a Fluorescence-guided cancer surgery Quirijn Tummers surgeryFluorescence-guided cancer Quirijn Fluorescence-guided cancer surgery using clinical available and innovative tumor-specifc contrast agents Quirijn Tummers 46151 Tummers cover.indd 1 09-08-17 11:17 Fluorescence-guided cancer surgery using clinical available and innovative tumor-specifc contrast agents Quirijn Tummers 46151 Quirijn Tummers.indd 1 16-08-17 13:01 © Q.R.J.G. Tummers 2017 ISBN: 978-94-6332-197-6 Lay-out: Ferdinand van Nispen, Citroenvlinder DTP & Vormgeving, my-thesis.nl Printing: GVO Drukkers & Vormgevers All rights reserved. No parts of this thesis may be reproduced, distributed, stored in a retrieval system or transmitted in any form or by any means, without prior written permission of the author. The research described in this thesis was fnancially supported by the Center for Translational Molecular Imaging (MUSIS project), Dutch Cancer Society and National Institutes of Health. Financial support by Raad van Bestuur HMC Den Haag, Quest Medical Imaging, On Target Laboratories, Centre for Human Drug Research, Curadel, LUMC, Nederlandse Vereniging voor Gastroenterologie, Karl Storz Endoscopie Nederland B.V., ABN-AMRO and Chipsoft for the printing of this thesis is gratefully acknowledged. 46151 Quirijn Tummers.indd 2 16-08-17 13:01 Fluorescence-guided cancer surgery using clinical available and innovative tumor-specifc contrast agents Proefschrift ter verkrijging van de graad van Doctor aan de Universiteit Leiden, op gezag van Rector Magnifcus prof. mr. C.J.J.M. Stolker, volgens besluit van het College voor Promoties te verdedigen op woensdag 11 oktober 2017 klokke 15:00 uur door Quirijn Robert Johannes Guillaume Tummers geboren te Leiden in 1986 46151 Quirijn Tummers.indd 3 16-08-17 13:01 Promotor Prof. dr. C.J.H. van de Velde Co-promotor Dr. A.L. Vahrmeijer Leden promotiecommissie Prof. dr. J. Burggraaf Prof. dr. V.T.H.B.M. Smit Prof. dr. C.W.G.M. Löwik (Erasmus MC, Rotterdam) Prof. dr. G.M. van Dam (UMCG, Groningen) Dr. K.N. Gaarenstroom 46151 Quirijn Tummers.indd 4 16-08-17 13:01 46151 Quirijn Tummers.indd 5 16-08-17 13:01 TABLE OF CONTENTS Chapter 1 General introduction and thesis outline 9 Part I Exploring clinical available fuorescent contrast 19 agents in cancer surgery Chapter 2 Near-infrared fuorescence sentinel lymph node 21 detection in gastric cancer: a pilot study Chapter 3 Real-time intraoperative detection of breast cancer 39 using near-infrared fuorescence imaging and Methylene Blue Chapter 4 First experience on laparoscopic near-infrared 57 fuorescence imaging of hepatic uveal melanoma metastases using indocyanine green Chapter 5 Intraoperative identifcation of normal pituitary gland 69 and adenoma using near-infrared fuorescence imaging and low-dose indocyanine green Chapter 6 Intraoperative near-infrared fuorescence imaging of a 85 paraganglioma using Methylene Blue: a case report Chapter 7 Intraoperative guidance in parathyroid surgery using 97 near-infrared fuorescence imaging and low-dose Methylene Blue. Chapter 8 The value of intraoperative near-infrared fuorescence 113 imaging based on enhanced permeability and retention of indocyanine green: feasibility and false- positives in ovarian cancer 46151 Quirijn Tummers.indd 6 16-08-17 13:01 Part II Clinical translation of innovative tumor-specifc 131 fuorescent contrast agents Chapter 9 Intraoperative imaging of folate receptor alpha positive 133 ovarian and breast cancer using the tumor specifc agent EC17 Chapter 10 A novel tumor-specifc agent targeting the folate 155 receptor-alpha for intraoperative near-infrared fuorescence imaging: a translational study in healthy volunteers and patients with ovarian cancer Part III 179 Chapter 11 Summary and future perspectives 181 Appendices 193 Nederlandse samenvatting en toekomstperspectieven 195 List of publications 20 Curriculum Vitae 215 Dankwoord 219 46151 Quirijn Tummers.indd 7 17-08-17 20:40 46151 Quirijn Tummers.indd 8 16-08-17 13:01 Chapter 1 GENERAL INTRODUCTION AND THESIS OUTLINE 46151 Quirijn Tummers.indd 9 16-08-17 13:01 46151 Quirijn Tummers.indd 10 16-08-17 13:01 General introduction and thesis outline 11 Over the past decades multiple preoperative imaging modalities have become available that have the ability to non-invasively detect tumors, improve accuracy of staging and preoperative planning, and can identify sentinel lymph nodes (SLN) of various tumor types or vital structures1;2. However, during surgery, translation of these preoperative obtained images can be challenging due to altering in body position and tissue manipulation by the surgeon. Therefore surgeons mainly have to rely on their eyes and hands to identify structures that need to be resected or spared. Distinction between malignant and healthy