Size and depth of residual tumor after neoadjuvant chemoradiotherapy in rectal cancer - implications for the development of new imaging modalities for response assessment

With the shift towards organ preserving treatment strategies in rectal cancer it has become increasingly important to accurately discriminate between a complete and good clinical response after neoadjuvant chemoradiotherapy (CRT). Standard of care imaging techniques such as CT and MRI are well equipped for initial staging of rectal tumors, but discrimination between a good clinical and complete response remains difficult due to their limited ability to detect small residual vital tumor fragments. To identify new promising imaging techniques that could fill this gap, it is crucial to know the size and invasion depth of residual vital tumor tissue since this determines the requirements with regard to the resolution and imaging depth of potential new optical imaging techniques. We analyzed 198 pathology slides from 30 rectal cancer patients with a Mandard tumor regression grade 2 or 3 after CRT that underwent surgery. For each patient we determined response pattern, size of the largest vital tumor fragment or bulk and the shortest distance from the vital tumor to the luminal surface. The response pattern was shrinkage in 14 patients and fragmentation in 16 patients. For both groups combined, the largest vital tumor fragment per patient was smaller than 1mm for 38% of patients, below 0.2mm for 12% of patients and for one patient as small as 0.06mm. For 29% of patients the vital tumor remnant was present within the first 0.01mm from the luminal surface and for 87% within 0.5mm. Our results explain why it is difficult to differentiate between a good clinical and complete response in rectal cancer patients using endoscopy and MRI, since in many patients submillimeter tumor fragments remain below the luminal surface. To detect residual vital tumor tissue in all patients included in this study a technique with a spatial resolution of 0.06mm and an imaging depth of 8.9mm would have been required. Optical imaging techniques offer the possibility of detecting majority of these cases due to the potential of both high-resolution imaging and enhanced contrast between tissue types. These techniques could thus serve as a complimentary tool to conventional methods for rectal cancer response assessment.

Considering the Influence of Coronary Motion on Artery-Specific Biomechanics Using Fluid-Structure Interaction Simulation

The endothelium in the coronary arteries is subject to wall shear stress and vessel wall strain, which influences the biology of the arterial wall. This study presents vessel-specific fluid-structure interaction (FSI) models of three coronary arteries, using directly measured experimental geometries and boundary conditions. FSI models are used to provide a more physiologically complete representation of vessel biomechanics, and have been extended to include coronary bending to investigate its effect on shear and strain. FSI both without- and with-bending resulted in significant changes in all computed shear stress metrics compared to CFD (p = 0.0001). Inclusion of bending within the FSI model produced highly significant changes in Time Averaged Wall Shear Stress (TAWSS) + 9.8% LAD, + 8.8% LCx, - 2.0% RCA; Oscillatory Shear Index (OSI) + 208% LAD, 0% LCx, + 2600% RCA; and transverse wall Shear Stress (tSS) + 180% LAD, + 150% LCx and + 200% RCA (all p < 0.0001). Vessel wall strain was homogenous in all directions without-bending but became highly anisotropic under bending. Changes in median cyclic strain magnitude were seen for all three vessels in every direction. Changes shown in the magnitude and distribution of shear stress and wall strain suggest that bending should be considered on a vessel-specific basis in analyses of coronary artery biomechanics.

Tissue Classification of Breast Cancer by Hyperspectral Unmixing

(1) Background: Assessing the resection margins during breast-conserving surgery is an important clinical need to minimize the risk of recurrent breast cancer. However, currently there is no technique that can provide real-time feedback to aid surgeons in the margin assessment. Hyperspectral imaging has the potential to overcome this problem. To classify resection margins with this technique, a tissue discrimination model should be developed, which requires a dataset with accurate ground-truth labels. However, establishing such a dataset for resection specimens is difficult. (2) Methods: In this study, we therefore propose a novel approach based on hyperspectral unmixing to determine which pixels within hyperspectral images should be assigned to the ground-truth labels from histopathology. Subsequently, we use this hyperspectral-unmixing-based approach to develop a tissue discrimination model on the presence of tumor tissue within the resection margins of ex vivo breast lumpectomy specimens. (3) Results: In total, 372 measured locations were included on the lumpectomy resection surface of 189 patients. We achieved a sensitivity of 0.94, specificity of 0.85, accuracy of 0.87, Matthew's correlation coefficient of 0.71, and area under the curve of 0.92. (4) Conclusion: Using this hyperspectral-unmixing-based approach, we demonstrated that the measured locations with hyperspectral imaging on the resection surface of lumpectomy specimens could be classified with excellent performance.

