Evaluation of intraoperative fluorescence imaging-guided surgery in cancer-bearing dogs: a prospective proof-of-concept phase II study in 9 cases

Defining the relevance of surgical margins. Part two: Strategies to improve prediction of recurrence risk

Due to the complex nature of tumour biology and the integration between host tissues and molecular processes of the tumour cells, a continued reliance on the status of the microscopic cellular margin should not remain our only determinant of the success of a curative-intent surgery for patients with cancer. Based on current evidence, relying on a purely cellular focus to provide a binary indication of treatment success can provide an incomplete interpretation of potential outcome. A more holistic analysis of the cancer margin may be required. If we are to move ahead from our current situation - and allow treatment plans to be more intelligently tailored to meet the requirements of each individual tumour - we need to improve our utilisation of techniques that either improve recognition of residual tumour cells within the surgical field or enable a more comprehensive interrogation of tumour biology that identifies a risk of recurrence. In the second article in this series on defining the relevance of surgical margins, the authors discuss possible alternative strategies for margin assessment and evaluation in the canine and feline cancer patient. These strategies include considering adoption of the residual tumour classification scheme; intra-operative imaging systems including fluorescence-guided surgery, optical coherence tomography and Raman spectroscopy; molecular analysis and whole transcriptome analysis of tissues; and the development of a biologic index (nomogram). These techniques may allow evaluation of individual tumour biology and the status of the resection margin in ways that are different to our current techniques. Ultimately, these techniques seek to better define the risk of tumour recurrence following surgery and provide the surgeon and patient with more confidence in margin assessment.

Performance of two clinical fluorescence imaging systems with different targeted and non-targeted near-infrared fluorophores: a cadaveric explorative study

Introduction

Near-infrared (NIR) fluorescence-guided surgery is increasingly utilized in humans and pets. As clinical imaging systems are optimized for Indocyanine green (ICG) detection, the usage of targeted dyes necessitates the validation of these systems for each dye. We investigated the impact of skin pigmentation and tissue overlay on the sensitivity of two NIR cameras (IC-Flow^TM, Visionsense^TM VS3 Iridum) for the detection of non-targeted (ICG, IRDye800) and targeted (Angiostamp^TM, FAP-Cyan) NIR fluorophores in an ex vivo big animal model.

Methods

We quantitatively measured the limit of detection (LOD) and signal-to-background ratio (SBR) and implemented a semi-quantitative visual score to account for subjective interpretation of images by the surgeon.

Results

Visionsense^TM VS3 Iridum outperformed IC-Flow^TM in terms of LOD and SBR for the detection of all dyes except FAP-Cyan. Median SBR was negatively affected by skin pigmentation and tissue overlay with both camera systems. Level of agreement between quantitative and semi-quantitative visual score and interobserver agreement were better with Visionsense^TM VS3 Iridum.

Conclusion

The overlay of different tissue types and skin pigmentation may negatively affect the ability of the two tested camera systems to identify nanomolar concentrations of targeted-fluorescent dyes and should be considered when planning surgical applications.

A comparative biodistribution study of polymeric and lipid-based nanoparticles

Biodistribution of nanoencapsulated bioactive compounds is primarily determined by the size, shape, chemical composition and surface properties of the encapsulating nanoparticle, and, thus, less dependent on the physicochemical properties of the active pharmaceutical ingredient encapsulated. In the current work, we aimed to investigate the impact of formulation type on biodistribution profile for two clinically relevant nanoformulations. We performed a comparative study of biodistribution in healthy rats at several dose levels and durations up to 14-day post-injection. The studied nanoformulations were nanostructured lipid carriers incorporating the fluorescent dye IR780-oleyl, and polymeric nanoparticles containing the anticancer agent cabazitaxel. The biodistribution was approximated by quantification of the cargo in blood and relevant organs. Several clear and systematic differences in biodistribution were observed, with the most pronounced being a much higher (more than 50-fold) measured concentration ratio between cabazitaxel in all organs vs. blood, as compared to IR780-oleyl. Normalized dose linearity largely showed opposite trends between the two compounds after injection. Cabazitaxel showed a higher brain accumulation than IR780-oleyl with increasing dose injected. Interestingly, cabazitaxel showed a notable and prolonged accumulation in lung tissue compared to other organs. The latter observations could warrant further studies towards a possible therapeutic indication within lung and conceivably brain cancer for nanoformulations of this highly antineoplastic compound, for which off-target toxicity is currently dose-limiting in the clinic.

