Noninvasive Vascular Characterization with Low-cost, Label-free Optical Spectroscopy and Dark Field Microscopy Enables Head and Neck Cancer Diagnosis and Prognosis
Worldwide, head and neck squamous cell cancers (HNSCC) account for over 375,000 deaths annually. The majority of these cancers arise in the outermost squamous cells which progress through a series of precancerous changes before developing into invasive HNSCC. It is widely accepted that prognosis is strongly correlated to the stage of diagnosis, with early detection more than doubling the patient’s chance of survival. Currently, however, 60% of HNSCCs are diagnosed when they have already progressed to stage 3 or stage 4 disease. The current diagnostic method of visual examination often fails to recognize early indicators of HNSCC, thereby missing an important prevention window.
Determination of cancer from non-malignant tissues is dependent on pathological examination of lesion biopsies. Thus, all patients with any clinically suspicious lesions undergo surgical biopsies. Furthermore, these surgical biopsies carry risks. In addition to the risk of general anesthesia for patients undergoing panedoscopy, some patients have poor healing and develop ulcerations or infections as a result of surgical biopsy at any anatomical site. Additionally, studies have shown that approximately 50% of suspected biopsies are later pathologically confirmed normal. An enormous amount of labor, facility, and monetary resources are expended on non-malignant biopsies and patients who ultimately have no malignancy. It would be of immense overall benefit to clinicians and patients to have a non-invasive and portable technique that could rapidly identify those patients that would benefit from further surgical biopsy from those that only need follow-up clinical observations.
Once carcinoma is confirmed in a patient, treatment currently involves modalities of surgery, radiation, and chemotherapy. Radiotherapy plays a significant role, particularly in the management of localized HNSCC, because it is a non-invasive and function-preserving modality. However, the effectiveness of radiotherapy is limited by hypoxia. Previous studies showed that tumors reoxygenated during radiotherapy treatment may have a better prognosis. Despite decades of work, there is still no reliable, cost-effective way for measuring tumor hypoxia over multiple time points to estimate the prognosis.
To address these unmet clinical needs, three aims were proposed. The first aim was to improve early detection by identifying biomarkers of early pre-cancer as well as developing an objective algorithm to detect early disease. Neovasculature is an important biomarker for early cancer diagnosis. Even before the development of a clinically detectable lesion, the tumor vasculature undergoes structural and morphological changes in response to oncogenic signaling pathways . Without receiving a sufficient supply of oxygen and nutrients to proliferate, early tumor growth is limited to only 1-2 mm. High-resolution optical imaging is well suited to characterize the earliest neovascularization changes that accompany neoplasia owing to its sensitivity to hemoglobin absorption and resolution to visualize capillary level architecture. Dark field microscopy is a low-cost and robust method to image the neovasculature. We imaged neovascularization in vivo in a spontaneous hamster oral mucosa carcinogen model using a label-free, reflected-light spectral dark field microscope. Hamsters’ cheek pouches were painted with 7, 12-Dimethylbenz[a]anthracene (DMBA) to induce precancerous to cancerous changes, or mineral oil as control. Spectral dark field images were obtained during carcinogenesis and in control oral mucosa, and quantitative vascular features were computed. Vascular tortuosity increased significantly in oral mucosa diagnosed as hyperplasia, dysplasia and squamous cell carcinoma (SCC) compared to normal. Vascular diameter and area fraction decreased significantly in dysplasia and SCC compared to normal. The areas under the receiver operative characteristic (ROC) curves (AUC) computed using a Support Vector Machine (SVM) were 0.95 and 0.84 for identifying SCC or dysplasia, respectively, vs. normal and hyperplasia oral mucosa combined. To improve AUCs for identifying dysplasia, quantitative vascular features were computed again after the vessels were split into large and small vessels based on diameter. The large vessels preserved the same significant trends, while small vessels demonstrated the opposite trends. Significant increases in diameter and decreases in area fraction were observed in SCC and dysplasia. The AUCs were improved to 0.99 and 0.92 for identifying SCC and dysplasia. These results suggest that dark field vascular imaging is a promising tool for pre-cancer detection.
