# Patent

## Title
Folate targeted enhanced tumor and folate receptor positive tissue optical imaging technology

## Abstract

A method of differentiating tumors from healthy cells in tissue is disclosed. The method includes the steps of providing a marker-folate conjugate, placing the marker-folate conjugate in contact with the tissue and viewing the tissue.

## Background
REFERENCE TO OTHER APPLICATIONS
This application is a continuation of U.S. application Ser. No. 13/468,010, filed May 9, 2012, now abandoned, which is a continuation of U.S. application Ser. No. 13/279,849, filed Oct. 24, 2011, now abandoned, which is a continuation application of U.S. application Ser. No. 10/360,001 filed Feb. 6, 2003, now U.S. Pat. No. 8,043,602, which claims the benefit of U.S. Provisional Application No. 60/355,417 filed Feb. 7, 2002, each of which is hereby incorporated by reference.


BACKGROUND AND SUMMARY
Cancer survival statistics establish the importance of early detection and thorough tumor resection for maximization of patient lifespan. Recent efforts to better achieve these objectives have focused on development of safer, more sensitive, and more discriminating imaging methodologies. MRI techniques rely on differences in water relaxivity between malignant lesions and healthy cells to achieve the desired contrast. PET imaging and methodologies generally exploit differences in metabolic fluxes between cancer and normal cells to allow tumor visualization. Some radiological imaging methods rely on the elevated passive vascular permeability of many neoplasms to achieve contrast with healthy tissues. Whereas radiological and magnetic resonance imaging modalities have clearly led the field in early detection, increased interest has arisen in developing optical imaging techniques for tumor diagnosis, largely because of safety concerns with the routine use of other methodologies.
Described herein is a method of use for a tumor targeting ligand, the vitamin folic acid, by which folic acid delivers optical probes to both primary and metastatic tumors overexpressing the folate receptor. Furthermore, an apparatus is disclosed to allow viewing of the tumor both excised and in-vivo. Upon laser excitation, derived images of normal tissues generally show little or no fluorescence, whereas images of folate receptor-expressing tumors display bright fluorescence that can be easily distinguished from adjacent normal tissue with the naked eye. Further, with the aid of appropriate optics, metastatic tumor loci of submillimeter size can also be visualized. The sharp distinction between tumor and normal tissues enabled by this technique finds application in the localization and resection of tumor tissue during surgery or in the enhanced endoscopic detection and staging of cancers.
According to a first embodiment of the present invention, a method of differentiating tumors from healthy cells in tissue is disclosed. The method includes the steps of providing a marker-folate conjugate, placing the marker-folate conjugate in contact with the tissue, and viewing the tissue.
According to another embodiment of the present invention, a method of resectioning tumor cells in tissue is provided. The method includes the steps of providing a marker-folate conjugate, exposing the tissue to the marker-folate conjugate, exposing the tissue to light, viewing the tissue, and resectioning the tissue based on the fluorescence of cells in the tissue.
According to still another embodiment of the present invention, a method of differentiating tumor cells from healthy cells in tissue is provided. The method includes the steps of providing a flourescein-ligand conjugate, enabling contact between the flourescein-ligand conjugate and the tissue, and viewing the tissue.
According to another embodiment of the present invention, an apparatus for differentiating tissue treated with a marker-ligand conjugate is provided. The apparatus comprises a light source configured to illuminate the tissue to cause tumor cells to appear different than healthy cells, a microscope including a lens, and a filter configured to reduce the amount of light from the light source that is transferred to the lens.
According to another embodiment of the present invention, an apparatus for differentiating in-vivo tissue treated with a marker-ligand conjugate is provided. The apparatus comprises a diffusing lens, a light source configured to emit light, the light configured to pass through the diffusing lens to illuminate the in-vivo tissue, a camera configured to receive images of the in-vivo tissue, and a filter configured to alter the amount of light that is received by the camera.
According to another embodiment of the present invention, an apparatus for differentiating in-vivo tissue treated with a marker-ligand conjugate is provided. The apparatus comprises an endoscope, a light source configured to emit light, the light configured to pass through the endoscope to illuminate the in-vivo tissue, a camera coupled to the endoscope and configured to receive images of the in-vivo tissue, and a filter configured to alter the amount of light that is received by the camera.
According to another embodiment of the present invention, a method of differentiating arthritic tissue from healthy tissue is provided. The method includes the steps of providing a marker-folate conjugate, placing the marker-folate conjugate in contact with the tissues, and viewing the tissues.
Additional features of the present invention will become apparent to those skilled in the art upon consideration of the following detailed description of the invention.



