Academic Appointments

  • Instructor, Otolaryngology - Head & Neck Surgery Divisions

Honors & Awards

  • NIH K99/R00 Pathway to Independence Award, NCI (2022)
  • Stanford Translational Medicine Scholar, Stanford (2022)
  • Stanford Cancer Institute Cancer Innovation Award, Stanford (2021-2022)
  • Stanford Molecular Imaging Scholar (SMIS Fellow), Stanford (2018-2021)
  • Industry Selected Poster Award, World Molecular Imaging Congress (WMIC) (2018)
  • Student Travel Award, World Molecular Imaging Congress (WMIC) (2017)
  • Outstanding Translational Research Award, Department of Biomedical Engineering at Georgia Institute of Technology and Emory University (2016)
  • Rising Stars in Biomedical Engineering and Science, Massachusetts Institute of Technology, Cambridge (2016)
  • Outstanding Research Poster Award, Inauguration Workshop and Launch of the Integrative Cancer Imaging Research Initiative, Emory&Gatech (2016)
  • Coulter Fellowship, The Wallace H. Coulter Foundation (2009-2012)
  • Excellent Academic Scholarship, Shanghai Jiao Tong University (2009-2012)
  • BOSCH Academic Scholarship, Shanghai Jiao Tong University (2011)
  • BlackBerry Academic Scholarship, Shanghai Jiao Tong University (2011)
  • National Scholarship of China, Ministry of Education of the P. R. China (2005)

Professional Education

  • Doctor of Philosophy, Georgia Institute of Technology and Emory University, Biomedical Engineering
  • Master of Science, Georgia Institute of Technology, Electrical and Computer Engineering
  • Master of Science, Shanghai Jiao Tong University, Precision Instrument and Machinery

All Publications

  • Highly multiplexed spatial profiling with CODEX: bioinformatic analysis and application in human disease. Seminars in immunopathology Kuswanto, W., Nolan, G., Lu, G. 2022


    Multiplexed imaging, which enables spatial localization of proteins and RNA to cells within tissues, complements existing multi-omic technologies and has deepened our understanding of health and disease. CODEX, a multiplexed single-cell imaging technology, utilizes a microfluidics system that incorporates DNA barcoded antibodies to visualize 50+cellular markers at the single-cell level. Here, we discuss the latest applications of CODEX to studies of cancer, autoimmunity, and infection as well as current bioinformatics approaches for analysis of multiplexed imaging data from preprocessing to cell segmentation and marker quantification to spatial analysis techniques. We conclude with a commentary on the challenges and future developments for multiplexed spatial profiling.

    View details for DOI 10.1007/s00281-022-00974-0

    View details for PubMedID 36414691

  • A real-time GPU-accelerated parallelized image processor for large-scale multiplexed fluorescence microscopy data. Frontiers in immunology Lu, G., Baertsch, M. A., Hickey, J. W., Goltsev, Y., Rech, A. J., Mani, L., Forgo, E., Kong, C., Jiang, S., Nolan, G. P., Rosenthal, E. L. 2022; 13: 981825


    Highly multiplexed, single-cell imaging has revolutionized our understanding of spatial cellular interactions associated with health and disease. With ever-increasing numbers of antigens, region sizes, and sample sizes, multiplexed fluorescence imaging experiments routinely produce terabytes of data. Fast and accurate processing of these large-scale, high-dimensional imaging data is essential to ensure reliable segmentation and identification of cell types and for characterization of cellular neighborhoods and inference of mechanistic insights. Here, we describe RAPID, a Real-time, GPU-Accelerated Parallelized Image processing software for large-scale multiplexed fluorescence microscopy Data. RAPID deconvolves large-scale, high-dimensional fluorescence imaging data, stitches and registers images with axial and lateral drift correction, and minimizes tissue autofluorescence such as that introduced by erythrocytes. Incorporation of an open source CUDA-driven, GPU-assisted deconvolution produced results similar to fee-based commercial software. RAPID reduces data processing time and artifacts and improves image contrast and signal-to-noise compared to our previous image processing pipeline, thus providing a useful tool for accurate and robust analysis of large-scale, multiplexed, fluorescence imaging data.

    View details for DOI 10.3389/fimmu.2022.981825

    View details for PubMedID 36211386

  • Tumour-specific fluorescence-guided surgery for pancreatic cancer using panitumumab-IRDye800CW: a phase 1 single-centre, open-label, single-arm, dose-escalation study. The lancet. Gastroenterology & hepatology Lu, G., van den Berg, N. S., Martin, B. A., Nishio, N., Hart, Z. P., van Keulen, S., Fakurnejad, S., Chirita, S. U., Raymundo, R. C., Yi, G., Zhou, Q., Fisher, G. A., Rosenthal, E. L., Poultsides, G. A. 2020


    BACKGROUND: Complete surgical resection remains the primary curative option for pancreatic ductal adenocarcinoma, with positive margins in 30-70% of patients. In this study, we aimed to evaluate the use of intraoperative tumour-specific imaging to enhance a surgeon's ability to detect visually occult cancer in real time.METHODS: In this single-centre, open-label, single-arm study, done in the USA, we enrolled patients who had clinically suspicious or biopsy-confirmed pancreatic ductal adenocarcinomas and were scheduled for curative surgery. Eligible patients were 19 years of age or older with a life expectancy of more than 12 weeks and a Karnofsky performance status of at least 70% or an Eastern Cooperative Oncology Group or Zubrod level of one or lower, who were scheduled to undergo curative surgery. Patients were sequentially enrolled into each dosing group and 2-5 days before surgery, patients were intravenously infused with 100 mg of unlabelled panitumumab followed by 25 mg, 50 mg, or 75 mg of the near-infrared fluorescently labelled antibody (panitumumab-IRDye800CW). The primary endpoint was to determine the optimal dose of panitumumab-IRDye800CW in identifying pancreatic ductal adenocarcinomas as measured by tumour-to-background ratio in all patients. The tumour-to-background ratio was defined as the fluorescence signal of the tumour divided by the fluorescence signal of the surrounding healthy tissue. The dose-finding part of this study has been completed. This study is registered with, NCT03384238.FINDINGS: Between April, 2018, and July, 2019, 16 patients were screened for enrolment onto the study. Of the 16 screened patients, two (12%) patients withdrew from the study and three (19%) were not eligible; 11 (69%) patients completed the trial, all of whom were clinically diagnosed with pancreatic ductal adenocarcinoma. The mean tumour-to-background ratio of primary tumours was 3·0 (SD 0·5) in the 25 mg group, 4·0 (SD 0·6) in the 50 mg group, and 3·7 (SD 0·4) in the 75 mg group; the optimal dose was identified as 50 mg. Intraoperatively, near-infrared fluorescence imaging provided enhanced visualisation of the primary tumours, metastatic lymph nodes, and small (<2 mm) peritoneal metastasis. Intravenous administration of panitumumab-IRDye800CW at the doses of 25 mg, 50 mg, and 75 mg did not result in any grade 3 or higher adverse events. There were no serious adverse events attributed to panitumumab-IRDye800CW, although four possibly related adverse events (grade 1 and 2) were reported in four patients.INTERPRETATION: To our knowledge, this study presents the first clinical use of panitumumab-IRDye800CW for detecting pancreatic ductal adenocarcinomas and shows that panitumumab-IRDye800CW is safe and feasible to use during pancreatic cancer surgery. Tumour-specific intraoperative imaging might have added value for treatment of patients with pancreatic ductal adenocarcinomas through improved patient selection and enhanced visualisation of surgical margins, metastatic lymph nodes, and distant metastasis.FUNDING: National Institutes of Health and the Netherlands Organization for Scientific Research.

