Improved urethral fluorescence during low rectal surgery: a new dye and a new method

BACKGROUND

The aim of this study was to demonstrate highlighting of the urethra during surgery through the use of two different methods: a new near-infrared fluorophore IRDye800BK, and indocyanine green (ICG) mixed with silicone.

METHODS

Male cadavers from the department of anatomy at the University of Oxford were used to visualise the urethra during near-infrared fluorescence excitation. To assess IRDye800BK, a perineal incision was utilised after infiltrating the urethra directly with an IRDye800BK solution mixed with Instillagel. ICG-silicone was assessed when the urethra was purposely exposed as part of a simulated transanal total mesorectal dissection. ICG was previously mixed with ethanol and silicone and left to set in a Foley catheter. Fluorescence was visualised using an in-house manufactured fluorescence-enabled laparoscopic system.

RESULTS

IRDye800BK demonstrated excellent penetration and visualisation of the urethra under fluorescence at an estimated tissue depth of 2 cm. An ICG-silicone catheter demonstrated excellent fluorescence without leaving any residual solution behind in the urethra after its removal.

CONCLUSIONS

The newly described ICG-silicone method opens up the possibility of new technologies in this area of fluorescence guided surgery. IRDye800BK is a promising alternative to ICG in visualising the urethra using fluorescence imaging. Its greater depth of penetration may allow earlier detection of the urethra during surgery and prevent wrong plane surgery sooner.

Electrically tunable fluidic lens imaging system for laparoscopic fluorescence-guided surgery

The addition of fluorescence guidance in laparoscopic procedures has gained significant interest in recent years, particularly through the use of near infrared (NIR) markers. In this work we present a novel laparoscope camera coupler based on an electrically tunable fluidic lens that permits programmable focus control and has desirable achromatic performance from the visible to the NIR. Its use extends the lower working distance limit and improves detection sensitivity, important for work with molecularly targeted fluorescence markers. We demonstrate its superior optical performance in laparoscopic fluorescence-guided surgery. In vivo results using a tumor specific molecular probe and a nonspecific NIR dye are presented.

A Novel Optical Bioimaging Method for Direct Assessment of Ovarian Cancer Chemotherapy Response at Laparoscopy

In patients with advanced ovarian cancer (AOC), additional imaging of disseminated disease at laparoscopy could complement conventional imaging for estimation of chemotherapy response. We developed an image segmentation method and evaluated its use in making accurate and objective measurements of peritoneal metastases in comparison to Response Evaluation Criteria In Solid Tumors (RECIST) criteria. A software tool using a custom ImageJ macro-based approach was employed to estimate lesion size by converting image pixels into unit length. The software tool was tested as a proof-of-principle in an AOC patient with two isolated peritoneal deposits. Image analysis of representative laparoscopic snapshots before and after three cycles of neoadjuvant chemotherapy (NACT) revealed an average tumor nodule response ratio (TNRR) of 40% (partial response), which was in concordance with RECIST evaluation by computed tomography (CT). We demonstrated the feasibility of using this novel anatomical analysis for direct assessment of chemotherapy response in an AOC patient as an adjunct to RECIST criteria.

A prospective pilot study of detection of sentinel lymph nodes in gynaecological cancers using a novel near infrared fluorescence imaging system

BACKGROUND

Sentinel Lymph Node (SLN) sampling may significantly reduce surgical morbidity by avoiding needless radical lymphadenectomy. In gynaecological cancers, the current practice in the UK is testing the accuracy of SLN detection using radioactive isotopes within the context of clinical trials. However, radioactive tracers pose significant logistic problems. We, therefore, conducted a pilot, observational study to assess the feasibility of a novel optical imaging device for SLN detection in gynaecological cancers using near infrared (NIR) fluorescence.

METHODS

A novel, custom-made, optical imaging system was developed to enable detection of multiple fluorescence dyes and allow simultaneous bright-field imaging during open surgery and laparoscopic procedures. We then evaluated the performance of the system in a prospective study of 49 women with early stage vulval, cervical and endometrial cancer who were scheduled to undergo complete lymphadenectomy. Clinically approved fluorescent contrast agents indocyanine green (ICG) and methylene blue (MB) were used. The main outcomes of the study included SLN mapping detection rates, false negative rates using the NIR fluorescence technique and safety of the procedures. We also examined the association between injection sites and differential lymphatic drainage in women with endometrial cancer by fluorescence imaging of ICG and MB.

