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Background: With the next generation of Human Epidermal Growth Factor Receptor 2 (HER2) -targeting therapies, such as antibody-drug conjugates, showing benefit in "HER2 low" and even "HER2 ultralow" patients, the need for novel methods to quantify HER2 expression accurately becomes even more important for clinical decision making. A HER2 PET/CT imaging assessment could evaluate HER2 positive disease locations while improving patient care, reducing the need for invasive biopsies. A single-domain antibody (sdAb)-based PET tracer could combine the high specificity of sdAbs with short-lived radionuclides such as fluorine-18 ( 18 F) and gallium-68 ( 68 Ga). SdAb-based PET tracers have clinically been used via a 68 Ga-chelator approach. However, the distribution of 68 Ga-labelled pharmaceuticals to peripheral PET centres is more challenging to organize due to the short half-life of 68 Ga, most certainly when the available activity is limited by a generator. Cyclotron produced 68 Ga has removed this limitation. Distribution of 18 F-labelled pharmaceuticals remains less challenging due to its slightly longer half-life, and radiofluorination of sdAbs via N-succinimidyl-4-[ 18 F]fluorobenzoate ([ 18 F]SFB) has shown to be a promising strategy for developing sdAb-based PET tracers. Although [ 18 F]SFB automation has been reported, automating protein conjugation proves challenging. Herein we report the fully automated, cartridge-based production of [ 18 F]FB-HER2 sdAb on a single synthesis module., Results: [ 18 F]FB-HER2 sdAb (> 6 GBq) was obtained after a fully automated production (95 min), with a RCP > 95%, apparent molar activity > 20 GBq/µmol and decay-corrected radiochemical yield (RCY d.c.) of 14 ± 2% (n = 4). Further upscaling amounted to production batches of 16 GBq with an apparent molar activity > 40 GBq/µmol and RCY d.c. of 8 ± 1% (n = 4). Ex vivo biodistribution and PET imaging showed specific HER2-positive tumour targeting and low kidney retention., Conclusion: The [ 18 F]FB-HER2 sdAb tracer was produced with clinically relevant activities using a fully automated production method. The automated production method was designed to ease the translation to the clinic and has the potential to be used not only in mono-centre but also multi-centre clinical trials with one central production site. [ 18 F]FB-HER2 sdAb showed a favourable biodistribution pattern and could be a valuable alternative to 68 Ga-labelled sdAb-based PET tracers in the clinic., Competing Interests: Ethics approval and consent to participate The ethical committee approved the animal study protocols for animal experiments at the Vrije Universiteit Brussel (22–272-3). All mice experiments were executed in accordance with the European guidelines for animal experimentation. Written informed consent was not required for this study. Consent for publications Not applicable. Competing interests J.B. and T.L. have patents on using sdAbs for imaging and therapy. T.L. has ownership in AbScint and holds ownership in Precirix. L.N. is an employee of Precirix. J.B is an unpaid board member of eSRR., (© 2024. The Author(s).)

Single-domain antibodies (sdAbs) demonstrate favorable pharmacokinetic profiles for molecular imaging applications. However, their renal excretion and retention are obstacles for applications in targeted radionuclide therapy (TRT). Methods: Using a click-chemistry-based pretargeting approach, we aimed to reduce kidney retention of a fibroblast activation protein α (FAP)-targeted sdAb, 4AH29, for 177 Lu-TRT. Key pretargeting parameters (sdAb-injected mass and lag time) were optimized in healthy mice and U87MG (FAP + ) xenografts. A TRT study in a pancreatic ductal adenocarcinoma (PDAC) patient-derived xenograft (PDX) model was performed as a pilot study for sdAb-based pretargeting applications. Results: Modification of 4AH29 with trans -cyclooctene (TCO) moieties did not modify the sdAb pharmacokinetic profile. A 200-µg injected mass of 4AH29-TCO and an 8-h lag time for the injection of [ 177 Lu]Lu-DOTA-PEG 7 -tetrazine resulted in the highest kidney therapeutic index (2.0 ± 0.4), which was 5-fold higher than that of [ 177 Lu]Lu-DOTA-4AH29 (0.4 ± 0.1). FAP expression in the tumor microenvironment was validated in a PDAC PDX model with both immunohistochemistry and PET/CT imaging. Mice treated with the pretargeting high-activity approach (4AH29-TCO + [ 177 Lu]Lu-DOTA-PEG 7 -tetrazine; 3 × 88 MBq, 1 injection per week for 3 wk) demonstrated prolonged survival compared with the vehicle control and conventionally treated ([ 177 Lu]Lu-DOTA-4AH29; 3 × 37 MBq, 1 injection per week for 3 wk) mice. Mesangial expansion was reported in 7 of 10 mice in the conventional cohort, suggesting treatment-related kidney morphologic changes, but was not observed in the pretargeting cohort. Conclusion: This study validates pretargeting to mitigate sdAbs' kidney retention with no observation of morphologic changes on therapy regimen at early time points. Clinical translation of click-chemistry-based pre-TRT is warranted on the basis of its ability to alleviate toxicities related to biovectors' intrinsic pharmacokinetic profiles. The absence of representative animal models with extensive stroma and high FAP expression on cancer-associated fibroblasts led to a low mean tumor-absorbed dose even with high injected activity and consequently to modest survival benefit in this PDAC PDX., (© 2024 by the Society of Nuclear Medicine and Molecular Imaging.)

