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Objective: We used near-infrared fluorescence lymphatic imaging in a pilot study to assess the lymphatics in preulcerative (C2-C4) venous insufficiency and determine whether involvement and/or degradation of lymphatic anatomy or function could play a role in the progression of chronic venous insufficiency. We also explored the role of lymphatics in early peripheral arterial disease., Methods: After informed consent and intradermal injections of indocyanine green for rapid lymphatic uptake, near-infrared fluorescence lymphatic imaging was used to assess the lymphatic anatomic structure and quantify the lymphatic propulsion rates in subjects with early venous insufficiency. The anatomic observations included interstitial backflow, characterized by the abnormal spreading of indocyanine green from the injection site primarily into the surrounding interstitial tissues; dermal backflow, characterized by the retrograde movement of dye-laden lymph from collecting lymphatics into the lymphatic capillaries; and lymphatic vessel segmentation and dilation., Results: Ten subjects with venous insufficiency were enrolled, resulting in two legs with C2 disease, nine legs with C3 disease, eight legs with C4 disease, and one leg with C5 disease. Interstitial and/or dermal backflow were observed in 25%, 33%, and 41% of the injection sites in each limb with C2, C3, and C4 disease, respectively. Distinct vessel segmentation and dilation were observed in limbs with a C3 and higher classification, and dermal backflow proximal to the injection sites was observed in two legs with C4 disease and in the inguinal region of the C5 study subject. The overall average lymph propulsion rates were 1.3 ± 0.4, 1.2 ± 0.7, and 0.8 ± 0.5 contractile events/min for limbs with C2, C3, and C4 disease, respectively. One subject with peripheral arterial disease, who had previously undergone bypass surgery, presented with extensive dermal backflow and lymphatic reflux., Conclusions: Near-infrared fluorescence lymphatic imaging demonstrated that, compared with normal health subjects, the lymphatic anatomy and contractile function generally degrade with the severity of venous insufficiency. Lymphatic abnormalities mimic those in early cancer-acquired lymphedema subjects, as previously observed by us and others. Additional studies are needed to decipher the relationship, including any causality, between lymphatic dysfunction and peripheral vascular disease and venous insufficiency., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Recently, fluorescence imaging using shortwave infrared light (SWIR, 1,000-2,000 nm) has been proposed as having advantage over conventional near-infrared fluorescence (NIRF) imaging due to the reduced tissue scattering, negligible autofluorescence, comparable tissue absorption, and the discovery that indocyanine green (ICG), used clinically as a NIRF contrast agent, also has fluorescence emission in SWIR regime. Images of ICG in small animals acquired by commercial Si-based and InGaAs-based imaging cameras have been qualitatively compared, however the lack of working standards to quantify performance of these imaging systems limits quantitative comparison. Without quantification using a traceable in vitro test, clinical adoption of rapidly evolving advances in both NIRF and SWIR imaging devices will become limited. In this work, we developed an ICG based fluorescent solid working standard calibrated with SI units (mW [Formula: see text]cm [Formula: see text]sr -1 ) for quantification of measurement sensitivity of Si, GaAs-intensified Si, and InGaAs based camera systems, their signal-to-noise ratio (SNR), and contrast in non-clinical tests. In addition, we present small animal and large animal imaging with ICG for qualitative comparison of the same SWIR fluorescence and NIRF imaging systems. Results suggest that SWIR fluorescence imaging of ICG may have superior resolution in small animal imaging compared to NIRF imaging, but lack of measurement sensitivity, SNR, contrast, as well as water absorption limits deep penetration in large animals.

Near-infrared fluorescence (NIRF) molecular imaging holds great promise as a new "point-of-care" medical imaging modality that can potentially provide the sensitivity of nuclear medicine techniques, but without the radioactivity that can otherwise place limitations of usage. Recently, NIRF imaging devices of a variety of designs have emerged in the market and in investigational clinical studies using indocyanine green (ICG) as a non-targeting NIRF contrast agent to demark the blood and lymphatic vasculatures both non-invasively and intraoperatively. Approved in the USA since 1956 for intravenous administration, ICG has been more recently used off label in intradermal or subcutaneous administrations for fluorescence imaging of the lymphatic vasculature and lymph nodes. Herein, we summarize the devices of a variety of designs, summarize their performance in lymphatic imaging in a tabular format and comment on necessary efforts to develop standards for device performance to compare and use these emerging devices in future, NIRF molecular imaging studies.

