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Toubat O, Han JJ, Predina JD, Goldberg LR, Ibrahim ME. Heart Transplantation for Uhl Anomaly in an Adult. JACC Case Rep 2024; 29:102322. [PMID: 38601846 PMCID: PMC11002861 DOI: 10.1016/j.jaccas.2024.102322] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Uhl anomaly is characterized by the morphologic absence of right ventricular myocardium and is an exceedingly rare cause of nonischemic cardiomyopathy. We report the first case of a successful heart transplantation in a 41-year-old patient who presented in cardiogenic shock from Uhl anomaly causing decompensated right ventricular failure.
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Affiliation(s)
- Omar Toubat
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason J. Han
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jarrod D. Predina
- Division of Thoracic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lee R. Goldberg
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael E. Ibrahim
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Onwugbufor MT, Soni ML, Predina JD, Knoll S, Hung YP, Mathisen DJ, Colson YL, Gaissert HA. Lobectomy for Suspected Lung Cancer Without Prior Diagnosis. Ann Thorac Surg 2023; 116:694-701. [PMID: 37271441 DOI: 10.1016/j.athoracsur.2023.05.017] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/13/2023] [Accepted: 05/16/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND We describe use, patients, and outcome of diagnostic lobectomy for suspected lung cancer without pathologic confirmation. METHODS A retrospective review of consecutive lobectomy or bilobectomy for suspected or confirmed primary pulmonary malignancy was conducted using our participant's sample of The Society of Thoracic Surgeons database. Surgeons performed lobectomy based on clinical diagnosis or confirmation on a biopsy specimen. Lung cancer confirmed by biopsy specimen was compared with cases clinically suspected. Univariate and multivariate analyses identified variables associated with lobectomy without biopsy specimen confirmation. RESULTS Among 2651 lobectomies performed between 2006 and 2019 in 2617 patients, lung cancer was confirmed by preoperative biopsy specimen in 51.6% (1368 of 2651) or was clinically suspected before the operation in 48.4% (1283 of 2651). The intraoperative biopsy specimen in 585 of 1283 cases (45.6%) proved lung cancer before lobectomy, whereas lobectomy proceeded in 698 cases (54.4%) without a diagnosis. Final pathology proved lung cancer in 90% (628 of 698) without a diagnosis before lobectomy and nonmalignant disease in 10% (70 of 698). Nonneoplastic pathology included granulomas (30 of 70 [43%]), pneumonia (12 of 70 [17%]), bronchiectasis (7 of 70 [10%]), and other lesions (21 of 70 [30%]). Operative mortality was 0.94% (25 of 2651) for the cohort and 1.0% (7 of 698) for diagnostic lobectomy only. Multivariate analysis identified patient age, type of lobectomy (right middle lobe), and the intermediate study tercile as associated with diagnostic lobectomy. CONCLUSIONS Lobectomy for suspected lung cancer without diagnosis is common, represents practice variation, and infrequently (10% diagnostic, 2.6% all lobectomies) removes nonmalignant disease. Tissue confirmation before lobectomy is preferred, particularly when operative risk is increased. Diagnostic lobectomy is acceptable in carefully selected patients and lesions.
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Affiliation(s)
- Michael T Onwugbufor
- Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Monica L Soni
- Georgetown University School of Medicine, Washington, DC
| | - Jarrod D Predina
- Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sheila Knoll
- Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yin P Hung
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yolonda L Colson
- Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Henning A Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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3
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Predina JD, Singhal S. Commentary: Following the (near-infrared) light? Don’t throw out your other navigational tools just yet…. J Thorac Cardiovasc Surg 2022; 165:e252-e253. [PMID: 36400584 DOI: 10.1016/j.jtcvs.2022.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
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Predina JD, Onwugbufor M, Llewellyn M, Schumacher L. A video atlas for robotic lingulectomy. JTCVS Tech 2022; 15:155-160. [PMID: 36276669 PMCID: PMC9579708 DOI: 10.1016/j.xjtc.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 06/17/2022] [Accepted: 06/27/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
| | | | | | - Lana Schumacher
- Address for reprints: Lana Schumacher, MD, 7th Floor, Austen Building, 55 Fruit St, Boston, MA 02114.
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5
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Predina JD, Morse CR. Minimally invasive esophagectomy for esophageal carcinoma. Video-assist Thorac Surg 2021. [DOI: 10.21037/vats-2019-mie-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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6
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Affiliation(s)
- Michael T Onwugbufor
- 2348 Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jarrod D Predina
- 2348 Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Asishana A Osho
- 2348 Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lana Y Schumacher
- 2348 Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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7
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Predina JD, Haas AR, Martinez M, O'Brien S, Moon EK, Woodruff P, Stadanlick J, Corbett C, Frenzel-Sulyok L, Bryski MG, Eruslanov E, Deshpande C, Langer C, Aguilar LK, Guzik BW, Manzanera AG, Aguilar-Cordova E, Singhal S, Albelda SM. Neoadjuvant Gene-Mediated Cytotoxic Immunotherapy for Non-Small-Cell Lung Cancer: Safety and Immunologic Activity. Mol Ther 2021; 29:658-670. [PMID: 33160076 PMCID: PMC7854297 DOI: 10.1016/j.ymthe.2020.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 08/13/2020] [Revised: 10/01/2020] [Accepted: 10/31/2020] [Indexed: 11/28/2022] Open
Abstract
Gene-mediated cytotoxic immunotherapy (GMCI) is an immuno-oncology approach involving local delivery of a replication-deficient adenovirus expressing herpes simplex thymidine kinase (AdV-tk) followed by anti-herpetic prodrug activation that promotes immunogenic tumor cell death, antigen-presenting cell activation, and T cell stimulation. This phase I dose-escalation pilot trial assessed bronchoscopic delivery of AdV-tk in patients with suspected lung cancer who were candidates for surgery. A single intra-tumoral AdV-tk injection in three dose cohorts (maximum 1012 viral particles) was performed during diagnostic staging, followed by a 14-day course of the prodrug valacyclovir, and subsequent surgery 1 week later. Twelve patients participated after appropriate informed consent. Vector-related adverse events were minimal. Immune biomarkers were evaluated in tumor and blood before and after GMCI. Significantly increased infiltration of CD8+ T cells was found in resected tumors. Expression of activation, inhibitory, and proliferation markers, such as human leukocyte antigen (HLA)-DR, CD38, Ki67, PD-1, CD39, and CTLA-4, were significantly increased in both the tumor and peripheral CD8+ T cells. Thus, intratumoral AdV-tk injection into non-small-cell lung cancer (NSCLC) proved safe and feasible, and it effectively induced CD8+ T cell activation. These data provide a foundation for additional clinical trials of GMCI for lung cancer patients with potential benefit if combined with other immune therapies.
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Affiliation(s)
- Jarrod D Predina
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew R Haas
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marina Martinez
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Shaun O'Brien
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edmund K Moon
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick Woodruff
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Stadanlick
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher Corbett
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lydia Frenzel-Sulyok
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mitchell G Bryski
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Evgeniy Eruslanov
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Charuhas Deshpande
- Pulmonary and Mediastinal Pathology, Department of Clinical Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Corey Langer
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, MA, USA
| | - Laura K Aguilar
- Advantagene, Inc. d.b.a. Candel Therapeutics, Needham, MA, USA
| | - Brian W Guzik
- Advantagene, Inc. d.b.a. Candel Therapeutics, Needham, MA, USA
| | | | | | - Sunil Singhal
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven M Albelda
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Newton AD, Predina JD, Frenzel-Sulyok LG, Low PS, Singhal S, Roses RE. Intraoperative Molecular Imaging Utilizing a Folate Receptor-Targeted Near-Infrared Probe Can Identify Macroscopic Gastric Adenocarcinomas. Mol Imaging Biol 2020; 23:11-17. [PMID: 33033941 DOI: 10.1007/s11307-020-01549-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/23/2020] [Accepted: 09/29/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE Current methods of assessing disease burden in gastric adenocarcinoma are imperfect. Improved visualization during surgery with intraoperative molecular imaging (IMI) could improve gastric adenocarcinoma staging and guide surgical decision-making. The goal of this study was to evaluate if IMI with a folate receptor-targeted near-infrared fluorescent agent, OTL38, could identify gastric adenocarcinomas during surgery. PROCEDURES Five patients were enrolled in an IMI clinical trial. Patients received a folate receptor-targeted near-infrared dye (OTL38) 1.5-6 h prior to surgery. During staging laparoscopy and gastric resection, IMI was utilized to identify the primary tumor and any fluorescent lymph nodes. Resected tumors were analyzed for folate receptor alpha (FRα) and CD68 expression using immunohistochemistry. Microscopic OTL38 accumulation was examined with immunofluorescence. RESULTS Four out of five patients underwent total or subtotal gastrectomy; one had a staging laparoscopy only. All four patients who underwent gastric resection had invasive gastric adenocarcinoma; three had fluorescent tumors, mean tumor to background ratio (TBR) 4.1 ± 2.9. The one patient with a non-fluorescent tumor had a T1a tumor with two 0.4 cm tumor foci within a larger polyp. In each case with a fluorescent tumor, the fluorescence was evident from the exterior of the stomach. Two of the fluorescent tumors had modest FRα expression and no CD68 expression. One fluorescent tumor had high CD68 expression and no FRα expression. CONCLUSIONS Intraoperative molecular imaging of gastric adenocarcinoma with OTL38 is feasible. Further studies should evaluate the clinical utility of this technique.
