Detection properties of indium-111 and IRDye800CW for intraoperative molecular imaging use across tissue phantom models.

Significance: Intraoperative molecular imaging (IMI) enables the detection and visualization of cancer tissue using targeted radioactive or fluorescent tracers. While IMI research has rapidly expanded, including the recent Food and Drug Administration approval of a targeted fluorophore, the limits of detection have not been well-defined. Aim: The ability of widely available handheld intraoperative tools (Neoprobe and SPY-PHI) to measure gamma decay and fluorescence intensity from IMI tracers was assessed while varying characteristics of both the signal source and the intervening tissue or gelatin phantoms. Approach: Gamma decay signal and fluorescence from tracer-bearing tumors (TBTs) and modifiable tumor-like inclusions (TLIs) were measured through increasing thicknesses of porcine tissue and gelatin in custom 3D-printed molds. TBTs buried beneath porcine tissue were used to simulate IMI-guided tumor resection. Results: Gamma decay from TBTs and TLIs was detected through significantly thicker tissue and gelatin than fluorescence, with at least 5% of the maximum signal observed through up to 5 and 0.5 cm, respectively, depending on the overlying tissue type or gelatin. Conclusions: We developed novel systems that can be fine-tuned to simulate variable tumor characteristics and tissue environments. These were used to evaluate the detection of fluorescent and gamma signals from IMI tracers and simulate IMI surgery.

A Phase 2 Multicenter Clinical Trial of Intraoperative Molecular Imaging of Lung Cancer with a pH-Activatable Nanoprobe.

PURPOSE: Intraoperative molecular imaging (IMI) uses tumor-targeted optical contrast agents to improve identification and clearance of cancer. Recently, a probe has been developed that only fluoresces when activated in an acidic pH, which is common to many malignancies. We report the first multicenter Phase 2 trial of a pH-activatable nanoprobe (pegsitacianine, ONM-100) for IMI of lung cancer. METHODS: Patients with suspected or biopsy-confirmed lung cancer scheduled for sublobar resection were administered a single intravenous infusion of pegsitacianine (1 mg/kg) one to three days prior to surgery. Intraoperatively, the patients underwent a white light thoracoscopic evaluation, and then were imaged with an NIR thoracoscope to detect tumor fluorescence. The primary study endpoint was the proportion of patients with a clinically significant event (CSE) which was defined as an intraoperative discovery during IMI that led to a change in the surgical procedure. Possible CSEs included (i) localizing the index lung nodule that could not be located by white light, (ii) identifying a synchronous malignant lesion, or (iii) recognizing a close surgical margin (< = 10 mm). Secondary endpoints were sensitivity, specificity, NPV, and PPV of pegsitacianine in detecting tumor-containing tissue. The safety evaluation was based on adverse event reporting, clinical laboratory parameters, and physical examinations. RESULTS: Twenty patients were confirmed as eligible and administered pegsitacianine. Most of the patients were female (n = 12 [60%]), middle-aged (mean age 63.4 years), and former smokers (n = 13 [65%], 28.6 mean pack years). Mean lesion size was 1.9 cm, and most lesions (n = 17 [85%]) were malignant. The most common histologic subtype was adenocarcinoma (n = 9). By utilizing IMI with pegsitacianine, one patient had a CSE in the detection of a close margin and another had localization of a tumor not detectable by traditional surgical means. Six of 19 (31.6%) malignant lesions fluoresced with mean tumor-to-background ratio (TBR) of 3.00, as compared to TBR of 1.20 for benign lesions (n = 3). Sensitivity and specificity of pegsitacianine-based IMI for detecting malignant tissue was 31.6% and 33.3%, respectively. Positive predictive value (PPV) and negative predictive value (NPV) of pegsitacianine-based IMI was 75% and 7.1%, respectively. Pegsitacianine-based imaging was not effective in differentiating benign and malignant lymph nodes. From a safety perspective, no drug-related serious adverse events occurred. Four patients experienced mild pegsitacianine-related infusion reactions which required discontinuing the study drug with complete resolution of symptoms. CONCLUSIONS: Pegsitacianine-based IMI, though well tolerated from a safety perspective, does not consistently label lung tumors during resection and does not provide significant clinical benefit over existing standards of surgical care. The biology of lung tumors may not be as acidic as other solid tumors in the body thereby not activating the probe as predicted.

