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To this day, multiple myeloma remains an incurable cancer. For many patients, recurrence is unavoidably a result of lacking treatment options in the minimal residual disease stage. This is due to residual and treatment-resistant myeloma cells that can cause disease relapse. However, patient-specific membrane-expressed paraproteins could hold the key to target these residual cells responsible for disease recurrence. Here, we describe the therapeutic potential of radiolabeled, anti-idiotypic camelid single-domain antibody fragments (sdAbs) as tumor-restrictive vehicles against a membrane-bound paraprotein in the syngeneic mouse 5T33 myeloma model and analogously assess the feasibility of sdAb-based personalized medicine for patients with multiple myeloma. Llamas were immunized using extracts containing paraprotein from either murine or human sera, and selective sdAbs were retrieved using competitive phage display selections of immune libraries. An anti-5T33 idiotype sdAb was selected for targeted radionuclide therapy with the β−-particle emitter 177Lu and the α-particle emitter 225Ac. sdAb-based radionuclide therapy in syngeneic mice with a low 5T33 myeloma lesion load significantly delayed tumor progression. In five of seven patients with newly diagnosed myeloma, membrane expression of the paraprotein was confirmed. Starting from serum-isolated paraprotein, for two of three selected patients anti-idiotype sdAbs were successfully generated.

Supplementary Data

Molecular fluorescence-guided surgery using near-infrared light has the potential to improve the rate of complete resection of cancer. Typically, monoclonal antibodies are being used as targeting moieties, however smaller fragments, such as single-domain antibodies (i.e., Nanobodies®) improve tumor specificity and enable tracer injection on the same day as surgery. In this study, the feasibility of a carcinoembryonic antigen-targeting Nanobody (NbCEA5) conjugated to two zwitterionic dyes (ZW800-1 Forte [ZW800F] and ZW800-1) for visualization of pancreatic ductal adenocarcinoma (PDAC) was investigated. After site-specific conjugation of NbCEA5 to the zwitterionic dyes, binding specificity was evaluated on human PDAC cell lines with flow cytometry. A dose escalation study was performed for both NbCEA5-ZW800F and NbCEA5-ZW800-1 in mice with subcutaneously implanted pancreatic tumors. Fluorescence imaging was performed up to 24 h after intravenous injection. Furthermore, the optimal dose for NbCEA5-ZW800-1 was injected in mice with orthotopically implanted pancreatic tumors. A dose-escalation study showed superior mean fluorescence intensities for NbCEA5-ZW800-1 compared to NbCEA5-ZW800F. In the orthotopic tumor models, NbCEA5-ZW800-1 accumulated specifically in pancreatic tumors with a mean in vivo tumor-to-background ratio of 2.4 (SD = 0.23). This study demonstrated the feasibility and potential advantages of using a CEA-targeted Nanobody conjugated to ZW800-1 for intraoperative PDAC imaging.

To this day, multiple myeloma remains an incurable cancer. For many patients, recurrence is unavoidably a result of lacking treatment options in the minimal residual disease stage. This is due to residual and treatment-resistant myeloma cells that can cause disease relapse. However, patient-specific membrane-expressed paraproteins could hold the key to target these residual cells responsible for disease recurrence. Here, we describe the therapeutic potential of radiolabeled, anti-idiotypic camelid single-domain antibody fragments (sdAbs) as tumor-restrictive vehicles against a membrane-bound paraprotein in the syngeneic mouse 5T33 myeloma model and analogously assess the feasibility of sdAb-based personalized medicine for patients with multiple myeloma. Llamas were immunized using extracts containing paraprotein from either murine or human sera, and selective sdAbs were retrieved using competitive phage display selections of immune libraries. An anti-5T33 idiotype sdAb was selected for targeted radionuclide therapy with the β−-particle emitter 177Lu and the α-particle emitter 225Ac. sdAb-based radionuclide therapy in syngeneic mice with a low 5T33 myeloma lesion load significantly delayed tumor progression. In five of seven patients with newly diagnosed myeloma, membrane expression of the paraprotein was confirmed. Starting from serum-isolated paraprotein, for two of three selected patients anti-idiotype sdAbs were successfully generated.

Background/objectives Nanobodies are the smallest biologic antigen-binding fragments derived from camelid-derived antibodies. Nanobodies effect a peak tumor signal within minutes of injection and present a novel opportunity for fluorescence-guided surgery (FGS). The present study demonstrates the efficacy of an anti-CEA nanobody conjugated to near-infrared fluorophore LICOR-IRDye800CW for rapid intraoperative tumor labeling of colon cancer. Methods LS174T human colon cancer cells or fragments of patient-derived colon cancer were implanted subcutaneously or orthotopically in nude mice. Anti-CEA nanobodies were conjugated with IRDye800CW and 1-3 nmol were injected intravenously. Mice were serially imaged over time. Peak fluorescence signal and tumor-to-background ratio (TBR) were recorded. Results Colon cancer tumors were detectable using fluorescent anti-CEA nanobody within 5 min of injection at all three doses. Maximal fluorescence intensity was observed within 15 min-3 h for all three doses with TBR values ranging from 1.3 to 2.3. In the patient-derived model of colon cancer, fluorescence was detectable with a TBR of 4.6 at 3 h. Conclusions Fluorescent anti-CEA nanobodies rapidly and specifically labeled colon cancer in cell-line-based and patient-derived orthotopic xenograft (PDOX) models. The kinetics of nanobodies allow for same day administration and imaging. Anti-CEA-nb-800 is a promising and practical molecule for FGS of colon cancer.

