Patent Application
20110233421
Not applicable.
The present disclosure relates to the detection of radiation and more particularly to the in vivo detection of radiation sources bound to target tissue.
The concept of radioguided surgery was developed over 60 years ago. “Radioguided surgery” involves the use of a radiation detection probe system for the intraoperative detection of radionuclides. Today, it is a well-recognized tool for use in the surgical management of cancer. It also is used as a diagnostic tool, for example, for intraoperative lymphatic mapping, where a radiotracer is injected at the site of skin cancer and a radiation probe used to trace the movement of the radiotracer to the sentinel node for its removal. Regardless of whether surgery is involved, the use of a hand-held probe to locate radionuclides has many clinical applications, especially in the location and differentiation of neoplastic tissue.
An excellent review of radioguided surgery using gamma detection is by Povoski, et al., “A comprehensive overview of radioguided surgery using gamma detection probe technology”, World Journal of Surgical Oncology 2009, 7:11 (see also http://www.wjso.com/content/7/11), the disclosure of which is expressly incorporated herein by reference. Radionuclides and preferential locators are extensively reviewed in this article. A “preferential locator” is an agent that selectively and specifically binds to target tissue, which usually is neoplastic or cancerous. A preferential locator can be biologic (e.g., an antibody) or chemical, optionally radioactive. This article also mentions beta radionuclides and positron emitting radionuclides.
For each different source of radiation, a different probe often is designed and used. Different radiation energies require differing crystal geometries to be housed within separate probe constructions. The present disclosure makes use of an intermediate medium to allow a wide range of energies to be detected with a single crystal configuration.
A radiation-detecting probe instrument has a forward working portion housing a radiation detector and a rearward user directed portion. The probe instrument is in communication with a control assembly for processing and outputting signals received from the radiation detector correlative to an in vivo located radionuclide source emitting energy above about a typical value of 100 KeV, depending on the radionuclide used in the application. The disclosed probe instrument forward portion has an annular housing having a radiation transparent tip. The radiation detector is disposed behind the radiation transparent tip. An intermediate metallic wafer (in the present example, Pb) is disposed between the radiation transparent tip and the radiation detector. A W shield is disposed adjacent to the radiation detector on the side opposite the Pb wafer. Radiation emitted from the in vivo radionuclide source strikes the Pb wafer causing the Pb wafer to characteristic x-rays for Pb, which strikes the radiation detector for generating signals for communication the control assembly.
Another disclosed aspect is a method for detecting an external imaging radionuclide source emitting energy above 88 KeV, wherein the external imaging radionuclide source is bound to a preferential locator that binds to neoplastic tissue. Initially, the external imaging radionuclide source bound preferential locator is administered to a patient suspected of having neoplastic tissue. The patient then is subjected to external imaging. Finally, the patient also is surgically accessed and the probe of claim 1 is used to locate said external imaging radionuclide source and, hence, neoplastic tissue in the patient.
Advantages of the disclosed probe include the ability to detect any radionuclide source have an energy emission of greater than 88 KeV. Another advantage is the probe's ability to detect alpha emissions, gamma emissions, positron annihilation emissions, etc. These and other advantages will be apparent to those skilled in the art based on the disclosure set forth herein.
For a fuller understanding of the nature and advantages of the present device, reference should be had to the following detailed description taken in connection with the accompanying drawings, in which:
These drawings will be described in further detail below.
L to K transitions produce “K alpha” emission. Because there are several energy sublevels in the L from which electrons can drop down to fill in the K-shell, there are in fact “K alpha 1” and “K alpha 2” peaks which are very close to one another in energy. Other characteristic x-ray transitions are possible to detect. K alpha emissions are used for illustration purposes, then, and are not a limitation on the disclosed instrument. For present purposes, either of the two K-alpha peaks is acceptable. Elements, which are useful for present purposes, should be relatively inexpensive, safe to handle, and convenient to handle. Kα1 radiation can be generated in easy to detect amounts from, for example, Pb, Bi, TI, Hg, and the like elements or metallic alloys. For cost, safety, and handling purposes, Pb is an element of choice for present purposes.
