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Bou-Samra P, Singhal S. Precision Oncology in Lung Cancer Surgery. Surg Oncol Clin N Am 2024; 33:311-320. [PMID: 38401912 DOI: 10.1016/j.soc.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2024]
Abstract
Precision in lung cancer surgery is our ability to use the most cutting edge and up to date information to provide personalized and targeted surgical care to our patients. It aims to tailor patient care to patient and tumor characteristics and susceptibilities as well as to optimize the ways treatments are administered. This may include specific perioperative medical treatment, changing operative techniques to more minimally invasive ones if the situation permits, performing sub-anatomical surgeries when possible, and using innovative tumor visualization methods to enhance detection of previously occult disease to ultimately decrease the extent of the planned resection.
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Affiliation(s)
- Patrick Bou-Samra
- The University of Pennsylvania - Stemmler Hall, 3450 Hamilton Walk, Philadelphia, PA 19104, USA
| | - Sunil Singhal
- Department of Thoracic Surgery, Perelman School of Medicine, University of Pennsylvania, 14th Floor PCAM South Tower, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Vreeburg MTA, Donswijk ML, Albersen M, Parnham A, Ayres B, Protzel C, Pettaway C, Spiess PE, Brouwer OR. New EAU/ASCO guideline recommendations on sentinel node biopsy for penile cancer and remaining challenges from a nuclear medicine perspective. Eur J Nucl Med Mol Imaging 2024:10.1007/s00259-023-06586-6. [PMID: 38216778 DOI: 10.1007/s00259-023-06586-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/12/2023] [Indexed: 01/14/2024]
Abstract
INTRODUCTION The European Association of Urology (EAU) and the American Society of Clinical Oncology (ASCO) recently issued updated guidelines on penile cancer, emphasising dynamic sentinel node biopsy (DSNB) as the preferred method for surgical staging among patients with invasive penile tumours and no palpable inguinal lymphadenopathy. This paper outlines the rationale behind this new recommendation and describes remaining challenges, as well as strategies for promoting DSNB worldwide. MAIN TEXT DSNB offers high diagnostic accuracy with the lowest postoperative complications compared to open or minimally invasive inguinal lymph node dissection (ILND), prompting its preference in the new guidelines. Nevertheless, despite its advantages, there are challenges hampering the widespread adoption of DSNB. This includes the false-negative rate associated with DSNB and the potential negative impact on patient outcome. To address this issue, improvements should be made in several areas, including refining the timing and interpretation of the lymphoscintigraphy and the single photon emission computed tomography/computed tomography images. In addition, the quantity of tracer employed and choice of the injection site for the radiopharmaceutical should be optimised. Finally, limiting the removal of nodes without tracer activity during surgery may help minimise complication rates. CONCLUSION Over the years, DSNB has evolved significantly, related to the dedicated efforts and innovations in nuclear medicine and subsequent clinical studies validating its efficacy. It is now strongly recommended for surgical staging among selected penile cancer patients. To optimise DSNB further, multidisciplinary collaborative research is required to improve SN identification for better diagnostic accuracy and fewer complications.
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Affiliation(s)
- Manon T A Vreeburg
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands, Amsterdam, The Netherlands
| | - Maarten L Donswijk
- Department of Nuclear Medicine, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Maarten Albersen
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Arie Parnham
- Department of Urology, The Christie NHS Foundation Trust, Manchester, UK
| | - Benjamin Ayres
- Penile Cancer Centre, St George's University Hospitals NHS Trust, London, UK
| | - Chris Protzel
- Department of Urology, University Hospital of Rostock, Rostock, Germany
| | - Curtis Pettaway
- Department of Urology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, 77030-4009, USA
| | | | - Oscar R Brouwer
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands, Amsterdam, The Netherlands.
