Dissertation (Ph.D.) --University of Texas Graduate School of Biomedical Sciences at San Antonio, 2008. / Vita. Includes bibliographical references.

Background: Mounting evidence suggests that inflammation is involved in the pathophysiology of both Major Depressive Disorder (MDD) and schizophrenia. The presence of inflammation in the brain, however, is less clear. Microglial activation, a measure of neuroinflammation, can be quantified using PET ligands that bind to the Translocator Protein (TSPO) which is overexpressed by activated microglia. Previous PET studies using TSPO radioligands have shown some evidence for neuroinflammation in both MDD and schizophrenia. However some of these studies have been confounded by antidepressant/antipsychotic medication, low numbers and mild severity. We aimed to address some of these issues and investigate the relationship between neuroinflammation and peripheral inflammation, medication status, symptom severity and cognitive function. Method: Fourteen patients in a Major Depressive Episode (MDE) of at least moderate severity, sixteen patients with a diagnosis of schizophrenia of at least moderate severity and a total of eighteen age and gender-matched healthy volunteers underwent a 60 minute dynamic PET scan with the TSPO radioligand [11C](R)-PK11195 on the High Resolution Research Tomograph (HRRT). Parametric maps of binding potential (BPND) were generated using the simplified reference tissue model and a grey matter cerebellum input function. All of the MDD patients were antidepressant-free for at least eight months prior to scanning. Of the sixteen schizophrenia patients, eight were antipsychotic-free (for at least twelve months) and eight were on a long-acting injection of risperidone or paliperidone. All patients and healthy volunteers were medically healthy and had drug or alcohol abuse within the previous year. Results: We found a 26% mean increase in BPND values, indicative of microglial activation, in MDD patients compared to healthy volunteers. Exploratory analysis revealed significantly higher [11C](R)-PK11195 binding in the anterior cingulate cortex (ACC). We found no significant correlations between [11C](R)-PK11195 binding and peripheral markers of inflammation or with symptom severity. We also found a mean 27% increase in BPND values in the schizophrenia patients compared to healthy volunteers. There were significant correlations between [11C](R)-PK11195 and negative symptoms across multiple brain regions. When breaking the cohort down according to medication status, there was no difference between antipsychotic-free patients and healthy volunteers. However, mean BPND values were 30% higher in the ACC. The medicated patients exhibited higher BPND values than healthy volunteers, with a mean increase of 48%. Exploratory t-tests revealed significant increases in dorsolateral prefrontal cortex and ACC.Conclusions: Our findings are largely consistent with previous PET findings of increased microglial activation in a sample of antidepressant-free patients in a moderate-to-severe MDE, suggesting that neuroinflammation is present in MDD. We also investigated neuroinflammation in antipsychotic-free patients for the first time and found no evidence of microglial activation. However it is likely that the subgroup sample was underpowered. The medicated patients exhibited a 48% increase in [11C](R)-PK11195 binding compared to controls, suggesting that either medication or duration of illness might potentiate microglial activation. Our findings also point to an association between neuroinflammation and the negative symptoms of schizophrenia. The PET findings from both cohorts are largely overlapping, suggesting that neuroinflammation is not specific to either disorder but rather a common mechanism. This could reflect a common aetiology and/or an overlap in symptoms. Our findings suggest that inflammation could be used as a potential biomarker as well as a target for novel treatment strategies in both MDD and schizophrenia.

In recent years tumour hypoxia has been extensively investigated, mainly because it is a source of resistance to the common radio and chemo therapies. In fact, the low levels and heterogeneous distribution of oxygen in hypoxic microenvironment render ionizing radiation ineffective in treating cell proliferation. Furthermore, a low oxygen concentration promotes the activation of HIF-1 transcription factor, which favours the development of a more malignant and resistant cancer cell phenotype often associated with poor prognosis. Positron Emission Tomography (PET) imaging is a valuable diagnostic tool for investigating hypoxia in vivo by means of radiotracers, which incorporates both a radioisotope and a hypoxia-sensitive function. The aim of this multidisciplinary project was to develop small libraries of radiolabelled compounds starting from the biological and chemical features of the two gold standard hypoxia PET tracers [18F]FMISO and [18F]FAZA as well as those of the promising new tracer [18F]HX4. These new radiocompounds display the following peculiar structural characteristics: a 2-nitroimidazole hypoxia-sensitive moiety, different spacers to modulate steric constraint, lipophilicity and metabolic stability and a fluorinated aldopentose sugar as prosthetic group (e.g. [18F]FDR). Two series of compounds were designed and developed based on the conjugation method used to introduce the prosthetic group, namely the oxime bond formation and the thiazolidine ring closure. Six radiotracers belonging to the oxime-derivatives series were tested in vitro on MCF7 breast cancer cell lines in hypoxic conditions and a lead radiocompound incorporating a cyclopropyl group was identified. This new hypoxia tracer showed a better kinetic profile than both [18F]FMISO and [18F]FAZA in MCF7 cancer cell lines and comparable uptake values on a panel of different cancer cell lines, up to 120 min post administration at 1% of O2. These promising results will pave the way for futures in vivo studies.

