Autofluorescence and Raman microspectroscopy of tissue sections of oral lesions

Integration of the fluorescence based portable device with the AI tools for the real-time monitoring of oral mucosal lesions

There is a need for non-invasive, sensitive, real-time, and user-friendly optical devices integrated with artificial intelligence (AI) based tools for the detection of oral mucosal lesions at early stage. Research on the development of optical devices has been executed by several research groups for the cancer detection and it is still being continued. We have also contributed towards it by developing a steady- state fluorescence-based portable device. The in-house developed device is equipped with 405 nm laser diode, UV visible spectrometer, optical components, and other accessories. Laser light irradiated on the oral cavity of diseased (cancerous) and non-diseased (normal) groups, excites the two endogenous fluorophores namely FAD and porphyrin. We observed an enhancement in the porphyrin fluorescence of cancerous patients (OSCC and Dysplasia) than the normal group. Data analysis carried out by AI tools i.e., Naïve Bayes, LDA, and QDA showed slightly higher accuracy for QDA. QDA was able to discriminate among Normal to OSCC, Normal to Dysplasia, and Dysplasia to OSCC with accuracies of 95.34%, 100%, and 97.43% respectively.

Detection of oral mucosal lesions by the fluorescence spectroscopy and classification of cancerous stages by support vector machine

Detection of oral mucosal lesions has been performed by an in-house developed fluorescence-based portable device in the present study. A laser diode of 405 nm wavelength and a UV-visible spectrometer are utilized in the portable device as excitation and detection sources. At the 405 nm excitation wavelength, the flavin adenine dinucleotide (FAD) band at 500 nm and three porphyrin bands at 634, 676, and 703 nm are observed in the fluorescence spectrum of the oral cavity tissue. We have conducted this clinical study on a total of 189 tissue sites of 36 oral squamous cell carcinoma (OSCC) patients, 18 dysplastic (precancerous) patients, and 34 volunteers. Analysis of the fluorescence data has been performed by using the principal component analysis (PCA) method and support vector machine (SVM) classifier. PCA is applied first in the spectral data to reduce the dimension, and then classification among the three groups has been executed by employing the SVM. The SVM classifier includes linear, radial basis function (RBF), polynomial, and sigmoid kernels, and their classification efficacies are computed. Linear and RBF kernels on the testing data sets differentiated OSCC and dysplasia to normal with an accuracy of 100% and OSCC to dysplasia with an accuracy of 95% and 97%, respectively. Polynomial and sigmoid kernels showed less accuracy values among the groups ranging from 48 to 88% and 51 to 100%, respectively. The result indicates that fluorescence spectroscopy and the SVM classifier can help to identify early oral mucosal lesions with significant high accuracy.

Effect of fluorescein dye concentration in oral cancer tissue: Statistical and spectroscopic analysis

Oral cancer screening with exogenous agents is highly demanding due to high sensitivity, as the early diagnosis plays a vital role in achieving favorable outcomes for oral squamous cell carcinomas (OSCC) by facilitating prompt detection and comprehensive surgical removal. Optical techniques utilizing the local application of fluorescein dye or fluorescence-guided surgery offer potential for early OSCC detection. The use of fluorescein dye in oral cancer is significantly less, and there is a need to inspect the local application of fluorescein dye in oral cancer patients. Concentration-based investigations of the dye with OSCC patients are essential to ensure accurate fluorescence-guided surgery and screening with fluorescein labeling and to mitigate possible adverse effects. Additionally, analyzing the dye distribution within OSCC tissues can provide insights into their heterogeneity, a critical indicator of malignancy. The present study includes a concentration-based statistical and spectroscopic analysis of fluorescein dye in ex-vivo and in-vivo OSCC patients. In the ex-vivo examination of OSCC tissues, five concentrations (18.66 ± 0.06, 9.51 ±    0.02, 6.38 ± 0.01, 4.80 ± 0.004, and 3.85 ± 0.002 millimolar) are employed for optical analysis. The ex-vivo OSCC tissues are analyzed for multiple statistical parameters at all concentrations, and the results are thoroughly described. Additionally, spectroscopic analysis is conducted on all concentrations for a comprehensive evaluation. Following optical analysis of all five concentrations in the ex-vivo study, two concentrations, 6.38 ± 0.01 and 4.80 ± 0.004 millimolar, are identified as suitable for conducting in-vivo investigations of oral cancer. A detailed spectroscopic and statistical study of OSCC tissues in-vivo has been done using these two concentrations.