Model for the diffuse reflectance in spatial frequency domain imaging

Significance

In spatial frequency domain imaging (SDFI), tissue is illuminated with sinusoidal intensity patterns at different spatial frequencies. For low spatial frequencies, the reflectance is diffuse and a model derived by Cuccia et al. (doi 10.1117/1.3088140) is commonly used to extract optical properties. An improved model resulting in more accurate optical property extraction could lead to improved diagnostic algorithms.

Aim

To develop a model that improves optical property extraction for the diffuse reflectance in SFDI compared to the model of Cuccia et al.

Approach

We derive two analytical models for the diffuse reflectance, starting from the theoretical radial reflectance R ( ρ ) for a pencil-beam illumination under the partial current boundary condition (PCBC) and the extended boundary condition (EBC). We compare both models and the model of Cuccia et al. to Monte Carlo simulations.

Results

The model based on the PCBC resulted in the lowest errors, improving median relative errors compared to the model of Cuccia et al. by 45% for the reflectance, 10% for the reduced scattering coefficient and 64% for the absorption coefficient.

Conclusions

For the diffuse reflectance in SFDI, the model based on the PCBC provides more accurate results than the currently used model by Cuccia et al.

Comparison of preprocessing techniques to reduce nontissue-related variations in hyperspectral reflectance imaging

SIGNIFICANCE

Hyperspectral reflectance imaging can be used in medicine to identify tissue types, such as tumor tissue. Tissue classification algorithms are developed based on, e.g., machine learning or principle component analysis. For the development of these algorithms, data are generally preprocessed to remove variability in data not related to the tissue itself since this will improve the performance of the classification algorithm. In hyperspectral imaging, the measured spectra are also influenced by reflections from the surface (glare) and height variations within and between tissue samples.

AIM

To compare the ability of different preprocessing algorithms to decrease variations in spectra induced by glare and height differences while maintaining contrast based on differences in optical properties between tissue types.

APPROACH

We compare eight preprocessing algorithms commonly used in medical hyperspectral imaging: standard normal variate, multiplicative scatter correction, min-max normalization, mean centering, area under the curve normalization, single wavelength normalization, first derivative, and second derivative. We investigate conservation of contrast stemming from differences in: blood volume fraction, presence of different absorbers, scatter amplitude, and scatter slope-while correcting for glare and height variations. We use a similarity metric, the overlap coefficient, to quantify contrast between spectra. We also investigate the algorithms for clinical datasets from the colon and breast.

CONCLUSIONS

Preprocessing reduces the overlap due to glare and distance variations. In general, the algorithms standard normal variate, min-max, area under the curve, and single wavelength normalization are the most suitable to preprocess data used to develop a classification algorithm for tissue classification. The type of contrast between tissue types determines which of these four algorithms is most suitable.

Toward improved endoscopic surveillance with multidiameter single fiber reflectance spectroscopy in patients with Barrett's esophagus

Patients with Barrett's esophagus are at an increased risk to develop esophageal cancer and, therefore, undergo regular endoscopic surveillance. Early detection of neoplasia enables endoscopic treatment, which improves outcomes. However, early Barrett's neoplasia is easily missed during endoscopic surveillance. This study investigates multidiameter single fiber reflectance spectroscopy (MDSFR) to improve Barrett's surveillance. Based on the concept of field cancerization, it may be possible to identify the presence of a neoplastic lesion from measurements elsewhere in the esophagus or even the oral cavity. In this study, MDSFR measurements are performed on non-dysplastic Barrett's mucosa, squamous mucosa, oral mucosa, and the neoplastic lesion (if present). Based on logistic regression analysis on the scattering parameters measured by MDSFR, a classifier is developed that can predict the presence of neoplasia elsewhere in the Barrett's segment from measurements on the non-dysplastic Barrett's mucosa (sensitivity 91%, specificity 71%, AUC = 0.77). Classifiers obtained from logistic regression analysis for the squamous and oral mucosa do not result in an AUC significantly different from 0.5.

