A pilot study of photoacoustic imaging system for improved real-time visualization of neurovascular bundle during radical prostatectomy

Perspectives on endoscopic functional photoacoustic microscopy

Endoscopy, enabling high-resolution imaging of deep tissues and internal organs, plays an important role in basic research and clinical practice. Recent advances in photoacoustic microscopy (PAM), demonstrating excellent capabilities in high-resolution functional imaging, have sparked significant interest in its integration into the field of endoscopy. However, there are challenges in achieving functional PAM in the endoscopic setting. This Perspective article discusses current progress in the development of endoscopic PAM and the challenges related to functional measurements. Then, it points out potential directions to advance endoscopic PAM for functional imaging by leveraging fiber optics, microfabrication, optical engineering, and computational approaches. Finally, it highlights emerging opportunities for functional endoscopic PAM in basic and translational biomedicine.

Adaptation of a Clinical High-Frequency Transrectal Ultrasound System for Prostate Photoacoustic Imaging: Implementation and Pre-clinical Demonstration

OBJECTIVE

High-frequency, high-resolution transrectal micro-ultrasound (micro-US: ≥15 MHz) imaging of the prostate is emerging as a beneficial tool for scoring disease risk and accurately targeting biopsies. Adding photoacoustic (PA) imaging to visualize abnormal vascularization and accumulation of contrast agents in tumors has potential for guiding focal therapies. In this work, we describe a new imaging platform that combines a transrectal micro-US system with transurethral light delivery for PA imaging.

METHODS

A clinical transrectal micro-US system was adapted to acquire PA images synchronous to a tunable laser pulse. A transurethral side-firing optical fiber was developed for light delivery. A polyvinyl chloride (PVC)-plastisol phantom was developed and characterized to image PA contrast agents in wall-less channels. After resolution measurement in water, PA imaging was demonstrated in phantom channels with dyes and biodegradable nanoparticle contrast agents called porphysomes. In vivo imaging of a tumor model was performed, with porphysomes administered intravenously.

RESULTS

Photoacoustic imaging data were acquired at 5 Hz, and image reconstruction was performed offline. PA image resolution at a 14-mm depth was 74 and 261 μm in the axial and lateral directions, respectively. The speed of sound in PVC-plastisol was 1383 m/s, and the attenuation was 4 dB/mm at 20 MHz. PA signal from porphysomes was spectrally unmixed from blood signals in the tumor, and a signal increase was observed 3 h after porphysome injection.

CONCLUSION

A combined transrectal micro-US and PA imaging system was developed and characterized, and in vivo imaging demonstrated. High-resolution PA imaging may provide valuable additional information for diagnostic and therapeutic applications in the prostate.

Cavernous nerve mapping methods for radical prostatectomy

INTRODUCTION

Preserving the cavernous nerves, the main autonomic nerve supply of the penis, is a major challenge of radical prostatectomy. Cavernous nerve injury during radical prostatectomy predominantly accounts for post-radical prostatectomy erectile dysfunction. The cavernous nerve is a bilateral structure that branches in a weblike distribution over the prostate surface and varies anatomically in individuals, such that standard nerve-sparing methods do not sufficiently sustain penile erection ability. As a consequence, researchers have focused on developing personalized cavernous nerve mapping methods applied to the surgical procedure aiming to improve postoperative sexual function outcomes.

OBJECTIVES

We provide an updated overview of preclinical and clinical data of cavernous nerve mapping methods, emphasizing their strengths, limitations, and future directions.

METHODS

A literature review was performed via Scopus, PubMed, and Google Scholar for studies that describe cavernous nerve mapping/localization.

RESULTS

Several cavernous nerve mapping methods have been investigated based on various properties of the nerve structures including stimulation techniques, spectroscopy/imaging techniques, and assorted combinations of these methods. More recent methods have portrayed the course of the main cavernous nerve as well as its branches based on real-time mapping, high-resolution imaging, and functional imaging. However, each of these methods has distinctive limitations, including low spatial accuracy, lack of standardization for stimulation and response measurement, superficial imaging depth, toxicity risk, and lack of suitability for intraoperative use.

CONCLUSION

While various cavernous nerve mapping methods have provided improvements in identification and preservation of the cavernous nerve during radical prostatectomy, no method has been implemented in clinical practice due to their distinctive limitations. To overcome the limitations of existing cavernous nerve mapping methods, the development of new imaging techniques and mapping methods is in progress. There is a need for further research in this area to improve sexual function outcomes and quality of life after radical prostatectomy.

Functional photoacoustic imaging: from nano- and micro- to macro-scale

Functional photoacoustic imaging is a promising biological imaging technique that offers such unique benefits as scalable resolution and imaging depth, as well as the ability to provide functional information. At nanoscale, photoacoustic imaging has provided super-resolution images of the surface light absorption characteristics of materials and of single organelles in cells. At the microscopic and macroscopic scales. photoacoustic imaging techniques have precisely measured and quantified various physiological parameters, such as oxygen saturation, vessel morphology, blood flow, and the metabolic rate of oxygen, in both human and animal subjects. This comprehensive review provides an overview of functional photoacoustic imaging across multiple scales, from nano to macro, and highlights recent advances in technology developments and applications. Finally, the review surveys the future prospects of functional photoacoustic imaging in the biomedical field.

Label-free intraoperative nerve detection and visualization using ratiometric diffuse reflectance spectroscopy

Iatrogenic nerve injuries contribute significantly to postoperative morbidity across various surgical disciplines and occur in approximately 500,000 cases annually in the US alone. Currently, there are no clinically adopted means to intraoperatively visualize nerves beyond the surgeon's visual assessment. Here, we report a label-free method for nerve detection using diffuse reflectance spectroscopy (DRS). Starting with an in vivo rat model, fiber- and imaging-based DRS independently identified similar wavelengths that provided optimal contrast for nerve identification with an accuracy of 92%. Optical property measurements of rat and human cadaver tissues verify that the source of contrast between nerve and surrounding tissues is largely due to higher scattering in nerve and differences in oxygenated hemoglobin content. Clinical feasibility was demonstrated in patients undergoing thyroidectomies using both probe-based and imaging-based approaches where the nerve were identified with 91% accuracy. Based on our preliminary results, DRS has the potential to both provide surgeons with a label-free, intraoperative means of nerve visualization and reduce the incidence of iatrogenic nerve injuries along with its detrimental complications.