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Bou-Samra P, Joffe J, Chang A, Guo E, Segil A, Azari F, Kennedy G, Din A, Hwang WT, Singhal S. Preoperative predictors of successful tumour localization by intraoperative molecular imaging with pafolacianine in lung cancer to create predictive nomogram. Eur J Cardiothorac Surg 2024; 65:ezad392. [PMID: 38191994 DOI: 10.1093/ejcts/ezad392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/17/2023] [Accepted: 01/05/2024] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVES Intraoperative molecular imaging (IMI) uses cancer-targeted fluorescent probe to locate nodules. Pafolacianine is a Food and Drug Administration-approved fluorescent probe for lung cancer. However, it has a 8-12% false negative rate for localization. Our goal is to define preoperative predictors of tumour localization by IMI. METHODS We performed a retrospective review of patients who underwent IMI using pafolacianine for lung lesions from June 2015 to August 2019. Candidate predictors including sex, age, body mass index, smoking history, tumour size, distance of tumour from surface, use of neoadjuvant therapy and positron emission tomography avidity were included. The outcome was fluorescence in vivo and comprehensively included those who were true or false positives negatives. Multiple imputation was used to handle the missing data. The final model was evaluated using the area under the receiver operating characteristic curve. RESULTS Three hundred nine patients were included in our study. The mean age was 64 (standard deviation 13) and 68% had a smoking history. The mean distance of the tumours from the pleural surface was 0.4 cm (standard deviation 0.6). Smoking in pack-years and distance from pleura had an odds ratio of 0.99 [95% confidence interval: 0.98-0.99; P = 0.03] and 0.46 [95% confidence interval: 0.27-0.78; P = 0.004], respectively. The final model had an area under the receiver operating characteristic curve of 0.68 and was used to create a nomogram that gives a probability of fluorescence in vivo. CONCLUSIONS Primary tumours that are deeper from the pleural surface, especially in patients with a higher pack-years, are associated with a decreased likelihood of intraoperative localization. We identified a nomogram to predict the likelihood of tumour localization with IMI with pafolacianine.
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Affiliation(s)
- Patrick Bou-Samra
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jonah Joffe
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics (DBEI), The University of Pennsylvania, Philadelphia, PA, USA
| | - Austin Chang
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Emily Guo
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alix Segil
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Feredun Azari
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gregory Kennedy
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Azra Din
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Wei-Ting Hwang
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics (DBEI), The University of Pennsylvania, Philadelphia, PA, USA
| | - Sunil Singhal
- University of Pennsylvania, Perlman School of Medicine, Department of Surgery, Philadelphia, PA, USA
- Abramson Cancer Center, Department Of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Valdés Olmos RA, Collarino A, Rietbergen DDD, Pereira Arias-Bouda L, Giammarile F, Vidal-Sicart S. Setting-up a training programme for intraoperative molecular imaging and sentinel node mapping: how to teach? How to learn? Eur J Nucl Med Mol Imaging 2023:10.1007/s00259-023-06496-7. [PMID: 38030743 DOI: 10.1007/s00259-023-06496-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND The current expansion of image-guided surgery is closely related to the role played by radio-guided surgery in supporting the sentinel node (SN) procedure during more than three decades. The so-called triple approach (lymphoscintigraphy, gamma probe detection and blue dye) was not only essential in the seminal validation of the SN procedure but also a first collective learning effort based on skill transfer and outcome-related evaluation which laid the fundaments to delineate the field of intraoperative molecular imaging (IMI) based on a similar multimodality approach and multidisciplinary practice. METHODS These elements are also becoming valid in the current incorporation of SPECT/CT and PET/CT to existing and new protocols of IMI procedures and SN mapping concerning other clinical applications. On the other hand, there is a growing tendency to combine novel modern technologies in an allied role with gamma guidance in the operating room following the development of hybrid tracers and multimodal detection approaches. Against this background, learning initiatives are required for professionals working in this area. RESULTS This objective has led to a group of European practitioners with large experience in SN mapping and IMI applications to give shape to a programme made up out of specific learning modules aimed to be used as a conductive thread in peripherical or centralised training instances concerning the topic. CONCLUSION The presented work, written as a tutorial review, is placed in an available prior-art context and is primarily aimed at medical and paramedical practitioners as well as at hardware and software developers.
