Fluorescence-guided surgery in colorectal cancer; A review on clinical results and future perspectives

Raman spectroscopy for colorectal tumor margin assessment: A promising tool for real-time surgical delimitation

Raman spectroscopy is a promising non-invasive technique not only for the rapid and accurate detection of colorectal cancer (CRC) but also for the identification of positive surgical margins. In this study, micro-Raman spectroscopy was used to explore biochemical differences in surgically resected intestinal segments, with a focus on boundary tumor zone. Spectral and statistical analyses, including Partial least squares discriminant analysis (PLS-DA), were performed to identify significant molecular signatures and distinguish different tissue types. Our findings suggest that boundary tumor zone contain a mix of cancerous and normal cells, complicating the discrimination of these regions. Despite this challenge, we achieved a classification accuracy of 82 % for tumor margin differentiation from normal tissue along with identifying several biochemically significant spectroscopic differences. Rapid Raman measurements using a portable system, taken from resected tissues immediately after surgery, further demonstrated the technique's ability to differentiate cancerous from healthy tissues with 97 % accuracy, 98 % sensitivity, and 96 % specificity, underscoring the potential of Raman spectroscopy for real-time clinical applications in CRC surgery.

A new EGFR and c-Met bispecific NIR-II fluorescent probe for visualising colorectal cancer and metastatic lymph nodes

BACKGROUND

The aim of the study was to increase the specificity and targeting of tumour imaging, targeting molecules that enable the simultaneous recognition and binding of multiple tumour-associated receptors. We constructed a NIR-II fluorescence probe based on a bispecific antibody to epidermal growth factor receptor (EGFR) and cellular mesenchymal-epithelial transition factor (c-Met) for visualising colorectal cancers (CRCs) and metastatic lymph nodes.

METHODS

The expression of EGFR and c-Met in tumour and metastatic lymph node specimens from patients with CRC was examined using immunohistochemistry. The EGFR and c-Met bispecific antibody (Rybrevant) was labelled, and its cell-specific binding ability was assessed using laser confocal microscopy. Subcutaneous CRC and orthotopic tumour models were constructed to evaluate the fluorescence imaging of the probe in vivo. To assess the performance of Rybrevant-IRDye800CW in the differential diagnosis of metastatic lymph nodes, a CRC lymph node metastasis model was constructed using human CRC cells implanted in mouse claw pads. Finally, surgically resected CRC tumours and lymph node specimens were incubated with Rybrevant-IRDye800CW for fluorescence NIR-II imaging to evaluate the efficacy of Rybrevant-IRDye800CW for preclinical visualisation.

FINDINGS

The combined expression rate of EGFR and c-Met in CRC and metastatic lymph nodes was significantly higher than the single-target expression rate. The bispecific probe Rybrevant-IRDye800CW was successfully synthesised, and its fluorescence signal could be extended up to 1600 nm using NIR-II imaging. Cell incubation experiments showed that the fluorescence intensity of Rybrevant-IRDye800CW was strongly correlated with EGFR and c-Met overexpression of the cells. NIR-II in vivo fluorescence imaging showed that double-positively expressing subcutaneous tumours significantly uptook Rybrevant-IRDye800CW after tail vein injection of the probe, which rapidly accumulated within the tumours in about 6 h. In EGFR and or c-Met blockade assays, subcutaneous tumours showed weaker uptake of Rybrevant-IRDye800CW. Similarly, Rybrevant-IRDye800CW was specifically identified in orthotopic CRC and lymph node metastasis models, with all orthotopic tumours showing high tumour-to-background ratios in NIR-II imaging. In a NIR-II preclinical study, Rybrevant-IRDye800CW could specifically identify fresh human CRC and its metastatic lymph node tissue.

INTERPRETATION

This study confirmed the complementary EGFR and c-Met expression in CRC and its metastatic lymph nodes. Compared to single-target probes, EGFR and c-Met dual-specific fluorescent probes identified CRC and its metastatic lymph nodes using NIR-II imaging. Thus, NIR-II-guided R0 surgery was performed to resect the CRC and metastatic lymph nodes.

FUNDINGS

This study was supported by the Beijing Natural Science Foundation (Grant numbers: L222054, 7244517, 4232058, L248026, L232020), National Natural Science Foundation of China (NSFC) (92059207, 92359301, 92259303, 62027901, 81930053, 81227901, U21A20386), CAS Youth Interdisciplinary Team (JCTD-2021-08), and the Fundamental Research Funds for the Central Universities (Grant no. JK2024-2-35-02).

The optimization and application of photodynamic diagnosis and autofluorescence imaging in tumor diagnosis and guided surgery: current status and future prospects

Photodynamic diagnosis (PDD) and autofluorescence imaging (AFI) are emerging cancer diagnostic technologies that offer significant advantages over traditional white-light endoscopy in detecting precancerous lesions and early-stage cancers; moreover, they hold promising potential in fluorescence-guided surgery (FGS) for tumors. However, their shortcomings have somewhat hindered the clinical application of PDD and AFI. Therefore, it is imperative to enhance the efficacy of PDD and AFI, thereby maximizing their potential for practical clinical use. This article reviews the principles, characteristics, current research status, and advancements of PDD and AFI, focusing on analyzing and discussing the optimization strategies of PDD and AFI in tumor diagnosis and FGS scenarios. Considering the practical and technical feasibility, optimizing PDD and AFI may result in an effective real-time diagnostic tool to guide clinicians in tumor diagnosis and surgical guidance to achieve the best results.

Biodegradable lipid bilayer-assisted indocyanine green J- aggregates for photothermal therapy: Formulation, in vitro toxicity and in vivo clearance

Indocyanine green (ICG) J-aggregates (IJA) are a unique form of aggregation that exhibits superior properties to monomeric ICG. Despite their higher photoacoustic (PA) signals for imaging and heating stability during photothermal therapy (PTT), they exhibit low stability under a biological milieu. Our group previously proposed a simple procedure for in-situ preparation of IJA into liposomes, accelerating their formation and optical properties. To comprehend their potential applications, we systematically investigated the effect of the lipid bilayer composition on ICG J-aggregation and stability. Moreover, their in vitro compatibility and photothermal toxicity in monolayers and cancer spheroids, besides their in vivo biodistribution and clearance were evaluated. Our findings revealed the importance of high cholesterol and PEG-lipid content and low charged lipids (∼ 5 mol %) in liposomes to promote a high IJA/ICG ratio and, thus, high heating stability. More importantly, IJA-liposomes revealed high biocompatibility in monolayer and cancer spheroids with efficient photothermal toxicity. Finally, IJA-liposomes were cleared from the body without toxicity. Interestingly, IJA-liposomes mainly showed lower affinity to the liver than monomeric ICG, resulting in higher renal clearance. Overall, our biodegradable IJA-liposomes could be an excellent alternative to gold-based agents suitable for PA imaging and cancer PTT.

Partial cystectomy as a surgical option for colorectal cancer patients with pathological bladder invasion: an original retrospective study

Background

Limited research exists on colorectal cancer (CRC) patients with bladder invasion, with survival outcomes post-cystectomy underexplored and a debate between partial and total cystectomy ongoing.

Objective

The study aimed to evaluate the effect of pathological bladder invasion on the long-term tumour prognosis of patients with clinically diagnosed bladder invasion in CRC after cystectomy.

Design

Retrospective, cohort study.

Methods

Our study involving 105 CRC patients with bladder invasion who had partial or total cystectomy from 2012 to 2020 collected surgical and pathological data. Groups were divided by pathological bladder invasion presence and compared for 3-year overall survival (OS) and recurrence-free survival (RFS) rates. Multiphoton imaging assessed collagen features in some samples.

