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Folate receptor-targeted molecular imaging improves identification of malignancy during pulmonary resection: a case report.

ABSTRACT: BACKGROUND:During minimally invasive pulmonary resection, both limited visualization and tactile feedback can make localization of pulmonary nodules and assessment for synchronous disease challenging. Intraoperative molecular imaging is an emerging technology that can enhance a surgeon's ability to detect cancers at the time of resection. CASE PRESENTATION:In this report, we describe the application of a folate receptor-targeted, near infrared optical contrast agent (OTL38) for the detection of an invasive pulmonary adenocarcinoma. During molecular imaging, an otherwise undetectable synchronous nodule was also identified. This finding resulted in intraoperative upstaging and operative plan modifications. CONCLUSION:This report marks the first successful utilization of a targeted, near infrared intraoperative molecular imaging probe useful for thoracic malignancies. This rapidly evolving technology may enhance the surgeon's ability to perform a number of oncologic procedures including tumor localization, margin assessment and intraoperative staging.

SUBMITTER: Predina JD

PROVIDER: S-EPMC5716373 | biostudies-literature | 2017 Dec

REPOSITORIES: biostudies-literature

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Folate receptor-targeted molecular imaging improves identification of malignancy during pulmonary resection: a case report.

Predina Jarrod D JD Newton Andrew A Connolly Courtney C Singhal Sunil S

Journal of cardiothoracic surgery 20171204 1

<h4>Background</h4>During minimally invasive pulmonary resection, both limited visualization and tactile feedback can make localization of pulmonary nodules and assessment for synchronous disease challenging. Intraoperative molecular imaging is an emerging technology that can enhance a surgeon's ability to detect cancers at the time of resection.<h4>Case presentation</h4>In this report, we describe the application of a folate receptor-targeted, near infrared optical contrast agent (OTL38) for th ...[more]

PMID: 29202877

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Project description:PURPOSE:Intraoperative localization and resection of ill-defined pulmonary ground-glass opacities (GGOs) during minimally invasive pulmonary resection is technically challenging. Current preoperative techniques to facilitate localization of GGOs include microcoil and hook wire placement, both of which have logistic limitations, carry safety concerns, and do not help with margin assessment. In this clinical trial, we explored an alternative method involving near-infrared molecular imaging with a folate receptor-targeted agent, OTL38, to improve localization of GGOs and confirmation of resection margins. METHODS:In a human trial, 20 subjects with pulmonary GGOs who were eligible for video-assisted thoracoscopic surgery (VATS) resection received 0.025 mg/kg of OTL38 before the resection. The primary objectives were to (1) determine whether use of OTL38 allows safe localization of GGOs and assessment of margins during VATS and (2) determine patient, radiographic, and histopathologic variables that predict the amount of fluorescence during near-infrared imaging. RESULTS:We observed no toxicity. Of the 21 GGOs, 20 accumulated OTL38 and displayed fluorescence upon in situ or back table evaluation. Intraoperatively, near-infrared imaging localized 15 of 21 lesions whereas VATS alone localized 10 of 21 (p = 0.05). The addition of molecular imaging affected care of nine of 21 subjects by improving intraoperative localization (n = 6) and identifying close margins (n = 3). This approach was most effective for subpleural lesions measuring less than 2 cm. For lesions deeper than 1.5 cm from the pleural surface, intraoperative localization using fluorescent feedback was limited. CONCLUSIONS:This approach provides a safe alternative for intraoperative localization of small, peripherally located pulmonary lesions. In contrast to alternative localization techniques, use of OTL38 also allows confirmation of adequate margins. Future studies will compare this approach to alternative localization techniques in a clinical trial.