Recent advancements in the field of immune-oncology have led to a significant increase in life expectancy of patients with diverse forms of cancer, such as hematologic malignancies, melanoma and lung cancer. Unfortunately, these encouraging results are not observed in the majority of patients, who remain unresponsive and/or encounter adverse events. Currently, researchers are collecting more insight into the cellular and molecular mechanisms that underlie these variable responses. As an example, the human lymphocyte activation gene-3 (huLAG-3), an inhibitory immune checkpoint receptor, is increasingly studied as a therapeutic target in immune-oncology. Noninvasive molecular imaging of the immune checkpoint programmed death protein-1 (PD-1) or its ligand PD-L1 has shown its value as a strategy to guide and monitor PD-1/PD-L1-targeted immune checkpoint therapy. Yet, radiotracers that allow dynamic, whole body imaging of huLAG-3 expression are not yet described. We here developed single-domain antibodies (sdAbs) that bind huLAG-3 and showed that these sdAbs can image huLAG-3 in tumors, therefore representing promising tools for further development into clinically applicable radiotracers. Supplementary Information The online version contains supplementary material available at 10.1186/s13550-021-00857-9.

Purpose The combination of standard-of-care radiation therapy (RT) with immunotherapy is moving to the mainstream of non-small cell lung cancer treatment. Multiple preclinical studies reported on the CD8+ T cell stimulating properties of RT, resulting in abscopal therapeutic effects. A literature search demonstrates that most preclinical lung cancer studies applied subcutaneous lung tumor models. Hence, in-depth immunologic evaluation of clinically relevant RT in orthotopic lung cancer models is lacking. Methods and Materials We studied the therapeutic and immunologic effects of low-dose fractionated RT on lungs from C57BL/6 mice, challenged 2 weeks before with firefly luciferase expressing Lewis lung carcinoma cells via the tail vein. Low-dose fractionation was represented by 4 consecutive daily fractions of image guided RT at 3.2 Gy. Results We showed reduced lung tumor growth upon irradiation using in vivo bioluminescence imaging and immunohistochemistry. Moreover, significant immunologic RT-induced changes were observed in irradiated lungs and in the periphery (spleen and blood). First, a significant decrease in the number of CD8+ T cells and trends toward more CD4+ and regulatory T cells were seen after RT in all evaluated tissues. Notably, only in the periphery did the remaining CD8+ T cells show a more activated phenotype. In addition, a significant expansion of neutrophils and monocytes was observed upon RT locally and systemically. Locally, RT increased the influx of tumor-associated macrophages and conventional type 2 dendritic cells, whereas the alveolar macrophages and conventional type 1 DCs dramatically decreased. Functionally, these antigen-presenting cells severely reduced their CD86 expression, suggesting a reduced capacity to induce potent immunity. Conclusions Our results imply that low-dose fractionated RT of tumor-bearing lung tissue shifts the immune cell balance toward an immature myeloid cell dominating profile. These data argue for myeloid cell repolarizing strategies to enhance the abscopal effects in patients with non-small cell lung cancer treated with fractionated RT.

Immune checkpoints, such as programmed death-ligand 1 (PD-L1), limit T-cell function and tumor cells use this ligand to escape the anti-tumor immune response. Treatments with monoclonal antibodies blocking these checkpoints have shown long-lasting responses, but only in a subset of patients. This study aims to develop a Nanobody (Nb)-based probe in order to assess human PD-L1 (hPD-L1) expression using positron emission tomography imaging, and to compare the influence of two different radiolabeling strategies, since the Nb has a lysine in its complementarity determining region (CDR), which may impact its affinity upon functionalization. The Nb has been conjugated with the NOTA chelator site-specifically via the Sortase-A enzyme or randomly on its lysines. [68Ga]Ga-NOTA-(hPD-L1) Nbs were obtained in &gt, 95% radiochemical purity. In vivo tumor targeting studies at 1 h 20 post-injection revealed specific tumor uptake of 1.89 &plusmn, 0.40%IA/g for the site-specific conjugate, 1.77 &plusmn, 0.29%IA/g for the random conjugate, no nonspecific organ targeting, and excretion via the kidneys and bladder. Both strategies allowed for easily obtaining 68Ga-labeled hPD-L1 Nbs in high yields. The two conjugates were stable and showed excellent in vivo targeting. Moreover, we proved that the random lysine-conjugation is a valid strategy for clinical translation of the hPD-L1 Nb, despite the lysine present in the CDR.

BACKGROUND: Nanobodies, derived from camelid antibodies made of only heavy chains, are the smallest, biologic, antigen-binding fragments (~15kDa) with faster pharmacokinetics and better tumor penetration efficiency than standard antibodies. The present study evaluates the efficacy of a fluorescent, anti-carcinoembryonic antigen nanobody for rapid tumor labeling in an orthotopic mouse model of pancreatic cancer. METHODS: Anti-carcinoembryonic antigen or control nanobodies were conjugated with the near-infrared fluorophore IRDye 800CW. Fragments of BxPC3 or MiaPACA2 human pancreatic cancer cell lines were orthotopically implanted into the pancreatic tail of nude mice. After tumors reached 7 to 10 mm in size, 2 nmol anti-carcinoembryonic antigen or control nanobody-IRDye800CW was injected intravenously. Mice were imaged at various time points hours postinjection. RESULTS: Carcinoembryonic antigen-expressing, BxPC3 pancreatic orthotopic tumors were fluorescently labeled with aCEA-nb-800 3 hours after injection. The signal was present as early as 15 minutes after injection and was robust at 1 to 3 hours after injection with a tumor-to-background ratio of 2.66. In contrast, there was very low accumulation in the low carcinoembryonic antigen-expressing, MiaPACA2 pancreatic orthotopic tumors. The fluorophore-conjugated nanobody was specific for carcinoembryonic antigen-expressing tumors, while the control nanobody did not show any tumor-specific signal. Both nanobodies had strong kidney uptake as expected for small-molecule probes. The fluorescence signal was detectable using 2 clinical, Food and Drug Administration-approved, 800 nm imaging devices as well as small animal imaging systems. CONCLUSION: This anti-carcinoembryonic antigen, nanobody-based, fluorescent probe labeled pancreatic orthotopic tumors within 15 minutes of intravenous injection. Fluorescent anti-carcinoembryonic antigen nanobodies have labeling kinetics that approach the speed of nonspecific dyes such as indocyanine green but with the specificity of antibodies. The use of fluorescently-labeled, intact antibodies leads to a labeling delay of 48 to 96 hours between probe administration and the necessarily delayed time of operation, which can be avoided with nanobodies. The kinetics of a nanobody-based probe makes it a practical agent for same-day, patient administration and fluorescence-guided surgery.