Purpose: Targeted radionuclide therapy (TRT) is a cancer treatment with relative therapeutic efficacy across various cancer types. We studied the therapeutic potential of TRT using fibroblast activation protein-α (FAP) targeting sdAbs (4AH29) labelled with 225 Ac or 131 I in immunocompetent mice in a human FAP (hFAP) expressing lung cancer mouse model. We further explored the combination of TRT with programmed cell death ligand 1 (PD-L1) immune checkpoint blockade (ICB)., Methods: We studied the biodistribution and tumour uptake of [ 131 I]I-GMIB-4AH29 and [ 225 Ac]Ac-DOTA-4AH29 by ex vivo γ-counting. Therapeutic efficacy of [ 131 I]I-GMIB-4AH29 and [ 225 Ac]Ac-DOTA-4AH29 was evaluated in an immunocompetent mouse model. Flow cytometry analysis of tumours from [ 225 Ac]Ac-DOTA-4AH29 treated mice was performed. Treatment with [ 225 Ac]Ac-DOTA-4AH29 was repeated in combination with PD-L1 ICB., Results: The biodistribution showed high tumour uptake of [ 131 I]I-GMIB-4AH29 with 3.5 ± 0.5% IA/g 1 h post-injection (p.i.) decreasing to 0.9 ± 0.1% IA/g after 24 h. Tumour uptake of [ 225 Ac]Ac-DOTA-4AH29 was also relevant with 2.1 ± 0.5% IA/g 1 h p.i. with a less steep decrease to 1.7 ± 0.2% IA/g after 24 h. Survival was significantly improved after treatment with low and high doses [ 131 I]I-GMIB-4AH29 or [ 225 Ac]Ac-DOTA-4AH29 compared to vehicle solution. Moreover, we observed significantly higher PD-L1 expression in tumours of mice treated with [ 225 Ac]Ac-DOTA-4AH29 compared to vehicle solution. Therefore, we combined high dose [ 225 Ac]Ac-DOTA-4AH29 with PD-L1 ICB showing therapeutic synergy., Conclusion: [ 225 Ac]Ac-DOTA-4AH29 and [ 131 I]I-GMIB-4AH29 exhibit high and persistent tumour targeting, translating into prolonged survival in mice bearing aggressive tumours. Moreover, we demonstrate that the combination of PD-L1 ICB with [ 225 Ac]Ac-DOTA-4AH29 TRT enhances its therapeutic efficacy., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Radiofluorination of single domain antibodies (sdAbs) via N-succinimidyl-4-[ 18 F]fluorobenzoate ([ 18 F]SFB) has shown to be a promising strategy in the development of sdAb-based PET tracers. While automation of the prosthetic group (PG) [ 18 F]SFB production, has been successfully reported, no practical method for large scale sdAb labelling has been reported. Therefore, we optimized and automated the PG production, enabling a subsequently efficient manual conjugation reaction to an anti-fibroblast activation protein (FAP)-α sdAb (4AH29) and an anti-folate receptor (FR)-α sdAb (2BD42). Both the alpha isoform of FAP and the FR are established tumour markers. FAP-α is known to be overexpressed mainly by cancer-associated fibroblasts in breast, ovarian, and other cancers, while its expression in normal tissues is low or undetectable. FR-α has an elevated expression in epithelial cancers, such as ovarian, brain and lung cancers. Non-invasive imaging techniques, such as PET-imaging, using tracers targeting specific tumour markers can provide molecular information over both the tumour and its environment, which aides in the diagnosis, therapy selection and assessment of the cancer treatment., Results: [ 18 F]SFB was synthesized using a fully automated three-step, one-pot reaction. The total procedure time was 54 min and results in [ 18 F]SFB with a RCP > 90% and a RCY d.c. of 44 ± 4% (n = 13). The manual conjugation reaction after purification