Imaging of Lymphatics Background The lymphatics represent the third circulation in the body and are an important route of spread for tumors. Lymphangiogenesis is a property of some tumors that allows them to propagate via the lymphatics. This process has been difficult to study because the lymphatics are small and inaccessible. However, by injecting various kinds of macromolecular contrast agents, including radiolabeled, optically labeled and magnetically labeled it is possible to identify the lymphatics and their drainage patterns(1). Moreover, the knowledge gained in this process has implications for the diagnosis and management of primary and secondary lymphedema, which can be a serious complication of cancer therapy. Finally, the development of macromolecular contrast agents has implications for other diseases. Pre-clinical research The MIP is investigating the role of the lymphatics in cancer using imaging methods. We have found that macromolecular agents of between 5-10nm in diameter are ideal for studying the lymphatics based on their rapid uptake and transit to the sentinel nodes. Sentinel node imaging is of importance because current methods rely on cumbersome blue dyes and radioactive sulfur colloid. We have developed a dendrimer that is dual labeled for MRI imaging and optical imaging that would allow the identification of the sentinel node without ionizing radiation using MRI and optical imaging(2). By comparing different sized dendrimers optimization of the lymphatic agent was achieved(3). We found that very small agents leaked from the lymphatics and were unsatisfactory whereas large agents were too slow. Therefore, the Generation 6 dendrimer loaded with Gadolinium and an optical fluorophore appears ideal(3-5). Working with Martin Brechbiel and Gary Griffiths we have developed and tested dendrimers with new syntheses that should simplify the chemistry for possible clinical translation(6). We have also used IgG as a carrier molecule for lymphatic imaging and shown it to be a biocompatible and suitably sized for lymphatic imaging. Furthermore, we are investigating the FDA-approved drug Ablavar for lymphatic imaging as this gadolinium chelate binds albumin and effectively becomes macromolecular. We are currently working on a dendrimer loaded with Gadolinium for potential human use. This agent uses medical grade dendrimers with a high affinity chelate, DOTA. This could be useful in the pre operative mapping of lymphatic obstruction and malformations. We have found that a commercially available, FDA approved Gadolinium based agent, gadofosveset (Ablavar) may be sufficient to identify the lymphatic channels because it binds to albumin creating a virtual macromolecule. Our early studies in large animals was very promising and our colleagues at the Boston Childrens Hospital (Steve Fishman and Lori Sena) will conduct a trial in humans to see if this approach is feasible. In addition we are exploring the role of quantum dots (QD) in identifying the lymphatics. QDs have the advantages of high quantum efficiency and very narrow emission spectra allowing multiple QDs of different wavelength to be used simultaneously(7, 8). We have employed two color QDs to investigate the drainage of the breast and arm to the axillary lymph nodes and found that some mice had independent drainage systems whereas other mice demonstrated dual draining nodes , i.e. nodes that partly drained the breast and partly drained the limb(7, 8). Additionally we have explored the use of up to 5 QDs of differing wavelength simultaneously in order to establish the complex lymphatic drainage patterns in the head and neck. Clinical Translation: We have been collaborating with Boston Childrens Hospital to develop a MR contrast agent for use in human children with primary lymphedema. Ferumoxytol is an iron containing oxide that accumulates in normal nodes. We are testing this agent in patients with GU malignancies to see if it is suitable for detectinglymph node metastases. A preliminary study of 20 patients with prostate cancer has concluded and a new study will be underway in late 2013. 1. Barrett, T., Choyke, P. L., and Kobayashi, H. Imaging of the lymphatic system: new horizons. Contrast Media Mol Imaging, 1: 230-245, 2006. 2. Talanov, V. S., Regino, C. A., Kobayashi, H., Bernardo, M., Choyke, P. L., and Brechbiel, M. W. Dendrimer-based nanoprobe for dual modality magnetic resonance and fluorescence imaging. Nano Lett, 6: 1459-1463, 2006. 