Amy S. Yu

In Vivo Quantitation of Glucose Metabolism in Mice Using Small-Animal PET and a Microfluidic Device

The challenge of sampling blood from small animals has hampered the realization of quantitative small-animal PET. Difficulties associated with the conventional blood-sampling procedure need to be overcome to facilitate the full use of this technique in mice. Methods: We developed an automated blood-sampling device on an integrated microfluidic platform to withdraw small blood samples from mice. We demonstrate the feasibility of performing quantitative small-animal PET studies using 18F-FDG and input functions derived from the blood samples taken by the new device. 18F-FDG kinetics in the mouse brain and myocardial tissues were analyzed. Results: The studies showed that small (∼220 nL) blood samples can be taken accurately in volume and precisely in time from the mouse without direct user intervention. The total blood loss in the animal was <0.5% of the body weight, and radiation exposure to the investigators was minimized. Good model fittings to the brain and the myocardial tissue time–activity curves were obtained when the input functions were derived from the 18 serial blood samples. The R2 values of the curve fittings are >0.90 using a 18F-FDG 3-compartment model and >0.99 for Patlak analysis. The 18F-FDG rate constants \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(K_{1}^{{\ast}}\) \end{document}, \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(k_{2}^{{\ast}}\) \end{document}, \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(k_{3}^{{\ast}}\) \end{document}, and \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(k_{4}^{{\ast}}\) \end{document}, obtained for the 4 mouse brains, were comparable. The cerebral glucose metabolic rates obtained from 4 normoglycemic mice were 21.5 ± 4.3 μmol/min/100 g (mean ± SD) under the influence of 1.5% isoflurane. By generating the whole-body parametric images of \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(K_{FDG}^{{\ast}}\) \end{document} (mL/min/g), the uptake constant of 18F-FDG, we obtained similar pixel values as those obtained from the conventional regional analysis using tissue time–activity curves. Conclusion: With an automated microfluidic blood-sampling device, our studies showed that quantitative small-animal PET can be performed in mice routinely, reliably, and safely in a small-animal PET facility.

Functional expression of SGLTs in rat brain

This work provides evidence of previously unrecognized uptake of glucose via sodium-coupled glucose transporters (SGLTs) in specific regions of the brain. The current understanding of functional glucose utilization in brain is largely based on studies using positron emission tomography (PET) with the glucose tracer 2-deoxy-2-[F-18]fluoro-D-glucose (2-FDG). However, 2-FDG is only a good substrate for facilitated-glucose transporters (GLUTs), not for SGLTs. Thus, glucose accumulation measured by 2-FDG omits the role of SGLTs. We designed and synthesized two high-affinity tracers: one, α-methyl-4-[F-18]fluoro-4-deoxy-D-glucopyranoside (Me-4FDG), is a highly specific SGLT substrate and not transported by GLUTs; the other one, 4-[F-18]fluoro-4-deoxy-D-glucose (4-FDG), is transported by both SGLTs and GLUTs and will pass through the blood brain barrier (BBB). In vitro Me-4FDG autoradiography was used to map the distribution of uptake by functional SGLTs in brain slices with a comparable result from in vitro 4-FDG autoradiography. Immunohistochemical assays showed that uptake was consistent with the distribution of SGLT protein. Ex vivo 4-FDG autoradiography showed that SGLTs in these areas are functionally active in the normal in vivo brain. The results establish that SGLTs are a normal part of the physiology of specific areas of the brain, including hippocampus, amygdala, hypothalamus, and cerebral cortices. 4-FDG PET imaging also established that this BBB-permeable SGLT tracer now offers a functional imaging approach in humans to assess regulation of SGLT activity in health and disease.

