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Intraoperative molecular imaging with pafolacianine as an adjunct for localization and surgical management of semi-solid and ground glass opacities
Ryan Levy1, Nicholas Baker2, Tadeusz Witek1, Omar Awais1, Navid Ajabshir1, Thomas Melvin1, Evan T. Alicuben1
1Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States, 2Cardiothoracic Surgery, West Virginia University, Morgantown, West Virginia, United States
Objectives: Intraoperative molecular imaging (IMI) can improve the localization of semi solid and ground glass opacities and enhance the ability to perform sublobar resection. This report encompasses our experience following the integration of a folate receptor (FR)-targeted fluorescent agent into a minimally invasive thoracic surgery practice for purposes of the management of ground glass and semi solid lesions.
Methods: Cases from June 2023 through October 2024 were reviewed to identify all patients with one or more semi solid or ground glass opacity with plans for sublobar pulmonary resection. Pafolacianine infusion was performed within 24 hours of surgery. Pre-operative CT scan were used to determine lesion size and depth. The lung was inspected for fluorescence using a proprietary imaging system.
Results: There were 42 patients (28 females, 14 males, mean age 69 years) encompassing 53 separate lesions. The median lesion size was 14 mm (range 6-32 mm) and depth was 3 mm (range 1-27 mm). Minimally invasive (robotic n=20 VATS n=22) resection was performed in all patients (segmentectomy n=13, wedge resection n=19, segmentectomy and wedge resection n=3, lobectomy n=4). In 40.4% (17/42) of patients, the target lesions were not detectable under visual inspection with white light but were visualized with IMI. Lesion depth was higher in lesions not visualized with IMI compared to those that were (11.6 mm vs. 5.2 mm, p=0.008). Final histology demonstrated malignancy in 86.7% (46/53). Benign lesions included granuloma and parenchymal scar. All final margins were negative.
Conclusions: This is the first report of experience with pafolacianine for cancer in the lung with a specific focus on localization of semi solid and ground glass opacities. These data reflect a meaningful practice change for the surgical management of these often hard to localize, small and multifocal lesions. Moreover, the use of IMI during resection of these early stage lung cancers enhances the ability to perform sublobar, parenchymal sparing resections.
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