Tiresias: Bring it on

“I have had a most rare vision.”

William Shakespeare

"Any sufficient advanced technology is indistinguishable from magic."

Arthur C Clarke

My friends,

Tiresias likes to use the old methods of augury, but he also keeps up with the latest medical literature too. He has been reading on the latest publications and developments in the combination of cancer cell labelling in vivo, Optiscan Confocal Laser Endomicroscopy(CLE), machine learning, and ”robotic surgery”. Today Tiresias would like to turn his attention to his favourite topic; the one that originally interested him in Optiscan; the brain. Though brain tumour surgery will not ultimately be Optiscan’s biggest area, the brain and brain tumour are of special interest to Tiresias.

As Tiresias has mentioned before the current art of neurosurgery is actually quite primitive. You will excuse Tiresias his little joke, but cancer neurosurgery is not exactly rocket science. If you see a brain tumour operation, at the actual level where brain tissue is being removed, and not be distracted by the whole theatre and costumery of the neurosurgical operating theatre, you will not be surprised the whole drama has made no difference to the survival of patient with malignant brain tumour in the last 60 years.

You see, my friends, the surgeon does not have a clue of whether he is in the tumour or normal brain. The surgeon does not know if he is removing normal brain or malignancy. Macro Medical Imaging, MRI, shows the gross tumour, but where it counts, at the edges, which determine the outcome of surgery, the surgeon does not know whether he or she is in the tumour or the brain. The surgeon does not know if he is removing normal brain cells or malignant cancer cells. The surgeon does not know if he has left brain tumour cells behind. Post-surgical histopathological examination is too late. It is as useful to the patient and to the surgeon as a post-mortem. As Tiresias is has indicated before, leaving just a tiny piece of invisible tumour tissue leave millions of malignant cells and leads to the inevitable regrowth of the tumour. Removal of all brain tumour cells is the ultimate aim of surgery for brain tumour. This has been an impossibility, until now!

But, ”.. the times, they are a changin”. There is now, right now, a technology combining labelling of brain tumour cells either by injection or topical application of fluorescence, before or at the time of surgery, to make the invisible visible, to shine out like stars on a dark sky, to see brain tumour cells not only at the surface of the surface of the operating field, but also beneath the surface, at a depth of up to 200 microns. With Optiscans/Zeiss CONVIVO Confocal Laser Endomicroscope , machine learning virtually live visualisation real-time pathology, the removal of brain tumour cells and preservation of normal brain cells is possible. This is a game changer for brain surgery for malignant brain tumour.

But as they say on late night TV; “but there is more”. Tiresias sees an even greater advance. My friends who are in Tiresias’s age bracket, will no doubt have heard of robotic prostate cancer. As is usual with medicine, and especially surgery, “robotic” is of course a gross exaggeration. No robots are involved. It’s just surgery, making the surgeons movements finer and more accurate, done with computer and instruments assistance. However, similar but real robotic surgery for malignant brain tumour, using fluorescent, CLE, real-time AI/machine histopathology, and computer guided robotic surgery is now really possible, feasible and inevitable. It will be transformational for brain tumour surgery. With this system in place, complete removal of malignancy, cell by cell becomes a reality. The technology is here and now. The brain surgeon whose shaking hand, the sucker, and cautery; the main instruments at present, would act only in a supervisory role. Tiresias sees the role of the brain surgeon would be that of pilot of today’s advanced airliners; monitoring and supervision. And not before time. Bring it on and bring it on quickly. The world awaits.