1
|
Bou-Samra P, Kennedy GT, Chang A, Guo E, Azari FS, Din A, Santini JT, Bensen ES, Singhal S. Phase 2 Clinical Trial of VGT-309 for Intraoperative Molecular Imaging During Pulmonary Resection. Ann Thorac Surg 2024:S0003-4975(24)00396-5. [PMID: 38823756 DOI: 10.1016/j.athoracsur.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/23/2024] [Accepted: 05/06/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Advances in intraoperative molecular imaging (IMI) may improve surgical outcomes when resecting tumors in the lung. A single-center trial was conducted using VGT-309, a cathepsin-targeted near-infrared imaging agent that causes lung nodules to fluoresce during surgical resection. The end point of this phase 2 study was to evaluate the frequency that IMI with VGT-309 resulted in a clinically significant event (CSE): localization of pulmonary nodules, discovery of unsuspected additional cancers, or identification of positive margins. METHODS Patients undergoing surgical resection for known or suspected cancer in the lung received VGT-309 (0.32 mg/kg) preoperatively. During the surgical procedure, localization and resection of the nodules were performed using standard surgical techniques. Near-infrared imaging was then used to localize nodules, seek occult lesions, and assess resection margins. Efficacy was measured by the frequency of CSEs. RESULTS Of the 40 patients who underwent pulmonary resection with VGT-309, 17 (42.5%) had at least 1 CSE. Near-infrared imaging identified lesions not found by standard surgical methods in 16 patients, additional cancers not found by preoperative imaging in 1 patient, and margins within 5 mm of the closest staple line in 2 patients. VGT-309 performance was tested across a broad range of tumor types and commercial near-infrared imaging systems. VGT-309 appeared safe, well-tolerated, with no infusion reactions, and no drug-related serious adverse events. CONCLUSIONS This phase 2 study demonstrated the utility of IMI with VGT-309 in localizing pulmonary nodules, recognizing synchronous lesions, and identifying positive margins. A multi-institutional study will further evaluate the efficacy of VGT-309.
Collapse
Affiliation(s)
- Patrick Bou-Samra
- Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania
| | - Gregory T Kennedy
- Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania
| | - Austin Chang
- Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania
| | - Emily Guo
- Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania
| | - Feredun S Azari
- Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania
| | - Azra Din
- Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania
| | | | | | - Sunil Singhal
- Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania.
| |
Collapse
|
2
|
Li C, Li C, Zhou J, Wang Y, Wu H, Xu L, Li Y, Sui X, Jiang G, Li Y, Hu Z, Tian J, Yang F. Application of Epithelial Growth Factor Receptor-Targeted Magnetic Resonance Imaging and Near-Infrared II Dual-Modal Probe in Lung Cancer Diagnosis and Surgical Resection. Mol Pharm 2024. [PMID: 38686930 DOI: 10.1021/acs.molpharmaceut.3c01137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
There has been an increase in the use of molecular probe diagnostic techniques for lung cancer, and magnetic resonance imaging (MRI) offers specific advantages for diagnosing pulmonary carcinoma. Furthermore, advancements in near-infrared II (NIR-II) fluorescence have provided a new method for precise intraoperative tumor resection. However, few probes combine preoperative diagnosis with intraoperative imaging. This study aims to fill this research void by employing a dual-modal probe that targets the epidermal growth factor receptor for MR and NIR-II imaging, enabling the preoperative diagnosis of lung cancer using MRI and precise intraoperative tumor localization using NIR-II with a single probe. The imaging effects and targeting ability of the probe were confirmed in cell lines, mouse models, and clinical samples. The MR signal decreased within 24 h in the patient-derived xenograft mouse model. The average signal-to-background ratio of NIR-II reached 3.98 ± 0.27. The clinical sample also showed a decrease in the T2 signal using MRI, and the NIR-II optical signal-to-background ratio was 3.29. It is expected that this probe can improve the diagnostic rate of lung cancer using MRI and enable precise intraoperative tumor resection using NIR-II.
