Clinical Trial Details
— Status: Active, not recruiting
Administrative data
| NCT number |
NCT06227416 |
| Other study ID # |
H-20009236 |
| Secondary ID |
|
| Status |
Active, not recruiting |
| Phase |
N/A
|
| First received |
|
| Last updated |
|
| Start date |
June 15, 2020 |
| Est. completion date |
May 31, 2025 |
Study information
| Verified date |
January 2024 |
| Source |
Bispebjerg Hospital |
| Contact |
n/a |
| Is FDA regulated |
No |
| Health authority |
|
| Study type |
Interventional
|
Clinical Trial Summary
The purpose of the study is to investigate the ability of mass spectrometry imaging to locate
aggregates of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) ex-vivo, and to
distinguish areas containing these carcinomas from normal skin. It is suggested that
non-melanoma skin cancer (NMSC) cells show a different profile of endogenous lipids than
healthe skin tissue which can be used as identifying biomarkers. If that hypothesis is
correct it will be possible in the future to develop real-time tissue diagnosis and treatment
of NMSC using mass spectrometry guided surgery.
Method
between 60 and 100 patients with BCCs, SCCs, and actinic keratoses (AK) will be recruited.
For patients referred for Mohs surgical procedure at the Department of Dermatology,
Bispebjerg Hospital, to treat BCCs or SCCs, three skin sections (5-10 um thick) of the tissue
that is already removed will be use in our study. One section will be HE stained so we know
exactly where the regions of interest are. Two sections will be used for MS analysis (MSI
spectrum and REIMS spectrum).
When patients are referred for a procedure to have treated several actinic keratoses (grade
1, 2 or 3) at Department of Dermatology, Bispebjerg Hospital we will take an extra punch
biopsy (2-4 mm) depending on the size of the lesion. The biopsy is embedded and sectioned. We
will use 3 skin sections (5-10 um thick) we will again use one section for HE staining and
two for MS analysis.
Multivariate statistical analysis will be performed on all mass spectra using Matlab or
similar program. Linear discriminant analysis will be used to identify spectral differences
between pre-malignant, cancer and normal tissue. Classification performance will be recorded
with a leave-one- patient- out cross- validation scheme.
Description:
1. Title Skin tumor biomarkers by mass spectrometry imaging
2. Aim 2.1 Problem definition More than 1 million patients were diagnosed with non-melanoma
skin cancer (NMSC) worldwide in 2018 and this number could be underestimated due to the
lack of registries or incomplete registration of this type of cancer [1]. Timely
detection of microscopic tumors is of utmost importance in cancer diagnostics. We
believe that mass spectrometry imaging (MSI) can successfully locate microscopic
aggregates of a common skin cancer, basal cell carcinoma (BCC) and squamous cell
carcinoma (SCC), and distinguish them from adjacent normal skin ex-vivo. MSI unveils an
altered chemical profile in BCC and SCC region (lipid patterns) and does not rely on
visual identification of histopathologic features.
2.2 Hypothesis We hypothesize that NMSC cells exhibit specific, endogenous biomarkers
(lipid patterns) that differ from healthy skin tissue in sections of skin biopsies. If
that hypothesis is correct it will be possible in the future to develop real-time tissue
diagnosis and treatment of NMSC using mass spectrometry guided surgery.
2.3 Outcome measures
- Identification of masses and distributions of selected lipid biomarkers in sections
from removed BCC and SCC tissue from Mohs surgery.
- Identification of masses and distributions of selected lipid biomarkers in sections
from biopsies with actinic keratoses (pre-malignant lesions).
2.4 Background The incidence of non-melanoma skin cancer (NMSC) was of 1 million people
in 2018, according to the Skin Cancer Report of 2019 by World Cancer Research Fund,
being classified as the more commonly occurring cancer worldwide [1]. The NMSC englobes
primarily basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).
In Denmark and other Western countries the occurrence of these tumors is also high [2],
and Danish incidence continue to rise, amounting to 15.000 per year. The main risk
factor to NMSC is exposure to ultraviolet radiation (UVR). Light skin color, light or
red hair, light eye color and immunocompromised people are other established causes to
NMSC [1,3].
The Danish population is predominantly fair-skinned, geographically mobile and
exceedingly sun-loving, which increases the risks of developing skin cancer. Daily, ~44
Danes receive a NMSC diagnosis, consisting of either BCC or SCC, with 40% developing new
tumors in the following years [4] NMSC has a low mortality, however it has a notable
patient morbidity due to its high prevalence and recurrence [2], costing more than 19
million Euro yearly to Denmark, exceeding the cost of health management and health care
costs of melanoma [5]. Care for NMSC is primarily by dermatologists, and multiple
modalities can be used on the treatment of NMSC, such as Mohs micrographic surgery,
excision, cryotherapy, and different topical modalities [2].