Precision Oncology in Lung Cancer Surgery.

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.

Preoperative predictors of successful tumour localization by intraoperative molecular imaging with pafolacianine in lung cancer to create predictive nomogram.

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.

New EAU/ASCO guideline recommendations on sentinel node biopsy for penile cancer and remaining challenges from a nuclear medicine perspective.

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.

Setting-up a training programme for intraoperative molecular imaging and sentinel node mapping: how to teach? How to learn?

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.

Intraoperative Molecular Imaging of Lung Cancer.

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.

Preclinical Lymph Node Model for Intraoperative Molecular Imaging of Cancer.

Purpose: Lymph node(LN) dissection is part of most oncologic resections. Intraoperatively identifying a positive LN(+ LN), that harbors malignant cells, can be challenging. We hypothesized that intraoperative molecular imaging(IMI) using a cancer-targeted fluorescent prober can identify + LNs. This study aimed to develop a preclinical model of a + LN and test it using an activatable cathepsin-based enzymatic probe, VGT-309. Procedures: In the first model, we used peripheral blood mononuclear cells (PBMC), representing the lymphocytic composition of the LN, mixed with different concentrations of human lung adenocarcinoma cell line A549. Then, they were embedded in a Matrigel® matrix. A black dye was added to mimic LN anthracosis. Model two was created using a murine spleen, the largest lymphoid organ, injected with various concentrations of A549. To test these models, we co-cultured A549 cells with VGT-309. Mean fluorescence intensity(MFI) was. An independent sample t-test was used to compare the average MFI of each A549:negative control ratio. Results: A significant difference in MFI from our PBMC control was noted when A549 cells were 25% of the LN (p = 0.046) in both 3D cell aggregate models-where the LNs native parenchyma is replaced and the one where the tumor grows over the native parenchyma. For the anthracitic equivalents of these models, the first significant MFI compared to the control was when A549 cells were 9% of the LN (p = 0.002) in the former model, and 16.7% of the LN (p = 0.033) in the latter. In our spleen model, we first noted significance in MFI when A549 cells were 16.67% of the cellular composition.(p = 0.02). Conclusions: A + LN model allows for a granular evaluation of different cellular burdens in + LN that can be assessed using IMI. This first exvivo + LN model can be used in preclinical testing of several existing dyes and in creating more sensitive cameras for IMI-guided LN detection.

Intraoperative molecular imaging: 3rd biennial clinical trials update.

Significance: This third biennial intraoperative molecular imaging (IMI) conference shows how optical contrast agents have been applied to develop clinically significant endpoints that improve precision cancer surgery. Aim: National and international experts on IMI presented ongoing clinical trials in cancer surgery and preclinical work. Previously known dyes (with broader applications), new dyes, novel nonfluorescence-based imaging techniques, pediatric dyes, and normal tissue dyes were discussed. Approach: Principal investigators presenting at the Perelman School of Medicine Abramson Cancer Center's third clinical trials update on IMI were selected to discuss their clinical trials and endpoints. Results: Dyes that are FDA-approved or currently under clinical investigation in phase 1, 2, and 3 trials were discussed. Sections on how to move benchwork research to the bedside were also included. There was also a dedicated section for pediatric dyes and nonfluorescence-based dyes that have been newly developed. Conclusions: IMI is a valuable adjunct in precision cancer surgery and has broad applications in multiple subspecialties. It has been reliably used to alter the surgical course of patients and in clinical decision making. There remain gaps in the utilization of IMI in certain subspecialties and potential for developing newer and improved dyes and imaging techniques.

Single-institution experience of 500 pulmonary resections guided by intraoperative molecular imaging.

