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.


• Tissue physiology: Increased microvascular blood supply

• Tissue morphology: Alterations in tissue microarchitecture


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


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


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


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

)


(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%



• Tissue morphology: Alterations in tissue (fractal) microarchitecture


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



• 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.

Documents

Existing Methodology