Purpose: Wide-field surgical excision reduces the chance of residual disease, but can also lead to disfigurement and devastating morbidities when resection is close to critical structures. We hypothesize that near-infrared fluorescence (NIRF) imaging can enable accurate detection of tumor margins for image-guided resection., Experimental Design: An orthotopic model of human prostate cancer (PCa) was used to assess primary tumor margins using a NIRF-labeled antibody against epithelial cell adhesion molecule (EpCAM). PCa cells stably expressing far red fluorescent gene reporter, iRFP, enabled colocalization with NIRF signals for direct assessment of tumor margins., Results: Using receiver operating characteristic analysis, far red fluorescence was validated against standard pathology of primary and metastatic lesions with >96 % accuracy. Primary tumor margins were more accurately detected by quantitative NIRF imaging using the EpCAM-targeting antibody as compared to a NIRF-labeled isotype control antibody., Conclusions: NIRF molecular imaging may enable real-time and accurate assessment of tumor margins.

Molecular imaging is used for the detection of biochemical processes through the development of target-specific contrast agents. Separately, modalities such as nuclear and near-infrared fluorescence (NIRF) imaging have been shown to non-invasively monitor disease. More recently, merging of these modalities has shown promise owing to their comparable detection sensitivity and benefited from the development of dual-labeled imaging agents. Dual-labeled agents hold promise for whole-body and intraoperative imaging and could bridge the gap between surgical planning and image-guided resection with a single, molecularly targeted agent. In this review, we summarized the literature for dual-labeled antibodies and peptides that have been developed and have highlighted key considerations for incorporating NIRF dyes into nuclear labeling strategies. We also summarized our findings on several commercially available NIRF dyes and offer perspectives for developing a toolkit to select the optimal NIRF dye and radiometal combination for multimodality imaging.

Purpose: The aim of this study was to develop and characterize a novel peptide imaging agent for noninvasive near-infrared fluorescence imaging of protein transport by the lymphatics. An imaging agent consisting of a cyclic albumin-binding domain (cABD) peptide, with sequence, Arg-Leu-Ile-Glu-Asp-Ile-Cys-Leu-Pro-Arg-Trp-Gly-Cys-Leu-Trp-Glu-Asp-Asp-Lys, was conjugated to a near-infrared fluorophore, IRDye800CW, allowing for enhanced vascular uptake, retention, and fluorescence imaging., Procedure: Characterization of the cABD-IRDye800 peptide conjugate was performed using fluorescence spectroscopy to assess optical properties and SDS-PAGE and Biacore binding assays to determine binding affinity and specificity. Fluorescence imaging of normal C57BL/6 mice was conducted to monitor lymphatic uptake and retention., Results: cABD-IRDye800 exhibited approximately six times greater fluorescent yield and greater stability than indocyanine green, an agent previously used in humans to image lymphatic vasculature. The agent exhibited affinity for albumin with IC(50) and Kd in the nanomolar range and demonstrated superior retention characteristics within mouse lymphatics when compared with IRDye800CW., Conclusions: cABD-IRDye800 has utility for assessing lymphatic function in mouse models of human lymphatic disease and the potential for use in clinical diagnostic imaging of the lymphatic vasculature.

Prior to imaging agent use in preclinical studies and clinical diagnostics, biological activity must be validated. The Lindmo assay has been used conventionally to quantify radiolabeled antibody (Ab) immunoreactivity, although published findings suggest it does not provide consistently accurate results. We developed and tested a near-infrared (NIR) flow cytometry (FC) method for quantifying biological activity of a dual-labeled Ab for use as a multimodal contrast agent in small animal and human positron emission tomography and NIR fluorescence imaging. Antibody specific for epithelial cell adhesion molecule was conjugated to DOTA-NHS-ester, labeled with IRDye 800CW and further labeled with (64)Cu or nonradioactive Cu prior to reacting with human prostate cancer cells for testing by the Lindmo or FC method, respectively. Immunoreactivity of the dual-labeled agent was found to be 76.4 ± 15.7% by the Lindmo assay. When tested with and without Cu labeling using NIR FC, the biological activity was found to be 73.1 ± 7.7 and 79.4 ± 8.1%, respectively. No significant differences were found between these activity levels (p > 0.05), supporting NIR FC as an alternative method for measuring immunoreactivity and demonstrating that Cu labeling does not significantly affect the agent's ability to bind to its target. Biological activity was significantly reduced when the NIR dye-to-protein ratio was increased 3- to 4-fold in agent preparations when tested by FC and the Lindmo assay. In summary, NIR FC is an alternative with similar specificity and sensitivity, and greater reproducibility relative to the Lindmo assay for quantifying biological activity of NIR fluorophore-labeled, multimodal imaging agents., (Copyright © 2012 John Wiley & Sons, Ltd.)