A multistep in vitro hemocompatibility testing protocol recapitulating the foreign body reaction to nanocarriers

The development of drug nanocarriers based on polymeric, lipid and ceramic biomaterials has been paving the way to precision medicine, where the delivery of poorly soluble active compounds and personalized doses are made possible. However, the nano-size character of these carriers has been demonstrated to have the potential to elicit pathways of the host response different from those of the same biomaterials when engineered as larger size implants and of the drugs when administered without a carrier. Therefore, a specific regulatory framework needs to be made available that can offer robust scientific insights and provide safety data by reliable tests of these novel nano-devices. In this context, the present work presents a multistep protocol for the in vitro assessment of the hemocompatibility of nanocarriers of different physicochemical properties. Poly (ethyl butyl cyanoacrylate) nanoparticles and lipid-based (LipImage™ 815) nanoparticles of comparable hydrodynamic diameter were tested through a battery of assays using human peripheral blood samples and recapitulating the main pathways of the host response upon systemic administration; i.e., protein interactions, fibrinogen-platelet binding, cytotoxicity, and inflammatory response. The data showed the sensitivity and reproducibility of the methods adopted that were also demonstrated to determine individual variability as well as to discriminate between activation of pathways of inflammation and unintended release of inflammatory signaling caused by loss of cell integrity. Therefore, this multistep testing is proposed as a reliable protocol for nanoparticle development and emerging regulatory frameworks.

A path toward the clinical translation of nano-based imaging contrast agents

Recently, nanoparticles have evolved ubiquitously in therapeutic applications to treat a range of diseases. Despite their regular use as therapeutic agents in the clinic, we have yet to see much progress in their clinical translation as diagnostic imaging agents. Several clinical and preclinical studies support their use as imaging contrast agents, but their use in the clinical setting has been limited to off-label imaging procedures (i.e., Feraheme). Since diagnostic imaging has been historically used as an exploratory tool to rule out disease or to screen patients for various cancers, nanoparticle toxicity remains a concern, especially when introducing exogenous contrast agents into a potentially healthy patient population, perhaps rationalizing why several nano-based therapeutic agents have been clinically translated before nano-based imaging agents. Another potential hindrance toward their clinical translation could be their market potential, as most therapeutic drugs have higher earning potential than small-molecule imaging contrast agents. With these considerations in mind, perhaps a clinical path forward for nano-based imaging contrast agents is to help guide/manage therapy. Several studies have demonstrated the ability of nanoparticles to produce more accurate imaging preoperatively, intraoperatively, and postoperatively. These applications illustrate a more reliable method of cancer detection and treatment that can prevent incomplete tumor resection and incorrect assessment of tumor progression following treatment. The aim of this review is to highlight the research that supports the use of nanoparticles in biomedical imaging applications and offer a new perspective to illustrate how nano-based imaging agents have the potential to better inform therapeutic decisions. This article is categorized under: Diagnostic Tools > In Vivo Nanodiagnostics and Imaging.

Image-guided tumor surgery: The emerging role of nanotechnology

Surgical resection is a mainstay treatment for solid tumors. Yet, methods to distinguish malignant from healthy tissue are primarily limited to tactile and visual cues as well as the surgeon's experience. As a result, there is a possibility that a positive surgical margin (PSM) or the presence of residual tumor left behind after resection may occur. It is well-documented that PSMs can negatively impact treatment outcomes and survival, as well as pose an economic burden. Therefore, surgical tumor imaging techniques have emerged as a promising method to decrease PSM rates. Nanoparticles (NPs) have unique characteristics to serve as optical contrast agents during image-guided surgery (IGS). Recently, there has been tremendous growth in the volume and types of NPs used for IGS, including clinical trials. Herein, we describe the most recent contributions of nanotechnology for surgical tumor identification. This article is categorized under: Therapeutic Approaches and Drug Discovery > Nanomedicine for Oncologic Disease Implantable Materials and Surgical Technologies > Nanoscale Tools and Techniques in Surgery Diagnostic Tools > in vivo Nanodiagnostics and Imaging.