RESULTS

A total of 64 SLNs were detected during both open surgery and laparoscopy. Following dose optimisation and the learning phase, SLN detection rate approached 100 % for all cancer types with no false negatives detected. Fluorescence from ICG and MB detected para-aortic SLNs in women with endometrial cancer following uterine injection. Percutaneous SLN detection was also achieved in most women with vulval cancer. No adverse reactions associated with the use of either dyes were observed.

CONCLUSIONS

This study demonstrated the successful clinical application of a novel NIR fluorescence imaging system for SLN detection across different gynaecological cancers. We showcased the first in human imaging, during the same procedure, of two fluorescence dyes in women with endometrial cancer.

Toward operative in vivo fluorescence imaging of the c-Met proto-oncogene for personalization of therapy in ovarian cancer

BACKGROUND

Standard biomarker testing of a single macroscopic disease site is unlikely to be sufficient because of tumor heterogeneity. A focus on examining global biomarker expression or activity, particularly in microscopic residual chemotherapy-resistant disease, is needed for the appropriate selection of targeted therapies. This study was aimed at establishing a technique for the assessment of biomarkers of ovarian cancer peritoneal spread.

METHODS

An in-house developed fluorescent imaging device was used to detect the expression of the c-Met oncogene in ovarian cancer. A modified cyanine 5-tagged peptide, GE137, with a high in vitro affinity for the human c-Met protein, was tested in a panel of ovarian cancer cell lines. Finally, the feasibility of detecting submillimeter ovarian cancer cell peritoneal metastases in vivo was tested through the intravenous injection of GE137 into mice with tumor xenografts.

RESULTS

Using optical imaging it was possible to detect c-Met expression in submillimeter peritoneal metastases that were freshly excised from a human high-grade serous ovarian cancer. GE137 selectively bound to the c-Met tyrosine kinase without activating survival signaling pathways (AKT or extracellular signal-regulated kinase phosphorylation) downstream of c-Met. GE137 specifically accumulated in SKOv3 ovarian cancer cells expressing c-Met via clathrin-mediated endocytosis and emitted a fluorescent signal that lasted for at least 8 hours in tumor xenografts in vivo with a sustained high signal-to-noise ratio.

CONCLUSIONS

Our results suggest that intraoperative optical imaging could provide a new paradigm for selecting cancer patients for appropriate targeted therapies, particularly after initial chemotherapy.

Abstract LB-164: Towards operative in vivo fluorescence imaging of c-Met proto-oncogene for personalization of therapy in ovarian cancer

The recent recognition of the scale of the problem of tumour heterogeneity has made it clear that standard biomarker testing of a single macroscopic disease sites is unlikely to be sufficient. A focus on examining global biomarker expression or activity is needed for appropriate selection of targeted therapies. A particular attention to microscopic residual chemotherapy-residual disease (MRCD) would ensure appropriate targeting of chemotherapy resistance. However, the techniques for global assessment of biomarkers in patients with MRCD have not established.

Using an in-house developed fluorescent imaging device we show that it is possible to identify global c-Met expression in submillimeter peritoneal metastases that were freshly excised from a human high-grade serous ovarian cancer. We evaluated a modified Cy5-tagged peptide (GE137) that selectively binds to the c-Met tyrosine kinase and demonstrated the feasibility of detecting submillimeter ovarian cancer cell peritoneal metastases in vivo following intravenous injection of this peptide. GE137 specifically accumulated in cells that express c-Met via clathrin-mediated endocytosis and emitted a fluorescent signal that lasted for at least 8 hours in tumour xenografts in vivo with a sustained high signal to noise ratio. Thus, intraoperative optical imaging could provide a new paradigm for selecting cancer patients with MRCD for appropriate targeted therapies following initial chemotherapy.

