Tumour-targeted fluorescence-guided surgery in gastrointestinal cancer: A systematic review of preclinical and clinical research

Abstract

Background: Gastrointestinal cancers remain a leading cause of cancer-related morbidity and mortality worldwide, with surgery being central to curative treatment. Tumour-targeted fluorescence-guided surgery (tFGS) has emerged as a promising approach to improve intraoperative visualisation and oncological precision.

Methods: We conducted a systematic review of preclinical and clinical studies on tFGS in gastrointestinal oncology, registered in PROSPERO (ID: 558994) and following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches of PubMed and Embase identified 133 eligible studies.

Results: Nine tracers have currently been evaluated in clinical trials, targeting the following biomarkers: carcinoembryonic antigen, vascular endothelial growth factor, epidermal growth factor receptor, folate receptor α and/or β, integrin αvβ3, 5-aminolevulinic acid and acidic tumour microenvironment.Clinical trials demonstrated that tracers like SGM-101 and panitumumab–IRDye800CW can achieve high tumour-to-background ratios (TBRs) up to 6.1 ex vivo and alter surgical strategy in up to 35% of cases. Preclinical research identified additional promising targets, including mucins, epithelial cell adhesion molecules, urokinase receptors, tumour-associated glycoproteins, gamma-glutamyl transferase, organic anion transporting polypeptides, human epidermal growth factors 1/2 and Lewis antibodies, with TBRs frequently exceeding three.Despite encouraging feasibility and safety data, translation into routine practice is hampered. Confirmation from early health technology assessments is needed to advance tFGS. Besides, standardisation of protocols and phase III confirmatory trials are required to establish clinical benefit and support regulatory approval.

Conclusion: tFGS holds considerable potential to transform surgical oncology in GI cancers by enabling more precise resections and guiding organ-preserving strategies. Future innovations in multimodal tracers, NIR-II fluorophores and theranostics may further enhance the precision and therapeutic potential of tFGS.

Key points:

Keywords

gastrointestinal cancers / tumour-targeted fluorescence-guided surgery

References

[1] Sung H, Ferlay J, Siegel RL, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021; 71(3): 209-249.

[2] Benson AB, Venook AP, Al-Hawary MM, et al. Colon cancer, version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2021; 19(3): 329-359.

[3] Tummers WS, Groen JV, Sibinga Mulder BG, et al. Impact of resection margin status on recurrence and survival in pancreatic cancer surgery. Br J Surg. 2019; 106(8): 1055-1065.

[4] Kawakatsu S, Ohashi M, Hiki N, Nunobe S, Nagino M, Sano T. Use of endoscopy to determine the resection margin during laparoscopic gastrectomy for cancer. Br J Surg. 2017; 104(13): 1829-1836.

[5] Manisundaram N, DiBrito SR, Hu C, et al. Reporting of circumferential resection margin in rectal cancer surgery. JAMA Surg. 2023; 158(11): 1195-1202.

[6] Hoogstins CES, Boogerd LSF, Sibinga Mulder BG, et al. Image-guided surgery in patients with pancreatic cancer: first results of a clinical trial using SGM-101, a novel carcinoembryonic antigen-targeting, near-infrared fluorescent agent. Ann Surg Oncol. 2018; 25(11): 3350-3357.

[7] Terwisscha van Scheltinga AGT, van Dam GM, Nagengast WB, et al. Intraoperative near-infrared fluorescence tumor imaging with vascular endothelial growth factor and human epidermal growth factor receptor 2 targeting antibodies. J Nucl Med. 2011; 52(11): 1778-1785.

[8] Vahrmeijer AL, Hutteman M, van der Vorst JR, van de Velde CJH, Frangioni JV. Image-guided cancer surgery using near-infrared fluorescence. Nat Rev Clin Oncol. 2013; 10(9): 507-518.

[9] Alander JT, Kaartinen I, Laakso A, et al. A review of indocyanine green fluorescent imaging in surgery. Int J Biomed Imaging. 2012; 2012:940585.

[10] Hernot S, van Manen L, Debie P, Mieog JSD, Vahrmeijer AL. Latest developments in molecular tracers for fluorescence image-guided cancer surgery. Lancet Oncol. 2019; 20(7): e354-e367.

[11] Lwin T, Hoffman R, Bouvet M. Unique benefits of tumor-specific nanobodies for fluorescence guided surgery. Biomolecules. 2021; 11(2): 311.

[12] Boogerd LSF, Hoogstins CES, Schaap DP, et al. Safety and effectiveness of SGM-101, a fluorescent antibody targeting carcinoembryonic antigen, for intraoperative detection of colorectal cancer: a dose-escalation pilot study. Lancet Gastroenterol Hepatol. 2018; 3(3): 181-191.

[13] Cox KE, Turner MA, Amirfakhri S, et al. Humanized anti-carcinoembryonic antigen antibodies brightly target and label gastric cancer in orthotopic mouse models. J Surg Res. 2024; 293: 701-708.

