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Wang LG, Montaño AR, Masillati AM, Jones JA, Barth CW, Combs JR, Kumarapeli SU, Shams NA, van den Berg NS, Antaris AL, Galvis SN, McDowall I, Rizvi SZH, Alani AWG, Sorger JM, Gibbs SL. Nerve Visualization using Phenoxazine-Based Near-Infrared Fluorophores to Guide Prostatectomy. Adv Mater 2024; 36:e2304724. [PMID: 37653576 DOI: 10.1002/adma.202304724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/27/2023] [Indexed: 09/02/2023]
Abstract
Fluorescence-guided surgery (FGS) is poised to revolutionize surgical medicine through near-infrared (NIR) fluorophores for tissue- and disease-specific contrast. Clinical open and laparoscopic FGS vision systems operate nearly exclusively at NIR wavelengths. However, tissue-specific NIR contrast agents compatible with clinically available imaging systems are lacking, leaving nerve tissue identification during prostatectomy a persistent challenge. Here, it is shown that combining drug-like molecular design concepts and fluorophore chemistry enabled the production of a library of NIR phenoxazine-based fluorophores for intraoperative nerve-specific imaging. The lead candidate readily delineated prostatic nerves in the canine and iliac plexus in the swine using the clinical da Vinci Surgical System that has been popularized for minimally invasive prostatectomy procedures. These results demonstrate the feasibility of molecular engineering of NIR nerve-binding fluorophores for ready integration into the existing surgical workflow, paving the path for clinical translation to reduce morbidity from nerve injury for prostate cancer patients.
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Affiliation(s)
- Lei G Wang
- Biomedical Engineering Department, Oregon Health and Science University, Portland, OR, 97201, USA
- Knight Cancer Institute, Oregon Health and Science University, Portland, OR, 97201, USA
| | - Antonio R Montaño
- Biomedical Engineering Department, Oregon Health and Science University, Portland, OR, 97201, USA
| | - Anas M Masillati
- Biomedical Engineering Department, Oregon Health and Science University, Portland, OR, 97201, USA
| | - Jocelyn A Jones
- Biomedical Engineering Department, Oregon Health and Science University, Portland, OR, 97201, USA
| | - Connor W Barth
- Biomedical Engineering Department, Oregon Health and Science University, Portland, OR, 97201, USA
| | - Jason R Combs
- Biomedical Engineering Department, Oregon Health and Science University, Portland, OR, 97201, USA
| | | | - Nourhan A Shams
- Biomedical Engineering Department, Oregon Health and Science University, Portland, OR, 97201, USA
| | | | | | - S N Galvis
- Intuitive Surgical, Sunnyvale, CA, 94086, USA
| | | | - Syed Zaki Husain Rizvi
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Portland, OR, 97201, USA
| | - Adam W G Alani
- Knight Cancer Institute, Oregon Health and Science University, Portland, OR, 97201, USA
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Portland, OR, 97201, USA
| | | | - Summer L Gibbs
- Biomedical Engineering Department, Oregon Health and Science University, Portland, OR, 97201, USA
- Knight Cancer Institute, Oregon Health and Science University, Portland, OR, 97201, USA
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2
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Nguyen HG, van den Berg NS, Antaris AL, Xue L, Greenberg S, Rosenthal JW, Muchnik A, Klaassen A, Simko JP, Dutta S, Sorger JM, Munster P, Carroll PR. First-in-human Evaluation of a Prostate-specific Membrane Antigen-targeted Near-infrared Fluorescent Small Molecule for Fluorescence-based Identification of Prostate Cancer in Patients with High-risk Prostate Cancer Undergoing Robotic-assisted Prostatectomy. Eur Urol Oncol 2024; 7:63-72. [PMID: 37516587 DOI: 10.1016/j.euo.2023.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/22/2023] [Accepted: 07/07/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Men with high-risk prostate cancer undergoing surgery likely recur due to failure to completely excise regional and/or local disease. OBJECTIVE The first-in-human evaluation of safety, pharmacokinetics, and exploratory efficacy of IS-002, a novel near-infrared prostate-specific membrane antigen (PSMA)-targeted fluorescence imaging agent, designed for intraoperative prostate cancer visualization. DESIGN, SETTING, AND PARTICIPANTS A phase 1, single-center, dose-escalation study was conducted in 24 men with high-risk prostate cancer scheduled for robotic-assisted radical prostatectomy with (extended) pelvic lymph node dissection using the da Vinci surgical system. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Adverse events (AEs), vital signs, complete blood count, complete metabolic panel, urinalysis, and electrocardiogram were assessed over a 14-d period and compared with baseline. The pharmacokinetic profile of IS-002 was determined. Diagnostic accuracy was assessed for exploratory efficacy. RESULTS AND LIMITATIONS AEs predominantly included discoloration of urine (n = 22/24; expected, related, grade 1). There were no grade ≥2 AEs. IS-002 Cmax and area under the curve increased with increasing dose. Plasma concentrations declined rapidly in a biphasic manner, with the median terminal half-lives ranging from 5.0 to 7.6 h, independent of dose and renal function. At 25 μg/kg, the exploratory efficacy readouts for the negative and positive predictive values were, 97% and 45% for lymph nodes, and 100% and 80% for residual/locoregional disease detection, respectively. CONCLUSIONS IS-002 is safe and well tolerated, and has the potential to enable intraoperative tumor detection that could not be identified using standard imaging. PATIENT SUMMARY IS-002 is a new imaging agent that specifically targets the prostate-specific membrane antigen receptor. In this study, we tested IS-002 for the first time in men with high-risk prostate cancer undergoing surgery and found that IS-002 is safe, is cleared from the body quickly, and potentially allows identification of prostate cancer in areas that would not be identified by conventional white light imaging.
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Affiliation(s)
- Hao G Nguyen
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | | | | | - Lingru Xue
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Scott Greenberg
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | | | | | | | - Jeffry P Simko
- Department of Pathology, University of California, San Francisco, CA, USA
| | | | | | - Pamela Munster
- Department of Medicine, Phase 1 Clinic, University of California, San Francisco, CA, USA
| | - Peter R Carroll
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA.
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3
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Marumo T, Maduka CV, Ural E, Apu EH, Chung SJ, Tanabe K, van den Berg NS, Zhou Q, Martin BA, Miura T, Rosenthal EL, Shibahara T, Contag CH. Flavinated SDHA underlies the change in intrinsic optical properties of oral cancers. Commun Biol 2023; 6:1134. [PMID: 37945749 PMCID: PMC10636189 DOI: 10.1038/s42003-023-05510-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
The molecular basis of reduced autofluorescence in oral squamous cell carcinoma (OSCC) cells relative to normal cells has been speculated to be due to lower levels of free flavin adenine dinucleotide (FAD). This speculation, along with differences in the intrinsic optical properties of extracellular collagen, lies at the foundation of the design of currently-used clinical optical detection devices. Here, we report that free FAD levels may not account for differences in autofluorescence of OSCC cells, but that the differences relate to FAD as a co-factor for flavination. Autofluorescence from a 70 kDa flavoprotein, succinate dehydrogenase A (SDHA), was found to be responsible for changes in optical properties within the FAD spectral region, with lower levels of flavinated SDHA in OSCC cells. Since flavinated SDHA is required for functional complexation with succinate dehydrogenase B (SDHB), decreased SDHB levels were observed in human OSCC tissue relative to normal tissues. Accordingly, the metabolism of OSCC cells was found to be significantly altered relative to normal cells, revealing vulnerabilities for both diagnosis and targeted therapy. Optimizing non-invasive tools based on optical and metabolic signatures of cancers will enable more precise and early diagnosis leading to improved outcomes in patients.
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Affiliation(s)
- Tomoko Marumo
- Department of Oral and Maxillofacial Surgery, Tokyo Dental College, 2-9-18 Kanda-Misakicho, Chiyoda-ku, Tokyo, 101-0061, Japan
- Department of Biomedical Engineering, Michigan State University, East Lansing, MI, 48824, USA
- Institute for Quantitative Health Science & Engineering, Michigan State University, East Lansing, MI, 48824, USA
| | - Chima V Maduka
- Department of Biomedical Engineering, Michigan State University, East Lansing, MI, 48824, USA
- Institute for Quantitative Health Science & Engineering, Michigan State University, East Lansing, MI, 48824, USA
- Comparative Medicine & Integrative Biology, Michigan State University, East Lansing, MI, 48824, USA
- BioFrontiers Institute, University of Colorado, Boulder, CO, 80303, USA
| | - Evran Ural
- Department of Biomedical Engineering, Michigan State University, East Lansing, MI, 48824, USA
- Institute for Quantitative Health Science & Engineering, Michigan State University, East Lansing, MI, 48824, USA
| | - Ehsanul Hoque Apu
- Department of Biomedical Engineering, Michigan State University, East Lansing, MI, 48824, USA
- Institute for Quantitative Health Science & Engineering, Michigan State University, East Lansing, MI, 48824, USA
- Division of Hematology and Oncology, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Seock-Jin Chung
- Department of Biomedical Engineering, Michigan State University, East Lansing, MI, 48824, USA
- Institute for Quantitative Health Science & Engineering, Michigan State University, East Lansing, MI, 48824, USA
| | - Koji Tanabe
- Department of Biomedical Engineering, Iwate Medical University, 1-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3694, Japan
| | - Nynke S van den Berg
- Department of Otolaryngology - Division of Head and Neck Surgery, Stanford University School of Medicine, 269 Campus Drive, Stanford, CA, 94305, USA
| | - Quan Zhou
- Department of Otolaryngology - Division of Head and Neck Surgery, Stanford University School of Medicine, 269 Campus Drive, Stanford, CA, 94305, USA
| | - Brock A Martin
- Department of Pathology, Stanford University School of Medicine, 3100 Pasteur Drive, Stanford, CA, 94305, USA
| | - Tadashi Miura
- Oral Health Science Center, Tokyo Dental College, 2-1-14 Kanda-Misakicho, Chiyoda-ku, Tokyo, 101-0061, Japan
| | - Eben L Rosenthal
- Department of Otolaryngology - Division of Head and Neck Surgery, Stanford University School of Medicine, 269 Campus Drive, Stanford, CA, 94305, USA
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232, USA
| | - Takahiko Shibahara
- Department of Oral and Maxillofacial Surgery, Tokyo Dental College, 2-9-18 Kanda-Misakicho, Chiyoda-ku, Tokyo, 101-0061, Japan
| | - Christopher H Contag
- Department of Biomedical Engineering, Michigan State University, East Lansing, MI, 48824, USA.
- Institute for Quantitative Health Science & Engineering, Michigan State University, East Lansing, MI, 48824, USA.
- Department of Microbiology & Molecular Genetics, Michigan State University, East Lansing, MI, 48824, USA.
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4
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Marumo T, Maduka CV, Ural E, Apu EH, Chung SJ, van den Berg NS, Zhou Q, Martin BA, Rosenthal EL, Shibahara T, Contag CH. Flavinated SDHA Underlies the Change in Intrinsic Optical Properties of Oral Cancers. bioRxiv 2023:2023.07.30.551184. [PMID: 37577521 PMCID: PMC10418065 DOI: 10.1101/2023.07.30.551184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
The molecular basis of reduced autofluorescence in oral squamous cell carcinoma (OSCC) cells relative to normal cells has been speculated to be due to lower levels of free flavin adenine dinucleotide (FAD). This speculation, along with differences in the intrinsic optical properties of extracellular collagen, lie at the foundation of the design of currently-used clinical optical detection devices. Here, we report that free FAD levels may not account for differences in autofluorescence of OSCC cells, but that the differences relate to FAD as a co-factor for flavination. Autofluorescence from a 70 kDa flavoprotein, succinate dehydrogenase A (SDHA), was found to be responsible for changes in optical properties within the FAD spectral region with lower levels of flavinated SDHA in OSCC cells. Since flavinated SDHA is required for functional complexation with succinate dehydrogenase B (SDHB), decreased SDHB levels were observed in human OSCC tissue relative to normal tissues. Accordingly, the metabolism of OSCC cells was found to be significantly altered relative to normal cells, revealing vulnerabilities for both diagnosis and targeted therapy. Optimizing non-invasive tools based on optical and metabolic signatures of cancers will enable more precise and early diagnosis leading to improved outcomes in patients.
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Affiliation(s)
- Tomoko Marumo
- Department of Oral and Maxillofacial Surgery, Tokyo Dental College, 2-9-18 Kanda-Misakicho, Chiyoda-ku, Tokyo 101-0061, Japan
- Department of Biomedical Engineering, Michigan State University, East Lansing, MI 48824, USA
- Institute for Quantitative Health Science & Engineering, Michigan State University, East Lansing, MI 48824, USA
| | - Chima V. Maduka
- Department of Biomedical Engineering, Michigan State University, East Lansing, MI 48824, USA
- Institute for Quantitative Health Science & Engineering, Michigan State University, East Lansing, MI 48824, USA
- Comparative Medicine & Integrative Biology, Michigan State University, East Lansing, MI 48824, USA
| | - Evran Ural
- Department of Biomedical Engineering, Michigan State University, East Lansing, MI 48824, USA
- Institute for Quantitative Health Science & Engineering, Michigan State University, East Lansing, MI 48824, USA
| | - Ehsanul Hoque Apu
- Department of Biomedical Engineering, Michigan State University, East Lansing, MI 48824, USA
- Institute for Quantitative Health Science & Engineering, Michigan State University, East Lansing, MI 48824, USA
- Division of Hematology and Oncology, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Seock-Jin Chung
- Department of Biomedical Engineering, Michigan State University, East Lansing, MI 48824, USA
- Institute for Quantitative Health Science & Engineering, Michigan State University, East Lansing, MI 48824, USA
| | - Nynke S. van den Berg
- Department of Otolaryngology – Division of Head and Neck Surgery, Stanford University School of Medicine, 269 Campus Drive, Stanford, CA 94305, USA
| | - Quan Zhou
- Department of Otolaryngology – Division of Head and Neck Surgery, Stanford University School of Medicine, 269 Campus Drive, Stanford, CA 94305, USA
| | - Brock A. Martin
- Department of Pathology, Stanford University School of Medicine, 3100 Pasteur Drive, Stanford, CA 94305, USA
| | - Eben L. Rosenthal
- Department of Otolaryngology – Division of Head and Neck Surgery, Stanford University School of Medicine, 269 Campus Drive, Stanford, CA 94305, USA
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232
| | - Takahiko Shibahara
- Department of Oral and Maxillofacial Surgery, Tokyo Dental College, 2-9-18 Kanda-Misakicho, Chiyoda-ku, Tokyo 101-0061, Japan
| | - Christopher H. Contag
- Department of Biomedical Engineering, Michigan State University, East Lansing, MI 48824, USA
- Institute for Quantitative Health Science & Engineering, Michigan State University, East Lansing, MI 48824, USA
- Department of Microbiology & Molecular Genetics, Michigan State University, East Lansing, MI 48824, USA
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5
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Krishnan G, Cousins A, Pham N, Milanova V, Nelson M, Krishnan S, van den Berg NS, Shetty A, Rosenthal EL, Wormald P, Thierry B, Foreman A, Krishnan S. Preclinical feasibility of robot-assisted sentinel lymph node biopsy using multi-modality magnetic and fluorescence guidance in the head and neck. Head Neck 2022; 44:2696-2707. [PMID: 36082404 PMCID: PMC9825899 DOI: 10.1002/hed.27177] [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] [Received: 05/02/2022] [Revised: 07/08/2022] [Accepted: 08/16/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) is a staging procedure dependent on accurate mapping of draining lymphatics via tracers. Robot-assisted SLNB enables access to multiple neck levels with a single incision and intraoperative fluorescence guidance to the SLN. METHODS Lymphatic mapping in swine was done using a magnetic tracer and fluorescent dye, injected into the tongue. MRI preoperatively mapped lymphatic spread of the magnetic tracer. Dissection was performed using a da Vinci Xi robot guided by fluorescence-imaging of the dye. RESULTS Robot-assisted SLNB was successfully performed in all animals (n = 5). A novel MRI protocol differentiated SLNs (n = 6) from lower echelon nodes (n = 11) based on flow progression. Fluorescence imaging provided valuable intraoperative guidance and correlated with magnetic-positive nodes. CONCLUSIONS This study demonstrates preclinical feasibility of a robot-assisted approach to SLNB using magnetic and fluorescent tracers in the head and neck, enabling both preoperative mapping and intraoperative guidance.