tissue based on inspection and palpation can often be very difcult. Therefore, incomplete resections (R1) still occur in a signifcant number of cancer patients. In breast cancer for example, the number of patients with positive resection margins ranges from 11% to 46% after resection of the primary tumor3. Because complete resections are the cornerstone of curative cancer surgery, this leads to unfavorable patient outcomes, resulting in additional surgical procedures, delays in adjuvant treatment, increased morbidity rates and increased healthcare costs, and most likely decreased quality of life. Next to imaging solitary tumors, improving the detection of metastasized disease could also improve patient outcomes. In metastasized ovarian cancer for example, identifcation of malignant lesions can improve staging procedures and facilitate treatment decisions between primary surgery and systemic therapy. Moreover, it can increase the number of optimal debulking procedures resulting in prolonged survival4-6. In metastasized uveal melanoma, intraoperative identifcation of hepatic metastases can assist in selecting patients that will beneft from resection, and expedite adjuvant systemic therapies for patients with miliary disease7-9. Moreover, minimally invasive procedures are increasingly applied in daily clinical practice, limiting the possibility to palpate tissue and making the visual inspection more important for identifcation of malignant tissue and normal structures. Therefore, there is a clear unmet need for imaging modalities that facilitate the detection of cancer tissue and vital structures in real time during the surgical procedure. Fluorescence imaging Fluorescence imaging is an innovative optical imaging technique that can assist in the intraoperative identifcation of tumor tissue, SLNs, and vital 46151 Quirijn Tummers.indd 11 16-08-17 13:01 12 Chapter 1 structures10. This technique, like medical imaging techniques in general, is based on the ability to create a contrast ratio between the tissue of interest and its surrounding normal tissue. Figure 1. NIR fuorescence imaging NIR fuorescent contrast agents are administered intravenously. During surgery, the agent is visualized using a NIR fuorescent imaging system of the desired form factor (above the surgical feld for open surgery or encased within minimal invasive surgery). All systems must have adequate NIR excitation light, collection optics, flter sets and a camera sensitive to NIR fuorescent emission light. An optimal imaging system includes simultaneous visible (white) light illumination of the surgical feld, which can be merged with the generated NIR fuorescence images. The surgeon’s display can be one of several form factors, including a standard computer monitor, goggles or a wall projector. Abbreviations: LED, light emitting diode; NIR, near-infrared. Illustration and caption are depicted from Vahrmeijer et al., Nat Rev 201310. Fluorescence can be captured by a specialized imaging system and made visible for the human eye in real-time. Advantages of this technology include high sensitivity and high resolution. Depending on the wavelength of the 46151 Quirijn Tummers.indd 12 16-08-17 13:01 General introduction and thesis outline 13 emission light, penetration into tissue can be micrometers in the visible light spectrum (400 – 600nm), up to several millimeters to a centimeter in the near- infrared (NIR) light spectrum (700 – 900nm)11;12. For intraoperative fuorescence imaging, both an imaging system and fuorescent contrast agent are needed. Moreover, the combination of imaging device and optical properties of the fuorophore is of paramount importance for successful intraoperative imaging. The imaging system contains an excitation light source and a detection device to capture emitted fuorescence from the exited fuorophores. Several imaging systems, either investigational or commercially available, have been developed over the past years for intraoperative fuorescence imaging13. As fuorescence imaging is gaining more attention, systems optimized for open surgery14-19 and endoscopic surgery20-23 are available at present. With respect to fuorescent contrast agents, there are only a few that have become clinically available over the past decades. These include fuorescein24, methylene blue (MB)25, 5-aminolevulinic acid (5-ALA)26 and indocyanine green27. Although some of these contrast agents possess properties to specifcally accumulate inside or around tumors, they are not ligand- targeted contrast agents. This limits the clinical applicability of these compounds for a broad application. Tumor imaging For intraoperative tumor imaging, accumulation of a contrast agent in or around the tumor is essential to diferentiate between tumors and surrounding normal