Fluorescence-guided surgery (FGS) has the potential to significantly enhance patient outcomes by enabling precise real-time visualization of vital nerve structures during surgical procedures. However, a clinically approved nerve-specific contrast agent does not exist. To address this need, we adopted a medicinal chemistry approach to design and develop novel near-infrared (NIR) nerve-binding small molecule fluorophore libraries. Our first-in-class NIR nerve-binding small molecule fluorophores represent a significant advancement in the field. By enabling precise nerve visualization in real-time during surgery, these contrast agents have the potential to revolutionize nerve-sparing procedures and ultimately improve patient outcomes.
Iatrogenic nerve injuries are a major concern in various surgical fields, causing significant morbidity. These injuries lead to impaired sensory and motor functions, chronic pain, reduced limb control, and increased healthcare needs. Surgeons use techniques like white light visualization and intraoperative neuromonitoring (e.g., electromyography [EMG]) to identify nerve damage. However, the incidence rate remains high, necessitating better alternatives. Our team developed near-infrared (NIR) nerve-specific fluorophores to enhance nerve visualization, and one of our lead fluorophores exhibited reduced fluorescence intensity in injured nerve regions, providing contrast shortly after nerve injury. These results led us to hypothesize that the fluorophore could be used as an intraoperative neuromonitoring tool during fluorescence-guided surgery. Ultimately, this tool can be used intraoperatively to aid surgeons in timely detection and accurate assessment of nerve health, mitigating complications and improving patient outcomes. The culmination of our work will bring forth a novel methodology for localizing nerve injuries, benefiting both patients and surgical procedures.
SignificancePositive margin status due to incomplete removal of tumor tissue during radical prostatectomy for high-risk localized prostate cancer requires reoperation or adjuvant therapy, which increases morbidity and mortality. Adverse effects of prostate cancer treatments commonly include erectile dysfunction, urinary incontinence, and bowel dysfunction, making successful initial curative prostatectomy imperative.AimCurrent intraoperative tumor margin assessment is largely limited to frozen section analysis, which is a lengthy, labor-intensive process that is obtrusive to the clinical workflow within the operating room (OR). Therefore, a rapid method for prostate cancer margin assessment in the OR could improve outcomes for patients.ApproachDual probe difference specimen imaging (DDSI), which uses paired antibody-based probes that are labeled with spectrally distinct fluorophores, was shown herein for prostate cancer margin assessment. The paired antibody-based probes consisted of a targeted probe to prostate-specific membrane antigen (PSMA) and an untargeted probe, which were used as a cocktail to stain resected murine tissue specimens including prostate tumor, adipose, muscle, and normal prostate. Ratiometric images (i.e., DDSI) of the difference between targeted and untargeted probe uptake were calculated and evaluated for accuracy using receiver operator characteristic curve analysis with area under the curve values used to evaluate the utility of the DDSI method to detect PSMA positive prostate cancer.ResultsTargeted and untargeted probe uptake was similar between the high and low PSMA expressing tumor due to nonspecific probe uptake after topical administration. The ratiometric DDSI approach showed substantial contrast difference between the PSMA positive tumors and their respective normal tissues (prostate, adipose, muscle). Furthermore, DDSI showed substantial contrast difference between the high PSMA expressing tumors and the minimally PSMA expressing tumors due to the ratiometric correction for the nonspecific uptake patterns in resected tissues.ConclusionsPrevious work has shown that ratiometic imaging has strong predictive value for breast cancer margin status using topical administration. Translation of the ratiometric DDSI methodology herein from breast to prostate cancers demonstrates it as a robust, ratiometric technique that provides a molecularly specific imaging modality for intraoperative margin detection. Using the validated DDSI protocol on resected prostate cancers permitted rapid and accurate assessment of PSMA status as a surrogate for prostate cancer margin status. Future studies will further evaluate the utility of this technology to quantitatively characterize prostate margin status using PSMA as a biomarker.
Iatrogenic nerve injury is a major source of morbidity common to all surgical specialties. Prostate cancer, the second leading cause of cancer-related death among men in the U.S, is often treated surgically via prostatectomy. But visibility of the nerve plexus is extremely limited and nerve damage affects 60% of patients leading to post-surgical comorbidities.