Collapse
Affiliation(s)
- Chao Li
- Peking University People's Hospital, 11 Xizhimen South Street, Beijing 100044, China
| | - Changjian Li
- School of Engineering Medicine, Beihang University, Beijing 100191, China
- Key Laboratory of Big Data-Based Precision Medicine (Beihang University), Ministry of Industry and Information Technology, Beijing 100191, China
| | - Jian Zhou
- Peking University People's Hospital, 11 Xizhimen South Street, Beijing 100044, China
| | - Yueqi Wang
- CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing 100190, China
| | - Hainan Wu
- School of Engineering Medicine, Beihang University, Beijing 100191, China
| | - Luzheng Xu
- Peking University Medical and Health Analysis Center, Beijing 100191, China
| | - Yifeng Li
- School of Engineering Medicine, Beihang University, Beijing 100191, China
| | - Xizhao Sui
- Peking University People's Hospital, 11 Xizhimen South Street, Beijing 100044, China
| | - Guanchao Jiang
- Peking University People's Hospital, 11 Xizhimen South Street, Beijing 100044, China
| | - Yun Li
- Peking University People's Hospital, 11 Xizhimen South Street, Beijing 100044, China
| | - Zhenhua Hu
- CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing 100190, China
| | - Jie Tian
- School of Engineering Medicine, Beihang University, Beijing 100191, China
- Key Laboratory of Big Data-Based Precision Medicine (Beihang University), Ministry of Industry and Information Technology, Beijing 100191, China
- CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing 100190, China
| | - Fan Yang
- Peking University People's Hospital, 11 Xizhimen South Street, Beijing 100044, China
| |
Collapse
|
3
|
Sarkaria IS, Martin LW, Rice DC, Blackmon SH, Slade HB, Singhal S. Pafolacianine for intraoperative molecular imaging of cancer in the lung: The ELUCIDATE trial. J Thorac Cardiovasc Surg 2023; 166:e468-e478. [PMID: 37019717 DOI: 10.1016/j.jtcvs.2023.02.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 12/06/2022] [Accepted: 02/12/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE The study objective was to determine the clinical utility of pafolacianine, a folate receptor-targeted fluorescent agent, in revealing by intraoperative molecular imaging folate receptor α positive cancers in the lung and narrow surgical margins that may otherwise be undetected with conventional visualization. METHODS In this Phase 3, 12-center trial, 112 patients with suspected or biopsy-confirmed cancer in the lung scheduled for sublobar pulmonary resection were administered intravenous pafolacianine within 24 hours before surgery. Participants were randomly assigned to surgery with or without intraoperative molecular imaging (10:1 ratio). The primary end point was the proportion of participants with a clinically significant event, reflecting a meaningful change in the surgical operation. RESULTS No drug-related serious adverse events occurred. One or more clinically significant event occurred in 53% of evaluated participants compared with a prespecified limit of 10% (P < .0001). In 38 participants, at least 1 event was a margin 10 mm or less from the resected primary nodule (38%, 95% confidence interval, 28.5-48.3), 32 being confirmed by histopathology. In 19 subjects (19%, 95% confidence interval, 11.8-28.1), intraoperative molecular imaging located the primary nodule that the surgeon could not locate with white light and palpation. Intraoperative molecular imaging revealed 10 occult synchronous malignant lesions in 8 subjects (8%, 95% confidence interval, 3.5-15.2) undetected using white light. Most (73%) intraoperative molecular imaging-discovered synchronous malignant lesions were outside the planned resection field. A change in the overall scope of surgical procedure occurred for 29 of the subjects (22 increase, 7 decrease). CONCLUSIONS Intraoperative molecular imaging with pafolacianine improves surgical outcomes by identifying occult tumors and close surgical margins.
Collapse
Affiliation(s)
- Inderpal S Sarkaria
- University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Linda W Martin
- University of Virginia Medical School, Charlottesville, Va
| | - David C Rice
- The University of Texas MD Anderson Cancer Center, Houston, Tex
| | | | - Herbert B Slade
- Deptartment of Pediatrics, University of North Texas Health Science Center, Fort Worth, Tex
| | - Sunil Singhal
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa.
| |
Collapse
|
4
|
Wong LY, Lui NS. Intraoperative Molecular Imaging of Lung Cancer. Thorac Surg Clin 2023; 33:227-232. [PMID: 37414478 DOI: 10.1016/j.thorsurg.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Intraoperative molecular imaging innovations have been propelled by the development of fluorescent contrast agents that specifically target tumor tissues and advanced camera systems that can detect the specified fluorescence. The most promising agent to date is OTL38, a targeted and near-infrared agent that was recently approved by the Food and Drug Administration for intraoperative imaging for lung cancer.
Collapse
Affiliation(s)
- Lye-Yeng Wong
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Falk Building, Stanford, CA 94305, USA. https://twitter.com/LyeYengWongMD
| | - Natalie S Lui
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Falk Building, Stanford, CA 94305, USA.
| |
Collapse
|
5
|
Pini C, Picchio M, Mapelli P. Optical imaging in lung cancer-follow the light, towards molecular imaging-guided precision surgery. Eur J Nucl Med Mol Imaging 2023; 50:2244-2245. [PMID: 37178352 DOI: 10.1007/s00259-023-06267-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Affiliation(s)
- Cristiano Pini
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
- Nuclear Medicine Department, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Maria Picchio
- Nuclear Medicine Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Paola Mapelli
- Nuclear Medicine Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
6
|
Kennedy GT, Azari FS, Chang A, Nadeem B, Bernstein E, Segil A, Din A, Desphande C, Okusanya O, Keating J, Predina J, Newton A, Kucharczuk JC, Singhal S. Single-institution experience of 500 pulmonary resections guided by intraoperative molecular imaging. J Thorac Cardiovasc Surg 2023; 165:1928-1938.e1. [PMID: 36863974 PMCID: PMC10311075 DOI: 10.1016/j.jtcvs.2022.12.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 12/04/2022] [Accepted: 12/06/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Intraoperative molecular imaging (IMI) using tumor-targeted optical contrast agents can improve thoracic cancer resections. There are no large-scale studies to guide surgeons in patient selection or imaging agent choice. Here, we report our institutional experience with IMI for lung and pleural tumor resection in 500 patients over a decade. METHODS Between December 2011 and November 2021, patients with lung or pleural nodules undergoing resection were preoperatively infused with 1 of 4 optical contrast tracers: EC17, TumorGlow, pafolacianine, or SGM-101. Then, during resection, IMI was used to identify pulmonary nodules, confirm margins, and identify synchronous lesions. We retrospectively reviewed patient demographic data, lesion diagnoses, and IMI tumor-to-background ratios (TBRs). RESULTS Five hundred patients underwent resection of 677 lesions. We found that there were 4 types of clinical utility of IMI: detection of positive margins (n = 32, 6.4% of patients), identification of residual disease after resection (n = 37, 7.4%), detection of synchronous cancers not predicted on preoperative imaging (n = 26, 5.2%), and minimally invasive localization of nonpalpable lesions (n = 101 lesions, 14.9%). Pafolacianine was most effective for adenocarcinoma-spectrum malignancies (mean TBR, 2.84), and TumorGlow was most effective for metastatic disease and mesothelioma (TBR, 3.1). False-negative fluorescence was primarily seen in mucinous adenocarcinomas (mean TBR, 1.8), heavy smokers (>30 pack years; TBR, 1.9), and tumors greater than 2.0 cm from the pleural surface (TBR, 1.3). CONCLUSIONS IMI may be effective in improving resection of lung and pleural tumors. The choice of IMI tracer should vary by the surgical indication and the primary clinical challenge.