Quantification of Surface GalNAc Ligands Decorating Nanostructured Lipid Carriers by UPLC-ELSD

Nanoparticles have been extensively studied for drug delivery and targeting to specific organs. The functionalization of the nanoparticle surface by site-specific ligands (antibodies, peptides, saccharides) can ensure efficient recognition and binding with relevant biological targets. One of the main challenges in the development of these decorated nanocarriers is the accurate quantification of the amount of ligands on the nanoparticle surface. In this study, nanostructured lipid carriers (NLC) were functionalized with N-acetyl-D-galactosamine (GalNAc) units, known to target the asialoglycoprotein receptor (ASGPR). Different molar percentages of GalNAc-functionalized surfactant (0%, 2%, 5%, and 14%) were used in the formulation. Based on ultra-high-performance liquid chromatography separation and evaporative light-scattering detection (UPLC-ELSD), an analytical method was developed to specifically quantify the amount of GalNAc units present at the NLC surface. This method allowed the accurate quantification of GalNAc surfactant and therefore gave some insights into the structural parameters of these multivalent ligand systems. Our data show that the GalNAc decorated NLC possess large numbers of ligands at their surface and suitable distances between them for efficient multivalent interaction with the ASGPR, and therefore promising liver-targeting efficiency.

Comparison between optical coherence tomographic and histopathologic appearances of artifacts caused by common surgical conditions and instrumentation

OBJECTIVE

To document the appearance of artifacts created by commonly encountered surgical conditions and instrumentation on optical coherence tomography (OCT) and to compare these findings with histopathology.

STUDY DESIGN

Ex vivo study.

ANIMALS

Five canine cadavers.

METHODS

Skin, subcutaneous fat, skeletal muscle, and fascia samples were obtained from fresh canine cadavers. Blood pooling, hemostatic crushing, scalpel blade cut, monopolar electrosurgery, bipolar vessel sealing device, and ultrasonic energy surgical artifacts were induced on each tissue type. Each specimen was imaged with OCT and subsequently histologically processed.

RESULTS

Most surgical instrumentation used for tumor excision created a high-scattering region with local architectural disruption. Blood pooling was visible as a high-scattering layer overlying tissue with normal architecture. Only the scalpel blade created a focal, low-scattering area representing a sharply demarcated cut within the tissue distinct from the appearance of other instrumentation.

CONCLUSION

Common surgical instruments and conditions encountered during tumor excision produced high-scattering OCT artifacts in tissues commonly seen at surgical margins.

CLINICAL SIGNIFICANCE

The clinical value of OCT hinges on the ability of personnel to interpret this novel imaging and recognize artifacts. Defining and describing the appearance of common surgical artifacts provides a foundation to create image libraries with known histological and OCT interpretation, ultimately improving the diagnostic accuracy of OCT for assessment of surgical margins.

Measuring Particle Size Distribution by Asymmetric Flow Field Flow Fractionation: A Powerful Method for the Preclinical Characterization of Lipid-Based Nanoparticles

Particle size distribution and stability are key attributes for the evaluation of the safety and efficacy profile of medical nanoparticles (Med-NPs). Measuring particle average size and particle size distribution is a challenging task which requires the combination of orthogonal high-resolution sizing techniques, especially in complex biological media. Unfortunately, despite its limitations, due to its accessibility, low cost, and easy handling, batch mode dynamic light scattering (DLS) is still very often used as the only approach to measure particle size distribution in the nanomedicine field. In this work the use of asymmetric flow field flow fractionation coupled to multiangle light scattering and dynamic light scattering detectors (AF4-MALS-DLS) was evaluated as an alternative to batch mode DLS to measure the physical properties of lipid-based nanoparticles. A robust standard operating procedure (SOPs) developed by the Nanomedicine Characterization Laboratory (EUNCL) was presented and tested to assess size stability, batch to batch consistency, and the behavior of the lipid-based nanoparticles in plasma. Orthogonal sizing techniques, such as transmission electron microscopy (TEM) and particle tracking analysis (PTA) measurements, were performed to support the results. While batch mode DLS could be applied as a fast and simple method to provide a preliminary insight into the integrity and polydispersity of samples, it was unsuitable to resolve small modifications of the particle size distribution. The introduction of nanoparticle sorting by field-flow fractionation coupled to online DLS and MALS allowed assessment of batch to batch variability and changes in the size of the lipid nanoparticles induced by the interaction with serum proteins, which are critical for quality control and regulatory aspects. In conclusion, if a robust SOP is followed, AF4-MALS-DLS is a powerful method for the preclinical characterization of lipid-based nanoparticles.

