Enhancing surgical precision in ovarian cancer with FRα-fluorescence-guided surgery

Introduction: Complete cytoreduction is a key prognostic factor in advanced ovarian cancer. Folate receptor alpha (FRα)-targeted intraoperative fluorescence imaging has emerged as a promising tool to enhance identification of tumor localization. Agents like pafolacianine (OTL38) and EC17 improve real-time visualization of malignant lesions, overcoming limitations of conventional methods relying on visual inspection and palpation. Materials and methods: we conducted a systematic review to evaluate the safety, efficacy, and feasibility of FRα-targeted fluorescence imaging in ovarian cancer surgery. Studies were identified through comprehensive searches in PubMed, Scopus, and Web of Science. Clinical and preclinical studies assessing FRα-targeted agents with near-infrared or other fluorescence modalities were included. Bias risk was assessed using the Cochrane Risk of Bias Tool for randomized trials and the Newcastle-Ottawa Scale for non-randomized studies. Results: Eleven studies, including clinical and preclinical trials, were analyzed. OTL38 significantly improved lesion detection, identifying additional malignant lesions in 33 % of patients undergoing debulking surgery and enhancing detection by 29 % over standard methods, with sensitivity exceeding 85 %. EC17, assessed in smaller studies, identified 16 % more malignant lesions undetected by conventional methods, though autofluorescence was a challenge. Adverse events, predominantly mild, included nausea, vomiting, and transient skin flushing. Conclusions: FRα-targeted imaging may enhance lesion detection during cytoreductive surgery, increasing resection completeness. While EC17 shows feasibility, larger trials support the potential of OTL38. Future research should optimize imaging agents to reduce autofluorescence and assess their impact on survival outcomes.