Posts Tagged ‘3D surgical guides’

New method for 3D imaging of brain tumors

Larry H. Bernstein, MD, FCAP, Curator




Third-Harmonic Generation Microscopy Provides In Situ Brain Tumor Imaging

AMSTERDAM, Netherlands, April 25, 2015 — A technique involving third-harmonic generation microscopy could allow neurosurgeons to image and assess brain tumor boundaries during surgery, providing optical biopsies in near-real time and increasing the accuracy of tissue removal.

Pathologists typically use staining methods, in which chemicals like hematoxylin and eosin turn different tissue components blue and red, revealing its structure and whether there are any tumor cells. A definitive diagnosis can take up to 24 hours, meaning surgeons may not realize some cancerous tissue has escaped from their attention until after surgery — requiring a second operation and more risk.

Tissue from a patient diagnosed with low-grade glioma.

Tissue from a patient diagnosed with low-grade glioma. The green image is taken with the new method, while the pink uses conventional hematoxylin and eosin staining. From the upper left to the lower right, both images show increasing cell density due to more tumor tissue. The insets reveal the high density of tumor cells. Courtesy of N.V. Kuzmin et al./VU University Amsterdam.

Brain tumors — specifically glial brain tumors — are often spread out and mixed in with the healthy tissue, presenting a particular challenge. Surgery, irradiation and chemotherapy often cause substantial collateral damage to the surrounding brain tissue.

Now researchers from VU University Amsterdam, led by professor Marloes Groot, have demonstrated a label-free optical method for imaging cancerous brain tissue. They were able to produce most images in under a minute; smaller ones took <1 s, while larger images of a few square millimeters took 5 min.

The study involved firing short, 200-fs, 1200-nm laser pulses into the tissue. When three photons converged at the same time and place, the photons interacted with the nonlinear optical properties of the tissue. Through the phenomena of third harmonic generation, the interactions produced a single 400- or 600-nm photon (in the case of third or second harmonic generation, respectively).

The shorter-wavelength photon scatters in the tissue, and when it reaches a detector — in this case a high-sensitivity GaAsP photomultiplier tube — it reveals what the tissue looks like inside. The resulting images enabled clear recognition of cellularity, nuclear pleomorphism and rarefaction of neuropil in the tissue.

While this technique has been used in other applications — to image insects and fish embryos, for example — the researchers said this is the first time it’s been used to analyze glial brain tumors.

Groot and her team are now developing a handheld device for tumor border detection during surgery. The incoming laser pulses can only reach a depth of about 100 μm into the tissue currently; to reach further, Groot envisions attaching a needle that can pierce the tissue and deliver photons deeper.

The research was published in Biomedical Optics Express, a publication of The Optical Society (OSA) (doi: 10.1364/boe.7.001889).


Third harmonic generation imaging for fast, label-free pathology of human brain tumors

Biomedical Optics Express 2016  7(5):1889-1904    doi: 10.1364/BOE.7.001889

In brain tumor surgery, recognition of tumor boundaries is key. However, intraoperative assessment of tumor boundaries by the neurosurgeon is difficult. Therefore, there is an urgent need for tools that provide the neurosurgeon with pathological information during the operation. We show that third harmonic generation (THG) microscopy provides label-free, real-time images of histopathological quality; increased cellularity, nuclear pleomorphism, and rarefaction of neuropil in fresh, unstained human brain tissue could be clearly recognized. We further demonstrate THG images taken with a GRIN objective, as a step toward in situ THG microendoscopy of tumor boundaries. THG imaging is thus a promising tool for optical biopsies.


Glial tumors (gliomas) account for almost 80% of the tumors originating from brain tissue. The vast majority of these tumors are so-called ‘diffuse gliomas’ as they show very extensive (‘diffuse’) growth into the surrounding brain parenchyma. With surgical resection, irradiation, and/or chemotherapy it is impossible to eliminate all glioma cells without serious damage to the brain tissue. As a consequence, until now, patients with a diffuse glioma have had a poor prognosis, a situation which strongly contributes to the fact that brain tumor patients experience more years of life lost than patients with any other type of cancer [1,2].