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Affiliation(s)
- Giri Krishnan
- Department of Otolaryngology, Head and Neck SurgeryThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Aidan Cousins
- Future Industries InstituteUniversity of South Australia, Mawson Lakes CampusAdelaideSouth AustraliaAustralia
| | - Nguyen Pham
- Key Centre for Polymers and Colloids, School of Chemistry and University of Sydney Nano InstituteThe University of SydneySydneyNew South WalesAustralia
| | - Valentina Milanova
- Future Industries InstituteUniversity of South Australia, Mawson Lakes CampusAdelaideSouth AustraliaAustralia
| | | | - Shridhar Krishnan
- Department of Oral and Maxillofacial SurgeryThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Nynke S. van den Berg
- Department of Otolaryngology—Division of Head and Neck SurgeryStanford University School of MedicineStanfordCaliforniaUSA
| | - Anil Shetty
- Ferronova Pty LtdAdelaideSouth AustraliaAustralia
| | - Eben L. Rosenthal
- Department of Otolaryngology—Division of Head and Neck SurgeryStanford University School of MedicineStanfordCaliforniaUSA
| | - Peter‐John Wormald
- Department of Otolaryngology, Head and Neck SurgeryThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Benjamin Thierry
- Future Industries InstituteUniversity of South Australia, Mawson Lakes CampusAdelaideSouth AustraliaAustralia
| | - Andrew Foreman
- Department of Otolaryngology, Head and Neck SurgeryThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Suren Krishnan
- Department of Otolaryngology, Head and Neck SurgeryThe University of AdelaideAdelaideSouth AustraliaAustralia
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6
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Goodyer WR, Beyersdorf BM, Duan L, van den Berg NS, Mantri S, Galdos FX, Puluca N, Buikema JW, Lee S, Salmi D, Robinson ER, Rogalla S, Cogan DP, Khosla C, Rosenthal EL, Wu SM. In vivo visualization and molecular targeting of the cardiac conduction system. J Clin Invest 2022; 132:e156955. [PMID: 35951416 PMCID: PMC9566899 DOI: 10.1172/jci156955] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 08/09/2022] [Indexed: 11/22/2022] Open
Abstract
Accidental injury to the cardiac conduction system (CCS), a network of specialized cells embedded within the heart and indistinguishable from the surrounding heart muscle tissue, is a major complication in cardiac surgeries. Here, we addressed this unmet need by engineering targeted antibody-dye conjugates directed against the CCS, allowing for the visualization of the CCS in vivo following a single intravenous injection in mice. These optical imaging tools showed high sensitivity, specificity, and resolution, with no adverse effects on CCS function. Further, with the goal of creating a viable prototype for human use, we generated a fully human monoclonal Fab that similarly targets the CCS with high specificity. We demonstrate that, when conjugated to an alternative cargo, this Fab can also be used to modulate CCS biology in vivo, providing a proof of principle for targeted cardiac therapeutics. Finally, in performing differential gene expression analyses of the entire murine CCS at single-cell resolution, we uncovered and validated a suite of additional cell surface markers that can be used to molecularly target the distinct subcomponents of the CCS, each prone to distinct life-threatening arrhythmias. These findings lay the foundation for translational approaches targeting the CCS for visualization and therapy in cardiothoracic surgery, cardiac imaging, and arrhythmia management.
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Affiliation(s)
- William R. Goodyer
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
- Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Benjamin M. Beyersdorf
- Department of Cardiovascular Surgery, Institute Insure (Institute for Translational Cardiac Surgery), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Lauren Duan
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Nynke S. van den Berg
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Sruthi Mantri
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Francisco X. Galdos
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Nazan Puluca
- Department of Cardiovascular Surgery, Institute Insure (Institute for Translational Cardiac Surgery), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Jan W. Buikema
- Department of Cardiology, Utrecht Regenerative Medicine Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department of Cardiology, Amsterdam University Medical Center, Location VUmc, Amsterdam, Netherlands
| | - Soah Lee
- Department of Pharmacy, Bioconvergence Program, Sungkyunkwan University, Suwon, South Korea
| | | | - Elise R. Robinson
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Stephan Rogalla
- Division of Gastroenterology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Dillon P. Cogan
- Departments of Chemistry and Chemical Engineering and Sarafan ChEM-H Institute, Stanford University, Stanford, California, USA
| | - Chaitan Khosla
- Departments of Chemistry and Chemical Engineering and Sarafan ChEM-H Institute, Stanford University, Stanford, California, USA
| | - Eben L. Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sean M. Wu
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
- Department of Pediatrics, Stanford University, Stanford, California, USA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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7
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Lee YJ, van den Berg NS, Duan H, Azevedo EC, Ferri V, Hom M, Raymundo RC, Valencia A, Castillo J, Shen B, Zhou Q, Freeman L, Koran ME, Kaplan MJ, Colevas AD, Baik FM, Chin FT, Martin BA, Iagaru A, Rosenthal EL. 89Zr-panitumumab Combined With 18F-FDG PET Improves Detection and Staging of Head and Neck Squamous Cell Carcinoma. Clin Cancer Res 2022; 28:4425-4434. [PMID: 35929985 DOI: 10.1158/1078-0432.ccr-22-0094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/16/2022] [Accepted: 08/02/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE Determine the safety and specificity of a tumor-targeted radiotracer (89Zr-pan) in combination with 18F-FDG PET/CT to improve diagnostic accuracy in head and neck squamous cell carcinoma (HNSCC). EXPERIMENTAL DESIGN Adult patients with biopsy-proven HNSCC scheduled for standard-of-care surgery were enrolled in a clinical trial and underwent systemic administration of 89Zirconium-panitumumab and panitumumab-IRDye800 followed by preoperative 89Zr-pan PET/CT and intraoperative fluorescence imaging. The sensitivity, specificity, and AUC were evaluated. RESULTS A total of fourteen patients were enrolled and completed the study. Four patients (28.5%) had areas of high 18F-FDG uptake outside the head and neck region with maximum standardized uptake values (SUVmax) greater than 2.0 that were not detected on 89Zr-pan PET/CT. These four patients with incidental findings underwent further workup and had no evidence of cancer on biopsy or clinical follow-up. Forty-eight lesions (primary tumor, LNs, incidental findings) with SUVmax ranging 2.0-23.6 were visualized on 18F-FDG PET/CT; 34 lesions on 89Zr-pan PET/CT with SUVmax ranging 0.9-10.5. The combined ability of 18F-FDG PET/CT and 89Zr-pan PET/CT to detect HNSCC in the whole body was improved with higher specificity of 96.3% [confidence interval (CI), 89.2%-100%] compared to 18F-FDG PET/CT alone with specificity of 74.1% (CI, 74.1%-90.6%). One possibly related grade 1 adverse event of prolonged QTc (460 ms) was reported but resolved in follow-up. CONCLUSIONS 89Zr-pan PET/CT imaging is safe and may be valuable in discriminating incidental findings identified on 18F-FDG PET/CT from true positive lesions and in localizing metastatic LNs.
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Affiliation(s)
- Yu-Jin Lee
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine. Stanford, California
| | | | - Heying Duan
- Department of Radiology, Stanford University School of Medicine. Stanford, California
| | - E Carmen Azevedo
- Department of Radiology, Stanford University School of Medicine. Stanford, California
| | - Valentina Ferri
- Department of Radiology, Stanford University School of Medicine. Stanford, California
| | - Marisa Hom
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center. Nashville, Tennessee
| | - Roan C Raymundo
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine. Stanford, California
| | - Alex Valencia
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine. Stanford, California
| | - Jessa Castillo
- Department of Radiology, Stanford University School of Medicine. Stanford, California
| | - Bin Shen
- Department of Radiology, Stanford University School of Medicine. Stanford, California
| | - Quan Zhou
- Department of Neurosurgery, Stanford University School of Medicine. Stanford, California
| | - Laura Freeman
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine. Stanford, California
| | - Mary Ellen Koran
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center. Nashville, Tennessee
| | - Michael J Kaplan
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine. Stanford, California
| | - A Dimitrios Colevas
- Department of Medicine - Division of Medical Oncology, Stanford University School of Medicine. Stanford, California
| | - Fred M Baik
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine. Stanford, California
| | - Frederick T Chin
- Department of Radiology, Stanford University School of Medicine. Stanford, California
| | - Brock A Martin
- Department of Pathology, University of Louisville. Louisville, Kentucky
| | - Andrei Iagaru
- Department of Radiology, Stanford University School of Medicine. Stanford, California
| | - Eben L Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center. Nashville, Tennessee
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8
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Krishnan G, van den Berg NS, Nishio N, Kapoor S, Pei J, Freeman L, Lee YJ, Zhou Q, van Keulen S, Farkurnejad S, Condon J, Baik FM, Martin BA, Rosenthal EL. Fluorescent Molecular Imaging Can Improve Intraoperative Sentinel Margin Detection in Oral Squamous Cell Carcinoma. J Nucl Med 2022; 63:1162-1168. [PMID: 35027369 PMCID: PMC9364343 DOI: 10.2967/jnumed.121.262235] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 03/03/2021] [Accepted: 11/16/2021] [Indexed: 02/03/2023] Open
Abstract
In head and neck cancer, a major limitation of current intraoperative margin analysis is the ability to detect areas most likely to be positive based on specimen palpation, especially for larger specimens where sampling error limits detection of positive margins. This study aims to prospectively examine the clinical value of fluorescent molecular imaging to accurately identify "the sentinel margin," the point on a specimen at which the tumor lies closest to the resected edge in real-time during frozen section analysis. Methods: Eighteen patients with oral squamous cell carcinoma were enrolled into a prospective clinical trial and infused intravenously with 50 mg of panitumumab-IRDye800CW 1-5 d before surgery. Resected specimens were imaged in a closed-field near-infrared optical imaging system in near real-time, and custom-designed software was used to identify locations of highest fluorescence on deep and peripheral margins. The surgeon identified the sentinel margin masked to optical specimen mapping, and then the regions of highest fluorescence were identified and marked for frozen analysis. Final pathology based on specimen reconstruction was used as reference standard. Results: Resected specimens were imaged in the operating room, and fluorescence had a higher interobserver agreement with pathology (Cohen κ value 0.96) than the surgeon (Cohen κ value of 0.82) for the location of the closest margin. Plotting margin distance at the predicted sentinel margin location of each observer versus the actual closest margin distance at pathology demonstrated best correlation between fluorescence and pathology (R2 = 0.98) with surgeon (R2 = 0.75). Conclusion: Fluorescence imaging can improve identification of the sentinel margin in head and neck cancer resections, holding promise for rapid identification of positive margins and improved oncologic outcomes.
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Affiliation(s)
- Giri Krishnan
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California;,Department of Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Nynke S. van den Berg
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Naoki Nishio
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California;,Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Shrey Kapoor
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Jaqueline Pei
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Laura Freeman
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Yu-Jin Lee
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Quan Zhou
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Stan van Keulen
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Shayan Farkurnejad
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - James Condon
- Department of Public Health, School of Medicine, The University of Adelaide, Adelaide, SA, Australia; and
| | - Fred M. Baik
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Brock A. Martin
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Eben L. Rosenthal
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
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9
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Pal R, Hom M, van den Berg NS, Lwin TM, Lee YJ, Prilutskiy A, Faquin W, Yang E, Saladi SV, Varvares MA, Rosenthal EL, Kumar ATN. First Clinical Results of Fluorescence Lifetime-enhanced Tumor Imaging Using Receptor-targeted Fluorescent Probes. Clin Cancer Res 2022; 28:2373-2384. [PMID: 35302604 PMCID: PMC9167767 DOI: 10.1158/1078-0432.ccr-21-3429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/23/2021] [Accepted: 03/15/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE Fluorescence molecular imaging, using cancer-targeted near infrared (NIR) fluorescent probes, offers the promise of accurate tumor delineation during surgeries and the detection of cancer specific molecular expression in vivo. However, nonspecific probe accumulation in normal tissue results in poor tumor fluorescence contrast, precluding widespread clinical adoption of novel imaging agents. Here we present the first clinical evidence that fluorescence lifetime (FLT) imaging can provide tumor specificity at the cellular level in patients systemically injected with panitumumab-IRDye800CW, an EGFR-targeted NIR fluorescent probe. EXPERIMENTAL DESIGN We performed wide-field and microscopic FLT imaging of resection specimens from patients injected with panitumumab-IRDye800CW under an FDA directed clinical trial. RESULTS We show that the FLT within EGFR-overexpressing cancer cells is significantly longer than the FLT of normal tissue, providing high sensitivity (>98%) and specificity (>98%) for tumor versus normal tissue classification, despite the presence of significant nonspecific probe accumulation. We further show microscopic evidence that the mean tissue FLT is spatially correlated (r > 0.85) with tumor-specific EGFR expression in tissue and is consistent across multiple patients. These tumor cell-specific FLT changes can be detected through thick biological tissue, allowing highly specific tumor detection and noninvasive monitoring of tumor EFGR expression in vivo. CONCLUSIONS Our data indicate that FLT imaging is a promising approach for enhancing tumor contrast using an antibody-targeted NIR probe with a proven safety profile in humans, suggesting a strong potential for clinical applications in image guided surgery, cancer diagnostics, and staging.
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Affiliation(s)
- Rahul Pal
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 13 Street, Building 149, Charlestown MA 02129
| | - Marisa Hom
- Department of Otolaryngology, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232
| | | | - Thinzar M Lwin
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston MA
| | - Yu-Jin Lee
- Department of Otolaryngology, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford CA
| | - Andrey Prilutskiy
- Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison WI
| | - William Faquin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston MA
| | - Eric Yang
- Department of Pathology, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford CA
| | - Srinivas V. Saladi
- Department of Otolaryngology and Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, 55 Fruit Street, Boston MA
| | - Mark A. Varvares
- Department of Otolaryngology and Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, 55 Fruit Street, Boston MA
| | - Eben L. Rosenthal
- Department of Otolaryngology, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232
| | - Anand T. N. Kumar
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 13 Street, Building 149, Charlestown MA 02129
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10
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Zhou Q, van den Berg NS, Kang W, Pei J, Nishio N, van Keulen S, Engelen MA, Lee YJ, Hom M, Vega Leonel JCM, Hart Z, Vogel H, Cayrol R, Martin BA, Roesner M, Shields G, Lui N, Hayden Gephart M, Raymundo RC, Yi G, Granucci M, Grant GA, Li G, Rosenthal EL. Factors for differential outcome across cancers in clinical molecular-targeted fluorescence imaging. J Nucl Med 2022; 63:1693-1700. [PMID: 35332092 PMCID: PMC9635681 DOI: 10.2967/jnumed.121.263674] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 03/22/2022] [Indexed: 11/16/2022]
Abstract
Clinical imaging performance using a fluorescent antibody was compared across three cancers to elucidate physical and biological factors contributing to differential translation of epidermal growth factor receptor (EGFR) expression to macroscopic fluorescence in tumors. Methods: Thirty-one patients with high-grade glioma (HGG, n = 5), head-and-neck squamous cell carcinoma (HNSCC, n = 23) or lung adenocarcinoma (LAC, n = 3) were systemically infused with 50 mg panitumumab-IRDye800, 1 - 3 days prior to surgery. Intraoperative open-field fluorescent images of the surgical field were acquired, where imaging device settings and operating room lighting conditions were tested on tissue-mimicking phantoms. Fluorescence contrast and margin size were measured on resected specimen surface. Antibody distribution and EGFR immunoreactivity were characterized in macroscopic and microscopic histological structures. Integrity of the blood-brain barrier (BBB) was examined via tight junction protein (claudin-5) expression with immunohistochemistry. Stepwise multivariate linear regression of biological variables was performed to identify independent predictors of panitumumab-IRDye800 concentration in tissue. Results: Optimally acquired at the lowest gain for tumor detection with ambient light, intraoperative fluorescence imaging enhanced tissue-size dependent tumor contrast by 5.2-fold, 3.4-fold and 1.4-fold in HGG, HNSCC and LAC, respectively. Tissue surface fluorescence target-to-background ratio correlated with margin size and identified 78 - 97% of at-risk resection margins ex vivo. In 4 µm-thick tissue sections, fluorescence detected tumor with 0.85 - 0.89 areas under the receiver operating characteristic curves. Preferential breakdown of BBB in HGG improved tumor specificity of intratumoral antibody distribution relative to that of EGFR (96% vs 80%) despite its reduced concentration (3.9 ng/mg tissue) compared to HNSCC (8.1 ng/mg) and LAC (6.3 ng/mg). Cellular EGFR expression, tumor cell density, plasma antibody concentration and delivery barrier were independently associated with local intratumoral panitumumab-IRDye800 concentration with 0.62 goodness-of-fit of prediction. Conclusion: In multi-cancer clinical imaging of receptor-ligand based molecular probe, plasma antibody concentration, delivery barrier, as well as intratumoral EGFR expression driven by cellular biomarker expression and tumor cell density, led to heterogeneous intratumoral antibody accumulation and spatial distribution while tumor size, resection margin, and intraoperative imaging settings substantially influenced macroscopic tumor contrast.
