Guiding brain tumor resection using surface-enhanced Raman scattering nanoparticles and a hand-held Raman scanner

When surface-enhanced Raman spectroscopy meets complex biofluids: A new representation strategy for reliable and comprehensive characterization

BACKGROUND

Surface-enhanced Raman spectroscopy (SERS) has gained increasing importance in molecular detection due to its high specificity and sensitivity. Complex biofluids (e.g., cell lysates and serums) typically contain large numbers of different bio-molecules with various concentrations, making it extremely challenging to be reliably and comprehensively characterized via conventional single SERS spectra due to uncontrollable electromagnetic hot spots and irregular molecular motions. The traditional approach of directly reading out the single SERS spectra or calculating the average of multiple spectra is less likely to take advantage of the full information of complex biofluid systems.

RESULTS

Herein, we propose to construct a spectral set with unordered multiple SERS spectra as a novel representation strategy to characterize full molecular information of complex biofluids. This new SERS representation not only contains details from each single spectra but captures the temporal/spatial distribution characteristics. To address the ordering-independent property of traditional chemometric methods (e.g., the Euclidean distance and the Pearson correlation coefficient), we introduce Wasserstein distance (WD) to quantitatively and comprehensively assess the quality of spectral sets on biofluids. WD performs its superiority for the quantitative assessment of the spectral sets. Additionally, WD benefits from its independence of the ordering of spectra in a spectral set, which is undesirable for traditional chemometric methods. With experiments on cell lysates and human serums, we successfully achieve the verification for the reproducibility between parallel samples, the uniformity at different positions in the same sample, the repeatability from multiple tests at one location of the same sample, and the cardinality effect of the spectral set. SERS spectral sets also manage to distinguish different classes of human serums and achieve higher accuracy than the traditional prostate-specific antigen in prostate cancer classification.

SIGNIFICANCE

The proposed SERS spectral set is a robust representation approach in accessing full information of biological samples compared to relying on a single or averaged spectra in terms of reproducibility, uniformity, repeatability, and cardinality effect. The application of WD further demonstrates the effectiveness and robustness of spectral sets in characterizing complex biofluid samples, which extends and consolidates the role of SERS.

SERS in 3D cell models: a powerful tool in cancer research

Unraveling the cellular and molecular mechanisms underlying tumoral processes is fundamental for the diagnosis and treatment of cancer. In this regard, three-dimensional (3D) cancer cell models more realistically mimic tumors compared to conventional 2D cell cultures and are more attractive for performing such studies. Nonetheless, the analysis of such architectures is challenging because most available techniques are destructive, resulting in the loss of biochemical information. On the contrary, surface-enhanced Raman spectroscopy (SERS) is a non-invasive analytical tool that can record the structural fingerprint of molecules present in complex biological environments. The implementation of SERS in 3D cancer models can be leveraged to track therapeutics, the production of cancer-related metabolites, different signaling and communication pathways, and to image the different cellular components and structural features. In this review, we highlight recent progress in the use of SERS for the evaluation of cancer diagnosis and therapy in 3D tumoral models. We outline strategies for the delivery and design of SERS tags and shed light on the possibilities this technique offers for studying different cellular processes, through either biosensing or bioimaging modalities. Finally, we address current challenges and future directions, such as overcoming the limitations of SERS and the need for the development of user-friendly and robust data analysis methods. Continued development of SERS 3D bioimaging and biosensing systems, techniques, and analytical strategies, can provide significant contributions for early disease detection, novel cancer therapies, and the realization of patient-tailored medicine.

New insights into targeted therapy of glioblastoma using smart nanoparticles

In recent times, the intersection of nanotechnology and biomedical research has given rise to nanobiomedicine, a captivating realm that holds immense promise for revolutionizing diagnostic and therapeutic approaches in the field of cancer. This innovative fusion of biology, medicine, and nanotechnology aims to create diagnostic and therapeutic agents with enhanced safety and efficacy, particularly in the realm of theranostics for various malignancies. Diverse inorganic, organic, and hybrid organic-inorganic nanoparticles, each possessing unique properties, have been introduced into this domain. This review seeks to highlight the latest strides in targeted glioblastoma therapy by focusing on the application of inorganic smart nanoparticles. Beyond exploring the general role of nanotechnology in medical applications, this review delves into groundbreaking strategies for glioblastoma treatment, showcasing the potential of smart nanoparticles through in vitro studies, in vivo investigations, and ongoing clinical trials.

A review of clinical use of surface-enhanced Raman scattering-based biosensing for glioma

Glioma is the most common malignant tumor of the nervous system in recent centuries, and the incidence rate of glioma is increasing year by year. Its invasive growth and malignant biological behaviors make it one of the most challenging malignant tumors. Maximizing the resection range (EOR) while minimizing the impact on normal brain tissue is crucial for patient prognosis. Changes in metabolites produced by tumor cells and their microenvironments might be important indicators. As a powerful spectroscopic technique, surface-enhanced Raman scattering (SERS) has many advantages, including ultra-high sensitivity, high specificity, and non-invasive features, which allow SERS technology to be widely applied in biomedicine, especially in the differential diagnosis of malignant tumor tissues. This review first introduced the clinical use of responsive SERS probes. Next, the sensing mechanisms of microenvironment-responsive SERS probes were summarized. Finally, the biomedical applications of these responsive SERS probes were listed in four sections, detecting tumor boundaries due to the changes of pH-responsive SERS probes, SERS probes to guide tumor resection, SERS for liquid biopsy to achieve early diagnosis of tumors, and the application of free-label SERS technology to detect fresh glioma specimens. Finally, the challenges and prospects of responsive SERS detections were summarized for clinical use.

Advancing Brain Research through Surface-Enhanced Raman Spectroscopy (SERS): Current Applications and Future Prospects

Surface-enhanced Raman spectroscopy (SERS) has recently emerged as a potent analytical technique with significant potential in the field of brain research. This review explores the applications and innovations of SERS in understanding the pathophysiological basis and diagnosis of brain disorders. SERS holds significant advantages over conventional Raman spectroscopy, particularly in terms of sensitivity and stability. The integration of label-free SERS presents promising opportunities for the rapid, reliable, and non-invasive diagnosis of brain-associated diseases, particularly when combined with advanced computational methods such as machine learning. SERS has potential to deepen our understanding of brain diseases, enhancing diagnosis, monitoring, and therapeutic interventions. Such advancements could significantly enhance the accuracy of clinical diagnosis and further our understanding of brain-related processes and diseases. This review assesses the utility of SERS in diagnosing and understanding the pathophysiological basis of brain disorders such as Alzheimer's and Parkinson's diseases, stroke, and brain cancer. Recent technological advances in SERS instrumentation and techniques are discussed, including innovations in nanoparticle design, substrate materials, and imaging technologies. We also explore prospects and emerging trends, offering insights into new technologies, while also addressing various challenges and limitations associated with SERS in brain research.