We’ve developed a synthetic strategy to improve key properties of fluorophores with potential clinical translatability to generate an optimal 700 nm fluorophore to pair with a fluorescently labeled probe optimized for the 800 nm channel in FGS systems targeting PSMA via the EUK targeting sequence for use in two-color prostatectomy.
These new water-soluble, NIR, nerve-specific fluorophores show improved nerve specificity and in vivo brightness, require a lower dose to achieve contrast of superficial and buried nerve tissue and negate formulation development, improving safety profiles and lowering the cost of clinical translation.
Cranial and spinal nerve repair occurs at a very slow rate, and in most cases the iatrogenic injury can’t be fully repaired, leading to permanent motor or sensory disabilities as well as incurable neuropathies. The visualization and evaluation of tumor-involved nerves is extremely difficult during minimally invasive surgical procedures such as through at the skull base. Recently, our group developed a library of nerve-specific near infrared (NIR) oxazine scaffold dyes that have high specificity for cranial nerves, and the ability to permeate the Blood-Brain Barrier (BBB), which resulted in different degrees of the obtained cranial nerves SBR. These cranial nerve-specific fluorophores will significantly improve nerve visualization at depth, enhancing the ability to visualize and evaluate buried and tumor-involved cranial nerves. This could significantly decrease post-surgical morbidity rates and could solve the unmet clinical need for an intraoperative tool that enhances visualization.
Nerve damage ruins the lives of many patients post surgery, significantly affecting post-surgical quality of life. Intraoperative nerve detection is completed using anatomical knowledge and conventional white light visualization when possible. However, nerves can be difficult or impossible to identify by white light visualization and neuroanatomy is often varied between patients. We have developed nerve specific fluorescence guided surgery (FGS) contrast agents that provide real time direct visualization of nerves intraoperatively. These nerve-specific fluorophores represent the first of their kind and are capable of translation to clinical studies using existing clinical infrastructure of FGS systems. Work is underway to complete the preclinical pharmacology and toxicology testing required for a successful investigational new drug application to the FDA for first-in-human clinical trials and translation to surgical use should be feasible within the next five years.
We have co-developed a first-in-kind model of fluorophore testing in freshly amputated human limbs. Ex vivo human tissue provides a unique opportunity for the testing of pre-clinical fluorescent agents, collection of imaging data, and histopathologic examination in human tissue prior to performing in vivo experiments. Existing pre-clinical fluorescent agent studies rely primarily on animal models, which do not directly predict fluorophore performance in humans and can result in wasted resources and time if an agent proves ineffective in early human trials. Because fluorophores have no desired therapeutic effect, their clinical utility is based solely on their safety and ability to highlight tissues of interest. Advancing to human trials even via the FDA’s phase 0/microdose pathway still requires substantial resources, single-species pharmacokinetic testing, and toxicity testing. In a recently concluded study using amputated human lower limbs, we were able to test successfully a nerve-specific fluorophore in pre-clinical development. This study used systemic administration via vascular cannulization and a cardiac perfusion pump. We envision that this model may assist with early lead agent testing selection for fluorophores with various targets and mechanisms.
Iatrogenic nerve injury is a common complication across all surgical specialties. Better nerve visualization and identification during surgery will improve outcomes and reduce nerve injuries. The Gibbs Laboratory at Oregon Health and Science University has developed a library of near-infrared, nerve-specific fluorophores to highlight nerves intraoperatively and aid surgeons in nerve identification and visualization; the current lead agent is LGW16-03. Prior to this study, testing of LGW16-03 was restricted to animal models; therefore, it was unknown how LGW16-03 performs in human tissue. To advance LGW16-03 to clinic, we sought to test this current lead agent in ex vivo human tissues from a cohort of patients and determine if the route of administration affects LGW16-03 fluorescence contrast between nerves and adjacent background tissues (muscle and adipose). LGW16-03 was applied to ex vivo human tissue from lower limb amputations via two strategies: (1) systemic administration of the fluorophore using our first-in-kind model for fluorophore testing, and (2) topical application of the fluorophore. Results showed no statistical difference between topical and systemic administration. However, in vivo human validation of these findings is required.