Yes / Vascular calcification is a complex biological process that is a hallmark of atherosclerosis. While macrocalcification confers plaque stability, microcalcification is a key feature of highrisk atheroma and is associated with increased morbidity and mortality. Positron emission tomography and X-ray computed tomography (PET/CT) imaging of atherosclerosis using 18F-sodium fluoride (18F-NaF) has the potential to identify pathologically high-risk nascent microcalcification. However, the precise molecular mechanism of 18F-NaF vascular uptake is still unknown. Here we use electron microscopy, autoradiography, histology and preclinical and clinical PET/CT to analyse 18F-NaF binding. We show that 18F-NaF adsorbs to calcified deposits within plaque with high affinity and is selective and specific. 18F-NaF PET/CT imaging can distinguish between areas of macro- and microcalcification. This is the only currently available clinical imaging platform that can non-invasively detect microcalcification in active unstable atherosclerosis. The use of 18F-NaF may foster new approaches to developing treatments for vascular calcification.

This thesis describes the application of the radioisotope 11C to the synthesis of two analogues of the neurohormone melatonin. The labelled compounds were intended to be used as tracers for the medical imaging technology Positron Emission Tomography (PET). [ 11C]Carbon dioxide, produced in a small on-site cyclotron by the nuclear reaction 14N(p,a)11C, was converted into [11C]CH3COC1 by reaction first with CH3MgBr, followed by reaction with phthaloyl dichloride. The labelled acid chloride was distilled into a solution of an amine, yielding the corresponding 11C-labelled amide, which was purified by a simple solid-phase extraction method. An apparatus was designed and built that allowed the remote synthesis with several hundred millicuries of [11C]C02• The apparatus was mounted in a hot cell and operated remotely with a Macintosh Powerbook programmed in Hypercard. The apparatus and software are generic for these acylation reactions. The individual reaction steps were optimized in terms of reaction time, solvents and equipment; radiosyntheses of a number of purified labelled acetamides were completed in 35 minutes. The radiochemical yields ranged from 15 to 20% with specific activities in the 500 mCi/J..tmol range at the end of the synthesis. 2-Iodo-[11C-acetyl]melatonin (11) and 7-methoxynaphthylenyl-1-ethyl-N-[11Cacetyl] acetamide (15) were synthesized for the first time for PET studies. It was shown that both compounds readily cross the blood-brain-barrier and penetrate into all brain tissues. Specific binding to the melatonin receptors in the suprachiasmatic nuclei of the hypothalamus could not be visualized with either one of the 11C-labelled ligands because of low specific activity and high nonspecific binding. / Thesis / Master of Science (MSc)

Diss. (sammanfattning) Uppsala : Uppsala universitet, 2006. / Härtill 5 uppsatser.