Results

Pathological bladder invasion was confirmed in 50 patients (48%). Of 94 who had partial cystectomy, 41 were in the bladder invasion (+) group. The 3-year OS and RFS rates were 62.97% and 57.35% for the bladder invasion (+) group, and 77.16% and 58.68% for the bladder invasion (-) group, with no significant differences in recurrence rates between groups (p > 0.05). There are also no significant differences in 3-year local recurrence and intravesical recurrence rates between the two groups (18.62% vs 25.83%, 7.73% vs 11.82%, p > 0.05). Distant metastasis was identified as an independent risk factor for OS and RFS by univariate and multivariate Cox regression analyses. Of the 24 samples that underwent multi-photon imaging, 142 collagen features extracted did not show statistical differences.

Conclusion

Pathological bladder invasion impacts CRC patients' post-cystectomy survival may be less than what clinical practice implies. Partial cystectomy in cases with pathological bladder invasion might offer similar survival rates to total cystectomy.

Trial registration

ChiCTR2300077861.

Advances in the diagnosis of colorectal cancer: the application of molecular biomarkers and imaging techniques: a literature review

Background

Following neoplasms of the lung and breast, colorectal cancer (CRC) is the third most frequent malignancy globally. Screening for CRC at the age of 50 years is strongly encouraged for prompt earlier diagnosis owing to prognoses being greatly correlated with time of detection and cancer staging.

Aim

This review aimed to elucidate the most recent advancements in the detection of CRC, with an emphasis on the latest innovations in diagnostic molecular biomarkers in conjunction with radiological imaging alongside stool-based tests for CRC screening.

Methods

A comprehensive review of the literature was performed, focusing on specific terms in different electronic databases, including that of PubMed/MEDLINE. Keywords pertaining to "colorectal cancer," "diagnosis," "screening," "imaging," and "biomarkers," among others, were employed in the search strategy. Articles screened and evaluated were deemed relevant to the study aim and were presented in the medium of the English language.

Results

There have been several innovations in the diagnostics and identification of CRC. These generally comprise molecular biomarkers, currently being studied for suitability in disease detection. Examples of these include genetic, epigenetic, and protein biomarkers. Concurrently, recent developments in CRC diagnostics highlight the advancements made in radiological imaging that offer precise insights on tumor biology in addition to morphological information. Combining these with statistical methodologies will increase the sensitivity and specificity of CRC diagnostics. However, putting these strategies into reality is hampered by several issues.

Conclusion

Progress in diagnostic technology alongside the identification of a few prognostic predictive molecular biomarkers suggested great promise for prompt detection and management of CRC. This clearly necessitates further efforts to learn more in this specific sector.

Effects of Neoadjuvant Therapy on Tumour Target Expression of Oesophageal Cancer Tissue for NIR Fluorescence Imaging

PURPOSE

Oesophaegal cancer patients with a clinical complete response (CR) after neoadjuvant chemoradiotherapy (nCRT) are candidates for an active surveillance strategy. Regrowth rates of 40% after initial clinical CR indicate that identification of a true complete response to nCRT remains challenging. Near-infrared tumour-specific fluorescence endoscopic imaging might help to discriminate patients with a true complete response from patients with residual disease. This study aims to find potential markers to enable molecular imaging in oesophageal cancer and to assess the effect of nCRT on marker expression.

PROCEDURES

Oesophageal cancer tissue slides of diagnostic biopsies (n = 41) (pre-treatment) and paired surgical specimens (n = 31) (post-treatment) were collected. Tissue slides of patients with adenocarcinoma (n = 29) and squamous cell carcinoma (n = 12)) were included. Immunohistochemistry was performed to assess expression of the tumour markers CEA, EpCAM, VEGF-α, EGFR, and c-MET in the tumour and compared to the expression of these markers in surrounding healthy tissue. A total immunostaining score (TIS, range 0-12), which combines the percentage and intensity of stained cells, was calculated. The TIS of pre-treated biopsies were compared with the TIS of the post-treatment surgical specimens to assess the effect of neoadjuvant therapy on the marker expression.

RESULTS

The median TIS of EpCAM in adenocarcinomas was 10, vs. 0 in healthy mucosa (p < 0.001). The median TIS of EGFR in squamous cell carcinoma was 12, vs. 4 in healthy mucosa (p < 0.001). Neoadjuvant therapy did not affect the expression of the markers.

CONCLUSION

EpCAM and EGFR appear to be the most suitable targets for tumour-specific NIR fluorescence imaging of oesophageal adenocarcinoma and squamous cell carcinoma, respectively. Unaffected expression of all suitable markers by neoadjuvant therapy implies that the diagnostic biopsy can be used to select a patient-specific target for response evaluation by molecular imaging.

Fluorescence-guided tumor visualization of colorectal cancer using tumor-initiating probe yellow in preclinical models

Fluorescence-guided surgery has emerged as an innovative technique with promising applications in the treatment of various tumors, including colon cancer. Tumor-initiating probe yellow (TiY) has been discovered for identifying tumorigenic cells by unbiased phenotypic screening with thousands of diversity-oriented fluorescence library (DOFL) compounds in a patient-derived lung cancer cell model. This study demonstrated the clinical feasibility of TiY for tumor-specific fluorescence imaging in the tissues of patients with colorectal cancer (CRC). To evaluate the efficacy of TiY in tumor imaging, surgical specimens were obtained, consisting of 36 tissues from 18 patients with CRC, for ex vivo molecular fluorescence imaging, histology, and immunohistochemistry. Orthotopic and chemically induced CRC mice models were administered TiY topically, and distinct tumor lesions were observed in 10 min by real-time fluorescence colonoscopy and ex vivo imaging. In a hepatic metastasis mouse model using splenic injection, TiY accumulation was detected in metastatic liver lesions through fluorescence imaging. Correlation analysis between TiY intensity and protein expression, assessed via immunohistochemistry and Western blotting, revealed a positive correlation between TiY and vimentin and Zeb1, which are known as epithelial-mesenchymal transition (EMT) markers of cancers. A comparative analysis of TiY with other FDA-approved fluorescence probes such as ICG revealed greater quantitative differences in TiY fluorescence intensity between tumor and normal tissues than those observed with ICG. Altogether, these results demonstrated that TiY has a strong potential for visualizing CRC by fluorescence imaging in various preclinical models, which can be further translated for clinical use such as fluorescence-guided surgery. Furthermore, our data indicate that TiY is preferentially uptaken by cells with EMT induction and progression, and overexpressing vimentin and Zeb1 in patients with CRC.

Tumour Marker Expression in Head and Neck Malignancies to Identify Potential Targets for Intraoperative Molecular Near-Infrared Imaging

BACKGROUND

Oral and laryngeal squamous cell carcinoma (OSCC and LSCC) and papillary thyroid carcinoma (PTC) are common head and neck cancers (HNCs) typically treated surgically. Challenges in tumour delineation often lead to inadequate resection margins in OSCC and LSCC, and missed multifocality in PTC. Fluorescence imaging (FLI) using near-infrared tumour-targeting tracers may improve intraoperative identification of malignancy, facilitating precise excision. This study evaluates six potential FLI targets in OSCC, LSCC and PTC.

MATERIALS AND METHODS

Immunohistochemical staining was performed on OSCC (n = 20), LSCC (n = 10) and PTC (n = 10), assessing CEA, c-Met, EpCAM, EGFR, integrin αvβ6 and VEGF-α. Expression was scored (0-12) using the total immunostaining score (TIS) system, and categorized into absent (TIS 0), low (TIS 1-5), moderate (TIS 6-8) or high (TIS 9-12).

RESULTS

Integrin αvβ6 showed significant overexpression in OSCC (TIS: 12; p < 0.001) and LSCC (TIS: 8; p = 0.002), with 80% of OSCC and 90% of LSCC exhibiting moderate-high expression. Similarly, EGFR expression was moderate-high in most OSCC (87.5%; TIS: 8) and universally high in LSCC (100%; TIS: 12). In PTC, EGFR and VEGF-α expressions were low-moderate, but significantly higher than in healthy tissue (TIS: 6; p < 0.006).

