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Walk EL, McLaughlin SL, Weed SA. High-frequency Ultrasound Imaging of Mouse Cervical Lymph Nodes. J Vis Exp 2015:e52718. [PMID: 26274059 DOI: 10.3791/52718] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
High-frequency ultrasound (HFUS) is widely employed as a non-invasive method for imaging internal anatomic structures in experimental small animal systems. HFUS has the ability to detect structures as small as 30 µm, a property that has been utilized for visualizing superficial lymph nodes in rodents in brightness (B)-mode. Combining power Doppler with B-mode imaging allows for measuring circulatory blood flow within lymph nodes and other organs. While HFUS has been utilized for lymph node imaging in a number of mouse model systems, a detailed protocol describing HFUS imaging and characterization of the cervical lymph nodes in mice has not been reported. Here, we show that HFUS can be adapted to detect and characterize cervical lymph nodes in mice. Combined B-mode and power Doppler imaging can be used to detect increases in blood flow in immunologically-enlarged cervical nodes. We also describe the use of B-mode imaging to conduct fine needle biopsies of cervical lymph nodes to retrieve lymph tissue for histological analysis. Finally, software-aided steps are described to calculate changes in lymph node volume and to visualize changes in lymph node morphology following image reconstruction. The ability to visually monitor changes in cervical lymph node biology over time provides a simple and powerful technique for the non-invasive monitoring of cervical lymph node alterations in preclinical mouse models of oral cavity disease.
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Affiliation(s)
- Elyse L Walk
- Department of Neurobiology and Anatomy, West Virginia University; Mary Babb Randolph Cancer Center, West Virginia University
| | - Sarah L McLaughlin
- Animal Models and Imaging Facility, West Virginia University; Mary Babb Randolph Cancer Center, West Virginia University
| | - Scott A Weed
- Department of Neurobiology and Anatomy, West Virginia University; Mary Babb Randolph Cancer Center, West Virginia University;
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Walk EL, McLaughlin S, Coad J, Weed SA. Use of high frequency ultrasound to monitor cervical lymph node alterations in mice. PLoS One 2014; 9:e100185. [PMID: 24955984 PMCID: PMC4067293 DOI: 10.1371/journal.pone.0100185] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 05/23/2014] [Indexed: 01/19/2023] Open
Abstract
Cervical lymph node evaluation by clinical ultrasound is a non-invasive procedure used in diagnosing nodal status, and when combined with fine-needle aspiration cytology (FNAC), provides an effective method to assess nodal pathologies. Development of high-frequency ultrasound (HF US) allows real-time monitoring of lymph node alterations in animal models. While HF US is frequently used in animal models of tumor biology, use of HF US for studying cervical lymph nodes alterations associated with murine models of head and neck cancer, or any other model of lymphadenopathy, is lacking. Here we utilize HF US to monitor cervical lymph nodes changes in mice following exposure to the oral cancer-inducing carcinogen 4-nitroquinoline-1-oxide (4-NQO) and in mice with systemic autoimmunity. 4-NQO induces tumors within the mouse oral cavity as early as 19 wks that recapitulate HNSCC. Monitoring of cervical (mandibular) lymph nodes by gray scale and power Doppler sonography revealed changes in lymph node size eight weeks after 4-NQO treatment, prior to tumor formation. 4-NQO causes changes in cervical node blood flow resulting from oral tumor progression. Histological evaluation indicated that the early 4-NQO induced changes in lymph node volume were due to specific hyperproliferation of T-cell enriched zones in the paracortex. We also show that HF US can be used to perform image-guided fine needle aspirate (FNA) biopsies on mice with enlarged mandibular lymph nodes due to genetic mutation of Fas ligand (Fasl). Collectively these studies indicate that HF US is an effective technique for the non-invasive study of cervical lymph node alterations in live mouse models of oral cancer and other mouse models containing cervical lymphadenopathy.
