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Cytomorphological Characterization of Individual Metastatic Tumor Cells from Gastrointestinal Cancer Patient Lymph Nodes with Imaging Flow Cytometry

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Cytomorphological Characterization of Individual Metastatic Tumor Cells from Gastrointestinal Cancer Patient Lymph Nodes with Imaging Flow Cytometry Communication Cytomorphological Characterization of Individual Metastatic Tumor Cells from Gastrointestinal Cancer Patient Lymph Nodes with Imaging Flow Cytometry Marnie Winter 1 , Rachel Gibson 2, Andrew Ruszkiewicz 3 and Benjamin Thierry 1,* 1 Future Industries Institute and ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, University of South Australia, Adelaide 5095, Australia; [email protected] 2 Faculty of Health and Medical Sciences, University of Adelaide, Adelaide 5000, Australia; [email protected] 3 Department of Surgical Pathology, SA Pathology, Centre for Cancer Biology, University of South Australia, Adelaide 5000, Australia; [email protected] * Correspondence: [email protected]; Tel.: +61-8-8302-368 Received: 16 July 2019; Accepted: 19 September 2019; Published: 26 September 2019 Abstract: The presence or absence of tumor cells within patient lymph nodes is an important prognostic indicator in a number of cancer types and an essential element of the staging process. However, patients with the same pathological stage will not necessarily have the same outcome. Therefore, additional factors may aid in identifying patients at a greater risk of developing metastasis. In this proof of principle study, initially, spiked tumor cells in rat lymph nodes were used to mimic a node with a small cancer deposit. Next, human lymph nodes were obtained from cancer patients for morphological characterization. Nodes were dissociated with a manual tissue homogenizer and stained with fluorescent antibodies against CD45 and Pan-Cytokeratin and then imaging flow cytometry (AMNIS ImageStreamX Mark II) was performed. We show here that imaging flow cytometry can be used for the detection and characterization of small numbers of cancer cells in lymph nodes and we also demonstrate the phenotypical and morphological characterization of cancer cells in gastrointestinal cancer patient lymph nodes. When used in addition to conventional histological techniques, this high throughput detection of tumor cells in lymph nodes may offer additional information assisting in the staging process with therapeutic and prognostic applications. Keywords: imaging flow cytometry; lymph node; metastasis; cellular morphology; cancer 1. Introduction The presence of metastatic cancer cells within regional lymph nodes, including in sentinel lymph nodes (SLNs), is a significant prognostic indicator in a number of cancer types including gastrointestinal (GI) cancers [1]. Importantly, positive identification of metastatic tumor cells in lymph nodes may indicate the need for adjuvant therapy [2]. The size of cancer deposits in lymph nodes is also clinically relevant. These can be defined as either (1): Macrometastasis (>2 mm), (2): Micrometastasis (0.2–2 mm), or (3): Isolated tumor cells (ITCs; <0.2 mm) [1]. Prognostic significance for the smaller deposits (including micrometastasis and ITC) is highly debated and is likely to vary between cancer types [3–7]. Determining which patients with positive nodes require Axillary Lymph Node Dissection (ALND) and that would benefit from adjuvant radiotherapy and systemic treatment is a problem [8] as some lymph node metastasis may never develop into clinically detectable disease [9]. Therefore, additional approaches to identify individuals with a higher likelihood of developing metastatic disease are required to provide better prognostication and selection for adjuvant treatment [10]. Gastrointest. Disord. 2019, 1, 372–384; doi:10.3390/gidisord1040030 www.mdpi.com/journal/gastrointestdisord Gastrointest.Gastrointest. Disord. 20192019,, 11 FOR PEER REVIEW 3732 Currently, lymph node involvement by tumor is assessed using histological methods which may be complementedCurrently, lymph by nodeimmunohistochemical involvement by tumor (IHC) is assessedanalysis usingof formalin histological fixed methodsparaffin whichembedded may be(FFPE) complemented tissue postoperatively by immunohistochemical or frozen sections (IHC) analysis intra-operatively of formalin [11]. fixed Increasing paraffin embedded the number (FFPE) of tissuesections postoperatively examined of the or frozenresected sections node analyzed, intra-operatively accompanied [11]. with Increasing the use the of numbertargeted of molecular sections examinedmethods increases of the resected small deposit node analyzed, detection accompanied [1]; however, with these the methods use of targetedare not routinely molecular used methods in the increasespathological small practice deposit as detection their reliability [1]; however, to detec theset methodssmall deposits