropropylacetamide (EF5) and 18F-flortanidazole (HX4). As technical development provides the opportunity to increase the radiation dose to subregions of the tumor, such as hypoxic areas, it has to be ensured that these regions are stable not only from imaging to treatment but also through the course of radiotherapy. The aim of this review is therefore to characterize the behavior of tumor hypoxia during radiotherapy for the whole tumor and for subregions by using hypoxia PET tracers, with focus on head and neck cancer patients.
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Affiliation(s)
- Sonja Stieb
- Department of Radiation Oncology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland. .,Institute of Diagnostic and Interventional Radiology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Afroditi Eleftheriou
- Department of Pharmacology and Toxicology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland
| | - Geoffrey Warnock
- Department of Pharmacology and Toxicology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland.,Department of Nuclear Medicine, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Oliver Riesterer
- Department of Radiation Oncology, University Hospital and University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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22
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Kelada OJ, Rockwell S, Zheng MQ, Huang Y, Liu Y, Booth CJ, Decker RH, Oelfke U, Carson RE, Carlson DJ. Quantification of Tumor Hypoxic Fractions Using Positron Emission Tomography with [ 18F]Fluoromisonidazole ([ 18F]FMISO) Kinetic Analysis and Invasive Oxygen Measurements. Mol Imaging Biol 2018; 19:893-902. [PMID: 28409339 DOI: 10.1007/s11307-017-1083-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study is to use dynamic [18F]fluoromisonidazole ([18F]FMISO) positron emission tomography (PET) to compare estimates of tumor hypoxic fractions (HFs) derived by tracer kinetic modeling, tissue-to-blood ratios (TBR), and independent oxygen (pO2) measurements. PROCEDURES BALB/c mice with EMT6 subcutaneous tumors were selected for PET imaging and invasive pO2 measurements. Data from 120-min dynamic [18F]FMISO scans were fit to two-compartment irreversible three rate constant (K 1, k 2, k 3) and Patlak models (K i). Tumor HFs were calculated and compared using K i, k 3, TBR, and pO2 values. The clinical impact of each method was evaluated on [18F]FMISO scans for three non-small cell lung cancer (NSCLC) radiotherapy patients. RESULTS HFs defined by TBR (≥1.2, ≥1.3, and ≥1.4) ranged from 2 to 85 % of absolute tumor volume. HFs defined by K i (>0.004 ml min cm-3) and k 3 (>0.008 min-1) varied from 9 to 85 %. HF quantification was highly dependent on metric (TBR, k 3, or K i) and threshold. HFs quantified on human [18F]FMISO scans varied from 38 to 67, 0 to 14, and 0.1 to 27 %, for each patient, respectively, using TBR, k 3, and K i metrics. CONCLUSIONS [18F]FMISO PET imaging metric choice and threshold impacts hypoxia quantification reliability. Our results suggest that tracer kinetic modeling has the potential to improve hypoxia quantification clinically as it may provide a stronger correlation with direct pO2 measurements.
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Affiliation(s)
- Olivia J Kelada
- Department of Therapeutic Radiology, Yale University School of Medicine, P.O. Box 208040, New Haven, CT, 06520-8040, USA.,Department of Medical Physics in Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Sara Rockwell
- Department of Therapeutic Radiology, Yale University School of Medicine, P.O. Box 208040, New Haven, CT, 06520-8040, USA.,Department of Pharmacology, Yale University School of Medicine, New Haven, CT, USA
| | - Ming-Qiang Zheng
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Yiyun Huang
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Yanfeng Liu
- Department of Therapeutic Radiology, Yale University School of Medicine, P.O. Box 208040, New Haven, CT, 06520-8040, USA
| | - Carmen J Booth
- Section of Comparative Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, P.O. Box 208040, New Haven, CT, 06520-8040, USA
| | - Uwe Oelfke
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Richard E Carson
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - David J Carlson
- Department of Therapeutic Radiology, Yale University School of Medicine, P.O. Box 208040, New Haven, CT, 06520-8040, USA.
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Gago-Arias A, Sánchez-Nieto B, Espinoza I, Karger CP, Pardo-Montero J. Impact of different biologically-adapted radiotherapy strategies on tumor control evaluated with a tumor response model. PLoS One 2018; 13:e0196310. [PMID: 29698534 PMCID: PMC5919644 DOI: 10.1371/journal.pone.0196310] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 04/10/2018] [Indexed: 11/26/2022] Open
Abstract
Motivated by the capabilities of modern radiotherapy techniques and by the recent developments of functional imaging techniques, dose painting by numbers (DPBN) was proposed to treat tumors with heterogeneous biological characteristics. This work studies different DPBN optimization techniques for virtual head and neck tumors assessing tumor response in terms of cell survival and tumor control probability with a previously published tumor response model (TRM). Uniform doses of 2 Gy are redistributed according to the microscopic oxygen distribution and the density distribution of tumor cells in four virtual tumors with different biological characteristics. In addition, two different optimization objective functions are investigated, which: i) minimize tumor cell survival (OFsurv) or; ii) maximize the homogeneity of the density of surviving tumor cells (OFstd). Several adaptive schemes, ranging from single to daily dose optimization, are studied and the treatment response is compared to that of the uniform dose. The results show that the benefit of DPBN treatments depends on the tumor reoxygenation capability, which strongly differed among the set of virtual tumors investigated. The difference between daily (fraction by fraction) and three weekly optimizations (at the beginning of weeks 1, 3 and 4) was found to be small, and higher benefit was observed for the treatments optimized using OFsurv. This in silico study corroborates the hypothesis that DPBN may be beneficial for treatments of tumors which show reoxygenation during treatment, and that a few optimizations may be sufficient to achieve this therapeutic benefit.
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Affiliation(s)
- Araceli Gago-Arias
- Instituto de Física, Pontificia Universidad Católica de Chile, Santiago, Chile
- * E-mail:
| | | | - Ignacio Espinoza
- Instituto de Física, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Christian P. Karger
- National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Juan Pardo-Montero
- Grupo de Imaxe Molecular, Instituto de Investigación Sanitaria (IDIS), Santiago de Compostela, Spain
- Servizo de Radiofísica e Protección Radiolóxica, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
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Gkika E, Oehlke O, Bunea H, Wiedenmann N, Adebahr S, Nestle U, Zamboglou C, Kirste S, Fennell J, Brunner T, Gainey M, Baltas D, Langer M, Urbach H, Bock M, Meyer PT, Grosu AL. Biological imaging for individualized therapy in radiation oncology: part II medical and clinical aspects. Future Oncol 2018. [DOI: 10.2217/fon-2017-0465] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Positron emission tomography and multiparametric MRI provide crucial information concerning tumor extent and normal tissue anatomy. Moreover, they are able to visualize biological characteristics of the tumor, which can be considered in the radiation treatment planning and monitoring. In this review we discuss the impact of biological imaging positron emission tomography and multiparametric MRI for radiation oncology, based on the data of the literature and on the experience of our own institution in this field.