BRIEF DESCRIPTION OF THE DRAWINGS
The patent or application file contains at least one drawing executed in color. Copies of this patent or patent application publication with color drawing(s) will be provided by the Office upon request and payment of the necessary fee.
The detailed description particularly refers to the accompanying figures in which:
FIG. 1 is a schematic of the instrumentation used for obtaining images and spectra of excised and dissected tissues;
FIG. 2 is a schematic of instrumentation used for obtaining images and spectra of in-vivo tissues;
FIG. 3a shows the structure of folate-γ-fluorescein. MW 872. C42H36N10O10S;
FIG. 3b shows the structure of folate-indocyanine;
FIG. 4a is a chart showing emission spectra of tissues from a mouse injected with folate-fluorescein;
FIG. 4b is a chart showing emission spectra of tissues from a mouse with nothing injected;
FIG. 5a includes pictures of M109 tumor tissue from a Balb/c mouse injected with folate-fluorescein (left) next to muscle tissue from the same mouse (right) under fluorescent illumination; FIG. 5a-1 includes pictures of M109 tumor tissue from a Balb/c mouse injected with folate-fluorescein (left) next to muscle tissue from the same mouse (right) under normal light;
FIG. 5b includes pictures of a subcutaneous L1210 tumor in a DBA mouse before dissection under fluorescent illumination; FIG. 5b-1 includes pictures of a subcutaneous L1210 tumor in a DBA mouse before dissection under normal light;
FIG. 5c includes pictures of an L1210 tumor (left) and muscle tissue (right) from a DBA mouse injected with folate-fluorescein under fluorescent illumination; FIG. 5c-1 includes pictures of an L1210 tumor (left) and muscle tissue (right) from a DBA mouse injected with folate-fluorescein under normal light;
FIG. 6 is a chart showing a fluorescence intensity comparison of tissues from mice injected with folate-fluorescein and from control mice with nothing injected;
FIG. 7 is a view of the peritoneal cavity of a Balb/c mouse with an M109 ip-induced tumor after injection of folate-fluorescein;
FIG. 8 includes views of M109 tumor nodules in a mouse lung after injection of folate-fluorescein under normal light and under fluorescent illumination;
FIG. 9a is a view of L1210 tumor nodules on the bottom of the liver of a DBA mouse under fluorescent illumination; FIG. 9a-1 is a view of L1210 tumor nodules on the bottom of the liver of a DBA mouse under normal light;
FIG. 9b is a view of L1210 tumor nodules on the top of the liver of a DBA mouse under fluorescent illumination; FIG. 9b-1 is a view of L1210 tumor nodules on the top of the liver of a DBA mouse under normal light;
FIG. 10a includes views of L1210 tumor nodules in the spleen of a DBA mouse after injection of folate-fluorescein under fluorescent illumination; FIG. 10a-1 includes views of L1210 tumor nodules in the spleen of a DBA mouse after injection of folate-fluorescein under normal light;
FIG. 10b includes views of L1210 tumor nodules in the muscle tissue on the neck of a DBA mouse after injection of folate-fluorescein under fluorescent illumination; FIG. 10b-1 includes views of L1210 tumor nodules in the muscle tissue on the neck of a DBA mouse after injection of folate-fluorescein under normal light;
FIG. 11 is a schematic of a system similar to the instrumentation of FIGS. 1-2 to allow imaging and spectra to be performed with an endoscope;
FIG. 12 is a schematic of an assembled and disassembled laser receiving apparatus which is part of the system of FIG. 11;
FIG. 13a is a view of rat paws without arthritis;
FIG. 13b is a view of rat paws with arthritis.