Intra-operative imaging of surgical margins of canine soft tissue sarcoma using optical coherence tomography

Optical coherence tomography (OCT) is a rapid non-invasive imaging technique that has shown high sensitivity for intra-operative surgical margin assessment in human breast cancer clinical trials. This promising technology has not been evaluated in veterinary medicine. The objective of this study was to correlate normal and abnormal histological features with OCT images for surgical margins from excised canine soft tissue sarcoma (STS) and to establish image evaluation criteria for identifying positive surgical margins. Fourteen client-owned dogs underwent surgical resection of a STS and OCT imaging of 2 to 4 areas of interest on the resected specimen were performed. Following imaging these areas were marked with surgical ink and trimmed for histopathology evaluation. Results showed that different tissue types had distinct characteristic appearances on OCT imaging. Adipose tissue exhibited a relatively low scattering and a honey-comb texture pattern. Skeletal muscle and sarcoma tissue were both dense and highly scattering. While sarcoma tissue was highly scattering, it did not have organized recognizable structure in contrast to muscle which showed clear fibre alignment patterns. In this investigation, we showed different tissue types had different and characteristic scattering and image texture appearances on OCT, which closely correlate with low-power histology images. Given the differentiation between tissue types the results support that OCT could be used to identify positive surgical margins immediately following resection of STS. Further research is needed to assess the diagnostic accuracy of this method for surgical margin assessment.

Fluorescence-guided surgery for cancer patients: a proof of concept study on human xenografts in mice and spontaneous tumors in pets

Surgery is often the first treatment option for patients with cancer. Patient survival essentially depends on the completeness of tumor resection. This is a major challenge, particularly in cases of peritoneal carcinomatosis, where tumors are widely disseminated in the large peritoneal cavity. Any development to help surgeons visualize these residual cells would improve the completeness of the surgery. For non-disseminated tumors, imaging could be used to ensure that the tumor margins and the draining lymph nodes are free of tumor deposits.

Near-infrared fluorescence imaging has been shown to be one of the most convenient imaging modalities. Our aim was to evaluate the efficacy of a near-infrared fluorescent probe targeting the αvβ3 integrins (Angiostamp™) for intraoperative detection of tumors using the Fluobeam® device.

We determined whether different human tumor nodules from various origins could be detected in xenograft mouse models using both cancer cell lines and patient-derived tumor cells. We found that xenografts could be imaged by fluorescent staining irrespective of their integrin expression levels. This suggests imaging of the associated angiogenesis of the tumor and a broader potential utilization of Angiostamp™. We therefore performed a veterinary clinical trial in cats and dogs with local tumors or with spontaneous disseminated peritoneal carcinomatosis. Our results demonstrate that the probe can specifically visualize both breast and ovarian nodules, and suggest that Angiostamp™ is a powerful fluorescent contrast agent that could be used in both human and veterinary clinical trials for intraoperative detection of tumors.

Development and validation of an HPLC-fluorescence method for the quantification of IR780-oleyl dye in lipid nanoparticles

A reversed-phase (RP) high-performance liquid chromatography (HPLC) method for the content determination of IR780-oleyl (IRO) dye in lipid nanoparticles was developed and validated. Chromatographic separation was performed on a RP C18 column with a gradient program of water and acetonitrile both with 0.1% (v/v) TFA, at a flow rate of 1.0mL/min and a total run of 21min. IRO dye detection was made by fluorescence at emission wavelength of 773nm (excitation wavelength: 744nm). According to ICH guidelines, the developed method was shown to be specific, linear in the range 3-8μg/mL (R²=0.9998), precise at the intra-day and inter-day levels as reflected by the coefficient of variation (CV≤1.98%) at three different concentrations (4, 6 and 8 μg/mL) and accurate, with recovery rates between 98.2-101.6% and 99.2-100.5%. The detection and quantitation limits were 0.41 and 1.24μg/mL, respectively. Stability studies of sample processing showed that IRO dye was stable after 24h in the autosampler or after three freeze/thaw cycles. Combined with fluorescence measurements, the developed method was successfully applied to optimize the loading capacity of IRO dye in the core of lipid nanoparticles.

Near infrared fluorescent imaging of brain tumor with IR780 dye incorporated phospholipid nanoparticles

Background

Near-IR fluorescence (NIRF) imaging is becoming a promising approach in preclinical tumor detection and clinical image-guided oncological surgery. While heptamethine cyanine dye IR780 has excellent tumor targeting and imaging potential, its hydrophobic property limits its clinical use. In this study, we developed nanoparticle formulations to facilitate the use of IR780 for fluorescent imaging of malignant brain tumor.

