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Bou-Samra P, Joffe J, Chang A, Guo E, Segil A, Azari F, Kennedy G, Din A, Hwang WT, Singhal S. Preoperative predictors of successful tumour localization by intraoperative molecular imaging with pafolacianine in lung cancer to create predictive nomogram. Eur J Cardiothorac Surg 2024; 65:ezad392. [PMID: 38191994 DOI: 10.1093/ejcts/ezad392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/17/2023] [Accepted: 01/05/2024] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVES Intraoperative molecular imaging (IMI) uses cancer-targeted fluorescent probe to locate nodules. Pafolacianine is a Food and Drug Administration-approved fluorescent probe for lung cancer. However, it has a 8-12% false negative rate for localization. Our goal is to define preoperative predictors of tumour localization by IMI. METHODS We performed a retrospective review of patients who underwent IMI using pafolacianine for lung lesions from June 2015 to August 2019. Candidate predictors including sex, age, body mass index, smoking history, tumour size, distance of tumour from surface, use of neoadjuvant therapy and positron emission tomography avidity were included. The outcome was fluorescence in vivo and comprehensively included those who were true or false positives negatives. Multiple imputation was used to handle the missing data. The final model was evaluated using the area under the receiver operating characteristic curve. RESULTS Three hundred nine patients were included in our study. The mean age was 64 (standard deviation 13) and 68% had a smoking history. The mean distance of the tumours from the pleural surface was 0.4 cm (standard deviation 0.6). Smoking in pack-years and distance from pleura had an odds ratio of 0.99 [95% confidence interval: 0.98-0.99; P = 0.03] and 0.46 [95% confidence interval: 0.27-0.78; P = 0.004], respectively. The final model had an area under the receiver operating characteristic curve of 0.68 and was used to create a nomogram that gives a probability of fluorescence in vivo. CONCLUSIONS Primary tumours that are deeper from the pleural surface, especially in patients with a higher pack-years, are associated with a decreased likelihood of intraoperative localization. We identified a nomogram to predict the likelihood of tumour localization with IMI with pafolacianine.
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Affiliation(s)
- Patrick Bou-Samra
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jonah Joffe
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics (DBEI), The University of Pennsylvania, Philadelphia, PA, USA
| | - Austin Chang
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Emily Guo
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alix Segil
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Feredun Azari
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gregory Kennedy
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Azra Din
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Wei-Ting Hwang
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics (DBEI), The University of Pennsylvania, Philadelphia, PA, USA
| | - Sunil Singhal
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Bou-Samra P, Chang A, Arambepola S, Guo E, Azari F, Kennedy G, Segil A, Singhal S. Preclinical Lymph Node Model for Intraoperative Molecular Imaging of Cancer. Res Sq 2023:rs.3.rs-2953015. [PMID: 37398120 PMCID: PMC10312951 DOI: 10.21203/rs.3.rs-2953015/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Purpose Lymph node(LN) dissection is part of most oncologic resections. Intraoperatively identifying a positive LN(+ LN), that harbors malignant cells, can be challenging. We hypothesized that intraoperative molecular imaging(IMI) using a cancer-targeted fluorescent prober can identify + LNs. This study aimed to develop a preclinical model of a + LN and test it using an activatable cathepsin-based enzymatic probe, VGT-309. Procedures In the first model, we used peripheral blood mononuclear cells (PBMC), representing the lymphocytic composition of the LN, mixed with different concentrations of human lung adenocarcinoma cell line A549. Then, they were embedded in a Matrigel® matrix. A black dye was added to mimic LN anthracosis. Model two was created using a murine spleen, the largest lymphoid organ, injected with various concentrations of A549. To test these models, we co-cultured A549 cells with VGT-309. Mean fluorescence intensity(MFI) was. An independent sample t-test was used to compare the average MFI of each A549:negative control ratio. Results A significant difference in MFI from our PBMC control was noted when A549 cells were 25% of the LN (p = 0.046) in both 3D cell aggregate models-where the LNs native parenchyma is replaced and the one where the tumor grows over the native parenchyma. For the anthracitic equivalents of these models, the first significant MFI compared to the control was when A549 cells were 9% of the LN (p = 0.002) in the former model, and 16.7% of the LN (p = 0.033) in the latter. In our spleen model, we first noted significance in MFI when A549 cells were 16.67% of the cellular composition.(p = 0.02). Conclusions A + LN model allows for a granular evaluation of different cellular burdens in + LN that can be assessed using IMI. This first exvivo + LN model can be used in preclinical testing of several existing dyes and in creating more sensitive cameras for IMI-guided LN detection.
