Onco4D(TM) Biodynamic Chemotherapy Selection for Bladder Cancer Patients

STUDY RATIONALE: The demonstrated ability of MCT to accurately assess tumor xenografts may
establish it as a reliable technique for patient tumor stratification based on predicted
response to therapy, which could enable a treatment selection based on the personal needs of
an individual patient. This study is designed to assess MCT as an assay for predicting
chemosensitivity to treatment with chemotherapy agents routinely used in the neoadjuvant and
adjuvant treatment of bladder cancer. If positive, the results of this study will provide the
basis for expanded clinical trials and use of MCT in therapy selection.

BACKGROUND: Live cell imaging has become the standard for high-content analysis and drug
discovery applications. The most common assays on live cells include viability, proliferation
and cytotoxicity assays as cellular physiology and function are measured responding to
applied perturbations of xenobiotics. Cellular and tissue viability assays are typically
measured using exogenous vital dyes as biomarkers of membrane integrity or cellular metabolic
activity. However, dyes are invasive, potentially toxic, and often require fixing of the
tissue or permeabilization of the membranes. Furthermore, the common format of high content
analysis and flow cytometry requires isolated cells, or cells distributed on flat hard
surfaces. Isolated cells lack many of the biologically-relevant intercellular connections and
communications that are hallmarks of healthy tissue, and flattened cells on plates have
pathological shapes and anisotropic cellular adhesions.

Discovery of technology that can predict response to cancer therapy is an urgent priority.
While many technologies exist to evaluate early response to drugs ex vivo, the need to
perform viability, cytotoxicity and proliferation assays in three-dimensional tissue or
culture has become increasingly urgent, as drug response in 2D is often not the same as drug
response in biologically-relevant three dimensional culture. This is in part because genomic
profiles are not preserved in monolayer cultures. There have been several studies that have
tracked the expression of genes associated with cell survival, proliferation, differentiation
and resistance to therapy that are expressed differently in 2D cultures relative to
three-dimensional culture. For example, cell lines of epithelial ovarian cancer,
hepatocellular carcinoma, or colon cancer display expression profiles more like those from
tumor tissues when measured in three-dimensional culture, but not when grown in 2D. In
addition, the three-dimensional environment of 3D culture presents different pharmacokinetics
than 2D monolayer culture and produce differences in cancer drug sensitivities. Finally, most
current technologies rely on destructive end-point assessment, preventing meaningful
longitudinal observation of therapy response over time.

One of the main challenges to migrating drug-response assays to the third and fourth
dimensions has been to find a means to extract vital information from deep (up to a
millimeter) inside living tissue. Tissue is translucent and light can propagate diffusively
many centimeters. Furthermore, the dynamic motions of living cells cause dynamic light
scattering that produces phase fluctuations on the scattered light fields that can be
measured as dynamic speckle in diffusely reflected light from tissue. This is the basis of
diffusing wave spectroscopy (DWS) and diffusion correlation spectroscopy (DCS), but these
techniques lack depth resolution. A powerful tool in the characterization of light
propagation in tissues is the use of interferometry. Interferometric detection is the
underlying process in optical coherence tomography (OCT), which is a point-scanning technique
that suppresses speckle, although speckle decorrelation in OCT data can provide similar
information as provided by DCS. This has been used to measure intracellular rheology and to
find dynamic signatures of apoptosis. Transport also can be detected at cellular resolution
using phase contrast microscopy, but this approach cannot be used in thick tissues.

Dr. Nolte and colleagues have developed volumetrically-resolved tissue dynamic imaging that
uses the advantages of depth selectivity from low-coherence interferometry, combined with
high speckle contrast in broad-illumination digital holography. The technique is called
Motility Contrast Tomography (MCT) and uses low-coherence digital holography to penetrate up
to 1 millimeter into living tissue to measure speckle dynamics from light scattering from
dynamic motion in living cells. It was previously applied as a cytotoxicity assay to study
the efficacy of anti-mitotic drugs. In essence, the technology works by profiling the
'movement' of cellular organelles. Specific changes in organelle motion are detectable very
early in cells undergoing response to chemotherapy treatment, and may be usable as an early
predictor of chemotherapy response.

MCT is based on optical coherence imaging (OCI). OCI is a full-field short-coherence
holography that collects backscattered speckle. With the help of coherence gating, OCI can
optically section tissue up to 1 mm deep. MCT specifically uses intracellular motion as the
endogenous contrast to characterize submicron subcellular motion inside three-dimensional
living tissue.

EX VIVO CANCER CHEMOSENSITIVITY ANALYSIS MCT was previously applied to study the efficacy of
anti-mitotic drugs using multicellular tumor spheroids. When applying MCT to tumor
xenografts, it is also capable of showing a significantly different response between two cell
lines under cisplatin. After applying the drug, the normalized standard deviation (NSD) value
of the platinum-sensitive cell line (A2780) drops from 0.7 to 0.1 in 8 hours. In contrast,
the NSD value of the platinum-resistant cell line (A2780-CP70) remains nearly constant (0.81
to 0.80) 9 hours after applying drug. The NSD value of normal mouse tissue attached to the
tumor xenograft decreases only a little (0.6 to 0.52) compared with A2780.

In a further study in a veterinary clinical setting, MCT has been used to predict patient
outcome for canine non-Hodgkin's lymphoma. Canine non-Hodgkin's lymphomas are initially
characterized by tumoral infiltration of peripheral lymph nodes. Canine non-Hodgkin's
lymphomas are diverse in their clinical aggressiveness and response to chemotherapy. The only
current biomarker for chemoresponsiveness is tumor cell immunophenotype (i.e. T-cell vs.
B-cell origin), but chemoresponsiveness varies tremendously within immunophenotype, which
reduces the clinical utility of this biomarker. In our study, we used MCT to measure the
heterogeneous response of canine lymphoma biopsies to the standard-of-care doxorubicin. The
biodynamic signatures of doxorubicin responsivity ex vivo were correlated with canine patient
outcome. These studies have demonstrated, for the first time, the utility of label-free
intracellular biodynamic markers to predict therapeutic efficacy for cancer treatment in
dogs.

SPECIFIC AIMS The primary study objective is to examine the feasibility of using MCT as a
chemosensitivity assay among bladder cancer patients receiving neoadjuvant chemotherapy by
comparing MCT patterns consistent with chemotherapy response or resistance ex-vivo to
confirmed response or resistance to chemotherapy as measured by Response Evaluation Criteria
in Solid Tumors (RECIST) v1.1 criteria.

PRIMARY ENDPOINT: Objective pathological response measured at the time of surgery.

INCLUSION CRITERIA: To be eligible for the study, participants must meet the following
criteria:

1. Ability to understand and willingness to sign an informed consent and authorization
for release of tissue not required for pathologic diagnosis to be used for research
purposes

2. ≥ 18 years old at time of consent

3. Patients undergoing a TURBT procedure due to diagnose muscle invasive bladder cancer

EXCLUSION CRITERIA: To be eligible for the study, participants must not be or have any of
the following:

1. Women who are pregnant or breastfeeding

2. Known tumor genetics or other factors, which in the treating physician's professional
judgement, make the patient an unlikely candidate to receive chemotherapy (either
neoadjuvantly or adjuvantly)