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Affiliation(s)
- Eleni Gkika
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, D-69120, Germany
| | - Oliver Oehlke
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, D-69120, Germany
| | - Hatice Bunea
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, D-69120, Germany
| | - Nicole Wiedenmann
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, D-69120, Germany
| | - Sonja Adebahr
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, D-69120, Germany
| | - Ursula Nestle
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, D-69120, Germany
| | - Constantinos Zamboglou
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, D-69120, Germany
| | - Simon Kirste
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, D-69120, Germany
| | - Jamina Fennell
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, D-69120, Germany
| | - Thomas Brunner
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, D-69120, Germany
| | - Mark Gainey
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, D-69120, Germany
| | - Dimos Baltas
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, D-69120, Germany
| | - Mathias Langer
- Department of Radiology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
| | - Michael Bock
- Department of Radiology – Medical Physics, Department of Radiology, Faculty of Medicine, Medical Center, University of Freiburg, D-79106, Germany
| | - Philipp T Meyer
- German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, D-69120, Germany
- Department of Nuclear Medicine, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, D-79106, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, D-69120, Germany
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Kanoto M, Kirii K, Hiraka T, Toyoguchi Y, Sugai Y, Matsuda K, Sakurada K, Sonoda Y, Hatazawa J, Hosoya T. Correlation between hypoxic area in primary brain tumors and WHO grade: differentiation from malignancy using 18F-fluoromisonidazole positron emission tomography. Acta Radiol 2018; 59:229-235. [PMID: 28534419 DOI: 10.1177/0284185117711474] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background 18F-fluoromisonidazole positron emission tomography (FMISO-PET) has been used for identification of hypoxic areas in tumors, and since hypoxia causes hypoxia-inducible factor-1 and enhancement of tumor growth, identifying the hypoxic area in the tumor tissue is important. Purpose To evaluate the usefulness of FMISO-PET in the grading of primary brain tumors. Material and Methods FMISO-PET was performed preoperatively on 41 consecutive patients with pathologically confirmed brain tumor. A neuroradiologist retrospectively measured both maximum standardized uptake value (SUVmax) and mean SUV (SUVmean) in the tumor and normal cerebellar parenchyma. Maximum tumor/normal control ratio (T/Nmax) and mean tumor/normal control ratio (T/Nmean) were calculated and analyzed. Results There was a positive correlation between World Health Organization (WHO) grade and both T/Nmax and T/Nmean (r = 0.731 and 0.713, respectively). When all cases were divided into benign (WHO grade II) and malignant groups (III and IV), there were significant differences between the two groups in both T/Nmax and T/Nmean ( P < 0.001). If the cutoff value was defined as T/Nmax = 1.25 and T/Nmean = 1.23, T/Nmax had a sensitivity of 90.0% and a specificity of 90.9% while T/Nmean had a sensitivity of 93.3% and a specificity of 90.9% in differentiating the benign group from the malignant group. Conclusion Both T/Nmax and T/Nmean in FMISO-PET have a positive correlation with primary brain tumor grading, making FMISO-PET useful in diagnosing the malignancy of primary brain tumors.
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Affiliation(s)
- Masafumi Kanoto
- Department of Diagnostic Radiology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Kazukuni Kirii
- Department of Diagnostic Radiology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Toshitada Hiraka
- Department of Diagnostic Radiology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Yuuki Toyoguchi
- Department of Diagnostic Radiology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Yukio Sugai
- Department of Diagnostic Radiology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Kenichiro Matsuda
- Department of Neurosurgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Kaori Sakurada
- Department of Neurosurgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Yukihiko Sonoda
- Department of Neurosurgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Jun Hatazawa
- Department of Nuclear Medicine and Tracer Kinetics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takaaki Hosoya
- Department of Diagnostic Radiology, Yamagata University Faculty of Medicine, Yamagata, Japan
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Nehmeh SA, Schwartz J, Grkovski M, Yeung I, Laymon CM, Muzi M, Humm JL. Inter-operator variability in compartmental kinetic analysis of 18F-fluoromisonidazole dynamic PET. Clin Imaging 2018; 49:121-127. [PMID: 29414505 DOI: 10.1016/j.clinimag.2017.12.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 12/13/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess the inter-operator variability in compartment analysis (CA) of dynamic-FMISO (dyn-FMISO) PET. METHODS Study-I: Five investigators conducted CA for 23 NSCLC dyn-FMISO tumor time-activity-curves. Study-II: Four operators performed CA for four NSCLC dyn-FMISO datasets. Repeatability of Kinetic-Rate-Constants (KRCs) was assessed. RESULTS Study-I: Strong correlation (ICC > 0.9) and interchangeable results among operators existed for all KRCs. Study-II: Up to 103% variability in tumor segmentation, and weaker ICC in KRCs (ICC-VB = 0.53; ICC-K1 = 0.91; ICC-K1/k2 = 0.25; ICC-k3 = 0.32; ICC-Ki = 0.54) existed. All KRCs were repeatable among the different operators. CONCLUSIONS Inter-operator variability in CA of dyn-FMISO was shown to be within statistical errors.
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Affiliation(s)
- Sadek A Nehmeh
- Weill Cornell Medical College, New York, NY, United States.
| | - Jazmin Schwartz
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Milan Grkovski
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Ivan Yeung
- Department of Medical Physics, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Charles M Laymon
- Departments of Radiology and Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - Mark Muzi
- Department of Radiology, University of Washington, Seattle, WA, United States
| | - John L Humm
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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27
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Taylor E, Gottwald J, Yeung I, Keller H, Milosevic M, Dhani NC, Siddiqui I, Hedley DW, Jaffray DA. Impact of tissue transport on PET hypoxia quantification in pancreatic tumours. EJNMMI Res 2017; 7:101. [PMID: 29273939 PMCID: PMC5741574 DOI: 10.1186/s13550-017-0347-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 11/28/2017] [Indexed: 12/26/2022] Open
Abstract
Background The clinical impact of hypoxia in solid tumours is indisputable and yet questions about the sensitivity of hypoxia-PET imaging have impeded its uptake into routine clinical practice. Notably, the binding rate of hypoxia-sensitive PET tracers is slow, comparable to the rate of diffusive equilibration in some tissue types, including mucinous and necrotic tissue. This means that tracer uptake on the scale of a PET imaging voxel—large enough to include such tissue and hypoxic cells—can be as much determined by tissue transport properties as it is by hypoxia. Dynamic PET imaging of 20 patients with pancreatic ductal adenocarcinoma was used to assess the impact of transport on surrogate metrics of hypoxia: the tumour-to-blood ratio [TBR(t)] at time t post-tracer injection and the trapping rate k3 inferred from a two-tissue compartment model. Transport quantities obtained from this model included the vascular influx and efflux rate coefficients, k1 and k2, and the distribution volume vd≡k1/(k2+k3). Results Correlations between voxel- and whole tumour-scale k3 and TBR values were weak to modest: the population average of the Pearson correlation coefficients (r) between voxel-scale k3 and TBR (1 h) [TBR(2 h)] values was 0.10 [0.01] in the 20 patients, while the correlation between tumour-scale k3 and TBR(2 h) values was 0.58. Using Patlak’s formula to correct uptake for the distribution volume, correlations became strong (r=0.80[0.52] and r=0.93, respectively). The distribution volume was substantially below unity for a large fraction of tumours studied, with vd ranging from 0.68 to 1 (population average, 0.85). Surprisingly, k3 values were strongly correlated with vd in all patients. A model was proposed to explain this in which k3 is a combination of the hypoxia-sensitive tracer binding rate kb and the rate keq of equilibration in slow-equilibrating regions occupying a volume fraction 1−vd of the imaged tissue. This model was used to calculate the proposed hypoxia surrogate marker kb. Conclusions Hypoxia-sensitive PET tracers are slow to reach diffusive equilibrium in a substantial fraction of pancreatic tumours, confounding quantification of hypoxia using both static (TBR) and dynamic (k3) PET imaging. TBR is reduced by distribution volume effects and k3 is enhanced by slow equilibration. We proposed a novel model to quantify tissue transport properties and hypoxia-sensitive tracer binding in order to improve the sensitivity of hypoxia-PET imaging. Electronic supplementary material The online version of this article (doi:10.1186/s13550-017-0347-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Edward Taylor
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada. .,Techna Institute, University Health Network, Toronto, Canada.
| | - Jennifer Gottwald
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Ivan Yeung
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Harald Keller
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Michael Milosevic
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Neesha C Dhani
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Iram Siddiqui
- Department of Pathology, Hospital for Sick Children, Toronto, Canada
| | - David W Hedley
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - David A Jaffray
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Techna Institute, University Health Network, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Institute for Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
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28
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Molecular Imaging of Tumor Hypoxia: Existing Problems and Their Potential Model-Based Solutions. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017. [PMID: 27526129 DOI: 10.1007/978-3-319-38810-6_12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Molecular imaging of tissue hypoxia generates contrast in hypoxic areas by applying hypoxia-specific tracers in organisms. In cancer tissue, the injected tracer needs to be transported over relatively long distances and accumulates slowly in hypoxic regions. Thus, the signal-to-background ratio of hypoxia imaging is very small and a non-specific accumulation may suppress the real hypoxia-specific signals. In addition, the heterogeneous tumor microenvironment makes the assessment of the tissue oxygenation status more challenging. In this study, the diffusion potential of oxygen and of a hypoxia tracer for 4 different hypoxia subtypes: ischemic acute hypoxia, hypoxemic acute hypoxia, diffusion-limited chronic hypoxia and anemic chronic hypoxia are theoretically assessed. In particular, a reaction-diffusion equation is introduced to quantitatively analyze the interstitial diffusion of the hypoxia tracer [(18)F]FMISO. Imaging analysis strategies are explored based on reaction-diffusion simulations. For hypoxia imaging of low signal-to-background ratio, pharmacokinetic modelling has advantages to extract underlying specific binding signals from non-specific background signals and to improve the assessment of tumor oxygenation. Different pharmacokinetic models are evaluated for the analysis of the hypoxia tracer [(18)F]FMISO and optimal analysis model were identified accordingly. The improvements by model-based methods for the estimation of tumor oxygenation are in agreement with experimental data. The computational modelling offers a tool to explore molecular imaging of hypoxia and pharmacokinetic modelling is encouraged to be employed in the corresponding data analysis.
