Imaging of soft-tissue sarcomas with indium-111-labeled monoclonal antimyosin Fab fragments

Some soft-tissue sarcomas contain intracellular myosin. We therefore studied the possibility of localizing various soft-tissue sarcomas with 111In-labeled monoclonal antibody Fab fragments binding specifically to myosin, assuming that damage to the cell membrane could expose intracellular myosin. Nineteen patients with different types of soft-tissue sarcomas were studied. Eighteen patients were found to have abnormal antibody uptakes. Antibody uptake was not observed in an additional patient operated for a benign tumor (gastric leiomyoma). The immunoscintigraphy results were generally in good agreement with those of other radiologic findings (computed tomography, ultrasound, magnetic resonance imaging). Surprisingly, the immunohistochemistry results showed that tumors not stainable for myosin can also be imaged with antimyosin. Thus, the mechanism of antibody uptake does not seem to be related entirely to specific antigen recognition. Irrespective of the exact mechanism for the uptake of labeled antibody this method appears to be useful for localizing soft-tissue sarcomas.     

Indium-111 antimyosin monoclonal antibody Fab imaging in patients with cardiomyopathy

Six patients with cardiomyopathy were imaged following intravenous injection of an indium-111 labeled monoclonal antibody directed against the heavy chain of cardiac myosin. Two patients had hypertrophic non-obstructive cardiomyopathy (HNCM), two patients had dilated cardiomyopathy (DCM), and two patients had specific heart muscle disease. One of 2 patients with HNCM and one of 2 patients with DCM had a positive antimyosin scan. The 2 patients with specific heart muscle disease manifested persistent blood pool activity of the antibody, thereby precluding interpretation of the images. The present report demonstrates that antimyosin antibody imaging may provide evidence of myocardial injury, or necrosis in some patients with cardiomyopathy.     

Clinical role of indium-111 antimyosin imaging

Myocyte necrosis occurs in ischaemic, inflammatory and toxic heart diseases and can be detected by indium-111 antimyosin imaging. This allows a non-invasive evaluation of the site, extent and quantitation of the severity of myocardial necrosis. Simultaneous imaging of perfusion in patients with myocardial infarction allows the differentiation of necrosed and perfused areas and the varying degrees of mismatch and overlap, which has prognostic significance.¹¹¹In-antimyosin imaging is useful in the assessment of patients with unstable angina and in those for whom the diagnosis of infarction or unstable angina is not clear. In suspected myocarditis, a positive scan indicates the necessity for endomyocardial biopsy to confirm inflammation, whereas a negative scan makes the diagnosis of myocarditis unlikely. Anti-myosin imaging is not useful as a marker of rejection in the 1 year post-transplant, but uptake after this period is associated with an increased rejection rate and is therefore an important tool in planning management strategies. Most patients on anthracycline treatment have demonstrable uptake, which is related to the cumulative dose and to the ejection fraction. Its role in this situation is as yet unclear. The use of new ligands and radioisotopes (^99mTc) is likely to allow earlier imaging and produce improved quality.     

Clinical role of indium-111 antimyosin imaging.

Myocyte necrosis occurs in ischaemic, inflammatory and toxic heart diseases and can be detected by indium-111 antimyosin imaging. This allows a non-invasive evaluation of the site, extent and quantitation of the severity of myocardial necrosis. Simultaneous imaging of perfusion in patients with myocardial infarction allows the differentiation of necrosed and perfused areas and the varying degrees of mismatch and overlap, which has prognostic significance. 111In-antimyosin imaging is useful in the assessment of patients with unstable angina and in those for whom the diagnosis of infarction or unstable angina is not clear. In suspected myocarditis, a positive scan indicates the necessity for endomyocardial biopsy to confirm inflammation, whereas a negative scan makes the diagnosis of myocarditis unlikely. Antimyosin imaging is not useful as a marker of rejection in the 1 year post-transplant, but uptake after this period is associated with an increased rejection rate and is therefore an important tool in planning management strategies. Most patients on anthracycline treatment have demonstrable uptake, which is related to the cumulative dose and to the ejection fraction. Its role in this situation is as yet unclear. The use of new ligands and radioisotopes (99mTc) is likely to allow earlier imaging and produce improved quality.     