[14] Turner MA, Amirfakhri S, Nishino H, et al. PEGylated fluorescent anti-carcinoembryonic antigen antibody labels colorectal cancer tumors in orthotopic mouse models. J Surg Res. 2023; 291: 596-602.

[15] Cox KE, Turner MA, Lwin TM, et al. Targeting patient-derived orthotopic gastric cancers with a fluorescent humanized Anti-CEA antibody. Ann Surg Oncol. 2024; 31(9): 6291-6299.

[16] Cox KE, Amirfakhri S, Lwin TM, et al. Bright and specific targeting of metastatic lymph nodes in orthotopic mouse models of gastric cancer with a fluorescent anti-CEA antibody. Ann Surg Oncol. 2025; 32(5): 3796-3803.

[17] Cox KE, Amirfakhri S, Lwin TM, et al. A new locoregional mouse model of gastric cancer for identifying probes for fluorescence guided surgery. Surgery. 2025; 181:109270.

[18] Lee K, Cox KE, Amirfakhri S, et al. Accurate co-localization of luciferase expression and fluorescent anti-CEA antibody targeting of liver metastases in an orthotopic mouse model of colon cancer. Cancers. 2024; 16(19): 3341.

[19] DeLong JC, Murakami T, Yazaki PJ, Hoffman RM, Bouvet M. Near-infrared-conjugated humanized anti-carcinoembryonic antigen antibody targets colon cancer in an orthotopic nude-mouse model. J Surg Res. 2017; 218: 139-143.

[20] Elekonawo FMK, Lütje S, Franssen GM, et al. A pretargeted multimodal approach for image-guided resection in a xenograft model of colorectal cancer. EJNMMI Res. 2019; 9(1): 86.

[21] Rijpkema M, Oyen WJ, Bos D, Franssen GM, Goldenberg DM, Boerman OC. SPECT- and fluorescence image-guided surgery using a dual-labeled carcinoembryonic antigen-targeting antibody. Journal of nuclear medicine : official publication, Society of Nuclear Medicine. 2014; 55(9): 1519-1524.

[22] Hollandsworth HM, Amirfakhri S, Filemoni F, et al. Anti-carcinoembryonic antigen-related cell adhesion molecule antibody for fluorescence visualization of primary colon cancer and metastases in patient-derived orthotopic xenograft mouse models. Oncotarget. 2020; 11(4): 429-439.

[23] Lwin TM, Murakami T, Miyake K, et al. Tumor-specific labeling of pancreatic cancer using a humanized anti-CEA antibody conjugated to a near-infrared fluorophore. Ann Surg Oncol. 2018; 25(4): 1079-1085.

[24] Lwin TM, Miyake K, Murakami T, et al. Fluorescent humanized anti-CEA antibody specifically labels metastatic pancreatic cancer in a patient-derived orthotopic xenograft (PDOX) mouse model. Oncotarget. 2018; 9(99): 37333-37342.

[25] Lwin TM, Hernot S, Hollandsworth H, et al. Tumor-specific near-infrared nanobody probe rapidly labels tumors in an orthotopic mouse model of pancreatic cancer. Surgery. 2020; 168(1): 85-91. United States.

[26] Lwin TM, Turner MA, Nishino H, et al. Fluorescent anti-CEA nanobody for rapid tumor-targeting and imaging in mouse models of pancreatic cancer. Biomolecules. 2022; 12(5): 711.

[27] Lwin TM, Turner MA, Amirfakhri S, et al. Rapid tumor-labeling kinetics with a site-specific near-infrared anti-CEA nanobody in a patient-derived orthotopic xenograft mouse model of colon cancer. J Surg Oncol. 2021; 124(7): 1121-1127.

[28] Lwin TM, Minnix M, Li L, et al. Multimodality PET and near-infrared fluorescence intraoperative imaging of CEA-positive colorectal cancer. Mol Imaging Biol. 2023; 25(4): 727-734.

[29] Yazaki PJ, Lwin TM, Minnix M, et al. Improved antibody-guided surgery with a near-infrared dye on a pegylated linker for CEA-positive tumors. J Biomed Opt. 2019; 24(6): 1-9.

[30] Boonstra MC, Tolner B, Schaafsma BE, et al. Preclinical evaluation of a novel CEA-targeting near-infrared fluorescent tracer delineating colorectal and pancreatic tumors. Int J Cancer. 2015; 137(8): 1910-1920.

[31] Guo X, Li C, Jia X, et al. NIR-II fluorescence imaging-guided colorectal cancer surgery targeting CEACAM5 by a nanobody. EBioMedicine. 2023; 89:104476.

[32] Hekman MCH, Rijpkema M, Bos DL, et al. Detection of micrometastases using SPECT/fluorescence dual-modality imaging in a CEA-expressing tumor model. Journal of nuclear medicine : official publication, Society of Nuclear Medicine. 2017; 58(5): 706-710.

