Clinical applications of the C-arm cone-beam CT-based 3D needle guidance system in performing percutaneous transthoracic needle biopsy of pulmonary lesions

PURPOSEThis study explored the value of flat detector C-arm CT-guidance system in performing percutaneous transthoracic needle biopsy (PTNB) for lung lesions in clinical practice.METHODSA total of 110 patients with solid lung lesions were enrolled to undergo PTNB procedures. The mean diameter of lesions was 4.63 cm (range, 0.6–15cm). The needle path was carefully planned and calculated on the C-arm CT system, which acquired three-dimensional CT-like cross-sectional images. The PTNB procedures were performed under needle guidance with fluoroscopic feedbacks.RESULTSHistopathologic tissue was successfully obtained from 108 patients with a puncture success rate of 98.2% (108/110). The diagnostic accuracy rate was found to be 96.3% (104/108). There was only one case of pneumothorax (0.9%) requiring therapy. The rates of mild pneumothorax and hemoptysis were low (12.0% and 6.5%, respectively). In addition, procedural time could be limited with this technique, which helped to reduce X-ray exposure.CONCLUSIONOur study shows that C-arm CT-based needle guidance enables reliable and efficient needle positioning and progression by providing real-time intraoperative guidance

Practical recommendations for performing ultrasound scanning in the urological and andrological fields

Aim: US scanning has been defined as the urologist's stethoscope. These recommendations have been drawn up with the aim of ensuring minimum standards of excellence for ultrasound imaging in urological and andrological practice. A series of essential recommendations are made, to be followed during ultrasound investigations in kidney, prostate, bladder, scrotal and penile diseases. Methods: Members of the Imaging Working Group of the Italian Society of Urology (SIU) in collaboration with the Italian Society of Ultrasound in Urology, Andrology and Nephrology (SIEUN) identified expert Urologists, Andrologists, Nephrologists and Radiologists. The recommendations are based on review of the literature, previously published recommendations, books and the opinions of the experts. The final document was reviewed by national experts, including members of the Italian Society of Radiology. Results: Recommendations are listed in 5 chapters, focused on: kidney, bladder, prostate and seminal vesicles, scrotum and testis, penis, including penile echo-doppler. In each chapter clear definitions are made of: indications, technological standards of the devices, the method of performance of the investigation. The findings to be reported are described and discussed, and examples of final reports for each organ are included. In the tables, the ultrasound features of the principal male uro-genital diseases are summarized. Diagnostic accuracy and second level investigations are considered. Conclusions: Ultrasound is an integral part of the diagnosis and follow-up of diseases of the urinary system and male genitals in patients of all ages, in both the hospital and outpatient setting. These recommendations are dedicated to enhancing communication and evidence-based medicine in an inter- and multi-disciplinary approach. The ability to perform and interpret ultrasound imaging correctly has become an integral part of clinical practice in uro-andrology, but intra and inter-observer variability is a well known limitation. These recommendations will help to improve reliability and reproducibility in uro-andrological ultrasound scanning

Multi Parametric Magnetic Resonance Imaging in the early detection and risk stratification of prostate cancer: The PROMIS trial

Although prostate cancer is the most common cancer in men, it remains a difficult and controversial disease in terms of its diagnostic, risk stratification and treatment pathway. This is mainly due to the shortcomings of the standard diagnostic test, trans rectal ultrasound guided biopsy (TRUSBx), that is triggered following an elevated serum prostate specific antigen (PSA) test and the lack of agreement on disease thresholds that correlate to patient risk, if left untreated (and thus undetected). These factors often complicate the selection of the appropriate management that best fits the individual patient. In this doctoral thesis I propose, examine and validate a different approach that aims to shift the current diagnostic paradigm to that of incorporating an imaging test, multi-parametric magnetic resonance imaging (MP-MRI), prior to TRUS biopsy. First, I will discuss the nature of prostate cancer and highlight the shortcomings of the current diagnostic pathway and their implications. Second, I will analyze the shortcomings in early MP-MRI research that might have hindered its acceptance and adoption into the pathway and review the advances in research that occurred since I started my research. Third, I will discuss the rationale and methodological design considerations behind the PROstate Mri Imaging Study (PROMIS). PROMIS was a multicentre diagnostic paired validating confirmatory cohort study conducted to provide level 1b evidence on diagnostic accuracy of MP-MRI. It was designed to avoid the pitfalls identified in the current literature. I will discuss and analyze the design, conduct and results of the trial and its implications. Finally, I will discuss the wider implications of my work on the clinical practice of prostate cancer management and the future research opportunities made possible by the PROMIS data and its findings

