The use of 5-aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) fluorescence has shown promise as a surgical adjunct for maximizing the extent of surgical resection in gliomas. To date, the clinical utility of 5-ALA in meningiomas is not fully understood, with most descriptive studies using qualitative approaches to 5-ALA-PpIX.
To assess the diagnostic performance of 5-ALA-PpIX fluorescence during surgical resection of meningioma.
ALA was administered to 15 patients with meningioma undergoing PpIX fluorescence-guided surgery at our institution. At various points during the procedure, the surgeon performed qualitative, visual assessments of fluorescence by using the surgical microscope, followed by a quantitative fluorescence measurement by using an intra-operative probe. Specimens were collected at each point for subsequent neuropathological analysis. Clustered data analysis of variance was used to ascertain a difference between groups, and receiver operating characteristic analyses were performed to assess diagnostic capabilities.
Red-pink fluorescence was observed in 80% (12/15) of patients, with visible fluorescence generally demonstrating a strong, homogenous character. Quantitative fluorescence measured diagnostically significant PpIX concentrations (CPpIx) in both visibly and nonvisibly fluorescent tissues, with significantly higher CPpIx in both visibly fluorescent (P < .001) and tumor tissue (P = .002). Receiver operating characteristic analyses also showed diagnostic accuracies up to 90% for differentiating tumor from normal dura.
ALA-induced PpIX fluorescence guidance is a potential and promising adjunct in accurately detecting neoplastic tissue during meningioma resective surgery. These results suggest a broader reach for PpIX as a biomarker for meningiomas than was previously noted in the literature.
5-Aminolevulinic acid; Biophotonics; Brain tumor; Fluorescence-guided surgery; Meningioma Optical spectroscopy; Protoporphyrin IX
Diffuse fluorescence tomography requires high contrast-to-background ratios to accurately reconstruct inclusions of interest. This is a problem when imaging the uptake of fluorescently labeled molecularly targeted tracers in tissue, which can result in high levels of heterogeneously distributed background uptake. We present a dual-tracer background subtraction approach, wherein signal from the uptake of an untargeted tracer is subtracted from targeted tracer signal prior to image reconstruction, resulting in maps of targeted tracer binding. The approach is demonstrated in simulations, a phantom study, and in a mouse glioma imaging study, demonstrating substantial improvement over conventional and homogenous background subtraction image reconstruction approaches.
image reconstruction; cancer; targeted imaging agent; small animal
In vivo tissue imaging using near-infrared light suffers from low spatial resolution and poor contrast recovery because of highly scattered photon transport. For diffuse optical tomography (DOT) and fluorescence molecular tomography (FMT), the resolution is limited to about 5–10% of the diameter of the tissue being imaged, which puts it in the range of performance seen in nuclear medicine. This paper introduces the mathematical formalism explaining why the resolution of FMT can be significantly improved when using instruments acquiring fast time-domain optical signals. This is achieved through singular-value analysis of the time-gated inverse problem based on weakly diffused photons. Simulations relevant to mouse imaging are presented showing that, in stark contrast to steady-state imaging, early time-gated intensities (within 200 ps or 400 ps) can in principle be used to resolve small fluorescent targets (radii from 1.5 to 2.5 mm) separated by less than 1.5 mm.
A diffuse fluorescence tomography system, based upon time-correlated single photon counting, is presented with an automated algorithm to allow dynamic range variation through exposure control. This automated exposure control allows the upper and lower detection levels of fluorophore to be extended by an order of magnitude beyond the previously published performance and benefits in a slight decrease in system effective noise. The effective noise level is used as a metric to characterize the system performance, integrating both model-mismatch and calibration bias errors into a single parameter. This effective error is near 7% of the reconstructed fluorescent yield value, when imaging in just few minutes. Quantifying protoporphyrin IX concentrations down to 50 ng/ml is possible, for tumor-sized regions. This fluorophore has very low fluorescence yield, but high biological relevance for tumor imaging, given that it is produced in the mitochondria, and upregulated in many tumor types.