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Affiliation(s)
- Quan Zhou
- Department of Neurosurgery, Stanford University School of Medicine, United States
| | | | - Wenying Kang
- Department of Otolaryngology, Stanford University School of Medicine
| | - Jacqueline Pei
- Department of Otolaryngology, Stanford University School of Medicine
| | - Naoki Nishio
- Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine
| | - Stan van Keulen
- Department of Oral and Maxillofacial Surgery and Oral Pathology, Amsterdam UMC
| | - Myrthe A Engelen
- Department of Mechanical Engineering, Delft University of Technology
| | - Yu-Jin Lee
- Department of Otolaryngology, Stanford University School of Medicine
| | - Marisa Hom
- Department of Otolaryngology, Stanford University School of Medicine
| | | | - Zachary Hart
- Department of Otolaryngology, Stanford University School of Medicine
| | | | | | | | - Mark Roesner
- Stanford Health Care, Stanford University Medical Center
| | - Glenn Shields
- Stanford Health Care, Stanford University Medical Center
| | - Natalie Lui
- Department of Cardiothoracic Surgery, Stanford University Medical Center
| | | | - Roan C Raymundo
- Cancer Clinical Trials Office, Stanford University School of Medicine
| | - Grace Yi
- Cancer Clinical Trials Office, Stanford University School of Medicine
| | - Monica Granucci
- Cancer Clinical Trials Office, Stanford University School of Medicine
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University School of Medicine, United States
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, United States
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11
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Berger DMS, van den Berg NS, van der Noort V, van der Hiel B, Valdés Olmos RA, Buckle TA, KleinJan GH, Brouwer OR, Vermeeren L, Karakullukçu B, van den Brekel MWM, van de Wiel BA, Nieweg OE, Balm AJM, van Leeuwen FWB, Klop WMC. Technologic (R)Evolution Leads to Detection of More Sentinel Nodes in Patients with Melanoma in the Head and Neck Region. J Nucl Med 2021; 62:1357-1362. [PMID: 33637591 PMCID: PMC8724899 DOI: 10.2967/jnumed.120.246819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/28/2021] [Indexed: 11/16/2022] Open
Abstract
Sentinel lymph node (SN) biopsy (SNB) has proven to be a valuable tool for staging melanoma patients. Since its introduction in the early 1990s, this procedure has undergone several technologic refinements, including the introduction of SPECT/CT, as well as radioguidance and fluorescence guidance. The purpose of the current study was to evaluate the effect of this technologic evolution on SNB in the head and neck region. The primary endpoint was the false-negative (FN) rate. Secondary endpoints were number of harvested SNs, overall operation time, operation time per harvested SN, and postoperative complications. Methods: A retrospective database was queried for cutaneous head and neck melanoma patients who underwent SNB at The Netherlands Cancer Institute between 1993 and 2016. The implementation of new detection techniques was divided into 4 groups: 1993-2005, with preoperative lymphoscintigraphy and intraoperative use of both a γ-ray detection probe and patent blue (n = 30); 2006-2007, with addition of preoperative road maps based on SPECT/CT (n = 15); 2008-2009, with intraoperative use of a portable γ-camera (n = 40); and 2010-2016, with addition of near-infrared fluorescence guidance (n = 192). Results: In total, 277 patients were included. At least 1 SN was identified in all patients. A tumor-positive SN was found in 59 patients (21.3%): 10 in group 1 (33.3%), 3 in group 2 (20.0%), 6 in group 3 (15.0%), and 40 in group 4 (20.8%). Regional recurrences in patients with tumor-negative SNs resulted in an overall FN rate of 11.9% (group 1, 16.7%; group 2, 0%; group 3, 14.3%; group 4, 11.1%). The number of harvested nodes increased with advancing technologies (P = 0.003), whereas Breslow thickness and operation time per harvested SN decreased (P = 0.003 and P = 0.017, respectively). There was no significant difference in percentage of tumor-positive SNs, overall operation time, and complication rate between the different groups. Conclusion: The use of advanced detection technologies led to a higher number of identified SNs without an increase in overall operation time, possibly indicating an improved surgical efficiency. Operation time per harvested SN decreased; the average FN rate remained 11.9% and was unchanged over 23 y. There was no significant change in postoperative complication rate.
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Affiliation(s)
- Danique M S Berger
- Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands;
| | - Nynke S van den Berg
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Vincent van der Noort
- Department of Biometrics, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Bernies van der Hiel
- Department of Nuclear Medicine, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Renato A Valdés Olmos
- Department of Nuclear Medicine, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Tessa A Buckle
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gijs H KleinJan
- Department of Urology, Leiden University Medical Center, Leiden, The Netherlands
| | - Oscar R Brouwer
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Lenka Vermeeren
- Department of Otorhinolaryngology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Baris Karakullukçu
- Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Michiel W M van den Brekel
- Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Bart A van de Wiel
- Department of Pathology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands; and
| | - Omgo E Nieweg
- Melanoma Institute Australia and Central Medical School, University of Sydney, Sydney, Australia
| | - Alfons J M Balm
- Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - W Martin C Klop
- Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
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12
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Abstract
Objective In this review, we provide examples of applications of fluorescence imaging in urologic, gynecologic, general, and endocrine surgeries. Background While robotic-assisted surgery has helped increase the availability of minimally invasive procedures across surgical specialties, there remains an opportunity to reduce adverse events associated with open, laparoscopic, and robotic-assisted methods. In 2011, fluorescence imaging was introduced as an option to the da Vinci Surgical System, and has been standard equipment since 2014. Without interfering with surgical workflow, this fluorescence technology named Firefly® allows for acquisition and display of near-infrared fluorescent signals that are co-registered with white light endoscopic images. As a result, robotic surgeons of all specialties have been able to explore the clinical utility of fluorescence guided surgery. Methods Literature searches were performed using the PubMed and MEDLINE databases using the keywords "robotic-assisted fluorescence surgery", "ICG robotic surgery", and "fluorescence guided surgery" covering the years 2011-2020. Conclusions Real-time intraoperative fluorescence guidance has shown great potential in helping guide surgeons in both simple and complex surgical interventions. Indocyanine green is one of the most widely-used imaging agents in fluorescence guided surgery, and other targeted, near-infrared imaging agents are in various stages of development. Fluorescence is becoming a reliable tool that can help surgeons in their decision-making process in some specialties, while explorations continue in others.
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Affiliation(s)
- Yu-Jin Lee
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, CA, USA
| | | | - Ryan K Orosco
- Moores Cancer Center, La Jolla, CA, USA.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California, San Diego, San Diego, CA, USA
| | - Eben L Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, CA, USA
| | - Jonathan M Sorger
- Department of Research, Intuitive Surgical, Inc., Sunnyvale, CA, USA
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13
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Meershoek P, van den Berg NS, Lutjeboer J, Burgmans MC, van der Meer RW, van Rijswijk CSP, van Oosterom MN, van Erkel AR, van Leeuwen FWB. Assessing the value of volume navigation during ultrasound-guided radiofrequency- and microwave-ablations of liver lesions. Eur J Radiol Open 2021; 8:100367. [PMID: 34286051 PMCID: PMC8273361 DOI: 10.1016/j.ejro.2021.100367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 04/28/2021] [Revised: 06/25/2021] [Accepted: 06/30/2021] [Indexed: 11/26/2022] Open
Abstract
Purpose The goal of our study was to determine the influence of ultrasound (US)-coupled volume navigation on the use of computed tomography (CT) during minimally-invasive radiofrequency and microwave ablation procedures of liver lesions. Method Twenty-five patients with 40 liver lesions of different histological origin were retrospectively analysed. Lesions were ablated following standard protocol, using 1) conventional US-guidance, 2) manual registered volume navigation (mVNav), 3) automatic registered (aVNav) or 4) CT-guidance. In case of ultrasonographically inconspicuous lesions, conventional US-guidance was abandoned and mVNav was used. If mVNav was also unsuccessful, the procedure was either continued with aVNav or CT-guidance. The number, size and location of the lesions targeted using the different approaches were documented. Results Of the 40 lesions, sixteen (40.0 %) could be targeted with conventional US-guidance only, sixteen (40.0 %) with mVNav, three (7.5 %) with aVNav and five (12.5 %) only through the use of CT-guidance. Of the three alternatives (mVNav, aVNav and CT only) the mean size of the lesions targeted using mVNav (9.1 ± 4.6 mm) was significantly smaller from those targeted using US-guidance only (20.4 ± 9.4 mm; p < 0.001). The location of the lesions did not influence the selection of the modality used to guide the ablation. Conclusions In our cohort, mVNav allowed the ablation procedure to become less dependent on the use of CT. mVNav supported the ablation of lesions smaller than those that could be ablated with US only and doubled the application of minimally-invasive US-guided ablations.
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Affiliation(s)
- Philippa Meershoek
- Interventional Radiology Section, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands.,Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| | - Nynke S van den Berg
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| | - Jacob Lutjeboer
- Interventional Radiology Section, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| | - Mark C Burgmans
- Interventional Radiology Section, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| | - Rutger W van der Meer
- Interventional Radiology Section, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| | - Catharina S P van Rijswijk
- Interventional Radiology Section, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| | - Matthias N van Oosterom
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| | - Arian R van Erkel
- Interventional Radiology Section, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
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14
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Krishnan G, Berg NSVD, Nishio N, Juniper G, Pei J, Zhou Q, Lu G, Lee YJ, Ramos K, Iagaru AH, Baik FM, Colevas AD, Martin BA, Rosenthal EL. Metastatic and sentinel lymph node mapping using intravenously delivered Panitumumab-IRDye800CW. Theranostics 2021; 11:7188-7198. [PMID: 34158844 PMCID: PMC8210603 DOI: 10.7150/thno.55389] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/07/2021] [Indexed: 12/19/2022] Open
Abstract
Rationale: Sentinel lymph node biopsy (SLNB) is a well-established minimally invasive staging procedure that maps the spread of tumour metastases from their primary site to the regional lymphatics. Currently, the procedure requires the local peri-tumoural injection of radiolabelled and/or optical agents, and is therefore operator dependent, disruptive to surgical workflow and restricted largely to a small subset of malignancies that can be readily accessed externally for local tracer injection. The present study set out to determine whether intravenous (IV) infusion of a tumor-targeted tracer could identify sentinel and metastatic lymph nodes (LNs) in order to overcome these limitations. Methods: We examined 27 patients with oral squamous cell carcinoma (OSCC), 18 of whom were clinically node negative (cN0). Patients were infused intravenously with 50mg of Panitumumab-IRDye800CW prior to surgical resection of their primary tumour with neck dissection and/or SLNB. Lymphadenectomy specimens underwent fluorescence molecular imaging to evaluate tracer distribution to LNs. Results: A total of 960 LNs were analysed, of which 34 (3.5%) contained metastatic disease. Panitumumab-IRDye800CW preferentially localized to metastatic and sentinel LNs as evidenced by a higher fluorescent signal relative to other lymph nodes. The median MFI of metastatic LNs was significantly higher than the median MFI of benign LNs (0.06 versus 0.02, p < 0.05). Furthermore, selecting the highest five fluorescence intensity LNs from individual specimens resulted in 100% sensitivity, 85.8% specificity and 100% negative predictive value (NPV) for the detection of occult metastases and 100% accuracy for clinically staging the neck. In the cN+ cohort, assessment of the highest 5 fluorescence LNs per patient had 87.5% sensitivity, 93.2% specificity and 99.1% NPV for the detection of metastatic nodes. Conclusion: When intravenously infused, a tumour-targeted tracer localized to sentinel and metastatic lymph nodes. Further validation of an IV tumor-targeted tracer delivery approach for SLNB could dramatically change the practice of SLNB, allowing its application to other malignancies where the primary tumour is not accessible for local tracer injection.
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15
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Zhou Q, van den Berg NS, Rosenthal EL, Iv M, Zhang M, Vega Leonel JCM, Walters S, Nishio N, Granucci M, Raymundo R, Yi G, Vogel H, Cayrol R, Lee YJ, Lu G, Hom M, Kang W, Hayden Gephart M, Recht L, Nagpal S, Thomas R, Patel C, Grant GA, Li G. EGFR-targeted intraoperative fluorescence imaging detects high-grade glioma with panitumumab-IRDye800 in a phase 1 clinical trial. Theranostics 2021; 11:7130-7143. [PMID: 34158840 PMCID: PMC8210618 DOI: 10.7150/thno.60582] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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: 03/17/2021] [Accepted: 04/24/2021] [Indexed: 12/12/2022] Open
Abstract
Rationale: First-line therapy for high-grade gliomas (HGGs) includes maximal safe surgical resection. The extent of resection predicts overall survival, but current neuroimaging approaches lack tumor specificity. The epidermal growth factor receptor (EGFR) is a highly expressed HGG biomarker. We evaluated the safety and feasibility of an anti-EGFR antibody, panitumuab-IRDye800, at subtherapeutic doses as an imaging agent for HGG. Methods: Eleven patients with contrast-enhancing HGGs were systemically infused with panitumumab-IRDye800 at a low (50 mg) or high (100 mg) dose 1-5 days before surgery. Near-infrared fluorescence imaging was performed intraoperatively and ex vivo, to identify the optimal tumor-to-background ratio by comparing mean fluorescence intensities of tumor and histologically uninvolved tissue. Fluorescence was correlated with preoperative T1 contrast, tumor size, EGFR expression and other biomarkers. Results: No adverse events were attributed to panitumumab-IRDye800. Tumor fragments as small as 5 mg could be detected ex vivo and detection threshold was dose dependent. In tissue sections, panitumumab-IRDye800 was highly sensitive (95%) and specific (96%) for pathology confirmed tumor containing tissue. Cellular delivery of panitumumab-IRDye800 was correlated to EGFR overexpression and compromised blood-brain barrier in HGG, while normal brain tissue showed minimal fluorescence. Intraoperative fluorescence improved optical contrast in tumor tissue within and beyond the T1 contrast-enhancing margin, with contrast-to-noise ratios of 9.5 ± 2.1 and 3.6 ± 1.1, respectively. Conclusions: Panitumumab-IRDye800 provided excellent tumor contrast and was safe at both doses. Smaller fragments of tumor could be detected at the 100 mg dose and thus more suitable for intraoperative imaging.
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Affiliation(s)
- Quan Zhou
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Nynke S. van den Berg
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Eben L. Rosenthal
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cancer Center, Stanford University, Stanford, CA, USA
| | - Michael Iv
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Shannon Walters
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Naoki Nishio
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Monica Granucci
- Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford, CA, USA
| | - Roan Raymundo
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford, CA, USA
| | - Grace Yi
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford, CA, USA
| | - Hannes Vogel
- Department of Neuropathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Romain Cayrol
- Department of Neuropathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Yu-Jin Lee
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Guolan Lu
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Marisa Hom
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Wenying Kang
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Larry Recht
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Seema Nagpal
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Reena Thomas
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Chirag Patel
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gerald A. Grant
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
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16
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Lee YJ, Krishnan G, Nishio N, van den Berg NS, Lu G, Martin BA, van Keulen S, Colevas AD, Kapoor S, Liu JTC, Rosenthal EL. Intraoperative Fluorescence-Guided Surgery in Head and Neck Squamous Cell Carcinoma. Laryngoscope 2021; 131:529-534. [PMID: 33593036 DOI: 10.1002/lary.28822] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 05/03/2020] [Accepted: 05/15/2020] [Indexed: 02/06/2023]
Abstract
The rate of positive margins in head and neck cancers has remained stagnant over the past three decades and is consistently associated with poor overall survival. This suggests that significant improvements must be made intraoperatively to ensure negative margins. We discuss the important role of fluorescence imaging to guide surgical oncology in head and neck cancer. This review includes a general overview of the principles of fluorescence, available fluorophores used for fluorescence imaging, and specific clinical applications of fluorescence-guided surgery, as well as challenges and future directions in head and neck surgical oncology. Laryngoscope, 131:529-534, 2021.
