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Development of the

[
18
F]Fluorodeoxyglucose Method:
A Serendipitous Journey
From Bench to Bedside
Louis Sokoloff, NIMH
Presented at
Brookhaven National Laboratory
October 19, 2012
as the New York Section
of the American Chemical Society
honors BNL Chemistry Department
2 3
After the wars end, Bush actively cam-
paigned in support of the idea that a rich nation
like the USA could and should, in its own best
interests, support scientists to conduct basic
research of their own choosing and curiosity,
and this would ultimately prove benecial to the
country and to humanity. The many fortuitous
circumstances in the development of the
18
FDG
method and its applications are, I believe, an
excellent example of the validity of his vision.
As a participant in this history, I would like to
briey review the background and history of
its development.
In 1948 Seymour Kety and Carl Schmidt
published their nitrous oxide method for the
measurement of average rates of blood ow and
oxygen consumption in the brain as whole in
human beings. Applications of this method
demonstrated changes in the brains energy
metabolism in conditions in which conscious-
ness was depressed, but failed to detect any
changes in conditions in which normal brain
functions were certainly altered, such as normal
sleep, performance of arithmetical calculations,
and a number of other conditions. This was in
contrast to ndings in other organs in which
altered functional activities were clearly
associated with changes in oxygen consumption
and blood ow. A popular explanation for the
failure to nd the same in brain was that the
energy required for specic functions in the
brain was negligible compared to the energy
consumed by the baseline housekeeping
functions of the brain. Kety and his group,
however, hypothesized that specic functions
are localized to specic regions of
the brain, and that when they are altered,
their effects on metabolism and blood ow
are localized only to those regions and diluted
out in measurements of average rates of blood
ow and energy metabolism in the brain as a
whole. What was needed, we believed, was a
Congratulations
Local changes in blood ow in brain associated with visual stimulation
Functional activity is localized to specic cells, e.g., neurons, which do not have their own private
blood ows. Blood ow supplies a wider area surrounding the cells, and, furthermore, cerebral blood
ow is markedly affected by chemical constituents in the blood. Energy metabolism, however, is
conned only to cells, and could, therefore, be expected to provide more specic and better spatial
localization within the brain. Glucose is an essential and the almost exclusive substrate for the brains
energy metabolism, and its consumption is almost completely stoichiometric with the brains oxygen
Congratulations to Joanna Fowler and the Chemistry Laboratory at the Brookhaven National
Laboratory for this honor being bestowed on them by the American Chemical Society. It is well
deserved. I regret that health issues prevent my direct participation in this celebration, but I hope
that this videotape will be an acceptable substitute.
In 1944 Vannevar Bush, President Roosevelts Science Advisor during World War II, sent him
a memorandum which contained the following passage below.
method to measure energy metabolism and/or
blood ow locally in the appropriate anatomical
regions of the brain.
There was at that time no obvious approach
to measuring local brain energy metabolism.
Kety, however, had previously worked on the
principles of inert gas exchange between blood
and tissues which included a theoretical basis
for a method for measuring local rates of blood
ow in the brain. Kety, and a group of us that
included William Landau, Walter Freygang,
Lewis Rowland, and myself, applied these
principles to develop a method for measuring
local cerebral blood ow. We used the freely
diffusible, radioactive gas
131
I-labeled triuo-
roiodomethane as the tracer because
it is chemically and biologically inert in tracer
amounts, and its radioactive label facilitated
assay of its concentrations in the blood and
brain tissues that were required by the method.
Blood concentrations were measured by
standard scintillation counting. Local brain
tissue concentrations were measured by a
specially developed quantitative autoradiograph-
ic technique applied to frozen brain sections,
which, of course, limited use of the method to
animals. The autoradiograms displayed images
of the labels distribution within the brain slices
as well as those of calibrated standards from
which local tissue tracer concentrations could
be determined by densitometry. The local tissue
blood ows could then be computed from the
tissue and blood concentrations. Fortuitously,
with the procedure adopted, the local tissue
tracer concentrations imaged in the autoradio-
grams closely reected the local rates of blood
ow, the darker the image, the greater the blood
ow. Applications of the method clearly showed
that blood ow does indeed increase and could
be visualized in the functionally activated regions
of the brain. For example, visual stimulation with
light ashes increased blood ow in those
regions involved in vision that was clearly visible
in the autoradiograms.
Eyes Patched Eyes Open & Stimulated with Light Flashes
The Endless Frontier
(Excerpted From Scientic Advisor Vannevar Bushs Recommendation
to President Roosevelt in 1944)
SUMMARY OF THE REPORT
SCIENTIFIC PROGRESS IS ESSENTIAL
Progress in the war against disease depends upon a ow of new scientic knowledge.