are not is routinely questioned used [12]. in the Advances pathological for practicedisseminated as their tumor reliability cell to(DTC) detect detection small deposits in lymp is questionedh nodes have [12]. Advancesprimarily forfocused disseminated on increasing tumor cellsensitivity (DTC) detectionof detection in lymphand increasing nodes have speed primarily of diagnosis. focused DTC on increasinginclude cancer sensitivity cells that of detectionleave the andprimary increasing tumor speedvia the of lymphatics diagnosis. and DTC can include lodge cancer in lymph cells nodes that leave and go the on primary to form tumor a metastatic via the lymphaticsdeposit. To anddate, can individual lodge in lymphtumor nodescell morpholo and go ongy to following form a metastatic isolation deposit.from lymph To date, nodes individual has not tumorbeen investigated, cell morphology despite following the fact isolation it could fromprovid lymphe clinically nodes important has not been information. investigated, Conversely, despite the a factvery it intensive could provide research clinically effort has important been undertaken information. in recent Conversely, years to elucidate a very intensive the clinical research significance effort hasof circulating been undertaken tumor cells in recent (CTCs) years [13–15] to elucidate and plasma the circulating clinical significance tumor DNA of circulating(ctDNA) in tumor peripheral cells (CTCs)blood [16]. [13– 15Recent] and plasmaadvances circulating in molecular tumor analysis DNA (ctDNA) of ctDNA in peripheralwith next bloodgeneration [16]. Recentsequencing advances and inadvanced molecular computational analysis of ctDNA analysis with allows next generation for tumor sequencing genotyping and and advanced has demonstrated computational clinically analysis allowsrelevant for mutational tumor genotyping analysis [16]. and has demonstrated clinically relevant mutational analysis [16]. Importantly,Importantly, thethe isolationisolation andand characterizationcharacterization ofof CTCsCTCs isis aa veryvery activeactive research topictopic providingproviding clinicallyclinically relevant relevant information information on on the the metastatic metastatic progression progression of disease of disease in a number in a number of human of humancancers cancers[13–15]. [The13– 15main]. The advantage main advantage of assessing of assessingCTCs and CTCsctDNA and is the ctDNA ease isof theblood ease sample of blood acquisition sample acquisition(liquid biopsies) (liquid at multiple biopsies) time at multiple points in time contrast points to invasive in contrast procedures to invasive required procedures to collect required tumor totissue. collect With tumor the tissue.advent Withof advanced the advent isolation of advanced technologies, isolation individual technologies, cellular individual morphological cellular morphologicalcharacterization characterization of cancer cells of and cancer the cells importance and the importance of morphology of morphology for correlation for correlation with patient with patientprognosis prognosis has been has investigated been investigated [17–21]. [ 17–21]. TheThe aimsaims of of the the current current study study were were to demonstrate to demon thestrate feasibility the feasibility of using of imaging using flowimaging cytometry flow (IFC)cytometry for the (IFC) cytomorphological for the cytomorphological detection of detection tumor cells of tumor in lymph cells nodes. in lymph IFC isnodes. a technique IFC is a combining technique thecombining high throughput the high throughput quantitative quantitative nature of flownature cytometry of flow cytometry with high with resolution high resolution imaging. imaging. The use ofThe IFC use is of aIFC rapidly is a rapidly emerging emerging area witharea with a number a number of studiesof studies demonstrating demonstrating its its capabilities capabilities andand advantagesadvantages [[22–25].22–25]. Recently, DoanDoan and colleagues discussed the potential of imaging flow flow cytometry withwith aa particular focus on promising promising developments developments that that would would make make IFC IFC more more clinically clinically viable viable as as a adiagnostic diagnostic and and prognostic prognostic tool, tool, including including deep deep lear learningning and and cloud cloud computing computing [26]. [26 We]. We conducted conducted an aninitial initial model model study study using using rat rat lymph lymph nodes nodes spiked spiked with with a small a small number number ofof cancer cancer cells cells simulating simulating a amodel model of of a alymph lymph node node with with ITC ITC or or micrometastasi micrometastasis.s. Once Once the feasibility was demonstrated,demonstrated, wewe proposedproposed aa methodmethod toto detectdetect and and characterize characterize tumor tumor cells cells from from resected resected GI GI patient patient
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