produced [ 18 F]FB-sdAbs with a RCP > 95%, an end of synthesis activity > 600 MBq and an apparent molar activity > 10 GBq/µmol. Overall RCY d.c., corrected to the trapping of [ 18 F]F - on the QMA, were 9% (n = 1) and 5 ± 2% (n = 3) for [ 18 F]FB-2BD42 and [ 18 F]FB-4AH29, respectively., Conclusion: [ 18 F]SFB synthesis was successfully automated and upscaled on a Trasis AllInOne module. The anti-hFAP-α and anti-hFR-α sdAbs were radiofluorinated, yielding similar RCYs d.c. and RCPs, showing the potential of this method as a generic radiofluorination strategy for sdAbs. The radiofluorinated sdAbs showed a favourable biodistribution pattern and are attractive for further characterization as new PET tracers for FAP-α and FR-α imaging., (© 2024. The Author(s).)

Human epidermal growth factor receptor 2 (HER2) status is used for decision-making in breast carcinoma treatment. The status is obtained through immunohistochemistry or in situ hybridization. These two methods have the disadvantage of necessitating tissue sampling, which is prone to error due to tumor heterogeneity or interobserver variability. Whole-body imaging might be a solution to map HER2 expression throughout the body. Methods: Twenty patients with locally advanced or metastatic breast carcinoma (5 HER2-positive and 15 HER2-negative patients) were included in this phase II trial to assess the repeatability of uptake quantification and the extended safety of the [ 68 Ga]Ga-NOTA-anti-HER2 single-domain antibody (sdAb). The tracer was injected, followed by a PET/CT scan at 90 min. Within 8 d, the procedure was repeated. Blood samples were taken for antidrug antibody (ADA) assessment and liquid biopsies. On available tissues, immunohistochemistry, in situ hybridization, and mass spectrometry were performed to determine the correlation of HER2 status with uptake values measured on PET. If relevant preexisting [ 18 F]FDG PET/CT images were available (performed as standard of care), a comparison was made. Results: With a repeatability coefficient of 21.8%, this imaging technique was repeatable. No clear correlation between PET/CT uptake values and pathology could be established, as even patients with low levels of HER2 expression showed moderate to high uptake. Comparison with [ 18 F]FDG PET/CT in 16 patients demonstrated that in 7 patients, [ 68 Ga]Ga-NOTA-anti-HER2 shows interlesional heterogeneity within the same patient, and [ 18 F]FDG uptake did not show the same heterogeneous uptake in all patients. In some patients, the extent of disease was clearer with the [ 68 Ga]Ga-NOTA-anti-HER2-sdAb. Sixteen adverse events were reported but all without a clear relationship to the tracer. Three patients with preexisting ADAs did not show adverse reactions. No new ADAs developed. Conclusion: [ 68 Ga]Ga-NOTA-anti-HER2-sdAb PET/CT imaging shows similar repeatability to [ 18 F]FDG. It is safe for clinical use. There is tracer uptake in cancer lesions, even in patients previously determined to be HER2-low or -negative. The tracer shows potential in the assessment of interlesional heterogeneity of HER2 expression. In a subset of patients, [ 68 Ga]Ga-NOTA-anti-HER2-sdAb uptake was seen in lesions with no or low [ 18 F]FDG uptake. These findings support further clinical development of [ 68 Ga]Ga-NOTA-anti-HER2-sdAb as a PET/CT tracer in breast cancer patients., (© 2024 by the Society of Nuclear Medicine and Molecular Imaging.)