Intraoperative Molecular Imaging for Cancer

Intraoperative molecular imaging (IMI) is a surgical technique used during procedures to remove cancerous tumors. Depending on the type and location of tumors in the body, surgeons may have a hard time telling the difference between healthy tissue and cancerous tissue.

IMI helps surgeons “see” the cancer cells better because of a special dye, called a tracer. The tracer attaches to cancer cells and shows up in fluorescent colors under specially designed imaging technology.

The dyes are not harmful to the body. They can be taken as a pill before surgery or injected as an IV once your child is asleep.

Once inside the body, these dyes make the cancer cells glow in bright colors. This makes it easier and safer for surgeons to remove certain tissues.

IMI can make a difference in doctors being able to find and remove all the cancer cells and in preventing cancer from coming back.

This technique is especially helpful during minimally invasive surgeries in which surgeons cannot feel tumors or organs with their own hands during the surgery.

IMI is also used in trickier cancer surgeries where cancerous cells may be hidden or microscopic.

The margins of cancerous cells are the small outlines of healthy tissue around the infected tissue that must be removed to make sure all cancer cells are taken out of the body. If cancer is left behind at those margins, it could grow back and spread.

IMI technology shows surgeons the exact size and outline of the tumor. It allows them to have a more precise view of what to remove and what healthy tissues can be left behind. In addition to making surgery more effective, it can also make it safer.

Why do you use IMI in children?

IMI has many benefits during cancer surgery in children:

• IMI technology highlights the cancerous cells, so surgeons can better avoid important structures, such as organs, muscles, nerves, and bones. It is important to preserve as much healthy tissue as possible in a child’s developing body for the best chance of survival and recovery.
• A more precise view means surgeons can be more accurate with their tumor removal, lessening the likelihood of future surgeries. This is a big win for children, as every surgery runs the risk of infection or future complications.
• IMI is great at finding tumor cells that are impossible to see or hiding in certain areas. This makes it an important resource for complicated cancer surgeries of the brain, spine, chest, abdomen, liver, and lungs.

Before surgery, your child’s care team will discuss how they will give your child the tracer and what to expect during surgery.

They may choose for your child to take the tracer by mouth before surgery, like a pill. Or, they may inject it through an IV either before or during surgery. During the time your child is prepped for surgery, the tracer will bind itself to the cancer cells.

During the procedure, your child’s surgeon will use a special camera that can detect fluorescence from the dye to scan the location of the tumors. The tracer and camera work together to show the surgeon exactly where the tumor is and what shape and size it is.

The tracer allows the surgeon to:

• Confirm that all cancerous cells have been removed (no more fluorescent light on the imaging).
• Check the areas surrounding the tumors, including lymph nodes and other areas of concern, for hidden or stubborn cancer cells.
• Protect and preserve normal, healthy tissues and organs.

Once all the cancer cells are removed, your child’s surgeon will stitch up any incisions. Your child will recover the same way they would from any cancer-removing surgery.

The dye doesn’t stay in the body permanently. It will work through your child’s organs and be flushed out through the liver and kidneys with normal body wastes.

Is intraoperative molecular imaging right for my child?

If your child has a cancer diagnosis that requires surgical removal, IMI may be the right technique for the procedure. Your child’s care team will discuss the options with you and tell you if IMI could be used for their surgery.

When general anesthesia is needed, there are important rules for eating and drinking that must be followed in the hours before the surgery.

One business day before your child’s surgery, you will receive a phone call from a nurse between the hours of 1 and 9 p.m. (Nurses do not make these calls on weekends or holidays.) Please have paper and a pen ready to write down these important instructions.

The nurse will give you specific eating and drinking instructions for your child based on your child’s age.

The following are the usual instructions given for eating and drinking. No matter what age your child is, you should follow the specific instructions given to you on the phone by the nurse.

For children older than 12 months

• After midnight the night before the surgery, do not give any solid food or non-clear liquids. That includes milk, formula, juices with pulp, coffee, and chewing gum or candy.

For infants under 12 months

• Up to six hours before the scheduled arrival time, formula-fed babies may be given formula.
• Up to four hours before the scheduled arrival time, breastfed babies may nurse.

For all children

• Up to two hours before the scheduled arrival time, give only clear liquids. Clear liquids include water, Pedialyte®, Kool-Aid®, and juices you can see through, such as apple or white grape juice. Milk is not a clear liquid.
• In the 2 hours before the scheduled arrival time, give them nothing to eat or drink.

Once your child has been registered for the surgery, a member of the anesthesia staff will meet with you to take your child’s vital signs, weight, and medical history.

A pediatric anesthesiologist — a doctor who specializes in anesthesia for children — will meet with you before the surgery. They will ask questions about your child’s health and about when your child last ate.