Regional distribution of SGLT activity in rat brain in vivo

Na(+)-glucose cotransporter (SGLT) mRNAs have been detected in many organs of the body, but, apart from kidney and intestine, transporter expression, localization, and functional activity, as well as physiological significance, remain elusive. Using a SGLT-specific molecular imaging probe, α-methyl-4-deoxy-4-[(18)F]fluoro-D-glucopyranoside (Me-4-FDG) with ex vivo autoradiography and immunohistochemistry, we mapped in vivo the regional distribution of functional SGLTs in rat brain. Since Me-4-FDG is not a substrate for GLUT1 at the blood-brain barrier (BBB), in vivo delivery of the probe into the brain was achieved after opening of the BBB by an established procedure, osmotic shock. Ex vivo autoradiography showed that Me-4-FDG accumulated in regions of the cerebellum, hippocampus, frontal cortex, caudate nucleus, putamen, amygdala, parietal cortex, and paraventricular nucleus of the hypothalamus. Little or no Me-4-FDG accumulated in the brain stem. The regional accumulation of Me-4-FDG overlapped the distribution of SGLT1 protein detected by immunohistochemistry. In summary, after the BBB is opened, the specific substrate for SGLTs, Me-4-FDG, enters the brain and accumulates in selected regions shown to express SGLT1 protein. This localization and the sensitivity of these neurons to anoxia prompt the speculation that SGLTs may play an essential role in glucose utilization under stress such as ischemia. The expression of SGLTs in the brain raises questions about the potential effects of SGLT inhibitors under development for the treatment of diabetes.

Quantification of Cerebral Glucose Metabolic Rate in Mice Using 18F-FDG and Small-Animal PET

The aim of this study was to evaluate various methods for estimating the metabolic rate of glucose utilization in the mouse brain (cMRglc) using small-animal PET and reliable blood curves derived by a microfluidic blood sampler. Typical values of 18F-FDG rate constants of normal mouse cerebral cortex were estimated and used for cMRglc calculations. The feasibility of using the image-derived liver time–activity curve as a surrogate input function in various quantification methods was also evaluated. Methods: Thirteen normoglycemic C57BL/6 mice were studied. Eighteen blood samples were taken from the femoral artery by the microfluidic blood sampler. Tissue time–activity curves were derived from PET images. cMRglc values were calculated using 2 different input functions (one derived from the blood samples [IFblood] and the other from the liver time–activity curve [IFliver]) in various quantification methods, which included the 3-compartment 18F-FDG model (from which the 18F-FDG rate constants were derived), the Patlak analysis, and operational equations. The estimated cMRglc value based on IFblood and the 3-compartment model served as a standard for comparisons with the cMRglc values calculated by the other methods. Results: The values of \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(\mathrm{K}_{1}^{{\ast}}\) \end{document}, \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(k_{2}^{{\ast}}\) \end{document}, \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(k_{3}^{{\ast}}\) \end{document}, \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(k_{4}^{{\ast}}\) \end{document}, and \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(\mathrm{K}_{\mathrm{FDG}}^{{\ast}}\) \end{document} estimated by IFblood and the 3-compartment model were 0.22 ± 0.05 mL/min/g, 0.48 ± 0.09 min−1, 0.06 ± 0.02 min−1, 0.025 ± 0.010 min−1, and 0.024 ± 0.007 mL/min/g, respectively. The standard cMRglc value was, therefore, 40.6 ± 13.3 μmol/100 g/min (lumped constant = 0.6). No significant difference between the standard cMRglc and the cMRglc estimated by the operational equation that includes \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(k_{4}^{{\ast}}\) \end{document} was observed. The standard cMRglc was also found to have strong correlations (r > 0.8) with the cMRglc value estimated by the use of IFliver in the 3-compartment model and with those estimated by the Patlak analysis (using either IFblood or IFliver). Conclusion: The 18F-FDG rate constants of normal mouse cerebral cortex were determined. These values can be used in the \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(k_{4}^{{\ast}}\) \end{document}-included operational equation to calculate cMRglc. IFliver can be used to estimate cMRglc in most methods included in this study, with proper linear corrections applied. The validity of using the Patlak analysis for estimating cMRglc in mouse PET studies was also confirmed.

Revisiting the physiological roles of SGLTs and GLUTs using positron emission tomography in mice.