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Affiliation(s)
| | - Austin Chang
- University of Pennsylvania Perelman School of Medicine
| | | | - Emily Guo
- University of Pennsylvania Perelman School of Medicine
| | - Feredun Azari
- University of Pennsylvania Perelman School of Medicine
| | | | - Alix Segil
- University of Pennsylvania Perelman School of Medicine
| | - Sunil Singhal
- University of Pennsylvania Perelman School of Medicine
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Bou-Samra P, Chang A, Azari F, Kennedy G, Segil A, Guo E, Marmarelis M, Langer C, Singhal S. Epidemiological, therapeutic, and survival trends in malignant pleural mesothelioma: A review of the National Cancer Database. Cancer Med 2023. [PMID: 37062067 DOI: 10.1002/cam4.5915] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/09/2023] [Accepted: 03/27/2023] [Indexed: 04/17/2023] Open
Abstract
BACKGROUND Malignant pleural mesothelioma (MPM) is an aggressive cancer of the cells lining the pleural cavity with a low overall incidence. The National Cancer Database (NCDB) released in August 2022 updated data that reflect the newest trends in MPM. METHODS The NCDB was queried for patients diagnosed with MPM between 2004 and 2020. Variables collected included demographics, tumor characteristics, and treatment. Student's t-test and independent-samples proportions test were used for means analysis. Survival was assessed by the Kaplan-Meier method using SPSS version 28. RESULTS A total of 41,074 patients were diagnosed with mesothelioma, with a steady incidence (0.25%) between 2004 and 2017. The mean age of diagnosis was 70 (SD 13). 73.2% of the patients were males, 69% had no comorbidities, and 93.3% were white. More patients were diagnosed at Stage 1 after 2008 (p < 0.001). Since 2010, there has been a significant increase in patients offered treatment with 73.9% receiving some therapy (p < 0.01): 50.5% received chemotherapy, 27.6% surgery, 8.6% radiation, and 5.4% immunotherapy. The median overall survival was 10.3 months from diagnosis [95% CI: 10.2-10.5]. Risk factors associated with 30-day mortality from surgical intervention included age (OR = 1.02, p < 0.001), male gender (OR = 1.3, p = 0.03), poorly differentiated grade (OR = 2.1, p < 0.001), Stage 4 (OR = 1.4, p = 0014), and epithelioid histology (OR = 0.51, p = 0.03). CONCLUSION The current management of MPM is based on stage and histologic subtype. Due to the small numbers of patients at most academic centers, the NCDB provides a robust dataset to draw upon broad data points in treatment discussions with patients.