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Affiliation(s)
- Yu-Jin Lee
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - Giri Krishnan
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, U.S.A.,Department of Otolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, SA, Australia
| | - Naoki Nishio
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - Nynke S van den Berg
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - Guolan Lu
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - Brock A Martin
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - Stan van Keulen
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - Alexander D Colevas
- Department of Medicine, Division of Oncology, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - Shrey Kapoor
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - Jonathan T C Liu
- Department of Mechanical Engineering, University of Washington, Seattle, WA, U.S.A.,Department of Bioengineering, University of Washington, Seattle, WA, U.S.A.,Department of Pathology, University of Washington, Seattle, WA, U.S.A
| | - Eben L Rosenthal
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, U.S.A.,Department of Radiology, Stanford University School of Medicine, Stanford, CA, U.S.A
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17
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Lu G, Nishio N, van den Berg NS, Martin BA, Fakurnejad S, van Keulen S, Colevas AD, Thurber GM, Rosenthal EL. Co-administered antibody improves penetration of antibody-dye conjugate into human cancers with implications for antibody-drug conjugates. Nat Commun 2020; 11:5667. [PMID: 33168818 PMCID: PMC7652891 DOI: 10.1038/s41467-020-19498-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [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: 04/23/2020] [Accepted: 10/13/2020] [Indexed: 02/03/2023] Open
Abstract
Poor tissue penetration remains a major challenge for antibody-based therapeutics of solid tumors, but proper dosing can improve the tissue penetration and thus therapeutic efficacy of these biologics. Due to dose-limiting toxicity of the small molecule payload, antibody-drug conjugates (ADCs) are administered at a much lower dose than their parent antibodies, which further reduces tissue penetration. We conducted an early-phase clinical trial (NCT02415881) and previously reported the safety of an antibody-dye conjugate (panitumumab-IRDye800CW) as primary outcome. Here, we report a retrospective exploratory analysis of the trial to evaluate whether co-administration of an unconjugated antibody could improve the intratumoral distribution of the antibody-dye conjugate in patients. By measuring the multiscale distribution of the antibody-dye conjugate, this study demonstrates improved microscopic antibody distribution without increasing uptake (toxicity) in healthy tissue when co-administered with the parent antibody, supporting further clinical investigation of the co-administration dosing strategy to improve the tumor penetration of ADCs.
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Affiliation(s)
- Guolan Lu
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Naoki Nishio
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
- Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Nynke S van den Berg
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Brock A Martin
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Shayan Fakurnejad
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Stan van Keulen
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Alexander D Colevas
- Department of Medicine, Division of Oncology, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Greg M Thurber
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Eben L Rosenthal
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA.
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18
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Nishio N, van den Berg NS, Martin BA, van Keulen S, Fakurnejad S, Rosenthal EL, Wilson KE. Photoacoustic Molecular Imaging for the Identification of Lymph Node Metastasis in Head and Neck Cancer Using an Anti-EGFR Antibody-Dye Conjugate. J Nucl Med 2020; 62:648-655. [PMID: 33008927 PMCID: PMC8844260 DOI: 10.2967/jnumed.120.245241] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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: 03/17/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022] Open
Abstract
The presence of lymph node (LN) metastases is an essential prognostic indicator in patients with head and neck squamous cell carcinoma (HNSCC). This study assessed photoacoustic molecular imaging (PAMI) of the antiepidermal growth factor receptor antibody (panitumumab) conjugated to a near-infrared fluorescent dye, IRDye800CW (panitumumab-IRDye800CW; pan800), for the identification of occult metastatic LNs in patients with HNSCC (n = 7). Methods: After in vitro photoacoustic imaging characterization of pan800, PAMI was performed on excised neck specimens from patients infused with pan800 before surgery. Freshly obtained neck specimens were imaged with 3-dimensional, multiwavelength spectroscopic PAMI (wavelengths of 680, 686, 740, 800, 860, 924, and 958 nm). Harvested LNs were then imaged with a closed-field near-infrared fluorescence imager and histologically examined by the pathologist to determine their metastatic status. Results: In total, 53 LNs with a maximum diameter of 10 mm were analyzed with photoacoustic and fluorescence imaging, of which 4 were determined to be metastatic on the final histopathologic report. Photoacoustic signals in the LNs corresponding to accumulated pan800 were spectrally unmixed using a linear least-square-error classification algorithm. The average thresholded photoacoustic signal intensity corresponding to pan800 was 5-fold higher for metastatic LNs than for benign LNs (2.50 ± 1.09 arbitrary units [a.u.] vs. 0.53 ± 0.32 a.u., P < 0.001). Fluorescence imaging showed that metastatic LNs had a 2-fold increase in fluorescence signal compared with benign LNs ex vivo (P < 0.01, 0.068 ± 0.027 a.u. vs. 0.035 ± 0.018 a.u.). Moreover, the ratio of the average of the highest 10% of the photoacoustic signal intensity over the total average, representative of the degree of heterogeneity in the pan800 signal in LNs, showed a significant difference between metastatic LNs and benign LNs (11.6 ± 13.4 vs. 1.8 ± 0.7, P < 0.01) and an area under the receiver-operating-characteristic curve of 0.96 (95% CI, 0.91-1.00). Conclusion: The data indicate that PAMI of IRDye800-labeled tumor-specific antibody may have the potential to identify occult LN metastasis perioperatively in HNSCC patients.
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Affiliation(s)
- Naoki Nishio
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California.,Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Nynke S van den Berg
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Brock A Martin
- Department of Pathology, Stanford University School of Medicine, Stanford, California; and
| | - Stan van Keulen
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Shayan Fakurnejad
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Eben L Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Katheryne E Wilson
- Department of Radiology, Stanford University School of Medicine, Stanford, California
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19
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Pei J, Juniper G, van den Berg NS, Nisho N, Broadt T, Welch AR, Yi GS, Raymundo RC, Chirita SU, Lu G, Krishnan G, Lee YJ, Kapoor S, Zhou Q, Colevas AD, Lui NS, Poultsides GA, Li G, Zinn KR, Rosenthal EL. Safety and Stability of Antibody-Dye Conjugate in Optical Molecular Imaging. Mol Imaging Biol 2020; 23:109-116. [PMID: 32880818 DOI: 10.1007/s11307-020-01536-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 04/22/2020] [Revised: 08/03/2020] [Accepted: 08/20/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE The development of molecularly targeted tracers is likely to improve the accuracy of diagnostic, screening, and therapeutic tools. Despite the many therapeutic antibodies that are FDA-approved with known toxicity, only a limited number of antibody-dye conjugates have been introduced to the clinic. Thorough evaluation of the safety, stability, and pharmacokinetics of antibody conjugates in the clinical setting compared with their parental components could accelerate the clinical approval of antibodies as agents for molecular imaging. Here we investigate the safety and stability of a near-infrared fluorescent dye (IRDye800CW) conjugated panitumumab, an approved therapeutic antibody, and report on the product stability, pharmacokinetics, adverse events, and QTc interval changes in patients. PROCEDURES Panitumumab-IRDye800CW was made under good manufacturing practice (GMP) conditions in a single batch on March 26, 2014, and then evaluated over 4.5 years at 0, 3, and 6 months, and then at 6-month intervals thereafter. We conducted early phase trials in head and neck, lung, pancreas, and brain cancers with panitumumab-IRDye800CW. Eighty-one patients scheduled to undergo standard-of-care surgery were infused with doses between 0.06 to 2.83 mg/kg of antibody. Patient ECGs, blood samples, and adverse events were collected over 30-day post-infusion for analysis. RESULTS Eighty-one patients underwent infusion of the study drug at a range of doses. Six patients (7.4 %) experienced an adverse event that was considered potentially related to the drug. The most common event was a prolonged QTc interval which occurred in three patients (3.7 %). Panitumumab-IRDye800CW had two OOS results at 42 and 54 months while meeting all other stability testing criteria. CONCLUSIONS Panitumumab-IRDye800CW was safe and stable to administer over a 54-month window with a low rate of adverse events (7.4 %) which is consistent with the rate associated with panitumumab alone. This data supports re-purposing therapeutic antibodies as diagnostic imaging agents with limited preclinical toxicology studies.
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Affiliation(s)
- Jacqueline Pei
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Georgina Juniper
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Nynke S van den Berg
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Naoki Nisho
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Trevor Broadt
- Biopharmaceutical Development Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Anthony R Welch
- Biological Resources Branch/DTP/DCTD, National Cancer Institute, Frederick, MD, USA
| | - Grace S Yi
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Roan C Raymundo
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Stefania U Chirita
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Guolan Lu
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Giri Krishnan
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Yu-Jin Lee
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Shrey Kapoor
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Quan Zhou
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - A Dimitrios Colevas
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Natalie S Lui
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - George A Poultsides
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Kurt R Zinn
- Department of Radiology, Institute for Quantitative Health Science and Engineering, Michigan State University, East Lansing, MI, USA
| | - Eben L Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA.
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20
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Tholen M, Yim JJ, Groborz K, Yoo E, Martin BA, van den Berg NS, Drag M, Bogyo M. Design of Optical-Imaging Probes by Screening of Diverse Substrate Libraries Directly in Disease-Tissue Extracts. Angew Chem Int Ed Engl 2020; 59:19143-19152. [PMID: 32589815 DOI: 10.1002/anie.202006719] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 05/08/2020] [Revised: 06/25/2020] [Indexed: 12/13/2022]
Abstract
Fluorescently quenched probes that are specifically activated in the cancer microenvironment have great potential application for diagnosis, early detection, and surgical guidance. These probes are often designed to target specific enzymes associated with diseases by direct optimization using single purified enzymes. However, this can result in painstaking chemistry efforts to produce a probe with suboptimal performance when applied in vivo. We describe here an alternate, unbiased activity-profiling approach in which whole tissue extracts are used to directly identify optimal peptide sequences for probe design. Screening of tumor extracts with a hybrid combinatorial substrate library (HyCoSuL) identified a combination of natural and non-natural amino-acid residues that was used to generate highly efficient tumor-specific probes. This new strategy simplifies and enhances the process of probe optimization without any a priori knowledge of enzyme targets and has the potential to be applied to diverse disease states using clinical or animal-model tissue samples.
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Affiliation(s)
- Martina Tholen
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Joshua J Yim
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.,Department of Chemical and System Biology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Katarzyna Groborz
- Department of Chemical Biology and Bioimaging, Faculty of Chemistry, Wrocław University of Science and Technology, Wrocław, Poland
| | - Euna Yoo
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.,Current address: Chemical Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, MD, 20850, USA
| | - Brock A Martin
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Nynke S van den Berg
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Marcin Drag
- Department of Chemical Biology and Bioimaging, Faculty of Chemistry, Wrocław University of Science and Technology, Wrocław, Poland
| | - Matthew Bogyo
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.,Department of Chemical and System Biology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.,Microbiology and Immunology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
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21
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Napier TS, Udayakumar N, Jani AH, Hartman YE, Houson HA, Moore L, Amm HM, van den Berg NS, Sorace AG, Warram JM. Comparison of Panitumumab-IRDye800CW and 5-Aminolevulinic Acid to Provide Optical Contrast in a Model of Glioblastoma Multiforme. Mol Cancer Ther 2020; 19:1922-1929. [PMID: 32606015 DOI: 10.1158/1535-7163.mct-19-0819] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 01/16/2020] [Accepted: 06/15/2020] [Indexed: 01/02/2023]
Abstract
Maximal safe resection of malignant tissue is associated with improved progression-free survival and better response to radiation and chemotherapy for patients with glioblastoma (GBM). 5-Aminolevulinic acid (5-ALA) is the current FDA-approved standard for intraoperative brain tumor visualization. Unfortunately, autofluorescence in diffuse areas and high fluorescence in dense tissues significantly limit discrimination at tumor margins. This study is the first to compare 5-ALA to an investigational new drug, panitumumab-IRDye800CW, in the same animal model. A patient-derived GBM xenograft model was established in 16 nude mice, which later received injections of 5-ALA, panitumumab-IRDye800CW, IRDye800CW, 5-ALA and IRDye800CW, or 5-ALA and panitumumab-IRDye800CW. Brains were prepared for multi-instrument fluorescence imaging, IHC, and quantitative analysis of tumor-to-background ratio (TBR) and tumor margin accuracy. Statistical analysis was compared with Wilcoxon rank-sum or paired t test. Panitumumab-IRDye800CW had a 30% higher comprehensive TBR compared with 5-ALA (P = 0.0079). SDs for core and margin regions of interest in 5-ALA-treated tissues were significantly higher than those found in panitumumab-IRDye800CW-treated tissues (P = 0.0240 and P = 0.0284, respectively). Panitumumab-IRDye800CW specificities for tumor core and margin were more than 10% higher than those of 5-ALA. Higher AUC for panitumumab-IRDye800CW indicated strong capability to discriminate between normal and malignant brain tissue when compared with 5-ALA. This work demonstrates that panitumumab-IRDye800CW shows potential as a targeting agent for fluorescence intraoperative detection of GBM. Improved margin definition and surgical resection using panitumumab-IRDye800 has the potential to improve surgical outcomes and survival in patients with GBM compared with 5-ALA.
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Affiliation(s)
- Tiara S Napier
- Graduate Biomedical Sciences, University of Alabama at Birmingham, Birmingham, Alabama
| | - Neha Udayakumar
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aditi H Jani
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yolanda E Hartman
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Hailey A Houson
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lindsay Moore
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Hope M Amm
- Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nynke S van den Berg
- Department of Otolaryngology, Stanford University Medical School, Stanford, California
| | - Anna G Sorace
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jason M Warram
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama. .,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama
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22
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Lu G, van den Berg NS, Martin BA, Nishio N, Hart ZP, van Keulen S, Fakurnejad S, Chirita SU, Raymundo RC, Yi G, Zhou Q, Fisher GA, Rosenthal EL, Poultsides GA. Tumour-specific fluorescence-guided surgery for pancreatic cancer using panitumumab-IRDye800CW: a phase 1 single-centre, open-label, single-arm, dose-escalation study. Lancet Gastroenterol Hepatol 2020; 5:753-764. [PMID: 32416764 DOI: 10.1016/s2468-1253(20)30088-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [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: 01/08/2020] [Revised: 03/12/2020] [Accepted: 03/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Complete surgical resection remains the primary curative option for pancreatic ductal adenocarcinoma, with positive margins in 30-70% of patients. In this study, we aimed to evaluate the use of intraoperative tumour-specific imaging to enhance a surgeon's ability to detect visually occult cancer in real time. METHODS In this single-centre, open-label, single-arm study, done in the USA, we enrolled patients who had clinically suspicious or biopsy-confirmed pancreatic ductal adenocarcinomas and were scheduled for curative surgery. Eligible patients were 19 years of age or older with a life expectancy of more than 12 weeks and a Karnofsky performance status of at least 70% or an Eastern Cooperative Oncology Group or Zubrod level of one or lower, who were scheduled to undergo curative surgery. Patients were sequentially enrolled into each dosing group and 2-5 days before surgery, patients were intravenously infused with 100 mg of unlabelled panitumumab followed by 25 mg, 50 mg, or 75 mg of the near-infrared fluorescently labelled antibody (panitumumab-IRDye800CW). The primary endpoint was to determine the optimal dose of panitumumab-IRDye800CW in identifying pancreatic ductal adenocarcinomas as measured by tumour-to-background ratio in all patients. The tumour-to-background ratio was defined as the fluorescence signal of the tumour divided by the fluorescence signal of the surrounding healthy tissue. The dose-finding part of this study has been completed. This study is registered with ClinicalTrials.gov, NCT03384238. FINDINGS Between April, 2018, and July, 2019, 16 patients were screened for enrolment onto the study. Of the 16 screened patients, two (12%) patients withdrew from the study and three (19%) were not eligible; 11 (69%) patients completed the trial, all of whom were clinically diagnosed with pancreatic ductal adenocarcinoma. The mean tumour-to-background ratio of primary tumours was 3·0 (SD 0·5) in the 25 mg group, 4·0 (SD 0·6) in the 50 mg group, and 3·7 (SD 0·4) in the 75 mg group; the optimal dose was identified as 50 mg. Intraoperatively, near-infrared fluorescence imaging provided enhanced visualisation of the primary tumours, metastatic lymph nodes, and small (<2 mm) peritoneal metastasis. Intravenous administration of panitumumab-IRDye800CW at the doses of 25 mg, 50 mg, and 75 mg did not result in any grade 3 or higher adverse events. There were no serious adverse events attributed to panitumumab-IRDye800CW, although four possibly related adverse events (grade 1 and 2) were reported in four patients. INTERPRETATION To our knowledge, this study presents the first clinical use of panitumumab-IRDye800CW for detecting pancreatic ductal adenocarcinomas and shows that panitumumab-IRDye800CW is safe and feasible to use during pancreatic cancer surgery. Tumour-specific intraoperative imaging might have added value for treatment of patients with pancreatic ductal adenocarcinomas through improved patient selection and enhanced visualisation of surgical margins, metastatic lymph nodes, and distant metastasis. FUNDING National Institutes of Health and the Netherlands Organization for Scientific Research.