    View details for DOI 10.1016/S2468-1253(20)30088-1

    View details for PubMedID 32416764

  • Translating a fluorescent DNA-repair inhibitor. Nature biomedical engineering Lu, G., Rosenthal, E. L. 2020; 4 (3): 247–49

    View details for DOI 10.1038/s41551-020-0537-6

    View details for PubMedID 32165734

  • Predicting Therapeutic Antibody Delivery into Human Head and Neck Cancers. Clinical cancer research : an official journal of the American Association for Cancer Research Lu, G., Fakurnejad, S., Martin, B. A., van den Berg, N. S., van Keulen, S., Nishio, N., Zhu, A. J., Chirita, S. U., Zhou, Q., Gao, R. W., Kong, C. S., Fischbein, N., Penta, M., Colevas, A. D., Rosenthal, E. L. 2020


    PURPOSE: The efficacy of antibody-based therapeutics depends on successful drug delivery into solid tumors, therefore there is a clinical need to measure intratumoral antibody distribution. This study aims to develop and validate an imaging and computation platform to directly quantify and predict antibody delivery into human head and neck cancers in a clinical study.EXPERIMENTAL DESIGN: Twenty-four patients received systemic infusion of a near-infrared (NIR) fluorescence-labeled therapeutic antibody followed by surgical tumor resection. A computational platform was developed to quantify the extent of heterogeneity of intratumoral antibody distribution. Both univariate and multivariate regression analysis were used to select the most predictive tumor biological factors for antibody delivery. Quantitative image features from the pre-treatment magnetic resonance imaging (MRI) were extracted and correlated with fluorescence imaging of antibody delivery.RESULTS: This study not only confirmed heterogeneous intratumoral antibody distribution in line with many preclinical reports, but also quantified the extent of inter-patient, inter-tumor, and intra-tumor heterogeneity of antibody delivery. This study demonstrated the strong predictive value of tumor size for intratumoral antibody accumulation and its significant impact on antibody distribution in both primary tumor and lymph node metastasis. Furthermore, this study established the feasibility of using contrast-enhanced MRI to predict antibody delivery.CONCLUSIONS: This study provides a clinically translatable platform to measure antibody delivery into solid tumors and yields valuable insight into clinically relevant antibody tumor penetration, with implications in the selection of patients amenable to antibody therapy and the design of more effective dosing strategies.

    View details for DOI 10.1158/1078-0432.CCR-19-3717

    View details for PubMedID 31980465

  • Co-administered antibody improves penetration of antibody-dye conjugate into human cancers with implications for antibody-drug conjugates. Nature communications Lu, G., Nishio, N., van den Berg, N. S., Martin, B. A., Fakurnejad, S., van Keulen, S., Colevas, A. D., Thurber, G. M., Rosenthal, E. L. 2020; 11 (1): 5667


    Poor tissue penetration remains a major challenge for antibody-based therapeutics of solid tumors, but proper dosing can improve the tissue penetration and thus therapeutic efficacy of these biologics. Due to dose-limiting toxicity of the small molecule payload, antibody-drug conjugates (ADCs) are administered at a much lower dose than their parent antibodies, which further reduces tissue penetration. We conducted an early-phase clinical trial (NCT02415881) and previously reported the safety of an antibody-dye conjugate (panitumumab-IRDye800CW) as primary outcome. Here, we report a retrospective exploratory analysis of the trial to evaluate whether co-administration of an unconjugated antibody could improve the intratumoral distribution of the antibody-dye conjugate in patients. By measuring the multiscale distribution of the antibody-dye conjugate, this study demonstrates improved microscopic antibody distribution without increasing uptake (toxicity) in healthy tissue when co-administered with the parent antibody, supporting further clinical investigation of the co-administration dosing strategy to improve the tumor penetration of ADCs.

    View details for DOI 10.1038/s41467-020-19498-y

    View details for PubMedID 33168818

  • Histopathology Feature Mining and Association with Hyperspectral Imaging for the Detection of Squamous Neoplasia. Scientific reports Lu, G., Wang, D., Qin, X., Muller, S., Little, J. V., Wang, X., Chen, A. Y., Chen, G., Fei, B. 2019; 9 (1): 17863


    Hyperspectral imaging (HSI) is a noninvasive optical modality that holds promise for early detection of tongue lesions. Spectral signatures generated by HSI contain important diagnostic information that can be used to predict the disease status of the examined biological tissue. However, the underlying pathophysiology for the spectral difference between normal and neoplastic tissue is not well understood. Here, we propose to leverage digital pathology and predictive modeling to select the most discriminative features from digitized histological images to differentiate tongue neoplasia from normal tissue, and then correlate these discriminative pathological features with corresponding spectral signatures of the neoplasia. We demonstrated the association between the histological features quantifying the architectural features of neoplasia on a microscopic scale, with the spectral signature of the corresponding tissue measured by HSI on a macroscopic level. This study may provide insight into the pathophysiology underlying the hyperspectral dataset.

    View details for DOI 10.1038/s41598-019-54139-5

    View details for PubMedID 31780698

    View details for PubMedCentralID PMC6882850

  • Detection and delineation of squamous neoplasia with hyperspectral imaging in a mouse model of tongue carcinogenesis Journal of Biophotonics Lu, G., Wang, D., Qin, X., Muller, S., Wang, X., Chen, A. Y., Chen, Z. G., Fei, B. 2018 ; 11 (3): e201700078

    View details for DOI 10.1002/jbio.201700078

  • Detection of Head and Neck Cancer in Surgical Specimens Using Quantitative Hyperspectral Imaging. Clinical cancer research : an official journal of the American Association for Cancer Research Lu, G., Little, J. V., Wang, X., Zhang, H., Patel, M. R., Griffith, C. C., El-Deiry, M. W., Chen, A. Y., Fei, B. 2017; 23 (18): 5426-5436


    Purpose: This study intends to investigate the feasibility of using hyperspectral imaging (HSI) to detect and delineate cancers in fresh, surgical specimens of patients with head and neck cancers.Experimental Design: A clinical study was conducted in order to collect and image fresh, surgical specimens from patients (N = 36) with head and neck cancers undergoing surgical resection. A set of machine-learning tools were developed to quantify hyperspectral images of the resected tissue in order to detect and delineate cancerous regions which were validated by histopathologic diagnosis. More than two million reflectance spectral signatures were obtained by HSI and analyzed using machine-learning methods. The detection results of HSI were compared with autofluorescence imaging and fluorescence imaging of two vital-dyes of the same specimens.Results: Quantitative HSI differentiated cancerous tissue from normal tissue in ex vivo surgical specimens with a sensitivity and specificity of 91% and 91%, respectively, and which was more accurate than autofluorescence imaging (P < 0.05) or fluorescence imaging of 2-NBDG (P < 0.05) and proflavine (P < 0.05). The proposed quantification tools also generated cancer probability maps with the tumor border demarcated and which could provide real-time guidance for surgeons regarding optimal tumor resection.Conclusions: This study highlights the feasibility of using quantitative HSI as a diagnostic tool to delineate the cancer boundaries in surgical specimens, and which could be translated into the clinic application with the hope of improving clinical outcomes in the future. Clin Cancer Res; 23(18); 5426-36. ©2017 AACR.

    View details for DOI 10.1158/1078-0432.CCR-17-0906

    View details for PubMedID 28611203

  • Deep convolutional neural networks for classifying head and neck cancer using hyperspectral imaging. Journal of biomedical optics Halicek, M., Lu, G., Little, J. V., Wang, X., Patel, M., Griffith, C. C., El-Deiry, M. W., Chen, A. Y., Fei, B. 2017; 22 (6): 60503


    Surgical cancer resection requires an accurate and timely diagnosis of the cancer margins in order to achieve successful patient remission. Hyperspectral imaging (HSI) has emerged as a useful, noncontact technique for acquiring spectral and optical properties of tissue. A convolutional neural network (CNN) classifier is developed to classify excised, squamous-cell carcinoma, thyroid cancer, and normal head and neck tissue samples using HSI. The CNN classification was validated by the manual annotation of a pathologist specialized in head and neck cancer. The preliminary results of 50 patients indicate the potential of HSI and deep learning for automatic tissue-labeling of surgical specimens of head and neck patients.

    View details for DOI 10.1117/1.JBO.22.6.060503

    View details for PubMedID 28655055

    View details for PubMedCentralID PMC5482930

  • A Minimum Spanning Forest-Based Method for Noninvasive Cancer Detection With Hyperspectral Imaging IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING Pike, R., Lu, G., Wang, D., Chen, Z. G., Fei, B. 2016; 63 (3): 653-663


    The purpose of this paper is to develop a classification method that combines both spectral and spatial information for distinguishing cancer from healthy tissue on hyperspectral images in an animal model.An automated algorithm based on a minimum spanning forest (MSF) and optimal band selection has been proposed to classify healthy and cancerous tissue on hyperspectral images. A support vector machine classifier is trained to create a pixel-wise classification probability map of cancerous and healthy tissue. This map is then used to identify markers that are used to compute mutual information for a range of bands in the hyperspectral image and thus select the optimal bands. An MSF is finally grown to segment the image using spatial and spectral information.The MSF based method with automatically selected bands proved to be accurate in determining the tumor boundary on hyperspectral images.Hyperspectral imaging combined with the proposed classification technique has the potential to provide a noninvasive tool for cancer detection.