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Affiliation(s)
- Andrew D Newton
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Jarrod D Predina
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lydia G Frenzel-Sulyok
- Department of Surgery, University of Pennsylvania Perelman 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 Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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9
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Aguilar LK, Predina JD, Haas A, O'Brien S, Moon EK, Martinez M, Corbett C, Sulyok LF, Bryski MG, Eruslanov E, Deshpande C, Guzik BW, Manzanera AG, Aguilar-Cordova E, Singhal S, Albelda SM. Neoadjuvant endobronchial delivery of gene mediated cytotoxic immunotherapy (GMCI) for non-small cell lung cancer (NSCLC): Safety and immunologic activity. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.9050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9050 Background: GMCI is a tumor-specific immuno-oncology approach implemented through local delivery of aglatimagene besadenovec(AdV-tk) followed by anti-herpetic prodrug. This leads to immunogenic tumor cell death, antigen presenting cell activation, and T cell stimulation resulting in CD8+ T cell dependent protection, as demonstrated in preclinical models and clinical trials in other tumor types. This is the first study to assess endobronchial delivery of AdV-tk for NSCLC. Methods: This Phase I dose escalation trial enrolled patients with suspected NSCLC who were candidates for surgery. A single AdV-tk injection was performed by endobronchial ultrasound (n = 11) or mediastinoscopy (n = 1) during the diagnostic staging procedure 3 weeks prior to surgery. Three dose levels were evaluated: 2.5x 1011, 5x1011, and 1x1012 vector particles (vp) in a 3+3 design. Valacyclovir was administered for 14 days, starting the day after AdV-tk injection. To assess the local and systemic effects of GMCI, immune biomarkers were evaluated in blood and tumor samples before and after GMCI. Results: From 2017-2019, 12 patients (9 men, 3 women, median age 65 [range 55-80]) received GMCI followed by surgery. Average tumor size was 5.1 cm (largest diameter) and final pathologic stage was I (n = 4), II (n = 3), and III (n = 5). Treatment-related adverse events were CTC grade 1 fever (n = 1), flu-like symptoms (n = 1) and nausea/vomiting/diarrhea (n = 1). The only > grade 2 lab abnormality was transient grade 3 lymphopenia (n = 2). A measurable reduction in tumor size was observed in one patient. The average amount of tumor necrosis was 29.4%. Significant infiltration of CD8+T cells (5.2-fold compared to baseline, p = 0.001) was found in tumor 19-22 days after AdV-tk injection. Within the CD8+tumor infiltrating lymphocytes, there was increased expression of CD38 (2.5-fold, p = 0.002), Ki67 (4.8-fold, p = 0.02), PD1 (1.9-fold, p = 0.002), CD39 (2.9-fold, p = 0.04) and CTLA-4 (4.8-fold, p < 0.001), without significant detected differences in Tim3 or TIGIT. Simultaneously, peripheral blood CD8+ cells displayed significant increases in CD38 (3.4-fold, p = 0.006), HLA-DR (4.2-fold, p = 0.002), and Ki67 (5.8-fold, p = 0.017). Conclusions: Intratumoral injection of AdV-tk into lung tumors was safe and feasible. Further, AdV-tk effectively induced peripheral blood and intra-tumoral CD8 T cell activation. Consequent upregulation of inhibitory receptors suggests a potential benefit for combination therapies. Clinical trial information: NCT03131037.
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Affiliation(s)
| | - Jarrod D. Predina
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andrew Haas
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Shaun O'Brien
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Edmund K. Moon
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Marina Martinez
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Christopher Corbett
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Mitchell G. Bryski
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Evgeniy Eruslanov
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Charuhas Deshpande
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Sunil Singhal
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Steven M. Albelda
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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10
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Newton AD, Predina JD, Shin MH, Frenzel-Sulyok LG, Vollmer CM, Drebin JA, Singhal S, Lee MK. Intraoperative Near-infrared Imaging Can Identify Neoplasms and Aid in Real-time Margin Assessment During Pancreatic Resection. Ann Surg 2019; 270:12-20. [PMID: 31188797 PMCID: PMC11068217 DOI: 10.1097/sla.0000000000003201] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [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: 12/17/2022]
Abstract
OBJECTIVE To determine if intraoperative near-infrared (NIR) imaging carries benefit in resection of pancreatic neoplasms. BACKGROUND Resection of pancreatic malignancies is hindered by high rates of local and distant recurrence from positive margins and unrecognized metastases. Improved tumor visualization could improve outcomes. We hypothesized that intraoperative NIR imaging with a clinically approved optical contrast agent could serve as a useful adjunct in assessing margins and extent of disease during pancreatic resections. METHODS Twenty patients were enrolled in an open-label clinical trial from July 2016 to May 2018. Subjects received second window indocyanine green (ICG) (2.5-5 mg/kg) 24 hours prior to pancreatic resection. NIR imaging was performed during staging laparoscopy and after pancreas mobilization in situ and following resection ex vivo. Tumor fluorescence was quantified using tumor-to-background ratio (TBR). Fluorescence at the specimen margin was compared to pathology evaluation. RESULTS Procedures included 9 pancreaticoduodenectomies, 10 distal pancreatectomies, and 1 total pancreatectomy; 21 total specimens were obtained. Three out of 8 noninvasive tumors were fluorescent (mean TBR 2.59 ± 2.57). Twelve out of 13 invasive malignancies (n = 12 pancreatic adenocarcinoma, n = 1 cholangiocarcinoma) were fluorescent (mean TBR 4.42 ± 2.91). Fluorescence at the transection margin correlated with final pathologic assessment in 12 of 13 patients. Following neoadjuvant therapy, 4 of 5 tumors were fluorescent; these 4 tumors showed no treatment response on pathology assessment. One tumor had a significant treatment response and showed no fluorescence. CONCLUSIONS Second window ICG reliably accumulates in invasive pancreatic malignancies and provides real-time feedback during pancreatectomy. NIR imaging may help to assess the response to neoadjuvant therapy.
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Affiliation(s)
- Andrew D. Newton
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jarrod D. Predina
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Michael H. Shin
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Lydia G. Frenzel-Sulyok
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Charles M. Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jeffrey A. Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Major K. Lee
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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11
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Predina JD, Runge J, Newton A, Mison M, Xia L, Corbett C, Shin M, Sulyok LF, Durham A, Nie S, Singhal S, Holt D. Evaluation of Aminolevulinic Acid-Derived Tumor Fluorescence Yields Disparate Results in Murine and Spontaneous Large Animal Models of Lung Cancer. Sci Rep 2019; 9:7629. [PMID: 31113971 PMCID: PMC6529469 DOI: 10.1038/s41598-019-40334-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 12/28/2018] [Indexed: 11/09/2022] Open
Abstract
Fluorescence guided surgery is an emerging technology that may improve accuracy of pulmonary resection for non-small cell lung cancer (NSCLC). Herein we explore optical imaging for NSCLC surgery using the well-studied protoporphyrin IX (PPIX)/5-aminiolevulinic acid (5-ALA) system. More specifically, we evaluate fluorescent patterns observed when using (1) commonly utilized in vitro and murine NSCLC models and with (2) spontaneous canine NSCLCs, which closely mimic human disease. Using flow cytometry and fluorescent microscopy, we confirmed that NSCLC models fluoresce after exposure to 5-ALA in vitro. High levels of fluorescence were similarly observed in murine tumors within 2 hours of systemic 5-ALA delivery. When evaluating this approach in spontaneous canine NSCLC, tumor fluorescence was observed in 6 of 7 canines. Tumor fluorescence, however, was heterogenous owing to intratumoral variations in cellularity and necrosis. Margin and lymph node detection was inaccurate. These data demonstrate the importance of incorporating reliable cancer models into preclinical evaluations of optical agents. Utilization of spontaneous large animal models of cancer may further provide an important intermediate in the path to human translation of optical contrast agents.
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Affiliation(s)
- Jarrod D Predina
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
| | - Jeffrey Runge
- Department of Clinical Studies, University of Pennsylvania School of Veterinary Medicine, Philadelphia, USA
| | - Andrew Newton
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Michael Mison
- Department of Clinical Studies, University of Pennsylvania School of Veterinary Medicine, Philadelphia, USA
| | - Leilei Xia
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Christopher Corbett
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Michael Shin
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Lydia Frenzel Sulyok
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Amy Durham
- Department of Pathobiology, University of Pennsylvania School of Veterinary Medicine, Philadelphia, USA
| | - Shuming Nie
- Departments of Biomedical Engineering and Chemistry, Emory University, Atlanta, Georgia
| | - Sunil Singhal
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - David Holt
- Department of Clinical Studies, University of Pennsylvania School of Veterinary Medicine, Philadelphia, USA
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12
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Predina JD, Keating J, Newton A, Corbett C, Xia L, Shin M, Frenzel Sulyok L, Deshpande C, Litzky L, Nie S, Kucharczuk JC, Singhal S. A clinical trial of intraoperative near-infrared imaging to assess tumor extent and identify residual disease during anterior mediastinal tumor resection. Cancer 2018; 125:807-817. [PMID: 30561757 DOI: 10.1002/cncr.31851] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/19/2018] [Accepted: 08/23/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND The management of most solid tumors of the anterior mediastinum involves complete resection. Because of their location near mediastinal structures, wide resection is not possible; therefore, surgeons must use subjective visual and tactile cues to determine disease extent. This clinical trial explored intraoperative near-infrared (NIR) imaging as an approach to improving tumor delineation during mediastinal tumor resection. METHODS Twenty-five subjects with anterior mediastinal lesions suspicious for malignancy were enrolled in an open-label feasibility trial. Subjects were administered indocyanine green (ICG) at a dose of 5 mg/kg, 24 hours before resection (via a technique called TumorGlow). The NIR imaging systems included Artemis (Quest, Middenmeer, the Netherlands) and Iridium (VisionSense Corp, Philadelphia, Pennsylvania). Intratumoral ICG uptake was evaluated. The clinical value was determined via an assessment of the ability of NIR imaging to detect phrenic nerve involvement or incomplete resection. Clinical and histopathologic variables were analyzed to determine predictors of tumor fluorescence. RESULTS No drug-related toxicity was observed. Optical imaging added a mean of 10 minutes to case duration. Among the subjects with solid tumors, 19 of 20 accumulated ICG. Fluorescent tumors included thymomas (n = 13), thymic carcinomas (n = 4), and liposarcomas (n = 2). NIR feedback improved phrenic nerve dissection (n = 4) and identified residual disease (n = 2). There were no false-positives or false-negatives. ICG preferentially accumulated in solid tumors; this was independent of clinical and pathologic variables. CONCLUSIONS NIR imaging for anterior mediastinal neoplasms is safe and feasible. This technology may provide a real-time tool capable of determining tumor extent and specifically identify phrenic nerve involvement and residual disease.
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Affiliation(s)
- Jarrod D Predina
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jane Keating
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew Newton
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher Corbett
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leilei Xia
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Shin
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lydia Frenzel Sulyok
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charuhas Deshpande
- Department of Pathology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leslie Litzky
- Department of Pathology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shuming Nie
- Department of Chemistry, University of Illinois, Urbana, Illinois
| | - John C Kucharczuk
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sunil Singhal
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Predina JD, Newton AD, Corbett C, Shin M, Sulfyok LF, Okusanya OT, Delikatny EJ, Nie S, Gaughan C, Jarrar D, Pechet T, Kucharczuk JC, Singhal S. Near-infrared intraoperative imaging for minimally invasive pulmonary metastasectomy for sarcomas. J Thorac Cardiovasc Surg 2018; 157:2061-2069. [PMID: 31288365 DOI: 10.1016/j.jtcvs.2018.10.169] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [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: 05/23/2018] [Revised: 10/18/2018] [Accepted: 10/31/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Complete pulmonary metastasectomy for sarcoma metastases provides patients an opportunity for long-term survival and possible cure. Intraoperative localization of preoperatively identified metastases and identification of occult lesions can be challenging. In this trial, we evaluated the efficacy of near-infrared (NIR) intraoperative imaging using second window indocyanine green during metastasectomy to identify known metastases and to detect occult nodules. METHODS Thirty patients with pulmonary nodules suspicious for sarcoma metastases were enrolled in an open-label, feasibility study (NCT02280954). All patients received intravenous indocyanine green (5 mg/kg) 24 hours before metastasectomy. Patients 1 through 10 (cohort 1) underwent metastasectomy via thoracotomy to assess fluorescence patterns of nodules detected by traditional methods (preoperative imaging and intraoperative visualization/bimanual palpation). After confirming reliability within cohort 1, patients 11 through 30 (cohort 2) underwent video-assisted thoracic surgery metastasectomy with NIR imaging. RESULTS In cohort 1, 14 out of 16 preoperatively identified pulmonary metastases (87.5%) displayed tumor fluorescence. Nonfluorescent metastases were deeper than fluorescent metastases (2.1 cm vs 1.3 cm; P = .03). Five out of 5 metastases identified during thoracotomy displayed fluorescence. NIR imaging identified 3 additional occult lesions in this cohort. In cohort 2, 33 out of 37 known pulmonary metastases (89.1%) displayed fluorescence. Nonfluorescent tumors were deeper than 2.0 cm (P = .007). NIR imaging identified 24 additional occult lesions. Of 24 occult lesions, 21 (87.5%) were confirmed metastases and the remaining 3 nodules were lymphoid aggregates. CONCLUSIONS NIR intraoperative imaging with indocyanine green (5 mg/kg and 24 hours before surgery) localizes known sarcoma pulmonary metastases and identifies otherwise occult lesions. This approach may be a useful intraoperative adjunct to improve metastasectomy.
