Title: iEndoscope: Colonoscopy Using Rapid Evaporative Ionization Mass Spectrometry (REIMS) for precision phenotyping of colonic adenomas and early colorectal cancer.
Funder: Department of Health and Social Care

Abstract: The research plan will be delivered across five parallel work packages. WP1 Instrument development: We will perform precision manufacturing in collaboration with our partners at Waters and Medwork. i) Snare and energy deployment &ndash; We will optimised the snare design and standard operating procedures for safe and efficient deployment using ex vivo synthetic simulators. ii) Aspiration of aerosol during colonoscopy: For the efficient analysis of tissue in the presence of fluid from the colon or endoscope we will develop a Venturi air-jet pump with momentum-selective capture of particles , eliminating direct contact between the patient and the mass spectrometer. We will create a device ready for clinical feasibility testing. WP2 Data collection and feasibility testing: 1. ex vivo analysis. A mass spectral database will be created by analysing over 300 biobanked specimens collected as part of our ongoing research activities. All polyps will be sent for H+E staining by an independent histopathologist and molecular phenotyping using the Cancer Hotspot Panel v2. 2. in vivo analysis: The device will be prospectively tested in 73 patients undergoing elective colonoscopy for endoscopic mucosal resection (EMR) for high-risk polyps (>1cm) with a primary endpoint of diagnostic accuracy for detecting dysplasia in adenomas. Endoscopists will be blinded to the data, and machine performance will be benchmarked against NBI and multispectral imaging techniques. We will perform feasibility testing to assess barriers to clinical trials, safety and patient recruitment and establish the diagnostic accuracy to power a prospective trial. WP3 Competitor analysis: 1. Systematic review of competing technologies: We have previously reviewed margin detection technologies in breast cancer, and this methodology will be adapted for use with endoscopy. 2: Multispectral imaging: Fresh ex vivo polyps analysed by the iEndoscope will undergo analysis using DRS and ESS to generate a comparative diagnostic sensitivity analysis. We will develop a novel probe that incorporates both REIMS and imaging analysis using DRS, ESS and Fluorescence spectroscopy for seamless in-vivo use during the prospective phase. 3. Narrow Band Imaging: The primary outcome measure will be diagnostic accuracy for dysplasia detection in adenomas. Clinical staff will undergo training to standardise analysis. A qualitative questionnaire will be given to staff to assess machine stability and performance. WP4 Data storage, processing, analysis and interpretation. Data will be curated using an SQL database on a dedicated, secure computer. Suitable data processing workflows will be developed, and will include mass recalibration, profile alignment and peak picking and normalisation protocols. The statistical integration of the mass spectra with clinical, histological and molecular metadata will be performed using various uni- and multi-variate statistical techniques such as canonical correlation and partial least squares analyses. This approach will identify associations between metabolites and clinical and molecular variables. Bayesian approaches will also be used to update the classification probabilities as more data becomes available throughout the length of the study. Determination of tissue classes and molecular subtypes will be performed using a panel of machine learning techniques with appropriate controls for leave-one-patient-out cross-validation to prevent over-fitting of statistical models. Data visualisation tools will be created. WP5 Economic analysis and service delivery: Foundational work will be performed as follows: 1) the development of a methodological framework for this and future research on the impact of the iEndoscope and imaging technology in endoscopy, encompassing cost-effectiveness and feasibility analysis. 2) A prospective health resource utilization study to estimate the comparative economic costs of existing techniques, which will be used to establish cost-benefit thresholds. 3). We will develop a business plan for appropriate development of the iEndoscope

Lay abstract: 41,000 cases of colon cancer are diagnosed in the UK each year and it s the third commonest cause of cancer deaths. Colonoscopy is a test where a doctor or a nurse looks at the inside of the bowel with a small camera on a long flexible tube, and it is the most effective diagnostic test for colon cancer. 4 in 10 patients screened by colonoscopy will have a polyp, which could be pre-cancerous. There are no gene indicators for diagnosing cancer within a polyp or for identifying the risk that a polyp may progress into cancer which can be used during a telescope test. This information could change how doctors treat polyps during endoscopy but they currently have to rely on a tissue sample and cell analysis, which take days. Additionally, during the removal of large polyps, abnormal tissue is left behind in up to 13% of cases, necessitating a further colonoscopy which is unpleasant for the patient. The iEndoscope improves the diagnostic accuracy of colonoscopy and the safety of polyp removal by analysing the chemical content of smoke generated from instruments used to remove polyps. The iEndoscope measures thousands of chemicals and gives doctors information immediately using a technique called mass spectrometry. It provides cell and chemical information on the type of polyp being examined instantly and it can ensure that no abnormal tissue is left behind during removal. This project will develop the iEndoscope to work safely and reliably so it can be used as a product within the NHS. We will compare the performance of the iEndoscope against competing imaging technologies used during colonoscopy for assessing polyps and assess if the iEndoscope is better for patient welfare. Finally we will calculate the potential costs and savings to the NHS to create a financial case for its adoption.

Research activity codes: 4.2 EVALUATION OF MARKERS AND TECHNOLOGIES;4.1 DISCOVERY AND PRECLINICAL TESTING OF MARKERS AND TECHNOLOGIES
Health categories: CANCER AND NEOPLASMS