Safety and Feasibility of PARP1/2 Imaging with F-Parpi in Patients with Head and Neck Cancer

Published OnlineFirst April 3, 2020; DOI: 10.1158/1078-0432.CCR-19-3484

CLINICAL CANCER RESEARCH | RESEARCH BRIEFS: CLINICAL TRIAL BRIEF REPORT

Safety and Feasibility of PARP1/2 Imaging with 18F-PARPi in Patients with Head and Neck Cancer A C Heiko Schoder€ 1,2, Paula Demetrio De Souza Franca¸ 1,3, Reiko Nakajima1, Eva Burnazi4, Sheryl Roberts1, Christian Brand1, Milan Grkovski5, Audrey Mauguen6, Mark P. Dunphy1,2, Ronald A. Ghossein7, Serge K. Lyashchenko1,2,4, Jason S. Lewis1,2,4,8, Joseph A. O'Donoghue5, Ian Ganly9, Snehal G. Patel9, Nancy Y. Lee10, and Thomas Reiner1,2,11

ABSTRACT ◥ ﬁ n ¼ ¼ Purpose: We performed a rst-in-human clinical trial. The aim had focal uptake in all primary lesions ( 10, SUVmax 2.8 1.2) of this study was to determine safety and feasibility of PET imaging and all 18F-FDG–positive lymph nodes (n ¼ 34). 18F-PARPi uptake with 18F-PARPi in patients with head and neck cancer. was seen in 18F-FDG–negative lymph nodes of 3 patients (n ¼ 6). Focal Patients and Methods: Eleven patients with newly diagnosed uptake of tracer in primary and metastatic lesions was corroborated by or recurrent oral and oropharyngeal cancer were injected with CT alone or in combination with 18F-FDG.Theoveralleffectivedose 18F-PARPi (331 42 MBq), and dynamic PET/CT imaging was with 18F-PARPi PET was 3.9 mSv – 5.2 mSv, contrast was high ¼ performed between 0 and 25 minutes postinjection. Static PET/CT [SUVmax(lesion)/SUVmax(trapezius muscle) 4.5] and less variable scans were obtained at 30, 60, and 120 minutes postinjection. Blood than 18F-FDG when compared with the genioglossus muscle (1.3 vs. samples for tracer concentration and metaboliteanalysiswerecollect- 6.0, P ¼ 0.001). ed. Blood pressure, ECG, oxygen levels, clinical chemistry, and com- Conclusions: Imaging of head and neck cancer with 18F-PARPi is plete blood count were obtained beforeandaftertraceradministration. feasible and safe. 18F-PARPi detects primary and metastatic Results: 18F-PARPi was well-tolerated by all patients without any lesions, and retention in tumors is longer than in healthy safety concerns. Of the 11 patients included in the analysis, 18F-PARPi tissues.