Experimental validation of a recently developed model for single-fiber reflectance spectroscopy

SIGNIFICANCE

We recently developed a model for the reflectance measured with (multi-diameter) single-fiber reflectance (SFR) spectroscopy as a function of the reduced scattering coefficient μs', the absorption coefficient μa, and the phase function parameter psb. We validated this model with simulations.

AIM

We validate our model experimentally. To prevent overfitting, we investigate the wavelength-dependence of psb and propose a parametrization with only three parameters. We also investigate whether this parametrization enables measurements with a single fiber, as opposed to multiple fibers used in multi-diameter SFR (MDSFR).

APPROACH

We validate our model on 16 phantoms with two concentrations of Intralipid-20% (μs'=13 and 21  cm  -  1 at 500 nm) and eight concentrations of Evans Blue (μa  =  1 to 20  cm  -  1 at 605 nm). We parametrize psb as 10  -  5  ·    (  p1  (  λ  /  650  )    +  p2(λ/650)2  +  p3(λ/650)3  )  .

RESULTS

Average errors were 7% for μs', 11% for μa, and 16% with the parametrization of psb; and 7%, 17%, and 16%, respectively, without. The parametrization of psb improved the fit speed 25 times (94 s to <4  s). Average errors for only one fiber were 50%, 33%, and 186%, respectively.

CONCLUSIONS

Our recently developed model provides accurate results for MDSFR measurements but not for a single fiber. The psb parametrization prevents overfitting and speeds up the fit.

Subdiffuse scattering and absorption model for single fiber reflectance spectroscopy

Single fiber reflectance (SFR) spectroscopy is a technique that is sensitive to small-scale changes in tissue. An additional benefit is that SFR measurements can be performed through endoscopes or biopsy needles. In SFR spectroscopy, a single fiber emits and collects light. Tissue optical properties can be extracted from SFR spectra and related to the disease state of tissue. However, the model currently used to extract optical properties was derived for tissues with modified Henyey-Greenstein phase functions only and is inadequate for other tissue phase functions. Here, we will present a model for SFR spectroscopy that provides accurate results for a large range of tissue phase functions, reduced scattering coefficients, and absorption coefficients. Our model predicts the reflectance with a median error of 5.6% compared to 19.3% for the currently used model. For two simulated tissue spectra, our model fit provides accurate results.

Noise and bias in optical coherence tomography intensity signal decorrelation

Functional optical coherence tomography (OCT) imaging based on the decorrelation of the intensity signal has been used extensively in angiography and is finding use in flowmetry and therapy monitoring. In this work, we present a rigorous analysis of the autocorrelation function, introduce the concepts of contrast bias, statistical bias and variability, and identify the optimal definition of the second-order autocorrelation function (ACF) g ⁽²⁾ to improve its estimation from limited data. We benchmark different averaging strategies in reducing statistical bias and variability. We also developed an analytical correction for the noise contributions to the decorrelation of the ACF in OCT that extends the signal-to-noise ratio range in which ACF analysis can be used. We demonstrate the use of all the tools developed in the experimental determination of the lateral speckle size depth dependence in a rotational endoscopic probe with low NA, and we show the ability to more accurately determine the rotational speed of an endoscopic probe to implement NURD detection. We finally present g ⁽²⁾-based angiography of the finger nailbed, demonstrating the improved results from noise correction and the optimal bias mitigation strategies.

Analytical model for diffuse reflectance in single fiber reflectance spectroscopy

Cancer progression leads to changing scattering properties of affected tissues. Single fiber reflectance (SFR) spectroscopy detects these changes at small spatial scales, making it a promising tool for early in situ detection. Despite its simplicity and versatility, SFR signal modeling is hugely complicated so that, presently, only approximate models exist. We use a classic approach from geometrical probability to derive accurate analytical expressions for diffuse reflectance in SFR that shows a strong improvement over existing models. We consider the case of limited collection efficiency and the presence of absorption. A Monte Carlo light transport study demonstrates that we adequately describe the contribution of diffuse reflectance to the SFR signal. Additional steps are required to include semi-ballistic, non-diffuse reflectance also present in the SFR measurement.