Technical developments in near-infrared fluorescence (NIRF) imaging and tomography have enabled recent translation into investigational human studies. Noninvasive imaging of the lymphatic vasculature for diagnosis and assessment of function has been uniquely accomplished with NIR using indocyanine green (ICG), a nonspecific dye that has comparatively poor fluorescent properties compared to emerging dyes. Adjunct use of NIRF-ICG for (a) intraoperative sentinel lymph node mapping for cancer staging, (b) video-angiography during surgery, and (c) discrimination of malignant from benign breast lesions detected by mammography and ultrasongraphy also evidences the clinical utility of NIRF. Future NIRF imaging agents that consist of bright fluorescent dyes conjugated to disease-targeting moieties promise molecular imaging and image-guided surgery. In this review, emerging NIRF imaging is described within the context of nuclear imaging technologies that remain the "gold standard" of molecular imaging.

Background: After intravenous (i.v.) administration, indocyanine green (ICG) is known to be secreted into bile from the liver via the biliary tracts, enabling fluorescent delineation of the intestine. In addition, ICG is a near-infrared (NIR) excitable fluorophore, capable of providing exogenous contrast for rapid NIR fluorescence imaging. We sought to quantify the intestinal motility using dynamic NIR fluorescence imaging after injection of ICG., Methods: C57BL6 mice were dynamically imaged immediately before and up to 24h after i.v. and intradermal (i.d.) injection of 50 and 10μL of ICG, respectively. Necropsy was also performed 1h postinjection and the entire gastrointestinal tract was isolated and exposed for ex vivo fluorescence imaging., Key Results: The secretion of ICG-laden fluorescent bile into the duodenum was observed in vivo and confirmed in situ. Different patterns of the intestinal motility, such as peristaltic and segmental motions, were dynamically imaged in vivo. Our imaging data showed that the frequency of contractions ranged from 27 to 35cyclesmin(-1) and the propagation velocity of peristaltic waves ranged from 0.82±0.5 to 2.04±1.12cms(-1) ., Conclusions & Inferences: Dynamic NIR fluorescence imaging with injection of ICG can provide a method for diagnostic motility testing for intestinal motility disorders or dysfunction and for potential evaluation of therapeutic agents., (© 2011 Blackwell Publishing Ltd.)

Purpose: Fluorescence-enhanced optical imaging using near-infrared (NIR) light developed for in vivo molecular targeting and reporting of various diseases provides promising opportunities for diagnostic imaging. However, the measurement sensitivity of NIR fluorescence (NIRF) optical imaging systems is limited by the leakage of the strong backscattered excitation light through rejection filters. In this article, the authors present a systematic method for improving sensitivity and validating the NIRF optical imager currently used for clinical imaging of human lymphatic function., Methods: The proposed systemic method consists of an appropriate filter combination and a collimation optics adapted to an NIRF optical imager. The spectral contributions were first assessed due to the excitation light backscattered from the tissue and from non-normal-incidence of the excitation light on the optical filters used in the authors' NIRF clinical imaging system. Then two tests were conducted to assess the system with and without the components of appropriate filters combination and collimation optics using: (1) a phantom to evaluate excitation light leakage as a function of target depth and (2) deployment in an actual human study., Results: The phantom studies demonstrate as much as two to three orders of magnitude reduction in the transmission ratio, indicating that the excitation light leakage can be reduced upon using the appropriate filter combination and collimation optics while an in vivo investigatory human study confirms improved imaging., Conclusions: The method for reducing the excitation light leakage is presented for validating collected signals for fluorescence imaging.