Over the past 2 decades, increasing evidence has accumulated correlating more complete surgical resection of malignant glioma with improved survival. Numerous surgical technologies have been developed to facilitate optimal resection, many of which function to guide the surgeon during resection. This article focuses on the use of 5-aminolevulinic acid (5-ALA)-induced fluorescence and its present role in the surgical resection of high-grade gliomas.
5-ALA; Fluorescence; Glioma; Surgery
Diffuse fluorescence tomography systems that employ highly sensitive photo-multiplier tubes for single-photon detection are pushing the sensitivity limits of the field. However, each of these detectors only offers a single data projection to be collected, implying these imaging systems either require many detectors or long scan times to collect full data sets for image reconstruction. This study presents a method of utilizing the time-resolved collection capabilities of time-correlated single-photon counting techniques to increase spatial resolution and to reduce the number of data projections to produce reliable fluorescence reconstructions. Experimental tissue phantom results demonstrate that using data at 10 time gates in the fluorescence reconstructions for only 40 data projections provided superior image accuracy when compared to reconstructions on 320 continuous-wave data projections.
We used single-photon counting (SPC) detection for diffuse fluorescence tomography to image nanomolar (nM) concentrations of reporter dyes through a rat. Detailed phantom data are presented to show that every centimeter increase in tissue thickness leads to 1 order of magnitude decrease in the minimum fluorophore concentration detectable for a given detector sensitivity. Specifically, here, detection of Alexa Fluor 647 dyes is shown to be achievable for concentrations as low as 1 nM (<200 fM) through more than 5 cm in tissue phantoms, which indicates that this is feasible in larger rodent models. Because it is possible to detect sub-nM fluorescent inclusions with SPC technology in rats, it follows that it is possible to localize subpicomolar fluorophore concentrations in mice, putting the concentration sensitivity limits on the same order as nuclear medicine methods.
Fluorescence sampling of cellular function is widely used in all aspects of biology, allowing the visualization of cellular and sub-cellular biological processes with spatial resolutions in the range from nanometers up to centimeters. Imaging of fluorescence in vivo has become the most commonly used radiological tool in all pre-clinical work. In the last decade, full-body pre-clinical imaging systems have emerged with a wide range of utilities and niche application areas. The range of fluorescent probes that can be excited in the visible to near-infrared part of the electromagnetic spectrum continues to expand, with the most value for in vivo use being beyond the 630 nm wavelength, because the absorption of light sharply decreases. Whole-body in vivo fluorescence imaging has not yet reached a state of maturity that allows its routine use in the scope of large-scale pre-clinical studies. This is in part due to an incomplete understanding of what the actual fundamental capabilities and limitations of this imaging modality are. However, progress is continuously being made in research laboratories pushing the limits of the approach to consistently improve its performance in terms of spatial resolution, sensitivity and quantification. This paper reviews this imaging technology with a particular emphasis on its potential uses and limitations, the required instrumentation, and the possible imaging geometries and applications. A detailed account of the main commercially available systems is provided as well as some perspective relating to the future of the technology development. Although the vast majority of applications of in vivo small animal imaging are based on epi-illumination planar imaging, the future success of the method relies heavily on the design of novel imaging systems based on state-of-the-art optical technology used in conjunction with high spatial resolution structural modalities such as MRI, CT or ultra-sound.
fluorescence; imaging; tomography; commercial; molecular; fluorophore; small animal; diagnostic
Near-infrared spectroscopy (NIRS) of tissue provides quantification of absorbers, scattering and luminescent agents in bulk tissue through the use of measurement data and assumptions. Prior knowledge can be critical about things such as (i) the tissue shape and/or structure, (ii) spectral constituents, (iii) limits on parameters, (iv) demographic or biomarker data, and (v) biophysical models of the temporal signal shapes. A general framework of NIRS imaging with prior information is presented, showing that prior information datasets could be incorporated at any step in the NIRS process, with the general workflow being: (i) data acquisition, (ii) pre-processing, (iii) forward model, (iv) inversion/reconstruction, (v) post-processing, and (vi) interpretation/diagnosis. Most of the development in NIRS has used ad hoc or empirical implementations of prior information such as pre-measured absorber or fluorophore spectra, or tissue shapes as estimated by additional imaging tools. A comprehensive analysis would examine what prior information maximizes the accuracy in recovery and value for medical diagnosis, when implemented at separate stages of the NIRS sequence. Individual applications of prior information can show increases in accuracy or improved ability to estimate biochemical features of tissue, while other approaches may not. Most beneficial inclusion of prior information has been in the inversion/reconstruction process, because it solves the mathematical intractability. However, it is not clear that this is always the most beneficial stage.