Collapse
Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Ashley Chang
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Bilal Nadeem
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Alix Segil
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Azra Din
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | | | - Jane Keating
- Department of Surgery, Hartford Hospital, Hartford, Conn
| | - Jarrod Predina
- Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Andrew Newton
- Department of Surgery, MD Anderson Cancer Center, Houston, Tex
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa.
| |
Collapse
|
7
|
Romao RLP, van der Steeg AFW, Malek M, Irtan S, Gow K, Ghandour K, Biasoni D, Davidoff A, Pachl M. Technical advances in the surgical management of Wilms tumors in children. Pediatr Blood Cancer 2023; 70 Suppl 2:e30267. [PMID: 36815577 DOI: 10.1002/pbc.30267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/19/2022] [Accepted: 01/11/2023] [Indexed: 02/24/2023]
Abstract
Surgery is one of the cornerstones of Wilms tumor treatment. In this article, we present technical advancements that are finding their way into the armamentarium of pediatric cancer surgeons. We discuss the current approaches, challenges, opportunities, and future directions of minimally invasive surgery (laparoscopic and robotics), image-guided surgery, and fluorescence-guided surgery. Furthermore, we discuss the use of intraoperative ultrasonography, as well as the use of new techniques to improve the quality of lymph node sampling.
Collapse
Affiliation(s)
- Rodrigo L P Romao
- Departments of Surgery and Urology, IWK Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alida F W van der Steeg
- Department of Pediatric Surgery, Princess Maxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Marcus Malek
- Division of Pediatric General and Thoracic Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sabine Irtan
- Department of Visceral and Neonatal Pediatric Surgery, Sorbonne Université, Armand-Trousseau Hospital - APHP, Paris, France
| | - Kenneth Gow
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Khalil Ghandour
- Department of Surgery, King Hussein Cancer Foundation and Center, Amman, Jordan
| | - David Biasoni
- Department of Pediatric Surgery, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Andrew Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Max Pachl
- Department of Pediatric Surgery, Birmingham Women's and Children's Hospital, Birmingham, UK
| |
Collapse
|
8
|
Azari F, Kennedy G, Bernstein E, Delikatny J, Lee JYK, Kucharczuk J, Low PS, Singhal S. Evaluation of OTL38-Generated Tumor-to-Background Ratio in Intraoperative Molecular Imaging-Guided Lung Cancer Resections. Mol Imaging Biol 2023; 25:85-96. [PMID: 34101106 PMCID: PMC8651846 DOI: 10.1007/s11307-021-01618-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/19/2021] [Accepted: 05/23/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Cancer surgery has multiple challenges including localizing small lesions, ensuring negative margins, and identifying synchronous cancers. One of the tools proposed to address these issues is intraoperative molecular imaging (IMI). An important consideration in IMI is the quantification of the tumor fluorescence during the procedure and using that data to add clinical value. Currently, the most commonly cited measure of quantification is the tumor-to-background ratio (TBR). Our goal was to evaluate the clinical value of TBR measured with OTL38 NIR tracer during a lung cancer resection. METHODS Intraoperative data was retrospectively reviewed from a prospectively collected 5-year database. Between 2015 and 2020, 279 patients were included in the study. For standardization, all patients underwent infusion of the same targeted molecular optical contrast agent (OTL38) for lung cancer resections; then, the mean fluorescence intensity of the tumors and background tissues were calculated. To evaluate the clinical efficacy of the TBR calculation, the results were correlated with patient, biologic, tumor, and technological factors. RESULTS For pulmonary surgery, patient factors such as gender, age, smoking history, and time from infusion of OTL38 to surgery did not have any statistical significance in predicting the TBR during surgery. In addition, TBR measurements did not correlate with location of the tumor in the lung (p = 0.123). There was no statistical correlation of preoperative positron emission tomography measurements (standardized uptake value) with intraoperative TBR. However, there was statistically significant negative correlation of in situ TBR measurement and the distance of the lesion from the surface of the organ (p < 0.001). Adenocarcinoma spectrum lesions overall had statistically significant correlation with in situ fluorescence compared to other NSCLC malignancies (p < 0.01) but TBR measurements could not identify histopathologic subtype on univariate analysis (p = 0.089). There was a tendency for in situ fluorescence for moderately and well-differentiated adenocarcinoma spectrum lesions, but this was not statistically significant. When comparing the in situ TBR of benign to malignant nodules in the lung, there was no statistically significant association (p = 0.145). In subset analysis, adenocarcinoma spectrum lesions tend to fluoresce at brighter with OTL38 compared to other histologic subtypes. CONCLUSION In our various iterations, the results of our retrospective analysis did not show that TBR measurements during OTL38-guided surgery provide clinically useful information about the nature of the nodule or cancer. The true value of IMI is in the ability for the surgeon to use the fluorescence to guide the surgeon to the tumor and margins, but that sophisticated quantification of the amount of fluorescence may not have clinical utility.