SignificanceThis first-in-kind, perfused, and amputated human limb model allows for the collection of human data in preclinical selection of lead fluorescent agents. The model facilitates more accurate selection and testing of fluorophores with human-specific physiology, such as differential uptake and signal in fat between animal and human models with zero risk to human patients. Preclinical testing using this approach may also allow for the determination of tissue toxicity, clearance time of fluorophores, and the production of harmful metabolites.AimThis study was conducted to determine the fluorescence intensity values and tissue specificity of a preclinical, nerve tissue targeted fluorophore, as well as the capacity of this first-in-kind model to be used for lead fluorescent agent selection in the future.ApproachFreshly amputated human limbs were perfused for 30 min prior to in situ and ex vivo imaging of nerves with both open-field and closed-field commercial fluorescence imaging systems.ResultsIn situ, open-field imaging demonstrated a signal-to-background ratio (SBR) of 4.7 when comparing the nerve with adjacent muscle tissue. Closed-field imaging demonstrated an SBR of 3.8 when the nerve was compared with adipose tissue and 4.8 when the nerve was compared with muscle.ConclusionsThis model demonstrates an opportunity for preclinical testing, evaluation, and selection of fluorophores for use in clinical trials as well as an opportunity to study peripheral pathologies in a controlled environment.
This Conference Presentation, “Utilization of near infrared nerve-specific fluorescent contrast agents as an intraoperative assessment methodology for nerve damage,” was recorded for Photonics West BiOS 2022 On-Demand.
Rapid expansion in the field of fluorescence guided surgery (FGS) has yielded a wide range of contrast agent types under development with diverse characteristics. Currently, 105 active or completed clinical trials are registered in clinicaltrials.gov studying 39 unique novel FGS contrast agents. For these 39 contrast agents, there exists 6 distinct classes or types of probes: nanoparticle, antibody, protein, affibody, peptide, and small molecule. This diversity yields unique advantages and disadvantages among each type of contrast agent, which change throughout the various stages of development and clinical translation. In this review, we outline the relevant advantages and disadvantages for each type of FGS contrast agent at each stage of development. As the field continues to progress and expand, this diversity in FGS contrast agent type and their respective unique characteristics will enable broad applicability to shift the surgical paradigm and improve outcomes for patients across all surgical specialties.
Fluorescence-guided surgery (FGS) to aid in the precise visualization of vital nerve structures in real-time intraoperatively could greatly improve patient outcomes. We took a medicinal chemistry approach that facilitated the design of our first-in-class NIR nerve-binding small molecule fluorophore libraries with excitation and emission profiles compatible with the “700-” and “800-” nm fluorescence imaging channels in the clinical grade FGS systems. Molecular engineering of the lead candidates allowed for the development of water-soluble nerve-specific contrast agents with improved safety profile that has great potential for clinical translation in the near future.
Fluorescent contrast agents targeted to cancer biomarkers are increasingly being explored for cancer detection, surgical guidance, and response monitoring. Efforts have been underway to topically apply such biomarker-targeted agents to freshly excised specimen for detecting cancer cell receptors on the surface as a method for intraoperative surgical margin assessment, including dual-probe staining methods introduce a second ‘non-specific’ optical agent as a control to help compensate for heterogeneous uptake and normalize the imaging field. Still, such specimen staining protocols introduce multifaceted complexity with unknown variables, such as tissue-specific diffusion, cell-specific binding and disassociation rates, and other factors, affecting the interpreted cancer-biomarker distribution across the specimen surface. The ability to recover three-dimensional dual-probe biodistributions throughout whole-specimens could offer a ground-truth validation method for examining topical staining uptake behaviors. Herein, we report on a novel method for characterizing dual-probe accumulation with 3D depth-profiles observed from a dual-probe fresh-specimen staining experiment.
Nerve damage plagues surgical outcomes, significantly affecting post-surgical quality of life. Intraoperative nerve detection is difficult since neuroanatomy is varilable between patients, and nerves are typically protected deep within the tissue. Fluorescence-guided surgery (FGS) offers a potential means for enhanced intraoperative nerve identification and preservation. We have developed the first near infrared (NIR) nerve-specific fluorophores for use during FGS. Lead optimization has yielded water soluble derivatives with excellent safety and pharmacology parameters. Work is underway to plan and execute preclinical toxicity testing to enable first-in-human clincial trials.