Meanwhile it has also been demonstrated that the prognosis of patients with a diffuse glioma correlates with the extent of resection [3–5]. During brain surgery, however, it is extremely difficult for the neurosurgeon to determine the boundary of the tumor, i.e. whether a brain area contains tumor cells or not. If the neurosurgeon could have histopathological information on the tumor boundaries during brain surgery, then recognition of these tumor boundaries and with that, the surgical resection, could be significantly improved.

Occasionally, intra-operative analysis using hematoxylin-and-eosin (H&E) stained sections of snap-frozen material or smear preparations is performed by the pathologist to help establish brain tumor boundaries, but this procedure only allows analysis of small, selected regions, can only be performed on tissue fragments that are already resected, and is rather time consuming (frozen section diagnosis) or does not allow analysis of tumor in the histological context (smear preparations). Fluorescence imaging techniques are increasingly used during surgery [6,7] but are associated with several drawbacks, such as heterogeneous delivery and nonspecific staining [8,9]. In particular, low-grade gliomas and normal brain tissue have an intact blood-brain barrier and take up little circulating dye [10–12]. Alternative techniques are therefore required, that can detect the presence of tumor cells in tissue without fluorescent labels and with a speed that enables ‘live’ feedback to the surgeon while he/she operates.

The past year has seen exciting new developments in which optical coherence tomography [13] and stimulated Raman microscopy [14,15] were reported to reliably detect tumor tissue in the brain of human glioma patients, and a handheld Raman spectroscopy device was even implemented intra-surgical to assess brain tissue prior to excision [16]. These techniques are especially sensitive in densely tumor-infiltrated areas, and for the Raman spectroscopy device study a sensitivity limit of 17 tumor cells in an area of 150 × 150 μm2 was reported. The discriminating power of the Raman techniques is based on subtle differences in the vibrational spectra of tumor tissue and healthy tissue, and they require extensive comparison of experimental spectra against libraries of reference spectra. A technique capable of directly visualizing the classical histopathological hallmark criteria currently used by pathologists for classification of tumor tissue could potentially be even more reliable and make the transition from the current practice—histopathological analysis of fixated tissue—to in situ optical biopsy easier. Diffuse gliomas are histopathologically characterized by variably increased cellularity, nuclear pleomorphism and—especially in higher-grade neoplasms—brisk mitotic activity, microvascular proliferation, and necrosis. To visualize these features in live tissue, a technique that elucidates the morphology of tissue is required. In this context, third harmonic generation (THG) microscopy is a promising tool because of its capacity to visualize almost the full morphology of tissue. THG is a nonlinear optical process that relies on spatial variations of the third-order non-linear susceptibility χ(3) intrinsic to the tissue and (in the case of brain tissue) mainly arises from interfaces with lipid-rich molecules [17–27]. SHG signals arise from an optical nonlinear process involving non-centrosymmetric molecules present in, for example, microtubules and collagen. THG has been successfully applied to image unstained samples such as insect embryos, plant seeds and intact mammalian tissue [28], epithelial tissues [29–31], zebra fish embryos [32], and the zebra fish nervous system [33]. In brain tissue of mice, augmented by co-recording of SHG signals, THG was shown to visualize cells, nuclei, the inner and outer contours of axons, blood cells, and vessels, resulting in the visualization of both gray and white matter (GM and WM) as well as vascularization, up to a depth of 350 μm [24,26]. Here, we explore the potential of THG and SHG imaging for real time analysis of ex-vivo human brain tissue in the challenging cases of diffuse tumor invasion in low-grade brain tumors as well as of high-grade gliomas and structurally normal brain tissues.