Advances in Diagnostic Tools and Therapeutic Approaches for Gliomas: A Comprehensive Review

Gliomas, a prevalent category of primary malignant brain tumors, pose formidable clinical challenges due to their invasive nature and limited treatment options. The current therapeutic landscape for gliomas is constrained by a "one-size-fits-all" paradigm, significantly restricting treatment efficacy. Despite the implementation of multimodal therapeutic strategies, survival rates remain disheartening. The conventional treatment approach, involving surgical resection, radiation, and chemotherapy, grapples with substantial limitations, particularly in addressing the invasive nature of gliomas. Conventional diagnostic tools, including computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET), play pivotal roles in outlining tumor characteristics. However, they face limitations, such as poor biological specificity and challenges in distinguishing active tumor regions. The ongoing development of diagnostic tools and therapeutic approaches represents a multifaceted and promising frontier in the battle against this challenging brain tumor. The aim of this comprehensive review is to address recent advances in diagnostic tools and therapeutic approaches for gliomas. These innovations aim to minimize invasiveness while enabling the precise, multimodal targeting of localized gliomas. Researchers are actively developing new diagnostic tools, such as colorimetric techniques, electrochemical biosensors, optical coherence tomography, reflectometric interference spectroscopy, surface-enhanced Raman spectroscopy, and optical biosensors. These tools aim to regulate tumor progression and develop precise treatment methods for gliomas. Recent technological advancements, coupled with bioelectronic sensors, open avenues for new therapeutic modalities, minimizing invasiveness and enabling multimodal targeting with unprecedented precision. The next generation of multimodal therapeutic strategies holds potential for precision medicine, aiding the early detection and effective management of solid brain tumors. These innovations offer promise in adopting precision medicine methodologies, enabling early disease detection, and improving solid brain tumor management. This review comprehensively recognizes the critical role of pioneering therapeutic interventions, holding significant potential to revolutionize brain tumor therapeutics.

Surgical Management and Advances in the Treatment of Glioma

The care of patients with both high-grade glioma and low-grade glioma necessitates an interdisciplinary collaboration between neurosurgeons, neuro-oncologists, neurologists and other practitioners. In this review, we aim to detail the considerations, approaches and advances in the neurosurgical care of gliomas. We describe the impact of extent-of-resection in high-grade and low-grade glioma, with particular focus on primary and recurrent glioblastoma. We address advances in surgical methods and adjunct technologies such as intraoperative imaging and fluorescence guided surgery that maximize extent-of-resection while minimizing the potential for iatrogenic neurological deficits. Finally, we review surgically-mediated therapies other than resection and discuss the role of neurosurgery in emerging paradigm-shifts in inter-disciplinary glioma management such as serial tissue sampling and "window of opportunity trials".

Rapid, label-free classification of glioblastoma differentiation status combining confocal Raman spectroscopy and machine learning

Label-free identification of tumor cells using spectroscopic assays has emerged as a technological innovation with a proven ability for rapid implementation in clinical care. Machine learning facilitates the optimization of processing and interpretation of extensive data, such as various spectroscopy data obtained from surgical samples. The here-described preclinical work investigates the potential of machine learning algorithms combining confocal Raman spectroscopy to distinguish non-differentiated glioblastoma cells and their respective isogenic differentiated phenotype by means of confocal ultra-rapid measurements. For this purpose, we measured and correlated modalities of 1146 intracellular single-point measurements and sustainingly clustered cell components to predict tumor stem cell existence. By further narrowing a few selected peaks, we found indicative evidence that using our computational imaging technology is a powerful approach to detect tumor stem cells in vitro with an accuracy of 91.7% in distinct cell compartments, mainly because of greater lipid content and putative different protein structures. We also demonstrate that the presented technology can overcome intra- and intertumoral cellular heterogeneity of our disease models, verifying the elevated physiological relevance of our applied disease modeling technology despite intracellular noise limitations for future translational evaluation.

Intraoperative Imaging and Optical Visualization Techniques for Brain Tumor Resection: A Narrative Review

Advancements in intraoperative visualization and imaging techniques are increasingly central to the success and safety of brain tumor surgery, leading to transformative improvements in patient outcomes. This comprehensive review intricately describes the evolution of conventional and emerging technologies for intraoperative imaging, encompassing the surgical microscope, exoscope, Raman spectroscopy, confocal microscopy, fluorescence-guided surgery, intraoperative ultrasound, magnetic resonance imaging, and computed tomography. We detail how each of these imaging modalities contributes uniquely to the precision, safety, and efficacy of neurosurgical procedures. Despite their substantial benefits, these technologies share common challenges, including difficulties in image interpretation and steep learning curves. Looking forward, innovations in this field are poised to incorporate artificial intelligence, integrated multimodal imaging approaches, and augmented and virtual reality technologies. This rapidly evolving landscape represents fertile ground for future research and technological development, aiming to further elevate surgical precision, safety, and, most critically, patient outcomes in the management of brain tumors.

Hybrid Polypyrrole and Polydopamine Nanosheets for Precise Raman/Photoacoustic Imaging and Photothermal Therapy

The development of near-infrared light responsive conductive polymers provides a useful theranostic platform for malignant tumors by maximizing spatial resolution with deep tissue penetration for diagnosis and photothermal therapy. Herein, the self-assembly of ultrathin 2D polypyrrole nanosheets utilizing dopamine as a capping agent and a monolayer of octadecylamine as a template is demonstrated. The 2D polypyrrole-polydopamine nanostructure has tunable size distribution which shows strong absorption in the first and second near-infrared windows, enabling photoacoustic imaging and photothermal therapy. The hybrid double-layer is demonstrated to increase Raman intensity for 3D Raman imaging (up to two orders of magnitude enhancement and spatial resolution up to 1 µm). The acidic environment drives reversible doping of polypyrrole, which can be detected by Raman spectroscopy. The combined properties of the nanosheets can substantially enhance performance in dual-mode Raman and photoacoustic guided photothermal therapy, as shown by the 69% light to heat conversion efficiency and higher cytotoxicity against cancer spheroids. These pH-responsive features highlight the potential of 2D conductive polymers for applications in accurate, highly efficient theranostics.