Referring to
By windowing direct radiation peaks of the radioisotope of interest are excluded from being detected and counted to the exclusive detection and counting of characteristic x-ray radiation, which is the same about 75 KeV for each and every radioisotope; thus, permitting the crystal package, probe tip, circuitry, and analytical tools to be optimized to only the characteristic x-ray radiation signal regardless of isotope. Windowing out (excluding) signals below about 50 KeV can be practiced also. A probe for detection of a wide variation in isotope energies with significantly improved absorption efficiency, thus, is revealed.
Radionuclides useful for present purposes can generate positron emission, gamma radiation, beta radiation, or the like. Practical animal uses, however, limit the radionuclides to those that are approved for animal (including human) use. Examples of detectable labels include, for example, 15O, 13N, 11C, 18F, 124I, and 82Rb. Gamma emitters (i.e., gamma radiation emitters) include, for example, 67Ga, 111In, 123I, 131I, 99mTc, 57Co, 201TI, and the like. Radionuclides approved for animal use and which can strike the fluorescing materials to generate detectable characteristic x-ray radiation are useful for present purposes; however, the choice of radionuclide also may be affected by half-life, disposal issues, and like factors.
“Detectable” for present purposes means that the probe can detect, locate, and differentiate detector-generated characteristic x-ray radiation from and over other (including background) sources of characteristic x-ray radiation presented concomitantly to the probe.
A sectional view of a representative crystal/shield/Pb sub-assembly, 8, for detecting characteristic x-ray radiation is illustrated in
Crystal 12 disposed within probe tip 8 is connected to a control unit by a cable, 22, as illustrated in
Another probe tip embodiment, 30, is illustrated in
The basic components needed for the disclosed characteristic x-ray radiation probe and controller assemblies are illustrated in
In
With respect to the characteristic x-ray radiation pre-amplifiers in
The K-alpha emissions generate electron-hole pairs within the Cadmium-Zinc-Telluride crystal lattice. This free charge (electrons) migrates to the high voltage anode end of the crystal while the positive holes in the lattice migrate to the cathode. The resulting electrical signal is a charge pulse of a less than a microsecond in duration. The first stage of the pre-amplifier converts this charge pulse to a detectable level by integrating the charge to a voltage pulse of a few microvolts. The discrete form of the circuit is described subsequently.
The high voltage DC bias is removed from the charge pulse signal by capacitor C3. The JFET transistor, Q1, provides high input impedance and voltage to current gain by virtue of transconductance. Since the drain resistor (R18) is also connected to the emitter of the Q3 bipolar junction transistor, the change in drain current in Q1 drives a voltage change in the collectors of the Q3 and Q2 Cascade transistor pair. This three-transistor circuit provides a voltage gain of approximately 500. The R3 and C5 feedback impedance between the Q2-Q3 collectors and the gate of Q1 increases the pulse duration by integrating the charge of the voltage pulse.
The output voltage pulse (Q2-Q3 collector voltage) is further amplified in a two stage operational amplifier circuit and the rise and fall time of the pulse are set using a high pass filter (C7 and R5) and a low pass filter (R17 and C9). The total gain of the circuit is adjusted such that the final output signal is 6 millivolts per each KeV of the energy pulse interacting with the CZT crystal.
In another embodiment of the pre-amplifier circuit, the three-transistor configuration is replaced with an operational amplifier specifically designed for charge amplification. The LTC6240HV is designed with a FET input to provide the high impedance necessary to detect the CZT pulse without significant loading just as the Q1 JFET in the previous circuit. The integration is performed by the R3 and C5 feedback path, also corresponding to the previous circuit. The subsequent gain stages and filtering are identical.
In both the semi-conductor crystal embodiment and the scintillation crystal embodiment, an output signal correlates directly with the energy of the radioisotope being detected through quanta of detected radiation results. The ability to convert virtually any radioisotope signal into a constant characteristic x-ray radiation signal makes the disclosed probe system unique and highly useful, especially in the detection of cell bound radioisotopes in vivo and ex vivo.
