Intraoperative Identification Research Articles

Bevacizumab-IRDye800CW for tumor detection in fluorescence-guided meningioma surgery (LUMINA trial): a single-center phase I study.

Meningiomas are one of the most frequently occurring brain tumors and can be curatively treated with gross-total resection. A subtotal resection increases the chances of recurrence. The intraoperative identification of invisible tumor remnants by using a fluorescent tracer targeting an upregulated biomarker could help to optimize meningioma resection. This is called molecular fluorescence-guided surgery (MFGS). Vascular endothelial growth factor α (VEGFα) has been identified as a suitable meningioma biomarker and can be targeted with bevacizumab-IRDye800CW. The aim of this prospective phase I trial was to determine the safety and feasibility of bevacizumab-IRDye800CW for MFGS for intracranial meningiomas by administering 4.5, 10, or 25 mg of the tracer 2-4 days prior to surgery. Fluorescence was verified during the operation with the standard neurosurgical microscope, and tissue specimens were postoperatively analyzed with fluorescence imaging systems (Pearl and Odyssey CLx) and spectroscopy to determine the optimal dose. Uptake was compared in several tissue types and correlated with VEGFα expression. No adverse events related to the use of bevacizumab-IRDye800CW occurred. After two interim analyses, 10 mg was the optimal dose based on ex vivo tumor-to-background ratio. Although the standard intraoperative imaging revealed no fluorescence, postoperative analyses with tailored imaging systems showed high fluorescence uptake in tumor compared with unaffected dura mater and brain. Additionally, tumor invasion of the dura mater (dural tail) and invasion of bone could be distinguished using fluorescence imaging. Fluorescence intensity showed a good correlation with VEGFα expression. Bevacizumab-IRDye800CW can be safely used in patients with meningioma; 10 mg bevacizumab-IRDye800CW provided an adequate tumor-to-background ratio. Adjustments of the currently available neurosurgical microscopes are needed to achieve visualization of targeted IRDye800CW intraoperatively. A phase II/III trial is needed to methodically investigate the benefit of MFGS with bevacizumab-IRDye800CW for meningioma surgery in a larger cohort of patients.

Enhancing Intraoperative Tissue Identification: Investigating a Smart Electrosurgical Knife's Functionality During Electrosurgery.

Detecting the cancerous growth margin and achieving a negative margin is one of the challenges that surgeons face during cancer procedures. A smart electrosurgical knife with integrated optical fibers has been designed previously to enable real-time use of diffuse reflectance spectroscopy for intraoperative margin assessment. In this paper, the thermal effect of the electrosurgical knife on tissue sensing is investigated. Porcine tissues and phantoms were used to investigate the performance of the smart electrosurgical knife after electrosurgery. The fat-to-water content ratio (F/W-ratio) served as the discriminative parameter for distinguishing tissues and tissue mimicking phantoms with varying fat content. The F/W-ratio of tissues and phantoms was measured with the smart electrosurgical knife before and after 14 minutes of electrosurgery. Additionally, a layered porcine tissue and phantom were sliced and measured from top to bottom with the smart electrosurgical knife. Mapping the thermal activity of the electrosurgical knife's electrode during animal tissue electrosurgery revealed temperatures exceeding 400 °C. Electrosurgery for 14 minutes had no impact on the device's accurate detection of the F/W-ratio. The smart electrosurgical knife enables real-time tissue detection and predicts the fat content of the next layer from 4 mm ahead. The design of the smart electrosurgical knife outlined in this paper demonstrates its potential utility for tissue detection during electrosurgery. In the future, the smart electrosurgical knife could be a valuable intraoperative margin assessment tool, aiding surgeons in detecting tumor borders and achieving negative margins.

Testosterone therapy at the time of vasectomy reversal: Impact on intraoperative decision-making and interpretation of postoperative outcomes.

