Rosenthal Lab

Research Light Guided Surgery

For a surgical oncologist, the most commonly asked question by patients after an operation is, “Did you get all the cancer?”  The answer is most commonly, “I removed everything I could see.

Removing Tumors with Fluorescent Dye

Light Guided Surgery uses fluorescent markers that light up the tumor during surgery. 

We are currently investigating if this approach will help surgeons to remove tumor tissue. 

Today, surgeons rely on their vision and touch to assess what should be removed during tumor resection; however, 15-30% of all head and neck cancer patients leave the operation room with tumor cells left behind. For these patients, the chances of tumor recurrence are high and overall survival low.

We are currently investigating if Light Guided Surgery could help solve this problem.

 

How We Investigate in LGS

1) Infusion of fluorescent dye that reaches the tumor.

2) The tumor will light up with a special camera during surgery.

3) The surgeon will outline the tumor.

4) The surgeon will remove the tumor.

5) After tumor resection, the surgeon checks the wound bed for remaining cancer.

6) The tumor is removed.

Examples of how LGS could potentially change surgery in the future

Assessment of tumor extent

25% of patients leave the operation room with tumor cells left behind.

 

Detection of a second tumor

Second tumors represent the second leading cause of death in head and neck cancer patients.

 

Patient Information

At Stanford, we are establishing Light Guided Surgery as tomorrows standard of care. Patients who are eligible can potentially join the research. To find out if you are eligible please contact your doctor. Currently, we are including patients in the following clinical trials: Brain Cancer, Head & Neck Cancer, Lung Cancer & Pancreas Cancer.

To be considered for these trials you must be:

  • Be 19 years or older
  • Not be pregnant or breastfeeding
  • Have a biopsy-proven diagnosis of Squamous Cell Carcinoma of the head and neck
  • Be planned for standard of care surgery of the tumor
  • Be determined a suitable candidate for the clinical trial by your physician

 

Dual-modality Imaging Study

Cervical lymph node staging if of great prognostic value for patients with head and neck cancer. Currently, to identify the presence of metastatic lymph nodes during the surgical resection of head and neck cancer, patients undergo a neck dissection or sentinel node biopsy procedure whereby some or all of the lymph nodes are taken out of the neck and sent for pathological evaluation.

We hope to show that the combined use (i.e. dual-modality) of 89Zr‑panitumumab and panitumumab‑IRDye800 can help surgeons to identify metastatic lymph nodes prior to and during the surgical procedure with equal or better accuracy than the current methods.

Panitumumab‑IRDye800 is an investigational imaging agent that contains a dye molecule that surgeons and researchers can image using light waves both during surgery and after the surgery on removed tissues. Recently we have shown that using this drug, we can identify metastatic lymph nodes from benign, normal lymph nodes based on the fluorescent signal that comes from the panitumumab‑IRDye800. However, because of the limited penetration depth of the fluorescence signal, it is challenging to detect these lymph node(s) in the body.

89Zr‑panitumumab is an investigational imaging agent that contains a small amount of radiation, which makes it visible in positron emission tomography (PET) scans. We hypothesize that by using 89Zr‑panitumumab we can identify metastatic lymph nodes on preoperatively acquired (non-invasive) PET scans. If so, this information we can then use to guide us during the surgery. Because for the dual-modality study we will intravenously infuse both panitumumab-IRDye800 and 89Zr‑panitumumab, we can use the fluorescent signal coming from panitumumab-IRDye800 to precisely localize the metastatic lymph node(s).

PREOPERATIVE IMAGING 89Zr-panitumumab (radiotracer)

Day 0

At 2 hours we see the tracer mainly circulating in the blood. All the large blood vessels are clearly visible.We also see some excretion into the liver and kidneys.

 

Day 2

At 22 hours, besides the blood vessels and the liver we see some tracer accumulation at the primary tumor site.

 

Day 4

At 95 hours we hardly see any tracer circulating in the blood anymore (you don’t see the blood vessels anymore) and we see that excretion of the tracer has increased (liver, kidneys, intestine).

Here we see an axial image of the head. The circled area demonstrates the area where the tumor is located. We see that over time more tracer accumulates at the tumor site.

INTRAOPERATIVE IMAGING panitumumab-IRDye800 (fluorescence)

Primary tumor prior to resection

Wound bed post re-resection of tumor

Fluorescence imaging of the tumor was performed prior to resection and after resection to “check” the wound bed. In the upper row the tumor is clearly visible with fluorescence and in the bottom row you can see that the wound bed is empty – there is no suspicious fluorescence left. The middle column of tiles show the fluorescence signal in black and white where the “white” represents the tumor and the black the background (= no fluorescence signal). The right column of tiles shows the overlay of the brightfield photo (in greyscale) and the fluorescence (red-yellow-blue heatmap). This image provides anatomical context to the surgeon – the surgeon can see where is the fluorescence located with regard to the tumor area.