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Affiliation(s)
- Jarrod D Predina
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Andrew D Newton
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Christopher Corbett
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Michael Shin
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Lydia Frenzel Sulfyok
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Olugbenga T Okusanya
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Edward J Delikatny
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Shuming Nie
- Department of Chemistry, University of Illinois, Champaign, Ill
| | - Colleen Gaughan
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Doraid Jarrar
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Taine Pechet
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - John C Kucharczuk
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Sunil Singhal
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.
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Predina JD, Okusanya O, D Newton A, Low P, Singhal S. Standardization and Optimization of Intraoperative Molecular Imaging for Identifying Primary Pulmonary Adenocarcinomas. Mol Imaging Biol 2018; 20:131-138. [PMID: 28497233 DOI: 10.1007/s11307-017-1076-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE Intraoperative molecular imaging (IMI) is an emerging technology used to locate pulmonary adenocarcinomas and identify positive margins during surgery. Background noise and tissue autofluorescence have been major obstacles. The goal of this study is to optimize the image quality of folate receptor alpha (FRα) targeted IMI for pulmonary adenocarcinomas by modifying emission data. PROCEDURES A total of 15 lung cancer patients were enrolled in a pilot study. In the first cohort, FRα upregulation within pulmonary adenocarcinoma tumors was confirmed by analyzing specimens from five pulmonary adenocarcinoma patients with flow cytometry and immunohistochemistry. Next, in a cohort of five additional patients, autofluorescence of intrathoracic structures and tissues was quantified. Lastly, five patients with tumors at various depths from the pleural surface were enrolled and received the FRα-targeted optical contrast agent, EC17. In this final cohort, resected pulmonary adenocarcinomas were imaged at a wide range of fluorescence exposure times (0 to 200 ms), various laser powers, and with unique filter configurations. Tumor-to-noise ratio (TNR) for images was generated using region of interest software. RESULTS Pulmonary adenocarcinomas highly express FRα. Significant autofluorescence from native thoracic tissues was found with the highest fluorescent signals at the bronchial stump (547 ± 98, range 423-699), the pulmonary artery (267 ± 64, range 200-374), and cortical bone (266 ± 17, range 243-287). High levels of autofluorescence were appreciated after systemic administration of EC17; however, TNR was improved by altering exposure settings at the time of the imaging. Optimal fluorescent exposure time occurs at 40 ms (25 frames/s). CONCLUSIONS Exposure properties can be manipulated to maximize TNR thus allowing for successful intraoperative detection of pulmonary adenocarcinomas during surgery. Optimization of the conditions for intraoperative molecular imaging sets the stage for future clinical trials utilizing targeted IMI techniques which can aid the surgeon at the time of cancer resection.
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Affiliation(s)
- Jarrod D Predina
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania School of Medicine, 6 White Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA.,Center for Precision Surgery, Abramson Cancer Center, University of Pennsylvania School of Medicine, Philadelphia, PA, 19104, USA
| | - Olugbenga Okusanya
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania School of Medicine, 6 White Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA.,Center for Precision Surgery, Abramson Cancer Center, University of Pennsylvania School of Medicine, Philadelphia, PA, 19104, USA
| | - Andrew D Newton
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania School of Medicine, 6 White Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA.,Center for Precision Surgery, Abramson Cancer Center, University of Pennsylvania School of Medicine, Philadelphia, PA, 19104, USA
| | - Philip Low
- Department of Chemistry, Purdue University, West Lafayette, IN, USA
| | - Sunil Singhal
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania School of Medicine, 6 White Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA. .,Center for Precision Surgery, Abramson Cancer Center, University of Pennsylvania School of Medicine, Philadelphia, PA, 19104, USA.
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15
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Newton AD, Predina JD, Corbett CJ, Frenzel-Sulyok LG, Xia L, Petersson EJ, Tsourkas A, Nie S, Delikatny EJ, Singhal S. Optimization of Second Window Indocyanine Green for Intraoperative Near-Infrared Imaging of Thoracic Malignancy. J Am Coll Surg 2018; 228:188-197. [PMID: 30471345 DOI: 10.1016/j.jamcollsurg.2018.11.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [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: 10/07/2018] [Revised: 11/11/2018] [Accepted: 11/12/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Near-infrared (NIR) imaging using the second time window of indocyanine green (ICG) allows localization of pulmonary, pleural, and mediastinal malignancies during surgery. Based on empirical evidence, we hypothesized that different histologic tumor types fluoresce optimally at different ICG doses. STUDY DESIGN Patients with thoracic tumors biopsy-proven or suspicious for malignancy were enrolled in an NIR imaging clinical trial. Patients received a range of ICG doses 1 day before surgery: 1 mg/kg (n = 8), 2 mg/kg (n = 8), 3 mg/kg (n = 13), 4 mg/kg (n = 8), and 5 mg/kg (n = 8). Intraoperatively, NIR imaging was performed. The endpoint was to identify the highest tumor-to-background fluorescence ratio (TBR) for each tumor type at each dose. Final pathology confirmed tumor histology. RESULTS Of 45 patients, 41 had malignancies (18 non-small cell lung cancers [NSCLC], 3 pulmonary neuroendocrine tumors, 13 thoracic metastases, 4 thymomas, 3 mesotheliomas). At doses of 4 to 5 mg/kg, the TBR from primary NSCLC vs other malignancies was no different (2.70 vs 3.21, p = 1.00). At doses of 1 to 3 mg/kg, the TBR was greater for the NSCLCs (3.19 vs 1.49, p = 0.0006). Background fluorescence from the heart or ribs was observed in 1 of 16 cases at 1 to 2 mg/kg, 5 of 13 cases at 3 mg/kg, and 14 of 16 cases at 4 to 5 mg/kg; this was a major determinant of dose optimization. CONCLUSIONS This is the first study to demonstrate that the optimal NIR contrast agent dose varies by tumor histology. Lower dose ICG (2 to 3 mg/kg) is superior for nonprimary lung cancers, and high dose ICG (4 to 5 mg/kg) is superior for lung cancers. This will have major implications as more intraoperative imaging trials surface in other specialties, will significantly reduce costs and may facilitate wider application.
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Affiliation(s)
- Andrew D Newton
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Jarrod D Predina
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Christopher J Corbett
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Lydia G Frenzel-Sulyok
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Leilei Xia
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - E James Petersson
- Department of Chemistry, University of Pennsylvania, Philadelphia, PA
| | - Andrew Tsourkas
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA
| | - Shuming Nie
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Urbana, IL
| | - Edward J Delikatny
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Kennedy GT, Ukert BD, Predina JD, Newton AD, Kucharczuk JC, Polsky D, Singhal S. Implications of Hospital Volume on Costs Following Esophagectomy in the United States. J Gastrointest Surg 2018; 22:1845-1851. [PMID: 30066065 DOI: 10.1007/s11605-018-3849-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 03/12/2018] [Accepted: 06/15/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND With increasing focus on health care quality and cost containment, volume-based referral strategies have been proposed to improve value in high-cost procedures, such as esophagectomy. While the effect of hospital volume on outcomes has been demonstrated, our goal was to evaluate the economic consequences of volume-based referral practices for esophagectomy. METHODS The nationwide inpatient sample (NIS) was queried for the years 2004-2013 for all patients undergoing esophagectomy. Patients were stratified by hospital volume quartile and substratified by preoperative risk and age. Clustered multivariable hierarchical logistic regression analysis was used to assess adjusted costs and mortality. RESULTS In total, 9270 patients were clustered based on annual hospital volume quartiles of < 7, 7 to 22, 23 to 87, and > 87 esophagectomies. After stratification by patient variables, high-volume centers performed esophagectomies in high-risk patients at the same cost as low-volume centers without significant difference in resource utilization. Overall, mortality decreased across volume quartiles (lowest 8.9 versus highest 3.6%, p < 0.0001). The greatest volume-mortality differences were observed among patients aged between 70 and 80 years (lowest 12.2 versus highest 6.2%, p = 0.009). Patients with high preoperative risk also derived mortality benefits with increasing hospital volume (lowest 17.5 versus highest 11.8%, p < 0.0001). CONCLUSIONS This study demonstrates that the mortality improvements for high-risk patients undergoing esophagectomy at high-volume centers do not come at increased costs. These results suggest that health systems should consider selectively referring high-risk patients to high-volume centers within their region.
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Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Benjamin D Ukert
- The Wharton School and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jarrod D Predina
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Andrew D Newton
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Daniel Polsky
- The Wharton School and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA.
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Newton AD, Predina JD, Nie S, Low PS, Singhal S. Intraoperative fluorescence imaging in thoracic surgery. J Surg Oncol 2018; 118:344-355. [PMID: 30098293 DOI: 10.1002/jso.25149] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 06/04/2018] [Indexed: 12/19/2022]
Abstract
Intraoperative fluorescence imaging (IFI) can improve real-time identification of cancer cells during an operation. Phase I clinical trials in thoracic surgery have demonstrated that IFI with second window indocyanine green (TumorGlow® ) can identify subcentimeter pulmonary nodules, anterior mediastinal masses, and mesothelioma, while the use of a folate receptor-targeted near-infrared agent, OTL38, can improve the specificity for diagnosing tumors with folate receptor expression. Here, we review the existing preclinical and clinical data on IFI in thoracic surgery.