New products, new industries, and more jobs require continuous additions to knowledge
of the laws of nature, and the application of that knowledge to practical purposes. Similarly,
our defense against aggression demands new knowdledge so that we can develop new
and improved weapons. This essential, new knowledge
can be obtained only through basic scientic research.
Functional Activation of Local Cerebral Blood Flow in Visual Pathways
4 5
Sols and Crane had previously reported
that 2-deoxyglucose could be phosphorylated
to 2-deoxyglucose-6-phosphate by glucose
hexokinase, the enzyme that catalyzes the phos-
phorylation of glucose to glucose-6-phosphate,
the rst step in the glycolytic pathway of glucose
metabolism. The 2-deoxyglucose-induced coma
could not. however, be due to competitive inhibi-
tion of glucose utilization at this step because
the coma could not be reversed by glucose
administration. In 1959, I learned about studies
by Wick, Tower, and their respective cowork-
ers that claried the mechanism. Both glucose
and deoxyglucose cross the blood-brain barrier
and are converted in the brain by hexokinase to
their hexose-6-phosphate derivatives. Nor-
mally, the glucose-6-phophate is isomerized by
glucose-6-phosphate isomerase to fructose-
6-phosphate, which is then metabolized down
the glycolytic pathway to pyruvate and lactate,
which are then oxidized to CO
2
and H
2
O.
2-Deoxyglucose-6-phosphate can also bind
to the glucose-6-phosphate isomerase, but be-
cause it lacks the hydroxyl group in its 2-carbon
position, it cannot be isomerized, and other
enzyme activities that might remove it are negli-
gible in brain. The 2-deoxygluose-6-phosphate,
therefore, accumulates in the brain, and with
pharmacological doses of 2-deoxyglucose rises
to levels high enough to competitively inhibit
glucose-6-phosphate conversion to fructose-
6-phoshate, thus blocking glucose utilization and
causing coma. On learning that its phosphorylat-
ed product remains and accumulates in brain, it
occurred to me that radioactive 2-deoxyglucose,
in tracer doses too low to block glycolysis, might
be used with the quantitative autoradiographic
technique to measure local rates of glucose
phosphorylation and thus glucose utilization
in the brain. Differences in enzyme kinetics
between glucose and 2-deoxyglucose phos-
phorylation by hexokinase would, of course, have
to be addressed. My lab was then fully engaged
in studies of biochemical mechanisms of action
of thyroid hormones, and so I led the idea away
for future study.
In 1964 Martin Reivich joined us at NIH where
he modied the [
131
I]triuoroiodomethane auto-
radiographic local blood method for use with a
non-volatile
14
C-labeled tracer. He used [
14
C]anti-
pyrine as the tracer which required adapting the
quantitative autoradiographic technique for use
Kinetic Model and Operational Equation of 2-[
14
C]Deoxyglucose Method
Chemical Structure of Glucose, 2-Deoxyglucose, and
3-O-Methylglucose
consumption. I, therefore, made an attempt to use radioactive glucose and the quantitative autoradiographic
technique to measure local rates of glucose utilization in the brain, but failed because the labeled products of
glucose metabolism, carbon dioxide and water, were lost too rapidly from the brain.
In 1957 I learned that high doses of the glucose analogue, 2-deoxyglucose, caused a coma very much
like insulin-induced hypoglycemic coma.
D-GLUCOSE 2-DEOXY-D-GLUCOSE 3-O-METHYL-D-GLUCOSE
with
14
C. The availability of quantitative
14
C-autora-
diography resurrected the idea of using
14
C-labeled
2-deoxyglucose to measure local cerebral glucose
utilization. Shortly after he returned to the University
of Pennsylvania in 1966, Reivich and I initiated a
collaboration to develop such a method. The initial
experiments were done with brain slices in his lab,
and they conrmed that the approach was feasible.
We then developed a model and operational equa-
tion that were based on the one used for the local
blood ow technique but with the addition of a term
for metabolic trapping of the tracer. The model
was theoretically sound but technically impractical
because it required simultaneous measurements
of local cerebral blood ow along with the 2-[
14
C]
deoxygluose uptake and also included some
parameters that were difcult to quantify.
Again serendipitously, in 1968 I took the oppor-
tunity to spend a sabbatical year in the Laboratory
of General and Comparative Biochemistry in the
College of France in Paris. I joined an ongoing
project on the peroxidase-catalyzed iodination of
tyrosine residues in proteins, a model system for
thyroxine biosynthesis in the thyroid gland. The
reaction exhibited very atypical enzyme kinetics
which required me to become relatively procient
in enzyme kinetics. This new knowledge led me to
consider a new approach to the 2-deoxyglucose
method, one based on enzyme kinetics. Soon after
returning to NIH, studies based on this idea were
initiated in collaboration with Charles Kennedy,
Michel des Rosiers, and others at NIH, and Reivich
at Penn.