DETAILED DESCRIPTION OF THE EMBODIMENTS OF THE INVENTION
In-vivo tumor imaging requires the establishment of some type of measurable contrast between the tumor and surrounding normal tissues. The present imaging method exploits the overexpression of receptors for the vitamin folic acid on cancer cells to target attached imaging/contrast agents specifically to malignant cells.
The present folic acid-based targeting strategy utilizes i) the high affinity of folate for its cell surface receptor (Kd ̃10−10), ii) the inaccessibility of the receptor to circulating folates on those few normal cells that express it (the folate receptor on normal cells is primarily confined to the apical membranes of polarized epithelia where it is not easily accessed from the blood), and iii) the elevated expression of the folate receptor (“FR”) on many tumor cells. Those tumors that commonly overexpress FR include cancers of the ovary, breast, kidney, lung, endometrium, myeloid cells, and brain.
During debulking surgery, where malignant loci can be difficult to identify, the presence of a fluorescent signal may assist with their localization. Further, when tumors are situated near the body surface and frequent analysis of tumor progression is required, the present optical imaging methodology can be repeatedly applied without danger of toxicity. Also, in the course of an endoscopic examination, fluorescence imaging can allow precise assessment of the location, size, and invasiveness of a tumor.
The present invention provides the ability to visualize folate receptor expressing cancer tissues in various peritoneal, subcutaneous, and metastatic murine tumor models following intravenous administration of a folate-fluorescein conjugate. Tumors as small as a few millimeters can be easily detected with the unaided eye. The present invention provides instrumentation to detect malignant lesions larger and smaller than 1 mm using folate-targeted fluorophores as aids in the localization and characterization of tumors during surgery and endoscopic examination as well as in excised tissue.
To obtain tumors for examination, M109 cells, a murine lung carcinoma cell line of Balb/c mouse origin, were grown subcutaneously in Balb/c mice. The tumors were excised under sterile conditions, minced into small pieces, and incubated for 4 hours in RPMI media (GIBCO, Grand Island, N.Y.) containing 200 U/ml of collagenase type 1A (Sigma, St. Louis, Mo.). M109 tumor cells were removed from the tumor pieces and washed twice with phosphate buffered saline (PBS) by centrifugation. The cells were then cultured overnight in folate-free RPMI (GIBCO, Grand Island, N.Y.), supplemented with 10% fetal calf serum (GIBCO, Grand Island, N.Y.), penicillin (100 IU), and streptomycin (100 μg/mL) (Sigma, St. Louis, Mo.). After removing remaining debris, the cells were passaged by treatment with trypsin (0.05%) (Sigma, St. Louis, Mo.) in Ca+2 and Mg+-free PBS. In order to retain high viability in Balb/c mice, M109 cells were discarded after the fourth passage in culture. L1210 cells, a lymphocyte-derived cell line of DBA mouse origin, were cultured in folate-free RPMI with a change of medium every 3-4 days.
To prepare the animals for in-vivo tumor imaging, Balb/c or DBA mice are placed on a folate-deficient diet (Dyets, Bethlehem, Pa.) three weeks prior to each experiment to lower the folate levels in the blood to the physiological range. Tumors are induced subcutaneously by injecting 100 μL of cell culture solution containing approximately 500,000 M109 or L1210 cells. Imaging of mice with subcutaneous tumors is performed when the tumors reach approximately 200 mm3 in size. For intraperitoneal (i.p.) tumors, approximately 500,000 M109 or L1210 cells are implanted in the peritoneal cavity and allowed to proliferate for approximately 2 weeks prior to analysis, which is sufficient time for tumor masses greater than 1 mm3 to appear. Metastatic tumors are initiated by injection of approximately 200,000 M109 or L1210 cells into the femoral vein, and the imaging is performed two weeks afterwards in a variety of tissues.
A folate-fluorescein conjugate, as shown in FIG. 3a and provided by Endocyte (West Lafayette, Ind.) (or the non-targeted control, fluorescein amine), is injected into the femoral vein by making an incision in the leg to expose the vein. FIG. 3a shows the conjugate provided by Endocyte having fluorescein amine bonded at the gamma carboxyl group of folic acid. A conjugate having fluorescein amine bonding at the alpha carboxyl group was also synthesized and provided similar results as the gamma bonded conjugate. 100 μL of a PBS solution containing 8.7 μL (10 nmol) of folate-fluorescein conjugate (or 3.3 μg (10 nmol) of fluorescein amine in the case of a control) is then injected. The wound is then closed using Vetbond (The Butler Co., Indianapolis, Ind.). Two hours following intravenous injection of folate-fluorescein, the tumor-bearing mice were euthanized and their tumors imaged using both tungsten lamp (direct view) and argon laser (fluorescence view) illumination. To allow the illumination of the tumors, three systems 10, 110, 210 have been created as shown in FIGS. 1, 2, and 11.