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Affiliation(s)
- Renato A Valdés Olmos
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Angela Collarino
- Nuclear Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daphne D D Rietbergen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Lenka Pereira Arias-Bouda
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Francesco Giammarile
- Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency (IAEA), Vienna, Austria
| | - Sergi Vidal-Sicart
- Department of Nuclear Medicine, Hospital Clinic Barcelona, Barcelona, Catalonia, Spain
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Wong LY, Lui NS. Intraoperative Molecular Imaging of Lung Cancer. Thorac Surg Clin 2023; 33:227-232. [PMID: 37414478 DOI: 10.1016/j.thorsurg.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Intraoperative molecular imaging innovations have been propelled by the development of fluorescent contrast agents that specifically target tumor tissues and advanced camera systems that can detect the specified fluorescence. The most promising agent to date is OTL38, a targeted and near-infrared agent that was recently approved by the Food and Drug Administration for intraoperative imaging for lung cancer.
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Affiliation(s)
- Lye-Yeng Wong
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Falk Building, Stanford, CA 94305, USA. https://twitter.com/LyeYengWongMD
| | - Natalie S Lui
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Falk Building, Stanford, CA 94305, USA.
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Azari F, Zhang K, Kennedy G, Bou-Samra P, Chang A, Nadeem B, Chang A, Galandarova A, Ibrahimli A, Karimov Z, Din A, Kucharczuk J, Doraid J, Pechet T, Delikatny E, Singhal S. Prospective validation of tumor folate receptor expression density with the association of pafolacianine fluorescence during intraoperative molecular imaging-guided lung cancer resections. Eur J Nucl Med Mol Imaging 2023; 50:2453-2465. [PMID: 36905412 PMCID: PMC10314365 DOI: 10.1007/s00259-023-06141-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 02/08/2023] [Indexed: 03/12/2023]
Abstract
PURPOSE Pafolacianine, a folate receptor alpha-targeted NIR tracer, has demonstrated clear efficacy in intraoperative molecular imaging-guided (IMI) lung cancer surgery. However, the selection of patients who would benefit from IMI remains challenging given the variability of fluorescence with patient-associated and histopathologic factors. Our goal in this study was to prospectively evaluate whether preoperative FRα/FRβ staining can predict pafolacianine-based fluorescence during real-time lung cancer resections. METHODS This was a prospective study conducted between 2018 and 2022 that reviewed core biopsy and intraoperative data from patients with suspected lung cancer. A total of 196 patients were deemed eligible, of whom core biopsies were taken from 38 patients and assessed for FRα and FRβ expression by immunohistochemistry (IHC). All patients underwent infusion of pafolacianine 24 h prior to surgery. Intraoperative fluorescence images were captured with the VisionSense bandpass filter-enabled camera. All histopathologic assessments were performed by a board-certified thoracic pathologist. RESULTS Of the 38 patients, 5 (13.1%) were found to have benign lesions (necrotizing granulomatous inflammation, lymphoid aggregates) and 1 had metastatic non-lung nodule. Thirty (81.5%) had malignant lesions, with the vast majority (23, 77.4%) being lung adenocarcinoma (7 (22.5%) SCC). None of the benign tumors (0/5, 0%) exhibited in vivo fluorescence (mean TBR of 1.72), while 95% of the malignant tumors fluoresced (mean TBR of 3.11 ± 0.31) compared to squamous cell carcinoma (1.89 ± 0.29) of the lung and sarcomatous lung metastasis (2.32 ± 0.09) (p < 0.01). The TBR was significantly higher in the malignant tumors (p = 0.009). The median FRα and FRβ staining intensities were both 1.5 for benign tumors, while the FRα and FRβ staining intensities were 3 and 2 for malignant tumors, respectively. Increased FRα expression was significantly associated with the presence of fluorescence (p = 0.01), CONCLUSION: This prospective study sought to determine whether preoperative FRα and FRβ expression on core biopsy IHC correlates with intraoperative fluorescence during pafolacianine-guided surgery. These results, although of small sample size, including limited non-adenocarcinoma cohort, suggest that performing FRα IHC on preoperative core biopsies of adenocarcinomas as compared to squamous cell carcinomas could provide low-cost, clinically useful information for optimal patient selection which should be further explored in advanced clinical trials.