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Affiliation(s)
- Andrew D Newton
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jarrod D Predina
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Shuming Nie
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Philip S Low
- Department of Chemistry, Purdue University, West Lafayette, Indiana
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
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Predina JD, Newton AD, Corbett C, Xia L, Shin M, Sulfyok LF, Okusanya OT, Cengel KA, Haas A, Litzky L, Kucharczuk JC, Singhal S. A Clinical Trial of TumorGlow to Identify Residual Disease During Pleurectomy and Decortication. Ann Thorac Surg 2018; 107:224-232. [PMID: 30028985 DOI: 10.1016/j.athoracsur.2018.06.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/08/2018] [Accepted: 06/04/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Macroscopic complete resection can improve survival in a select group of patients with malignant pleural mesothelioma. During resection, differentiating residual tumor from inflammation or scar can be challenging. This trial evaluated near-infrared (NIR) intraoperative imaging using TumorGlow (a novel NIR imaging approach utilizing high-dose indocyanine green and delayed imaging) technology to improve detection of macroscopic residual disease. METHODS Twenty subjects were enrolled in an open-label clinical trial of NIR intraoperative imaging with TumorGlow (Indocyanine Green for Solid Tumors [NCT02280954]). Twenty-four hours before pleural biopsy or pleurectomy and decortication (P/D), patients received intravenous indocyanine green. All specimens identified during standard-of-care surgical resection and with NIR imaging underwent histopathologic profiling and correlative microscopic fluorescent tomographic evaluation. For subjects undergoing P/D (n = 13), the hemithorax was evaluated with NIR imaging during P/D to assess for residual disease. When possible, additional fluorescent lesions were resected. RESULTS Of 203 resected specimens submitted for evaluation, indocyanine green accumulated within 113 of 113 of resected mesothelioma specimens, with a mean signal-to-background fluorescence ratio of 3.1 (SD, 2.2 to 4.8). The mean signal-to-background fluorescence ratio of benign tissues was 2.2 (SD, 1.4 to 2.4), which was significantly lower than in malignant specimens (p = 0.001). NIR imaging identified occult macroscopic residual disease in 10 of 13 subjects. A median of 5.6 resectable residual deposits per patient (range, 0 to 11 deposits per patient), with a mean size of 0.3 cm (range, 0.1 to 1.5 cm), were identified. CONCLUSIONS TumorGlow for malignant pleural mesothelioma is safe and feasible. Excellent sensitivity allows for to reliable detection of macroscopic residual disease during cytoreductive surgical procedures.
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Affiliation(s)
- Jarrod D Predina
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew D Newton
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher Corbett
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leilei Xia
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Shin
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lydia Frenzel Sulfyok
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Olugbenga T Okusanya
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Keith A Cengel
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew Haas
- Division of Pulmonology, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leslie Litzky
- Division of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John C Kucharczuk
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sunil Singhal
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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Newton AD, Predina JD, Frenzel-Sulyok LG, Shin MH, Wang Y, Singhal S. Intraoperative near-infrared imaging can identify sub-centimeter colorectal cancer lung metastases during pulmonary metastasectomy. J Thorac Dis 2018; 10:E544-E548. [PMID: 30174930 DOI: 10.21037/jtd.2018.06.161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Andrew D Newton
- Center for Precision Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jarrod D Predina
- Center for Precision Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lydia G Frenzel-Sulyok
- Center for Precision Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael H Shin
- Center for Precision Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yiqing Wang
- College of Engineering and Applied Sciences, Nanjing University, Nanjing 210000, China
| | - Sunil Singhal
- Center for Precision Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Predina JD, Newton A, Corbett C, Xia L, Sulyok LF, Shin M, Deshpande C, Litzky L, Barbosa E, Low PS, Kucharczuk JC, Singhal S. Localization of Pulmonary Ground-Glass Opacities with Folate Receptor-Targeted Intraoperative Molecular Imaging. J Thorac Oncol 2018; 13:1028-1036. [PMID: 29626619 PMCID: PMC6015787 DOI: 10.1016/j.jtho.2018.03.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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: 12/21/2017] [Revised: 03/12/2018] [Accepted: 03/18/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Intraoperative localization and resection of ill-defined pulmonary ground-glass opacities (GGOs) during minimally invasive pulmonary resection is technically challenging. Current preoperative techniques to facilitate localization of GGOs include microcoil and hook wire placement, both of which have logistic limitations, carry safety concerns, and do not help with margin assessment. In this clinical trial, we explored an alternative method involving near-infrared molecular imaging with a folate receptor-targeted agent, OTL38, to improve localization of GGOs and confirmation of resection margins. METHODS In a human trial, 20 subjects with pulmonary GGOs who were eligible for video-assisted thoracoscopic surgery (VATS) resection received 0.025 mg/kg of OTL38 before the resection. The primary objectives were to (1) determine whether use of OTL38 allows safe localization of GGOs and assessment of margins during VATS and (2) determine patient, radiographic, and histopathologic variables that predict the amount of fluorescence during near-infrared imaging. RESULTS We observed no toxicity. Of the 21 GGOs, 20 accumulated OTL38 and displayed fluorescence upon in situ or back table evaluation. Intraoperatively, near-infrared imaging localized 15 of 21 lesions whereas VATS alone localized 10 of 21 (p = 0.05). The addition of molecular imaging affected care of nine of 21 subjects by improving intraoperative localization (n = 6) and identifying close margins (n = 3). This approach was most effective for subpleural lesions measuring less than 2 cm. For lesions deeper than 1.5 cm from the pleural surface, intraoperative localization using fluorescent feedback was limited. CONCLUSIONS This approach provides a safe alternative for intraoperative localization of small, peripherally located pulmonary lesions. In contrast to alternative localization techniques, use of OTL38 also allows confirmation of adequate margins. Future studies will compare this approach to alternative localization techniques in a clinical trial.
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Affiliation(s)
- Jarrod D Predina
- Center for Precision Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew Newton
- Center for Precision Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher Corbett
- Center for Precision Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leilei Xia
- Center for Precision Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lydia Frenzel Sulyok
- Center for Precision Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Shin
- Center for Precision Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charuhas Deshpande
- Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leslie Litzky
- Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eduardo Barbosa
- Center for Precision Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Philip S Low
- Department of Chemistry, Purdue University, West Lafayette, Indiana; Purdue Institute for Drug Discovery, Purdue University, West Lafayette, Indiana
| | - John C Kucharczuk
- Center for Precision Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sunil Singhal
- Center for Precision Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Predina JD, Newton A, Kennedy G, Lee MK, Singhal S. Near-Infrared Intraoperative Imaging Can Successfully Identify Malignant Pleural Mesothelioma After Neoadjuvant Chemotherapy. Mol Imaging 2018; 16:1536012117723785. [PMID: 28856921 PMCID: PMC5582655 DOI: 10.1177/1536012117723785] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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] [Indexed: 11/17/2022] Open
Abstract
Malignant pleural mesothelioma is a deadly disease. Complete surgical resection provides patients with the best opportunity for long-term survival. Unfortunately, identification of disease during resection can be challenging. In this report, we describe successful intraoperative utilization of the near-infrared imaging agent, indocyanine green, to help the surgeon identify malignant disease in a patient with malignant pleural mesothelioma who had previously received neoadjuvant chemotherapy. This technology may ultimately enhance the thoracic surgeon's ability to identify small disease deposits at the time of resection.
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Affiliation(s)
- Jarrod D Predina
- 1 Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,2 Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew Newton
- 1 Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,3 Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Greg Kennedy
- 1 Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - M Kenneth Lee
- 3 Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sunil Singhal
- 1 Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,2 Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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22
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Predina JD, Newton AD, Xia L, Corbett C, Connolly C, Shin M, Sulyok LF, Litzky L, Deshpande C, Nie S, Kularatne SA, Low PS, Singhal S. An open label trial of folate receptor-targeted intraoperative molecular imaging to localize pulmonary squamous cell carcinomas. Oncotarget 2018; 9:13517-13529. [PMID: 29568374 PMCID: PMC5862595 DOI: 10.18632/oncotarget.24399] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 01/09/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Clinical applicability of folate receptor-targeted intraoperative molecular imaging (FR-IMI) has been established for surgically resectable pulmonary adenocarcinoma. A role for FR-IMI in other lung cancer histologies has not been studied. In this study, we evaluate feasibility of FR-IMI in patients undergoing pulmonary resection for squamous cell carcinomas (SCCs). METHODS In a human clinical trial (NCT02602119), twelve subjects with pulmonary SCCs underwent FR-IMI with a near-infrared contrast agent that targets the folate receptor-α (FRα), OTL38. Near-infrared signal from tumors and benign lung was quantified to calculate tumor-to-background ratios (TBR). Folate receptor-alpha expression was characterized, and histopathologic correlative analyses were performed to evaluate patterns of OTL38 accumulation. An exploratory analysis was performed to determine patient and histopathologic variables that predict tumor fluorescence. RESULTS 9 of 13 SCCs (in 9 of 12 of subjects) displayed intraoperative fluorescence upon NIR evaluation (median TBR, 3.9). OTL38 accumulated within SCCs in a FRα-dependent manner. FR-IMI was reliable in localizing nodules as small as 1.1 cm, and prevented conversion to thoracotomy for nodule localization in three subjects. Upon evaluation of patient and histopathologic variables, in situ fluorescence was associated with distance from the pleural surface, and was independent of alternative variables including tumor size and metabolic activity. CONCLUSIONS This work demonstrates that FR-IMI is potentially feasible in 70% of SCC patients, and that molecular imaging can improve localization during minimally invasive pulmonary resection. These findings complement previous data demonstrating that ∼98% of pulmonary adenocarcinomas are localized during FR-IMI and suggest broad applicability for NSCLC patients undergoing resection.
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Affiliation(s)
- Jarrod D Predina
- Center for Precision Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew D Newton
- Center for Precision Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Leilei Xia
- Center for Precision Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
- Division of Urology, Department of Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher Corbett
- Center for Precision Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Courtney Connolly
- Center for Precision Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Shin
- Center for Precision Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Lydia Frezel Sulyok
- Center for Precision Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Leslie Litzky
- Pathology and Laboratory Medicine at The Hospital of The University of Pennsylvania, Philadelphia, PA, USA
| | - Charuhas Deshpande
- Pathology and Laboratory Medicine at The Hospital of The University of Pennsylvania, Philadelphia, PA, USA
| | - Shuming Nie
- Department Biomedical Engineering and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Sumith A Kularatne
- Department of Chemistry, and Purdue Institute for Drug Discovery, Purdue University, West Lafayette, IN, USA
| | - Philip S Low
- Department of Chemistry, and Purdue Institute for Drug Discovery, Purdue University, West Lafayette, IN, USA
| | - Sunil Singhal
- Center for Precision Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
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23
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Predina JD, Newton AD, Keating J, Dunbar A, Connolly C, Baldassari M, Mizelle J, Xia L, Deshpande C, Kucharczuk J, Low PS, Singhal S. A Phase I Clinical Trial of Targeted Intraoperative Molecular Imaging for Pulmonary Adenocarcinomas. Ann Thorac Surg 2018; 105:901-908. [PMID: 29397932 PMCID: PMC10959252 DOI: 10.1016/j.athoracsur.2017.08.062] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [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: 02/07/2017] [Revised: 08/21/2017] [Accepted: 08/25/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Intraoperative identification of pulmonary nodules, particularly small lesions, can be challenging. We hypothesize that folate receptor-targeted intraoperative molecular imagining can be safe and improve localization of pulmonary nodules during resection. METHODS Twenty subjects with biopsy-proven pulmonary adenocarcinomas were enrolled in a phase I clinical trial to test the safety and feasibility of OTL38, a novel folate receptor-α (FRα) targeted optical contrast agent. During resection, tumors were imaged in situ and ex vivo and fluorescence was quantified. Resected specimens were analyzed to confirm diagnosis, and immunohistochemistry was utilized to quantify FRα expression. A multivariate analysis using clinical and tumor data was performed to determine variables impacting tumor fluorescence. RESULTS Of the 20 subjects, three grade I adverse events were observed: all transient nausea/abdominal pain. All symptoms resolved after completing the infusion. Sixteen of 20 subjects (80%) had tumors with in situ fluorescence with a mean tumor-to-background fluorescence level of 2.9 (interquartile range, 2.1 to 4.2). The remaining 4 subjects' tumors fluoresced ex vivo. In situ fluorescence was dependent on depth from the pleural surface. Four subcentimeter nodules not identified on preoperative imaging were detected with intraoperative imaging. CONCLUSIONS This phase I trial provides preliminary evidence suggesting that folate receptor-targeted molecular imaging with OTL38 is safe, with tolerable grade I toxicity. These data also suggest that OTL38 accumulates in known lung cancers and may improve identification of synchronous malignancies. Our group is initiating a five-center, phase II study to better understand the clinical implications of intraoperative molecular imaging using OTL38.