The disclosed probe can be mounted into a small assembly formed as a finger ring for use by a surgeon (“finger probe”), mounted into a thin handle assembly for laparoscopic use of the probe, or any other convenient probe construction. The following patents show various probe constructions and controller details. Many of such probe bodies and controllers find use for constructing and controlling the disclosed Kα1 radiation probe: U.S. Pat. Nos. 4,801,803, 4,893,013, 4,889.991, 6,070,878, 5,151,598, 5,429,133, 5,383,456, 5,441,050, 5,495,111, 5,475,219, 5,732,704, 5,857,463, 5,987,350, 5,682,888, 5,916,167, 5,928,150, 6,222,193, 6,204,505, 6,191,422, 6,218,669, 6,259,095, 6,272,373, and 6,144,876, the discloses of which are expressly incorporated herein by reference.
A prototype probe using a 19 mm CdTe crystal and Pb characteristic x-ray (in this instance, K-alpha) radiation generator, as illustrated in
Tumor-associated antigen (TAG-72) is a human mucin (MUC1) like glycoprotein complex with molecular weight of 106 Da. It is over-expressed in several epithelial-derived cancers, including most ductal carcinomas of the breast, common epithelial ovarian carcinomas, non-small cell lung carcinomas, gastric, pancreatic, and colorectal carcinomas. Murine monoclonal antibody (B72.3) was generated using membrane-enriched extracts of human metastatic mammary carcinoma lesions, while the second generation monoclonal antibody (CC49) was generated against purified TAG-72 from colon cancer. These antibodies have been extensively evaluated in animal models and human for detection of various cancers, one of which has been approved by FDA for the detection of both colorectal and ovarian cancers with in gamma camera scanning in conjunction with computerized tomography. (111Indium labeled B72.3 antibody, CYT-103, Cytogen).
TAG-72 antibody shows selective reactivity for human adenocarcinomas, demonstrating that 94% of colon carcinomas express the TAG-72, while normal colon epithelium does not show any reactivity to the antibody. Murine monoclonal B72.3 also reacted with cells in areas of “atypia” within adenomas. It also showed reactivity with other human carcinomas including 84% of invasive ductal breast cancer, 100% of ovarian cancers tested, and 96% lung of adenocarcinomas, while it showed only weak or no reactivity in the corresponding normal tissues except secretory endometrium.
B72.3 antibody has been evaluated in tissue culture and xenograft models. Interestingly, this antibody is not reactive to vast majority of human carcinoma cell lines in cultures due to limitations in this special configuration. However, it is highly expressed in colon cancer cell lines (e.g., LS 174T) and breast cancer cells lines (e.g., MCF-7). When these cells were grown in spheroid culture, suspension cultures or on agar, TAG-72 expression increased by 2-10 fold. Additionally, when the LS 174T cell line was injected into athymic mice to generate xenograft models, the level of TAG-72 antigen increased over 100-fold, which is similar to expression levels seen in the metastatic tumor masses from patients. I125-labeled B72.3 was tested in xenograft mice models with LS-174 cancer cells for tumor localization. After intravenous injection of 1.5 μCi of 125I-labeled B72.3, 10% of injected dose per gram of body weight (% ID/g) was determined after two days. Interestingly, the total amount of 125I-B72.3 activity in the tumor stayed constant during 30 days, while the activity in the rest of the body including blood, kidney, liver, spleen, and lung decreased significantly. For example, The % ID/g of 125I-B72.3 in tumors stayed at 6.49% to 10.75% in 7 days period, while it decreased from 9.94% to 1.38% in blood, 1.82% to 0.34% in kidney, 2.23% to 0.37% in spleen, 5.52% to 0.75% in lung, and 1.89% to 0.37%. The distribution ratio of tumor compared to other normal organs (liver, kidney, lung) reached 18:1 at day 7, while tumor to blood ratio reached 5:1 at day 7. In xenograft models with A375 cells without TAG-72 expression, B72.3 did not show any tumor localization. In xenograft models implanting LS 174T with high levels of TAG-72, other control antibodies such as 125I-MOPC-21 IgG did not show tumor localization either.
