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1.  Phase I Study of ARN-509, a Novel Antiandrogen, in the Treatment of Castration-Resistant Prostate Cancer 
Journal of Clinical Oncology  2013;31(28):3525-3530.
Purpose
ARN-509 is a novel androgen receptor (AR) antagonist for the treatment of castration-resistant prostate cancer (CRPC). ARN-509 inhibits AR nuclear translocation and AR binding to androgen response elements and, unlike bicalutamide, does not exhibit agonist properties in the context of AR overexpression. This first-in-human phase I study assessed safety, tolerability, pharmacokinetics, pharmacodynamics, and antitumor activity of ARN-509 in men with metastatic CRPC.
Patients and Methods
Thirty patients with progressive CRPC received continuous daily oral ARN-509 at doses between 30 and 480 mg, preceded by administration of a single dose followed by a 1-week observation period with pharmacokinetic sampling. Positron emission tomography/computed tomography imaging was conducted to monitor [18F]fluoro-α-dihydrotestosterone (FDHT) binding to AR in tumors before and during treatment. Primary objective was to determine pharmacokinetics, safety, and recommended phase II dose.
Results
Pharmacokinetics were linear and dose proportional. Prostate-specific antigen declines at 12 weeks (≥ 50% reduction from baseline) were observed in 46.7% of patients. Reduction in FDHT uptake was observed at all doses, with a plateau in response at ≥ 120-mg dose, consistent with saturation of AR binding. The most frequently reported adverse event was grade 1/2 fatigue (47%). One dose-limiting toxicity event (grade 3 abdominal pain) occurred at the 300-mg dose. Dose escalation to 480 mg did not identify a maximum-tolerated dose.
Conclusion
ARN-509 was safe and well tolerated, displayed dose-proportional pharmacokinetics, and demonstrated pharmacodynamic and antitumor activity across all dose levels tested. A maximum efficacious dose of 240 mg daily was selected for phase II exploration based on integration of preclinical and clinical data.
doi:10.1200/JCO.2013.50.1684
PMCID: PMC3782148  PMID: 24002508
2.  Bone Scan Index: A Quantitative Treatment Response Biomarker for Castration-Resistant Metastatic Prostate Cancer 
Journal of Clinical Oncology  2012;30(5):519-524.
Purpose
There is currently no imaging biomarker for metastatic prostate cancer. The bone scan index (BSI) is a promising candidate, being a reproducible, quantitative expression of tumor burden seen on bone scintigraphy. Prior studies have shown the prognostic value of a baseline BSI. This study tested whether treatment-related changes in BSI are prognostic for survival and compared BSI to prostate-specific antigen (PSA) as an outcome measure.
Patients and Methods
We retrospectively examined serial bone scans from patients with castration-resistant metastatic prostate cancer (CRMPC) enrolled in four clinical trials. We calculated BSI at baseline and at 3 and 6 months on treatment and performed univariate and bivariate analyses of PSA, BSI, and survival.
Results
Eighty-eight patients were scanned, 81 of whom have died. In the univariate analysis, the log percent change in BSI from baseline to 3 and 6 months on treatment prognosticated for survival (hazard ratio [HR], 2.44; P = .0089 and HR, 2.54; P < .001, respectively). A doubling in BSI resulted in a 1.9-fold increase in risk of death. Log percent change in PSA at 6 months on treatment was also associated with survival (HR, 1.298; P = .013). In the bivariate analysis, change in BSI while adjusting for PSA was prognostic at 3 and 6 months on treatment (HR, 2.368; P = .012 and HR, 2.226; P = .002, respectively), but while adjusting for BSI, PSA was not prognostic.
Conclusion
These data furnish early evidence that on-treatment changes in BSI are a response indicator and support further exploration of bone scintigraphy as an imaging biomarker in CRMPC.
doi:10.1200/JCO.2011.36.5791
PMCID: PMC3295554  PMID: 22231045
3.  Evaluation of glycodendron and synthetically-modified dextran clearing agents for multi-step targeting of radioisotopes for molecular imaging and radioimmunotherapy 
Molecular pharmaceutics  2013;11(2):400-416.
A series of N-acetylgalactosamine-dendrons (NAG-dendrons) and dextrans bearing biotin moieties were compared for their ability to complex with and sequester circulating bispecific anti-tumor antibody (scFv4) streptavidin (SA) fusion protein (scFv4-SA) in vivo, to improve tumor to normal tissue concentration ratios for targeted radioimmunotherapy and diagnosis. Specifically, a total of five NAG-dendrons employing a common synthetic scaffold structure containing 4, 8, 16, or 32 carbohydrate residues and a single biotin moiety were prepared (NAGB), and for comparative purposes, a biotinylated-dextran with average molecular weight (MW) of 500 kD was synthesized from amino-dextran (DEXB). One of the NAGB compounds, CA16, has been investigated in humans; our aim was to determine if other NAGB analogs (e.g. CA8 or CA4) were bioequivalent to CA16 and/or better suited as MST reagents. In vivo studies included dynamic positron-emission tomography (PET) imaging of 124I-labelled-scFv4-SA clearance and dual-label biodistribution studies following multi-step targeting (MST) directed at subcutaneous (s.c.) human colon adenocarcinoma xenografts in mice. The MST protocol consists of three injections: first, a bispecific antibody specific for an anti-tumor associated glycoprotein (TAG-72) single chain genetically-fused with SA (scFv4-SA); second, CA16 or other clearing agent; and third, radiolabeled biotin. We observed using PET imaging of 124I-labelled-scFv4-SA clearance that the spatial arrangement of ligands conjugated to NAG (i.e. biotin) can impact the binding to antibody in circulation and subsequent liver uptake of the NAG-antibody complex. Also, NAGB CA32-LC or CA16-LC can be utilized during MST to achieve comparable tumor- to-blood ratios and absolute tumor uptake seen previously with CA16. Finally, DEXB was equally effective as NAGB CA32-LC at lowering scFv4-SA in circulation, but at the expense of reducing absolute tumor uptake of radiolabeled biotin.
doi:10.1021/mp4003128
PMCID: PMC4270281  PMID: 24219178
asialoglycoprotein; pretargeting; radioimmunotherapy; bispecific antibodies
4.  PROGNOSTIC VALUE OF BASELINE [18F] FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY AND 99mTc-MDP BONE SCAN IN PROGRESSING METASTATIC PROSTATE CANCER 
Clinical Cancer Research  2010;16(24):6093-6099.