Quantitative evaluation of acute myocardial infarction by In-111 antimyosin Fab myocardial imaging]

For quantitative evaluation of acute myocardial infarction, In-111 antimyosin Fab myocardial imaging (InAM) was performed in 17 patients with myocardial infarction who underwent Tl-201 (TL) and Tc-99m pyrophosphate (PYP) myocardial imaging in acute phase. For calculating the infarct size, voxel counter method was used for analysis in PYP and InAM, and extent and severity score were used on bull's-eye polar map in TL. The most appropriate cut-off level ranged from 65 to 80% by the fundamental experiment using cardiac phantom. The cut-off level of 0.70 (InAM) and 0.65 (PYP) were used for clinical application of voxel counter analysis. The infarct size calculated by InAM and PYP was compared with wall motion abnormality index by echocardiography (WMAI), TL extent score, TL severity score, peak CK and sigma CK. Infarct size by InAM showed the following correlations with other indices. PYP: r = 0.26 (ns), TL extent score: r = 0.72 (p less than 0.01), TL severity score: r = 0.65 (p less than 0.05), WMAI: r = 0.69 (p less than 0.05). The infarct size by PYP did not show any correlations with these indices. Therefore, the infarct size by InAM showed better correlations with TL and WMAI than that of PYP. So InAM was considered superior to PYP for quantitative evaluation of acute myocardial infarction.     

Radioimmunodetection of human melanoma with indium-111-labeled monoclonal antibody

The purpose of the study was threefold: (1) to evaluate the efficacy of an 111In-labeled murine monoclonal antibody (ZME-018) directed against a heavy molecular weight melanoma associated glycoprotein in localizing metastatic disease; (2) to determine the effect of unlabeled antibody mass (2.5, 5, 10, 20, and 40 mg) on labeled antibody blood clearance, biodistribution and lesion detection; (3) to estimate radiation dosimetry. Twenty-five patients with previously documented disease received an intravenous infusion of 2.5 to 40 mg of monoclonal antibody with 1 mg of the antibody labeled with 5 mCi of 111In. There were no acute reactions. Patients were scanned without computer enhancement or background subtraction techniques at 24 and 72 hr after injection. Imaging detected tumor in 14/18 (78%) patients with active disease, identified 24/44 (77%) of lesions greater than 1 cm and changed or specifically directed patient management in 22% (4/18) patients with tumor. There was a prolongation in blood clearance associated with decreased liver and spleen activity following administration of 20 and 40 mg of antibody compared to the three lower antibody dose levels. Assuming a biodistribution similar to [111In]ZME-018, the radiation dose delivered to normal tissues by [90Y]ZME-018 would restrict its use as a routine vehicle for radioimmunotherapy; however, it may be possible to deliver substantial tumor doses in selected patients.     

Immunoscintigraphy with 111In antimyosin Fab

Monoclonal 111In antimyosin Fab is a marker for myocytes which have lost their membrane integrity. Because of the slow blood pool clearance of the radiopharmaceutical, imaging is usually started 24-48 h after intravenous injection of 74 MBq of the tracer. This long postinjection interval restricts its utilization in the primary diagnosis of acute myocardial infarction. However, antimyosin may help to differentiate between necrotic and viable myocardium in the subacute stage of incomplete myocardial infarction. Serial endomyocardial biopsy for early detection of transplant rejection after heart transplantation may be partially replaced or supplemented by antimyosin scintigraphy. The compound may facilitate the diagnosis of myocarditis. Other potential indications may be prognostic assessment of dilated cardiomyopathy, monitoring cardiotoxic side-effects of chemotherapeutics, recognition of cardiac contusion as well as diagnosis of rhabdo- and leiomyosarcoma. In specific clinical situations 111In antimyosin Fab immunoscintigraphy may provide valuable diagnostic information.     