OBJECTIVE: Intraoperative molecular imaging (IMI) using tumor-targeted optical contrast agents can improve thoracic cancer resections. There are no large-scale studies to guide surgeons in patient selection or imaging agent choice. Here, we report our institutional experience with IMI for lung and pleural tumor resection in 500 patients over a decade. METHODS: Between December 2011 and November 2021, patients with lung or pleural nodules undergoing resection were preoperatively infused with 1 of 4 optical contrast tracers: EC17, TumorGlow, pafolacianine, or SGM-101. Then, during resection, IMI was used to identify pulmonary nodules, confirm margins, and identify synchronous lesions. We retrospectively reviewed patient demographic data, lesion diagnoses, and IMI tumor-to-background ratios (TBRs). RESULTS: Five hundred patients underwent resection of 677 lesions. We found that there were 4 types of clinical utility of IMI: detection of positive margins (n = 32, 6.4% of patients), identification of residual disease after resection (n = 37, 7.4%), detection of synchronous cancers not predicted on preoperative imaging (n = 26, 5.2%), and minimally invasive localization of nonpalpable lesions (n = 101 lesions, 14.9%). Pafolacianine was most effective for adenocarcinoma-spectrum malignancies (mean TBR, 2.84), and TumorGlow was most effective for metastatic disease and mesothelioma (TBR, 3.1). False-negative fluorescence was primarily seen in mucinous adenocarcinomas (mean TBR, 1.8), heavy smokers (>30 pack years; TBR, 1.9), and tumors greater than 2.0 cm from the pleural surface (TBR, 1.3). CONCLUSIONS: IMI may be effective in improving resection of lung and pleural tumors. The choice of IMI tracer should vary by the surgical indication and the primary clinical challenge.

Mucins as contrast agent targets for fluorescence-guided surgery of pancreatic cancer.

Pancreatic cancer is difficult to resect due to its unique challenges, often leading to incomplete tumor resections. Fluorescence-guided surgery (FGS), also known as intraoperative molecular imaging and optical surgical navigation, is an intraoperative tool that can aid surgeons in complete tumor resection through an increased ability to detect the tumor. To target the tumor, FGS contrast agents rely on biomarkers aberrantly expressed in malignant tissue compared to normal tissue. These biomarkers allow clinicians to identify the tumor and its stage before surgical resection and provide a contrast agent target for intraoperative imaging. Mucins, a family of glycoproteins, are upregulated in malignant tissue compared to normal tissue. Therefore, these proteins may serve as biomarkers for surgical resection. Intraoperative imaging of mucin expression in pancreatic cancer can potentially increase the number of complete resections. While some mucins have been studied for FGS, the potential ability to function as a biomarker target extends to the entire mucin family. Therefore, mucins are attractive proteins to investigate more broadly as FGS biomarkers. This review summarizes the biomarker traits of mucins and their potential use in FGS for pancreatic cancer.

Prospective validation of tumor folate receptor expression density with the association of pafolacianine fluorescence during intraoperative molecular imaging-guided lung cancer resections.

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/FRß 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 FRß 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 FRß staining intensities were both 1.5 for benign tumors, while the FRα and FRß 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 FRß 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.

Effects of Light-absorbing Carbons in Intraoperative Molecular Imaging-Guided Lung Cancer Resections.

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.

Evaluation of OTL38-Generated Tumor-to-Background Ratio in Intraoperative Molecular Imaging-Guided Lung Cancer Resections.

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.

Three-Dimensional Near-Infrared Specimen Mapping Can Identify the Distance from the Tumor to the Surgical Margin During Resection of Pulmonary Ground Glass Opacities.

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.

Cathepsin detection to identify malignant cells during robotic pulmonary resection.