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Affiliation(s)
- Guolan Lu
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford University, CA, USA
| | - Nynke S van den Berg
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford University, CA, USA
| | - Brock A Martin
- Department of Pathology, Stanford University School of Medicine, Stanford University, CA, USA
| | - Naoki Nishio
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford University, CA, USA
| | - Zachary P Hart
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford University, CA, USA
| | - Stan van Keulen
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford University, CA, USA
| | - Shayan Fakurnejad
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford University, CA, USA
| | - Stefania U Chirita
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford University, CA, USA; Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford University, CA, USA
| | - Roan C Raymundo
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford University, CA, USA; Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford University, CA, USA
| | - Grace Yi
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford University, CA, USA; Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford University, CA, USA
| | - Quan Zhou
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford University, CA, USA
| | - George A Fisher
- Department of Medical Oncology, Stanford University School of Medicine, Stanford University, CA, USA
| | - Eben L Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford University, CA, USA; Stanford Cancer Center, Stanford University School of Medicine, Stanford University, CA, USA
| | - George A Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford University, CA, USA.
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23
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Lu G, Fakurnejad S, Martin BA, van den Berg NS, van Keulen S, Nishio N, Zhu AJ, Chirita SU, Zhou Q, Gao RW, Kong CS, Fischbein N, Penta M, Colevas AD, Rosenthal EL. Predicting Therapeutic Antibody Delivery into Human Head and Neck Cancers. Clin Cancer Res 2020; 26:2582-2594. [PMID: 31980465 DOI: 10.1158/1078-0432.ccr-19-3717] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/20/2019] [Accepted: 01/21/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE The efficacy of antibody-based therapeutics depends on successful drug delivery into solid tumors; therefore, there is a clinical need to measure intratumoral antibody distribution. This study aims to develop and validate an imaging and computation platform to directly quantify and predict antibody delivery into human head and neck cancers in a clinical study. EXPERIMENTAL DESIGN Twenty-four patients received systemic infusion of a near-infrared fluorescence-labeled therapeutic antibody followed by surgical tumor resection. A computational platform was developed to quantify the extent of heterogeneity of intratumoral antibody distribution. Both univariate and multivariate regression analyses were used to select the most predictive tumor biological factors for antibody delivery. Quantitative image features from the pretreatment MRI were extracted and correlated with fluorescence imaging of antibody delivery. RESULTS This study not only confirmed heterogeneous intratumoral antibody distribution in-line with many preclinical reports, but also quantified the extent of interpatient, intertumor, and intratumor heterogeneity of antibody delivery. This study demonstrated the strong predictive value of tumor size for intratumoral antibody accumulation and its significant impact on antibody distribution in both primary tumor and lymph node metastasis. Furthermore, this study established the feasibility of using contrast-enhanced MRI to predict antibody delivery. CONCLUSIONS This study provides a clinically translatable platform to measure antibody delivery into solid tumors and yields valuable insight into clinically relevant antibody tumor penetration, with implications in the selection of patients amenable to antibody therapy and the design of more effective dosing strategies.
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Affiliation(s)
- Guolan Lu
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | | | - Brock A Martin
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Nynke S van den Berg
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Stan van Keulen
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Naoki Nishio
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Ashley J Zhu
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Stefania U Chirita
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Quan Zhou
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Rebecca W Gao
- Stanford University School of Medicine, Stanford, California
| | - Christina S Kong
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Nancy Fischbein
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Mrudula Penta
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Alexander D Colevas
- Department of Medicine, Division of Oncology, Stanford University School of Medicine, Stanford, California
| | - Eben L Rosenthal
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, California. .,Department of Radiology, Stanford University School of Medicine, Stanford, California
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24
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Fakurnejad S, Krishnan G, van Keulen S, Nishio N, Birkeland AC, Baik FM, Kaplan MJ, Colevas AD, van den Berg NS, Rosenthal EL, Martin BA. Intraoperative Molecular Imaging for ex vivo Assessment of Peripheral Margins in Oral Squamous Cell Carcinoma. Front Oncol 2020; 9:1476. [PMID: 31998640 PMCID: PMC6965069 DOI: 10.3389/fonc.2019.01476] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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] [Received: 08/12/2019] [Accepted: 12/09/2019] [Indexed: 12/12/2022] Open
Abstract
Objective: Complete surgical resection is the standard of care for treatment of oral cancer although the positive margin rate remains 15–30%. Tissue sampling from the resected specimen and from the wound bed for frozen section analysis (FSA) remains the mainstay for intraoperative margin assessment but is subject to sampling error and can require the processing of multiple samples. We sought to understand if an ex vivo imaging strategy using a tumor-targeted fluorescently labeled antibody could accurately identify the closest peripheral margin on the mucosal surface of resected tumor specimen, so that this “sentinel margin” could be used to guide pathological sampling. Materials and Methods: Twenty-nine patients with oral squamous cell carcinoma scheduled for surgical resection were consented for the study and received systemic administration of a tumor-targeted fluorescently labeled antibody (Panitumumab IRDye800CW). After surgical resection, the tumor specimen was imaged using a closed-field fluorescent imaging device. Relevant pathological data was available for five patients on retrospective review. For each of these five patients, two regions of highest fluorescence intensity at the peripheral margin and one region of lowest fluorescence intensity were identified, and results were correlated with histology to determine if the region of highest fluorescence intensity along the mucosal margin (i.e., the sentinel margin) was truly the closest margin. Results: Imaging acquisition of the mucosal surface of the specimen immediately after surgery took 30 s. In all of the specimens, the region of highest fluorescence at the specimen edge had a significantly smaller margin distance than other sampled regions. The average margin distance at the closest, “sentinel,” margin was 3.2 mm compared to a margin distance of 8.0 mm at other regions (p < 0.0001). Conclusions: This proof-of-concept study suggests that, when combined with routine FSA, ex vivo fluorescent specimen imaging can be used to identify the closest surgical margin on the specimen. This approach may reduce sampling error of intraoperative evaluation, which should ultimately improve the ability of the surgeon to identify the sentinel margin. This rapid sentinel margin identification improves the surgeon's orientation to areas most likely to be positive in the surgical wound bed and may expedite pathology workflow.
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Affiliation(s)
- Shayan Fakurnejad
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Giri Krishnan
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States.,The Department of Otorhinolaryngology, Head and Neck Surgery, The University of Adelaide, Woodville South, SA, Australia
| | - Stan van Keulen
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States.,Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Naoki Nishio
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Andrew C Birkeland
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Fred M Baik
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Michael J Kaplan
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - A Dimitrios Colevas
- Division of Medical Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Nynke S van den Berg
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Eben L Rosenthal
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Brock A Martin
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
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25
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Nishio N, van Keulen S, van den Berg NS, Lu G, LaRochelle EP, Davis SC, Martin BA, Fakurnejad S, Zhou Q, Birkeland AC, Kaplan MJ, Divi V, Colevas AD, Pogue BW, Rosenthal EL. Probe-based fluorescence dosimetry of an antibody-dye conjugate to identify head and neck cancer as a first step to fluorescence-guided tissue preselection for pathological assessment. Head Neck 2020; 42:59-66. [PMID: 31571335 DOI: 10.1002/hed.25964] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 05/21/2019] [Revised: 08/24/2019] [Accepted: 09/06/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Despite the rapid growth of fluorescence imaging, accurate sampling of tissue sections remains challenging. Development of novel technologies to improve intraoperative assessment of tissue is needed. METHODS A novel contact probe-based fluorescence dosimeter device, optimized for IRDye800CW quantification, was developed. After evaluation of the device in a phantom setup, its clinical value was defined ex vivo in patients with head and neck squamous cell carcinoma who received panitumumab-IRDye800CW. RESULTS Ten patients were enrolled with a total of 216 data points obtained. Final histopathology showed tumor in 119 spots and normal tissue in 97 spots. Fluorescence-to-excitation ratios in tumor tissue were more than three times higher than those in normal tissue. The area under the curve was 0.86 (95% CI: 0.81-0.91) for tumor detection. CONCLUSIONS Fluorescence-guided tissue preselection using a fluorescence dosimeter could have substantial impact on tissue sampling for frozen section analysis and potentially reduce sampling errors.
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Affiliation(s)
- Naoki Nishio
- Department of Otolaryngology - Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California.,Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Stan van Keulen
- Department of Otolaryngology - Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California.,Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Center/Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands
| | - Nynke S van den Berg
- Department of Otolaryngology - Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Guolan Lu
- Department of Otolaryngology - Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | | | - Scott C Davis
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Brock A Martin
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Shayan Fakurnejad
- Department of Otolaryngology - Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Quan Zhou
- Department of Otolaryngology - Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Andrew C Birkeland
- Department of Otolaryngology - Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael J Kaplan
- Department of Otolaryngology - Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Vasu Divi
- Department of Otolaryngology - Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - A Dimitrios Colevas
- Department of Medicine, Division of Medical Oncology, Stanford University, Stanford, California
| | - Brian W Pogue
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Eben L Rosenthal
- Department of Otolaryngology - Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
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26
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Hart ZP, Nishio N, Krishnan G, Lu G, Zhou Q, Fakurnejad S, Wormald PJ, van den Berg NS, Rosenthal EL, Baik FM. Endoscopic Fluorescence-Guided Surgery for Sinonasal Cancer Using an Antibody-Dye Conjugate. Laryngoscope 2019; 130:2811-2817. [PMID: 31854462 PMCID: PMC7754277 DOI: 10.1002/lary.28483] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 11/12/2019] [Accepted: 12/08/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Endoscopic resection of sinonasal squamous cell carcinoma has become the standard of care, but challenges remain in obtaining clear resection margins. The current study evaluated the feasibility of endoscopic fluorescence-guided surgery (FGS) to improve surgical resection in a human sinus surgical model. METHODS A fluorescence endoscope optimized for near-infrared (NIR) fluorescence detection was evaluated in a phantom study. Various endoscope diameters (4 and 10 mm) and viewing angles (0, 30, and 45 degrees) were evaluated to determine the sensitivity of the system for IRDye800CW detection at various working distances (1-5 cm). Endoscopic FGS was then validated in a three-dimensional human sinus surgical model to which squamous cell tumors derived from mice were inserted. Mice had received intravenous panitumumab-IRDye800CW and upon fluorescence-guided tumor resection, mean fluorescence intensity (MFI) and tumor-to-background ratio (TBR) were calculated in in situ and ex vivo settings. RESULTS A significantly higher fluorescence intensity was found when using the 10-mm diameter endoscope compared to the 4mm diameter endoscope (P < .001). No significant difference in MFI was found among the viewing angles of the 4-mm diameter endoscope. Using the human sinus model, the highest MFI and TBR were obtained at a 1-cm working distance compared to longer working distances. CONCLUSION We demonstrate that clinically acceptable TBRs were obtained with several working distances to discriminate tumor tissue from adjacent normal tissue in a human sinus model, and that endoscopic FGS may have great potential in identifying residual tumor tissue regions during surgery. Laryngoscope, 2019.
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Affiliation(s)
- Zachary P Hart
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Naoki Nishio
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, U.S.A.,Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Giri Krishnan
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, U.S.A.,Department of Surgery-Otorhinolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia
| | - Guolan Lu
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Quan Zhou
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Shayan Fakurnejad
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Peter John Wormald
- Department of Surgery-Otorhinolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia
| | - Nynke S van den Berg
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Eben L Rosenthal
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Fred M Baik
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, U.S.A
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27
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van Keulen S, Nishio N, Fakurnejad S, van den Berg NS, Lu G, Birkeland A, Martin BA, Forouzanfar T, Colevas AD, Rosenthal EL. Intraoperative Tumor Assessment Using Real-Time Molecular Imaging in Head and Neck Cancer Patients. J Am Coll Surg 2019; 229:560-567.e1. [PMID: 31568855 DOI: 10.1016/j.jamcollsurg.2019.09.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/14/2019] [Accepted: 09/03/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND In head and neck cancer, surgical resection using primarily visual and tactile feedback is considered the gold standard for solid tumors. Due to high numbers of tumor-involved surgical margins, which are directly correlated to poor clinical outcomes, intraoperative optical imaging trials have rapidly proliferated over the past 5 years. However, few studies report on intraoperative in situ imaging data that could support surgical resection. To demonstrate the clinical application of in situ surgical imaging, we report on the imaging data that are directly (ie in real-time) available to the surgeon. STUDY DESIGN Fluorescence intensities and tumor-to-background ratios (TBRs) were determined from the intraoperative imaging data-the view as seen by the surgeon during tumor resection-of 20 patients, and correlated to patient and tumor characteristics including age, sex, tumor site, tumor size, histologic differentiation, and epidermal growth factor receptor (EGFR) expression. Furthermore, different lighting conditions in regard to surgical workflow were evaluated. RESULTS Under these circumstances, intraoperative TBRs of the primary tumors averaged 2.2 ± 0.4 (range 1.5 to 2.9). Age, sex, tumor site, and tumor size did not have a significant effect on open-field intraoperative molecular imaging of the primary tumors (p > 0.05). In addition, variation in EGFR expression levels or the presence of ambient light did not seem to alter TBRs. CONCLUSIONS We present the results of successful in situ intraoperative imaging of primary tumors alongside the optimal conditions with respect to both molecular image acquisition and surgical workflow. This study illuminates the potentials of open-field molecular imaging to assist the surgeon in achieving successful cancer removal.
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Affiliation(s)
- Stan van Keulen
- Department of Otolaryngology, Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA; Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Center/Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands
| | - Naoki Nishio
- Department of Otolaryngology, Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Shayan Fakurnejad
- Department of Otolaryngology, Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Nynke S van den Berg
- Department of Otolaryngology, Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Guolan Lu
- Department of Otolaryngology, Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Andrew Birkeland
- Department of Otolaryngology, Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Brock A Martin
- Department of Clinical Pathology, Stanford University School of Medicine, Stanford, CA
| | - Tymour Forouzanfar
- Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Center/Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands
| | - A Dimitrios Colevas
- Department of Medicine, Division of Medical Oncology, Stanford University School of Medicine, Stanford, CA
| | - Eben L Rosenthal
- Department of Otolaryngology, Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA.
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28
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Nishio N, van den Berg NS, van Keulen S, Martin BA, Fakurnejad S, Teraphongphom N, Chirita SU, Oberhelman NJ, Lu G, Horton CE, Kaplan MJ, Divi V, Colevas AD, Rosenthal EL. Optical molecular imaging can differentiate metastatic from benign lymph nodes in head and neck cancer. Nat Commun 2019; 10:5044. [PMID: 31695030 PMCID: PMC6834597 DOI: 10.1038/s41467-019-13076-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [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: 03/06/2019] [Accepted: 10/15/2019] [Indexed: 12/26/2022] Open
Abstract
Identification of lymph node (LN) metastasis is essential for staging of solid tumors, and as a result, surgeons focus on harvesting significant numbers of LNs during ablative procedures for pathological evaluation. Isolating those LNs most likely to harbor metastatic disease can allow for a more rigorous evaluation of fewer LNs. Here we evaluate the impact of a systemically injected, near-infrared fluorescently-labeled, tumor-targeting contrast agent, panitumumab-IRDye800CW, to facilitate the identification of metastatic LNs in the ex vivo setting for head and neck cancer patients. Molecular imaging demonstrates a significantly higher mean fluorescence signal in metastatic LNs compared to benign LNs in head and neck cancer patients undergoing an elective neck dissection. Molecular imaging to preselect at-risk LNs may thus allow a more rigorous examination of LNs and subsequently lead to improved prognostication than regular neck dissection.
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Affiliation(s)
- Naoki Nishio
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA.,Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Nynke S van den Berg
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Stan van Keulen
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA.,Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Center/Academic Centre for Dentistry Amsterdam (ACTA), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Brock A Martin
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Shayan Fakurnejad
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Nutte Teraphongphom
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Stefania U Chirita
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Nicholas J Oberhelman
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Guolan Lu
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Crista E Horton
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Michael J Kaplan
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Vasu Divi
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - A Dimitrios Colevas
- Department of Medicine, Division of Medical Oncology, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - Eben L Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA, 94305, USA.
