Intraoperative Tumor Detection Using Pafolacianine

Abstract

Cancer is a leading cause of death worldwide, with increasing numbers of new cases each year. For the vast majority of cancer patients, surgery is the most effective procedure for the complete removal of the malignant tissue. However, relapse due to the incomplete resection of the tumor occurs very often, as the surgeon must rely primarily on visual and tactile feedback. Intraoperative near-infrared imaging with pafolacianine is a newly developed technology designed for cancer detection during surgery, which has been proven to show excellent results in terms of safety and efficacy. Therefore, pafolacianine was approved by the U.S. Food and Drug Administration (FDA) on 29 November 2021, as an additional approach that can be used to identify malignant lesions and to ensure the total resection of the tumors in ovarian cancer patients. Currently, various studies have demonstrated the positive effects of pafolacianine's use in a wide variety of other malignancies, with promising results expected in further research. This review focuses on the applications of the FDA-approved pafolacianine for the accurate intraoperative detection of malignant tissues. The cancer-targeting fluorescent ligands can shift the paradigm of surgical oncology by enabling the visualization of cancer lesions that are difficult to detect by inspection or palpation. The enhanced detection and removal of hard-to-detect cancer tissues during surgery will lead to remarkable outcomes for cancer patients and society, specifically by decreasing the cancer relapse rate, increasing the life expectancy and quality of life, and decreasing future rates of hospitalization, interventions, and costs.

Keywords: fluorescent imaging; folate receptor; intraoperative; near-infrared spectrum; pafolacianine; tumor detection.

Figure 1

Overexpression of FRα in different types of malignancies. (created based on the information from references [11,12,13,14,15,16,17,18,19,20,21,22]).

Figure 2

Mechanism of the pafolacianine-based intraoperative detection of tumors. (A) Pafolacianine is intravenously administered within a couple of hours before the surgery. As the agent circulates through the blood flow, only the tissues that overexpress FRα capture the dye. FRα upregulation in ovarian cancer lesions enables the binding of pafolacianine and near-infrared fluorescence imaging during surgery. (B) Pafolacianine binds FRα overexpressed in ovarian cancer tumors. The dye accumulates in the cells via endocytosis [6].