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Affiliation(s)
- Jarrod D Predina
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Andrew D Newton
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jane Keating
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ashley Dunbar
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Courtney Connolly
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael Baldassari
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jack Mizelle
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Leilei Xia
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Charuhas Deshpande
- Pathology and Laboratory Medicine at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Kucharczuk
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Philip S Low
- Purdue Institute for Drug Discovery, Purdue University, West Lafayette, Indiana
| | - Sunil Singhal
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, Philadelphia, Pennsylvania.
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Predina JD, Newton A, Deshpande C, Low P, Singhal S. Utilization of targeted near-infrared molecular imaging to improve pulmonary metastasectomy of osteosarcomas. J Biomed Opt 2018; 23:1-4. [PMID: 29302953 PMCID: PMC5753425 DOI: 10.1117/1.jbo.23.1.016005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 12/01/2017] [Indexed: 06/07/2023]
Abstract
Pulmonary metastasectomy for osteosarcoma provides a select group of patients an opportunity for long-term survival and possible cure. Unfortunately, a complete metastasectomy is challenging due an inability to accurately identify lesions that lay below the threshold of preoperative imaging or intraoperative visual and tactile inspection. Growing evidence suggests that osteosarcomas express a number of unique molecular markers, including the folate receptor alpha. In this case report, we describe the application of a folate receptor-targeted, near-infrared optical contrast agent (OTL38) to improve osteosarcoma localization during minimally invasive pulmonary resection. In addition to localizing preoperatively identified lesions, this technology helped identify additional disease that was undetected on preoperative imaging or with traditional intraoperative techniques. This report marks the first successful utilization of a molecular imaging probe useful for osteosarcomas. This technology may provide a unique approach to improve pulmonary metastasectomy of osteosarcomas.
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Affiliation(s)
- Jarrod D. Predina
- The Perelman School of Medicine at the University of Pennsylvania, Center for Precision Surgery, Philadelphia, Pennsylvania, United States
- The Perelman School of Medicine at the University of Pennsylvania, Division of Thoracic Surgery, Department of Surgery, Philadelphia, Pennsylvania, United States
| | - Andrew Newton
- The Perelman School of Medicine at the University of Pennsylvania, Center for Precision Surgery, Philadelphia, Pennsylvania, United States
- The Perelman School of Medicine at the University of Pennsylvania, Department of Surgery, Philadelphia, Pennsylvania, United States
| | - Charuhas Deshpande
- The Perelman School of Medicine at the University of Pennsylvania, Department of Pathology, Philadelphia, Pennsylvania, United States
| | - Philip Low
- Purdue University, Department of Chemistry, Philadelphia, Pennsylvania, United States
| | - Sunil Singhal
- The Perelman School of Medicine at the University of Pennsylvania, Center for Precision Surgery, Philadelphia, Pennsylvania, United States
- The Perelman School of Medicine at the University of Pennsylvania, Division of Thoracic Surgery, Department of Surgery, Philadelphia, Pennsylvania, United States
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25
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Predina JD, Newton A, Connolly C, Singhal S. Folate receptor-targeted molecular imaging improves identification of malignancy during pulmonary resection: a case report. J Cardiothorac Surg 2017; 12:110. [PMID: 29202877 PMCID: PMC5716373 DOI: 10.1186/s13019-017-0664-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 06/29/2017] [Accepted: 11/15/2017] [Indexed: 11/12/2022] Open
Abstract
Background During minimally invasive pulmonary resection, both limited visualization and tactile feedback can make localization of pulmonary nodules and assessment for synchronous disease challenging. Intraoperative molecular imaging is an emerging technology that can enhance a surgeon’s ability to detect cancers at the time of resection. Case presentation In this report, we describe the application of a folate receptor-targeted, near infrared optical contrast agent (OTL38) for the detection of an invasive pulmonary adenocarcinoma. During molecular imaging, an otherwise undetectable synchronous nodule was also identified. This finding resulted in intraoperative upstaging and operative plan modifications. Conclusion This report marks the first successful utilization of a targeted, near infrared intraoperative molecular imaging probe useful for thoracic malignancies. This rapidly evolving technology may enhance the surgeon’s ability to perform a number of oncologic procedures including tumor localization, margin assessment and intraoperative staging. Electronic supplementary material The online version of this article (10.1186/s13019-017-0664-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jarrod D Predina
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA. .,Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, 6 White building; 3400 Spruce St, Philadelphia, PA 19104, USA.
| | - Andrew Newton
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.,Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Courtney Connolly
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.,Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Sunil Singhal
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA. .,Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, 6 White building; 3400 Spruce St, Philadelphia, PA 19104, USA.
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26
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Affiliation(s)
- Jarrod D. Predina
- Center of Precision Surgery, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School
- Department of Surgery, University of Pennsylvania Perelman School of Medicine
| | - David Fedor
- Center of Precision Surgery, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine
- Department of Surgery, University of Pennsylvania Perelman School of Medicine
| | - Andrew Newton
- Center of Precision Surgery, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine
- Department of Surgery, University of Pennsylvania Perelman School of Medicine
| | - Leilei Xia
- Center of Precision Surgery, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine
- Department of Urology, University of Pennsylvania School of Medicine
| | - John YK Lee
- Center of Precision Surgery, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine
- Department of Neurosurgery, University of Pennsylvania School of Medicine
| | - Thomas Guzzo
- Center of Precision Surgery, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine
- Department of Urology, University of Pennsylvania School of Medicine
| | - Jeffrey Drebin
- Center of Precision Surgery, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine
- Department of Surgery, University of Pennsylvania Perelman School of Medicine
| | - Sunil Singhal
- Center of Precision Surgery, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine
- Department of Surgery, University of Pennsylvania Perelman School of Medicine
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27
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Singhal K, Newton AD, Corbett C, Predina JD. Management of partial anomalous pulmonary venous connections in patients requiring pulmonary resection: a case report and systematic review. J Thorac Dis 2017; 9:5434-5439. [PMID: 29312754 DOI: 10.21037/jtd.2017.11.68] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Partial anomalous pulmonary venous connections (PAPVCs) are rare congenital anomalies that are frequently asymptomatic in adults. When PAPVCs are encountered in the patient requiring pulmonary resection, improper management can result in fulminant right-heart failure and death. In this report, we note our management of a 70-year-old male who presented with a right upper lobe ground-glass opacity (GGO) and a PAPVC. We also provide a systematic review of all contemporary reports and provide an algorithm for PAPVC management in the adult patient requiring pulmonary resection.
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Affiliation(s)
- Kieran Singhal
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew D Newton
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher Corbett
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jarrod D Predina
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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28
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Newton AD, Predina JD, Xia L, Roses RE, Karakousis GC, Dempsey DT, Williams NN, Kucharczuk JC, Singhal S. Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk. Ann Surg Oncol 2017; 25:318-325. [PMID: 29147928 DOI: 10.1245/s10434-017-6238-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND In early-stage esophageal adenocarcinoma (EAC), esophagectomy improves staging but also increases mortality compared with endoscopic resection. Our objective was to quantify esophagectomy mortality and lymph node metastasis (LNM) risk in early-stage EAC to improve surgical treatment allocation. METHODS We identified National Cancer Database (2004-2014) patients with nonmetastatic, Tis, T1a, or T1b EAC who had primary surgical resection and microscopic examination of at least 15 lymph nodes. Univariate and multivariable logistic regression identified predictors of LNM. Cox regression identified predictors of death. The Kaplan-Meier method predicted overall survival (OS). RESULTS In 782 patients, LNM rates were: all patients 13.8%, Tis 0%, T1a 3.6%, T1b 23.4%. Independent predictors of LNM were submucosal invasion, lymphovascular invasion (LVI), decreasing differentiation, and tumor size ≥ 2 cm (P < 0.05). For T1a tumors with poor differentiation or size ≥ 2 cm, LNM rates were 10.2 and 6.7%, respectively; 90-day mortality was 3.1%. The LNM rate in well differentiated T1b tumors < 2 cm was 4.2%; 90-day mortality was 6.0%. Estimated 5-year OS was 80.2% versus 64.4% (T1a vs. T1b). LNM increased risk of death for T1a (hazard ratio [HR] 8.52, 95% confidence interval [CI] 3.13-23.22, P < 0.001) and T1b tumors (HR 2.52, 95% CI 1.59-4.00, P < 0.001). CONCLUSIONS In T1a EAC with poor differentiation or size ≥ 2 cm, esophagectomy should be considered, whereas in T1b EAC with low-risk features (well-differentiated T1b EAC < 2 cm without LVI), endoscopic resection may be sufficient. Treatment guidelines for early-stage EAC should include all high-risk tumor features for LNM and stage-specific esophagectomy mortality.
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Affiliation(s)
- Andrew D Newton
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA.
| | - Jarrod D Predina
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Leilei Xia
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Giorgos C Karakousis
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Daniel T Dempsey
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Noel N Williams
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
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Predina JD, Newton AD, Desphande C, Singhal S. Near-infrared intraoperative imaging during resection of an anterior mediastinal soft tissue sarcoma. Mol Clin Oncol 2017; 8:86-88. [PMID: 29387401 DOI: 10.3892/mco.2017.1491] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 11/06/2017] [Indexed: 11/06/2022] Open
Abstract
Sarcomas are rare malignancies that are generally treated with multimodal therapy protocols incorporating complete local resection, chemotherapy and radiation. Unfortunately, even with this aggressive approach, local recurrences are common. Near-infrared intraoperative imaging is a novel technology that provides real-time visual feedback that can improve identification of disease during resection. The presented study describes utilization of a near-infrared agent (indocyanine green) during resection of an anterior mediastinal sarcoma. Real-time fluorescent feedback provided visual information that helped the surgeon during tumor localization, margin assessment and dissection from mediastinal structures. This rapidly evolving technology may prove useful in patients with primary sarcomas arising from other locations or with other mediastinal neoplasms.