Molecular Fingerprint Detection Using Raman and Infrared Spectroscopy Technologies for Cancer Detection: A Progress Review

Molecular vibrations play a crucial role in physical chemistry and biochemistry, and Raman and infrared spectroscopy are the two most used techniques for vibrational spectroscopy. These techniques provide unique fingerprints of the molecules in a sample, which can be used to identify the chemical bonds, functional groups, and structures of the molecules. In this review article, recent research and development activities for molecular fingerprint detection using Raman and infrared spectroscopy are discussed, with a focus on identifying specific biomolecules and studying the chemical composition of biological samples for cancer diagnosis applications. The working principle and instrumentation of each technique are also discussed for a better understanding of the analytical versatility of vibrational spectroscopy. Raman spectroscopy is an invaluable tool for studying molecules and their interactions, and its use is likely to continue to grow in the future. Research has demonstrated that Raman spectroscopy is capable of accurately diagnosing various types of cancer, making it a valuable alternative to traditional diagnostic methods such as endoscopy. Infrared spectroscopy can provide complementary information to Raman spectroscopy and detect a wide range of biomolecules at low concentrations, even in complex biological samples. The article concludes with a comparison of the techniques and insights into future directions.

Design and Synthesis of SERS Materials for In Vivo Molecular Imaging and Biosensing

Surface-enhanced Raman scattering (SERS) is a feasible and ultra-sensitive method for biomedical imaging and disease diagnosis. SERS is widely applied to in vivo imaging due to the development of functional nanoparticles encoded by Raman active molecules (SERS nanoprobes) and improvements in instruments. Herein, the recent developments in SERS active materials and their in vivo imaging and biosensing applications are overviewed. Various SERS substrates that have been successfully used for in vivo imaging are described. Then, the applications of SERS imaging in cancer detection and in vivo intraoperative guidance are summarized. The role of highly sensitive SERS biosensors in guiding the detection and prevention of diseases is discussed in detail. Moreover, its role in the identification and resection of microtumors and as a diagnostic and therapeutic platform is also reviewed. Finally, the progress and challenges associated with SERS active materials, equipment, and clinical translation are described. The present evidence suggests that SERS could be applied in clinical practice in the future.

Toward a New Era of SERS and TERS at the Nanometer Scale: From Fundamentals to Innovative Applications

Surface-enhanced Raman scattering (SERS) and tip-enhanced Raman scattering (TERS) have opened a variety of exciting research fields. However, although a vast number of applications have been proposed since the two techniques were first reported, none has been applied to real practical use. This calls for an update in the recent fundamental and application studies of SERS and TERS. Thus, the goals and scope of this review are to report new directions and perspectives of SERS and TERS, mainly from the viewpoint of combining their mechanism and application studies. Regarding the recent progress in SERS and TERS, this review discusses four main topics: (1) nanometer to subnanometer plasmonic hotspots for SERS; (2) Ångström resolved TERS; (3) chemical mechanisms, i.e., charge-transfer mechanism of SERS and semiconductor-enhanced Raman scattering; and (4) the creation of a strong bridge between the mechanism studies and applications.

Raman Spectroscopy on Brain Disorders: Transition from Fundamental Research to Clinical Applications

Brain disorders such as brain tumors and neurodegenerative diseases (NDs) are accompanied by chemical alterations in the tissues. Early diagnosis of these diseases will provide key benefits for patients and opportunities for preventive treatments. To detect these sophisticated diseases, various imaging modalities have been developed such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). However, they provide inadequate molecule-specific information. In comparison, Raman spectroscopy (RS) is an analytical tool that provides rich information about molecular fingerprints. It is also inexpensive and rapid compared to CT, MRI, and PET. While intrinsic RS suffers from low yield, in recent years, through the adoption of Raman enhancement technologies and advanced data analysis approaches, RS has undergone significant advancements in its ability to probe biological tissues, including the brain. This review discusses recent clinical and biomedical applications of RS and related techniques applicable to brain tumors and NDs.

Application of nanomaterials in diagnosis and treatment of glioblastoma

Diagnosing and treating glioblastoma patients is currently hindered by several obstacles, such as tumor heterogeneity, the blood-brain barrier, tumor complexity, drug efflux pumps, and tumor immune escape mechanisms. Combining multiple methods can increase benefits against these challenges. For example, nanomaterials can improve the curative effect of glioblastoma treatments, and the synergistic combination of different drugs can markedly reduce their side effects. In this review, we discuss the progression and main issues regarding glioblastoma diagnosis and treatment, the classification of nanomaterials, and the delivery mechanisms of nanomedicines. We also examine tumor targeting and promising nano-diagnosis or treatment principles based on nanomedicine. We also summarize the progress made on the advanced application of combined nanomaterial-based diagnosis and treatment tools and discuss their clinical prospects. This review aims to provide a better understanding of nano-drug combinations, nano-diagnosis, and treatment options for glioblastoma, as well as insights for developing new tools.

Novel exploration of Raman microscopy and non-linear optical imaging in adenomyosis

Background

Adenomyosis is a common gynecological disease in women. A relevant literature search found that approximately 82% of patients with adenomyosis chose to undergo hysterectomy. However, women of childbearing age are more likely to undergo surgery to preserve the uterus. Because it is difficult to determine the extent of adenomyosis, it is almost impossible to resect adenomyotic tissue and retain the uterus at the same time.

Materials and methods

Following ethics approval and patient consent, tissue samples were resected and prepared to create frozen slices for analysis. One slice was subjected to H&E staining while the remaining slices were photographed with Coherent Anti-Stokes Raman Scattering (CARS), Second-Harmonic Generation (SHG) microscopy, and Raman spectroscopy. Comparative observations and analyses at the same positions were carried out to explore the diagnostic ability of CARS, SHG, and Raman spectroscopy for adenomyosis.

Results

In adenomyotic tissue, we found two characteristic peaks at 1,155 and 1,519 cm^–1 in the Raman spectrum, which were significantly different from normal tissue. The substances shown in the CARS spectrum were represented by peaks of 1,519 cm^–1. SHG microscopy showed a distribution of collagen at the focus of the adenomyosis.