Purpose
To compare the diagnostic and prognostic value of FDG PET and bone scans (BS) in the assessment of osseous lesions in patients with progressing prostate cancer.
Experimental Design
In a prospective imaging trial, 43 patients underwent FDG PET and BS prior to experimental therapies. Bone scan index (BSI) and standardized uptake value (SUV) on FDG PET were recorded. Patients were followed until death (n=36) or at least 5 years (n=7). Imaging findings were correlated with survival.
Results
Osseous lesions were detected in 39 patients on BS and 32 on FDG PET (p=0.01). Follow-up was available for 105 FDG-positive lesions, and 84 (80%) became positive on subsequent BS. Prognosis correlated inversely with SUV (median survival 14.4 vs. 32.8 mos if SUVmax > 6.10 vs. ≤ 6.10, p=0.002) and BSI (14.7 vs. 28.2 mos if BSI >1.27 vs. < 1.27; p=0.004). Only SUV was an independent factor in multivariate analysis. In castrate resistant patients combining a nomogram for progressive prostate cancer with SUV dichotomized patients into a high vs. low risk group (median survival 14.4 vs. 34.6 mos, p=.015) more prognostic than either nomogram or SUV alone.
Conclusion
The current study of progressive prostate cancer confirms earlier work that BSI is a strong prognostic factor. Most FDG-only lesions at baseline become detectable on follow-up BS, suggesting their strong clinical relevance. FDG SUV is an independent prognostic factor and provides complementary prognostic information.
doi:10.1158/1078-0432.CCR-10-1357
PMCID: PMC3402086  PMID: 20975102
prostate cancer; positron emission tomography; FDG; bone scan; prognosis
5.  N-Acetylgalactosamino Dendrons as Clearing Agents to Enhance Liver Targeting of Model Antibody-Fusion Protein 
Bioconjugate chemistry  2013;24(12):2088-2103.
Dendrimer clearing agents represent a unique class of compounds for use in multistep targeting (MST) in radioimmunotherapy and imaging. These compounds were developed to facilitate the removal of excess tumor-targeting monoclonal antibody (mAb) prior to administration of the radionuclide to minimize exposure of normal tissue to radiation. Clearing agents are designed to capture the circulating mAb, and target it to the liver for metabolism. Glycodendrons are ideally suited for MST applications as these highly branched compounds are chemically well-defined thus advantageous over heterogeneous macromolecules. Previous studies have described glycodendron 3 as a clearing agent for use in three-step MST protocols, and early in vivo assessment of 3 showed promise. However, synthetic challenges have hampered its availability for further development. In this report we describe a new sequence of chemical steps which enables the straightforward synthesis and analytical characterization of this class of dendrons. With accessibility and analytical identification solved, we sought to evaluate both lower and higher generation dendrons for hepatocyte targeting as well as clearance of a model protein. We prepared a series of clearing agents where a single biotin is connected to glycodendrons displaying four, eight, sixteen or thirty-two α-thio-N-acetylgalactosamine (α–SGalNAc) units, resulting in compounds with molecular weights ranging from 2 to 17 kDa, respectively. These compounds were fully characterized by LCMS and NMR. We then evaluated the capacity of these agents to clear a model 131I-labeled single chain variable fragment antibody-streptavidin (131I-scFv-SAv) fusion protein from blood and tissue in mice, and compared their clearing efficiencies to that of a 500 kDa dextran-biotin conjugate. Glycodendrons and dextran-biotin exhibited enhanced blood clearance of the scFv-SAv construct. Biodistribution analysis showed liver targeting/uptake of the scFv-SAv construct to be two-fold higher for compounds 1 to 4, as well as for the 500 kDa dextran, over saline. Additionally, the data suggest the glycodendrons clear through the liver, whereas the dextran through reticuloendothelial system (RES) metabolism.
doi:10.1021/bc400333m
PMCID: PMC3900322  PMID: 24147780
6.  124I-Labeled Engineered Anti-CEA Minibodies and Diabodies Allow High-Contrast, Antigen-Specific Small-Animal PET Imaging of Xenografts in Athymic Mice 
Prolonged clearance kinetics have hampered the development of intact antibodies as imaging agents, despite their ability to effectively deliver radionuclides to tumor targets in vivo. Genetically engineered antibody fragments display rapid, high-level tumor uptake coupled with rapid clearance from the circulation in the athymic mouse/LS174T xenograft model. The anticarcinoembryonic antigen (CEA) T84.66 minibody (single-chain Fv fragment [scFv]-CH3 dimer, 80 kDa) and T84.66 diabody (non-covalent dimer of scFv, 55 kDa) exhibit pharmacokinetics favorable for radioimmunoimaging. The present work evaluated the minibody or diabody labeled with 124I, for imaging tumor-bearing mice using a high-resolution small-animal PET system.
Methods
Labeling was conducted with 0.2–0.3 mg of protein and 65–98 MBq (1.7–2.6 mCi) of 124I using an iodination reagent. Radiolabeling efficiencies ranged from 33% to 88%, and immunoreactivity was 42% (diabody) or >90% (minibody). In vivo distribution was evaluated in athymic mice bearing paired LS174T human colon carcinoma (CEA-positive) and C6 rat glioma (CEA-negative) xenografts. Mice were injected via the tail vein with 1.9–3.1 MBq (53–85 μCi) of 124I-minibody or with 3.1 MBq (85 μCi) of 124I-diabody and imaged at 4 and 18 h by PET. Some mice were also imaged using 18F-FDG 2 d before imaging with 124I-minibody.
