Patent Publication Number: US-2018028692-A1

Title: Hypoosmotic Solutions for Lymph Node Detection

Description:
RELATED APPLICATIONS 
     This application is a divisional of U.S. patent application Ser. No. 14/202,178, filed on Mar. 10, 2014, which claims priority to U.S. Provisional Patent Application 61/775,780 filed Mar. 11, 2013, the entire contents of each of which are herein incorporated by reference. 
    
    
     FIELD OF THE INVENTION 
     The invention relates to the field of medical diagnostics in general and diagnostic methods and devices for locating tissue for surgical excision. 
     BACKGROUND 
     Approximately 1.25 million new cases of breast cancer are diagnosed each year. In a majority of these cases, there is an urgent need for surgery to remove the tumor and to excise the sentinel lymph nodes and inspect them histologically to determine whether the cancer has spread to other sites in the body. The sentinel lymph nodes are the first nodes to receive lymphatic drainage from the tumor. They are called this because they reliably alert the clinician to any cancer spread. A sentinel lymph node biopsy is a standard of care in breast cancer operations today. 
     Locating sentinel nodes during surgery is difficult. One method for locating the sentinel node is to inject a dark blue dye into the lymphatic system in the breast. The dye then disperses throughout the breast lymphatic system and the surgeon removes any colored nodes. This method is recognized as being error-prone. 
     An improved method involves injecting a radioactive dye into the lymph nodes. In a similar manner, the dye drains through the lymphatic system and the surgeon then uses a radiation detector to help locate the sentinel nodes. However, the use of radioisotopes presents a significant, and an expensive, logistical burden, because of the need to allocate the time and resources of a nuclear medicine radiologist in addition to the surgeon for what is otherwise a routine operation. Further, many patients are reluctant to receive a radioactive injection. These factors can become a significant barrier to the use of radioisotopes to locate the sentinel nodes. 
     A further improved method involved injecting suspensions of magnetic particles into the lymph nodes and waiting for the magnetic particles to drain though the lymphatic system. The particles are then detected using a magnetometer, which reveals the location of the lymph nodes. See US2011/0133730. Prior art solutions, such as Sienna+®, have a very low osmolality of about 30 mOsm/kg. Sienna+® is an aqueous solution of maghemite nanoparticles coated in carboxydextran, having an iron concentration of about 25.5 to 29.5 mg/mL. It takes about 30 minutes for the magnetic particles in a Sienna+® injection to drain sufficiently through the lymphatic system to ensure accurate lymph node detection, which can potentially cause significant and costly downtime during surgical procedures. Consequently, impatient physicians may attempt to detect the lymph nodes too soon—i.e., before the magnetic particles have sufficiently drained through the lymphatic system—which could result in incomplete lymph node detection. 
     A need therefore exists for compositions that enable more efficient procedures. 
     The present invention addresses this need. 
     SUMMARY OF THE INVENTION 
     The invention relates to a hypoosmotic suspension for medical injection. In one embodiment, the composition includes about 13 mg/mL to about 200 mg/mL of magnetic particles, and an osmolyte from either about 0.01% w/v to about 0.6% w/v of an inorganic salt (e.g., sodium chloride) or about 0.5% w/v to about 1.5% w/v of a glycol. 
     Embodiments of the hypoosmotic suspensions can include one or more of the following features: 
     The magnetic particles can be iron oxide particles, such as superparamagetic iron oxide particles (e.g., maghemite). 
     The magnetic particles can be coated, such as with dextran (e.g. carboxydextran). 
     The suspensions can have about 13 mg/mL of magnetic particles, about 28 mg/mL of magnetic particles, 56 mg/ml of magnetic particles, 100 mg/ml of magnetic particles, 140 mg/ml of magnetic particles or about 200 mg/mL of magnetic particles. 
     The suspension can have an osmolality of about 80 mOsm/kg to about 160 mOsm/kg. 
     The suspension can include an excipient. 
     The inorganic salt can be present in the amount of about 0.01% w/v-0.6% w/v , about 0.05% w/v-0.3% w/v, about 0.1% w/v-0.3% w/v, less than about 0.6% w/v or about less than about 0.3% w/v. 
     The invention also provides a method of locating a lymph node in a patient (e.g., a human). The method includes the steps of: providing a hypoosmotic suspension; injecting the hypoosmotic suspension into the patient; waiting until the magnetic particles become entrapped in a lymph node; and detecting the location of the lymph node by detecting the location of the magnetic particles. 
     The method can include one or more of the following features: 
     The method can include injecting 0.2 mL of hypoosmotic suspension, 0.4 mL of hypoosmotic suspension, or 0.8 mL of hypoosmotic suspension into the patient. 
     The detecting can be performed using a magnetometer. 
     The invention also provides a method of rapidly locating a lymph node in a patient (e.g., a human). The method can include the steps of: providing a hypoosmotic suspension comprising magnetic particles; injecting the hypoosmotic suspension into the patient; and detecting a lymph node within 10 minutes, or within as little as 5 minutes, of injection by detecting the location of the magnetic particles, the detecting sufficient to immediately begin a medical procedure on the lymph node based on the detecting. 
     The invention also provides a method of treating a patient using magnetic hyperthermia, the method comprising the steps of: providing the hypoosmotic suspension; injecting the hypoosmotic suspension into the patient; and exposing the patient to an alternating magnetic field. 
    