Review on ultrasound-guided photoacoustic imaging for complementary analyses of biological systems in vivo

Photoacoustic imaging has been developed as a new biomedical molecular imaging modality. Due to its similarity to conventional ultrasound imaging in terms of signal detection and image generation, dual-modal photoacoustic and ultrasound imaging has been applied to visualize physiological and morphological information in biological systems in vivo. By complementing each other, dual-modal photoacoustic and ultrasound imaging showed synergistic advances in photoacoustic imaging with the guidance of ultrasound images. In this review, we introduce our recent progresses in dual-modal photoacoustic and ultrasound imaging systems at various scales of study, from preclinical small animals to clinical humans. A summary of the works reveals various strategies for combining the structural information of ultrasound images with the molecular information of photoacoustic images.

Absolute Grüneisen parameter measurement in deep tissue based on X-ray-induced acoustic computed tomography

The Grüneisen parameter is a primary parameter of the initial sound pressure signal in the photoacoustic effect, which can provide unique biological information and is related to the temperature change information of an object. The accurate measurement of this parameter is of great significance in biomedical research. Combining X-ray-induced acoustic tomography and conventional X-ray computed tomography, we proposed a method to obtain the absolute Grüneisen parameter. The theory development, numerical simulation, and biomedical application scenarios are discussed. The results reveal that our method not only can determine the Grüneisen parameter but can also obtain the body internal temperature distribution, presenting its potential in the diagnosis of a broad range of diseases.

Contrast Agents for Photoacoustic Imaging: A Review Focusing on the Wavelength Range

Photoacoustic imaging using endogenous chromophores as a contrast has been widely applied in biomedical studies owing to its functional imaging capability at the molecular level. Various exogenous contrast agents have also been investigated for use in contrast-enhanced imaging and functional analyses. This review focuses on contrast agents, particularly in the wavelength range, for use in photoacoustic imaging. The basic principles of photoacoustic imaging regarding light absorption and acoustic release are introduced, and the optical characteristics of tissues are summarized according to the wavelength region. Various types of contrast agents, including organic dyes, semiconducting polymeric nanoparticles, gold nanoparticles, and other inorganic nanoparticles, are explored in terms of their light absorption range in the near-infrared region. An overview of the contrast-enhancing capacity and other functional characteristics of each agent is provided to help researchers gain insights into the development of contrast agents in photoacoustic imaging.

Tapered catheter-based transurethral photoacoustic and ultrasonic endoscopy of the urinary system

Early diagnosis is critical for treating bladder cancer, as this cancer is very aggressive and lethal if detected too late. To address this important clinical issue, a photoacoustic tomography (PAT)-based transabdominal imaging approach was suggested in previous reports, in which its in vivo feasibility was also demonstrated based on a small animal model. However, successful translation of this approach to real clinical settings would be challenging because the human bladder is located at a depth that far exceeds the typical penetration depth of PAT (∼3 cm for in vivo cases). In this study, we developed a tapered catheter-based, transurethral photoacoustic and ultrasonic endoscopic probe with a 2.8 mm outer diameter to investigate whether the well-known benefits of PAT can be harnessed to resolve unmet urological issues, including early diagnosis of bladder cancer. To demonstrate the in vivo imaging capability of the proposed imaging probe, we performed a rabbit model-based urinary system imaging experiment and acquired a 3D microvasculature map distributed in the wall of the urinary system, which is a first in PAT, to the best of our knowledge. We believe that the results strongly support the use of this transurethral imaging approach as a feasible strategy for addressing urological diagnosis issues.

Whole-Body Photoacoustic Imaging Techniques for Preclinical Small Animal Studies

Photoacoustic imaging is a hybrid imaging technique that has received considerable attention in biomedical studies. In contrast to pure optical imaging techniques, photoacoustic imaging enables the visualization of optical absorption properties at deeper imaging depths. In preclinical small animal studies, photoacoustic imaging is widely used to visualize biodistribution at the molecular level. Monitoring the whole-body distribution of chromophores in small animals is a key method used in preclinical research, including drug-delivery monitoring, treatment assessment, contrast-enhanced tumor imaging, and gastrointestinal tracking. In this review, photoacoustic systems for the whole-body imaging of small animals are explored and summarized. The configurations of the systems vary with the scanning methods and geometries of the ultrasound transducers. The future direction of research is also discussed with regard to achieving a deeper imaging depth and faster imaging speed, which are the main factors that an imaging system should realize to broaden its application in biomedical studies.

State of the Art in Carbon Nanomaterials for Photoacoustic Imaging

Photoacoustic imaging using energy conversion from light to ultrasound waves has been developed as a powerful tool to investigate in vivo phenomena due to their complex characteristics. In photoacoustic imaging, endogenous chromophores such as oxygenated hemoglobin, deoxygenated hemoglobin, melanin, and lipid provide useful biomedical information at the molecular level. However, these intrinsic absorbers show strong absorbance only in visible or infrared optical windows and have limited light transmission, making them difficult to apply for clinical translation. Therefore, the development of novel exogenous contrast agents capable of increasing imaging depth while ensuring strong light absorption is required. We report here the application of carbon nanomaterials that exhibit unique physical, mechanical, and electrochemical properties as imaging probes in photoacoustic imaging. Classified into specific structures, carbon nanomaterials are synthesized with different substances according to the imaging purposes to modulate the absorption spectra and highly enhance photoacoustic signals. In addition, functional drugs can be loaded into the carbon nanomaterials composite, and effective in vivo monitoring and photothermal therapy can be performed with cell-specific targeting. Diverse applied cases suggest the high potential of carbon nanomaterial-based photoacoustic imaging in in vivo monitoring for clinical research.

