Molecular fluorescence-guided surgery of peritoneal carcinomatosis of colorectal origin: A narrative review

Abstract

Patients with peritoneal carcinomatosis (PC) from colorectal origin may undergo cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) as a curative approach. One major prognostic factor that affects survival is completeness of cytoreduction. Molecular Fluorescence Guided Surgery (MFGS) is a novel intraoperative imaging technique that may improve tumor identification in the future, potentially preventing over- and under-treatment in these patients. This narrative review outlines a chronological overview of MFGS development in patients with PC of colorectal origin.

Keywords: colorectal cancer; molecular fluorescence-guided surgery; peritoneal carcinomatosis; review.

Figure 1

Concept of molecular fluorescence guided surgery (MFGS). Prior to surgery a fluorescent target tracer is injected intravenously (A). During the operation the surgeon will receive real‐time feedback by a molecular fluorescence camera in the detection tumor tissue (B). Unpublished figure from previously published study Harlaar et al107

Figure 2

Intraoperative imaging with white‐light, NIR fluorescence and the overlay of both. Intraoperative imaging of a patient with PC of colorectal origin following intravenous administration of 4.5 mg of the fluorescent tracer bevacizumab‐800CW targeting VEGF‐A. A white‐light image (A), NIR fluorescence image (B), and overlay of both (C) clearly show fluorescent signals at the location of a clinically suspect peritoneal lesion. Back‐table imaging directly after surgery of a different peritoneal lesion of the same patient is depicted (D‐F). Both peritoneal lesions proved to be tumor metastasis upon final histopathology. Unpublished figures from previously published study Harlaar et al.107

Figure 3

Fluorescence imaging probes. Overview of fluorescent imaging probes with different mechanisms of action. The effect of non‐targeted fluorescent probes is based on tissue distribution by perfusion (A), whereas antibody‐based (B), peptide‐based (C), and small molecule‐ based (D) imaging enables targeted fluorescence imaging through binding to specific receptors or proteins overexpressed by the tumor. Smart activatable fluorescent probes are activated upon cleavage by specific enzymes or proteases secreted by the tumor (E), whereas pH activated probes becomes fluorescent through a change in molecular structure due to the characteristic acidotic environment of a tumor (F)