CONCLUSION

This study highlights integrin αvβ6 and EGFR as viable FLI targets in OSCC and LSCC, especially integrin αvβ6 for tumour margin delineation. In PTC, despite lower expressions, the significant overexpression of VEGF-α, c-MET, and EGFR suggests their potential as FLI targets. Our findings support the development of tumour-targeted FLI tracers to improve surgical precision in HNC.

Efficacy and Safety of Fluorescence-Guided Surgery Compared to Conventional Surgery in the Management of Colorectal Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

The use of fluorescence agents and imaging systems is a promising adjunct in the surgical management of colorectal cancer. This systematic review and meta-analysis aimed to assess the safety and efficacy of fluorescence-guided surgery in the management of colorectal cancer, with a comparison to conventional (non-fluorescence-guided) surgery.

METHODS

A literature search of MEDLINE, Embase, Emcare, and CINAHL databases was performed for studies that reported data on the outcomes of fluorescence-guided surgery, with or without a comparison group undergoing conventional surgery, for colorectal cancer between January 2000 and January 2024. A meta-analysis was performed using random-effect models, and between-study heterogeneity was assessed.

RESULTS

35 studies of 3217 patients with colorectal cancer were included: 26 studies (964 patients) reported on fluorescence-guided surgery and 9 studies (2253 patients) reported on fluorescence versus conventional surgery. The weighted mean of the cancer detection rate of fluorescence-guided surgery was 71% (95% CI 0.55-0.85), with no significant difference in lymph node yield ratio (WMD -0.04; 95% CI -0.10-0.02; p = 0.201) between fluorescence and conventional surgery groups. There was a significantly lower blood loss (WMD -4.38; 95% CI -7.05--1.70; p = 0.001) and complication rate (WMD -0.04; 95% CI -0.07-0.00; p = 0.027) in the fluorescence-guided surgery group, with a potentially lower anastomotic leak rate (WMD -0.05; 95% CI -0.10-0.01; p = 0.092).

CONCLUSIONS

Fluorescence-guided surgery is a safe and effective approach in the management of colorectal cancer, potentially reducing blood loss and complications. Further randomised controlled trials are required comparing fluorescence-guided surgery with conventional surgery to determine its prognostic benefit and where it should precisely fit within the management pathway of colorectal cancer.

Indocyanine green near-infrared fluorescence bowel perfusion assessment to prevent anastomotic leakage in minimally invasive colorectal surgery (AVOID): a multicentre, randomised, controlled, phase 3 trial

BACKGROUND

Anastomotic leakage is a severe postoperative complication in colorectal surgery and compromised bowel perfusion is considered a major contributing factor. Conventional methods to assess bowel perfusion have a low predictive value for anastomotic leakage. We therefore aimed to evaluate the efficacy of real-time assessment with near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) in the prevention of anastomotic leakage.

METHODS

This multicentre, randomised, controlled, phase 3 trial was done in eight hospitals in the Netherlands. We included adults (aged >18 years) who were scheduled for laparoscopic or robotic colorectal surgery (with planned primary anastomosis) for benign and malignant diseases. Preoperatively, patients were randomly assigned (1:1) to fluorescence-guided bowel anastomosis (FGBA) or conventional bowel anastomosis (CBA) by variable block randomisation (block sizes 4, 6, and 8) and stratified by site. The operating surgeon and investigators analysing the data were not masked to group assignment. Patients were unmasked after the surgical procedure or after study end. In the FGBA group, surgeons marked anastomosis levels per conventional perfusion assessment and then administered 5 mg of ICG by 2 mL intravenous bolus. They assessed bowel perfusion using NIR fluorescence imaging and adjusted (or kept) transection lines accordingly. Only conventional methods for bowel perfusion assessment were used in the CBA group. The primary outcome was the difference in the rate of clinically relevant anastomotic leakage (ie, requiring active therapeutic intervention but manageable without reoperation [grade B] or requiring reoperation [grade C], per the International Study Group of Rectal Cancer) between the FGBA group and the CBA group within 90 days post-surgery. The primary outcome and safety were assessed in the intention-to-treat population. This study was registered with ToetsingOnline.nl (NL7502) and ClinicalTrials.gov (NCT04712032) and is complete.

FINDINGS

Between July 2, 2020, and Feb 21, 2023, 982 patients were enrolled, of whom 490 were assigned to FGBA and 492 were assigned to CBA. After excluding 51 patients, the intention-to-treat population comprised 931 (463 assigned FGBA and 468 assigned CBA). Patients had a median age of 68·0 years (IQR 59·0-75·0) and 485 (52%) were male and 446 (48%) were female. Ethnicity data were not available. The overall 90-day rate of clinically relevant anastomotic leakage was not significantly different between the FGBA group (32 [7%] of 463 patients) and the CBA group (42 [9%] of 468 patients; relative risk 0·77 [95% CI 0·50-1·20]; p=0·24). No adverse events related to ICG use were observed. 313 serious adverse events in 229 (25%) patients were at 90-day follow-up (159 serious adverse events in 113 [24%] patients in the FGBA group and 154 serious adverse events in 116 [25%] patients in the CBA group). 18 (2%) people died by 90 days (ten in the FGBA group and eight in the CBA group).

INTERPRETATION

ICG NIR fluorescence imaging did not reduce 90-day anastomotic leakage rates in this trial across all types of colorectal surgeries. Further research should be done in subgroups, such as rectosigmoid resections, for which evidence suggests ICG NIR might be beneficial.

FUNDING

Olympus Medical, Diagnostic Green, and Intuitive Foundation.

Intraoperative near infrared functional imaging of rectal cancer using artificial intelligence methods - now and near future state of the art

Colorectal cancer remains a major cause of cancer death and morbidity worldwide. Surgery is a major treatment modality for primary and, increasingly, secondary curative therapy. However, with more patients being diagnosed with early stage and premalignant disease manifesting as large polyps, greater accuracy in diagnostic and therapeutic precision is needed right from the time of first endoscopic encounter. Rapid advancements in the field of artificial intelligence (AI), coupled with widespread availability of near infrared imaging (currently based around indocyanine green (ICG)) can enable colonoscopic tissue classification and prognostic stratification for significant polyps, in a similar manner to contemporary dynamic radiological perfusion imaging but with the advantage of being able to do so directly within interventional procedural time frames. It can provide an explainable method for immediate digital biopsies that could guide or even replace traditional forceps biopsies and provide guidance re margins (both areas where current practice is only approximately 80% accurate prior to definitive excision). Here, we discuss the concept and practice of AI enhanced ICG perfusion analysis for rectal cancer surgery while highlighting recent and essential near-future advancements. These include breakthrough developments in computer vision and time series analysis that allow for real-time quantification and classification of fluorescent perfusion signals of rectal cancer tissue intraoperatively that accurately distinguish between normal, benign, and malignant tissues in situ endoscopically, which are now undergoing international prospective validation (the Horizon Europe CLASSICA study). Next stage advancements may include detailed digital characterisation of small rectal malignancy based on intraoperative assessment of specific intratumoral fluorescent signal pattern. This could include T staging and intratumoral molecular process profiling (e.g. regarding angiogenesis, differentiation, inflammatory component, and tumour to stroma ratio) with the potential to accurately predict the microscopic local response to nonsurgical treatment enabling personalised therapy via decision support tools. Such advancements are also applicable to the next generation fluorophores and imaging agents currently emerging from clinical trials. In addition, by providing an understandable, applicable method for detailed tissue characterisation visually, such technology paves the way for acceptance of other AI methodology during surgery including, potentially, deep learning methods based on whole screen/video detailing.