The research study that we are conducting is looking for 14 patients with head and neck cancer that are scheduled to undergo surgery for removal of the primary tumor and/or lymph nodes of the neck. Should you be interested in participating in the study, please reach out to Dr. Eben Rosenthal at (650)-723-4250 and/or Ms. Roan Raymundo (650)-722-4071.

Fluorescently-labeled panitumumab to image brain cancer during surgery

Patients with glioma often undergo surgical procedures to reduce or remove their cancer.  Doctors who perform this type of surgery are well‑trained in removing all the cancer that can be seen during your operation. However, there are times when the tumor looks like normal brain tissue or there are cancer deposits that are too small to be seen by the surgeon.

We hope to show that panitumumab-IRDye800, an imaging agent, is safe to use in brain cancer patients. We will also evaluate if panitumumab-IRDye800 can help surgeons to better distinguish cancer cells from normal brain tissue and identify small cancer lesions that cannot be seen using current imaging methods.   

Panitumumab‑IRDye800 is an investigational imaging agent that contains a dye molecule that surgeons and researchers can image using light waves both during surgery and after the surgery on removed tissues.

The research study that we are conducting is looking for 22 participants undergoing surgery for removal of brain tumors. Enrollment will occur at Stanford University and the University of Alabama (Birmingham). Stanford will enroll up to 12 research participants. Should you be interested in participating in the study, please reach out to Dr. Gordon Li at (650) 498-6000, Dr. Eben Rosenthal at (650)-723-4250, and/or the study coordinator for this study, Ms. Roan Raymundo (650)-721-4071.

You may also want to read the recent interview that was held with Dr. Li and Dr. Rosenthal on novel imaging technologies to identify brain cancer:

Fluorescently-labeled panitumumab to image pancreatic cancer during surgery

Patients with pancreatic cancer often undergo surgical procedures to reduce or remove their cancer.  Doctors who perform this type of surgery are well‑trained in removing all the cancer that can be seen during your operation.  However, there are times when there are cancer deposits that are too small to be seen by the surgeon.

We hope to show that panitumumab-IRDye800, an imaging agent, is safe to use in pancreatic cancer patients and learn whether panitumumab-IRDye800 can help surgeons identify small cancer lesions that cannot be seen using current imaging methods.

Panitumumab‑IRDye800 is an investigational imaging agent that contains a dye molecule that surgeons and researchers can image using light waves both during surgery and after the surgery on removed tissues.

Intraoperative fluorescence imaging of the pancreas part that contains tumor

Fluorescence imaging of the tumor area was performed before removal. The tumor area light up fluorescently and so does a lymph node (LN) that is located on top of the tumor area. We can also see some lymphatic ducts (or additional LNs).

On the bottom left you can see the bright field (white light image). On top row you see fluorescence overlay images– blue illustrates low fluorescence and red high fluorescence. These fluorescence images are overlayed on top of the bright field image. The bottom middle and right image are “raw” fluorescence images – this raw mode is the most sensitive mode for detection of, in this particular case, lymphatic ducts.

In situ fluorescence imaging of the wound bed

After removal of the pancreas part that contains tumor fluorescence imaging was performed to check that there was no

residual fluorescence left in the wound bed. No fluorescence was found in the wound bed. A little bit of background fluorescence was found in the intestine.

On the left you can see the bright field (white light image). On the right you can see the fluorescence image – blue illustrates low fluorescence and red high fluorescence. The fluorescence image is overlayed on top of the bright field image.

“Laboratory fluorescence imaging in a black box”

Black box fluorescence imaging is the most sensitive method to assess the fluorescence signal coming from the antibody in the tumor. We look at the top (anterior) surface of the pancreas and the bottom (posterior; “flipped side). The tumor area is clearly distinguishable (in read) from the “normal” surrounding pancreatic tissue as well as the intestine (duodenum).

The research study that we are conducting is looking for 27 participants undergoing surgery to remove pancreatic cancer.  Should you be interested in participating in the study, please reach out to Dr. Poultsides at (650) 723-2967, Dr. Eben Rosenthal at (650)-723-4250, and/or the study coordinator for this study, Ms. Roan Raymundo (650)-721-4071.

About Us

Dr. Rosenthal Team

Dr. Rosenthal

Dr. Rosenthal is committed to improve survival for patients that undergo surgery for cancer. As a surgeon-scientist, he has the unique opportunity to act as a direct bridge between science and the patient. He specializes in the treatment of head and neck cancer patients and has a strong interest in the development of imaging modalities to enhance successful tumor removal in all cancer types.

With a team of medical doctors, post-doctoral students and visiting scholars from all over the world, professor E. Rosenthal is working hard to take Light Guided Surgery into clinical practice.

 

Contact the Lab

Eben Rosenthal
Professor and Medical Director Stanford Cancer Center

erosenthal@stanfordhealthcare.org

Heather Restificar
Administrative assistant

hrestificar@stanfordhealthcare.org

Roan Raymundo
Study Coordinator

rcraymun@stanford.edu

Subject: Study Trial NCT02741470

Tel: (650)–723–1423