Citation Format: Shujuan Liu, Yong Zheng, Davide Volpi, Muna El-Kasti, Daniel Klotz, Iain Tullis, Andrea Henricks, Leticia Campo, Kevin Myers, Alex Laios, Peter Thomas, Tony Ng, Sunanda Dhar, Christian Becker, Borivoj Vojnovic, Ahmed A. Ahmed. Towards operative in vivo fluorescence imaging of c-Met proto-oncogene for personalization of therapy in ovarian cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr LB-164. doi:10.1158/1538-7445.AM2014-LB-164

Multislice CT in emergency room management of patients with chest pain and medium-low probability of acute coronary syndrome

PURPOSE

The main cause of acute chest pain, which accounts for 6.5% of urgent medical examinations in emergency rooms in Italy, is acute coronary syndrome (ACS). We performed this prospective study to evaluate the diagnostic accuracy of a 16-channel computed tomography (CT) scanner with dedicated software in a group of patients with chest pain and medium to low risk of ACS.

MATERIALS AND METHODS

This study involved a selected group of 31 patients reporting chest pain with a medium to low probability of ACS, defined on the basis of preliminary tests [electrocardiogram (ECG) and serum cardiac markers]. Coronary angiography, performed within 24 h of MSCT, was used as the gold standard.

RESULTS

MSCT identified the presence of occlusions and significant (>50%) or nonsignificant stenoses in the main coronary segments, with a sensitivity of 65%, a specificity of 98.8%, a positive predictive value (PPV) of 81.2%, a negative predictive value (NPV) of 97.3% and an accuracy of 96.4%. Significant stenoses and occlusions were detected with a sensitivity of 71.4%, a specificity of 99.6%, a PPV of 93.7%, an NPV of 97.7% and an accuracy of 97.5%.

CONCLUSIONS

Due to its high NPV, this technique can rule out significant stenoses or coronary occlusions provided that image quality is excellent. In patients with a medium to low coronary risk, MSCT is a more accurate indicator of the need for coronary angiography than is exercise stress testing, which is less expensive but has lower predictive values.

Magnetic Resonance Imaging in Comparison to Clinical Palpation in Assessing the Response of Breast Cancer to Epirubicin Primary Chemotherapy

PURPOSE

To investigate whether magnetic resonance imaging (MRI) is superior to clinical palpation in the assessment of response of breast cancer to primary chemotherapy (PC).

PATIENTS AND METHODS

Seventy-three patients with T2-4, N0, M0 breast cancer were treated with 3-4 cycles of single agent epirubicin before definitive surgery. MRI was performed at baseline condition and at the end of chemotherapy.

RESULTS

According to the WHO criteria, 20 (27.4%) patients attained a complete response (CR) by clinical palpation and 41 (56.2%) a partial response. The corresponding response rate by MRI was 11 (15.1%) and 34 (46.6%), respectively. Residual tumor assessed by MRI better correlated with pathologic measurements (Spearman r : 0.72) than residual tumor assessed by clinical palpation (Spearman r : 0.58). Post-chemotherapy histology evaluation revealed pathologic CR in three cases, only one of them was considered as complete responder by MRI. Residual disease consisted in in situ carcinoma in four cases, one of them was complete responder at MRI, the remaining three showed residual abnormal contrast enhancement indistinguishable from that of invasive tumors.

CONCLUSIONS

As compared to pathology specimens, MRI is able to represent the extent of cancer more accurately than clinical palpation. It constitutes a promising technique in assessing the BC response to PC. The current limit of MRI is the scarce specificity in predicting the nature of residual disease.

Capsulo-labro-ligamentous lesions of the shoulder: evaluation with MR arthrography

PURPOSE

The aim of the study was to analyse the accuracy of MR arthrography in the evaluation of capsulo-labro-ligamentous lesions of the shoulder in patients with glenohumeral joint instability.

MATERIALS AND METHODS

From 1999 to 2001 fifty-eight patients with glenohumeral joint instability were studied by MR arthrography. Twenty-seven patients underwent surgical repair: 11 by arthroscopic and 16 by arthrotomic approach. All shoulder evaluations were performed with T1 and T2 weighted axial, coronal and sagittal oblique images, before and after intra-articular injection of gadolinium contrast.

