Feasibility of folate receptor-targeted intraoperative fluorescence imaging during staging procedures for early ovarian cancer

Objectives: Completeness of staging is an independent prognostic factor for survival in surgical staging procedures for early ovarian cancer. Near-infrared (NIR) fluorescence imaging has the potential to improve the intraoperative assessment of metastatic spread and thus completeness of staging. Feasibility of folate receptor alpha (FRα) targeted fluorescence imaging using OTL-38, a folate analogue conjugated to an NIR fluorescent dye, has been previously demonstrated in advanced ovarian cancer. The present authors hypothesized that in early ovarian cancer, fluorescence imaging using OTL-38 could lead to more accurate detection of (occult) ovarian cancer metastases, allowing gynecologic surgeons to take targeted rather than blind biopsy samples. Materials and Methods: Six patients scheduled to undergo a staging procedure for suspected early stage ovarian cancer, received an intravenous infusion of 0.0125 mg/kg OTL38 2-3 hours prior to surgery. The authors assessed tolerability, pharmacokinetics, and the feasibility of intraoperative NIR fluorescence detection of ovarian cancer lesions. Feasibility was evaluated using histopathological analysis, tumor-to-background ratio, and number of false positive and negative lesions. Results: Distinction between a malignant and benign primary tumor was possible with OTL-38 based fluorescence imaging. In addition, nine fluorescent lesions, all lymph node (LN) clusters, were detected intraoperatively. Tumor cells were not demonstrated in any of the biopsy samples taken during staging procedures, including the fluorescent lesions. Therefore all fluorescent LNs were false positives. Conclusions: Metastatic lesions were not present in the patients with confirmed early ovarian cancer; hence the anticipated added value of NIR fluorescence imaging could not be demonstrated in this study. Fluorescence imaging led to resection of non-malignant LNs, as comprehensive lymph node dissection should be pursued in surgical staging procedures, this should not impede application of OTL38. Importantly, fluorescence imaging allowed distinction between a malignant and benign primary tumor and had no false negatives.

Early-stage ovarian carcinoma; Surgical staging; Image-guided surgery; Fluorescence; Lymph node metastasis

[1] Chang S.J., Bristow R.E., Ryu H.S.: “Impact of complete cytoreduction leaving no gross residual disease associated with radical cytoreductive surgical procedures on survival in advanced ovarian cancer”. Ann. Surg. Oncol., 2012, 19, 4059.

[2] Vergote I., Trope C.G., Amant F., Kristensen G.B., Ehlen T., Johnson N., et al.: “Neoadjuvant chemotherapy or primary surgery in stage IIIC or IV ovarian cancer”. N. Engl. J. Med., 2010, 363, 943.

[3] Trimbos B., Timmers P., Pecorelli S., Coens C., Ven K., van der Burg M., et al.: “Surgical staging and treatment of early ovarian cancer: long-term analysis from a randomized trial”. J. Natl. Cancer Inst., 2010, 102, 982.

[4] Trimbos J.B., Vergote I., Bolis G., Vermorken J.B., Mangioni C., Madronal C., et al.: “Impact of adjuvant chemotherapy and surgical staging in early-stage ovarian carcinoma: European Organisation for Research and Treatment of Cancer-Adjuvant ChemoTherapy in Ovarian Neoplasm trial”. J. Natl. Cancer Inst., 2003, 95, 113.

[5] Zanetta G., Rota S., Chiari S., Bonazzi C., Bratina G., Torri V., et al.: “The accuracy of staging: an important prognostic determinator in stage I ovarian carcinoma. A multivariate analysis”. Ann. Oncol., 1998, 9, 1097.

[6] Vahrmeijer A.L., Hutteman M., van der Vorst J.R., van de Velde C.J., Frangioni J.V.: “Image-guided cancer surgery using near-infrared fluorescence”. Nat. Rev. Clin. Oncol., 2013, 10, 507.

[7] Chance B.: “Near-infrared images using continuous, phase-modu- lated, and pulsed light with quantitation of blood and blood oxygenation”. Ann. N. Y. Acad. Sci., 1998, 838, 29.

[8] Frangioni J.V.: “In vivo near-infrared fluorescence imaging”. Curr. Opin. Chem. Biol., 2003, 7, 626.

[9] Keereweer S., Kerrebijn J.D., van Driel P.B., Xie B, Kaijzel E.L., Snoeks T.J., et al.: “Optical image-guided surgery—where do we stand?” Mol. Imaging Biol., 2011, 13, 199.

[10] Handgraaf H.J., Verbeek F.P., Tummers Q.R., Boogerd L.S., van de Velde C.J., Vahrmeijer A.L., et al.: “Real-time near-infrared fluorescence guided surgery in gynecologic oncology: a review of the current state of the art”. Gynecol. Oncol., 2014, 135, 606.