Results
PET images using 124I-labeled mini-body or diabody showed specific localization to the CEA-positive xenografts and relatively low activity elsewhere in the mice, particularly by 18 h. Target-to-background ratios for the LS174T tumors versus soft tissues using 124I-minibody were 3.05 at 4 h and 11.03 at 18 h. Similar values were obtained for the 124I-diabody (3.95 at 4 h and 10.93 at 18 h). These results were confirmed by direct counting of tissues after the final imaging. Marked reduction of normal tissue activity, especially in the abdominal region, resulted in high-contrast images at 18 h for the 124I-anti-CEA diabody. CEA-positive tumors as small as 11 mg (<3 mm in diameter) could be imaged, and 124I-anti-CEA minibodies, compared with 18F-FDG, demonstrated highly specific localization.
Conclusion
124I labeling of engineered antibody fragments provides a promising new class of tumor-specific probes for PET imaging of tumors and metastases.
PMCID: PMC4167879  PMID: 14660722
radioimmunoimaging; engineered antibody fragments; carcinoembryonic antigen; 124I; PET
7.  Repetitively Dosed Docetaxel and 153Samarium-EDTMP as an Anti-Tumor Strategy for Metastatic Castration-Resistant Prostate Cancer 
Cancer  2013;119(17):3186-3194.
Background
Beta-emitting bone-seeking radiopharmaceuticals have historically been administered for pain palliation while docetaxel prolongs life in metastatic castration-resistant prostate cancer (mCRPC). In combination, these agents simultaneously target the bone stroma and cancer cell to optimize anti-tumor effects. The toxicity and efficacy when each agent is combined at full, recommended doses, in a repetitive fashion is not well established.
Methods
Patients with progressive mCRPC and ≥3 bone lesions received 153Sm-EDTMP 1.0 mCi/kg every 9 weeks and docetaxel 75mg/m2 every 3 weeks. In the absence of unacceptable toxicity, patients were allowed to continue additional cycles, defined by 9 weeks of treatment, until intolerance or biochemical/radiographic progression.
Results
Of 30 patients treated, 50% were taxane-naïve, 36.7% taxane-refractory, and 13.3% previously exposed to taxanes but not considered refractory. Patients received on average 2.5 cycles: 6.5 doses of docetaxel and 2.5 doses of 153Sm-EDTMP. Twelve (40%) demonstrated decline in prostate-specific antigen of ≥50%. Median progression-free survival (biochemical or radiographic) was 7.0 months and overall survival was 14.3 months. Nine patients (30%) did not recover platelet counts above 100 K/mm3 after a median of 3 cycles to allow for additional treatment, with four experiencing prolonged thrombocytopenia. The most common reasons for trial discontinuation were progressive disease and hematologic toxicity.
Discussion
153Sm-EDTMP can be safely combined with docetaxel at full doses on an ongoing basis. Thrombocytopenia limited therapy for some patients; preliminary efficacy supports the strategy of combining a radiopharmaceutical with chemotherapy, an appealing strategy given the anticipated availability of alpha emitters that can prolong survival.
doi:10.1002/cncr.28103
PMCID: PMC3775970  PMID: 23765638
prostate cancer; 153Sm-EDTMP; docetaxel; chemotherapy; radiopharmaceutical
8.  Pharmacokinetic Assessment of the Uptake of 16β-[18F]-Fluoro-5α Dihydrotestosterone (FDHT) in Prostate Tumors as Measured by PET 
Objective
The aim of this study was to develop a clinically applicable non-invasive method to quantify changes in androgen receptor (AR) levels based on 18F-FDHT PET in prostate cancer patients undergoing therapy.
Methods
Thirteen patients underwent dynamic 18F-FDHT PET scans over a selected tumor. Concurrent venous blood samples were acquired for blood metabolite analysis. A second cohort of 25 patients, injected with 18F-FDHT underwent dynamic PET imaging of the heart. These data were used to generate a population-based input function, essential for pharmacokinetic modeling. Linear compartmental pharmacokinetic models of increasing complexity were tested on the tumor tissue data. Four suitable models were applied and compared using the Bayesian Information Criterion (BIC). Model 1 consisted of an instantaneously equilibrating space followed by a unidirectional trap. Models 2a and 2b contained a reversible space between the instantaneously equilibrating space and the trap, into which metabolites were excluded (2a) or allowed (2b). Model 3 built upon Model 2b with the addition of a second reversible space preceding the unidirectional trap and from which metabolites were excluded.
Results
The half-life of the 18F-FDHT in blood was determined to be between 6-7 minutes. As a consequence, the uptake of 18F-FDHT in prostate cancer lesions reached a plateau within 20-minutes as the blood-borne activity was consumed. Radiolabeled metabolites were shown not to bind to AR in in-vitro studies with CWR22 cells. Model 1 produced reasonable and robust fits for all datasets and was judged best by the BIC for 16 out of 26 tumor scans. Models 2a, 2b and 3 were judged best in seven, two and one case, respectively.
Conclusion
Our study explores the clinical potential of using 18F-FDHT PET to make estimates of free AR concentration. This process involved the estimation of a net-uptake parameter such as Model 1’s ktrap that could serve as a surrogate measure of AR expression in metastatic prostate cancer. Our initial studies suggest a simple body-mass normalized standard uptake value (SUV) is reasonably well correlated to model based ktrap estimates, which we surmise may be proportional to AR expression. Validation studies to test this hypothesis are underway.
doi:10.2967/jnumed.109.066159
PMCID: PMC2866076  PMID: 20080885
9.  Non-invasive mapping of deep-tissue lymph nodes in live animals using a multimodal PET/MRI nanoparticle 
Nature communications  2014;5:3097.
