Existing Methodology
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Transcript of Existing Methodology
Existing Methodology
Question: Will we be able to do this?
Question: What is “normal” tissue?
Surrogate Anatomic Sites for Evaluating Cancer Risk
Vadim Backman, Ph.D.Biomedical Engineering Department
Northwestern University
Colorectal Cancer (CRC)
#2 cause of cancer deaths, ~155K cases annually #2 cause of cancer deaths, ~155K cases annually and ~57K deaths – stagnant for 20 yearsand ~57K deaths – stagnant for 20 years
90%+ survival rate if caught early but today the 90%+ survival rate if caught early but today the majority (61%) are later stagemajority (61%) are later stage
Colonoscopy detects and removes a precursor to Colonoscopy detects and removes a precursor to colon cancer, adenomatous polyp, thus decreasing colon cancer, adenomatous polyp, thus decreasing future occurrence of CRC by 75-90% future occurrence of CRC by 75-90%
Problem: Current guidelines: everybody over age 50 is recommended to everybody over age 50 is recommended to undergo undergo colonoscopy at least once every 10 yearscolonoscopy at least once every 10 years. There are >90 million Americans over age 50. 70-80% of colonoscopies are negative and unnecessary Colonoscopic screening of this entire eligible population is impossible due to
- expense (annual cost would be ~$50 billion)- insufficient number of endoscopists- patient reluctance (hate prep!)- complication rate.
85% of the population receives no colonoscopic CRC screening.
Solution: Develop a minimally invasive technology to identify patients who are at risk for CRC and would benefit from colonoscopy.
Precedent:Precedent: Cervical cancer screening with Pap smear in the last 50 years Cervical cancer screening with Pap smear in the last 50 years reduced mortality from #1 cancer in women to #13!reduced mortality from #1 cancer in women to #13!
Why Colon Cancer Screening Program Does Not Work?
Factors for A Successful Screening Test: Inexpensive, No
Prep, & Sensitive
*Sensitivity relative to colonoscopy for precancerous advanced adenomas (polyps >1cm). Precancerous polyps, not cancer, is the most clinically relevant for the screening population.
**Gold standard with assumed sensitivity of 100%. Colonoscopy is estimated to miss up to 10% of advanced lesions (>1cm) and up to 35% of smaller lesions
Not yet approved for colon imagingYesYes, >$2,000Imaging
capsule
YesVirtual colonoscopy
18%NoYes, $700Fecal DNA
10%NoNoFOBT
YesYes, >$1,000Colonoscopy
Bowel preparation required?
Expensive?Technique
Not yet approved for colon imagingYesYes, >$2,000Imaging
capsule
55-80%YesYes, ~$1,000Virtual colonoscopy
18%NoFecal DNA
NoNoFOBT
100%**YesYes, >$1,000Colonoscopy
Sensitivity*Bowel
preparation required?
Expensive?Technique
Requirements for a population screening test:
• No bowel preparation• Performed by a PCP• Sensitive• Inexpensive
Exploiting the Field EffectField Effect:Field Effect: the genetic/environmental milieu that results in a neoplastic the genetic/environmental milieu that results in a neoplastic lesion in one area of the colon exists throughout the organ.lesion in one area of the colon exists throughout the organ.
• Conventional wisdom: tissue in a tumor is abnormal, tissue surrounding tissue is normal.
• This is only an approximation
• New methodology: detection of carcinogenesis by analysis of normal appearing cells in an accessible part of an organ.
Commonly Used Biomarkers of Field Effect in CRC
• Focal Neoplastic Lesions to predict Proximal NeoplasiaFocal Neoplastic Lesions to predict Proximal Neoplasia• Adenoma on flexible sigmoidoscopyAdenoma on flexible sigmoidoscopy
((Arch Intern Med. 2004 1881-7).Arch Intern Med. 2004 1881-7).
• Rectal aberrant crypt foci Rectal aberrant crypt foci ((Takayama et al N Engl J Med. 1998; 339:1277.)
• Diffuse Alterations in the Histologically Normal MucosaDiffuse Alterations in the Histologically Normal Mucosa• Decreased apoptosis Decreased apoptosis
(Bernstein et al. Cancer Res. 1999 59:2353-7)(Bernstein et al. Cancer Res. 1999 59:2353-7)
• Increased proliferation Increased proliferation (Ponz de Leon, et al Cancer Res. 1988 ;48:4121).(Ponz de Leon, et al Cancer Res. 1988 ;48:4121).
