Enhancing Surgical Vision by Using Real-Time Imaging of αvβ3-Integrin Targeted Near-Infrared Fluorescent Agent

BackgroundThis study was designed to improve the surgical procedure and outcome of cancer surgery by means of real-time molecular imaging feedback of tumor spread and margin delineation using targeted near-infrared fluorescent probes with specificity to tumor biomarkers. Surgical excision of cancer often is confronted with difficulties in the identification of cancer spread and the accurate delineation of tumor margins. Currently, the assessment of tumor borders is afforded by postoperative pathology or, less reliably, intraoperative frozen sectioning. Fluorescence imaging is a natural modality for intraoperative use by directly relating to the surgeon’s vision and offers highly attractive characteristics, such as high-resolution, sensitivity, and portability. Via the use of targeted probes it also becomes highly tumor-specific and can lead to significant improvements in surgical procedures and outcome.MethodsMice bearing xenograft human tumors were injected with αvβ3-integrin receptor-targeted fluorescent probe and in vivo visualized by using a novel, real-time, multispectral fluorescence imaging system. Confirmatory ex vivo imaging, bioluminescence imaging, and histopathology were used to validate the in vivo findings.ResultsFluorescence images were all in good correspondence with the confirming bioluminescence images in respect to signal colocalization. Fluorescence imaging detected all tumors and successfully guided total tumor excision by effectively detecting small tumor residuals, which occasionally were missed by the surgeon. Tumor tissue exhibited target-to-background ratio of ~4.0, which was significantly higher compared with white-light images representing the visual contrast. Histopathology confirmed the capability of the method to identify tumor negative margins with high specificity and better prediction rate compared with visual inspection.ConclusionsReal-time multispectral fluorescence imaging using tumor specific molecular probes is a promising modality for tumor excision by offering real time feedback to the surgeon in the operating room.

[1]  H Stepp,et al.  Intraoperative detection of malignant gliomas by 5-aminolevulinic acid-induced porphyrin fluorescence. , 1998, Neurosurgery.

[2]  G. Stevens,et al.  Long‐term review of a breast conservation series and patterns of care over 18 years , 2003, ANZ journal of surgery.

[3]  R. Pleijhuis,et al.  Obtaining Adequate Surgical Margins in Breast-Conserving Therapy for Patients with Early-Stage Breast Cancer: Current Modalities and Future Directions , 2009, Annals of Surgical Oncology.

[4]  M M Haglund,et al.  Enhanced optical imaging of rat gliomas and tumor margins. , 1994, Neurosurgery.

[5]  M. Orringer,et al.  Transhiatal esophagectomy for distal and cardia cancers: implications of a positive gastric margin. , 2007, The Annals of thoracic surgery.

[6]  Vasilis Ntziachristos,et al.  Looking and listening to light: the evolution of whole-body photonic imaging , 2005, Nature Biotechnology.

[7]  H Stepp,et al.  Fluorescence-guided resections of malignant gliomas--an overview. , 2003, Acta neurochirurgica. Supplement.

[8]  Vasilis Ntziachristos,et al.  Multispectral imaging using multiple-bandpass filters. , 2008, Optics letters.

[9]  Bohumil Bednar,et al.  Dual In Vivo Quantification of Integrin-targeted and Protease-activated Agents in Cancer Using Fluorescence Molecular Tomography (FMT) , 2010, Molecular Imaging and Biology.

[10]  Ralph Weissleder,et al.  A multimodal nanoparticle for preoperative magnetic resonance imaging and intraoperative optical brain tumor delineation. , 2003, Cancer research.

[11]  N. Kieffer,et al.  Integrin αvβ3 expression confers on tumor cells a greater propensity to metastasize to bone , 2002, FASEB journal : official publication of the Federation of American Societies for Experimental Biology.

[12]  R. Simmons,et al.  Ductal carcinoma in situ with microinvasion. , 2003, American journal of surgery.

[13]  P. Argani,et al.  Separate Cavity Margin Sampling at the Time of Initial Breast Lumpectomy Significantly Reduces the Need for Reexcisions , 2005, The American journal of surgical pathology.

[14]  K. Thomas,et al.  Hexylaminolaevulinate ‘blue light’ fluorescence cystoscopy in the investigation of clinically unconfirmed positive urine cytology , 2009, BJU international.

[15]  J. Oosterhuis,et al.  Lymphatic Staging in Colorectal Cancer: Pathologic, Molecular, and Sentinel Node Techniques , 2005, Diseases of the colon and rectum.

[16]  I. Gage,et al.  Pathologic margin involvement and the risk of recurrence in patients treated with breast‐conserving therapy , 1996 .

[17]  Victor X D Yang,et al.  Increased brain tumor resection using fluorescence image guidance in a preclinical model , 2004, Lasers in surgery and medicine.

[18]  L. Lilge,et al.  In vivo quantification of fluorescent molecular markers in real‐time by ratio imaging for diagnostic screening and image‐guided surgery , 2007, Lasers in surgery and medicine.

[19]  E Biganzoli,et al.  Vascular integrin alpha(v)beta3: a new prognostic indicator in breast cancer. , 1998, Clinical cancer research : an official journal of the American Association for Cancer Research.