    
     
       BRIEF DESCRIPTION OF DRAWINGS 
       The figures are not necessarily to scale, emphasis instead generally being placed upon illustrative principles. The figures are to be considered illustrative in all aspects and are not intended to limit the invention, the scope of which is defined only by the claims. 
         FIG. 1 . SentiMag® magnetometer measurements (Abs Unit) at the lymph gland for various salt-based hypoosmotic solutions. Results presented as mean±SEM from 0 to 2 h, n=3. 
         FIG. 2 . SentiMag® magnetometer measurements (Abs Unit) at the lymph node for various salt- and non-salt-based hypoosmotic solutions. Results presented as mean ±SEM from 0 to 120 min, n=3. 
     
    
    
     DETAILED DESCRIPTION 
     The invention relates in part to the discovery of compositions useful for rapid detection of lymph nodes in patients. These compositions include suspensions of magnetic particles in a hypoosmotic solution. The osmolality of the hypoosmotic solutions facilitates rapid drainage or transport of the magnetic particles through the lymphatic system after injection, thereby reducing downtime between initial injection and lymph node detection. Lymph nodes adjacent the injection site can be detected robustly in as little as 5 to 15 minutes after initial injection, which is at least 50% faster than current methods, thereby permitting more efficient pre-operative examination. In addition, the hypoosmotic solutions of the invention are versatile solvents and can be used with a wider range of excipients than isotonic or hypertonic solutions. Furthermore, rapid movement to the lymph nodes may reduce residual marking, or tattooing, at the site of injection. 
     Hypoosmotic solutions within the meaning of the invention are aqueous solutions having an osmolality of about 80 mOsm to about 160 mOsm. Isotonic solutions have an osmolaltiy of around 300 mOsm, and Hyperosmotic solutions have an osmolaltiy of greater than 350 mOsm. 
     In preferred embodiments, an inorganic salt (e.g., sodium chloride) or a glycol (e.g., propylene glycol) is used to create the hypoosmotic solution. Inorganic salt solutions (e.g., sodium chloride) having about 0.01% w/v to about 0.6% w/v of a salt yield suitable hypoosomotic solutions for use with the invention. Glycol solutions (e.g., propylene glycol) having about 0.5% w/v to about 1.5% w/v of a glycol yield suitable hypoosomotic solutions for use with the invention. 
     Hypoosmotic solutions can be made using suitable inorganic salts including, for example, monovalent and divalent salts such as sodium chloride, potassium chloride, magnesium chloride, ammonium chloride, sodium bicarbonate, sodium bisulfate, sodium sulfate, ammonium sulfate, sodium phosphate, potassium phosphate, calcium chloride, magnesium sulfate, potassium acetate, and sodium acetate. 
     Hypoosmotic solutions can be made using suitable glycols including, for example, short chain, linear or branched alkyl glycols, such as propylene glycol. 