Introduction Presence of pathologic regional lymph nodes is the most powerful and consistent predictor of outcome for oral cancers (1), and the ability Diagnosis and treatment of many malignant tumors have dramat- to accurately assign the exact extent of metastatic spread within the ically improved in recent decades, and oral and oropharyngeal squa- neck lymphatic system is therefore of great significance (1, 2). Com- mous cell carcinoma are no exception to this trend. However, most plete surgical removal of metastatic disease in the neck has a clear patients with oral and oropharyngeal squamous cell carcinoma still impact on prognosis, but it often remains unclear until histopathologic present with advanced disease and regional or distant metastases at the analysis is complete, if a lymph node was metastatic or not (3, 4). time of diagnosis. Clinical palpation of the neck is inadequate, as are the available radiologic investigative tools. This is because many patients present with enlarged lymph nodes due to inflammation around the tumor 1Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, site. These inflamed lymph nodes may mimic neck metastases on CT New York. 2Department of Radiology, Weill Cornell Medical College, New York, scans and are often 18F-FDG PET avid (5). On the other hand, some New York. 3Department of Otorhinolaryngology and Head and Neck Surgery, metastatic neck nodes may not be enlarged and show no abnormal 4 Federal University of Sao~ Paulo, Sao~ Paulo, Brazil. Radiochemistry and Molec- 18F-FDG uptake. For these reasons, elective neck dissection or irra- ular Imaging Probes Core, Memorial Sloan Kettering Cancer Center, New York, diation are often recommended in patients with head and neck cancer New York. 5Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York. 6Department of Epidemiology & Biostatistics, for prophylactic treatment of occult metastases. Ideally; however, these Memorial Sloan Kettering Cancer Center, New York, New York. 7Department of procedures, which can lead to increased comorbidities and reduced Pathology, Memorial Sloan Kettering Cancer Center, New York, New York. quality of life due to overtreatment (6, 7), would be avoided if the 8Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, presence of occult metastases could be definitively ruled out. New York, New York. 9Department of Surgery, Memorial Sloan Kettering Cancer 10 PARP PET imaging could potentially provide a solution for this Center, New York, New York. Department of Radiation Oncology, Memorial unmet clinical need. Because of its importance for cell survival, PARP Sloan Kettering Cancer Center, New York, New York. 11Chemical Biology Pro- gram, Memorial Sloan Kettering Cancer Center, New York, New York. is overexpressed in many malignancies, including oral and oropharyngeal squamous cell carcinoma (8, 9). Several radiolabeled PARP Note: Supplementary data for this article are available at Clinical Cancer inhibitors were tested in preclinical studies, showing correlation of Research Online (http://clincancerres.aacrjournals.org/). uptake with PARP1 expression, and suggesting that imaging is possible Corresponding Authors: Thomas Reiner, Memorial Sloan Kettering Cancer with little unspecific uptake in healthy head and neck tissue (10, 11). Center, 1275 York Avenue, New York, NY 10065. Phone: 646-888-3461; Fax: 18 646-422-0408; E-mail: [email protected]; and Heiko Schoder,€ The purpose of this study was to clinically translate F-PARPi, a [email protected] PARP inhibitor derived from the core scaffold of olaparib (12), and to provide a first step toward validating the tracer as a clinical tool. Other Clin Cancer Res 2020;XX:XX–XX PARP inhibitor–based imaging agents, based on different core scaf- doi: 10.1158/1078-0432.CCR-19-3484 folds, were translated earlier (13, 14). In this first-in-human phase I 2020 American Association for Cancer Research. clinical trial in patients with oral and oropharyngeal cancer, we