During vasectomy reversal (VR), accurate intraoperative microscopic assessment of the vasal fluid for sperm presence and quality is essential in determining the indication for a vasovasostomy (VV) or vasoepididymostomy (VE). The use of testosterone therapy (TT), known to supress spermatogenesis, can potentially interfere with this determination. This initiative evaluated the impact of TT on vasal and epididymal fluid sperm characteristics and intraoperative decision-making among men on TT at the time of VR. Of 2622 consecutive VRs performed from 2007-2023, patients actively using TT at the time of VR were identified. Details as to the type, dose, and duration of TT were documented. All patients were counselled regarding the impact of TT on spermatogenesis and encouraged to discontinue TT if possible. During VR, vasal and epididymal fluid (as indicated) was sampled and each aspirate underwent microscopic evaluation for sperm presence and quality, and categorized as: motile sperm/intact-non-motile sperm/sperm parts/no sperm. Rates of sperm presence/absence in the vasal/epididymal fluid, frequency of VV/VE, postoperative patency (presence of motile sperm), and semen parameters were compared among patients on TT vs. clinically matched patients not using TT at the time of VR. Among the 2622 VRs reviewed, 54 men (2%) reported using TT at the time of their VR. Despite its impact on spermatogenesis, intraoperative microscopic analysis of the reproductive fluid (vasal or epididymal) identified the presence of sperm in 95% (51/54) of patients. Testis biopsy confirmed sperm production among three patients with absence of sperm within the vasal or epididymal fluid. Rates of VV or VE did not significantly differ among men using TT at the time of VR compared to nonusers. Postoperative patency rates (TT: 78 % vs. no TT: 93%) and mean total motile sperm counts (TMC) were lower among patients using TT at the time of VR (7.9 vs. 28.3, p=0.02). Use of TT at the time of VR does not appear to impact rates of intraoperative microscopic identification of sperm within the reproductive fluid or the indication for VV/VE. Postoperative patency rates and total motile sperm counts may be lowered by use of TT. Moreover, the determination to the etiology azoospermia postoperatively (production vs. obstruction) may be clouded by the use of TT during VR.

A Minimally Invasive Robotic Tissue Palpation Device.

Robot-assisted minimally invasive surgery remains limited by the absence of haptic feedback, which surgeons routinely rely on to assess tissue stiffness. This limitation hinders surgeons' ability to identify and treat abnormal tissues, such as tumors, during robotic surgery. To address this challenge, we developed a robotic tissue palpation device capable of rapidly and non-invasively quantifying the stiffness of soft tissues, allowing surgeons to make objective and data-driven decisions during minimally invasive procedures. We evaluated the effectiveness of our device by measuring the stiffness of phantoms as well as lung, heart, liver, and skin tissues obtained from both rats and swine. Results demonstrated that our device can accurately determine tissue stiffness and identify tumor mimics. Specifically, in swine lung, we determined elastic modulus (E) values of 9.1 ± 2.3, 16.8 ± 1.8, and 26.0 ± 3.6 kPa under different internal pressure of the lungs (PIP) of 2, 25, and 45 cmH2O, respectively. Using our device, we successfully located a 2-cm tumor mimic embedded at a depth of 5 mm in the lung subpleural region. Additionally, we measured E values of 33.0 ± 5.4, 19.2 ± 2.2, 33.5 ± 8.2, and 22.6 ± 6.0 kPa for swine heart, liver, abdominal skin, and muscle, respectively, which closely matched existing literature data. Results suggest that our robotic palpation device can be utilized during surgery, either as a stand-alone or additional tool integrated into existing robotic surgical systems, to enhance treatment outcomes by enabling accurate intraoperative identification of abnormal tissue.

Clear neuroimaging margin at the brain-tumor interface is associated with gross total resection and longer survival in non-enhancing diffuse gliomas.