Introduction. Aortic stenosis is characterised both by progressive narrowing of the valve and the hypertrophic response of the left ventricle. The purpose of this thesis was to study the contribution of inflammation and calcification to valve narrowing using Positron Emission and Computed Tomography (PET/CT) and to investigate the hypertrophic response using cardiovascular magnetic resonance (CMR). Methods. PET/CT studies. Patients with aortic sclerosis and mild, moderate and severe stenosis were prospectively compared to matched control subjects. Aortic valve severity was determined by echocardiography. Calcification and inflammation in the aortic valve and coronary arteries were assessed by sodium 18-­‐fluoride (18F-­‐NaF) and 18-­‐fluorodeoxyglucose (18F-­‐FDG) uptake using PET. CMR studies. Consecutive patients with moderate or severe aortic stenosis undergoing CMR were enrolled into a registry. Patients who received gadolinium contrast were categorised into absent, mid-­‐ wall or infarct patterns of late gadolinium enhancement (LGE) by blinded independent observers. Patients follow-­‐up was completed using patient questionnaires, source record data and the National Strategic Tracing Scheme. After excluding those patients with concomitant triggers to LV remodeling, the extent and patterns of hypertrophy were investigated based upon measurements of indexed LV mass, indexed LV volume and the relative wall mass. Results. PET/CT studies. 121 subjects (20 controls; 20 aortic sclerosis; 25 mild, 33 moderate and 23 severe aortic stenosis) were studied. Quantification of tracer uptake within the valve demonstrated excellent inter-­‐observer reproducibility with no biases and limits of agreement of ±0.21 (18F-­‐NaF) and ±0.13 (18F-­‐FDG) for maximum tissue-­‐to-­‐background ratios (TBR). Activity of both tracers was higher in patients with aortic stenosis than control subjects (18F-­‐NaF: 2.87±0.82 vs 1.55±0.17; 18F-­‐ FDG: 1.58±0.21 vs 1.30±0.13; both P<0.001). 18F-­‐NaF uptake displayed a progressive rise with valve severity (r2=0.540, P<0.001) with a more modest increase observed for 18F-­‐FDG (r2=0.218; P<0.001). Amongst patients with aortic stenosis, 91% had increased 18F-­‐NaF (>1.97) and 35% increased 18F-­‐ FDG (>1.63) uptake. Increased 18F-­‐NaF uptake was also observed in the coronary arteries in a subset of patients with atherosclerosis. These patients (n=40) had higher rates of prior cardiovascular events (p=0.016) and angina (p=0.023), and higher Framingham risk scores (p=0.011). CMR studies. 143 patients (aged 68±14 years; 97 male) were followed up for 2.0±1.4 years and 27 died. Compared to those with no LGE (n=49), univariate analysis revealed that patients with mid-­‐wall fibrosis (n=54) had an eight-­‐fold increase in all-­‐cause mortality despite similar aortic stenosis severity and coronary artery disease burden. Patients with an infarct pattern (n=40) had a six-­‐fold increase. Mid-­‐wall fibrosis (HR 5.35 [95% CI 1.16-­‐24.56]; P=0.03) emerged as an independent predictor of all cause mortality by multivariate analysis. The pattern of LV remodelling was studied in 91 patients (61±21 years; 57 male) and displayed wide variation comprising normal ventricular geometry (n=11), concentric remodelling (n=11), asymmetric remodelling (n=11), concentric hypertrophy (n=34), asymmetric hypertrophy (n=14) and LV decompensation (n=10). The magnitude of the hypertrophic response was unrelated to the severity of aortic valve narrowing. Conclusions. Modern imaging techniques have provided important insights in to the pathology underlying aortic stenosis and suggest that valvular calcification and myocardial fibrosis have a key role. Both represent important potential targets for future therapeutic interventions.

Fluorine-18 Fluorodeoxyglucose positron emission tomography-computed tomography (F-18 FDG PET-CT) is now established in the staging, restaging and therapy response monitoring of Hodgkin’s lymphoma (HL) and high grade Non-Hodgkin’s lymphoma (HG NHL), specifically for nodal disease and extra-nodal disease excluding the bone marrow. The role of FDG PET-CT for evaluating bone marrow involvement in HL and HG NHL has not been established yet. There are however several publications on this subject but no consensus has been reached. Bone marrow trephine biopsy (BMB) is the gold standard for bone marrow assessment in lymphoma. Although the occurrence of adverse effects is uncommon, BMB is an invasive procedure that may induce anxiety in patients. A retrospective review of FDG PET-CT bone marrow findings of HL patients referred for a staging scan from June 2008 to January 2014 was done, these findings were compared to the BMB findings also done as part of initial staging. The findings of 55 patients were reviewed analysed.