[33] Metildi CA, Kaushal S, Lee C, et al. An LED light source and novel fluorophore combinations improve fluorescence laparoscopic detection of metastatic pancreatic cancer in orthotopic mouse models. J Am Coll Surg. 2012; 214: 997-1007.e2. United States.

[34] Metildi CA, Kaushal S, Pu M, et al. Fluorescence-guided surgery with a fluorophore-conjugated antibody to carcinoembryonic antigen (CEA), that highlights the tumor, improves surgical resection and increases survival in orthotopic mouse models of human pancreatic cancer. Ann Surg Oncol. 2014; 21(4): 1405-1411.

[35] Metildi CA, Kaushal S, Luiken GA, Hoffman RM, Bouvet M. Advantages of fluorescence-guided laparoscopic surgery of pancreatic cancer labeled with fluorescent anti-carcinoembryonic antigen antibodies in an orthotopic mouse model. J Am Coll Surg. 2014; 219: 132-141. United States.

[36] Tran Cao HS, Kaushal S, Metildi CA, et al. Tumor-specific fluorescence antibody imaging enables accurate staging laparoscopy in an orthotopic model of pancreatic cancer. Hepatogastroenterology. 2012; 59(118): 1994-1999.

[37] Hiroshima Y, Maawy A, Metildi CA, et al. Successful fluorescence-guided surgery on human colon cancer patient-derived orthotopic xenograft mouse models using a fluorophore-conjugated anti-CEA antibody and a portable imaging system. Journal of laparoendoscopic & advanced surgical techniques Part A. 2014; 24(4): 241-247.

[38] Metildi CA, Kaushal S, Luiken GA, Talamini MA, Hoffman RM, Bouvet M. Fluorescently labeled chimeric anti-CEA antibody improves detection and resection of human colon cancer in a patient-derived orthotopic xenograft (PDOX) nude mouse model. J Surg Oncol. 2014; 109(5): 451-458.

[39] Nishino H, Hollandsworth HM, Amirfakhri S, et al. A novel color-coded liver metastasis mouse model to distinguish tumor and adjacent liver segment. J Surg Res. 2021; 264: 327-333.

[40] Gutowski M, Carcenac M, Pourquier D, et al. Intraoperative immunophotodetection for radical resection of cancers: evaluation in an experimental model. Clinical cancer research : an official journal of the American Association for Cancer Research. 2001; 7(5): 1142-1148.

[41] Feng Q, Wang S, Ning B, et al. Evaluation of the tumor-targeting specific imaging and killing effect of a CEA-targeting nanoparticle in colorectal cancer. Biochem Biophys Res Commun. 2024; 719:150084.

[42] Maawy AA, Hiroshima Y, Zhang Y, Luiken GA, Hoffman RM, Bouvet M. Specific tumor labeling enhanced by polyethylene glycol linkage of near infrared dyes conjugated to a chimeric anti-carcinoembryonic antigen antibody in a nude mouse model of human pancreatic cancer. J Biomed Opt. 2014; 19(10):101504.

[43] Hiroshima Y, Lwin TM, Murakami T, et al. Effective fluorescence-guided surgery of liver metastasis using a fluorescent anti-CEA antibody. J Surg Oncol. 2016; 114(8): 951-958.

[44] Gutowski M, Framery B, Boonstra MC, et al. SGM-101: an innovative near-infrared dye-antibody conjugate that targets CEA for fluorescence-guided surgery. Surg Oncol. 2017; 26(2): 153-162.

[45] Framery B, Gutowski M, Dumas K, et al. Toxicity and pharmacokinetic profile of SGM-101, a fluorescent anti-CEA chimeric antibody for fluorescence imaging of tumors in patients. Toxicology Reports. 2019; 6: 409-415.

[46] Jeong K, Koo AE, Yoo J, et al. Feasibility of anti-CEA dye conjugate for cancer-specific imaging in gastric cancer cell lines and mouse xenograft models. Cancers. 2025; 17(17): 2937.

[47] de Gooyer JM, Elekonawo FMK, Bos DL, et al. Multimodal CEA-targeted image-guided colorectal cancer surgery using (111)In-labeled SGM-101. Clin Cancer Res. 2020; 26(22): 5934-5942.

[48] van Manen L, de Muynck LDAN, Baart VM, et al. Near-infrared fluorescence imaging of pancreatic cancer using a fluorescently labelled anti-CEA nanobody probe: a preclinical study. Biomolecules. 2023; 13(4): 618.

[49] Ito A, Ito Y, Matsushima S, et al. New whole-body multimodality imaging of gastric cancer peritoneal metastasis combining fluorescence imaging with ICG-labeled antibody and MRI in mice. Gastric Cancer. 2014; 17(3): 497-507. Japan.

[50] Tiernan JP, Ingram N, Marston G, et al. CEA-targeted nanoparticles allow specific in vivo fluorescent imaging of colorectal cancer models. Nanomedicine (London, England). 2015; 10(8): 1223-1231.