This study aimed to determine whether the presence of distinct glioma margins on preoperative imaging is correlated with improved intraoperative identification of tumor-brain interfaces and overall improved surgical outcomes of non-enhancing gliomas. This is a retrospective study of all primary glioma resections at our institution between 2000-2020. Tumors with contrast enhancement or with final pathology other than diffuse infiltrative glial neoplasm (WHO II or WHO III) were excluded. Tumors were stratified into two groups: those with distinct radiographical borders between tumor and brain, and those with ill-defined radiographical margins. Multivariate analysis was performed to determine the impact of clear preoperative margins on the primary outcome of gross-total resection. Within the study period, 59 patients met inclusion criteria, of which 31 (53%) had distinct margins. These patients were predominantly younger (37.6 vs. 48.1 years, P=0.007). Tumor and other patient characteristics were similar in both cohorts, including gender, laterality, size, location, tumor type, grade, and surgical adjuncts utilized (P>0.05). Multivariate regression identified that distinct preoperative margins correlated with increased rates of gross total resection (P=0.02). Distinct margins on preoperative neuroimaging also correlated positively with surgeon identification of intra-operative margins (P<0.0001), fewer deaths over the study period (P=0.01), and longer overall survival (P=0.03). Distinct glioma-parenchyma margins on preoperative imaging are associated with improved surgical resection for diffuse gliomas, as distinct margins may correlate with distinguishable glioma-brain interfaces intraoperatively. Further prospective studies may discover additional clinical uses for these findings.

A case series on the determination of pre-operative risk factors for anticipation of post operative hypocalcaemia in thyroidectomy

During thyroidectomy, careful dissection of the parathyroid and tracing of their blood supply is the dictum. But it may not always be possible. We aim to highlight some of the common situations faced by ENT surgeons during thyroidectomy, where intraoperative identification and preservation of either the parathyroid glands or their blood supply may be difficult or the glands may have to be sacrificed. We wish to highlight 5 cases where hypocalcemic tetany occurred after total thyroidectomy and pre operative anticipation of their risk factors and the reasoning for the same. Extra precaution should be taken to try and identify and preserve at least one parathyroid gland to prevent lifelong morbidity due to hypocalcemia. Additionally, one must be on the lookout for such challenging cases preoperatively and appropriate consent should be taken from the patient.

A Miniaturized Endoscopic Device Integrating Raman Spectroscopy and Laser Speckle Technology Via an Image Fusion Algorithm for Intraoperative Identification and Functional Protection of Parathyroid Glands

Abstract The importance of parathyroid glands (PGs) protection is increasingly recognized by thyroid surgeons in the field of minimally invasive video-assisted thyroidectomy (MIVAT). However, current techniques for intra-operative identification and vascularity assessment of the PGs are contentious and complex. This study presents the design and validation of a miniaturized device for fusion near-infrared autofluorescence (NIRAF) based on Raman spectroscopy and laser speckle contrast imaging (LSCI) via an image fusion algorithm for functional protection of PGs in the MIVAT. Our light source components include an integrated light emitting diode (LED) light source fiber, an NIRAF optical fiber, an acquisition optical fiber, and a laser speckle optical fiber in the endoscopic system to achieve identification and vascularity assessment of PGs using a single endoscopic probe. It has been validated in ex vivo tissue experiments that the fluorescence intensity detected by the device was equivalent to that of the marker indocyanine green (ICG) in visual images and superior to that of the thyroid and all other tissues in the neck. Based on clinical studies, MIVAT using functional fluorescence endoscopy, compared with the White light pattern group, the NIRAF combined with LSCI modality group increased the number of intra-operative confirmations of the PGs (P &amp;lt; 0.001), declined the decrease in parathyroid hormone (PTH) (P &amp;lt; 0.05) and calcium levels (P &amp;lt; 0.05) on the first postoperative day, and reduced the incidence of symptomatic hypocalcemia (P &amp;lt; 0.05). Our device may reduce the incidence of postoperative permanent hypoparathyroidism. Application of an miniaturized functional fluorescence endoscope for real-time and label-free PGs identification and vascularity assessment in MIVAT could be realized.

Emphasizing the Clinical Diagnosis of Acute Appendicitis Amidst Technological Advancements.