Conclusion

This study represents a novel analysis of Raman microscopy, CARS, and SHG in the analysis of adenomyotic lesions. We found the diffraction spectrum useful in determining the focal boundary and the diagnosis of adenomyosis in the tested samples.

Miniaturized Raman Instruments for SERS-Based Point-of-Care Testing on Respiratory Viruses

As surface-enhanced Raman scattering (SERS) has been used to diagnose several respiratory viruses (e.g., influenza A virus subtypes such as H1N1 and the new coronavirus SARS-CoV-2), SERS is gaining popularity as a method for diagnosing viruses at the point-of-care. Although the prior and quick diagnosis of respiratory viruses is critical in the outbreak of infectious disease, ELISA, PCR, and RT-PCR have been used to detect respiratory viruses for pandemic control that are limited for point-of-care testing. SERS provides quantitative data with high specificity and sensitivity in a real-time, label-free, and multiplex manner recognizing molecular fingerprints. Recently, the design of Raman spectroscopy system was simplified from a complicated design to a small and easily accessible form that enables point-of-care testing. We review the optical design (e.g., laser wavelength/power and detectors) of commercialized and customized handheld Raman instruments. As respiratory viruses have prominent risk on the pandemic, we review the applications of handheld Raman devices for detecting respiratory viruses. By instrumentation and commercialization advancements, the advent of the portable SERS device creates a fast, accurate, practical, and cost-effective analytical method for virus detection, and would continue to attract more attention in point-of-care testing.

Neurosurgical Clinical Trials for Glioblastoma: Current and Future Directions

The mainstays of glioblastoma treatment, maximal safe resection, radiotherapy preserving neurological function, and temozolomide (TMZ) chemotherapy have not changed for the past 17 years despite significant advances in the understanding of the genetics and molecular biology of glioblastoma. This review highlights the neurosurgical foundation for glioblastoma therapy. Here, we review the neurosurgeon’s role in several new and clinically-approved treatments for glioblastoma. We describe delivery techniques such as blood–brain barrier disruption and convection-enhanced delivery (CED) that may be used to deliver therapeutic agents to tumor tissue in higher concentrations than oral or intravenous delivery. We mention pivotal clinical trials of immunotherapy for glioblastoma and explain their outcomes. Finally, we take a glimpse at ongoing clinical trials and promising translational studies to predict ways that new therapies may improve the prognosis of patients with glioblastoma.

How Surface-Enhanced Raman Spectroscopy Could Contribute to Medical Diagnoses

In the last decade, there has been a rapid increase in the number of surface-enhanced Raman scattering (SERS) spectroscopy applications in medical research. In this article we review some recent, and in our opinion, most interesting and promising applications of SERS spectroscopy in medical diagnostics, including those that permit multiplexing within the range important for clinical samples. We focus on the SERS-based detection of markers of various diseases (or those whose presence significantly increases the chance of developing a given disease), and on drug monitoring. We present selected examples of the SERS detection of particular fragments of DNA or RNA, or of bacteria, viruses, and disease-related proteins. We also describe a very promising and elegant ‘lab-on-chip’ approach used to carry out practical SERS measurements via a pad whose action is similar to that of a pregnancy test. The fundamental theoretical background of SERS spectroscopy, which should allow a better understanding of the operation of the sensors described, is also briefly outlined. We hope that this review article will be useful for researchers planning to enter this fascinating field.

Fast synthesis of gold nanostar SERS substrates based on ion-track etched membrane by one-step redox reaction

Surface-enhanced Raman scattering (SERS), due to its high detecting sensitivity and rapid data acquisition ability, has been considered as a powerful technique for label-free ultrasensitive detection of chemical and biochemical analytes. As an important part, the uniform SERS substrate is the prerequisite for this technology being used in all the related areas. Therefore, seeking the fast, convenient and low-cost way to obtain the SERS substrate with high performance and reproducibility never stops in recent decades. In this work, the PC membrane with uniform nanopores obtained by ion irradiation and chemical etching (i.e., ion-track etched PC membrane) was first used to prepare the gold nanostar SERS substrate. The monolayer gold nanostars can be obtained through a one-step redox reaction on the surface of the PC membrane, which not only can act as the base of SERS substrate but also can work as the reaction adjuster. By optimizing the growth conditions, the SERS substrate with uniform monolayer gold nanostars can be fabricated without any complicated procedures and costly equipment fast (in 20 mins). Meanwhile, the prepared flexible gold nanostar SERS substrate exhibits excellent Raman performance, which can effectively detect the analyte R6G with the concentration as low as 1 × 10^-10 M and the SERS enhancement factors can be around 3.70 × 10⁵. The new facile SERS substrate preparation method is cost-effective, convenient, fast and easily scale up, which can satisfy the requests of the real applications in many fields.

Multiplexed imaging in oncology

In oncology, technologies for clinical molecular imaging are used to diagnose patients, establish the efficacy of treatments and monitor the recurrence of disease. Multiplexed methods increase the number of disease-specific biomarkers that can be detected simultaneously, such as the overexpression of oncogenic proteins, aberrant metabolite uptake and anomalous blood perfusion. The quantitative localization of each biomarker could considerably increase the specificity and the accuracy of technologies for clinical molecular imaging to facilitate granular diagnoses, patient stratification and earlier assessments of the responses to administered therapeutics. In this Review, we discuss established techniques for multiplexed imaging and the most promising emerging multiplexing technologies applied to the imaging of isolated tissues and cells and to non-invasive whole-body imaging. We also highlight advances in radiology that have been made possible by multiplexed imaging.

Plasmonic Metal Nanoparticles Hybridized with 2D Nanomaterials for SERS Detection: A Review

In SERS analysis, the specificity of molecular fingerprints is combined with potential single-molecule sensitivity so that is an attractive tool to detect molecules in trace amounts. Although several substrates have been widely used from early on, there are still some problems such as the difficulties to bind some molecules to the substrate. With the development of nanotechnology, an increasing interest has been focused on plasmonic metal nanoparticles hybridized with (2D) nanomaterials due to their unique properties. More frequently, the excellent properties of the hybrids compounds have been used to improve the drawbacks of the SERS platforms in order to create a system with outstanding properties. In this review, the physics and working principles of SERS will be provided along with the properties of differently shaped metal nanoparticles. After that, an overview on how the hybrid compounds can be engineered to obtain the SERS platform with unique properties will be given.

