Image demonstrating identification of cancer cells during TumorGlow fluorescent-guided surgery.
Figure 1: A small lesion (0.7 cm) appears under near-infrared light in the lower left lobe of a patient thought to have Stage IA pulmonary adenocarcinoma. The lesion was undetected by PET/CT scan and visual examination; this patient was subsequently re-staged to stage IIIA.

At Penn Medicine, surgeons are using TumorGlow®, a molecular imaging technology, to prevent cancer recurrence by improving the detection of residual cancer cells during surgery.

Complete surgical resection is substantially more effective than chemotherapy or radiation therapy as a treatment for almost all solid tumors. Moreover, surgery is the most important predictor of long-term survival in cancer patients in the United States. However, the overall success of cancer surgery is diminished by local recurrence in up to a third of patients.

Recurrence is typically due to malignant cells that remain in the surgical field even when the algorithm for their eradication involves meticulous resection at the surgical margins, excision of both involved lymph nodes and satellite lesions, and the use of intraoperative frozen sectioning by pathologists to ensure the complete eradication of cancer during surgery. That these efforts so often fail demonstrates the challenge of identifying invasive and occult cancer cells through traditional observation and palpation during surgery. 

To improve the long-term efficacy of cancer surgery, thoracic surgeons and radiation oncologists at Penn Medicine are using TumorGlow®, an intraoperative imaging system developed at Penn Medicine, to visually enhance residual cancer cells and the abnormal tissue densities typical of malignant lesions. These systems use fluorescent contrast dyes that have an organic tropism for cancer cells. Once absorbed, these agents glow under certain lighting conditions, permitting lesions and cancerous cells to be identified and readily removed.

Using TumorGlow® in separate applications during surgery, the team at Penn Medicine has identified nodules as deep as 1.3 cm from the surface of solid organs and as small as 0.2 cm in size, as well as nodules in organs other than that of the primary tumor. In addition, cancer cells that are invisible to optical observation have been identified at the margins of surgery in lung cancer patients.

CASE STUDY

Mrs. M, a 64-year-old woman, was referred to Penn Thoracic Surgery for evaluation following six-months of persistent cough and bronchial irritation. A non-smoker, Mrs. M’s medical history was unremarkable.

However, a chest X-ray at Penn revealed a mass (>3.5 cm) in the upper lobe of her left lung in close proximity to the pleura. A PET/CT scan found no evidence of spread to nearby lymph nodes or metastases. A transthoracic needle aspiration biopsy of the mass revealed malignant cells, and a histological analysis identified a moderately-differentiated cancer with clear cell features consistent with a primary pulmonary adenocarcinoma.

Cytogenetic analysis for EGFR/Kras mutations and ALK rearrangement was negative; there was no evidence of metastases. Mrs. M’s cancer was classified as a surgically resectable Stage IA pulmonary adenocarcinoma. After a consultation, she provided informed consent for surgery with TumorGlow®.

Prior to her procedure, Mrs. M had CT scanning. The scan was reviewed by a radiologist to confirm the presence of a solitary pulmonary nodule. Twenty-four hours prior to surgery, an intravenous contrast agent was administered.

During surgery, the primary nodule was identified by visual inspection and manual palpation. Following an examination of the ipsilateral lung that found no other lesions, the operating room lights were removed, and the near-infrared spectroscopy (NIR) imaging system was sterilely draped and positioned above Mrs. M’s chest.

The primary nodule was imaged and photo-documented by white light and fluorescence. Using the TumorGlow® system, a single small (0.7 cm)lesion was then found in the lower lobe of the left lung (Figure 1) close to the pleural surface, as well as two lymph nodes near the primary tumor. Both lesions and the lymph nodes were removed and re-imaged for confirmation in the operating room before being submitted to pathology.

Mrs. M’s cancer was then re-staged to stage IIIA.Mrs. M remained in the hospital for two days following her surgery and was discharged home, where her recovery was unremarkable.Subsequently, she received adjuvant chemotherapy and radiation therapy without significant morbidity. At her six-month and one-year follow-up visits,X-rays and CT/PET scans found no evidence of recurrent cancer.

ACCESS

Penn Thoracic Surgery Perelman
Perelman Center for Advanced Medicine
West Pavilion, 1st Floor
3400 Civic Center Boulevard
Philadelphia, PA 19104

Abramson Cancer Center Perelman 2nd Floor West
Perelman Center for Advanced Medicine
West Pavilion, 2nd Floor
3400 Civic Center Boulevard
Philadelphia, PA 19104

Penn Thoracic Surgery Presbyterian
Penn Medicine University City
4th Floor
3737 Market Street
Philadelphia, PA 19104

Penn Thoracic Surgery Pennsylvania Hospital
Pennsylvania Hospital
Farm Journal Building, 2nd Floor
230 West Washington Square
Philadelphia, PA 19106

Published on: December 15, 2016

Penn Faculty Team

Edward Cantu, III, MD

Associate Professor of Surgery at the Hospital of the University of Pennsylvania

Keith Cengel, MD, PhD

Director, Photodynamic Therapy Program

Executive Director, Penn Mesothelioma and Pleural Diseases Program

Associate Professor of Radiation Oncology at the Hospital of the University of Pennsylvania

John P. Christodouleas, MD

Service Line Liaison, Genitourinary Service, Radiation Oncology

Adjunct Assistant Professor of Radiation Oncology

Colleen B. Gaughan, MD

Assistant Professor of Clinical Surgery

Andrew R. Haas, MD, PhD

Bronchoscopy Director, Hospital of the University of Pennsylvania

Director, Section of Interventional Pulmonology and Thoracic Oncology

Associate Professor of Medicine at the Hospital of the University of Pennsylvania

Doraid Jarrar, MD, FACS, FCCP

Assistant Professor of Clinical Surgery

John C. Kucharczuk, MD

Chief, Division of Thoracic Surgery

Associate Professor of Surgery at the Hospital of the University of Pennsylvania and the Presbyterian Medical Center of Philadelphia and the Pennsylvania Hospital

Corey J. Langer, MD

Director, Thoracic Oncology

Professor of Medicine at the Hospital of the University of Pennsylvania

Taine T.V. Pechet, MD

Chief of Surgery, Penn Presbyterian Medical Center

Associate Professor of Clinical Surgery

Sunil Singhal, MD

Director, Thoracic Surgery Research Laboratory

William Maul Measey Associate Professor in Surgical Research

Anil Vachani, MD

Director of Clinical Research, Section of Interventional Pulmonary and Thoracic Oncology

Associate Professor of Medicine at the Hospital of the University of Pennsylvania and the Veteran's Administration Medical Center

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