131I labeled B72.3 IgG has been used clinically for diagnostic imaging of colorectal, ovary, and breast cancer. The data demonstrate the specific localization of B72.3 antibody in cancer tissues in patients. After intravenous (IV) administered 131I-labeled B72.3 IgG prior to surgery, radio-localization indices (RI) were calculated by cpm of 131I-labeled antibody per gram of tumor versus cpm per gram of normal tissues. Seventy percent (99 of 142) of tumor lesions showed RI is of greater than 3 (antibody localization in tumors is 3 times greater than normal tissue). In addition, high-performance liquid chromatography (HPLC) and SDS-polyacrylamide gel electrophoresis demonstrated that the radioactivity in patient's sera was associated with intact 131I-B72.3 antibody as visualized in autoradiography or IgG peak in HPLC analysis after IV administration of dose range 0.5-20 mg. Interestingly, when 131I-labeled B72.3 IgG was administered intraperitoneally in colon cancer patients, the localization in colon tumor verse normal tissue was 70:1. However, IV administration of this labeled antibody is more efficient in targeting lymph node metastases.
125I-labeled B72.3 also has been used for radio-immunoguided surgery (RIGS®, U.S. Pat. No. 4,782,840) with an intraoperative hand-held probe to localize the residual tumor tissue for resection. The RIGS system also has been successfully used with the B72.3 antibody for clinical colorectal cancer patients. 125I labeled-antibody has localized 75%-80% of primary colorectal tumor lesion, and 63%-73% of metastatic lesions in lymph nodes and liver.
The second-generation antibody CC49 was generated against TAG-72 purified from colon cancer. CC49 showed higher binding affinity than B72.3 to TAG-72 in carcinomas including breast, colorectal, ovarian, and lung carcinomas, while CC49 exhibited minimum reactivity with normal tissues. When 125I-CC49 was administered in xenograft models with colon cancer cells LS 174T, the plasma clearance was much faster than B72.3, which results in much higher tumor to normal tissue distribution ratio. For example, the tumor to blood ratio was 18.1, tumor to liver ratio 3.81, tumor to spleen ratio 16.64, tumor to kidney ratio 36.48, and tumor to lung ratio 25.82. In RIGS studies of 300 patients with colorectal cancers, CC49 was able to successfully detect tumors in 86% of patients with primary tumors and 95% of patients with recurrent tumors. In addition, clinical studies of a modified humanized antibody HuCC49ΔCH2 with a deletion in glycosylation sites of the antibody showed similar results with CC49 in detection of colorectal cancer. See, for example, the following reported clinical trial: Pilot Study Using a Humanized CC49 Monoclonal Antibody (HuCC49ΔCH2) to Localize Recurrent Colorectal Carcinoma Doreen M. Agnese, MD, Shahab F. Abdessalam, MD, William E. Burak, Jr., MD, Mark W. Arnold, MD, Denise Soble, RN, George H. Hinkle, RPh, Donn Young, PhD, M. B. Khazalaeli, PhD, and Edward W. Martin, Jr., MD Annals of Surgical Oncology, 11(2): 197-202; and Pharmacokinetics and Clinical Evaluation of 125I-Radiolabeled Humanized CC49 Monoclonal Antibody (HuCC49ΔCH2) in Recurrent and Metastatic Colorectal Cancer Patients Jim Xiao, Sara Horst, George Hinkle, Xianhua Cao, Ergun Kocak, Jing Fang, Donn Young, M. Khazaeli, Doreen Agnese, Duxin Sun, and Edward Martin, Jr., Cancer Biotherapy & Radiopharmaceuticals, Volume 20, Number 1, 2005. See also, Agnese, et al., “Pilot Study Using CC49 Monoclonal Antibody (HuCC49ΔCH2) to Localize Recurrent Colorectal Carcinoma”, Annals of Surgical Oncology 11(2): 197-202 (“TAG-72 is an antigen expressed in several epithelial-derived cancers, including most colonic adenocarcinomas, invasive ductal carcinomas of the breast, non-small cell lung carcinomas, common epithelial ovarian carcinomas, and most pancreatic, gastric and esophageal cancers evaluated.”); Thor, et al., “Distribution of Oncofetal Antigen Tumor-associated Glycoprotein-72 Defined by Monoclonal Antibody B72.3” Cancer Research 46, 3118-3124, June 1986, (TAG-72 was shown to be expressed in several epithelial-derived cancers including 94% of colonic adenocarcinomas, 84% of invasive ductal carcinomas of the breast, 96% of non-small cell lung carcinomas, 100% of common epithelial ovarian carcinomas, as well as the majority of pancreatic, gastric and esophageal cancers evaluated. TAG-72 expression was not observed, however, in tumors of neural, hematopoietic, or sarcomatous derivation, suggesting that the TAG-72 antigen is “pancarcinoma” in nature. Appreciable monoclonal antibody B72.3 reactivity was generally not observed in adult normal tissues, with limited reactivity noted in a few benign lesions of the breast and colon. TAG-72 antigen expression was detected, however, in fetal colon, stomach, and esophagus, thus defining TAG-72 as an oncofetal antigen.”).