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Affiliation(s)
- Patrick Bou-Samra
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Austin Chang
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Feredun Azari
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Gregory Kennedy
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Alix Segil
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Emily Guo
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Melina Marmarelis
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Division of Hematology & Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Corey Langer
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Division of Hematology & Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
| | - Sunil Singhal
- University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, Philadelphia, USA
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Azari F, Kennedy G, Zhang K, Bernstein E, Chang A, Nadeem B, Segil A, Desphande C, Delikatny J, Kucharczuk J, Singhal S. Effects of Light-absorbing Carbons in Intraoperative Molecular Imaging-Guided Lung Cancer Resections. Mol Imaging Biol 2023; 25:156-167. [PMID: 35290565 PMCID: PMC9474735 DOI: 10.1007/s11307-021-01699-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND One of the novel advancements to enhance the visual aspects of lung cancer identification is intraoperative molecular imaging (IMI), which can reliably detect tumors that would otherwise be missed by standard techniques such as tactile and visual feedback, particularly for sub-centimeter or ground-glass nodules. However, there remains a subset of patients who do not benefit from IMI due to excessive background fluorescence secondary to parenchymal light-absorbing carbon deposition. Our goal was to identify the effects of these carbonaceous materials on the quality of IMI-guided lung cancer resections. STUDY DESIGN AND METHODS Between July 2014 and May 2021, a total of 311 patients were included in the study. Patients underwent infusion of the study drug OTL38 or ICG up to 24 h prior to VATS for lung cancer. Several factors such as age, tumor subtype, PET SUV, smoking, demographics, chronic lung conditions, patient domicile, and anthracosis were analyzed with respect to lung fluorescence during IMI. P values < 0.05 were considered statistically significant. RESULTS Variables such as age, sex, and race had no statistical correlation to IMI success. However, smoking status and pack year had a statistically significant correlation with background parenchymal fluorescence and lung inflammation (p < 0.05). MFI of background (lung parenchyma) correlated with smoking history (p < 0.05) which led to decreased tumor-to-background ratio (TBR) measurements for all patients with proven malignancy (p < 0.05). Patients with chronic lung disease appear to have increased background parenchymal fluorescence regardless of smoking history (287 vs. 154, p < 0.01). City dwellers compared to other groups appear to be exposed to higher pollutant load and have higher rates of anthracosis, but living location's impact on fluorescence quantification appears to be not statistically significant. CONCLUSION Smokers with greater than 10 PPY and those with chronic lung disease appear to have decreased lesion-to-background discrimination, significant anthracosis, and reduced IMI efficacy secondary to light-absorbing carbon deposition.
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Affiliation(s)
- Feredun Azari
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gregory Kennedy
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kevin Zhang
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Elizabeth Bernstein
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ashley Chang
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Bilal Nadeem
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alix Segil
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - James Delikatny
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - John Kucharczuk
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Kennedy GT, Azari FS, Chang A, Nadeem B, Bernstein E, Segil A, Din A, Desphande C, Okusanya O, Keating J, Predina J, Newton A, Kucharczuk JC, Singhal S. Single-institution experience of 500 pulmonary resections guided by intraoperative molecular imaging. J Thorac Cardiovasc Surg 2023; 165:1928-1938.e1. [PMID: 36863974 DOI: 10.1016/j.jtcvs.2022.12.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 12/04/2022] [Accepted: 12/06/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Intraoperative molecular imaging (IMI) using tumor-targeted optical contrast agents can improve thoracic cancer resections. There are no large-scale studies to guide surgeons in patient selection or imaging agent choice. Here, we report our institutional experience with IMI for lung and pleural tumor resection in 500 patients over a decade. METHODS Between December 2011 and November 2021, patients with lung or pleural nodules undergoing resection were preoperatively infused with 1 of 4 optical contrast tracers: EC17, TumorGlow, pafolacianine, or SGM-101. Then, during resection, IMI was used to identify pulmonary nodules, confirm margins, and identify synchronous lesions. We retrospectively reviewed patient demographic data, lesion diagnoses, and IMI tumor-to-background ratios (TBRs). RESULTS Five hundred patients underwent resection of 677 lesions. We found that there were 4 types of clinical utility of IMI: detection of positive margins (n = 32, 6.4% of patients), identification of residual disease after resection (n = 37, 7.4%), detection of synchronous cancers not predicted on preoperative imaging (n = 26, 5.2%), and minimally invasive localization of nonpalpable lesions (n = 101 lesions, 14.9%). Pafolacianine was most effective for adenocarcinoma-spectrum malignancies (mean TBR, 2.84), and TumorGlow was most effective for metastatic disease and mesothelioma (TBR, 3.1). False-negative fluorescence was primarily seen in mucinous adenocarcinomas (mean TBR, 1.8), heavy smokers (>30 pack years; TBR, 1.9), and tumors greater than 2.0 cm from the pleural surface (TBR, 1.3). CONCLUSIONS IMI may be effective in improving resection of lung and pleural tumors. The choice of IMI tracer should vary by the surgical indication and the primary clinical challenge.