Background The clinical diagnosis of acute appendicitis (AA) can be challenging. This study aimed to evaluate the significance of this diagnosis amidst technological progress. It compared clinical diagnosis to radiology-aided diagnostic outcomes and negative appendicectomy rates (NAR). Methodology This study conducted a single-center retrospective and prospective cohort observational study on all adult patients presenting with suspected AA in 2018 at a major tertiary teaching hospital in Perth, Western Australia. Key demographics, clinicopathological, radiology, and operative reports were reviewed. Data were analyzed using SPSS v.27. Results Of 418 patients with suspected AA, 234 (56%) were in the retrospective group. The median age was 35 (IQR=26), and 224 (54%) were female. The overall NAR was 18.6% (95% CI (14.8-22.4)) and 20.8% for clinical diagnosis. Notably, the NAR for ultrasound (USS)-reported AA (false positive) was 17.6% (95% CI (10.6-27.4)). Three-quarters of the patients, 298 (71.3%), had radiological imaging. The most common modality was CT 176 (59.1%), and 33 (7.9%) had both CT and USS imaging performed. Compared with final histopathology, no significant difference was found in the accuracy of clinically diagnosed and USS-diagnosed cases, with rates of 83.5% and 82.5%, respectively (p=0.230). CT had the best positive predictive value at 82.1%. Single-modality imaging did not cause a significant surgical delay (p=0.914), but multi-modal imaging showed a non-significant trend toward delay (p=0.065). When surgeons assessed an appendix as normal, 54 (12.9%), the histopathological assessment revealed pathology in 28 (51.9%). The inter-observer agreement was only fair to moderate, Kappa=0.46 (95% CI (0.33-0.58); p<0.001). The intraoperative identification of a normal appendix inversely correlated to the grade of the primary surgeon, which was likely related to the number of surgical personnel in the theater (p<0.001). Conclusion This study showed that clinical diagnosis matches the diagnostic accuracy of imaging technologies. Utilizing diagnostic imaging methods promptly and appropriately did not lead to considerable delays in surgery. Surgeons' capability to diagnose appendicitis during surgery is moderately accurate. Most patients underwent imaging, with CT scans being the most common. Moving forward, practitioners must minimize excessive reliance on imaging techniques as this can be resource-intensive, especially in developing countries. Future clinical practice should balance embracing technological advancements and preserving essential clinical diagnostic expertise, for medicine is both a science and an art.

Results of Using Intraoperative Sentinel Lymph Node Identification in the Surgical Management of Stage IA-IIA Non-Small Cell Lung Cancer

Results of Using Intraoperative Sentinel Lymph Node Identification in the Surgical Management of Stage IA-IIA Non-Small Cell Lung Cancer

Abstract PO2-23-05: Practice patterns and outcomes in the ongoing neoadjuvant ATNEC trial: node marking, response to NACT and breast conservation rates

Abstract Background In ATNEC trial, cT1-3N1M0 patients receive NACT followed by SNB/TAD. If the sentinel nodes(SNs) have converted to benign(ypN0), patients are randomly assigned to Axillary Treatment vs no Axillary Treatment. The study promotes standardized node marking procedures and includes a radiotherapy quality assurance program. Objectives – This study prospectively evaluates practice patterns, NACT response, adoption of node marking, rates of marked node identification, and breast conservation rates in the ongoing ATNEC trial across 70 centers in the UK. The trial aims to recruit 1900 patients. Materials and Methods Data from 196 randomized patients (median age: 54 [range: 28-79] years; median BMI: 26.5 [range: 17.6-51.1]) from December 2021 to June 28, 2023, across 70 UK centers were analyzed. These patients presented with cT1-3N1M0 breast cancer, received NACT, and exhibited no residual nodal disease (ypN0) on SNB/TAD. Results Among the randomised patients 54%(106) were post-menopausal, 71%(140) underwent breast conserving surgery(BCS) and 29%(56) mastectomy. At presentation, 12% (23) had T3, 63% (124) had T2, and 23% (46) had T1 tumors. Grade 3 tumors accounted for 70% (138) of cases. Among the patients, 60% (117) were HER2 positive, 31% (61) were triple negative, and 9% (18) were HER2 negative (ER or PgR positive). Anthracycline and taxane-based NACT were administered to 57% (106), while 38% (71) received a platinum-containing regimen. During SNB/TAD, a median of 4 nodes (interquartile range, 3-5) were removed. Among 184 patients with node marking data, 74% (136) had the involved node marked. The marked node was successfully removed in 94% (128) of these patients. Clip/coil only, Magseed and black dye were the commonest techniques used for node marking. The marked node was the sentinel node in 83% (106) of cases. Among 185 randomized patients with post-NACT response data, 68% (125) achieved a complete pathological response (pCR) in the breast, while 8% (15) had DCIS only and 22% (41) had invasive cancer. Among 105 patients with complete breast tumor response on imaging, 15% (16) had residual DCIS or invasive cancer. In the subset of patients with partial response or stable breast tumors on imaging (69 patients), 46% (32) had no residual tumor on histology (ypT0). Furthermore, 14% (26) exhibited partial or stable disease in the axilla on imaging but achieved complete pathological response on histology. Conclusions HER2-positive and triple-negative breast cancer cases predominate among patients undergoing NACT in the UK. Although 68% achieved a complete pCR (ypT0) in the breast, rates of BCS remain low. Notably, around 75% of randomized patients underwent node marking, with an intra-operative identification rate of 94%, demonstrating the successful implementation of node marking in the UK through the ATNEC trial. Citation Format: Amit Goyal, Andrea Marshall, Sophie Nicholls, Natalie Hammonds, Beatrix Elsberger, Duncan Wheatley, Janice Rose, Helen-Teresa Edwards, Abeer Shaaban, Roeum Butt, Gareth Jackson, Tara Homer, Luke Vale, Samreen Ahmed, Shama Puri, Sophie Gasson, Julie Bruce, Helen Higgins, Janet Dunn. Practice patterns and outcomes in the ongoing neoadjuvant ATNEC trial: node marking, response to NACT and breast conservation rates [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-23-05.