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heart, lungs, liver, and kidneys) was acquired to study the biodistribu- Translational Relevance tion and clearance of the tracer. For the subsequent 5 patients, the Preclinically, labeled PARP1-targeted olaparib derivatives have dynamic PET scan was centered on the head and neck region. In all been used to visualize several malignancies with high contrast, instances, the CT component of the dynamic PET/CT was acquired including head and neck cancer. These results suggest that PARP1- with a tube current of 40 mA. Immediately after the dynamic study, a targeted imaging agents could potentially be used as a quantitative static PET/CT scan (extending from skull vertex to upper thighs in 6 whole-body imaging test for primary and metastatic lesions, patients, and over the head and neck region in 5 patients) was obtained improving diagnostic sensitivity and specificity compared with (30 minutes postinjection; CT tube current: 80 mA). Two further static the standard of care. This first-in-human study of 18F-PARP1 in PET/CT scans were taken at approximately 60 and 120 minutes patients with head and neck cancer established that imaging with postinjection (CT tube current: 10 mA). the olaparib-based PARP1 imaging agent18F-PARPi is feasible and A total of 5 blood samples (at approximately 1, 5, 30, 90, and 150 safe, and that contrast ratios in the head and neck region are minutes postinjection) were drawn to quantify blood pool activity and comparable with 18F-FDG. Retention in tumors and metastatic to study 18F-PARPi metabolites. After imaging, vital signs were nodes is longer than in physiologic tissues, including the salivary obtained and an ECG performed, and blood samples were collected glands. The number of PET avid lymph nodes is higher for for hematology and blood chemistry analysis. A follow-up phone 18F-PARPi than for 18F-FDG, and a subset of 18F-PARPi– interview (1–3 days after the imaging study) was conducted to positive and 18F-FDG–negative lymph nodes resolved after che- document any side effects occurring after completion of the imaging moradiation. Further study of 18F-PARPi in head and neck cancer study. is being pursued. IHC Paraffin-embedded slides from surgical specimen or core biopsies of the primary tumor were obtained from consented patients and pro- determined the safety and feasibility of 18F-PARPi imaging. We also cessed at the molecular cytology core facility at MSKCC (New York, correlated 18F-PARPi uptake in tumors and normal tissue to standard NY). PARP1 IHC was performed using the Discovery XT processor of care 18F-FDG imaging. (Ventana Medical Systems). The anti-PARP1 rabbit mAb (46D11, Cell Signaling Technology) specifically bound both human PARP1 (0.4 mg/mL). Paraffin-embedded formalin fixed 3-mm sections were Patients and Methods deparaffinized with EZPrep buffer, antigen retrieval was performed Further description of the experimental procedures and methods, with CC1 buffer (both Ventana Medical Systems), and sections were including radiopharmaceutical preparation, tracer formulation and blocked for 30 minutes with Background Buster solution (Innovex). quality control can be found in the Supplementary Materials. Anti-PARP1 antibody was incubated for 5 hours, followed by 1 hour of incubation with biotinylated goat anti-rabbit IgG (PK6106, Vector Study design Laboratories) at a 1:200 dilution. For IHC detection, a DAB detection This exploratory, phase I, single-center, open-label, prospective kit (Ventana Medical Systems) was used according to the manufac- Health Insurance Portability and Accountability Act (HIPAA) com- turer's instructions, sections were counterstained with hematoxylin pliant study was approved by the Memorial Sloan Kettering (MSKCC) and cover-slipped with Permount (Thermo Fisher Scientific). Incu- Institutional Review Board and conducted in accordance with the bating with a rabbit IgG instead of the primary antibody controlled for Declaration of Helsinki (Clinicaltrials.gov NCT03631017). Written nonspecific binding of the secondary antibody. Slides were scanned informed consent was obtained from all patients. The primary objec- (Mirax, 3DHISTECH) to allow for digital histologic correlation. tives of this phase I trial were to evaluate the safety and feasibility of Hematoxylin and eosin (H&E)-stained slides were used to determine 18F-PARPi. We report the biodistribution and radiation dosimetry, areas of tumor and areas of normal muscle. Those exact same areas and describe the tumor uptake of 18F-PARPi compared with 18F-FDG. were used for PARP1 quantification using a consecutive slide. Patients were accrued between January 2019 and September 2019 and referred to the MSK Molecular Imaging and Therapy Service for their Blood clearance and metabolite analysis newly diagnosed or recurrent oral or oropharyngeal cancer. Twelve Blood clearance measurements were performed as previously patients were enrolled on this study protocol. Of these, 11 patients reported (15). Briefly, multiple venous blood samples were obtained completed the study (8 patients with oropharyngeal squamous cell between 1 and 150 minutes after intravenous injection of 18F-PARPi. carcinoma and 3 patients with oral cavity squamous cell carcinoma). Activity in whole blood and plasma was measured in duplicate using a One patient withdrew consent before administration of 18F-PARPi. No calibrated NaI (Tl) Wallac Wizard 2480 automatic g-counter (Perkin patients were excluded from the analysis. Inclusion and exclusion Elmer, Inc.). The measured activity concentrations were converted to criteria are summarized in Supplementary Table S1. percentage injected activity per kilogram (%ID/kg). Metabolite analysis of activity in plasma was performed by reverse-phase HPLC with Procedures in-line radiation (Posi-RAM model 4, LabLogic) detection using a All patients underwent clinical examination, baseline vital signs, Kinetex Biphenyl column (Phenomenex, 150 4.6 mm; 5 mm particle pulse oximetry, ECG, and blood tests (<2 weeks prior to imaging). No size) and a mobile phase gradient of 10%–75% acetonitrile (0.1% TFA) fasting was required prior to 18F-PARPi imaging. On the day of in water (0.1% TFA) over 20 minutes. Intact 18F-PARPi elutes at 16 imaging, two intravenous catheters were placed in each forearm, one minutes and a number of metabolites elute from 7–8 minutes. for injection of 18F-PARPi and one for drawing of IV blood samples. 18F-PARPi was administered to patients at an average activity of 333 Dosimetry 44 MBq (9.0 1.2 mCi) by intravenous bolus injection. For the first 6 Absorbed radiation doses to normal tissues were estimated for the patients, a dynamic PET scan (with the field of view including the first 6 patients of the study, based on dynamic and static PET/CT

