Development and Validation of a Tumour Oxygenation Monitoring Probe
Conditions: Cancer
Sponsor: Imperial College London

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Development and Validation of a Tumour Oxygenation Monitoring Probe 
 
 
 
 
Version 1.0 21/03/2019 
 
 
 
 
MAIN SPONSOR: Imperial College London 
FUNDERS: Biomedical Research Centre 
STUDY COORDINATION CENTRE: Imperial College London 
 
IRAS Project ID: 264082 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Study Management Group 
 
Chief Investigator: Ara Darzi 
 
Co-investigators: Daniel Leff, Alexander Thompson, James Avery, Simon Dryden 
 
Statistician: Hutan Ashrafian 
 
Study Management: Simon Dryden 
 
 
Study Coordination Centre St Mary’s Hospital 
 
For general queries, supply of study documentation, and collection of data, please contact: 
 
Study Coordinator: Simon Dryden 
Address: 1092 QEQM St Mary’s Hospital London, W21NY 
Tel: 07828464949 
 
 
 
 
 
E-mail:  simon.dryden@imperial.ac.uk 
 
 
Clinical Queries 
 
Clinical queries should be directed to Simon Dryden who will direct the query to the appropriate 
person 
 
 
Sponsor 
 
Imperial College London is the main research Sponsor for this study.  For further information 
regarding the sponsorship conditions, please contact the Head of Regulatory Compliance at: 
 
Joint Research Compliance Office 
Imperial College London and Imperial College Healthcare NHS Trust 
Room 215, Level 2, Medical School Building 
Norfolk Place 
London, W2 1PG 
Tel: 0207 594 9459/ 0207 594 1862 
http://www3.imperial.ac.uk/clinicalresearchgovernanceoffice 
 
Funder 
 
Biomedical Research Centre 
 
This protocol describes the Development and Validation of a Tumour Oxygenation Monitoring 
Probe.  Every care was taken in its drafting, but corrections or amendments may be necessary. 
These will be circulated to investigators in the study.  Problems relating to this study should be 
referred, in the first instance, to the Chief Investigator. 
 
This study will adhere to the principles outlined in the UK Policy Frame Work for Health and Social 
Care Research. It will be conducted in compliance with the protocol, the Data Protection Act and 
other regulatory requirements as appropriate. 

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Table of Contents                                                              Page No 
Study Management Group 
 
 
 
 
2 
Glossary 
 
 
 
 
 
 
4 
Study Summary 
 
 
 
 
 
5 
1. Background 
 
 
 
 
 
6 
2. Study Objectives  
 
 
 
 
8 
3. Study Design 
 
 
 
 
 
8 
4. Participant Entry  
 
 
 
 
10 
5. Regulatory Issues  
 
 
 
 
10 
6. Study Management 
 
 
 
 
11 
7. Publication Policy  
 
 
 
 
11 
8. References 
 
 
 
 
 
11 

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GLOSSARY OF ABBREVIATIONS 
BOLD-MRI 
Blood Oxygen Level Dependant- Magnetic Resonance Image 
DICOM 
Digital Imaging Communications in Medicine 
DRS 
Diffuse Reflectance Spectroscopy 
ICHNT 
Imperial College NHS Trust 
HIF 
Hypoxia Inducible Factor 
pCR 
Pathological Complete Response 
PET-FDG 
Positron Emission Tomography - Fluorodeoxyglucose 
STL 
Standard Tessellation Language 
TAM 
Tumour Associated Macrophage 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
KEYWORDS 
Tumour, Oxygenation, Sensor, Diffuse Reflectance Spectroscopy 
 
 
 
 
 
 