Laser Imaging and Spectral Analysis In-Vivo
Whole-tissue fluorescent imaging is performed using the imaging system 110 shown in FIG. 2 including an argon laser 12 (Spectra-Physics, Mountain View, Calif.) operating at 488 nm with a total laser power of 200 mW reaching the 2 cm sample field of view 114. Fluorescence is detected by a colored CCD camera 116 such as a JAI CV-53200N manufactured by Edmund Industrial Optics, Barrington, N.J. with a sensing area of 768×494 pixels and a pixel size of 8.4×98 μm2. An f/5.6 152-457 mm 10×CCD zoom lens 118, also produced by Edmund Industrial Optics, Barrington, N.J., is used to collect fluorescence from the 2.0 cm×2.0 cm field of view 114. A band pass filter 120 with less than 80% T at 515-585 nm (Inter, Inc., Socorro, N. Mex.) is placed between the lens 118 and the CCD Camera 116 in order to reject laser light 20 and suppress tissue auto-fluorescence outside the fluorescein fluorescence band. The images are digitally acquired using SNAPPY software v. 4.0 manufactured by Play, Inc., Sacramento, Calif.
The light 20 of laser 12 is aimed via a plurality of mirrors 26 such that the light 20 passes through a diffusing lens 124 to illuminate the field of view 114 as shown in FIG. 2. The CCD camera 116 and SNAPPY software can then take a picture through the lens 118 and the filter 120. Likewise, the CCD camera 116 can register fluorescent spectra such as those shown in FIG. 5.
Laser Imaging and Spectral Analysis for Excised Tissue
FIG. 1 is a schematic of an apparatus used to acquire images and spectra of excised and dissected tissue. In this case, the laser 12 is used to illuminate a 5 mm diameter area of a sample placed on an OLYMPUS BH-2 microscope 14 stage (Olympus, Inc., Melville, N.Y.). The fluorescent light from the treated tissue is collected with a 4× objective 16 and directed from the sample toward a holographic Super-Notch filter 18 (HNF, Kaiser Optical, Ann Arbor, Mich.) using a 99% reflective mirror 26 placed above the microscope objective 16. The HNF 18 is used to reject the laser light 20 at 488 nm, and the fluorescent light transmitted through the HNF 18 is focused on the spectrograph 22 (Spectra Pro-150, Acton Research Corporation, Acton, Mass.) entrance (slit width=200 μm) using a lens 24 of 21 mm focal length. FIGS. 4a and b shows fluorescence spectra that are obtained with the thermoelectric cooled CCD 22 (ST6, SBIG Instruments, Santa Barbara, Calif.) with 375×242 pixels and a pixel size of 23×25 μm2. The spectrograph 22 is equipped with a 600 g/mm grating tuned to a wavelength of 535 nm and spanning a 495 nm to 575 nm window on the CCD detector 22. The fluorescence spectra are acquired using KESTREL Spec software (Princeton Instruments, Trenton, N.J.) with an integration time of 5 s, and fluorescence wavelengths are calibrated against neon lamp calibration lines.
Once again, light 28 from an argon laser 12 is directed via mirrors 26 so as to illuminate tissue on a stage 32 of microscope 14. Any fluorescence is captured by camera 34 via filter 35, similar to filter 120, and by the spectrograph 22.
Spectra were taken of various tissues removed from mice two hours after an injection with 8.7 μg of folate-linked fluorescein. Spectra were also taken of control samples taken from mice with nothing injected.
As seen in FIGS. 5a-c, tumors are significantly more fluorescent than adjacent normal tissues. In fact, the differences in fluorescence intensity were readily apparent to the naked eye without the assistance of optical equipment as shown in the upper pictures of FIGS. 5a-c. Therefore, folate-linked fluorophores are useful for optical imaging wherever tumor location allows access to incident and fluorescent light.
To more accurately quantify the difference in the targeted fluorescence between normal and malignant tissue, spectral properties of various tissues using more analytical spectrofluorimetric methods was examined. For this purpose, tissue samples from both folate-fluorescein injected and noninjected tumor-bearing mice were examined using a spectrograph equipped with laser 12 excitation. Although tumor tissue from injected mice consistently showed an approximately fivefold greater fluorescence than the autofluorescence of noninjected controls, liver and muscle tissues, which did not express the folate receptor, displayed no difference in fluorescence intensity, regardless of the presence or absence of folate-fluorescein pretreatment (FIG. 6). Therefore, these results strongly suggest that folate targeting is responsible for the enhanced fluorescence seen in the diseased tissue.