RESULTS

Forty capsulo-ligamentous lesions (including 14 capsular ruptures with extravasation of the contrast medium) were detected by MR arthrography. Fifty-two labral tears (36 of the anterior, 13 of the superior and 3 of the posterior glenoid labrum) were identified: 11 out of 52 were not recognized before gadolinium contrast injection. Five rotator cuff tears were identified, one of which was not shown in the pre-injection examination. Surgical results confirmed the MR arthrographic findings in 25/27 patients. In one case MR arthrography did not recognize a SLAP lesion; in another case it identified a tear of the capsule but not of the glenoid labrum.

CONCLUSIONS

In many cases of subacute glenohumeral joint lesions with intracapsular fluid, MR may accurately evaluate capsulo-labral-ligamentous lesions. Indeed, the examination of lesions is limited by the absence of the natural contrast determined by fluid; in such cases, intra-articular injection of gadolinium contrast is necessary. MR arthrography evaluates the degree of capsulo-labro-ligamentous tears and may guide the surgical approach.

Thermodynamics of the high-affinity interaction of TCF4 with beta-catenin

The formation of a complex between beta-catenin and members of the TCF/LEF family of high-mobility group proteins is a key regulatory event in the wnt-signaling pathway, essential for embryonal development as well as the growth of normal and malignant colon epithelium. We have characterized the binding of TCF4 to human beta-catenin by steady-state intrinsic fluorescence quenching experiments, surface plasmon resonance (SPR) and isothermal titration calorimetry (ITC). Binding studies in solution and in heterogeneous phase showed that TCF4 binds reversibly to beta-catenin with an affinity (KB) of 3(+/-1) 10(8) M(-1). Site-directed mutagenesis, together with calorimetric measurements, revealed that residue D16 in TCF4 plays a crucial role in high-affinity binding. Mutation of this residue to alanine resulted in a decrease of KB by two orders of magnitude as well as a significant reduction in binding enthalpy. Binding of TCF4 to beta-catenin gave rise to a large negative enthalpy change at 25 degrees C (-29.7 kcal/mol). Binding enthalpies were strongly temperature dependent, which resulted in the determination of a large heat capacity change upon binding of -1.5 kcal/(mol K). The molecular events that take place upon complex formation are discussed using the measured thermodynamic data together with the crystal structure of the beta-catenin arm repeat region/TCF complex.

[Hypertonic saline solutions in resuscitation in hemorrhagic shock. An experimental study]

The aim of the study was to evaluate the use of hypertonic solutions in restoring intravascular volume in a model of hemorrhagic shock. Eighteen pigs underwent general anesthesia and were instrumented with a carotid catheter to record mean arterial pressure (MAP), a pulmonary artery catheter for pulmonary arterial pressure (MPAP) and cardiac output (CO) monitoring and an electromagnetic flowmeter around the abdominal supraceliac aorta for aortic flow measurement (Vaor). Oxygen delivery (DO2) and oxygen consumption (VO2) data were calculated by standard formulas. The animals were hemorrhaged to a MAP of 45 mmHg, held for 1 hour. They were resuscitated during the following hour until the aortic flow regained its basal value, using three different solutions: normotonic saline (NS = NaCl 0.9%), hypertonic saline (HS = NaCl 7.5%), hypertonic saline added with dextran (HSDX = NaCl 7.5% + 6% dextran 70). An hour of autologous blood transfusion and a two hours follow-up concluded the experiment. Volumes infused were remarkably lower administering HS (13.70 +/- 1.44 ml/kg) and HSDX (9.11 +/- 1.20 ml/kg) compared to NS (90.32 +/- 24.83 ml/kg). MAP, CO and DO2 values resulted significantly higher in the HSDX animals, with lower MPAP levels. During the two hours follow-up only the animals reinfused with HSDX maintained hemodynamic and oxygen transport values at normal levels. We conclude that the administration of hypertonic saline solutions during hemorrhagic shock allows the saving of infusion volumes, thus diminishing the occurrence of interstitial edema formation. The adding of dextran to the solution prolongs the hemodynamic effects.