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Figure 1. Schematic overview and ﬂow chart of the 18F-PARPi phase I clinical trial.

images. Activity concentration–time curves were generated by analysis (Hermes Medical Solutions) representing standard human. Organ of VOIs generated for liver, kidney, spleen, cardiac blood pool, bone, masses were rescaled if body mass differed by more than 15% from lung, gallbladder and urinary bladder. Red marrow activity concen- the standard value (73.7 kg for males; 56.9 kg for females). Organ tration was assumed equal to that of blood. Whole-body time–activity– residence times were derived by dividing organ AUC values by time curves, generated using the 4 points deﬁned by the administered administered activity. For urinary bladder contents, residence times activity (time zero) and the total activities in the three whole-body PET were estimated by the OLINDA/EXM 2.0 voiding bladder model based scans, were used to calculate monoexponential clearance half-times. on the fraction of activity clearing via urinary bladder, the mono- The area under activity concentration–time curves (AUC) were esti- exponential whole-body biological half-time, and an assumed voiding mated by trapezoidal integration with a terminal contribution calcu- interval of 1 hour. Residence times for the remainder of body were lated by extrapolation from the last measured value using the shorter of derived by subtracting all the individually estimated residence times apparent terminal clearance rate or physical decay. Whole-organ from the whole-body residence time. Absorbed radiation doses to the AUCs were obtained by multiplying the activity concentration AUC whole body and various organs were calculated using OLINDA/EXM by organ mass. Baseline values of organ mass were taken from the Oak 2.0 with effective doses based on the tissue weighting factors of ICRP Ridge National Laboratory (ORNL) phantoms of OLINDA/EXM 2.0 Report 103 (16).

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Figure 2. Biodistribution, histology, and dosimetry of 18F-PARPi. A, Maximum intensity projections at 30, 60, and 120 minutes post 18F-PARPi injection in a 67-year-old men with oropharyngeal squamous cell carcinoma. Green arrow, primary tumor; red arrow, metastatic lymph node. B, Dosimetry of select organs, whole body, and effective dose in patients (n ¼ 6) injected with 18F-PARP (see Supplementary Table S4 for the comprehensive dataset). C, PARP1 IHC and corresponding H&E images of the primary lesion of a 49-year-old man with carcinoma in the right palatine tonsil and corresponding H&E images. D, PARP1 IHC and corresponding H&E images of the primary lesion of a 51-year-old man with oral tongue carcinoma.

PET/CT imaging and analysis Statistical analysis All PET/CT images were obtained on a Discovery 710 PET/CT Uptake values are presented as mean SE, unless otherwise scanner (GE Healthcare), using low dose CT settings (10–80 mA, specified. Distribution of uptake with 18F-PARPi and 18F-FDG (on 120 kV) for CT images that were used for attenuation correction and lesions where both were available) were compared using a Wilcoxon anatomic correlation. All studies were reviewed using the Hybrid Signed Rank test for paired data, while their variances were compared Viewer display and analysis application (Hermes Medical Solutions). using a Levene test. R version 3.6.0 was used for analysis. 18F-PARPi PET/CT and 18F-FDG PET/CT studies were interpreted by two nuclear medicine physicians with at least 10 years of PET/CT experience. Three-dimensional threshold-based volumetric regions of Results interest (VOI) were placed in reference regions [bilateral submandib- Patient population ular gland, parotid gland, blood pool of neck, contralateral posterior A total of 11 patients with cytologically or histologically confirmed neck muscles (trapezius and semispinalis), genioglossus muscle, bone squamous cell carcinoma of the oral cavity or oropharynx completed marrow, mediastinal blood pool, myocardium, normal liver, renal the study protocol. Supplementary Table S2 lists the patient demo- cortex, and spleen] and over all sites of abnormal uptake in lymph graphics and key diagnostic parameters, including stage and lymph nodes, or soft-tissue lesions with reference to the PET/CT images. node status, and Fig. 1 shows a schematic overview of the study Abnormal 18F-PARPi and 18F-FDG uptake was defined as outside workflow. There were 10 males and one female, with a mean age of physiologic sites (such as palatine tonsils or skeletal muscle) and of 64 years. At the time of imaging, 8 patients had newly diagnosed intensity greater than regional background. Uptake of 18F-PARPi in disease (all with the primary lesion in the oropharynx). The 3 patients the soft-tissue lesions and lymph nodes was assessed by measuring the that had recurrent disease at the time of imaging had previously been maximum standardized uptake values (SUVmax). diagnosed with oral cavity squamous cell carcinoma. One patient had