In order to test the ability of folate-fluorescein to facilitate detection of microscopic tumor nodules, metastatic tumors of M109 cell origin were induced by inoculation of cells either into the peritoneal cavity (ip) or femoral vein (iv) of the syngeneic mice. After allowing sufficient time for tumor growth, tumor loci were again imaged by intravenous administration of folate-fluorescein followed by laser excitation. As seen in FIG. 7, metastatic tumor nodules 50 smaller than 0.5 mm were readily observable in both lungs of the intravenously inoculated mice, and all tumor metastases fluoresced intensely compared to adjacent nonmalignant tissue. Similar results were also obtained in the intraperitoneal metastatic tumor model when the peritoneal cavity was opened and imaged as above.
To further explore the ability of folate-fluorescein to image small metastatic lesions, L1210 cells were also inoculated intravenously into syngeneic mice and the various anatomical regions were again imaged as above. Since L1210 cells are lymphocytic in origin and relatively small in size, they are capable of forming tumor nodules throughout the body after iv injection, rather than becoming entrapped primarily in the lung capillary network. As shown in FIG. 8, both the under surface (panel a) and the top surface (panel b) of the liver contained multiple microscopic nodules 50 that were clearly revealed under laser illumination. Further, the animal's spleen was almost entirely filled with minute tumor loci (FIG. 9a) and was consequently enlarged to roughly twice its normal size. Tumor nodules were also found in muscle tissue near the shoulder (FIG. 9b) and in the brain, spinal cord, and along the pleura. In fact, tumor nodules were seen in most tissues of the body and no nodules were identified that did not fluoresce under laser illumination.
Finally, a major limitation of this imaging methodology has been the requirement to expose the tumor before image collection. This requirement was mandated by the inability of visible light to penetrate most tissues more than a few mm deep. Therefore, to begin to examine whether the same technology might be adapted to noninvasive imaging of deeper tumor loci, a second folate conjugate linked to a longer wavelength fluorophore, namely indocyanine (lambdaex=745 nm, lambdaem=785 nm) was constructed. The rationale for this construct derived from the fact that absorption of heme and related compounds reaches a minimum near 700 nm, allowing light of this wavelength to penetrate much farther into normal tissue (see structure in FIG. 3b). As seen in FIG. 10, folate-carbocyanine can image a subcutaneous M109 tumor in an intact animal, showing a significant fluorescent enhancement over adjacent normal tissue. Whereas the tumor-targeted fluorescein probe proved most effective in imaging malignant masses that could be directly excited with incident light, an indocyanine-based probe was preferred when the exciting light had to penetrate normal tissue in order to illuminate the transformed cells. Likewise, near infrared based probes are envisioned.
The efficacy of targeted imaging agents such as fluorescein, that reveal a malignancy when the tumor is easily exposed, is affected by the instrumentation 10, 110, 210 that can allow such illumination to occur. Therefore, two possible applications are specifically suggested herein for such fluorescent probes. First, the ability of highly fluorescent conjugates to reveal a tumor's location under direct illumination may be exploited to guide a surgeon's knife during tumor resection. For example, ovarian cancers, which are strongly folate receptor positive, are usually asymptomatic during early stages of the disease, resulting in initial diagnoses at stage III or IV in 70% of all patients. At these late stages, there is significant spread of the cancer throughout the peritoneal cavity, with lesions commonly attached to the omentum, intestines, and other internal organs. Current treatment for such advanced cancers involves debulking surgery followed by chemotherapy. Importantly, optimal tumor debulking has been shown to significantly increase the rate of patient survival, suggesting that if otherwise undetected malignant masses were to be removed, a further increase in survival might be realized. Use of folate-fluorescein or a related probe in conjunction with the appropriate intraoperative viewing lenses could conceivably enable this objective.
Second, in many cases, a patient must undergo a second-look surgery to determine whether relapse has occurred. In this situation, an optical method that could readily distinguish cancer from non-cancer tissue during an endoscopic exam could prove beneficial.
