Gastrointestinal stromal tumours: incidence, recurrence and mortality. A decade of patients from a New Zealand tertiary surgical centre.

BACKGROUND: Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract. The New Zealand (NZ) population incidence has not previously been documented nor has the potential effect of ethnicity been reviewed. We furthermore wanted to assess the difference between those undergoing a wedge resection versus a more extensive operation which we hypothesised would correlate with recurrence and mortality. METHODS: All patients (n = 103) with a GIST diagnosed and treated at Te Whatu Ora Waitemata (Auckland, New Zealand) between 2012 and 2021 are presented. Patient demographics, method of GIST detection, management approach, index surgery, histological features, use of adjuvant and neoadjuvant imatinib, follow-up, recurrence and mortality rates were analysed. RESULTS: This paper reports the largest NZ GIST cohort to date and estimates an incidence of 17 cases per million per year. Eighty-four patients underwent surgical resection, 58 received a wedge resection and 17 received a more extensive operation. Five-year disease-free survival rates were 100% in the low/very low risk, 90% in the intermediate and 59% in the high risk groups as determined by the modified NIH criteria. Our overall 5-year GIST-specific survival rate was 83%; it was 91% in those who underwent a wedge resection and 60% in the extensive operation group. There is evidence that Maori have higher rates of GIST recurrence compared to non-Maori and are more likely to require an extensive surgical resection.

Microliter-scale reaction arrays for economical high-throughput experimentation in radiochemistry.

The increasing number of positron-emission tomography (PET) tracers being developed to aid drug development and create new diagnostics has led to an increased need for radiosynthesis development and optimization. Current radiosynthesis instruments are designed to produce large-scale clinical batches and are often limited to performing a single synthesis before they must be decontaminated by waiting for radionuclide decay, followed by thorough cleaning or disposal of synthesizer components. Though with some radiosynthesizers it is possible to perform a few sequential radiosyntheses in a day, none allow for parallel radiosyntheses. Throughput of one or a few experiments per day is not well suited for rapid optimization experiments. To combat these limitations, we leverage the advantages of droplet-radiochemistry to create a new platform for high-throughput experimentation in radiochemistry. This system contains an array of 4 heaters, each used to heat a set of 16 reactions on a small chip, enabling 64 parallel reactions for the rapid optimization of conditions in any stage of a multi-step radiosynthesis process. As examples, we study the syntheses of several 18F-labeled radiopharmaceuticals ([18F]Flumazenil, [18F]PBR06, [18F]Fallypride, and [18F]FEPPA), performing > 800 experiments to explore the influence of parameters including base type, base amount, precursor amount, solvent, reaction temperature, and reaction time. The experiments were carried out within only 15 experiment days, and the small volume (~ 10 µL compared to the ~ 1 mL scale of conventional instruments) consumed ~ 100 × less precursor per datapoint. This new method paves the way for more comprehensive optimization studies in radiochemistry and substantially shortening PET tracer development timelines.

A simple and efficient automated microvolume radiosynthesis of [18F]Florbetaben.

BACKGROUND: Current automated radiosynthesizers are generally optimized for producing large batches of PET tracers. Preclinical imaging studies, however, often require only a small portion of a regular batch, which cannot be economically produced on a conventional synthesizer. Alternative approaches are desired to produce small to moderate batches to reduce cost and the amount of reagents and radioisotope needed to produce PET tracers with high molar activity. In this work we describe the first reported microvolume method for production of [18F]Florbetaben for use in imaging of Alzheimer's disease. PROCEDURES: The microscale synthesis of [18F]Florbetaben was adapted from conventional-scale synthesis methods. Aqueous [18F]fluoride was azeotropically dried with K2CO3/K222 (275/383 nmol) complex prior to radiofluorination of the Boc-protected precursor (80 nmol) in 10 µL DMSO at 130 °C for 5 min. The resulting intermediate was deprotected with HCl at 90 °C for 3 min and recovered from the chip in aqueous acetonitrile solution. The crude product was purified via analytical scale HPLC and the collected fraction reformulated via solid-phase extraction using a miniature C18 cartridge. RESULTS: Starting with 270 ± 100 MBq (n = 3) of [18F]Fluoride, the method affords formulated product with 49 ± 3% (decay-corrected) yield,> 98% radiochemical purity and a molar activity of 338 ± 55 GBq/µmol. The miniature C18 cartridge enables efficient elution with only 150 µL of ethanol which is diluted to a final volume of 1.0 mL, thus providing a sufficient concentration for in vivo imaging. The whole procedure can be completed in 55 min. CONCLUSIONS: This work describes an efficient and reliable procedure to produce [18F]Florbetaben in quantities sufficient for large-scale preclinical applications. This method provides very high yields and molar activities compared to reported literature methods. This method can be applied to higher starting activities with special consideration given to automation and radiolysis prevention.

Multi-GBq production of the radiotracer [18F]fallypride in a droplet microreactor.