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Affiliation(s)
- Feredun Azari
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Kevin Zhang
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gregory Kennedy
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Patrick Bou-Samra
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
- Ohio State University School of Medicine, Ohio, Columbus, USA
| | - Ashley Chang
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Bilal Nadeem
- Ankara Yildirim Beyazit Faculty of Medicine, Ankara, Turkey
| | - Austin Chang
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | | | | | - Ziya Karimov
- Faculty of Medicine, Ege University, Izimir, Turkey
| | - Azra Din
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - John Kucharczuk
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Jarrar Doraid
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Taine Pechet
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Edward Delikatny
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA.
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Azari F, Kennedy G, Bernstein E, Delikatny J, Lee JYK, Kucharczuk J, Low PS, Singhal S. Evaluation of OTL38-Generated Tumor-to-Background Ratio in Intraoperative Molecular Imaging-Guided Lung Cancer Resections. Mol Imaging Biol 2023; 25:85-96. [PMID: 34101106 PMCID: PMC8651846 DOI: 10.1007/s11307-021-01618-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/19/2021] [Accepted: 05/23/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Cancer surgery has multiple challenges including localizing small lesions, ensuring negative margins, and identifying synchronous cancers. One of the tools proposed to address these issues is intraoperative molecular imaging (IMI). An important consideration in IMI is the quantification of the tumor fluorescence during the procedure and using that data to add clinical value. Currently, the most commonly cited measure of quantification is the tumor-to-background ratio (TBR). Our goal was to evaluate the clinical value of TBR measured with OTL38 NIR tracer during a lung cancer resection. METHODS Intraoperative data was retrospectively reviewed from a prospectively collected 5-year database. Between 2015 and 2020, 279 patients were included in the study. For standardization, all patients underwent infusion of the same targeted molecular optical contrast agent (OTL38) for lung cancer resections; then, the mean fluorescence intensity of the tumors and background tissues were calculated. To evaluate the clinical efficacy of the TBR calculation, the results were correlated with patient, biologic, tumor, and technological factors. RESULTS For pulmonary surgery, patient factors such as gender, age, smoking history, and time from infusion of OTL38 to surgery did not have any statistical significance in predicting the TBR during surgery. In addition, TBR measurements did not correlate with location of the tumor in the lung (p = 0.123). There was no statistical correlation of preoperative positron emission tomography measurements (standardized uptake value) with intraoperative TBR. However, there was statistically significant negative correlation of in situ TBR measurement and the distance of the lesion from the surface of the organ (p < 0.001). Adenocarcinoma spectrum lesions overall had statistically significant correlation with in situ fluorescence compared to other NSCLC malignancies (p < 0.01) but TBR measurements could not identify histopathologic subtype on univariate analysis (p = 0.089). There was a tendency for in situ fluorescence for moderately and well-differentiated adenocarcinoma spectrum lesions, but this was not statistically significant. When comparing the in situ TBR of benign to malignant nodules in the lung, there was no statistically significant association (p = 0.145). In subset analysis, adenocarcinoma spectrum lesions tend to fluoresce at brighter with OTL38 compared to other histologic subtypes. CONCLUSION In our various iterations, the results of our retrospective analysis did not show that TBR measurements during OTL38-guided surgery provide clinically useful information about the nature of the nodule or cancer. The true value of IMI is in the ability for the surgeon to use the fluorescence to guide the surgeon to the tumor and margins, but that sophisticated quantification of the amount of fluorescence may not have clinical utility.
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Affiliation(s)
- Feredun Azari
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Gregory Kennedy
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Elizabeth Bernstein
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - James Delikatny
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - John Kucharczuk
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Phil S Low
- Department of Chemistry, Purdue University, West Lafayette, IN, USA
| | - Sunil Singhal
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA.
