Noninvasive in vivo deoxycytidine kinase (dCK)-PET identifies tumor-draining lymph nodes upon immune checkpoint inhibitor therapy

Abstract Efficient application of immunotherapy necessitates advanced whole-body imaging techniques to monitor sites of immune cell activation. Deoxycytidine kinase (dCK), a key enzyme in the deoxynucleotide salvage pathway, is upregulated in proliferating immune cells and can be targeted by the radiotracers [ 18 F]FAC (preclinical) and [ 18 F]CFA (clinical), allowing for noninvasive monitoring of immune activation in lymphatic organs via positron emission tomography (PET). In this study, we aimed to assess the efficacy of [ 18 F]FAC in detecting immune activation upon immune checkpoint inhibitor therapy (CIT). In vitro, activated T cells and macrophages exhibited significantly higher [ 18 F]FAC uptake compared to their naïve counterparts. In vivo, preclinical [ 18 F]FAC-PET/MRI revealed a CIT-induced significant increase in [ 18 F]FAC uptake in tumor-draining lymph nodes (TDLNs) compared to contralateral lymph nodes, independent of tumor responsiveness. This phenomenon was absent in TDLNs of sham-treated experimental mice. Ex vivo cell sorting further confirmed elevated [ 18 F]FAC uptake in T cells from TDLNs following CIT. Consistently, [ 18 F]CFA-PET/CT imaging in metastatic melanoma patients demonstrated CIT-induced enhanced regional LN uptake. Together, these findings establish a strong correlation between CIT-induced immune activation and [ 18 F]FAC/[ 18 F]CFA uptake, underscoring the critical role of TDLNs in cancer immuotherapy. The radiotracers [ 18 F]FAC and [ 18 F]CFA provide valuable tools for noninvasive monitoring of immune cell activation, potentially unveiling tumor-microenvironment-related resistance mechanisms and advancing the utility of PET imaging in immunotherapy monitoring and patient stratification.