HER2-targeted therapies have drastically improved the outcome for breast cancer patients. However, when metastasis to the brain is involved, current strategies fail to hold up to the same promise. Camelid single-domain antibody-fragments (sdAbs) have been demonstrated to possess favorable properties for detecting and treating cancerous lesions in vivo using different radiolabeling methods. Here we evaluate the anti-HER2 sdAb 2Rs15d, coupled to diagnostic &gamma, and therapeutic &alpha, and &beta, &minus, emitting radionuclides for the detection and treatment of HER2pos brain lesions in a preclinical setting. 2Rs15d was radiolabeled with 111In, 225Ac and 131I using DTPA- and DOTA-based bifunctional chelators and Sn-precursor of SGMIB respectively and evaluated in orthotopic tumor-bearing athymic nude mice. Therapeutic efficacy as well as systemic toxicity were determined for 131I- and 225Ac-labeled sdAbs and compared to anti-HER2 monoclonal antibody (mAb) trastuzumab in two different HER2pos tumor models. Radiolabeled 2Rs15d showed high and specific tumor uptake in both HER2pos SK-OV-3-Luc-IP1 and HER2pos MDA-MB-231Br brain lesions, whereas radiolabeled trastuzumab was unable to accumulate in intracranial SK-OV-3-Luc-IP1 tumors. Administration of [131I]-2Rs15d and [225Ac]-2Rs15d alone and in combination with trastuzumab showed a significant increase in median survival in 2 tumor models that remained largely unresponsive to trastuzumab treatment alone. Histopathological analysis revealed no significant early toxicity. Radiolabeled sdAbs prove to be promising vehicles for molecular imaging and targeted radionuclide therapy of metastatic lesions in the brain. These data demonstrate the potential of radiolabeled sdAbs as a valuable add-on treatment option for patients with difficult-to-treat HER2pos metastatic cancer.

Intraoperative guidance using targeted near-infrared (NIR) fluorescent tracers can provide surgeons with real-time feedback on the presence of residual tumour tissue. To overcome the still limited depth penetration of NIR light, and limit potentially missing residual occult or deeper lying lesions, the combination of fluorescence with nuclear imaging is proposed. We describe the design and preclinical validation of the anti-HER2 nanobody 2Rs15d, conjugated with a ‘multifunctional single attachment point’ (MSAP), which integrates a Cy5 fluorophore and diethylenetriaminepentaacetic acid (DTPA) chelator into a single label. After random conjugation to primary amines in the nanobody, functionality of the tracer and stability after 111In labelling were evaluated in vitro. Using SKOV3 (HER2+) and MDA-MB-435S (HER2-) xenografted mice, the in vivo biodistribution of 2Rs15d-MSAP.111In was determined by SPECT/CT (1h post-injection) and fluorescence imaging (1h30 post-injection). Ensuing, the ex vivo biodistribution was determined 2h (both xenograft models) and 24h post-injection (SKOV3 only). The tracer retained its affinity after conjugation of the MSAP and remained stable over 24h in both PBS and human serum after 111In labelling. The in vivo SPECT/CT and fluorescence images corresponded well, showing the expected biodistribution pattern for nanobody tracers, meaning low background except for high renal uptake due to clearance, and specific tumour uptake in HER2-overexpressing tumours. Ex vivo biodistribution data revealed a SKOV3 tumour-specific uptake of 7.0 ± 2.5 %ID/g after 2h, significantly higher than 1.1 ± 1.2 %ID/g for control tumours. The tumour-to-blood ratio was 47.6± 25.4, tumour-to-muscle ratio 23.2 ± 11.6, and tumour-to-liver ratio 6.9 ± 3.7. After 24h SKOV3 tumour uptake was 5.6 ± 1.9 %ID/g, tumour-to-blood ratio 229.1 ± 85.1, tumour-to-muscle ratio 16.8 ± 8.0, and tumour-to-liver ratio 5.1 ± 1.9. In conclusion, functional bimodal nuclear/fluorescent nanobody-tracers can be conveniently generated by conjugation of a single-molecule MSAP-reagent carrying both fluorophore and a chelator.