Multi-Foci Beamforming Using Curved Linear Array Transducer for Qualitative Identification of Lipids in Human Liver

Nonalcoholic fatty liver disease (NAFLD) is the leading cause of liver chronic diseases in the U.S. and its prevalence is growing in the world. In the United States, it affects an estimate of 80 to 100 million people. In less than a decade, NAFLD will likely become the number one cause of liver transplants in the country. NAFLD cases have risen rapidly over the last three decades and is the most common liver disease in children. NAFLD encompasses a disease spectrum of a variety of liver conditions ranging from simple steatosis (SS) to nonalcoholic steatohepatitis (NASH). SS is a benign form of the disease, characterized by the accumulation of lipid in the liver. On the other hand, NASH is defined by hepatic steatosis with cell injury, hepatic ballooning and various degrees of fibrosis. NASH may further develop into cirrhosis, liver failure and hepatocellular carcinoma (HCC). A non-invasive, early detection and accurate staging of NAFLD may allow for a timely intervention and treatment to prevent the progression of the disease to cirrhosis and HCC. We hypothesized a new dual-modality ultrasound imaging combining acoustic radiation force impulse (ARFI) imaging and thermal strain imaging (TSI) implemented on a clinical ultrasound probe. ARFI imaging utilizes high intensity focused ultrasound to generate a push in a region of interest (ROI). The response of the tissue inside the region of excitation due to the acoustic radiation push is determined by estimating the displacement between the pre-push reference frames and the post-push tracking frames. TSI has been used in the field of medical imaging for detecting lipids in atherosclerotic plaques and quantification of liver fat in ob/ob mice. TSI is based on the fact that the speed of sound changes differently in respect to the increase in temperature for different tissue composition. Lipids register a decreasing sound speed with increasing temperature, whereas water-bearing tissue exhibit an increasing sound speed with increasing temperature. Development of the proposed multi-modality system will be a step towards a novel clinical system which would permit the creation of a single co-registered image featuring information regarding lipid content and liver stiffness

A study of Raman spectroscopy for the early detection and characterization of prostate cancer using blood plasma and prostate tissue biopsy.

Prostate cancer (PC) is the most common cancer in men after non-melanoma skin cancer in the United Kingdom (Cancer Research UK, 2019). Current diagnostic methods (PSA, DRE, MRI & prostate biopsy) have limitations as these are unable to distinguish between low-risk cancers that do not need active treatment from cancers which are more likely to progress. In addition, prostate biopsy is invasive with potential side effects. There is an urgent need to identify new biomarkers for early diagnosis and prognostication in PC. Raman spectroscopy (RS) is an optical technique that utilises molecular-specific, inelastic scattering of light photons to interrogate biological samples. When laser light is incident on a biological sample, the photons from the laser light can interact with the intramolecular bonds present within the sample. The Raman spectrum is a direct function of the molecular composition of the tissue, providing a molecular fingerprint of the phenotypic expression of the cells and tissues, which can give good objective information regarding the pathological state of the biological sample under interrogation. We applied a technique of drop coating deposition Raman (DCDR) spectroscopy using both blood plasma and sera to see if a more accurate prediction of the presence and progression of prostate cancer could be achieved than PSA which would allow for blood sample triage of patients into at risk groups. 100 participants were recruited for this study (100 blood plasma and 100 serum samples). Secondly, 79 prostate tissue samples (from the same cohort) were interrogated with the aid of Raman micro-spectroscopy to ascertain if Raman spectroscopy can provide molecular fingerprint that can be utilised for real time in vivo analysis. Multivariate analysis of support vector machine (SVM) learning and linear discriminant analysis (LDA) were utilised differently to test the performance accuracy of the discriminant model for distinguishing between benign and malignant mean plasma spectra. SVM gave a better performance accuracy than LDA with sensitivity and specificity of 96% and 97% respectively and an area under the curve (AUC) of 0.98 as opposed to sensitivity and specificity of 51% and 80% respectively with AUC of 0.74 using LDA. Slightly lower performance accuracy was also observed when blood serum mean spectra analysis was compared with blood plasma mean spectra analysis for both machine learning algorithms (SVM & LDA). Tissue spectral analysis on the other hand recorded an overall accuracy of 80.8% and AUC of 0.82 with the SVM algorithm compared to performance accuracy of 75% and AUC of 0.77 with LDA algorithm (better performance noted with the SVM algorithm). The small sample size of 79 prostate biopsy tissues was responsible for the low sensitivity and specificity. Therefore, the tissues were insufficient to describe all the variances in each group as well as the variability of the gold standard technique. Conclusion: Raman spectroscopy could be a potentially useful technique in the management of Prostate Cancer in areas such as tissue diagnosis, assessment of surgical margin after radical prostatectomy, detection of metastasis, Prostate Cancer screening as well as monitoring and prognosticating patients with Prostate Cancer. However, more needs to be done to validate the approaches outlined in this thesis using prospective collection of new samples to test the classification models independently with sufficient statistical power. At this stage only the fluid-based models are likely to be large enough for this validation process