    View details for DOI 10.1109/TBME.2015.2468578

    View details for Web of Science ID 000371933800021

    View details for PubMedID 26285052

    View details for PubMedCentralID PMC4791052

  • Framework for hyperspectral image processing and quantification for cancer detection during animal tumor surgery JOURNAL OF BIOMEDICAL OPTICS Lu, G., Wang, D., Qin, X., Halig, L., Muller, S., Zhang, H., Chen, A., Pogue, B. W., Chen, Z. G., Fei, B. 2015; 20 (12)


    Hyperspectral imaging (HSI) is an imaging modality that holds strong potential for rapid cancer detection during image-guided surgery. But the data from HSI often needs to be processed appropriately in order to extract the maximum useful information that differentiates cancer from normal tissue. We proposed a framework for hyperspectral image processing and quantification, which includes a set of steps including image preprocessing, glare removal, feature extraction, and ultimately image classification. The framework has been tested on images from mice with head and neck cancer, using spectra from 450- to 900-nm wavelength. The image analysis computed Fourier coefficients, normalized reflectance, mean, and spectral derivatives for improved accuracy. The experimental results demonstrated the feasibility of the hyperspectral image processing and quantification framework for cancer detection during animal tumor surgery, in a challenging setting where sensitivity can be low due to a modest number of features present, but potential for fast image classification can be high. This HSI approach may have potential application in tumor margin assessment during image-guided surgery, where speed of assessment may be the dominant factor.

    View details for DOI 10.1117/1.JBO.20.12.126012

    View details for Web of Science ID 000368440300037

    View details for PubMedID 26720879

    View details for PubMedCentralID PMC4691647

  • Spectral-spatial classification for noninvasive cancer detection using hyperspectral imaging JOURNAL OF BIOMEDICAL OPTICS Lu, G., Halig, L., Wang, D., Qin, X., Chen, Z. G., Fei, B. 2014; 19 (10)


    Early detection of malignant lesions could improve both survival and quality of life of cancer patients. Hyperspectral imaging (HSI) has emerged as a powerful tool for noninvasive cancer detection and diagnosis, with the advantage of avoiding tissue biopsy and providing diagnostic signatures without the need of a contrast agent in real time. We developed a spectral-spatial classification method to distinguish cancer from normal tissue on hyperspectral images. We acquire hyperspectral reflectance images from 450 to 900 nm with a 2-nm increment from tumor-bearing mice. In our animal experiments, the HSI and classification method achieved a sensitivity of 93.7% and a specificity of 91.3%. The preliminary study demonstrated that HSI has the potential to be applied in vivo for noninvasive detection of tumors.

    View details for DOI 10.1117/1.JBO.19.10.106004

    View details for Web of Science ID 000345837200021

    View details for PubMedID 25277147

    View details for PubMedCentralID PMC4183763

  • Semantic interpretation of robust imaging features for Fuhrman grading of renal carcinoma. Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual Conference Champion, A., Lu, G., Walker, M., Kothari, S., Osunkoya, A. O., Wang, M. D. 2014; 2014: 6446-9


    Pattern recognition in tissue biopsy images can assist in clinical diagnosis and identify relevant image characteristics linked with various biological characteristics. Although previous work suggests several informative imaging features for pattern recognition, there exists a semantic gap between characteristics of these features and pathologists' interpretation of histopathological images. To address this challenge, we develop a clinical decision support system for automated Fuhrman grading of renal carcinoma biopsy images. We extract 1316 color, shape, texture and topology features and develop one vs. all models for four Fuhrman grades. Our models are highly accurate with 90.4% accuracy in a four-class prediction. Predictivity analysis suggests good generalization of the model development methodology through robustness to dataset sampling in cross-validation. We provide a semantic interpretation for the imaging features used in these models by linking features to pathologists' grading criteria. Our study identifies novel imaging features that are semantically linked to Fuhrman grading criteria.

    View details for DOI 10.1109/EMBC.2014.6945104

    View details for PubMedID 25571472

    View details for PubMedCentralID PMC4983417

  • Medical hyperspectral imaging: a review JOURNAL OF BIOMEDICAL OPTICS Lu, G., Fei, B. 2014; 19 (1)


    Hyperspectral imaging (HSI) is an emerging imaging modality for medical applications, especially in disease diagnosis and image-guided surgery. HSI acquires a three-dimensional dataset called hypercube, with two spatial dimensions and one spectral dimension. Spatially resolved spectral imaging obtained by HSI provides diagnostic information about the tissue physiology, morphology, and composition. This review paper presents an overview of the literature on medical hyperspectral imaging technology and its applications. The aim of the survey is threefold: an introduction for those new to the field, an overview for those working in the field, and a reference for those searching for literature on a specific application.

    View details for DOI 10.1117/1.JBO.19.1.010901

    View details for Web of Science ID 000331892700001

    View details for PubMedID 24441941

    View details for PubMedCentralID PMC3895860

  • Metastatic and sentinel lymph node mapping using intravenously delivered Panitumumab-IRDye800CW. Theranostics Krishnan, G., van den Berg, N. S., Nishio, N., Juniper, G., Pei, J., Zhou, Q., Lu, G., Lee, Y. J., Ramos, K., Iagaru, A. H., Baik, F. M., Colevas, A. D., Martin, B. A., Rosenthal, E. L. 2021; 11 (15): 7188-7198


    Rationale: Sentinel lymph node biopsy (SLNB) is a well-established minimally invasive staging procedure that maps the spread of tumour metastases from their primary site to the regional lymphatics. Currently, the procedure requires the local peri-tumoural injection of radiolabelled and/or optical agents, and is therefore operator dependent, disruptive to surgical workflow and restricted largely to a small subset of malignancies that can be readily accessed externally for local tracer injection. The present study set out to determine whether intravenous (IV) infusion of a tumor-targeted tracer could identify sentinel and metastatic lymph nodes (LNs) in order to overcome these limitations. Methods: We examined 27 patients with oral squamous cell carcinoma (OSCC), 18 of whom were clinically node negative (cN0). Patients were infused intravenously with 50mg of Panitumumab-IRDye800CW prior to surgical resection of their primary tumour with neck dissection and/or SLNB. Lymphadenectomy specimens underwent fluorescence molecular imaging to evaluate tracer distribution to LNs. Results: A total of 960 LNs were analysed, of which 34 (3.5%) contained metastatic disease. Panitumumab-IRDye800CW preferentially localized to metastatic and sentinel LNs as evidenced by a higher fluorescent signal relative to other lymph nodes. The median MFI of metastatic LNs was significantly higher than the median MFI of benign LNs (0.06 versus 0.02, p < 0.05). Furthermore, selecting the highest five fluorescence intensity LNs from individual specimens resulted in 100% sensitivity, 85.8% specificity and 100% negative predictive value (NPV) for the detection of occult metastases and 100% accuracy for clinically staging the neck. In the cN+ cohort, assessment of the highest 5 fluorescence LNs per patient had 87.5% sensitivity, 93.2% specificity and 99.1% NPV for the detection of metastatic nodes. Conclusion: When intravenously infused, a tumour-targeted tracer localized to sentinel and metastatic lymph nodes. Further validation of an IV tumor-targeted tracer delivery approach for SLNB could dramatically change the practice of SLNB, allowing its application to other malignancies where the primary tumour is not accessible for local tracer injection.