Collapse
Affiliation(s)
- Feredun Azari
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Gregory Kennedy
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Elizabeth Bernstein
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - James Delikatny
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - John Kucharczuk
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Phil S Low
- Department of Chemistry, Purdue University, West Lafayette, IN, USA
| | - Sunil Singhal
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA.
| |
Collapse
|
9
|
Kennedy GT, Azari FS, Bernstein E, Deshpande C, Kucharczuk JC, Delikatny EJ, Singhal S. Three-Dimensional Near-Infrared Specimen Mapping Can Identify the Distance from the Tumor to the Surgical Margin During Resection of Pulmonary Ground Glass Opacities. Mol Imaging Biol 2023; 25:203-211. [PMID: 35831734 PMCID: PMC10237678 DOI: 10.1007/s11307-022-01750-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lung cancers can recur locally due to inadequate resection margins. Achieving adequate margin distances is challenging in pulmonary ground glass opacities (GGOs) because they are not easily palpable. To improve margin assessment during resection of GGOs, we propose a novel technique, three-dimensional near-infrared specimen mapping (3D-NSM). METHODS Twenty patients with a cT1 GGO were enrolled and received a fluorescent tracer preoperatively. After resection, specimens underwent 3D-NSM in the operating room. Margins were graded as positive or negative based upon fluorescence at the staple line. Images were analyzed using ImageJ to quantify the distance from the tumor edge to the nearest staple line. This margin distance calculated by 3D-NSM was compared to the margin distance reported on final pathology several days postoperatively. RESULTS 3D-NSM identified 20/20 GGOs with no false positive or false negative diagnoses. Mean fluorescence intensity for lesions was 110.92 arbitrary units (A.U.) (IQR: 77.77-122.03 A.U.) compared to 23.68 A.U. (IQR: 19.60-27.06 A.U.) for background lung parenchyma (p < 0.0001). There were 4 tumor-positive or close margins in the study cohort, and all 4 (100%) were identified by 3D-NSM. 3D-NSM margin distances were nearly identical to margin distances reported on final pathology (R2 = 0.9362). 3D-NSM slightly under-predicted margin distance, and the median difference in margins was 1.9 mm (IQR 0.5-4.3 mm). CONCLUSIONS 3D-NSM rapidly localizes GGOs by fluorescence and detects tumor-positive or close surgical margins. 3D-NSM can accurately quantify the resection margin distance as compared to formal pathology, which allows surgeons to rapidly determine whether sublobar resection margin distances are adequate.
Collapse
Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Charuhas Deshpande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Edward J Delikatny
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA.
| |
Collapse
|
10
|
Azari F, Kennedy G, Chang A, Nadeem B, Sullivan N, Marfatia I, Din A, Desphande C, Kucharczuk J, Delikatny EJ, Singhal S. Presence of non-Newtonian fluid in invasive pulmonary mucinous adenocarcinomas impacts fluorescence during intraoperative molecular imaging of lung cancer. Eur J Nucl Med Mol Imaging 2022; 49:4406-4418. [PMID: 35876868 PMCID: PMC10292759 DOI: 10.1007/s00259-022-05912-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/10/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intraoperative molecular imaging (IMI) with folate-targeted NIR tracers has been shown to improve lesion localization in more than 80% of lung adenocarcinomas. However, mucinous adenocarcinomas (MAs) and invasive mucinous adenocarcinomas (IMAs) of the lung, which are variants of adenocarcinoma, appear to have decreased fluorescence despite appropriate folate receptor expression on the tumor surface. We hypothesized that the etiology may be related to light excitation and emission through non-Newtonian fluid (mucin) produced by goblet and columnar cancer cells. METHODS Intraoperative data for 311 subjects were retrospectively reviewed from a prospectively collected 6-year database. For standardization, all patients underwent infusion of the same targeted molecular optical contrast agent (pafolacianine, folate receptor-targeted NIR fluorochrome) for lung cancer resections. Then, the ratio of the mean fluorescence intensity of the tumors and background tissues (TBR) was calculated. Tumors were examined for mucin, FRa, FRb, and immunofluorescent tracer uptake by a board-certified pathologist. The optical properties of mucin analyzed by imaging software were used to create in vitro gel models to explore the effects on NIR tracer fluorescence intensity. RESULTS A large proportion (192, 62%) of the patients were female, with an average of 62.8 years and a 34-year mean pack smoking history. There were no severe (Clavien-Dindo > III) complications related to pafolacianine infusion. A total of 195 lesions in the study were adenocarcinomas, of which 19 (6.1%) were of the mucinous subtype. A total of 14/19 of the patients had a smoking history, and more than 74% of the IMA lesions were in the lower lobes. IMA lesions had a lower in situ TBR than nonmucinous adenocarcinomas (2.64 SD 0.23) vs (3.45 SD 0.11), respectively (p < 0.05). Only 9/19 (47%) were localized in situ. Tumor bisection and removal of mucin from IMAs significantly increased pafolacianine fluorescence, with resultant TBR not being significantly different from the control group (4.67 vs 4.89) (p = 0.19). Of the 16 lesions that underwent FR expression analysis, 15/16 had FR presence on cancer cells or tumor-associated macrophages in the tumor microenvironment. There was no statistically significant difference in fluorescence intensity during immunofluorescence analysis (4.99 vs 5.08) (p = 0.16). Physical removal of mucin from IMAs improved the TBR from 3.11 to 4.67 (p < 0.05). In vitro analysis of the impact of synthetic non-Newtonian fluid (agarose 0.5%) on NIR tracer fluorescence showed a decrease in MFI by a factor of 0.25 regardless of the concentration for each 5 mm thickness of mucin. CONCLUSION The mucinous subtype of lung adenocarcinomas presents a unique challenge in pafolacianine-targeted IMI-guided resections. The presence of non-Newtonian fluids presents a physical barrier that dampens the excitation of the tracer and fluorescence emission detected by the camera. Knowledge of this phenomenon can allow the surgeon to critically analyze lesion fluorescence parameters during IMI-guided lung cancer resections.