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Mönnich D, Thorwarth D, Leibfarth S, Pfannenberg C, Reischl G, Mauz PS, Nikolaou K, la Fougère C, Zips D, Welz S. Overlap of highly FDG-avid and FMISO hypoxic tumor subvolumes in patients with head and neck cancer. Acta Oncol 2017; 56:1577-1582. [PMID: 28849721 DOI: 10.1080/0284186x.2017.1363910] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND PET imaging may be used to personalize radiotherapy (RT) by identifying radioresistant tumor subvolumes for RT dose escalation. Using the tracers [18F]-fluorodeoxyglucose (FDG) and [18F]-fluoromisonidazole (FMISO), different aspects of tumor biology can be visualized. FDG depicts various biological aspects, e.g., proliferation, glycolysis and hypoxia, while FMISO is more hypoxia specific. In this study, we analyzed size and overlap of volumes based on the two markers for head-and-neck cancer patients (HNSCC). MATERIAL AND METHODS Twenty five HNSCC patients underwent a CT scan, as well as FDG and dynamic FMISO PET/CT prior to definitive radio-chemotherapy in a prospective FMISO dose escalation study. Three PET-based subvolumes of the primary tumor (GTVprim) were segmented: a highly FDG-avid volume VFDG, a hypoxic volume on the static FMISO image acquired four hours post tracer injection (VH) and a retention/perfusion volume (VM) using pharmacokinetic modeling of dynamic FMISO data. Absolute volumes, overlaps and distances to agreement (DTA) were evaluated. RESULTS Sizes of PET-based volumes and the GTVprim are significantly different (GTVprim>VFDG>VH >VM; p < .05). VH is covered by VFDG or DTAs are small (mean coverage 74.4%, mean DTA 1.4 mm). Coverage of VM is less pronounced. With respect to VFDG and VH, the mean coverage is 48.7% and 43.1% and the mean DTA is 5.3 mm and 6.3 mm, respectively. For two patients, DTAs were larger than 2 cm. CONCLUSIONS Hypoxic subvolumes from static PET imaging are typically covered by or in close proximity to highly FDG-avid subvolumes. Therefore, dose escalation to FDG positive subvolumes should cover the static hypoxic subvolumes in most patients, with the disadvantage of larger volumes, resulting in a higher risk of dose-limiting toxicity. Coverage of subvolumes from dynamic FMISO PET is less pronounced. Further studies are needed to explore the relevance of mismatches in functional imaging.
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Affiliation(s)
- David Mönnich
- Department of Radiation Oncology, Section for Biomedical Physics, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, Tübingen, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Daniela Thorwarth
- Department of Radiation Oncology, Section for Biomedical Physics, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, Tübingen, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sara Leibfarth
- Department of Radiation Oncology, Section for Biomedical Physics, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Christina Pfannenberg
- Department of Diagnostic and Interventional Radiology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Gerald Reischl
- Department of Diagnostic and Interventional Radiology, Preclinical Imaging and Radiopharmacy, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Paul-Stefan Mauz
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Christian la Fougère
- Department of Radiology, Nuclear Medicine, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Daniel Zips
- German Cancer Consortium (DKTK), Partner Site Tübingen, Tübingen, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Stefan Welz
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
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30
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Busk M, Munk OL, Jakobsen SS, Horsman MR. Hypoxia positron emission tomography imaging: combining information on perfusion and tracer retention to improve hypoxia specificity. Acta Oncol 2017; 56:1583-1590. [PMID: 28840765 DOI: 10.1080/0284186x.2017.1355114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Static positron emission tomography (PET) allows mapping of tumor hypoxia, but low resolution and slow tracer retention/clearance results in poor image contrast and the risk of missing areas where hypoxic cells and necrosis are intermixed. Fully dynamic PET may improve accuracy but scan protocols suitable for routine clinical use are warranted. A modeling study proposed that hypoxia specificity can be improved by a clinically feasible blood-flow normalization procedure that only requires a 10- to 15-min dynamic scan (perfusion), followed by a short late static scan, but experimental validation is desired. METHODS Tumor-bearing mice were administered pimonidazole (hypoxia marker) and the PET hypoxia-tracer 18F-azomycin arabinoside (FAZA) and scanned for 3h. Subsequently, the distributions of FAZA (autoradiography) and hypoxic cells (pimonidazole) were compared on tissue sections. PET images collected in 10-min time intervals between 60 and 90 min post-injection (PETearly), which mimics the image contrast seen in patients, were compared voxel-by-voxel to 3-h PET (PETlate). For comparison, PETearly was normalized to the perfusion peak area, deduced from the first 10 min of the scan (PETperf), and the resulting parameter PETearly/PETperf was compared with PETlate. RESULTS Tissue analysis revealed a near-perfect spatial match between FAZA signal and hypoxic cell density (pimonidazole) 3 h post-injection, regardless of the tumor type. Only a weak inverse or no correlation between PETperf and PETlate was seen, and the correlation between PETearly/PETperf and PETlate proved inferior to the correlation between PETearly and PETlate. CONCLUSIONS Late PET scans in rodents, unlike patients, provide an accurate map of hypoxia against which earlier time-point scans can be compared. PETearly and PETlate correlated to a variable extent but the correlation was lowered by normalization to perfusion (PETearly/PETperf). Our study challenges the validity/robustness of a perfusion normalization approach. This may reflect that the chaotic tumor vasculature uncouples microregional blood flow and oxygen extraction.
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Affiliation(s)
- Morten Busk
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Ole L. Munk
- PET Centre, Aarhus University Hospital, Aarhus, Denmark
| | | | - Michael R. Horsman
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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31
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Shi K, Bayer C, Astner ST, Gaertner FC, Vaupel P, Schwaiger M, Huang SC, Ziegler SI. Quantitative Analysis of [ 18F]FMISO PET for Tumor Hypoxia: Correlation of Modeling Results with Immunohistochemistry. Mol Imaging Biol 2017; 19:120-129. [PMID: 27379986 DOI: 10.1007/s11307-016-0975-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Quantitative evaluation of tumor hypoxia based on H-1-(3-[18F]fluoro-2-hydroxypropyl)-2-nitroimidazole ([18F]FMISO) positron emission tomography (PET) can deliver important information for treatment planning in radiotherapy. However, the merits and limitations of different analysis methods in revealing the underlying physiological feature are not clear. This study aimed to assess these quantitative analysis methods with the support of immunohistological data. PROCEDURES Sixteen nude mice bearing xenografted human squamous cell carcinomas (FaDu or CAL-33) were scanned using 2-h dynamic [18F]FMISO PET. Tumors were resected and sliced, and the hypoxia marker pimonidazole was immunostained followed by H&E staining. The pimonidazole signal was segmented using a k-means clustering algorithm, and the hypoxic fraction (HF) was calculated as the hypoxic area/viable tumor-tissue-area ratio pooled over three tissue slices from the apical, center, and basal layers. PET images were analyzed using various methods including static analysis [standard uptake value (SUV), tumor-to-blood ratio (T/B), tumor-to-muscle ratio (T/M)] and kinetic modeling (Casciari αk A , irreversible and reversible two-tissue compartment k 3, Thorwarth w A k 3, Patlak K i , Logan V d , Cho K), and correlated with HF. RESULTS No significant correlation was found for static analysis. A significant correlation between k 3 of the irreversible two-tissue compartment model and HF was observed (r = 0.61, p = 0.01). The correlation between HF and αk A of the Casciari model could be improved through reducing local minima by testing more sets of initial values (r = 0.59, p = 0.02) or by reducing the model complexity by fixing three parameters (r = 0.63, p = 0.0008). CONCLUSIONS With support of immunohistochemistry data, this study shows that various analysis methods for [18F]FMISO PET perform differently for assessment of tumor hypoxia. A better fitting quality does not necessarily mean a higher physiological correlation. Hypoxia PET analysis needs to consider both the mathematical stability and physiological fidelity. Based on the results of this study, preference should be given to the irreversible two-tissue compartment model as well as the Casciari model with reduced parameters.