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29
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Kiss B, van den Berg NS, Ertsey R, McKenna K, Mach KE, Zhang CA, Volkmer JP, Weissman IL, Rosenthal EL, Liao JC. CD47-Targeted Near-Infrared Photoimmunotherapy for Human Bladder Cancer. Clin Cancer Res 2019; 25:3561-3571. [PMID: 30890547 PMCID: PMC7039531 DOI: 10.1158/1078-0432.ccr-18-3267] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [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: 10/10/2018] [Revised: 01/09/2019] [Accepted: 03/05/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Near-infrared photoimmunotherapy (NIR-PIT) is a localized molecular cancer therapy combining a photosensitizer-conjugated mAb and light energy. CD47 is an innate immune checkpoint widely expressed on bladder cancer cells, but absent from luminal normal urothelium. Targeting CD47 for NIR-PIT has the potential to selectively induce cancer cell death and minimize damage to normal urothelium. EXPERIMENTAL DESIGN The cytotoxic effect of NIR-PIT with anti-CD47-IR700 was investigated in human bladder cancer cell lines and primary human bladder cancer cells derived from fresh surgical samples. Phagocytosis assays were performed to evaluate macrophage activity after NIR-PIT. Anti-CD47-IR700 was administered to murine xenograft tumor models of human bladder cancer for in vivo molecular imaging and NIR-PIT. RESULTS Cytotoxicity in cell lines and primary bladder cancer cells significantly increased in a light-dose-dependent manner with CD47-targeted NIR-PIT. Phagocytosis of cancer cells significantly increased with NIR-PIT compared with antibody alone (P = 0.0002). In vivo fluorescence intensity of anti-CD47-IR700 in tumors reached a peak 24-hour postinjection and was detectable for at least 14 days. After a single round of CD47-targeted NIR-PIT, treated animals showed significantly slower tumor growth compared with controls (P < 0.0001). Repeated CD47-targeted NIR-PIT treatment further slowed tumor growth (P = 0.0104) and improved survival compared with controls. CONCLUSIONS CD47-targeted NIR-PIT increased direct cancer cell death and phagocytosis resulting in inhibited tumor growth and improved survival in a murine xenograft model of human bladder cancer.
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Affiliation(s)
- Bernhard Kiss
- Department of Urology, Stanford University School of Medicine, Stanford, California
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California
| | - Nynke S van den Berg
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Robert Ertsey
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | | | - Kathleen E Mach
- Department of Urology, Stanford University School of Medicine, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Chiyuan Amy Zhang
- Department of Urology, Stanford University School of Medicine, Stanford, California
| | | | - Irving L Weissman
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California
| | - Eben L Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Joseph C Liao
- Department of Urology, Stanford University School of Medicine, Stanford, California.
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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30
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van Keulen S, Nishio N, Birkeland A, Fakurnejad S, Martin B, Forouzanfar T, Cunanan K, Colevas AD, S van den Berg N, Rosenthal E. The Sentinel Margin: Intraoperative Ex Vivo Specimen Mapping Using Relative Fluorescence Intensity. Clin Cancer Res 2019; 25:4656-4662. [PMID: 31142505 DOI: 10.1158/1078-0432.ccr-19-0319] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 03/27/2019] [Accepted: 05/14/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Despite major advancements in surgical oncology, the positive margin rate for primary head and neck cancer resection remains around 15%-30%. In particular, the deep surface margin is the most challenging to adequately assess. Inadequate margins are directly correlated to poor survival, and as such, mitigation of these rates is critical to improve patient outcomes. We have developed an ex vivo imaging strategy that utilizes fluorescence intensity peaks (relative to background signal) of an injected anti-EGFR antibody conjugated to a fluorescent probe to locate potential close or positive margins on the deep surface of the resected tumor specimen. EXPERIMENTAL DESIGN Twelve patients with head and neck cancer scheduled for surgery received systemic administration of a tumor-specific contrast-agent (panitumumab-IRDye800CW). After surgical resection, the tumor specimen was imaged using a fluorescence imager. The three highest fluorescence intensity-peaks on the deep surface of the specimen were isolated and correlated to histology to determine the margin distance at these regions. RESULTS Relative fluorescence peak intensities identified the closest margin on the deep surface of the specimen within 2.5 minutes. The highest intensity peak consistently (100%) detected the closest margin to the tumor. The difference in tumor margin distance between the first and second highest fluorescence intensity peak averaged 2.1 ± 1.4 mm. The tumor-margin difference between the second and third highest peak averaged 1.6 ± 0.6 mm. CONCLUSIONS Fluorescence intensity peaks can identify the region on the specimen where tumor is closest to specimen's edge on the deep surface. This technique could have broad applications in obtaining adequate margins in oncological surgery.
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Affiliation(s)
- Stan van Keulen
- Department of Otolaryngology-Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California.,Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Center/Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, the Netherlands
| | - Naoki Nishio
- Department of Otolaryngology-Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Andrew Birkeland
- Department of Otolaryngology-Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Shayan Fakurnejad
- Department of Otolaryngology-Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Brock Martin
- Department of Clinical Pathology, Stanford University School of Medicine, Stanford, California
| | - Tim Forouzanfar
- Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Center/Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, the Netherlands
| | - Kristen Cunanan
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - A Dimitrios Colevas
- Department of Medicine, Division of Medical Oncology, Stanford University School of Medicine, Stanford, California
| | - Nynke S van den Berg
- Department of Otolaryngology-Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Eben Rosenthal
- Department of Otolaryngology-Division of Head and Neck Surgery, Stanford University School of Medicine, Stanford, California.
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van Keulen S, Nishio N, Fakurnejad S, Birkeland A, Martin BA, Lu G, Zhou Q, Chirita SU, Forouzanfar T, Colevas AD, van den Berg NS, Rosenthal EL. The Clinical Application of Fluorescence-Guided Surgery in Head and Neck Cancer. J Nucl Med 2019; 60:758-763. [PMID: 30733319 PMCID: PMC6581234 DOI: 10.2967/jnumed.118.222810] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [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: 11/01/2018] [Accepted: 12/29/2018] [Indexed: 01/17/2023] Open
Abstract
Although surgical resection has been the primary treatment modality of solid tumors for decades, surgeons still rely on visual cues and palpation to delineate healthy from cancerous tissue. This may contribute to the high rate (up to 30%) of positive margins in head and neck cancer resections. Margin status in these patients is the most important prognostic factor for overall survival. In addition, second primary lesions may be present at the time of surgery. Although often unnoticed by the medical team, these lesions can have significant survival ramifications. We hypothesize that real-time fluorescence imaging can enhance intraoperative decision making by aiding the surgeon in detecting close or positive margins and visualizing unanticipated regions of primary disease. The purpose of this study was to assess the clinical utility of real-time fluorescence imaging for intraoperative decision making. Methods: Head and neck cancer patients (n = 14) scheduled for curative resection were enrolled in a clinical trial evaluating panitumumab-IRDye800CW for surgical guidance (NCT02415881). Open-field fluorescence imaging was performed throughout the surgical procedure. The fluorescence signal was quantified as signal-to-background ratios to characterize the fluorescence contrast of regions of interest relative to background. Results: Fluorescence imaging was able to improve surgical decision making in 3 cases (21.4%): identification of a close margin (n = 1) and unanticipated regions of primary disease (n = 2). Conclusion: This study demonstrates the clinical applications of fluorescence imaging on intraoperative decision making. This information is required for designing phase III clinical trials using this technique. Furthermore, this study is the first to demonstrate this application for intraoperative decision making during resection of primary tumors.
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Affiliation(s)
- Stan van Keulen
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, California.,Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Center/Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands
| | - Naoki Nishio
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, California
| | - Shayan Fakurnejad
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, California
| | - Andrew Birkeland
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, California
| | - Brock A Martin
- Department of Clinical Pathology, Stanford University School of Medicine, Stanford, California
| | - Guolan Lu
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, California
| | - Quan Zhou
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, California
| | - Stefania U Chirita
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, California.,Cancer Clinical Trials Office, Stanford Cancer Center, Stanford University School of Medicine, Stanford, California; and
| | - Tymour Forouzanfar
- Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Center/Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands
| | - A Dimitrios Colevas
- Division of Medical Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Nynke S van den Berg
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, California
| | - Eben L Rosenthal
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, California
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Meershoek P, van den Berg NS, Brouwer OR, Teertstra HJ, Lange CAH, Valdés-Olmos RA, van der Hiel B, Balm AJM, Klop WMC, van Leeuwen FWB. Three-Dimensional Tumor Margin Demarcation Using the Hybrid Tracer Indocyanine Green- 99mTc-Nanocolloid: A Proof-of-Concept Study in Tongue Cancer Patients Scheduled for Sentinel Node Biopsy. J Nucl Med 2018; 60:764-769. [PMID: 30504140 DOI: 10.2967/jnumed.118.220202] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 09/12/2018] [Accepted: 10/26/2018] [Indexed: 12/15/2022] Open
Abstract
For radical resection of squamous cell carcinoma of the oral cavity, a tumor-free margin of at least 5 mm is required. Unfortunately, establishing in-depth margins is a surgical conundrum. Knowing that the hybrid sentinel node (SN) tracer indocyanine green (ICG)-99mTc-nanocolloid generates temporary tattoolike markings at the site of administration, we studied the ability to apply this tracer for tumor margin demarcation combined with SN biopsy. Methods: Nineteen patients with clinical T1-T2 oral tongue tumors received the traditional superficial 3 or 4 deposits of ICG-99mTc-nanocolloid (0.1 mL each), and in 12 patients additional deposits were placed deeply using ultrasound guidance (total of 6; 0.07 mL each). SN mapping was performed using lymphoscintigraphy and SPECT/CT. Before and directly after tumor excision, fluorescence imaging was performed to monitor the tracer deposits in the patient (fluorescent deposits were not used to guide the surgical excision). At pathologic examination, primary tumor samples were studied in detail. Results: The number of tracer depositions did not induce a significant difference in the number of SNs visualized (P = 0.836). Reproducible and deep tracer deposition proved to be challenging. The fluorescent nature of ICG-99mTc-nanocolloid supported in vivo and ex vivo identification of the tracer deposits surrounding the tumor. Pathologic examination indicated that in 66.7% (8/12), all fluorescence was observed within the resection margins. Conclusion: This study indicates that tumor margin demarcation combined with SN identification has potential but that some practical challenges need to be overcome if this technique is to mature as a surgical guidance concept. Future studies need to define whether the technology can improve the radical nature of the resections.
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Affiliation(s)
- Philippa Meershoek
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Head-and-Neck Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Nynke S van den Berg
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Oscar R Brouwer
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - H Jelle Teertstra
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; and
| | - Charlotte A H Lange
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; and
| | - Renato A Valdés-Olmos
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bernies van der Hiel
- Department of Nuclear Medicine, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Alfons J M Balm
- Department of Head-and-Neck Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - W Martin C Klop
- Department of Head-and-Neck Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands .,Department of Head-and-Neck Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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van Keulen S, van den Berg NS, Nishio N, Birkeland A, Zhou Q, Lu G, Wang HW, Middendorf L, Forouzanfar T, Martin BA, Colevas AD, Rosenthal EL. Rapid, non-invasive fluorescence margin assessment: Optical specimen mapping in oral squamous cell carcinoma. Oral Oncol 2018; 88:58-65. [PMID: 30616798 DOI: 10.1016/j.oraloncology.2018.11.012] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/04/2018] [Accepted: 11/07/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Surgical resection remains the primary treatment for the majority of solid tumors. Despite efforts to obtain wide margins, close or positive surgical margins (<5 mm) are found in 15-30% of head and neck cancer patients. Obtaining negative margins requires immediate, intraoperative feedback of margin status. To this end, we propose optical specimen mapping of resected tumor specimens immediately after removal. MATERIALS AND METHODS A first-in-human pilot study was performed in patients (n = 8) after infusion of fluorescently labeled antibody, panitumumab-IRDye800 to allow surgical mapping of the tumor specimen. Patients underwent standard of care surgical resection for head and neck squamous cell carcinoma (HNSCC). Optical specimen mapping was performed on the primary tumor specimen and correlated with pathological findings after tissue processing. RESULTS Optical mapping of the specimen had a 95% sensitivity and 89% specificity to detect cancer within 5 mm (n = 160) of the cut surface. To detect tumor within 2 mm of the specimen surface, the sensitivity of optical specimen mapping was 100%. The maximal observed penetration depth of panitumumab-IRDye800 through human tissue in our study was 6.3 mm. CONCLUSION Optical specimen mapping is a highly sensitive and specific method for evaluation of margins within <5 mm of the tumor mass in HNSCC specimens. This technology has potentially broad applications for ensuring adequate tumor resection and negative margins in head and neck cancers.
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Affiliation(s)
- Stan van Keulen
- Department of Otolaryngology, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA 94305, United States; Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Center/Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, the Netherlands.
| | - Nynke S van den Berg
- Department of Otolaryngology, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA 94305, United States.
| | - Naoki Nishio
- Department of Otolaryngology, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA 94305, United States.
| | - Andrew Birkeland
- Department of Otolaryngology, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA 94305, United States.
| | - Quan Zhou
- Department of Otolaryngology, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA 94305, United States.
| | - Guolan Lu
- Department of Otolaryngology, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA 94305, United States.
| | - Han-Wei Wang
- LI-COR Biosciences, 4647 Superior St, Lincoln, NE 68504, United States
| | - Lyle Middendorf
- LI-COR Biosciences, 4647 Superior St, Lincoln, NE 68504, United States
| | - Tymour Forouzanfar
- Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Center/Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, the Netherlands
| | - Brock A Martin
- Department of Clinical Pathology, Stanford University School of Medicine, 300 Pasteur Dr, Palo Alto, CA 94304, United States.
| | - A Dimitrios Colevas
- Department of Medicine, Division of Medical Oncology, University School of Medicine, 269 Campus Drive, Stanford, CA 94305, United States
| | - Eben L Rosenthal
- Department of Otolaryngology, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford, CA 94305, United States.
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Tummers WS, Warram JM, van den Berg NS, Miller SE, Swijnenburg RJ, Vahrmeijer AL, Rosenthal EL. Recommendations for reporting on emerging optical imaging agents to promote clinical approval. Am J Cancer Res 2018; 8:5336-5347. [PMID: 30555550 PMCID: PMC6276089 DOI: 10.7150/thno.27384] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 08/22/2018] [Indexed: 01/12/2023] Open
Abstract
Intraoperative fluorescence imaging is particularly well-suited for surgical applications due to its inherently high sensitivity, resolution, and ability to provide images in real-time. To date, the intraoperative observation of fluorescence has largely been subjective. With the need to show objective evidence in order to demonstrate the benefit of this technique, quantitative data needs to be provided to overseeing regulatory bodies. Standardization of fluorescence imaging protocols would improve reproducibility and minimize inter- and intra-institution variance. This would allow studies to be conducted using the same injection techniques, imaging times, reconstruction methods, and analyses. Here, we provide recommendations for standardized methodologies with the goal of setting a minimum requirement for reporting fluorescence-guided surgery results based on both qualitative and (semi-) quantitative data collection. Clinical trials using fluorescence-guided surgery should present results of three critical elements; 1) intra-operative imaging, 2) specimen mapping and pathology correlation, and 3) target validation. Qualitative analyses should consist of a bright field image, black-and-white fluorescence image, pseudo-colored fluorescence overlay image, and/or heat-map whereby fluorescence signal intensity differences are displayed on a color spectrum. Quantitative analyses should include 1) intraoperative data (consisting of images or video, raw numeric values and ratios); 2) specimen mapping, for correlation of fluorescence with the presence of disease (performed using fresh tissue); and 3) target validation (designed to determine fluorescence intensity relative to receptor density of a specific area). Including the aforementioned methods of both qualitative and quantitative analyses will ensure that trial results are comparable and could be collated in future studies to expedite FDA approval.
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Gao RW, Teraphongphom NT, van den Berg NS, Martin BA, Oberhelman NJ, Divi V, Kaplan MJ, Hong SS, Lu G, Ertsey R, Tummers WSFJ, Gomez AJ, Holsinger FC, Kong CS, Colevas AD, Warram JM, Rosenthal EL. Determination of Tumor Margins with Surgical Specimen Mapping Using Near-Infrared Fluorescence. Cancer Res 2018; 78:5144-5154. [PMID: 29967260 DOI: 10.1158/0008-5472.can-18-0878] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/03/2018] [Accepted: 06/25/2018] [Indexed: 12/22/2022]
Abstract
For many solid tumors, surgical resection remains the gold standard and tumor-involved margins are associated with poor clinical outcomes. Near-infrared (NIR) fluorescence imaging using molecular agents has shown promise for in situ imaging during resection. However, for cancers with difficult imaging conditions, surgical value may lie in tumor mapping of surgical specimens. We thus evaluated a novel approach for real-time, intraoperative tumor margin assessment. Twenty-one adult patients with biopsy-confirmed squamous cell carcinoma arising from the head and neck (HNSCC) scheduled for standard-of-care surgery were enrolled. Cohort 1 (n = 3) received panitumumab-IRDye800CW at an intravenous microdose of 0.06 mg/kg, cohort 2A (n = 5) received 0.5 mg/kg, cohort 2B (n = 7) received 1 mg/kg, and cohort 3 (n = 6) received 50 mg. Patients were followed 30 days postinfusion and adverse events were recorded. Imaging was performed using several closed- and wide-field devices. Fluorescence was histologically correlated to determine sensitivity and specificity. In situ imaging demonstrated tumor-to-background ratio (TBR) of 2 to 3, compared with ex vivo specimen imaging TBR of 5 to 6. We obtained clear differentiation between tumor and normal tissue, with a 3-fold signal difference between positive and negative specimens (P < 0.05). We achieved high correlation of fluorescence intensity with tumor location with sensitivities and specificities >89%; fluorescence predicted distance of tumor tissue to the cut surface of the specimen. This novel method of detecting tumor-involved margins in surgical specimens using a cancer-specific agent provides highly sensitive and specific, real-time, intraoperative surgical navigation in resections with complex anatomy, which are otherwise less amenable to image guidance.Significance: This study demonstrates that fluorescence can be used as a sensitive and specific method of guiding surgeries for head and neck cancers and potentially other cancers with challenging imaging conditions, increasing the probability of complete resections and improving oncologic outcomes. Cancer Res; 78(17); 5144-54. ©2018 AACR.