Toward a SERS Diagnostic Tool for Discrimination between Cancerous and Normal Bladder Tissues via Analysis of the Extracellular Fluid

Vibrational spectroscopy provides the possibility for sensitive and precise detection of chemical changes in biomolecules due to development of cancers. In this work, label-free near-infrared surface enhanced Raman spectroscopy (SERS) was applied for the differentiation between cancerous and normal human bladder tissues via analysis of the extracellular fluid of the tissue. Specific cancer-related SERS marker bands were identified by using a 1064 nm excitation wavelength. The prominent spectral marker band was found to be located near 1052 cm^-1 and was assigned to the C-C, C-O, and C-N stretching vibrations of lactic acid and/or cysteine molecules. The correct identification of 80% of samples is achieved with even limited data set and could be further improved. The further development of such a detection method could be implemented in clinical practice for the aid of surgeons in determining of boundaries of malignant tumors during the surgery.

Discrimination of glioma patient-derived cells from healthy astrocytes by exploiting Raman spectroscopy

Glioblastoma multiforme (GBM) is one of the most common and aggressive brain tumors. It presents a very bad prognosis with a patients' overall survival of 12-15 months; treatment failure is mainly ascribable to tumor recurrence. The development of new tools, that could help the precise detection of the tumor border, is thus an urgent need. During the last decades, different vibrational spectroscopy techniques have been developed to distinguish cancer tissue from heathy tissue; in the present work, we compared GBM cells deriving from four patients with healthy human astrocytes using Raman spectroscopy. We have shown that the region between 1000 and 1300 cm^-1 is enough informative for this discrimination, indeed highlighting that peaks related to DNA/RNA and cytochrome c are increased in cancer cells. Finally, our model has been able to discriminate cancer cells from healthy cells with an average accuracy of 92.5%. We believe that this study might help to further understand which are the essential Raman peaks exploitable in the detection of cancer cells, with important perspectives under a diagnostic point of view.

Neurosurgery at the crossroads of immunology and nanotechnology. New reality in the COVID-19 pandemic

Neurosurgery as one of the most technologically demanding medical fields rapidly adapts the newest developments from multiple scientific disciplines for treating brain tumors. Despite half a century of clinical trials, survival for brain primary tumors such as glioblastoma (GBM), the most common primary brain cancer, or rare ones including primary central nervous system lymphoma (PCNSL), is dismal. Cancer therapy and research have currently shifted toward targeted approaches, and personalized therapies. The orchestration of novel and effective blood-brain barrier (BBB) drug delivery approaches, targeting of cancer cells and regulating tumor microenvironment including the immune system are the key themes of this review. As the global pandemic due to SARS-CoV-2 virus continues, neurosurgery and neuro-oncology must wrestle with the issues related to treatment-related immune dysfunction. The selection of chemotherapeutic treatments, even rare cases of hypersensitivity reactions (HSRs) that occur among immunocompromised people, and number of vaccinations they have to get are emerging as a new chapter for modern Nano neurosurgery.

Advances in Surface Enhanced Raman Spectroscopy for in Vivo Imaging in Oncology

In the last two decades, the application of surface enhanced Raman scattering (SERS) nanoparticles for preclinical cancer imaging has attracted increasing attention. Raman imaging with SERS nanoparticles offers unparalleled sensitivity, providing a platform for molecular targeting, and granting multiplexed and multimodal imaging capabilities. Recent progress has been facilitated not only by the optimization of the SERS contrast agents themselves, but also by the developments in Raman imaging approaches and instrumentation. In this article, we review the principles of Raman scattering and SERS, present advances in Raman instrumentation specific to cancer imaging, and discuss the biological means of ensuring selective in vivo uptake of SERS contrast agents for targeted, multiplexed, and multimodal imaging applications. We offer our perspective on areas that must be addressed in order to facilitate the clinical translation of SERS contrast agents for in vivo imaging in oncology.

Advanced plasmonic technologies for multi-scale biomedical imaging

Plasmonic technologies are available for multi-scale biomedical imaging ranging from micrometre to angstrom level.

From Raman to SESORRS: moving deeper into cancer detection and treatment monitoring

Raman spectroscopy is a non-invasive technique that allows specific chemical information to be obtained from various types of sample. The detailed molecular information that is present in Raman spectra permits monitoring of biochemical changes that occur in diseases, such as cancer, and can be used for the early detection and diagnosis of the disease, for monitoring treatment, and to distinguish between cancerous and non-cancerous biological samples. Several techniques have been developed to enhance the capabilities of Raman spectroscopy by improving detection sensitivity, reducing imaging times and increasing the potential applicability for in vivo analysis. The different Raman techniques each have their own advantages that can accommodate the alternative detection formats, allowing the techniques to be applied in several ways for the detection and diagnosis of cancer. This feature article discusses the various forms of Raman spectroscopy, how they have been applied for cancer detection, and the adaptation of the techniques towards their use for in vivo cancer detection and in clinical diagnostics. Despite the advances in Raman spectroscopy, the clinical application of the technique is still limited and certain challenges must be overcome to enable clinical translation. We provide an outlook on the future of the techniques in this area and what we believe is required to allow the potential of Raman spectroscopy to be achieved for clinical cancer diagnostics.

The Development of Nanoparticles for the Detection and Imaging of Ovarian Cancers

Ovarian cancer remains as one of the most lethal gynecological cancers to date, with major challenges associated with screening, diagnosis and treatment of the disease and an urgent need for new technologies that can meet these challenges. Nanomaterials provide new opportunities in diagnosis and therapeutic management of many different types of cancers. In this review, we highlight recent promising developments of nanoparticles designed specifically for the detection or imaging of ovarian cancer that have reached the preclinical stage of development. This includes contrast agents, molecular imaging agents and intraoperative aids that have been designed for integration into standard imaging procedures. While numerous nanoparticle systems have been developed for ovarian cancer detection and imaging, specific design criteria governing nanomaterial targeting, biodistribution and clearance from the peritoneal cavity remain key challenges that need to be overcome before these promising tools can accomplish significant breakthroughs into the clinical setting.