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Affiliation(s)
- Kuangyu Shi
- Department of Nuclear Medicine, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse. 22, 81675, Munich, Germany.
| | - Christine Bayer
- Department of Radiooncology and Radiotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Sabrina T Astner
- Department of Radiooncology and Radiotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Florian C Gaertner
- Department of Nuclear Medicine, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse. 22, 81675, Munich, Germany
| | - Peter Vaupel
- Department of Radiooncology and Radiotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Markus Schwaiger
- Department of Nuclear Medicine, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse. 22, 81675, Munich, Germany
| | - Sung-Cheng Huang
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Sibylle I Ziegler
- Department of Nuclear Medicine, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse. 22, 81675, Munich, Germany
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Xu Z, Li XF, Zou H, Sun X, Shen B. 18F-Fluoromisonidazole in tumor hypoxia imaging. Oncotarget 2017; 8:94969-94979. [PMID: 29212283 PMCID: PMC5706929 DOI: 10.18632/oncotarget.21662] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/21/2017] [Indexed: 12/19/2022] Open
Abstract
Hypoxia is a common feature of solid tumors that is closely associated with radiotherapy and chemotherapy resistance, metastasis and tumors prognosis. Thus, it is important to assess hypoxia in tumors for estimating prognosis and selecting appropriate treatment procedures. 18F-Fluoromisonidazole positron emission tomography (18F-FMISO PET) has been widely used to visualize tumor hypoxia in a comprehensive and noninvasive way, both in the clinical and preclinical settings. Here we review the concept, mechanisms and detection methods of tumor hypoxia. Furthermore, we discuss the correlation between 18F-FMISO PET and other detection methods, current applications of 18F-FMISO PET and the development prospects of this imaging technology.
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Affiliation(s)
- Zuoyu Xu
- Molecular Imaging Research Center (MIRC), Harbin Medical University, Harbin, Heilongjiang, China.,TOF-PET/CT/MR Center, The Fourth Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xiao-Feng Li
- Molecular Imaging Research Center (MIRC), Harbin Medical University, Harbin, Heilongjiang, China.,TOF-PET/CT/MR Center, The Fourth Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Hongyan Zou
- Molecular Imaging Research Center (MIRC), Harbin Medical University, Harbin, Heilongjiang, China
| | - Xilin Sun
- Molecular Imaging Research Center (MIRC), Harbin Medical University, Harbin, Heilongjiang, China.,TOF-PET/CT/MR Center, The Fourth Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Baozhong Shen
- Molecular Imaging Research Center (MIRC), Harbin Medical University, Harbin, Heilongjiang, China.,TOF-PET/CT/MR Center, The Fourth Hospital of Harbin Medical University, Harbin, Heilongjiang, China
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33
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Thorwarth D, Wack LJ, Mönnich D. Hypoxia PET imaging techniques: data acquisition and analysis. Clin Transl Imaging 2017. [DOI: 10.1007/s40336-017-0250-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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34
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Löck S, Perrin R, Seidlitz A, Bandurska-Luque A, Zschaeck S, Zöphel K, Krause M, Steinbach J, Kotzerke J, Zips D, Troost EGC, Baumann M. Residual tumour hypoxia in head-and-neck cancer patients undergoing primary radiochemotherapy, final results of a prospective trial on repeat FMISO-PET imaging. Radiother Oncol 2017; 124:533-540. [PMID: 28843726 DOI: 10.1016/j.radonc.2017.08.010] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 08/07/2017] [Accepted: 08/07/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hypoxia is a well recognised parameter of tumour resistance to radiotherapy, a number of anticancer drugs and potentially immunotherapy. In a previously published exploration cohort of 25 head and neck squamous cell carcinoma (HNSCC) patients on [18F]fluoromisonidazole positron emission tomography (FMISO-PET) we identified residual tumour hypoxia during radiochemotherapy, not before start of treatment, as the driving mechanism of hypoxia-mediated therapy resistance. Several quantitative FMISO-PET parameters were identified as potential prognostic biomarkers. Here we present the results of the prospective validation cohort, and the overall results of the study. METHODS FMISO-PET/CT images of further 25 HNSCC patients were acquired at four time-points before and during radiochemotherapy (RCHT). Peak standardised uptake value, tumour-to-background ratio, and hypoxic volume were analysed. The impact of the potential prognostic parameters on loco-regional tumour control (LRC) was validated by the concordance index (ci) using univariable and multivariable Cox models based on the exploration cohort. Log-rank tests were employed to compare the endpoint between risk groups. RESULTS The two cohorts differed significantly in several baseline parameters, e.g., tumour volume, hypoxic volume, HPV status, and intercurrent death. Validation was successful for several FMISO-PET parameters and showed the highest performance (ci=0.77-0.81) after weeks 1 and 2 of treatment. Cut-off values for the FMISO-PET parameters could be validated after week 2 of RCHT. Median values for the residual hypoxic volume, defined as the ratio of the hypoxic volume in week 2 of RCHT and at baseline, stratified patients into groups of significantly different LRC when applied to the respective other cohort. CONCLUSION Our study validates that residual tumour hypoxia during radiochemotherapy is a major driver of therapy resistance of HNSCC, and that hypoxia after the second week of treatment measured by FMISO-PET may serve as biomarker for selection of patients at high risk of loco-regional recurrence after state-of-the art radiochemotherapy.
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Affiliation(s)
- Steffen Löck
- OncoRay - National Center for Radiation Research in Oncology, Biostatistics and Modeling in Radiation Oncology Group, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 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, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, Germany
| | - Rosalind Perrin
- OncoRay - National Center for Radiation Research in Oncology, Biostatistics and Modeling in Radiation Oncology Group, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Germany; Center for Proton Therapy, Paul Scherrer Institute, Switzerland
| | - Annekatrin Seidlitz
- OncoRay - National Center for Radiation Research in Oncology, Biostatistics and Modeling in Radiation Oncology Group, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Anna Bandurska-Luque
- OncoRay - National Center for Radiation Research in Oncology, Biostatistics and Modeling in Radiation Oncology Group, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Sebastian Zschaeck
- OncoRay - National Center for Radiation Research in Oncology, Biostatistics and Modeling in Radiation Oncology Group, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Klaus Zöphel
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; National Center for Tumor Diseases, partner site Dresden, Germany
| | - Mechthild Krause
- OncoRay - National Center for Radiation Research in Oncology, Biostatistics and Modeling in Radiation Oncology Group, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, Germany; National Center for Tumor Diseases, partner site Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Germany; Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Jörg Steinbach
- National Center for Tumor Diseases, partner site Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Germany
| | - Jörg Kotzerke
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; National Center for Tumor Diseases, partner site Dresden, Germany
| | - Daniel Zips
- Department of Radiation Oncology, Eberhard Karls Universität Tübingen, Germany; German Cancer Consortium (DKTK), partner site Tübingen, Germany
| | - Esther G C Troost
- OncoRay - National Center for Radiation Research in Oncology, Biostatistics and Modeling in Radiation Oncology Group, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, Germany; National Center for Tumor Diseases, partner site Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Germany.
| | - Michael Baumann
- OncoRay - National Center for Radiation Research in Oncology, Biostatistics and Modeling in Radiation Oncology Group, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, Germany; National Center for Tumor Diseases, partner site Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Germany; Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
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Incerti E, Mapelli P, Vuozzo M, Fallanca F, Monterisi C, Bettinardi V, Moresco RM, Gianolli L, Picchio M. Clinical PET imaging of tumour hypoxia in lung cancer. Clin Transl Imaging 2017. [DOI: 10.1007/s40336-017-0243-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Grimes DR, Warren DR, Warren S. Hypoxia imaging and radiotherapy: bridging the resolution gap. Br J Radiol 2017; 90:20160939. [PMID: 28540739 PMCID: PMC5603947 DOI: 10.1259/bjr.20160939] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Oxygen distribution is a major determinant of treatment success in radiotherapy, with well-oxygenated tumour regions responding by up to a factor of three relative to anoxic volumes. Conversely, tumour hypoxia is associated with treatment resistance and negative prognosis. Tumour oxygenation is highly heterogeneous and difficult to measure directly. The recent advent of functional hypoxia imaging modalities such as fluorine-18 fluoromisonidazole positron emission tomography have shown promise in non-invasively determining regions of low oxygen tension. This raises the prospect of selectively increasing dose to hypoxic subvolumes, a concept known as dose painting. Yet while this is a promising approach, oxygen-mediated radioresistance is inherently a multiscale problem, and there are still a number of substantial challenges that must be overcome if hypoxia dose painting is to be successfully implemented. Current imaging modalities are limited by the physics of such systems to have resolutions in the millimetre regime, whereas oxygen distribution varies over a micron scale, and treatment delivery is typically modulated on a centimetre scale. In this review, we examine the mechanistic basis and implications of the radiobiological oxygen effect, the factors influencing microscopic heterogeneity in tumour oxygenation and the consequent challenges in the interpretation of clinical hypoxia imaging (in particular fluorine-18 fluoromisonidazole positron emission tomography). We also discuss dose-painting approaches and outline challenges that must be addressed to improve this treatment paradigm.