Purpose: Macrophage accumulation characterizes the development of atherosclerotic plaques, and the presence of certain macrophage subsets might be an indicator of plaque phenotype and (in)stability. The macrophage mannose receptor (MMR) is expressed on alternatively activated macrophages and found at sites of intraplaque hemorrhage and neovascularization. It has been proposed as target to identify vulnerable plaques. Therefore, we aimed to assess the feasibility of using anti-MMR nanobodies (Nbs) as molecular tracers for nuclear imaging in an animal model of atherosclerosis. Procedure: Anti-MMR and control Nb, radiolabeled with Tc-99m, were injected in ApoE −/− and/or C57Bl/6 mice (n = 6). In vivo competition studies involving pre-injection of excess of unlabeled anti-MMR Nb (n = 3) and injection of anti-MMR Nb in MMR −/− mice (n = 3) were performed to demonstrate specificity. At 3 h p.i. radioactive uptake in organs, tissues and aorta segments were evaluated. Autoradiography and immunofluorescence were performed on aortic sections. Results: Significantly higher uptake was observed in all aortic segments of ApoE −/− mice injected with anti-MMR Nb compared to control Nb (1.36 ± 0.67 vs 0.38 ± 0.13 percent of injected dose per gram (%ID/g), p ≤ 0.001). Surprisingly, high aortic uptake was also observed in C57Bl/6 mice (1.50 ± 0.43%ID/g, p ≥ 0.05 compared to ApoE −/−), while aortic uptake was reduced to background levels in the case of competition and in MMR −/− mice (0.46 ± 0.10 and 0.22 ± 0.06%ID/g, respectively; p ≤ 0.001). Therefore, expression of MMR along healthy aortas was suggested. Autoradiography showed no specific radioactive signal within atherosclerotic plaques, but rather localization of the signal along the aorta, correlating with MMR expression in perivascular tissue as demonstrated by immunofluorescence. Conclusions: No significant uptake of MMR-specific Nb could be observed in atherosclerotic lesions of ApoE −/− mice in this study. A specific perivascular signal causing a non-negligible background level was demonstrated. This observation should be considered when using MMR as a target in molecular imaging of atherosclerosis, as well as use of translational animal models with vulnerable plaques.

Real-time intraoperative guidance is essential during oncological surgery for complete and safe tumour resection. Fluorescence imaging in the near-infrared spectrum has shown potential for guiding surgeons during complex interventions. Recently, there has been a shift towards the use of fluorescence contrast agents for molecular imaging. The first targeted fluorescent agents, of which most consist of approved therapeutic antibodies conjugated to a fluorescent dye, have been evaluated in several early-phase clinical trials. Moreover, advances in protein engineering and drug design have led to the development of a variety of tracers suitable for molecular fluorescence image-guided surgery. In this Review, we discuss preclinical and clinical evidence, ongoing clinical trials, and the latest developments in the field of molecular near-infrared tracers for fluorescence-guided cancer surgery.

Fluorescence imaging using near-infrared (NIR) fluorescent contrast agents is increasingly being investigated as intraoperative tool to visualize, in real-time, tissues of interest such as tumors, lymph nodes or nerve bundles. Generally, spectral imaging systems are used that measure the intensity of fluorescent signals. However, to aid in a more specific detection of these fluorescent signals, fluorescence lifetime can be added to the image. The lifetime is independent of the intensity and in addition, multiple tracers emitting around the same wavelengths can still be distinguished based on their difference in lifetime. Imaging lifetimes, however, requires a much more advanced imaging system. None of the currently approved fluorescence guidance systems support fluorescence lifetime and today’s available lifetime imaging technology (TCSPC, ICCD) does not allow imaging the sub-nanosecond lifetimes of NIR dyes with the efficiency needed to reach video frame rates. In this paper, we present a 32×32-pixel proof-of-concept camera based on our novel CAPS-pixel based gated image sensor. This camera is specifically targeted at imaging fluorescence lifetimes at NIR wavelengths with high efficiency for the use in fluorescence-guided surgery and is a first step towards a full camera with video resolution at video frame rates. We describe the camera system and how it is used to image fluorescence lifetimes. Next, we show the lifetime imaging capability by imaging the lifetimes of two different nanosecond visible dyes (fluorescein and acridine orange) in cuvette and two more challenging (sub-)nanosecond NIR dyes (ICG and IRDye800CW). Lastly, we validate the camera by imaging NIR fluorescence phantoms in a mouse.

A compound's intratumoural distribution is an important determinant for the effectiveness of molecular therapy or imaging. Antibodies (Abs), though often used in the design of targeted compounds, struggle to achieve a homogenous distribution due to their large size and bivalent binding mechanism. In contrast, smaller compounds like nanobodies (Nbs) are expected to distribute more homogenously, though this has yet to be demonstrated in vivo at the microscopic level. We propose an intravital approach to evaluate the intratumoural distribution of different fluorescently labeled monomeric and dimeric Nb tracers and compare this with a monoclonal antibody (mAb). Monomeric and dimeric formats of the anti-HER2 (2Rb17c and 2Rb17c-2Rb17c) and control (R3B23 and R3B23-R3B23) Nb, as well as the dimeric monovalent Nb 2Rb17c-R3B23 were generated and fluorescently labeled with a Cy5 fluorophore. The mAb trastuzumab-Cy5 was also prepared. Whole-body biodistribution of all constructs was investigated in mice bearing subcutaneous xenografts (HER2+ SKOV3) using in vivo epi-fluorescence imaging. Next, for intravital experiments, GFP-expressing SKOV3 cells were grown under dorsal window chambers on athymic nude mice (n = 3/group), and imaged under a fluorescence stereo microscope immediately after intravenous injection of the tracers. Consecutive fluorescence images within the tumour were acquired over the initial 20 min after injection and later, single images were taken at 1, 3 and 24 h post-injection. Additionally, two-photon microscopy was used to investigate the colocalization of GFP (tumour cells) and Cy5 fluorescence (tracers) at higher resolution. Whole-body images showed rapid renal clearance of all Nbs, and fast tumour targeting for the specific Nbs. Specific tumour uptake of the mAb could only be clearly distinguished from background after several hours. Intravital imaging revealed that monomeric Nb tracers accumulated rapidly and distributed homogenously in the tumour mere minutes after intravenous injection. The dimeric compounds initially achieved lower fluorescence intensities than the monomeric. Furthermore, whereas the HER2-specific dimeric bivalent compound remained closely associated to the blood vessels over 24 h, the HER2-specific dimeric monovalent tracer achieved a more homogenous tumour distribution from 1 h post-injection onwards. Non-specific tracers were not retained in the tumour. Trastuzumab had the most heterogenous intratumoural distribution of all evaluated compounds, while -due to the long blood retention- achieving the highest overall tumour uptake at 24 h post-injection. In conclusion, monomeric Nbs very quickly and homogenously distribute through tumour tissue, at a rate significantly greater than dimeric Nbs and mAbs. This underlines the potential of monomeric Nb tracers and therapeutics in molecular imaging and targeted therapies. ispartof: JOURNAL OF CONTROLLED RELEASE vol:317 pages:34-42 ispartof: location:Netherlands status: published