A Concept for Preoperative and Intraoperative Molecular Imaging and Detection for Assessing Extent of Disease of Solid Tumors

The authors propose a concept of "systems engineering," the approach to assessing the extent of diseased tissue (EODT) in solid tumors. We modeled the proof of this concept based on our clinical experience with colorectal carcinoma (CRC) and gastrinoma that included short and long-term survival data of CRC patients. This concept, applicable to various solid tumors, combines resources from surgery, nuclear medicine, radiology, pathology, and oncology needed for preoperative and intraoperative assessments of a patient's EODT. The concept begins with a patient presenting with biopsy-proven cancer. An appropriate preferential locator (PL) is a molecule that preferentially binds to a cancer-related molecular target (i.e., tumor marker) lacking in non-malignant tissue and is the essential element. Detecting the PL after an intravenous injection requires the PL labeling with an appropriate tracer radionuclide, a fluoroprobe, or both. Preoperative imaging of the tracer's signal requires molecular imaging modalities alone or in combination with computerized tomography (CT). These include positron emission tomography (PET), PET/CT, single-photon emission computed tomography (SPECT), SPECT/CT for preoperative imaging, gamma cameras for intraoperative imaging, and gamma-detecting probes for precise localization. Similarly, fluorescent-labeled PLs require appropriate cameras and probes. This approach provides the surgeon with real-time information needed for R0 resection.

A multispectral 3D live organoid imaging platform to screen probes for fluorescence guided surgery

Achieving complete tumor resection is challenging and can be improved by real-time fluorescence-guided surgery with molecular-targeted probes. However, pre-clinical identification and validation of probes presents a lengthy process that is traditionally performed in animal models and further hampered by inter- and intra-tumoral heterogeneity in target expression. To screen multiple probes at patient scale, we developed a multispectral real-time 3D imaging platform that implements organoid technology to effectively model patient tumor heterogeneity and, importantly, healthy human tissue binding.

Extrahepatic perfusion and incomplete hepatic perfusion after hepatic arterial infusion pump implantation: incidence and clinical implications

INTRODUCTION

This study investigates the incidence of extrahepatic perfusion and incomplete hepatic perfusion at intraoperative methylene blue testing and on postoperative nuclear imaging in patients undergoing hepatic arterial infusion pump (HAIP) chemotherapy.

METHODS

The first 150 consecutive patients who underwent pump implantation in the Netherlands were included. All patients underwent surgical pump implantation with the catheter in the gastroduodenal artery. All patients underwent intraoperative methylene blue testing and postoperative nuclear imaging (99mTc-Macroaggregated albumin SPECT/CT) to determine perfusion via the pump.

RESULTS

Patients were included between January-2018 and December-2021 across eight centers. During methylene blue testing, 29.3% had extrahepatic perfusion, all successfully managed intraoperatively. On nuclear imaging, no clinically relevant extrahepatic perfusion was detected (0%, 95%CI: 0.0-2.5%). During methylene blue testing, 2.0% had unresolved incomplete hepatic perfusion. On postoperative nuclear imaging, 8.1% had incomplete hepatic perfusion, leading to embolization in only 1.3%.

CONCLUSION

Methylene blue testing during pump placement for intra-arterial chemotherapy identified extrahepatic perfusion in 29.3% of patients, but could be resolved intraoperatively in all patients. Postoperative nuclear imaging found no clinically relevant extrahepatic perfusion and led to embolization in only 1.3% of patients. The role of routine nuclear imaging after HAIP implantation should be studied in a larger cohort.

A Review on Emerging Techniques for Diagnosis of Colorectal Cancer

Common detection methods in practice for diagnosing colorectal cancer (CRC) are painful and invasive leading to less participation of individuals for CRC diagnosis. Whereas, improved or enhanced imaging systems and other minimally invasive techniques with shorter detection times deliver greater detail and less discomfort in individuals. Thus, this review is a summary of the diagnostic tests, ranging from the simple potential use in developing a flexible CRC treatment to the patient's potential benefits in receiving less invasive procedures and the advanced treatments that might provide a better assessment for the diagnosis of CRC and reduce the mortality related to CRC.

Factors Affecting the Efficiency of Near-Infrared Indocyanine Green (NIR/ICG) in Lymphatic Mapping for Colorectal Cancer: A Systematic Review

As laparoscopy gained global popularity in oncologic surgery, the challenge of detecting lymph nodes spurred researchers to explore innovative techniques and approach the situation from a fresh perspective. While many proposed methods have faded into obscurity, the utilization of indocyanine green (ICG) in the surgical treatment of oncologic patients has continued to advance. The immense potential of this dye is widely acknowledged, yet its full extent and limitations in lymphatic mapping for colorectal cancer remain to be precisely determined. This article aims to assess the magnitude of its potential and explore the constraints based on insights from clinical studies published by pioneering researchers. A systematic review of the existing literature, comprising articles in English, was conducted using the Scopus, PubMed, and Springer Link databases. The search employed keywords such as "colorectal cancer" AND/OR "indocyanine green," "fluorescence" AND/OR "lymphatic mapping" AND/OR "lymph nodes." Initially identifying 129 articles, the application of selection criteria narrowed down the pool to 10 articles, which served as the primary sources of data for our review. Despite the absence of a standardized protocol for the application of ICG in colorectal cancer, particularly in the context of lymphatic mapping, the detection rates have exhibited considerable variation across studies. Nevertheless, all authors unanimously regarded this technique as beneficial and promising. Additionally, it is advocated as an adjunctive tool to enhance the accuracy of cancer staging. Near-infrared (NIR)-enhanced surgery holds the promise of transforming the landscape of oncologic surgery, emerging as a valuable tool for surgeons. However, the absence of a standardized technique and the subjective nature of result assessment impose limitations on the potential of this method. Consequently, it can be inferred that the establishment of a universally accepted protocol, encompassing parameters such as dose, concentration, technique, and site of administration of ICG, along with the optimal time needed for fluorescence visualization, would enhance the outcomes. Emphasizing the accurate selection of patients is crucial to prevent the occurrence of false-negative results.

Consensus conference statement on fluorescence-guided surgery (FGS) ESSO course on fluorescence-guided surgery

BACKGROUND

Fluorescence-guided surgery (FGS) has emerged as an innovative technique with promising applications in various surgical specialties. However, clinical implementation is hampered by limited availability of evidence-based reference work supporting the translation towards standard-of-care use in surgical practice. Therefore, we developed a consensus statement on current applications of FGS.

METHODS

During an international FGS course, participants anonymously voted on 36 statements. Consensus was defined as agreement ≥70% with participation grade of ≥80%. All participants of the questionnaire were stratified for user and handling experience within five domains of applicability (lymphatics & lymph node imaging; tissue perfusion; biliary anatomy and urinary tracts; tumor imaging in colorectal, HPB, and endocrine surgery, and quantification and (tumor-) targeted imaging). Results were pooled to determine consensus for each statement within the respective sections based on the degree of agreement.

RESULTS

In total 43/52 (81%) course participants were eligible as voting members for consensus, comprising the expert panel (n = 12) and trained users (n = 31). Consensus was achieved in 17 out of 36 (45%) statements with highest level of agreement for application of FGS in tissue perfusion and biliary/urinary tract visualization (71% and 67%, respectively) and lowest within the tumor imaging section (0%).

CONCLUSIONS

FGS is currently established for tissue perfusion and vital structure imaging. Lymphatics & lymph node imaging in breast cancer and melanoma are evolving, and tumor tissue imaging holds promise in early-phase trials. Quantification and (tumor-)targeted imaging are advancing toward clinical validation. Additional research is needed for tumor imaging due to a lack of consensus.