Such an endoscopic imaging system 210 is shown in FIGS. 11-12. The system 210 includes a laser 12, a laser receiving apparatus 212, an endoscopic device 214, and a fiber optic 216 physically and optically linking the laser receiving apparatus 212 to the endoscopic device 214. The laser receiving apparatus 212 includes a positioning post 218, a translating lens mount 220 coupled to the positioning post 218, a lens 222, and a fiber optic holder 224. The positioning post 218 has an attachment device 226 configured to couple to the lens mount 220. The positioning post 218 is also able to selectively couple to a surface to fix its position. Therefore, the lens mount 220 via the positioning post 218 is translatable along a Z-axis. The translating lens mount 220 includes X and Y translating knobs 228, 230 and a transmission void 232, and is coupled to the lens 222 and the fiber optic holder 224. The lens 222 is illustratively a Plano-Convex lens with a focal length of 25.4 mm, a diameter of 25.4 mm, and anti-reflection coated for 350-650 nm. The lens 222 is mounted to one side of the lens mount 220 and the fiber optic holder 224 is mounted to an other side of the lens mount 220 such that the lens 222 and a fiber optic 216 as held by the fiber optic holder 224 are aligned with the transmission void 232. The X and Y translating knobs allow the lens 222 to be moved up and down (Y-axis) and left and right (X-axis). Therefore, in combination with the positioning post 218, the lens mount 220 allows the lens 222 to be moved in three directions, X, Y, and Z. The fiber optic holder 224 includes a fiber holding void 234 and a surface 235 to mount to the lens mount 220. The fiber optic 216 is illustratively a Karl Storz fiber optic model no. 4965A having a first end received in the fiber holding void 234.
A second end of the fiber optic 216 is coupled to the endoscopic device 214 shown in FIG. 11. The endoscopic device 214 includes a camera 236, a filter holder 238, a filter (not pictured), an endoscope holder 242, and an endoscope 244. The camera 236 is illustratively a Karl Storz Vetcam XL that is coupled to a computer 248 for imaging purposes. The camera 236 is also coupled to the filter holder 238. Any light that enters a 237 lens of the camera 236 must pass through the filter holder 238 and the filter placed therein. The filter is similar to the band pass filter 120 and operates to reject laser light 20 and suppress tissue auto-fluorescence outside the fluorescein fluorescence band. However, it should be appreciated that the filter, and all other filters 18, 120, may be chosen to have different qualities if different lasers, different wavelength laser light, or different markers are used. The filter holder 238 is also coupled to the endoscope holder 242 which is in turn coupled to the endoscope 244. The endoscope 244 is illustratively a Karl Storz endoscope 3.5 mm×17 cm Model No. 64018US. The endoscope 244 is able to receive the second end of the fiber optic 216 therein and aim any light from the fiber optic 216 to the field of the endoscope 244.
Light is provided to the fiber optic 216 via the laser receiving apparatus 212 described above. The laser 12 is aimed at the lens 222 so that the laser light 20 can be guided and focused into the fiber optic 216. Rather than directly aiming the laser 12 at the lens 222, the laser 12 may also be directed to the lens 222 via mirrors 26. The laser receiving apparatus 212 may be adjusted along the X, Y, and Z axes via the knobs 228, 230 and positioning post 218 to achieve the optimal light 20 transmission to the field of the endoscope 244.
Folate-Fluorescein conjugates have also shown usefulness in detecting arthritis. Folate-targeted photosensitizers may be targeted to arthritic joints in that macrophages involved in rheumatoid arthritis have been found to express the folate receptor. Targeting a photosensitizer to arthritic joints allow phototherapy to be applied to the arthritic joint while preventing toxicity to other tissues. Imaging of joints, using apparatus such as those shown in FIGS. 1, 2, and 11, showed discernable contrast between arthritic, FIG. 13b, and non-arthritic tissues, FIG. 13a. One potential application of arthritis imaging is in the area of sport animal medicine. Race animals, such as dogs or horses, that have arthritis, could be diagnosed in an easy, inexpensive, and nonradioactive manner by using fluorescent imaging agents.
While the present invention has been disclosed as using folate based conjugates, it should be appreciated that it is also envisioned that folate receptor-binding analogs of folate and other folate receptor-binding ligands may also be used in place of folate. Furthermore, although the invention has been described in detail with reference to certain embodiments, variations and modifications exist within the spirit and scope of the invention as described and defined in the following claims.