Because your child may have eaten more recently than is usually advised for surgery, the anesthesiologist may make adjustments to your child’s anesthesia. Once admitted, your child will not be able to have anything to eat or drink until after the operation.

• As the parent or legal guardian, you will be asked to sign a consent form before the anesthesia is given.
• If your child is very scared or upset, the doctor may give a special medication to help them relax. This medication is flavored and takes effect in about 10 to 15 minutes.
• If you wish, you may be allowed to go with your child to the room where the surgery will be done and stay while the sleep medication is given.
• Younger children will get their sleep medication through a “space mask” that will carry air mixed with medication. Your child may choose a favorite scent to flavor the air flowing through the mask. There are no shots or needles used while your child is still awake.
• Older children may choose between getting their medication through a mask or directly into a vein through an intravenous (IV) line.
• When your child has fallen asleep, you will be taken to the waiting room. If it has not already been done, an IV will be started so that medication can be given to keep your child sleeping throughout the surgery.

While your child is asleep, their heart rate, blood pressure, temperature, and blood oxygen level will be checked continuously. Your child will have a breathing tube placed while they are asleep. Your child might have a sore throat after the surgery.

To keep your child asleep during the surgery, they might be given anesthetic medication by mask, through the IV tube, or both. When the surgery is over, the medications will be stopped, and your child will begin to wake up.

After surgery, your child will be moved to the recovery room to allow the anesthetic to wear off. You will be called so that you can be there as they wake up.

• Children coming out of anesthesia react in different ways. Your child might cry, be fussy or confused, feel sick to their stomach, or vomit. These reactions are normal and will go away as the anesthesia wears off.
• While your child is in recovery, your surgeon will talk to you about the surgery. This is a good time to ask questions about pain medications, diet, and activity.
• When your child is awake enough, they might be given a Popsicle® or “slushy” to drink in the recovery room.
• Once the anesthesiologist sees that your child is recovering and their pain is controlled, they will be moved to their hospital room. This usually takes about an hour, but every child is different, so times may vary.

The most important role of a parent or guardian is to help your child stay calm and relaxed before the surgery. The best way to help your child stay calm is for you to stay calm.

• You are encouraged to talk to your child or hold their hand before the surgery, while sleep medication is given, and while in recovery.
• You may bring along a “comfort” item — such as a favorite stuffed animal or “blankie” — for your child to hold before and after the surgery.

During the surgery, your child will be given a numbing medication directly into the incision to relieve discomfort after the surgery.

After the surgery, your child will most likely have abdominal pain. Your child may take Tylenol^® or Motrin^®. If your child is still having pain, your child’s doctor may prescribe a stronger medication or a narcotic.

Before you go home, your doctor will prescribe pain medication for your child.

After your child is discharged and goes home, they should avoid strenuous activity for the next two to four weeks.

Bathing

Your child may take a shower one to three days after the surgery. Baths are allowed five to seven days after surgery.

Activity

Following the surgery, activity needs to be somewhat restricted.

• Your surgeon will determine when your child may resume normal activities.
• Your child may return to school when they feel up to it.
• Participation in contact sports and gym class is not permitted until cleared by the surgical team (typically two to four weeks after surgery).
• Swimming is permitted one to two weeks after surgery.
• Walking and stair climbing are encouraged.

If your child has a fever higher than 101.5 F, bleeding, or foul-smelling drainage from the area around the incisions, call your surgeon right away.

Also, call the doctor if your child has:

• Increased or unexplained pain.
• Increased swelling or redness at the incision site.
• Increased tenderness near the incision.
• Nausea, vomiting, diarrhea, or constipation that is not improving.

If you have any specific questions about your child’s surgery, you should discuss them with the surgeon before the surgery. After the surgery, you may call the Division of Pediatric General and Thoracic Surgery at UPMC Children’s and ask to speak with your child’s surgeon or speak with them during the follow-up visit, if needed.

If your child has any special needs or health issues you feel the doctor needs to know about, please call the Division of Pediatric General and Thoracic Surgery at UPMC Children's Hospital of Pittsburgh before the follow-up visit and ask to speak with a nurse. It is important to notify us in advance about any special needs your child might have.

At UPMC Children’s Hospital of Pittsburgh, every child facing a cancer diagnosis receives an individualized treatment plan and family-centered care.

• The surgeons at UPMC Children’s have trained at the nation’s leading pediatric cancer centers. They have extensive experience performing open and laparoscopic cancer surgeries on even the smallest of patients.
• In addition, surgeons at UPMC Children’s are pioneering the use of Intraoperative Molecular Imaging to help guide the most complete and safest resection of tumors as possible.