Both B72.3 and CC49 have demonstrated promising results in tumor detection utilizing the RIGS procedure to significantly improve patient survival rate. However, in many cases, patients have shown metastatic cancers or multiple lesions, which are not resectable. In such cases, even though the antibodies used with RIGS are able to detect the tumors, surgery cannot be employed to remove the tumors. The long half-life of 125I, waste disposal of 125I, and other problems associated with 125I also make this procedure difficult for the market to accept. Other labels, such as, for example, 18F with a 110-minute half life, will not work in this procedure, because of the need to wait 21 days after antibody injection in order for non-bound antibody to clear the body.
Thus, antibody CC49, its humanized and domain deleted forms, and related TAG antibodies have been described in the literature, such as, by Xiao, et al., “Pharmacokinetics and clinical evaluation of 125I-radiolabeled humanized CC49 monoclonal antibody (HuCC49ΔCH2) in recurrent and metastatic colorectal cancer patients”, Cancer Biother Radiopharm, vol. 20, number 1, 2005; Fang, et al., “Population pharmacokinetics and tumor targeting of HuCC49ΔCH2, a novel monoclonal antibody for tumor detection”, Fang, et al., J Clin Pharmacol 2007;47:227-237; U.S. Pat. Nos. 6,418,338 and 6,760,612 (which also show peptide, lectin, and other detector molecules. See also, Slavin-Chiorini, et al., “A CDR-Grafted (Humanized) Domain-Deleted Antitumor Antibody”, Cancer Biotherapy and Radiopharmaceuticals, Volume 12, Number 5, 1997, Mary Ann Liebert, Inc. (“The MAb chosen for engineering was CC49, which is directed against a pancarcinoma antigen designated TAG-72 that is expressed on the majority of colorectal, gastric, breast, ovarian, prostate, pancreatic and lung carcinomas.”).
Yet another humanized antibody of CC49 MAb is known as V59. Gonzales, et al., “Minimizing immunogenicity of the SDR-grafted humanized antibody CC49 by genetic manipulation of the framework residues”, Molecular Immunology 40 (2003) 337-349. V59 is reported to be a fully humanized version of CC49 MAb, making it a likely choice for use in accordance with the disclosure set forth herein.
In the early 1990s investigators utilized the RIGS system to locate, differentiate and stage other types of cancer, for instance, endocrine tumors involved, inter alia, with breast, children, gastrinomas, lung and nervous system. Generally, the approach was to administer a radiolabeled somatostatin congener to assess the patient with the RIGS probe. However, before subjecting the patient to such administration, an initial determination preferably was made as to whether the radiolabeled somatostatin congener would bind to the tumor site, i.e., whether somatostatin receptors are associated with the neoplastic tissue. This was conveniently done with a wide variety of endocrine tumors, which release peptides or hormones, referred to as “biochemical markers.” In order to make this determination, initially a biochemical marker-inhibiting dose of unlabeled somatastatin congener was administered to the patient. The biochemical marker associated with the neoplastic tissue then was monitored to determine whether the administered somatostatin congener reduces the presence of the marker in the patient. If the monitored presence of the marker was reduced, then the surgeon could be confident that the neoplastic tissue or tumor contains receptors to which the somatostatin would bind. Thus, the administration of radiolabeled somatostatin congener was appropriate for such patient. If the biochemical marker associated with the neoplastic tissue was not appropriately reduced following the administration of the unlabeled somatostatin congener, then the neoplastic tissue may not be determinable by the use of radiolabeled somatostatin congener and alternative modalities of treatment would be considered, such as the use of radiolabeled antibodies. See: O'Dorisio, et al., U.S. Pat. No. 5,590,656; entitled “Application of Peptide/Cell Receptor Kinetics Utilizing Radiolabeled Somatostatin Congeners in the In Situ, In Vivo Detection and Differentiation of Neoplastic Tissue”; issued Jan. 7, 1997 and incorporated herein by reference.