The lowest recurrence rates of Mohs micrographic surgery make this excisional surgery
the first choice of treatment for high risk NMSC [6]. During this microscope-guided
surgery, tissue is excised, sectioned, stained, and evaluated by a trained pathologist.
The patient waits on the operating table while tissue margins are inspected for cancer
cells, a finding that prompts further tissue removal from the treatment area.
Accordingly, Mohs surgery is time-consuming and expensive, due to limited number of
patients that can be treated per day and need for highly trained laboratory staff.
For decades, laboratories have benefitted from the impressive sensitivity and
specificity of mass spectrometry (MS). A well-established analytical technique, MS
ionizes compounds and sorts them based on their molecular mass. MS imaging (MSI)
visualizes the spatial distribution of molecules in a similar way. Scanning entire
tissue sections (e.g. skin) and generating a mass spectrum for each unit area, a map of
a compound's tissue distribution is provided.
MSI can detect many endogenous molecular species simultaneously, including lipids, small
proteins, as well as exogenous pharmaceutical drugs distributed in minute concentrations
within analyzed tissue [8].
Janfelt and colleagues [10] were able to distinguish between epidermis and dermis using
MSI on phospholipids. We will use this technique to identify endogenous tumor biomarkers
present in skin tumours but not present (or in different intensities) in adjacent normal
skin. Integrating MSI into the diagnostic arsenal for NMSC, using the technology to
differentiate in real-time, specific membrane lipid signatures of malignant and benign
tissue.
The long-term goal beyond this project, if it is possible to identify lipid patterns
able to distinguish malignant and healthy skin, is to introduce Rapid Evaporation
Ionization Mass Spectrometry (REIMS), also now as iKnife [11]. This method has the
potential to be far more sensitive by directly identifying chemical tumor signatures
rather than simple tissue anatomy, in addition to be less labor-intensive and
time-consuming. REIMS technique consists of an electrosurgical handpiece connected to a
mass spectrometer, capable of performing real-time tissue identification using the
aerosolised tissue produced during electrosurgery. Tissue identification is achieved by
automated matching of mass spectra recorded during surgery, with a preexisting
"reference library". The modality provides the surgeon with immediate information on
what type of tissue is being cut, guiding treatment by delineating cancer margins with
astounding precision. Lipidomic profiles showed variation between histological tumor
types, enabling distinction of tissues by acting as biomarkers [12]. REIMS has also
proven efficacious in other fields as a way of affirming product authenticity and
quality. Thus, in the food industry, REIMS is used to distinguish between beef and horse
meat in <3 seconds, boasting an accuracy of 100 % [13].
3. Method 3.1 Study design for patients with BCC and SCCs When patients are referred for
Mohs surgical procedure at the Department of Dermatology, Bispebjerg Hospital, BCCs or
SCCs are removed and the tissue is embedded, sectioned and stained for the Mohs surgeon
to evaluate whether more tissue is needed to be removed. Three skin sections (5-10 um
thick) of this tissue there is already removed will be use in our study. One section
will be HE stained so we know exactly where the regions of interest are. Two sections
will be used for MS analysis (MSI spectrum and REIMS spectrum).
Currently, we are doing Mohs surgery on high-risk BCCs at Department of Dermatology,
Bispebjerg Hospital, but Mohs Surgery of SCCs will be included within a year.
3.2 Study design for patients with actinic keratoses When patients are referred for a
procedure to have treated several actinic keratoses (grade 1, 2 or 3) at Department of
Dermatology, Bispebjerg Hospital we will take an extra punch biopsy (2-4 mm) depending
on the size of the lesion. The biopsy is embedded and sectioned. We will use 3 skin
sections (5-10 um thick). One section will be HE stained so we know exactly where the
regions of interest are. Two sections will be used for MS analysis at Department of
Pharmacy, University of Copenhagen. We will include actinic keratoses from up to 100
patients.
3.3 Tissue microarray The above-mentioned sectioning for MSI will provide knowledge
about a single tumor in comparison with the adjacent normal tissue. However, we also
need to compare patients with each other and therefore we need to make a tissue
microarray.
We will make the tissue microarray from the removed and embedded Aktinic
keratoses/BCC/SCC tissue. One section will analysed by MSI with the same procedure as
described above and extra sections will be HE stained for pathology evaluation and
traditional immunohistochemistry markers as Ki67 and p53.