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Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Ashley Chang
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Bilal Nadeem
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Alix Segil
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Azra Din
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | | | - Jane Keating
- Department of Surgery, Hartford Hospital, Hartford, Conn
| | - Jarrod Predina
- Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Andrew Newton
- Department of Surgery, MD Anderson Cancer Center, Houston, Tex
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa.
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Azari F, Kennedy GT, Chang A, Nadeem B, Bou-Samra P, Chang A, Segil A, Bernstein E, Sullivan NT, Eruslanov E, Delikatny J, Singhal S. Sodium Multivitamin Transporter-Targeted Fluorochrome Facilitates Enhanced Metabolic Evaluation of Tumors Through Coenzyme-R Dependent Intracellular Signaling Pathways. Mol Imaging Biol 2022; 25:569-585. [PMID: 36534331 DOI: 10.1007/s11307-022-01792-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Intraoperative molecular imaging (IMI)-guided resections have been shown to improve oncologic outcomes for patients undergoing surgery for solid malignancies. The technology utilizes fluorescent tracers targeting cancer cells without the use of any ionizing radiation. However, currently available targeted IMI tracers are effective only for tumors with a highly specific receptor expression profile, and there is an unmet need for IMI tracers to label a broader range of tumor types. Here, we describe the development and testing of a novel tracer (CR)-S0456) targeted to the sodium multivitamin transporter (SMVT). METHODS Preclinical models of fibrosarcoma (HT-1080), lung (A549), breast (4T1), and renal cancers (HEK-293 T) in vitro and in vivo were used for assessment of (CR)-S0456 specific tumor labeling via sodium-mediated SMVT uptake in dipotassium phosphate or choline chloride-containing media buffer. Additionally, pharmacologic inhibition of multiple intracellular coenzyme-R obligate signaling pathways, including holocarboxylase synthetase (sulconazole nitrate), PI3K/AKT/mTOR (omipalisib), and calmodulin-dependent phosphatase (calmidazolium), were investigated to assess (CR)-S0456 uptake kinetics. Human fibrosarcoma-bearing xenografts in athymic nude mice were used for tumor and metabolic-specific labeling. Novel NIR needle confocal laser endomicroscopic (nCLE) intratumoral sampling was performed to demonstrate single-cell specific labeling by CR-S0456. RESULTS CR-S0456 localization in vitro correlated with highly proliferative cell lines (MTT) and doubling time (p < 0.05) with the highest microscopic fluorescence detected in aggressive human fibrosarcomas (HT-1080). Coenzyme-R-specific localization was demonstrated to be SMVT-specific after competitive inhibition of internal localization with excess administration of pantothenic acid. Inhibiting the activity of SMVT by affecting sodium ion hemostasis prevented the complete uptake of CR-S0456. In vivo validation demonstrated (CR)-S0456 localization to xenograft models with accurate identification of primary tumors as well as margin assessment down to 1 mm3 tumor volume. Systemic treatment of xenograft-bearing mice with a dual PI3K/mTOR inhibitor suppressed intratumoral cell signaling and (CR)-S0456 uptake via a reduction in SMVT expression. Novel analysis of in vivo intratumoral cytologic fluorescence using near-infrared confocal laser endomicroscopy demonstrated the absence of coenzyme-R-mediated NIR fluorescence but not fibroblast activation protein (FAP)-conjugated fluorochrome, indicating specific intracellular inhibition of coenzyme-R obligate pathways. CONCLUSION These findings suggest that a SMVT-targeted NIR contrast agent can be a suitable tracer for imaging a wide range of malignancies as well as evaluating metabolic response to systemic therapies, similar to PET imaging with immune checkpoint inhibitors.