Agents combining thromboxane receptor antagonism with thromboxane synthase inhibition: [[[2-(1H-imidazol-1-yl)ethylidene]amino]oxy]alkanoic acids

A new class of compounds combining thromboxane-A2 (TxA2) receptor antagonism and thromboxane synthase inhibition is described. A first series of (E)- and (Z)-[[[2-(1H-imidazol-1-yl)ethylidene]amino]oxy]pentanoic acids showed relevant thromboxane synthase inhibition associated with weak TxA2 receptor antagonism, while a series of (+/-)-(E)-[[[2-(1H-imidazol-1-yl)-3-phenylpropylidene]amino]oxy] pentanoic acids, structurally derived from the former, showed potent and well-balanced dual activity. Structural requirements for significant single and dual activity are discussed. Two close congeners of the latter series, (+/-)-(E)-5-[[[1-cyclohexyl-2-(1H-imidazol-1-yl)-3- phenylpropylidene]amino]oxy]pentanoic acid 23c and its p-fluorophenyl analog 23m, inhibited TxB2 production in vitro, in rat whole blood during clotting, with IC50 of 0.06 and 0.37 microM and antagonized the binding of [3H]SQ 29548 to washed human platelets, with IC50 of 0.08 and 0.02 microM, respectively. These two compounds were selected for further pharmacological evaluation and were shown to antagonize U46619-induced platelet aggregation in human platelet rich plasma with IC50 of 0.30 and 0.44 microM, respectively. They were both orally available, and in particular 23m caused a long lasting ex vivo TxA2 synthase inhibition in the fed rat. The levorotatory enantiomer of 23c, stereospecifically synthesized as a model compound, was found to be more potent than racemic 23c with regard to TxA2 receptor antagonism (IC50 = 0.04 microM) and equivalent to the latter with regard to TxA2 synthase inhibition. A molecular modeling study concerning the levorotatory enantiomer of 23c (S), TxA2, and representative TxA2 antagonists of different classes led to the definition of a putative pharmacophoric model for the TxA2 receptor ligands.

Endothelin-1-selective binding sites are downregulated by transforming growth factor-beta and upregulated by basic fibroblast growth factor in a vascular smooth muscle-derived cell line

Endothelins (ETs) elicit in vivo and in vitro a potent vasoconstrictor activity after binding to high-affinity receptors on vascular smooth muscle cells (VSMC). A617 cells, a VSM-derived cell line, were used as an in vitro model system to study selected growth factors and cytokines involved in proliferative and/or inflammatory diseases of the vessel wall as possible regulators of the high-affinity binding capacity of ET-1 to the cells. Radioligand studies characterized the binding of ET-1 to the isopeptide selective ETA receptor subtype on A617 cells as a time- and temperature-dependent saturable process (Kd = 0.13 +/- 0.04 nM, Bmax = 49 +/- 7 fmol/10(6) cells). Pretreatment of A617 cells with basic fibroblast growth factor (bFGF), a mitogenic agent for vascular cells, resulted in a time- and dose-dependent increase in ET-1 binding capacity, whereas preexposure to transforming growth factor-beta (TGF-beta) induced a reduction of the Bmax for ET-1. Platelet-derived growth factor (PDGF), interleukin-6 (IL-6), tumor necrosis factor-alpha, and fetal bovine serum (FBS) pretreatments did not affect consequent ET-1 binding to A617 cells.