    View details for DOI 10.7150/thno.55389

    View details for PubMedID 34158844

    View details for PubMedCentralID PMC8210603

  • EGFR-targeted intraoperative fluorescence imaging detects high-grade glioma with panitumumab-IRDye800 in a phase 1 clinical trial. Theranostics Zhou, Q., van den Berg, N. S., Rosenthal, E. L., Iv, M., Zhang, M., Vega Leonel, J. C., Walters, S., Nishio, N., Granucci, M., Raymundo, R., Yi, G., Vogel, H., Cayrol, R., Lee, Y. J., Lu, G., Hom, M., Kang, W., Hayden Gephart, M., Recht, L., Nagpal, S., Thomas, R., Patel, C., Grant, G. A., Li, G. 2021; 11 (15): 7130-7143


    Rationale: First-line therapy for high-grade gliomas (HGGs) includes maximal safe surgical resection. The extent of resection predicts overall survival, but current neuroimaging approaches lack tumor specificity. The epidermal growth factor receptor (EGFR) is a highly expressed HGG biomarker. We evaluated the safety and feasibility of an anti-EGFR antibody, panitumuab-IRDye800, at subtherapeutic doses as an imaging agent for HGG. Methods: Eleven patients with contrast-enhancing HGGs were systemically infused with panitumumab-IRDye800 at a low (50 mg) or high (100 mg) dose 1-5 days before surgery. Near-infrared fluorescence imaging was performed intraoperatively and ex vivo, to identify the optimal tumor-to-background ratio by comparing mean fluorescence intensities of tumor and histologically uninvolved tissue. Fluorescence was correlated with preoperative T1 contrast, tumor size, EGFR expression and other biomarkers. Results: No adverse events were attributed to panitumumab-IRDye800. Tumor fragments as small as 5 mg could be detected ex vivo and detection threshold was dose dependent. In tissue sections, panitumumab-IRDye800 was highly sensitive (95%) and specific (96%) for pathology confirmed tumor containing tissue. Cellular delivery of panitumumab-IRDye800 was correlated to EGFR overexpression and compromised blood-brain barrier in HGG, while normal brain tissue showed minimal fluorescence. Intraoperative fluorescence improved optical contrast in tumor tissue within and beyond the T1 contrast-enhancing margin, with contrast-to-noise ratios of 9.5 ± 2.1 and 3.6 ± 1.1, respectively. Conclusions: Panitumumab-IRDye800 provided excellent tumor contrast and was safe at both doses. Smaller fragments of tumor could be detected at the 100 mg dose and thus more suitable for intraoperative imaging.

    View details for DOI 10.7150/thno.60582

    View details for PubMedID 34158840

    View details for PubMedCentralID PMC8210618

  • Molecular imaging of a fluorescent antibody against epidermal growth factor receptor detects high-grade glioma. Scientific reports Zhou, Q., Vega Leonel, J. C., Santoso, M. R., Wilson, C., van den Berg, N. S., Chan, C. T., Aryal, M., Vogel, H., Cayrol, R., Mandella, M. J., Schonig, F., Lu, G., Gambhir, S. S., Moseley, M. E., Rosenthal, E. L., Grant, G. A. 2021; 11 (1): 5710


    The prognosis for high-grade glioma (HGG) remains dismal and the extent of resection correlates with overall survival and progression free disease. Epidermal growth factor receptor (EGFR) is a biomarker heterogeneously expressed in HGG. We assessed the feasibility of detecting HGG using near-infrared fluorescent antibody targeting EGFR. Mice bearing orthotopic HGG xenografts with modest EGFR expression were imaged in vivo after systemic panitumumab-IRDye800 injection to assess its tumor-specific uptake macroscopically over 14days, and microscopically ex vivo. EGFR immunohistochemical staining of 59 tumor specimens from 35 HGG patients was scored by pathologists and expression levels were compared to that of mouse xenografts. Intratumoral distribution of panitumumab-IRDye800 correlated with near-infrared fluorescence and EGFR expression. Fluorescence distinguished tumor cells with 90% specificity and 82.5% sensitivity. Target-to-background ratios peaked at 14h post panitumumab-IRDye800 infusion, reaching 19.5 in vivo and 7.6 ex vivo, respectively. Equivalent or higher EGFR protein expression compared to the mouse xenografts was present in 77.1% HGG patients. Age, combined with IDH-wildtype cerebral tumor, was predictive of greater EGFR protein expression in human tumors. Tumor specific uptake of panitumumab-IRDye800 provided remarkable contrast and a flexible imaging window for fluorescence-guided identification of HGGs despite modest EGFR expression.

    View details for DOI 10.1038/s41598-021-84831-4

    View details for PubMedID 33707521

  • Intraoperative Fluorescence-Guided Surgery in Head and Neck Squamous Cell Carcinoma. The Laryngoscope Lee, Y. J., Krishnan, G., Nishio, N., van den Berg, N. S., Lu, G., Martin, B. A., van Keulen, S., Colevas, A. D., Kapoor, S., Liu, J. T., Rosenthal, E. L. 2021; 131 (3): 529-534


    The rate of positive margins in head and neck cancers has remained stagnant over the past three decades and is consistently associated with poor overall survival. This suggests that significant improvements must be made intraoperatively to ensure negative margins. We discuss the important role of fluorescence imaging to guide surgical oncology in head and neck cancer. This review includes a general overview of the principles of fluorescence, available fluorophores used for fluorescence imaging, and specific clinical applications of fluorescence-guided surgery, as well as challenges and future directions in head and neck surgical oncology. Laryngoscope, 131:529-534, 2021.

    View details for DOI 10.1002/lary.28822

    View details for PubMedID 33593036

  • EGFR-targeted intraoperative fluorescence imaging detects high-grade glioma with panitumumab-IRDye800 in a phase 1 clinical trial Theranostics Zhou, Q., van den Berg, N. S., Rosenthal, E. L., Iv, M., Zhang, M., Vega Leonel, J. C., Walters, S., Nishio, N., Granucci, M., Raymundo, R., Yi, G., Vogel, H., Cayrol, R., Lee, Y., Lu, G., Hom, M., Kang, W., Hayden Gephart, M., Recht, L. D., Nagpal, S., Thomas, R. P., Patel, C. B., Grant, G. A., Li, G. 2021; 11 (15): 7130-7143

    View details for DOI 10.7150/thno.60582

  • FIRST-IN-HUMAN FLUORESCENCE GUIDED SURGERY OF HIGH-GRADE GLIOMAS USING PANITUMUMAB-IRDYE800 Zhou, Q., van den Berg, N., Nishio, N., Lu, G., Chirita, S., Raymundo, R., Yi, G., Vogel, H., Cayrol, R., Rosenthal, E., Li, G. OXFORD UNIV PRESS INC. 2020: 52
  • Effect of Formalin Fixation for Near-Infrared Fluorescence Imaging with an Antibody-Dye Conjugate in Head and Neck Cancer Patients. Molecular imaging and biology Kapoor, S., Lu, G., van den Berg, N. S., Krishnan, G., Pei, J., Zhou, Q., Martin, B. A., Baik, F. M., Rosenthal, E. L., Nishio, N. 2020


    PURPOSE: This study evaluated the effect of formalin fixation for near-infrared (NIR) fluorescence imaging of an antibody-dye complex (panitumumab-IRDye800CW) that was intravenously administered to patients with head and neck squamous cell carcinoma (HNSCC) scheduled to undergo surgery of curative intent.PROCEDURES: HNSCC patients were infused with 25 or 50mg of panitumumab-IRDye800CW followed by surgery 1-5days later. Following resection, primary tumor specimens were imaged in a closed-field fluorescence imaging device, before and after formalin fixation. The fluorescence images of formalin-fixed specimens were compared with images prior to formalin fixation. Regions of interest were drawn on the primary tumor and on the adjacent normal tissue on the fluorescence images. The mean fluorescence intensity (MFI) and tumor-to-background ratios (TBRs) of the fresh and formalin-fixed tissues were compared.RESULTS: Of the 30 enrolled patients, 20 tissue specimens were eligible for this study. Formalin fixation led to an average of 10% shrinkage in tumor specimen size (p<0.0001). Tumor MFI in formalin-fixed specimens was on average 10.9% lower than that in the fresh specimens (p=0.0002). However, no statistical difference was found between the TBRs of the fresh specimens and those of the formalin-fixed specimens (p=0.85).CONCLUSIONS: Despite the 11% decrease in MFI between fresh and formalin-fixed tissue specimens, the relative difference between tumor and normal tissue as measured in TBR remained unchanged. This data suggests that evaluation of formalin-fixed tissue for assessing the accuracy of fluorescence-guided surgery approaches could provide a valid, yet more flexible, alternative to fresh tissue analysis.TRIAL REGISTRATION: NCT02415881.