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Affiliation(s)
- Feredun Azari
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Department of Thoracic Surgery, Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, 14th floor, South Pavilion, Philadelphia, PA, 19104, USA.
| | - Gregory T Kennedy
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ashley Chang
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Bilal Nadeem
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Patrick Bou-Samra
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Austin Chang
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alix Segil
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Elizabeth Bernstein
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Neil T Sullivan
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Evgeniy Eruslanov
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - James Delikatny
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Kennedy GT, Azari FS, Chang A, Nadeem B, Bernstein E, Segil A, Din A, Marfatia I, Desphande C, Okusanya O, Keating J, Predina J, Newton A, Kucharczuk JC, Singhal S. Comparative Experience of Short-wavelength Versus Long-wavelength Fluorophores for Intraoperative Molecular Imaging of Lung Cancer. Ann Surg 2022; 276:711-719. [PMID: 35837887 PMCID: PMC9463092 DOI: 10.1097/sla.0000000000005596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intraoperative molecular imaging (IMI) using tumor-targeted optical contrast agents can improve cancer resections. The optimal wavelength of the IMI tracer fluorophore has never been studied in humans and has major implications for the field. To address this question, we investigated 2 spectroscopically distinct fluorophores conjugated to the same targeting ligand. METHODS Between December 2011 and November 2021, patients with primary lung cancer were preoperatively infused with 1 of 2 folate receptor-targeted contrast tracers: a short-wavelength folate-fluorescein (EC17; λ em =520 nm) or a long-wavelength folate-S0456 (pafolacianine; λ em =793 nm). During resection, IMI was utilized to identify pulmonary nodules and confirm margins. Demographic data, lesion diagnoses, and fluorescence data were collected prospectively. RESULTS Two hundred eighty-two patients underwent resection of primary lung cancers with either folate-fluorescein (n=71, 25.2%) or pafolacianine (n=211, 74.8%). Most tumors (n=208, 73.8%) were invasive adenocarcinomas. We identified 2 clinical applications of IMI: localization of nonpalpable lesions (n=39 lesions, 13.8%) and detection of positive margins (n=11, 3.9%). In each application, the long-wavelength tracer was superior to the short-wavelength tracer regarding depth of penetration, signal-to-background ratio, and frequency of event. Pafolacianine was more effective for detecting subpleural lesions (mean signal-to-background ratio=2.71 vs 1.73 for folate-fluorescein, P <0.0001). Limit of signal detection was 1.8 cm from the pleural surface for pafolacianine and 0.3 cm for folate-fluorescein. CONCLUSIONS Long-wavelength near-infrared fluorophores are superior to short-wavelength IMI fluorophores in human tissues. Therefore, future efforts in all human cancers should likely focus on long-wavelength agents.
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Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Ashley Chang
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Bilal Nadeem
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Alix Segil
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Azra Din
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Isvita Marfatia
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Jane Keating
- Department of Surgery, Hartford Hospital, Hartford, CT
| | - Jarrod Predina
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Andrew Newton
- Department of Surgery, MD Anderson Cancer Center, Houston, TX
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
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Kennedy GT, Holt DE, Azari FS, Bernstein E, Nadeem B, Chang A, Sullivan NT, Segil A, Desphande C, Bensen E, Santini JT, Kucharczuk JC, Delikatny EJ, Bogyo M, Egan AJM, Bradley CW, Eruslanov E, Lickliter JD, Wright G, Singhal S. A Cathepsin-Targeted Quenched Activity-Based Probe Facilitates Enhanced Detection of Human Tumors during Resection. Clin Cancer Res 2022; 28:3729-3741. [PMID: 35792882 DOI: 10.1158/1078-0432.ccr-22-1215] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/02/2022] [Accepted: 07/01/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE Fluorescence-guided surgery using tumor-targeted contrast agents has been developed to improve the completeness of oncologic resections. Quenched activity-based probes that fluoresce after covalently binding to tumor-specific enzymes have been proposed to improve specificity, but none have been tested in humans. Here, we report the successful clinical translation of a cathepsin activity-based probe (VGT-309) for fluorescence-guided surgery. EXPERIMENTAL DESIGN We optimized the specificity, dosing, and timing of VGT-309 in preclinical models of lung cancer. To evaluate clinical feasibility, we conducted a canine study of VGT-309 during pulmonary tumor resection. We then conducted a randomized, double-blind, dose-escalation study in healthy human volunteers receiving VGT-309 to evaluate safety. Finally, we tested VGT-309 in humans undergoing lung cancer surgery. RESULTS In preclinical models, we found highly specific tumor cell labeling that was blocked by a broad spectrum cathepsin inhibitor. When evaluating VGT-309 for guidance during resection of canine tumors, we found that the probe selectively labeled tumors and demonstrated high tumor-to-background ratio (TBR; range: 2.15-3.71). In the Phase I human study, we found that VGT-309 was safe at all doses studied. In the ongoing Phase II trial, we report two cases in which VGT-309 localized visually occult, non-palpable tumors (TBRs = 2.83 and 7.18) in real time to illustrate its successful clinical translation and potential to improve surgical management. CONCLUSIONS This first-in-human study demonstrates the safety and feasibility of VGT-309 to label human pulmonary tumors during resection. These results may be generalizable to other cancers due to cathepsin overexpression in many solid tumors.