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Kennedy GT, Azari FS, Bernstein E, Deshpande C, Kucharczuk JC, Delikatny EJ, Singhal S. Three-Dimensional Near-Infrared Specimen Mapping Can Identify the Distance from the Tumor to the Surgical Margin During Resection of Pulmonary Ground Glass Opacities. Mol Imaging Biol 2023; 25:203-211. [PMID: 35831734 PMCID: PMC10237678 DOI: 10.1007/s11307-022-01750-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lung cancers can recur locally due to inadequate resection margins. Achieving adequate margin distances is challenging in pulmonary ground glass opacities (GGOs) because they are not easily palpable. To improve margin assessment during resection of GGOs, we propose a novel technique, three-dimensional near-infrared specimen mapping (3D-NSM). METHODS Twenty patients with a cT1 GGO were enrolled and received a fluorescent tracer preoperatively. After resection, specimens underwent 3D-NSM in the operating room. Margins were graded as positive or negative based upon fluorescence at the staple line. Images were analyzed using ImageJ to quantify the distance from the tumor edge to the nearest staple line. This margin distance calculated by 3D-NSM was compared to the margin distance reported on final pathology several days postoperatively. RESULTS 3D-NSM identified 20/20 GGOs with no false positive or false negative diagnoses. Mean fluorescence intensity for lesions was 110.92 arbitrary units (A.U.) (IQR: 77.77-122.03 A.U.) compared to 23.68 A.U. (IQR: 19.60-27.06 A.U.) for background lung parenchyma (p < 0.0001). There were 4 tumor-positive or close margins in the study cohort, and all 4 (100%) were identified by 3D-NSM. 3D-NSM margin distances were nearly identical to margin distances reported on final pathology (R2 = 0.9362). 3D-NSM slightly under-predicted margin distance, and the median difference in margins was 1.9 mm (IQR 0.5-4.3 mm). CONCLUSIONS 3D-NSM rapidly localizes GGOs by fluorescence and detects tumor-positive or close surgical margins. 3D-NSM can accurately quantify the resection margin distance as compared to formal pathology, which allows surgeons to rapidly determine whether sublobar resection margin distances are adequate.
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Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Feredun S Azari
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Elizabeth Bernstein
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Charuhas Deshpande
- Department of Pathology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Edward J Delikatny
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA.
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Azari F, Kennedy G, Zhang K, Bernstein E, Chang A, Nadeem B, Segil A, Desphande C, Delikatny J, Kucharczuk J, Singhal S. Effects of Light-absorbing Carbons in Intraoperative Molecular Imaging-Guided Lung Cancer Resections. Mol Imaging Biol 2023; 25:156-167. [PMID: 35290565 PMCID: PMC9474735 DOI: 10.1007/s11307-021-01699-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND One of the novel advancements to enhance the visual aspects of lung cancer identification is intraoperative molecular imaging (IMI), which can reliably detect tumors that would otherwise be missed by standard techniques such as tactile and visual feedback, particularly for sub-centimeter or ground-glass nodules. However, there remains a subset of patients who do not benefit from IMI due to excessive background fluorescence secondary to parenchymal light-absorbing carbon deposition. Our goal was to identify the effects of these carbonaceous materials on the quality of IMI-guided lung cancer resections. STUDY DESIGN AND METHODS Between July 2014 and May 2021, a total of 311 patients were included in the study. Patients underwent infusion of the study drug OTL38 or ICG up to 24 h prior to VATS for lung cancer. Several factors such as age, tumor subtype, PET SUV, smoking, demographics, chronic lung conditions, patient domicile, and anthracosis were analyzed with respect to lung fluorescence during IMI. P values < 0.05 were considered statistically significant. RESULTS Variables such as age, sex, and race had no statistical correlation to IMI success. However, smoking status and pack year had a statistically significant correlation with background parenchymal fluorescence and lung inflammation (p < 0.05). MFI of background (lung parenchyma) correlated with smoking history (p < 0.05) which led to decreased tumor-to-background ratio (TBR) measurements for all patients with proven malignancy (p < 0.05). Patients with chronic lung disease appear to have increased background parenchymal fluorescence regardless of smoking history (287 vs. 154, p < 0.01). City dwellers compared to other groups appear to be exposed to higher pollutant load and have higher rates of anthracosis, but living location's impact on fluorescence quantification appears to be not statistically significant. CONCLUSION Smokers with greater than 10 PPY and those with chronic lung disease appear to have decreased lesion-to-background discrimination, significant anthracosis, and reduced IMI efficacy secondary to light-absorbing carbon deposition.
