Multi-Wavelength Fluorescence in Image-Guided Surgery, Clinical Feasibility and Future Perspectives

Florian van Beurden, Danny M van Willigen, Borivoj Vojnovic, Matthias N van Oosterom, Oscar R Brouwer, Henk G van der Poel, Hisataka Kobayashi, Fijs W B van Leeuwen, Tessa Buckle, Florian van Beurden, Danny M van Willigen, Borivoj Vojnovic, Matthias N van Oosterom, Oscar R Brouwer, Henk G van der Poel, Hisataka Kobayashi, Fijs W B van Leeuwen, Tessa Buckle

Abstract

With the rise of fluorescence-guided surgery, it has become evident that different types of fluorescence signals can provide value in the surgical setting. Hereby a different range of targets have been pursued in a great variety of surgical indications. One of the future challenges lies in combining complementary fluorescent readouts during one and the same surgical procedure, so-called multi-wavelength fluorescence guidance. In this review we summarize the current clinical state-of-the-art in multi-wavelength fluorescence guidance, basic technical concepts, possible future extensions of existing clinical indications and impact that the technology can bring to clinical care.

Keywords: fluorescence-guided surgery; image-guided surgery; multicolor fluorescence imaging; multiplexing.

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Multi-wavelength imaging in neurosurgery. (A-i) White light image of the surgical field through a microscope showing a left MCA bifurcation aneurysm (asterisk) with corresponding (ii) Fluorescein-based vascular angiography (FL-VA), and (iii) ICG-based vascular angiography (ICG-VA) (Adapted form Lane et al). Intraoperative visualization of a left-frontal distant recurrence of a gliosarcoma via large field imaging with (B-i) a BLUE 400 filter (PpIX ALA in pink) and (ii) a YB 475 filter (Fluorescein in yellow) (Adapted from Suero Molina et al.).
Figure 2.
Figure 2.
Multiparameter fluorescence imaging of bladder cancer. Representative cytoscopic imaging in 5 patients showing white-light (WL) images and enhanced vascular contrast (EVC), PDD, protoporphyrin IX fluorescence (PpIX-F), and autofluorescence (AF) characteristics. An overlay of all detected features is provided as a multiparametric image (MP) in real-time (adapted from Kriegmair et al.).
Figure 3.
Figure 3.
Multi-wavelength imaging of hepatic lesions. A, (i) Widefield imaging of the surgical field (liver) in white light indicating liver metastases (white arrow). Fluorescence images of incised lesion after illumination of (ii) ICG and (iii) PpIX5ALA (adapted from Kaibori et al). B, (i) Widefield imaging in white-light image of a metastasis located in the omentum with corresponding (ii) NIR I and (iii) NIR II fluorescence images (adapted from Hu et al).
Figure 4.
Figure 4.
Parathyroid autofluorescence and ICG imaging. (A) Widefield white-light image of parathyroid glands (R = recurrent laryngeal nerve). (B) NIR-based autofluorescence signal of the parathyroid gland in blue and (C) NIR ICG fluorescence imaging showing the lack of vascularization of the parathyroid gland (ICG in blue; adapted from Ladurner et al.).
Figure 5.
Figure 5.
Multi-wavelength imaging of lymph nodes and lymphatic duct. Lymphatic co-localization (yellow arrow heads) of (A) MB and (B) ICG following uterine and cervical injection, respectively, in a patient with endometrial cancer (adapted from Laios et al). (C-i) Unprocessed multi-wavelength image of lymphatic ducts in a porcine model (Fluorescein; yellow arrow) and 2 (ICG-nanocolloid; pink arrow). Digitally separated images of the 2 signals: (ii) ICG and (iii) Fluorescein (adapted from Meershoek et al.).
Figure 6.
Figure 6.
Multiwavelength fluorescence as a means to provide depth assessment. Traffic light analogue for depth estimation using a marker seed filled with a mixture of ICG, TRITC and FITC. Depending on the number of colors used, an estimation of depth can be made based on the tissue penetration of each dye (top illustration). A camera system is required to detect the ICG signal and can aid in visualizing the TRITC and FITC signals (here depicted using (reversed) Rainbow color table; bottom illustration) (Chin et al.).

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