In-vivo Testing of Oral Mucosal Lesions with an In-house Developed Portable Imaging Device and Comparison with Spectroscopy Results

Progression of oral mucosal lesions is generally marked by changes in the concentration of the intrinsic fluorophores such as collagen, nicotinamide adenine dinucleotide (NADH), flavin adenine dinucleotide (FAD) and porphyrin present in the human oral tissue. In this study, we have probed the changes in FAD and porphyrin by exciting with 405 nm laser light on different sites (tongue, buccal mucosa, lip etc.) of the oral cavity. Testing has been done by an in-house developed fluorescence-based portable imaging device on oral squamous cell carcinoma (OSCC) patients, dysplastic patients and control (normal) group. Fluorescence images recorded from OSCC and dysplastic patients have displayed an enhancement in the red band (porphyrin) as compared to those from the normal volunteers. Porphyrin to FAD intensity ratio (I_Porphyrin/I_FAD), referred to red to green ratio (I_red/I_green) has been taken as the diagnostic marker for classification among the groups. Receiver operating characteristic (ROC) analysis applied on I_Porphyrin/I_FAD is able to discriminate OSCC to normal, dysplasia to normal and OSCC to dysplasia with sensitivities of 100%, 81%, 92% and specificities of 100%, 93% and 92% respectively. Fluorescence imaging probe can capture a large area of oral lesions in a single scan and hence would be useful for initial scanning. On comparison with spectroscopy studies performed by our group, it is found that combining both spectroscopy and imaging as a device may be effective for the early detection of oral lesions. This clinical study was registered on the date 13/10/2017 in the clinical trials registry-India (CTRI) with registration number CTRI/2017/10/010102.

Multimodal widefield fluorescence imaging with nonlinear optical microscopy workflow for noninvasive oral epithelial neoplasia detection: a preclinical study

SIGNIFICANCE

Early detection of epithelial cancers and precancers/neoplasia in the presence of benign lesions is challenging due to the lack of robust in vivo imaging and biopsy guidance techniques. Label-free nonlinear optical microscopy (NLOM) has shown promise for optical biopsy through the detection of cellular and extracellular signatures of neoplasia. Although in vivo microscopy techniques continue to be developed, the surface area imaged in microscopy is limited by the field of view. FDA-approved widefield fluorescence (WF) imaging systems that capture autofluorescence signatures of neoplasia provide molecular information at large fields of view, which may complement the cytologic and architectural information provided by NLOM.

AIM

A multimodal imaging approach with high-sensitivity WF and high-resolution NLOM was investigated to identify and distinguish image-based features of neoplasia from normal and benign lesions.

APPROACH

In vivo label-free WF imaging and NLOM was performed in preclinical hamster models of oral neoplasia and inflammation. Analyses of WF imaging, NLOM imaging, and dual modality (WF combined with NLOM) were performed.

RESULTS

WF imaging showed increased red-to-green autofluorescence ratio in neoplasia compared to inflammation and normal oral mucosa (p  <  0.01). In vivo assessment of the mucosal tissue with NLOM revealed subsurface cytologic (nuclear pleomorphism) and architectural (remodeling of extracellular matrix) atypia in histologically confirmed neoplastic tissue, which were not observed in inflammation or normal mucosa. Univariate and multivariate statistical analysis of macroscopic and microscopic image-based features indicated improved performance (94% sensitivity and 97% specificity) of a multiscale approach over WF alone, even in the presence of benign lesions (inflammation), a common confounding factor in diagnostics.

CONCLUSIONS

A multimodal imaging approach integrating strengths from WF and NLOM may be beneficial in identifying oral neoplasia. Our study could guide future studies on human oral neoplasia to further evaluate merits and limitations of multimodal workflows and inform the development of multiscale clinical imaging systems.

