Current and Future Intraoperative Imaging Strategies to Increase Radical Resection Rates in Pancreatic Cancer Surgery

Abstract

Prognosis of patients with pancreatic cancer is poor. Even the small minority that undergoes resection with curative intent has low 5-year survival rates. This may partly be explained by the high number of irradical resections, which results in local recurrence and impaired overall survival. Currently, ultrasonography is used during surgery for resectability assessment and frozen-section analysis is used for assessment of resection margins in order to decrease the number of irradical resections. The introduction of minimal invasive techniques in pancreatic surgery has deprived surgeons from direct tactile information. To improve intraoperative assessment of pancreatic tumor extension, enhanced or novel intraoperative imaging technologies accurately visualizing and delineating cancer cells are necessary. Emerging modalities are intraoperative near-infrared fluorescence imaging and freehand nuclear imaging using tumor-specific targeted contrast agents. In this review, we performed a meta-analysis of the literature on laparoscopic ultrasonography and we summarized and discussed current and future intraoperative imaging modalities and their potential for improved tumor demarcation during pancreatic surgery.

Impact of resection margin status on recurrence and survival in pancreatic cancer surgery

“…Involvement of the large vessels should be evaluated carefully during surgery, as the vascular margin is the margin at greatest risk of tumour involvement. New molecular imaging modalities, such as fluorescence or photoacoustic imaging, could be used to improve the detection of tumour‐positive lymph nodes and may facilitate radical resection, especially at difficult margins including the posterior one. These imaging techniques, with use of an exogenous agent directed against the tumour, allow the surgeon to image the lesion and may provide important additional information during the operation.…”

Toward optical guidance during endoscopic ultrasound-guided fine needle aspirations of pancreatic masses using single fiber reflectance spectroscopy: a feasibility study

“…40,41 This approach could be interesting as it allows visual distinction between pancreatic cancer cells and the surrounding stroma. 42,43 In addition, several clinical trials are currently investigating the safety and feasibility of intraoperative near-infrared fluorescence imaging using pancreatic cancer-specific contrast agents (NTR5673, NCT02736578).…”

Fluorescence‐ and multispectral optoacoustic imaging for an optimized detection of deeply located tumors in an orthotopic mouse model of pancreatic carcinoma

“…The challenge in the management of operable pancreatic tumors is an achievement of R0 resections, that is, complete removal of all tumor nodules. Unfortunately, 80% of pancreatic cancer surgeries are incomplete R1 resections, resulting in a further decreased overall survival …”

“…Unfortunately, 80% of pancreatic cancer surgeries are incomplete R1 resections, resulting in a further decreased overall survival. 1,2 Although surgeons still mostly rely on their visual perception and palpation, novel imaging methods such as fluorescence guided surgery (FGS) are evolving to assist the differentiation of healthy and tumor tissue. FGS, typically based on near infrared (NIR) fluorescent probes, visualizes the desired structures in real time.…”