Intraoperative pafolacianin for nodule detection during VATS metastasectomy in extremity metastatic sarcoma surgery performed concurrently.

backgroundIntraoperative molecular imaging using intravenous Pafolacianine (Cytalux) is reported to improve tumor detection in malignant pulmonary and ovarian lesions. Pafolacianine’s affinity for folate receptors in these specific tissues aided in the elucidation of adequate margins for diagnostic and therapeutic resections when administered prior to surgical intervention. The role for Pafolacianine for malignant lesions in other pathologies as well as the time in which Pafolacianine remains bound and fluoroscopically detectable is unknown. CASE PRESENTATION: Presented here is a case of a 27-year-old man found with recurrent malignant peripheral nerve sheath tumor (MPNST) of the right upper extremity who developed a new left lung nodule concerning for metastatic disease. Initially, we performed a left-sided video assisted thoracoscopy surgery (VATS) with perioperative Pafolacianine administration. Allowing us to successfully remove his metastatic pulmonary disease with wedge metastasectomy. Six days later during the reexcision of his MPNST we used the thoracoscopy which enabled us to identify his primary tumor within the left antecubital fossa. Since the primary tumor also emitted a fluoroscopic signal, it aided in resection of the cancerous lesion in a heavily scarred and radiated field.

conclusionTo date, there have been no reported cases of Pafolacianine retention within extra-pulmonary and ovarian tumor cells after an extended period of time. We believe our case demonstrates the prospective application and effectiveness of Pafolacianine in targeting cancer cells by fluorescence-guided resection. In summary, we theorize that there is a role for Pafolacianine in identifying malignant lesions regardless of tumor location. In addition, the retention of Pafolacianine within high folate acid receptor expressing cells is at least if not more than 6 days implying that the drug does not need to be readministered if additional resection is needed .