the use of non-invasive optical and molecular tests in the
TRANSCRIPT
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Separating the Good from the Bad and Ugly
The Use of Non-Invasive Optical and Molecular Tests in the Management of
an Oral Lesion
Dr. Catherine Poh, DDS, PhD Cert. Oral Pathology, FRCD (C), DABOMP
Clinician Scientist, BC Cancer Research Centre Professor, Faculty of Dentistry, UBC
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Faculty Disclosure
Ihavenoconflictofinterestinrela1ontothedevicesortoolsusedinthispresenta1on.
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Vancouver, British Columbia, Canada
University of British Columbia
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Patients with 1. Head and Neck Cancers: pre-, during, and post- radiation and/or
chemoradiation 2. Oral cancers: pre- and post- surgery 3. Oral precancerous management 4. Hematopoietic malignancies for pre-chemo or pre-BMT
assessment 5. Cancers require Biosphosphonates treatment
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Oral Mucosal Lesions
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Non-invasive Optical and Molecular Tests
1. VELScope®
2. Quantitative Cytology
3. Loss of Heterozygosity
Finding Solutions through Research !!
Early Detection and Risk Assessment
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VELScope®
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Calum MacAulay Pierre Lane
Building a Visualization Device
Lane et al., Simple device for the direct visualization of oral-cavity tissue fluorescence. 2006 11(2):024006. J Biomed Opt.
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Fluorescence Visualization (FV)
Fluorescence due to FAD/NADH (cellular level)
Fluorescence due to collagen cross-links & elastin (in the subtending stroma)
- Decomposition (or restructuring) of the of Collagen Matrix
- ↑ Metabolic Activity (↑ FADH/NAD)
- ↑ Micro-Vascularization
- ↑ Nuclear Scattering
- Epithelial Thickening
Long-pass filter
FVR (fluorescence visualization retained)
FVL (fluorescence visualization loss)
Poh et al., 2009 (book chapter)
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CIS
severe dysplasia
Identification of clinically not-apparent change
Poh et al., Head and Neck, 2007
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Diffuse non-homogenous leukoplakia at the right ventral tongue
FV helps on the decision of where to biopsy
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When to biopsy
12 months
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Clinical white light image – Invasive cancer and severe dysplasia (arrow)
Fluorescence visualization (FV)
The extension of the high-grade oral lesion
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Question 1: Can we use this tool in the operating room to assist the decision of surgical margin?
FV in the operating room
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16 Clin Can Res, 12(22), 6716-22, 2006
Carcinoma
No dysplasia No dysplasia
Severe dysplasia
FV in the operating room
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B D
C
D3S1300 D9S1751 tp53
D D D
D3S1234
c
D9INFA
H c H
tp53
c H
A
C C C
B
C
D
Ø FV can recognize histologically high-grade and molecularly high-risk areas.
Clin Can Res, 12(22), 6716-22, 2006
Ø 19/20 lesions has FV positive area outside the tumor area and the FV margin is not evenly around the tumor area
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Question 2: Does the tool really make impact on patient’s outcome, i.e., recurrence rate?
FV in the operating room
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Study Scheme: 2004-2009 British Columbia
Poh et al., JAMA Otolaryngol Head Neck Surg. 2016;142(3):209-216.
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FV appears to reduce local recurrence
BCpilotlongitudinalFVstudy
3-yearrecurrenceratereducesfrom41%to6.5%.
