Patients with cancer have the highest probability of recovering if tumors are completely removed. However, some tiny clusters of cancer cells may be difficult recognize and remove. Now a new camera makes hidden tumors visible during surgery, helping surgeons improve their patients survival.

Tumor removal surgeries pose a great challenge even to skillful and experienced surgeons. Often, tumor margins are blending into healthy tissue and are difficult to differentiate. Furthermore, distributed domains of cancer and pre-malignancies are difficult to recognize. Up to now, doctors depend exclusively upon their trained eyes when excising pieces of tumors. However, a new special camera system can help visualize during operation even the smallest, easy-to-overlook malignant pieces of tumor and support the surgeons during complicated interventions such as in the surgical removal of gliomas.

Removing large gliomas while, at the same time, sparing as much brain function as possible is a difficult challenge. In many cases systems, including advanced camera technology and intraoperative MRI or iMRI, are used in glioma surgery mainly to determine the extent of resection, allowing surgeons to immediately continue resection in case of residual tumor tissue. These systems are considered to be a helpful tool to increase the extent of resection in GBM surgery and thereby improve patient survival.[1]

Painting cancer
The new,multispectral fluorescence camera system, developed by researchers at the Fraunhofer Project Group for Automation in Medicine and Biotechnology(PAMB), which belongs to the Fraunhofer Institute for Manufacturing Engineering and Automation (IPA),can display fluorescent molecules that “paint” the cancer tissue. These are injected into the patients blood circulation prior to surgery and selectively attach onto the tumor during their trip through the body. If the corresponding area is then illumimated with a specific wavelength, fluorescence is emitted and the malignant tissue glows green, blue, red, or any other color, depending on the injected dye, while the healthy tissue appears the same. In this way, the surgeon can see clusters of tumors cells that cannot be recognized by the naked eye.

Reveals dyes simultaneously
The special camera can be integrate into various medical imaging systems such as, surgical microscopes and endoscopes.

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One of the unique aspects of the camera system is that it can display several fluorescent dyes and the reflectance image simultaneously in real time ? systems available until now have not been able to achieve this. This ability gives surgeons the ability to “color” and “see” arteries and delicate nerves that must not be injured during an intervention. These arteries and nerves can then be detected with the new camera, since they are set apart from their surroundings.

Set apart
“The visibility of the dye to the camera depends in large part on the selection of the correct set of fluorescence filters. The filter separates the incident excitation wavelengths from the fluorescing wavelengths so that the diseased tissue is also set apart from its surroundings, even at very low light intensities,” noted Nikolas Dimitriadis, head of the Biomedical Optics Group at PAMB.

The researchers require only one camera and one set of filters for their photographs, which can present up to four dyes at the same time. Software developed in-house analyses and processes the images in seconds and presents it continuously on a monitor during surgery. The information from the fluorescent image is superimposed on the normal color image. “The operator receives significantly more accurate information. Millimeter-sized tumor remnants or metastases that a surgeon would otherwise possibly overlook are recognizable in detail on the monitor. Patients operated under fluorescent light have improved chances of survival,” Dimitriadis noted.

In order to be able to employ the multispectral fluorescence camera system as adaptably as possible, it can be converted to other combinations of dyes. “One preparation that is already available to make tumors visible is 5-amino levulinic acid (5-ALA). Physicians employ this especially for glioblastomas ? one of the most frequent malignant brain tumors in adults,” Dimitriadis further explains. 5-ALA leads to an accumulation of a red dye in the tumor and can likewise be detected with the camera. The multispectral fluorescence imaging system should have passed testing for use with humans as soon as next year. The first clinical tests with patients suffering from glioblastomas are planned for 2014.

For more information:
Aldave G, Tejada S, Pay E, Marigil M, Bejarano B, Idoate MA, D?ez-Valle R. Prognostic value of residual fluorescent tissue in glioblastoma patients after gross total resection in 5-aminolevulinic Acid-guided surgery. Neurosurgery. 2013 Jun;72(6):915-20; discussion 920-1. doi: 10.1227/NEU.0b013e31828c3974.[PubMed]

Note: Fraunhofer Scientists from Mannheim, Germany, will present the debute of a prototype of this high-tech system at the Medica Trade Fair in D?sseldorf in the joint Fraunhofer booth (Halle 10, Booth F05) between 20-23 November 2013.

Photo Left: The new camera displays colored structures by means of fluorescent dyes (blue and green areas shown here). Photo Right: The same tissue shown without treatment. Photo courtesy: ?Fraunhofer IPA

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