In the past several decades, a number of novel fluorescence image-guided surgery (FGS) contrast agents have been under development, with many in clinical translation and undergoing clinical trials. In this review, we have identified and summarized the contrast agents currently undergoing clinical translation. In total, 39 novel FGS contrast agents are being studied in 85 clinical trials. Four FGS contrast agents are currently being studied in phase III clinical trials and are poised to reach FDA approval within the next two to three years. Among all novel FGS contrast agents, a wide variety of probe types, targeting mechanisms, and fluorescence properties exists. Clinically available FGS imaging systems have been developed for FDA approved FGS contrast agents, and thus further clinical development is required to yield FGS imaging systems tuned for the variety of contrast agents in the clinical pipeline. Additionally, study of current FGS contrast agents for additional disease types and development of anatomy specific contrast agents is required to provide surgeons FGS tools for all surgical specialties and associated comorbidities. The work reviewed here represents a significant effort from many groups and further development of this promising technology will have an enormous impact on surgical outcomes across all specialties.
Accidental nerve damage or transection of vital nerve structures remains an unfortunate reality that is often associated with surgery. Despite the existence of nerve-sparing techniques, the success of such procedures is not only complicated by anatomical variance across patients but is also highly dependent on a surgeon’s first-hand experience that is acquired over numerous procedures through trial and error, often with highly variable success rates. Fluorescent small molecules, such as rhodamines and fluoresceins have proven incredibly useful for biological imaging in the life sciences, and they appeared to have potential in illuminating vital nerve structures during surgical procedures. In order to make use of the current clinically relevant imaging systems and to provide surgeons with fluorescent contrast largely free from the interference of hemoglobin and water, it was first necessary to spectrally tune known fluorescent scaffolds towards near infrared (NIR) wavelengths. To determine whether the well-documented Si-substitution strategy could be applied towards developing a NIR fluorophore that retained nerve-specific properties of candidate molecules, an in vivo comparison was made between two compounds previously shown to highlight nervous structures – TMR and Rhodamine B – and their Si-substituted derivatives.
Fluorescent image-guided surgery has the potential to revolutionize surgery by providing direct tissue visualization using compact imaging systems and targeted contrast agents. Nerve targeting contrast agents are currently under development, where clinical use would decrease morbidity and benefit post-surgical outcomes for a variety of surgical procedures. Herein, we have applied a previously optimized direct administration methodology to resected human prostate specimens to validate the human nerve cross-reactivity of the nerve-specific fluorophore Oxazine 4. Nerves were clearly identified on the posterior lateral surfaces of stained prostate specimens, consistent with prostate neuroanatomy. Additionally, nerve signal-to-background ratios were consistent with the relevant postperfusion murine nerve models, suggesting that contrast levels will match results in murine models when Oxazine nerve-specific fluorophore is applied to human nerves in vivo. The positive human nerve staining demonstrated herein on resected prostate specimens using the optimized direct administration methodology provides a human nerve cross reactivity screening tool for future translational studies of near-infrared nerve specific contrast agents.
Accidental nerve transection or injury is a significant morbidity associated with many surgical interventions, resulting in persistent postsurgical numbness, chronic pain, and/or paralysis. Nervesparing can be a difficult task due to patient-to-patient variability and the difficulty of nerve visualization in the operating room. Fluorescence image-guided surgery to aid in the precise visualization of vital nerve structures in real time during surgery could greatly improve patient outcomes. To date, all nerve-specific contrast agents emit in the visible range. Developing a nearinfrared (NIR) nerve-specific fluorophore is poised to be a challenging task, as a NIR fluorophore must have enough “double-bonds” to reach the NIR imaging window, contradicting the requirement that a nerve-specific agent must have a relatively low molecular weight to cross the blood-nervebarrier (BNB). Herein we report our efforts to investigate the molecular characteristics for the nervespecific oxazine fluorophores, as well as their structurally analogous rhodamine fluorophores. Specifically, optical properties, physicochemical properties and their in vivo nerve specificity were evaluated herein.
