Precision at the Margin: Innovations and Challenges in Intraoperative Molecular Imaging for Thoracic Surgery

Area of Science:

• Thoracic surgical oncology
• Medical imaging
• Surgical technology

Background:

• Lung nodule detection is challenging due to smaller sizes and increased use of minimally invasive surgery (MIS).
• Surgeons face difficulties in tumor localization, margin assessment, and nodal evaluation during pulmonary resections.
• Intraoperative molecular imaging (IMI) offers real-time visualization of malignant tissue to aid decision-making.

Purpose of the Study:

• To review the current state of intraoperative molecular imaging in thoracic surgical oncology.
• To highlight key translational studies, clinical applications, and limitations of IMI.
• To outline future directions for IMI implementation in pulmonary surgery.

Main Methods:

• Systemic administration of tumor-targeting near-infrared fluorophores.
• Integration with fluorescence-capable imaging platforms for real-time visualization.
• Review of early clinical experiences and translational studies in thoracic surgery.

Main Results:

• IMI shows utility in localizing small/nonpalpable pulmonary nodules and improving margin assessment in MIS.
• Limitations include variable target expression, optical depth issues, false positives in inflammatory tissue, and workflow integration challenges.
• Nodal evaluation and staging applications are still investigational.

Conclusions:

• IMI is a promising adjunct for pulmonary resection, but barriers to adoption must be addressed.
• Future research should focus on quantitative fluorescence, standardized reporting, and outcomes-driven trials.
• Evidence-based implementation requires evaluation of margin adequacy, recurrence, staging, and cost-effectiveness.