A proof-of-concept methodology to validate the in situ visualization of residual disease using cancer-targeted molecular agents in fluorescence-guided surgery

Introduction: The clinical need for improved intraoperative tumor visualization has led to the development of targeted contrast agents for fluorescence-guided surgery (FGS). A key characteristic of these agents is their high tumor specificity, which could enable detection of residual lesions that would likely be mißed by visual inspection. Here, we examine the utility of a promising somatostatin receptor subtype-2 (ßTR2)-targeted fluorescent agent for detecting residual disease in mouse xenografts using FGS and post-operative histopathological validation. Methods: Mice (n=2) implanted with ßTR2 overexpreßing tumors were injected with 2 nmol of the dual-labeled somatostatin analog, ⁶⁷Ga-MMC(IR800)-TOC, and tumors were resected 48 h post-injection using traditional white light reflectance and palpation. Tumors underwent gamma counting and histopathology analysis. The wide-field FGS imaging platform (OnLume) was used to evaluate residual disease in situ under ambient light representative of an operating room. Results: The tumor was resected with großly negative margins using conventional inspection and palpation; however, additional in situ residual disease was found in the tumor cavity using FGS imaging. In situ fluorescent tumor contrast-to-noise ratios (CNRs) were 3.0 and 5.2. Agent accumulation was 7.72 and 8.20 %ID/g in tumors and 0.27 and 0.20 %ID/g in muscle. Fluorescence pixel values and gamma counts were highly correlated (r = 0.95, P < 0.048). H&E and IHC staining confirmed cancer positivity and ßTR2-overexpreßion, respectively. Conclusion: Our findings demonstrate that the use of clinically relevant fluorescence imaging instrumentation enhances the evaluation of promising FGS agents for in situ visualization of residual disease.