3. Kobayashi, H., Kawamoto, S., Bernardo, M., Brechbiel, M. W., Knopp, M. V., and Choyke, P. L. Delivery of gadolinium-labeled nanoparticles to the sentinel lymph node: comparison of the sentinel node visualization and estimations of intra-nodal gadolinium concentration by the magnetic resonance imaging. J Control Release, 111: 343-351, 2006. 4. Koyama, Y., Talanov, V. S., Bernardo, M., Hama, Y., Regino, C. A., Brechbiel, M. W., Choyke, P. L., and Kobayashi, H. A dendrimer-based nanosized contrast agent dual-labeled for magnetic resonance and optical fluorescence imaging to localize the sentinel lymph node in mice. J Magn Reson Imaging, 25: 866-871, 2007. 5. Hama, Y., Bernardo, M., Regino, C. A., Koyama, Y., Brechbiel, M. W., Krishna, M. C., Choyke, P. L., and Kobayashi, H. MR lymphangiography using dendrimer-based contrast agents: a comparison at 1.5T and 3.0T. Magn Reson Med, 57: 431-436, 2007. 6. Xu, H., Regino, C. A., Bernardo, M., Koyama, Y., Kobayashi, H., Choyke, P. L., and Brechbiel, M. W. Toward improved syntheses of dendrimer-based magnetic resonance imaging contrast agents: new bifunctional diethylenetriaminepentaacetic acid ligands and nonaqueous conjugation chemistry. J Med Chem, 50: 3185-3193, 2007. 7. Kobayashi, H., Hama, Y., Koyama, Y., Barrett, T., Regino, C. A., Urano, Y., and Choyke, P. L. Simultaneous multicolor imaging of five different lymphatic basins using quantum dots. Nano Lett, 7: 1711-1716, 2007. 8. Hama, Y., Koyama, Y., Urano, Y., Choyke, P. L., and Kobayashi, H. Two-Color Lymphatic Mapping Using Ig-Conjugated Near Infrared Optical Probes. J Invest Dermatol, 2007. 266. 9. Regino CA, Walbridge S, Bernardo M, Wong KJ, Johnson D, Lonser R, Oldfield EH, Choyke PL, Brechbiel MW. A dual CT-MR dendrimer contrast agent as a surrogate marker for convection-enhanced delivery of intracerebral macromolecular therapeutic agents. Contrast Media Mol Imaging. 2008 Jan;3(1):2-8. 274. 10. Longmire M, Choyke PL, Kobayashi H. Clearance properties of nano-sized particles and molecules as imaging agents: considerations and caveats. Nanomed. 2008 Oct;3(5):703-17 11. Kobayashi H, Ogawa M, Kosaka N, Choyke PL, Urano Y. Multicolor imaging of lymphatic function with two nanomaterials: quantum dot-labeled cancer cells and dendrimer-based optical agents. Nanomed. 2009 Jun;4(4):411-9. 12. Bumb A, Regino CA, Perkins MR, Bernardo M, Ogawa M, Fugger L, Choyke PL, Dobson PJ, Brechbiel MW.: Preparation and characterization of a magnetic and optical dual-modality molecular probe. Nanotechnology. 21(17):175704, 2010. 13. Kosaka N, Bernardo M, Mitsunaga M, Choyke PL, Kobayashi H.: MR and optical imaging of early micrometastases in lymph nodes: triple labeling with nano-sized agents yielding distinct signals. Contrast Media Mol Imaging.;7(2):247-253. 2012.

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Glastonbury, Christine M; Bhosale, Priya R; Choyke, Peter L et al. (2016) Do Radiologists Have Stage Fright? Tumor Staging and How We Can Add Value to the Care of Patients with Cancer. Radiology 278:11-2
Bouchelouche, Kirsten; Turkbey, Baris; Choyke, Peter L (2016) PSMA PET and Radionuclide Therapy in Prostate Cancer. Semin Nucl Med 46:522-535
Hao, Xing Pei; Lucero, Carissa M; Turkbey, Baris et al. (2015) Experimental colitis in SIV-uninfected rhesus macaques recapitulates important features of pathogenic SIV infection. Nat Commun 6:8020
Sankineni, Sandeep; Smedley, Jeremy; Bernardo, Marcelino et al. (2015) Ferumoxytol as an intraprostatic MR contrast agent for lymph node mapping of the prostate: a feasibility study in non-human primates. Acta Radiol :
Sankineni, Sandeep; Brown, Anna M; Fascelli, Michele et al. (2015) Lymph node staging in prostate cancer. Curr Urol Rep 16:30
Longmire, Michelle R; Ogawa, Mikako; Choyke, Peter L et al. (2014) Dendrimers as high relaxivity MR contrast agents. Wiley Interdiscip Rev Nanomed Nanobiotechnol 6:155-62
Choyke, Peter L (2014) Nanoparticles: take only pictures, leave only footprints. Sci Transl Med 6:260fs44
Turkbey, Baris; Kobayashi, Hisataka; Hoyt Jr, Robert F et al. (2014) Magnetic resonance lymphography of the thoracic duct after interstitial injection of gadofosveset trisodium: a pilot dosing study in a porcine model. Lymphat Res Biol 12:32-6
Smedley, Jeremy; Turkbey, Baris; Bernardo, Marcelino L et al. (2014) Tracking the luminal exposure and lymphatic drainage pathways of intravaginal and intrarectal inocula used in nonhuman primate models of HIV transmission. PLoS One 9:e92830
Nakajima, Takahito; Turkbey, Baris; Sano, Kohei et al. (2014) MR lymphangiography with intradermal gadofosveset and human serum albumin in mice and primates. J Magn Reson Imaging 40:691-7

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