Tetra-azolium Salts Induce Significant Cytotoxicity in Human Colon Cancer Cells In vitro

BACKGROUND

Azolium salts are the organic salts used as stable precursors for generating N-Heterocyclic Carbenes and their metal complexes. Azolium salts have also been reported to have significant biological potential. Hence, in the current study, four tetra-dentate azolium salts were derived from bis-azolium salts by a new synthetic strategy.

METHODS

The tetra azolium salts have been synthesized by reacting the imidazole or methyl imidazole with dibromo xylene (meta, para)/ 1-bromo methyl imidazole or dibromo ethane resulting in the mono or bis azolium salts namely I-IV. V-VII have been obtained by reacting I with II-IV, resulting in the tetra azolium salts. Each product was analyzed by various analytical techniques, i.e., microanalysis, FT-IR, and NMR (1H & 13C). Salts V-VII were evaluated for their antiproliferative effect against human colon cancer cells (HCT-116) using MTT assay.

RESULTS

Four chemical shifts for acidic protons between 8.5-9.5 δ ppm in 1H NMR and resonance of respective carbons around 136-146 δ ppm in 13C NMR indicated the successful synthesis of tetra azolium salts. Salt V showed the highest IC50 value, 24.8 μM among all synthesized compounds.

CONCLUSION

Tetra-azolium salts may play a better cytotoxicity effect compared to mono-, bi-& tri-azolium salts.

The Inhibitory Effects of Propofol on Colorectal Cancer Progression through the NF-κB/HIF-1α Signaling Pathway

BACKGROUND AND OBJECTIVE

Colorectal cancer (CRC) is a neoplastic disease that gradually develops due to genetic variations and epigenetic changes. Surgical excision is the first-line treatment for CRC. Accumulating evidence has shown that total intravenous anesthesia has beneficial effects for CRC patients as it decreases the probability of tumor recurrence and metastasis. Propofol is one of the most frequently used intravenous anesthetics in clinical practice. However, it remains unknown whether it can reduce recurrence and metastasis after surgery in cancer patients.

METHODS

CRC cell lines (HCT116 and SW480) were cultured in vitro, and different concentrations of propofol were added to the cell culture medium. The proliferation effect of propofol on CRC cell lines was evaluated by CCK-8 assay. The effect of propofol on the migration and invasion of CRC cells was evaluated by scratch healing and Transwell experiments. The inhibitory effects of propofol on NF-κB and HIF-1α expressions in CRC cell lines were determined by Western blotting and immunofluorescence assays to further clarify the regulatory effects of propofol on NF-κB and HIF-1α.

RESULTS

Compared to the control, propofol significantly inhibited the proliferation, migration, and invasion abilities of CRC cells (HCT116 and SW480) (p < 0.0001). The expression levels of NF-κB and HIF-1α gradually decreased with increasing propofol concentration in both cell lines. After activation and inhibition of NF-κB, the expression of HIF-1α changed. Further studies showed that propofol inhibited LPS-activated NF-κB-induced expression of HIF-1α, similar to the NF-κB inhibitor Bay17083 (p < 0.0001).

CONCLUSION

In vitro, propofol inhibited the proliferation, migration, and invasion of CRC cells (HCT116 and SW480) in a dose-dependent manner, possibly by participating in the regulation of the NF-κB/HIF-1α signaling pathway.

Fluorescent-guided surgery and the use of indocyanine green sentinel lymph node mapping in the pediatric and young adult oncology population

BACKGROUND

Technetium-99 (99m Tc) lymphoscintigraphy with blue dye injection is an accepted method for sentinel lymph node (SLN) mapping, but blue dye has known adverse effects, and injection of 99m Tc may increase time under anesthesia for pediatric patients. Indocyanine green (ICG) may serve as an adjunct to assist with visibility and identification of SLNs. We hypothesized that sensitivity of ICG was similar to blue dye in SLN biopsies.

METHODS

Thirty patients (36 procedures with 96 total specimens) underwent preoperative intradermal injection of 99m Tc, followed by intradermal injection of isosulfan blue and ICG. Test characteristics of blue dye, ICG, and 99m Tc included sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

ICG had a sensitivity of 87% and PPV of 83% for detection of 99m Tc-hot lymph nodes; blue dye had a sensitivity of 44% and PPV of 97%. For detection of pathologically confirmed lymph nodes, ICG had a sensitivity of 84% and a positive predictive value (PPV) of 91%. 99m Tc had a sensitivity of 82% and a PPV of 94%. ICG had no significant difference in odds of being positive in pathology-confirmed lymph nodes compared to 99m Tc (odds ratio [OR], 0.818; 95% confidence interval [CI], 0.3-2.172; p = .823) and had higher odds than isosulfan blue (OR, 0.025, 95% CI, 0.001-0.148; p < .001).

CONCLUSION

This study established the efficacy of ICG as an adjunct to SLNB in the pediatric and young adult population. ICG was safe, more efficacious than blue dye, and may obviate the need for lymphoscintigraphy in selected patients resulting in reduced time under anesthesia.

Tumor Segmentation in Colorectal Ultrasound Images Using an Ensemble Transfer Learning Model: Towards Intra-Operative Margin Assessment

Tumor boundary identification during colorectal cancer surgery can be challenging, and incomplete tumor removal occurs in approximately 10% of the patients operated for advanced rectal cancer. In this paper, a deep learning framework for automatic tumor segmentation in colorectal ultrasound images was developed, to provide real-time guidance on resection margins using intra-operative ultrasound. A colorectal ultrasound dataset was acquired consisting of 179 images from 74 patients, with ground truth tumor annotations based on histopathology results. To address data scarcity, transfer learning techniques were used to optimize models pre-trained on breast ultrasound data for colorectal ultrasound data. A new custom gradient-based loss function (GWDice) was developed, which emphasizes the clinically relevant top margin of the tumor while training the networks. Lastly, ensemble learning methods were applied to combine tumor segmentation predictions of multiple individual models and further improve the overall tumor segmentation performance. Transfer learning outperformed training from scratch, with an average Dice coefficient over all individual networks of 0.78 compared to 0.68. The new GWDice loss function clearly decreased the average tumor margin prediction error from 1.08 mm to 0.92 mm, without compromising the segmentation of the overall tumor contour. Ensemble learning further improved the Dice coefficient to 0.84 and the tumor margin prediction error to 0.67 mm. Using transfer and ensemble learning strategies, good tumor segmentation performance was achieved despite the relatively small dataset. The developed US segmentation model may contribute to more accurate colorectal tumor resections by providing real-time intra-operative feedback on tumor margins.

Targeted, Molecular Europium(III) Probes Enable Luminescence-Guided Surgery and 1 Photon Post-Surgical Luminescence Microscopy of Solid Tumors

Discrete luminescent lanthanide complexes represent a potential alternative to organic chromophores due to their tunability of optical properties, insensitivity to photobleaching, and large pseudo-Stokes shifts. Previously, we demonstrated that the lack of depth penetration of UV excitation required to sensitize discrete terbium and europium complexes can be overcome using Cherenkov radiation emitted by clinically employed radioisotopes in situ. Here, we show that the second-generation europium complexes [Eu(III)(pcta-PEPA2)] and [Eu(III)(tacn-pic-PEPA2)] (Φ = 57% and 76%, respectively) lower the limit of detection (LoD) to 1 nmol in the presence of 10 μCi of Cherenkov emitting isotopes, 18F and 68Ga. Bifunctionalization provides access to cysteine-linked peptide conjugates with comparable brightness and LoD. The conjugate, [Eu(tacn-(pic-PSMA)-PEPA2)], displays high binding affinity to prostate-specific membrane antigen (PSMA)-expressing PC-3 prostate cancer cells in vitro and can be visualized in the membrane-bound state using confocal microscopy. Biodistribution studies with the [86Y][Y(III)(tacn-(pic-PSMA)-PEPA2)] analogue in a mouse xenograft model were employed to study pharmacokinetics. Systemic administration of the targeted Cherenkov emitter, [68Ga][Ga(III)(PSMA-617)], followed by intratumoral injection or topical application of 20 or 10 nmol [Eu(III)(tacn-(pic-PSMA)-PEPA2)], respectively, in live mice resulted in statistically significant signal enhancement using conventional small animal imaging (620 nm bandpass filter). Optical imaging informed successful tumor resection. Ex vivo imaging of the fixed tumor tissue with 1 and 2 photon excitation further reveals the accumulation of the administered Eu(III) complex in target tissues. This work represents a significant step toward the application of luminescent lanthanide complexes for optical imaging in a clinical setting.