Review on Multispectral Photoacoustic Analysis of Cancer: Thyroid and Breast

In recent decades, photoacoustic imaging has been used widely in biomedical research, providing molecular and functional information from biological tissues in vivo. In addition to being used for research in small animals, photoacoustic imaging has also been utilized for in vivo human studies, achieving a multispectral photoacoustic response in deep tissue. There have been several clinical trials for screening cancer patients by analyzing multispectral responses, which in turn provide metabolomic information about the underlying biological tissues. This review summarizes the methods and results of clinical photoacoustic trials available in the literature to date to classify cancerous tissues, specifically of the thyroid and breast. From the review, we can conclude that a great potential exists for photoacoustic imaging to be used as a complementary modality to improve diagnostic accuracy for suspicious tumors, thus significantly benefitting patients’ healthcare.

High-speed photoacoustic microscopy: A review dedicated on light sources

In recent years, many methods have been investigated to improve imaging speed in photoacoustic microscopy (PAM). These methods mainly focused upon three critical factors contributing to fast PAM: laser pulse repetition rate, scanning speed, and computing power of the microprocessors. A high laser repetition rate is fundamentally the most crucial factor to increase the PAM speed. In this paper, we review methods adopted for fast PAM systems in detail, specifically with respect to light sources. To the best of our knowledge, ours is the first review article analyzing the fundamental requirements for developing high-speed PAM and their limitations from the perspective of light sources.

Investigation of photoacoustic tomography reconstruction with a limited view from linear array

SIGNIFICANCE

As linear array transducers are widely used in clinical ultrasound imaging, photoacoustic tomography (PAT) with linear arrays is similarly suitable for clinical applications. However, due to the limited-view problem, a linear array has limited performance and leads to artifacts and blurring, which has hindered its broader application. There is a need to address the limited-view problem in PAT imaging with linear arrays.

AIM

We investigate potential approaches for improving PAT reconstruction from linear array, by optimizing the detection geometry and implementing iterative reconstruction.

APPROACH

PAT imaging with a single-array, dual-probe configurations in parallel-shape and L-shape, and square-shape configuration are compared in simulations and phantom experiments. An iterative model-based algorithm based on the variance-reduced stochastic gradient descent (VR-SGD) method is implemented. The optimum configuration found in simulation is validated on phantom experiments.

RESULTS

PAT imaging with dual-probe detection and VR-SGD algorithm is found to improve the limited-view problem compared to a single probe and provide comparable performance as full-view geometry in simulation. This configuration is validated in experiments where more complete structure is obtained with reduced artifacts compared with a single array.

CONCLUSIONS

PAT with dual-probe detection and iterative reconstruction is a promising solution to the limited-view problem of linear arrays.

Combined Ultrasound and Photoacoustic Image Guidance of Spinal Pedicle Cannulation Demonstrated With Intact ex vivo Specimens

OBJECTIVE

Spinal fusion surgeries require accurate placement of pedicle screws in anatomic corridors without breaching bone boundaries. We are developing a combined ultrasound and photoacoustic image guidance system to avoid pedicle screw misplacement and accidental bone breaches, which can lead to nerve damage.

METHODS

Pedicle cannulation was performed on a human cadaver, with co-registered photoacoustic and ultrasound images acquired at various time points during the procedure. Bony landmarks obtained from coherence-based ultrasound images of lumbar vertebrae were registered to post-operative CT images. Registration methods were additionally tested on an ex vivo caprine vertebra.

RESULTS

Locally weighted short-lag spatial coherence (LW-SLSC) ultrasound imaging enhanced the visualization of bony structures with generalized contrast-to-noise ratios (gCNRs) of 0.99 and 0.98-1.00 in the caprine and human vertebrae, respectively. Short-lag spatial coherence (SLSC) and amplitude-based delay-and-sum (DAS) ultrasound imaging generally produced lower gCNRs of 0.98 and 0.84, respectively, in the caprine vertebra and 0.84-0.93 and 0.34-0.99, respectively, in the human vertebrae. The mean ± standard deviation of the area of -6 dB contours created from DAS photoacoustic images acquired with an optical fiber inserted in prepared pedicle holes (i.e., fiber surrounded by cancellous bone) and holes created after intentional breaches (i.e., fiber exposed to cortical bone) was 10.06 ±5.22 mm ² and 2.47 ±0.96 mm ², respectively (p 0.01).

CONCLUSIONS

Coherence-based LW-SLSC and SLSC beamforming improved visualization of bony anatomical landmarks for ultrasound-to-CT registration, while amplitude-based DAS beamforming successfully distinguished photoacoustic signals within the pedicle from less desirable signals characteristic of impending bone breaches.

SIGNIFICANCE

These results are promising to improve visual registration of ultrasound and photoacoustic images with CT images, as well as to assist surgeons with identifying and avoiding impending bone breaches during pedicle cannulation in spinal fusion surgeries.

Superiorized Photo-Acoustic Non-NEgative Reconstruction (SPANNER) for Clinical Photoacoustic Imaging

Photoacoustic (PA) imaging can revolutionize medical ultrasound by augmenting it with molecular information. However, clinical translation of PA imaging remains a challenge due to the limited viewing angles and imaging depth. Described here is a new robust algorithm called Superiorized Photo-Acoustic Non-NEgative Reconstruction (SPANNER), designed to reconstruct PA images in real-time and to address the artifacts associated with limited viewing angles and imaging depth. The method utilizes precise forward modeling of the PA propagation and reception of signals while accounting for the effects of acoustic absorption, element size, shape, and sensitivity, as well as the transducer's impulse response and directivity pattern. A fast superiorized conjugate gradient algorithm is used for inversion. SPANNER is compared to three reconstruction algorithms: delay-and-sum (DAS), universal back-projection (UBP), and model-based reconstruction (MBR). All four algorithms are applied to both simulations and experimental data acquired from tissue-mimicking phantoms, ex vivo tissue samples, and in vivo imaging of the prostates in patients. Simulations and phantom experiments highlight the ability of SPANNER to improve contrast to background ratio by up to 20 dB compared to all other algorithms, as well as a 3-fold increase in axial resolution compared to DAS and UBP. Applying SPANNER on contrast-enhanced PA images acquired from prostate cancer patients yielded a statistically significant difference before and after contrast agent administration, while the other three image reconstruction methods did not, thus highlighting SPANNER's performance in differentiating intrinsic from extrinsic PA signals and its ability to quantify PA signals from the contrast agent more accurately.