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Affiliation(s)
- Feredun Azari
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gregory Kennedy
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kevin Zhang
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Elizabeth Bernstein
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ashley Chang
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Bilal Nadeem
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alix Segil
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Charuhas Desphande
- Department of Pathology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - James Delikatny
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - John Kucharczuk
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Thoracic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Singhal S, Azari F, Caponetti GC, Kennedy GT. Novel intraoperative near-infrared imaging strategy to identify abnormalities in the anterior mediastinum. J Cardiothorac Surg 2022; 17:302. [PMID: 36494869 PMCID: PMC9734605 DOI: 10.1186/s13019-022-02054-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/03/2022] [Indexed: 12/13/2022] Open
Abstract
Thoracic surgeons are frequently asked to biopsy suspicious tissues in the anterior mediastinum to discriminate between a reactive versus malignant pathology such as lymph nodes. The most common benign cause of a mediastinal lymph node is a reactive lymph node from a prior infection or inflammatory process such as post-COVID or granulomatous disease. The most common malignant cause is a lymphoproliferative disorder but also metastatic disease from neck, breast and other regional cancers. Biopsies in this location are challenging because they are far from the trachea and the sternum is a barrier to most diagnostic procedures. Thus, a surgical biopsy is frequently required and a common procedure for Thoracic surgeons. Technically, identifying these lesions can be challenging, particularly for small lesions or those in patients with high body mass index. In order to improve contrast between diseased tissue in the anterior mediastinum and surrounding adipose tissue, we have been studying near-infrared imaging during surgery using indocyanine green (ICG) to give contrast to the abnormal tissues and to avoid an unnecessary extended resection. We developed a modified technique to give ICG to a patient during a biopsy in the anterior mediastinum to specifically highlight abnormal tissues. As a proof-of-principle, we present a case of a young woman with a suspicious 2 cm mediastinal lymph node that required surgical biopsy.
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Affiliation(s)
- Sonia Singhal
- grid.25879.310000 0004 1936 8972Department of Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA USA
| | - Feredun Azari
- grid.25879.310000 0004 1936 8972Department of Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA USA
| | - Gabriel C. Caponetti
- grid.25879.310000 0004 1936 8972Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA USA
| | - Gregory T. Kennedy
- grid.25879.310000 0004 1936 8972Department of Surgery, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA USA ,grid.411115.10000 0004 0435 0884Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104 USA
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11
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Azari F, Kennedy G, Chang A, Nadeem B, Sullivan N, Marfatia I, Din A, Desphande C, Kucharczuk J, Delikatny EJ, Singhal S. Presence of non-Newtonian fluid in invasive pulmonary mucinous adenocarcinomas impacts fluorescence during intraoperative molecular imaging of lung cancer. Eur J Nucl Med Mol Imaging 2022; 49:4406-4418. [PMID: 35876868 PMCID: PMC10292759 DOI: 10.1007/s00259-022-05912-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/10/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intraoperative molecular imaging (IMI) with folate-targeted NIR tracers has been shown to improve lesion localization in more than 80% of lung adenocarcinomas. However, mucinous adenocarcinomas (MAs) and invasive mucinous adenocarcinomas (IMAs) of the lung, which are variants of adenocarcinoma, appear to have decreased fluorescence despite appropriate folate receptor expression on the tumor surface. We hypothesized that the etiology may be related to light excitation and emission through non-Newtonian fluid (mucin) produced by goblet and columnar cancer cells. METHODS Intraoperative data for 311 subjects were retrospectively reviewed from a prospectively collected 6-year database. For standardization, all patients underwent infusion of the same targeted molecular optical contrast agent (pafolacianine, folate receptor-targeted NIR fluorochrome) for lung cancer resections. Then, the ratio of the mean fluorescence intensity of the tumors and background tissues (TBR) was calculated. Tumors were examined for mucin, FRa, FRb, and immunofluorescent tracer uptake by a board-certified pathologist. The optical properties of mucin analyzed by imaging software were used to create in vitro gel models to explore the effects on NIR tracer fluorescence intensity. RESULTS A large proportion (192, 62%) of the patients were female, with an average of 62.8 years and a 34-year mean pack smoking history. There were no severe (Clavien-Dindo > III) complications