Subdiffuse scattering model for single fiber reflectance spectroscopy

To detect small-scale changes in tissue with optical techniques, small sampling volumes are required. Single fiber reflectance (SFR) spectroscopy has a sampling depth of a few hundred micrometers. SFR spectroscopy uses a single fiber to emit and collect light. The only available model to determine optical properties with SFR spectroscopy was derived for tissues with modified Henyey-Greenstein phase functions. Previously, we demonstrated that this model is inadequate for other tissue phase functions. We develop a model to relate SFR measurements to scattering properties for a range of phase functions, in the absence of absorption. Since the source and detector overlap, the reflectance cannot be accurately described by diffusion theory alone: SFR measurements are subdiffuse. Therefore, we describe the reflectance as a combination of a diffuse and a semiballistic component. We use the model of Farrell et al. for the diffuse component, solved for an overlapping source and detector fiber. For the semiballistic component, we derive a new parameter, p_sb, which incorporates the integrals of the phase function over 1 deg in the backward direction and 23 deg in the forward direction. Our model predicts the reflectance with a median error of 2.1%, compared to 9.0% for the currently available model.

Imaging depth variations in hyperspectral imaging: Development of a method to detect tumor up to the required tumor-free margin width

Hyperspectral imaging is a promising technique for resection margin assessment during cancer surgery. Thereby, only a specific amount of the tissue below the resection surface, the clinically defined margin width, should be assessed. Since the imaging depth of hyperspectral imaging varies with wavelength and tissue composition, this can have consequences for the clinical use of hyperspectral imaging as margin assessment technique. In this study, a method was developed that allows for hyperspectral analysis of resection margins in breast cancer. This method uses the spectral slope of the diffuse reflectance spectrum at wavelength regions where the imaging depth in tumor and healthy tissue is equal. Thereby, tumor can be discriminated from healthy breast tissue while imaging up to a similar depth as the required tumor-free margin width of 2 mm. Applying this method to hyperspectral images acquired during surgery would allow for robust margin assessment of resected specimens. In this paper, we focused on breast cancer, but the same approach can be applied to develop a method for other types of cancer.

Refractive index measurement using single fiber reflectance spectroscopy

A method using single fiber reflectance spectroscopy to measure the refractive indices of transparent and turbid media over a broad wavelength range is presented and tested. For transparent liquid samples, the accuracy is within 0.2%, and the accuracy increases with increasing wavelength. For liquid turbid media, the accuracy is within 0.3% and increases with decreasing wavelength. For solid turbid samples, such as human skin, the accuracy critically depends on the optical contact between the fiber and sample surface. It is demonstrated that this technique has the potential to measure refractive indices of biological tissue in vivo.

Single fiber reflectance spectroscopy calibration

To accurately determine sample optical properties using single fiber reflectance spectroscopy (SFR), an absolute calibration of the reflectance is required. We investigated two SFR calibration methods, using a calibrated mirror and using the Fresnel reflection at the fiber tip as a reference. We compared these to commonly used calibration methods, using either Intralipid-20% in combination with Monte Carlo simulations or Spectralon as a reference. The Fresnel reflection method demonstrated the best reproducibility and yielded the most reliable result. We therefore recommend the Fresnel reflection method for the measured absolute reflectance calibration of SFR.

Modeling subdiffusive light scattering by incorporating the tissue phase function and detector numerical aperture

To detect small-scale changes in tissue with optical techniques, small sampling volumes and, therefore, short source–detector separations are required. In this case, reflectance measurements are not adequately described by the diffusion approximation. Previous studies related subdiffusive reflectance to ? or ? , which parameterize the phase function. Recently, it was demonstrated that ? predicts subdiffusive reflectance better than ? , and that ? becomes less predictive for lower numerical apertures (NAs). We derive and evaluate the parameter R p NA , which incorporates the NA of the detector and the integral of the phase function over the NA in the backward and forward directions. Monte Carlo simulations are performed for overlapping source/detector geometries for a range of phase functions, reduced scattering coefficients, NAs, and source/detector diameters. R p NA improves prediction of the measured reflectance compared to ? and ? . It is, therefore, expected that R p NA will improve derivation of optical properties from subdiffusive measurements.