Transrectal Ultrasound and Photoacoustic Imaging Probe for Diagnosis of Prostate Cancer

A combined transrectal ultrasound and photoacoustic (TRUS-PA) imaging probe was developed for the clear visualization of morphological changes and microvasculature distribution in the prostate, as this is required for accurate diagnosis and biopsy. The probe consisted of a miniaturized 128-element 7 MHz convex array transducer with 134.5° field-of-view (FOV), a bifurcated optical fiber bundle, and two optical lenses. The design goal was to make the size of the TRUS-PA probe similar to that of general TRUS probes (i.e., about 20 mm), for the convenience of the patients. New flexible printed circuit board (FPCB), acoustic structure, and optical lens were developed to meet the requirement of the probe size, as well as to realize a high-performance TRUS-PA probe. In visual assessment, the PA signals obtained with the optical lens were 2.98 times higher than those without the lens. Moreover, the in vivo experiment with the xenograft BALB/c (Albino, Immunodeficient Inbred Strain) mouse model showed that TRUS-PA probe was able to acquire the entire PA image of the mouse tight behind the porcine intestine about 25 mm depth. From the ex vivo and in vivo experimental results, it can be concluded that the developed TRUS-PA probe is capable of improving PA image quality, even though the TRUS-PA probe has a cross-section size and an FOV comparable to those of general TRUS probes.

Experimental Myocardial Infarction Elicits Time-Dependent Patterns of Vascular Hypoxia in Peripheral Organs and in the Brain

Aims: Microvascular alterations occurring after myocardial infarction (MI) may represent a risk factor for multi-organ failure. Here we used in vivo photoacoustic (PA) imaging to track and define the changes in vascular oxygen saturation (sO₂) occurring over time after experimental MI in multiple peripheral organs and in the brain.

Methods and Results: Experimental MI was obtained in BALB/c mice by permanent ligation of the left anterior descending artery. PA imaging (Vevo LAZR-X) allowed tracking mouse-specific sO₂ kinetics in the cardiac left ventricular (LV) anterior wall, brain, kidney, and liver at 4 h, 1 day, and 7 days post-MI. Here we reported a correlation between LV sO₂ and longitudinal anterior myocardial strain after MI (r = −0.44, p < 0.0001, n = 96). Acute LV dysfunction was associated with global hypoxia, specifically a decrease in sO₂ level in the brain (−5.9%), kidney (−6.4%), and liver (−7.3%) at 4 and 24 h post-MI. Concomitantly, a preliminary examination of capillary NG2DsRed pericytes indicated cell rarefication in the heart and kidney. While the cardiac tissue was persistently impacted, sO₂ levels returned to pre-MI levels in the brain and in peripheral organs 7 days after MI.

Conclusions: Collectively, our data indicate that experimental MI elicits precise trajectories of vascular hypoxia in peripheral organs and in the brain. PA imaging enabled the synchronous tracking of oxygenation in multiple organs and occurring post-MI, potentially enabling a translational diagnostic modality for the identification of vascular modifications in this disease setting.

Photoacoustic Tomography Opening New Paradigms in Biomedical Imaging

After the emergence of the ultrasound, X-ray CT, PET, and MRI, photoacoustic tomography (PAT) is now in the phase of its exponential growth, with its expected full maturation being another form of mainstream clinical imaging modality. By combining the high contrast benefit of optical imaging and the high-resolution deep imaging capability of ultrasound, PAT can provide unprecedented anatomical image contrasts at clinically relevant depths as well as enable the use of a variety of functional and molecular imaging information, which is not possible with conventional imaging modalities. With these strengths, PAT has achieved numerous breakthroughs in various biomedical applications and also provided new technical platforms that may be able to resolve unmet issues in clinics. In this chapter, we provide an overview of the development of PAT technology for several major biomedical applications and provide an approximate projection of the future of PAT.

Photoacoustic endoscopy: A progress review

Endoscopy has been widely used in biomedical imaging and integrated with various optical and acoustic imaging modalities. Photoacoustic imaging (PAI), one of the fastest growing biomedical imaging modalities, is a noninvasive and nonionizing method that owns rich optical contrast, deep acoustic penetration depth, multiscale and multiparametric imaging capability. Hence, it is preferred to miniaturize the volume of PAI and develop an emerged endoscopic imaging modality referred to as photoacoustic endoscopy (PAE). It has been developed for more than one decade since the first report of PAE. Unfortunately, until now, there is no mature photoacoustic endoscopic technique recognized in clinic due to various technical limitations. To address this concern, recent development of new scanning mechanisms, adoption of novel optical/acoustic devices, utilization of superior computation methods and exploration of multimodality strategies have significantly promoted the progress of PAE toward clinic. In this review, we comprehensively reviewed recent progresses in single- and multimodality PAE with new physics, mechanisms and strategies to achieve practical devices for potential applicable scenarios including esophageal, gastrointestinal, urogenital and intravascular imaging. We ended this review with challenges and prospects for future development of PAE.