spectroscopy; molecular; tomography; reconstruction; near-infrared; optical
Intraoperative visual fluorescence imaging (vFI) has emerged as a promising aid to surgical guidance, but does not fully exploit the potential of the fluorescent agents that are currently available. Here, we introduce a quantitative fluorescence imaging (qFI) approach that converts spectrally-resolved data into images of absolute fluorophore concentration pixel-by-pixel across the surgical field of view (FOV). The resulting estimates are linear, accurate, and precise relative to true values, and spectral decomposition of multiple fluorophores is also achieved. Experiments with protoporphyrin IX in a glioma rodent model demonstrate in vivo quantitative and spectrally-resolved fluorescence imaging of infiltrating tumor margins for the first time. Moreover, we present images from human surgery which detect residual tumor not evident with state-of-the-art vFI. The wide-field qFI technique has broad implications for intraoperative surgical guidance because it provides near real-time quantitative assessment of multiple fluorescent biomarkers across the operative field.
Bioluminescence Tomography attempts to quantify 3-dimensional luminophore distributions from surface measurements of the light distribution. The reconstruction problem is typically severely under-determined due to the number and location of measurements, but in certain cases the molecules or cells of interest form localised clusters, resulting in a distribution of luminophores that is spatially sparse. A Conjugate Gradient-based reconstruction algorithm using Compressive Sensing was designed to take advantage of this sparsity, using a multistage sparsity reduction approach to remove the need to choose sparsity weighting a priori. Numerical simulations were used to examine the effect of noise on reconstruction accuracy. Tomographic bioluminescence measurements of a Caliper XPM-2 Phantom Mouse were acquired and reconstructions from simulation and this experimental data show that Compressive Sensing-based reconstruction is superior to standard reconstruction techniques, particularly in the presence of noise.
(170.3010) Image reconstruction techniques; (170.6280) Spectroscopy, fluorescence and luminescence; (170.6960) Tomography
Small animal fluorescence molecular imaging (FMI) can be a powerful tool for preclinical drug discovery and development studies1. However, light absorption by tissue chromophores (e.g., hemoglobin, water, lipids, melanin) typically limits optical signal propagation through thicknesses larger than a few millimeters2. Compared to other visible wavelengths, tissue absorption for red and near-infrared (near-IR) light absorption dramatically decreases and non-elastic scattering becomes the dominant light-tissue interaction mechanism. The relatively recent development of fluorescent agents that absorb and emit light in the near-IR range (600-1000 nm), has driven the development of imaging systems and light propagation models that can achieve whole body three-dimensional imaging in small animals3.
Despite great strides in this area, the ill-posed nature of diffuse fluorescence tomography remains a significant problem for the stability, contrast recovery and spatial resolution of image reconstruction techniques and the optimal approach to FMI in small animals has yet to be agreed on. The majority of research groups have invested in charge-coupled device (CCD)-based systems that provide abundant tissue-sampling but suboptimal sensitivity4-9, while our group and a few others10-13 have pursued systems based on very high sensitivity detectors, that at this time allow dense tissue sampling to be achieved only at the cost of low imaging throughput. Here we demonstrate the methodology for applying single-photon detection technology in a fluorescence tomography system to localize a cancerous brain lesion in a mouse model.