Single domain antibodies (sdAbs) have proven to be valuable probes for molecular imaging. In order to produce such probes, one strategy is the functionalization of the reactive amine side chain of lysines with a chelator, resulting in a mixture of compounds with a different degree of conjugation. In this study, we implemented anion exchange chromatography (AEX) to separate the different compounds or fractions that were further characterized and evaluated to study the impact of the conjugation degree on pharmacokinetic properties and functionality. Anti-HER2 and anti-MMR sdAbs were functionalized with NOTA or DTPA chelator. Anion exchange chromatography was performed using 0.02 mol/L Tris pH 7.5 as the first solvent and 0.25 M or 0.4 M NaCl (in case of NOTA chelator or DTPA chelator, respectively) as the second solvent applied as a gradient. The fractions were characterized via mass spectrometry (MS), surface plasmon resonance (SPR), and isoelectric focusing gel electrophoresis (IEF), while in vivo studies were performed after radiolabeling with either 68Ga (NOTA) or 111In (DTPA) to assess the impact of the conjugation degree on pharmacokinetics. AEX could successfully be applied to separate fractions of (chelator)n-anti-HER2 and (chelator)n-anti-MMR sdAb constructs. MS confirmed the identity of different peaks obtained in the separation process. SPR measurement suggests a small loss of affinity for (chelator)3-anti-sdAb, while IEF revealed a correlated decrease in isoelectric point (pI) with the number of conjugated chelators. Interestingly, both the reduction in affinity and in pI was stronger with the DTPA chelator than with NOTA for both sdAbs. In vivo data showed no significant differences in organ uptake for any construct, except for (DTPA)n-anti-MMR, which showed a significantly higher liver uptake for (DTPA)1-anti-MMR compared to (DTPA)2-anti-MMR and (DTPA)3-anti-MMR. For all constructs in general, high kidney uptake was observed, due to the typical renal clearance of sdAb-based tracers. The kidney uptake showed significant differences between fractions of a same construct and indicates that a higher conjugation degree improves kidney clearance. AEX allows the separation of sdAbs with a different degree of conjugation and provides the opportunity to further characterize individual fractions. The conjugation of a chelator to sdAbs can alter some properties of the tracers, such as pI, however, the impact on the general biodistribution profile and tumor targeting was minimal.

Intraoperative guidance using targeted fluorescent tracers can potentially provide surgeons with real-time feedback on the presence of tumor tissue in resection margins. To overcome the limited depth penetration of fluorescent light, combining fluorescence with SPECT/CT imaging and/or gamma-ray tracing has been proposed. Here, we describe the design and preclinical validation of a novel bimodal nanobody-tracer, labeled using a “multifunctional single attachment point” (MSAP) label, integrating a Cy5 fluorophore and a diethylenetriaminepentaacetic acid (DTPA) chelator into a single structure. After conjugation of the bimodal MSAP to primary amines of the anti-HER2 nanobody 2Rs15d and 111In-labeling of DTPA, the tracer’s characteristics were evaluated in vitro. Subsequently, its biodistribution and tumor targeting were assessed by SPECT/CT and fluorescence imaging over 24 h. Finally, the tracer’s ability to identify small, disseminated tumor lesions was investigated in mice bearing HER2-overexpressing SKOV3.IP1 peritoneal lesions. [111In]In-MSAP.2Rs15d retained its affinity following conjugation and remained stable for 24 h. In vivo SPECT/CT and fluorescence images showed specific uptake in HER2-overexpressing tumors with low background. High tumor-to-muscle ratios were obtained at 1h p.i. and remained 19-fold on SPECT/CT and 3-fold on fluorescence images over 24 h. In the intraperitoneally disseminated model, the tracer allowed detection of larger lesions via nuclear imaging, while fluorescence enabled accurate removal of submillimeter lesions. Bimodal nuclear/fluorescent nanobody-tracers can thus be conveniently designed by conjugation of a single-molecule MSAP-reagent carrying a fluorophore and chelator for radioactive labeling. Such tracers hold promise for clinical applications.