Design, Development, and Multi-Characterization of an Integrated Clinical Transrectal Ultrasound and Photoacoustic Device for Human Prostate Imaging

The standard diagnostic procedure for prostate cancer (PCa) is transrectal ultrasound (TRUS)-guided needle biopsy. However, due to the low sensitivity of TRUS to cancerous tissue in the prostate, small yet clinically significant tumors can be missed. Magnetic resonance imaging (MRI) with TRUS fusion biopsy has recently been introduced as a way to improve the identification of clinically significant PCa in men. However, the spatial errors in coregistering the preprocedural MRI with the real-time TRUS causes false negatives. A real-time and intraprocedural imaging modality that can sensitively detect PCa tumors and, more importantly, differentiate aggressive from nonaggressive tumors could largely improve the guidance of biopsy sampling to improve diagnostic accuracy and patient risk stratification. In this work, we seek to fill this long-standing gap in clinical diagnosis of PCa via the development of a dual-modality imaging device that integrates the emerging photoacoustic imaging (PAI) technique with the established TRUS for improved guidance of PCa needle biopsy. Unlike previously published studies on the integration of TRUS with PAI capabilities, this work introduces a novel approach for integrating a focused light delivery mechanism with a clinical-grade commercial TRUS probe, while assuring much-needed ease of operation in the transrectal space. We further present the clinical potential of our device by (i) performing rigorous characterization studies, (ii) examining the acoustic and optical safety parameters for human prostate imaging, and (iii) demonstrating the structural and functional imaging capabilities using deep-tissue-mimicking phantoms. Our TRUSPA experimental studies demonstrated a field-of-view in the range of 130 to 150 degrees and spatial resolutions in the range of 300 μm to 400 μm at a soft tissue imaging depth of 5 cm.

Simultaneous transrectal ultrasound and photoacoustic human prostate imaging

Imaging technologies that simultaneously provide anatomical, functional, and molecular information are emerging as an attractive choice for disease screening and management. Since the 1980s, transrectal ultrasound (TRUS) has been routinely used to visualize prostatic anatomy and guide needle biopsy, despite limited specificity. Photoacoustic imaging (PAI) provides functional and molecular information at ultrasonic resolution based on optical absorption. Combining the strengths of TRUS and PAI approaches, we report the development and bench-to-bedside translation of an integrated TRUS and photoacoustic (TRUSPA) device. TRUSPA uses a miniaturized capacitive micromachined ultrasonic transducer array for simultaneous imaging of anatomical and molecular optical contrasts [intrinsic: hemoglobin; extrinsic: intravenous indocyanine green (ICG)] of the human prostate. Hemoglobin absorption mapped vascularity of the prostate and surroundings, whereas ICG absorption enhanced the intraprostatic photoacoustic contrast. Future work using the TRUSPA device for biomarker-specific molecular imaging may enable a fundamentally new approach to prostate cancer diagnosis, prognostication, and therapeutic monitoring.

Overview of Ultrasound Detection Technologies for Photoacoustic Imaging

Ultrasound detection is one of the major components of photoacoustic imaging systems. Advancement in ultrasound transducer technology has a significant impact on the translation of photoacoustic imaging to the clinic. Here, we present an overview on various ultrasound transducer technologies including conventional piezoelectric and micromachined transducers, as well as optical ultrasound detection technology. We explain the core components of each technology, their working principle, and describe their manufacturing process. We then quantitatively compare their performance when they are used in the receive mode of a photoacoustic imaging system.

GPU implementation of photoacoustic short-lag spatial coherence imaging for improved image-guided interventions

SIGNIFICANCE

Photoacoustic-based visual servoing is a promising technique for surgical tool tip tracking and automated visualization of photoacoustic targets during interventional procedures. However, one outstanding challenge has been the reliability of obtaining segmentations using low-energy light sources that operate within existing laser safety limits.

AIM

We developed the first known graphical processing unit (GPU)-based real-time implementation of short-lag spatial coherence (SLSC) beamforming for photoacoustic imaging and applied this real-time algorithm to improve signal segmentation during photoacoustic-based visual servoing with low-energy lasers.

APPROACH

A 1-mm-core-diameter optical fiber was inserted into ex vivo bovine tissue. Photoacoustic-based visual servoing was implemented as the fiber was manually displaced by a translation stage, which provided ground truth measurements of the fiber displacement. GPU-SLSC results were compared with a central processing unit (CPU)-SLSC approach and an amplitude-based delay-and-sum (DAS) beamforming approach. Performance was additionally evaluated with in vivo cardiac data.

RESULTS

The GPU-SLSC implementation achieved frame rates up to 41.2 Hz, representing a factor of 348 speedup when compared with offline CPU-SLSC. In addition, GPU-SLSC successfully recovered low-energy signals (i.e., ≤268  μJ) with mean ± standard deviation of signal-to-noise ratios of 11.2  ±  2.4 (compared with 3.5  ±  0.8 with conventional DAS beamforming). When energies were lower than the safety limit for skin (i.e., 394.6  μJ for 900-nm wavelength laser light), the median and interquartile range (IQR) of visual servoing tracking errors obtained with GPU-SLSC were 0.64 and 0.52 mm, respectively (which were lower than the median and IQR obtained with DAS by 1.39 and 8.45 mm, respectively). GPU-SLSC additionally reduced the percentage of failed segmentations when applied to in vivo cardiac data.

CONCLUSIONS

Results are promising for the use of low-energy, miniaturized lasers to perform GPU-SLSC photoacoustic-based visual servoing in the operating room with laser pulse repetition frequencies as high as 41.2 Hz.

Repurposing Molecular Imaging and Sensing for Cancer Image-Guided Surgery

Gone are the days when medical imaging was used primarily to visualize anatomic structures. The emergence of molecular imaging (MI), championed by radiolabeled ¹⁸F-FDG PET, has expanded the information content derived from imaging to include pathophysiologic and molecular processes. Cancer imaging, in particular, has leveraged advances in MI agents and technology to improve the accuracy of tumor detection, interrogate tumor heterogeneity, monitor treatment response, focus surgical resection, and enable image-guided biopsy. Surgeons are actively latching on to the incredible opportunities provided by medical imaging for preoperative planning, intraoperative guidance, and postoperative monitoring. From label-free techniques to enabling cancer-selective imaging agents, image-guided surgery provides surgical oncologists and interventional radiologists both macroscopic and microscopic views of cancer in the operating room. This review highlights the current state of MI and sensing approaches available for surgical guidance. Salient features of nuclear, optical, and multimodal approaches will be discussed, including their strengths, limitations, and clinical applications. To address the increasing complexity and diversity of methods available today, this review provides a framework to identify a contrast mechanism, suitable modality, and device. Emerging low-cost, portable, and user-friendly imaging systems make the case for adopting some of these technologies as the global standard of care in surgical practice.