The fluorescence tomography (FT) system employed single photon counting using photomultiplier tubes (PMT) and information-rich time-domain light detection in a non-contact conformation11. This provides a simultaneous collection of transmitted excitation and emission light, and includes automatic fluorescence excitation exposure control14, laser referencing, and co-registration with a small animal computed tomography (microCT) system15. A nude mouse model was used for imaging. The animal was inoculated orthotopically with a human glioma cell line (U251) in the left cerebral hemisphere and imaged 2 weeks later. The tumor was made to fluoresce by injecting a fluorescent tracer, IRDye 800CW-EGF (LI-COR Biosciences, Lincoln, NE) targeted to epidermal growth factor receptor, a cell membrane protein known to be overexpressed in the U251 tumor line and many other cancers18. A second, untargeted fluorescent tracer, Alexa Fluor 647 (Life Technologies, Grand Island, NY) was also injected to account for non-receptor mediated effects on the uptake of the targeted tracers to provide a means of quantifying tracer binding and receptor availability/density27. A CT-guided, time-domain algorithm was used to reconstruct the location of both fluorescent tracers (i.e., the location of the tumor) in the mouse brain and their ability to localize the tumor was verified by contrast-enhanced magnetic resonance imaging.
Though demonstrated for fluorescence imaging in a glioma mouse model, the methodology presented in this video can be extended to different tumor models in various small animal models potentially up to the size of a rat17.
Cancer Biology; Issue 65; Medicine; Physics; Molecular Biology; fluorescence; glioma; light transport; tomography; CT; molecular imaging; epidermal growth factor receptor; biomarker
Accurate discrimination between tumor and normal tissue is crucial for optimal tumor resection. Qualitative fluorescence of protoporphyrin IX (PpIX), synthesized endogenously following δ-aminolevulinic acid (ALA) administration, has been used for this purpose in high-grade glioma (HGG). The authors show that diagnostically significant but visually imperceptible concentrations of PpIX can be quantitatively measured in vivo and used to discriminate normal from neoplastic brain tissue across a range of tumor histologies.
The authors studied 14 patients with diagnoses of low-grade glioma (LGG), HGG, meningioma, and metastasis under an institutional review board–approved protocol for fluorescence-guided resection. The primary aim of the study was to compare the diagnostic capabilities of a highly sensitive, spectrally resolved quantitative fluorescence approach to conventional fluorescence imaging for detection of neoplastic tissue in vivo.
A significant difference in the quantitative measurements of PpIX concentration occurred in all tumor groups compared with normal brain tissue. Receiver operating characteristic (ROC) curve analysis of PpIX concentration as a diagnostic variable for detection of neoplastic tissue yielded a classification efficiency of 87% (AUC = 0.95, specificity = 92%, sensitivity = 84%) compared with 66% (AUC = 0.73, specificity = 100%, sensitivity = 47%) for conventional fluorescence imaging (p < 0.0001). More than 81% (57 of 70) of the quantitative fluorescence measurements that were below the threshold of the surgeon's visual perception were classified correctly in an analysis of all tumors.
These findings are clinically profound because they demonstrate that ALA-induced PpIX is a targeting biomarker for a variety of intracranial tumors beyond HGGs. This study is the first to measure quantitative ALA-induced PpIX concentrations in vivo, and the results have broad implications for guidance during resection of intracranial tumors.
ALA; PpIX; biophotonics; brain tumor; fluorescence-guided resection; optical spectroscopy; oncology; light-transport modeling; glioma
This paper is a theoretical exploration of spatial resolution in diffuse fluorescence tomography. It is demonstrated that, given a fixed imaging geometry, one cannot—relative to standard techniques such as Tikhonov regularization and truncated singular value decomposition—improve the spatial resolution of the optical reconstructions via increasing the node density of the mesh considered for modeling light transport. Using techniques from linear algebra, it is shown that, as one increases the number of nodes beyond the number of measurements, information is lost by the forward model. It is demonstrated that this information cannot be recovered using various common reconstruction techniques. Evidence is provided showing that this phenomenon is related to the smoothing properties of the elliptic forward model that is used in the diffusion approximation to light transport in tissue. This argues for reconstruction techniques that are sensitive to boundaries, such as L1-reconstruction and the use of priors, as well as the natural approach of building a measurement geometry that reflects the desired image resolution.