Inactivation of endothelin by polymorphonuclear leukocyte-derived lytic enzymes

Cultured bovine aortic endothelial cells (BAEC) released endothelin-1 (ET-1) in the culture medium in a time-dependent fashion. Coincubation of fMLP-activated human polymorphonuclear leukocytes (PMN) with BAEC caused a fast (maximal activity was reached within 15 minutes) and cell number-dependent disappearance of ET-1 from the medium. This effect was direct to ET-1, because it was also present when PMN were incubated with the synthetic peptide in the absence of BAEC. PMN-dependent disappearance of ET-1 was associated with loss of constrictor activity on isolated rabbit aorta. PMN-released products were responsible for ET-1 degrading activity, because supernatants of activated PMN were equally effective as the intact cells. Resting PMN, in the same time frame, were uneffective. Eglin C, a potent blocker of PMN-derived elastase and cathepsin G, reversed the ET-1 inhibitory activity of fMLP-stimulated PMN and of their supernatant. Direct addition of elastase and cathepsin G to synthetic ET-1 destroyed its immunoreactivity and this effect was blocked by eglin C. High-performance liquid chromatography (HPLC) analysis supported the hypothesis that ET-1 degradation by PMN was due to enzymatic proteolysis. These data provide evidence that activated PMN are able to degrade ET-1 through the release of proteases. Because physiologic concentrations of PMN can destroy high amounts (up to 100 nmol/L) of ET-1 within a few minutes, we propose that this mechanism of ET-1 inactivation has biologic relevance.

Effects of racemic, S- and R-indobufen on cyclooxygenase and lipoxygenase activities in human whole blood

Racemic indobufen inhibits human platelet aggregation by reducing thromboxane (TX) A2 biosynthesis. In order to ascertain which of the two optical isomers is responsible for its pharmacological activity, we compared the effects of racemic (SR +/-), S(+) enantiomer and R(-) enantiomer indobufen on cyclooxygenase and 5-lipoxygenase activities by assessing the biosynthesis of TXB2, prostaglandin (PG) E2 and leukotriene (LT) B4 in human whole blood stimulated with the Ca2+ ionophore A23187. Racemic indobufen caused a dose-dependent inhibition of TXB2 and PGE2 production (IC50: 0.53 +/- 0.06 and 0.34 +/- 0.02 micrograms/ml, respectively; mean +/- S.D., n = 4). S-Indobufen was approximately 2-fold more potent than the racemate in inhibiting the synthesis of cyclooxygenase products. R-Indobufen affected the same enzyme but only at considerably higher concentrations (IC50: 53 +/- 8 micrograms/ml, n = 3). Serum LTB4 concentrations were significantly reduced only at indobufen concentrations greater than 50 micrograms/ml. In conclusion, indobufen is a selective inhibitor of the cyclooxygenase activity of platelet PGG/H synthase in a concentration range corresponding to the therapeutic plasma levels in man. This inhibitory effect is largely due to the S isomer of the drug.

[Potentials of echography in the diagnosis of gallbladder carcinoma]

A study was carried out on 27 patients (22 women and 5 men) suffering from gallbladder carcinoma confirmed through surgery or autopsy. The examinations were performed with a real-time scanner and 3.5 MHz transducer. Lately, higher resolution transducers (5 MHz and 7.5 MHz) have been employed which have proven more effective due to their improved resolution. The importance is stressed of scanning patients in different positions in order to allow stones and echogenic material to redistribute inside the gallbladder. A correct diagnosis was obtained in 20/27 cases. Bile duct metastases were correctly evaluated by US in 13/13 cases; liver metastases in 25/27 patients. US proved unreliable in those cases where lymph nodes were involved (0/4). Six patients underwent scanning few months, or even years, before the onset of the symptoms. Three patients presented with fundic tumors, whose wall thickening and shadowing of the external wall had been incorrectly evaluated. In the other 3 cases the gallbladder was filled with stones and had thick and constricted walls. There was only a case of invisible carcinoma. Gallbladder carcinoma has often an unfavorable prognosis due to its being diagnosed in an advanced stage. The prognosis of such patients can be improved through an earlier US diagnosis only. The first step in this direction seems to be the identification of the precursor lesions.

Risk factors for intubation injury of the larynx

The endolaryngeal structures are subjected to insult from prolonged endotracheal intubation. Factors that may exacerbate this injury include intubation technique, duration of intubation, tube geometry and constitution, frequency of reintubation, and patient-related factors such as concomitant medical diseases. The contribution of underlying medical disease to laryngeal intubation injury was studied prospectively by sequential endoscopy from the time of tracheotomy. Diabetes mellitus, congestive heart failure, and a history of stroke or tuberculosis increased the likelihood of severe laryngeal injury. The association of these disorders with severe laryngeal injury should lead to consideration of earlier tracheotomy in such patients.