The invasion status of tumour-draining lymph nodes (LNs) is a critical indicator of cancer stage and is important for treatment planning. Clinicians currently use planar scintigraphy and single-photon emission computed tomography (SPECT) with 99mTc-radiocolloid to guide biopsy and resection of LNs. However, emerging multimodality approaches such as positron emission tomography combined with magnetic resonance imaging (PET/MRI) detect sites of disease with higher sensitivity and accuracy. Here we present a multimodal nanoparticle, 89Zr-ferumoxytol, for the enhanced detection of LNs with PET/MRI. For genuine translational potential, we leverage a clinical iron oxide formulation, altered with minimal modification for radiolabelling. Axillary drainage in naive mice and from healthy and tumour-bearing prostates was investigated. We demonstrate that 89Zr-ferumoxytol can be used for high-resolution tomographic studies of lymphatic drainage in preclinical disease models. This nanoparticle platform has significant translational potential to improve preoperative planning for nodal resection and tumour staging.
doi:10.1038/ncomms4097
PMCID: PMC4080716  PMID: 24445347
10.  Clearance Kinetics and External Dosimetry of Iodine-131-labeled Murine and Humanized Monoclonal Antibody A33 in Patients with Colon Cancer: Radiation Safety Implications 
Health physics  2009;96(5):550-557.
The monoclonal antibody (mAb) A33 detects a membrane antigen that is expressed on greater than 95% of metastatic human colorectal cancers. Previous studies have shown excellent tumor-targeting of iodine-131 labeled murine and humanized forms of the mAb. A retrospective analysis of whole body clearance in the murine form was performed for comparison to the humanized form. Serial whole-body dose rate measurements were obtained for 55 treatments on 30 patients participating in phase I/II dose escalation studies of therapeutic iodine-131-murine A33 mAb. Whole-body retention fractions over time were derived. Each treatment was fit with exponential curves to determine the effective half-lives and corresponding clearance fractions. There was a large variability in the calculated mono-exponential clearance effective half-life time, with a mean value of 36.5 h +/− 8.5 h. A bi-exponential fit of all combined data shows that 60% of the administered dose rapidly clears with a biological half-time of 23.9 h and 40% clears with a slower biological half-time of 101.2 h. The whole body clearance proved to be more rapid in the murine form when compared with recent studies on the humanized form of radiolabeled A33 mAb. The variability in whole body clearance reinforces the need for patient-specific tracer dosimetry for clinical care and radiation safety precautions. In addition, the slower clearance of the humanized form of the A33 mAb requires longer term radiation safety precautions than the earlier murine form. As other monoclonal antibodies progress from murine to humanized forms, radiopharmacokinetics should be evaluated for clinical and radiation safety implications.
doi:10.1097/01.HP.0000342831.26198.eb
PMCID: PMC4045026  PMID: 19359848
immunotherapy; radiotherapy; kinetics; monoclonal antibody; cancer; radiation protection
11.  Radioimmunotherapy Combined with Maintenance Anti-CD20 Antibody May Trigger Long-Term Protective T Cell Immunity in Follicular Lymphoma Patients 
Growing evidence suggests that the patient's immune response may play a major role in the long-term efficacy of antibody therapies of follicular lymphoma (FL). Particular long-lasting recurrence free survivals have been observed after first line, single agent rituximab or after radioimmunotherapy (RIT). Rituximab maintenance, furthermore, has a major efficacy in prolonging recurrence free survival after chemotherapy. On the other hand, RIT as a single step treatment showed a remarkable capacity to induce complete and partial remissions when applied in recurrence and as initial treatment of FL or given for consolidation. These clinical results strongly suggest that RIT combined with rituximab maintenance could stabilize the high percentages of patients with CR and PR induced by RIT. While the precise mechanisms of the long-term efficacy of these 2 treatments are not elucidated, different observations suggest that the patient's T cell immune response could be decisive. With this review, we discuss the potential role of the patient's immune system under rituximab and RIT and argue that the T cell immunity might be particularly promoted when combining the 2 antibody treatments in the early therapy of FL.
doi:10.1155/2013/875343
PMCID: PMC3858978  PMID: 24371449
12.  A novel ligand delivery system to non-invasively visualize and therapeutically exploit the IL13Rα2 tumor-restricted biomarker 
Neuro-Oncology  2012;14(10):1239-1253.
Our objective was to exploit a novel ligand-based delivery system for targeting diagnostic and therapeutic agents to cancers that express interleukin 13 receptor alpha 2 (IL13Rα2), a tumor-restricted plasma membrane receptor overexpressed in glioblastoma multiforme (GBM), meningiomas, peripheral nerve sheath tumors, and other peripheral tumors. On the basis of our prior work, we designed a novel IL13Rα2-targeted quadruple mutant of IL13 (TQM13) to selectively bind the tumor-restricted IL13Rα2 with high affinity but not significantly interact with the physiologically abundant IL13Rα1/IL4Rα heterodimer that is also expressed in normal brain. We then assessed the in vitro binding profile of TQM13 and its potential to deliver diagnostic and therapeutic radioactivity in vivo. Surface plasmon resonance (SPR; Biacore) binding experiments demonstrated that TQM13 bound strongly to recombinant IL13Rα2 (Kd∼5 nM). In addition, radiolabeled TQM13 specifically bound IL13Rα2-expressing GBM cells and specimens but not normal brain. Of importance, TQM13 did not functionally activate IL13Rα1/IL4Rα in cells or bind to it in SPR binding assays, in contrast to wtIL13. Furthermore, in vivo targeting of systemically delivered radiolabeled TQM13 to IL13Rα2-expressing subcutaneous tumors was demonstrated and confirmed non-invasively for the first time with 124I-TQM13 positron emission tomography imaging. In addition, 131I-TQM13 demonstrated in vivo efficacy against subcutaneous IL13Rα2-expressing GBM tumors and in an orthotopic synergeic IL13Rα2-positive murine glioma model, as evidenced by statistically significant survival advantage. Our results demonstrate that we have successfully generated an optimized biomarker-targeted scaffolding that exhibited specific binding activity toward the tumor-associated IL13Rα2 in vitro and potential to deliver diagnostic and therapeutic payloads in vivo.
doi:10.1093/neuonc/nos211
PMCID: PMC3452345  PMID: 22952195
glioblastoma multiforme; interleukin-13 receptor; PET; radioimmunotherapy
13.  A Novel Automated Platform for Quantifying the Extent of Skeletal Tumour Involvement in Prostate Cancer Patients Using the Bone Scan Index 
European Urology  2012;62(1):78-84.
