Human study on cancer diagnostic probe (CDP) for real-time excising of breast positive cavity side margins based on tracing hypoxia glycolysis; checking diagnostic accuracy in non-neoadjuvant cases

Abstract

Background: Cancer diagnostic probe (CDP) had been developed to detect involved breast cavity side margins in real-time (Miripour et al. Bioeng Transl Med. e10236.). Here, we presented the results of the in vivo human model CDP studies on non-neoadjuvant cases.

Methods: This study is a prospective, blind comparison to a gold standard, and the medical group recruited patients. CDP and frozen data were achieved before the permanent pathology experiment. The main outcome of the study is surgical margin status. From November 2018 to April 2020, 202 patients were registered, and 188 were assigned for the study. Breast-conserving surgery at any age or gender, re-surgery due to re-currency, or involved margins are acceptable. Patients must be non-neoadjuvant. The reliability of CDP scoring had been evaluated by the pathology of the scored IMs. Then, three models of the study were designed to compare CDP with the frozen sections. Receiver operating characteristic (ROC) curves and AUC were measured based on the permanent postoperative pathology gold standard.

Results: A matched clinical diagnostic categorization between the pathological results of the tested IMs and response peaks of CDP on 113 cases, was reported (sensitivity = 97%, specificity = 89.3%, accuracy = 92%, positive predictive value (PPV) = 84.2%, and negative predictive value (NPV) = 98%). Study A showed the independent ability of CDP for IM scoring (sensitivity = 80%, specificity = 90%, accuracy = 90%, PPV = 22.2%, and NPV = 99.2%). Study B showed the complementary role of CDP to cover the missed lesions of frozen sections (sensitivity = 93.8%, specificity = 91%, accuracy = 91%, PPV = 55.6%, and NPV = 99.2%). Study C showed the ability of CDP in helping the pathologist to reduce his/her frozen miss judgment (specificity = 92%, accuracy = 93%, PPV = 42.1%, and NPV = 100%). Results were reported based on the post-surgical permanent pathology gold standard.

Conclusion: CDP scoring ability in intra-operative margin detection was verified on non-neoadjuvant breast cancer patients. Non-invasive real-time diagnosis of IMs with pathological values may make CDP a distinct tool with handheld equipment to increase the prognosis of breast cancer patients.

Keywords: cancer surgery; clinical study; hypoxia assisted glycolysis; pathology.

FIGURE 1

(A) Schematic of applying cancer diagnostic probe (CDP) in real‐time detection of suspicious margins during breast cancer surgery. The assay was conducted on a suspicious margin inside the patient's body (lateral margin of patient ID: 2), which is the significance of CDP. It also positively scored the margin, and the removed specimen showed a negative result for malignancy in frozen analyses. Meanwhile, the permanent H&E showed the papillary lesion with the atypia region, which must be removed by the surgeon. Inferior IM of the other patient (ID 62) was negatively scored by CDP and confirmed by both frozen and permanent H&E as usual hyperplasia and (B) CDP as a surgeon‐assisted tool in the surgery room for finding involved IMs to pre‐invasive/invasive cells. (C) Four neighboring regions of a positive internal margin (had been scored by CDP) were checked by CDP, not only to prevent additional cutting of free lesions but also to remove remained involved regions (Movie S1)

FIGURE 2

(A) Clinical and pathological characteristics of patients were randomly assigned to this study, investigation of margins in 113 patients with breast cancer during surgery by cancer diagnostic probe (CDP), frozen H&E, permanent H&E, and IHC (if required), (B) The number of patients ID which all three CDP/frozen/permanent was positive (CFP+), (C) The number of patients ID that CDP and permanent was positive and frozen declared negatives (CP+), (D) The number of patient ID which CDP was positive and permanent H&E could not declare final diagnosis. Therefore, IHC was recommended and confirmed CDP results (C+), (E) The number of patients ID which all three CDP/frozen/permanent declared was negative (CFP‐). In each diagram, internal circles indicate the number of tested margins for one patient, (F) Comparison of the accuracy, sensitivity, specificity, and selectivity parameters for CDP, and conventional Frozen pathology for preclinical study. *Among 127 patients, 14 cases were excluded due to noisy responses of the system, refused to participate, and failed pathological specimens in tissue processing procedures

FIGURE 3

(A) The baseline of the clinical study A characteristic and overall study outcome, (B) Cancer diagnostic probe (CDP) positively scored anterior margin of patient ID 114, which was reported as free margin in frozen section but was confirmed as IDC nuclear grade 2 on its reciprocal EMs by permanent pathology, (C) Inferior margin of patient ID 138 positively scored by CDP while frozen declared free margin on its reciprocal margin (EM‐) but permanent pathology diagnosed margin involvement to DCIS on the same EM

FIGURE 4

(A) The baseline of the clinical study B characteristic and overall study outcome, (B) Invasive ductal carcinoma (IDC) grade 2/DCIS lesions found in an internal margin that positively scored by Cancer diagnostic probe (CDP) while frozen declared free margin on its reciprocal margin (EM‐) but permanent pathology diagnosed margin involvement on the same EM (patient ID:143), (C) LIN2 lesion which CDP score on IM was positive (ID 145), frozen on reciprocal EM was negative, and permanent on reciprocal EM was negative

FIGURE 5

(A) The baseline of the clinical study C characteristic and overall study outcome, medial margin of patient ID 183 positively scored by cancer diagnostic probe (CDP) which was reported as, (B) free margin in the frozen section, (C) but was confirmed as a focus of DCIS, intermediate grade on its reciprocal EMs by permanent pathology. (D) Lateral margin of patient ID 187 while frozen declared free margin on its reciprocal margin (EM‐), (E) but permanent pathology diagnosed margin involvement to ADH lesion on the same EM and confirmed CDP, receiver operating characteristic (ROC) diagram for (F) CDP and (G) frozen versus permanent pathology for total 450 EM and IM margins on 75 patients in the three clinical studies. (H) Area under the receiver operating characteristic (ROC) curve, confidence interval, p‐value, accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of four clinical study