    View details for DOI 10.1007/s11307-020-01553-1

    View details for PubMedID 33078373

  • Intraoperative Fluorescence-Guided Surgery in Head and Neck Squamous Cell Carcinoma LARYNGOSCOPE Lee, Y., Krishnan, G., Nishio, N., van den Berg, N. S., Lu, G., Martin, B. A., van Keulen, S., Colevas, A. D., Kapoor, S., Liu, J. C., Rosenthal, E. L. 2020

    View details for DOI 10.1002/lary.28822

    View details for Web of Science ID 000545528600001

  • Optimal Dosing Strategy for Fluorescence-Guided Surgery with Panitumumab-IRDye800CW in Head and Neck Cancer MOLECULAR IMAGING AND BIOLOGY Nishio, N., van den Berg, N. S., van Keulen, S., Martin, B. A., Fakurnejad, S., Zhou, Q., Lu, G., Chirita, S. U., Kaplan, M. J., Divi, V., Colevas, A. D., Rosenthal, E. L. 2020; 22 (1): 156–64
  • Safety and Stability of Antibody-Dye Conjugate in Optical Molecular Imaging. Molecular imaging and biology Pei, J. n., Juniper, G. n., van den Berg, N. S., Nisho, N. n., Broadt, T. n., Welch, A. R., Yi, G. S., Raymundo, R. C., Chirita, S. U., Lu, G. n., Krishnan, G. n., Lee, Y. J., Kapoor, S. n., Zhou, Q. n., Colevas, A. D., Lui, N. S., Poultsides, G. A., Li, G. n., Zinn, K. R., Rosenthal, E. L. 2020


    The development of molecularly targeted tracers is likely to improve the accuracy of diagnostic, screening, and therapeutic tools. Despite the many therapeutic antibodies that are FDA-approved with known toxicity, only a limited number of antibody-dye conjugates have been introduced to the clinic. Thorough evaluation of the safety, stability, and pharmacokinetics of antibody conjugates in the clinical setting compared with their parental components could accelerate the clinical approval of antibodies as agents for molecular imaging. Here we investigate the safety and stability of a near-infrared fluorescent dye (IRDye800CW) conjugated panitumumab, an approved therapeutic antibody, and report on the product stability, pharmacokinetics, adverse events, and QTc interval changes in patients.Panitumumab-IRDye800CW was made under good manufacturing practice (GMP) conditions in a single batch on March 26, 2014, and then evaluated over 4.5 years at 0, 3, and 6 months, and then at 6-month intervals thereafter. We conducted early phase trials in head and neck, lung, pancreas, and brain cancers with panitumumab-IRDye800CW. Eighty-one patients scheduled to undergo standard-of-care surgery were infused with doses between 0.06 to 2.83 mg/kg of antibody. Patient ECGs, blood samples, and adverse events were collected over 30-day post-infusion for analysis.Eighty-one patients underwent infusion of the study drug at a range of doses. Six patients (7.4 %) experienced an adverse event that was considered potentially related to the drug. The most common event was a prolonged QTc interval which occurred in three patients (3.7 %). Panitumumab-IRDye800CW had two OOS results at 42 and 54 months while meeting all other stability testing criteria.Panitumumab-IRDye800CW was safe and stable to administer over a 54-month window with a low rate of adverse events (7.4 %) which is consistent with the rate associated with panitumumab alone. This data supports re-purposing therapeutic antibodies as diagnostic imaging agents with limited preclinical toxicology studies.

    View details for DOI 10.1007/s11307-020-01536-2

    View details for PubMedID 32880818

  • Endoscopic Fluorescence-Guided Surgery for Sinonasal Cancer Using an Antibody-Dye Conjugate. The Laryngoscope Hart, Z. P., Nishio, N., Krishnan, G., Lu, G., Zhou, Q., Fakurnejad, S., Wormald, P. J., van den Berg, N. S., Rosenthal, E. L., Baik, F. M. 2019


    OBJECTIVE: Endoscopic resection of sinonasal squamous cell carcinoma has become the standard of care, but challenges remain in obtaining clear resection margins. The current study evaluated the feasibility of endoscopic fluorescence-guided surgery (FGS) to improve surgical resection in a human sinus surgical model.METHODS: A fluorescence endoscope optimized for near-infrared (NIR) fluorescence detection was evaluated in a phantom study. Various endoscope diameters (4 and 10mm) and viewing angles (0, 30, and 45 degrees) were evaluated to determine the sensitivity of the system for IRDye800CW detection at various working distances (1-5 cm). Endoscopic FGS was then validated in a three-dimensional human sinus surgical model to which squamous cell tumors derived from mice were inserted. Mice had received intravenous panitumumab-IRDye800CW and upon fluorescence-guided tumor resection, mean fluorescence intensity (MFI) and tumor-to-background ratio (TBR) were calculated in in situ and ex vivo settings.RESULTS: A significantly higher fluorescence intensity was found when using the 10-mm diameter endoscope compared to the 4mm diameter endoscope (P<.001). No significant difference in MFI was found among the viewing angles of the 4-mm diameter endoscope. Using the human sinus model, the highest MFI and TBR were obtained at a 1-cm working distance compared to longer working distances.CONCLUSION: We demonstrate that clinically acceptable TBRs were obtained with several working distances to discriminate tumor tissue from adjacent normal tissue in a human sinus model, and that endoscopic FGS may have great potential in identifying residual tumor tissue regions during surgery. Laryngoscope, 2019.

    View details for DOI 10.1002/lary.28483

    View details for PubMedID 31854462

  • Targeting MMP-14 for dual PET and fluorescence imaging of glioma in preclinical models. European journal of nuclear medicine and molecular imaging Kasten, B. B., Jiang, K., Cole, D., Jani, A., Udayakumar, N., Gillespie, G. Y., Lu, G., Dai, T., Rosenthal, E. L., Markert, J. M., Rao, J., Warram, J. M. 2019


    PURPOSE: There is a clinical need for agents that target glioma cells for non-invasive and intraoperative imaging to guide therapeutic intervention and improve the prognosis of glioma. Matrix metalloproteinase (MMP)-14 is overexpressed in glioma with negligible expression in normal brain, presenting MMP-14 as an attractive biomarker for imaging glioma. In this study, we designed a peptide probe containing a near-infrared fluorescence (NIRF) dye/quencher pair, a positron emission tomography (PET) radionuclide, and a moiety with high affinity to MMP-14. This novel substrate-binding peptide allows dual modality imaging of glioma only after cleavage by MMP-14 to activate the quenched NIRF signal, enhancing probe specificity and imaging contrast.METHODS: MMP-14 expression and activity in human glioma tissues and cells were measured in vitro by immunofluorescence and gel zymography. Cleavage of the novel substrate and substrate-binding peptides by glioma cells in vitro and glioma xenograft tumors in vivo was determined by NIRF imaging. Biodistribution of the radiolabeled MMP-14-binding peptide or substrate-binding peptide was determined in mice bearing orthotopic patient-derived xenograft (PDX) glioma tumors by PET imaging.RESULTS: Glioma cells with MMP-14 activity showed activation and retention of NIRF signal from the cleaved peptides. Resected mouse brains with PDX glioma tumors showed tumor-to-background NIRF ratios of 7.6-11.1 at 4 h after i.v. injection of the peptides. PET/CT images showed localization of activity in orthotopic PDX tumors after i.v. injection of 68Ga-binding peptide or 64Cu-substrate-binding peptide; uptake of the radiolabeled peptides in tumors was significantly reduced (p < 0.05) by blocking with the non-labeled-binding peptide. PET and NIRF signals correlated linearly in the orthotopic PDX tumors. Immunohistochemistry showed co-localization of MMP-14 expression and NIRF signal in the resected tumors.CONCLUSIONS: The novel MMP-14 substrate-binding peptide enabled PET/NIRF imaging of glioma models in mice, warranting future image-guided resection studies with the probe in preclinical glioma models.