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Affiliation(s)
- David Robert Grimes
- 1 Cancer Research UK/MRC Oxford Institute for Radiation Oncology, Gray Laboratory, University of Oxford, Old Road Campus Research Building, Off Roosevelt Drive, Oxford OX37DQ, UK.,2 Centre for Advanced and Interdisciplinary Radiation Research (CAIRR), School of Mathematics and Physics, Queen's University Belfast, UK
| | - Daniel R Warren
- 1 Cancer Research UK/MRC Oxford Institute for Radiation Oncology, Gray Laboratory, University of Oxford, Old Road Campus Research Building, Off Roosevelt Drive, Oxford OX37DQ, UK
| | - Samantha Warren
- 1 Cancer Research UK/MRC Oxford Institute for Radiation Oncology, Gray Laboratory, University of Oxford, Old Road Campus Research Building, Off Roosevelt Drive, Oxford OX37DQ, UK.,3 Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham, UK
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Welz S, Mönnich D, Pfannenberg C, Nikolaou K, Reimold M, La Fougère C, Reischl G, Mauz PS, Paulsen F, Alber M, Belka C, Zips D, Thorwarth D. Prognostic value of dynamic hypoxia PET in head and neck cancer: Results from a planned interim analysis of a randomized phase II hypoxia-image guided dose escalation trial. Radiother Oncol 2017; 124:526-532. [PMID: 28434798 DOI: 10.1016/j.radonc.2017.04.004] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/27/2017] [Accepted: 04/02/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE To prospectively assess the prognostic value of tumour hypoxia determined by dynamic [18F]Fluoromisonidazole (dynFMISO) PET/CT, and to evaluate both feasibility and toxicity in patients with locally advanced squamous cell carcinomas of the head and neck (LASCCHN) treated with dynFMISO image-guided dose escalation (DE) using dose-painting by contours. PATIENTS AND METHODS We present a planned interim analysis of a randomized phase II trial. N=25 patients with LASCCHN received baseline dynFMISO PET/CT to derive hypoxic volumes (HV). Patients with tumour hypoxia were randomized into standard radiochemotherapy (stdRT) (70Gy/35 fractions) or DE (77Gy/35 fractions) to the HV. Patients with non-hypoxic tumours were treated with stdRT. Loco-regional control (LRC) in hypoxic patients randomized to stdRT was compared to non-hypoxic patients. Feasibility and toxicity were analysed for patients in the DE arm and compared to stdRT. RESULTS With a mean follow-up of 27months, LRC in hypoxic patients receiving stdRT (n=10) was significantly worse compared to the non-hypoxic group (n=5) (2y-LRC 44.4% versus 100%, p=0.048). The respective LRC for the DE group (n=10) was 70.0%. Treatment compliance as well as acute and late toxicity did not show significant differences between the DE and the standard dose arms. CONCLUSION Tumour hypoxia determined by baseline dynFMISO PET/CT is associated with a high risk of local failure in patients with LASCCHN. First data suggest that DE to HV is feasible without excess toxicity.
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Affiliation(s)
- Stefan Welz
- Department of Radiation Oncology, University of Tübingen, Germany
| | - David Mönnich
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany
| | - Christina Pfannenberg
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, Germany
| | - Mathias Reimold
- Department of Nuclear Medicine, University of Tübingen, Germany
| | | | - Gerald Reischl
- Department of Preclinical Imaging and Radiopharmacy, University of Tübingen, Germany
| | - Paul-Stefan Mauz
- Department of Otorhinolaryngology, University of Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University of Tübingen, Germany
| | - Markus Alber
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany; Department of Radiation Oncology, University of Heidelberg, Germany
| | - Claus Belka
- Department of Radiation Oncology, University of Tübingen, Germany; Department of Radiation Oncology, LMU Munich, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University of Tübingen, Germany; German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tübingen, Germany; German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany.
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38
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Simoncic U, Leibfarth S, Welz S, Schwenzer N, Schmidt H, Reischl G, Pfannenberg C, Fougère CL, Nikolaou K, Zips D, Thorwarth D. Comparison of DCE-MRI kinetic parameters and FMISO-PET uptake parameters in head and neck cancer patients. Med Phys 2017; 44:2358-2368. [PMID: 28317128 PMCID: PMC5485084 DOI: 10.1002/mp.12228] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 03/08/2017] [Accepted: 03/12/2017] [Indexed: 11/09/2022] Open
Abstract
Purpose Tumor hypoxia is a major cause of radiation resistance, often present in various solid tumors. Dynamic [18F]‐fluoromisonidazole (FMISO) PET imaging is able to reliably assess tumor hypoxia. Comprehensive characterization of tumor microenvironment through FMISO‐PET and dynamic contrast enhanced (DCE) MR multimodality imaging might be a valuable alternative to the dynamic FMISO‐PET acquisition. The aim of this work was to explore the correlation between the FMISO‐PET and DCE‐MRI kinetic parameters. Methods This study was done on head and neck cancer patients (N = 6), who were imaged dynamically with FMISO‐PET and DCE‐MRI on the same day. Images were registered and analyzed for kinetics on a voxel basis. FMISO‐PET images were analyzed with the two‐tissue compartment three rate‐constant model. Additionally, tumor‐to‐muscle ratio (TMR) maps were evaluated. DCE‐MRI was analyzed with the extended Tofts model. Voxel‐wise Pearson's coefficients were calculated for each patient to assess pairwise parameter correlations. Results Median correlations between FMISO uptake parameters and DCE‐MRI kinetic parameters varied across the parameter pairs in the range from −0.05 to 0.71. The highest median correlation of r = 0.71 was observed for the pair Vb−vp, while the K1−Ktrans median correlation was r = 0.45. Median correlation coefficients for the K1−vp and the Ki−Ktrans pairs were r = 0.42 and r = 0.32, respectively. Correlations between FMISO uptake rate parameter Ki and DCE‐MRI kinetic parameters varied substantially across the patients, whereas correlations between the FMISO and DCE‐MRI vascular parameters were consistently high. Median TMR‐K1 and TMR‐Ktrans correlations were r = 0.52 and r = 0.46, respectively, but varied substantially across the patients. Conclusions Based on this clinical evidence, we can conclude that the vascular fraction parameters obtained through DCE‐MRI kinetic analysis or FMISO kinetic analysis measure the same biological property, while other kinetic parameters are unrelated. These results might be useful in the design of future clinical trials involving FMISO‐PET/DCE‐MR multimodality imaging for the assessment of tumor microenvironment.