Preoperative Angiographic Protocol for the Surgical Management of Spinal Dural Arteriovenous Fistulas: A Technical Nuance for Safe Minimally Invasive Surgery

BackgroundInterruption of the fistoulus point is the goal of the treatment of spinal dural arteriovenous fistula (dAVFs). Microsurgery still represents a highly efficient treatment in terms of complete occlusion with the lowest risk of recurrence rate. It is reported that the hardest step consists in finding the fistulous site itself, potentially extending surgical access and time, and increasing potential post-operative surgical-related complications. The accurate preoperative detection of the shunt and spinal level together is crucial for guiding optimal, fast and safe microsurgical treatment. MethodsIn the present paper, the authors describe a preoperative angiographic protocol for achieving a safe and simple resection of spinal dAVFs based on a six-year Institutional experience of forty-two patients who underwent minimally invasive. Two illustrative cases are also included in order to support the technical descriptions. ResultsThe suspected artery associated to the vascular malformation of interest is studied in our angiographic protocol through non-subtracted selective acquisitions in the lateral projection. The resulting frames are reconstructed with 3D Rotational Angiography. The implementation of the preoperative angiographic protocol allowed 100% of intraoperative identification of the fistoulus point in all cases with the use of minimally invasive approach. ConclusionsNowadays, neurosurgeons advocate for minimally invasive procedures and low morbidity risk procedures for the treatment of spinal dAVFs.Our preoperative approach for accurate angigoraphic localization of the fistoulus point through non-subtracted and 3D reconstructed angiography allowed to achieve safe and definitive occlusion of the shunt.

Enhancing surgical outcomes: accurate identification and removal of prostate cancer with B7-H3-targeted NIR-II molecular imaging.

One of the main reasons for prostate cancer (PCa) recurrence is the difficulty in identifying and removing cancerous lesions during surgery. Accurately localizing and excising cancerous tissue remains a significant challenge. The second near-infrared window (NIR-II, 1000-1700nm) fluorescence offers enhanced resolution, a high signal-to-noise ratio, and the potential for deeper tissue penetration. However, this technology is not currently employed for intraoperative imaging of PCa. This study aims to construct a new NIR-II probe targeting B7-H3 (AbB7-H3-800CW) for accurate intraoperative identification and resection of PCa. Based on the differential expression of B7-H3 in PCa, we designed a novel imaging probe to accurately identify and guide the resection of preclinical PCa models and ex vivo human PCa tissues using NIR-II fluorescence imaging technology. Analyzing tissue samples from 60 clinical cases of PCa, along with benign prostatic hyperplasia and normal prostate tissue from 22 cases, we observed a significant difference in B7-H3 protein expression levels (P < 0.001). Subcutaneous and orthotopic mouse models of PCa were imaged using NIR-II fluorescence after AbB7-H3-800CW injection, showing promising results with successful tumor targeting and high-contrast images achieved within 24-48h post-injection. The imaging also enabled the detection of occult PCa lesions approximately 1mm in diameter. In addition, imaging analysis of human PCa and adjacent tissues using AbB7-H3-800CW incubation revealed that cancer tissues exhibited a significantly higher fluorescence intensity than adjacent tissues (P < 0.05), which was conducive to the evaluation of tumor resection margin in vitro. The findings revealed that B7-H3 was a compelling imaging target for PCa. The AbB7-H3-800CW molecular imaging probe is capable of accurately identifying PCa lesions and guiding their removal. This approach can potentially reduce the rate of surgical margins under NIR-II fluorescence guidance.

