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AND-gate contrast agents for enhanced fluorescence-guided surgery

Nature Biomedical Engineering volume 5, pages 264–277 (2021)Cite this article

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Abstract

Surgical resection of tumours requires precisely locating and defining the margins between lesions and normal tissue. However, this is made difficult by irregular margin borders. Although molecularly targeted optical contrast agents can be used to define tumour margins during surgery in real time, the selectivity of the contrast agents is often limited by the target being expressed in both healthy and tumour tissues. Here, we show that AND-gate optical imaging probes that require the processing of two substrates by multiple tumour-specific enzymes produce a fluorescent signal with significantly improved specificity and sensitivity to tumour tissue. We evaluated the performance of the probes in mouse models of mammary tumours and of metastatic lung cancer, as well as during fluorescence-guided robotic surgery. Imaging probes that rely on multivariate activation to selectively target complex patterns of enzymatic activity should be useful in disease detection, treatment and monitoring.

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Fig. 1: The AND-gate strategy.
Fig. 2: Structure and in vitro validation of AND-gate probes.
Fig. 3: Enhanced selectivity and sensitivity of DEATH-CAT-2 in the 4T1 breast tumour model.
Fig. 4: Quantitative analysis of DEATH-CAT-2 compared with single substrates and negative controls in the 4T1 breast tumour model.
Fig. 5: Images from robotic fluorescence-guided surgery and quantification of fluorescence signal in healthy organs.
Fig. 6: Structure of the FAP-CAT AND-gate probe and evaluation in a 4T1 breast tumour model.
Fig. 7: Evaluation of AND-gate probes in a mouse model of lung metastasis.
Fig. 8: Evaluation of DEATH-CAT–FNIR in a mouse model of lung metastasis.

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Data availability

The main data supporting the results in this study are available within the paper and its Supplementary Information. The raw and analysed datasets generated during the study are too large to be publicly shared, yet they are available for research purposes from the corresponding author on reasonable request.

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Acknowledgements

We thank S. Snipas in the G. Salvesen laboratory at Sanford Burnham Prebys Medical Discovery Institute for gifting the recombinant caspases used in this study; members of the Turk laboratory at the J. Stefan Institute for providing the recombinant cathepsin proteases used in this study; S. A. Malaker and N. Riley at the C. Bertozzi laboratory at Stanford University for the high-resolution mass analysis of the AND-gate probes; M. P. Luciano and M. J. Schnermann at the National Cancer Institute for supplying the FNIR-Tag-OSu used to synthesize the DEATH-CAT–FNIR probe; members of the P. Santa Maria laboratory for use of their SpectraM2 plate reader; and members of the M. Winslow laboratory for providing the KrasG12D/+Tp53−/− lung adenocarcinoma cell line used in the lung metastases model. Tissue sectioning and H&E staining was performed by the Stanford Animal Histology Services (AHS). This work was supported by NIH grants (R01 EB026285, to M.B.) and Stanford Cancer Institute Translational Oncology Program seed grant (to M.B.), American Cancer Society–Grand View League Research Funding Initiative Postdoctoral Fellowship (PF-19-105-01-CCE, to J.C.W.), DFG Research Fellowship (TH2139/1-1, to M.T.) and Stanford ChEM-H Chemistry/Biology Interface Predoctoral Training Program and NSF Graduate Research Fellowship Grant (DGE-114747, to J.J.Y.).

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Authors and Affiliations

  1. Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA

    John C. Widen, Martina Tholen, Joshua J. Yim & Matthew Bogyo

  2. Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA, USA

    Joshua J. Yim & Matthew Bogyo

  3. Intuitive Surgical Inc., Sunnyvale, CA, USA

    Alexander Antaris, Alwin Klaassen & Jonathan Sorger

  4. Department of Comparative Medicine, Stanford University School of Medicine, Stanford, CA, USA

    Kerriann M. Casey

  5. Department of Medicine and Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA

    Stephan Rogalla

  6. Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA

    Stephan Rogalla

  7. Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA

    Matthew Bogyo

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Contributions

M.B. and J.C.W. conceived the AND-gate probe concept and designed all of the experiments. J.C.W. synthesized all of the AND-gate probes, conducted the fluorogenic substrate assays, live- and fixed-cell fluorescence microscopy experiments, and mouse model experiments. J.C.W. and M.B. wrote the text of the paper and constructed the figures with input from J.J.Y. and K.M.C.; M.T. and J.J.Y. helped to perform live and ex vivo imaging during the 4T1 cancer mouse model experiment, including dissection of the mice. S.R. assisted with experimental design of the cancer mouse model studies. M.T. helped with the immunohistochemical analysis of 4T1 tumours. A.A., A.K. and J.S. assisted with the robotic surgery. K.M.C. evaluated H&E sections for the lung metastasis and 4T1 breast cancer mouse models.

Corresponding author

Correspondence to Matthew Bogyo.

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Competing interests

J.S., A.K. and A.A. are employees of and shareholders of Intuitive Surgical Inc., which makes the da Vinci robotic surgical system used in this study. M.B. has received funding from Intuitive Surgical Inc. for work unrelated to the studies presented in this manuscript and does not hold stock or any advisory/consulting position with the company.

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Supplementary information

Supplementary Information

Supplementary methods, figures and references.

Reporting Summary

Supplementary Video 1

Application of the DEATH-CAT probe in a 4T1-tumour mouse model using the da Vinci surgical system.

Supplementary Video 2

Application of the DEATH-CAT probe in a lung-metastasis mouse model using the da Vinci surgical system.

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Widen, J.C., Tholen, M., Yim, J.J. et al. AND-gate contrast agents for enhanced fluorescence-guided surgery. Nat Biomed Eng 5, 264–277 (2021). https://doi.org/10.1038/s41551-020-00616-6

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