Multiphoton imaging

THG and SHG are nonlinear optical processes that may occur in tissue depending on the nonlinear susceptibility coefficients χ(3) and χ(2) of the tissue and upon satisfying phase matching conditions [17–19,21,23–27]. In the THG process, three incident photons are converted into one photon with triple energy and one third of the wavelength (Fig. 1(A)). In the SHG process, signals result from the conversion of an incident photon pair into one photon with twice the energy and half the wavelength. Two- and three photon excited fluorescence signals (2PF, 3PF) may simultaneously be generated by intrinsic proteins (Fig. 1(B)). As a result, a set of distinct (harmonic) and broadband (autofluorescence) spectral peaks is generated in the visible range. The imaging setup (Fig. 1(C)) to generate and collect these signals consisted of a commercial two-photon laser-scanning microscope (TriMScope I, LaVision BioTec GmbH) and a femtosecond laser source. The laser source was an optical parametric oscillator (Mira-OPO, APE) pumped at 810 nm by a Ti-sapphire oscillator (Coherent Chameleon Ultra II). The OPO generates 200 fs pulses at 1200 nm with a repetition rate of 80 MHz. We selected this wavelength as it falls in the tissue transparency window, providing deeper penetration and reduced photodamage compared to the 700–1000 nm range, as well as harmonic signals generated in the visible wavelength range, facilitating their collection and detection with conventional objectives and detectors. We focused the OPO beam on the sample using a 25 × /1.10 (Nikon APO LWD) water-dipping objective (MO). The 1200 nm beam focal spot size on the sample was dlateral ~0.7 μm and daxial ~4.1 μm. It was measured with 0.175 μm fluorescent microspheres (see Section 3.4) yielding two- and three-photon resolution values Δ2P,lateral ~0.5 μm, Δ2P,axial ~2.9 μm, Δ3P,lateral ~0.4 μm, and Δ3P,axial ~2.4 μm. Two high-sensitivity GaAsP photomultiplier tubes (PMT, Hamamatsu H7422-40) equipped with narrowband filters at 400 nm and 600 nm were used to collect the THG and SHG signals, respectively, as a function of position of the focus in the sample. The signals were filtered from the 1200 nm fundamental photons by a dichroic mirror (Chroma T800LPXRXT, DM1), split into SHG and THG channels by a dichroic mirror (Chroma T425LPXR, DM2), and passed through narrow-band interference filters (F) for SHG (Chroma D600/10X) and THG (Chroma Z400/10X) detection. The efficient back-scattering of the harmonic signals allowed for their detection in epi-direction. The laser beam was transversely scanned over the sample by a pair of galvo mirrors (GM). THG and SHG modalities are intrinsically confocal and therefore provide direct depth sectioning. We obtained a full 3D image of the tissue volume by scanning the microscope objective with a stepper motor in the vertical (z) direction. The mosaic imaging of the sample was performed by transverse (xy) scanning of the motorized translation stage. Imaging data was acquired with the TriMScope I software (“Imspector Pro”); image stacks were stored in 16-bit tiff-format and further processed and analyzed with “ImageJ” software (ver. 1.49m, NIH, USA). All images were processed with logarithmic contrast enhancement.

Fig. 1 THG/SHG microscopy for brain tissue imaging. (A) Energy level diagram of the second (SHG) and third (THG) harmonic generation process. (B) Energy level diagram of the two- (2PF) and three-photon (3PF) excited auto-fluorescence process. (C) Multiphoton microscope setup: Laser producing 200 fs pulses at 1200 nm; GM – X-Y galvo-scanner mirrors; SL – scan lens; TL – tube lens; MO – microscope objective; DM1 – dichroic mirror reflecting back-scattered THG/SHG photons to the PMT detectors; DM2 – dichroic mirror splitting SHG and THG channels; F – narrow-band SHG and THG interference filters; L – focusing lenses; PMT – photomultiplier tube detectors. (D) Infrared photons (white arrow) are focused deep in the brain tissue, converted to THG (green) and SHG (red) photons, scattered back (green/red arrows) and epi-detected. The nonlinear optical processes result in label-free contrast images with sub-cellular resolution and intrinsic depth sectioning. (E and F) Freshly-excised low-grade (E) and high-grade (F) glioma tissue samples in artificial cerebrospinal fluid (ACSF) in a Petri dish with a millimeter paper underneath for scale. (G) An agar-embedded tumor tissue sample under 0.17 mm glass cover slip with the microscope objective (MO) on top.   Download Full Size | PPT Slide