[51] de Valk KS, Deken MM, Schaap DP, et al. Dose-finding study of a CEA-targeting agent, SGM-101, for intraoperative fluorescence imaging of colorectal cancer. Ann Surg Oncol. 2021; 28(3): 1832-1844.

[52] Meijer RP, de Valk KS, Deken MM, et al. Intraoperative detection of colorectal and pancreatic liver metastases using SGM-101, a fluorescent antibody targeting CEA. Eur J Surg Oncol. 2021; 47(3 Pt B): 667-673.

[53] Schaap DP, Valk KS, Deken MM, et al. Carcinoembryonic antigen-specific, fluorescent image-guided cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for metastatic colorectal cancer. Br J Surg. 2020; 107(4): 334-337.

[54] Meijer RPJ, Galema HA, Faber RA, et al. Intraoperative molecular imaging of colorectal lung metastases with SGM-101: a feasibility study. Eur J Nucl Med Mol Imaging. 2024; 51(10): 2970-2979.

[55] de Gooyer JM, Elekonawo FMK, Bremers AJA, et al. Multimodal CEA-targeted fluorescence and radioguided cytoreductive surgery for peritoneal metastases of colorectal origin. Nat Commun. 2022; 13(1): 2621.

[56] Elekonawo FMK, de Gooyer JM, Bos DL, et al. Ex vivo assessment of tumor-targeting fluorescent tracers for image-guided surgery. Cancers. 2020; 12(4): 987.

[57] Darai A, de Gooyer JM, Ubels S, et al. Multimodal carcinoembryonic antigen-targeted fluorescence and radio-guided cytoreductive surgery for peritoneal metastases of colorectal origin: single-arm confirmatory trial. BJS open. 2025; 9(2):zraf045.

[58] Mulder BGS, Koller M, Duiker EW, et al. Intraoperative molecular fluorescence imaging of pancreatic cancer by targeting vascular endothelial growth factor: a multicenter feasibility dose-escalation study. J Nucl Med. 2023; 64: 82-89. United States.

[59] de Jongh SJ, Tjalma JJJ, Koller M, et al. Back-table fluorescence-guided imaging for circumferential resection margin evaluation using bevacizumab-800CW in Patients with locally advanced rectal cancer. Journal of nuclear medicine : official publication, Society of Nuclear Medicine. 2020; 61(5): 655-661.

[60] Schmidt I, Zhao X, van der Waaij AM, et al. Ultrasound-Guided Quantitative Fluorescence Molecular Endoscopy for Monitoring Response in Patients with Esophageal Cancer Following Neoadjuvant Chemoradiotherapy. Clin Cancer Res. 2024; 30(15): 3211-3219.

[61] Obaid G, Spring BQ, Bano S, Hasan T. Activatable clinical fluorophore-quencher antibody pairs as dual molecular probes for the enhanced specificity of image-guided surgery. J Biomed Opt. 2017; 22(12): 1-6.

[62] Thurber GM, Figueiredo J-L, Weissleder R. Detection limits of intraoperative near infrared imaging for tumor resection. J Surg Oncol. 2010; 102(7): 758-764.

[63] Wang L, Liang M, Xiao Y, et al. NIR-II navigation with an EGFR-targeted probe improves imaging resolution and sensitivity of detecting micrometastases in esophageal squamous cell carcinoma xenograft models. Mol Pharmaceutics. 2022; 19(10): 3563-3575.

[64] Saccomano M, Dullin C, Alves F, Napp J. Preclinical evaluation of near-infrared (NIR) fluorescently labeled cetuximab as a potential tool for fluorescence-guided surgery. Int J Cancer. 2016; 139(10): 2277-2289.

[65] Singh M, Nabavi E, Zhou Y, et al. Laparoscopic fluorescence image-guided photothermal therapy enhances cancer diagnosis and treatment. Nanotheranostics. 2019; 3(1): 89-102.

[66] Zeng X, Xiao Y, Lin J, et al. Near-infrared II dye-protein complex for biomedical imaging and imaging-guided photothermal therapy. Advanced healthcare materials. 2018; 7(18):e1800589.

[67] Bernhard W, El-Sayed A, Barreto K, et al. Near infrared fluorescence imaging of EGFR expression in vivo using IRDye800CW-nimotuzumab. Oncotarget. 2018; 9(5): 6213-6227.

[68] Lu J, Guo Y, Hao H, et al. Targeted delivery of cathepsin-activatable near-infrared fluorescence probe for ultrahigh specific imaging of peritoneal metastasis. Eur J Med Chem. 2023; 262:115909.

[69] Marston JC, Kennedy GD, Lapi SE, et al. Panitumumab-IRDye800CW for fluorescence-guided surgical resection of colorectal cancer. J Surg Res. 2019; 239: 44-51.

[70] Jin S, Li C, Jia X, et al. A new EGFR and c-Met bispecific NIR-II fluorescent probe for visualising colorectal cancer and metastatic lymph nodes. EBioMedicine. 2025; 115:105687.