Inducing Persistent Flow Disturbances Accelerates Atherogenesis and Promotes Thin Cap Fibroatheroma Development in D374Y-PCSK9 Hypercholesterolemic Minipigs

BACKGROUND

Although disturbed flow is thought to play a central role in the development of advanced coronary atherosclerotic plaques, no causal relationship has been established. We evaluated whether inducing disturbed flow would cause the development of advanced coronary plaques, including thin cap fibroatheroma.

METHODS AND RESULTS

D374Y-PCSK9 hypercholesterolemic minipigs (n=5) were instrumented with an intracoronary shear-modifying stent (SMS). Frequency-domain optical coherence tomography was obtained at baseline, immediately poststent, 19 weeks, and 34 weeks, and used to compute shear stress metrics of disturbed flow. At 34 weeks, plaque type was assessed within serially collected histological sections and coregistered to the distribution of each shear metric. The SMS caused a flow-limiting stenosis, and blood flow exiting the SMS caused regions of increased shear stress on the outer curvature and large regions of low and multidirectional shear stress on the inner curvature of the vessel. As a result, plaque burden was ≈3-fold higher downstream of the SMS than both upstream of the SMS and in the control artery (P<0.001). Advanced plaques were also primarily observed downstream of the SMS, in locations initially exposed to both low (P<0.002) and multidirectional (P<0.002) shear stress. Thin cap fibroatheroma regions demonstrated significantly lower shear stress that persisted over the duration of the study in comparison with other plaque types (P<0.005).

CONCLUSIONS

These data support a causal role for lowered and multidirectional shear stress in the initiation of advanced coronary atherosclerotic plaques. Persistently lowered shear stress appears to be the principal flow disturbance needed for the formation of thin cap fibroatheroma.

Early initiation of low-dose aspirin for reduction in preeclampsia risk in high-risk women: a secondary analysis of the MFMU High-Risk Aspirin Study

OBJECTIVE

Early initiation of low-dose aspirin (LDA) may reduce preeclampsia risk. We sought to determine whether LDA was beneficial when initiated <17w0d, within a trial of high-risk women enrolled <26w0d.

STUDY DESIGN

Secondary analysis of the Maternal-Fetal Medicine Units High-Risk Aspirin study, including women enrolled <17w0d, randomized to LDA (60 mg day(-1)) or placebo with chronic hypertension (CHTN, n=186), diabetes (n=191) or prior preeclampsia (n=146). The primary outcome was preeclampsia at any time in pregnancy, secondary outcomes were early preeclampsia (<34w0d), late preeclampsia (⩾34w), small for gestational age (SGA; neonatal birthweight <10th %) and composite (early preeclampsia or SGA). Outcomes were compared by exact Χ(2)-tests.

RESULTS

Baseline characteristics were similar between treatment groups. Aspirin was associated with a lower rate of late-onset preeclampsia ⩾34w (17.36% vs 24.42%, P=0.047), with a 41% reduction in women with CHTN (18.28% vs 31.18%, P=0.041). There were no other significant differences in the outcome.

CONCLUSION

Aspirin initiated <17w0d reduced the risk for late-onset preeclampsia by 29% supporting the practice of early initiation of aspirin in high-risk women.

Relationship between personality factors and adaptation to stress in a military institution

Personality factors mediating the adaptation to stress in military institutions were investigated. A comparison of Cattell 16 Factor PF scores was performed for Naval Academy plebes who dropped-out before the end of the first semester for non-academic reasons and those who remained. One personality factor significantly differentiated these two groups. Dropouts scored lower than remainders on the factor reflecting group-dependence. The results are discussed in light of the role of extraversion and affiliation in coping with stressful situations having interpersonal dimensions.