Background
There is little consensus on a standard approach to analysing bone scan images. The Bone Scan Index (BSI) is predictive of survival in patients with progressive prostate cancer (PCa), but the popularity of this metric is hampered by the tedium of the manual calculation.
Objective
Develop a fully automated method of quantifying the BSI and determining the clinical value of automated BSI measurements beyond conventional clinical and pathologic features.
Design, setting, and participants
We conditioned a computer-assisted diagnosis system identifying metastatic lesions on a bone scan to automatically compute BSI measurements. A training group of 795 bone scans was used in the conditioning process. Independent validation of the method used bone scans obtained ≤3 mo from diagnosis of 384 PCa cases in two large population-based cohorts. An experienced analyser (blinded to case identity, prior BSI, and outcome) scored the BSI measurements twice. We measured prediction of outcome using pretreatment Gleason score, clinical stage, and prostate-specific antigen with models that also incorporated either manual or automated BSI measurements.
Measurements
The agreement between methods was evaluated using Pearson’s correlation coefficient. Discrimination between prognostic models was assessed using the concordance index (C-index).
Results and limitations
Manual and automated BSI measurements were strongly correlated (ρ = 0.80), correlated more closely (ρ = 0.93) when excluding cases with BSI scores ≥10 (1.8%), and were independently associated with PCa death (p < 0.0001 for each) when added to the prediction model. Predictive accuracy of the base model (C-index: 0.768; 95% confidence interval [CI], 0.702–0.837) increased to 0.794 (95% CI, 0.727–0.860) by adding manual BSI scoring, and increased to 0.825 (95% CI, 0.754–0.881) by adding automated BSI scoring to the base model.
Conclusions
Automated BSI scoring, with its 100% reproducibility, reduces turnaround time, eliminates operator-dependent subjectivity, and provides important clinical information comparable to that of manual BSI scoring.
doi:10.1016/j.eururo.2012.01.037
PMCID: PMC3402084  PMID: 22306323
14.  Computer-aided quantitative bone scan assessment of prostate cancer treatment response 
Nuclear Medicine Communications  2012;33(4):384-394.
Objective
The development and evaluation of a computer-aided bone scan analysis technique to quantify changes in tumor burden and assess treatment effects in prostate cancer clinical trials.
Methods
We have developed and report on a commercial fully automated computer-aided detection system. Using this system, scan images were intensity normalized, then lesions identified and segmented by anatomic region-specific intensity thresholding. Detected lesions were compared against expert markings to assess the accuracy of the computer-aided detection system. The metrics Bone Scan Lesion Area, Bone Scan Lesion Intensity, and Bone Scan Lesion Count were calculated from identified lesions, and their utility in assessing treatment effects was evaluated by analyzing before and after scans from metastatic castration-resistant prostate cancer patients: 10 treated and 10 untreated. In this study, patients were treated with cabozantinib, a MET/VEGF inhibitor resulting in high rates of resolution of bone scan abnormalities.
Results
Our automated computer-aided detection system identified bone lesion pixels with 94% sensitivity, 89% specificity, and 89% accuracy. Significant differences in changes from baseline were found between treated and untreated groups in all assessed measurements derived by our system. The most significant measure, Bone Scan Lesion Area, showed a median (interquartile range) change from baseline at week 6 of 7.13% (27.61) in the untreated group compared with −73.76% (45.38) in the cabozantinib-treated group (P = 0.0003).
Conclusions
Our system accurately and objectively identified and quantified metastases in bone scans, allowing for interpatient and intrapatient comparison. It demonstrates potential as an objective measurement of treatment effects, laying the foundation for validation against other clinically relevant outcome measures.
doi:10.1097/MNM.0b013e3283503ebf
PMCID: PMC3294499  PMID: 22367858
computer-assisted detection; bone neoplasms; computer-assisted image processing; bone scan; radionuclide imaging; prostate cancer
15.  Imaging androgen receptor signaling with a radiotracer targeting free prostate specific antigen 
Cancer Discovery  2012;2(4):320-327.
Despite intense efforts to develop radiotracers to detect cancers or monitor treatment response, few are widely used due to challenges with demonstrating clear clinical utility. We reasoned that a radiotracer targeting a validated clinical biomarker could more clearly assess the advantages of imaging cancer. The virtues and shortcomings of measuring secreted prostate specific antigen (PSA), an androgen receptor (AR) target gene, in prostate cancer (PCa) patients are well documented, making it a logical candidate for assessing whether a radiotracer can reveal new (and useful) information beyond that conferred by serum PSA. Therefore, we developed 89Zr-5A10, a novel radiotracer that targets “free” PSA. 89Zr-5A10 localizes in an AR-dependent manner in vivo to models of castration resistant prostate cancer, a disease state where serum PSA may not reflect clinical outcomes. Finally, we demonstrate that 89Zr-5A10 can detect osseous PCa lesions, a context where bone scans fail to discriminate malignant and non-malignant signals.
doi:10.1158/2159-8290.CD-11-0316
PMCID: PMC3351274  PMID: 22576209
PET; prostate cancer; prostate specific antigen; androgen receptor; biomarker; PSA; PCa; AR; CRPC; 18F-FDG; fPSA; mAbs; PET; MRI; PSMA; ITLC
16.  Compartmental Intrathecal Radioimmunotherapy: Results for Treatment for Metastatic CNS Neuroblastoma 
Journal of neuro-oncology  2009;97(3):409-418.