[71] Tummers WS, Miller SE, Teraphongphom NT, et al. Intraoperative pancreatic cancer detection using tumor-specific multimodality molecular imaging. Ann Surg Oncol. 2018; 25(7): 1880-1888.

[72] Lu G, van den Berg NS, Martin BA, et al. Tumour-specific fluorescence-guided surgery for pancreatic cancer using panitumumab-IRDye800CW: a phase 1 single-centre, open-label, single-arm, dose-escalation study. Lancet Gastroenterol Hepatol. 2020; 5(8): 753-764. Netherlands.

[73] Schulz P, Dierkes C, Wiedenmann B, Grötzinger C. Near-infrared confocal laser endomicroscopy detects colorectal cancer via an integrin αvβ 3 optical probe. Mol Imaging Biol. 2015; 17(4): 450-460.

[74] Hutteman M, Mieog J, van der Vorst J, et al. Intraoperative near-infrared fluorescence imaging of colorectal metastases targeting integrin alphavbeta3 expression in a syngeneic rat model. Eur J Surg Oncol. 2011; 37(3): 252-257.

[75] Ren H, Zeng X, Zhao X, et al. A bioactivated in vivo assembly nanotechnology fabricated NIR probe for small pancreatic tumor intraoperative imaging. Nat Commun. 2022; 13(1): 418.

[76] Napp J, Stammes MA, Claussen J, et al. Fluorescence- and multispectral optoacoustic imaging for an optimized detection of deeply located tumors in an orthotopic mouse model of pancreatic carcinoma. Int J Cancer. 2018; 142(10): 2118-2129.

[77] Handgraaf HJ, Boonstra MC, Prevoo HA, et al. Real-time near-infrared fluorescence imaging using cRGDZW800- 1 for intraoperative visualization of multiple cancer types. Oncotarget. 2017; 8(13): 21054-21066.

[78] Keramidas M, Josserand V, Righini CA, Wenk C, Faure C, Coll JL. Intraoperative near-infrared image-guided surgery for peritoneal carcinomatosis in a preclinical experimental model. Br J Surg. 2010; 97: 737-743. England.

[79] Verbeek FPR, van der Vorst JR, Tummers QRJG, et al. Near-infrared fluorescence imaging of both colorectal cancer and ureters using a low-dose integrin targeted probe. Ann Surg Oncol. 2014; 21(0 4): S528-37.

[80] Trajkovic-Arsic M, Mohajerani P, Sarantopoulos A, et al. Multimodal molecular imaging of integrin αvβ3 for in vivo detection of pancreatic cancer. Journal of nuclear medicine : official publication, Society of Nuclear Medicine. 2014; 55(3): 446-451.

[81] Choi HS, Gibbs SL, Lee JH, et al. Targeted zwitterionic near-infrared fluorophores for improved optical imaging. Nat Biotechnol. 2013; 31(2): 148-153.

[82] Chen Q, Shang W, Zeng C, et al. Theranostic imaging of liver cancer using targeted optical/MRI dual-modal probes. Oncotarget. 2017; 8(20): 32741-32751.

[83] Zhang Y, Lv J, Liu P, et al. Contrast-enhanced multispectral photoacoustic imaging for irregular hepatectomy navigation: a pilot study. ACS biomaterials science & engineering. 2020; 6(10): 5874-5885.

[84] Tummers WS, Kimura RH, Abou-Elkacem L, et al. Development and preclinical validation of a cysteine knottin peptide targeting integrin αvβ6 for near-infrared fluorescent-guided surgery in pancreatic cancer. Clinical cancer research : an official journal of the American Association for Cancer Research. 2018; 24(7): 1667-1676.

[85] Ganguly T, Tang SY, Bauer N, Sutcliffe JL. Evaluation of two optical probes for imaging the integrin alphavbeta6- in vitro and in vivo in tumor-bearing mice. Mol Imaging Biol. 2020; 22(5): 1170-1181.

[86] Wen Q, Zhang Y, Li C, et al. NIR-II fluorescent self-assembled peptide nanochain for ultrasensitive detection of peritoneal metastasis. Angew Chem Int Ed Engl. 2019; 58(32): 11001-11006.

[87] Li J, Zhu F, Lou K, et al. Tumor microenvironment enhanced NIR II fluorescence imaging for tumor precise surgery navigation via tetrasulfide mesoporous silica-coated Nd-based rare-earth nanocrystals. Materials today Bio. 2022; 16:100397.

[88] Wang Q, Yan H, Jin Y, et al. A novel plectin/integrin-targeted bispecific molecular probe for magnetic resonance/near-infrared imaging of pancreatic cancer. Biomaterials. 2018; 183: 173-184.

[89] Dang Y, Liu X, Zheng Z, et al. Lutetium-based nanoprobes for radiosensitization with immune microenvironment remodeling and NIR-II fluorescence imaging-guided surgery in colorectal cancer. Advanced science (Weinheim, Baden-Wurttemberg, Germany). 2025; 12(38):e10136.

