Real-world localization of cancer in lungs with a commercially available folate receptor-targeted fluorescent agent for intraoperative molecular imaging.

Background: Intraoperative molecular imaging (IMI) can improve lung nodule localization and the ability to perform sublobar resection. Following Food and Drug Administration approval of pafolacianine, we report on the integration of this folate receptor (FR)-targeted fluorescent agent into a minimally invasive thoracic surgery practice. Methods: Cases from June 2023 through January 2024 were reviewed. Patients with primary or metastatic cancer in the lung with plans for sublobar pulmonary resection were included. Preoperative computed tomography scans were used to determine lesion size and depth. Pafolacianine infusion was performed within 24 hours of surgery. The lung was inspected for fluorescence using the Stryker 1788 imaging system. Results: The study cohort comprised 39 patients (28 females and 11 males), with a median age of 68 years. The median lesion size was 13 mm (range, 5-32 mm), and median depth was 6.4 mm (range, 0-30 mm). Minimally invasive resection (robotic-assisted thoracoscopic surgery, n = 21; video-assisted thoracoscopic surgery; n = 18) was performed in all patients (segmentectomy, n = 15; wedge resection, n = 17; segmentectomy and wedge resection, n = 3; lobectomy, n = 4). In 11 patients, the primary lesion was not detectable under visual inspection with white light but was visualized with IMI. The final histology included primary lung cancer in 28 patients and metastatic cancer in 11 patients. All margins were negative. Conclusions: This report of early postmarketing experience with pafolacianine for cancer in the lung demonstrated a high rate of nodule localization. These early experiences further reinforce IMI as an adjunct to surgical resection that may enhance the ability to perform minimally invasive parenchymal-sparing operations.