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Affiliation(s)
- Jarrod D Predina
- Center for Precision Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104, USA.,Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Andrew D Newton
- Center for Precision Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104, USA.,Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Charuhas Desphande
- Center for Precision Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104, USA.,Department of Pathology and Laboratory Medicine, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Sunil Singhal
- Center for Precision Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104, USA.,Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104, USA
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30
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Predina JD, Newton AD, Connolly C, Dunbar A, Baldassari M, Deshpande C, Cantu E, Stadanlick J, Kularatne SA, Low PS, Singhal S. Identification of a Folate Receptor-Targeted Near-Infrared Molecular Contrast Agent to Localize Pulmonary Adenocarcinomas. Mol Ther 2017; 26:390-403. [PMID: 29241970 DOI: 10.1016/j.ymthe.2017.10.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 10/19/2017] [Accepted: 10/20/2017] [Indexed: 11/29/2022] Open
Abstract
Non-small cell lung cancer (NSCLC) is the number one cancer killer in the United States. Despite attempted curative surgical resection, nearly 40% of patients succumb to recurrent disease. High recurrence rates may be partially explained by data suggesting that 20% of NSCLC patients harbor synchronous disease that is missed during resection. In this report, we describe the use of a novel folate receptor-targeted near-infrared contrast agent (OTL38) to improve the intraoperative localization of NSCLC during pulmonary resection. Using optical phantoms, fluorescent imaging with OTL38 was associated with less autofluorescence and greater depth of detection compared to traditional optical contrast agents. Next, in in vitro and in vivo NSCLC models, OTL38 reliably localized NSCLC models in a folate receptor-dependent manner. Before testing intraoperative molecular imaging with OTL38 in humans, folate receptor-alpha expression was confirmed to be present in 86% of pulmonary adenocarcinomas upon histopathologic review of 100 human pulmonary resection specimens. Lastly, in a human feasibility study, intraoperative molecular imaging with OTL38 accurately identified 100% of pulmonary adenocarcinomas and allowed for identification of additional subcentimeter neoplastic processes in 30% of subjects. This technology may enhance the surgeon's ability to identify NSCLC during oncologic resection and potentially improve long-term outcomes.
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Affiliation(s)
- Jarrod D Predina
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Andrew D Newton
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Courtney Connolly
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ashley Dunbar
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael Baldassari
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Charuhas Deshpande
- Pulmonary and Mediastinal Pathology, Department of Clinical Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Edward Cantu
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA; Division of Cardiac Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jason Stadanlick
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | | | - Philip S Low
- Department of Chemistry, Purdue University, West Lafayette, IN 479067, USA
| | - Sunil Singhal
- Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA; Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
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31
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Predina JD, Newton AD, Keating J, Barbosa EM, Okusanya O, Xia L, Dunbar A, Connolly C, Baldassari MP, Mizelle J, Delikatny EJ, Kucharczuk JC, Deshpande C, Kularatne SA, Low P, Drebin J, Singhal S. Intraoperative Molecular Imaging Combined With Positron Emission Tomography Improves Surgical Management of Peripheral Malignant Pulmonary Nodules. Ann Surg 2017; 266:479-488. [PMID: 28746152 PMCID: PMC11073793 DOI: 10.1097/sla.0000000000002382] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [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] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine if intraoperative molecular imaging (IMI) can improve detection of malignant pulmonary nodules. BACKGROUND 18-Fluorodeoxyglucose positron emission tomography (PET) is commonly utilized in preoperative assessment of patients with solid malignancies; however, false negatives and false positives remain major limitations. Using patients with pulmonary nodules as a study model, we hypothesized that IMI with a folate receptor targeted near-infrared contrast agent (OTL38) can improve malignant pulmonary nodule identification when combined with PET. METHODS Fifty patients with pulmonary nodules with imaging features suspicious for malignancy underwent preoperative PET. Patients then received OTL38 before pulmonary resection. During resection, IMI was utilized to evaluate known pulmonary nodules and identify synchronous lesions. Tumor size, PET standardized uptake value, and IMI tumor-to-background ratios were compared for known and synchronous nodules via paired and unpaired t tests, when appropriate. Test characteristics of PET and IMI with OTL38 were compared. RESULTS IMI identified 56 of 59 (94.9%) malignant pulmonary nodules identified by preoperative imaging. IMI located an additional 9 malignant lesions not identified preoperatively. Nodules only detected by IMI were smaller than nodules detected preoperatively (0.5 vs 2.4 cm; P < 0.01), but displayed similar fluorescence (tumor-to-background ratio 3.3 and 3.1; P = 0.50). Sensitivity of IMI and PET were 95.6% and 73.5% (P = 0.001), respectively; and positive predictive values were 94.2% and 89.3%, respectively (P > 0.05). Additionally, utilization of IMI clinically upstaged 6 (12%) subjects and improved management of 15 (30%) subjects. CONCLUSIONS These data suggest that combining IMI with PET may provide superior oncologic outcomes for patients with resectable lung cancer.
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Affiliation(s)
- Jarrod D. Predina
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Andrew D. Newton
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania
| | - Jane Keating
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania
| | - Eduardo M. Barbosa
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania
| | - Olugbenga Okusanya
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania
| | - Leilei Xia
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania
| | - Ashley Dunbar
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania
| | - Courtney Connolly
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania
| | - Michael P. Baldassari
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania
| | - Jack Mizelle
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania
| | - Edward J. Delikatny
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania
| | - John C. Kucharczuk
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania
| | - Charuhas Deshpande
- Pathology and Laboratory Medicine at the Hospital of the University of Pennsylvania
| | - Sumith A Kularatne
- Department of Chemistry, and Purdue Institute for Drug Discovery, Purdue University
- On Target Laboratories, West Lafayette, Indiana
| | - Phillip Low
- Department of Chemistry, and Purdue Institute for Drug Discovery, Purdue University
- On Target Laboratories, West Lafayette, Indiana
| | - Jeffrey Drebin
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania
| | - Sunil Singhal
- Center for Precision Surgery, Perelman School of Medicine at the University of Pennsylvania
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania
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McMillan MT, Ojerholm E, Verma V, Higgins KA, Singhal S, Predina JD, Berman AT, Grover S, Robinson CG, Simone CB. Radiation Treatment Time and Overall Survival in Locally Advanced Non-small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2017; 98:1142-1152. [PMID: 28721898 DOI: 10.1016/j.ijrobp.2017.04.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/06/2017] [Accepted: 04/03/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE Prolonged radiation treatment (RT) time (RTT) has been associated with worse survival in several malignancies. The present study investigated whether delays during RT are associated with overall survival (OS) in non-small cell lung cancer (NSCLC). METHODS AND MATERIALS The National Cancer Database was queried for patients with stage III NSCLC who had received definitive concurrent chemotherapy and fractionated RT to standard doses (59.4-70.0 Gy) and fractionation from 2004 to 2013. The RTT was classified as standard or prolonged for each treatment regimen according to the radiation dose and number of fractions. Cox proportional hazards models were used to evaluate the association between the following factors and OS: RTT, RT fractionation, demographic and pathologic factors, and chemotherapeutic agents. RESULTS Of 14,154 patients, the RTT was prolonged in 6262 (44.2%). Factors associated with prolonged RTT included female sex (odds ratio [OR] 1.21, P<.0001), black race (OR 1.20, P=.001), nonprivate health insurance (OR 1.30, P<.0001), and lower income (<$63,000 annually, OR 1.20, P<.0001). The median OS was significantly worse for patients with prolonged RTT than that for those with standard RTT (18.6 vs 22.7 months, P<.0001). Furthermore, the OS worsened with each cumulative interval of delay (standard RTT vs prolonged 1-2 days, 20.5 months, P=.009; prolonged 3-5 days, 17.9 months, P<.0001; prolonged 6-9 days, 17.7 months, P<.0001; prolonged >9 days, 17.1 months, P<.0001). On multivariable analysis, prolonged RTT was independently associated with inferior OS (hazard ratio 1.21, P<.0001). Prolonged RTT as a continuous variable was also significantly associated with worse OS (hazard ratio 1.001, P=.0007). CONCLUSIONS Delays during RT appear to negatively affect survival for patients with locally advanced NSCLC. We have detailed the demographic and socioeconomic barriers influencing prolonged RTT as a method to address the health disparities in this regard. Cumulative interruptions of RT should be minimized.
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Affiliation(s)
- Matthew T McMillan
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Eric Ojerholm
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kristin A Higgins
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jarrod D Predina
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Abigail T Berman
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland.
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Venegas O, Newton A, Vergara N, Singhal S, Predina JD. Tracheal Glomus Tumor: A Case Report and Review of the Literature. Rare Tumors 2017; 9:6848. [PMID: 28458792 PMCID: PMC5379231 DOI: 10.4081/rt.2017.6848] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 08/26/2016] [Accepted: 12/20/2016] [Indexed: 12/18/2022] Open
Abstract
Glomus tumors are rare neoplasms that typically occur within the dermis or subcutis of the subungual space. Primary glomus tumors of the thorax are exceedingly uncommon, thus standard-of-care management is lacking. In this report we describe the management of a patient presenting with a symptomatic glomus tumor of the posterior trachea, and provide a comprehensive review including all documented tracheal glomus tumor reports.
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Affiliation(s)
- Ollin Venegas
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew Newton
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Norge Vergara
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sunil Singhal
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jarrod D Predina
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Xia L, Venegas OG, Predina JD, Singhal S, Guzzo TJ. Intraoperative Molecular Imaging for Post-Chemotherapy Robot-Assisted Laparoscopic Resection of Seminoma Metastasis: A Case Report. Clin Genitourin Cancer 2017; 15:e61-e64. [PMID: 27793611 PMCID: PMC10998540 DOI: 10.1016/j.clgc.2016.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 09/16/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Leilei Xia
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Center for Precision Surgery, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ollin G Venegas
- Center for Precision Surgery, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Thoracic Surgery and Thoracic Surgery Research Laboratory, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jarrod D Predina
- Center for Precision Surgery, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Thoracic Surgery and Thoracic Surgery Research Laboratory, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sunil Singhal
- Center for Precision Surgery, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Thoracic Surgery and Thoracic Surgery Research Laboratory, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Thomas J Guzzo
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Center for Precision Surgery, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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Abstract
Intraoperative molecular imaging is a promising new technology with numerous applications in lung cancer surgery. Accurate identification of small nodules and assessment of tumor margins are two challenges in pulmonary resections for cancer, particularly with increasing use of video-assisted thoracoscopic surgery (VATS). One potential solution to these problems is intraoperative use of a fluorescent contrast agent to improve detection of cancer cells. This technology requires both a targeted fluorescent dye that will selectively accumulate in cancer cells and a specialized imaging system to detect the cells. In several studies, we have shown that intraoperative imaging with indocyanine green (ICG) can be used to accurately identify indeterminate pulmonary nodules. The use of a folate-tagged fluorescent molecule targeted to the folate receptor-α (FRα) further improves the sensitivity and specificity of detecting lung adenocarcinomas. We have demonstrated this technology can be used as an "optical biopsy" to differentiate adenocarcinoma versus other histological subtypes of pulmonary nodules. This strategy has potential applications in assessing bronchial stump margins, identifying synchronous or metachronous lesions, and rapidly assessing lymph nodes for lung adenocarcinoma.