Innovation in the management of brain metastases is needed. We evaluated the addition of compartmental intrathecal antibody-based radioimmunotherapy (cRIT) in patients with recurrent metastatic central nervous system (CNS) neuroblastoma following surgery, craniospinal irradiation, and chemotherapy. 21 patients treated for recurrent neuroblastoma metastatic to the CNS received a cRIT-containing salvage regimen incorporating intrathecal 131I-monoclonal antibodies (MoAbs) targeting GD2 or B7H3 following surgery and radiation. Most patients also received outpatient craniospinal irradiation, 3F8/GMCSF immunotherapy, 13-cis-retinoic acid and oral temozolomide for systemic control. Seventeen of 21 cRIT-salvage patients are alive 7-74 months (median 33) since CNS relapse, with all 17 remaining free of CNS neuroblastoma. One patient died of infection at 22 months with no evidence of disease at autopsy, and one of lung and bone marrow metastases at 15 months, and one of progressive bone marrow disease at 30 months. The cRIT-salvage regimen was well tolerated, notable for myelosuppression minimized by stem cell support (n=5), and biochemical hypothyroidism (n=5). One patient with a 7-year history of metastatic neuroblastoma is in remission from MLL-associated secondary leukemia. This is significantly improved to published results with non-cRIT based where relapsed CNS NB has a median time to death of approximately 6 months. The cRIT-salvage regimen for CNS metastases was well tolerated by young patients, despite their prior history of intensive cytotoxic therapies. It has the potential to increase survival with better than expected quality of life.
doi:10.1007/s11060-009-0038-7
PMCID: PMC3533371  PMID: 19890606
Neuroblastoma; Radioimmunotherapy; CNS metastases; intrathecal
17.  Fluorine-labeled Dasatinib Nanoformulations as Targeted Molecular Imaging Probes in a PDGFB-driven Murine Glioblastoma Model12 
Neoplasia (New York, N.Y.)  2012;14(12):1132-1143.
Dasatinib, a new-generation Src and platelet-derived growth factor receptor (PDGFR) inhibitor, is currently under evaluation in high-grade glioma clinical trials. To achieve optimum physicochemical and/or biologic properties, alternative drug delivery vehicles may be needed. We used a novel fluorinated dasatinib derivative (F-SKI249380), in combination with nanocarrier vehicles and metabolic imaging tools (microPET) to evaluate drug delivery and uptake in a platelet-derived growth factor B (PDGFB)-driven genetically engineered mouse model (GEMM) of high-grade glioma. We assessed dasatinib survival benefit on the basis of measured tumor volumes. Using brain tumor cells derived from PDGFB-driven gliomas, dose-dependent uptake and time-dependent inhibitory effects of F-SKI249380 on biologic activity were investigated and compared with the parent drug. PDGFR receptor status and tumor-specific targeting were non-invasively evaluated in vivo using 18F-SKI249380 and 18F-SKI249380-containing micellar and liposomal nanoformulations. A statistically significant survival benefit was found using dasatinib (95 mg/kg) versus saline vehicle (P < .001) in tumor volume-matched GEMM pairs. Competitive binding and treatment assays revealed comparable biologic properties for F-SKI249380 and the parent drug. In vivo, Significantly higher tumor uptake was observed for 18F-SKI249380-containing micelle formulations [4.9 percentage of the injected dose per gram tissue (%ID/g); P = .002] compared to control values (1.6%ID/g). Saturation studies using excess cold dasatinib showed marked reduction of tumor uptake values to levels in normal brain (1.5%ID/g), consistent with in vivo binding specificity. Using 18F-SKI249380-containing micelles as radiotracers to estimate therapeutic dosing requirements, we calculated intratumoral drug concentrations (24–60 nM) that were comparable to in vitro 50% inhibitory concentration values. 18F-SKI249380 is a PDGFR-selective tracer, which demonstrates improved delivery to PDGFB-driven high-grade gliomas and facilitates treatment planning when coupled with nanoformulations and quantitative PET imaging approaches.
PMCID: PMC3540940  PMID: 23308046
18.  A phase I trial of docetaxel and pulse-dose 17-allylamino-17-demethoxygeldanamycin in adult patients with solid tumors 
Cancer chemotherapy and pharmacology  2011;69(4):1089-1097.
Purpose
To define maximum tolerated dose (MTD), clinical toxicities, and pharmacokinetics of 17-allylamino-17-demethoxygeldanamycin (17-AAG) when administered in combination with docetaxel once every 21 days in patients with advanced solid tumor malignancies.
Experimental design
Docetaxel was administered over 1 h at doses of 55, 70, and 75 mg/m2. 17-AAG was administered over 1–2 h, following the completion of the docetaxel infusion, at escalating doses ranging from 80 to 650 mg/m2 in 12 patient cohorts. Serum was collected for pharmacokinetic and pharmacodynamic studies during cycle 1. Docetaxel, 17-AAG, and 17-AG levels were determined by high-performance liquid chromatography. Biologic effects of 17-AAG were monitored in peripheral blood mononuclear cells by immunoblot.
Results
Forty-nine patients received docetaxel and 17-AAG. The most common all-cause grade 3 and 4 toxicities were leukopenia, lymphopenia, and neutropenia. An MTD was not defined; however, three dose-limiting toxicities were observed, including 2 incidences of neutropenic fever and 1 of junctional bradycardia. Dose escalation was halted at docetaxel 75 mg/m2-17-AAG 650 mg/m2 due to delayed toxicities attributed to patient intolerance of the DMSO-based 17-AAG formulation. Of 46 evaluable patients, 1 patient with lung cancer experienced a partial response. Minor responses were observed in patients with lung, prostate, melanoma, and bladder cancers. A correlation between reduced docetaxel clearance and 17-AAG dose level was observed.
Conclusions
The combination of docetaxel and 17-AAG was well tolerated in adult patients with solid tumors, although patient intolerance to the DMSO formulation precluded further dose escalation. The recommended phase II dose is docetaxel 70 mg/m2 and 17-AAG 500 mg/m2.
doi:10.1007/s00280-011-1789-3
PMCID: PMC3471133  PMID: 22124669
17-AAG; Geldanamycin; Hsp90; Docetaxel; Phase I
19.  Automated Detection of Haemophilus influenzae 
Applied Microbiology  1973;25(6):1011-1012.
Addition of heme (X factor) and pyridine nucleotide (V factor) to the medium permits rapid growth of Haemophilus influenzae, with evolution of easily detectable amounts of 14CO2. Radiometric media containing X and V factor should be used when evaluating clinical specimens which might contain Haemophilus species.
PMCID: PMC380956  PMID: 4577481
20.  Developing imaging strategies for castration resistant prostate cancer 
Acta oncologica (Stockholm, Sweden)  2011;50(Suppl 1):39-48.
