“The future is still so much bigger than the past.”Tim...

“The future is still so much bigger than the past.”

Tim Berners-Lees

Tiresias has talked about frozen section histopathology and cytopathology in cancer surgery. In understanding the transformational and disruptive role of Optiscan’s real time in vivo confocal laser endomicroscopy (CLE), it is important to understand the current state of the art and what CLE will change. He says that it will and is already being used in the operating theatre. The reason why Tiresias was drawn to Optiscan is when he saw its potential in malignant brain tumour neurosurgery. Neurosurgery is viewed by most people as nothing short of magic. Take it from Tiresias, when it comes to brain tumours at this present time, magic it is not. No matter how fancy it looks on various television programs and YouTube posts, “The proof of the pudding is in the eating”. Survival of malignant brain tumour patients has not improved one iota in the last 60 years. Not a year, not a month, and certainly not even in sight of a cure. This in why in spite of all the advances in macro imaging; CT Scanning, MRI, PET, frozen section, stereo-surgical techniques etc there has been no progress. This is also why Carl Zeiss was drawn to neurosurgery first and has been working for the last 10 years to develop the ConVivo.

To understand and fully appreciate what Optiscan brings to the operating room it is important to understand exactly how things work now. Currently, after the surgeon has cut through the skull and covering tissues of the brain, and has made a cut in the brain, all he can see is a pink/grey oozing wound. He cannot tell what the tissue in view is, whether it is normal brain, to be left untouched, or malignant tumour to be removed. He cannot tell where the tumour begins or ends. This he attempts to achieve with frozen sect histopathology or cytopathology. It has been thus since about 1900. This is done with frozen section histopathology or cytopathology. The surgeon blindly cuts a small nubbin of this pink oozing tissue. This then carried, by an orderly, to the pathology laboratory, often far from the operating theatres, where it is frozen using a cryostat, invented in 1900. This is the then sliced using a cooled microtome, essentially a refrigerated salami slicer. These slices and then stained with and quickly examined by the histopathologist who then calls the surgeon in the theatre to tell them what they see. All this time which can be 15 to thirty minutes the patient is under anaesthetic and the surgical team is twiddling its thumbs. Rarely, the view under the microscope may be clear cut. The histopathologist can see obvious malignant cells, or obviously normal cells, and can call it confidently. But this process may need to be repeated many times in one operation. Most of the time however, the view under the microscope is anything but clear. Often, it is just guesswork. It's inaccurate and largely flawed, unsatisfactory to both the pathologist and the surgeon. It is no wonder that neurosurgery for brain tumour takes a long time and survival of malignant brain tumour has not improved.

So, what does Optiscan bring? It enables the surgeon to see at a cellular level, in real time, what the tissue he is dealing with. It will show where there is malignancy and where there is normal brain. It tells him what to remove and what not to touch. It enables him to preserve normal tissue and reduce the neurological deficit from unnecessarily removing normal brain. It enables him to see the last malignant cell that he would have no other way of imaging. What could be clearer? This is so obvious, so compelling, and offers such hope in a field where hope has been very limited. Its is almost a scandal that this has not been accelerated and brought forward much more quickly.