Collapse
Affiliation(s)
- Feredun Azari
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Gregory Kennedy
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Ashley Chang
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Bilal Nadeem
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Neil Sullivan
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Isvita Marfatia
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Azra Din
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Charuhas Desphande
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - John Kucharczuk
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Edward J Delikatny
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA.
| |
Collapse
|
11
|
Alicuben ET, Levesque RL, Ashraf SF, Christie NA, Awais O, Sarkaria IS, Dhupar R. State of the Art in Lung Nodule Localization. J Clin Med 2022; 11:6317. [PMID: 36362543 PMCID: PMC9656162 DOI: 10.3390/jcm11216317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/22/2022] [Accepted: 10/25/2022] [Indexed: 11/04/2023] Open
Abstract
Lung nodule and ground-glass opacity localization for diagnostic and therapeutic purposes is often a challenge for thoracic surgeons. While there are several adjuncts and techniques in the surgeon's armamentarium that can be helpful, accurate localization persists as a problem without a perfect solution. The last several decades have seen tremendous improvement in our ability to perform major operations with minimally invasive procedures and resulting lower morbidity. However, technological advances have not been as widely realized for lung nodule localization to complement minimally invasive surgery. This review describes the latest advances in lung nodule localization technology while also demonstrating that more efforts in this area are needed.
Collapse
Affiliation(s)
- Evan T. Alicuben
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Renee L. Levesque
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Surgical Services Division, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA
| | - Syed F. Ashraf
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Neil A. Christie
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Omar Awais
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Inderpal S. Sarkaria
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Rajeev Dhupar
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Surgical Services Division, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA
| |
Collapse
|
12
|
Kennedy GT, Azari FS, Chang A, Nadeem B, Bernstein E, Segil A, Din A, Marfatia I, Desphande C, Okusanya O, Keating J, Predina J, Newton A, Kucharczuk JC, Singhal S. Comparative Experience of Short-wavelength Versus Long-wavelength Fluorophores for Intraoperative Molecular Imaging of Lung Cancer. Ann Surg 2022; 276:711-719. [PMID: 35837887 PMCID: PMC9463092 DOI: 10.1097/sla.0000000000005596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intraoperative molecular imaging (IMI) using tumor-targeted optical contrast agents can improve cancer resections. The optimal wavelength of the IMI tracer fluorophore has never been studied in humans and has major implications for the field. To address this question, we investigated 2 spectroscopically distinct fluorophores conjugated to the same targeting ligand. METHODS Between December 2011 and November 2021, patients with primary lung cancer were preoperatively infused with 1 of 2 folate receptor-targeted contrast tracers: a short-wavelength folate-fluorescein (EC17; λ em =520 nm) or a long-wavelength folate-S0456 (pafolacianine; λ em =793 nm). During resection, IMI was utilized to identify pulmonary nodules and confirm margins. Demographic data, lesion diagnoses, and fluorescence data were collected prospectively. RESULTS Two hundred eighty-two patients underwent resection of primary lung cancers with either folate-fluorescein (n=71, 25.2%) or pafolacianine (n=211, 74.8%). Most tumors (n=208, 73.8%) were invasive adenocarcinomas. We identified 2 clinical applications of IMI: localization of nonpalpable lesions (n=39 lesions, 13.8%) and detection of positive margins (n=11, 3.9%). In each application, the long-wavelength tracer was superior to the short-wavelength tracer regarding depth of penetration, signal-to-background ratio, and frequency of event. Pafolacianine was more effective for detecting subpleural lesions (mean signal-to-background ratio=2.71 vs 1.73 for folate-fluorescein, P <0.0001). Limit of signal detection was 1.8 cm from the pleural surface for pafolacianine and 0.3 cm for folate-fluorescein. CONCLUSIONS Long-wavelength near-infrared fluorophores are superior to short-wavelength IMI fluorophores in human tissues. Therefore, future efforts in all human cancers should likely focus on long-wavelength agents.