Hypoxia is one of the hallmarks of cancer. It was first postulated to occur in solid tumours by Thomlinson and Gray in 1955.1 The presence of hypoxia has been demonstrated in different types of solid tumours.2 Intratumoral hypoxia is caused by the lack of functional blood vessels in proliferating tumour tissue, resulting in low intratumoral oxygen concentrations. If hypoxia is severe or prolonged, cell death occurs.3 Malignant cells can undergo genetic and adaptive changes that allow them to escape from dying of oxygen deprivation. These changes are associated with a more aggressive malignant phenotype 4,5 conferring resistance to radiation 6,7 and chemotherapeutic agents.3,8,9 Hence hypoxia is known to be a key factor responsible for tumour resistance in humans. / Invasive polarographic oxygen sensor measurements have demonstrated hypoxia in solid tumours and it is generally defined to occur at an oxygen tension less than ten mmHg.10 Perhaps of more importance is that hypoxia has been demonstrated to be a prognostic indicator for local control after treatment with radiotherapy in glioma, head and neck and cervical cancers.11-13 It has also been able to predict for survival and the presence of distant metastases in soft tissue sarcomas.14 Finally, the significance of hypoxia in the activation and induction of functional molecules such as hypoxia inducible factors (HIFs) and VEGF, the modulation of gene expression (e.g. carbonic anhydrase IX), increased proto-oncogene levels, activation of nuclear factors and accumulation of other proteins (e.g. TP53) although progressing, is yet to be defined.15,16 / Thus, it is of clinical interest to understand the levels of hypoxia and numbers of hypoxic cell populations in tumours, particularly those resistant to radiation and chemotherapy. In doing so clinicians and researchers may formulate more accurate prognostic information and develop treatments targeting hypoxic cells. Renal cell carcinoma (RCC) is a tumour resistant to radiation and chemotherapy that is yet to have its oxygen status investigated. / Although the “gold standard” of oxygen tension measurement is the Polarographic Oxygen Sensor (POS or Eppendorf pO2 histograph), non-invasive means of measuring oxygen status via imaging, immunohistochemistry or serum tumour markers are more practical. As highlighted by Menon and Fraker, it is imperative that reliable, globally usable, and technically simplistic methods be developed to yield a consistent, comprehensive, and reliable profile of tumour oxygenation. Until newer more reliable techniques are developed, existing independent techniques or appropriate combinations of techniques should be optimized and validated using known endpoints in tumour oxygenation status and/or treatment outcomes.17 / Hanahan and Weinberg 18 surmised that the field of cancer research has largely been guided by a reductionist focus on cancer cells and the genes within them- a focus that has produced an extraordinary body of knowledge. Looking forward in time, they believe that progress in cancer research would come from regarding tumours as complex tissues in which mutant cancer cells have conscripted and subverted normal cell types (endothelial cells, immune cells, fibroblasts) to serve as active collaborators in their neoplastic agenda. The interactions between the genetically altered malignant cells and these supporting coconspirators will prove critical to understanding cancer pathogenesis and to the development of novel, effective therapies.18 / Essentially, the background outlined here not only highlights the core aim of this thesis: to better understand the oxygen status of renal cell carcinoma and the relationship of this to angiogenesis so that better targeted therapies may be pursued in the future; but it also places this research in the context of the future proposed by Hanahan and Weinberg,18 by clearly focusing on collaborators in the neoplastic agenda, rather than just tumour cells themselves, to better understand RCC.

<p>Positron Emission Tomography (PET) has gained an important roll in clinical for diagnosis, staging and prognosis of a range of cancer types. Utilization of PET for monitoring and evaluation of cancer treatment is an attractive but almost new concept. The proper choice of PET-tracer as a biomarker for treatment follow-up is crucial. The important characteristic for a suitable tracer is its ability to reflect the response to a treatment at an early stage, before any morphologically changes occurs. It would be an advantage to screen a battery of PET tracers in a preclinical model and introduce a few potential tracers in clinical trial. </p><p>The most conventional pre-clinical approach in PET-oncology utilizes xenografts in mice or rats and requires a large number of subjects. It would be a great advantage to introduce a less demanding but still reliable preclinical method for a more efficient planning of studies in animal model and then in human trials. </p><p>The Multicellular Tumour Spheroid (MTS) system represents an intermediary level between cells growing as monolayer and solid tumours in experimental animals or patients. It mimics the growth of naturally occurring human tumours before neovascularization and appears to be more informative than monolayer and more economical and more ethical than animal models.</p><p>The aim of this work was to establish, refine and evaluate the application of MTS model as a preclinical approach in PET oncology. The vision was to introduce a preclinical method to probe and select PET tracer for treatment monitoring of anticancer drugs, which can hopefully be applied for optimization in breast cancer treatment.</p><p>In this thesis, a number of basic experiments were performed to explore the character of 2-[fluorine-18]-fluoro-2-deoxy-d-glucose (FDG) uptake in MTS. FDG as the most established PET tracer was an obvious initial option for the evaluation of the model. For further assess-ment, we studied effects on FDG uptake in MTS treated with five routinely used chemother-apy agents. For association of PET tracer uptake to size change of MTS, we developed a reliable and user-friendly method for size determination of MTS. The next step was to apply the MTS model to screen PET tracers for analysis of early response of chemotherapy in breast cancer. Finally the method was utilized for translational imaging exemplified with a new chemotherapy agent.</p><p>The results were encouraging and the MTS model was introduced and evaluated as a preclini-cal tool in PET oncology. The method was implicated to in vitro quickly assess a therapy profile of existing and newly developed anticancer drugs in order to investigate the effects of candidate drugs on tumour-growth, selection of appropriate PET tracer for treatment monitor-ing and finally understanding relation between growth inhibition and biomarkers as part of translational imaging activities.</p>