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Affiliation(s)
- Urban Simoncic
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany.,Faculty of Mathematics and Physics, University of Ljubljana, Ljubljana, Slovenia.,Jozef Stefan Institute, Ljubljana, Slovenia
| | - Sara Leibfarth
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Stefan Welz
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Nina Schwenzer
- Diagnostic and Interventional Radiology, Department of Radiology, University Hospital Tübingen, Tübingen, Germany
| | - Holger Schmidt
- Diagnostic and Interventional Radiology, Department of Radiology, University Hospital Tübingen, Tübingen, Germany
| | - Gerald Reischl
- Preclinical Imaging and Radiopharmacy, Department of Radiology, University Hospital Tübingen, Tübingen, Germany
| | - Christina Pfannenberg
- Diagnostic and Interventional Radiology, Department of Radiology, University Hospital Tübingen, Tübingen, Germany
| | - Christian la Fougère
- Nuclear Medicine, Department of Radiology, University Hospital Tübingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Diagnostic and Interventional Radiology, Department of Radiology, University Hospital Tübingen, Tübingen, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
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Schwartz J, Grkovski M, Rimner A, Schöder H, Zanzonico PB, Carlin SD, Staton KD, Humm JL, Nehmeh SA. Pharmacokinetic Analysis of Dynamic 18F-Fluoromisonidazole PET Data in Non-Small Cell Lung Cancer. J Nucl Med 2017; 58:911-919. [PMID: 28232611 DOI: 10.2967/jnumed.116.180422] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 10/19/2016] [Indexed: 01/08/2023] Open
Abstract
Hypoxic tumors exhibit increased resistance to radiation, chemical, and immune therapies. 18F-fluoromisonidazole (18F-FMISO) PET is a noninvasive, quantitative imaging technique used to evaluate the magnitude and spatial distribution of tumor hypoxia. In this study, pharmacokinetic analysis (PKA) of 18F-FMISO dynamic PET extended to 3 h after injection is reported for the first time, to our knowledge, in stage III-IV non-small cell lung cancer (NSCLC) patients. Methods: Sixteen patients diagnosed with NSCLC underwent 2 PET/CT scans (1-3 d apart) before radiation therapy: a 3-min static 18 F-FDG and a dynamic 18F-FMISO scan lasting 168 ± 15 min. The latter data were acquired in 3 serial PET/CT dynamic imaging sessions, registered with each other and analyzed using pharmacokinetic modeling software. PKA was performed using a 2-tissue, 3-compartment irreversible model, and kinetic parameters were estimated for the volumes of interest determined using coregistered 18F-FDG images for both the volume of interest-averaged and the voxelwise time-activity curves for each patient's lesions, normal lung, and muscle. Results: We derived average values of 18F-FMISO kinetic parameters for NSCLC lesions as well as for normal lung and muscle. We also investigated the correlation between the trapping rate (k3) and delivery rate (K1), influx rate (Ki ) constants, and tissue-to-blood activity concentration ratios (TBRs) for all tissues. Lesions had trapping rates 1.6 times larger, on average, than those of normal lung and 4.4 times larger than those in muscle. Additionally, for almost all cases, k3 and Ki had a significant strong correlation for all tissue types. The TBR-k3 correlation was less straightforward, showing a moderate to strong correlation for only 41% of lesions. Finally, K1-k3 voxelwise correlations for tumors were varied, but negative for 76% of lesions, globally exhibiting a weak inverse relationship (average R = -0.23 ± 0.39). However, both normal tissue types exhibited significant positive correlations for more than 60% of patients, with 41% having moderate to strong correlations (R > 0.5). Conclusion: All lesions showed distinct 18F-FMISO uptake. Variable 18F-FMISO delivery was observed across lesions, as indicated by the variable values of the kinetic rate constant K1 Except for 3 cases, some degree of hypoxia was apparent in all lesions based on their nonzero k3 values.
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Affiliation(s)
- Jazmin Schwartz
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Milan Grkovski
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Heiko Schöder
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Pat B Zanzonico
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean D Carlin
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Kevin D Staton
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - John L Humm
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sadek A Nehmeh
- National Center for Cancer Care and Research, Doha, Qatar
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Ramamonjisoa N, Ackerstaff E. Characterization of the Tumor Microenvironment and Tumor-Stroma Interaction by Non-invasive Preclinical Imaging. Front Oncol 2017; 7:3. [PMID: 28197395 PMCID: PMC5281579 DOI: 10.3389/fonc.2017.00003] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 01/05/2017] [Indexed: 12/13/2022] Open
Abstract
Tumors are often characterized by hypoxia, vascular abnormalities, low extracellular pH, increased interstitial fluid pressure, altered choline-phospholipid metabolism, and aerobic glycolysis (Warburg effect). The impact of these tumor characteristics has been investigated extensively in the context of tumor development, progression, and treatment response, resulting in a number of non-invasive imaging biomarkers. More recent evidence suggests that cancer cells undergo metabolic reprograming, beyond aerobic glycolysis, in the course of tumor development and progression. The resulting altered metabolic content in tumors has the ability to affect cell signaling and block cellular differentiation. Additional emerging evidence reveals that the interaction between tumor and stroma cells can alter tumor metabolism (leading to metabolic reprograming) as well as tumor growth and vascular features. This review will summarize previous and current preclinical, non-invasive, multimodal imaging efforts to characterize the tumor microenvironment, including its stromal components and understand tumor-stroma interaction in cancer development, progression, and treatment response.
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Affiliation(s)
- Nirilanto Ramamonjisoa
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ellen Ackerstaff
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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41
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Shi K, Bayer C, Gaertner FC, Astner ST, Wilkens JJ, Nüsslin F, Vaupel P, Ziegler SI. Matching the reaction-diffusion simulation to dynamic [ 18F]FMISO PET measurements in tumors: extension to a flow-limited oxygen-dependent model. Physiol Meas 2017; 38:188-204. [PMID: 28055983 DOI: 10.1088/1361-6579/aa5071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Positron-emission tomography (PET) with hypoxia specific tracers provides a noninvasive method to assess the tumor oxygenation status. Reaction-diffusion models have advantages in revealing the quantitative relation between in vivo imaging and the tumor microenvironment. However, there is no quantitative comparison of the simulation results with the real PET measurements yet. The lack of experimental support hampers further applications of computational simulation models. This study aims to compare the simulation results with a preclinical [18F]FMISO PET study and to optimize the reaction-diffusion model accordingly. Nude mice with xenografted human squamous cell carcinomas (CAL33) were investigated with a 2 h dynamic [18F]FMISO PET followed by immunofluorescence staining using the hypoxia marker pimonidazole and the endothelium marker CD 31. A large data pool of tumor time-activity curves (TAC) was simulated for each mouse by feeding the arterial input function (AIF) extracted from experiments into the model with different configurations of the tumor microenvironment. A measured TAC was considered to match a simulated TAC when the difference metric was below a certain, noise-dependent threshold. As an extension to the well-established Kelly model, a flow-limited oxygen-dependent (FLOD) model was developed to improve the matching between measurements and simulations. The matching rate between the simulated TACs of the Kelly model and the mouse PET data ranged from 0 to 28.1% (on average 9.8%). By modifying the Kelly model to an FLOD model, the matching rate between the simulation and the PET measurements could be improved to 41.2-84.8% (on average 64.4%). Using a simulation data pool and a matching strategy, we were able to compare the simulated temporal course of dynamic PET with in vivo measurements. By modifying the Kelly model to a FLOD model, the computational simulation was able to approach the dynamic [18F]FMISO measurements in the investigated tumors.
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Affiliation(s)
- Kuangyu Shi
- Department of Nuclear Medicine, Technische Universität München, Klinikum rechts der Isar, Germany
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Warren DR, Partridge M. The role of necrosis, acute hypoxia and chronic hypoxia in 18F-FMISO PET image contrast: a computational modelling study. Phys Med Biol 2016; 61:8596-8624. [PMID: 27880734 PMCID: PMC5717515 DOI: 10.1088/1361-6560/61/24/8596] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 09/14/2016] [Accepted: 10/26/2016] [Indexed: 12/22/2022]
Abstract
Positron emission tomography (PET) using 18F-fluoromisonidazole (FMISO) is a promising technique for imaging tumour hypoxia, and a potential target for radiotherapy dose-painting. However, the relationship between FMISO uptake and oxygen partial pressure ([Formula: see text]) is yet to be quantified fully. Tissue oxygenation varies over distances much smaller than clinical PET resolution (<100 μm versus ∼4 mm), and cyclic variations in tumour perfusion have been observed on timescales shorter than typical FMISO PET studies (∼20 min versus a few hours). Furthermore, tracer uptake may be decreased in voxels containing some degree of necrosis. This work develops a computational model of FMISO uptake in millimetre-scale tumour regions. Coupled partial differential equations govern the evolution of oxygen and FMISO distributions, and a dynamic vascular source map represents temporal variations in perfusion. Local FMISO binding capacity is modulated by the necrotic fraction. Outputs include spatiotemporal maps of [Formula: see text] and tracer accumulation, enabling calculation of tissue-to-blood ratios (TBRs) and time-activity curves (TACs) as a function of mean tissue oxygenation. The model is characterised using experimental data, finding half-maximal FMISO binding at local [Formula: see text] of 1.4 mmHg (95% CI: 0.3-2.6 mmHg) and half-maximal necrosis at 1.2 mmHg (0.1-4.9 mmHg). Simulations predict a non-linear non-monotonic relationship between FMISO activity (4 hr post-injection) and mean tissue [Formula: see text] : tracer uptake rises sharply from negligible levels in avascular tissue, peaking at ∼5 mmHg and declining towards blood activity in well-oxygenated conditions. Greater temporal variation in perfusion increases peak TBRs (range 2.20-5.27) as a result of smaller predicted necrotic fraction, rather than fundamental differences in FMISO accumulation under acute hypoxia. Identical late FMISO uptake can occur in regions with differing [Formula: see text] and necrotic fraction, but simulated TACs indicate that additional early-phase information may allow discrimination of hypoxic and necrotic signals. We conclude that a robust approach to FMISO interpretation (and dose-painting prescription) is likely to be based on dynamic PET analysis.