Identification of tumor margins in the operating room in real time is a critical challenge for surgical procedures that serve as cancer cure. Breast conserving surgery (BCS) is particularly affected by this problem, with current reexcision rates above 25%. Due to a lack of clinically available methodologies for detection of involved or close tumor margins, much effort is focused on developing intraoperative margin assessment modalities that can aid in addressing this unmet clinical need. BCS provides a unique opportunity to design contrast-based technologies that are able to assess tumor margins independent from the patient, providing a rapid pathway from bench to bedside at a much lower cost. Since resected tissue is removed from the patient’s blood supply, non-specific contrast agent uptake becomes a challenge due to the lack of clearance. Therefore, a dual probe, ratiometric fluorescence imaging approach was taken in an effort to reduce non-specific signal, and provide a modality that could demonstrate rapid, robust margin assessment on resected patient samples. Termed, dual-stain difference specimen imaging (DDSI), DDSI includes the use of spectrally unique, and fluorescently labeled target-specific, as well as non-specific biomarkers. In the present study, we have applied epidermal growth factor receptor (EGFR) targeted DDSI to tumor xenografts with variable EGFR expression levels using a previously optimized staining protocol, allowing for a quantitative assessment of the predictive power of the technique under biologically relevant conditions. Due to the presence of necrosis in the model tumors, ring analysis was employed to characterize diagnostic accuracy as measured by receiver operator characteristic (ROC) curve analysis. Our findings demonstrate the robust nature of the DDSI technique even in the presence of variable biomarker expression and spatial patterns. These results support the continued development of this technology as a robust diagnostic tool for tumor margin assessment in resected specimens during BCS.
Intraoperative margin assessment is imperative to cancer cure but is a continued challenge to successful surgery. Breast conserving surgery is a relevant example, where a cosmetically improved outcome is gained over mastectomy, but re-excision is required in >25 % of cases due to positive or closely involved margins. Clinical translation of margin assessment modalities that must directly contact the patient or required administered contrast agents are time consuming and costly to move from bench to bedside. Tumor resections provide a unique surgical opportunity to deploy margin assessment technologies including contrast agents on the resected tissues, substantially shortening the path to the clinic. However, staining of resected tissues is plagued by nonspecific uptake. A ratiometric imaging approach where matched targeted and untargeted probes are used for staining has demonstrated substantially improved biomarker quantification over staining with conventional targeted contrast agents alone. Our group has developed an antibody-based ratiometric imaging technology using fluorescently labeled, spectrally distinct targeted and untargeted antibody probes termed dual-stain difference specimen imaging (DDSI). Herein, the targeted biomarker expression level and pattern are evaluated for their effects on DDSI diagnostic potential. Epidermal growth factor receptor expression level was correlated to DDSI diagnostic potential, which was found to be robust to spatial pattern expression variation. These results highlight the utility of DDSI for accurate margin assessment of freshly resected tumor specimens.
Surgical nerve damage due to difficulty with identification remains a major risk for postsurgical complications and decreased quality of life. Fluorescence-guided surgery offers a means to specifically highlight tissues of interest such as nerves and a number of fluorescence-guided surgical systems are in clinical trial or are approved for clinical use. However, no clinically approved nerve-specific fluorophores exist. In addition, many preclinical nerve-specific fluorophores tend to accumulate in adipose tissue due to the molecular composition similarities between the two tissues, making it challenging to generate a specific nerve signal. To alleviate this difficulty, we have synthesized a library of oxazine fluorophores based on the Nile Red scaffold, with the goal of strong adipose specificity without nerve uptake to facilitate ratiometric imaging. The library was screened for tissue specificity ex vivo and in vivo, enabling quantification of adipose-, nerve- and muscle-specific uptake as well as selection of the best candidate for adipose selectivity without nerve signal. We showed our selected Nile Red fluorophore improved nerve contrast using ratiometric imaging, especially nerve-to-adipose contrast as compared to the parent Nile Red compound or nerve-specific imaging alone. This adipose-specific Nile Red derivative could be used in future fluorescence-guided surgery applications where adipose- or nerve-specific contrast is required.