PURPOSE: Debulking followed by combination chemotherapy is currently regarded as the most effective treatment for advanced ovarian cancer. Prognosis depends drastically on the degree of debulking. Accordingly, near-infrared (NIR) fluorescence imaging has been proposed to revolutionize cancer surgery by acting as a sensitive, specific, and real-time tool enabling visualization of cancer lesions. We have previously developed a NIR-labeled nanobody that allows fast, specific, and high-contrast imaging of HER2-positive tumors. In this study, we applied this tracer during fluorescence-guided surgery in a mouse model and investigated the effect on surgical efficiency. PROCEDURES: 0.5 × 106 SKOV3.IP1-Luc+ cells were inoculated intraperitoneally in athymic mice and were allowed to grow for 30 days. Two nanomoles of IRDye800CW-anti-HER2 nanobody was injected intravenously. After 1h30, mice were killed, randomized in two groups, and subjected to surgery. In the first animal group (n = 7), lesions were removed by a conventional surgical protocol, followed by excision of remaining fluorescent tissue using a NIR camera. The second group of mice (n = 6) underwent directly fluorescence-guided surgery. Bioluminescence imaging was performed before and after surgery. Resected tissue was categorized as visualized during conventional surgery or not, fluorescent or not, and bioluminescent positive or negative. RESULTS: Fluorescence imaging allowed clear visualization of tumor nodules within the abdomen, up to submillimeter-sized lesions. Fluorescence guidance resulted in significantly reduced residual tumor as compared to conventional surgery. Moreover, sensitivity increased from 59.3 to 99.0 %, and the percentage of false positive lesions detected decreased from 19.6 to 7.1 %. CONCLUSIONS: This study demonstrates the advantage of intraoperative fluorescence imaging using nanobody-based tracers on the efficiency of debulking surgery.

Macrophage accumulation characterizes the development of atherosclerotic plaques, and the presence of certain macrophage subsets might be an indicator of plaque phenotype and (in)stability. The macrophage mannose receptor (MMR) is expressed on alternatively activated macrophages and found at sites of intraplaque hemorrhage and neovascularization. It has been proposed as target to identify vulnerable plaques. Therefore, we aimed to assess the feasibility of using anti-MMR nanobodies (Nbs) as molecular tracers for nuclear imaging in an animal model of atherosclerosis.Anti-MMR and control Nb, radiolabeled with Tc-99m, were injected in ApoESignificantly higher uptake was observed in all aortic segments of ApoENo significant uptake of MMR-specific Nb could be observed in atherosclerotic lesions of ApoE

Advances in optical imaging technologies have stimulated the development of near-infrared (NIR) fluorescently labeled targeted probes for use in image-guided surgery. As nanobodies have already proven to be excellent candidates for molecular imaging, we aimed in this project to design NIR-conjugated nanobodies targeting the tumor biomarker HER2 for future applications in this field and to evaluate the effect of dye and dye conjugation chemistry on their pharmacokinetics during development. IRDye800CW or IRdye680RD were conjugated either randomly (via lysines) or site-specifically (via C-terminal cysteine) to the anti-HER2 nanobody 2Rs15d. After verification of purity and functionality, the biodistribution and tumor targeting of the NIR-nanobodies were assessed in HER2-positive and -negative xenografted mice. Site-specifically IRDye800CW- and IRdye680RD-labeled 2Rs15d as well as randomly labeled 2Rs15d-IRDye680RD showed rapid tumor accumulation and low nonspecific uptake, resulting in high tumor-to-muscle ratios at early time points (respectively 6.6 ± 1.0, 3.4 ± 1.6, and 3.5 ± 0.9 for HER2-postive tumors at 3 h p.i., while1.0 for HER2-negative tumors at 3 h p.i., p0.05). Contrarily, using the randomly labeled 2Rs15d-IRDye800CW, HER2-positive and -negative tumors could only be distinguished after 24 h due to high nonspecific signals. Moreover, both randomly labeled 2Rs15d nanobodies were not only cleared via the kidneys but also partially via the hepatobiliary route. In conclusion, near-infrared fluorescent labeling of nanobodies allows rapid, specific, and high contrast in vivo tumor imaging. Nevertheless, the fluorescent dye as well as the chosen conjugation strategy can affect the nanobodies' properties and consequently have a major impact on their pharmacokinetics.

INTRODUCTION: Lymphadenectomy, the surgical removal of lymph nodes (LNs), is performed in oncology patients to control the lymphatic tissue for signs of cancer. Depending on the cancer type and stage, either a regional or radical LN dissection is performed. Intraoperative identification of LNs can be a complex and demanding procedure. We propose to use fluorescence molecular imaging to highlight all LNs within the surgical field to facilitate node picking. To accomplish LN staining, we fluorescently labeled a previously developed anti-mannose receptor (MR) nanobody (Nb) that yields significant uptake in the LNs. METHODS: The nanobody MMR3.49 with high affinity for MR and a non-targeting control nanobody were labeled with Cy5 or IRDye800CW. One hour after intravenous injection of 2nmol of labeled compound in healthy mice (n=3 per group), axillary, inguinal and popliteal LNs were imaged in situ and ex vivo with the KIS650, Kaer Labs (for detection of Cy5 signal) or Fluobeam800, Fluoptics (for detection of IRDye800CW signal). The translational nature of the approach was explored by upscaling the experiment to healthy pigs (30-40kg; n=2 for Cy5, n=3 for IRDye800CW). Here, LN mapping in the cervical, abdominal, pelvic, and/or popliteal area was evaluated 90 minutes after intravenous injection of 73nmol of MMR3.49-Cy5/IRDye800CW. LNs and muscle were procured for further ex vivo assessment. Fluorescent signal and target-to-background ratios (TBRs) were quantified using ImageJ. RESULTS: Both Cy5 and IRDye800CW-labeled anti-MR nanobodies enabled clear and specific in situ visualization of the LNs in mice, with ex vivo TBRs of 2.64±0.63 and 4.62±0.50 respectively. No uptake in LNs was observed for the control nanobodies (TBR 1.40±0.18 and 1.14±0.32) (Figure 1). Comparably, in pigs, MMR3.49-Cy5/IRDye800CW allowed distinct in vivo fluorescent staining of the LNs and facilitated localizing them in situ (Figure 2). Ex vivo TBRs were calculated at 2.61±1.11 for Cy5 and 3.57±0.93 for IRDye800CW labeled anti-MR nanobody. CONCLUSIONS: Intravenous injection of fluorescently labeled anti-MR nanobodies enabled intraoperative localization of LNs within the whole surgical view. This could potentially increase the accuracy of both regional and radical nodal dissections. Early data suggests the imaging findings in mice are scalable to porcine models.

