Intraoperative confocal laser imaging – Experiences from a beginner's perspective
Isabelle Skambath (Lübeck), Jessica Kren (Lübeck), Jakob Matschke (Hamburg), Mario Matteo Bonsanto (Lübeck)
In recent years, intraoperative confocal laser imaging (CL imaging) has been presented as a pioneering alternative tool to conventional frozen section diagnostics, as it eliminates the need for physical biopsies. The frozen section procedure typically takes between 20 and 30 minutes from the time the biopsy is taken to the transmission of the diagnosis. The biopsy has to be frozen, sectioned and stained. CL imaging could be particularly useful in cases where large-scale tissue samples cannot be taken, which is often the case in brain tumor surgery. In a pilot project, a commercially available system was evaluated for its applicability and suitability for diagnosing brain tumors.
The confocal laser system was purchased in June 2022. By December 2023, 20 patients had been examined with the system. In addition to CL imaging, a biopsy was taken in the scanned areas and a frozen section was made. Questions about user-friendliness included the user interface, the artifact adhesion of the images, the duration of imaging and the product training offered.
We found that the application time differs significantly from that of a conventional frozen section. Image interpretation was hardly possible for experienced neuropathologists despite having undergone all available product training courses. In two out of twenty cases, the neuropathologist was able to provide a diagnosis for the transferred CL images. In both cases, the diagnosis was consistent with the final neuropathologic diagnosis. In 19 of the 20 cases, the neuropathologist was able to provide a diagnosis based on the frozen section, which was consistent with the final neuropathological diagnosis.
With CL imaging, it was possible to generate potentially suitable images within 5 minutes max, in contrast to at least 20 minutes for a frozen section.
We also found that the artifact retention and rejection of CL imaging is very high at 90%.
The idea of an optical biopsy is particularly interesting in brain surgery. In this project, an attempt was made to establish a commercially available CL system within a university cancer center. The cloud connection to the neuropathologist and the speed of image generation should be emphasized positively. We found that the non-comparability of the CL image modality with conventional frozen sections was a particular problem. It requires extensive training for the neuropathologist making the diagnosis in order to fully benefit from the technology.
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