    View details for DOI 10.1007/s00259-019-04607-x

    View details for PubMedID 31773232

  • Optical molecular imaging can differentiate metastatic from benign lymph nodes in head and neck cancer. Nature communications Nishio, N., van den Berg, N. S., van Keulen, S., Martin, B. A., Fakurnejad, S., Teraphongphom, N., Chirita, S. U., Oberhelman, N. J., Lu, G., Horton, C. E., Kaplan, M. J., Divi, V., Colevas, A. D., Rosenthal, E. L. 2019; 10 (1): 5044


    Identification of lymph node (LN) metastasis is essential for staging of solid tumors, and as a result, surgeons focus on harvesting significant numbers of LNs during ablative procedures for pathological evaluation. Isolating those LNs most likely to harbor metastatic disease can allow for a more rigorous evaluation of fewer LNs. Here we evaluate the impact of a systemically injected, near-infrared fluorescently-labeled, tumor-targeting contrast agent, panitumumab-IRDye800CW, to facilitate the identification of metastatic LNs in the ex vivo setting for head and neck cancer patients. Molecular imaging demonstrates a significantly higher mean fluorescence signal in metastatic LNs compared to benign LNs in head and neck cancer patients undergoing an elective neck dissection. Molecular imaging to preselect at-risk LNs may thus allow a more rigorous examination of LNs and subsequently lead to improved prognostication than regular neck dissection.

    View details for DOI 10.1038/s41467-019-13076-7

    View details for PubMedID 31695030

  • Probe-based fluorescence dosimetry of an antibody-dye conjugate to identify head and neck cancer as a first step to fluorescence-guided tissue preselection for pathological assessment. Head & neck Nishio, N., van Keulen, S., van den Berg, N. S., Lu, G., LaRochelle, E. P., Davis, S. C., Martin, B. A., Fakurnejad, S., Zhou, Q., Birkeland, A. C., Kaplan, M. J., Divi, V., Colevas, A. D., Pogue, B. W., Rosenthal, E. L. 2019


    BACKGROUND: Despite the rapid growth of fluorescence imaging, accurate sampling of tissue sections remains challenging. Development of novel technologies to improve intraoperative assessment of tissue is needed.METHODS: A novel contact probe-based fluorescence dosimeter device, optimized for IRDye800CW quantification, was developed. After evaluation of the device in a phantom setup, its clinical value was defined ex vivo in patients with head and neck squamous cell carcinoma who received panitumumab-IRDye800CW.RESULTS: Ten patients were enrolled with a total of 216 data points obtained. Final histopathology showed tumor in 119 spots and normal tissue in 97 spots. Fluorescence-to-excitation ratios in tumor tissue were more than three times higher than those in normal tissue. The area under the curve was 0.86 (95% CI: 0.81-0.91) for tumor detection.CONCLUSIONS: Fluorescence-guided tissue preselection using a fluorescence dosimeter could have substantial impact on tissue sampling for frozen section analysis and potentially reduce sampling errors.

    View details for DOI 10.1002/hed.25964

    View details for PubMedID 31571335

  • Fluorescence molecular imaging for identification of high-grade dysplasia in patients with head and neck cancer. Oral oncology Fakurnejad, S., van Keulen, S., Nishio, N., Engelen, M., van den Berg, N. S., Lu, G., Birkeland, A., Baik, F., Colevas, A. D., Rosenthal, E. L., Martin, B. A. 2019; 97: 50–55


    OBJECTIVE: High-grade dysplasia is associated with a risk of malignant transformation, and it is necessary to distinguish from normal epithelium or low-grade dysplasia, especially in the intraoperative setting. We hypothesize that an anti-epidermal growth factor receptor (EGFR) contrast agent can be used to differentiate high-grade dysplasia from low-grade dysplasia and normal epithelium.MATERIALS AND METHODS: Patients with biopsy proven head and neck squamous cell carcinoma (HNSCC) were enrolled in a clinical trial using systemically injected fluorescently labeled anti-EGFR antibody (panitumumab-IRDye800CW) (NCT02415881). Paraffin embedded tumor specimens from 11 patients were evaluated by fluorescence histopathology. Hematoxylin and eosin (H&E) slides were reviewed by a board-certified pathologist, and regions of invasive squamous cell carcinoma, high-grade dysplasia and low-grade dysplasia were delineated. EGFR expression was assessed for each patient by way of immunohistochemistry.RESULTS: 11 patients were included in the study with a total of 219 areas on tissue sections analyzed; 68 normal epithelium, 53 low-grade dysplasia, 48 high-grade dysplasia, and 50 malignant regions. The signal-to-background ratio (SBR) increased proportionally with increasing grade of dysplasia; normal epithelium (1.5 ± 0.1), low-grade dysplasia (1.8 ± 0.1), high-grade dysplasia: (2.3 ± 0.2). High-grade dysplasia had a significantly higher SBR when compared to normal or low-grade dysplasia (p < 0.05). Fluorescence histopathology positively correlated with EGFR expression by immunohistochemistry, which also increased proportionally with increasing degree of dysplasia.CONCLUSION: Molecular imaging with an anti-EGFR agent can successfully discriminate high-grade dysplastic lesions from low-grade dysplasia and normal epithelium.

    View details for DOI 10.1016/j.oraloncology.2019.08.008

    View details for PubMedID 31421471

  • The Clinical Application of Fluorescence-Guided Surgery in Head and Neck Cancer JOURNAL OF NUCLEAR MEDICINE van Keulen, S., Nishio, N., Fakurnejad, S., Birkeland, A., Martin, B. A., Lu, G., Zhou, Q., Chirita, S. U., Forouzanfar, T., Colevas, A., van den Berg, N. S., Rosenthal, E. L. 2019; 60 (6): 758–63
  • Optimal Dosing Strategy for Fluorescence-Guided Surgery with Panitumumab-IRDye800CW in Head and Neck Cancer. Molecular imaging and biology : MIB : the official publication of the Academy of Molecular Imaging Nishio, N., van den Berg, N. S., van Keulen, S., Martin, B. A., Fakurnejad, S., Zhou, Q., Lu, G., Chirita, S. U., Kaplan, M. J., Divi, V., Colevas, A. D., Rosenthal, E. L. 2019


    PURPOSE: To identify the optimal dosing strategy for fluorescence-guided surgery in patients with head and neck squamous cell carcinoma, we conducted a dose-ranging study evaluating the anti-epidermal growth factor receptor (EGFR) therapeutic antibody, panitumumab, that was fluorescently labeled with the near-infrared dye IRDye800CW.PROCEDURES: Patients (n=24) received either 0.5 or 1.0mg/kg panitumumab-IRDye800CW in the weight-based dosing group or 25 or 50mg panitumumab-IRDye800CW in the fixed dosing group. Following surgery, whole primary specimens were imaged in a closed-field device and the mean fluorescence intensity (MFI) and tumor-to-background ratio (TBR) were assessed. Clinical variables, including dose, time of infusion-to-surgery, age, unlabeled dose, gender, primary tumor site, and tumor size, were analyzed to evaluate the factors affecting the fluorescence intensity in order to identify the optimal dose for intraoperative fluorescence imaging.RESULTS: A total of 24 primary tumor specimens were imaged and analyzed in this study. Although no correlations between TBR and dose of panitumumab-IRDye800CW were found, there were moderate-strong correlations between the primary tumor MFI and panitumumab-IRDye800CW dose for fixed dose (mg) (R2=0.42) and for dose/weight (mg/kg) (R2=0.54). Results indicated that the optimal MFI was at approximately 50mg for fixed dose and 0.75mg/kg for dose/weight. No significant differences were found for the primary tumor MFI and TBRs between the weight-based dosing and the fixed dosing groups. MFIs significantly increased when the infusion-to-surgery window was reduced to within 2days (vs. 3days or more, p<0.05).CONCLUSIONS: Antibody-based imaging for surgical resection is under investigation in multiple clinical trials. Our data suggests that a fixed dose of 50mg is an appropriate diagnostic dose for successful surgical fluorescence imaging.