Recent advances in the understanding of castrate-resistant prostate cancer (CRPC) have lead to a growing number of experimental therapies, many of which are directed against the androgen-receptor (AR) signaling axis. These advances generate the need for reliable molecular imaging biomarkers to non-invasively determine efficacy, and to better guide treatment selection of these promising AR-targeted drugs.
Methods
We draw on our own experience, supplemented by review of the current literature, to discuss the systematic development of imaging biomarkers for use in the context of CRPC, with a focus on bone scintigraphy, F-18 fluorodeoxyglucose (FDG)-positron emission tomography (PET) and PET imaging of the AR signaling axis.
Results
The roadmap to biomarker development mandates rigorous standardization and analytic validation of an assay before it can be qualified successfully for use in an appropriate clinical context. The Prostate Cancer Working Group 2 (PCWG2) criteria for “radiographic” progression by bone scintigraphy serve as a paradigm of this process. Implemented by the Prostate Cancer Clinical Trials Consortium (PCCTC), these consensus criteria may ultimately enable the co-development of more potent and versatile molecular imaging biomarkers. Purported to be superior to single-photon bone scanning, the added value of Na18F-PET for imaging of bone metastases is still uncertain. FDG-PET already plays an integral role in the management of many diseases, but requires further evaluation before being qualified in the context of CRPC. PET tracers that probe the AR signaling axis, such as 18F-FDHT and 89Zr-591, are now under development as pharmacodynamic markers, and as markers of efficacy, in tandem with FDG-PET. Semi-automated analysis programs for facilitating PET interpretation may serve as a valuable tool to help navigate the biomarker roadmap.
Conclusions
Molecular imaging strategies, particularly those that probe the AR signaling axis, have the potential to accelerate drug development in CRPC. The development and use of analytically valid imaging biomarkers will increase the likelihood of clinical qualification, and ultimately lead to improved patient outcomes.
doi:10.3109/0284186X.2011.572914
PMCID: PMC3415271  PMID: 21604939
21.  18F-fluorodeoxy-glucose positron emission tomography (18FDG-PET) marks MYC-overexpressing human basal-like breast cancers 
Cancer research  2011;71(15):5164-5174.
In contrast to normal cells, cancer cells avidly take up glucose and metabolize it to lactate even when oxygen is abundant, a phenomenon referred to as the Warburg effect. This fundamental alteration in glucose metabolism in cancer cells enables their specific detection by Positron Emission Tomography (PET) following intravenous injection of the glucose analogue 18F-fluorodeoxy-glucose (18FDG). However, this useful imaging technique is limited by the fact that not all cancers avidly take up FDG. To identify molecular determinants of 18FDG-retention, we interogated the transcriptomes of human cancer cell lines and primary tumors for metabolic pathways associated with 18FDG radiotracer uptake. From 95 metabolic pathways that were interrogated, the glycolysis and several glycolysis-related pathways (pentose-phosphate, carbon fixation, aminoacyl-tRNA biosynthesis, one-carbon-pool by folate) showed the greatest transcriptional enrichment. This “FDG signature” predicted FDG-uptake in breast cancer cell lines and overlapped with established gene expression signatures for the “basal-like” breast cancer subtype and MYC-induced tumorigenesis in mice. Human breast cancers with nuclear MYC staining and high RNA expression of MYC target genes showed high 18FDG-PET uptake (p < 0.005). Presence of the FDG signature was similarly associated with MYC gene copy gain, increased MYC transcript levels, and elevated expression of metabolic MYC target genes in a human breast cancer genomic dataset. Together, our findings link clinical observations of glucose uptake with a pathologic and molecular subtype of human breast cancer. Further, they suggest related approaches to derive molecular determinants of radiotracer retention for other PET-imaging probes.
doi:10.1158/0008-5472.CAN-10-4633
PMCID: PMC3148325  PMID: 21646475
FDG-PET; breast cancer; MYC; basal-like; metabolism; imaging
22.  Practical Approach for Comparative Analysis of Multi-lesion Molecular Imaging Using a Semi-Automated Program for PET/CT 
We propose a standardized approach to quantitative molecular imaging (MI) in cancer patients with multiple lesions.
METHODS
Twenty castration-resistant-prostate-cancer patients underwent 18F-FDG and 18F-16β-fluoro-5α-dihydrotestosterone (18F-FDHT) PET/CT scans. Using a 5-point confidence-scale, two readers interpreted co-registered scan-sets on a PET-VCAR (General Electric) workstation. 203 sites/scan (specified in a lexicon) were reviewed. 18F-FDG-positive lesion bookmarks were propagated onto 18F-FDHT studies, then manually accepted or rejected. Discordant-positive 18F-FDHT lesions were similarly bookmarked. Lesional SUVmax was recorded. Tracer and tissue-specific background correction-factors were calculated via receiver-operating-characteristic analysis of 65 scan-sets.
RESULTS
Readers agreed on >99% of 18F-FDG and 18F-FDHT negative-sites. Positive-site agreement was 84% and 85%, respectively. Consensus-lesion SUVmax was highly reproducible (CCC>0.98). Receiver-operating-characteristic curves yielded four correction-factors (SUVmax 1.8-2.6). A novel scatter (“LFG”) plot depicted tumor burden and ΔSUVmax for response assessments.
CONCLUSION
Multi-lesion MI is optimized with a five-step approach incorporating a confidence scale, site lexicon, semi-automated PET software, background-correction and LFG-graphing.
doi:10.2967/jnumed.111.089326
PMCID: PMC3409842  PMID: 21984797
Molecular imaging; PET/CT; 18F-FDG; 18F-FDHT; semi-automated
23.  124I-huA33 Antibody Uptake Is Driven by A33 Antigen Concentration in Tissues from Colorectal Cancer Patients Imaged by Immuno-PET 
Journal of Nuclear Medicine  2011;52(12):1878-1885.
The primary aim of this analysis was to examine the quantitative features of antibody–antigen interactions in tumors and normal tissue after parenteral administration of antitumor antibodies to human patients.