FV-guided surgery
Control – white light guided surgery
Pro
babi
lity
of L
ocal
Rec
urre
nce
Free
Sur
viva
l
2004-2009 in BC : D3/CIS (N=90; FV=62; WL=28)
FV-guided surgery
Control – white light guided surgery
Pro
babi
lity
of L
ocal
Rec
urre
nce
Free
Sur
viva
l
2004-2009 in BC : SCC (N=156; FV=92; WL=64)
P < 0.001 P < 0.001
JAMA Otolaryngol Head Neck Surg. 2016;142(3):209-216
3-yearrecurrenceratereducesfrom39%to8%
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COOLS trial- Canadian Optically-guided approach for Oral Lesions Surgical Trial
• Phase III randomized controlled trial § 400 patients: Severe dysplasia/CIS; T1 and T2 oral cancer
§ 4.8 million, 6 – year project (September 1st, 2010) – milestone driven project
Eligiblepa1entIden1fica1onateachgeographicsite
Stra
tify
FV*-guidedsurgery(N=80+120)
Ran
dom
ize
White-light-guidedsurgery
(N=80+120)
EndpointLocal
recurrence
*FV:fluoresencevisualiza1on
Preinvasivehigh-gradelesions
(N=160)
Invasivecancers(N=240)
Poh et al. BMC Cancer 2011, 11:462
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Pan-Canadian Network for Oral Cancer Control
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Incidence and Mortality
*
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Masking by Infection and Inflammation
Oral candidiasis
Lichen planus
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4 weeks
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Oral candidiasis
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20070206
20061121
3 months
Lichen planus
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Quantitative Cytology using high-resolution microscopy imaging - cNPS (cytology-Nuclear Phenotype Score)
TargetedbrushingofDssue
Development of cNPS to automatically capture alterations in
1. DNA content (ploidy)
2. Nuclear morphology features (~110)
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*
Quantitative Cytology using high-resolution microscopy imaging - cNPS (cytology-Nuclear Phenotype Score)
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A.SCC B.Lichenplanus C.Normalmucosa
D E F
G H I
* * *
Quantitative cytology
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Two-step screening Step 1: Clinical white light and/or FV (VELScope® )
Step 2: Quantitative Cytology
FV retained (FVR)
FV loss (FVL)
cNPS- /FVL cNPS+/FVL
N=68 N=28 N=12
87% <10% 92% 20% 23% 100%
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Suspicious oral lesion
Biopsy
Persistent 3-4 weeks after eliminating
the possible etiologies
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BC Oral Biopsy Service
Suspicious oral lesion
Biopsy
Persistent 3-4 weeks after eliminating
the possible etiologies
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Infobahn Oral Biopsy Service (https://[email protected])
ü Accurate description and diagnosis
ü Get pathology report online
ü Manage patients and biopsy history
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MANAGE PATIENTS
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ORAL MUCOSAL BIOPSY
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ORAL MUCOSAL BIOPSY
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ORAL MUCOSAL BIOPSY
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SEARCH THROUGH YOUR PATIENTS
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ACCESS PATHOLOGY REPORT
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Gold standard for risk assessment
Presence and degree of dysplasia
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What is dysplasia?
I. At cellular level: Criteria often used for dysplasia (WHO): a. Irregular stratification or loss of polarity of the cells in the epithelium. b. Increased mitoses c. Nuclear hyperchromatism. d. Increased nuclear/cytoplasmic ratio. e. Polymorphism of cells. f. Abnormal keratinization...
II. At architectural level:
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Mild dysplasia Dysplastic cells involving basal and parabasal cells
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Moderate dysplasia Dysplastic cells involving the lower half of the epithelial cells
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Severe dysplasia Dysplastic cells involving the lower 2/3 of the epithelial cells
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Carcinoma in situ (CIS) Dysplastic cells involving all the epithelial layers from bottom to top
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Invasive squamous cell carcinoma Basement membrane is disrupted by the dysplastic cells
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BC Oral Biopsy Service
Risk assessment clinics @
Experienced community practitioners Combined Head & Neck and Oral Medicine Clinics
Treatment triage clinics @
Oral Oncology, BC Cancer Agency Community clinics
Suspicious oral lesion
Biopsy
Persistent 3-4 weeks after eliminating
the possible etiologies
No Dysplasia
Low-grade Lesion (verrucous hyperplasia, mild,
moderate dysplasia)
High-grade Lesion (severe dysplasia, carcinoma in situ,
squamous cell carcinoma)
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BC Oral Biopsy Service
Risk assessment clinics @
Experienced community practitioners Combined Head & Neck and Oral Medicine Clinics
Treatment triage clinics @
Oral Oncology, BC Cancer Agency Community clinics
Suspicious oral lesion
Biopsy
Persistent 3-4 weeks after eliminating
the possible etiologies
No Dysplasia
Low-grade Lesion (verrucous hyperplasia, mild,
moderate dysplasia)
High-grade Lesion (severe dysplasia, carcinoma in situ,
squamous cell carcinoma)
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Histological progression model of oral lesions
Hyperplasia Mild Dysplasia
Moderate Dysplasia
Severe Dysplasia/CIS
Invasive SCC
Low grade dysplasia High risk? Low risk?
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• Published retrospective (2000) and prospective (2012) studies using LOH at 3p14 and/or 9p21 to predict risk of progression (25-35% in 5 years)
Loss of Heterozygosity (LOH) to Predict Malignant Risk for Oral Premalignant Lesions
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Figure 4. Loss of heterozygosity (LOH) images and sequence analysis of normal (N) and dysplasia (D)paired samples with marker IFNA, D9S171, D9S1748 and D9S1751 in paraffin-embedded tissues. A:TL0/2 at IFNA; B: considerable loss of the upper allele D91751 in dysplasia DNA; C and D: no LOH atD91748 and D9171 in dysplasia DNA when compared to normalDNA.