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STUDY SUMMARY 
 
TITLE 
Development and Validation of a Tumour Oxygenation Monitoring Probe 
DESIGN 
Tumour oxygenation sensor validation using 3D-Printed tissue phantoms 
AIMS 
To design and validate a novel tumour oxygenation monitoring probe which may 
be used to monitor response to therapies in cancer, using 3D-printed phantoms 
OUTCOME MEASURES 
Correlation of sensor oxygenation measurements as compared to gold-standard 
oxygenation measurements in phantom tissue models 
POPULATION 
3D printed tissue phantoms, based upon breast and rectal cancer MRIs 
ELIGIBILITY 
20 Anonymised pre-treatment MRI scans for patients with locally advanced 
rectal cancer (10 scans) and breast cancer (10 scans) 
MRIs from patients younger than 18 years of age, or older than 99 years of age 
will be excluded. 
MRIs from patient who did not go on to receive neoadjuvant therapy will be 
excluded 
DURATION 
1 Year 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1. 
INTRODUCTION 
 
1.1 
BACKGROUND 
1.1.1 Tumour Oxygenation 
Tissue hypoxia is a common feature of most solid tumours. More than a just simple outstripping of 
vascular supply, tumour hypoxia results in complex interplay that affects malignant cellular 
function and the tumour microenvironment. Tumour hypoxia drives a selective pressure towards 
adaptations for increased cell survival and proliferation as well as angiogenesis. These 
adaptations are mediated primarily through the Hypoxia Inducible Factors (HIFs): transcription 
factors that respond to cellular hypoxia through expression of genes responsible for a diverse 
array of functions including inflammatory cell recruitment, angiogenesis and cell survival. Similarly, 
hypoxia alters the tumour microenvironment: necrosis attracts tumour associated macrophages 
(TAMs) and cancer associated fibroblasts, both of which are associated with increased mitogenic 
and metastatic potential. Angiogenesis in response to tumour hypoxia results in dysfunctional and 
permeable vessels that provide a route for metastasis. 
 
Tumour hypoxia is chemo- and radio-protective. A wealth of evidence has contributed to the 
development of the oxygen fixation hypothesis: an understanding that molecular oxygen is a 
necessary requirement for the mechanistic action of ionizing radiation. Oxygen is required for the 
generation of free radicals during ionization, and to establish breakages in DNA. Hypoxia is 
similarly associated with decreased responsiveness to chemotherapy: hypoxia induces changes 
which reduce susceptibility to DNA damage and induces cell cycle arrest, while localized 
hypoperfusion reduces chemotherapeutic delivery. 
 
Tumour hypoxia ultimately results in more aggressive tumours with increased metastatic potential 
and resistance to therapies. 
 
1.1.2 Current Methods of Tissue Oxygenation Monitoring 
The potential role for tissue oxygenation monitoring to assist in prognostication, guide treatment 
decisions and assess responses has driven the need for improved means of assessing tumour 
oxygenation. The ideal solution would provide accurate, quantitative and continuous assessment 
of tumour oxygenation, accounting for spatial variation within the tumour. 
 
Eppendorf electrodes provide direct and accurate measurements of tumour oxygenation. 
However, the invasive nature limits them to superficial tumours, and while providing quantitative 
assessment of tumour oxygenation, it does not provide a spatial representation of tumour 
oxygenation. 
 
Positron Emission Tomography with fluorodeoxyglucose (PET-FDG) or oxygen sensitizers such as 
Fluoromisonidazole or Copper-diacetylbis(4-methylthiosemicarbazonato) provides an indirect 
spatial representation of tumour oxygenation. It is, however, not quantitative and requires the 
administration of radioactive isotopes. 
 
Blood Oxygen Level Dependent Magnetic Resonance Imaging (BOLD-MRI) utilises differences in 
magnetic nature of oxy and deoxyhaemoglobin to provide an indirect assessment of tissue 
oxygenation. BOLD-MRI detailed spatial assessment of tumour tissue oxygenation without need 
for agents or isotopes. However, it only provides a snap-shot non-quantitative assessment of 
tumour oxygenation. 
 
1.1.3 Clinical Paradigms for Tumour Oxygenation Monitoring 

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Continuous tumour oxygenation assessment is likely to be a valuable adjunct in the management 
of many cancers. Two paradigms that demonstrate its potential include neoadjuvant 
chemoradiotherapy for locally advance rectal cancer, and neoadjuvant therapy for breast cancer. 
 