related to pafolacianine infusion. A total of 195 lesions in the study were adenocarcinomas, of which 19 (6.1%) were of the mucinous subtype. A total of 14/19 of the patients had a smoking history, and more than 74% of the IMA lesions were in the lower lobes. IMA lesions had a lower in situ TBR than nonmucinous adenocarcinomas (2.64 SD 0.23) vs (3.45 SD 0.11), respectively (p < 0.05). Only 9/19 (47%) were localized in situ. Tumor bisection and removal of mucin from IMAs significantly increased pafolacianine fluorescence, with resultant TBR not being significantly different from the control group (4.67 vs 4.89) (p = 0.19). Of the 16 lesions that underwent FR expression analysis, 15/16 had FR presence on cancer cells or tumor-associated macrophages in the tumor microenvironment. There was no statistically significant difference in fluorescence intensity during immunofluorescence analysis (4.99 vs 5.08) (p = 0.16). Physical removal of mucin from IMAs improved the TBR from 3.11 to 4.67 (p < 0.05). In vitro analysis of the impact of synthetic non-Newtonian fluid (agarose 0.5%) on NIR tracer fluorescence showed a decrease in MFI by a factor of 0.25 regardless of the concentration for each 5 mm thickness of mucin. CONCLUSION The mucinous subtype of lung adenocarcinomas presents a unique challenge in pafolacianine-targeted IMI-guided resections. The presence of non-Newtonian fluids presents a physical barrier that dampens the excitation of the tracer and fluorescence emission detected by the camera. Knowledge of this phenomenon can allow the surgeon to critically analyze lesion fluorescence parameters during IMI-guided lung cancer resections.
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Affiliation(s)
- Feredun Azari
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Gregory Kennedy
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Ashley Chang
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Bilal Nadeem
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Neil Sullivan
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Isvita Marfatia
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Azra Din
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Charuhas Desphande
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - John Kucharczuk
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Edward J Delikatny
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Thoracic Surgery, Perelman School of Medicine at University of Pennsylvania, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA.
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12
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Boekestijn I, van Oosterom MN, Dell'Oglio P, van Velden FHP, Pool M, Maurer T, Rietbergen DDD, Buckle T, van Leeuwen FWB. The current status and future prospects for molecular imaging-guided precision surgery. Cancer Imaging 2022; 22:48. [PMID: 36068619 PMCID: PMC9446692 DOI: 10.1186/s40644-022-00482-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 08/21/2022] [Indexed: 01/19/2023] Open
Abstract
Molecular imaging technologies are increasingly used to diagnose, monitor, and guide treatment of i.e., cancer. In this review, the current status and future prospects of the use of molecular imaging as an instrument to help realize precision surgery is addressed with focus on the main components that form the conceptual basis of intraoperative molecular imaging. Paramount for successful interventions is the relevance and accessibility of surgical targets. In addition, selection of the correct combination of imaging agents and modalities is critical to visualize both microscopic and bulk disease sites with high affinity and specificity. In this context developments within engineering/imaging physics continue to drive the growth of image-guided surgery. Particularly important herein is enhancement of sensitivity through improved contrast and spatial resolution, features that are critical if sites of cancer involvement are not to be overlooked during surgery. By facilitating the connection between surgical planning and surgical execution, digital surgery technologies such as computer-aided visualization nicely complement these technologies. The complexity of image guidance, combined with the plurality of technologies that are becoming available, also drives the need for evaluation mechanisms that can objectively score the impact that technologies exert on the performance of healthcare professionals and outcome improvement for patients.
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Affiliation(s)
- Imke Boekestijn
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.,Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Matthias N van Oosterom
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Paolo Dell'Oglio
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Floris H P van Velden
- Medical Physics, Department of Radiology , Leiden University Medical Center, Leiden, the Netherlands
| | - Martin Pool
- Department of Clinical Farmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tobias Maurer
- Martini-Klinik Prostate Cancer Centre Hamburg, Hamburg, Germany
| | - Daphne D D Rietbergen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.,Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tessa Buckle
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.