In Vivo Demonstration of Photoacoustic Image Guidance and Robotic Visual Servoing for Cardiac Catheter-Based Interventions

Cardiac interventional procedures are often performed under fluoroscopic guidance, exposing both the patient and operators to ionizing radiation. To reduce this risk of radiation exposure, we are exploring the use of photoacoustic imaging paired with robotic visual servoing for cardiac catheter visualization and surgical guidance. A cardiac catheterization procedure was performed on two in vivo swine after inserting an optical fiber into the cardiac catheter to produce photoacoustic signals from the tip of the fiber-catheter pair. A combination of photoacoustic imaging and robotic visual servoing was employed to visualize and maintain constant sight of the catheter tip in order to guide the catheter through the femoral or jugular vein, toward the heart. Fluoroscopy provided initial ground truth estimates for 1D validation of the catheter tip positions, and these estimates were refined using a 3D electromagnetic-based cardiac mapping system as the ground truth. The 1D and 3D root mean square errors ranged 0.25-2.28 mm and 1.24-1.54 mm, respectively. The catheter tip was additionally visualized at three locations within the heart: (1) inside the right atrium, (2) in contact with the right ventricular outflow tract, and (3) inside the right ventricle. Lasered regions of cardiac tissue were resected for histopathological analysis, which revealed no laser-related tissue damage, despite the use of 2.98 mJ per pulse at the fiber tip (379.2 mJ/cm² fluence). In addition, there was a 19 dB difference in photoacoustic signal contrast when visualizing the catheter tip pre- and post-endocardial tissue contact, which is promising for contact confirmation during cardiac interventional procedures (e.g., cardiac radiofrequency ablation). These results are additionally promising for the use of photoacoustic imaging to guide cardiac interventions by providing depth information and enhanced visualization of catheter tip locations within blood vessels and within the beating heart.

Photoacoustic image-guided interventions

Photoacoustic imaging has demonstrated its potential for diagnosis over the last few decades. In recent years, its unique imaging capabilities, such as detecting structural, functional and molecular information in deep regions with optical contrast and ultrasound resolution, have opened up many opportunities for photoacoustic imaging to be used during image-guided interventions. Numerous studies have investigated the capability of photoacoustic imaging to guide various interventions such as drug delivery, therapies, surgeries, and biopsies. These studies have demonstrated that photoacoustic imaging can guide these interventions effectively and non-invasively in real-time. In this minireview, we will elucidate the potential of photoacoustic imaging in guiding active and passive drug deliveries, photothermal therapy, and other surgeries and therapies using endogenous and exogenous contrast agents including organic, inorganic, and hybrid nanoparticles, as well as needle-based biopsy procedures. The advantages of photoacoustic imaging in guided interventions will be discussed. It will, therefore, show that photoacoustic imaging has great potential in real-time interventions due to its advantages over current imaging modalities like computed tomography, magnetic resonance imaging, and ultrasound imaging.

Towards clinical photoacoustic and ultrasound imaging: Probe improvement and real-time graphical user interface

Photoacoustic imaging is a non-invasive and non-ionizing biomedical technique that has been investigated widely for various clinical applications. By taking the advantages of conventional ultrasound imaging, hand-held operation with a linear array transducer should be favorable for successful clinical translation of photoacoustic imaging. In this paper, we present new key updates contributed to the previously developed real-time clinical photoacoustic and ultrasound imaging system for improving the clinical usability of the system. We developed a seamless image optimization platform, designed a real-time parameter control software with a user-friendly graphical user interface, performed Monte Carlo simulation of the optical fluence in the imaging plane, and optimized the geometry of the imaging probe. The updated system allows optimizing of all imaging parameters while continuously acquiring the photoacoustic and ultrasound images in real-time. The updated system has great potential to be used in a variety of clinical applications such as assessing the malignancy of thyroid cancer, breast cancer, and melanoma.

"Real-time" Assessment of Surgical Margins During Radical Prostatectomy: State-of-the-Art

Histopathologic examination of the pathologic specimens using hematoxylin & eosin stains represents the backbone of the modern pathology. It is time-consuming; thus, "real-time" assessment of prostatic and periprostatic tissue has gained special interest in the diagnosis and management of prostate cancer. The current study focuses on the review of the different available techniques for "real-time" evaluation of surgical margins during radical prostatectomy (RP). We performed a comprehensive search of the Medline database to identify all the articles discussing "real-time" or intraoperative assessment of surgical margins during RP. Several filters were applied to the search to include only English articles performed on human subjects and published between January 2000 and March 2019. The search revealed several options for pathologic assessment of surgical margins including intraoperative frozen sections, confocal laser endomicroscopy, optical spectroscopy, photodynamic diagnosis, optical coherence tomography, multiphoton microscopy, structured illumination microscopy, 3D augmented reality, and ex vivo fluorescence confocal microscope. Frozen section represents the gold standard technique for real-time pathologic examinations of surgical margins during RP; however, several other options showed promising results in the initial clinical trials, and considering the rapid development in the field of molecular and cellular imaging, some of these options may serve as an alternative to frozen section.

Photoacoustic clinical imaging

Photoacoustic is an emerging biomedical imaging modality, which allows imaging optical absorbers in the tissue by acoustic detectors (light in - sound out). Such a technique has an immense potential for clinical translation since it allows high resolution, sufficient imaging depth, with diverse endogenous and exogenous contrast, and is free from ionizing radiation. In recent years, tremendous developments in both the instrumentation and imaging agents have been achieved. These opened avenues for clinical imaging of various sites allowed applications such as brain functional imaging, breast cancer screening, diagnosis of psoriasis and skin lesions, biopsy and surgery guidance, the guidance of tumor therapies at the reproductive and urological systems, as well as imaging tumor metastases at the sentinel lymph nodes. Here we survey the various clinical and pre-clinical literature and discuss the potential applications and hurdles that still need to be overcome.