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Affiliation(s)
- Elyse L. Walk
- Department of Neurobiology and Anatomy, West Virginia University, Morgantown, West Virginia, United States of America
- Program in Cancer Cell Biology, West Virginia University, Morgantown, West Virginia, United States of America
- Mary Babb Randolph Cancer Center, West Virginia University, Morgantown, West Virginia, United States of America
| | - Sarah McLaughlin
- Animal Models and Imaging Facility, West Virginia University, Morgantown, West Virginia, United States of America
- Mary Babb Randolph Cancer Center, West Virginia University, Morgantown, West Virginia, United States of America
| | - James Coad
- Department of Pathology, West Virginia University, Morgantown, West Virginia, United States of America
| | - Scott A. Weed
- Department of Neurobiology and Anatomy, West Virginia University, Morgantown, West Virginia, United States of America
- Program in Cancer Cell Biology, West Virginia University, Morgantown, West Virginia, United States of America
- Mary Babb Randolph Cancer Center, West Virginia University, Morgantown, West Virginia, United States of America
- * E-mail:
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Kim H, Zhai G, Liu Z, Samuel S, Shah N, Helman EE, Knowles JA, Stockard CR, Fineberg NS, Grizzle WE, Zhou T, Zinn KR, Rosenthal EL. Extracelluar matrix metalloproteinase as a novel target for pancreatic cancer therapy. Anticancer Drugs 2012; 22:864-74. [PMID: 21730821 DOI: 10.1097/cad.0b013e328349311e] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The objective of this study was to evaluate extracellular matrix metalloproteinase (EMMPRIN) as a novel target in orthotopic pancreatic cancer murine models. MIA PaCa-2 human pancreatic tumor cells were implanted in groups 1 and 3-7, whereas MIA PaCa-2 EMMPRIN knockdown cells were implanted in group 2. Dosing with anti-EMMPRIN antibody started immediately after implantation for groups 1-3 (residual tumor model) and at 21 days after cell implantation for groups 4-7 (established tumor model). Groups 3, 5, and 7 were treated with anti-EMMRPIN antibody (0.2-1.0 mg) twice weekly for 2-3 weeks, whereas the other groups served as the control. In the residual tumor model, tumor growth of anti-EMMPRIN-treated group was successfully arrested for 21 days (15 ± 4 mm(3)), which was significantly lower than that of the EMMPRIN knockdown group (80 ± 15 mm(3); P=0.001) or the control group (240 ± 41 mm(3); P<0.001). In the established tumor model, anti-EMMPRIN therapy lowered tumor volume increase by approximately 40% compared with the control, regardless of the dose amount. Ki67-expressed cell density of group 5 was 939 ± 150 mm(-2), which was significantly lower than that of group 4 (1709 ± 145 mm(-2); P=0.006). Microvessel density of group 5 (30 ± 6 mm(-2)) was also significantly lower than that of group 4 (53 ± 5 mm(-2); P=0.014), whereas the microvessel size of group 5 (191 ± 22 μm(2)) was significantly larger than that of group 4 (113 ± 26 μm(2); P=0.049). These data show the high potential of anti-EMMPRIN therapy for pancreatic cancer and support its clinical translation.
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Affiliation(s)
- Hyunki Kim
- Department of Radiology, University of Alabama at Birmingham, USA.
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Ultrasound biomicroscopy in small animal research: applications in molecular and preclinical imaging. J Biomed Biotechnol 2011; 2012:519238. [PMID: 22163379 PMCID: PMC3202139 DOI: 10.1155/2012/519238] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 08/12/2011] [Indexed: 02/04/2023] Open
Abstract
Ultrasound biomicroscopy (UBM) is a noninvasive multimodality technique that allows high-resolution imaging in mice. It is affordable, widely available, and portable. When it is coupled to Doppler ultrasound with color and power Doppler, it can be used to quantify blood flow and to image microcirculation as well as the response of tumor blood supply to cancer therapy. Target contrast ultrasound combines ultrasound with novel molecular targeted contrast agent to assess biological processes at molecular level. UBM is useful to investigate the growth and differentiation of tumors as well as to detect early molecular expression of cancer-related biomarkers in vivo and to monitor the effects of cancer therapies. It can be also used to visualize the embryological development of mice in uterus or to examine their cardiovascular development. The availability of real-time imaging of mice anatomy allows performing aspiration procedures under ultrasound guidance as well as the microinjection of cells, viruses, or other agents into precise locations. This paper will describe some basic principles of high-resolution imaging equipment, and the most important applications in molecular and preclinical imaging in small animal research.