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13
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Li C, Buch L, Cho S, Lee JYK. Near-infrared intraoperative molecular imaging with conventional neurosurgical microscope can be improved with narrow band "boost" excitation. Acta Neurochir (Wien) 2019; 161:2311-8. [PMID: 31482242 DOI: 10.1007/s00701-019-04054-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 08/26/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Intraoperative visualization of brain tumors with near-infrared (NIR)-fluorescent dyes is an emerging method for tumor margin approximation but are limited by existing fluorescence detection platforms. We previously showed that a dedicated NIR imaging platform outperformed a state-of-the-art neurosurgical microscope in fluorescence signal characteristics. This study examined whether conventional neurosurgical microscope NIR signal could be improved with the addition of a narrow wavelength excitation source. METHODS Imaging was conducted with a broad-spectrum neurosurgical microscope and commercial near-infrared module. Addition of an 805-nm laser was used to "boost" NIR excitation of indocyanine green (ICG). In vitro quantification was performed on serial dilutions of ICG. Patients underwent tumor resection with delayed 24-h imaging of ICG infusion. NIR fluorescence of dura, cortex, or tumor was quantified from images prior to (pre-boost) and following added excitation with the laser (post-boost). Signal to background ratio (SBR) of pre- and post-boost was calculated as a readout of image enhancement. RESULTS In vitro, excitation boost effected a 29% increase in mean SBR in six serial dilutions of ICG. Intraoperative boost was performed in 11 patients including meningioma, glioblastoma multiforme, and metastases. Increase in tumor fluorescence was pronounced under direct tumor visualization. Across all patients, boost excitation resulted in 35% mean improvement from pre-boost SBR (p < 0.001). CONCLUSION Neurosurgical microscopes remain the preferred method of visualizing tumor during intracranial surgery. However, current modalities for NIR signal detection are suboptimal. We demonstrate that augmentation of a fluorescence microscope module with a focused excitation source is a simple mechanism of improving NIR tumor visualization. CLINICAL TRIAL REGISTRATION NCT03262636.
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14
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Li C, Sullivan PZ, Cho S, Nasrallah MP, Buch L, Isaac Chen HC, Lee JYK. Intraoperative Molecular Imaging with Second Window Indocyanine Green Facilitates Confirmation of Contrast-Enhancing Tissue During Intracranial Stereotactic Needle Biopsy: A Case Series. World Neurosurg 2019; 126:e1211-e1218. [PMID: 30885869 DOI: 10.1016/j.wneu.2019.02.231] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/24/2019] [Accepted: 02/25/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Stereotactic needle biopsy provides a minimally invasive option for the diagnosis of intracranial lesions but is limited by inconclusive diagnoses on frozen pathology. For rapid pathology, 5-aminovelunic acid and sodium fluorescein have previously demonstrated potential as diagnostic adjuvants. Stereotactic biopsy with near-infrared (NIR) fluorophores has not been reported. We identified 5 representative cases using NIR fluorescent dye indocyanine green (ICG) administered in a high dose, delayed manner. METHODS Five patients underwent second window indocyanine green (SWIG)-guided stereotactic biopsy for diagnosis of suspected glioma or tumor recurrence. Up to 5 mg/kg ICG was administered approximately 24 hours prior to surgery. Biopsies were conducted in the standard fashion, targeting regions of suspected tumor using intraoperative frameless navigation. Samples were examined intraoperatively under standard visible light and for fluorescence using conventional NIR imaging platforms. Findings were correlated with frozen and final tumor pathology for all cases. RESULTS A total of 10 biopsy specimens were obtained. Three did not fluoresce and did not demonstrate tumor on preliminary or final pathology, including a non-gadolinium-enhancing sample taken proximal to the final target. The remaining 7 fluoresced, of which 6 contained tumor and 1 contained necrosis. Fluorescence was also noted in a patient with radiation treatment effect. Overall fluorescence characteristics were highly concordant with preliminary and final diagnoses. CONCLUSIONS SWIG provides rapid intraoperative confirmation of pathologic brain tissue by permeating neoplastic or inflammatory brain tissue via a mechanism similar to that of gadolinium enhancement. SWIG-guided stereotactic biopsy can improve surgical efficiency by enhancing confidence in acquisition of target tissue.
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Affiliation(s)
- Carrie Li
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patricia Zadnik Sullivan
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steve Cho
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - MacLean P Nasrallah
- Department of Neuropathology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Love Buch
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Han-Chiao Isaac Chen
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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