Exploring the Topography of the Obturator Artery and Corona Mortis: a Detailed Analysis with Surgical Implications

Introduction and HypothesisThe obturator artery (ObA) is described as a branch of the anterior division of the internal iliac artery. It arises close to the origin of the umbilical artery, where it is crossed by the ureter. The main goal of the present study was to create an anatomical map of the ObA demonstrating the most frequent locations of the vessel’s origin and course.MethodsIn May 2022, an evaluation of the findings from 75 consecutive patients who underwent computed tomography angiography studies of the abdomen and pelvis was performed.ResultsThe presented results are based on a total of 138 arteries. Mostly, ObA originated from the anterior trunk of the internal iliac artery (79 out of 138; 57.2%). The median ObA diameter at its origin was found to be 3.34 mm (lower quartile [LQ] = 3.00; upper quartile [UQ] = 3.87). The median cross-sectional area of the ObA at its origin was found to be 6.31 mm2 (LQ = 5.43; UQ = 7.32).ConclusionsOur study developed a unique arterial anatomical map of the ObA, showcasing its origin and course. Moreover, we have provided more data for straightforward intraoperative identification of the corona mortis through simple anatomical landmarks, including the pubic symphysis. Interestingly, a statistically significant difference (p < 0.05) between the morphometric properties of the aberrant ObAs and the “normal” ObAs originating from the internal iliac artery was found. It is hoped that our study may aid in reducing the risk of serious hemorrhagic complications during various surgical procedures in the pelvic region.

Can preoperative ureteral stent placement help in the intraoperative identification of iatrogenic ureteral injury?

BackgroundThe benefits of prophylactic ureteral stent placement during colorectal surgery remain controversial.The aims of the present study were to determine the incidence of ureteral injury in colorectal operations, assess the complications associated with stent usage, and determine if their use leads to earlier identification and treatment of injury. MethodsRetrospective study of patients undergoing colorectal abdominal operations between 2015 and 2021. Variables were examined for possible association with ureteral stent placement. The primary study endpoint was ureteral injury identified within 30 days postoperatively. ResultsOf 6481 colorectal surgery patients, 970 (15%) underwent preoperative ureteral stent placement. Use of stents was significantly associated with a higher ASA classification, wound classification, and longer duration of surgery. A ureteral injury was identified in 28 patients (0.4%). Of these, 13 had no stent, and 15 had preoperative stents placed. After propensity matching, stent use was associated with increased risk of hematuria and UTI. Ureteral injury was identified intraoperatively in 14/28 (50%) patients and was not associated with ureteral stent use (p=0.45). ConclusionsIatrogenic ureteral injury was uncommon, while preoperative stent placement was relatively frequent. Earlier recognition of iatrogenic ureteral injury is not an expected advantage of preoperative ureteral stent placement.