Collapse
Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Ashley Chang
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Bilal Nadeem
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Alix Segil
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Azra Din
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Isvita Marfatia
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Jane Keating
- Department of Surgery, Hartford Hospital, Hartford, CT
| | - Jarrod Predina
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Andrew Newton
- Department of Surgery, MD Anderson Cancer Center, Houston, TX
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| |
Collapse
|
13
|
Transbronchial real-time lung tumor localization with folate receptor-targeted near-infrared molecular imaging: A proof of concept study in animal models. J Thorac Cardiovasc Surg 2022; 165:e240-e251. [PMID: 36882986 DOI: 10.1016/j.jtcvs.2022.09.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/06/2022] [Accepted: 09/11/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The diagnostic yield of bronchoscopy is not satisfactory, even with recent navigation technologies, especially for tumors located outside of the bronchial lumen. Our objective was to perform a preclinical assessment of folate receptor-targeted near-infrared imaging-guided bronchoscopy to detect peribronchial tumors. METHODS Pafolacianine, a folate receptor-targeted molecular imaging agent, was used as a near-infrared fluorescent imaging agent. An ultra-thin composite optical fiberscope was used for laser irradiation and fluorescence imaging. Subcutaneous xenografts of KB cells in mice were used as folate receptor-positive tumors. Tumor-to-background ratio was calculated by the fluorescence intensity value of muscle tissues acquired by the ultra-thin composite optical fiberscope system and validated using a separate spectral imaging system. Ex vivo swine lungs into which pafolacianine-laden KB tumors were transplanted at various sites were used as a peribronchial tumor model. RESULTS With the in vivo murine model, tumor-to-background ratio observed by ultra-thin composite optical fiberscope peaked at 24 hours after pafolacianine injection (tumor-to-background ratio: 2.56 at 0.05 mg/kg, 2.03 at 0.025 mg/kg). The fluorescence intensity ratios between KB tumors and normal mouse lung parenchyma postmortem were 6.09 at 0.05 mg/kg and 5.08 at 0.025 mg/kg. In the peribronchial tumor model, the ultra-thin composite optical fiberscope system could successfully detect fluorescence from pafolacianine-laden folate receptor-positive tumors with 0.05 mg/kg at the carina and those with 0.025 mg/kg and 0.05 mg/kg in the peripheral airway. CONCLUSIONS Transbronchial detection of pafolacianine-laden folate receptor-positive tumors by near-infrared imaging was feasible in ex vivo swine lungs. Further in vivo preclinical assessment is needed to confirm the feasibility of this technology.
Collapse
|
14
|
Lui NS, Singhal S. Intraoperative Molecular Imaging of Lung Cancer. Surg Oncol Clin N Am 2022; 31:685-693. [DOI: 10.1016/j.soc.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
15
|
Kennedy GT, Holt DE, Azari FS, Bernstein E, Nadeem B, Chang A, Sullivan NT, Segil A, Desphande C, Bensen E, Santini JT, Kucharczuk JC, Delikatny EJ, Bogyo M, Egan AJM, Bradley CW, Eruslanov E, Lickliter JD, Wright G, Singhal S. A Cathepsin-Targeted Quenched Activity-Based Probe Facilitates Enhanced Detection of Human Tumors during Resection. Clin Cancer Res 2022; 28:3729-3741. [PMID: 35792882 DOI: 10.1158/1078-0432.ccr-22-1215] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/02/2022] [Accepted: 07/01/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE Fluorescence-guided surgery using tumor-targeted contrast agents has been developed to improve the completeness of oncologic resections. Quenched activity-based probes that fluoresce after covalently binding to tumor-specific enzymes have been proposed to improve specificity, but none have been tested in humans. Here, we report the successful clinical translation of a cathepsin activity-based probe (VGT-309) for fluorescence-guided surgery. EXPERIMENTAL DESIGN We optimized the specificity, dosing, and timing of VGT-309 in preclinical models of lung cancer. To evaluate clinical feasibility, we conducted a canine study of VGT-309 during pulmonary tumor resection. We then conducted a randomized, double-blind, dose-escalation study in healthy human volunteers receiving VGT-309 to evaluate safety. Finally, we tested VGT-309 in humans undergoing lung cancer surgery. RESULTS In preclinical models, we found highly specific tumor cell labeling that was blocked by a broad spectrum cathepsin inhibitor. When evaluating VGT-309 for guidance during resection of canine tumors, we found that the probe selectively labeled tumors and demonstrated high tumor-to-background ratio (TBR; range: 2.15-3.71). In the Phase I human study, we found that VGT-309 was safe at all doses studied. In the ongoing Phase II trial, we report two cases in which VGT-309 localized visually occult, non-palpable tumors (TBRs = 2.83 and 7.18) in real time to illustrate its successful clinical translation and potential to improve surgical management. CONCLUSIONS This first-in-human study demonstrates the safety and feasibility of VGT-309 to label human pulmonary tumors during resection. These results may be generalizable to other cancers due to cathepsin overexpression in many solid tumors.
Collapse
Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - David E Holt
- Department of Clinical Sciences and Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Bilal Nadeem
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Ashley Chang
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Neil T Sullivan
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Alix Segil
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | | | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Edward J Delikatny
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Matthew Bogyo
- Department of Pathology, Stanford University, Palo Alto, California
| | - A J Matthew Egan
- Department of Pathology, St. Vincent's Hospital, Melbourne, Australia
| | - Charles W Bradley
- Department of Pathobiology, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania
| | - Evgeniy Eruslanov
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | - Gavin Wright
- Department of Surgery, St. Vincent's Hospital, University of Melbourne, Melbourne, Australia.,Victorian Comprehensive Cancer Centre Alliance, Melbourne, Australia
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
16
|
Kennedy GT, Azari FS, Bernstein E, Nadeem B, Chang A, Segil A, Sullivan N, Encarnado E, Desphande C, Kucharczuk JC, Leonard K, Low PS, Chen S, Criton A, Singhal S. Targeted detection of cancer cells during biopsy allows real-time diagnosis of pulmonary nodules. Eur J Nucl Med Mol Imaging 2022; 49:4194-4204. [PMID: 35788703 PMCID: PMC9525441 DOI: 10.1007/s00259-022-05868-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/09/2022] [Indexed: 12/19/2022]
Abstract
Background The diagnostic yield of biopsies of solitary pulmonary nodules (SPNs) is low, particularly in sub-solid lesions. We developed a method (NIR-nCLE) to achieve cellular level cancer detection during biopsy by integrating (i) near-infrared (NIR) imaging using a cancer-targeted tracer (pafolacianine), and (ii) a flexible NIR confocal laser endomicroscopy (CLE) system that can fit within a biopsy needle. Our goal was to assess the diagnostic accuracy of NIR-nCLE ex vivo in SPNs. Methods Twenty patients with SPNs were preoperatively infused with pafolacianine. Following resection, specimens were inspected to identify the lesion of interest. NIR-nCLE imaging followed by tissue biopsy was performed within the lesion and in normal lung tissue. All imaging sequences (n = 115) were scored by 5 blinded raters on the presence of fluorescent cancer cells and compared to diagnoses by a thoracic pathologist. Results Most lesions (n = 15, 71%) were adenocarcinoma-spectrum malignancies, including 7 ground glass opacities (33%). Mean fluorescence intensity (MFI) by NIR-nCLE for tumor biopsy was 20.6 arbitrary units (A.U.) and mean MFI for normal lung was 6.4 A.U. (p < 0.001). Receiver operating characteristic analysis yielded a high area under the curve for MFI (AUC = 0.951). Blinded raters scored the NIR-nCLE sequences on the presence of fluorescent cancer cells with sensitivity and specificity of 98% and 97%, respectively. Overall diagnostic accuracy was 97%. The inter-observer agreement of the five raters was excellent (κ = 0.95). Conclusions NIR-nCLE allows sensitive and specific detection of cancer cells in SPNs. This technology has far-reaching implications for diagnostic needle biopsies and intraprocedural decision-making. Supplementary Information The online version contains supplementary material available at 10.1007/s00259-022-05868-9.