Sensing Using Light: A Key Area of Sensors

This invited featured paper offers a Doctrinal Conception of sensing using Light (SuL) as an "umbrella" in which any sensing approach using Light Sciences and Technologies can be easily included. The key requirements of a sensing system will be quickly introduced by using a bottom-up methodology. Thanks to this, it will be possible to get a general conception of a sensor using Light techniques and know some related issues, such as its main constituted parts and types. The case in which smartness is conferred to the device is also considered. A quick "flight" over 10 significant cases using different principles, techniques, and technologies to detect diverse measurands in various sector applications is offered to illustrate this general concept. After reading this paper, any sensing approach using Light Sciences and Technologies may be easily included under the umbrella: sensing using Light or photonic sensors (PS).

Raman spectroscopy and surface-enhanced Raman spectroscopy (SERS) spectra of salivary glands carcinoma, tumor and healthy tissues and their homogenates analyzed by chemometry: Towards development of the novel tool for clinical diagnosis

In this study, two approaches to salivary glands studies are presented: Raman imaging (RI) of tissue cross-section and surface-enhanced Raman spectroscopy (SERS) of tissue homogenates prepared according to elaborated protocol. Collected and analyzed data demonstrate the significant potential of SERS combined with multivariate analysis for distinguishing carcinoma or tumor from the normal salivary gland tissues as a rapid, label-free tool in cancer detection in oncological diagnostics. Raman imaging allows a detailed analysis of the cell wall's chemical composition; thus, the compound's distribution can be semi-quantitatively analyzed, while SERS of tissue homogenates allow for detailed analysis of all moieties forming these tissues. In this sense, SERS is more sensitive and reliable to study any changes in the area of infected tissues. Principal component analysis (PCA), as an unsupervised pattern recognition method, was used to identify the differences in the SERS salivary glands homogenates. The partial least squares-discriminant analysis (PLS-DA), the supervised pattern classification technique, was also used to strengthen further the computed model based on the latent variables in the SERS spectra. Moreover, the chemometric quantification of obtained data was analyzed using principal component regression (PCR) multivariate calibration. The presented data prove that the PCA algorithm allows for 91% in seven following components and the determination between healthy and tumor salivary gland homogenates. The PCR and PLS-DA methods predict 90% and 95% of the variance between the studied groups (in 6 components and 4 factors, respectively). Moreover, according to calculated RMSEC (RMSEP), R2C (R2P) values and correlation accuracy (based on the ROC curve), the PLS-DA model fits better for the studied data. Thus, SERS methods combined with PLS-DA analysis can be used to differentiate healthy, neoplastic, and mixed tissues as a competitive tool in relation to the commonly used method of histopathological staining of tumor tissue.

Standardization of Raman spectra using variable penalty dynamic time warping

Raman spectroscopy can provide structural fingerprints to identify molecules by means of spectral library searching. However, it is difficult to share the spectral library between different Raman spectrometers because of the nonlinear displacement in Raman shift. In this study, we propose a Raman spectra Standardization method using Variable Penalty dynamic time warping (RS-VPdtw), which can synchronize the nonlinear displacement between spectra acquired with different spectrometers. We have compared the standardization performance of RS-VPdtw and MWFFT on the spectra of 13 real samples acquired with 6 different spectrometers. The mean spectral similarity of RS-VPdtw and MWFFT increased from 0.79 to 0.97 and 0.91 respectively. Results show that RS-VPdtw is significantly better than MWFFT in Raman spectra standardization. The Raman spectra acquired with different spectrometers can be standardized by RS-VPdtw to search the same spectral library, which can avoid the time-consuming and labor-intensive reestablishment of spectral libraries for different spectrometers. This means that RS-VPdtw is a promising and valuable method to solve the spectra standardization problem in large-scale applications of Raman spectroscopy.

Nanohybrids of Magnetically Intercalated Optical Metamaterials for Magnetic Resonance/Raman Imaging and In Situ Chemodynamic/Photothermal Therapy

Target-specific reactive oxygen species (ROS)-based cancer treatments with high therapeutic efficacy and minimal side effects have been identified recently as a potentially effective cancer management strategy. Herein, we report the fabrication of a targeted nanotheranostic agent built on an iron oxide nanoparticle-decorated graphene-gold hybrid [plasmonic magnetic nanoprobe (PMNP)] for self-guided magnetic resonance (MR)/surface-enhanced Raman scattering imaging and photothermal therapy (PTT)/chemodynamic therapy (CDT). In the presence of glutathione, which is abundant in the tumor environment, the iron oxide nanoparticles undergo in situ reduction, which in turn generates hydroxyl radicals via a Fenton reaction to realize targeted destruction of tumor cells. Moreover, the localized production of heat benefited from the near-infrared absorption of the PMNP accelerates the intratumoral ROS generation process, with a synergistic effect of CDT/PTT. Furthermore, the probe offers an accurate visualization of the intracellular localization of the material through SERS/MR dual imaging channels. In view of the advantages offered by the tumor-specific stimuli-responsive nature of the probe, the PMNP presents as an effective tool for cancer management.

Spontaneous Raman and Surface-Enhanced Raman Scattering Bioimaging

Raman spectroscopy is a specific, noninvasive and nondestructive optical technique and is able to obtain chemical information from molecules. Optical imaging based on Raman spectroscopy has been a powerful technique for monitoring minute chemical changes of biological samples and generating images through direct or indirect strategies. Two widely applied Raman imaging techniques include spontaneous Raman and surface-enhanced Raman scattering (SERS) imaging. In this chapter, we introduce the basic principles including the physics behind Raman and SERS imaging, design of Raman/SERS labels or probes, and current strategies for further improvements. The progress in the use of spontaneous Raman and SERS spectroscopy for bioimaging is discussed, either in fundamental studies or in biomedical theranostics. In addition, we give insights into the challenges and opportunities for improving Raman imaging performance.

A Spheroid-Forming Hybrid Gold Nanostructure Platform That Electrochemically Detects Anticancer Effects of Curcumin in a Multicellular Brain Cancer Model

In this study, a multifunctional platform that enables the highly efficient formation of 3D multicellular cancer spheroids and precise real-time assessments of the anticancer effects of curcumin in a brain tumor coculture model is reported. A highly conductive gold nanostructure (HCGN) is fabricated to facilitate cancer spheroid formation without using anti-cell adhesion molecules. A neuroblastoma (SH-SY5Y) and glioblastoma (U-87MG) coculture model is generated on HCGN with a specific cell-to-cell ratio (SH-SY5Y: U-87MG = 1:1), and their redox behaviors are successfully measured without destroying the distinct 3D structure of the multicellular spheroids. Using electrochemical signals as an indicator of spheroid viability, the effects of potential anticancer compounds on cocultured spheroids are further assessed. Remarkably, decreased cell viability in 3D spheroids caused by a low concentration of curcumin (30 µM) is detectable using the electrochemical method (29.4%) but not with a conventional colorimetric assay (CCK-8). The detection is repeated more than ten times for both short- (63 h) and long-term cultivation (144 h) without damaging the spheroids, enabling real-time, non-destructive pharmacokinetic analysis of various drug candidates. Therefore, it can be concluded that the hybrid platform is a highly promising, precise, and high-throughput drug screening tool based on 3D cell cultivation.