Endomicroscopy imaging

For endomicroscopic imaging we used a commercial high-numerical-aperture (NA) multi-element micro-objective lens (GT-MO-080-018-810, GRINTECH) composed of a plano-convex lens and two GRaded INdex (GRIN) lenses with aberration compensation, object NA = 0.80 and object working distance 200 µm (in water), image NA = 0.18 and image working distance 200 µm (in air), magnification × 4.8 and field-of-view diameter of 200 μm. The GRIN lenses and the plano-convex lens were mounted in a waterproof stainless steel housing with an outer diameter of 1.4 mm and a total length of 7.5 mm. Originally designed for a wavelength range of 800–900 nm [36–41], this micro-objective lens was used for focusing of 1200 nm femtosecond pulses and collection of back-scattered harmonic and fluorescence photons. A coupling lens with f = 40 mm (NA = 0.19, Qioptiq, ARB2 NIR, dia. 25 mm) focused the scanned laser beam in the image plane of the micro-objective lens and forwarded the epi-detected harmonic and fluorescence photons to the PMTs.

We characterized the lateral (x) and axial (z) resolution of the micro-objective lens by 3D imaging of fluorescence microspheres (PS-Speck Microscope Point Source Kit, P7220, Molecular Probes). We used “blue” and “deep red” microspheres, 0.175 ± 0.005 μm in diameter, with excitation/emission maxima at 360/440 nm and 630/660 nm to obtain three-photon (3P) and two-photon (2P) point spread function (PSF) profiles. The excitation wavelength was 1200 nm, and fluorescence signals were detected in the 400 ± 5 nm (3P) and 600 ± 5 nm (2P) spectral windows, just as in the brain tissue imaging experiments. 1 μL of “blue” and “deep red” sphere suspensions were applied to a propanol-cleaned 75 × 26 × 1 mm3 glass slide. The mixed microsphere suspension was left to dry for 20 min and was then imaged with the micro-objective lens via a water immersion layer. The assembly of the coupling lens and the micro-objective lens was vertically (z) scanned with a step of 0.5 μm, and stacks of two-/three-photon images were recorded. The line profiles were then taken over the lateral (xy) images of the fluorescent spheres with maximal intensity (in focus), and fluorescence counts were plotted as function of the lateral coordinate (x). The axial (z) scan values of the two- and three-photon fluorescence signals were acquired by averaging of the total fluorescence counts of the corresponding spheres and were plotted as function of the axial coordinate (z). Lateral (x) and axial (z) 2P/3P points were then fitted with Gaussian functions and full width at half-maximum (FWHM) values were measured.

……. Results….  Conclusions

The results shown here provide the first evidence that—by applying the same microscopic criteria that are used by the pathologist, i.e. increased cellularity, nuclear pleomorphism, and rarefaction of neuropil—THG/SHG ex-vivo microscopy can be used to recognize the presence of diffuse infiltrative glioma in fresh, unstained human brain tissue. Images and a first diagnosis can be provided in seconds, with the ‘inspection mode’, by moving the sample under the scanning microscope (see Visualization 4 and Visualization 5), or in about 5 minutes if an area has to be inspected with sub-cellular detail. The sensitivity of THG to interfaces provides images with excellent contrast in which cell-by-cell variations are visualized. The quality of the images and the speed with which they can be recorded make THG a promising tool for quick assessment of the nature of excised tissue. Importantly, because THG/SHG images are very close to those of histological slides, we expect that the surgeon (or pathologist) will need very little additional training for adequate interpretation of the images. We are planning to construct a THG/SHG ex-vivo tabletop device consisting of a compact laser source and a laser-scanning microscope requiring a physical footprint of only 1 m2, to be placed in an operating room, enabling immediate feedback to the surgeon on the nature of excised tissue, during the operation. With this device, we will perform a quantitative study of the added value of rapid THG/SHG pathological feedback during surgery for the final success of the neurosurgery. Finally, we note that THG/SHG imaging does not induce artifacts associated with fixation, freezing, and staining; therefore, tissue fragments examined ex-vivo can still be used for subsequent immunochemical and/or molecular analysis.