Fluorescence-guided thoracoscopic surgery for postoperative chylothorax: A technical note with video vignette

TechniqueThe surgical management for high-output postoperative chylothorax typically necessitates ligation of the thoracic duct (TD) above the leak site and/or sealing the leak with a clip. However, pinpointing these structures during subsequent surgeries can be challenging due to their variable course and the presence of traumatized tissues surrounding the leak area. In response to this, we have developed a novel, fluorescence-guided technique that significantly enhances intraoperative identification of the leak point and the TD. This method was applied in the case of a 52-year-old man suffering from refractory chylothorax following a previous lung cancer surgery. This study documents the surgical procedure and includes a video vignette for a comprehensive understanding. ResultsA bilateral inguinal lymph node injection of saline (10 mL), guided by ultrasound and containing 2.5 mg/mL indocyanine green (ICG), was administered 20 min prior to surgery. During thoracoscopic exploration, the leak point was precisely pinpointed in the right paratracheal area by transitioning from bright light to fluorescent mode. The TD was clearly identified, and upon ligation, there was no further leakage of fluorescent lymph, indicating a successful closure of the lymphatic structure. The surgery proceeded uneventfully, and the patient was able to resume oral intake on the third postoperative day. There was no evidence of recurring symptoms, leading to his discharge. ConclusionThe intralymphatic injection of ICG offers a rapid visualization of the TD's anatomy and can effectively pinpoint the leak point, even amidst traumatized tissues. Moreover, it provides prompt feedback on the efficacy of ligation.

Evaluating the effectiveness of dual dye combination of indocyanine green and carbon nanoparticles with parathyroid hormone test in preserving parathyroid gland during papillary thyroid cancer surgery: a single-center retrospective cohort study.

Preserving the integrity of parathyroid glands is crucial in papillary thyroid cancer (PTC) surgery to avoid hypoparathyroidism. In recent years, two novel dyes, activated carbon nanoparticles (CNP) and indocyanine green (ICG), have been utilized to assist in parathyroid gland identification. However, the use of CNP or ICG alone can result in extravasation of dye or excessive fluorescence of non-parathyroid tissue, which can affect the accuracy of surgical outcomes by yielding false negative or false positive results. Therefore, it is important to further optimize the application of these two dyes in surgery. We analyzed case files of 124 PTC patients who underwent routine total or near-total thyroidectomy with bilateral lymph node dissection in the central region at the Affiliated People's Hospital of Ningbo University from January to November 2022. The patients were randomly divided into three groups based on the type of intraoperative dye used. The CNP group (n = 38) received an intra-thyroidal injection of CNP dye. The ICG group (n = 42) used the ICG near-infrared fluorescence endoscopy system to show parathyroid fluorescence. The group that received a combined approach of ICG and CNP (n = 44) leveraged the advantages of both methods that allow for positive development of ICG and negative development of CNP to identify and preserve the parathyroid gland during operation. The parathyroid hormone detection reagent (PTH test method) was employed to verify the highly suspected parathyroid tissue in all three groups. We analyzed intraoperative data pertaining to intraoperative parathyroid identification, misexcision, number of autotransplantation, and postoperative hypoparathyroidism among the three groups. Compared with the ICG group and the CNP group, the combined group demonstrated more prominent advantages in identifying average the number of lower parathyroid glands (1.93 ± 0.26, p = 0.015), reducing the average numberrate of misexcision (0.45 ± 0.5, p = 0.004), and reducing the incidence of postoperative temporary hypothyroidism (3/44, p = 0.015). The combined use of ICG and CNP dual-dye with PTH test method appears to be more effective in both identifying and protecting parathyroid glands during PTC surgery.

Strong Correlation Between SUVmax on PSMA PET/CT and Numeric Drop-In γ-Probe Signal for Intraoperative Identification of Prostate Cancer Lesions.