Chen et al. Cancer Res 2004
TUMOR
Microarray evidence Proteomic evidence
Polley et al. Cancer Res 2006
Novel Biomarkers of Field Effect in CRC
Optically-detectable Markers of the Field Effect
• Tissue physiology: Increased mucosal microvascular blood supply
• Tissue morphology: Alterations in tissue fractal microarchitecture
• Intracellular morphology: Alterations in intracellular nanoscale architecture
• Our approach: sensing changes in tissue that CANNOT be detected by histopathology, spatially outside the extent of a neoplastic lesion.
Lessons from Animal Studies
AOM-treated rat and MIN-mouse models
Early increase in microvascular blood supply (EIBS) and alterations in tissue micro and nano-architecture develop prior to ACFs and microadenomas.
These alterations can be detected at a distance from the neoplastic focus.
Gastroenterology, 126, 1071-1081 (2004)Clinical Cancer Research, 19, 961-968 (2006)FEBS, 581, 3857-3862 (2007)Gut, 54, 654-660 (2005)
Sub
muc
osa
Muc
osa
Pericryptal capillary networkEpithelium
Lamina propria
Muscularismucosa
Muscularispropria
Arterioles
Mesenteric artery
Diffusely present in ~90% of tissue sites.
Depth-resolution is crucial: changes are only in the mucosa (top 100 m).
EIBS is caused in part by iNOS upregulation.
Optically-detectable Markers of the Field Effect
• Tissue physiology: Increased microvascular blood supply
• Tissue morphology: Alterations in tissue microarchitecture
• Intracellular morphology: Alterations in intracellular nanoscale architecture
EIBS: In Vivo Clinical Validation• Technology: polarization-gated spectroscopy sensitive to mucosal microcirculation
• Design: in vivo, during colonoscopy
• Patient characteristics:
• 220 average risk screening patients
• 51 with adenomas: 30 non-advanced adenomas, 9 multiple non-advanced adenomas,12 advanced
• 169 patients with no neoplasia including 26 with hyperplastic polyps
EIBS fiber-optic probe
colonoscope
0.8
1
1.2
1.4
Adenoma <10 cmfrom
adenoma
<30 cmfrom
adenoma
>30 cmfrom
adenoma
Control
Distance from adenomas
Oxy
gen
ated
Hb
co
nce
ntr
atio
n
0.8
1.2
1.6
2
Adenoma <10 cmfrom
adenoma
<30 cmfrom
adenoma
>30 cmfrom
adenoma
Control
Distance from adenomas
Deo
xyg
enat
ed H
b c
on
cen
trat
ion
*
*
*
*
* *
* Indicates significantly different from control group
0
0.5
1
1.5
2
2.5
3
Adenoma <10 cmfrom
hyperplasticpolyp
10-30 cmfrom
>30 cmfrom
No adenoma or hyperplastic
polyp
Su
per
fici
alD
eOx
y-H
bD
eox
ygen
ated
blo
od
co
nte
nt
in
sup
erfi
cial
tis
sue,
a.u
.
(b)
P-value=N.S.
hyperplasticpolyp
hyperplasticpolyp
0
0.5
1
1.5
2
2.5
3
Adenoma <10 cmfrom
hyperplasticpolyp
10-30 cmfrom
>30 cmfrom
No adenoma or hyperplastic
polyp
Su
per
fici
alD
eOx
y-H
bD
eox
ygen
ated
blo
od
co
nte
nt
in
sup
erfi
cial
tis
sue,
a.u
.
(b)
P-value=N.S.
hyperplasticpolyp
hyperplasticpolyp
0
1
2
3
1 2 3 4 5Advanced adenoma
Diminutive adenoma
10-30 cm from
advancedadenoma
10-30 cm from
diminutiveadenoma
Normal control
Deo
xyge
nate
d bl
ood
cont
ent
(nor
mal
ized
)
p<0.01all p-values<0.01
0
1
2
3
1 2 3 4 5Advanced adenoma
Diminutive adenoma
10-30 cm from
advancedadenoma
10-30 cm from
diminutiveadenoma
Normal control
Deo
xyge
nate
d bl
ood
cont
ent
(nor
mal
ized
)
p<0.01all p-values<0.01
0
1
2
3
1 2 3 4 5Advanced adenoma
Diminutive adenoma
10-30 cm from
advancedadenoma
10-30 cm from
diminutiveadenoma
Normal control
Deo
xyge
nate
d bl
ood
cont
ent
(nor
mal
ized
)
0
1
2
3
1 2 3 4 50
1
2
3
1 2 3 4 5Advanced adenoma
Diminutive adenoma
10-30 cm from
advancedadenoma
10-30 cm from
diminutiveadenoma
Normal control
Deo
xyge
nate
d bl
ood
cont
ent
(nor
mal
ized
)
p<0.01all p-values<0.01
(a) (b)
(c) (d)
Distance from hyperplastic polyps
HyperplasticpolypD
eoxy
gen
ated
Hb
con
cen
trat
ion
Deo
xyg
enat
ed H
bco
nce
ntr
atio
n
30
40
50
1 2 3 4 5
Oxy
gen
