Intraoperative Folate-fluorescein Conjugate (EC17) Lung Cancer (CA)

According to the World Health Organization, lung cancer is the most common cause of cancer-related death in men and women, and is responsible for 1.3 million deaths worldwide annually as of 2004. Surgery remains the best option for patients presenting with operable Stage I or II cancers, however the five year survival rate for these candidates remains at a dismal 53% for Stage I and 32% for Stage II. The high rates of recurrence suggest that surgeons are unable to completely detect and remove primary tumor nodules in a satisfactory manner as well as lingering metastases in sentinel lymph nodes. By ensuring a negative margin through imaging during surgery it would be possible for us to improve the rates of recurrence free patients and thus overall survival.

Thoracic malignancies are the ideal disease to investigate intra-operative imaging. Over 85% of lung and pleural malignancies express folate receptor alpha (FRA), and a fluorescent probe targeting FRA is readily available. It is important to note that FRA is expressed only in the proximal tubules of the kidneys, activated macrophages, and in the choroidal plexus. Thus, the false positive detection rate is expected to be extremely low. A group well known to us in the Netherlands has completed a pilot study utilizing a folate- fluorescein-5-isothiocyanate (FITC) conjugate in 12 patients with ovarian cancer. They have subsequently performed this study on 20 more patients without any adverse events (personal communication). They report excellent sensitivity and specificity with this technique with only grade 1 side effects (allergic reaction). All side effects reversed when the injection was halted. The only known allergy is those patients which have an insect reaction (fluorescein is derived from the firefly insect, folate is an essential vitamin). This drug has also been used at a higher dose for therapeutic purposes in patients with metastatic renal cell carcinoma in the United States. However, this drug will be used at a lower dose for a diagnostic purpose only.

• Lung and Pleural Malignancies
• Neoplasms
• Nodules

Inclusion Criteria:

1. Adult patients over 18 years of age
2. Patients presenting with a lung or pleural nodule or mass presumed to be resectable on pre-operative assessment
3. Good operative candidate
4. Subject capable of giving informed consent and participating in the process of consent.

Exclusion Criteria:

1. Pregnant women as determined by urinary or serum beta human chorionic gonadotropin (hCG) within 72 hours of surgery
2. Patients with a history of anaphylactic reactions to Folate-FITC or insects

3. At-risk patient populations

   1. Homeless patients
   2. Patients with drug or alcohol dependence
   3. Children and neonates
   4. Patients unable to participate in the consent process