By 1974 a model
based on enzyme kinet-
ics was designed from
which an operational
equation was derived
and a practical method
using
14
C autoradiog-
raphy developed. The
method was rst applied
in rats and monkeys.
,
6 7
As with the autoradiographic blood ow meth-
ods, the optical densities for the various tissues
in autoradiograms closely reected the rates of
glucose utilization, The autoradiograms, therefore,
provided visual representations of the relative
rates of local glucose utilization within the brain.
Applications of the method demonstrated dramatic
changes in glucose utilization in brain regions with
altered local functional activities that were easily
visualized in the autoradiograms.
Functional Imaging with 2-[
14
C]Deoxyglucose in the Visual Cortex
ACS: Visualizing Brain Chemistry in Action
Both Eyes Open Both Eyes Patched Right Eye Patched
The manual densitometry of the autoradiograms that the method required for full quantication
was tedious and time-consuming. We, therefore, acquired a computerized scanning microdensitome-
ter which scanned the lms and stored the local optical densities in a computer. Charles Goochee and
Wayne Rasband in our lab developed a program that used these stored optical densities to compute
the local rates of glucose utilization and then to reconstruct and display brain images in color with the
local rates of glucose utilization encoded in a scale based on the visible spectrum, the lower the rate
of glucose utilization, the lower the wave-length. The program was used in collaborative studies of vi-
sual functions in the monkey carried out with Mort Mishkins Laboratory of Neuropsychology at NIMH.
It was rst presented publicly at the Annual Meeting of the Society for Neuroscience in St. Louis in
1978 and was sensationally received. In fact, Chemical and Engineering News featured it on the
cover of its issue reporting on the meeting.
After its successful use in the laboratory,
Martin Reivich raised the question of adapting
the [
14
C]deoxyglucose method for use in man.
I was skeptical because it required autoradiog-
raphy of brain slices, not possible with humans.
Reivich then told us of a single-photon scanner
that Dave Kuhl had developed at. Penn.. This
instrument consisted of an array of scintillation
counter detectors that scanned the human brain
in vivo for -radiation and reproduced images
of the local isotope concentrations in cross-
sections of the brain. Deoxyglucose, however,
contains only hydrogen, oxygen, and carbon.
Hydrogen has no -emitting isotopes, and
oxygen and carbon have -emitting isotopes, but
with half-lives that seemed too short for organic
synthesis of labeled deoxyglucose. Serendipi-
tously, I belonged at that time to a wine-tasting
club of NIH biochemists. One of them, Peter
Goldman, was working on enzyme actions on
uorinated analogues of natural substrates, and
I knew of his nding that glutamic decarboxylase,
the enzyme that decarboxylates glutamate to
form the natural neurotransmitter -aminobutyric
acid, GABA, could also convert uoro-glutamate
to uoro-GABA. The explanation was that
because the uorine atom is so small, when
it replaces a hydrogen atom in a non-critical
position in the substrate, the enzyme acts on it
just like on the natural substrate. This suggested
that we use a -emitting uorinated analogue of
2-deoxyglucose. On searching the handbooks
of radioisotopes in my ofce, we found
18
F, a
-ray emitter with a 110 minute half-life. Now
the problem was how to synthesize
18
F-labeled-
uorodeoxyglucose.
Reivich returned to Penn with this idea,
and he and Kuhl organized a meeting at Penn
to discuss the possibility of using
18
F-labeled
uorodeoxyglucose with Kuhls scanner. Al Wolf
and Joanna Fowler, radiochemists from the
Brookhaven National Laboratory, were invited
and attended. The rst issue to be considered
was where to insert the
18
F in the deoxyglucose
molecule. Because the phosphorylation by hexo-
kinase is on the 6-carbon, it was reasoned that
the
18
F should be placed on a carbon as far from
the 6-position as possible. A uorine bonded
to the 1-carbon would be unstable, and so we
decided on the next most distant carbon, the
2-carbon. Wolf and Fowler were condent that
they could synthesize 2-
18
F-2-deoxyglucose-
D-glucose (2-
18
FDG). We asked them, however,
to rst synthesize
14
C-labeled 2-FDG so that we
could examine if it was phosphorylated by brain
hexokinase and behaved like 2-[
14
C]deoxyglu-
cose in the rat brain. They did so, and we used it
to conrm that 2-FDG was as good a tracer for
glucose metabolism in brain as 2-deoxyglucose.