Complete resection of skull base meningiomas provides patients with the best chance for a cure; however, surgery is frequently difficult given the proximity of lesions to vital structures, such as cranial nerves, major vessels, and venous sinuses. Accurate discrimination between tumor and normal tissue is crucial for optimal tumor resection. Qualitative assessment of protoporphyrin IX (PpIX) fluorescence following the exogenous administration of 5-aminolevulinic acid (ALA) has demonstrated utility in malignant glioma resection but limited use in meningiomas. Here the authors demonstrate the use of ALA-induced PpIX fluorescence guidance in resecting a skull base meningioma and elaborate on the advantages and disadvantages provided by both quantitative and qualitative fluorescence methodologies in skull base meningioma resection.
A 52-year-old patient with a sphenoid wing WHO Grade I meningioma underwent tumor resection as part of an institutional review board–approved prospective study of fluorescence-guided resection. A surgical microscope modified for fluorescence imaging was used for the qualitative assessment of visible fluorescence, and an intraoperative probe for in situ fluorescence detection was utilized for quantitative measurements of PpIX. The authors assessed the detection capabilities of both the qualitative and quantitative fluorescence approaches.
The patient harboring a sphenoid wing meningioma with intraorbital extension underwent radical resection of the tumor with both visibly and nonvisibly fluorescent regions. The patient underwent a complete resection without any complications. Some areas of the tumor demonstrated visible fluorescence. The quantitative probe detected neoplastic tissue better than the qualitative modified surgical microscope. The intraoperative probe was particularly useful in areas that did not reveal visible fluorescence, and tissue from these areas was confirmed as tumor following histopathological analysis.
Fluorescence-guided resection may be a useful adjunct in the resection of skull base meningiomas. The use of a quantitative intraoperative probe to detect PpIX concentration allows more accurate determination of neoplastic tissue in meningiomas than visible fluorescence and is readily applicable in areas, such as the skull base, where complete resection is critical but difficult because of the vital structures surrounding the pathology.
skull base meningioma; fluorescence-guided resection; protoporphyrin IX; 5-aminolevulinic acid; optical spectroscopy; biophotonics
The aim of this study was to investigate the relationships between intraoperative fluorescence, features on MR imaging, and neuropathological parameters in 11 cases of newly diagnosed glioblastoma multiforme (GBM) treated using protoporphyrin IX (PpIX) fluorescence-guided resection.
In 11 patients with a newly diagnosed GBM, δ-aminolevulinic acid (ALA) was administered to enhance endogenous synthesis of the fluorophore PpIX. The patients then underwent fluorescence-guided resection, coregistered with conventional neuronavigational image guidance. Biopsy specimens were collected at different times during surgery and assigned a fluorescence level of 0–3 (0, no fluorescence; 1, low fluorescence; 2, moderate fluorescence; or 3, high fluorescence). Contrast enhancement on MR imaging was quantified using two image metrics: 1) Gd-enhanced signal intensity (GdE) on T1-weighted subtraction MR image volumes, and 2) normalized contrast ratios (nCRs) in T1-weighted, postGd-injection MR image volumes for each biopsy specimen, using the biopsy-specific image-space coordinate transformation provided by the navigation system. Subsequently, each GdE and nCR value was grouped into one of two fluorescence categories, defined by its corresponding biopsy specimen fluorescence assessment as negative fluorescence (fluorescence level 0) or positive fluorescence (fluorescence level 1, 2, or 3). A single neuropathologist analyzed the H & E–stained tissue slides of each biopsy specimen and measured three neuropathological parameters: 1) histopathological score (0–IV); 2) tumor burden score (0–III); and 3) necrotic burden score (0–III).
Mixed-model analyses with random effects for individuals show a highly statistically significant difference between fluorescing and nonfluorescing tissue in GdE (mean difference 8.33, p = 0.018) and nCRs (mean difference 5.15, p < 0.001). An analysis of association demonstrated a significant relationship between the levels of intraoperative fluorescence and histopathological score (χ2 = 58.8, p < 0.001), between fluorescence levels and tumor burden (χ2 = 42.7, p < 0.001), and between fluorescence levels and necrotic burden (χ2 = 30.9, p < 0.001). The corresponding Spearman rank correlation coefficients were 0.51 (p < 0.001) for fluorescence and histopathological score, and 0.49 (p < 0.001) for fluorescence and tumor burden, suggesting a strongly positive relationship for each of these variables.