     The magnetic particles can be composed of a suitable magnetic material and one or more coatings. In some embodiments, the magnetic particles contain an iron oxide such as magnetite and/or maghemite. The magnetic core can be surrounded by a biocompatible coating to reduce toxicity, prevent agglomeration of the particles, or to modify residence time in the body. Suitable coatings include, for example, dextran, carboxydextran, other sugars, albumin, polyethylene glycol (PEG), biocompatible polymers, pegylated starch, polyvinyl alcohol (PVA), polyvinylpyrrolidone (PVP), polyethyleneimine (PEI), polyglucose sorbitol carboxymethylether and chitosan. Other coating materials include metals such as gold, pegylated colloidal gold nanoparticles, silver, carbon, silica, silicones, aminosilanes and ceramics. To exhibit superparamagnetic behavior, the magnetic cores of the particles should be below a certain diameter, typically in the range 3-25 nm, depending on the material and structure. 
     Magnetic particles can also be functionalized to allow them to localize in particular tissue or cell types, for example cancerous cells, or to target particular biological systems in order to deliver therapies to those areas. Functionalization is achieved by attaching or coating with biovectors comprising, for example, antibodies, enzymes or proteins. 
     In one embodiment, iron oxide is used as the magnetic core because of its low toxicity, but other materials that can form a superparamagnetic core also are acceptable. The core material should be capable of being magnetically ordered. It may be a metal, such as cobalt, iron, or nickel, a metal alloy, rare earth and transition metal alloy, M-type or spinel ferrite containing aluminium, barium, bismuth, cerium, chromium, cobalt, copper, dysprosium, erbium, europium, gadolinium, holmium, iron, lanthanum, lutetium, manganese, molybdenum, neodymium, nickel, niobium, palladium, platinum, praseodymium, promethium, samarium, strontium, terbium, thulium, titanium, vanadium, ytterbium, and yttrium or a mixture thereof. The core can also be formed by oxidising a combination of an iron(II) salt and another metal salt. The metal salts which are beneficial include salts of aluminium, barium, bismuth, cerium, chromium, cobalt, copper, dysprosium, erbium, europium, gadolinium, holmium, iron, lanthanum, lutetium, manganese, molybdenum, neodymium, nickel, niobium, palladium, platinum, praseodymium, promethium, samarium, strontium, terbium, thulium, titanium, vanadium, ytterbium, and yttrium. 
     The osmolality of the hypoosmotic solutions have the further advantage of permitting combination with a wide range of excipients, resulting in diverse formulation options. Suitable excipients that can be used with the hypoosmotic solutions of the invention include, for example:
         co-solvents such as ethanol, propylene glycol, polypropylene glycol, PEG 400, glycerol, benzyl alcohol, and combinations thereof;   oils such as lipids, liquid paraffin, sesame oil, PEG vegetable oil, and combinations thereof; surfactants such as polyoxylene fatty acid esters, polyoxyl 40 castor oil, polysorbate 20, polysorbate 80, and combinations thereof;   liposomes such as lecithin, egg lecithin, phosphatidyl glycerol, phospholipid, egg phospholipid, and combinations thereof;   carbohydrates such as dextrose;   amino acids or amino acid mixtures, such as Aminosyn® II, Travasol®, and HepatAmine®;   thickening/stabilizing agents such as carboxymethylcellulose; and   buffers suitable for injection.
 
If an excipient increases the osmolality of a solution, the amount of inorganic salt and/or glycol can be adjusted such that the total osmolality of the hypoosmotic solution is between about 80 mOsm and about 160 mOsm.
       