8 9
Autoradiograms of Rat Brains Labeled with
14
C-Labeled
Glucose Analogs
Wolf, postdoctoral Tatsuo Ido, and Fowler succeeded in developing a synthesis of 2-
18
FDG,
produced it in their lab in Brookhaven, and sent it to Penn where Reivich and Kuhl successfully used
it with Kuhls Mark IV scanner to measure, for the rst time, regional rates of glucose utilization in
the human brain.
Mark IV Scans of Regional Cerebral Glucose Utilization
in the Human Brain
PET
18
FDG Scans of Human Brain
18
FDG Studies of Drug Abuse
2-[
18
F]Fluorodeoxyglucose (
18
FDG)
Scan of Human Brain Done with with
Kuhls MARK IV Single Photon Scanner
Brookhaven National
Laboratory
Soon afterward, Kuhl moved to UCLA in
Los Angeles and took Michael Phelps and
Ed Hoffman with him. Both had been gradu-
ate students with Michael Ter-Pergossian at
Washington University where they developed
the rst Positron Emission Tomographic (PET)
scanners, and they soon acquired a PET scanner
at UCLA.
18
F is a positron emitter; and its -ray
emissions are derived from the interaction of the
emitted positrons with electrons in the absorbing
medium which results in two annihilation -rays
of equal energies radiating from the tissue at
approximately 180 with respect to each other.
Coincident counting of these -rays enables
much better spatial resolution and quantitative
accuracy than single photon tomography. Phelps,
Hoffman, and Kuhl then proceeded to adapt the
18
FDG method for use with PET scanning, and
they successfully applied it in a variety of normal
and pathological human conditions.
The publication of many applications of the
18
FDG method by the UCLA group and the
commercial availability of PET scanners led
to a proliferation of centers using the
18
FDG
method. The Chemistry Laboratory of the
Brookhaven National Laboratory soon acquired
one, and under the leadership of rst Al Wolf
and, subsequently, Joanna Fowler, it became
one of the worlds leading PET centers. It carried
out many outstanding studies, including the
classic studies by Joanna Fowler, Nora Volkow,
and their collaborators, in which they used the
18
FDG method to identify the sites and some of
the mechanisms of drug addiction in the brain of
addicted patients.
The legendary French chemist, Louis Pasteur, in studies of wine-production, had found that
glycolysis, the metabolic pathway that produces ethanol from glucose in yeast, is inhibited by oxygen.
This so-called Pasteur Effect also occurs in mammalian tissues in which the glycolytic conversion
of glucose to pyruvate and/or lactate is negatively regulated by oxygen consumption. The German
biochemist, Otto Warburg found that this negative regulation is impaired in tumor tissues, and be-
cause of this defect, glucose utilization in tumor cells is less inhibited by aerobic oxygen metabolism.
Consequently, glucose is consumed more rapidly in tumor tissues than in normal tissue, and the more
transformed and malignant the cells, the higher the rate of glucose utilization. Giovanni di Chiro at NIH
was the rst one to exploit this trait to localize and grade the malignancy of brain tumors in human
patients by means of
18
FDG and PET.
10
Localization of Brain Tumor with
18
FDG and PET
This biochemical abnormality in tumor tissue
is now the basis of the wide use of the
18
FDG
method to diagnose, localize, and stage a variety
of primary and metastatic malignant tumors.
18
FDG, I have been told, is now the most com-
monly used radiochemical in nuclear medicine
and is of great value in the practice of oncology
and clinical medicine.
When the 2-[
14
C]DG method was rst
presented at the Annual Meeting of the American
Society for Neurochemistry in 1944, the eminent
neurochemist Norman Radin remarked about
what a crazy idea it was to use an inhibitor of
a metabolic pathway to measure the rate of ux
through that pathway. It was indeed a crazy idea,
and yet the Federal government supported all
the basic research at NIH, Penn, Brookhaven,
and UCLA that led to the development of the
2-[
14
C]DG and
18
FDG methods. Who could have
foreseen that pursuing so basic a question of
whether functional activity in brain uses energy
would eventually lead to such practical benets
to the practice of medicine and to mankind?
What a conrmation of Vannevar Bushss
wisdom!
Glioblastoma
The Endless Frontier
(Excerpted From Scientic Advisor Vannevar Bushs Recommendation
to President Roosevelt in 1944)
SUMMARY OF THE REPORT
SCIENTIFIC PROGRESS IS ESSENTIAL
Progress in the war against disease depends upon a ow of new scientic knowledge.
New products, new industries, and more jobs require continuous additions to knowledge
of the laws of nature, and the application of that knowledge to practical purposes. Simi-
larly, our defense against aggression demands new knowdledge so that we can develop
new and improved weapons. This essential, new knowledge
can be obtained only through basic scientic research.
NOTES
7
ENERGY
U.S. DEPARTMENT OF

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