Collapse
Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Bilal Nadeem
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Ashley Chang
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Alix Segil
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Neil Sullivan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Emmanuel Encarnado
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | | | - Philip S Low
- Department of Chemistry, Purdue University, West Lafayette, IN, USA
| | | | | | - Sunil Singhal
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA.
| |
Collapse
|
17
|
Kennedy GT, Azari FS, Bernstein E, Nadeem B, Chang A, Segil A, Carlin S, Sullivan NT, Encarnado E, Desphande C, Kularatne S, Gagare P, Thomas M, Kucharczuk JC, Christien G, Lacombe F, Leonard K, Low PS, Criton A, Singhal S. Targeted detection of cancer at the cellular level during biopsy by near-infrared confocal laser endomicroscopy. Nat Commun 2022; 13:2711. [PMID: 35581212 PMCID: PMC9114105 DOI: 10.1038/s41467-022-30265-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/23/2022] [Indexed: 12/21/2022] Open
Abstract
Suspicious nodules detected by radiography are often investigated by biopsy, but the diagnostic yield of biopsies of small nodules is poor. Here we report a method-NIR-nCLE-to detect cancer at the cellular level in real-time during biopsy. This technology integrates a cancer-targeted near-infrared (NIR) tracer with a needle-based confocal laser endomicroscopy (nCLE) system modified to detect NIR signal. We develop and test NIR-nCLE in preclinical models of pulmonary nodule biopsy including human specimens. We find that the technology has the resolution to identify a single cancer cell among normal fibroblast cells when co-cultured at a ratio of 1:1000, and can detect cancer cells in human tumors less than 2 cm in diameter. The NIR-nCLE technology rapidly delivers images that permit accurate discrimination between tumor and normal tissue by non-experts. This proof-of-concept study analyzes pulmonary nodules as a test case, but the results may be generalizable to other malignancies.
Collapse
Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Bilal Nadeem
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Ashley Chang
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Alix Segil
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Sean Carlin
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Neil T Sullivan
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Emmanuel Encarnado
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | | | - Mini Thomas
- On Target Laboratories, West Lafayette, IN, USA
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | | | | | - Philip S Low
- Department of Chemistry, Purdue University, West Lafayette, IN, USA
| | | | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
18
|
Kennedy GT, Azari FS, Bernstein E, Nadeem B, Chang AE, Segil A, Sullivan N, Marfatia I, Din A, Desphande C, Kucharczuk JC, Low PS, Singhal S. A Prostate-Specific Membrane Antigen-Targeted Near-Infrared Conjugate for Identifying Pulmonary Squamous Cell Carcinoma during Resection. Mol Cancer Ther 2022; 21:546-554. [PMID: 35149546 PMCID: PMC8983600 DOI: 10.1158/1535-7163.mct-21-0821] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/13/2021] [Accepted: 01/24/2022] [Indexed: 11/16/2022]
Abstract
Pulmonary squamous cell carcinoma is the second most common lung cancer subtype and has a low 5-year survival rate at 17.6%. Complete resection with negative margins can be curative, but a high number of patients suffer early postoperative recurrence due to inadequate disease clearance at the index operation. Intraoperative molecular imaging (IMI) with tumor-targeted optical contrast agents is effective in improving resection completeness for other tumor types, but there are no IMI tracers targeted to pulmonary squamous cell carcinoma. In this report, we describe the use of a novel prostate-specific membrane antigen (PSMA)-targeted near-infrared conjugate (OTL78) to identify pulmonary squamous cell carcinoma. We identified PSMA as a viable target by examining its expression in human lung tumor specimens from a surgical cohort. Ninety-four percent of tumors expressed PSMA in either the pulmonary squamous cells or the tumor neovasculature. Using in vitro and in vivo models, we found that OTL78 reliably localized pulmonary squamous cell carcinoma in a PSMA-dependent manner. Finally, we found that IMI with OTL78 markedly improved surgeons' ability to identify residual disease after surgery in a preclinical model. Ultimately, this novel optical tracer may aid surgical resection of pulmonary squamous cell carcinoma and potentially improve long-term outcomes.