4. Statistical calculations Multivariate statistical analysis will be performed on all mass
spectra using Matlab or similar program. Linear discriminant analysis will be used to
identify spectral differences between pre-malignant, cancer and normal tissue.
Classification performance will be recorded with a leave-one- patient- out cross-
validation scheme. The number of samples is based on sample size calculation and
previous publications on other cancer forms and estimated to be sufficient to generate a
reference library. We are planning a study of a continuous response variable from
matched pairs of study subjects. Prior data indicate that the difference in the response
of matched pairs is normally distributed with standard deviation 8. If the true
difference in the mean response of matched pairs is 3, we will need to study 58 pairs of
subjects to be able to reject the null hypothesis that this response difference is zero
with probability (power) 0,8. The Type I error probability associated with this test of
this null hypothesis is 0,05. (programmed used for sample size calculation; Power and
Sample Size Calculation, PS, Vanderbilt University; version 3.1.2). Based on these
calculations will we recruit between 60 and 100 patients with BCCs, AKs and SCCs.
Minimum will be 180 patients and maximum 300 patients.
5. Participants In total maximum 300 patients will be recruited to enter the study. Men and
women aged 18 years or older who meet the inclusion and exclusion criteria are included.
All potential patients will be recruited from the Department of Dermatology, Bispebjerg
University Hospital.
Interested patients will be invited to a preliminary information screening visit at
which they will receive comprehensive oral information on the study by the primary
investigator, Catharina Lerche, Mohs surgeon Martin Gluud or project nurse June
Svendsen, and written information will be handed out. The meeting will take place in a
separate office to ensure a safe and calm environment. The patients are specifically
informed that they can bring one or more assessors to all meetings and interventions if
they so choose. Written informed consent will be secured at inclusion on the surgical
procedure day of which will take place at least 24 hours after the screening visit.
Each patient will be evaluated by the investigator to assess the suitability of entering
the study. To ensure a homogeneous group of optical comparison, recruitment will be
performed according to the following criteria:
5.1 Inclusion criteria • Patients above 18 years of age.
• Patients presenting with AKs, SCCs and BCCs.
• Written informed consent obtained from patient.
5.2 Exclusion criteria • Immunosuppressed patients
6. Potential risk and adverse effects All patients will be informed both verbally and in
written form about risks and possible side effects.
6.1 Punch biopsy For patients with BCC and SCC we will only use tissue there is already
removed by the standard Mohs Procedure. For patients with actinic keratoses, a biopsy
will be obtained under local anesthesia, with 2, 3 or 4 mm in diameter and 3 mm in
depth. Each biopsy will leave a round scar of 2 mm or 4 mm in diameter that hills within
2 weeks. Injection of local anesthesia may cause pain and a tingly/prickling sensation
at the injection site. There is a minimal chance for infection, but we will treat that
if it occurs.
7. Biobank A research biobank will be established in accordance to the committee-law §2 nr.
13. All potential biopsies/sections will be kept in a locked -80 °C freezer at the
Department of Dermatology, Bispebjerg University Hospital until analysis at the
Department of Pharmacy, University of Copenhagen, Universitetsparken 2, 2100 Copenhagen
Ø. We cannot always do the analysis within 5-7 days because it takes up to 20 hours to
make one MSI picture and if we have several BCC/SCC/Actinic keratoses patients in one
day there will be a delay. When making the tissue microarray we will gather tissue from
6-8 patients before analysis. After MSI analysis the samples will be destroyed.
Destruction of remaining parts of biopsy blocks and tissue microarrays blocks will be no
latter than 1. January 2025. No tissue will be kept for unspecific research.
8. Information from patient journals Health personnel will use information regarding the
pathology description of the suspected lesion from the patient journal when screening
possible patients to be included in this study. After the informed consent is signed by
the patient, information from the patient journal concerning description of tumor type,
location, size and whether it is recurrent lesion will be used.
9. Data protection, information storage & quality control 9.1 Quality control The
declaration of Helsinki II will be respected, as well the standards of good clinical
research. Respect of privacy as well as physically and mentally integrity of patients
will be maintained. The study will be registered with the Committee on Health Research
Ethics and The Danish data Agency protection.
9.2 Data protection and storage General Data Protection Regulation (Danish:
Databeskyttelsesloven/Persondataforordningen) will be respected. Research using Capital
Region of Denmark's data is considered public research. Use and distribution of data
collected in this study will be discussed with patients during the consent process. The
project will be reported to the Danish Knowledge Center on Data Protection Compliance
(Danish: Videncenter for Dataanmeldelse, Region Hovedstaden). List of screened and
patients including names, study ID number, and date of birth will be devised. All data
collected will be anonymized and protected by Danish law regarding management of
personal information and the Danish Health Act (Danish: Sundhedsloven). Data will be
registered and stored for 5 years after study termination at the Dermatological
Department, Bispebjerg Hospital.
