Linpeng Wei1, David W Roberts2,3,4,5, Nader Sanai6, Jonathan T C Liu7,8. 1. Department of Mechanical Engineering, University of Washington, Seattle, WA, 98195, USA. lpwei@uw.edu. 2. Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, 03756, USA. 3. Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, 03756, USA. 4. Thayer School of Engineering, Dartmouth College, Hanover, NH, 03755, USA. 5. Geisel School of Medicine, Dartmouth College, Hanover, NH, 03755, USA. 6. Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, 85013, USA. 7. Department of Mechanical Engineering, University of Washington, Seattle, WA, 98195, USA. 8. Department of Pathology, University of Washington, Seattle, WA, 98195, USA.
Abstract
INTRODUCTION: 5-ALA-based fluorescence-guided surgery has been shown to be a safe and effective method to improve intraoperative visualization and resection of malignant gliomas. However, it remains ineffective in guiding the resection of lower-grade, non-enhancing, and deep-seated tumors, mainly because these tumors do not produce detectable fluorescence with conventional visualization technologies, namely, wide-field (WF) surgical microscopy. METHODS: We describe some of the main factors that limit the sensitivity and accuracy of conventional WF surgical microscopy, and then provide a survey of commercial and research prototypes being developed to address these challenges, along with their principles, advantages and disadvantages, as well as the current status of clinical translation for each technology. We also provide a neurosurgical perspective on how these visualization technologies might best be implemented for guiding glioma surgeries in the future. RESULTS: Detection of PpIX expression in low-grade gliomas and at the infiltrative margins of all gliomas has been achieved with high-sensitivity probe-based visualization techniques. Deep-tissue PpIX imaging of up to 5 mm has also been achieved using red-light illumination techniques. Spectroscopic approaches have enabled more accurate quantification of PpIX expression. CONCLUSION: Advancements in visualization technologies have extended the sensitivity and accuracy of conventional WF surgical microscopy. These technologies will continue to be refined to further improve the extent of resection in glioma patients using 5-ALA-induced fluorescence.
INTRODUCTION:5-ALA-based fluorescence-guided surgery has been shown to be a safe and effective method to improve intraoperative visualization and resection of malignant gliomas. However, it remains ineffective in guiding the resection of lower-grade, non-enhancing, and deep-seated tumors, mainly because these tumors do not produce detectable fluorescence with conventional visualization technologies, namely, wide-field (WF) surgical microscopy. METHODS: We describe some of the main factors that limit the sensitivity and accuracy of conventional WF surgical microscopy, and then provide a survey of commercial and research prototypes being developed to address these challenges, along with their principles, advantages and disadvantages, as well as the current status of clinical translation for each technology. We also provide a neurosurgical perspective on how these visualization technologies might best be implemented for guiding glioma surgeries in the future. RESULTS: Detection of PpIX expression in low-grade gliomas and at the infiltrative margins of all gliomas has been achieved with high-sensitivity probe-based visualization techniques. Deep-tissue PpIX imaging of up to 5 mm has also been achieved using red-light illumination techniques. Spectroscopic approaches have enabled more accurate quantification of PpIX expression. CONCLUSION: Advancements in visualization technologies have extended the sensitivity and accuracy of conventional WF surgical microscopy. These technologies will continue to be refined to further improve the extent of resection in gliomapatients using 5-ALA-induced fluorescence.
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