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Affiliation(s)
- Andrew D Newton
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
| | - Gregory T Kennedy
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
| | - Jarrod D Predina
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, 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, Pennsylvania, PA, USA
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Predina JD, Keating J, Venegas O, Nims S, Singhal S. Neoadjuvant intratumoral immuno-gene therapy for non-small cell lung cancer. Discov Med 2016; 21:275-281. [PMID: 27232513] [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] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Non-small Cell Lung Cancer (NSCLC) remains a deadly disease despite aggressive treatment protocols which incorporate chemotherapy, radiation and surgery. These traditional approaches have reached a plateau in therapeutic benefit. There is emerging evidence suggesting that immunotherapy can serve as an alternative treatment modality for NSCLC. Our group has nearly two decades of experience involving immuno-gene therapy with Ad.hIFN-α and Ad.hIFN-β in human mesothelioma trials, and has observed both safety and efficacy in treatment of Thoracic malignancies. We have expanded the scope of our work and have obtained encouraging pre-clinical evidence suggesting a role for immunotherapy as a surgical adjuvant for NSCLC cancers. By combining immunotherapy with surgery, synergistic results have been observed. Based on these observations, we have prepared a Phase I Clinical Trial that pairs Ad.hIFN-α with surgery for patients with resectable NSCLC. Patient enrollment is likely to begin in the Summer of 2016. We hope that this trial will serve as a platform for future trials aimed at pairing immunotherapy with surgery for patients diagnosed with NSCLC.
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Affiliation(s)
- Jarrod D Predina
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory, University of Pennsylvania Perelman School of Medicine, Philadelphia PA 19104, USA
| | - Jane Keating
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory, University of Pennsylvania Perelman School of Medicine, Philadelphia PA 19104, USA
| | - Ollin Venegas
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory, University of Pennsylvania Perelman School of Medicine, Philadelphia PA 19104, USA
| | - Sarah Nims
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory, University of Pennsylvania Perelman School of Medicine, Philadelphia PA 19104, USA
| | - Sunil Singhal
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory, University of Pennsylvania Perelman School of Medicine, Philadelphia PA 19104, USA
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Predina JD, Keating J, Patel N, Nims S, Singhal S. Clinical implications of positive margins following non-small cell lung cancer surgery. J Surg Oncol 2015; 113:264-9. [PMID: 26719121 DOI: 10.1002/jso.24130] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 11/30/2015] [Indexed: 11/06/2022]
Abstract
Positive margins following pulmonary resection of non-small cell lung cancer (NSCLC) occur in approximately 5-15% of patients undergoing a curative procedure. The presence of positive margins negatively impacts long-term outcomes by setting the stage for local and potentially distant disease recurrence. Despite major clinical ramifications, there are very few dedicated reports that examine the implications of positive margins following surgery for NSCLC. Furthermore, published series are typically retrospective studies from single institutions. In this review we analyze published data with special consideration of four pertinent questions: (i) what are the long term outcomes of a positive margin following pulmonary resection?, (ii) is intraoperative margin assessment by frozen section reliable?, (iii) what is the optimal distance of the tumor margin to the surgical margin?, and (iv) should adjuvant chemotherapy and/or radiation therapy be used in the setting of a positive surgical margin?
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Affiliation(s)
- Jarrod D Predina
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jane Keating
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Neil Patel
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Sarah Nims
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Predina JD, Morse CR. Minimally invasive esophagectomy and its current role in esophageal cancer. MINERVA CHIR 2014; 69:363-370. [PMID: 25300696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The incidence of esophageal cancer has increased over the previous 4 decades. In 2014 alone, it is estimated that there will be 18,000 patients diagnosed with esophageal cancer, and 15,000 deaths from the disease.Esophagectomy, most commonly with adjuvant chemotherapy and radiation to treat locoregional spread, is the primary vehicle to offer patients cure. Open approaches (transthoracic Ivor Lewis, transhiatal, left thoracoabdominal, and 'three phase' McKeown esophagectomy) have been the most common, and are associated with significant morbidity and mortality.With this morbidity in mind, minimally invasive esophagectomy (MIE) has gained enthusiasm from the surgical community as an approach to minimize post-operative morbidity without sacrificing long-term outcomes. In this article, we review the basic steps of the three major approaches to MIE. We also review the recent data which supports the surgical field's growing enthusiasm for this approach to esophageal cancer. Based on our review of current data, we conclude that patients undergoing MIE have improved short-term outcomes with regard to morbidity and quality of life, with no adverse effects of the quality of oncologic resection.
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Affiliation(s)
- J D Predina
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA -
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Quatromoni JG, Suzuki E, Okusanya O, Judy BF, Bhojnagarwala P, Venegas O, Eruslanov E, Predina JD, Albelda SM, Singhal S. The timing of TGF-β inhibition affects the generation of antigen-specific CD8+ T cells. BMC Immunol 2013; 14:30. [PMID: 23865808 PMCID: PMC3725164 DOI: 10.1186/1471-2172-14-30] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 07/02/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transforming growth factor (TGF)-β is a potent immunosuppressive cytokine necessary for cancer growth. Animal and human studies have shown that pharmacologic inhibition of TGF-β slows the growth rate of established tumors and occasionally eradicates them altogether. We observed, paradoxically, that inhibiting TGF-β before exposing animals to tumor cells increases tumor growth kinetics. We hypothesized that TGF-β is necessary for the anti-tumor effects of cytotoxic CD8+ T lymphocytes (CTLs) during the early stages of tumor initiation. METHODS BALB/c mice were pretreated with a blocking soluble TGF-β receptor (sTGF-βR, TGF-β-blockade group, n=20) or IgG2a (Control group, n=20) before tumor inoculation. Tumor size was followed for 6 weeks. In vivo lymphocyte assays and depletion experiments were then performed to investigate the immunological basis of our results. Lastly, animals were pretreated with either sTGF-βR (n=6) or IgG2a (n=6) prior to immunization with an adenoviral vector encoding the human papillomavirus E7 gene (Ad.E7). One week later, flow cytometry was utilized to measure the number of splenic E7-specific CD8+ T cells. RESULTS Inhibition of TGF-β before the injection of tumor cells resulted in significantly larger average tumor volumes on days 11, 17, 22, 26 and 32 post tumor-inoculation (p < 0.05). This effect was due to the inhibition of CTLs, as it was not present in mice with severe combined immunodeficiency (SCID) or those depleted of CD8+ T cells. Furthermore, pretreatment with sTGF-βR inhibited tumor-specific CTL activity in a Winn Assay. Tumors grew to a much larger size when mixed with CD8+ T cells from mice pretreated with sTGF-βR than when mixed with CD8+ T cells from mice in the control group: 96 mm3 vs. 22.5 mm3, respectively (p < 0.05). In addition, fewer CD8+ T cells were generated in Ad.E7-immunized mice pretreated with sTGF-βR than in mice from the control group: 0.6% total CD8+ T cells vs. 1.9%, respectively (p < 0.05). CONCLUSIONS These studies provide the first in vivo evidence that TGF-β may be necessary for anti-tumor immune responses in certain cancers. This finding has important implications for our understanding of anti-tumor immune responses, the role of TGF-β in the immune system, and the future development of TGF-β inhibiting drugs.
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Affiliation(s)
- Jon G Quatromoni
- Division of Thoracic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
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Yu Z, Predina JD, Cheng G. Refractoriness of interferon-beta signaling through NOD1 pathway in mouse respiratory epithelial cells using the anticancer xanthone compound. World J Biol Chem 2013; 4:18-29. [PMID: 23710296 PMCID: PMC3652647 DOI: 10.4331/wjbc.v4.i2.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 03/19/2013] [Accepted: 04/29/2013] [Indexed: 02/05/2023] Open
Abstract
AIM: To explore the possibility that nucleotide oligomerization domain 1 (NOD1) pathway involved in refractoriness of interferon-β signaling in mouse respiratory epithelial cells induced by the anticancer xanthone compound, 5,6-dimethylxanthenone-4-acetic acid (DMXAA).
METHODS: C10 mouse bronchial epithelial cells were grown in Dulbecco’s modified Eagle’s medium supplemented with 10% fetal bovine serum, 2 mmol/L glutamine, 100 units/mL penicillin, 100 g/mL streptomycin. Pathogen-free female BALB/c mice were used to explore the mechanisms of refractoriness of interferon-signaling. Mouse thioglycollate-elicited peritoneal macrophages, bone marrow derived macrophages and bone marrow derived dendritic cells were collected and cultured. The amount of interferon (IFN)-inducible protein-10 (IP10/CXCL10), macrophage chemotactic protein (MCP1/CCL2) and interleukin (IL)-6 secreted by cells activated by DMXAA was quantified using enzyme-linked immunosorbent assay kits according to the instructions of the manufacturers. Total RNA was isolated from cells or nasal epithelium with RNeasy Plus Mini Kit, and cDNA was synthesized. Gene expression was checked using Applied Biosystems StepOne Real-Time Polymerase Chain Reaction System. Transfection of small interfering RNA (siRNA) control, NOD1 duplexed RNA oligonucleotides, and high-mobility group box 1/2/3 (HMGB1/2/3) siRNA was performed using siRNA transfection reagent.
RESULTS: DMXAA activates IFN-β pathway with high level of IFN-β dependent antiviral genes including 2’, 5’-oligoadenylate synthetase 1 and myxovirus resistance 1 in mouse thioglycollate-elicited peritoneal macrophages, bone marrow derived macrophages and bone marrow derived dendritic cells. Activation of IFN-β by DMXAA involved in NOD1, but not HMGB1/2/3 signal pathway demonstrated by siRNA. NOD1 pathway plays an important role in refractoriness of IFN-β signaling induced by DMXAA in mouse C10 respiratory epithelial cells and BALB/c mice nasal epithelia. These data indicate that DMXAA is not well adapted to the intrinsic properties of IFN-β signaling. Approaches to restore sensitivity of IFN-β signaling by find other xanthone compounds may function similarly, could enhance the efficacy of protection from influenza pneumonia and potentially in other respiratory viral infections.
CONCLUSION: NOD1 pathway may play an important role in refractoriness of IFN-β signaling in mouse respiratory epithelial cells induced by DMXAA.
