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Molecular Imaging
Molecular imaging unites molecular biology and in
vivo imaging for visualization of the cellular function
and molecular process in living organisms. It has a
potential for the diagnosis of diseases such as cancer,
neurological and cardiovascular disorders with an
aim to contribute in improving treatment. Different
modalities used for noninvasive molecular imaging are,
magnetic resonance imaging (MRI), optical imaging,
single photon emission computed tomography
(SPECT) and positron emission tomography (PET).
Visualization, characterization and measurement
of biological processes at the cellular level, and going
beyond to molecular levels in any living system is
molecular imaging. Application of molecular imaging
in clinical practice is known as molecular diagnostic
imaging. Molecular imaging goes beyond structural
assessment, and probes disease-specific abnormalities
at the molecular level distinguishing it from classical
diagnostic imaging. New genetic and molecular
causes of disease are continually being discovered by
means of molecular imaging. Molecular imaging has
been practiced as early as 1970s in the form of using
positron-emission tomography (PET) to assess blood
flow in the brain and other organs using Oxygen-15
(O-15) water. Molecular imaging has only recently
been defined as a separate entity. Many diseases have
cellular and molecular origins, it is now recognized
that imaging of processes intrinsic to metabolism may
be helped by molecular imaging.
A molecular imaging system consists of a target,
an agent and an imaging modality. Molecular imaging
necessitates the interaction of the target with a
labeled agent that can be detected externally by one
or more modalities. Three major ways of agent-target
interaction are recognized.
1. Targeted binding: The labeled agent selectively
binds to its target and is detected by an external
imaging modality. For example, neuroreceptor
imaging in the brain with radiopharmaceutical of
11
C, which binds to the type-2 dopamine receptor.
The interaction is detected externally by PET
imaging.
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Shrikant Nagare
2. Imaging agent accumulation in the cell: The
structure of an agent is modified by an enzymatic
action resulting in accumulation of agent in the
cell. The best example is 18F-fluorodeoxyglucose
(FDG), which, once inside the cell, is acted upon by
hexokinase, resulting in a phosphorylated version
that can neither cross the cell membrane again nor
undergo glycolysis. This results in the accumulation
of FDG in highly metabolic cells, such as in cancer
or infection/inflammation. The interaction can be
detected externally by PET imaging.
3. Activation of imaging agent by cellular components:
The imaging agent is activated by the enzymes
in cell, resulting in signal amplification, e.g.
bioluminescence in which the luciferase enzyme
expressed by the target cell acts on injected
luciferin. Emitted light is then detected externally
by specialized cameras.
Prior to agent-target interaction, the imaging
agent needs to be labeled. The most common labeling
method is the use of modified injectable agents from
known drug molecules. The in vivo characteristic of
the labeled molecules is determined first. Favorable
characteristics include, high specific activity of the
label, high site selectivity and specificity; appropriate
binding affinity; suitable hydro-lipophilicity and size
(these features govern the transport across barriers);
suitable metabolism; low immediate renal excretion,
low hepatic toxicity; low nonspecific binding to reduce
background signal contrast; and, the ability to achieve
high local concentrations.
A limitation for the use of injectable molecular
imaging agents is due to their pharmacological pro­
perties. Micro bubble ultrasound contrast agents and
magnetic resonance imaging (MRI) iron nanoparticles
are relatively bulky. They are restricted by body
membranes like vascular endothelium, the blood-brain
barrier or the cell membrane. Micro bubble ultrasound
contrast agents and nanoparticles are restricted much
more than low molecular weight agents.
The basis of molecular genetic imaging is indirect
labeling of reporter genes. The product of a reporter
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gene (protein) can be detected externally. A reporter
gene is genetically linked to a promoter of the gene
of interest to express the gene of interest. Many new
imaging agents for human reporter genes are subject
to active research in anticipation of their use in human
gene therapy.
Before transplantation the cells are labeled
using direct cell labeling techniques. Iron oxide
nanoparticles are used to label killer lymphocytes prior
to reintroduction of the labeled cells into the system.
These iron oxide particles provide strong negative
contrast when imaged with MRI. The 3-dimensional
distribution of infiltrating T-cells across the whole
tumor can be detected using MRI.
MODALITIES USED FOR NONINVASIVE
MOLECULAR IMAGING
Molecular imaging includes the nuclear medicine
and various other fields. Nuclear medicine uses
Fig. 23.1  Key advantages of the main molecular imaging modalities
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Molecular Imaging 121
radio-labeled tracer molecules that produce signals by
means of radioactive decay only. Molecular imaging
uses these as well as other molecules to image via
means of sound (ultrasound), magnetism magnetic
resonance imaging (MRI), or light (optical techniques
of bioluminescence and fluorescence) as well as other
emerging techniques.
The various molecular imaging technologies
differ in various aspects like spatial resolution, depth
penetration and use of ionizing or nonionizing
radiation, availability of injectable and biocompatible
molecular markers (Fig. 23.1).
Certain imaging techniques have advantages and
disadvantages over others. A variety of molecular
imaging strategies are available to accomplish the
increasingly sophisticated biologic interrogation of
cells.
The choice of the imaging modality is determined
by the temporal and spatial resolution; field of
view; sensitivity of the imaging system; depth of the
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 122 Textbook of Radiology: Physics
biological process; the molecular or cellular process to
image and the availability of suitable probes and labels
that can be delivered to the imaging target.
zz Ultrasound: Molecular imaging with ultrasound
utilizes small acoustically active gas-filled micro-
bubbles as specialized contrast agents. The micro
-bubbles are often coated with lipids, proteins or
polymers, with diameters of >1µm, which confines
them to the intravascular space.
zz Optical techniques: Optical techniques include 2
major classes: fluorescence and bioluminescence
imaging. Fluorescence refers to the property of
certain molecules to absorb light at a particular
wavelength and to emit light of a longer wavelength
after a brief interval. Photon wavelength influences
the depth resolution of optical imaging techniques.
