Multiphoton microscopy in surgical oncology- a systematic review and guide for clinical translatability

Abstract

Background: Multiphoton microscopy (MPM) facilitates three-dimensional, high-resolution functional imaging of unlabeled tissues in vivo and ex vivo. This systematic review discusses the diagnostic value, advantages and challenges in the practical use of MPM in surgical oncology.

Method and findings: A Medline search was conducted in April 2019. Fifty-three original research papers investigating MPM compared to standard histology in human patients with solid tumors were identified. A qualitative synopsis and meta-analysis of 14 blinded studies was performed. Risk of bias and applicability were evaluated. MPM can image fresh, frozen or fixed tissues up to a depth 1000 μm in the z-plane. Best results including functional imaging and virtual histochemistry are obtained by in vivo imaging or scanning fresh tissue immediately after excision. Two-photon excited fluorescence by natural fluorophores of the cytoplasm and second harmonic generation signals by fluorophores of the extracellular matrix can be scanned simultaneously, providing high resolution optical histochemistry comparable to standard histology. Functional parameters like fluorescence lifetime imaging or optical redox ratio provide additional objective information. A major concern is inability to visualize the nucleus. However, in a subpopulation analysis of 440 specimens, MPM yielded a sensitivity of 94%, specificity of 96% and accuracy of 95% for the detection of malignant tissue.

Conclusion: MPM is a promising emerging technique in surgical oncology. Ex vivo imaging has high sensitivity, specificity and accuracy for the detection of tumor cells. For broad clinical application in vivo, technical challenges need to be resolved.

Keywords: Multiphoton imaging; Second harmonic generation; Two-photon excited fluorescence.