Methods
Humanized anti-A33 antibody (10 mg) labeled with the positron-emitting radionuclide 124I (124I-huA33) was injected intravenously in 15 patients with colorectal cancer. Clinical PET/CT was performed approximately 1 wk later, followed by a detailed assay of surgically removed tissue specimens including radioactivity counting, autoradiography, immunohistochemistry, and antigen density determination.
Results
PET/CT showed high levels of antibody targeting in tumors and normal bowel. In tissue specimens, the spatial distribution of 124I-huA33 conformed to that of A33 antigen, and there was a linear relationship between the amount of bound antibody and antigen concentration. Antibody uptake was high in 1- to 2-mm regions of antigen-positive tumor cells (mean, ~0.05 percentage injected dose per gram) and in antigen-positive normal colonic mucosa (mean, ~0.03 percentage injected dose per gram). The estimated binding site occupancy for tumor and normal colon was 20%–50%.
Conclusion
The in vivo bio-distribution of 124I-huA33 in human patients 1 wk after antibody administration was determined by A33 antigen expression. Our data imply that the optimal strategy for A33-based radioimmunotherapy of colon cancer will consist of a multistep treatment using a radionuclide with short-range (α- or β-particle) emissions.
doi:10.2967/jnumed.111.095596
PMCID: PMC3394180  PMID: 22068895
huA33; colorectal cancer; 124I; immuno-PET; radioimmunotherapy
24.  124I-huA33 Antibody PET of Colorectal Cancer 
Journal of Nuclear Medicine  2011;52(8):1173-1180.
Humanized A33 (huA33) is a promising monoclonal antibody that recognizes A33 antigen, which is present in more than 95% of colorectal cancers and in normal bowel. In this study, we took advantage of quantitative PET to evaluate 124I huA33 targeting, biodistribution, and safety in patients with colorectal cancer. We also determined the biodistribution of 124I-huA33 when a large dose of human intravenous IgG (IVIG) was administered to manipulate the Fc receptor or when 124I-huA33 was given via hepatic arterial infusion (HAI).
Methods
We studied 25 patients with primary or metastatic colorectal cancer; 19 patients had surgical exploration or resection. Patients received a median of 343 MBq (44.4–396 MBq) and 10 mg of 124I-huA33. Nineteen patients received the antibody intravenously and 6 patients via HAI, and 5 patients also received IVIG.
Results
Ten of 12 primary tumors were visualized in 11 patients. The median concentration in primary colon tumors was 0.016% injected dose per gram, compared with 0.004% in normal colon. The PET-based median ratio of hepatic tumor uptake to normal-liver uptake was 3.9 (range, 1.8–22.2). Quantitation using PET, compared with well counting of serum and tissue, showed little difference. Prominent uptake in bowel hindered tumor identification in some patients. Pharmacokinetics showed that patients receiving IVIG had a significantly shorter serum half-time (41.6 ± 14.0 h) than those without (65.2 ± 9.8 h). There were no differences in clearance rates among the intravenous group, IVIG group, and HAI group, nor was there any difference in serum area under the curve, maximum serum concentration, or volume of distribution. Weak titers of human–anti-human antibodies were observed in 6 of 25 patients. No acute side effects or significant toxicities were associated with huA33.
Conclusion
Good localization of 124I-huA33 in colorectal cancer with no significant toxicity has been observed. PET-derived 124I concentrations agreed well with those obtained by well counting of surgically resected tissue and blood, confirming the quantitative accuracy of 124I-huA33 PET. The HAI route had no advantage over the intravenous route. No clinically significant changes in blood clearance were induced by IVIG.
doi:10.2967/jnumed.110.086165
PMCID: PMC3394182  PMID: 21764796
A33; 124I; antibody; arterial; positron; colon
25.  Bone Marrow Dosimetry Using 124I-PET 
Journal of Nuclear Medicine  2012;53(4):615-621.
Bone marrow is usually dose-limiting for radioimmunotherapy. In this study, we directly estimated red marrow activity concentration and the self-dose component of absorbed radiation dose to red marrow based on PET/CT of 2 different 124I-labeled antibodies (cG250 and huA33) and compared the results with plasma activity concentration and plasma-based dose estimates.
Methods
Two groups of patients injected with 124I-labeled monoclonal antibodies (11 patients with renal cancer receiving 124I-cG250 and 5 patients with colorectal cancer receiving 124I- huA33) were imaged by PET or PET/CT on 2 or 3 occasions after infusion. Regions of interest were drawn over several lumbar vertebrae, and red marrow activity concentration was quantified. Plasma activity concentration was also quantified using multiple patient blood samples. The red marrow–to–plasma activity concentration ratio (RMPR) was calculated at the times of imaging. The self-dose component of the absorbed radiation dose to the red marrow was estimated from the images, from the plasma measurements, and using a combination of both sets of measurements.
Results
RMPR was observed to increase with time for both groups of patients. Mean (±SD) time-dependent RMPR (RMPR(t)) for the cG250 group increased from 0.13 ± 0.06 immediately after infusion to 0.23 ± 0.09 at approximately 6 d after infusion. For the huA33 group, mean RMPR(t) was 0.10 ± 0.04 immediately after infusion, 0.13 ± 0.05 approximately 2 d after infusion, and 0.20 ± 0.09 approximately 7 d after infusion. Plasma-based estimates of red marrow self-dose tended to be greater than image-based values by, on average, 11% and 47% for cG250 and huA33, respectively, but by as much as −73% to 62% for individual patients. The hybrid method combining RMPR(t) and plasma activity concentration provided a closer match to the image-based dose estimates (average discrepancies, −2% and 18% for cG250 and huA33, respectively).
Conclusion
These results suggest that the assumption of time-independent proportionality between red marrow and plasma activity concentration may be too simplistic. Individualized imaged-based dosimetry is probably required for the optimal therapeutic delivery of radiolabeled antibodies, which does not compromise red marrow and may allow, for some patients, a substantial increase in administered activity and thus tumor dose.
doi:10.2967/jnumed.111.096453
PMCID: PMC3390781  PMID: 22414633
dosimetry; marrow; PET

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