In vivo detection of oral precancer using a fluorescence-based, in-house-fabricated device: a Mahalanobis distance-based classification

In vivo detection of oral precancer has been carried out by a fluorescence-based, in-house-developed handheld probe on three groups: oral squamous cell carcinoma (OSCC), dysplastic (precancer), and control (normal). Measurements have been performed on a total of 141 patients and volunteers of different age groups. Excitation wavelength of 405 nm was used and fluorescence emission spectra were recorded in the scan range of 450.14 to 763.41 nm at very low incident power (122 μW) from different oral sites buccal mucosa (BM), lateral boarder of tongue (LBT), and dorsal surface of tongue (DST). Spectral profiles are found to vary among the three groups as well as among the different oral sites. Major and minor bands of flavin adenine dinucleotide (FAD) and porphyrins near 500, 634, 676, 689, and 703 nm have been obtained. Porphyrin contribution is found to be more dominant than the FAD in OSCC and dysplastic groups as compared to the control group. A better classification has been observed using the entire spectral range rather than restricting to individual bands, by application of principal component analysis (PCA), Mahalanobis distance model, and receiver operating characteristic analysis (ROC). ROC on Mahalanobis distance differentiates OSCC to normal, dysplastic to normal, and OSCC to dysplastic with sensitivities from 71% to 98%, 92% to 94% and 81% to 93% and specificities 91% to 100%, 86% to 100% and 79% to 97% for oral sites BM, LBT and DST. LBT and DST appear to be more sensitive to dysplasia detection as compared to BM.

In-vivo optical imaging in head and neck oncology: basic principles, clinical applications and future directions

Head and neck cancers become a severe threat to human's health nowadays and represent the sixth most common cancer worldwide. Surgery remains the first-line choice for head and neck cancer patients. Limited resectable tissue mass and complicated anatomy structures in the head and neck region put the surgeons in a dilemma between the extensive resection and a better quality of life for the patients. Early diagnosis and treatment of the pre-malignancies, as well as real-time in vivo detection of surgical margins during en bloc resection, could be leveraged to minimize the resection of normal tissues. With the understanding of the head and neck oncology, recent advances in optical hardware and reagents have provided unique opportunities for real-time pre-malignancies and cancer imaging in the clinic or operating room. Optical imaging in the head and neck has been reported using autofluorescence imaging, targeted fluorescence imaging, high-resolution microendoscopy, narrow band imaging and the Raman spectroscopy. In this study, we reviewed the basic theories and clinical applications of optical imaging for the diagnosis and treatment in the field of head and neck oncology with the goal of identifying limitations and facilitating future advancements in the field.

Case series about ex vivo identification of squamous cell carcinomas by laser-induced autofluorescence and Fourier transform infrared spectroscopy

An ex vivo case series aimed at identification of normal laryngeal tissue from laryngeal epidermoid squamous keratinized carcinoma by measuring laser-induced autofluorescence (LIAF) and Fourier transform infrared-attenuated total reflectance (FTIR-ATR) spectra is presented. The case series results were obtained for paired samples extracted from three patients (exclusion: macroscopic changes of normal vocal cord observed during surgery; surgical intervention on vocal cord, treated only with chemotherapy or radiotherapy for carcinoma; inclusion: men, aged 57-68, non-smokers). For LIAF analysis, a 375-nm picosecond pulsed laser diode with 31 MHz pulse repetition rate, 100 ps full-time width at half-maximum, and average power 0.49 μW was used. LIAF and FTIR-ATR spectra show noticeable differences between normal and malignant tissues. LIAF spectra differed in shape of emitted band, peak position, and band relative intensity of the two kinds of samples, evidencing hypsochromic shift and mean fluorescence intensity decrease of (75.42 ± 3)% in malignant tissue with respect to the normal one. The lack of 1745 cm^-1 band in FTIR-ATR spectra for malignant tissues could be considered an important indicative of the presence of this kind of tissue; moreover, it resulted a greater contribution of lipids and proteins in normal tissue and of collagen in malignant tissue. Penetration depth of the evanescent wave was about 2 μm at an angle of 42°. The two spectroscopic methods are complementary, are applicable for real-time measurements, and may enhance cancer detection and diagnostics. Results presented in this study evidence the potential of the two methods for future in vivo studies.