[11] Parker N., Turk M.J., Westrick E., Lewis J.D., Low P.S., Leamon C.P.: “Folate receptor expression in carcinomas and normal tissues determined by a quantitative radioligand binding assay”. Anal. Biochem., 2005, 338, 284.

[12] O’Shannessy D.J., Somers E.B., Smale R., Fu Y.S.: “Expression of folate receptor-alpha (FRA) in gynecologic malignancies and its relationship to the tumor type”. Int. J. Gynecol. Pathol., 2013, 32, 258.

[13] Kalli K.R., Oberg A.L., Keeney G.L., Christianson T.J., Low P.S., Knutson K.L., et al.: “Folate receptor alpha as a tumor target in epithelial ovarian cancer”. Gynecol. Oncol., 2008, 108, 619.

[14] van Dam G.M., Themelis G., Crane L.M., Harlaar N.J., Pleijhuis R.G., Kelder W., et al.: “Intraoperative tumor-specific fluorescence imaging in ovarian cancer by folate receptor-alpha targeting: first inhuman results”. Nat. Med., 2011, 17, 1315.

[15] Hoogstins C.E., Tummers Q.R., Gaarenstroom K.N., de Kroon C.D., Trimbos J.B., Bosse T., et al.: “A Novel Tumor-Specific Agent for Intraoperative Near-Infrared Fluorescence Imaging: A Translational Study in Healthy Volunteers and Patients with Ovarian Cancer”. Clin. Cancer Res., 2016, 22, 2929.

[16] Tummers Q.R., Hoogstins C.E., Gaarenstroom K.N., de Kroon C.D., van Poelgeest M.I., Vuyk J., et al.: “Intraoperative imaging of folate receptor alpha positive ovarian and breast cancer using the tumor specific agent EC17”. Oncotarget, 2016, 7, 32144.

[17] Shen J., Hilgenbrink A.R., Xia W., Feng Y., Dimitrov D.S., Lock- wood M.B., et al.: “Folate receptor-beta constitutes a marker for human proinflammatory monocytes”. J. Leukoc. Biol., 2014, 96, 563.

[18] O’Shannessy D.J., Somers E.B., Wang L.C., Wang H., Hsu R.: “Ex- pression of folate receptors alpha and beta in normal and cancerous gynecologic tissues: correlation of expression of the beta isoform with macrophage markers”. J. Ovarian Res., 2015, 8, 29.

[19] Puig-Kroger A., Sierra-Filardi E., Dominguez-Soto A., Samaniego R., Corcuera M.T., Gomez-Aguado F., et al.: “Folate receptor beta is expressed by tumor-associated macrophages and constitutes a marker for M2 anti-inflammatory/regulatory macrophages”. Cancer Res., 2009, 69, 9395.

[20] van Driel P.B., van de Giessen M., Boonstra M.C., Snoeks T.J., Keereweer S., Oliveira S., et al.: “Characterization and evaluation of the artemis camera for fluorescence-guided cancer surgery”. Mol. Imaging Biol., 2015, 17, 413.

[21] Weaver D.L.: “Pathology evaluation of sentinel lymph nodes in breast cancer: protocol recommendations and rationale”. Mod. Pathol., 2010, 23, S26.

[22] Biswas S.K., Allavena P., Mantovani A.: “Tumor-associated macrophages: functional diversity, clinical significance, and open questions”. Semin. Immunopathol., 2013, 35, 585.

[23] Noy R., Pollard J.W.: “Tumor-associated macrophages: from mechanisms to therapy”. Immunity, 2014, 41, 49.

[24] Go Y., Tanaka H., Tokumoto M., Sakurai K., Toyokawa T., Kubo N., et al.: “Tumor-Associated Macrophages Extend Along Lymphatic Flow in the Pre-metastatic Lymph Nodes of Human Gastric Cancer”. Ann. Surg. Oncol., 2016, 23, S230.

[25] Trimbos J.B.: “Surgical treatment of early-stage ovarian cancer”. Best Pract. Res. Clin. Obstet. Gynaecol., 2017, 41, 60.

[26] Chan J.K., Urban R., Hu J.M., Shin J.Y., Husain A., Teng N.N., et al.: “The potential therapeutic role of lymph node resection in epithelial ovarian cancer: a study of 13918 patients”. Br. J. Cancer, 2007, 96, 1817.

[27] Kleppe M., van der Aa M.A., Van Gorp T., Slangen B.F., Kruitwagen R.F.: “The impact of lymph node dissection and adjuvant chemotherapy on survival: A nationwide cohort study of patients with clinical early-stage ovarian cancer”. Eur. J. Cancer, 2016, 66, 83.