Optical imaging can also be applied to quantifying other important characteristics of solid tumors in head and neck cancer (HNC), such as hypoxia, abnormal vascularity and cell proliferation. Diffuse reflectance spectroscopy is a simple and robust method to measure tissue oxygenation, vascularity and cell density. It is particularly suitable for applications in the operation room because of its compact design and portability. In addition, a fiber probe-based system is ideal for obtaining measurements at suspicious lesions in the head and neck area during surgery. Thus, my second aim was to reduce the number of unnecessary HNSCC biopsies by developing a robust tool and rapid analysis method appropriate for clinical settings. We propose the use of morphological optical biomarkers for rapid detection of human HNSCC by leveraging the underlying tissue characteristics in the aerodigestive tracts Prior to biopsy, diffuse reflectance spectra were obtained from malignant and contra-lateral non-malignant tissues of 57 patients undergoing panendoscopy. Oxygen saturation (SO2), total hemoglobin concentration ([THb]), and the reduced scattering coefficient were extracted using an inverse Monte Carlo (MC) method previously developed by former student in our lab. Differences in malignant and non-malignant tissues were examined based on two different groupings: by anatomical site and by morphological tissue type. Measurements were acquired from 252 sites, 51 of which were pathologically classified as SCC. Optical biomarkers exhibited statistical differences between malignant and non-malignant samples. Contrast was enhanced when parsing tissues by morphological classification rather than by anatomical subtype for unpaired comparisons. Corresponding linear discriminant models using multiple optical biomarkers showed improved predictive ability when accounting for morphological classification, particularly in node-positive lesions. The false-positive rate was retrospectively found to decrease by 34.2% in morphologically- vs. anatomically-derived predictive models. In glottic tissue, the surgeon exhibited a false-positive rate of 45.7% while the device showed a lower false-positive rate of only 12.4%. Additionally, comparisons of optical parameters were made to further understand the physiology of tumor staging and potential causes of high surgeon false-positive rates. Optical spectroscopy is a user-friendly, non-invasive tool capable of providing quantitative information to discriminate malignant from non-malignant head and neck tissues. Predictive models demonstrated promising results for diagnostics. Furthermore, the strategy described appears to be well suited to reduce the clinical false-positive rate.
To further improve the speed for extracting the tissue oxygenation and [THb] to reduce the time when patients were under anesthesia, the third aim was to develop a rapid heuristic ratiometric analysis for estimating tissue [THb] and SO2 from measured tissue diffuse reflectance spectra. The analysis was validated in tissue-mimicking phantoms and applied to clinical measurements in head and neck, cervical and breast tissues. The analysis works in two steps. First, a linear equation that translates the ratio of the diffuse reflectance spectra at 584 nm to 545 nm to estimate the tissue [THb] using a Monte carlo (MC)-based lookup table was developed. This equation is independent of tissue scattering and oxygen saturation. Second, SO2 was estimated using non-linear logistic equations that translate the ratio of the diffuse reflectance spectra at 539 nm to 545 nm into the tissue SO2. Correlations coefficients of 0.89 (0.86), 0.77 (0.71) and 0.69 (0.43) were obtained for the tissue hemoglobin concentration (oxygen saturation) values extracted using the full spectral MC and the ratiometric analysis, for clinical measurements in head and neck, breast and cervical tissues, respectively. The ratiometric analysis was more than 4000 times faster than the inverse MC analysis for estimating tissue [THb] and SO2 in simulated phantom experiments. In addition, the discriminatory power of the two analyses was similar. These results show the potential of such empirical tools to rapidly estimate tissue hemoglobin and oxygenation for real-time applications.
In addition to its use as a diagnostic marker for various cancers, tissue oxygenation is believed to play a role in the success of cancer therapies, particularly radiotherapy. However, since little effort has been made to develop tools to exploit this relationship, the fourth aim was to estimate patient prognosis by measuring tumor hypoxia over multiple time points so physicians are able to develop more informed and effective clinical treatment plan. To test if oxygenation kinetics correlates with the likelihood for local tumor control following fractionated radiotherapy, we again used diffuse reflectance spectroscopy to noninvasively measure tumor vascular oxygenation and [THb] associated with radiotherapy of 5 daily fractions (7.5, 9 or 13.5 Gy/day) in FaDu xenografts. Spectroscopy measurements were obtained immediately before each daily radiation fraction and during the week after radiotherapy. SO2 and [THb] were computed using an inverse MC model. Oxygenation kinetics during and after radiotherapy, but before a change in tumor volume, was associated with local tumor control. Locally controlled tumors exhibited significantly faster increases in oxygenation after radiotherapy (days 12-15) compared with tumors that recurred locally. (2) Within the group of tumors that recurred, faster increases in oxygenation during radiotherapy (days 3-5) were correlated with earlier recurrence times. An AUC of 0.74 was achieved when classifying the local control tumors from all irradiated tumors using the oxygen kinetics with a logistic regression model. (3) The rate of increase in oxygenation was radiation dose dependent. Radiation doses ≤9.5 Gy/day did not initiate an increase in oxygenation whereas 13.5 Gy/day triggered significant increases in oxygenation during and after radiotherapy. Additional confirmation is required in other tumor models, but these results suggest that monitoring tumor oxygenation kinetics could aid in the prediction of local tumor control after radiotherapy.
Angiogenesis is a highly regulated process to support tissue growth. Neovasculature is designed by nature to grow toward areas lacking nutrition and oxygen. Cancer cells proliferate too quickly to have their nutritional and oxygen needs completely satisfied, which results in an imbalanced state of angiogenesis leading to tortuous blood vessels, hypoxic tissues and radioresistance. We characterized the tumor-induced vascular features with simple, robust and low-cost dark field microscopy and spectroscopy to enable early cancer diagnosis, improvement of surgical biopsy accuracy and better predict the prognosis of radiotherapy for HNC. Our results demonstrated that these noninvasively measured, label-free vascular features are able to detect pre-cancer, reduce unnecessary surgical biopsies and predict prognosis of radiotherapy.
Dark field microscopy
Diffuse reflectance spectroscopy
Head and neck cancer
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