While the lymphatic system is increasingly associated with diseases of prevalence, study of these diseases is difficult owing to the paucity of imaging techniques with the sensitivity and temporal resolution to discriminate lymphatic function. Herein, we review the known, pertinent features of the human lymphatic system in health and disease and set the context for a number of emerging studies that use near-infrared fluorescence imaging to non-invasively assess tumor draining lymphatic basins in cancer patients, intraoperatively guide resection of first draining lymph nodes, and to interrogate the difference between normal and aberrant lymphatic structure and function.

We compare and contrast the development of optical molecular imaging techniques with nuclear medicine with a didactic emphasis for initiating readers into the field of molecular imaging. The nuclear imaging techniques of gamma scintigraphy, single-photon emission computed tomography, and positron emission tomography are first briefly reviewed. The molecular optical imaging techniques of bioluminescence and fluorescence using gene reporter/probes and gene reporters are described prior to introducing the governing factors of autofluorescence and excitation light leakage. The use of dual-labeled, near-infrared excitable and radio-labeled agents are described with comparative measurements between planar fluorescence and nuclear molecular imaging. The concept of time-independent and -dependent measurements is described with emphasis on integrating time-dependent measurements made in the frequency domain for 3-D tomography. Finally, we comment on the challenges and progress for translating near-infrared (NIR) molecular imaging agents for personalized medicine.

Functional lymphatic imaging was demonstrated in the abdomen and anterior hindlimb of anesthetized, intact Yorkshire swine by using near-infrared (NIR) fluorescence imaging following intradermal administration of 100-200 microl of 32 microM indocyanine green (ICG) and 64 microM hyaluronan NIR imaging conjugate to target the lymph vascular endothelial receptor (LYVE)-1 on the lymph endothelium. NIR fluorescence imaging employed illumination of 780 nm excitation light ( approximately 2 mW/cm(2)) and collection of 830 nm fluorescence generated from the imaging agents. Our results show the ability to image the immediate trafficking of ICG from the plexus, through the vessels and lymphangions, and to the superficial mammary, subiliac, and middle iliac lymph nodes, which were located as deep as 3 cm beneath the tissue surface. "Packets" of ICG-transited lymph vessels of 2-16 cm length propelled at frequencies of 0.5-3.3 pulses/min and velocities of 0.23-0.75 cm/s. Lymph propulsion was independent of respiration rate. In the case of the hyaluronan imaging agent, lymph propulsion was absent as the dye progressed immediately through the plexus and stained the lymph vessels and nodes. Lymph imaging required 5.0 and 11.9 microg of ICG and hyaluronan conjugate, respectively. Our results suggest that microgram quantities of NIR optical imaging agents and their conjugates have a potential to image lymph function in patients suffering from lymph-related disorders.

Fluorescence frequency-domain photon migration measurements were acquired from tissue phantoms, each containing a fluorescent target, by means of area illumination and area detection on the same surface and for the first time, to our knowledge, compared with predictions computed with a numerical solution to the coupled photon diffusion equations. We accomplished area illumination and area detection using a planar, intensity-modulated excitation light source and a gain-modulated intensified charge-coupled device camera, respectively. A 1-ml vessel containing 1-microm solution of Indocyanine Green in 1% Liposyn was immersed 1 cm deep in each 512-ml tissue phantom. For most tissue phantoms, the background surrounding the 1-ml target was composed of Liposyn solution containing Indocyanine Green or 3,3'-Diethylthiatricarbocyanine Iodide such that the target-to-background ratio of fluorescence yield was > or = 10:1. Measurements of fluorescence modulation amplitude and phase were predicted with a mean error ranging from 10.1% to 13.6% and 0.56 degrees to 1.72 degrees, respectively. These numbers are similar to those obtained by use of single-pixel frequency-domain photon migration techniques and validate the potential use of area illumination and area detection for biomedical imaging of tissues. Results also demonstrate that target-to-background ratios of fluorescence yield and fluorescence lifetime significantly affect target detectability.