Photoacoustic tomography for imaging the prostate: a transurethral illumination probe design and application

In vivo imaging of prostate cancer with photoacoustic tomography is currently limited by the lack of sufficient local fluence for deep tissue penetration and the risk of over-irradiation near the laser-tissue contact surface. We propose the design of a transurethral illumination probe that addresses those limitations. A high energy of 50 mJ/pulse is coupled into a 1000-µm-core diameter multimode fiber. A 2 cm diffusing end is fabricated, which delivers light in radial illumination. The radial illumination is then reflected and reshaped by a parabolic cylindrical mirror to obtain nearly parallel side illumination with a doubled fluence. The fiber assembly is housed in a 25 Fr cystoscope sheath to provide protection of the fiber and maintain a minimal laser-tissue contact distance of 5 mm. A large laser-tissue contact surface area of 4 cm² is obtained and the fluence on the tissue surface is kept below the maximum permissible exposure. By imaging a prostate mimicking phantom, a penetration depth of 3.5 cm at 10 mJ/cm² fluence and 700 nm wavelength is demonstrated. The results indicate that photoacoustic tomography with the proposed transurethral probe has the potential to image the entire prostate while satisfying the fluence maximum permissible exposure and delivering a high power to the tissue.

In vivo transrectal imaging of canine prostate with a sensitive and compact handheld transrectal array photoacoustic probe for early diagnosis of prostate cancer

In this study, we built a novel handheld array photoacoustic probe by integrating multiple optical components with a transrectal ultrasound (TRUS) transducer array. The optical components deliver laser energy and TRUS is used for photoacoustic signal detection. Compared to the previously reported probe, the new photoacoustic probe utilizes an optimized light illumination scheme to enhance the utilization-efficiency of the laser energy, thus improving the imaging sensitivity of the probe. In addition, the new probe is compact and easy to handle for clinicians. We validated the use of this photoacoustic probe for prostate cancer imaging through both phantom studies and in vivo canine model study, which mimics the prostate cancer conditions. The results showed that the probe is suitable for clinical use and can be used in the clinics for several potential clinical applications, including early diagnosis of prostate cancer, targeted image-guided biopsy, and image-guided intra-operative procedure.

Cylindrical illumination with angular coupling for whole-prostate photoacoustic tomography

Current diagnosis of prostate cancer relies on histological analysis of tissue samples acquired by biopsy, which could benefit from real-time identification of suspicious lesions. Photoacoustic tomography has the potential to provide real-time targets for prostate biopsy guidance with chemical selectivity, but light delivered from the rectal cavity has been unable to penetrate to the anterior prostate. To overcome this barrier, a urethral device with cylindrical illumination is developed for whole-prostate imaging, and its performance as a function of angular light coupling is evaluated with a prostate-mimicking phantom.

Strategies for Image-Guided Therapy, Surgery, and Drug Delivery Using Photoacoustic Imaging

Photoacoustic imaging is a rapidly maturing imaging modality in biological research and medicine. This modality uses the photoacoustic effect ("light in, sound out") to combine the contrast and specificity of optical imaging with the high temporal resolution of ultrasound. The primary goal of image-guided therapy, and theranostics in general, is to transition from conventional medicine to precision strategies that combine diagnosis with therapy. Photoacoustic imaging is well-suited for noninvasive guidance of many therapies and applications currently being pursued in three broad areas. These include the image-guided resection of diseased tissue, monitoring of disease states, and drug delivery. In this review, we examine the progress and strategies for development of photoacoustics in these three key areas with an emphasis on the value photoacoustics has for image-guided therapy.

Toward Intra-Operative Prostate Photoacoustic Imaging: Configuration Evaluation and Implementation Using the da Vinci Research Kit

We compare different possible scanning geometries for prostate photoacoustic tomography (PAT) while considering a realistic reconstruction scenario in which the limited view of the prostate and the directivity effect of the transducer are considered. Simulations and experiments confirm that an intra-operative configuration in which the photoacoustic signal is received by a pickup transducer from the anterior surface of the prostate provides the best approach. We propose a PAT acquisition system that includes a da Vinci system controlled by the da Vinci Research Kit, an illumination laser, and an ultrasound machine with parallel data acquisition. The robot maneuvers the pickup transducer to form a cylindrical detection surface around the prostate. The robot is programmed to acquire trajectories in which the transducer face is parallel to and oriented toward a rotational tomography axis, while the laser is fired and PAT data are collected at regular intervals. We present our initial images acquired with this novel system.

Hand-held optoacoustic imaging: A review

Optoacoustic imaging is a medical imaging modality that uses optical excitation and acoustic detection to generate images of tissue structures based up optical absorption within a tissue sample. This imaging modality has been widely explored as a tool for a number of clinical applications, including cancer diagnosis and wound healing tracking. Recently, the optoacoustic imaging community has published a number of reports of hand-held optoacoustic imaging devices and platforms; these hand-held configurations improve the modality's potential for commercial clinical implementation. Here, we review recent advancements in hand-held optoacoustic imaging platforms and methods, including recent pre-clinical applications, and we present an overview of the remaining limitations in optoacoustic imaging that must be addressed to increase the translation of the modality into commercial and clinical use.

Recent Development of Technology and Application of Photoacoustic Molecular Imaging Toward Clinical Translation

The deep imaging capability and optical absorption contrast offered by photoacoustic imaging promote the use of this technology in clinical applications. By exploiting the optical absorption properties of endogenous chromophores such as hemoglobin and lipid, molecular information at a depth of a few centimeters can be unveiled. This information shows promise to reveal lesions indicating early stage of various human diseases, such as cancer and atherosclerosis. In addition, the use of exogenous contrast agents can further extend the capability of photoacoustic imaging in clinical diagnosis and treatment. In this review, the current state of the art and applications of photoacoustic molecular probes will be critically reviewed, as well as some spearheading translational efforts that have taken place over the past 5 years. Some of the most critical barriers to clinical translation of this novel technology will be discussed, and some thoughts will be given on future endeavors and pathways.