Differential tissue expression of extracellular vesicle-derived proteins in prostate cancer

Abstract Background: Proteomic profiling of extracellular vesicles (EVs) from prostate cancer (PCa) and normal prostate cell lines, led to the identification of new candidate PCa markers. These proteins included the nuclear exportin proteins XPO1 (also known as CRM1), the EV‐associated PDCD6IP (also known as ALIX), and the previously published fatty acid synthase FASN. In this study, we investigated differences in expression of XPO1 and PDCD6IP on well‐characterized prostate cancer cohorts using mass spectrometry and tissue microarray (TMA) immunohistochemistry to determine their diagnostic and prognostic value. Methods: Protein fractions from 67 tissue samples (n = 33 normal adjacent prostate [NAP] and n = 34 PCa) were analyzed by mass spectrometry (nano‐LC‐MS‐MS). Label‐free quantification of EVs was performed to identify differentially expressed proteins between PCa and NAP. Prognostic evaluation of the candidate markers was performed with a TMA, containing 481 radical prostatectomy samples. Samples were stained for the candidate markers and correlated with patient information and clinicopathological outcome. Results: XPO1 was higher expressed in PCa compared to NAP in the MS data analysis (P > 0.0001). PDCD6IP was not significantly higher expressed (P = 0.0501). High cytoplasmic XPO1 staining in the TMA immunohistochemistry, correlated in a multivariable model with high Gleason scores (P = 0.002) and PCa‐related death (P = 0.009). Conclusion: High expression of cytoplasmic XPO1 shows correlation with prostate cancer and has added clinical value in tissue samples. Furthermore, as an extracellular vesicles‐associated protein, it might be a novel relevant liquid biomarker

MRI Susceptibility Mapping of Brachytherapy Seeds with Deep Learning

Contrast is an essential element of magnetic resonance imaging. Good contrast in an MR image is necessary to correctly differentiate between different tissue structures and make accurate diagnoses. However, objects with high magnetic susceptibility, like metallic objects, cause severe artifacts that interfere with operations and routine evaluations. In this work, we present a deep learning-based method to undo these effects, with a focus on brachytherapy seeds. We train the network on synthetic data to generate positive contrast images from magnetic field maps for localizing the seeds from their surroundings. We evaluate the model on other synthetic data, then show that the proposed model exhibits generalization to real MRI data and outputs a result quickly. We compare its performance with another positive contrast algorithm for brachytherapy seeds to demonstrate the potential of the deep learning implementation

Development of transcriptional amplification systems to target and characterize cancer cells based on gene expression altered during prostate cancer development and treatment

