Evolution of a “System” for Surgical Treatment of Adenocarcinomas Charles L. Hitchcock, M.D., Ph.D. Emeritus Faculty, Department of Pathology The Ohio State University College of Medicine Columbus, OH, USA

Clinicians Engineers Basic Scientists Cancer Surgeons Imaging ME/AE Nuc Med Pathology Surgical Oncology Engineers ME/AE EE/CE BME The James Cancer Hospital Wexner Medical Center Basic Scientists Chemistry Radiology Pathology Biostats

Monoclonal Antibody Fragments The System - Today Patient Clinical Management Surgery Pathology Medical Oncology Radiation Oncology Nuclear Medicine Molecular Probes Small Molecules Peptides Monoclonal Antibody Fragments Molecular Imaging & Detection Devices Scanners Gamma Camera Gamma Probes LFOVGC The system today Case of gastrinoma Images Results To understand where we want top go you have to understand our hhistory

The System – Proof of Concept Molecular Imaging Detection Devices Real Time Intraoperative Imaging Patient 17-year-old female Serum gastrin 2,620 pg/mL Spleen Kidney Tumors LFOVGC The system today Case of gastrinoma Images Results To understand where we want top go you have to understand our hhistory Molecular Probe In111–pentetreotide NC Hall et al. JACS 2015; 221:300-308

Monoclonal Antibody Fragments The System - Yesterday Patient Clinical Management Surgery Pathology Medical Oncology Rad Onc Nuclear Medicine Molecular Probes Small Molecules Peptides Monoclonal Antibody Fragments Molecular Imaging & Detection Devices Scanners Gamma Camera Gamma Probes LFOVGC Patients Colorectal Carcinomas Molecular Probe 125I-Murine CC49 anti-TAG-72 Imaging – CT Only Detection Devices Hand-held gamma detector probe Clinical Management Chemo

Why TAG-72? Sialyl-Tn linked mucin Associated with carcinomas Signet Ring Carcinoma Sialyl-Tn linked mucin Associated with carcinomas Breast >60% (~120,000/yr) Lung ~ 80% (72,000/yr) Prostate ~80% (168,000/yr) Colorectal ~85% (115,000/yr) Endometrium >90% (~27,000/yr) Pancreas ~90% (~42,000/yr) Sialyl-Tn Mucin

The System - Yesterday Patients Molecular Probe Imaging – CT Only Colorectal Carcinomas Molecular Probe Target TAG-72 125I-Murine CC49 Imaging – CT Only Detection Devices Hand held gamma detector Clinical Management Chemo

The System - Yesterday Patients Molecular Probe Imaging – CT Only AJCC Stage Patients Molecular Probe 125I-anti TAG-72 (Murine CC49) Imaging – CT Only Detection Devices Hand held gamma detector Clinical Management Chemo TAG (+) TAG (-) TAG-72 Status @ Closing

Monoclonal Antibody Fragments The System - Tomorrow Clinical Management Surgery Pathology Medical Oncology Radiation Oncology Nuclear Medicine Molecular Imaging & Detection Devices Scanners Gamma Camera Gamma Probes Patient The system today Case of gastrinoma Images Results To understand where we want top go you have to understand our hhistory LFOVGC Molecular Probes Monoclonal Antibody Fragments

The System – Tomorrow: Molecular Probes B72.3, CC49, CC83 ENL210 Anti-TAG 72 Monoclonal Antibody Whole Antibody 150kD ScFv, Diabody, Triabody, Tetrabody ~25kD Humanized No Yes Biologic Half-life 2-3 days 2-3 hours Tumor Localization 80% >90% Isotope 125I (T½ 60 days) 123I (T½ 13 hours) Decay Storage 2 Years 5 days Tumor : Background Ratio @ 24 hours 1 : 1 1 : 29 Preoperative Imaging Intraoperative Imaging Intraoperative Hand-Held Gamma Probe

The System – Evolution of Anti-TAG-72 MoAbs ENL210 is a 26 kD polypeptide, fully humanized antibody fragment Binds very tightly with a 3.6 nM apparent KD, ensuring low doses Highly stable molecule, apparent melting temperature of 66 ºC Stable to aggregation and degradation for >3 mo. at 4 ºC The linker is optimized to produce a stable, reproducible mixture of diabody, triabody and tetrabody About 95% of material clears from blood in 24 h, providing plenty of time for tumor binding and clear images in about 1 day ENL210

The System – Tomorrow: Imaging and Detection Pre-operative CT Imaging Pre-operative SPECT/CT Imaging Day of Surgery Radiology Suite 123I-ENL210 Real Time Intraoperative Imaging and Detection Operating Room

The System – Tomorrow: Imaging and Detection

The System: Tomorrow Did you get it all? Is the therapy working? Colorectal Carcinomas Colonoscopy CT scan (Primarily image anatomical differences in tissues; 50 % accurate FDG/PET/CT is non-specific and 50-60% accurate Problem For best results for the patient: Outcome Therapeutic decision making Ultimately survival Why change from current management? Solution If images show too much tumor… systemic therapy. Started and followed with more images to assess effectiveness of therapy. Preoperative Imaging Molecular Imaging 123I or 124I-ENL210 Appointment with medical oncologist: Systemic therapy Appointment with surgeon and review scans 2,3 weeks between appointment and surgery. Did you get it all? Is the therapy working? How am I doing? If image shows tumor Progression … consider phase 1 131I-ENL210 clinical trial Intraoperative imaging and probing with 123I-ENL210 Inject 123I-ENL210 18-36 hrs before surgery. Follow therapeutic effectiveness With Molecular Imaging with 123Ior 124I-ENL210

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