Development and Characterization of a Probe Device toward Intracranial Spectroscopy of Traumatic Brain Injury

Traumatic brain injury is a leading cause of mortality worldwide, often affecting individuals at their most economically active yet no primary disease-modifying interventions exist for their treatment. Real-time direct spectroscopic examination of the brain tissue within the context of traumatic brain injury has the potential to improve the understanding of injury heterogeneity and subtypes, better target management strategies and organ penetrance of pharmacological agents, identify novel targets for intervention, and allow a clearer understanding of fundamental biochemistry evolution. Here, a novel device is designed and engineered, delivering Raman spectroscopy-based measurements from the brain through clinically established cranial access techniques. Device prototyping is undertaken within the constraints imposed by the acquisition and site dimensions (standard intracranial access holes, probe’s dimensions), and an artificial skull anatomical model with cortical impact is developed. The device shows a good agreement with the data acquired via a standard commercial Raman, and the spectra measured are comparable in terms of quality and detectable bands to the established traumatic brain injury model. The developed proof-of-concept device demonstrates the feasibility for real-time optical brain spectroscopic interface while removing the noise of extracranial tissue and with further optimization and in vivo validation, such technology will be directly translatable for integration into currently available standards of neurological care.

Intraoperative Assessment and Photothermal Ablation of the Tumor Margins Using Gold Nanoparticles

Surgical resection is commonly used for therapeutic management of different solid tumors and is regarded as a primary standard of care procedure, but precise localization of tumor margins is a major intraoperative challenge. Herein, a generalized method by optimizing gold nanoparticles for intraoperative detection and photothermal ablation of tumor margins is introduced. These nanoparticles are detectable by highly sensitive surface-enhanced Raman scattering imaging. This non-invasive technique assists in delineating the two surgically challenged tumors in live mice with orthotopic colon or ovarian tumors. Any remaining residual tumors are also ablated by using post-surgical adjuvant photothermaltherapy (aPTT), which results in microscale heat generation due to interaction of these nanoparticles with near-infrared laser. Ablation of these post-operative residual micro-tumors prolongs the survival of mice significantly and delays tumor recurrence by 15 days. To validate clinical translatability of this method, the pharmacokinetics, biodistribution, Raman contrast, aPTT efficiency, and toxicity of these nanoparticles are also investigated. The nanoparticles have long blood circulation time (≈24 h), high tumor accumulation (4.87 ± 1.73%ID g-1) and no toxicity. This high-resolution and sensitive intraoperative approach is versatile and can be potentially used for targeted ablation of residual tumor after resection within different organs.

Leveraging the replication-competent avian-like sarcoma virus/tumor virus receptor-A system for modeling human gliomas

Gliomas are the most common primary intrinsic brain tumors occurring in adults. Of all malignant gliomas, glioblastoma (GBM) is considered the deadliest tumor type due to diffuse brain invasion, immune evasion, cellular, and molecular heterogeneity, and resistance to treatments resulting in high rates of recurrence. An extensive understanding of the genomic and microenvironmental landscape of gliomas gathered over the past decade has renewed interest in pursuing novel therapeutics, including immune checkpoint inhibitors, glioma-associated macrophage/microglia (GAMs) modulators, and others. In light of this, predictive animal models that closely recreate the conditions and findings found in human gliomas will serve an increasingly important role in identifying new, effective therapeutic strategies. Although numerous syngeneic, xenograft, and transgenic rodent models have been developed, few include the full complement of pathobiological features found in human tumors, and therefore few accurately predict bench-to-bedside success. This review provides an update on how genetically engineered rodent models based on the replication-competent avian-like sarcoma (RCAS) virus/tumor virus receptor-A (tv-a) system have been used to recapitulate key elements of human gliomas in an immunologically intact host microenvironment and highlights new approaches using this model system as a predictive tool for advancing translational glioma research.

Bioinspired protein corona strategy enhanced biocompatibility of Ag-Hybrid hollow Au nanoshells for surface-enhanced Raman scattering imaging and on-demand activation tumor-phototherapy

Silver-based hybrid nanoprobes for surface-enhanced Raman scattering (SERS) imaging show their tremendous potential for precise biological detection and mediated phototherapy. However, the severe toxicity induced by Ag to normal mammalian cells hinders its further application. Herein, we presented a versatile bioinspired protein corona strategy through assembling bovine serum albumin (BSA) protected Raman tag DTTC-conjugated Ag-hybrid hollow Au nanoshells (hollow AgAu-DTTC-BSA), which their silver ion release and reactive oxygen species (ROS) generation are significantly suppressed, enabling no damage to normal cells and tissues, but can be reactivated on-demand under laser-irradiation at the tumor site. These nanoshells could also produce strong localized surface plasmon resonance for efficient-stable photothermal effect and enhanced SERS activity under laser irradiation, approved by both theoretical and experimental calculations. Furthermore, the biocompatible hollow AgAu-DTTC-BSA could detect both primary tumor tissues and tiny liver metastases (~0.18 mm) in orthotopic/subcutaneous CT26 colon tumor-bearing mice models. We also demonstrate their excellent therapeutic efficacy for colorectal solid neoplasms by accurate SERS imaging-guided photothermal therapy, simultaneously assisted with toxic Ag ion and ROS. These results suggest that hollow AgAu-DTTC-BSA is promising imaging assisted photothermal agents for solid tumor theranostics and enhancing the potential of Ag-based nanoparticles for practical treatment.