     The compositions of the invention can be used to detect lymph nodes in humans or any other mammal, such as pigs. For example, a hypoosmotic solution comprising magnetic particles can be injected into a breast cancer patient. Magnetic particles in the solution are then detected using a magnetometer such as SentiMag® (Endomagnetics; Cambridge, U.K.) to reveal the location of the sentinel lymph nodes in the patient. 
     A further application of the hypoosmotic solution is in magnetic hyperthermia where the solution is administered to the body for the purpose of heating tissue. In this application the concentration of nanoparticles is between 20 and 200 mg/ml and more preferably between 100 and 140 mg/ml. 
     The hypoosmotic compositions of the invention can be supplied ready-to-use as part of a kit comprising a container, such as vial or syringe, and instructions for administering the compositions. 
     EXAMPLES 
     Example 1 
     Clinical trials with human patients using 2 ml Sienna+® (Endomagnetics; Cambridge, U.K.) was shown to give slow uptake in the axillary lymph nodes, with a poor external signal after 30 minutes. Sienna+® is highly hypotonic, with an osmolality of ˜30 mOsm/kg. It was speculated that when Sienna+® was injected into interstitial tissue, the surrounding cells rapidly absorbed water from the injection to maintain osmotic pressure. This would leave a more concentrated mass of Sienna+® while simultaneously reducing interstitial pressure, effectively reducing transport to the lymph system. It is believed that an increase in volume increases interstitial pressure and thereby increases the speed of uptake by the lymphatic system. However, large increases in volume might prove uncomfortable to the patient. In addition, some potential applications for sentinel lymph node biopsy (e.g., bowel, melanoma, some head and neck cancers) will not allow an increase in injection volume. It was hypothesized that an increased osmolality solution would provide a quicker response as the fluid volume and pressure in the interstitial fluid would be maintained (isotonic) or even increased (for hypertonic injection, where surrounding cells would expel water), thus increasing flow to the lymph nodes. 
     Methods 
     Pig mammaries were used as an in vivo lymph node model. An investigation was performed to assess the effects of concentration and volume of carboxydextran coated maghemite nanoparticle solution on the bio-distribution of superparamagnetic iron oxide particles in pigs, following an injection of the solution directly into the 3 rd  inguinal papillar. The maghemite core had a diameter of about 5 nm, and the carboxydextran coating increased particle diameter to about 60-70 nm. The aim of this study was to assess the bio-distribution of the superparamagnetic iron oxide particles in pig lymph nodes following injections of the maghemite nanoparticle solution prepared with 0.3, 0.6 and 0.9% w/v sodium chloride. The influence of tonicity upon lymph node bio-distribution of the particles was evaluated through use of a SentiMag® magnetic probe. 
     Prior to injection, pigs were sedated with an intramuscular combination of azaperone and ketamine, followed by general anesthesia with intravenous sodium thiopental. Before administration, the administration areas were washed and demarked. 
     All injections were made directly into the base of the 3rd inguinal papilla. Each pig received a different injection in the left papilla and the right papilla. Each of the test solutions was injected into three papilla of different pigs (n=3). Table 1 shows the tested formulations. In Table 1, the “System” column corresponds to the curves in  FIG. 1 . 
     
       
         
           
               
             
               
                 TABLE 1 
               
             
            
               
                   
               
               
                 Formulations tested. 
               
            
           
           
               
               
               
               
               
            
               
                   
                   
                   
                 Total  
                 Iron 
               
               
                 System 
                 Tonicity 
                 Injection Volume 
                 iron 
                 Concentration 
               
               
                   
               
               
                 a 
                 0.3% w/v saline 
                 0.4 mL 
                 10.4 mg 
                 26 mg/mL 
               
               
                 b 
                 0.6% w/v saline 
                 0.4 mL 
                 10.4 mg 
                 26 mg/mL 
               
               
                 c 
                 0.9% w/v saline 
                 0.4 mL 
                 10.4 mg 
                 26 mg/mL 
               
               
                 d 
                 0.9% w/v saline 
                 0.8 mL 
                 20.8 mg 
                 26 mg/mL 
               
               
                 e 
                 0 
                 0.2 mL 
                 10.4 mg 
                 52 mg/mL 
               
               
                 f 
                 0 
                 0.4 mL 
                 20.8 mg 
                 52 mg/mL 
               