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Kim H, Folks KD, Guo L, Sellers JC, Fineberg NS, Stockard CR, Grizzle WE, Buchsbaum DJ, Morgan DE, George JF, Zinn KR. Early Therapy Evaluation of Combined Cetuximab and Irinotecan in Orthotopic Pancreatic Tumor Xenografts by Dynamic Contrast-Enhanced Magnetic Resonance Imaging. Mol Imaging 2011. [DOI: 10.2310/7290.2010.00040] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Hyunki Kim
- From the Departments of Radiology, Biomedical Engineering, Surgery, Biostatistics, Pathology, Radiation Oncology, and Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Karri D. Folks
- From the Departments of Radiology, Biomedical Engineering, Surgery, Biostatistics, Pathology, Radiation Oncology, and Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Lingling Guo
- From the Departments of Radiology, Biomedical Engineering, Surgery, Biostatistics, Pathology, Radiation Oncology, and Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Jeffery C. Sellers
- From the Departments of Radiology, Biomedical Engineering, Surgery, Biostatistics, Pathology, Radiation Oncology, and Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Naomi S. Fineberg
- From the Departments of Radiology, Biomedical Engineering, Surgery, Biostatistics, Pathology, Radiation Oncology, and Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Cecil R. Stockard
- From the Departments of Radiology, Biomedical Engineering, Surgery, Biostatistics, Pathology, Radiation Oncology, and Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - William E. Grizzle
- From the Departments of Radiology, Biomedical Engineering, Surgery, Biostatistics, Pathology, Radiation Oncology, and Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Donald J. Buchsbaum
- From the Departments of Radiology, Biomedical Engineering, Surgery, Biostatistics, Pathology, Radiation Oncology, and Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Desiree E. Morgan
- From the Departments of Radiology, Biomedical Engineering, Surgery, Biostatistics, Pathology, Radiation Oncology, and Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - James F. George
- From the Departments of Radiology, Biomedical Engineering, Surgery, Biostatistics, Pathology, Radiation Oncology, and Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Kurt R. Zinn
- From the Departments of Radiology, Biomedical Engineering, Surgery, Biostatistics, Pathology, Radiation Oncology, and Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
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Kim H, Morgan DE, Buchsbaum DJ, Zeng H, Grizzle WE, Warram JM, Stockard CR, McNally LR, Long JW, Sellers JC, Forero A, Zinn KR. Early therapy evaluation of combined anti-death receptor 5 antibody and gemcitabine in orthotopic pancreatic tumor xenografts by diffusion-weighted magnetic resonance imaging. Cancer Res 2008; 68:8369-76. [PMID: 18922909 DOI: 10.1158/0008-5472.can-08-1771] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Early therapeutic efficacy of anti-death receptor 5 antibody (TRA-8) combined with gemcitabine was measured using diffusion-weighted magnetic resonance imaging (DWI) in an orthotopic pancreatic tumor model. Groups 1 to 4 of severe combined immunodeficient mice (n = 5-7 per group) bearing orthotopically implanted, luciferase-positive human pancreatic tumors (MIA PaCa-2) were subsequently (4-5 weeks thereafter) injected with saline (control), gemcitabine (120 mg/kg), TRA-8 (200 mug), or TRA-8 combined with gemcitabine, respectively, on day 0. DWI, anatomic magnetic resonance imaging, and bioluminescence imaging were done on days 0, 1, 2, and 3 after treatment. Three tumors from each group were collected randomly on day 3 after imaging, and terminal deoxyribonucleotidyl transferase-mediated dUTP nick end labeling staining was done to quantify apoptotic cellularity. At just 1 day after starting therapy, the changes of apparent diffusion coefficient (ADC) in tumor regions for group 3 (TRA-8) and group 4 (TRA-8/Gem) were 21 +/- 9% (mean +/- SE) and 27 +/- 3%, respectively, significantly higher (P < 0.05) than those of group 1 (-1 +/- 5%) and group 2 (-2 +/- 4%). There was no statistical difference in tumor volumes for the groups at this time. The mean ADC values of groups 2 to 4 gradually increased over 3 days, which were concurrent with tumor volume regressions and bioluminescence signal decreases. Apoptotic cell densities of tumors in groups 1 to 4 were 0.7 +/- 0.4%, 0.6 +/- 0.2%, 3.1 +/- 0.9%, and 4.7 +/- 1.0%, respectively, linearly proportional to the ADC changes on day 1. Further, the ADC changes were highly correlated with the previously reported mean survival times of animals treated with the same agents and doses. This study supports the clinical use of DWI for pancreatic tumor patients for early assessment of drug efficacy.