Fluorescence molecular imaging plays an essential role in clinical applications such as image-guided surgery by aiding surgeons in localizing and identifying tissues to resect or to preserve during oncological surgery. This technology relies increasingly on the use of targeted fluorescent agents that recognize specific biomarkers expressed by diseased or healthy tissue. Targeting moieties such as camelid-derived single-domain antibodies (sdAbs), characterized by high target affinity and fast systemic clearance, are excellent candidates for molecular imaging. Due to their mid-range size (~12-15 kDa), they offer considerable advantages over small molecules, peptides, and antibodies. Within this project, we generated, developed, and preclinically validated a panel of sdAbs with view of application in molecular-guided surgery. First, we present the capabilities of the generated sdAbs to bind on multiple types of cancer cells in vitro. Further, we report in vivo biodistribution and specific tumor binding of thesdAbs after radiolabeling (99mTc) in the subcutaneous tumor model in mice. Finally, we show the in vivo behavior and the capacity of the selected sdAbs to allow specifically visualize cancer tissue after conjugation of a novel fluorescent molecule (S775Z) in subcutaneous and orthotopic tumor models with clinically relevant target-to-background-ratios. We conclude that the generated compounds show a potential towards future clinical translation, for example as a contrast agent for image-guided surgery. This application could increase the accuracy of detection and removal completeness of number of cancers.

Background Immune checkpoint blockade revolutionized anti-cancer therapy but unfortunately not all patients can benefit from it. The development of innovative and efficacious diagnostic methods that can guide treatment decisions is warranted. Nanobodies (Nbs) are small antigen-binding moieties that efficiently penetrate cell-cell interfaces in tumors and generate high contrast in noninvasive imaging, making them prime candidates for development of novel imaging tracers. In this study, we generated and characterized Nbs as tools for nuclear imaging of the immune checkpoint LAG-3. Methods Nanobody generation was initiated by immunization of llamas with recombinant LAG-3. Periplasmic extracts were generated and analyzed for their binding to mouse LAG-3 using ELISA and flow cytometry. Selected Nbs were cloned in a vector for high yield production and purified in order to analyze their affinity using SPR. A total of 9 high affinity Nbs were subsequently evaluated for their labeling efficiency with Technetium-99m (99mTc), after which the biodistribution of 99mTc labeled Nbs was assessed in mice. Additionally, we evaluated the noninvasive detection of LAG-3 expressed by immune cells in the tumor environment of murine colon adenocarcinoma (MC38) using 99mTc-Nb3132. Results Nine high affinity Nbs were selected to evaluate their potential as noninvasive imaging tracers. Subsequently, Nb3132 was reported as the most potent tracer for noninvasive imaging of the immune checkpoint LAG-3 (1). SPECT/CT of MC38 tumor-bearing mice 1h after injection of 99mTc-Nb3132 presented specific uptake in spleen, thymus, lymph nodes as well as at the tumor site. This uptake pattern coincided with the presence of LAG-3 expressed on immune cells in these organs, as determined by flow cytometry and immunohistochemistry. No specific uptake was observed when injecting mice with a radiolabeled control Nb. Conclusion Nb3132 showed excellent in vivo imaging capacities to specifically identify LAG-3 expressing immune cells within the tumor site. These findings support the predictive potential of Nb3132 to noninvasively detect LAG-3 by nuclear imaging and to guide treatment decisions in future, improving the shortcomings of using full-sized antibody formats as diagnostic tracers. Legal entity responsible for the study Geert Raes. Funding Kom op tegen kanker and FWO flanders. Disclosure All authors have declared no conflicts of interest.