Thrombus imaging with indium-111 and iodine-131-labeled fibrin-specific monoclonal antibody and its F(ab')2 and Fab fragments

We have previously reported successful imaging of fresh (2-4 hr old) and aged (1-5 days old) canine thrombi with 131I-labeled intact monoclonal antibody (MAb) specific for fibrin. We now report thrombus imaging with 131I-labeled F(ab')2 and Fab and 111In-labeled intact MAb, F(ab')2, and Fab. Indium-111-labeled F(ab')2 proved to be the best imaging agent due to less nonspecific binding in the liver than whole IgG. Image quality was improved by the higher administered dose permissible with 111In and its better physical characteristics for imaging, compared to 131I. Immunofluorescence of fresh human histologic sections showed intact MAb and F(ab')2 binding to thrombi, pulmonary emboli, and atherosclerotic plaques, strengthening the feasibility of clinical thrombus imaging.     

Myocardial damage delineated by indium-111 antimyosin Fab and technetium-99m pyrophosphate

Technetium-99m-labeled pyrophosphate and radiolabeled antimyosin antibodies are two infarct localizing agents with apparently different kinetics of localization. To determine whether these agents localize in a similar fashion in early acute myocardial necrosis, we studied the simultaneous distribution of 111In-labeled antimyosin and 99mTc-labeled pyrophosphate in dogs after intracoronary (i.c.) (n = 9) or intravenous (i.v.) (n = 9) administration of a mixture of these two agents in a reperfused infarct model. The mean infarct size (+/- s.d.) delineated by pyrophosphate [20.2 +/- 14.1 (i.v.), 29.8 +/- 12.3 (i.c.)] was larger than that by antimyosin [14.2 +/- 11.3 (i.v.) (p = 0.05), 20.0 +/- 11.8 (i.c.) (p = 0.05)] which was larger than that by triphenyl tetrazolium chloride [13.9 +/- 8.0 (i.v.) (p = 0.05), 15.3 +/- 6.5 (i.c.) (p = 0.05)]. This overestimation persisted whether the radiopharmaceuticals were administered by intracoronary or intravenous injections, although the latter with antimyosin was only slightly larger (TTC:AM = 13.9:14.2) (p = n.s.). There was a good correlation, however, between antimyosin and pyrophosphate delineated infarct sizes in dogs with intracoronary injection (y = 0.82x + 13.33, r = 0.79) or i.v. injection (y = 1.208x + 3.01, r = 0.97) of the mixture of the two agents. Since the images of the 111In and 99mTc activities were obtained consecutively by identical methods, the overestimation of infarct size by pyrophosphate cannot be due to differences in spatial resolution of the techniques used. The differences in the areas of myocardial damage delineated by pyrophosphate and antimyosin in our study most probably denote the area of viable but compromised myocardium.     

Infectious imaging with indium-111-labeled nonspecific polyclonal human immunoglobulin

Nonspecific polyclonal immunoglobulin (IgG), prepared from pooled human serum gamma globulin and labeled with 111In has been reported to be equivalent to antigen-specific antibody in the detection of focal infection or inflammation during the first 24 hr after injection. We describe our experience in a Phase II clinical study using 111In-IgG in 15 patients (8 males, 7 females) ranging from 26 to 80 (mean = 50) yr of age with suspected focal infection/inflammation. Pathologic confirmation was obtained in 5/15 cases. A combination of clinical course, laboratory results, and other imaging procedures were used to categorize the other 10 patients. One possible false-negative involved a presumed aspiration pneumonia in a patient with a history of aspiration, bibasilar infiltrates on chest film, and no other identified source of infection. Otherwise, there were 10 confirmed positives, 4 confirmed negatives, and no false-positives. Our findings confirm earlier reports that 111In-IgG may be a superior imaging agent for infection/inflammation with practical advantages over 67Ga-citrate and 111In-labeled leukocytes.     