[20]  F. Albert,et al.  Laser-induced fluorescence detection of malignant gliomas using fluorescein-labeled serum albumin: Experimental and preliminary clinical results , 2000, Neurological research.

[21]  Tadashi Nariai,et al.  Intraoperative intrinsic optical imaging of neuronal activity from subdivisions of the human primary somatosensory cortex. , 2002, Cerebral cortex.

[22]  R. Weissleder,et al.  In vivo imaging of tumors with protease-activated near-infrared fluorescent probes , 1999, Nature Biotechnology.

[23]  Wenhu Chen,et al.  Surgical management of thymic epithelial tumors: a retrospective review of 204 cases. , 2005, The Annals of thoracic surgery.

[24]  Vasilis Ntziachristos,et al.  Multispectral opto-acoustic tomography of deep-seated fluorescent proteins in vivo , 2009 .

[25]  J. Pow-Sang,et al.  Alpha-V/beta-3 and alpha-V/beta-5 integrin distribution in neoplastic kidney. , 1996, American journal of nephrology.

[26]  J. Menéndez,et al.  αVβ3 integrin regulates heregulin (HRG)-induced cell proliferation and survival in breast cancer , 2005, Oncogene.

[27]  Vasilis Ntziachristos,et al.  Real-time intraoperative fluorescence imaging system using light-absorption correction. , 2009, Journal of biomedical optics.

[28]  N. Masumori,et al.  Treatment of invasive bladder cancer: lessons from the past and perspective for the future. , 2004, Japanese Journal of Clinical Oncology.

[29]  Yuman Fong,et al.  Real-Time Intraoperative Detection of Breast Cancer Axillary Lymph Node Metastases Using a Green Fluorescent Protein-Expressing Herpes Virus , 2006, Annals of surgery.

[30]  G. E. Moore,et al.  Fluorescein as an Agent in the Differentiation of Normal and Malignant Tissues. , 1947, Science.

[31]  Dimitrios H Roukos,et al.  Perspectives in the treatment of gastric cancer , 2005, Nature Clinical Practice Oncology.

[32]  Michael M Haglund,et al.  Imaging of Intrinsic Optical Signals in Primate Cortex during Epileptiform Activity , 2007, Epilepsia.

[33]  J. Lammers,et al.  Surgical treatment of Pancoast tumours. , 2004, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[34]  Hak Soo Choi,et al.  Image-Guided Oncologic Surgery Using Invisible Light: Completed Pre-Clinical Development for Sentinel Lymph Node Mapping , 2006, Annals of Surgical Oncology.

[35]  J. Menéndez,et al.  AlphaVbeta3 integrin regulates heregulin (HRG)-induced cell proliferation and survival in breast cancer. , 2005, Oncogene.

[36]  V. Rusch,et al.  Real‐time diagnostic imaging of tumors and metastases by use of a replication‐competent herpes vector to facilitate minimally invasive oncological surgery , 2006, FASEB journal : official publication of the Federation of American Societies for Experimental Biology.

[37]  D. Chi,et al.  Update on surgical treatment for endometrial cancer , 2005, Expert review of anticancer therapy.

[38]  John V Frangioni,et al.  Functional Near-Infrared Fluorescence Imaging for Cardiac Surgery and Targeted Gene Therapy , 2002, Molecular imaging.

[39]  A. Lowy,et al.  Surgery for pancreatic cancer: recent controversies and current practice. , 2005, Gastroenterology.

[40]  Vasilis Ntziachristos,et al.  Planar fluorescence imaging using normalized data. , 2005, Journal of biomedical optics.

[41]  H. Takeuchi,et al.  Experimental and clinical study of detection of glioma at surgery using fluorescent imaging by a surgical microscope after fluorescein administration. , 1997, Neurological research.

[42]  J. Frangioni,et al.  Functional Near-Infrared Imaging for Cardiac Surgery and Targeted Gene Therapy , 2002 .

[43]  F. Vicini,et al.  Factors associated with local recurrence of mammographically detected ductal carcinoma in situ in patients given breast‐conserving therapy , 2000, Cancer.

[44]  W. Mendenhall,et al.  Retroperitoneal soft tissue sarcoma , 2005, Cancer.

[45]  M M Haglund,et al.  Enhanced optical imaging of human gliomas and tumor margins. , 1996, Neurosurgery.

[46]  Victor X D Yang,et al.  A multispectral fluorescence imaging system: Design and initial clinical tests in intra‐operative Photofrin‐photodynamic therapy of brain tumors , 2003, Lasers in surgery and medicine.

[47]  J. Hanson,et al.  A population-based study of tumor-node relationship, resection margins, and surgeon volume on gastric cancer survival. , 2003, American journal of surgery.

[48]  M. Christiaens,et al.  Implications of the sentinel lymph node procedure for local and systemic adjuvant treatment , 2005, Current opinion in oncology.

[49]  H Stepp,et al.  Fluorescence-guided resection of glioblastoma multiforme by using 5-aminolevulinic acid-induced porphyrins: a prospective study in 52 consecutive patients. , 2000, Journal of neurosurgery.