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and/or ill-deﬁned irregular margins in a lymph node. Twenty-seven percent of patients (n ¼ 3) were HPV-negative (all oral cavity squamous cell carcinoma) and 73% were HPV-positive (all oropharyngeal cases).

Radiotracer characteristics The radiochemical synthesis of 18F-PARPi was performed using a synthetic route similar to what we have reported before (Supplemen- tary Fig. S1; ref. 12). We ﬁrst synthesized para-[18F]ﬂuoro-benzoic acid as a radiolabeled synthon before conjugation with the 1(2H)phthalazinone targeting group. On average, patients were therefore injected with 290 pmol of 18F-PARPi, 6.7 orders of magnitude lower than the twice daily administered dose of olaparib (2 300 mg) and therefore unlikely to elicit a pharmacodynamic response.

Adverse events and metabolism All patients tolerated the injection of 18F-PARPi well, and no adverse events were recorded related to the 18F-PARPi injection. One patient died within a 2-week window after completing the study, and one patient experienced grade 1 mucositis over the tumor site, which resolved the following day. The death was considered unrelated to the administered drug. The mucositis was considered possible related to the administered drug. For all patients, clinical chemistry and hematology were determined and an electrocardiogram was performed before and after the administration of 18F-PARPi (Supplementary Table S3). While some patients presented with abnormal ﬁndings before imaging, no clinically relevant changes were observed after radiotracer injection or at follow-up.

Biodistribution and dosimetry Maximum intensity projection PET images of a representative patient injected with 18F-PARPi (images obtained at 30, 60, and 120 minutes postinjection) are shown in Fig. 2A. At 120 minutes, uptake in the primary tumor had an SUVmax of 4.1, whereas the metastatic lymph node had an SUVmax of 3.6 (radiologic lymph node level 2). Across the entire patient population, the average primary tumor SUVmax was 2.8 1.1 at 120 minutes. The primary routes of excretion were renal and hepatobiliary with most of the tracer excreted renally. Activity in the renal cortex diminished over time (SUVmax ¼ 16 8 at 30 minutes, 9 4 at 60 minutes, and 7 5 at 120 minutes) with commensurate accumulation in the urinary bladder. The max- Figure 3. imal observed activity in the urinary bladder corresponded to 20%– 18 18 F-PARPi pharmacokinetics in physiologic tissue, F-PARPi avid lymph nodes, 38% of the total administered, typically at the 30–60 minute scan times. 18 and primary tumor. A, F-PARPi tracer accumulation in a 67-year-old man with Absorbed radiation doses to normal tissues from 18F-PARPi were oropharyngeal squamous cell carcinoma is initially high in the submandibular ﬁ gland (white triangles) and subsequently decreasing. In comparison, the primary estimated on the basis of the tracer biodistribution of the rst six tumor in the base of the tongue (black arrow) and metastatic lymph node (black patients. Key dosimetry data are plotted in Fig. 2B, and the entire triangles) exhibit more sustained retention of the radiotracer. Top row, PET dataset can be found in Supplementary Table S4. The effective dose of image only; bottom row, PET/CT. B, Time–activity curves of a 67-year-old man 18F-PARPi was 0.014 0.002 mSv/MBq, calculated with ICRP103. In a 18 patient, derived from the area with highest F-PARPi uptake (SUVmax, primary typical diagnostic setting, the effective radiation dose is projected to be tumor, and metastatic lymph node) or from the whole structure (SUVmean, 3.9 mSv–5.2 mSv. parotid gland, submandibular gland, and suboccipital muscle). C, SUVmax uptake values for normal structures (left) and primary tumor/metastatic lesions (right, PARP1 was highly expressed in both oral and oropharyngeal each n ¼ 6 patients with whole-body PET scans). squamous cell carcinoma in our patient population (Fig. 2C and D; Supplementary Fig. S2), corroborating earlier work (8, 9). their primary lesion surgically removed before imaging. Nodal Metabolism involvement (anatomically abnormal lymph nodes) was present in Research blood draws were obtained for 10 patients at ﬁve time- 9 of the 11 patients, and disease stage ranged from I to IVb (8th edition, points after tracer injection, activity counted, and metabolites analyzed AJCC). Lymph nodes were considered to be abnormal when at least (Supplementary Fig. S3A). Using a two-phase decay curve, we deter- one of following criteria was met: central necrosis or inhomogeneous mined the weighted blood half-life to be 4.2 minutes (whole blood, enhancement (contrast-enhanced CT and /or MRI), shortest axial Supplementary Fig. S3B). Only small quantities of metabolites were diameter greater than 11 mm in cervical regions and change in shape detected at 1 and 5 minutes (99.2% 1.5% and 89.9% 11.4%