Spectroscopic characterization of oral epithelial dysplasia and squamous cell carcinoma using multiphoton autofluorescence micro-spectroscopy

OBJECTIVE

Multiphoton autofluorescence microscopy (MPAM) has shown potential in identifying features that are directly related to tissue microstructural and biochemical changes throughout epithelial neoplasia. In this study, we evaluate the autofluorescence spectral characteristics of neoplastic epithelium in dysplasia and oral squamous cell carcinoma (OSCC) using multiphoton autofluorescence spectroscopy (MPAS) in an in vivo hamster model of oral neoplasia in order to identify unique signatures that could be used to delineate normal oral mucosa from neoplasia.

MATERIALS/METHODS

A 9,10-dimethyl-1,2-benzanthracene (DMBA) hamster model of oral precancer and OSCC was used for in vivo MPAM and MPAS. Multiphoton Imaging and spectroscopy were performed with 780 nm excitation while a bandpass emission 450-650 nm was used for MPAM. Autofluorescence spectra was collected in the spectral window of 400-650 nm.

RESULTS

MPAS with fluorescence excitation at 780 nm revealed an overall red shift of a primary blue-green peak (480-520 nm) that is attributed to NADH and FAD. In the case of oral squamous cell carcinoma (OSCC) and some high-grade dysplasia an additional prominent peak at 635 nm, attributed to PpIX was observed. The fluorescence intensity at 635 nm and an intensity ratio of the primary blue-green peak versus 635 nm peak, showed statistically significant difference between control and neoplastic tissue.

DISCUSSION

Neoplastic transformation in the epithelium is known to alter the intracellular homeostasis of important tissue metabolites such as NADH, FAD, and PpIX, which was observed by MPAS in their native environment. A combination of deep tissue microscopy owing to higher penetration depth of multiphoton excitation and depth resolved spectroscopy could prove to be invaluable in identification of cytologic as well as biomolecular spectral characteristic of oral epithelial neoplasia. Lasers Surg. Med. 49:866-873, 2017. © 2017 Wiley Periodicals, Inc.

Advances in fluorescent-image guided surgery

Fluorescence imaging is increasingly gaining intraoperative applications. Here, we highlight a few recent advances in the surgical use of fluorescent probes.

Investigation of the potential of Raman spectroscopy for oral cancer detection in surgical margins

The poor prognosis of oral cavity squamous cell carcinoma (OCSCC) patients is associated with residual tumor after surgery. Raman spectroscopy has the potential to provide an objective intra-operative evaluation of the surgical margins. Our aim was to understand the discriminatory basis of Raman spectroscopy at a histological level. In total, 127 pseudo-color Raman images were generated from unstained thin tissue sections of 25 samples (11 OCSCC and 14 healthy) of 10 patients. These images were clearly linked to the histopathological evaluation of the same sections after hematoxylin and eosin-staining. In this way, Raman spectra were annotated as OCSCC or as a surrounding healthy tissue structure (i.e., squamous epithelium, connective tissue (CT), adipose tissue, muscle, gland, or nerve). These annotated spectra were used as input for linear discriminant analysis (LDA) models to discriminate between OCSCC spectra and healthy tissue spectra. A database was acquired with 88 spectra of OCSCC and 632 spectra of healthy tissue. The LDA models could distinguish OCSCC spectra from the spectra of adipose tissue, nerve, muscle, gland, CT, and squamous epithelium in 100%, 100%, 97%, 94%, 93%, and 75% of the cases, respectively. More specifically, the structures that were most often confused with OCSCC were dysplastic epithelium, basal layers of epithelium, inflammation- and capillary-rich CT, and connective and glandular tissue close to OCSCC. Our study shows how well Raman spectroscopy enables discrimination between OCSCC and surrounding healthy tissue structures. This knowledge supports the development of robust and reliable classification algorithms for future implementation of Raman spectroscopy in clinical practice.