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Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - David E Holt
- Department of Clinical Sciences and Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Bilal Nadeem
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Ashley Chang
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Neil T Sullivan
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Alix Segil
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | | | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Edward J Delikatny
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Matthew Bogyo
- Department of Pathology, Stanford University, Palo Alto, California
| | - A J Matthew Egan
- Department of Pathology, St. Vincent's Hospital, Melbourne, Australia
| | - Charles W Bradley
- Department of Pathobiology, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania
| | - Evgeniy Eruslanov
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | - Gavin Wright
- Department of Surgery, St. Vincent's Hospital, University of Melbourne, Melbourne, Australia.,Victorian Comprehensive Cancer Centre Alliance, Melbourne, Australia
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Kennedy GT, Azari FS, Bernstein E, Nadeem B, Chang A, Segil A, Sullivan N, Encarnado E, Desphande C, Kucharczuk JC, Leonard K, Low PS, Chen S, Criton A, Singhal S. Targeted detection of cancer cells during biopsy allows real-time diagnosis of pulmonary nodules. Eur J Nucl Med Mol Imaging 2022; 49:4194-4204. [PMID: 35788703 PMCID: PMC9525441 DOI: 10.1007/s00259-022-05868-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/09/2022] [Indexed: 12/19/2022]
Abstract
Background The diagnostic yield of biopsies of solitary pulmonary nodules (SPNs) is low, particularly in sub-solid lesions. We developed a method (NIR-nCLE) to achieve cellular level cancer detection during biopsy by integrating (i) near-infrared (NIR) imaging using a cancer-targeted tracer (pafolacianine), and (ii) a flexible NIR confocal laser endomicroscopy (CLE) system that can fit within a biopsy needle. Our goal was to assess the diagnostic accuracy of NIR-nCLE ex vivo in SPNs. Methods Twenty patients with SPNs were preoperatively infused with pafolacianine. Following resection, specimens were inspected to identify the lesion of interest. NIR-nCLE imaging followed by tissue biopsy was performed within the lesion and in normal lung tissue. All imaging sequences (n = 115) were scored by 5 blinded raters on the presence of fluorescent cancer cells and compared to diagnoses by a thoracic pathologist. Results Most lesions (n = 15, 71%) were adenocarcinoma-spectrum malignancies, including 7 ground glass opacities (33%). Mean fluorescence intensity (MFI) by NIR-nCLE for tumor biopsy was 20.6 arbitrary units (A.U.) and mean MFI for normal lung was 6.4 A.U. (p < 0.001). Receiver operating characteristic analysis yielded a high area under the curve for MFI (AUC = 0.951). Blinded raters scored the NIR-nCLE sequences on the presence of fluorescent cancer cells with sensitivity and specificity of 98% and 97%, respectively. Overall diagnostic accuracy was 97%. The inter-observer agreement of the five raters was excellent (κ = 0.95). Conclusions NIR-nCLE allows sensitive and specific detection of cancer cells in SPNs. This technology has far-reaching implications for diagnostic needle biopsies and intraprocedural decision-making. Supplementary Information The online version contains supplementary material available at 10.1007/s00259-022-05868-9.
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Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Bilal Nadeem
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Ashley Chang
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Alix Segil
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Neil Sullivan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Emmanuel Encarnado
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | | | - Philip S Low
- Department of Chemistry, Purdue University, West Lafayette, IN, USA
| | | | | | - Sunil Singhal
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA.
