Repeatability of quantitative 18F-FLT uptake measurements in solid tumors: an individual patient data multi-center meta-analysis.

INTRODUCTION: 3'-deoxy-3'-[18F]fluorothymidine (18F-FLT) positron emission tomography (PET) provides a non-invasive method to assess cellular proliferation and response to antitumor therapy. Quantitative 18F-FLT uptake metrics are being used for evaluation of proliferative response in investigational setting, however multi-center repeatability needs to be established. The aim of this study was to determine the repeatability of 18F-FLT tumor uptake metrics by re-analyzing individual patient data from previously published reports using the same tumor segmentation method and repeatability metrics across cohorts. METHODS: A systematic search in PubMed, EMBASE.com and the Cochrane Library from inception-October 2016 yielded five 18F-FLT repeatability cohorts in solid tumors. 18F-FLT avid lesions were delineated using a 50% isocontour adapted for local background on test and retest scans. SUVmax, SUVmean, SUVpeak, proliferative volume and total lesion uptake (TLU) were calculated. Repeatability was assessed using the repeatability coefficient (RC = 1.96 × SD of test-retest differences), linear regression analysis, and the intra-class correlation coefficient (ICC). The impact of different lesion selection criteria was also evaluated. RESULTS: Images from four cohorts containing 30 patients with 52 lesions were obtained and analyzed (ten in breast cancer, nine in head and neck squamous cell carcinoma, and 33 in non-small cell lung cancer patients). A good correlation was found between test-retest data for all 18F-FLT uptake metrics (R2 ≥ 0.93; ICC ≥ 0.96). Best repeatability was found for SUVpeak (RC: 23.1%), without significant differences in RC between different SUV metrics. Repeatability of proliferative volume (RC: 36.0%) and TLU (RC: 36.4%) was worse than SUV. Lesion selection methods based on SUVmax ≥ 4.0 improved the repeatability of volumetric metrics (RC: 26-28%), but did not affect the repeatability of SUV metrics. CONCLUSIONS: In multi-center studies, differences ≥ 25% in 18F-FLT SUV metrics likely represent a true change in tumor uptake. Larger differences are required for FLT metrics comprising volume estimates when no lesion selection criteria are applied.

The meaning, measurement and modification of hypoxia in the laboratory and the clinic.

Hypoxia was identified as a microenvironmental component of solid tumours over 60 years ago and was immediately recognised as a potential barrier to therapy through the reliance of radiotherapy on oxygen to elicit maximal cytotoxicity. Over the last two decades both clinical and experimental studies have markedly enhanced our understanding of how hypoxia influences cellular behaviour and therapy response. Furthermore, they have confirmed early assumptions that low oxygenation status in tumours is an exploitable target in cancer therapy. Generally such approaches will be more beneficial to patients with hypoxic tumours, necessitating the use of biomarkers that reflect oxygenation status. Tissue biomarkers have shown utility in many studies. Further significant advances have been made in the non-invasive measurement of tumour hypoxia with positron emission tomography, magnetic resonance imaging and other imaging modalities. Here, we describe the complexities of defining and measuring tumour hypoxia and highlight the therapeutic approaches to combat it.

Optimization of methods for quantification of rCBF using high-resolution [¹5O]H2O PET images.

This study aimed to derive accurate estimates of regional cerebral blood flow (rCBF) from noisy dynamic [¹5O]H2O PET images acquired on the high-resolution research tomograph, while retaining as much as possible the high spatial resolution of this brain scanner (2-3 mm) in parametric maps of rCBF. The PET autoradiographic method and generalized linear least-squares (GLLS), with fixed or extended to include spatially variable estimates of the dispersion of the measured input function, were compared to nonlinear least-squares (NLLS) for rCBF estimation. Six healthy volunteers underwent two [¹5O]H2O PET scans with continuous arterial blood sampling. rCBF estimates were obtained from three image reconstruction methods (one analytic and two iterative, of which one includes a resolution model) to which a range of post-reconstruction filters (3D Gaussian: 2, 4 and 6 mm FWHM) were applied. The optimal injected activity was estimated to be around 11 MBq kg⁻¹ (800 MBq) by extrapolation of patient-specific noise equivalent count rates. Whole-brain rCBF values were found to be relatively insensitive to the method of reconstruction and rCBF quantification. The grey and white matter rCBF for analytic reconstruction and NLLS were 0.44 ± 0.03 and 0.15 ± 0.03 mL min⁻¹ cm⁻³, respectively, in agreement with literature values. Similar values were obtained from the other methods. For generation of parametric images using GLLS or the autoradiographic method, a filter of ≥ 4 mm was required in order to suppress noise in the PET images which otherwise produced large biases in the rCBF estimates.