Raman spectroscopy in biomedicine - non-invasive in vitro analysis of cells and extracellular matrix components in tissues

Raman spectroscopy is an established laser-based technology for the quality assurance of pharmaceutical products. Over the past few years, Raman spectroscopy has become a powerful diagnostic tool in the life sciences. Raman spectra allow assessment of the overall molecular constitution of biological samples, based on specific signals from proteins, nucleic acids, lipids, carbohydrates, and inorganic crystals. Measurements are non-invasive and do not require sample processing, making Raman spectroscopy a reliable and robust method with numerous applications in biomedicine. Moreover, Raman spectroscopy allows the highly sensitive discrimination of bacteria. Rama spectra retain information on continuous metabolic processes and kinetics such as lipid storage and recombinant protein production. Raman spectra are specific for each cell type and provide additional information on cell viability, differentiation status, and tumorigenicity. In tissues, Raman spectroscopy can detect major extracellular matrix components and their secondary structures. Furthermore, the non-invasive characterization of healthy and pathological tissues as well as quality control and process monitoring of in vitro-engineered matrix is possible. This review provides comprehensive insight to the current progress in expanding the applicability of Raman spectroscopy for the characterization of living cells and tissues, and serves as a good reference point for those starting in the field.

Stokes shift spectroscopy pilot study for cancerous and normal prostate tissues

Stokes shift spectroscopy (S3) is an emerging approach toward cancer detection. The goal of this paper is to evaluate the diagnostic potential of the S3 technique for the detection and characterization of normal and cancerous prostate tissues. Pairs of cancerous and normal prostate tissue samples were taken from each of eight patients. Stokes shift spectra were measured by simultaneously scanning both the excitation and emission wavelengths while keeping a fixed wavelength interval Δλ=20  nm between them. The salient features of this technique are the highly resolved emission peaks and significant spectral differences between the normal and cancerous prostate tissues, as observed in the wavelength region of 250 to 600 nm. The Stokes shift spectra of cancerous and normal prostate tissues revealed distinct peaks around 300, 345, 440, and 510 nm, which are attributed to tryptophan, collagen, NADH, and flavin, respectively. To quantify the spectral differences between the normal and cancerous prostate tissues, two spectral ratios were computed. The findings revealed that both ratio parameters R1=I297/I345 and R2=I307/I345 were excellent diagnostic ratio parameters giving 100% specificity and 100% sensitivity for distinguishing cancerous tissue from the normal tissue. Our results demonstrate that S3 is a sensitive and specific technique for detecting cancerous prostate tissue.

The future of medical diagnostics: review paper

While histopathology of excised tissue remains the gold standard for diagnosis, several new, non-invasive diagnostic techniques are being developed. They rely on physical and biochemical changes that precede and mirror malignant change within tissue. The basic principle involves simple optical techniques of tissue interrogation. Their accuracy, expressed as sensitivity and specificity, are reported in a number of studies suggests that they have a potential for cost effective, real-time, in situ diagnosis.

We review the Third Scientific Meeting of the Head and Neck Optical Diagnostics Society held in Congress Innsbruck, Innsbruck, Austria on the 11th May 2011. For the first time the HNODS Annual Scientific Meeting was held in association with the International Photodynamic Association (IPA) and the European Platform for Photodynamic Medicine (EPPM). The aim was to enhance the interdisciplinary aspects of optical diagnostics and other photodynamic applications. The meeting included 2 sections: oral communication sessions running in parallel to the IPA programme and poster presentation sessions combined with the IPA and EPPM posters sessions.

Synchronous fluorescence spectroscopy for the detection and characterization of cervical cancers in vitro

The objective of this study was to assess the diagnostic potential of synchronous fluorescence (SF) spectroscopy (SFS) technique for the detection and characterization of normal and different malignancy stages of moderately differentiated squamous cell carcinoma (MDSCC), poorly differentiated squamous cell carcinoma (PDSCC) cervical tissues. SF spectra were measured from 45 biopsies from 30 patients in vitro. Characteristic, highly resolved peaks and significant spectral differences between normal and MDSCC, PDSCC cervical tissues were obtained. Nine potential ratios were calculated and used as input variables for a discriminant analysis across different groups. The potentiality of the SFS technique was estimated by two discriminant analyses. Discriminant analysis I performed across normal and abnormal (including MDSCC and PDSCC) cervical tissues classified as 100% both original and the cross-validated grouped cases. In discriminant analysis II performed across the three groups, normal, MDSCC and PDSCC, 100% of both original and the cross-validated grouped cases were correctly classified. Using the SFS technique, one can obtain all the key biochemical markers such as tryptophan, collagen, hemoglobin, reduced form of nicotinamide adenine dinucleotide and flavin adenine dinucleotide in a single scan and hence they can be targeted as tumor markers in the detection of normal from abnormal cervical tissues.