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Kennedy GT, Azari FS, Bernstein E, Nadeem B, Chang A, Segil A, Carlin S, Sullivan NT, Encarnado E, Desphande C, Kularatne S, Gagare P, Thomas M, Kucharczuk JC, Christien G, Lacombe F, Leonard K, Low PS, Criton A, Singhal S. Targeted detection of cancer at the cellular level during biopsy by near-infrared confocal laser endomicroscopy. Nat Commun 2022; 13:2711. [PMID: 35581212 PMCID: PMC9114105 DOI: 10.1038/s41467-022-30265-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/23/2022] [Indexed: 12/21/2022] Open
Abstract
Suspicious nodules detected by radiography are often investigated by biopsy, but the diagnostic yield of biopsies of small nodules is poor. Here we report a method-NIR-nCLE-to detect cancer at the cellular level in real-time during biopsy. This technology integrates a cancer-targeted near-infrared (NIR) tracer with a needle-based confocal laser endomicroscopy (nCLE) system modified to detect NIR signal. We develop and test NIR-nCLE in preclinical models of pulmonary nodule biopsy including human specimens. We find that the technology has the resolution to identify a single cancer cell among normal fibroblast cells when co-cultured at a ratio of 1:1000, and can detect cancer cells in human tumors less than 2 cm in diameter. The NIR-nCLE technology rapidly delivers images that permit accurate discrimination between tumor and normal tissue by non-experts. This proof-of-concept study analyzes pulmonary nodules as a test case, but the results may be generalizable to other malignancies.
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Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Bilal Nadeem
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Ashley Chang
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Alix Segil
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Sean Carlin
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Neil T Sullivan
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Emmanuel Encarnado
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | | | - Mini Thomas
- On Target Laboratories, West Lafayette, IN, USA
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | | | | | - Philip S Low
- Department of Chemistry, Purdue University, West Lafayette, IN, USA
| | | | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Kennedy GT, Azari FS, Bernstein E, Nadeem B, Chang AE, Segil A, Sullivan N, Marfatia I, Din A, Desphande C, Kucharczuk JC, Low PS, Singhal S. A Prostate-Specific Membrane Antigen-Targeted Near-Infrared Conjugate for Identifying Pulmonary Squamous Cell Carcinoma during Resection. Mol Cancer Ther 2022; 21:546-554. [PMID: 35149546 PMCID: PMC8983600 DOI: 10.1158/1535-7163.mct-21-0821] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/13/2021] [Accepted: 01/24/2022] [Indexed: 11/16/2022]
Abstract
Pulmonary squamous cell carcinoma is the second most common lung cancer subtype and has a low 5-year survival rate at 17.6%. Complete resection with negative margins can be curative, but a high number of patients suffer early postoperative recurrence due to inadequate disease clearance at the index operation. Intraoperative molecular imaging (IMI) with tumor-targeted optical contrast agents is effective in improving resection completeness for other tumor types, but there are no IMI tracers targeted to pulmonary squamous cell carcinoma. In this report, we describe the use of a novel prostate-specific membrane antigen (PSMA)-targeted near-infrared conjugate (OTL78) to identify pulmonary squamous cell carcinoma. We identified PSMA as a viable target by examining its expression in human lung tumor specimens from a surgical cohort. Ninety-four percent of tumors expressed PSMA in either the pulmonary squamous cells or the tumor neovasculature. Using in vitro and in vivo models, we found that OTL78 reliably localized pulmonary squamous cell carcinoma in a PSMA-dependent manner. Finally, we found that IMI with OTL78 markedly improved surgeons' ability to identify residual disease after surgery in a preclinical model. Ultimately, this novel optical tracer may aid surgical resection of pulmonary squamous cell carcinoma and potentially improve long-term outcomes.
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Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Bilal Nadeem
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Ashley E Chang
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Alix Segil
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Neil Sullivan
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Isvita Marfatia
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Azra Din
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Philip S Low
- Department of Chemistry, Purdue University, West Lafayette, Indiana
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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