Introduction and aim: Colonoscopy is considered to be the most sensitive tool to detect colorectal neoplasms, including small and flat lesions. Nevertheless, detection of such lesions is still incomplete, giving rise to interval cancers, particularly in patients with Lynch syndrome and other hereditary disorders. To improve the detection of (pre)malignant lesions nearinfrared endoscopy, guided bymolecular targeted fluorescent tracers, may hold great promise. Therefore, we developed a combined white-light and near-infrared (WLNI) endoscopic system, as well as two clinically approved fluorescent labeled antibodies, targeting vascular endothelial growth factor-A (VEGF-A) and epithelial growth factor receptor (EGFR). In the present study we investigated VEGF-A and EGFR expression in adenomas and CRC of Lynch patients, as potential targets for (pre)malignant detection. Subsequently we validated the newly developed WLNI endoscopic system, together with intravenously injected fluorescent anti-VEGF-A and anti-EGFR antibodies, in human CRC mouse models. Materials and Methods: VEGF-A and EGFR expression was analyzed by immunohistochemical staining of 34 CRC, 64 high-grade dysplastic (HGD) adenomas, and adjacent normal colon crypts of Lynch patients. The endoscopic system consisted of a custom made clinically approved WLNI camera, comprising a color camera and an ultra-sensitive camera for concurrent white-light and NIR fluorescence acquisition, attached to either a clinical fiberscope or a multi-modal fiber-optic bundle. The WLNI system was evaluated in vivo in CRC subcutaneous (sc) and intraperitoneal (ip) mouse models of bioluminescent CRC cell lines (HCT116-luc, HT29luc2), using bevacizumab-800CW (anti-VEGF-A) and cetuximab-800CW (anti-EGFR). Results: VEGF-A and EGFR were significantly overexpressed in 95% and 74% of HGD adenomas and in 100% and 85% of CRC, compared to adjacent normal crypts (resp. P,0.001/P,0.05 and P,0.05/P,0.001). Tumor-to-background ratio was high (3.2±0.9 for bevacizumab-800CW and 5.7±2.9 for cetuximab-800CW in the HCT116-luc sc model). WLNI endoscopy demonstrated excellent instant visualization of the sc and ip tumors (diameter ≥1 mm), with clear tumor boundaries and a low background fluorescence, demonstrating very high sensitivity and specificity of our WLNI endoscopic system. Conclusion: VEGF-A and EGFR are attractive targets for molecular targeted fluorescence endoscopy in Lynch patients based on their expression patterns. The newly developed WLNI endoscopic system using clinically approved molecular targeted fluorescent antibodies, enables instant visualization of very small tumor lesions in CRC mice models, with an excellent sensitivity and specificity. These results support clinical evaluation of WLNI endoscopy, in order to enhance early detection of colorectal (pre)malignancies and improve potentially outcome in patients.
Read full abstract