Noninvasive in vitro and in vivo assessment of epidermal hyperkeratosis and dermal fibrosis in atopic dermatitis

Atopic dermatitis (AD) is characterized by hyperkeratosis of epidermis and fibrosis within dermis in chronic skin lesions. Thus far, the histology of skin lesions has been evaluated only by examination of excised specimens. A noninvasive in vivo tool is essential to evaluate the histopathological changes during the clinical course of AD. We used Cr:forsterite laser-based multimodality nonlinear microscopy to analyze the endogenous molecular signals, including third-harmonic generation (THG), second-harmonic generation (SHG), and two-photon fluorescence (TPF) from skin lesions in AD. Significant differences in thickness of epidermis and stratum corneum (SC), and modified degrees of fibrosis in dermis (measured by THG signals and SHG signals, respectively), are clearly demonstrated in in vitro studies. Increased TPF levels are positively associated with the levels of the THG signals from the SC. Our in vitro observations of histological changes are replicated in the in vivo studies. These findings were reproducible in skin lesions from human AD. For the first time, we demonstrate the feasibility of preclinical applications of Cr:forsterite laser-based nonlinear microscopy. Our findings suggest that the optical signatures of THG, TPF, and SHG can be used as molecular markers to assess the pathophysiological process of AD and the effects of local treatment.

Microscopic localisation of protoporphyrin IX in normal mouse skin after topical application of 5-aminolevulinic acid or methyl 5-aminolevulinate

Light fractionation does not enhance the response to photodynamic therapy (PDT) after topical methyl-aminolevulinate (MAL) application, whereas it is after topical 5-aminolevulinic acid (ALA). The differences in biophysical and biochemical characteristics between MAL and ALA may result in differences in localisation that cause the differences in response to PDT. We therefore investigated the spatial distribution of protoporphyrin IX (PpIX) fluorescence in normal mouse skin using fluorescence microscopy and correlated that with the PDT response histologically observed at 2.5, 24 and 48 h after PDT. As expected high fluorescence intensities were observed in the epidermis and pilosebaceous units and no fluorescence in the cutaneous musculature after both MAL and ALA application. The dermis showed localised fluorescence that corresponds to the cytoplasma of dermal cells like fibroblast and mast cells. Spectral analysis showed a typical PpIX fluorescence spectrum confirming that it is PpIX fluorescence. There was no clear difference in the depth and spatial distribution of PpIX fluorescence between the two precursors in these normal mouse skin samples. This result combined with the conclusion of Moan et al. that ALA but not MAL is systemically distributed after topical application on mouse skin [Moan et al., Pharmacology of protoporphyrin IX in nude mice after application of ALA and ALA esters, Int. J. Cancer 103 (2003) 132-135] suggests that endothelial cells are involved in increased response of tissues to ALA-PDT using light fractionation. Histological analysis 2.5h after PDT showed more edema formation after ALA-PDT compared to MAL-PDT that was not accompanied by a difference in the inflammatory response. This suggests that endothelial cells respond differently to ALA and MAL-PDT. Further investigation is needed to determine the role of endothelial cells in ALA-PDT and the underlying mechanism behind the increased effectiveness of light fractionation using a dark interval of 2h found after ALA but not after MAL-PDT.

Analysis of ghost cells in calcifying cystic odontogenic tumors by confocal laser scanning microscopy

OBJECTIVE

The confocal laser scanning microscope represents an effective tool for studying biological samples stained for fluorescence observation. In this study we have used the confocal microscope to analyze ghost cells in calcifying cystic odontogenic tumors.

STUDY DESIGN

Specimens from 15 calcifying cystic odontogenic tumor cases were stained with hematoxylin and eosin, and scanned by a confocal laser scanning microscope to generate optically sectioned images.

RESULTS

All of the analyzed samples presented autofluorescent cells that were identified as ghost cells. The degree of autofluorescence intensity was variable and may be a result of the presence of hard keratin.

CONCLUSION

The confocal laser scanning microscope may be of help in analyzing and defining the nature and extent of keratinization processes in calcifying cystic odontogenic tumor ghost cells.