Type I collagen–targeted PET probe for pulmonary fibrosis detection and staging in preclinical models by Pauline Désogère, Luis F. Tapias, Lida P. Hariri,

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Type I collagen–targeted PET probe for pulmonary fibrosis detection and staging in preclinical models by Pauline Désogère, Luis F. Tapias, Lida P. Hariri, Nicholas J. Rotile, Tyson A. Rietz, Clemens K. Probst, Francesco Blasi, Helen Day, Mari Mino-Kenudson, Paul Weinreb, Shelia M. Violette, Bryan C. Fuchs, Andrew M. Tager, Michael Lanuti, and Peter Caravan Sci Transl Med Volume 9(384):eaaf4696 April 5, 2017 Copyright © 2017, American Association for the Advancement of Science

Fig. 1. Probe 68Ga-CBP8 monitors disease progression in the BM mouse model of pulmonary fibrosis. Probe 68Ga-CBP8 monitors disease progression in the BM mouse model of pulmonary fibrosis. (A) Representative images of lung tissue stained with hematoxylin and eosin (H&E) and Sirius Red (magnification, ×10; scale bar, 300 μm) for sham and BM-treated mice at days 7 and 14 after BM instillation; higher-magnification views are also displayed (×40; scale bar, 60 μm). (B to D) Disease progresses in a stepwise fashion as determined by histological Ashcroft scoring of lung fibrosis (B), by histological quantification of the area affected by disease (C), and by hydroxyproline analysis (D). (E) Ex vivo lung uptake of 68Ga-CBP8 increases with disease progression in the BM-treated mice: 5-fold higher in BM mice 14 days after instillation than in sham animals and 1.5-fold higher in BM mice 14 days after instillation than in BM mice 7 days after instillation. (F) Correlation of ex vivo 68Ga-CBP8 lung uptake and Ashcroft score. (G) Correlation between ex vivo lung uptake of 68Ga-CBP8 and lung hydroxyproline. Data were analyzed with one-way analysis of variance (ANOVA), followed by post hoc Tukey tests with two-tailed distribution. For (B) to (F), data are displayed as box plots, with the dark band inside the box representing the mean, the bottom and top of the box representing the first and third quartiles, and the whiskers representing the minimum and maximum values. For all of the experiments shown in this figure: n = 11 for sham, n = 4 for BM-treated mice at day 7, and n = 7 for BM-treated mice at day 14. Pauline Désogère et al., Sci Transl Med 2017;9:eaaf4696 Copyright © 2017, American Association for the Advancement of Science

Fig. 2. 68Ga-CBP8 is specifically taken up by fibrotic but not healthy lungs (BM model). 68Ga-CBP8 is specifically taken up by fibrotic but not healthy lungs (BM model). (A) Representative fused PET-CT images show specific accumulation of 68Ga-CBP8 (left images) in fibrotic but not in control lungs; 68Ga-CBP12 (right images) showed no preferential uptake in the lungs of BM-treated mice compared to control mice. Grayscale image shows CT image, and color scale image shows PET image from integrated data 50 to 80 min after probe injection. (B) Hydroxyproline level was significantly higher in fibrotic BM-treated than in sham-treated animals. (C) PET activity values for 68Ga-CBP8 and 68Ga-CBP12 in sham- and BM-treated mice (50 to 80 min after injection). Data are expressed as percent injected dose per cubic centimeter of tissue (% ID/cc). Data show significantly higher uptake in fibrotic lungs with 68Ga-CBP8. (D) Ex vivo uptake of 68Ga-CBP8 and 68Ga-CBP12 in lungs from sham- and BM-treated mice 150 min after injection expressed as % ID/lung. (E) Distribution of 68Ga-CBP8 and 68Ga-CBP12, expressed as percent injected dose per gram of tissue (% ID/g) (mean ± SE) in various organs, was similar except in fibrotic lungs. (Inset) Same data as in (E) expressed as % ID/lung. Data were analyzed using one-way ANOVA, followed by post hoc Tukey tests with two-tailed distribution. For all of the experiments shown in this figure: n = 4 for sham injected with 68Ga-CBP12, n = 4 for BM-treated mice injected with 68Ga-CBP12, n = 11 for sham injected with 68Ga-CBP8, and n = 7 for BM-treated mice injected with 68Ga-CBP8. For (B) to (D), data are displayed as box plots, with the dark band inside the box representing the mean, the bottom and top of the box representing the first and third quartiles, and the whiskers representing the minimum and maximum values. Pauline Désogère et al., Sci Transl Med 2017;9:eaaf4696 Copyright © 2017, American Association for the Advancement of Science