In broader contexts, a locator that specifically binds a marker produced by or associated with neoplastic tissue is used in accordance with the present teachings, with antibodies and somatostatin congener being representative such locators. Broader, however, a “locator” includes a substance that preferentially concentrates at the tumor sites by binding with a marker (the cancer cell or a product of the cancer cell, for example) produced by or associated with neoplastic tissue or neoplasms. Appropriate locators today primarily include antibodies (whole and monoclonal), antibody fragments, chimeric versions of whole antibodies and antibody fragments, and humanized versions thereof. It will be appreciated, however, that single chain antibodies (SCAs, such as disclosed in U.S. Pat. No. 4,946,778, incorporated herein by reference) and like substances have been developed and may similarly prove efficacious. For example, genetic engineering has been used to generate a variety of modified antibody molecules with distinctive properties. These include various antibody fragments and various antibody formats. An antibody fragment is intended to mean any portion of a complete antibody molecule. This includes both terminal deletions and protease digestion-derived molecules, as well as immunoglobulin molecules with internal deletions; such as deletions in the IgG constant region that alter Fc mediated antibody effector functions. Thus, an IgG heavy chain with a deletion of the Fc CH2 domain is an example of an antibody fragment. It is also useful to engineer antibody molecules to provide various antibody formats. In addition to single chain antibodies, useful antibody formats include divalent antibodies, tetrabodies, triabodies, diabodies, minibodies, camelid derived antibodies, shark derived antibodies, and other antibody formats. Aptimers and peptides form yet further classes of preferential locators. All of these antibody-derived molecules are example of preferential locators.
In addition to antibodies, biochemistry and genetic engineering have been used to produce protein molecules that mimic the function of antibodies. Avimers are an example of such molecules. See, generally, Jeong, et al., “Avimers hold their own”, Nature Biotechnology Vol. 23 No. 12 (December 2005). Avimers are useful because they have low immunogenicity in vivo and can be engineered to preferentially locate to a wide range of target molecules such as cell specific cell surface molecules. Although such substances may not be subsumed within the traditional definition of “antibody”, avimer molecules that selectively concentrate at the sites of neoplastic tissue are intended to be included within the definition of preferential locator. Thus, the terms “locator” was chosen, to include present-day antibodies and equivalents thereof, such as avimers, as well as other engineered proteins and substances, either already demonstrated or yet to be discovered, which mimic the specific binding properties of antibodies in the inventive method disclosed therein.
Thus, while monoclonal antibodies can be used to advantage in the present disclosure and will be used herein to illustrate the precepts disclosed herein, as noted above, a variety of additional detector molecules for markers associated with cancer cells (TAG), are suitable for use in the present context. Thus, detector molecule should be interpreted broadly for present purposes.
While the apparatus has been described with reference to various embodiments, those skilled in the art will understand that various changes may be made and equivalents may be substituted for elements thereof without departing from the scope and essence of the disclosure. Additionally, many modifications may be made to adapt a particular situation or material to the teachings of the disclosure without departing from the essential scope thereof. Therefore, it is intended that the disclosure may not be limited to the particular embodiments disclosed, but that the disclosure will include all embodiments falling within the scope of the appended claims. In this application the US measurement system is used, unless otherwise expressly indicated. Also, all citations referred to herein are expressly incorporated herein by reference.
This application claims benefit of application Ser. No. 12/730,324 filed on Mar. 24, 2010; and priority on provisional application Ser. No. 61/162,768, filed on Mar. 24, 2009, the disclosures of which are expressly incorporated herein by reference.
| Number | Date | Country | |
|---|---|---|---|
| Parent | 12730324 | Mar 2010 | US |
| Child | 13076495 | US |