Le cancer de la prostate (CaP) est le cancer dont l’incidence augmente le plus vite parmi les hommes. Selon la Société Canadienne du Cancer, en 2015, 24 000 nouveaux cas de cancer de la prostate seront diagnostiqués et 4 100 patients en décèderont. Bien que des techniques cliniques pour la détection, le diagnostique et le traitement du CaP soient disponibles et importantes dans le traitement actuel de la maladie, elles sont cependant limitées. L’exploitation de plusieurs promoteurs dont l’activité est altérée au cours du développement du cancer est un moyen pour surmonter ces limitations. L’ARN non codant PCA3 est un biomarqueur unique du CaP qui a été largement étudié et dont l’expression est 60 fois plus forte dans les cellules de CaP que dans les cellules bégnines de prostate. Le gène de l’APS (PSEBC) est un marqueur important en clinique, il reflète la réponse au traitement par privation androgénique. Ces études ont pour objectif de développer des systèmes d’amplification transcriptionnel avec les promoteurs PCA3 et PSEBC pour non seulement cibler mais aussi caractériser les cellules cancéreuses de prostate lors de la progression de la maladie. Nous avons générés plusieurs systèmes dans des adénovirus contenant différentes constructions avec le promoteur proximal PCA3 de 152 pb, le système d’amplification TSTA et le gène rapporteur de la luciférase. Nous avons testé leur spécificité pour les cellules du CaP par infection transitoire. Nous avons amélioré le système TSTA et généré le PCA3-3STA. Nous avons ensuite intégré le promoteur PCA3 avec le promoteur PSA pour générer un autre nouveau système d’amplification transcriptionnelle qui se nomme le système «Multiple Promoter Integrated Transcriptional Amplification (MP-ITSTA)». Ces systèmes ont ensuite été exploités avec un microscope à bioluminescence pour cibler des cellules de CaP provenant de biopsies liquides de patients. Dans le chapitre deux, nous avons montré que l’activité de PCA3-3STA était hautement spécifique pour les cellules de CaP. Son activité était de 98,7 à 108 fois plus fortes dans les cellules de CaP que dans les cellules primaires bégnines de prostate ou dans les cellules cancéreuses nonprostatiques. Dans des modèles murins de xénogreffes de lignées cellulaires de CaP, nous avons montré que PCA3-3STA pouvait imager de manière très sensible l’activité du promoteur PCA3. De plus, sur des modèles de cultures primaires de biopsies, nous avons montré que le système PCA3-3STA ciblait spécifiquement les cellules épithéliales de CaP sans affecter les cellules stromales. Dans le chapitre trois, nous avons ensuite développé une technique en combinat la microscopie à bioluminescence avec le système TSTA et le promoteur PSA pour cibler les cellules de CaP purifiées de sang de patients et évaluer, cellule par cellule, l’hétérogénéité de leur réponse aux anti-androgènes. Cette technique a aussi montré que la microscopie à bioluminescence est hautement quantitative et a la capacité de détecter les changements moléculaires à l’échelle de la cellule. Le quatrième chapitre présente le système MP-ITSTA. Le système intègre l’activation combinée de deux promoteurs qui contrôlent l’expression d’un seul gène rapporteur. La combinaison du promoteur PCA3 avec celui de l’APS permet d’évaluer, cellule par cellule, la réponse aux anti-androgènes de cellules de CaP prélevés à partir d’urine de patients. C’est pourquoi, les systèmes PCA3-3STA et MP-ITSTA sont des systèmes d’expression spécifiques au cancer de la prostate avec le potentiel de cibler et détecter avec précision les cellules épithéliales de CaP ainsi que leur réponse aux traitements thérapeutiques in vivo et ex vivo. Ces systèmes peuvent jouer un rôle important pour l’imagerie moléculaire, l’immunothérapie et la thérapie génique.Development Of Transcriptional Amplification Systems To Target and Interrogate Cancer Cells Based On Gene Expression Altered During Cancer Development and Treatment Prostate cancer (PCa) is the fastest rising cancer among the males. According to the Canadian Cancer Society in 2015 it was estimated that 24 000 new cases will be diagnosed with prostate cancer and 4100 patients will die from the disease. Although already available clinical techniques for the detection, prognosis and treatment of PCa play an important role in decision making, they are limited in terms of the ability of detecting PCa cells, prognosis and increasing over all survival of patients. Exploitation of several gene promoters altered during cancer development act as important tool to overcome these limitations. PCA3 noncoding long RNA is a unique PCa biomarker that has been widely studied for its sixty-fold overexpression in PCa cells, compared to benign prostate cells. PSA (PSEBC) gene is of high clinical significance as it can give an account of response to androgen deprivation treatments. These studies aim to develop Transcriptional Amplification Systems that can target as well as characterise cancer cells during disease progression using PCA3 and PSA gene promoters. Various adenovirus constructs incorporating the proximal 152 bp PCA3 promoter, the TSTA system and the Firefly luciferase reporter gene were generated and the specificity of the promoter was tested in PCa cells by transient infection. We have improved the TSTA system and generated the (PCA3-3STA). We further integrated the PCA3 promoter along with the PSA promoter to generate a new transcriptional amplification system that we named the Multiple Promoter Integrated Transcriptional Amplification (MP-ITSTA) system. These systems were further applied to target PCa cells from body fluids of patients using bioluminescence microscopy. In chapter two we show that PCA3-3STA activity was highly specific for PCa cells, ranging between 98.7 and 108.0-fold higher, respectively, than that for benign prostate or non-PCa cells. In PCa cell line mouse xenografts, PCA3-3STA was shown to image PCA3 promoter activity with high sensitivity. Moreover, when primary PCa biopsies were infected with PCA3-3STA, it managed to image PCa epithelial cells but not stromal cells. In chapter three we further developed a bioluminescence microscopy technique using the TSTA system with PSA promoter to target PCa cells from blood of patients and assess heterogeneous single cell response to antiandrogens. This technique also shows that bioluminescence microscopy is highly quantitative and has the ability to detect molecular changes at the cellular level. The fourth chapter presents the MP-ITSTA system. This system integrates the combined activation of two promoters giving a single reporter gene expression. PCA3 when combined with the PSA promoter could assess single cell response to antiandrogens in cells isolated from urine of patients. Hence, PCA3-3STA and MP-ITSTA utilizing the bioluminescence microscopy represent a prostate- and PCa-specific expression systems with the potential to target, with high accuracy, PCa epithelial cells, assess their response to therapy in vivo and ex vivo. This can play an important role for imaging, immunotherapy, or gene therapy

