Intraoperative Molecular Imaging Can Detect Large Nerve Perineural Invasion: A Case Report

BACKGROUND: Perineural invasion (PNI) in head and neck squamous cell carcinoma (SCC) results in worse overall survival. Diagnosis requires resection and microscopic evaluation. METHODS: A 63-year-old male with persistent cT4aN0 p16-positive SCC of the left base of tongue following chemoradiotherapy underwent salvage total glossectomy. Fluorescence-guided imaging of the wound bed was performed with PDE-GEN3 near-infrared (NIR) imaging following infusion of an optically EGFR-targeted antibody, Panitumumab-IRDye800 (pan800). RESULTS: The proximal resected hypoglossal nerve was imaged intraoperatively and demonstrated a strong green fluorescence signal, raising concern for subclinical PNI. Biopsy of the nerve revealed SCC on frozen section analysis. This was re-resected with subsequent proximal margin negative for carcinoma. Postoperatively, ex vivo imaging of the nerve using PDE-GEN3 NIR imaging again demonstrated the presence of pan800 within the initial positive nerve margin, confirming subclinical PNI. CONCLUSIONS: This case shows the feasibility of intraoperative fluorescence as a method to help identify subclinical PNI. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05945875.