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Affiliation(s)
- Rebecca W Gao
- Stanford University School of Medicine, Stanford, California
| | - Nutte T Teraphongphom
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, California
| | - Nynke S van den Berg
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, California
| | - Brock A Martin
- Department of Pathology, Stanford University, Stanford, California
| | - Nicholas J Oberhelman
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, California
| | - Vasu Divi
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, California
| | - Michael J Kaplan
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, California
| | - Steven S Hong
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, California
| | - Guolan Lu
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, California
| | - Robert Ertsey
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, California
| | | | - Adam J Gomez
- Department of Pathology, Stanford University, Stanford, California
| | - F Christopher Holsinger
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, California
| | - Christina S Kong
- Department of Pathology, Stanford University, Stanford, California
| | - Alexander D Colevas
- Department of Medicine, Division of Oncology, Stanford University, Stanford, California
| | - Jason M Warram
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Eben L Rosenthal
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, California.
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Miller SE, Tummers WS, Teraphongphom N, van den Berg NS, Hasan A, Ertsey RD, Nagpal S, Recht LD, Plowey ED, Vogel H, Harsh GR, Grant GA, Li GH, Rosenthal EL. First-in-human intraoperative near-infrared fluorescence imaging of glioblastoma using cetuximab-IRDye800. J Neurooncol 2018; 139:135-143. [PMID: 29623552 PMCID: PMC6031450 DOI: 10.1007/s11060-018-2854-0] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 03/31/2018] [Indexed: 12/31/2022]
Abstract
Introduction Maximizing extent of surgical resection with the least morbidity remains critical for survival in glioblastoma patients, and we hypothesize that it can be improved by enhancements in intraoperative tumor detection. In a clinical study, we determined if therapeutic antibodies could be repurposed for intraoperative imaging during resection. Methods Fluorescently labeled cetuximab-IRDye800 was systemically administered to three patients 2 days prior to surgery. Near-infrared fluorescence imaging of tumor and histologically negative peri-tumoral tissue was performed intraoperatively and ex vivo. Fluorescence was measured as mean fluorescence intensity (MFI), and tumor-to-background ratios (TBRs) were calculated by comparing MFIs of tumor and histologically uninvolved tissue. Results The mean TBR was significantly higher in tumor tissue of contrast-enhancing (CE) tumors on preoperative imaging (4.0 ± 0.5) compared to non-CE tumors (1.2 ± 0.3; p = 0.02). The TBR was higher at a 100 mg dose than at 50 mg (4.3 vs. 3.6). The smallest detectable tumor volume in a closed-field setting was 70 mg with 50 mg of dye and 10 mg with 100 mg. On sections of paraffin embedded tissues, fluorescence positively correlated with histological evidence of tumor. Sensitivity and specificity of tumor fluorescence for viable tumor detection was calculated and fluorescence was found to be highly sensitive (73.0% for 50 mg dose, 98.2% for 100 mg dose) and specific (66.3% for 50 mg dose, 69.8% for 100 mg dose) for viable tumor tissue in CE tumors while normal peri-tumoral tissue showed minimal fluorescence. Conclusion This first-in-human study demonstrates the feasibility and safety of antibody based imaging for CE glioblastomas.
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Affiliation(s)
- Sarah E Miller
- Department of Otolaryngology, Stanford University, Stanford, USA
| | - Willemieke S Tummers
- Department of Radiology, Molecular Imaging Program at Stanford (MIPS), Stanford University, Stanford, USA
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | | | | | - Alifia Hasan
- Department of Otolaryngology, Stanford University, Stanford, USA
| | - Robert D Ertsey
- Department of Otolaryngology, Stanford University, Stanford, USA
| | - Seema Nagpal
- Department of Neurology, Stanford University, Stanford, USA
| | | | | | - Hannes Vogel
- Department of Pathology, Stanford University, Stanford, USA
| | - Griffith R Harsh
- Department of Neurosurgery, Stanford University, Stanford, CA, 94305, USA
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University, Stanford, CA, 94305, USA
| | - Gordon H Li
- Department of Neurosurgery, Stanford University, Stanford, CA, 94305, USA
| | - Eben L Rosenthal
- Department of Otolaryngology, Stanford University, Stanford, USA.
- Stanford Cancer Center, Stanford, CA, USA.
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Gao RW, Teraphongphom N, de Boer E, Berg NSVD, Divi V, Kaplan MJ, Oberhelman NJ, Hong SS, Capes E, Colevas AD, Warram JM, Rosenthal EL. Safety of panitumumab-IRDye800CW and cetuximab-IRDye800CW for fluorescence-guided surgical navigation in head and neck cancers. Am J Cancer Res 2018; 8:2488-2495. [PMID: 29721094 PMCID: PMC5928904 DOI: 10.7150/thno.24487] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/20/2018] [Indexed: 01/24/2023] Open
Abstract
Purpose: To demonstrate the safety and feasibility of leveraging therapeutic antibodies for surgical imaging. Procedures: We conducted two phase I trials for anti-epidermal growth factor receptor antibodies cetuximab-IRDye800CW (n=12) and panitumumab-IRDye800CW (n=15). Adults with biopsy-confirmed head and neck squamous cell carcinoma scheduled for standard-of-care surgery were eligible. For cetuximab-IRDye800CW, cohort 1 was intravenously infused with 2.5 mg/m2, cohort 2 received 25 mg/m2, and cohort 3 received 62.5 mg/m2. For panitumumab-IRDye800CW, cohorts received 0.06 mg/kg, 0.5 mg/kg, and 1 mg/kg, respectively. Electrocardiograms and blood samples were obtained, and patients were followed for 30 days post-study drug infusion. Results: Both fluorescently labeled antibodies had similar pharmacodynamic properties and minimal toxicities. Two infusion reactions occurred with cetuximab and none with panitumumab. There were no grade 2 or higher toxicities attributable to cetuximab-IRDye800CW or panitumumab-IRDye800CW; fifteen grade 1 adverse events occurred with cetuximab-IRDye800CW, and one grade 1 occurred with panitumumab-IRDye800CW. There were no significant differences in QTc prolongation between the two trials (p=0.8). Conclusions: Panitumumab-IRDye800CW and cetuximab-IRDye800CW have toxicity and pharmacodynamic profiles that match the parent compound, suggesting that other therapeutic antibodies may be repurposed as imaging agents with limited preclinical toxicology data.
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KleinJan GH, Karakullukçu B, Klop WMC, Engelen T, van den Berg NS, van Leeuwen FWB. Introducing navigation during melanoma-related sentinel lymph node procedures in the head-and-neck region. EJNMMI Res 2017; 7:65. [PMID: 28819936 PMCID: PMC5560283 DOI: 10.1186/s13550-017-0312-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [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: 06/11/2017] [Accepted: 07/25/2017] [Indexed: 11/10/2022] Open
Abstract
Background Intraoperative sentinel node (SN) identification in patients with head-and-neck malignancies can be challenging due to unexpected drainage patterns and anatomical complexity. Here, intraoperative navigation-based guidance technologies may provide outcome. In this study, gamma camera-based freehandSPECT was evaluated in combination with the hybrid tracer ICG-99mTc-nanocolloid. Materials and methods Eight patients with melanoma located in the head-and-neck area were included. Indocyanine green (ICG)-99mTc-nanocolloid was injected preoperatively, whereafter lymphoscintigraphy and SPECT/CT imaging were performed in order to define the location of the SN(s). FreehandSPECT scans were generated in the operation room using a portable gamma camera. For lesion localization during surgery, freehandSPECT scans were projected in an augmented reality video-view that was used to spatially position a gamma-ray detection probe. Intraoperative fluorescence imaging was used to confirm the accuracy of the navigation-based approach and identify the exact location of the SNs. Results Preoperatively, 15 SNs were identified, of which 14 were identified using freehandSPECT. Navigation towards these nodes using the freehandSPECT approach was successful in 13 nodes. Fluorescence imaging provided optical confirmation of the navigation accuracy in all patients. In addition, fluorescence imaging allowed for the identification of (clustered) SNs that could not be identified based on navigation alone. Conclusions The use of gamma camera-based freehandSPECT aids intraoperative lesion identification and, with that, supports the transition from pre- to intraoperative imaging via augmented reality display and directional guidance.
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Affiliation(s)
- Gijs H KleinJan
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Hospital, Albinusdreef 2, C2-S zone, 9600, 2300 RC, Leiden, the Netherlands.,Department of Nuclear Medicine, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Baris Karakullukçu
- Department of Head and Neck Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - W Martin C Klop
- Department of Head and Neck Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Thijs Engelen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Hospital, Albinusdreef 2, C2-S zone, 9600, 2300 RC, Leiden, the Netherlands
| | - Nynke S van den Berg
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Hospital, Albinusdreef 2, C2-S zone, 9600, 2300 RC, Leiden, the Netherlands.,Department of Head and Neck Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Hospital, Albinusdreef 2, C2-S zone, 9600, 2300 RC, Leiden, the Netherlands. .,Department of Head and Neck Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands.
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van Willigen DM, van den Berg NS, Buckle T, KleinJan GH, Hardwick JC, van der Poel HG, van Leeuwen FWB. Multispectral fluorescence guided surgery; a feasibility study in a phantom using a clinical-grade laparoscopic camera system. Am J Nucl Med Mol Imaging 2017; 7:138-147. [PMID: 28721307 PMCID: PMC5511123] [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] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 06/30/2017] [Indexed: 06/07/2023]
Abstract
Although the possibilities in image guided surgery are advancing rapidly, complex surgical procedures such as nerve sparing prostatectomy still lack precision regarding differentiation between diseased and delicate anatomical structures. Here, the use of complementary fluorescent tracers in combination with a dedicated multispectral fluorescence camera system could support differentiation between healthy and diseased tissue. In this study, we provide proof of concept data indicating how a modified clinical-grade fluorescence laparoscope can be used to sensitively detect white light and three fluorescent dyes (fluorescein, Cy5, and ICG) in a sequential fashion. Following detailed analysis of the system properties and detection capabilities, the potential of laparoscopic three-color multispectral imaging in combination with white light imaging is demonstrated in a phantom set-up for prostate cancer.
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Affiliation(s)
- Danny M van Willigen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical CenterAlbinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Nynke S van den Berg
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical CenterAlbinusdreef 2, 2300 RC, Leiden, The Netherlands
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek HospitalPlesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Tessa Buckle
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical CenterAlbinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Gijs H KleinJan
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical CenterAlbinusdreef 2, 2300 RC, Leiden, The Netherlands
- Department of Nuclear Medicine, The Netherlands Cancer Institute-Antoni van Leeuwenhoek HospitalPlesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - James C Hardwick
- Department of Gastroenterology, Leiden University Medical CenterAlbinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Henk G van der Poel
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek HospitalPlesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Fijs WB van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical CenterAlbinusdreef 2, 2300 RC, Leiden, The Netherlands
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek HospitalPlesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
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Wit EM, Acar C, Grivas N, Yuan C, Horenblas S, Liedberg F, Valdes Olmos RA, van Leeuwen FW, van den Berg NS, Winter A, Wawroschek F, Hruby S, Janetschek G, Vidal-Sicart S, MacLennan S, Lam TB, van der Poel HG. Sentinel Node Procedure in Prostate Cancer: A Systematic Review to Assess Diagnostic Accuracy. Eur Urol 2017; 71:596-605. [DOI: 10.1016/j.eururo.2016.09.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 09/02/2016] [Indexed: 01/08/2023]
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van der Poel HG, Wit EM, Acar C, van den Berg NS, van Leeuwen FWB, Valdes Olmos RA, Winter A, Wawroschek F, Liedberg F, Maclennan S, Lam T. Sentinel node biopsy for prostate cancer: report from a consensus panel meeting. BJU Int 2017; 120:204-211. [DOI: 10.1111/bju.13810] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Esther M. Wit
- Department of Urology; Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Cenk Acar
- Department of Urology; Eryaman Hospital; Ankara Turkey
| | - Nynke S. van den Berg
- Department of Radiology; University of Leiden Medical Centre; Leiden The Netherlands
| | | | | | - Alexander Winter
- Klinikum Oldenburg; School of Medicine and Health Sciences; University Hospital for Urology; Oldenburg Germany
| | - Friedhelm Wawroschek
- Klinikum Oldenburg; School of Medicine and Health Sciences; University Hospital for Urology; Oldenburg Germany
| | - Fredrik Liedberg
- Department of Urology; Skåne University Hospital; Malmö Sweden
- Department of Translational Medicine Lund University; Lund Sweden
| | | | - Thomas Lam
- Academic Urology Unit; University of Aberdeen; Aberdeen UK
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Burgmans MC, den Harder JM, Meershoek P, van den Berg NS, Chan SXJM, van Leeuwen FWB, van Erkel AR. Phantom Study Investigating the Accuracy of Manual and Automatic Image Fusion with the GE Logiq E9: Implications for use in Percutaneous Liver Interventions. Cardiovasc Intervent Radiol 2017; 40:914-923. [PMID: 28204959 PMCID: PMC5409927 DOI: 10.1007/s00270-017-1607-3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 02/03/2017] [Indexed: 01/05/2023]
Abstract
Purpose To determine the accuracy of automatic and manual co-registration methods for image fusion of three-dimensional computed tomography (CT) with real-time ultrasonography (US) for image-guided liver interventions. Materials and Methods CT images of a skills phantom with liver lesions were acquired and co-registered to US using GE Logiq E9 navigation software. Manual co-registration was compared to automatic and semiautomatic co-registration using an active tracker. Also, manual point registration was compared to plane registration with and without an additional translation point. Finally, comparison was made between manual and automatic selection of reference points. In each experiment, accuracy of the co-registration method was determined by measurement of the residual displacement in phantom lesions by two independent observers. Results Mean displacements for a superficial and deep liver lesion were comparable after manual and semiautomatic co-registration: 2.4 and 2.0 mm versus 2.0 and 2.5 mm, respectively. Both methods were significantly better than automatic co-registration: 5.9 and 5.2 mm residual displacement (p < 0.001; p < 0.01). The accuracy of manual point registration was higher than that of plane registration, the latter being heavily dependent on accurate matching of axial CT and US images by the operator. Automatic reference point selection resulted in significantly lower registration accuracy compared to manual point selection despite lower root-mean-square deviation (RMSD) values. Conclusion The accuracy of manual and semiautomatic co-registration is better than that of automatic co-registration. For manual co-registration using a plane, choosing the correct plane orientation is an essential first step in the registration process. Automatic reference point selection based on RMSD values is error-prone.
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Affiliation(s)
- Mark Christiaan Burgmans
- Department of Radiology, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
| | - J Michiel den Harder
- Department of Radiology, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Philippa Meershoek
- Department of Radiology, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Interventional and Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nynke S van den Berg
- Interventional and Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Shaun Xavier Ju Min Chan
- Department of Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Fijs W B van Leeuwen
- Interventional and Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arian R van Erkel
- Department of Radiology, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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KleinJan GH, Hellingman D, van den Berg NS, van Oosterom MN, Hendricksen K, Horenblas S, Valdes Olmos RA, van Leeuwen FWB. Hybrid Surgical Guidance: Does Hardware Integration of γ- and Fluorescence Imaging Modalities Make Sense? J Nucl Med 2016; 58:646-650. [DOI: 10.2967/jnumed.116.177154] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 09/08/2016] [Indexed: 12/31/2022] Open
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Buckle T, KleinJan GH, Engelen T, van den Berg NS, DeRuiter MC, van der Heide U, Valdes Olmos RA, Webb A, van Buchem MA, Balm AJ, van Leeuwen FWB. Diffusion-weighted-preparation (D-prep) MRI as a future extension of SPECT/CT based surgical planning for sentinel node procedures in the head and neck area? Oral Oncol 2016; 60:48-54. [PMID: 27531872 DOI: 10.1016/j.oraloncology.2016.06.015] [Citation(s) in RCA: 10] [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: 04/25/2016] [Revised: 06/18/2016] [Accepted: 06/21/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE Even when guided by SPECT/CT planning of nodal resection in the head-and-neck area is challenging due to the many critical anatomical structures present within the surgical field. In this study the potential of a (SPECT/)MRI-based surgical planning method was explored. Hereby MRI increases the identification of SNs within clustered lymph nodes (LNs) and vital structures located adjacent to the SN (such as cranial nerve branches). METHOD AND PATIENTS SPECT/CT and pathology reports from 100 head-and-neck melanoma and 40 oral cavity cancer patients were retrospectively assessed for SN locations in levels I-V and degree of nodal clustering. A diffusion-weighted-preparation magnetic resonance neurography (MRN) sequence was used in eight healthy volunteers to detect LNs and peripheral nerves. RESULTS In 15% of patients clustered nodes were retrospectively shown to be present at the location where the SN was identified on SPECT/CT (level IIA: 37.2%, level IIB: 21.6% and level III: 15.5%). With MRN, improved LN delineation enabled discrimination of individual LNs within a cluster. Uniquely, this MRI technology also provided insight in LN distribution (23.2±4 LNs per subject) and size (range 21-372mm(3)), and enabled non-invasive assessment of anatomical variances in the location of the LNs and facial nerves. CONCLUSION Diffusion-weighted-preparation MRN enabled improved delineation of LNs and their surrounding delicate anatomical structures in the areas that most often harbor SNs in the head-and-neck. Based on our findings a combined SPECT/MRI approach is envisioned for future surgical planning of complex SN resections in this region.
