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Quantitative fluorescence endoscopy: an innovative endoscopy approach to evaluate neoadjuvant treatment response in locally advanced rectal cancer
  1. Jolien J J Tjalma1,
  2. Marjory Koller2,
  3. Matthijs D Linssen1,3,
  4. Elmire Hartmans1,
  5. Steven de Jongh1,
  6. Annelies Jorritsma-Smit3,
  7. Arend Karrenbeld4,
  8. Elisabeth G de Vries5,
  9. Jan H Kleibeuker1,
  10. Jan Pieter Pennings6,
  11. Klaas Havenga2,
  12. Patrick HJH Hemmer2,
  13. Geke AP Hospers5,
  14. Boudewijn van Etten2,
  15. Vasilis Ntziachristos7,
  16. Gooitzen M van Dam2,
  17. Dominic J Robinson8,
  18. Wouter B Nagengast1
  1. 1 Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
  2. 2 Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
  3. 3 Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
  4. 4 Department of Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
  5. 5 Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
  6. 6 Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
  7. 7 Institute for Biological and Medical Imaging, Helmholtz Zentrum München, Munich, Germany
  8. 8 Otolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
  1. Correspondence to Dr Wouter B Nagengast, Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen 9700, Netherlands; w.b.nagengast{at}umcg.nl

https://doi.org/10.1136/gutjnl-2019-319755

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    Quantitative fluorescence endoscopy (QFE) is a new technique that can visualise and quantify fluorescently tagged tumour tissue. In 25 patients with locally advanced rectal cancer (LARC), we evaluated QFE targeting vascular endothelial growth factor A (VEGFA) to detect residual tumour after neoadjuvant chemoradiotherapy (nCRT). QFE detected significantly higher fluorescence in tumour compared with normal rectal tissue and fibrosis, and improved prediction of final pathology results in 16% of patients compared with standard MRI and white-light endoscopy. QFE is a promising technique to aid clinical response assessment in patients with LARC and warrants further validation in larger clinical trials. ClinicalTrials.gov (NCT01972373).

    In more detail

    Patients with LARC receive nCRT followed by surgery to achieve local disease control. Interestingly, 15%–27% of patients have a pathological complete response, that is, no residual cancer cells are found in the surgical specimen.1–3 There is an increasing interest in identifying patients with a clinical complete response before surgery, as non-operative management for these patients is associated with high survival rates, reduced morbidity and improved functional outcomes.4–8 However, assessing tumour response after nCRT is challenging. White-light endoscopy provides only morphological information, while MRI cannot always distinguish viable tumour from fibrosis.9–11 QFE is a novel endoscopy technique that visualises and quantitatively measures the presence of targeted fluorescence tracers in tissue. We hypothesised that VEGFA-targeted QFE can be of additional value in restaging patients with LARC. In untreated patients, QFE showed clearly enhanced fluorescence in all rectal tumours compared with normal rectal tissue (figure 1A). The tumour-to-normal ratio of 3.1 (figure 1B) signifies QFE can be used to localise rectal cancer.

    Figure 1

    (A) Representative fluorescence images of the quantitative fluorescence endoscopy (QFE) procedure in untreated rectal cancer. From left to right: a high-definition white-light video endoscope image; a white-light image from the QFE fibreoptic, followed by the corresponding near-infrared …

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