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Figure 4. Comparison of standard-of-care 18F-FDG and 18F-PARPi in a 52-year-old man with cancer in the base of the tongue. A, 18F-PARPi PET at the level of the epiglottis (black triangles) showed an 18F-PARPi avid primary lesion in the base of tongue (white arrows) and metastatic lymph node (right level 2, black arrow) at 120 minutes after 18F-PARPi administration. B, 18F-FDG PET at the same level showed 18F-FDG avid lesion in the base of tongue (white arrows) and metastatic lymph nodes (black

arrow). C, Postcontrast T1-weighted axial MRI image (epiglottis level) showed a large expansile multicompartmental heterogeneously, ill-deﬁned enhancing lesion centered in the base of tongue with effacement of the bilateral valleculae and extension along the median and lateral glossoepiglottic folds into the epiglottis. 18 18 D, Comparison of SUVmax values obtained for F-PARPi versus F-FDG in tumors and lymph nodes across the patient population. E, SUVmax-based uptake ratios 18 18 (lesion and trapezius muscle) for F-PARPi and F-FDG without separation of primary lesion and lymph nodes. F, SUVmax-based uptake ratios (lesion and genioglossus muscle) for 18F-PARPi and 18F-FDG without separation of primary lesion and lymph nodes.

18F-PARPi, respectively, Supplementary Fig. S3C). At 30 minutes, and values declining by just 13% for both primary and PET-avid lymph ¼ with decreasing blood pool concentration of the injected tracer, we nodes [SUVmax(tumor, 30 minutes) 3.4 0.8 and SUVmax(tumor, detected a radiometabolite with a retention time of 7–8 minutes (50.9% 120 minutes) ¼ 3.0 1.1; SUVmax(lymph node, 30 minutes) ¼ 3.3 ¼ 11.5%; Supplementary Fig. S4). 1.3 and SUVmax (lymph node, 120 minutes) 2.9 1.1].

Organ residence time 18F-FDG and 18F-PARPi in primary tumor and normal neck Investigating the specificity of 18F-PARPi, we looked at the resi- tissues dence times of the tracer in tumors, metastatic nodes, and healthy To determine whether 18F-PARPi could be a relevant imaging tracer tissues (Fig. 3). In spleen and liver, which both express large phys- for the head and neck region, we compared its retention with that of iologic amounts of PARP1 and PARP2 (17), initial uptake was high, standard-of-care 18F-FDG (Fig. 4). For both imaging agents, uptake followed by rapid clearance over the 2-hour imaging period was corroborated with tumor outlines defined by standard-of-care ¼ [SUVmax(spleen, 30 minutes) 6.1 1.3 and SUVmax(spleen, T1-weighted Gd-MRI imaging (Fig. 4C). Across the patient popula- ¼ 18 120 min) 2.2 0.6, representing a 64% drop]. Similarly, the SUVmax tion, F-FDG had higher average tumor SUVmax values than 18 18 in bone marrow was high in the 30-minute PET/CT scan, but values F-PARPi, but SUVmax values for F-FDG decreased for level 2 and declined by 53% between 30 and 120 minutes. Comparably, fast level 3 lymph nodes. A smaller decrease in SUVmax values was found clearance was found for physiologic structures within the head and for 18F-PARPi (66% and 15% for 18F-PARPi and 18F-FDG, respec- neck region. Uptake in the submandibular and parotid glands tively, when grouping primary/level 1 lymph nodes and level 2/level 3 decreased by 57% and 56%, respectively. In contrast, tracer retention lymph nodes; Fig. 4D). Uptake ratios [SUVmax(lesion)/SUVmax(tra- fi 18 18 in tumor and metastatic nodes was signi cantly longer, with SUVmax pezius muscle)] for F-FDG were higher than for F-PARPi (median

