Fluorescence-guided surgery and intervention - An AAPM emerging technology blue paper.

Fluorescence-guided surgery (FGS) and other interventions are rapidly evolving as a class of technologically driven interventional approaches in which many surgical specialties visualize fluorescent molecular tracers or biomarkers through associated cameras or oculars to guide clinical decisions on pathological lesion detection and excision/ablation. The technology has been commercialized for some specific applications, but also presents technical challenges unique to optical imaging that could confound the utility of some interventional procedures where real-time decisions must be made. Accordingly, the AAPM has initiated the publication of this Blue Paper of The Emerging Technology Working Group (TETAWG) and the creation of a Task Group from the Therapy Physics Committee within the Treatment Delivery Subcommittee. In describing the relevant issues, this document outlines the key parameters, stakeholders, impacts, and outcomes of clinical FGS technology and its applications. The presentation is not intended to be conclusive, but rather to inform the field of medical physics and stimulate the discussions needed in the field with respect to a seemingly low-risk imaging technology that has high potential for significant therapeutic impact. This AAPM Task Group is working toward consensus around guidelines and standards for advancing the field safely and effectively.

UV radiation increases carcinogenic risks for oral tissues compared to skin.

People can expose their oral cavities to UV (290-400 nm) by simply opening their mouths while outdoors. They can also have their oral cavities exposed to UV indoors to different UV-emitting devices used for diagnoses, treatments and procedures like teeth whitening. Because the World Health Organization declared UV radiation as a complete human carcinogen in 2009, we asked if oral tissues are at a similar or higher carcinogenic risk compared to skin tissue. To understand the UVB (290-320 nm)-related carcinogenic risks to these tissues, we measured initial DNA damage in the form of cyclobutane pyrimidine dimers (CPD), the repair rate of CPD (24 h) and the number of apoptotic dead cells over time resulting from increasing doses of erythemally weighted UV radiation. We used commercially available 3D-engineered models of human skin (EpiDerm™), gingival (EpiGingival™) and oral (EpiOral™) tissues and developed an analytical approach for our tri-labeling fluorescent procedure to identify total DNA, CPD and apoptotic cells so we can simultaneously quantify DNA repair rates and dead cells. Both DNA repair and apoptotic cell numbers are significantly lower in oral cells compared with skin cells. The combined results suggest UVB-exposed oral tissues are at a significantly higher carcinogenic risk than skin tissues.

Broadband ultraviolet-visible optical property measurement in layered turbid media.

The ability to accurately measure layered biological tissue optical properties (OPs) may improve understanding of spectroscopic device performance and facilitate early cancer detection. Towards these goals, we have performed theoretical and experimental evaluations of an approach for broadband measurement of absorption and reduced scattering coefficients at ultraviolet-visible wavelengths. Our technique is based on neural network (NN) inverse models trained with diffuse reflectance data from condensed Monte Carlo simulations. Experimental measurements were performed from 350 to 600 nm with a fiber-optic-based reflectance spectroscopy system. Two-layer phantoms incorporating OPs relevant to normal and dysplastic mucosal tissue and superficial layer thicknesses of 0.22 and 0.44 mm were used to assess prediction accuracy. Results showed mean OP estimation errors of 19% from the theoretical analysis and 27% from experiments. Two-step NN modeling and nonlinear spectral fitting approaches helped improve prediction accuracy. While limitations and challenges remain, the results of this study indicate that our technique can provide moderately accurate estimates of OPs in layered turbid media.

Optical coherence tomography imaging of retinal damage in real time under a stimulus electrode.

We have developed a novel method to study the effects of electrical stimulation of the local retina directly under an epiretinal stimulus electrode in real time. Using optical coherence tomography (OCT) and a superfused retinal eyecup preparation, we obtained high-resolution images of the rabbit retina directly under an optically transparent saline-filled fluoropolymer stimulation tube electrode. During OCT imaging, 50 Hz trains of biphasic current pulses 1 ms/phase (23-749 µC cm(-2) ph(-1)) were applied to the retinal surface for 5 min. After imaging, the stimulated regions were stained with the dye propidium iodide (PI) to reveal cytotoxic damage. Pulse train stimulation at 44-133 µC cm(-2) ph(-1) had little effect on the retina; however, trains ≥442 µC cm(-2) ph(-1) caused increases in the reflectance of the inner plexiform layer (IPL) and edema. The damage seen in retinal OCT images matched the pattern observed in histological sections, and in the PI staining. With pulse trains ≥442 µC cm(-2) ph(-1), rapid increases in the reflectivity of the IPL could be observed under the stimulus electrode. Below the electrode, we observed a ring-like pattern of retinal detachment in the subretinal space. The OCT imaging method may be useful for analyzing overstimulation of neuronal tissue by electrodes in many brain regions.

Optical characterization of cutaneous transilluminators for eye safety.

Cutaneous transilluminators are light-emitting devices used to localize blood vessels for various medical procedures. They are often used in populations that may be at increased risk for skin burns, such as neonates and the elderly. While there is a known potential for skin burns, little is known about the ophthalmic risk from the use of these devices. This paper will report on the laboratory evaluation of the potential ocular hazards from transilluminators (TIs). Our results indicate that transilluminators which incorporate white-light LEDs have emissions that have the potential for producing injury to the retina, especially in patients who may have a reduced aversion response.

Depth-sensitive reflectance measurements using obliquely oriented fiber probes.

Computer simulation is used to facilitate the design of fiber-probe geometries that enable enhanced detection of optical signals arising from specific tissue depths. Obtaining understanding of the relationship between fiber-probe design and tissue interrogation is critical when developing strategies for optical detection of epithelial precancers that originate at known depths from the tissue surface. The accuracy of spectroscopic diagnostics may be enhanced by discretely probing the optical properties of epithelium and underlying stroma, within which the morphological and biochemical features vary as a function of depth. While previous studies have investigated controlling tissue-probing depth for fluorescence-based modalities, in this study we focus on the detection of reflected light scattered by tissue. We investigate how the depth of optical interrogation may be controlled through combinations of collection angles, source-detector separations, and numerical apertures. We find that increasing the obliquity of collection fibers at a given source-detector separation can effectively enhance the detection of superficially scattered signals. Fiber numerical aperture provides additional depth selectivity; however, the perturbations in sampling depth achieved through this means are modest relative to the changes generated by modifying the angle of collection and source-detection separation.