Determination of epithelial growth factor receptor mutations in circulatory tumour cells from non-small cell lung cancer patients isolated using a novel microfluidic device

Patients with epidermal growth factor receptor (EGFR) sensitizing mutations in non small cell lung cancer (NSCLC) receive benefit from Tyrosine Kinase inhibitors. Accurate selection of patients before treatment is highly dependent on precise molecular diagnosis of EGFR mutations. Presently in the clinic, the diagnostic samples routinely used tumour biopsy and/or cell free DNA (cfDNA), are not sufficiently effective for precise diagnosis. Circulatory tumour cells (CTC) in blood have been explored successfully as alternative and complementary diagnostic markers to the current clinical tools. However, utility in the clinics has been hampered by the relatively low concentration of CTC in blood, and the lack of robust technologies that are adaptable for routine use. The present study describes the design and optimization of an immunomagnetic based microfluidic device (Lung card version II) that isolates CTC expressing the epithelial cell adhesion molecule (EpCAM) from blood with high capture efficiency and purity. The device is a 2-part system comprising a disposable chip that is simple in design and a reusable microfluidic unit that contains a mobile magnetic arm. The simple design and work-flow process of the device ensures cost efficiency for scalability and, ultimately, use in the clinic. The device was initially validated for its capability to isolate EpCAM positive cells. Results from spiking carboxylfluorescein succinimidyl ester stained EpCAM positive cells in media/blood showed a capture efficiency of ≥ 65% and a purity ≥ 97% from a 13ml sample in 50 minutes. The isolated CTC from NSCLC patients (n=38) were analysed for mRNA markers specific to malignant cells and were characterized for EGFR mutations following PCR and next generation sequencing. The mutational status of CTC was compared to that obtained from matched, tumour biopsy, samples. Significantly more mutations (P=0.0173) were detected in CTC enriched samples than the matched biopsy. Interestingly, mutations were detected in only 4 biopsy samples and the mutations detected in the biopsy were only concordant with results from CTC enriched samples for 1 patient. Exon 19 deletion was the most frequent mutation detected (86.7%) with rare mutations such as: L792P, C797S, H509R also been detected in CTC, and the present study reports the detection of K708R mutation in NSCLC for the first time. The clinical outcomes of patients who were positive for EGFR mutation from CTC, but had been placed on therapies based on mutation results from tissue biopsy were evaluated in this study. The results showed that no significant progression free survival (PFS) benefit was attained when comparing treatment response between patients whose CTC possessed an EGFR mutation and patients whose CTC possessed no EGFR mutation (10 months vs26 months p value-0.3420 HR- 0.76 95% CI- 0.2498-2.319). In summary the results from this study showed that the microfluidic device captured CTC with efficiency equal to other immuno-affinity based devices but had better purity rates and throughput and also that the device can be utilized for CTC processing for downstream analysis. Results from this current study further demonstrated the clinical potential of CTC+NGS matrix for the detection of EGFR mutations and the prospective impact it would have for precision oncology in NSCLC are discussed