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Affiliation(s)
- Hyunki Kim
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama 35294-0012, USA
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DeRosier LC, Buchsbaum DJ, Oliver PG, Huang ZQ, Sellers JC, Grizzle WE, Wang W, Zhou T, Zinn KR, Long JW, Vickers SM. Combination treatment with TRA-8 anti death receptor 5 antibody and CPT-11 induces tumor regression in an orthotopic model of pancreatic cancer. Clin Cancer Res 2007; 13:5535s-5543s. [PMID: 17875786 PMCID: PMC3045836 DOI: 10.1158/1078-0432.ccr-07-1075] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE Evaluate the response of human pancreatic cancer cell lines and orthotopic tumors to TRA-8, an agonistic antibody to death receptor 5, in combination with irinotecan (CPT-11). EXPERIMENTAL DESIGN MIA PaCa-2 and S2VP10 cells were treated with TRA-8 and/or CPT 11. Cell viability was determined by ATP assay. JC-1 mitochondrial depolarization and Annexin V assays confirmed cell death by apoptosis. Immunoblotting was used to evaluate protein changes. MIA PaCa-2 cells were injected into the pancreas of severe combined immunodeficient mice. Mice underwent abdominal ultrasound to quantitate tumor size before and after treatment with twice weekly injections of 200 microg TRA-8 and/or 25 mg/kg CPT-11 for one or two treatment cycles, each lasting 2 weeks. RESULTS MIA PaCa-2 cells were more sensitive to TRA-8 and showed additive cytotoxicity, whereas S2VP10 cells showed synergistic cytotoxicity when treated with TRA-8 and CPT-11. Cell death occurred via apoptosis with increased cleavage of caspase-3, caspase-8, and caspase-9 and proapoptotic proteins Bid and poly(ADP)ribose polymerase after combination treatment compared with either agent alone. XIAP and Bcl-XL inhibitors of apoptosis were down-regulated. After a single cycle of in vivo combination therapy, tumor sizes had diminished significantly (P<0.001) at 8 days posttreatment compared with no treatment, CPT-11, and TRA-8; and there was a 50-day increase in survival with combination treatment over untreated controls (P=0.0002), 30 days over TRA-8, and a 36-day increase over CPT-11 monotherapy (P=0.0003). With two cycles of TRA-8/CPT-11 treatment, mean survival time increased significantly (P<0.001) to 169 days versus untreated controls, TRA-8 or CPT-11 (76, 121, or 108 days, respectively). CONCLUSIONS Combination TRA-8 and CPT-11 therapy produced enhanced cytotoxicity and survival in the MIA PaCa-2 orthotopic model of pancreatic cancer.