Bias in iterative reconstruction of low-statistics PET data: benefits of a resolution model.

Iterative image reconstruction methods such as ordered-subset expectation maximization (OSEM) are widely used in PET. Reconstructions via OSEM are however reported to be biased for low-count data. We investigated this and considered the impact for dynamic PET. Patient listmode data were acquired in [(11)C]DASB and [(15)O]H(2)O scans on the HRRT brain PET scanner. These data were subsampled to create many independent, low-count replicates. The data were reconstructed and the images from low-count data were compared to the high-count originals (from the same reconstruction method). This comparison enabled low-statistics bias to be calculated for the given reconstruction, as a function of the noise-equivalent counts (NEC). Two iterative reconstruction methods were tested, one with and one without an image-based resolution model (RM). Significant bias was observed when reconstructing data of low statistical quality, for both subsampled human and simulated data. For human data, this bias was substantially reduced by including a RM. For [(11)C]DASB the low-statistics bias in the caudate head at 1.7 M NEC (approx. 30 s) was -5.5% and -13% with and without RM, respectively. We predicted biases in the binding potential of -4% and -10%. For quantification of cerebral blood flow for the whole-brain grey- or white-matter, using [(15)O]H(2)O and the PET autoradiographic method, a low-statistics bias of <2.5% and <4% was predicted for reconstruction with and without the RM. The use of a resolution model reduces low-statistics bias and can hence be beneficial for quantitative dynamic PET.

Abnormal prefrontal activation directly related to pre-synaptic striatal dopamine dysfunction in people at clinical high risk for psychosis.

Schizophrenia is characterized by altered prefrontal activity and elevated striatal dopaminergic function. To investigate the relationship between these abnormalities in the prodromal phase of the illness, we combined functional Magnetic Resonance Imaging and (18)F-Dopa Positron Emission Tomography. When performing a verbal fluency task, subjects with an At-Risk Mental State showed greater activation in the inferior frontal cortex than controls. Striatal dopamine function was greater in the At-Risk group than in controls. Within the At-Risk group, but not the control group, there was a direct correlation between the degree of left inferior frontal activation and the level of striatal dopamine function. Altered prefrontal activation in subjects with an At-Risk Mental State for psychosis is related to elevated striatal dopamine function. These changes reflect an increased vulnerability to psychosis and predate the first episode of frank psychosis.

Development and validation of a variance model for dynamic PET: uses in fitting kinetic data and optimizing the injected activity.

The precision of biological parameter estimates derived from dynamic PET data can be limited by the number of acquired coincidence events (prompts and randoms). These numbers are affected by the injected activity (A(0)). The benefits of optimizing A(0) were assessed using a new model of data variance which is formulated as a function of A(0). Seven cancer patients underwent dynamic [(15)O]H(2)O PET scans (32 scans) using a Biograph PET-CT scanner (Siemens), with A(0) varied (142-839 MBq). These data were combined with simulations to (1) determine the accuracy of the new variance model, (2) estimate the improvements in parameter estimate precision gained by optimizing A(0), and (3) examine changes in precision for different size regions of interest (ROIs). The new variance model provided a good estimate of the relative variance in dynamic PET data across a wide range of A(0)s and time frames for FBP reconstruction. Patient data showed that relative changes in estimate precision with A(0) were in reasonable agreement with the changes predicted by the model: Pearson's correlation coefficients were 0.73 and 0.62 for perfusion (F) and the volume of distribution (V(T)), respectively. The between-scan variability in the parameter estimates agreed with the estimated precision for small ROIs (<5 mL). An A(0) of 500-700 MBq was near optimal for estimating F and V(T) from abdominal [(15)O]H(2)O scans on this scanner. This optimization improved the precision of parameter estimates for small ROIs (<5 mL), with an injection of 600 MBq reducing the standard error on F by a factor of 1.13 as compared to the injection of 250 MBq, but by the more modest factor of 1.03 as compared to A(0) = 400 MBq.

Evidence for endogenous opioid release in the amygdala during positive emotion.