Fig. 3. 68Ga-CBP8 detects and stages disease in a mouse model of pulmonary fibrosis with enhanced vascular permeability. 68Ga-CBP8 detects and stages disease in a mouse model of pulmonary fibrosis with enhanced vascular permeability. (A) Treatment scheme for the LDBVL group, which was treated with a low dose of BM (0.1 U/kg) and the vascular leak agent FTY720. (B to F) Mice were treated with a very low dose of BM (LDB), the vascular leak agent FTY720 (FTY), or both, administered together (LDBVL). The LDBVL group, but not the LDB or FTY group, exhibited a fibrotic response as determined by histological Ashcroft scoring of lung fibrosis (B), by Sirius Red staining (% total area affected by disease) (C), and by hydroxyproline analysis (D). Data show significantly higher uptake of 68Ga-CBP8 in the lungs of LDBVL animals compared to FTY or LDB animals, as quantified by PET data (% ID/cc) (E) and by ex vivo uptake (% ID/lung) (F). (G and H) Correlations between hydroxyproline levels and % ID/cc (G) and % ID/lung (H). Data were analyzed using one-way ANOVA, followed by post hoc Tukey tests with two-tailed distribution. For all of the experiments shown in this figure: n = 6 for the FTY group, n = 4 for the LDB group, and n = 9 for the LDBVL group. For (B) to (F), data are displayed as box plots, with the dark band inside the box representing the mean, the bottom and top of the box representing the first and third quartiles, and the whiskers representing the minimum and maximum values. Pauline Désogère et al., Sci Transl Med 2017;9:eaaf4696 Copyright © 2017, American Association for the Advancement of Science

Fig. 4. 68Ga-CBP8 PET allows monitoring of the response to antifibrotic therapy in mice. 68Ga-CBP8 PET allows monitoring of the response to antifibrotic therapy in mice. (A) Representative images of lung tissue stained with H&E and Sirius Red (magnification, ×10; scale bar, 300 μm) for mice treated with 3G9 only (n = 5), for mice treated with a low dose of BM and FTY720 (LDBVL; n = 9), for LDBVL mice receiving 3G9 (LDBVL + 3G9; n = 11), and for LDBVL mice receiving 1E6 (LDBVL + 1E6; n = 11); higher-magnification views are also displayed (×40; scale bar, 60 μm). (B) Representative fused PET-CT images show specific accumulation of 68Ga-CBP8 in the lungs of mice from the LDBVL and LDBVL + 1E6 groups but low PET signal in the lungs of the control 3G9 or treated LDBVL + 3G9 groups. Grayscale image shows CT image, and color scale image shows PET image from integrated data 50 to 80 min after probe injection. (C) Hydroxyproline content was significantly higher in animals from the LDBVL and LDBVL + 1E6 groups than in those from the 3G9 and LDBVL + 3G9 groups. (D and E) Similar effects were seen for quantitative PET data (D) and ex vivo uptake in the lungs. Data were analyzed using one-way ANOVA, followed by post hoc Tukey tests with two-tailed distribution. For (C) to (E), data are displayed as box plots, with the dark band inside the box representing the mean, the bottom and top of the box representing the first and third quartiles, and the whiskers representing the minimum and maximum values. For all of the experiments shown in this figure: n = 5 for the 3G9 group, n = 9 for the LDBVL group, n = 11 for the LDBVL + 3G9 group, and n = 11 for the LDBVL + 1E6 group. Pauline Désogère et al., Sci Transl Med 2017;9:eaaf4696 Copyright © 2017, American Association for the Advancement of Science

Fig. 5. Probe 68Ga-CBP8 signal reflects changes in collagen concentration in human IPF lung tissues. Probe 68Ga-CBP8 signal reflects changes in collagen concentration in human IPF lung tissues. (A) Uptake of 68Ga-CBP8 in human lung samples taken from the upper, middle, and lower lobes of explanted lung of IPF patients. The uptake is defined as % ID/g lung tissue (mean ± SE). Data were analyzed using one-way ANOVA, followed by post hoc Tukey tests with two-tailed distribution. For patient 1, n = 5 (upper lobe), n = 5 (middle lobe), and n = 6 (lower lobe). For patient 2, n = 8 (upper lobe), n = 6 (middle lobe), and n = 6 (lower lobe). For patient 3, n = 5 (upper lobe), n = 5 (middle lobe), and n = 9 (lower lobe). (B) Representative images of Sirius Red staining of collagen showing early stage of IPF (left, lung section taken from the upper lobe of patient 2) characterized by thickening of the alveolar septa and knot-like formation and late stage of fibrosis (right, lung section taken from the lower lobe of patient 2) characterized by a denser deposition of collagen. (C) Correlation of 68Ga-CBP8 (n = 9) and 68Ga-CBP12 (n = 9) uptake in lung tissue samples from IPF patients with histological staining of collagen, as measured by quantification of % collagen staining (Sirius Red) in the area affected by disease (for 68Ga-CBP8, r2 = 0.94, P < 0.0001). Pauline Désogère et al., Sci Transl Med 2017;9:eaaf4696 Copyright © 2017, American Association for the Advancement of Science