Rectal Cancer: 
The addition of neoadjuvant chemoradiotherapy to transanal mesorectal excision marked a 
significant advance in the management of locally advanced rectal cancer. 50.4 Gray of external 
beam radiotherapy given over 28 fractions in conjunction with chemotherapy reduces the risk of 
circumferential involvement at surgery and improves overall survival. However, the response rates 
are highly variable, and as low as 30%. The potential benefit is balanced significant costs, with 
18% of patients suffering from grade III/IV toxicities. Continuous oxygenation monitoring could 
provide a useful adjunct in the monitoring of neoadjuvant chemotherapy, potentially allowing for 
personalisation of management. 
 
Breast Cancer: 
Neoadjuvant therapy in breast cancer is used to reduce tumour size, which may convert 
inoperable tumours to operable ones, allow for breast conserving therapy, and in some cases 
result in a complete pathological response (pCR). Endocrine therapies, tyrosine kinase inhibitor, 
and chemotherapy are given alone, or in combination for up to 6 months before surgery. MRI is 
the preferred modality for assessing response to neoadjuvant therapy and surgical planning, 
particularly with regards to breast-conserving therapy. However, the diagnostic accuracy of MRI is 
only 70% and is particularly confounded in cancers with areas of fibrosis. Continuous tumour 
oxygenation monitoring has the potential to monitor response to neoadjuvant therapy for breast 
cancer and may provide a valuable adjunct in surgical planning. 
 
1.1.4 Tissue Oxygenation Monitoring Using Diffuse Reflectance Spectroscopy 
Diffuse reflectance spectroscopy can measure the oxygenation status tissue due to the differing 
absorbance profiles of oxygenated and deoxygenated haemoglobin (Figure 1A). DRS is well 
suited to oxygenation monitoring as it provides oxygenation measurements that are dynamic (real-
time), spatially accurate and quantifiable. Furthermore, it has the potential to be miniaturized into 
an implantable device. 
 
Figure 1: Optical absorbance of oxygenated and deoxygenated haemoglobin. 
 
 
1.1.5 A Novel Tumour Oxygenation Monitor using DRS 
Tumour oxygenation monitoring has the potential to provide valuable insights into tumour 
prognostication and management. The Institute for Global Health Innovation plans to develop an 
implantable tumour oxygenation sensor, providing a novel modality for tumour assessment and 

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monitoring. This research describes the development and validation of oxygenation sensing probe 
(Figure 2). Successful development and validation of the probe will be followed by future research 
to miniaturise and incorporate the technology into an implantable device. 
 
 
Figure 2: A tumour oxygenation monitoring probe using diffuse reflectance spectroscopy. 
 
 
1.2 
RATIONALE FOR CURRENT STUDY 
Overall Research Hypothesis: 
• 
Dynamic 
tumour 
oxygenation 
monitoring 
can 
predict 
treatment 
response 
in 
chemoradiotherapy for rectal and breast cancer. 
 
Current Research Hypothesis: 
• 
A novel-designed tumour oxygenation monitor, utilising diffuse reflectance spectroscopy, 
can provide accurate tissue oxygenation assessment in tumour phantom models. 
 
 
2.  STUDY OBJECTIVES 
 
Primary Objective: 
• 
To develop and validate a novel tumour oxygenation monitoring probe which may be used 
to monitor response to therapies in cancer, using 3D-printed phantoms. 
 
Secondary Objectives: 
• 
Define the correlation between sensor-derived oxygenation measurements and Gold-
standard measured oxygenation in 3D-printed tissue phantoms 
• 
Define the spatial resolution of the sensor oxygenation measurements 
 
3.  STUDY DESIGN 
 
3.1 Anonymised MRIs 
Anonymised MRIs representative of the chosen breast and rectal clinical paradigms will be used to 
ensure the generalisability of this research. 
 