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Affiliation(s)
| | - Donald J. Buchsbaum
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Patsy G. Oliver
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Zhi-Qiang Huang
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey C. Sellers
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - William E. Grizzle
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Wenquan Wang
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Tong Zhou
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kurt R. Zinn
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joshua W. Long
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Selwyn M. Vickers
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Rosenthal EL, Kulbersh BD, King T, Chaudhuri TR, Zinn KR. Use of fluorescent labeled anti-epidermal growth factor receptor antibody to image head and neck squamous cell carcinoma xenografts. Mol Cancer Ther 2007; 6:1230-8. [PMID: 17431103 DOI: 10.1158/1535-7163.mct-06-0741] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Physicians and surgeons rely on subtle tissue changes to detect the extent of tumors and the presence of residual disease in the clinical setting. The development of a cancer-specific fluorescent contrast agent has the potential to provide real-time tumor imaging in the clinic or operating room. Because epidermal growth factor receptor (EGFR) is highly overexpressed on the surface of head and neck squamous cell carcinoma (HNSCC), we sought to determine if fluorescently labeled anti-EGFR antibody could be used to image HNSCC xenografts in vivo. Cetuximab or control isotype-matched IgG1 was conjugated with the Cy5.5 fluorochrome and systemically injected into mice bearing human split thickness skin grafts, tumor cell line xenografts, transplanted human tumor xenografts, or mouse mesothelioma tumors. Xenografts were imaged by time-domain fluorescence imaging or fluorescence stereomicroscopy. Both imaging modalities detected specific uptake of cetuximab-Cy5.5 in HNSCC xenografts with significantly higher fluorescence levels relative to control IgG1-Cy5.5. Tumor xenograft fluorescence was higher compared with background (before injection), human split thickness skin grafts, or mouse mesothelioma tumors at 24, 48, and 72 h. Fluorescence was detected in multiple HNSCC tumor cell lines with variable EGFR expression levels. Mock resections of flank tumors using fluorescence stereomicroscopy showed that small (2 mm) specimens could be detected in the surgical wound bed. These results show the feasibility of using fluorescently labeled anti-EGFR antibody to detect human tumors in the surgical setting.
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MESH Headings
- Animals
- Antibodies, Monoclonal/pharmacology
- Antibodies, Monoclonal, Humanized
- Antineoplastic Agents/pharmacology
- Carcinoma, Squamous Cell/diagnosis
- Carcinoma, Squamous Cell/pathology
- Cell Line, Tumor
- Cetuximab
- ErbB Receptors/antagonists & inhibitors
- Fluorescent Dyes/metabolism
- Green Fluorescent Proteins/metabolism
- Head and Neck Neoplasms/diagnosis
- Head and Neck Neoplasms/pathology
- Humans
- Imaging, Three-Dimensional
- Male
- Mice
- Mice, SCID
- Microscopy, Fluorescence
- Skin Transplantation
- Transplantation, Heterologous
- Xenograft Model Antitumor Assays
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Affiliation(s)
- Eben L Rosenthal
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294-0012, USA.
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Rosenthal EL, Kulbersh BD, Duncan RD, Zhang W, Magnuson JS, Carroll WR, Zinn K. In Vivo Detection of Head and Neck Cancer Orthotopic Xenografts by Immunofluorescence. Laryngoscope 2006; 116:1636-41. [PMID: 16954995 DOI: 10.1097/01.mlg.0000232513.19873.da] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To determine whether Cy5.5-labeled antiepidermal growth factor (EGFR) antibody could be used to detect head and neck squamous cell carcinoma (HNSCC) xenografts in vivo. METHODS AntiEGFR antibody (cetuximab) was labeled with Cy5.5, a fluorophore with emission in the near infrared range. The cetuximab-Cy5.5 conjugate was systemically administered in subtherapeutic doses (50 microg) to mice bearing orthotopically xenografted HNSCC cell lines (SCC1, CAL27, and FaDu). As a control, isotype-matched human immunoglobulin (Ig)G1k antibody labeled with Cy5.5 was systemically injected in parallel experiments. All tumor regions (n = 6) were imaged by fluorescent stereomicroscopy at 0, 6, 24, 48, or 72 hours. Tumor size was measured by high-frequency ultrasonography at 72 hours. Transcervical partial and near-total resections were then performed with stereomicroscopic imaging after each resection. The mandible and associated structures were then resected, paraffin embedded, and then serial sectioned for analysis. RESULTS Tumors could be clearly visualized by near infrared fluorescent stereomicroscopy at 48 and 72 hours after systemic administration of cetuximab-Cy5.5 but not after administration with the labeled isotype control antibody, IgG1k-Cy5.5. Ultrasound measurement of tumors (n = 5) correlated with fluorescent measurements of tumor (Spearman's coefficient, 0.92, P </= .01). When fluorescent stereomicroscopic findings were correlated with histologic findings in near-total resections, this technique could accurately identify residual tumor less than 1 mm in size. CONCLUSION Fluorescent immunoguided neoplasm detection may be used as a diagnostic tool and to guide surgical therapy by providing real-time imaging information about the extent of disease or the presence of residual disease.
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Affiliation(s)
- Eben L Rosenthal
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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