Glucose transporters are central players in glucose homeostasis. There are two major classes of glucose transporters in the body, the passive facilitative glucose transporters (GLUTs) and the secondary active sodium‐coupled glucose transporters (SGLTs). In the present study, we report the use of a non‐invasive imaging technique, positron emission tomography, in mice aiming to evaluate the role of GLUTs and SGLTs in controlling glucose distribution and utilization. We show that GLUTs are most significant for glucose uptake into the brain and liver, whereas SGLTs are important in glucose recovery in the kidney. This work provides further support for the use of SGLT imaging in the investigation of the role of SGLT transporters in human physiology and diseases such as diabetes and cancer.

Dapagliflozin Binds Specifically to Sodium-Glucose Cotransporter 2 in the Proximal Renal Tubule

Kidneys contribute to glucose homeostasis by reabsorbing filtered glucose in the proximal tubules via sodium-glucose cotransporters (SGLTs). Reabsorption is primarily handled by SGLT2, and SGLT2-specific inhibitors, including dapagliflozin, canagliflozin, and empagliflozin, increase glucose excretion and lower blood glucose levels. To resolve unanswered questions about these inhibitors, we developed a novel approach to map the distribution of functional SGLT2 proteins in rodents using positron emission tomography with 4-[18F]fluoro-dapagliflozin (F-Dapa). We detected prominent binding of intravenously injected F-Dapa in the kidney cortexes of rats and wild-type and Sglt1-knockout mice but not Sglt2-knockout mice, and injection of SGLT2 inhibitors prevented this binding. Furthermore, imaging revealed only low levels of F-Dapa in the urinary bladder, even after displacement of kidney binding with dapagliflozin. Microscopic ex vitro autoradiography of kidney showed F-Dapa binding to the apical surface of early proximal tubules. Notably, in vivo imaging did not show measureable specific binding of F-Dapa in heart, muscle, salivary glands, liver, or brain. We propose that F-Dapa is freely filtered by the kidney, binds to SGLT2 in the apical membranes of the early proximal tubule, and is subsequently reabsorbed into blood. The high density of functional SGLT2 transporters detected in the apical membrane of the proximal tubule but not detected in other organs likely accounts for the high kidney specificity of SGLT2 inhibitors. Overall, these data are consistent with data from clinical studies on SGLT2 inhibitors and provide a rationale for the mode of action of these drugs.

Noninvasive pulmonary nodule elastometry by CT and deformable image registration.

BACKGROUND AND PURPOSE To develop a noninvasive method for determining malignant pulmonary nodule (MPN) elasticity, and compare it against expert dual-observer manual contouring. METHODS AND MATERIALS We analyzed breath-hold images at extreme tidal volumes of 23 patients with 30 MPN treated with stereotactic ablative radiotherapy. Deformable image registration (DIR) was applied to the breath-hold images to determine the volumes of the MPNs and a ring of surrounding lung tissue (ring) in each state. MPNs were also manually delineated on deep inhale and exhale images by two observers. Volumes were compared between observers and DIR by Dice similarity. Elasticity was defined as the absolute value of the volume ratio of the MPN minus one normalized to that of the ring. RESULTS For all 30 tumors the Dice coefficient was 0.79±0.07 and 0.79±0.06 between DIR with observers 1 and 2, respectively, close to the inter-observer Dice value, 0.81±0.1. The elasticity of MPNs was 1.24±0.26, demonstrating that volume change of the MPN was less than that of the surrounding lung. CONCLUSION We developed a noninvasive CT elastometry method based on DIR that measures the elasticity of biopsy-proven MPN. Our future direction would be to develop this method to distinguish malignant from benign nodules.

Anatomic optimization of lung tumor stereotactic ablative radiation therapy

PURPOSE The purpose of this study was to demonstrate that anatomic optimization through selection of the degree of breath hold that yields the largest separation between the target and nearby organ at risk could result in dosimetrically superior treatment plans. METHODS AND MATERIALS Thirty patients with 41 plans were included in this planned secondary analysis of a prospective trial. Fifteen plans were created for treatment with use of natural end exhale (NEE), and 26 plans used deep inspiration breath hold (DIBH). To evaluate whether the original plan was dosimetrically optimal, we replanned treatment using the opposite respiratory state with the same beam configuration as the original plan. A treatment plan was deemed superior if it met protocol constraints when the other did not. If both plans met or violated the constraints, the plans were deemed equivalent. RESULTS Of the 26 plans originally planned with DIBH and replanned with NEE, 3 plans were dosimetrically superior with NEE, 1 plan was dosimetrically superior with DIBH, and 22 plans were dosimetrically equivalent. Of the 15 plans originally planned with NEE, 4 plans were dosimetrically superior with NEE, 2 plans were dosimetrically superior with DIBH, and 9 plans were dosimetrically equivalent. CONCLUSIONS For 10 of 41 plans, planning with 1 respiratory state was superior. To obtain uniformly optimal plans, individual anatomic optimization would be needed.