## Claims

1. A method of imaging a tumor during surgery, the method comprising the steps of:
administering to a patient a folate conjugate comprising folate, or a folate receptor binding analog thereof, linked to a fluorescent agent; and
imaging the patient during surgery to detect the tumor, wherein the tumor is smaller than 1 mm in size.

2. The method of claim 1 wherein the fluorescent agent is illuminated.

3. The method of claim 1 wherein the fluorescent agent is fluorescein.

4. The method of claim 1 wherein the fluorescent agent is a near infrared compound.

5. The method of claim 1 wherein the fluorescent agent is phycoerythrin.

6. The method of claim 1 wherein the fluorescent agent is indocyanine.

7. The method of claim 2 wherein the fluorescent agent is illuminated using a laser.

8. The method of claim 1 wherein the tumor is subcutaneous, wherein the folate conjugate causes a difference in fluorescence intensity between the tumor and normal tissue, and the difference is caused by a fluorescent emission capable of being transmitted through skin.

9. The method of claim 1 wherein the patient is an animal.

10. The method of claim 1 wherein the patient is a human patient.

11. The method of claim 1 wherein the tumor is imaged using an endoscopic device.

12. The method of claim 1 wherein the folate is an α-isomer of folate.

13. The method of claim 1 wherein the folate is a γ-isomer of folate.

14. The method of claim 1 wherein the imaging is optical imaging.

15. The method of claim 1 wherein the tumor is subcutaneous.