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Yang RL, Hashimoto DA, Predina JD, Bowens NM, Sonnenberg EM, Cleveland EC, Lawson C, Morris JB, Kelz RR. The virtual-patient pilot: testing a new tool for undergraduate surgical education and assessment. J Surg Educ 2013; 70:394-401. [PMID: 23618451 DOI: 10.1016/j.jsurg.2012.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 11/18/2012] [Accepted: 12/03/2012] [Indexed: 06/02/2023]
Abstract
BACKGROUND The virtual patient (VP) is a web-based tool that allows students to test their clinical decision-making skills using simulated patients. METHODS Three VP cases were developed using commercially available software to simulate common surgical scenarios. Surgical clerks volunteered to complete VP cases. Upon case completion, an individual performance score (IPS, 0-100) was generated and a 16-item survey was administered. Surgery shelf exam scores of clerks who completed VP cases were compared with a cohort of students who did not have exposure to VP cases. Descriptive statistics were performed to characterize survey results and mean IPS. RESULTS Surgical clerks felt that the VP platform was simple to use, and both the content and images were well presented. They also felt that VPs enhanced learning and were helpful in understanding surgical concepts. Mean IPS at conclusion of the surgery clerkship was 69.2 (SD 26.5). Mean performance on the surgery shelf exam for the student cohort who had exposure to VPs was 86.5 (SD 7.4), whereas mean performance for the unexposed student cohort was 83.5 (SD 9). DISCUSSION The VP platform represents a new educational tool that allows surgical clerks to direct case progression and receive feedback regarding clinical-management decisions. Its use as an assessment tool will require further validation.
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Affiliation(s)
- Rachel L Yang
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania 19104, USA
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Predina JD, Kapoor V, Judy BF, Cheng G, Fridlender ZG, Albelda SM, Singhal S. Cytoreduction surgery reduces systemic myeloid suppressor cell populations and restores intratumoral immunotherapy effectiveness. J Hematol Oncol 2012; 5:34. [PMID: 22742411 PMCID: PMC3418164 DOI: 10.1186/1756-8722-5-34] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2012] [Accepted: 05/28/2012] [Indexed: 01/08/2023] Open
Abstract
Background Multiple immunotherapy approaches have improved adaptive anti-tumor immune responses in patients with early stage disease; however, results have been less dramatic when treating patients with late stage disease. These blunted responses are likely due to a host of factors, including changes in the tumor microenvironment and systemic immunosuppressive features, which accompany advanced tumor states. We hypothesized that cytoreductive surgery could control these immunosuppressive networks and restore the potency of immunotherapy in advanced disease scenarios. Methods To test these hypotheses, two representative intratumoral immunotherapies (an adenoviral vector encoding a suicide gene, AdV-tk, or a type-I interferon, Ad.IFNα) were tested in murine models of lung cancer. Cytoreductive surgery was performed following treatment of advanced tumors. Mechanistic underpinnings were investigated using flow cytometry, in vivo leukocyte depletion methods and in vivo tumor neutralization assays. Results AdV-tk and Ad.IFNα were effective in treating early lung cancers, but had little anti-tumor effects in late stage cancers. Interestingly, in late stage scenarios, surgical cytoreduction unmasked the anti-tumor potency of both immunotherapeutic approaches. Immune mechanisms that explained restoration in anti-tumor immune responses included increased CD8 T-cell trafficking and reduced myeloid derived suppressor cell populations. Conclusion This study demonstrates that surgical resection combined with immunotherapy may be a rational therapeutic option for patients with advanced stage cancer.
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Affiliation(s)
- Jarrod D Predina
- Department of Surgery, Thoracic Surgery Research Laboratory, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Predina JD, Judy B, Fridlender ZG, Aliperti LA, Madajewski B, Kapoor V, Cheng G, Quatromoni J, Okusanya O, Singhal S. A positive-margin resection model recreates the postsurgical tumor microenvironment and is a reliable model for adjuvant therapy evaluation. Cancer Biol Ther 2012; 13:745-55. [PMID: 22617772 DOI: 10.4161/cbt.20557] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Up to 30% of cancer patients undergoing curative surgery develop local recurrences due to positive margins. Patients typically receive adjuvant chemotherapy, immunotherapy and/or radiation to prevent such relapses. Interestingly, evidence supporting these therapies is traditionally derived in animal models of primary tumors, thus failing to consider surgically induced tumor microenvironment changes that may influence adjuvant therapy efficacy. To address this consideration, we characterized a murine model of local cancer recurrence. This model was reproducible and generated a postoperative inflammatory tumor microenvironment that resembles those observed following human cancer surgery. To further validate this model, antagonists of two pro-inflammatory mediators, TGFβ and COX-2, were tested and found to be effective in decreasing the growth of recurrent tumors. We appreciated that preoperative TGFβ inhibition led to wound dehiscence, while postoperative initiation of COX-2 inhibition resulted in a loss of efficacy. In summary, although not an exact replica of all human cancer surgeries, our proposed local recurrence approach provides a biologically relevant and reliable model useful for preclinical evaluation of novel adjuvant therapies. The use of this model yields results that may be overlooked using traditional preclinical cancer models that fail to incorporate a surgical component.
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Affiliation(s)
- Jarrod D Predina
- Thoracic Surgery Research Laboratory, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Predina JD, Judy B, Kapoor V, Blouin A, Aliperti LA, Levine D, Okusanya OT, Quatromoni J, Fridlender ZG, Singhal S. Characterization of surgical models of postoperative tumor recurrence for preclinical adjuvant therapy assessment. Am J Transl Res 2012; 4:206-218. [PMID: 22611473 PMCID: PMC3353530] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 02/27/2012] [Indexed: 06/01/2023]
Abstract
PURPOSE Nearly 30% of cancer patients undergoing curative surgery succumb to distant recurrent disease. Despite large implications and known differences between primary and recurrent tumors, preclinical adjuvant therapy evaluation frequently occurs only in primary tumors and not recurrent tumors. We hypothesized that well characterized and reproducible models of postoperative systemic recurrences should be used for preclinical evaluation of adjuvant approaches. EXPERIMENTAL DESIGN We examined traditional animal models of cancer surgery that generate systemic cancer recurrences. We also investigated models of systemic cancer recurrences that incorporate spontaneously metastatic cell lines and surgical resection. For each model, we critiqued feasibility, reproducibility and similarity to human recurrence biology. Using our novel model, we then tested the adjuvant use of a novel systemic inhibitor of TGF-β, 1D11. RESULTS Traditional surgical models are confounded by immunologic factors including concomitant immunity and perioperative immunosuppression. A superior preclinical model of postoperative systemic recurrences incorporates spontaneously metastatic cell lines and primary tumor excision. This approach is biologically relevant and readily feasible. Using this model, we discovered that "perioperative" TGF-β blockade has strong anti-tumor effects in the setting of advanced disease that would not be appreciated in primary tumor cell lines or other surgical models. CONCLUSIONS There are multiple immunologic effects that rendered previous models of postoperative cancer recurrences inadequate. Use of spontaneously metastatic cell lines followed by surgical resection eliminates these confounders, and best resembles the clinical scenario. This preclinical model provides more reliable preclinical information when evaluating new adjuvant therapies.
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Affiliation(s)
- Jarrod D Predina
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine6 White Building,3400 Spruce Street, Philadelphia, PA, 19104
| | - Brendan Judy
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine6 White Building,3400 Spruce Street, Philadelphia, PA, 19104
| | - Veena Kapoor
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine6 White Building,3400 Spruce Street, Philadelphia, PA, 19104
| | - Aaron Blouin
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine6 White Building,3400 Spruce Street, Philadelphia, PA, 19104
| | - Louis A Aliperti
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine6 White Building,3400 Spruce Street, Philadelphia, PA, 19104
| | - Daniel Levine
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine6 White Building,3400 Spruce Street, Philadelphia, PA, 19104
| | - Olugbenga T Okusanya
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine6 White Building,3400 Spruce Street, Philadelphia, PA, 19104
| | - Jon Quatromoni
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine6 White Building,3400 Spruce Street, Philadelphia, PA, 19104
| | - Zvi G Fridlender
- Institute of Pulmonary Medicine, Hadassah-Hebrew University Medical CenterPOB 12000, Jerusalem 91120, Israel
| | - Sunil Singhal
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine6 White Building,3400 Spruce Street, Philadelphia, PA, 19104
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Predina JD, Anolik RB, Judy B, Akers S, Freiman D, Ahmad N, Singhal S. Intramural esophageal dissection in a young man with eosinophilic esophagitis. Ann Thorac Cardiovasc Surg 2011; 18:31-5. [PMID: 21959190 DOI: 10.5761/atcs.cr.10.01629] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Intramural esophageal dissection is a rare disorder that should be considered in patients presenting with chest pain, dysphagia, and hematemesis. Although most commonly occurring in elderly women with impaired coagulation, esophageal dissection has also been observed in other demographics including in those with eosinophilic esophagitis. In our report, we present the case of a 19-year-old man who was found to have an intramural esophageal dissection in the setting of undiagnosed eosinophilic esophagitis. There have been multiple, proposed management strategies; however, we implemented a nonoperative approach and obtained successful results. Intramural esophageal dissection is an important diagnosis for thoracic surgeons to be aware of as these patients often present as surgical emergencies, but often do not require an acute surgical intervention.
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Affiliation(s)
- Jarrod D Predina
- Division of Thoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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Predina JD, Judy BF, Kapoor V, Blouin A, Aliperti L, Singhal S. Neoadjuvant immune stimulation improves long-term outcomes for esophageal carcinoma. J Am Coll Surg 2011. [DOI: 10.1016/j.jamcollsurg.2011.06.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Predina JD, Kotloff RM, Miller WT, Singhal S. Recurrent spontaneous pneumothorax in a patient with Birt–Hogg–Dubé syndrome☆. Eur J Cardiothorac Surg 2011; 39:404-6. [DOI: 10.1016/j.ejcts.2010.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 06/01/2010] [Accepted: 06/09/2010] [Indexed: 11/29/2022] Open
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Predina JD, Kunkala M, Aliperti LA, Singhal AK, Singhal S. Sleeve lobectomy: current indications and future directions. Ann Thorac Cardiovasc Surg 2010; 16:310-318. [PMID: 21030916] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 04/28/2010] [Indexed: 05/30/2023] Open
Abstract
Sleeve lobectomy was initially conceived as an alternative to pneumonectomy for patients with low-grade, centrally located lesions and limited cardiopulmonary reserve. Over the last several decades, advances in patient selection criteria and surgical techniques have allowed sleeve lobectomy to evolve from a compromise to pneumonectomy to first line intervention for centrally located lesions of all grades. Although more challenging than pneumonectomy, long-term outcomes and cost-effective measures favor sleeve lobectomy. The use of sleeve lobectomy has been expanded for locally advanced disease, and results remain superior to alternative procedures. Current literature has also shown evidence supporting the use of neoadjuvant treatment and minimally invasive techniques. It is likely that future results will continue to improve making sleeve lobectomy an even more attractive treatment option for qualifying patients.
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Affiliation(s)
- Jarrod D Predina
- University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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Predina JD, Aliperti LA, Kapoor V, Blouin A, Ridge N, Albelda SM, Singhal S. Modulation of cancer immunobiology to prevent recurrences following surgery for non-small cell lung cancer (NSCLC). J Am Coll Surg 2010. [DOI: 10.1016/j.jamcollsurg.2010.06.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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