    View details for PubMedID 31054001

  • The Clinical Application of Fluorescence-Guided Surgery in Head and Neck Cancer. Journal of nuclear medicine : official publication, Society of Nuclear Medicine van Keulen, S., Nishio, N., Fakurnejad, S., Birkeland, A., Martin, B. A., Lu, G., Zhou, Q., Chirita, S. U., Forouzanfar, T., Colevas, D., van den Berg, N. S., Rosenthal, E. L. 2019


    Although surgical resection has been the primary treatment modality of solid tumors for decades, surgeons still rely on visual cues and palpation to delineate healthy from cancerous tissue. This may contribute to the high rate (up to 30%) of positive margins in head and neck cancer resections. Margin status in these patients is the most important prognostic factor for overall survival. In addition, second primary lesions may be present at the time of surgery. Although often unnoticed by the medical team, these lesions can have significant survival ramifications. We hypothesize that real-time fluorescence imaging can enhance intraoperative decision-making by aiding the surgeon in detecting close or positive margins and visualizing unanticipated regions of primary disease. The purpose of this study was to assess the clinical utility of real-time fluorescence imaging for intraoperative decision-making. Methods: Head and neck cancer patients (n = 14) scheduled for curative resection were enrolled in a clinical trial evaluating panitumumab-IRDye800CW for surgical guidance (NCT02415881). Open-field fluorescence imaging was performed throughout the surgical procedure. The fluorescence signal was quantified as signal-to-background ratios to characterize the fluorescence contrast of regions of interest relative to background. Results: Fluorescence imaging was able to improve surgical decision-making in three cases (21.4%); identification of a close margin (n = 1) and unanticipated regions of primary disease (n = 2). Conclusion: This study demonstrates the clinical applications of fluorescence imaging on intraoperative decision-making. This information is required for designing phase III clinical trials using this technique. Furthermore, this study is the first to demonstrate this application for intraoperative decision-making during resection of primary tumors.

    View details for PubMedID 30733319

  • Rapid, non-invasive fluorescence margin assessment: Optical specimen mapping in oral squamous cell carcinoma. Oral oncology van Keulen, S., van den Berg, N. S., Nishio, N., Birkeland, A., Zhou, Q., Lu, G., Wang, H., Middendorf, L., Forouzanfar, T., Martin, B. A., Colevas, A. D., Rosenthal, E. L. 2019; 88: 58–65


    OBJECTIVE: Surgical resection remains the primary treatment for the majority of solid tumors. Despite efforts to obtain wide margins, close or positive surgical margins (<5 mm) are found in 15-30% of head and neck cancer patients. Obtaining negative margins requires immediate, intraoperative feedback of margin status. To this end, we propose optical specimen mapping of resected tumor specimens immediately after removal.MATERIALS AND METHODS: A first-in-human pilot study was performed in patients (n = 8) after infusion of fluorescently labeled antibody, panitumumab-IRDye800 to allow surgical mapping of the tumor specimen. Patients underwent standard of care surgical resection for head and neck squamous cell carcinoma (HNSCC). Optical specimen mapping was performed on the primary tumor specimen and correlated with pathological findings after tissue processing.RESULTS: Optical mapping of the specimen had a 95% sensitivity and 89% specificity to detect cancer within 5 mm (n = 160) of the cut surface. To detect tumor within 2 mm of the specimen surface, the sensitivity of optical specimen mapping was 100%. The maximal observed penetration depth of panitumumab-IRDye800 through human tissue in our study was 6.3 mm.CONCLUSION: Optical specimen mapping is a highly sensitive and specific method for evaluation of margins within <5 mm of the tumor mass in HNSCC specimens. This technology has potentially broad applications for ensuring adequate tumor resection and negative margins in head and neck cancers.

    View details for PubMedID 30616798

  • Intraoperative Tumor Assessment Using Real-Time Molecular Imaging in Head and Neck Cancer Patients. Journal of the American College of Surgeons Keulen, S. v., Nishio, N. n., Fakurnejad, S. n., van den Berg, N. S., Lu, G. n., Birkeland, A. n., Martin, B. A., Forouzanfar, T. n., Dimitrios Colevas, A. n., Rosenthal, E. L. 2019


    In head and neck cancer, surgical resection using primarily visual and tactile feedback is considered gold standard for solid tumors. Due to high numbers of tumor-involved surgical margins which are directly correlated to poor clinical outcome, intraoperative optical imaging trials have rapidly proliferated over the past five years. However, few studies report on intraoperative in situ imaging data that could support surgical resection. To demonstrate the clinical application of in situ surgical imaging, we report on the imaging data that is directly (i.e. in real-time) available to the surgeon.Fluorescence intensities and tumor-to-background ratios (TBRs) were determined from the intraoperative imaging data - the view as seen by the surgeon during tumor resection - of 20 patients and correlated to patient and tumor characteristics including age, sex, tumor site, tumor size, histological differentiation and EGFR expression. Furthermore, different lighting conditions in regard to surgical workflow were evaluated.Under these circumstances, intraoperative TBRs of the primary tumors averaged 2.2±0.4 (range 1.5-2.9). Age, sex, tumor site, and tumor size did not have a significant effect on open-field intraoperative molecular imaging of the primary tumors (p>0.05). In addition, variation in EGFR expression levels or the presence of ambient light did not seem to alter TBRs.We present the results of successful in situ intraoperative imaging of primary tumors alongside the optimal conditions with respect to both molecular image acquisition and surgical workflow. This study illuminates the potentials of open-field molecular imaging to assist the surgeon in achieving successful cancer removal.

    View details for DOI 10.1016/j.jamcollsurg.2019.09.007

    View details for PubMedID 31568855

  • Rapid, non-invasive fluorescence margin assessment: Optical specimen mapping in oral squamous cell carcinoma ORAL ONCOLOGY van Keulen, S., van den Berg, N. S., Nishio, N., Birkeland, A., Zhou, Q., Lu, G., Wang, H., Middendorf, L., Forouzanfar, T., Martin, B. A., Colevas, A., Rosenthal, E. L. 2019; 88: 58–65
  • Selective modification of fluciclovine (F-18) transport in prostate carcinoma xenografts AMINO ACIDS Tade, F., Wiles, W. G., Lu, G., Bilir, B., Akin-Akintayo, O., Lee, J. S., Patil, D., Yu, W., Gherasim, C., Fei, B., Moreno, C. S., Osunkoya, A. O., Teoh, E. J., Oka, S., Okudaira, H., Goodman, M. M., Schuster, D. M. 2018; 50 (9): 1301–5


    We investigated if previously demonstrated inhibition of fluciclovine (18F) in vitro could be replicated in a PC3-Luc xenograft mouse model. Following intratumoral injection of 2-aminobicyclo-(2,2,1)-heptane-2-carboxylic acid (BCH), alpha-(methylamino)isobutyric acid (MeAIB) or saline, fluciclovine PET tumor-to-background activity was 43.6 (± 5.4)% and 25.3 (± 5.2)% lower in BCH (n = 6) and MeAIB (n = 5) injected PC3 Luc xenografts, respectively, compared to saline-injected controls (n = 2). Partial inhibition of fluciclovine uptake by BCH and MeAIB can be demonstrated in vivo similar to previous in vitro modeling.

    View details for PubMedID 29905905

  • Determination of Tumor Margins with Surgical Specimen Mapping Using Near-Infrared Fluorescence. Cancer research Gao, R. W., Teraphongphom, N. T., van den Berg, N. S., Martin, B. A., Oberhelman, N. J., Divi, V., Kaplan, M. J., Hong, S. S., Lu, G., Ertsey, R., Tummers, W. S., Gomez, A. J., Holsinger, F. C., Kong, C. S., Colevas, A. D., Warram, J. M., Rosenthal, E. L. 2018


    For many solid tumors, surgical resection remains the gold standard and tumor-involved margins are associated with poor clinical outcomes. Near-infrared (NIR) fluorescence imaging using molecular agents has shown promise for in situ imaging during resection. However, for cancers with difficult imaging conditions, surgical value may lie in tumor-mapping of surgical specimens. We thus evaluated a novel approach for real-time, intraoperative tumor margin assessment. 21 adult patients with biopsy-confirmed squamous cell carcinoma arising from the head and neck (HNSCC) scheduled for standard-of-care surgery were enrolled. Cohort 1 (n=3) received panitumumab-IRDye800CW at an intravenous microdose of 0.06 mg/kg, cohort 2A (n=5) received 0.5mg/kg, cohort 2B (n=7) received 1mg/kg, and cohort 3 (n=6) received 50 mg. Patients were followed 30 days post-infusion and adverse events were recorded. Imaging was performed using several closed- and wide-field devices. Fluorescence was histologically correlated to determine sensitivity and specificity. In situ imaging demonstrated tumor-to-background ratio (TBR) of 2-3, compared to ex vivo specimen imaging TBR of 5-6. We obtained clear differentiation between tumor and normal tissue, with a three-fold signal difference between positive and negative specimens (p<0.05). We achieved high correlation of fluorescence intensity with tumor location with sensitivities and specificities >89%; fluorescence predicted distance of tumor tissue to the cut surface of the specimen. This novel method of detecting tumor-involved margins in surgical specimens using a cancer-specific agent provides highly sensitive and specific, real-time, intraoperative surgical navigation in resections with complex anatomy which are otherwise less amenable to image guidance.