               
                 g 
                 0 
                 0.4 mL 
                 10.4 mg 
                 26 mg/mL 
               
               
                   
                   
                 (Sienna + ®, control) 
                   
                   
               
               
                 h 
                 0 
                 0.8 mL 
                 10.4 mg 
                 13 mg/mL 
               
               
                   
               
            
           
         
       
     
     Carboxydextran coated maghemite nanoparticle solutions were prepared in water. NaCl was added to the maghemite solution to the appropriate concentration. For example, a 0.3% salt magnetic particle suspension was created by adding 0.3 mg of NaCl to a prediluted maghemite nanoparticle solution. Sienna+® (˜26 mg/mL maghemite, 0.4 mL dose; system g) served as the control. 
     Multiple readings were taken for each pig using an SentiMag® device, as detailed in Table 2. Following the 72 h readings, the site of papilla and lymph nodes were removed from all animals for histological analysis. The results in  FIG. 1  are averages (n=3) of the measurements taken at the lymph nodes. 
     
       
         
           
               
             
               
                 TABLE 2 
               
             
            
               
                   
               
               
                 SentiMag ® measurement sites and time points. 
               
            
           
           
               
               
               
               
            
               
                   
                   
                   
                 After injection 
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
               
            
               
                 Measurement 
                 Prior to 
                 30 
                 2 
                 5 
                 15 
                 30 
                 1 
                 2 
                 6 
                 24 
                 72 
               
               
                 location 
                 injection 
                 s 
                 min 
                 min 
                 min 
                 min 
                 h 
                 h 
                 h 
                 h 
                 h 
               
               
                   
               
               
                 Directly on papillar 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
               
               
                 2nd inguinal papillar 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
               
               
                 Lymph node 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
               
               
                   
               
            
           
         
       
     
     Results 
     Sienna+® in 0.3% w/v saline solution ( FIG. 1 , system a) was found to be as efficacious as both the 0.6% and 0.9% saline solutions ( FIG. 1 , systems b and c, respectively). This was surprising because a 0.3% w/v solution is hypotonic (156 mOsm) compared to 0.6% w/v (270 mOsm—approximately isotonic) and 0.9% w/v (384 mOsm—hypertonic). Such strong results for a 0.3% w/v solution are unexpected. It is believed that the low tonicity will extend the range of formulation additives (excipients) that can be used, as compared to 0.6% and 0.9% solutions. 
     Specifically, increasing tonicity results in significantly more rapid transport of iron particles through the lymphatic system. At 5 minutes post injection, the addition of 0.3%, 0.6%, and 0.9% salt to Sienna+® ( FIG. 1 , systems a, b, and c, respectively) result in a five-fold increase in signal measured at the lymph gland as compared to the control, Sienna+® ( FIG. 1 , system g). As a result, a treating physician need only wait 5-15 minutes before beginning a procedure, which reduces the wait time by at least 50% as compared to Sienna+® alone. 
     Furthermore, at the 30 minute time point, the impact of adding 0.3%, 0.6%, or 0.9% w/v sodium chloride to Sienna+® ( FIG. 1 , systems a, b and c, respectively) is equivalent to doubling the concentration of iron ( FIG. 1 , system f). Consequently, increasing tonicity requires less total iron be used per injection, thereby reducing costs and side effects. 
     Thus, a hypoosmotic &lt;0.6% NaCl solution and more preferably &lt;0.3% NaCl solution provides the same rapid transport to the lymph nodes as an isotonic (e.g. 0.6% NaCl) or even a hypotonic (e.g. 0.9% NaCl) solution but without requiring such a large amount of salt to be included in the solution. 
     A more hypotonic solution containing 0.05% w/v NaCl showed no significant improvement over Sienna+®. The “trigger-point” for tonicity benefit is therefore somewhere between about 80 mOsm and about 156 mOsm. Thus, a 0.05% to 0.3% NaCl solution or preferably a 0.1% to 0.3% NaCl solution, or more preferably a 0.2% to 0.3% NaCl solution exhibits both rapid uptake and versatility as an excipient. 
     Example 2 
     Similar in vivo pig studies were undertaken to investigate hypoosmotic solutions comprising alternative solutes. All injections were made directly into the base of the 3rd inguinal papilla. Each pig received a different injection in the left papilla and the right papilla. Each test solution was injected into the three papilla of different pigs (n=3). Table 3 shows the tested formulations. In Table 3, the “System” column corresponds to the curves in  FIG. 2 . 
     