Microfluidics offers numerous advantages for the synthesis of short-lived radiolabeled imaging tracers: performing 18F-radiosyntheses in microliter-scale droplets has exhibited high efficiency, speed, and molar activity as well as low reagent consumption. However, most reports have been at the preclinical scale. In this study we integrate a [18F]fluoride concentrator and a microdroplet synthesizer to explore the possibility of synthesizing patient doses and multi-patient batches of clinically-acceptable tracers. In the integrated system, [18F]fluoride (up to 41 GBq [1.1 Ci]) in [18O]H2O (1 mL) was first concentrated ∼80-fold and then efficiently transferred to the 8 µL reaction chip as a series of small (∼0.5 µL) droplets. Each droplet rapidly dried at the reaction site of the pre-heated chip, resulting in localized accumulation of large amounts of radioactivity in the form of dried [18F]TBAF complex. The PET tracer [18F]fallypride was synthesized from this concentrated activity in an overall synthesis time of ∼50 min (including radioisotope concentration and transfer, droplet radiosynthesis, purification, and formulation), in amounts up to 7.2 GBq [0.19 Ci], sufficient for multiple clinical PET scans. The resulting batches of [18F]fallypride passed all QC tests needed to ensure safety for clinical injection. This integrated technology enabled for the first time the impact of a wide range of activity levels on droplet radiosynthesis to be studied. Furthermore, this substantial increase in scale expands the applications of droplet radiosynthesis to the production of clinically-relevant amounts of radiopharmaceuticals, and potentially even centralized production of clinical tracers in radiopharmacies. The overall system could be applied to fundamental studies of droplet-based radiochemical reactions, or to the production of radiopharmaceuticals labeled with a variety of isotopes used for imaging and/or targeted radiotherapeutics.

Ultra-compact, automated microdroplet radiosynthesizer.

Application of microfluidics offers numerous advantages in the field of radiochemistry and could enable dramatic reductions in the cost of producing radiotracers for positron emission tomography (PET). Droplet-based microfluidics, in particular, requires only microgram quantities of expensive precursors and reagents (compared to milligram used in conventional radiochemistry systems), and occupies a more compact footprint (potentially eliminating the need for specialized shielding facilities, i.e. hot cells). However, the reported platforms for droplet radiosynthesis have several drawbacks, including high cost/complexity of microfluidic reactors, requirement for manual intervention (e.g. for adding reagents), or difficulty in precise control of droplet processes. We describe here a platform based on a particularly simple chip, where reactions take place atop a hydrophobic substrate patterned with a circular hydrophilic liquid trap. The overall supporting hardware (heater, rotating carousel of reagent dispensers, etc.) is very simple and the whole system could be packaged into a very compact format (about the size of a coffee cup). We demonstrate the consistent synthesis of [18F]fallypride with high yield, and show that protocols optimized using a high-throughput optimization platform we have developed can be readily translated to this device with no changes or re-optimization. We are currently exploring the use of this platform for routine production of a variety of 18F-labeled tracers for preclinical imaging and for production of tracers in clinically-relevant amounts by integrating the system with an upstream radionuclide concentrator.

A novel multi-reaction microdroplet platform for rapid radiochemistry optimization.

During the development of novel tracers for positron emission tomography (PET), the optimization of the synthesis is hindered by practical limitations on the number of experiments that can be performed per day. Here we present a microliter droplet chip that contains multiple sites (4 or 16) to perform reactions simultaneously under the same or different conditions to accelerate radiosynthesis optimization.

Automated concentration of [18F]fluoride into microliter volumes.

Concentration of [18F]fluoride has been mentioned in literature, however, reports have lacked details about system designs, operation, and performance. Here, we describe in detail a compact, fast, fully-automated concentration system based on a micro-sized strong anion exchange cartridge. The concentration of radionuclides enables scaled-up microfluidic synthesis. Our system can also be used to provide highly concentrated [18F]fluoride with minimal water content. We demonstrate how the concentrator can produce varying concentrations of [18F]fluoride for the macroscale synthesis of N-boc-5-[18F]fluoroindole without an azeotropic drying process, while enabling high starting radioactivity. By appropriate choice of solid-phase resin, flow conditions, and eluent solution, we believe this approach can be extended beyond [18F]fluoride to other radionuclides.

Performing multi-step chemical reactions in microliter-sized droplets by leveraging a simple passive transport mechanism.

Despite the increasing importance of positron emission tomography (PET) imaging in research and clinical management of disease, access to myriad new radioactive tracers is severely limited due to their short half-lives (which requires daily production) and the high cost and complexity of tracer production. The application of droplet microfluidics based on electrowetting-on-dielectric (EWOD) to the field of radiochemistry can significantly reduce the amount of radiation shielding necessary for safety and the amount of precursor and other reagents needed for the synthesis. Furthermore, significant improvements in the molar activity of the tracers have been observed. However, widespread use of this technology is currently hindered in part by the high cost of prototype chips and the operating complexity. To address these issues, we developed a novel microfluidic device based on patterned wettability for multi-step radiochemical reactions in microliter droplets and implemented automated systems for reagent loading and collection of the crude product after synthesis. In this paper, we describe a simple and inexpensive method for fabricating the chips, demonstrate the feasibility of prototype chips for performing multi-step radiochemical reactions to produce the PET tracers [18F]fallypride and [18F]FDG, and further show that synthesized [18F]fallypride can be used for in vivo mouse imaging.

Automatic concentration and reformulation of PET tracers via microfluidic membrane distillation.

Short-lived radiolabeled tracers for positron emission tomography (PET) must be rapidly synthesized, purified, and formulated into injectable solution just prior to imaging. Current radiosynthesizers are generally designed for clinical use, and the HPLC purification and SPE formulation processes often result in a final volume that is too large for preclinical and emerging in vitro applications. Conventional technologies and techniques for reducing this volume tend to be slow, resulting in radioactive decay of the product, and often require manual handling of the radioactive materials. We present a fully-automated microfluidic system based on sweeping gas membrane distillation to rapidly perform the concentration and formulation process. After detailed characterization of the system, we demonstrate fast and efficient concentration and formulation of several PET tracers, evaluate residual solvent content to establish the safety of the formulated tracers for injection, and show that the formulated tracer can be used for in vivo imaging.