Loss of heterozygosity at 9p21
Collaborate with Cancer Genomic Lab, BCCA Funded by Genome BC
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An actionable test using loss of heterozygosity in identifying high-risk oral premalignant lesions. Liu et al., (2018)
High-risk profile of tongue and MR3 (LOH at 9p21 and/or 3p14, and 17p13) was significantly associated with progression (HR,6.7; 95% CI, 2.6-17.6) with a specificity of 98.4% at identifying progressors.
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54 Liu et al., 126 (1), 54–62(2018)
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ddPCR platform- • Using internal control – no need for control
samples • Can detect homozygous deletion • Can be used to test brushing samples – non
invasive approach
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David Lu
Curtis Hughesman
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ddPCR platform- non-invasive approach
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Gains: 3q, 5p, 7p, 8q, 11q, 20p Loss: 3p, 4q, 8p, 9p, 18q
Gains: 3q, 5p, 7p, 8q, 11q, 20q Loss: 4q
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57 Oral Cancer Discovery and Translation Lab
iTOP Clinic Combined Otolaryngology Head & Neck Surgery & Oral Medicine Clinics
944.735 km² 4.8 million
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iTOP clinic
• in vivo Optical Devices • Quantitative Cytology using Nuclear Phenotype Score • Molecular tests
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A good picture is better than a thousand words!
High resolution digital clinical images
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High resolution digital clinical images
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Toluidine blue (TB) is a metachromatic, acidophilic stain (Tolonium Chloride) and has higher affinity to nucleic acid. Possible mechanisms: • é DNA &/or RNA and/or • Defective intercellular barrier à the dye to reach deeper cell layers with higher DNA and RNA content
Toluidine Blue
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Where is the lesion and where to biopsy?
62 Toluidine Blue
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55 y/o M, smoker, HCV + (#4278); Smoking tobacco since age 13, 40 pack year smoking history.
Carcinoma in situ
FV
TB
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How to manage these at-risk oral lesions
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Manage these at-risk oral lesions: 1. Cryotherapy 2. Topical Photodynamic Therapy
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20161028 20170127
84 F NS
3 months
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20180127
20170420
Cryotherapy using liquid nitrogen 20170127
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Topical Photodynamic Therapy using 20% 5-ALA (5-Aminolevulinic Acid)
Sainin and Poh (2013) Photodynamic therapy: a review and its prospective role in the management of oral potentially malignant disorders.
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20130325
20141208
58F NS Family cancer history
18 months
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20171218 20180129 3rd Topical photo dynamic therapy using 20% 5-ALA
20141208
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71 Oral Cancer Discovery and Translation Lab
2016 0715
Topical Photodynamic Therapy using 20% 5-ALA (Aminolevulinic Acid)
31 F Nonsmoker, moderate dysplasia follow up for 7 years
2009
PDT x 2
2016 0930
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72 Oral Cancer Discovery and Translation Lab
2016 July 15
2017 March 24
Topical Photodynamic Therapy
32 F Nonsmoker
2017 March 24
Effective Management of Oral Precancers Clinical Trials of Effective Topical Treatments
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A PATIENT’S JOURNEY
Oral lesion Precancer Cancer
Reactive lesion
? ?
Screened by GPs or dentists, using conventional white-light ( VELScope exam)
QC brushing automatic cytology to sieve off trauma, inflammation, infection
Specialists for assessment & biopsy
REGISTRY (iOBS) of all mucosal biopsies Patient information, pathology, molecular information ( LOH, etc)
Cryotherapy Topical photodynamic therapy
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Acknowledgement Collaborators
COOLS study group Dr. Don Anderson Dr. Ken Berean Dr. Penny Brasher Dr. Scott Durham Dr. Cathie Garnis Dr. Martial Guillaud Dr. Cheryl Ho Dr. Steven Jones Dr. Aly Karsan Dr. Pierre Lane Dr. Calum MacAulay Dr. Samson Ng Dr. Stuart Peacock Dr. Eitan Prisman (Dr. Michele Williams) Dr. Jonn Wu Dr. Stephen Yip Dr. Lewei Zhang (in alphabetical order)
OC Discovery & Translational Lab
Dr. Sarah Zhu Cindy Cui Alisa Kami Tony Han Jessica Chen
All patients & families
Curtis Hughesman Maria Lopes David Lu Kelly Liu Katya Parfenova