[90] Yu M, Zhu L, Dong G, et al. Spatiotemporal mapping of lymphatic metastases in gastric cancer using tumor-trackable and enzyme-activatable near-infrared fluorescent nanoprobes. ACS nano. 2024; 18(52): 35490-35506.

[91] de Valk K, Deken MM, Handgraaf HJM, et al. First-in-human assessment of cRGD-ZW800-1, a zwitterionic, integrin-targeted, near-infrared fluorescent peptide in colon carcinoma. Clin Cancer Res. 2020; 26(15): 3990-3998. United States.

[92] Gahlen J, Pietschmann M, Prosst RL, Herfarth C. Systemic vs local administration of delta-aminolevulinic acid for laparoscopic fluorescence diagnosis of malignant intra-abdominal tumors: experimental study. Surg Endosc. 2001; 15(2): 196-199.

[93] Orth K, Russ D, Steiner R, Beger H. Fluorescence detection of small gastrointestinal tumours: principles, technique, first clinical experience. Langenbeck's Archives of Surgery. 2000; 385(7): 488-494.

[94] Namikawa T, Inoue K, Uemura S, et al. Photodynamic diagnosis using 5-aminolevulinic acid during gastrectomy for gastric cancer. J Surg Oncol. 2014; 109(3): 213-217.

[95] Kurumi H, Sakaguchi T, Hashiguchi K, et al. Photodynamic diagnosis for the identification of intestinal-type gastric cancers and high-grade adenomas. Front Oncol. 2022; 12:861868.

[96] Inoue Y, Tanaka R, Komeda K, Hirokawa F, Hayashi M, Uchiyama K. Fluorescence detection of malignant liver tumors using 5-aminolevulinic acid-mediated photodynamic diagnosis: principles, technique, and clinical experience. World J Surg. 2014; 38(7): 1786-1794.

[97] Kondo Y, Murayama Y, Konishi H, et al. Fluorescent detection of peritoneal metastasis in human colorectal cancer using 5-aminolevulinic acid. Int J Oncol. 2014; 45(1): 41-46.

[98] Yonemura Y, Canbay E, Ishibashi H, et al. 5-Aminolevulinic acid fluorescence in detection of peritoneal metastases. Asian Pacific journal of cancer prevention : APJCP. 2016; 17(4): 2271-2275.

[99] Voskuil FJ, Steinkamp PJ, Zhao T, et al. Exploiting metabolic acidosis in solid cancers using a tumor-agnostic pH-activatable nanoprobe for fluorescence-guided surgery. Nat Commun. 2020; 11(1): 3257.

[100] Wagner P, Levine EA, Kim AC, et al. Detection of residual peritoneal metastases following cytoreductive surgery using pegsitacianine, a pH-sensitive imaging agent: final results from a phase II study. Ann Surg Oncol. 2024; 31(7): 4726-4734.

[101] Pan Q, Li K, Kang X, et al. Rational design of NIR-II molecule-engineered nanoplatform for preoperative downstaging and imaging-guided surgery of orthotopic hepatic tumor. Journal of nanobiotechnology. 2023; 21(1): 489.

[102] Yan Z, Wang Y, Qiu M, et al. Persistent luminescence nanoparticles with high intensity for colorectal cancer surgery navigation and precision resection. Journal of materials chemistry B. 2024; 12: 8655-8661.

[103] Newton AD, Predina JD, Frenzel-Sulyok LG, Low PS, Singhal S, Roses RE. Intraoperative molecular imaging utilizing a folate receptor-targeted near-infrared probe can identify macroscopic gastric adenocarcinomas. 2021; 23: 11-17. United States.

[104] Dindere ME, Tanca A, Rusu M, Liehn EA, Bucur O. Intraoperative tumor detection using pafolacianine. Int J Mol Sci. 2022; 23(21):12842.

[105] Lehane A, Polites SF, Dodd A, Goldstein SD, Lautz TB. Let it glow: intraoperative visualization of pulmonary metastases using pafolacianine, a next-generation fluorescent agent, for young adults undergoing pulmonary metastasectomy. Pediatr Blood Cancer. 2024; 71(11):e31293.

[106] Kogan-Zviagin I, Shamay Y, Nissan A, Sella-Tavor O, Golan M, David A. Intra-colonic administration of a polymer-bound NIRF probe for improved colorectal cancer detection during colonoscopy. Journal of controlled release : official journal of the Controlled Release Society. 2014; 192: 182-191.

[107] Turner MA, Hollandsworth HM, Amirfakhri S, et al. Anti-mucin 4 fluorescent antibody brightly targets colon cancer in patient-derived orthotopic xenograft mouse models: a proof-of-concept study for future clinical applications. Am J Surg. 2022; 224(4): 1081-1085.

[108] Jaiswal S, Cox KE, Amirfakhri S, et al. Targeting human pancreatic cancer with a fluorophore-conjugated mucin 4 (muc4) antibody: initial characterization in orthotopic cell line mouse models. J Clin Med. 2024; 13(20): 6211.