Prostate-specific membrane antigen (PSMA) PET is used to select patients with recurrent prostate cancer for metastasis-directed therapy. A surgical approach can be achieved through radioguided surgery (RGS), using a Drop-In γ-probe that traces lesions that accumulate the radioactive signal. With the aim of guiding patient selection for salvage surgery, we studied the correlation between the SUVmax of lesions on preoperative PSMA PET/CT and their intraoperative counts/s measured using the Drop-In γ-probe. Methods: A secondary analysis based on the prospective, single-arm, and single-center feasibility study was conducted (NCT03857113). Patients (n = 29) with biochemical recurrence after previous curative-intent therapy and a maximum of 3 suggestive lesions within the pelvis on preoperative PSMA PET/CT were included. Patients treated with androgen deprivation therapy within 6 mo before surgery were excluded. All patients received an intravenous injection of 99mTc-PSMA-I&S 1 d before surgery. Radioguidance was achieved using a Drop-In γ-probe. Correlation was determined using the Spearman rank correlation coefficient (ρs). Subgroup analysis was based on the median SUVmax Results: In total, 33 lesions were visible on the PSMA PET/CT images, with a median overall SUVmax of 6.2 (interquartile range [IQR], 4.2-9.7). RGS facilitated removal of 31 lesions. The median Drop-In counts/s were 134 (IQR, 81-220) invivo and 109 (IQR, 72-219) ex vivo. The intensity of the values correlated with SUVmax (ρs = 0.728 and 0.763, respectively; P < 0.001). Subgroup analysis based on median SUVmax in the group with an SUVmax of less than 6 showed no statistically significant correlation with the numeric signal invivo (ρs = 0.382; P = 0.221) or the signal-to-background-ratio (ρs = 0.245; P = 0.442), whereas the group with an SUVmax of 6 or more showed respective statistically significant positive correlations (ρs = 0.774 [P < 0.001] and ρs = 0.647 [P = 0.007]). Conclusion: Our findings indicate that there is a direct relation between SUVmax on PSMA PET/CT and the readout recorded by the surgical Drop-In probe, thereby indicating that SUVmax can be used to select patients for PSMA RGS. For more definitive subgroup definitions for treatment recommendations, further studies are necessary to validate the present findings.

Development and prospective validation of an artificial intelligence-based smartphone app for rapid intraoperative pituitary adenoma identification

BackgroundIntraoperative pathology consultation plays a crucial role in tumor surgery. The ability to accurately and rapidly distinguish tumor from normal tissue can greatly impact intraoperative surgical oncology management. However, this is dependent on the availability of a specialized pathologist for a reliable diagnosis. We developed and prospectively validated an artificial intelligence-based smartphone app capable of differentiating between pituitary adenoma and normal pituitary gland using stimulated Raman histology, almost instantly.MethodsThe study consisted of three parts. After data collection (part 1) and development of a deep learning-based smartphone app (part 2), we conducted a prospective study that included 40 consecutive patients with 194 samples to evaluate the app in real-time in a surgical setting (part 3). The smartphone app’s sensitivity, specificity, positive predictive value, and negative predictive value were evaluated by comparing the diagnosis rendered by the app to the ground-truth diagnosis set by a neuropathologist.ResultsThe app exhibits a sensitivity of 96.1% (95% CI: 89.9–99.0%), specificity of 92.7% (95% CI: 74–99.3%), positive predictive value of 98% (95% CI: 92.2–99.8%), and negative predictive value of 86.4% (95% CI: 66.2–96.8%). An external validation of the smartphone app on 40 different adenoma tumors and a total of 191 scanned SRH specimens from a public database shows a sensitivity of 93.7% (95% CI: 89.3–96.7%).ConclusionsThe app can be readily expanded and repurposed to work on different types of tumors and optical images. Rapid recognition of normal versus tumor tissue during surgery may contribute to improved intraoperative surgical management and oncologic outcomes. In addition to the accelerated pathological assessments during surgery, this platform can be of great benefit in community hospitals and developing countries, where immediate access to a specialized pathologist during surgery is limited.

Monoclonal Antibodies for Targeted Fluorescence-Guided Surgery: A Review of Applicability across Multiple Solid Tumors.

This study aims to review the status of the clinical use of monoclonal antibodies (mAbs) that have completed or are in ongoing clinical trials for targeted fluorescence-guided surgery (T-FGS) for the intraoperative identification of the tumor margins of extra-hematological solid tumors. For each of them, the targeted antigen, the mAb generic/commercial name and format, and clinical indications are presented, together with utility, doses, and the timing of administration. Based on the current scientific evidence in humans, the top three mAbs that could be prepared in a GMP-compliant bank ready to be delivered for surgical purposes are proposed to speed up the translation to the operating room and produce a few readily available "off-the-shelf" injectable fluorescent probes for safer and more effective solid tumor resection.

Anatomic Markers for Intraoperative Identification of the Heuter Interval in the Direct Anterior Approach to the Hip

Anatomic Markers for Intraoperative Identification of the Heuter Interval in the Direct Anterior Approach to the Hip