Pharmacokinetics of an indium-111-labeled monoclonal antibody in cancer patients

We have evaluated the pharmacokinetics in patients of a monoclonal antibody (19-9) F(ab')2 fragment coupled with DTPA and labeled with 111In. In addition to imaging and organ uptake determinations, serum and urine samples were analyzed to help determine the in vivo behavior of the label. Using a competitive binding assay, the immunoreactivity of the coupled fragment was found to be indistinguishable from that of the unmodified fragment. The absence of radiocolloids in the injectate was confirmed as was the in vivo stability of the attached DTPA groups. By a variety of techniques, we show that the only significant source of label instability was transcomplexation to circulating transferrin. About 9% per day of label exposed to transferrin (about 1-2% of the injected dose) dissociated with slight bone marrow accumulation. Following i.v. administration, serum activity levels fell rapidly (T 1/2 alpha 2 hr, T 1/2 beta 19 hr). Whole-body clearance of the label was slow (T 1/2 160 hr) and may be attributed entirely to urinary excretion (0.26% of the injected dose per hour). Organ accumulation was greatest in the liver and persisted after rapidly attaining high values (20% of the injected dose). A total of 14 cancer patients were studied, nine with identifiable sites of metastatic disease from colorectal [8], pancreatic [2], ovarian [3], or small cell lung [1] primaries. Eight of the 12 sites of documented tumor were visualized by external imaging (67%) most distinctly at 48-72 hr postadministration.     

Metabolic imaging with gallium-68- and indium-111-labeled low-density lipoprotein

Low-density lipoprotein (LDL) labeled with either gallium-68 (68Ga) or indium-111 (111In) was evaluated as a potential PET or SPECT radiopharmaceutical for determination of hepatic lipoprotein metabolism in rabbits. Gallium-68 or 111In was linked to LDL via diethylenetriaminepentaacetic acid (DTPA) with a 25-70% radiochemical yield. Studies in vivo that compared 68Ga- or 111In-DTPA-LDL with dilactitol-[125I]-tyramine LDL and 131I-LDL showed that both 68Ga- and 111In-labeled LDL behaved as residualizing radiotracers. Localization of radioactivity within the liver of normal rabbits was visualized clearly with [68Ga]DTPA-LDL by PET and with [111In]DTPA-LDL by gamma scintigraphy. Significant differences were observed in hepatic uptake of normal compared with hypercholesterolemic rabbits in which low-capacity LDL receptor-mediated catabolism was saturated. Gallium-68 and 111In-DTPA-LDL are attractive radiopharmaceuticals for noninvasive delineation of tissue LDL metabolism under normal and pathophysiologic conditions.     

Sequential imaging of indium-111-labeled monoclonal antibody in human mammary tumors hosted in nude mice

Using a bifunctional chelating agent, indium-111 was attached to a monoclonal antibody 10- 3D2 , specific for a 126-kilodalton phosphoglycoprotein antigen associated with human mammary carcinoma, and was then used to localize and visualize human mammary tumors hosted in nude mice. Simultaneous tumor concentration of In-111-10- 3D2 was eight times greater than that of control I-125-MOPC-21. Uptake of F(ab')2 and Fab of 10- 3D2 was also compared. the scintigrams demonstrated that intact antibody provided the best images. Control In-111-labeled MOPC-21 and plasma did not show specific localization in the tumor. Uptake of In-111-labeled 10- 3D2 was also compared in two lines of human mammary tumors, BT-20 and HS- 578T . Imaging with 10- 3D2 was better for BT-20 than for HS- 578T . These studies demonstrated that (a) In-111-10- 3D2 can be utilized to image human mammary tumors hosted in nude mice; (b) intact antibody provided the best tumor images, although F(ab')2 had optimal target-to-background ratios for earlier imaging; and (c) different mammary tumor lines with possibly different concentrations of tumor-associated antigen showed different rates of uptake and apparent saturation with 10- 3D2 .     