A three-dimensional image reconstruction for fluorescence-enhanced frequency-domain photon migration (FDPM) measurements in turbid media is developed and investigated for three different simulated measurement types: 1) absolute emission measurement, or emission measurements of phase and amplitude attenuation made for a given incident point source of excitation light; 2) referenced emission measurements made relative to an excitation measurement conducted at a single reference point away from the incident source; and 3) referenced emission measurements made relative to the excitation measurement conducted at identical points of detection. The image reconstruction algorithm employs a gradient-based constrained truncated Newton (CONTN) method which implements a bounding parameter, which can be used to govern the level of contrast used to discriminate tissue volumes from heterogeneous background tissues. Reverse differentiation technique is used to calculate the gradients. Using simulated data with superimposed noise to achieve a signal-to-noise ratio of 55 and 35 dB to mimic experimental excitation and emission FDPM measurements, respectively, we show the robustness of emission measurements referenced to excitation light. We investigate the performance of algorithm CONTN using these measurement techniques and show that the absorption coefficients due to fluorophore are reconstructed by CONTN accurately and efficiently. Furthermore, we demonstrate the performance of the bounding parameter for rejection of background artifacts owing to background tissue heterogeneity.

Fluorescence frequency-domain photon migration (FDPM) through tissue refers to the propagation of intensity-modulated fluorescent light that originates from tissue-laden fluorophores following illumination with an intensity-modulated excitation light source. FDPM measurements of modulation amplitude and phase are ultimately employed in an inversion algorithm for tomographic reconstruction of interior optical and fluorescent property maps that delineate disease enhanced with fluorescent contrast agent. Because the inverse problem is underdetermined, measurement precision and accuracy crucially impact its solution. Reported here are the precision and accuracy of FDPM measurements acquired using an intensified CCD homodyne detection system. By introducing 32 phase delays between the oscillators used to modulate the intensifier gain and light source intensity at 100 MHz, mean precision is maximized at +/-0.46% and +/-0.26 deg for measurements of modulation amplitude and phase, respectively. Measurement precision improves when the number of phase delays increases. Measurements of fluorescence modulation amplitude and phase, acquired from the surface of a tissue phantom at distances ranging between 0.71 and 3.6 cm from an incident excitation point source, exhibit a mean accuracy of 17% and 1.9 deg, respectively. Measurement accuracy deteriorates with increasing distance from the point source, but for distances up to 1.0 cm from the point source, measurements of fluorescence modulation amplitude and phase exhibit a mean accuracy of 5.4% and 0.30 deg, respectively., (Copyright 2003 Society of Photo-Optical Instrumentation Engineers)

The advent of recent advances in near-infrared laser diodes and fast electro-optic detection has spawned a new research field of diagnostic spectroscopy and imaging based on targeting and reporting exogenous fluorescent agents. This review seeks to concisely address the physics, instrumentation, advancements in tomography, and near-infrared fluorescent contrast agent development that promises selective and specific molecular targeting of diseased tissues. As an example of one area of the field, recent work focusing on pharmacokinetic analysis of fluorophores targeting the epidermal growth factor receptor (EGFR) is presented in a human breast cancer xenograft mouse model to demonstrate specificity of molecularly targeted contrast agents. Finally, a critical evaluation of the limitations and the opportunities for future translation of fluorescence-enhanced optical imaging of deep tissues is presented.

The deep tissue propagation of near-infrared (NIR) light between 700-900 nm offers new opportunities for diagnostic imaging when employing sensitive detection techniques and NIR excitable fluorescent agents that target and report disease and metabolism. Herein, we highlight approaches for illuminating tissues and monitoring the re-emitted fluorescence for tomographic reconstruction, strategies for developing fluorescent dye constructs, and clinical opportunities for fluorescence-enhanced NIR optical imaging.

The use of near-infrared (NIR) light to interrogate deep tissues has enormous potential for molecular-based imaging when coupled with NIR excitable dyes. More than a decade has now passed since the initial proposals for NIR optical tomography for breast cancer screening using time-dependent measurements of light propagation in the breast. Much accomplishment in the development of optical mammography has been demonstrated, most recently in the application of time-domain, frequency-domain, and continuous-wave measurements that depend on endogenous contrast owing to angiogenesis and increased hemoglobin absorbance for contrast. Although exciting and promising, the necessity of angiogenesis-mediated absorption contrast for diagnostic optical mammography minimizes the potential for using NIR techniques to assess sentinel lymph node staging, metastatic spread, and multifocality of breast disease, among other applications. In this review, we summarize the progress made in the development of optical mammography, and focus on the emerging work underway in the use of diagnostic contrast agents for the molecular-based, diagnostic imaging of breast.