Use of Near-Infrared Fluorescence Techniques in Minimally Invasive Surgery for Colorectal Liver Metastases

Colorectal liver metastases (CRLM) afflict a significant proportion of patients with colorectal cancer (CRC), ranging from 25% to 30% of patients throughout the course of the disease. In recent years, there has been a surge of interest in the application of near-infrared fluorescence (NIRF) imaging as an intraoperative imaging technique for liver surgery. The utilisation of NIRF-guided liver surgery, facilitated by the administration of fluorescent dye indocyanine green (ICG), has gained traction in numerous medical institutions worldwide. This innovative approach aims to enhance lesion differentiation and provide valuable guidance for surgical margins. The use of ICG, particularly in minimally invasive surgery, has the potential to improve lesion detection rates, increase the likelihood of achieving R0 resection, and enable anatomically guided resections. However, it is important to acknowledge the limitations of ICG, such as its low specificity. Consequently, there has been a growing demand for the development of tumour-specific fluorescent probes and the advancement of camera systems, which are expected to address these concerns and further refine the accuracy and reliability of intraoperative fluorescence imaging in liver surgery. While NIRF imaging has been extensively studied in patients with CRLM, it is worth noting that a significant proportion of published research has predominantly focused on the detection of hepatocellular carcinoma (HCC). In this study, we present a comprehensive literature review of the existing literature pertaining to intraoperative fluorescence imaging in minimally invasive surgery for CRLM. Moreover, our analysis places specific emphasis on the techniques employed in liver resection using ICG, with a focus on tumour detection in minimal invasive surgery (MIS). Additionally, we delve into recent developments in this field and offer insights into future perspectives for further advancements.

Tailoring renal-clearable zwitterionic cyclodextrin for colorectal cancer-selective drug delivery

Although cyclodextrin-based renal-clearable nanocarriers have a high potential for clinical translation in targeted cancer therapy, their designs remain to be optimized for tumour retention. Here we report on the design of a tailored structure for renal-clearable zwitterionic cyclodextrin for colorectal cancer-selective drug delivery. Twenty cyclodextrin derivatives with different charged moieties and spacers are synthesized and screened for colloidal stability. The resulting five candidates are evaluated for biodistribution and an optimized structure is identified. The optimized cyclodextrin shows a high tumour accumulation and is used for delivery of doxorubicin and ulixertinib. Higher tumour accumulation and tumour penetration facilitates tumour elimination. The improved antitumour efficacy is demonstrated in heterotopic and orthotopic colorectal cancer models.

Lymphatic Mapping in Colon Cancer Depending on Injection Time and Tracing Agent: A Systematic Review and Meta-Analysis of Prospective Designed Studies

An optimized lymph node yield leads to better survival in colon cancer, but extended lymphadenectomy is not associated with survival benefits. Lymphatic mapping shows several colon cancers feature aberrant drainage pathways inducing local recurrence when not resected. Currently, different protocols exist for lymphatic mapping procedures. This meta-analysis assessed which protocol has the best capacity to detect tumor-draining and possibly metastatic lymph nodes. A systematic review was conducted according to PRISMA guidelines, including prospective trials with in vivo tracer application. The risk of bias was evaluated using the QUADAS-2 tool. Traced lymph nodes, total resected lymph nodes, and aberrant drainage detection rate were analyzed. Fifty-eight studies met the inclusion criteria, of which 42 searched for aberrant drainage. While a preoperative tracer injection significantly increased the traced lymph node rates compared to intraoperative tracing (30.1% (15.4, 47.3) vs. 14.1% (11.9, 16.5), p = 0.03), no effect was shown for the tracer used (p = 0.740) or the application sites comparing submucosal and subserosal injection (22.9% (14.1, 33.1) vs. 14.3% (12.1, 16.8), p = 0.07). Preoperative tracer injection resulted in a significantly higher rate of detected aberrant lymph nodes compared to intraoperative injection (26.3% [95% CI 11.5, 44.0] vs. 2.5% [95% CI 0.8, 4.7], p < 0.001). Analyzing 112 individual patient datasets from eight studies revealed a significant impact on aberrant drainage detection for injection timing, favoring preoperative over intraoperative injection (OR 0.050 [95% CI 0.010-0.176], p < 0.001) while indocyanine green presented itself as the superior tracer (OR 0.127 [95% CI 0.018-0.528], p = 0.012). Optimized lymphatic mapping techniques result in significantly higher detection of aberrant lymphatic drainage patterns and thus enable a personalized approach to reducing local recurrence.

Fluorescence-guided surgery: comprehensive review

BACKGROUND

Despite significant improvements in preoperative workup and surgical planning, surgeons often rely on their eyes and hands during surgery. Although this can be sufficient in some patients, intraoperative guidance is highly desirable. Near-infrared fluorescence has been advocated as a potential technique to guide surgeons during surgery.

METHODS

A literature search was conducted to identify relevant articles for fluorescence-guided surgery. The literature search was performed using Medical Subject Headings on PubMed for articles in English until November 2022 and a narrative review undertaken.

RESULTS

The use of invisible light, enabling real-time imaging, superior penetration depth, and the possibility to use targeted imaging agents, makes this optical imaging technique increasingly popular. Four main indications are described in this review: tissue perfusion, lymph node assessment, anatomy of vital structures, and tumour tissue imaging. Furthermore, this review provides an overview of future opportunities in the field of fluorescence-guided surgery.

CONCLUSION

Fluorescence-guided surgery has proven to be a widely innovative technique applicable in many fields of surgery. The potential indications for its use are diverse and can be combined. The big challenge for the future will be in bringing experimental fluorophores and conjugates through trials and into clinical practice, as well as validation of computer visualization with large data sets. This will require collaborative surgical groups focusing on utility, efficacy, and outcomes for these techniques.

Can fluorescence-guided surgery improve optimal surgical treatment for ovarian cancer? A systematic scoping review of clinical studies

BACKGROUND

The predicament of achieving optimal surgical intervention faced by surgeons in treating ovarian cancer has driven research into improving intra-operative detection of cancer using fluorescent materials.

OBJECTIVE

To provide a literature overview on the clinical use of intra-operative fluorescence-guided surgery for ovarian cancer, either for cytoreductive surgery or sentinel lymph node (SLN) biopsy.

METHODS

The systematic review included studies from June 2002 until October 2021 from PubMed, Web of Science, and Scopus as well as those from a search of related literature. Studies were included if they investigated the use of fluorescence-guided surgery in patients with a diagnosis of ovarian cancer. Authors charted variables related to study characteristics, patient demographics, baseline clinical characteristics, fluorescence-guided surgery material, and treatment details, and surgical, oncological, and survival outcome variables. After screening 2817 potential studies, 24 studies were included.

RESULTS

Studies investigating the role of fluorescence-guided surgery to visualize tumor deposits or SLN biopsy included the data of 410 and 118 patients, respectively. Six studies used indocyanine green tracer with a mean SLN detection rate of 92.3% with a pelvic and para-aortic detection rate of 94.8% and 96.7%, respectively. The sensitivity, specificity, and positive predictive value for micrometastases detection of OTL38 and 5-aminolevulinc acid at time of cytoreduction were 92.2% vs 79.8%, 67.3% vs 94.8%, and 55.8% vs 95.8%, respectively.