Project description:BackgroundPhyllodes tumours (PTs) are fibroepithelial breast tumours, which can be classified as benign, borderline or malignant, according to their histological characteristics. While various huge borderline or malignant PTs have been previously described, a benign PT with a pulmonary nodule mimicking malignancy has not yet been reported. In order that doctors may have a comprehensive understanding of super-giant benign PTs (≥ 20 cm), we also performed a literature review to summarize the clinical features, differential diagnosis, and treatment of this disease.Case summaryA 42-year-old woman with severe anaemia presented with a rapidly enlarging right breast mass, measuring approximately 30 cm × 25 cm × 20 cm that was first noticed 1 year previously. A region of skin ulceration and necrosis (20 cm × 15 cm) was observed on the lateral side of the mass. Computed tomography (CT) of the chest revealed a pulmonary nodule, which initially suggested a diagnosis of metastasis. CT showed that the boundaries between the pectoralis major and the mass were blurred, which was presumed to be due to tumour invasion. However, two core needle biopsies of the mass showed no evidence of malignancy. Following these results, the tumour was removed by mastectomy of the right breast. Interestingly, postoperative pathology finally proved the diagnosis of a benign PT. After 1 year of follow-up, wedge resection of the small pulmonary nodule was performed, and it was confirmed that the lung nodule was actually adenocarcinoma rather than metastatic breast cancer. The patient recovered very well without any postoperative treatment.ConclusionThis case is unique in that the giant breast mass initially mimicking a malignant clinical presentation was eventually pathologically confirmed to be a benign PT, which misled the diagnosis and complemented the atypical features of benign PTs. The pathological and immunohistochemical results were important in the differential diagnosis. In addition, total mastectomy should be recommended due to difficulty in the precise diagnosis of PTs, especially in large breast masses. In the literature, almost one-half of super-giant benign cases were thought to be malignant tumours before surgery. This finding is a reminder to consider all conditions in order to make an accurate diagnosis and avoid excessive treatment.

Project description:BackgroundHemangioblastomas are benign (World Health Organization Grade I), highly vascular neoplasms commonly associated with Von Hippel-Lindau (VHL) disease.[2] The VHL tumor-suppressor gene, located on chromosome 3, is implicated in sporadic cases and cases associated with VHL disease. Hemangioblastomas most commonly arise in the posterior fossa; however, they may also be found supratentorially or within the spinal cord.[3] Surgical intervention is indicated for symptomatic lesions with a goal of complete resection of the enhancing nodule.[1].Case descriptionWe demonstrate the case of a 69-year-old man with a history of multiple hemangioblastomas who had undergone two previous craniotomies and Gamma-Knife radiosurgery (Video https://drive.google.com/file/d/1lUwsb80NLmIW2Enp-DVdtM9_Oqbid3Ih/view?usp=sharing). He presented with progressive imbalance and diplopia and was found to have a new lesion within the suprasellar cistern. Digital subtraction angiography (DSA) and magnetic resonance imaging (MRI) characteristics were typical of hemangioblastoma. Surgery was determined to be indicated, with a goal of vision preservation. Preoperative embolization was not possible because preoperative DSA demonstrated vascular supply by only small perforators directly from the internal carotid artery. Hypopituitarism was identified preoperatively, although diabetes insipidus was not present. The patient underwent a right orbitozygomatic craniotomy and extradural anterior clinoidectomy for access. The tumor was noted to encapsulate the infundibulum, which necessitated its sacrifice. Postoperatively, the patient remained at his neurologic baseline. He had a positive triphasic diabetes insipidus response and was discharged home on maintenance desmopressin. Postoperative MRI demonstrated complete lesion resection.The patient gave informed consent for treatment and video recording. Institutional review board approval was deemed unnecessary.ConclusionThis video highlights a safe and effective surgical technique for suprasellar lesions as well as the complex anatomy observed through an orbitozygomatic approach.

Dataset Information

Folate receptor-targeted molecular imaging improves identification of malignancy during pulmonary resection: a case report.

Publications

Folate receptor-targeted molecular imaging improves identification of malignancy during pulmonary resection: a case report.

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