atio
n,
%
30
40
50
1 2 3 4 5
Oxy
gen
atio
n,
%
EIBS: In Vivo Clinical Validation
*
**
*
Rectal EIBS is Indicative of Presence of Adenomas Throughout the Colon
Rect
al EIB
S
EIBS reading: rectum onlyAdenoma location: throughout the colon
Patients with no dysplasia vs. patients with advanced adenomas
Area under ROC curve =90%
**
Sensitivity = 100%Specificity = 75%
Optically-detectable Markers of the Field Effect
• Tissue physiology: Increased microvascular blood supply
• Tissue morphology: Alterations in tissue (fractal) microarchitecture
• Intracellular morphology: Alterations in intracellular nanoscale architecture
Alterations in Mucosal Microarchitecture: Clinical Study
Results• Technology: low-coherence enhanced backscattering (LEBS)
spectroscopy
• Design: rectal biopsy
• Patient characteristics: Patient characteristics: • 233 patients undergoing screening colonoscopy233 patients undergoing screening colonoscopy
• Mean age 56.8 ±10.7Mean age 56.8 ±10.7
• 47% female 47% female
• 60 with adenomas (17 advanced adenomas)60 with adenomas (17 advanced adenomas)
• 9 with previous h/o adenomas but none on present colonoscopy9 with previous h/o adenomas but none on present colonoscopy
• 158 with no current, prior or family history of adenomas158 with no current, prior or family history of adenomas
Human Clinical Study Results
-2
-1
0
1
2
LEB
S M
arke
r
ANOVA p-value = 5 x 10-6
No Dysplasia
0-4mm Adenoma
5-9mm Adenoma
Advanced Adenoma
*
*
100%NPV
42%PPV
88%Specificity*
100%Sensitivity*
LEBS
100%NPV
42%PPV
88%Specificity*
100%Sensitivity*
LEBS
94%95%
18%11%
Fecal DNA**
FOBT**
94%95%
18%11%
Fecal DNA**
FOBT**
0 0.2 0.4 0.6 0.8 10
0.2
0.4
0.6
0.8
1
1 - Specificity
Sen
siti
vity
AUC = 0.8947 (Advanced Adenoma)
AUC = 0.7066(Any Adenoma)
80%
Potential Confounding Factors Do Not Appear to Affect LEBS
Diagnosis
-3
-2
-1
0Normal
HyperplasticPolyp Hemorrhoids
DiverticulosisDiverticulitis
LE
BS
Ma
rke
r
ANOVA p-value = 0.91
0.640.20regression p-value
-0.0380.10correlation coefficient
BMIage
0.640.20regression p-value
-0.0380.10correlation coefficient
BMIage
0.6526age
0.9278medication history
0.5857BMI
0.5847gender
0.0443alcohol history
0.2235race
0.0209smoking history
0.0000presence of neoplasia
ANCOVA p-value
0.6526age
0.9278medication history
0.5857BMI
0.5847gender
0.0443alcohol history
0.2235race
0.0209smoking history
0.0000presence of neoplasia
ANCOVA p-value
Optically-detectable Markers of the Field Effect
• Tissue physiology: Increased microvascular blood supply
• Tissue morphology: Alterations in tissue microarchitecture
• Intracellular morphology: Alterations in cell nanoscale architecture
Alterations in Epithelial Nanoarchitecture: Clinical Study
Results• Technology: partial wave spectroscopic (PWS) microscopy
• Design: rectal mucosal brushings
• Patient characteristics: Patient characteristics: • 35 patients 35 patients
• 21 with no neoplasia21 with no neoplasia
• 14 with adenomas, 4 advanced14 with adenomas, 4 advanced
1 µm 1 µm
Human Clinical Study Results
7
8
9
10
11
12
13
Control Adenoma Advancedadenoma
Dis
ord
er
str
en
gth
Ld
(mm
)
x 10-7
*
*
* p-value < 0.0001
Disorder in nanoscale density fluctuations in endoscopically-normal rectal mucosa is increased in patients with sporadic adenomas
no neoplasia
neoplasia
SensitivitySensitivity 100%100%
SpecificitySpecificity 95%95%
Colonoscopy-free Screening for Colon Cancer Using Optical Detection of the
Field Effect
Colonoscopy
+ _
Only patients with adenomas receive colonoscopies Most (all) patients with adenomas are screened Patients are more compliant Better allocation of colonoscopic resource
Annual population screening by PCP’s during an annual exam without colonoscopy and preparation
LEBS probe
Does LEBS Work in Other Organs?
Does LEBS Work in Other Organs?