Endogenous opioid release has been linked to relief from aversive emotional memories, thereby promoting a euphoric state and subsequent interactions towards social stimuli resulting in the formation of social preferences. However, this theory remains controversial. Using positron emission tomography and [(11)C]diprenorphine (DPN) in healthy volunteers, we found significantly reduced DPN binding to opioid receptor in the hippocampus during positive mood induction compared to neutral mood. Furthermore, the magnitude of positive mood change correlated negatively with DPN binding in the amygdala bilaterally. Our finding of reduced DPN binding is consistent with increased release of endogenous opioids, providing direct evidence that localised release of endogenous opioids is involved in the regulation of positive emotion in humans.

Multi-resolution Bayesian regression in PET dynamic studies using wavelets.

In the kinetic analysis of dynamic PET data, one usually posits that the variation of the data through one dimension, time, can be described by a mathematical model encapsulating the relevant physiological features of the radioactive tracer. In this work, we posit that the remaining dimension, space, can also be modeled as a physiological feature, and we introduce this concept into a new computational procedure for the production of parametric maps. An organ and, in the instance considered here, the brain presents similarities in the physiological properties of its elements across scales: computationally, this similarity can be implemented in two stages. Firstly, a multi-scale decomposition of the dynamic frames is created through the wavelet transform. Secondly, kinetic analysis is performed in wavelet space and the kinetic parameters estimated at low resolution are used as priors to inform estimates at higher resolutions. Kinetic analysis in the above scheme is achieved by extension of the Patlak analysis through Bayesian linear regression that retains the simplicity and speed of the original procedure. Application to artificial and real data (FDG and FDOPA) demonstrates the ability of the procedure to reduce remarkably the variance of parametric maps (up to 4-fold reduction) without introducing sizeable bias. Significance of the methodology and extension of the procedure to other data (fMRI) and models are discussed.

Equilibration of 6-[18F]fluoro-L-m-tyrosine between plasma and erythrocytes.

UNLABELLED: Intracranial or intraventricular blood pools have been suggested as noninvasive sources of an input function for quantitative PET. These techniques measure the concentration of the tracer in whole blood, but the concentration in plasma depends on the equilibration of the tracer between plasma and erythrocytes. METHODS: FDG, 6-[18F]fluoro-L-m-tyrosine (FmT), or its major metabolite, 6-[18F]fluoro-3-hydroxyphenylacetic acid (FHPAA), was added to blood samples obtained from healthy fasting volunteers along with radioiodinated human serum albumin (RIHSA). Samples were incubated at 37 degrees C for times between 10 s and 2 h and then plunged into an ice bath and centrifuged. Whole blood and plasma were counted for 18F and 125I activities. The resulting time courses were fit to successively more complex models, evaluated using an F test. RESULTS: All radioactivity associated with RIHSA remained in the plasma, whereas FDG equilibrated instantaneously between plasma and erythrocytes. FmT took about 1 h to equilibrate between plasma and erythrocytes; this time course could be described by a single exponential with a half-life of 10 min. FHPAA equilibrated within the first 5 min of the study. CONCLUSION: Our results show that, unlike FDG, the partitioning of FmT between plasma and erythrocytes is a relatively slow process. We present an analytic correction that may be applied to the measured time course of radioactivity in whole blood to obtain the time course of the tracer in plasma.

Regions of interest in the venous sinuses as input functions for quantitative PET.

UNLABELLED: As clinical PET becomes increasingly available, quantitative methods that are feasible in busy clinical settings are becoming necessary. We investigated the use of intracranial blood pools as sources of an input function for quantitative PET. METHODS: We studied 25 patients after the intravenous injection of [18F]6-fluoro-L-m-tyrosine and compared sampled blood time-activity curves with those obtained in small regions of interest (ROIs) defined in the blood pools visible in the PET images. Because of the comparatively large dimensions of the blood pool at the confluence of the superior sagittal, straight and transverse sinuses, a venous ROI input function was chosen for further analysis. We applied simple corrections to the ROI-derived time-activity curves, deriving expressions for partial volume, spillover and partition of tracer between plasma and red blood cells. The results of graphic and compartmental analysis using both sampled [Cs(t)] and ROI [Cr(t)] venous input functions for each patient were compared. We also used an analytic approach to examine possible differences between venous and arterial input functions in the cerebral circulation. RESULTS: Cr(t) peaked significantly earlier and higher than Cs(t) in this patient population, although the total integral under the curves did not differ significantly. We report some apparent differences in the results of modeling using the two input functions; however, neither the graphically determined influx constant, Ki, nor the model parameter that reflects presynaptic dopaminergic metabolism, k3, differed significantly between the two methods. The analytic results suggest that the venous ROI input function may be closer to the arterial supply of radiotracer to the brain than arterialized venous blood, at least in some patient populations. CONCLUSION: We present a simple method of obtaining an input function for PET that is applicable to a wide range of tracers and quantitative methods and is feasible for diagnostic PET imaging.