       
         
           
               
             
               
                 TABLE 3 
               
             
            
               
                   
               
               
                 Solution formulations. 
               
            
           
           
               
               
               
            
               
                   
                   
                 Tonicity  
               
               
                 System 
                 Solution 
                 (mOsm/kg) 
               
               
                   
               
            
           
           
               
               
               
            
               
                 1 
                 Sienna + with 0.3% NaCl and 0.1% HA 
                 132 
               
               
                 3 
                 Sienna + with 0.3% NaCl and 1% polysorbate 20 
                 135 
               
               
                 5 
                 Sienna + with 0.5% propylene glycol 
                 128 
               
               
                 6 
                 Sienna + with 0.3% NaCl (control) 
                 126 
               
               
                 7 
                 Sienna + 0.75% glycerol 
                 136 
               
               
                 13 
                 Sienna + 0.5% propylene glycol and 1.8% glycerol 
                 297 
               
               
                   
               
            
           
         
       
     
     System 6, Sienna+® with 0.3% NaCL served as the control. Multiple readings were taken for each pig using a SentiMag® device, as detailed in Table 4. The results in  FIG. 2  are averages (n=3) of the measurements taken at the lymph nodes. 
     
       
         
           
               
             
               
                 TABLE 4 
               
             
            
               
                   
               
               
                 SentiMag ® measurement sites and time points. 
               
            
           
           
               
               
               
            
               
                 Measurement 
                 Prior to 
                 After injection 
               
            
           
           
               
               
               
               
               
               
               
               
               
               
            
               
                 location 
                 injection 
                 30 s 
                 2 min 
                 5 min 
                 15 min 
                 30 min 
                 1 h 
                 2 h 
                 72 h 
               
               
                   
               
               
                 Injection site 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
               
               
                 2nd inguinal papillar 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
               
               
                 Inguinal lymph node 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
                 x 
               
               
                   
               
            
           
         
       
     
     As shown in  FIG. 2 , system 6 (Sienna+0.3% NaCl—CONTROL) resulted in the fastest delivery to the lymph gland. Salt therefore appears to be the best potentiator for delivery. 0.5% polyethylene glycol (system 5) also appears to be efficacious, resulting in rapid delivery to the lymph gland within 5-15 minutes of injection. Accordingly, in some embodiments, glycols can be used as a solute to create a hypoosomotic solution comprising magnetic particles. 
     The polysorbate (system 3) and glycerol (system 7) formulations were the poorest performing formulations over the first two hours, despite the tonicity being equal to that of the NaCl control (system 6), indicating that polysorbate and glycerol potentially inhibit delivery to the lymph glands. Similarly, addition of hyaluronic acid (MW 108,000 Daltons) appears to retard delivery when combined with 0.3% NaCl. 
     It should be noted that the method of administration of the solution will depend on the particular site in the body at which it is being administered. For sentinel lymph node biopsy, the injection may be interstitial, sub-cutaneous, intradermal or intramuscular. For magnetic hyperthermia, the solution may be administered by any of these injection methods or via a catheter or infusion into a region of tissue, a body cavity, or vessel. 
     It should be understood that the order of steps or order for performing certain actions is immaterial, provided that the invention remains operable. Moreover, two or more steps or actions may be conducted simultaneously. 
     Where a range or list of values is provided, each intervening value between the upper and lower limits of that range or list of values is individually contemplated and is encompassed within the invention as if each value were specifically enumerated herein. In addition, smaller ranges between and including the upper and lower limits of a given range are contemplated and encompassed within the invention. The listing of exemplary values or ranges is not a disclaimer of other values or ranges between and including the upper and lower limits of a given range.