Methods

Self-assembled IR780-liposomes and IR780-phospholipid micelles were prepared and their NIRF properties were characterized. The intracellular accumulation of IR780-nanoparticles in glioma cells were determined using confocal microscopy. The in vivo brain tumor targeting and NIRF imaging capacity of IR780-nanoparticles were evaluated using U87MG glioma ectopic and orthotopic xenograft models and a spontaneous glioma mouse model driven by RAS/RTK activation.

Results

The loading of IR780 into liposomes or phospholipid micelles was efficient. The particle diameter of IR780-liposomes and IR780-phospholipid micelles were 95 and 26 nm, respectively. While stock solutions of each preparation were maintained at ready-to-use condition, the IR780-phospholipid micelles were more stable. In tissue culture cells, IR780-nanoparticles prepared by either method accumulated in mitochondria, however, in animals the IR780-phospholipid micelles showed enhanced intra-tumoral accumulation in U87MG ectopic tumors. Moreover, IR780-phospholipid micelles also showed preferred intracranial tumor accumulation and potent NIRF signal intensity in glioma orthotopic models at a real-time, non-invasive manner.

Conclusion

The IR780-phospholipid micelles demonstrated tumor-specific NIRF imaging capacity in glioma preclinical mouse models, providing great potential for clinical imaging and image-guided surgery of brain tumors.

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-016-1115-2) contains supplementary material, which is available to authorized users.

Comparison between the indocyanine green fluorescence and blue dye methods for sentinel lymph node biopsy using novel fluorescence image-guided resection equipment in different types of hospitals

Sentinel lymph node biopsy (SLNB) has become a standard of care to detect axillary lymph metastasis in early-stage breast cancer patients with clinically negative axillary lymph nodes. Current SLNB detection modalities comprising a blue dye, a radioactive tracer, or a combination of both have advantages as well as disadvantages. Thus, near-infrared fluorescence imaging using indocyanine green (ICG) has recently been regarded as a novel method that has generated interest for SLNB around the world. However, the lack of appropriate fluorescence imaging systems has hindered further research and wide application of this method. Therefore, we developed novel fluorescence image-guided resection equipment (FIRE) to detect sentinel lymph nodes (SLNs). Moreover, to compare the ICG fluorescence imaging method with the blue dye method and to explore the universal feasibility of the former, a different type of hospital study was conducted. Ninety-nine eligible patients participated in the study at 3 different types of hospitals. After subcutaneous ICG allergy testing, all the patients were subcutaneously injected with methylene blue and ICG into the subareolar area. Consequently, 276 SLNs (range 1-7) were identified in 98 subjects (detection rate: 99%) by using the ICG fluorescence imaging method. In contrast, the blue dye method only identified 202 SLNs (range 1-7) in 91 subjects (detection rate: 91.92%). Besides, the results of the fluorescence imaging method were similar in the 3 hospitals. Our findings indicate the universal feasibility of the ICG fluorescence imaging method for SLNB using the fluorescence image-guided resection equipment in early breast cancer detection.

Phase-0/phase-I study of dye-loaded lipid nanoparticles for near-infrared fluorescence imaging in healthy dogs

Near-infrared (NIR) fluorescence imaging using FDA-approved indocyanine green (ICG) has been the subject of numerous studies during the past few years. It could constitute a potentially exciting new paradigm shift in veterinary oncology, especially to develop in vivo fluorescence imaging diagnostics and surgery guidance methods. The objective of this study was to evaluate the pharmacologic and toxicological characteristics in healthy beagle dogs of LipImage™ 815, a formulation made of NIR-dye-loaded lipid nanoparticles. The initial dosage for the evaluation of biodistribution was extrapolated from data in mice and then adapted to define the more adapted dose (MAD) according to the fluorescence results obtained in 5 dogs using a Fluobeam® 800 imaging device (phase 0 study). A single dose acute toxicity study was then performed (3 dogs, phase I study). Before the systemic administration of LipImage™ 815, the dogs presented a very mild residual fluorescence, particularly in the liver and kidneys. After injection, the plasma fluorescence continuously decreased, and the signal was relatively homogeneously distributed throughout the different organs, though more pronounced in the liver and to a lesser extent in the steroid-rich organs (adrenal, ovaries), intestines, lymph nodes and kidneys. A MAD of 2.0μg/kg was found. No evidence of acute or delayed general, hepatic, renal or hematologic toxicity was observed at 1-fold, 5-fold or 10-fold MAD. The results of this phase-0/phase-I study showed that an optimal dosage of LipImage™ 815 of 2.0μg/kg allowed the achievement of a fluorescence signal suitable for surgery guidance application without any acute side effects.