MRI DICOM files will be provided by Imperial College NHS Trust Department (ICHNT) of 
Radiology. The raw DICOM files will be anonymised by the Department of Radiology prior to being 
received by the research team. The research team will never have access to identifiable 
information of the MRIs. The MRIs will be stored on a password protected encrypted hard drive. 
 

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10 Breast MRIs will be identified by Professor Deborah Cunningham (consultant radiologist 
specialising in breast malignancy at ICHNT) from previous breast multidisciplinary meetings. The 
MRIs will be segmented by Dr Simon Dryden (and verified by Prof Cunningham) using slicer 
(slicer.org) open-source software to delineate malignant tissue. 
 
10 Breast MRIs will be identified by Dr Lesley Honeyfield (consultant radiologist specialising in 
gastrointestinal malignancy at ICHNT) from previous GI multidisciplinary meetings. The MRIs will 
be segmented by Dr Simon Dryden (and verified by Prof Honeyfield) using slicer (slicer.org) open-
source software to delineate malignant tissue. 
 
3.2 TOAST++ Simulations 
The TOAST++ framework is software which models the diffuse light transport in tissue, which first 
requires a Finite Element Mesh of the target issue [8]. These meshes will be constructed based 
upon the requested anonymised MRI segmentations. Optical signals will be simulated for a variety 
of sensor/probe/implant designs for a range of tissue parameters, based on scattering and 
absorption values from the literature [9]. These simulations will be used to initially verify the extent 
of sensitive volume within the tumours, allowing for optimisation of the sensor-detector spacing. 
Then hypoxic regions will be simulated based on distributions from the literature and any potential 
candidates from the MRIs. These simulations will demonstrate the sensitivity of the sensor to 
changes in oxygenation.  
 
3.3 3D-Printing of Phantoms 
Prototype sensor designs will be verified in experiments using phantoms with realistic geometry, 
based on the same meshes of the MRI segmentations used simulations. The tissue phantoms will 
be 3D printed tissue phantoms will be produced according to the methodology described by 
Dempsey et al. First the tumour segmentations will be converted to 3D surfaces in standard 
tessellation language (STL) file format. The phantoms will be printed using a Formlabs 3D printer, 
using resin containing titanium oxide and near-infrared (NIR) dye (Projet 900NP) so as to mimic 
tissue absorption and scattering properties. 
 
3.4 Sensor Measurement Collection 
Measurements of oxygenation within the 3D printed phantoms will first be performed using a 
benchtop spectrometer to provide a “gold standard”. This benchtop system allows for 
measurements with a high spectral resolution over a broad spectral range, whereas the sensor by 
necessity is targeted at key wavelengths (Figure 1). The results of these experiments will assess 
the suitability of the sensor design for monitoring oxygenation in tumours.  
 
 

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Figure 3: Schematic demonstrating a 3D printed phantom, TOAST++ simulation, novel monitoring 
probe and future miniaturised device (left to right) 
 
 
3.5 Statistical Analysis 
The fraction of the volume of the tumour to which the sensor is sensitive will be expressed as a % 
of the total volume, and the fraction for each tumour will be expressed as a mean+SD summary 
statistic.  
 
4. 
PARTICIPANT ENTRY  
 
4.1 
INCLUSION CRITERIA 
10 Breast MRIs from patients identified from multidisciplinary team meeting (MDT) records who 
went on to have neoadjuvant chemo and hormonal therapy for locally advanced breast cancer. 
The MRIs will be anonymised by the care team before being made available to the research team. 
 
10 Rectal MRIs from patients identified from MDT records who went on to have neoadjuvant 
radiotherapy for locally advanced rectal cancer. The MRIs will be anonymised by the care team 
before being made available to the research team. 
 
4.2 
EXCLUSION CRITERIA 
MRIs from patients under the age of 18, or older than 99 years old will be excluded. 
 
MRIs from patients who did not receive neoadjuvant therapy for cancer will be excluded. 
 