[109] Jaiswal S, Amirfakhri S, Bravo J, et al. Mucin4 (MUC4) antibody labeled with an NIR dye brightly targets pancreatic cancer liver metastases and peritoneal carcinomatosis. Cancers (Basel). 2025; 17(12): 2031.

[110] Olson MT, Aguilar EN, Brooks CL, et al. Preclinical evaluation of a humanized, near-infrared fluorescent antibody for fluorescence-guided surgery of muc16-expressing pancreatic cancer. Mol Pharmaceutics. 2022; 19(10): 3586-3599.

[111] Olson MT, Wojtynek NE, Talmon GA, et al. Development of a MUC16-targeted near-infrared fluorescent antibody conjugate for intraoperative imaging of pancreatic cancer. Mol Cancer Ther. 2020; 19(8): 1670-1681.

[112] Turner MA, Cox KE, Neel N, et al. Highly selective targeting of pancreatic cancer in the liver with a near-infrared anti-MUC5AC probe in a PDOX mouse model: a proof-of-concept study. journal of personalized medicine. 2023; 13(5): 857.

[113] Turner MA, Hollandsworth HM, Nishino H, et al. Fluorescent Anti-MUC5AC brightly targets pancreatic cancer in a patient-derived orthotopic xenograft. In Vivo. 2022; 36(1): 57-62.

[114] van Driel PB, Boonstra MC, Prevoo HA, et al. EpCAM as multi-tumour target for near-infrared fluorescence guided surgery. BMC Cancer. 2016; 16(1): 884.

[115] Boogerd LSF, Boonstra MC, Prevoo HAJM, et al. Fluorescence-guided tumor detection with a novel anti-EpCAM targeted antibody fragment: preclinical validation. Surg Oncol. 2019; 28: 1-8.

[116] Houvast RD, Badr N, March T, et al. Preclinical evaluation of EpCAM-binding designed ankyrin repeat proteins (DARPins) as targeting moieties for bimodal near-infrared fluorescence and photoacoustic imaging of cancer. Eur J Nucl Med Mol Imaging. 2024; 51(8): 2179-2192.

[117] Huang M, Qi M, Yang H, et al. Noninvasive strategies for the treatment of tiny liver cancer: integrating photothermal therapy and multimodality imaging EpCAM-guided nanoparticles. ACS Appl Mater Interfaces. 2023; 15(18): 21843-21853.

[118] Boonstra MC, van Driel PBAA, van Willigen DM, et al. uPAR-targeted multimodal tracer for pre- and intraoperative imaging in cancer surgery. Oncotarget. 2015; 6(16): 14260-14273.

[119] Juhl K, Christensen A, Rubek N, Karnov KKS, Buchwald CV, Kjaer A. Improved surgical resection of metastatic pancreatic cancer using uPAR targeted in vivo fluorescent guidance: comparison with traditional white light surgery. Oncotarget. 2019; 10(59): 6308-6316.

[120] Baart VM, van Manen L, Bhairosingh SS, et al. Side-by-side comparison of uPAR-targeting optical imaging antibodies and antibody fragments for fluorescence-guided surgery of solid tumors. Mol Imaging Biol. 2023; 25: 122-132. United States.

[121] Mateusiak Ł, Hakuno S, de Jonge-Muller ES, et al. Fluorescent nanobodies for enhanced guidance in digestive tumors and liver metastasis surgery. Eur J Surg Oncol. 2025; 51(3):109537.

[122] Gong L, Ding H, Long NE, et al. A 3E8.scFv.Cys-IR800 conjugate targeting TAG-72 in an orthotopic colorectal cancer model. Mol Imaging Biol. 2018; 20(1): 47-54.

[123] Hollandsworth HM, Amirfakhri S, Filemoni F, et al. Humanized anti-tumor-associated glycoprotein-72 for submillimeter near-infrared detection of colon cancer in metastatic mouse models. J Surg Res. 2020; 252: 16-21.

[124] Hollandsworth HM, Nishino H, Turner M, et al. Humanized fluorescent tumor-associated glycoprotein-72 antibody selectively labels colon-cancer liver metastases in orthotopic mouse models. In Vivo. 2020; 34(5): 2303-2307.

[125] Miyata Y, Ishizawa T, Kamiya M, et al. Intraoperative imaging of hepatic cancers using γ-glutamyltranspeptidase-specific fluorophore enabling real-time identification and estimation of recurrence. Sci Rep. 2017; 7(1): 3542.

[126] Liu Y, Feng B, Cao X, et al. A novel “AIE + ESIPT” near-infrared nanoprobe for the imaging of γ-glutamyl transpeptidase in living cells and the application in precision medicine. Analyst. 2019; 144(17): 5136-5142.

[127] Zhang B, Lu J, Lin X, et al. Injectable and sprayable fluorescent nanoprobe for rapid real-time detection of human colorectal tumors. Advanced materials (Deerfield Beach, Fla). 2024; 36(36):e2405275.