10. Financial considerations The study is conceived by principle investigator Catharina M.
Lerche. No financial support has been conceived by commercial companies. The department
of Dermatology, Bispebjerg University Hospital will provide salary for the principal
investigator Catharina M Lerche. Other expenses related to project are covered by the
Danish Cancer Society (Knæk Cancer midler 1.6 mill DKK) and the Lundbeck Foundation (10
mill DKK). Principle investigator Catharina M. Lerche and the collaborators do not have
any personal relation or economic stake in the Danish Cancer Society or the Lundbeck
Foundation.
11. Reimbursements There will be no reimbursements to the patients.
12. Information to patients The primary investigator, Catharina M. Lerche, is responsible
for giving clear verbal and writing information about aim, design and risks of the
study, as stated in "Information og samtykke til deltagelse I sundhedsvidenskabelige
forskningsprojekter" by Danish Ministry of Healthy (Danish: Sundheds- og
Ældreministeriet). In an undisturbed setting, the participant will be made aware of
their right to have an/or more assessor(s) present, that participant is voluntary, and
that withdrawal is possible at any time during the study. Patients will be given
adequate consideration time (minimum 24 hours). Patients will be asked to sign a consent
form.
The patient will be urged to read enclosed material on study participant's right. No
study procedures will be started before the participants has signed the informed
consent. Additional questions from patients will be addressed by the contact person,
Catharina M. Lerche
13. Publication of results Positive, negative and inconclusive results will be published.
The aim is to publish and present the results in a peer-reviewed international
dermatology journal or/and at dermatological conferences. The intellectual property
rights to the results belong to Bispebjerg University Hospital. Publications will be in
accordance to the Vancouver guidelines.
14. Ethics The biopsies will be taken at Department of Dermatology, Bispebjerg University
Hospital. Personal information and samples are treated under the Act on Personal Data
and Health Act. The project is furthermore carried out with minimal health and safety
risks to the participants.
Surgical procedures are daily events at hospitals and clinics all over the world. This study
of NMSC biomarkers and development of new treatment of skin cancer based on mass spectrometry
has the potential to reduce tumor recurrence, morbidity and costs. A study of NMSC biomarkers
and clinical implementation of REIMS in the treatment of skin cancer has not yet been
performed. It is anticipated that the potential risks for adverse effects in this study are
small and that there is a potential benefit of improvement in tumor recurrence, morbidity,
costs, less labor-intensive and time-consuming. The potential of evidence -based future gains
and the future perspectives this study may provide, should be held against the participants
discomfort during the biopsy, and extra visit to Bispebjerg Hospital. Danish laws regarding
patients' rights and compensation will be followed.
15. Insurance Bispebjerg Hospital
16. References
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3. Jensen, A. et al. Intake of alcohol may modify the risk for non-melanoma skin cancer:
Results of a large danish prospective cohort study. J. Invest. Dermatol. 132, 2718-2726
(2012).
4. Kyrgidis, A., Tzellos, T. G., Vahtsevanos, K. & Triaridis, S. New Concepts for Basal
Cell Carcinoma. Demographic, Clinical, Histological Risk Factors, and Biomarkers. A
Systematic Review of Evidence Regarding Risk for Tumor Development, Susceptibility for
Second Primary and Recurrence. J. Surg. Res. 159, 545-556 (2010).
5. Bentzen, J. et al. Costs of illness for melanoma and nonmelanoma skin cancer in Denmark.
Eur. J. Cancer Prev. 22, 569-576 (2013).
6. Smeets, N. W. J. et al. Mohs' micrographic surgery for treatment of basal cell carcinoma
of the face - Results of a retrospective study and review of the literature. Br. J.
Dermatol. 151, 141-147 (2004).
8. Nilsson, A. et al. Mass spectrometry imaging in drug development. Anal. Chem. 87,
1437-1455 (2015).
10. Sørensen, I. S. et al. Combination of MALDI-MSI and cassette dosing for evaluation of
drug distribution in human skin explant. Anal. Bioanal. Chem. 409, 4993-5005 (2017).
11. Balog, J. et al. Identification of biological tissues by rapid evaporative ionization
mass spectrometry. Anal. Chem. 82, 7343-7350 (2010).
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mass spectrometry. Sci. Transl. Med. 5, (2013).
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