    View details for PubMedID 29967260

  • Ultrasound Imaging Technologies for Breast Cancer Detection and Management: A Review. Ultrasound in medicine & biology Guo, R., Lu, G., Qin, B., Fei, B. 2018; 44 (1): 37-70


    Ultrasound imaging is a commonly used modality for breast cancer detection and diagnosis. In this review, we summarize ultrasound imaging technologies and their clinical applications for the management of breast cancer patients. The technologies include ultrasound elastography, contrast-enhanced ultrasound, 3-D ultrasound, automatic breast ultrasound and computer-aided detection of breast ultrasound. We summarize the study results seen in the literature and discuss their future directions. We also provide a review of ultrasound-guided, breast biopsy and the fusion of ultrasound with other imaging modalities, especially magnetic resonance imaging (MRI). For comparison, we also discuss the diagnostic performance of mammography, MRI, positron emission tomography and computed tomography for breast cancer diagnosis at the end of this review. New ultrasound imaging techniques, ultrasound-guided biopsy and the fusion of ultrasound with other modalities provide important tools for the management of breast patients.

    View details for DOI 10.1016/j.ultrasmedbio.2017.09.012

    View details for PubMedID 29107353

  • Label-free reflectance hyperspectral imaging for tumor margin assessment: a pilot study on surgical specimens of cancer patients. Journal of biomedical optics Fei, B., Lu, G., Wang, X., Zhang, H., Little, J. V., Patel, M. R., Griffith, C. C., El-Diery, M. W., Chen, A. Y. 2017; 22 (8): 1-7


    A label-free, hyperspectral imaging (HSI) approach has been proposed for tumor margin assessment. HSI data, i.e., hypercube (x,y,λ), consist of a series of high-resolution images of the same field of view that are acquired at different wavelengths. Every pixel on an HSI image has an optical spectrum. In this pilot clinical study, a pipeline of a machine-learning-based quantification method for HSI data was implemented and evaluated in patient specimens. Spectral features from HSI data were used for the classification of cancer and normal tissue. Surgical tissue specimens were collected from 16 human patients who underwent head and neck (H&N) cancer surgery. HSI, autofluorescence images, and fluorescence images with 2-deoxy-2-[(7-nitro-2,1,3-benzoxadiazol-4-yl)amino]-D-glucose (2-NBDG) and proflavine were acquired from each specimen. Digitized histologic slides were examined by an H&N pathologist. The HSI and classification method were able to distinguish between cancer and normal tissue from the oral cavity with an average accuracy of 90%±8%, sensitivity of 89%±9%, and specificity of 91%±6%. For tissue specimens from the thyroid, the method achieved an average accuracy of 94%±6%, sensitivity of 94%±6%, and specificity of 95%±6%. HSI outperformed autofluorescence imaging or fluorescence imaging with vital dye (2-NBDG or proflavine). This study demonstrated the feasibility of label-free, HSI for tumor margin assessment in surgical tissue specimens of H&N cancer patients. Further development of the HSI technology is warranted for its application in image-guided surgery.

    View details for DOI 10.1117/1.JBO.22.8.086009

    View details for PubMedID 28849631

    View details for PubMedCentralID PMC5572439

  • Functional MRI of the Eustachian Tubes in Patients With Nasopharyngeal Carcinoma: Correlation With Middle Ear Effusion and Tumor Invasion AMERICAN JOURNAL OF ROENTGENOLOGY Mo, Y., Zhuo, S., Tian, L., Zhou, J., Lu, G., Zhang, Y., Liu, L. 2016; 206 (3): 617-622


    We sought to combine the Valsalva maneuver with MRI to evaluate eustachian tube function in patients with nasopharyngeal carcinoma (NPC) and to correlate the extent of tumor invasion with the presence of middle ear effusion (MEE) and eustachian tube dysfunction (ETD).We performed MRI along the lengths of the eustachian tubes, before and after the Valsalva maneuver was performed, in 53 patients with untreated NPC. The images were reviewed by two radiologists.A total of 106 eustachian tubes and middle ears were studied. There was dysfunction in 37 eustachian tubes, which was always ipsilateral to the NPC. There was MEE in 26 ears of 22 patients. In all cases of MEE, there was ipsilateral ETD. ETD was correlated with tumor invasion of the ipsilateral pharyngeal recess (p < 0.001), pharyngeal opening of the eustachian tube (p < 0.001), the cartilaginous eustachian tube (p < 0.001), the eustachian cartilage (p < 0.001), Ostmann fat pad (p < 0.001), the levator veli palatine muscle (p < 0.001), and the tensor veli palatine muscle (p < 0.001). There was a strong correlation between the grade of parapharyngeal space invasion and ETD (r = 0.809; p < 0.001) and MEE (r = 0.693; p < 0.001).Combining the Valsalva maneuver with MRI is helpful in assessing the function of the eustachian tube in patients with NPC. The cause of MEE in patients with NPC is dysfunction of the eustachian tube opening, which is associated with tumor invasion around the eustachian tube.

    View details for DOI 10.2214/AJR.15.14751

    View details for Web of Science ID 000370848400028

    View details for PubMedID 26901020

  • Simulating cardiac ultrasound image based on MR diffusion tensor imaging MEDICAL PHYSICS Qin, X., Wang, S., Shen, M., Lu, G., Zhang, X., Wagner, M. B., Fei, B. 2015; 42 (9): 5144-5156


    Cardiac ultrasound simulation can have important applications in the design of ultrasound systems, understanding the interaction effect between ultrasound and tissue and setting the ground truth for validating quantification methods. Current ultrasound simulation methods fail to simulate the myocardial intensity anisotropies. New simulation methods are needed in order to simulate realistic ultrasound images of the heart.The proposed cardiac ultrasound image simulation method is based on diffusion tensor imaging (DTI) data of the heart. The method utilizes both the cardiac geometry and the fiber orientation information to simulate the anisotropic intensities in B-mode ultrasound images. Before the simulation procedure, the geometry and fiber orientations of the heart are obtained from high-resolution structural MRI and DTI data, respectively. The simulation includes two important steps. First, the backscatter coefficients of the point scatterers inside the myocardium are processed according to the fiber orientations using an anisotropic model. Second, the cardiac ultrasound images are simulated with anisotropic myocardial intensities. The proposed method was also compared with two other nonanisotropic intensity methods using 50 B-mode ultrasound image volumes of five different rat hearts. The simulated images were also compared with the ultrasound images of a diseased rat heart in vivo. A new segmental evaluation method is proposed to validate the simulation results. The average relative errors (AREs) of five parameters, i.e., mean intensity, Rayleigh distribution parameter σ, and first, second, and third quartiles, were utilized as the evaluation metrics. The simulated images were quantitatively compared with real ultrasound images in both ex vivo and in vivo experiments.The proposed ultrasound image simulation method can realistically simulate cardiac ultrasound images of the heart using high-resolution MR-DTI data. The AREs of their proposed method are 19% for the mean intensity, 17.7% for the scale parameter of Rayleigh distribution, 36.8% for the first quartile of the image intensities, 25.2% for the second quartile, and 19.9% for the third quartile. In contrast, the errors of the other two methods are generally five times more than those of their proposed method.The proposed simulation method uses MR-DTI data and realistically generates cardiac ultrasound images with anisotropic intensities inside the myocardium. The ultrasound simulation method could provide a tool for many potential research and clinical applications in cardiac ultrasound imaging.

    View details for DOI 10.1118/1.4927788

    View details for Web of Science ID 000360645000017

    View details for PubMedID 26328966

    View details for PubMedCentralID PMC4537486