Intrafractional Tracking Accuracy of a Transperineal Ultrasound Image Guidance System for Prostate Radiotherapy

Purpose: The aim of this study is to evaluate the tracking accuracy of a commercial ultrasound system under relevant treatment conditions and demonstrate its clinical utility for detecting significant treatment deviations arising from inadvertent intrafractional target motion. Methods: A multimodality male pelvic phantom was used to simulate prostate image-guided radiotherapy with the system under evaluation. Target motion was simulated by placing the phantom on a motion platform. The tracking accuracy of the ultrasound system was evaluated using an independent optical tracking system under the conditions of beam-on, beam-off, poor image quality with an acoustic shadow introduced, and different phantom motion cycles. The time delay between the ultrasound-detected and actual phantom motion was investigated. A clinical case example of prostate treatment is presented as a demonstration of the utility of the system in practice. Results: Time delay between the motion phantom and ultrasound tracking system is 223 ± 45.2 milliseconds including video and optical tracking system frame rates. The tracking accuracy and precision were better with a longer period. The precision of ultrasound tracking performance in the axial (superior–inferior) direction was better than that in the lateral (left–right) direction (root mean square errors are 0.18 and 0.25 mm, respectively). The accuracy of ultrasound tracking performance in the lateral direction was better than that in the axial direction (the mean position errors are 0.23 and 0.45 mm, respectively). Interference by radiation and image quality do not affect tracking ability significantly. Further, utilizing the tracking system as part of a clinical study for prostate treatment further verified the accuracy and clinical appropriateness. Conclusions: It is feasible to use transperineal ultrasound daily to monitor prostate motion during treatment. Our results verify the accuracy and precision of an ultrasound system under typical external beam treatment conditions and further demonstrate that the tracking system was able to identify important prostate shifts in a clinical case.

A novel‐integrated quality assurance phantom for radiographic and nonradiographic radiotherapy localization and positioning systems

Purpose Various localization and positioning systems utilizing radiographic or nonradiographic methods have been developed to improve the accuracy of radiation treatment. Each quality assurance (QA) procedure requires its own phantom and is independent from each other, so the deviation between each system is unavailable. The purpose of this work is to develop and evaluate a single‐integrated QA phantom for different localization and positioning systems. Methods The integrated phantom was designed in three‐dimensional (3D) CAD software and 3D printed. The phantom was designed with laser alignment marks, a raised letter “S” on the anterior surface for optical surface monitoring system registration, a core for radiofrequency (RF) tracking system alignment, eight internal fiducials for image alignment, and an isocentric bearing for Winston–Lutz test. Tilt legs and rotational stage were designed for rotational verification of optical surface mapping system and RF tracking system, respectively. The phantom was scanned using a CT scanner and a QA plan was created. This prototype phantom was evaluated against established QA techniques. Results The QA result between the proposed procedure and established QA technique are 1.12 ± 0.31 and 1.14 ± 0.31 mm, respectively, for RF tracking system and 0.18 ± 0.06 and 0.18 ± 0.05 mm for Winston–Lutz test. There is no significant difference for the QA results between the established QA and proposed procedure (P > 0.05, t test). The accuracy of rotational verification for surface mapping system and RF tracking system are less than 0.5 and 1° compared the predefined value. The isocenter deviation of each location system is around l mm. Conclusion We have designed and evaluated a novel‐integrated phantom for radiographic and nonradiographic localization and positioning systems for radiotherapy. With this phantom, we will reduce the variation in measurements and simplify the QA procedures.