Complete removal of malignant tissue during primary breast cancer resection is a critical prognostic indicator of local recurrence and overall patient survival, making intraoperative tumor margin assessment essential. Positive margin status following breast-conserving surgery (BCS) is a common difficulty reported in 20-60% of patients, with re-excision rates >55%. Re-excision increases the risk of morbidity and delays the use of adjuvant therapy, thus significant efforts are underway to develop successful intraoperative margin assessment strategies to eliminate repeat surgery. One novel strategy uses topical application of dual probe staining and a fluorescence imaging strategy termed dual probe difference specimen imaging (DDSI) where a receptor-targeted fluorescent probe and an untargeted, spectrally-distinct fluorescent probe are topically applied to the fresh resected specimen. While conceptually simple, resected specimen staining is dominated by non-specific uptake of fluorescent probes in normal tissue, requiring the use of a dual probe strategy for accuracy. DDSI permits fluorescence images from both the targeted and untargeted probes to be used to calculate a normalized difference image, facilitating quantitative identification of targeted probe tumor distribution in the specimen. While previous reports suggested this approach is a promising new tool for surgical guidance, advancing the approach into the clinic requires methodical protocol optimization and validation. Current work is focused on development of targeted and untargeted small molecule affinity tags, facilitating access to intracellular breast cancer biomarkers and quantitative assessment of DDSI signal in the context of varied biomarker expression level.
Nerve damage plagues surgical outcomes, significantly affecting post-surgical quality of life. Surprisingly, no method exists to enhance direct nerve visualization in the operating room, and nerve detection is completed through a combination of palpation and visualization when possible. Fluorescence image-guided surgery offers a potential means of enhanced nerve identification and preservation, however a clinically approved nerve-specific contrast agent does not yet exist. Several classes of nerve-specific fluorophores have recently been demonstrated including the distyrylbenzenes (DSB), select oxazines (oxazine 4 perchlorate), and certain cyanines (3,3’-diethylthiatricarbocyanine iodine), which could provide intraoperative guidance. The nerve-sparing radical prostatectomy is a surgical procedure that could benefit from fluorescence image-guided nerve identification. Although the nerve-sparing surgical technique was developed over 30 years ago, nerve damage following radical prostatectomy is reported in some form in up to 60% of patients one to two years post-surgery. To facilitate clinical translation of fluorescence image guided surgery to the nerve sparing prostatectomy, a direct administration methodology was developed that allows selective nerve highlighting with a significantly lower fluorophore dose than systemic administration, where large animal studies have confirmed the technique’s translatability. Tissue penetration will be critical for clinical feasibility of the direct administration methodology and novel formulation strategies have been explored to enhance tissue penetration for identifying buried nerves. In addition, several biomolecular targets of Oxazine 4, a promising candidate for nerve-specific fluorophore development into a near-infrared (NIR) agent, have been identified, providing insight into the mechanism of nerve-specificity. Fluorophore development has made progress towards the goal of creating a NIR nerve-specific fluorophore and determining the structure-activity relationship responsible for nerve binding.
Nerve damage plagues surgical outcomes and remains a major burden for patients, surgeons, and the healthcare
system. Fluorescence image-guided surgery using nerve specific small molecule fluorophores offers a solution to
diminish surgical nerve damage through improved intraoperative nerve identification and visualization. Oxazine 4 has
shown superior nerve specificity in initial testing in vivo, while exhibiting a red shifted excitation and emission spectra
compared to other nerve-specific fluorophores. However, Oxazine 4 does not exhibit near-infrared (NIR) excitation and
emission, which would be ideal to improve penetration depth and nerve signal to background ratios for in vivo imaging.
Successful development of a NIR nerve-specific fluorophore will require understanding of the molecular target of
fluorophore nerve specificity. While previous small molecule nerve-specific fluorophores have demonstrated excellent
ex vivo nerve specificity, Oxazine 4 ex vivo nerve specific fluorescence has been difficult to visualize. In the present
study, we examined each step of the ex vivo fluorescence microscopy sample preparation procedure to discover how in
vivo nerve-specific fluorescence is changed during ex vivo tissue sample preparation. Through step-by-step examination
we found that Oxazine 4 fluorescence was significantly diminished by washing and mounting tissue sections for
microscopy. A method to preserve Oxazine 4 nerve specific fluorescence ex vivo was determined, which can be utilized
for visualization by fluorescence microscopy.
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