Collapse
Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Bilal Nadeem
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Ashley E Chang
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Alix Segil
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Neil Sullivan
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Isvita Marfatia
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Azra Din
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Philip S Low
- Department of Chemistry, Purdue University, West Lafayette, Indiana
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
19
|
Neijenhuis LKA, de Myunck LDAN, Bijlstra OD, Kuppen PJK, Hilling DE, Borm FJ, Cohen D, Mieog JSD, Steup WH, Braun J, Burggraaf J, Vahrmeijer AL, Hutteman M. Near-Infrared Fluorescence Tumor-Targeted Imaging in Lung Cancer: A Systematic Review. Life (Basel) 2022; 12:life12030446. [PMID: 35330197 PMCID: PMC8950608 DOI: 10.3390/life12030446] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 12/24/2022] Open
Abstract
Lung cancer is the most common cancer type worldwide, with non-small cell lung cancer (NSCLC) being the most common subtype. Non-disseminated NSCLC is mainly treated with surgical resection. The intraoperative detection of lung cancer can be challenging, since small and deeply located pulmonary nodules can be invisible under white light. Due to the increasing use of minimally invasive surgical techniques, tactile information is often reduced. Therefore, several intraoperative imaging techniques have been tested to localize pulmonary nodules, of which near-infrared (NIR) fluorescence is an emerging modality. In this systematic review, the available literature on fluorescence imaging of lung cancers is presented, which shows that NIR fluorescence-guided lung surgery has the potential to identify the tumor during surgery, detect additional lesions and prevent tumor-positive resection margins.
Collapse
Affiliation(s)
- Lisanne K. A. Neijenhuis
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
- Centre for Human Drug Research, 2333 CL Leiden, The Netherlands;
| | - Lysanne D. A. N. de Myunck
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
| | - Okker D. Bijlstra
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
| | - Peter J. K. Kuppen
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
| | - Denise E. Hilling
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
- Department of Surgery, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Frank J. Borm
- Department of Pulmonology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Danielle Cohen
- Department of Pathology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
| | - Willem H. Steup
- Department of Surgery, HAGA Hospital, 2545 AA The Hague, The Netherlands;
| | - Jerry Braun
- Department of Cardiothoracic Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | | | - Alexander L. Vahrmeijer
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
| | - Merlijn Hutteman
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
- Department of Cardiothoracic Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
- Correspondence: ; Tel.: +31-71-526-51-00
| |
Collapse
|
20
|
Su KW, Singhal S, Sarkaria IS. Intraoperative imaging and localization techniques for part-solid nodules. JTCVS Tech 2021; 10:468-472. [PMID: 34984397 PMCID: PMC8691937 DOI: 10.1016/j.xjtc.2021.10.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 10/13/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Katherine W. Su
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Sunil Singhal
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Inderpal S. Sarkaria
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, Pittsburgh, Pa
- Address for reprints: Inderpal S. Sarkaria, MD, UPMC Shadyside Medical Building, 5200 Centre Ave, Suite 715, Pittsburgh, PA 15232.
| |
Collapse
|
21
|
Kennedy GT, Azari FS, Bernstein E, Desphande C, Din A, Marfatia I, Kucharczuk JC, Delikatny EJ, Low PS, Singhal S. 3D Specimen Mapping Expedites Frozen Section Diagnosis of Non-Palpable Ground Glass Opacities. Ann Thorac Surg 2021; 114:2115-2123. [PMID: 34774493 PMCID: PMC9188686 DOI: 10.1016/j.athoracsur.2021.09.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/07/2021] [Accepted: 09/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pulmonary ground glass opacities (GGOs) are early-stage adenocarcinoma spectrum lesions that are not easily palpable. Challenges in localizing GGOs during intraoperative pathology can lead to imprecise diagnoses and additional time under anesthesia. To improve localization of GGOs during frozen section diagnosis, we evaluated a novel technique, three-dimensional near-infrared specimen mapping (3D-NSM). METHODS Fifty-five patients with a cT1 GGO were enrolled and received a fluorescent tracer preoperatively. After resection, specimens were inspected to identify lesions. Palpable and non-palpable nodules underwent 3D-NSM and the area of highest fluorescence was marked with a suture. Time for 3D-NSM, time for frozen section diagnosis, and number of tissue sections examined were recorded. To compare 3D-NSM to standard-of-care techniques, a control cohort of twenty subjects with identical inclusion criteria were enrolled. Specimens did not undergo 3D-NSM and were sent directly to pathology. RESULTS 3D-NSM localized 54/55 lesions with one false negative. All 41 palpable lesions were identified by 3D-NSM. Thirteen of 14 non-palpable lesions (92.8%) were located by 3D-NSM. Time to diagnosis for the 3D-NSM cohort was 23.5 minutes, compared to 26.0 minutes in the control cohort (p=0.04). 3D-NSM did not affect time to diagnosis of palpable lesions (23.2 min vs. 21.4 minutes, p=0.10). 3D-NSM significantly reduced time to diagnosis for non-palpable lesions (t=23.3 min vs. 34.4 minutes, p<0.0001). 3D-NSM also reduced the number of tissue sections analyzed in non-palpable lesions (4.50 vs. 11.00, p<0.0001). CONCLUSIONS 3D-NSM accurately localizes GGOs and expedites intraoperative diagnosis by reducing the number of tissue sections analyzed for non-palpable GGOs.
Collapse
Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Azra Din
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Isvita Marfatia
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Edward J Delikatny
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Philip S Low
- Department of Chemistry, Purdue University, West Lafayette, IN
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA.
| |
Collapse
|