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Affiliation(s)
- Tessa Buckle
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gijs H KleinJan
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Nuclear Medicine, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Thijs Engelen
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nynke S van den Berg
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Head and Neck Surgery and Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Marco C DeRuiter
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Uulke van der Heide
- Department of Radiotherapy, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Renato A Valdes Olmos
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Nuclear Medicine, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Andrew Webb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alfons J Balm
- Department of Head and Neck Surgery and Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Fijs W B van Leeuwen
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Head and Neck Surgery and Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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van den Berg NS, Buckle T, KleinJan GH, van der Poel HG, van Leeuwen FWB. Multispectral Fluorescence Imaging During Robot-assisted Laparoscopic Sentinel Node Biopsy: A First Step Towards a Fluorescence-based Anatomic Roadmap. Eur Urol 2016; 72:110-117. [PMID: 27345689 DOI: 10.1016/j.eururo.2016.06.012] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [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: 03/18/2016] [Accepted: 06/08/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND During (robot-assisted) sentinel node (SN) biopsy procedures, intraoperative fluorescence imaging can be used to enhance radioguided SN excision. For this combined pre- and intraoperative SN identification was realized using the hybrid SN tracer, indocyanine green-99mTc-nanocolloid. Combining this dedicated SN tracer with a lymphangiographic tracer such as fluorescein may further enhance the accuracy of SN biopsy. OBJECTIVE Clinical evaluation of a multispectral fluorescence guided surgery approach using the dedicated SN tracer ICG-99mTc-nanocolloid, the lymphangiographic tracer fluorescein, and a commercially available fluorescence laparoscope. DESIGN, SETTING, AND PARTICIPANTS Pilot study in ten patients with prostate cancer. Following ICG-99mTc-nanocolloid administration and preoperative lymphoscintigraphy and single-photon emission computed tomograpy imaging, the number and location of SNs were determined. Fluorescein was injected intraprostatically immediately after the patient was anesthetized. A multispectral fluorescence laparoscope was used intraoperatively to identify both fluorescent signatures. SURGICAL PROCEDURE Multispectral fluorescence imaging during robot-assisted radical prostatectomy with extended pelvic lymph node dissection and SN biopsy. MEASUREMENTS (1) Number and location of preoperatively identified SNs. (2) Number and location of SNs intraoperatively identified via ICG-99mTc-nanocolloid imaging. (3) Rate of intraoperative lymphatic duct identification via fluorescein imaging. (4) Tumor status of excised (sentinel) lymph node(s). (5) Postoperative complications and follow-up. RESULTS AND LIMITATIONS Near-infrared fluorescence imaging of ICG-99mTc-nanocolloid visualized 85.3% of the SNs. In 8/10 patients, fluorescein imaging allowed bright and accurate identification of lymphatic ducts, although higher background staining and tracer washout were observed. The main limitation is the small patient population. CONCLUSION Our findings indicate that a lymphangiographic tracer can provide additional information during SN biopsy based on ICG-99mTc-nanocolloid. The study suggests that multispectral fluorescence image-guided surgery is clinically feasible. PATIENT SUMMARY We evaluated the concept of surgical fluorescence guidance using differently colored dyes that visualize complementary features. In the future this concept may provide better guidance towards diseased tissue while sparing healthy tissue, and could thus improve functional and oncologic outcomes.
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Affiliation(s)
- Nynke S van den Berg
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Tessa Buckle
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gijs H KleinJan
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Henk G van der Poel
- Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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KleinJan GH, van den Berg NS, van Oosterom MN, Wendler T, Miwa M, Bex A, Hendricksen K, Horenblas S, van Leeuwen FWB. Toward (Hybrid) Navigation of a Fluorescence Camera in an Open Surgery Setting. J Nucl Med 2016; 57:1650-1653. [PMID: 27230927 DOI: 10.2967/jnumed.115.171645] [Citation(s) in RCA: 28] [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: 12/22/2015] [Accepted: 04/11/2016] [Indexed: 01/15/2023] Open
Abstract
With the introduction of the hybrid tracer indocyanine green (ICG)-99mTc-nanocolloid, a direct relation between preoperative imaging and intraoperative fluorescence guidance was established. However, fluorescence guidance remains limited by its superficial nature. This study evaluated the feasibility of a nuclear medicine-based navigation concept that allowed intraoperative positioning of a fluorescence camera (FC) in the vicinity of preoperatively defined ICG-99mTc-nanocolloid containing sentinel nodes (SNs). METHODS Five patients with penile cancer scheduled for SN biopsy were injected with ICG-99mTc-nanocolloid followed by preoperative SPECT/CT imaging. The navigation device was used to provide a real-time augmented reality overlay of the SPECT/CT images and video output of the FC. This overlay was then used for FC navigation. RESULTS SPECT/CT identified 13 SNs in 9 groins. FC navigation was successful for all 12 intraoperatively evaluated SNs (average error, 8.8 mm; range, 0-20 mm). CONCLUSION This study reveals the potential benefits of FC navigation during open surgery procedures.
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Affiliation(s)
- Gijs H KleinJan
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands Department of Nuclear Medicine, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Nynke S van den Berg
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Matthias N van Oosterom
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas Wendler
- Institut für Informatik, Computer Aided Medical Procedures (CAMP), Technische Universität München, Munich, Germany SurgicEye GmbH, Munich, Germany; and
| | - Mitsuharu Miwa
- Business Incubator, Development Center, Hamamatsu Photonics K.K., Hamamatsu City, Japan
| | - Axel Bex
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Kees Hendricksen
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Simon Horenblas
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Bunschoten A, van Willigen DM, Buckle T, van den Berg NS, Welling MM, Spa SJ, Wester HJ, van Leeuwen FWB. Tailoring Fluorescent Dyes To Optimize a Hybrid RGD-Tracer. Bioconjug Chem 2016; 27:1253-8. [PMID: 27074375 DOI: 10.1021/acs.bioconjchem.6b00093] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Quantitative assessment of affinity and kinetics is a critical component in the development of (receptor-targeted) radiotracers. For fluorescent tracers, such an assessment is currently not yet applied, while (small) changes in chemical composition of the fluorescent component might have substantial influence on the overall properties of a fluorescent tracer. Hybrid imaging labels that contain both a radiolabel and a fluorescent dye can be used to evaluate both the affinity (fluorescent label) and the in vivo distribution (radiolabel) of a targeted tracer. We present a hybrid label oriented and matrix-based scoring approach that enabled quantitative assessment of the influence of (overall) charge and lipophilicity of the fluorescent label on the (in vivo) characteristics of αvβ3-integrin targeted tracers. Systematic chemical alterations in the fluorescent dye were shown to result in a clear difference in the in vivo distribution of the different hybrid tracers. The applied evaluation technique resulted in an optimized targeted tracer for αvβ3-integrin, which combined the highest T/M ratio with the lowest uptake in other organs. Obviously this selection concept would also be applicable during the development of other (receptor-targeted) imaging tracers.
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Affiliation(s)
- Anton Bunschoten
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center , Albinusdreef 2, PO BOX 9600, 2300 RC, Leiden, The Netherlands
| | - Danny M van Willigen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center , Albinusdreef 2, PO BOX 9600, 2300 RC, Leiden, The Netherlands
| | - Tessa Buckle
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center , Albinusdreef 2, PO BOX 9600, 2300 RC, Leiden, The Netherlands
| | - Nynke S van den Berg
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center , Albinusdreef 2, PO BOX 9600, 2300 RC, Leiden, The Netherlands.,Departments of Urology and Head and Neck Surgery & Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital , Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Mick M Welling
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center , Albinusdreef 2, PO BOX 9600, 2300 RC, Leiden, The Netherlands
| | - Silvia J Spa
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center , Albinusdreef 2, PO BOX 9600, 2300 RC, Leiden, The Netherlands
| | - Hans-Jürgen Wester
- Pharmaceutical Radiochemistry, Faculties of Chemistry and Medicine, Technische Universität München , 85748 Garching, Germany
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center , Albinusdreef 2, PO BOX 9600, 2300 RC, Leiden, The Netherlands.,Departments of Urology and Head and Neck Surgery & Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital , Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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KleinJan GH, Bunschoten A, van den Berg NS, Olmos RAV, Klop WMC, Horenblas S, van der Poel HG, Wester HJ, van Leeuwen FWB. Fluorescence guided surgery and tracer-dose, fact or fiction? Eur J Nucl Med Mol Imaging 2016; 43:1857-67. [PMID: 27020580 PMCID: PMC4969335 DOI: 10.1007/s00259-016-3372-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [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: 12/22/2015] [Accepted: 03/11/2016] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Fluorescence guidance is an upcoming methodology to improve surgical accuracy. Challenging herein is the identification of the minimum dose at which the tracer can be detected with a clinical-grade fluorescence camera. Using a hybrid tracer such as indocyanine green (ICG)-(99m)Tc-nanocolloid, it has become possible to determine the accumulation of tracer and correlate this to intraoperative fluorescence-based identification rates. In the current study, we determined the lower detection limit of tracer at which intraoperative fluorescence guidance was still feasible. METHODS Size exclusion chromatography (SEC) provided a laboratory set-up to analyze the chemical content and to simulate the migratory behavior of ICG-nanocolloid in tissue. Tracer accumulation and intraoperative fluorescence detection findings were derived from a retrospective analysis of 20 head-and-neck melanoma patients, 40 penile and 20 prostate cancer patients scheduled for sentinel node (SN) biopsy using ICG-(99m)Tc-nanocolloid. In these patients, following tracer injection, single photon emission computed tomography fused with computed tomography (SPECT/CT) was used to identify the SN(s). The percentage injected dose (% ID), the amount of ICG (in nmol), and the concentration of ICG in the SNs (in μM) was assessed for SNs detected on SPECT/CT and correlated with the intraoperative fluorescence imaging findings. RESULTS SEC determined that in the hybrid tracer formulation, 41 % (standard deviation: 12 %) of ICG was present in nanocolloid-bound form. In the SNs detected using fluorescence guidance a median of 0.88 % ID was present, compared to a median of 0.25 % ID in the non-fluorescent SNs (p-value < 0.001). The % ID values could be correlated to the amount ICG in a SN (range: 0.003-10.8 nmol) and the concentration of ICG in a SN (range: 0.006-64.6 μM). DISCUSSION The ability to provide intraoperative fluorescence guidance is dependent on the amount and concentration of the fluorescent dye accumulated in the lesion(s) of interest. Our findings indicate that intraoperative fluorescence detection with ICG is possible above a μM concentration.
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Affiliation(s)
- Gijs H KleinJan
- Interventional Molecular Imaging Laboratory, Department of Radiology, C2-S zone, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Department of Nuclear Medicine, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Anton Bunschoten
- Interventional Molecular Imaging Laboratory, Department of Radiology, C2-S zone, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Nynke S van den Berg
- Interventional Molecular Imaging Laboratory, Department of Radiology, C2-S zone, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Renato A Valdès Olmos
- Interventional Molecular Imaging Laboratory, Department of Radiology, C2-S zone, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Department of Nuclear Medicine, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - W Martin C Klop
- Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Simon Horenblas
- Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Henk G van der Poel
- Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Hans-Jürgen Wester
- Pharmaceutical Radiochemistry, Technical University Munich, Walther-Meißner-Str. 3, 85748, Garching, Germany
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, C2-S zone, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands. .,Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands. .,Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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van den Berg NS, Miwa M, KleinJan GH, Sato T, Maeda Y, van Akkooi ACJ, Horenblas S, Karakullukcu B, van Leeuwen FWB. (Near-Infrared) Fluorescence-Guided Surgery Under Ambient Light Conditions: A Next Step to Embedment of the Technology in Clinical Routine. Ann Surg Oncol 2016; 23:2586-95. [PMID: 27020586 PMCID: PMC4927603 DOI: 10.1245/s10434-016-5186-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [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: 11/29/2015] [Indexed: 12/02/2022]
Abstract
Background and Purpose In open surgery procedures, after temporarily dimming the lights in the operation theatre, the Photo Dynamic Eye (PDE) fluorescence camera has, amongst others, been used for fluorescence-guided sentinel node (SN) biopsy procedures. To improve the clinical utility and logistics of fluorescence-guided surgery, we developed and evaluated a prototype modified PDE (m-PDE) fluorescence camera system. Methods The m-PDE works under ambient light conditions and includes a white light mode and a pseudo-green-colored fluorescence mode (including a gray-scaled anatomical background). Twenty-seven patients scheduled for SN biopsy for (head and neck) melanoma (n = 16), oral cavity (n = 6), or penile (n = 5) cancer were included. The number and location of SNs were determined following an indocyanine green-99mTc-nanocolloid injection and preoperative imaging. Intraoperatively, fluorescence guidance was used to visualize the SNs. The m-PDE and conventional PDE were compared head-to-head in a phantom study, and in seven patients. In the remaining 20 patients, only the m-PDE was evaluated. Results Phantom study: The m-PDE was superior over the conventional PDE, with a detection sensitivity of 1.20 × 10−11 M (vs. 3.08 × 10−9 M) ICG in human serum albumin. In the head-to-head clinical comparison (n = 7), the m-PDE was also superior: (i) SN visualization: 100 versus 81.4 %; (ii) transcutaneous SN visualization: 40.7 versus 22.2 %; and (iii) lymphatic duct visualization: 7.4 versus 0 %. Findings were further underlined in the 20 additionally included patients. Conclusion The m-PDE enhanced fluorescence imaging properties compared with its predecessor, and provides a next step towards routine integration of real-time fluorescence guidance in open surgery. Electronic supplementary material The online version of this article (doi:10.1245/s10434-016-5186-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nynke S van den Berg
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Mitsuharu Miwa
- Business Incubator, Development Center, Hamamatsu Photonics K.K., Hamamatsu, Japan
| | - Gijs H KleinJan
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Nuclear Medicine, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Takayuki Sato
- Business Incubator, Development Center, Hamamatsu Photonics K.K., Hamamatsu, Japan
| | - Yoshiki Maeda
- Planning and Project Group, Business Planning and Development, Hamamatsu Photonics K.K., Hamamatsu, Japan
| | - Alexander C J van Akkooi
- Department of Surgical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Simon Horenblas
- Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Baris Karakullukcu
- Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands. .,Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands. .,Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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Fuerst B, Sprung J, Pinto F, Frisch B, Wendler T, Simon H, Mengus L, van den Berg NS, van der Poel HG, van Leeuwen FWB, Navab N. First Robotic SPECT for Minimally Invasive Sentinel Lymph Node Mapping. IEEE Trans Med Imaging 2016; 35:830-838. [PMID: 26561283 DOI: 10.1109/tmi.2015.2498125] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
In this paper we present the usage of a drop-in gamma probe for intra-operative Single-Photon Emission Computed Tomography (SPECT) imaging in the scope of minimally invasive robot-assisted interventions. The probe is designed to be inserted and reside inside the abdominal cavity during the intervention. It is grasped during the procedure using a robotic laparoscopic gripper enabling full six degrees of freedom handling by the surgeon. We demonstrate the first deployment of the tracked probe for intra-operative in-patient robotic SPECT enabling augmented-reality image guidance. The hybrid mechanical- and image-based in-patient probe tracking is shown to have an accuracy of 0.2 mm. The overall system performance is evaluated and tested with a phantom for gynecological sentinel lymph node interventions and compared to ground-truth data yielding a mean reconstruction accuracy of 0.67 mm.
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