Value of blood-pool subtraction in cardiac indium-111-labeled platelet imaging

Blood-pool subtraction has been proposed to enhance 111In-labeled platelet imaging of intracardiac thrombi. We tested the accuracy of labeled platelet imaging, with and without blood-pool subtraction, in ten subjects with cardiac thrombi of varying age, eight with endocarditis being treated with antimicrobial therapy and ten normal controls. Imaging was performed early after labeled platelet injection (24 hr or less) and late (48 hr or more). Blood-pool subtraction was carried out. All images were graded subjectively by four experienced, "blinded" readers. Detection accuracy was measured by the sensitivity at three fixed levels of specificity estimated from receiver operator characteristic curve analysis and tested by three-way analysis of variance. Detection accuracy was generally improved on delayed images. Blood-pool subtraction did not improve accuracy. Although blood-pool subtraction increased detection sensitivity, this was offset by decreased specificity. For this population studied, blood-pool subtraction did not improve subjective detection of abnormal platelet deposition by 111In platelet imaging.     

Evaluation of indium-111-labeled anti-fibrin antibody for imaging vascular thrombi

Monoclonal antibody 59D8 developed by Hui et al., binds to fibrin but not fibrinogen. An 111In-labeled Fab fragment of 59D8 was studied in vitro and in animal models to evaluate its potential for imaging thrombi and emboli in man. Rabbits and dogs were used as models for studying thrombus uptake in vivo. Thrombi and emboli up to 4 days old were successfully visualized at 4-24 hr postinjection in five of eight rabbits. In dogs, 0.5-hr-old and 24-hr-old thrombi were successfully imaged at 24 hr in six of eight animals, and 3/6 of these were positive at 3-4 hr postinjection. Thrombus-to-blood ratios in the dogs averaged 7.1 +/- 1.3. The findings suggest this antibody may be useful for imaging thrombi in man.     

Clinical evaluation of indium-111-labeled leukocyte imaging in bone infection

In-111-oxine-labeled leukocyte imaging was performed on twenty-one patients suspected of having bone infection. Nine of eleven cases (82%) were diagnosed as having active infection as demonstrated by abnormal accumulation of In-111-labeled leukocytes at the site of infection. There are two false negative (18%) cases. Two cases without active infection showed abnormal uptake. Four cases revealed cold defects on the scintigraphy. Marked uptake of radiotracer was noted not only in the case of acute osteomyelitis with acute septicaemia but also in the case with persistent chronic active osteomyelitis. It was observed that for precise evaluation of the test results it was equally important to compare the imaging findings with physical signs and laboratory investigations. It is concluded that In-111-oxine-labeled leukocyte imaging is a useful tool for the evaluation of the progression of bone infection.     

Myocardial uptake of indium-111-labeled antimyosin in acute subendocardial infarction: clinical, histochemical, and autoradiographic correlation of myocardial necrosis

Indium-111-labeled antimyosin has been utilized in the diagnosis and localization of acute transmural myocardial infarction. The present report describes a patient who presented with a massive subendocardial infarction. Two days after the injection of antimyosin, the patient's clinical status markedly deteriorated and he expired. Postmortem examination demonstrated severe three-vessel coronary artery disease with extensive myocyte death in the endocardium. Autoradiography and histochemical staining of the prosected heart demonstrated high correlation for myocardial necrosis and corresponded to clinical evidence for diffuse subendocardial infarction.     

Immunolymphoscintigraphy in patients with lymphoma after subcutaneous injection of indium-111-labeled T101 monoclonal antibody

Indium-111-labeled T101 antibody was injected subcutaneously (s.c.) into the web spaces between the toes of two patients with cutaneous T-cell lymphoma. Computer-assisted gamma scintigraphy was used to measure uptake in lymph nodes and clearance from injection sites. Antibodies passed rapidly and very efficiently from the feet to the inguinal-femoral and iliac lymph nodes after s.c. administration. Contrasting patterns of uptake were seen in patients with different lymph node histology, but additional experience will be required to test the possible correlation with degree of lymph node involvement. This technique provides an efficient, noninvasive method for imaging normal and abnormal lymphoid elements in regional lymph nodes, and it may prove useful in the evaluation of patients with lymphoma or other lymph node disorders.