# Real-time margin assessment and image-guided surgery as the global standard

Source: https://onco.cc/ideas/idea-moon-image-guided-surgery-everywhere/  
OnCo record `idea-moon-image-guided-surgery-everywhere` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Surgeons often cannot see where a tumour ends. Fluorescent dyes and AI-read imaging in the operating theatre can show them, cutting repeat operations. Make this routine everywhere.

## Summary

Positive margins lead to re-operation or recurrence in breast, head and neck, prostate and gastrointestinal surgery. Tumour-targeted fluorescent agents (pegulicianine approved for breast lumpectomy, PSMA- and folate-targeted agents), intraoperative mass spectrometry and rapid AI histology can assess margins during surgery. The proposal is a programme to standardise and validate these tools across common operations, integrate them into low-cost surgical imaging platforms suitable for district hospitals, and make margin status with intraoperative assessment a quality indicator.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Hypothesis: Routine intraoperative margin assessment halves positive margin rates and re-operations in breast and head and neck surgery, and low-cost versions perform equivalently in resource-limited hospitals.
- Rationale: Surgery remains the most curative treatment for most solid tumours and its main technical failure is invisible margins; the imaging agents and readers now exist.
- Proposed test: Randomised trials of image-guided versus standard surgery in breast and oral cancer with positive margin rate as primary endpoint, plus a validation of low-cost imaging systems in two middle-income countries.
- Maturity: early-clinical
- Actor: engineering

## Sources

- Bottleneck evidence (Surgery and radiotherapy cure most, get least): Sullivan et al., Global cancer surgery (Lancet Oncology Commission 2015): https://doi.org/10.1016/S1470-2045(15)00223-5

## Connected records

- cancers: [Head and neck squamous cell carcinoma](https://onco.cc/cancers/head-and-neck/), [HR-positive / HER2-negative breast cancer](https://onco.cc/cancers/breast-hr-positive/), [Prostate cancer](https://onco.cc/cancers/prostate/)
- technologies: [Digital pathology & AI](https://onco.cc/technologies/digital-pathology-ai/), [Fluorescence-guided surgery](https://onco.cc/technologies/fluorescence-guided-surgery/), [Optical & fluorescence imaging](https://onco.cc/technologies/optical-imaging/)
- bottlenecks: [Most of the world has almost no cancer care](https://onco.cc/bottlenecks/b-global-access/), [Surgery and radiotherapy cure most, get least](https://onco.cc/bottlenecks/b-surgery-radiation-innovation/)
- key papers: [Global cancer surgery: delivering safe, affordable, and timely cancer surgery](https://onco.cc/key-papers/paper-sullivan-lancet-oncol/)

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