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¼ 10.4 vs. 4.5, P < 0.0001, Fig. 4E). Interestingly, when comparing upcoming phase II study will be to determine the sensitivity and fi 18 uptake ratios [SUVmax(lesion)/SUVmax(genioglossus muscle)], we speci city of F-PARPi in head and neck cancer. found similar median values for 18F-FDG and 18F-PARPi (median In conclusion, we performed the first-in-human translation of ¼ 3.0 vs. 3.3, P ¼ 0.23), although the variance was less for 18F-PARPi 18F-PARPi, a PARP-targeted 1(2H)phthalazinone, and the first imag- than for 18F-FDG (1.3 vs. 6.0, P ¼ 0.001, Fig. 4F). This could be of ing of PARP in head and neck cancer. Administration of 18F-PARPi potential relevance in patients with recurrent oral cancers or in the was safe, and aside from a grade 1 mucositis, which was possibly posttreatment setting, leading to asymmetric uptake in the oral cavity related, no adverse events were attributed to the tracer injection. or higher uptake in the genioglossus muscle secondary to partial 18F-PARPi is a promising new agent for the imaging of head and glossectomy, tongue movement, or hypoglossal palsy (18–20). neck squamous cell carcinoma. 18F-FDG and 18F-PARPi uptake matched with respect to the presence and location of the primary lesion. However, the two tracers had Disclosure of Potential Conflicts of Interest divergent uptake patterns in the lymphatic system (Supplementary J.A. O'Donoghue is an employee/paid consultant for Janssen Research & Fig. S5). For 18F-FDG, 34 lymph nodes were PET-avid. For Development, LLC. S.G. Patel is an advisory board member/unpaid consultant 18F-PARPi, we observed 40 18F-PARPi avid lymph nodes. These 40 for Summit Biomedical Imaging LLC. T. Reiner is an employee/paid consultant for and reports receiving commercial research grants from Theragnostics, other lymph nodes included all of the lymph nodes that were detected using commercial research support from Pfizer, Immunogen, and Summit Biomedical 18 F-FDG. No evidence of additional FDG-avid and PARPi-avid adeno- Imaging, and holds ownership interest (including patents) in and reports pathy or distant metastatic disease was seen. Because of protocol receiving other remuneration from Summit Biomedical Imaging. N.Y. Lee is an regulations, no biopsy material was available for the additional 6 lymph advisory board member at Merck, Merck Serono, Pfizer, and Eli Lilly and receives nodes; however, a subset of them resolved after chemoradiation (which, commercial research support from Astra-Zeneca and Pfizer. No potential conflicts however, does not prove malignancy, Supplementary Fig. S5A and S5B). of interest were disclosed by the other authors. Authors’ Contributions Discussion Conception and design: H.M. Schoder,€ S.K. Lyashchenko, N.Y. Lee, T. Reiner Development of methodology: E.M. Burnazi, C. Brand, S.K. Lyashchenko, J.S. Lewis, Recently, PARP-targeted agents have received considerable atten- J.A. O'Donoghue, S.G. Patel, T. Reiner tion as imaging agents (10, 21) based on the ubiquitous expression of Acquisition of data (provided animals, acquired and managed patients, provided PARP in many types of cancers, with the promise to serve as an facilities, etc.): H.M. Schoder,€ P.D.D.S. Franca,¸ E.M. Burnazi, S. Roberts, C. Brand, accurate sensor of malignancy where standard-of-care methods cur- M. Grkovski, J.A. O'Donoghue, I. Ganly, S.G. Patel, N.Y. Lee rently fail. Analysis and interpretation of data (e.g., statistical analysis, biostatistics, computational analysis): H.M. Schoder,€ P.D.D.S. Franca,¸ R. Nakajima, Radiation doses associated with 18F-PARPi PET imaging were – E.M. Burnazi, M. Grkovski, A. Mauguen, R. Ghossein, J.A. O'Donoghue, T. Reiner relatively low. The overall equivalent dose was 3.9 mSv 5.2 mSv, lower Writing, review, and/or revision of the manuscript: H.M. Schoder,€ P.D.D.S. Franca,¸ 18 than that reported for F-FDG (8.1 1.2 mSv; ref. 22). This was, in R. Nakajima, E.M. Burnazi, M. Grkovski, A. Mauguen, M.P.S. Dunphy, R. Ghossein, part, due to the selective uptake of the tracer, paired with a short blood S.K. Lyashchenko, J.S. Lewis, J.A. O'Donoghue, I. Ganly, S.G. Patel, N.Y. Lee, T. Reiner half-life and fast clearance. 18F-PARPi rapidly cleared from the Administrative, technical, or material support (i.e., reporting or organizing data, € ¸ circulatory system and accumulated in the urinary bladder and constructing databases): H.M. Schoder, P.D.D.S. Franca, J.S. Lewis, S.G. Patel, T. Reiner gallbladder following respective transit through the kidneys and liver. Study supervision: H.M. Schoder,€ N.Y. Lee, T. Reiner PARP1 is located in the nuclei of cells. Consequently, the cell 18 membrane and nuclear membrane permeability of F-PARPi has to Acknowledgments be high, allowing both fast uptake of radiotracer and clearance of This work was supported in part by NIH grants R01 CA204441, R35 CA232130, unbound material for image contrast generation. This was seen in the and P30 CA008748, the Tow Foundation, the MSK Center for Molecular Imaging & – submandibular glands, where the SUVmax at 20 30 minutes was higher Nanotechnology, the MSK Imaging and Radiation Sciences Program, and the MSK than in the primary tumor for 80% (n ¼ 10 evaluable patients) of all Molecularly Targeted Intraoperative Imaging Fund. We acknowledge and thank patients (Fig. 3). Subsequently, the delivered activity in these healthy Stephen Carlin and Kevin Staton for help with clinical radiochemistry; Aisha Shickler and Yorann Roux for blood and metabolite analysis; Ryan Min for patient coordi- tissues cleared quickly, whereas the activity persisted longer in tumor nation; Christopher Riedl, MD, PhD, for help with the clinical workflow; and Susanne and metastatic nodes (Fig. 3B). At 120 minutes postinjection the Kossatz, PhD and Wolfgang A. Weber, MD for helpful discussions and help with situation had inverted, and none of the submandibular glands showed preparing the clinical trial. activity higher than the primary tumor. Similar rapid clearance of radiotracer was noted in other healthy organs, including the spleen, The costs of publication of this article were defrayed in part by the genioglossus muscles, parotid glands, and bone marrow. For future payment of page charges. This article must therefore be hereby marked studies, imaging with PARP inhibitors after longer time intervals advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate postinjection might yield further improved contrast ratios. this fact. Because this is a phase I study, we were unable to collect unstained histologic slides (for primary and metastatic lesions) from a statisti- Received October 23, 2019; revised January 15, 2020; accepted March 30, 2020; cally meaningful number of patients. Consequently, the focus of an published first April 3, 2020.

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OF8 Clin Cancer Res; 2020 CLINICAL CANCER RESEARCH

Safety and Feasibility of PARP1/2 Imaging with 18F-PARPi in Patients with Head and Neck Cancer

Heiko Schöder, Paula Demétrio De Souza França, Reiko Nakajima, et al.

Clin Cancer Res Published OnlineFirst April 3, 2020.

Updated version Access the most recent version of this article at: doi:10.1158/1078-0432.CCR-19-3484

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