Detection of chemotherapy-induced cardiotoxicity with antimyosin pretargeted imaging
Detection of chemotherapy-induced cardiotoxicity with antimyosin pretargeted imaging
H. William Strauss 0 2
Giuliano Mariani 0
0 Reprint requests: H. William Strauss, MD, Molecular Imaging and Therapy Section, Memorial Sloan Kettering Cancer Center , New York, NY , USA
1 Regional Center of Nuclear Medicine, University of Pisa , Pisa , Italy
2 Molecular Imaging and Therapy Section, Memorial Sloan Kettering Cancer Center , New York, NY , USA
Antimyosin antibody was created in response to a
challenge Edgar Haber, MD, Chief of Cardiology at the
Massachusetts General Hospital, gave his post-doctoral
student, Ban An Khaw, PhD to develop a technique to
specifically identify acute myocardial necrosis. Since
Dr. Khaw had completed his training in immunology,
his thoughts led him to consider creating an antibody
that would recognize one of the least soluble proteins in
the body, the heavy chain of cardiac myosin. Drs. Khaw
and Haber reasoned that areas of severely damaged
myocardium lose cell membrane integrity, allowing
macromolecules such as enzymes and troponin to leak
out, and allow macromolecules, such as antibodies
recognizing insoluble cardiac myosin, to leak in and bind to
the residual myosin protein at the site of damage. After
numerous challenges were overcome, Khaw, Haber, and
their colleagues Beller and Smith published a seminal
article in The Journal of Clinical Investigation titled:
‘Localization of cardiac myosin-specific antibody in
myocardial infarction’1 describing localization of intact
radiolabeled polyclonal antimyosin antibody and
localization of a radiolabeled (Fab0)2 antimyosin antibody
fragment in experimental canine infarction. Although
the concept worked, the intact antibody (molecular
weight * 150 kDa) had a long residence time in the
circulation, requiring a delay between antibody injection
and imaging. To increase the rate of blood clearance, the
antimyosin antibody was partially digested to produce
the (Fab0)2 fragment (molecular weight * 110 kDa).
Even the lower molecular weight (Fab0)2 required
waiting up to 48 hours for sufficient blood clearance to
record diagnostic images in experimental animals. To
further decrease the interval between injection and
imaging, Dr. Khaw purified the Fab (molecular
weight * 50 kDa).2 Although the Fab had the
advantage of faster blood clearance, it had the disadvantage of
decreased affinity for the heavy chain of cardiac myosin,
since the Fab has only a single antigen recognition arm,
while the larger (Fab0)2 had two. In spite of this
limitation, the Fab worked well in experimental studies, and
was selected for testing in human subjects. In parallel
with the evolution from intact antibody to Fab fragment,
Dr. Khaw changed radiolabels from 131I for the intact
antibody to 111In-DTPA for the (Fab0)2, and
subsequently to 99mTc-DTPA coupled to human antimyosin
Fab for studies in patients with acute infarction.3 Further
fragmentation of antimyosin, to single chain sFv
(molecular weight * 28 kDa, radiolabeled with 99mTc)
was tested in mice and in a canine model of infarction.4
The single chain fragment had similar immunoreactivity
to the Fab. The half-time of sFv blood clearance was
reduced from 2.8 hours for the Fab to 0.54 hours for the
sFv, while achieving similar uptake in the experimental
infarct. Infarcts were clearly visible 1 hour after sFv
injection, while 3 hours was required for imaging with
In addition to detecting acute myocardial infarction,
antimyosin has been used to detect myocyte necrosis
due to myocarditis5-8 drug-induced cardiotoxicity9,10
and heart transplant rejection.11-14
In spite of the published sensitivity of antimyosin
imaging for the detection of myocyte necrosis, there
remain a number of challenges to the use of this agent,
including localization of antibody fragments in the liver,
interfering with detection of small regions of myocardial
uptake, and high uptake in the kidneys, a factor limiting
the administered dose. In this issue of the Journal
Panwar and colleagues apply both a ‘pretargeting’ approach
to antimyosin imaging15 to reduce the time required for
clearance of the radiotracer from the blood and a charge
modification approach to reduce non-specific tracer
uptake in normal tissue.
Altai et al defined pretargeting16 as follows:
The core premise of pretargeting lies in
administering the targeting vector and radioisotope
separately and having the 2 components combine
within the body. In this manner, pretargeting
strategies decrease the circulation time of the
radioactivity, reduce the uptake of the radionuclide
in healthy non-target tissues, and facilitate the use
of short-lived radionuclides that would otherwise
be incompatible with antibody-based vectors.
Pretargeting was described by Claude Meares,
David Goodwin and colleagues
17 in 1985
. The technique
has been primarily used in oncology, but about a decade
ago bispecific pretargeted antibody imaging was applied
to detect vascular disease.18,19 Panwar et al applied the
pretargeting concept using an Fab0 recognizing DTPA
and an Fab recognizing myosin as the bispecific
antibody for pretargeting. Eighteen hours after bispecific
antibody administration 99mTc-DTPA1 was
administered. Images were recorded at 15 minutes, 3 and
24 hours after tracer administration. The investigators
clearly demonstrate marked myocardial antimyosin
uptake in animals treated with doxorubicin. The
investigators also describe a less cardiotoxic form of
doxorubicin, DTPA, and doxorubicin-conjugated
polyglutamic acid (D-Dox-PGA). There was a marked
decrease in myocardial uptake of the bispecific
antimyosin-anti-DTPA in the mice treated with the modified
doxorubicin, D-Dox-PGA, compared to the animals
treated with unmodified doxorubicin (Figures 7A and B
in the Panwar manuscript).
We congratulate the investigators on their
impressive results confirming the quality of pretargeted
antimyosin antibody images. The demonstration of
decreased cardiotoxicity with a modified doxorubicin,
however may be of equal or even greater importance to
patients with cancer. Additional studies appear
warranted to document maintained tumoricidal activity of
1 Tc-99m-DTPA was conjugated to succinylated polylysine.
The polylysine altered the charge of the molecule to reduce
the modified doxorubicin in tumor bearing animals, as
well as decreased cardiotoxicity in patients.
Although other imaging techniques, such as
MIBG20,21 and 99mTc-annexin V,22 have been advocated
to detect chemotherapy cardiotoxicity, clinical
experience with these techniques is limited.
The major clinical approach to detect cardiotoxicity
that has stood the test of time continues to be serial
measurements of left ventricular ejection fraction.23 The
criteria for a significant reduction in LVEF described by
Alexander et al24 in his seminal publication remain
The authors declare that there is no conflict of interest to
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