These results demonstrate a significant relationship between contrast enhancement on preoperative MR imaging and observable intraoperative PpIX fluorescence. The finding that preoperative MR image signatures are predictive of intraoperative PpIX fluorescence is of practical importance for identifying candidates for the procedure. Furthermore, this study provides evidence that a strong relationship exists between tumor aggressiveness and the degree of tissue fluorescence that is observable intraoperatively, and that observable fluorescence has an excellent positive predictive value but a low negative predictive value.
δ-aminolevulinic acid; contrast enhancement; fluorescence-guided resection; malignant glioma; protoporphyrin IX
In this study, several key optimization steps are outlined for a non-contact, time-correlated single photon counting small animal optical tomography system, using simultaneous collection of both fluorescence and transmittance data. The system is presented for time-domain image reconstruction in vivo, illustrating the sensitivity from single photon counting and the calibration steps needed to accurately process the data. In particular, laser time- and amplitude-referencing, detector and filter calibrations, and collection of a suitable instrument response function are all presented in the context of time-domain fluorescence tomography and a fully automated workflow is described. Preliminary phantom time-domain reconstructed images demonstrate the fidelity of the workflow for fluorescence tomography based on signal from multiple time gates.
(170.0110) Imaging systems; (170.3010) Image reconstruction techniques; (170.3660) Light propagation in tissues
Optical and radiologic imaging are commonly used in preclinical research, and research into combined instruments for human applications is showing promise. The purpose of this article is to outline the fundamental limitations and advantages and to review the available systems. The emerging developments and future potential will be summarized.
Integration of hybrid systems is now routine at the preclinical level and appears in the form of specialized packages in which performance varies considerably. The synergy is commonly focused on using spatial localization from radiographs to provide structural data for spectroscopy; however, applications also exist in which the spectroscopy informs the use of radiologic imaging. Examples of clinical systems under research and development are shown.
CT; bioluminescence; fluorescence; optical spectroscopy; radiography; x-ray
The use of the spectral derivative method in visible and near-infrared optical spectroscopy is presented, whereby instead of using discrete measurements around several wavelengths, the difference between nearest neighbouring spectral measurements is utilized. The proposed technique is shown to be insensitive to the unknown tissue and fibre contact coupling coefficients providing substantially increased accuracy as compared to more conventional techniques. The self-calibrating nature of the spectral derivative techniques increases its robustness for both clinical and industrial applications, as is demonstrated based on simulated results as well as experimental data.
The spatial resolution and recovered contrast of images reconstructed from diffuse fluorescence tomography data are limited by the high scattering properties of light propagation in biological tissue. As a result, the image reconstruction process can be exceedingly vulnerable to inaccurate prior knowledge of tissue optical properties and stochastic noise. In light of these limitations, the optimal source-detector geometry for a fluorescence tomography system is non-trivial, requiring analytical methods to guide design. Analysis of the singular value decomposition of the matrix to be inverted for image reconstruction is one potential approach, providing key quantitative metrics, such as singular image mode spatial resolution and singular data mode frequency as a function of singular mode. In the present study, these metrics are used to analyze the effects of different sources of noise and model errors as related to image quality in the form of spatial resolution and contrast recovery. The image quality is demonstrated to be inherently noise-limited even when detection geometries were increased in complexity to allow maximal tissue sampling, suggesting that detection noise characteristics outweigh detection geometry for achieving optimal reconstructions.
(170.0110) Imaging systems; (170.3010) Image reconstruction techniques; (170.3660) Light propagation in tissues
Tomographic imaging of a glioma tumor with endogenous fluorescence is demonstrated using a non-contact single photon counting fan-beam acquisition system interfaced with microCT imaging. The fluorescence from protoporphyrin IX was found to be detectable, and allowed imaging of the tumor from within the cranium, even though the tumor presence was not visible in the microCT image. The combination of single photon counting detection and normalized fluorescence to transmission detection at each channel allowed robust imaging of the signal. This demonstrated use of endogenous fluorescence stimulation from aminolevulinic acid, provides the first in vivo demonstration of deep tissue tomographic imaging with protoporphyrin IX.