[128] Yang Z, Yang Z, Wang Z, et al. Zero-crosstalk tumor-targeting ratiometric near-infrared gamma-glutamyltranspeptidase probe for fluorescent-guided surgical resection of orthotopic hepatic tumor. Anal Chem. 2025; 97(1): 185-193.

[129] An J, Zhao N, Zhang C, et al. Heptamethine carbocyanine DZ-1 dye for near-infrared fluorescence imaging of hepatocellular carcinoma. Oncotarget. 2017; 8(34): 56880-56892.

[130] Song J, Ren T, Duan Y, et al. Near-infrared fluorescence imaging of hepatocellular carcinoma cells regulated by beta-catenin signaling pathway. Front Oncol. 2023; 13:1140256.

[131] Rietbergen DDD, Buckle T, Slof LJ, et al. Hepato-Cy5, a bimodal tracer for image-guided hepatobiliary surgery. Journal of nuclear medicine : official publication, Society of Nuclear Medicine. 2024; 65(8): 1301-1306.

[132] Li C, Lin Q, Hu F, Bao R, Cai H, Gu Y. Based on lapatinib innovative near-infrared fluorescent probes targeting HER1/HER2 for in vivo tumors imaging. Biosens Bioelectron. 2022; 214:114503.

[133] Hama Y, Urano Y, Koyama Y, Choyke PL, Kobayashi H. Activatable fluorescent molecular imaging of peritoneal metastases following pretargeting with a biotinylated monoclonal antibody. Cancer Res. 2007; 67(8): 3809-3817.

[134] Jeong K, Kong S, Bae S, et al. Evaluation of near-infrared fluorescence-conjugated peptides for visualization of human epidermal receptor 2-overexpressed gastric cancer. Journal of Gastric Cancer. 2021; 21(2): 191-202.

[135] Inagaki FF, Fujimura D, Furusawa A, et al. Fluorescence imaging of tumor-accumulating antibody-IR700 conjugates prior to near-infrared photoimmunotherapy (NIR-PIT) using a commercially available camera designed for indocyanine green. Mol Pharmaceutics. 2021; 18(3): 1238-1246.

[136] McElroy M, Kaushal S, Luiken GA, et al. Imaging of primary and metastatic pancreatic cancer using a fluorophore-conjugated anti-CA19-9 antibody for surgical navigation. World J Surg. 2008; 32(6): 1057-1066.

[137] Hiroshima Y, Maawy A, Zhang Y, et al. Metastatic recurrence in a pancreatic cancer patient derived orthotopic xenograft (PDOX) nude mouse model is inhibited by neoadjuvant chemotherapy in combination with fluorescence-guided surgery with an anti-CA 19-9-conjugated fluorophore. PLoS One. 2014; 9(12):e114310.

[138] Cox KE, Bravo J, Jaiswal S, et al. Brightly visualizing pancreatic cancer margins in orthotopic mouse models with an anti-CA19-9 antibody conjugated to a near-infrared fluorophore. Cancers (Basel). 2025; 17(16): 2617.

[139] Houghton JL, Zeglis BM, Abdel-Atti D, et al. Site-specifically labeled CA19.9-targeted immunoconjugates for the PET, NIRF, and multimodal PET/NIRF imaging of pancreatic cancer. Proc Natl Acad Sci USA. 2015; 112(52): 15850-15855.

[140] Adumeau P, Carnazza KE, Brand C, et al. A pretargeted approach for the multimodal PET/NIRF imaging of colorectal cancer. Theranostics. 2016; 6(12): 2267-2277.

[141] Houvast RD, Baart VM, Bhairosingh SS, et al. Glycan-based near-infrared fluorescent (NIRF) imaging of gastrointestinal tumors: a preclinical proof-of-concept in vivo study. Mol Imaging Biol. 2020; 22(6): 1511-1522.

[142] Houvast RD, Sier VQ, van Duijvenvoorde M, et al. Preclinical evaluation of glycan-targeting monoclonal antibodies for bimodal near-infrared fluorescence and photoacoustic imaging of gastrointestinal cancers. EJNMMI Res. 2025; 15(1): 67.

[143] Keizers B, Stroet MCM, Ali M, et al. Reflect: reporting guidelines for preclinical, translational and clinical fluorescence molecular imaging studies. npj Imaging. 2025; 3(1): 62.

[144] Warmerdam MI, Creemers DMJ, Kusters M, et al. Long-term local control following CEA-targeted fluorescence-guided surgery in patients with locally advanced and recurrent rectal cancer. Mol Imaging Biol. 2025; 27(4): 629-637.

[145] Torres-Ruiz T, Obaid O, Al-Alwan A, Kenner M, Jamil T, Bosio RJ. The grass is not always greener: large scale study reveals indocyanine green near-infrared visualization during elective colorectal surgeries is not associated with improved anastomotic or oncologic outcomes. Am Surg. 2025:31348251372426.

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