Beyond Navigation - Tissue-contacting Fluorescent Lifetime Imaging reveals a pathology-linked lung cancer phenotype at the point of biopsy

Background: Accurate sampling of suspected peripheral lung cancers depends on access to the lesion and confirmation that the biopsy tool is in contact with target tissue. Current bronchoscopic navigation and imaging techniques can guide instruments to a target but do not provide real-time biological confirmation at the point of sampling. Fluorescence lifetime imaging microscopy (FLIM) provides molecular contrast by measuring fluorescence decay - how long photons continue to be emitted from fluorescent molecules. In the Precision Lung clinical study (ISRCTN15093468), the Prothea Imaging System (Generation 1) identified a candidate tumour-associated phenotype of spatially overlapped low fluorescence lifetime and low intensity (LLLI) from in-vivo imaging. We used this observation as the basis for a reverse-translational study to determine whether the LLLI phenotype is linked to cancer pathology; reproducible with the Imaging System (Generation 2); and distinguishable from normal lung tissue. Methods: Previously reported Precision Lung findings were used as the clinical starting observation and were not re-analysed. Validation was then performed using: (i) pathology linked benchtop FLIM of early-stage non-small-cell lung tissue microarrays encompassing malignant cell clusters of approximately 300 um2, matched to the EoT imaging scale; (ii) five sequential fresh lung-cancer resections imaged at tumour and comparator regions, including visibly blood-rich contact sites, using the (Generation 2) Imaging System; and (iii) systematic mapping of two ventilated non-cancer donor lungs, one from a smoker and one from a non-smoker, across all available lobes. The LLLI phenotype was defined as spatial co-localisation of low intensity and short lifetime. Results: Using a real time fibre based FLIM system, capable of deployment through a working channel of a bronchoscope, the LLLI tumour phenotype was optically identified in freshly resected tumour tissue. The same phenotype was identified in fixed tissue samples with known pathology, and with images taken in the Precision Lung clinical study. Whole human lung controls did not show evidence of the tumour phenotype. Conclusions: This evidence forms a reverse-translational chain that supports the concept of the Prothea Imaging System - as a platform that confirms that the tool is in contact with a region of cancer in the lesion, while preserving continuous access for biopsy or intervention.