Introduction Fluorescence molecular imaging plays a crucial role in clinical applications such as image-guided surgery. The technology relies on the use of targeted fluorescent agents against specific biomarkers expressed by diseased tissue. Targeting moieties such as Nanobodies (Nbs), single-domain antibodies, are characterized by excellent kinetic parameters due to their small size and robustness. As their pharmacokinetics is influenced by the chemical structure of conjugated fluorescent dyes, we compared in this study the biodistribution and tumor targeting of Nbs labelled with three derivatives of Cy5. Methods The chemical design of sulfoCy5 dye was modified by alkylation of the indole-nitrogen, resulting in three Cy5-variants with differences in charge (quaternary amine, methyl or sulfonate group was introduced) (Fig.1) [1][2]. The Cy5-derivatives were conjugated to the lysines of an anti-HER2 Nb [3] via NHS chemistry. Compounds were characterized regarding purity and stability; functionality was assessed via in vitro cell binding studies. After IV injection of the different Cy5-Nbs, their in vivo biodistribution and tumor targeting was evaluated over 24h by 2D fluorescence imaging in nude mice bearing either a HER2+ (SKOV3) or HER2- (MDA-MB-435) tumor (n=3 per group). Urine samples were collected to study the metabolism of the tracers. Results/Discussion The three Cy5 variants were successfully conjugated to the Nb. All conjugates maintained their affinity and remained stable in PBS. In vivo fluorescence imaging allowed clear visualization of the HER2+ tumors after 1h for Nb-Cy5-Sulfonate and -Cy5-QAmine (Fig.2). No tumor uptake was detected in HER2- tumors. Contrarily, for Nb-Cy5-Methyl sufficient contrast was only attained after several hours (> 3h) due to higher background signal (including the liver). Interestingly, while all Nb-based tracers underwent renal clearance, Nb-Cy5-Sulfonate showed significantly less kidney retention with almost no kidney signal after 6h (intense kidney signal was still visible for Nb-Cy5-QAmine at 24h). Conclusions This study demonstrates that the chemical character of Cy5-derived dyes does significantly influence the biodistribution profile and tumor targeting of Nb-based tracers. The fluorescent dye Cy5-Sulfonate was found to have the most promising properties to use in combination with Nbs, as the resulting conjugates showed good tumor binding with negligible background and rapid excretion from the kidneys. References [1] Bunschoten A, Willigen DM Van, Buckle T, et al (2016) Tailoring Fluorescent Dyes to Optimize a Hybrid RGD-Tracer. Bioconjug Chem 27:1253–1258 [2] Spa SJ, Hensbergen AW, Wal S van der, et al (2018) The influence of systematic structure alterations on the photophysical properties and conjugation characteristics of asymmetric cyanine 5 dyes. Dye Pigment 152:19–28 [3] Vaneycken I, Devoogdt N, Gassen N Van, et al (2011) Preclinical screening of anti-HER2 nanobodies for molecular imaging of breast cancer. FASEB J 25:2433–46

Introduction Lymphadenectomy, the surgical removal of lymph nodes (LNs), is performed in clinically node-negative patients who have a high chance of nodal metastases. For quality assurance, often a minimum number of LNs in the area of interest needs to be harvested. Intraoperative identification of LNs can be a demanding procedure. We propose to use fluorescence molecular imaging to highlight all LNs within the surgical field to facilitate node picking. To realize LN staining we fluorescently labeled a previously developed anti-mannose receptor (MR) nanobody (Nb) that yields significant uptake in LNs [1]. Methods The nanobody MMR3.49 with high affinity for MR as well as a control nanobody were fluorescently-labeled with Cy5 or IRDye800CW. One hour after intravenous injection of 2 nmol of labeled compound in healthy mice (n=3 per group), axillary, inguinal and popliteal LNs were imaged in situ and ex vivo with the KIS (Kaer Labs) for Cy5 signals or Fluobeam800® (Fluoptics) for IRDye800CW signals. The translational nature of the approach was studied by upscaling the experiment to a healthy porcine model (n=1; 35 kg). Here, LN mapping in the pelvic area, following intravenous injection of 73 nmol of MMR3.49-Cy5, was evaluated 90 min after injection. LNs, muscle and fat were procured for further ex vivo assessment. Fluorescent signals and target-to-background ratios (TBRs) were quantified using ImageJ. Results/Discussion Both Cy5 and IRDye800CW-labeled anti-MR nanobodies enabled clear and specific in situ visualization of the LNs in mice, with ex vivo TBRs of 2.64±0.63 and 4.62±0.50 respectively. No uptake in LNs was observed for the control nanobodies (TBR 1.40±0.18 and 1.14±0.32) (Figure 1). Comparably, in the pig, MMR3.49-Cy5 helped to realize distinct in vivo fluorescent staining of pelvic LNs (Figure 2). Conclusions Intravenous injection of fluorescently-labeled anti-MR nanobodies enables intraoperative localization of LNs within the whole surgical view. This could potentially increase the accuracy of extended nodal dissections. Early data suggests the imaging findings in mice are scalable to porcine models. References 1 Xavier, C, Blykers, A, Laoui, D, Bolli, E, Vaneyken, I, Bridoux, J, Baudhuin, H, Raes, G, Everaert, H, Movahedi, K, Van Ginderachter, JA, Devoogdt, N, Caveliers, V, Lahoutte, T, Keyaerts, M 2019, ‘Clinical Translation of [68Ga]Ga-NOTA-anti-MMR-sdAb for PET/CT Imaging of Protumorigenic Macrophages’, Mol Imaging Biol, 21, 898, Springer International Publishing

Coronary artery disease (CAD) contributes to millions of deaths each year. The identification of vulnerable plaques is essential to the diagnosis of CAD but is challenging. Molecular probes can improve the detection of these plaques using intravascular imaging methods. Fluorescence lifetime sensing is a safe and robust method to image these molecular probes. We present two variations of an optical system for intravascular near-infrared (NIR) fluorescence lifetime sensing through a multimode fiber. Both systems are built around a recently developed fast and efficient CMOS detector, the current-assisted photonic sampler (CAPS) that is optimized for sub-nanosecond NIR fluorescence lifetime sensing. One system mimics the optical setup of an epifluorescence microscope while the other uses a practical fiber optic coupler to separate fluorescence excitation and emission. We test both systems by measuring the lifetime of several NIR dyes in DMSO solutions and we show that these systems are capable of detecting lifetimes of solutions with concentrations down to 370 nM and this with short acquisition times. These results are compared with time-correlated single photon counting (TCSPC) measurements for reference. © (2016) COPYRIGHT Society of Photo-Optical Instrumentation Engineers (SPIE). Downloading of the abstract is permitted for personal use only.