5. 
REGULATORY ISSUES 
 
5.1 
ETHICS APPROVAL 
The Study Coordination Centre has obtained approval from the Health Regulator Authority (HRA). 
The study will be conducted in accordance with the recommendations for physicians involved in 
research on human subjects adopted by the 18th World Medical Assembly, Helsinki 1964 and 
later revisions. 
 
5.2 
CONFIDENTIALITY 
MRIs will be anonymised by the ICHNT Department of Radiology prior to transfer of data to the 
research team. The research team will never have access to personal identifiable information. 
 
The Chief Investigator will preserve the confidentiality of retrospective data used in the study and 
is registered under the Data Protection Act. 
 
5.3 
INDEMNITY 
Imperial College London holds negligent harm and non-negligent harm insurance policies which 
apply to this study. 
 
5.4 
SPONSOR 
Imperial College London will act as the main Sponsor for this study. 
 
5.5 
FUNDING 
The Biomedical Research Council are funding this study 
 

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5.6 
AUDITS  
The study may be subject to inspection and audit by Imperial College London under their remit as 
sponsor and other regulatory bodies to ensure adherence to GCP and the UK Policy Framework 
for Health and Social Care Research. 
 
 
6. 
STUDY MANAGEMENT 
 
The day-to-day management of the study will be co-ordinated by Dr Simon Dryden. 
 
 
 
 
7. 
PUBLICATION POLICY 
 
It is intended a peer-reviewed paper describing the development and validation of the tumour 
oxygenation sensor 
 
The peer reviewed paper will be published in line with Imperial College London’s open access 
policy. 
 
 
8. 
REFERENCES 
[1] Lindsey, I. Predicting response to chemoradiotherapy in rectal cancer: Are we there yet? Color. 
Dis. 15, 1199–1200 (2013). 
[2] Challapalli, A., Carroll, L. & Aboagye, E. O. Molecular mechanisms of hypoxia in cancer. Clin. 
Transl. Imaging 5, 225–253 (2017). 
[3] Sevick, E., Chance, B., Leigh, J., Nioka, S. & Maris, M. Quantitation of time- and frequency-
resolved optical spectra for the determination of tissue oxygenation. Anal. Biochem. 195, 330–351 
(1991). 
[4] Stratonnikov, A. A. & Loschenov, V. B. Evaluation of blood oxygen saturation in vivo from 
diffuse reflectance spectra. J. Biomed. Opt. 6, 457 (2001). 
[5] Reichelt, S. et al. Development of an implantable pulse oximeter. IEEE Trans. Biomed. Eng. 
55, 581–588 (2008). 
[6] Chen, C. M., Kwasnicki, R., Lo, B. & Yang, G. Z. Wearable tissue oxygenation monitoring 
sensor and a forearm vascular phantom design for data validation. Proc. - 11th Int. Conf. 
Wearable Implant. Body Sens. Networks, BSN 2014 64–68 (2014). doi:10.1109/BSN.2014.33 
[7] Schonle, P. et al. Towards an implantable telemetry system for SpO2 and PWV measurement 
in small animals. in 2017 IEEE Biomedical Circuits and Systems Conference (BioCAS) 1–4 (IEEE, 
2017) 
[8] Schweiger, M. & Arridge, S. The Toast++ software suite for forward and inverse modeling in 
optical tomography. J. Biomed. Opt. 19, 040801 (2014). 
[9] 
S. L. Jacques, “Optical properties of biological tissues: a review,” Physics in Medicine & 
Biology 58: R37-R61, (2013) 
[10] Dempsey, L. A., Persad, M., Powell, S., Chitnis, D. & Hebden, J. C. Geometrically complex 
3D-printed phantoms for diffuse optical imaging. Biomed. Opt. Express 8, 1754 (2017). 
[11] Anastasova, S., Kassanos, P. & Yang, G. Z. Multi-parametric rigid and flexible, low-cost, 
disposable sensing platforms for biomedical applications. Biosens. Bioelectron. 102, 668–675 
(2018).