Accurate in vivo tumor detection using plasmonic-enhanced shifted-excitation Raman difference spectroscopy (SERDS)

For the majority of cancer patients, surgery is the primary method of treatment. In these cases, accurately removing the entire tumor without harming surrounding tissue is critical; however, due to the lack of intraoperative imaging techniques, surgeons rely on visual and physical inspection to identify tumors. Surface-enhanced Raman scattering (SERS) is emerging as a non-invasive optical alternative for intraoperative tumor identification, with high accuracy and stability. However, Raman detection requires dark rooms to work, which is not consistent with surgical settings.

Methods: Herein, we used SERS nanoprobes combined with shifted-excitation Raman difference spectroscopy (SERDS) detection, to accurately detect tumors in xenograft murine model.

Results: We demonstrate for the first time the use of SERDS for in vivo tumor detection in a murine model under ambient light conditions. We compare traditional Raman detection with SERDS, showing that our method can improve sensitivity and accuracy for this task.

Conclusion: Our results show that this method can be used to improve the accuracy and robustness of in vivo Raman/SERS biomedical application, aiding the process of clinical translation of these technologies.

DNA Nanostructures and DNA-Functionalized Nanoparticles for Cancer Theranostics

In the last two decades, DNA has attracted significant attention toward the development of materials at the nanoscale for emerging applications due to the unparalleled versatility and programmability of DNA building blocks. DNA-based artificial nanomaterials can be broadly classified into two categories: DNA nanostructures (DNA-NSs) and DNA-functionalized nanoparticles (DNA-NPs). More importantly, their use in nanotheranostics, a field that combines diagnostics with therapy via drug or gene delivery in an all-in-one platform, has been applied extensively in recent years to provide personalized cancer treatments. Conveniently, the ease of attachment of both imaging and therapeutic moieties to DNA-NSs or DNA-NPs enables high biostability, biocompatibility, and drug loading capabilities, and as a consequence, has markedly catalyzed the rapid growth of this field. This review aims to provide an overview of the recent progress of DNA-NSs and DNA-NPs as theranostic agents, the use of DNA-NSs and DNA-NPs as gene and drug delivery platforms, and a perspective on their clinical translation in the realm of oncology.

Injectable In Situ Self-Cross-Linking Hydrogels Based on Hemoglobin, Carbon Quantum Dots, and Sodium Alginate for Real-Time Detection of Wound Bacterial Infection and Efficient Postoperative Prevention of Tumor Recurrence

Postoperative wound repair of solid tumors resection, which is afflicted by the complex tumor microenvironment (TME) and associated with the bacterial infection, is worsening and demands prompt solutions. Meanwhile, the tumor recurrence is frequently seen during the subsequent treatment due to intraoperative bleeding. For effective postoperative cancer therapy, nanoscale carriers occur as innovative and sensitive tools for monitoring the wound state, avoiding bacterial infection, and restraining tumor recurrence. Herein, a multifunctional sodium alginate (SA) hydrogel immobilizing hemoglobin (Hb) and pH-sensitive fluorescent changing carbon quantum dots (CQDs) is rationally designed. The multifunctionalization of obtained alginate@hemoglobin@CQDs hydrogel (SA@Hb@CQDs) simultaneously consists of detection, hemostasis, and chemodynamic therapy (CDT) with monitoring of wound pH based on CQDs, stanching triggered from SA hydrogel, and Fenton reaction induced by Hb. We demonstrated that SA@Hb@CQDs can stop bleeding quickly, collect wound status information in real-time, and avert bacterial infection as well as inhibit local tumor recurrence effectively. Therefore, our work provides a promising combination approach for postoperative tumor therapy.

An Oxygen-Enriched Photodynamic Nanospray for Postsurgical Tumor Regression

Postoperative local recurrence and metastasis are non-negligible challenges in clinical cancer treatment. Photodynamic therapy (PDT) has presented a great potential in preventing cancer recurrence owing to its noninvasiveness and high specificity for local irradiation of tumor sites. However, the application of conventional PDT is often limited by insufficient oxygen supply, making it difficult to achieve high PDT efficacy. Herein, we combined liposomes with photosensitizer indocyanine green (ICG) and perfluorooctyl bromide (PFOB) to develop a new oxygen-enriched photodynamic nanospray (Lip-PFOB-ICG) for cancer postoperative treatment. The Lip-PFOB-ICG not only has good biocompatibility but also enhanced the PDT effect under near-infrared light. More importantly, PFOB can continuously absorb oxygen, thus improving the collision energy transfer between the ICG photosensitizer and oxygen, and significantly inhibit local tumor recurrence in the subcutaneous tumor recurrence model. This oxygen-enriched photodynamic nanospray strategy may open up new avenues for effective postoperative cancer therapy in the clinic.

Recent advances in applications of nanoparticles in SERS in vivo imaging

Surface-enhanced Raman scattering (SERS) technique has been regarded as one of the most important research methods in the field of single-molecule science. Since the previous decade, the application of nanoparticles for in vivo SERS imaging becomes the focus of research. To enhance the performance of SERS imaging, researchers have developed several SERS nanotags such as gold nanostars, copper-based nanomaterials, semiconducting quantum dots, and so on. The development of Raman equipment is also necessary owing to the current limitations. This review describes the recent advances of SERS nanoparticles and their applications for in vivo imaging in detail. Specific examples highlighting the in vivo cancer imaging and treatment application of SERS nanoparticles. A perspective on the challenges and opportunities of nanoparticles in SERS in vivo imaging is also provided. This article is categorized under: Diagnostic Tools > in vivo Nanodiagnostics and Imaging Therapeutic Approaches and Drug Discovery > Nanomedicine for Oncologic Disease.

Stimulus-responsive surface-enhanced Raman scattering: a "Trojan horse" strategy for precision molecular diagnosis of cancer

Molecular diagnosis has played an increasingly important role in cancer detection. However, it remains challenging to develop an in situ analytical method capable of profiling the molecular phenotype of tumors for precision cancer diagnosis. A "Trojan horse" strategy based on stimulus-responsive surface-enhanced Raman scattering (SR-SERS) is reported here for selectively recording the comprehensive molecular information of tumors in situ, without resorting to destructive sample preparation and complex data analysis. This technique is employed to delineate the margin between tumors and normal tissues with high accuracy, and to further discriminate the molecular fingerprints of tumors in the early and late stages. Based on molecular profiling, we discovered that the signal ratios of fatty acid-to-phenylalanine could serve as promising indicators for identifying the primary tumors in different stages. This simple SR-SERS technique also provides a potential useful means for identifying tumor classifications or distinguishing primary and metastatic tumors.