CONCLUSION

Fluorescence -guided surgery is a technique that may improve the detection rate of micrometastases and SLN identification in ovarian cancer. Further research is needed to establish whether this will lead to improved patient outcomes.

Colorectal polyps: Targets for fluorescence-guided endoscopy to detect high-grade dysplasia and T1 colorectal cancer

BACKGROUND

Differentiating high-grade dysplasia (HGD) and T1 colorectal cancer (T1CRC) from low-grade dysplasia (LGD) in colorectal polyps can be challenging. Incorrect recognition of HGD or T1CRC foci can lead to a need for additional treatment after local resection, which might not have been necessary if it was recognized correctly. Tumor-targeted fluorescence-guided endoscopy might help to improve recognition.

OBJECTIVE

Selecting the most suitable HGD and T1CRC-specific imaging target from a panel of well-established biomarkers: carcinoembryonic antigen (CEA), c-mesenchymal-epithelial transition factor (c-MET), epithelial cell adhesion molecule (EpCAM), folate receptor alpha (FRα), and integrin alpha-v beta-6 (αvβ6).

METHODS

En bloc resection specimens of colorectal polyps harboring HGD or T1CRC were selected. Immunohistochemistry on paraffin sections was used to determine the biomarker expression in normal epithelium, LGD, HGD, and T1CRC (scores of 0-12). The differential expression in HGD-T1CRC components compared to surrounding LGD and normal components was assessed, just as the sensitivity and specificity of each marker.

RESULTS

60 specimens were included (21 HGD, 39 T1CRC). Positive expression (score >1) of HGD-T1CRC components was found in 73.3%, 78.3%, and 100% of cases for CEA, c-MET, and EpCAM, respectively, and in <40% for FRα and αvβ6. Negative expression (score 0-1) of the LGD component occurred more frequently for CEA (66.1%) than c-MET (31.6%) and EpCAM (0%). The differential expression in the HGD-T1CRC component compared to the surrounding LGD component was found for CEA in 66.7%, for c-MET in 43.1%, for EpCAM in 17.2%, for FRα in 22.4%, and for αvβ6 in 15.5% of the cases. Moreover, CEA showed the highest combined sensitivity (65.0%) and specificity (75.0%) for the detection of an HGD-T1CRC component in colorectal polyps.

CONCLUSION

Of the tested targets, CEA appears the most suitable to specifically detect HGD and T1 cancer foci in colorectal polyps. An in vivo study using tumor-targeted fluorescence-guided endoscopy should confirm these findings.

Real-Time Monitoring of Colorectal Cancer Location and Lymph Node Metastasis and Photodynamic Therapy Using Fucoidan-Based Therapeutic Nanogel and Near-Infrared Fluorescence Diagnostic-Therapy System

We report real-time monitoring of colorectal cancer, lymph node metastasis of colorectal cancer cells, and tumor growth inhibition through photodynamic therapy (PDT) using a near-infrared fluorescence diagnostic-therapy system with a light source for PDT and a fucoidan-based theranostic nanogel (CFN-gel) with good accumulation efficiency in cancer cells. To confirm the effect of the fabricated system and developed CFN-gel, in vitro and in vivo experiments were performed. Chlorin e6 (Ce6) and 5-aminolevulinic acid (5-ALA) were used for comparison. We confirmed that CFN-gel has a high accumulation efficiency in cancer cells and high fluorescence signals in near-infrared light for a long period, and only CFN-gel delayed the growth rate of cancer in terms of its size in PDT. In addition, using the near-infrared fluorescence diagnostic-therapy system and CFN-gel prepared for these experiments, the lymph node metastasis of cancer cells was imaged in real time, and the metastasis was confirmed through H&E staining. The possibility of image-guided surgery and identification of lymph node metastasis in colorectal cancer can be confirmed through CFN-gel and a near-infrared fluorescence diagnostic-therapy system that includes various light sources.

NIR-II fluorescence imaging-guided colorectal cancer surgery targeting CEACAM5 by a nanobody

BACKGROUND

Surgery is the cornerstone of colorectal cancer (CRC) treatment, yet complete removal of the tumour remains a challenge. The second near-infrared window (NIR-II, 1000-1700 nm) fluorescent molecular imaging is a novel technique, which has broad application prospects in tumour surgical navigation. We aimed to evaluate the ability of CEACAM5-targeted probe for CRC recognition and the value of NIR-II imaging-guided CRC resection.

METHODS

We constructed the probe 2D5-IRDye800CW by conjugated anti-CEACAM5 nanobody (2D5) with near-infrared fluorescent dye IRDye800CW. The performance and benefits of 2D5-IRDye800CW at NIR-II were confirmed by imaging experiments in mouse vascular and capillary phantom. Then mouse colorectal cancer subcutaneous tumour model (n = 15), orthotopic model (n = 15), and peritoneal metastasis model (n = 10) were constructed to investigate biodistribution of probe and imaging differences between NIR-I and NIR-II in vivo, and then tumour resection was guided by NIR-II fluorescence. Fresh human colorectal cancer specimens were incubated with 2D5-IRDye800CW to verify its specific targeting ability.

FINDINGS

2D5-IRDye800CW had an NIR-II fluorescence signal extending to 1600 nm and bound specifically to CEACAM5 with an affinity of 2.29 nM. In vivo imaging, 2D5-IRDye800CW accumulated rapidly in tumour (15 min) and could specifically identify orthotopic colorectal cancer and peritoneal metastases. All tumours were resected under NIR-II fluorescence guidance, even smaller than 2 mm tumours were detected, and NIR-II had a higher tumour-to-background ratio than NIR-I (2.55 ± 0.38, 1.94 ± 0.20, respectively). 2D5-IRDye800CW could precisely identify CEACAM5-positive human colorectal cancer tissue.

INTERPRETATION

2D5-IRDye800CW combined with NIR-II fluorescence has translational potential as an aid to improve R0 surgery of colorectal cancer.

FUNDINGS

This study was supported by Beijing Natural Science Foundation (JQ19027), the National Key Research and Development Program of China (2017YFA0205200), National Natural Science Foundation of China (NSFC) (61971442, 62027901, 81930053, 92059207, 81227901, 82102236), Beijing Natural Science Foundation (L222054), CAS Youth Interdisciplinary Team (JCTD-2021-08), the Strategic Priority Research Program of the Chinese Academy of Sciences (XDA16021200), the Zhuhai High-level Health Personnel Team Project (Zhuhai HLHPTP201703), the Fundamental Research Funds for the Central Universities (JKF-YG-22-B005) and Capital Clinical Characteristic Application Research (Z181100001718178). The authors would like to acknowledge the instrumental and technical support of the multi-modal biomedical imaging experimental platform, Institute of Automation, Chinese Academy of Sciences.

Retroperitoneal Lymph Node Dissection in Colorectal Cancer with Lymph Node Metastasis: A Systematic Review

The benefits and prognosis of RPLND in CRC have not yet been fully established. This systematic review aimed to evaluate the outcomes for CRC patients with RPLNM undergoing RPLND. A literature search of MEDLINE, EMBASE, EMCare, and CINAHL identified studies from between January 1990 and June 2022 that reported data on clinical outcomes for patients who underwent RPLND for RPLNM in CRC. The following primary outcome measures were derived: postoperative morbidity, disease free-survival (DFS), overall survival (OS), and re-recurrence. Nineteen studies with a total of 541 patients were included. Three hundred and sixty-three patients (67.1%) had synchronous RPLNM and 178 patients (32.9%) had metachronous RPLNM. Perioperative chemotherapy was administered in 496 (91.7%) patients. The median DFS was 8.6-38.0 months and 5-year DFS was 24.4% (10.0-60.5%). The median OS was 25.0-83.0 months and 5-year OS was 47.0% (15.0-87.5%). RPLND is a feasible treatment option with limited morbidity and possible oncological benefit for both synchronous and metachronous RPLNM in CRC. Further prospective clinical trials are required to establish a better evidence base for RPLND in the context of RPLNM in CRC and to understand the timing of RPLND in a multimodality pathway in order to optimise treatment outcomes for this group of patients.