Near-infrared photons currently provide the
greatest wavelengths (650 nm to 900 nm) and the
best depth of penetration (>1 cm).
Bioluminescence imaging uses reporter genes
that lead to expression of luciferase proteins.
Upon injection of the luciferin, light is emitted as
a result of a chemical reaction involving luciferase,
luciferin, oxygen and ATP. The emitted light is
detected externally. Optical imaging techniques
are characterized by their spatial resolution varying
from several millimeters to micrometer resolution
and by their excellent sensitivity.
zz MRI: MRI provides very high resolution (up to
10 µm) and unlimited depth of penetration.
MRI is limited by its low sensitivity. Therefore,
amplification techniques are often needed to
image molecular processes. The best recognized
MRI amplification technique is the use of iron
oxide particles as contrast agents. These provide
negative MR contrast through local increase of the
relaxivity of the tissue. Superparamagnetic iron
oxide (SPIO) particles are biodegradable by cellular
enzymes and they provide the strongest contrast
available for MR imaging. Detection is possible at
micromolar concentrations of iron.
zz Nuclear medicine: Nuclear medicine techniques
provide unlimited depth penetration and have very
high sensitivities. PET and single photon emission
computed tomography (SPECT) cause radiation
exposure and has relatively low resolution (2 mm
to 5 mm for PET, 8 mm to 12 mm for SPECT). They
are the most commonly used human molecular
imaging modalities. PET has approximately
100 times higher sensitivity than SPECT, in
large measure due to the ability to avoid using
collimators during imaging. The most commonly
used PET radionuclides are 11C and 18F. SPECT
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tracers have longer half-lives, allowing the study of
molecular processes that evolve over longer times.
SPECT provides many readily usable radiotracers,
and a local cyclotron is not needed for operation.
CLINICAL APPLICATIONS
Frequently used modalities include MRI, PET and
SPECT. Optical techniques and ultrasound applications
remain of limited use but they retain high potential.
Oncology
FDG is the most widely used molecular imaging agent
in oncology. FDG is used as a marker of metabolism in
tumor cells. FDG plays a major role in the diagnosis,
evaluation and follow-up of different tumors, including
lymphoma, lung cancer, brain cancer, head-and-neck
tumors, melanoma, and breast cancer. FDG uptake
in tumors is reflective of increased glycolysis. In brain
tumors, FDG use is limited by high normal background
uptake of the tracer, since the brain uses glucose as its
main source of energy. This can be overcome by use
of C11 methionine (MET) instead of FDG due to the
lower background uptake of MET, resulting in higher
tumor-to-background ratios and better visualization
of the tumor.
DNA synthesis is another molecular imaging target
in tumors. Thymidine kinase 1 (TK1) is an enzyme
overexpressed during the DNA synthesis phase of
the cell cycle. TK1 reflects cellular proliferation.
18
F-Fluorothymidine (FLT) is a radio labeled nucleoside
analog that is phosphorylated by TK1, rendering it
unable to leave the cell. FLT has been successfully
used in the original evaluation as well as the follow-up
and assessment of treatment response in many tumors
such as lung cancer, lymphoma, head-and-neck
cancer, and breast cancer.
Coated iron oxide particles are used for MRI
detection of metastatic disease in lymph nodes or the
liver. When injected systemically iron oxide particles
are phagocytosed by macrophages and are then
transported to the lymph nodes. A metastatic lymph
node, in which the normal macrophage population
has been replaced by tumor cells, will demonstrate
partial or no drop in signal, while a normal lymph
node, in which the iron particles have localized, will
have decreased signal.
Inflammation and Infection
Increased FDG uptake can be seen in infectious and
inflammatory conditions since FDG-PET targets the
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cells with relative increase in glucose metabolism
in neoplastic cells over normal parenchymal cells.
The main limitation of using FDG in inflammation
imaging, thus, is its lack of specificity. FDG uptake of
benign tumors, inflammatory processes and malignant
neoplasms can sometimes overlap. To improve
differentiation between neoplastic and infectious/
inflammatory processes, multiple molecular imaging
targets of infection/inflammation have been evaluated.
Use of monoclonal antigranulocyte antibodies, such
99m
Tc-fanolesomab, which binds the CD15 antigen
expressed on neutrophils. Radiolabeled antibiotics,
on the other hand, have been used to directly target
bacteria, rather than reactive cells.
Neuroimaging
Alzheimer’s dementia (AD) is the most common cause
of dementia. Earlier diagnosis of AD is sought for more
accurate prognosis and education of the patients and
their families. Several gene therapy trials are being
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Molecular Imaging 123
attempted to halt or even reverse progression of AD. On
FDG-PET imaging there is decreased FDG uptake in AD
secondary to regional impairment of cerebral glucose
metabolism in neocortical association areas. Primary
visual areas, the sensorimotor cortex, basal ganglia,
and cerebellum are relatively well preserved. FDG-
PET abnormalities however are not pathognomonic of
AD. Alternative molecular imaging targets are sought
for higher specificity. The most intuitive targets are the
pathologic associates of AD, namely neurofibrillary
tangles (NFTs) and amyloid plaques (APs). Novel
PET and SPECT ligands for NFTs and APs are under
investigation. The best known amyloid ligand
currently is the 11C-labeled Pittsburgh compound B
(PIB). AD patients show increased retention of PIB
in association cortex areas known to contain large
amounts of amyloid deposits in AD, compared with
controls. However, cognitively normal controls with
higher than normal PIB uptake were noted, raising the
possibility of those subjects being predisposed to
develop AD.
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