Background: Intraoperative molecular imaging (IMI) uses a fluorescent probe to identify occult cancers. VGT-309 is a quenched activity-based probe that is activated in the presence of cathepsins, enzymes overexpressed in cancer cells, and detected by near-infrared (NIR) light. This study aims to evaluate the sensitivity and the positive predictive value (PPV) of robotic-assisted thoracic surgery (RATS) with intraoperative molecular imaging (RIMI) using VGT-309 to localize tumors using NIR light to detect areas with increased cathepsin activity. Our secondary outcome was to compare RIMI to video-assisted thoracic surgery (VATS) with intraoperative molecular imaging (VIMI). Methods: In a phase 2 clinical trial at the University of Pennsylvania, patients (n=10) with suspicious pulmonary lesions underwent RATS. First, white light was used followed by RIMI to identify tissues with increased cathepsin activity. Then, VIMI was performed to compare the sensitivity and PPV in identifying the cathepsin activity. The resected specimens were then evaluated for fluorescence and underwent histopathological analysis for cathepsin expression. Image analysis was performed using ImageJ software. Statistical analysis was conducted using IBM SPSS Statistics software. A P value of 0.05 or less was considered significant. Results: RATS with white light identified 6 out of the 10 pulmonary nodules, whereas adding RIMI identified an additional 4 more pulmonary nodules. RIMI and VIMI were able to detect the same 8/10 (80%) nodules. The addition of VIMI did not identify any lesions that RIMI may have missed. The mean fluorescence intensity of tumors visualized by RIMI was 115.81 A.U. [standard deviation (SD) =58.57] compared to 95.6 A.U. (SD =14.81) by VIMI (P=0.41). The mean tumor-to-background ratios (TBR) of tumors visualized by RIMI was 9.20 (SD =9.12) compared to 2.29 A.U. (SD =1.11) using VIMI (P=0.1). The sensitivity of RIMI and VIMI was 88.9% which was superior to that of RATS (55.6%). The PPV of RATS was 83.3% compared to 100% in RIMI and VIMI. Conclusions: RIMI is a valuable option for visualization of occult disease using VGT-309-guided IMI through identifying areas of increased cathepsin activity. In this small series, RIMI and VIMI showed clinical equivalence in sensitivity and PPV of detecting cathepsin activity.

Novel intraoperative near-infrared imaging strategy to identify abnormalities in the anterior mediastinum.

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.

Intraoperative identification of pulmonary nodules during minimally invasive thoracic surgery: a narrative review.

Background and Objective: The increasingly widespread application of computed tomography (CT) in the screening and follow-up of patients with lung disease has concomitantly increased the detection rate of pulmonary nodules. Currently, minimally invasive thoracic surgery (MITS) has become the preferred method of surgery for patients with pulmonary ground-glass nodules (GGNs) due to its advantages minimal invasiveness and rapid recovery. However, target nodule identification during MITS is sometimes challenging due to the inherent characteristics of these nodules, especially when they are small and distant from the pleura. This review details the many methods used for the intraoperative localization of pulmonary nodules. Methods: Literature published in the Cochrane Library, PubMed, ClinicalTrials, and China National Knowledge Infrastructure from 1990 to 2022 were searched and analyzed to obtain a comprehensive review of the different methods of identifying pulmonary nodules. Literature related to animal testing were excluded. Key Content and Findings: An overview of the recent progress in the clinical methods for intraoperative localization of pulmonary nodules [including CT-guided percutaneous placement of markers; bronchoscopy-guided placement of markers; intraoperative ultrasonography; three-dimensional (3D) printing technology; artificial intelligence (AI); and intraoperative molecular imaging (IMI)] was conducted. The advantages and disadvantages, as well as the complications associated with existing research methods, were summarized to assist doctors in the development of optimized clinical strategies. Conclusions: Clinicians can communicate with the multidisciplinary team and select the appropriate positioning method according to each patient's individual situation and the available support of the equipment and technology of the institution. Certain non-invasive and specific identification methods may have clinical potential in pulmonary nodule localization in the future.

Intraoperative Molecular Imaging of Lung Cancer: A Review.

Intraoperative molecular imaging shows great promise in the surgical treatment of lung cancer, in particular tumor localization, margin assessment, identification of additional nodules, and even potentially lymph node assessment. Advances in imaging agents and fluorescence surgical cameras will be the key. Although no imaging agent is currently Food and Drug Administration approved, targeted, near-infrared agents such as OTL38 are in phase III trials.

The current status and future prospects for molecular imaging-guided precision surgery.

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.