Design, fabrication, and preclinical testing of a miniaturized, multispectral, chip-on-tip, imaging probe for intraluminal fluorescence imaging of the gastrointestinal tract

Gastrointestinal cancers continue to account for a disproportionately large percentage of annual cancer deaths in the US. Advancements in miniature imaging technology combined with a need for precise and thorough tumor detection in gastrointestinal cancer screenings fuel the demand for new, small-scale, and low-cost methods of localization and margin identification with improved accuracy. Here, we report the development of a miniaturized, chip-on-tip, multispectral, fluorescence imaging probe designed to port through a gastroscope working channel with the aim of detecting cancerous lesions in point-of-care endoscopy of the gastrointestinal lumen. Preclinical testing has confirmed fluorescence sensitivity and supports that this miniature probe can locate structures of interest via detection of fluorescence emission from exogenous contrast agents. This work demonstrates the design and preliminary performance evaluation of a miniaturized, single-use, chip-on-tip fluorescence imaging system, capable of detecting multiple fluorochromes, and devised for deployment via the accessory channel of a standard gastroscope.

Fluorescence-guided lymph node sampling is feasible during up-front or delayed nephrectomy for Wilms tumor

BACKGROUND

Lymph node sampling is critical to surgical staging in Wilms tumor; failure to sample lymph nodes is associated with under-staging and an increased incidence of local relapse. However, no standard lymphatic mapping method is currently being utilized for Wilms tumor to aid identification of regional draining lymph nodes. Herein, we describe the use of fluorescence-guided lymphatic mapping for Wilms tumor.

MATERIALS AND METHODS

Two tertiary level referral centers independently began indocyanine green (ICG) fluorescence-guided nodal mapping. In one center, this was achieved with ipsilateral intra-parenchymal (IP) injection of ICG during minimally invasive tumor nephrectomy (MIN) following neoadjuvant chemotherapy and in the other, with Peri‑Hilar (PH) injection during upfront, open tumor nephrectomy (ON). Successful lymph node mapping was defined as the presence of fluorescence signal in draining lymph nodes.

RESULTS

Eight patients (median age of 2.5 years) underwent fluorescence-guided lymphatic mapping (four IP and four PH injection). Lymphatic mapping was successful in seven patients (88%) including each of the four patients with IP injection.

CONCLUSIONS

Fluorescence-guided lymphatic mapping of Wilms tumor drainage is feasible by both IP injection and PH injection techniques. However, whether lymphatic mapping improves the precision of lymph node sampling is unknown and should be studied in prospective trials.

Experimental study of the quantification of indocyanine green fluorescence in ischemic and non-ischemic anastomoses, using the SERGREEN software program

Tissue ischemia is a key risk factor in anastomotic leak (AL). Indocyanine green (ICG) is widely used in colorectal surgery to define the segments with the best vascularization. In an experimental model, we present a new system for quantifying ICG fluorescence intensity, the SERGREEN software. Controlled experimental study with eight pigs. In the initial control stage, ICG fluorescence intensity was analyzed at the level of two anastomoses, in the right and in the left colon. Control images of the two segments were taken after ICG administration. The images were processed with the SERGREEN program. Then, in the experimental ischemia stage, the inferior mesenteric artery was sectioned at the level of the anastomosis of the left colon. Fifteen minutes after the section, sequential images of the two anastomoses were taken every 30 min for the following 2 h. At the control stage, the mean scores were 134.2 (95% CI 116.3–152.2) for the right colon and 147 (95% CI 134.7–159.3) for the left colon (p = 0.174) (Scale RGB—Red, Green, Blue). The right colon remained stable throughout the experiment. In the left colon, intensity fell by 47.9 points with respect to the pre-ischemia value (p < 0.01). After the first post-ischemia determination, the values of the ischemic left colon remained stable throughout the experiment. The relative decrease in ICG fluorescence intensity of the ischemic left colon was 32.6%. The SERGREEN program quantifies ICG fluorescence intensity in normal and ischemic situations and detects differences between them. A reduction in ICG fluorescence intensity of 32.6% or more was correlated with complete tissue ischemia.

ZhenQi FuZheng formula inhibits the growth of colorectal tumors by modulating intestinal microflora-mediated immune function

Zhenqi Fuzheng formula (ZQFZ), of which the main ingredients are Astragalus membranaceus and Ligustrum lucidum, has immune system regulatory functions and potential anti-tumor bioactivity. The inhibition of colorectal tumor growth by ZQFZ was analyzed in inflammatory cells and B6/JGpt-Apc^em1Cin(MinC)/Gpt (Apc^Min/+) mice. ZQFZ exhibited anti-inflammatory activity by decreasing the phosphorylation of nuclear factor-kappa B (NF-κB) pathway-related proteins in lipopolysaccharide-induced RAW264.7 cells. After 56 days of treatment, ZQFZ alleviated the progression of colorectal cancer (CRC) and increased the body weight and thymic index values of the Apc^Min/+ mice. An analysis of the intestinal microflora showed that ZQFZ affected the abundance of certain immune-related bacteria, which may explain its immunomodulatory effects. Moreover, the percentages of T cells and NK cells in peripheral blood were significantly increased and 15 immune-related cytokines were regulated in serum or the colon or both. ZQFZ upregulated the levels of CD4 and CD8 in the spleen and colorectal tumors and decreased the expression levels of cytotoxic T-lymphocyte-associated protein 4 and programmed death-ligand 1 in colorectal tumors. ZQFZ promoted an anti-tumor immune response and inhibited the occurrence and development of CRC by regulating the immune system. This study provides the experimental basis for the application of ZQFZ as a therapeutic agent for CRC.

Mesenchymal-epithelial transition factor (MET) immunoreactivity in positive sentinel nodes from patients with melanoma

OBJECTIVE

Patients with cutaneous melanoma and a positive sentinel node (SN) are currently eligible for adjuvant treatment with targeted therapy and immune checkpoint inhibitors. Near-infrared (NIR) fluorescence imaging could be an alternative and less invasive tool for SN biopsy to select patients for adjuvant treatment. One potential target for NIR is the mesenchymal-epithelial transition factor (MET). This study aimed to assess MET immunoreactivity in positive SNs and to evaluate its potential diagnostic, prognostic and therapeutic value.

METHODS

In this retrospective study, positive SN samples from patients with primary cutaneous melanoma were collected to assess MET immunoreactivity. To this end, paraffin-embedded SNs were stained for MET (monoclonal antibody D1C2). A 4-point Histoscore was used to determine cytoplasmic and membranous immunoreactivity (0 negative/1 weak/2 moderate/3 strong). Samples were considered positive when ≥10% of the cancer cells showed MET expression (staining intensity ≥1). Patient and clinicopathological characteristics were used for descriptive statistics, binary logistic regression, and survival analyses.

RESULTS

Positive MET immunohistochemistry was observed in 24 out of 37 samples (65%). No statistically significant associations were found between MET positivity and the following prognostic factors: Breslow thickness (P = 0.961), ulceration (P = 1.000), and SN tumor burden (P = 0.792). According to MET positivity, Kaplan-Meier curves showed no significant differences in survival.

CONCLUSION

This exploratory study found no evidence to support MET immunoreactivity in positive SNs as a possible diagnostic or prognostic indicator in patients with melanoma.