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Affiliation(s)
- Daniel R Warren
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
| | - Mike Partridge
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
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Taylor E, Yeung I, Keller H, Wouters BG, Milosevic M, Hedley DW, Jaffray DA. Quantifying hypoxia in human cancers using static PET imaging. Phys Med Biol 2016; 61:7957-7974. [PMID: 27779123 DOI: 10.1088/0031-9155/61/22/7957] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Compared to FDG, the signal of 18F-labelled hypoxia-sensitive tracers in tumours is low. This means that in addition to the presence of hypoxic cells, transport properties contribute significantly to the uptake signal in static PET images. This sensitivity to transport must be minimized in order for static PET to provide a reliable standard for hypoxia quantification. A dynamic compartmental model based on a reaction-diffusion formalism was developed to interpret tracer pharmacokinetics and applied to static images of FAZA in twenty patients with pancreatic cancer. We use our model to identify tumour properties-well-perfused without substantial necrosis or partitioning-for which static PET images can reliably quantify hypoxia. Normalizing the measured activity in a tumour voxel by the value in blood leads to a reduction in the sensitivity to variations in 'inter-corporal' transport properties-blood volume and clearance rate-as well as imaging study protocols. Normalization thus enhances the correlation between static PET images and the FAZA binding rate K 3, a quantity which quantifies hypoxia in a biologically significant way. The ratio of FAZA uptake in spinal muscle and blood can vary substantially across patients due to long muscle equilibration times. Normalized static PET images of hypoxia-sensitive tracers can reliably quantify hypoxia for homogeneously well-perfused tumours with minimal tissue partitioning. The ideal normalizing reference tissue is blood, either drawn from the patient before PET scanning or imaged using PET. If blood is not available, uniform, homogeneously well-perfused muscle can be used. For tumours that are not homogeneously well-perfused or for which partitioning is significant, only an analysis of dynamic PET scans can reliably quantify hypoxia.
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Affiliation(s)
- Edward Taylor
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada. Techna Institute, University Health Network, Toronto, Canada
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Lee N, Schoder H, Beattie B, Lanning R, Riaz N, McBride S, Katabi N, Li D, Yarusi B, Chan S, Mitrani L, Zhang Z, Pfister DG, Sherman E, Baxi S, Boyle J, Morris LGT, Ganly I, Wong R, Humm J. Strategy of Using Intratreatment Hypoxia Imaging to Selectively and Safely Guide Radiation Dose De-escalation Concurrent With Chemotherapy for Locoregionally Advanced Human Papillomavirus-Related Oropharyngeal Carcinoma. Int J Radiat Oncol Biol Phys 2016; 96:9-17. [PMID: 27511842 PMCID: PMC5035649 DOI: 10.1016/j.ijrobp.2016.04.027] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 03/29/2016] [Accepted: 04/28/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To report a small substudy of an ongoing large, multi-arm study using functional imaging to assess pre-/intratreatment hypoxia for all head and neck cancer, in which we hypothesized that pre- and early-treatment hypoxia assessment using functional positron emission tomography (PET) imaging may help select which human papillomavirus (HPV)-positive (HPV(+)) oropharyngeal cancer (OPC) patients can safely receive radiation de-escalation without jeopardizing treatment outcomes. METHODS AND MATERIALS Patients with HPV(+) oropharyngeal carcinoma were enrolled on an institutional review board-approved prospective study of which de-escalation based on imaging response was done for node(s) only. Pretreatment (18)F-fluorodeoxyglucose and dynamic (18)F-FMISO (fluoromisonidazole) positron emission tomography (PET) scans were performed. For patients with pretreatment hypoxia on(18)F-FMISO PET (defined as a >1.2 tumor to muscle standard uptake value ratio), a repeat scan was done 1 week after chemoradiation. Patients without pretreatment hypoxia or with resolution of hypoxia on repeat scan received a 10-Gy dose reduction to metastatic lymph node(s). The 2-year local, regional, distant metastasis-free, and overall survival rates were estimated using the Kaplan-Meier product-limit method. A subset of patients had biopsy of a hypoxic node done under image guidance. RESULTS Thirty-three HPV(+) OPC patients were enrolled in this pilot study. One hundred percent showed pretreatment hypoxia (at primary site and/or node[s]), and among these, 48% resolved (at primary site and/or node[s]); 30% met criteria and received 10-Gy reduction to the lymph node(s). At the median follow-up of 32 months (range, 21-61 months), the 2-year locoregional control rate was 100%. One patient failed distantly with persistence of hypoxia on (18)F-FMISO PET. The 2-year distant metastasis-free rate was 97%. The 2-year OS rate was 100%. Hypoxia on imaging was confirmed pathologically. CONCLUSIONS Hypoxia is present in HPV(+) tumors but resolves within 1 week of treatment in 48% of cases either at the primary site and/or lymph node(s). Our 100% locoregional control rate suggests that intratreatment functional imaging used to selectively de-escalate node(s) to 60 Gy was confirmed safe using our stringent imaging criteria. Intratreatment functional imaging warrants further study to determine its ultimate role in de-escalation treatment strategies.
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Affiliation(s)
- Nancy Lee
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York.
| | - Heiko Schoder
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Brad Beattie
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ryan Lanning
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Sean McBride
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Nora Katabi
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Duan Li
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Brett Yarusi
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Susie Chan
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Lindsey Mitrani
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - David G Pfister
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Eric Sherman
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Shrujal Baxi
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jay Boyle
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Luc G T Morris
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ian Ganly
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Richard Wong
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - John Humm
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
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Tong X, Srivatsan A, Jacobson O, Wang Y, Wang Z, Yang X, Niu G, Kiesewetter DO, Zheng H, Chen X. Monitoring Tumor Hypoxia Using (18)F-FMISO PET and Pharmacokinetics Modeling after Photodynamic Therapy. Sci Rep 2016; 6:31551. [PMID: 27546160 PMCID: PMC4992876 DOI: 10.1038/srep31551] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 07/13/2016] [Indexed: 11/09/2022] Open
Abstract
Photodynamic therapy (PDT) is an efficacious treatment for some types of cancers. However, PDT-induced tumor hypoxia as a result of oxygen consumption and vascular damage can reduce the efficacy of this therapy. Measuring and monitoring intrinsic and PDT-induced tumor hypoxia in vivo during PDT is of high interest for prognostic and treatment evaluation. In the present study, static and dynamic (18)F-FMISO PET were performed with mice bearing either U87MG or MDA-MB-435 tumor xenografts immediately before and after PDT at different time points. Significant difference in tumor hypoxia in response to PDT over time was found between the U87MG and MDA-MB-435 tumors in both static and dynamic PET. Dynamic PET with pharmacokinetics modeling further monitored the kinetics of (18)F-FMISO retention to hypoxic sites after treatment. The Ki and k3 parametric analysis provided information on tumor hypoxia by distinction of the specific tracer retention in hypoxic sites from its non-specific distribution in tumor. Dynamic (18)F-FMISO PET with pharmacokinetics modeling, complementary to static PET analysis, provides a potential imaging tool for more detailed and more accurate quantification of tumor hypoxia during PDT.