Example: Pancreatic Cancer• No existing technique is capable of accurate diagnosis of pancreatic carcinogenesis in preinvasive (PanIN) or resectable stage.
• 95% mortality within a year after diagnosis.
• Problem: pancreatic duct exam is not suitable for screening due to a high rate of complications including acute pancreatitis (~5-20%).
• Solution: PWS analysis of duodenal periampullary cells brushed during upper endoscopy.
Prospect of Pancreatic Cancer Screening
Testing set:Sensitivity = 85% Specificity = 80%
204 patients total204 patients total84 Healthy control84 Healthy control26 Family History26 Family History29 Cyst29 Cyst45 Pancreatic Adenocarcinoma45 Pancreatic Adenocarcinoma20 Other diseases20 Other diseases
LEBS (Microarchitecture): PWS (Nanoarchitecture):
35 patients total35 patients total26 Healthy control26 Healthy control 9 Pancreatic Adenocarcinoma9 Pancreatic Adenocarcinoma
Sensitivity = 90% Specificity = 81%
Example III: Lung Cancer• >80% of lung cancer patients had altered nuclear texture features
Us-Krasovec et al., Anal Quant Cytol Histol. 2005 Oct;27(5):254-62
•Automated Quantitative cytology of buccal nuclei correlated with lung cancer
• 66% sensitivity and 70% specificity for lung cancers• 61% sensitivity for stage 1
Turic et al, Chest 2005 (abstract)
• Increased incidence of head and neck cancer in patients with lung cancerJohnson et al., B. J. Natl. Cancer Inst., 1998
• Genetic changes in the histologically normal large-airway epithelial cells obtained at bronchoscopy.
Guo, M. et al. Clin. Cancer Res. 2004.
• 80% sensitivity and 84% specificitySpira et al., Nat Med 2006.
Lung Cancer Screening by PWS Analysis of Buccal Cells
Normal - Nonsmokers - 5 Cancer - Nonsmokers - 3 COPD (smokers) - 31 COPD – Family Hx - 7 Lung cancer (smokers) - 53 Other cancers - 4 Smokers (no COPD or cancer) - 5
Number of Patients: 108
PWS Images are Different for Non-cancer and Cancer Patients
No
n-c
an
cer
(CO
PD
) pa
tien
ts
Dis
ord
er
stre
ngth
(L
d),
um
Lun
g c
an
cer
pat
ien
ts
PW
SB
right
fiel
dB
right
fiel
dP
WS
Disorder in Nanoarchitecture is Increased in Buccal Cells
in Lung Cancer Patients
Control (COPD)
2.E-06
3.E-06
4.E-06
5.E-06
COPD-all Cancer
Dis
ord
er s
tren
gth
(L
d)
(um
)
Lung cancer
P<0.001
0.0
00
.25
0.5
00
.75
1.0
0S
en
sitiv
ity
0.00 0.25 0.50 0.75 1.001 - Specificity
Area under ROC curve = 0.8393
Area under ROC curve = 84%
Sensitivity = 90%Specificity = 77%
Potential Confounding Effects
• Can the differences in cell nanoarchitecture be simply due to difference in age among COPD and lung cancer patients?
• Can the differences be due to different smoking history?
Age Pack years
Control 71±9 78±38
Cancer 70±12 59±46
Demographic factor
P-value (Effect on Ld)
P-value (Effect on SDLd)
Age 0.56 0.45
Smoking 0.65 0.48
Race 0.60 0.40
Gender 0.79 0.93
Conclusions
• What we call “histologically normal tissue” is not entirely normal in patients with neoplasia
• Not only neoplastic lesions but also tissue outside neoplastic lesions is abnormal
• Biophotonics can detect field effects associated with carcinogenesis in the colon, pancreatic and lung
• Optically-detectable markers of the field effect include increased mucosal blood supply, micro and nano-architectural changes in the mucosa
• Potential for colon, pancreatic and lung cancer screening/risk-stratification through biophotonics detection of the field effect
Acknowledgements
Funding
National Institutes of HealthR01CA128641, R01 CA109861, R01 EB003682, R01 CA112315, R01 CA118794, R33CA122017, R21 EB006742, U01 CA11125
National Science FoundationCBET- 0733868, CBET-0238903
V Foundation Coulter FoundationAACR
Northwestern UniversityVladimir Turzhitsky Andrew GomezHariharan SubramanianSarah RudermanJeremy Rogers, Ph.D.Young Kim, Ph.D. Yang Liu, Ph.D.Prabhakar Pradhad, Ph.D.Xu Li, Ph.D.Alexei Kromine
Evanston HospitalHemant Roy, M.D.Ramesh Wali, Ph.D.Randall Brand, M.D.M. Goldberg, M.D.