The microendoscopy THG/SHG imaging results represent an important step toward the development of a THG/SHG-based bioptic needle, and show that the use of such a needle for in situ optical sampling for optimal resection of gliomas is indeed a viable prospect, as has been demonstrated also before for multi-photon microscopies [38,49–54]. Although there are several issues associated with the operation of a needle-like optical device, such as the fact that blood in the surgical cavity may obscure the view, and the fact that only small areas can be biopsied with a needle, it may be a valuable tool in cases where sparing healthy tissue is of such vital importance as in brain surgery. Therefore, the reasonably good quality of the THG images taken with the GRIN micro-objective shown here, together with the developments in the field of microendoscopy, warrant further development of THG/SHG into a true handheld device. This next step, a true handheld bioptic needle, requires an optical fiber to transport the light from a small footprint laser to the GRIN micro-objective, and a small 2D scanner unit, to enable placing the laser at a sufficient distance from the patient. Patient-safe irradiation levels for THG imaging will have to be determined but are expected to lie in the 10–50 mW range [55–58]. This implies that only minor optimization of signal collection efficiency needs to be achieved, because the images of Fig. 10 were measured with 50 mW incident power.

THG/SHG imaging thus holds great promise for improving surgical procedures, thereby reducing the need for second surgeries and the loss of function by excising non-infiltrated brain tissue, as well as improving survival and quality of life of the patients. In addition, the success in the challenging case of diffuse gliomas promises great potential of THG/SHG-based histological analysis for a much wider spectrum of diagnostic applications.

References and links

1. N. G. Burnet, S. J. Jefferies, R. J. Benson, D. P. Hunt, and F. P. Treasure, “Years of life lost (YLL) from cancer is an important measure of population burden–and should be considered when allocating research funds,” Br. J. Cancer 92(2), 241–245 (2005). [PubMed]  

2. J. A. Schwartzbaum, J. L. Fisher, K. D. Aldape, and M. Wrensch, “Epidemiology and molecular pathology of glioma,” Nat. Clin. Pract. Neurol. 2(9), 494–516 (2006). [CrossRef]   [PubMed]  

3. J. S. Smith, E. F. Chang, K. R. Lamborn, S. M. Chang, M. D. Prados, S. Cha, T. Tihan, S. Vandenberg, M. W. McDermott, and M. S. Berger, “Role of extent of resection in the long-term outcome of low-grade hemispheric gliomas,” J. Clin. Oncol. 26(8), 1338–1345 (2008). [CrossRef]   [PubMed]  

4. N. Sanai and M. S. Berger, “Glioma extent of resection and its impact on patient outcome,” Neurosurgery 62(4), 753–766 (2008). [CrossRef]   [PubMed]  

5. I. Y. Eyüpoglu, M. Buchfelder, and N. E. Savaskan, “Surgical resection of malignant gliomas-role in optimizing patient outcome,” Nat. Rev. Neurol. 9(3), 141–151 (2013). [CrossRef]  [PubMed]  

6. U. Pichlmeier, A. Bink, G. Schackert, and W. Stummer, “Resection and survival in glioblastoma multiforme: An RTOG recursive partitioning analysis of ALA study patients,” Neuro-oncol. 10(6), 1025–1034 (2008). [CrossRef]   [PubMed]  

7. W. Stummer, J. C. Tonn, C. Goetz, W. Ullrich, H. Stepp, A. Bink, T. Pietsch, and U. Pichlmeier, “5-Aminolevulinic Acid-Derived Tumor Fluorescence: The Diagnostic Accuracy of Visible Fluorescence Qualities as Corroborated by Spectrometry and Histology and Postoperative Imaging,” Neurosurgery 74(3), 310–320 (2014). [CrossRef]   [PubMed]  

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Tables (1)

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Table 1 Pre-operative diagnoses and cell densities observed in the studied brain tissue samples by THG imaging and corresponding H&E histopathology.

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Reporter: Irina Robu, PhD

Materialise’s PROPLAN CMF pre-surgical planning software allows doctors to carefully plan the operation. Dr. Wan enlisted the help of Dr. Sun Jian and Dr. Xu Li Qun from Shanghai Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine who where experienced in using Materialise software and in creating 3D printed surgical guides, so they stepped in to collaborate on the procedure.

With help from the software, the doctors were able to create very precise, customized surgical guides printed by Materialise. Once in the operating room, Dr. Wan and his colleagues were able to operate with much more confidence and accuracy, having already gone through the procedure virtually. The 3D surgical guides told them exactly where to cut, and the surgery was, according to Dr. Xu.

According to Dr. Wan “without this technology, virtual planning and surgical guides, it’s a lot like eye-balling”.




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