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Affiliation(s)
- Xiao Tong
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, Maryland 20892, United States.,Paul C. Lauterbur Research Center for Biomedical Imaging, Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Avinash Srivatsan
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, Maryland 20892, United States
| | - Orit Jacobson
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, Maryland 20892, United States
| | - Yu Wang
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, Maryland 20892, United States
| | - Zhantong Wang
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, Maryland 20892, United States
| | - Xiangyu Yang
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, Maryland 20892, United States
| | - Gang Niu
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, Maryland 20892, United States
| | - Dale O Kiesewetter
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, Maryland 20892, United States
| | - Hairong Zheng
- Paul C. Lauterbur Research Center for Biomedical Imaging, Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Xiaoyuan Chen
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, Maryland 20892, United States
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Karakatsanis NA, Casey ME, Lodge MA, Rahmim A, Zaidi H. Whole-body direct 4D parametric PET imaging employing nested generalized Patlak expectation-maximization reconstruction. Phys Med Biol 2016; 61:5456-85. [PMID: 27383991 DOI: 10.1088/0031-9155/61/15/5456] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Whole-body (WB) dynamic PET has recently demonstrated its potential in translating the quantitative benefits of parametric imaging to the clinic. Post-reconstruction standard Patlak (sPatlak) WB graphical analysis utilizes multi-bed multi-pass PET acquisition to produce quantitative WB images of the tracer influx rate K i as a complimentary metric to the semi-quantitative standardized uptake value (SUV). The resulting K i images may suffer from high noise due to the need for short acquisition frames. Meanwhile, a generalized Patlak (gPatlak) WB post-reconstruction method had been suggested to limit K i bias of sPatlak analysis at regions with non-negligible (18)F-FDG uptake reversibility; however, gPatlak analysis is non-linear and thus can further amplify noise. In the present study, we implemented, within the open-source software for tomographic image reconstruction platform, a clinically adoptable 4D WB reconstruction framework enabling efficient estimation of sPatlak and gPatlak images directly from dynamic multi-bed PET raw data with substantial noise reduction. Furthermore, we employed the optimization transfer methodology to accelerate 4D expectation-maximization (EM) convergence by nesting the fast image-based estimation of Patlak parameters within each iteration cycle of the slower projection-based estimation of dynamic PET images. The novel gPatlak 4D method was initialized from an optimized set of sPatlak ML-EM iterations to facilitate EM convergence. Initially, realistic simulations were conducted utilizing published (18)F-FDG kinetic parameters coupled with the XCAT phantom. Quantitative analyses illustrated enhanced K i target-to-background ratio (TBR) and especially contrast-to-noise ratio (CNR) performance for the 4D versus the indirect methods and static SUV. Furthermore, considerable convergence acceleration was observed for the nested algorithms involving 10-20 sub-iterations. Moreover, systematic reduction in K i % bias and improved TBR were observed for gPatlak versus sPatlak. Finally, validation on clinical WB dynamic data demonstrated the clinical feasibility and superior K i CNR performance for the proposed 4D framework compared to indirect Patlak and SUV imaging.
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Affiliation(s)
- Nicolas A Karakatsanis
- Division of Nuclear Medicine and Molecular Imaging, School of Medicine, University of Geneva, Geneva, CH-1211, Switzerland
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47
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Okamoto S, Shiga T, Yasuda K, Watanabe S, Hirata K, Nishijima KI, Magota K, Kasai K, Onimaru R, Tuchiya K, Kuge Y, Shirato H, Tamaki N. The reoxygenation of hypoxia and the reduction of glucose metabolism in head and neck cancer by fractionated radiotherapy with intensity-modulated radiation therapy. Eur J Nucl Med Mol Imaging 2016; 43:2147-2154. [DOI: 10.1007/s00259-016-3431-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 05/23/2016] [Indexed: 12/19/2022]
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48
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Holman BF, Cuplov V, Hutton BF, Groves AM, Thielemans K. The effect of respiratory induced density variations on non-TOF PET quantitation in the lung. Phys Med Biol 2016; 61:3148-63. [PMID: 27007013 DOI: 10.1088/0031-9155/61/8/3148] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Accurate PET quantitation requires a matched attenuation map. Obtaining matched CT attenuation maps in the thorax is difficult due to the respiratory cycle which causes both motion and density changes. Unlike with motion, little attention has been given to the effects of density changes in the lung on PET quantitation. This work aims to explore the extent of the errors caused by pulmonary density attenuation map mismatch on dynamic and static parameter estimates. Dynamic XCAT phantoms were utilised using clinically relevant (18)F-FDG and (18)F-FMISO time activity curves for all organs within the thorax to estimate the expected parameter errors. The simulations were then validated with PET data from 5 patients suffering from idiopathic pulmonary fibrosis who underwent PET/Cine-CT. The PET data were reconstructed with three gates obtained from the Cine-CT and the average Cine-CT. The lung TACs clearly displayed differences between true and measured curves with error depending on global activity distribution at the time of measurement. The density errors from using a mismatched attenuation map were found to have a considerable impact on PET quantitative accuracy. Maximum errors due to density mismatch were found to be as high as 25% in the XCAT simulation. Differences in patient derived kinetic parameter estimates and static concentration between the extreme gates were found to be as high as 31% and 14%, respectively. Overall our results show that respiratory associated density errors in the attenuation map affect quantitation throughout the lung, not just regions near boundaries. The extent of this error is dependent on the activity distribution in the thorax and hence on the tracer and time of acquisition. Consequently there may be a significant impact on estimated kinetic parameters throughout the lung.
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Affiliation(s)
- Beverley F Holman
- Institute of Nuclear Medicine, UCLH, 235 Euston Road (T-5), London, NW1 2BU, UK
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49
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Yu Y, Chan C, Ma T, Liu Y, Gallezot JD, Naganawa M, Kelada OJ, Germino M, Sinusas AJ, Carson RE, Liu C. Event-by-Event Continuous Respiratory Motion Correction for Dynamic PET Imaging. J Nucl Med 2016; 57:1084-90. [DOI: 10.2967/jnumed.115.167676] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 02/01/2016] [Indexed: 11/16/2022] Open
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50
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Toyonaga T, Hirata K, Yamaguchi S, Hatanaka KC, Yuzawa S, Manabe O, Kobayashi K, Watanabe S, Shiga T, Terasaka S, Kobayashi H, Kuge Y, Tamaki N. (18)F-fluoromisonidazole positron emission tomography can predict pathological necrosis of brain tumors. Eur J Nucl Med Mol Imaging 2016; 43:1469-76. [PMID: 26841941 DOI: 10.1007/s00259-016-3320-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 01/15/2016] [Indexed: 01/09/2023]
Abstract
PURPOSE Tumor necrosis is one of the indicators of tumor aggressiveness. (18)F-fluoromisonidazole (FMISO) is the most widely used positron emission tomography (PET) tracer to evaluate severe hypoxia in vivo. Because severe hypoxia causes necrosis, we hypothesized that intratumoral necrosis can be detected by FMISO PET in brain tumors regardless of their histopathology. We applied FMISO PET to various types of brain tumors before tumor resection and evaluated the correlation between histopathological necrosis and FMISO uptake. METHODS This study included 59 brain tumor patients who underwent FMISO PET/computed tomography before any treatments. According to the pathological diagnosis, the brain tumors were divided into three groups: astrocytomas (group 1), neuroepithelial tumors except for astrocytomas (group 2), and others (group 3). Two experienced neuropathologists evaluated the presence of necrosis in consensus. FMISO uptake in the tumor was evaluated visually and semi-quantitatively using the tumor-to-normal cerebellum ratio (TNR). RESULTS In visual analyses, 26/27 cases in the FMISO-positive group presented with necrosis, whereas 28/32 cases in the FMISO-negative group did not show necrosis. Mean TNRs with and without necrosis were 3.49 ± 0.97 and 1.43 ± 0.42 (p < 0.00001) in group 1, 2.91 ± 0.83 and 1.44 ± 0.20 (p < 0.005) in group 2, and 2.63 ± 1.16 and 1.35 ± 0.23 (p < 0.05) in group 3, respectively. Using a cut-off value of TNR = 1.67, which was calculated by normal reference regions of interest, we could predict necrosis with sensitivity, specificity, and accuracy of 96.7, 93.1, and 94.9 %, respectively. CONCLUSIONS FMISO uptake within the lesion indicated the presence of histological micro-necrosis. When we used a TNR of 1.67 as the cut-off value, intratumoral micro-necrosis was sufficiently predictable. Because the presence of necrosis implies a poor prognosis, our results suggest that FMISO PET could provide important information for treatment decisions or surgical strategies of any type of brain tumor.
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Affiliation(s)
- Takuya Toyonaga
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Kenji Hirata
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Shigeru Yamaguchi
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-Ku, Sapporo, 060-8638, Japan. .,Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Kanako C Hatanaka
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan
| | - Sayaka Yuzawa
- Department of Cancer Pathology, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Osamu Manabe
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Kentaro Kobayashi
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Shiro Watanabe
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Tohru Shiga
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Shunsuke Terasaka
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroyuki Kobayashi
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuji Kuge
- Central Institute of Isotope Science, Hokkaido University, Sapporo, Japan
| | - Nagara Tamaki
- Department of Nuclear Medicine, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-Ku, Sapporo, 060-8638, Japan
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