Calretinin-immunoreactive neurons in the human thalamus.

The distribution of the calcium-binding protein calretinin in the thalamus of normal human individuals was studied with immunohistochemistry. Calretinin immunoreactivity was weak in the geniculate bodies and in nuclei of the ventral and posterior groups, moderate in the reticular nucleus and in nuclei of the anterior, medial, and lateral groups, and strong in nuclei of the midline group and anterior intralaminar nuclei. The mediodorsal nucleus was unique among thalamic nuclei because it contained a wide variety of intensely immunostained perikarya embedded in a moderately-labelled neuropil. The reticular nucleus displayed several small and uniformly distributed neuronal clusters composed of immunostained perikarya lying in a moderately-labelled neuropil. Intense and uniform immunostaining was observed in all midline nuclei and in the anterior intralaminar nuclei, including the paracentral and central lateral nuclei. These nuclei, which harboured numerous intensely-stained perikarya lying in a dense immunoreactive neuropil, were the most strongly-immunoreactive structures of the entire human thalamus. At the level of the posterior intralaminar nuclei, the central median nucleus was virtually free of immunostaining whereas the parafascicular nucleus was moderately labelled. The nucleus submedius located just beneath the central median/parafascicular complex displayed a very intense calretinin immunostaining. This study has provided evidence for the presence of the protein calretinin in the human thalamus. The pattern of distribution of calretinin, as delineated in the present study, suggests that this calcium-binding protein may participate in various subcortical and cortical thalamic systems involved in the modulation of emotional and motivational states.

Calretinin immunoreactivity in the thalamus of the squirrel monkey.

The distribution of the calcium-binding protein, calretinin, in the thalamus of the squirrel monkey (Saimiri sciureus) was studied with immunohistochemical methods. Calretinin was found to be heterogeneously distributed in the primate thalamus and to occur only in specific neuronal populations of certain thalamic nuclei. Neuronal cells and fibers in midline nuclei and their dorsolateral extension, which includes the parataenial and central superior lateral nuclei, displayed the most intense calretinin immunoreactivity. The immunoreactivity for cells and fibers in the intralaminar nuclei was moderate rostrally but very weak caudally. The centre mèdian nucleus, together with the medial habenular nucleus, were virtually devoid of calretinine immunostaining. The mediodorsal nucleus displayed a markedly heterogeneous staining, with numerous clusters of labeled cells and fibers in its central parvicellular part. Cell and fiber immunoreactivity ranged from moderate to high in the nuclei of the anterior and lateral groups, but was very weak in the nuclei of the ventral and posterior groups. There was a small to moderate number of heterogeneously distributed calretinin-immunoreactive cells and fibers in the lateral and medial geniculate bodies, as well as in the reticular nucleus. The present study provides the first evidence for the existence of calretinin in primate thalamus, where this protein is distributed according to a highly heterogeneous pattern. This specific pattern of distribution suggests that calretlnin may play a role that is complementary to those of the other calcium-binding proteins parvalbumin and calbindin D-28k in the thalamus of primates.

Striatal changes in preproenkephalin mRNA levels in parkinsonian monkeys.

Levels of preproenkephalin (PPE) mRNA were measured in different sectors of the striatum with in situ hybridization histochemistry in both normal and parkinsonian (MPTP-treated) squirrel monkeys. In parkinsonian monkeys, a marked increase in PPE mRNA levels was noted in the dorsolateral third of the precommissural putamen and in most of the postcommissural putamen. These regions largely correspond to the sensorimotor striatal territory. The other striatal sectors, including the caudate nucleus, did not exhibit significant changes, despite the fact that the loss of the dopaminergic input was severe in most of the striatum. These results reveal that PPE mRNA expression is specifically altered in striatal regions involved in sensorimotor processing in parkinsonian monkeys.