Spectral-differential-based unmixing for multispectral photoacoustic imaging

We propose the use of a spectral differential method (SDM) to emphasize the spectral peaks of multispectral photoacoustic images. Because contrast agent signals have spectral peaks at the contrast agent absorption peak, the SDM can selectively emphasize contrast agent signals. Unlike the conventional spectral fitting method (SFM), the SDM does not require reference background spectra and, consequently, does not suffer from separation error caused by the deviation of reference spectra from the measured spectra. We performed multispectral photoacoustic imaging of tissue-mimicking phantoms and subcutaneous tumors of mice injected with small organic molecule-based contrast agents. Contrast agent images obtained by the SDM were clearer than those obtained by SFM.

Feasibility of photoacoustic-guided teleoperated hysterectomies

Hysterectomies (i.e., surgical removal of the uterus) are the prevailing solution to treat medical conditions such as uterine cancer, endometriosis, and uterine prolapse. One complication of hysterectomies is accidental injury to the ureters located within millimeters of the uterine arteries that are severed and cauterized to hinder blood flow and enable full uterus removal. This work explores the feasibility of using photoacoustic imaging to visualize the uterine arteries (and potentially the ureter) when this imaging method is uniquely combined with a da Vinci^® surgical robot that enables teleoperated hysterectomies. We developed a specialized light delivery system to surround a da Vinci^® curved scissor tool, and an ultrasound probe was placed externally, representing a transvaginal approach, to receive the acoustic signals. Photoacoustic images were acquired while sweeping the tool across our custom 3-D uterine vessel model covered in ex vivo bovine tissue that was placed between the 3-D model and the fiber, as well as between the ultrasound probe and the 3-D model. Four tool orientations were explored, and the robot kinematics were used to provide tool position and orientation information simultaneously with each photoacoustic image acquisition. The optimal tool orientation produced images with contrast >10  dB and background signal-to-noise ratios (SNRs) >1.7, indicating minimal acoustic clutter from the tool tip. We achieved similar contrast and SNR measurements with four unique wrist orientations explored with the scissor tool in open and closed configurations. Results indicate that photoacoustic imaging is a promising approach to enable visualization of the uterine arteries to guide hysterectomies (and other gynecological surgeries). These results are additionally applicable to other da Vinci^® surgeries and other surgical instruments with similar tip geometry.

Hemispherical photoacoustic imaging of myocardial infarction: in vivo detection and monitoring

OBJECTIVES

This study aimed to demonstrate the capacity for noninvasive localisation and characterisation of myocardial infarction (MI) in vivo using a hemispherical photoacoustic imaging (PAI) system. MI remains a leading cause of morbidity and mortality worldwide. To enable optimal treatment of patients, timely and accurate diagnosis and longitudinal monitoring is critical.

METHODS

Ischaemia was induced in Balb/c mice by ligation of the left anterior descending artery. The hemispherical PAI system, equipped with 128 ultrasonic transducers spirally distributed on the surface, along with parallel data acquisition, was applied for imaging of the mouse heart.

RESULTS

Our study showed that hemispherical PAI can delineate thoracic vessels and the morphology of the entire heart. Longitudinal PAI images revealed gradual expansion of the infarcted area along with necrosis and fibrosis, which were quantitatively validated by triphenyltetrazolium chloride staining. After MI modelling, the photoacoustic (PA) signal intensity decreased by 399.1 ± 56.3 (p < 0.001), a ~2.5-fold reduction compared to that of healthy cardiac tissue. The calculated size of the enlarged heart, 10.4 ± 6.0 mm² (p < 0.001), represents an increase of ~18% versus that of a healthy heart.

CONCLUSIONS

PAI enables MI diagnosis and injury localisation with its capabilities for both deep organ imaging and lesion region differentiation.

KEY POINTS

• Photoacoustic imaging (PAI), combining optical absorption and ultrasonic resolution, can delineate cardiac anatomy. • PAI can diagnose myocardial infarction lesions with 10 mm imaging depth in vivo. • Quantified results are in excellent agreement with enzyme and histological examinations. • PAI can serve as a complementary modality to SPECT and ultrasound imaging. • This study will encourage further PAI development for clinical use.

Targeting aggressive prostate cancer-associated CD44v6 using phage display selected peptides

There is a crucial need to identify new biomarkers associated with aggressive prostate cancer (PCa) including those associated with cancer stem cells (CSCs). CD44v6, generated by alternative splicing of CD44, has been proposed as a CSC biomarker due to its correlation with aggressive PCa disease. We hypothesized that phage display selected peptides that target CD44v6 may serve as theranostic agents for aggressive PCa. Here, a 15 amino acid peptide ("PFT") was identified by affinity selection against a peptide derived from the v6 region of CD44v6. Synthesized PFT exhibited specific binding to CD44v6 with an equilibrium dissociation constant (Kd) of 743.4 nM. PFT also bound CD44v6 highly expressed on human PCa cell lines. Further, an aggressive form of PCa cells (v6A3) was isolated and tagged by a novel CSC reporter vector. The v6A3 cells had a CSC-like phenotype including enriched CD44v6 expression, enhanced clonogenicity, resistance to chemotherapeutics, and generation of heterogeneous offspring. PFT exhibited preferential binding to v6A3 cells compared to parental cells. Immunohistofluorescence studies with human PCa tissue microarrays (TMA) indicated that PFT was highly accurate in detecting CD44v6-positive aggressive PCa cells, and staining positivity was significantly higher in late stage, metastatic and higher-grade samples. Taken together, this study provides for the first time phage display selected peptides that target CD44v6 overexpressed on PCa cells. Peptide PFT may be explored as an aid in the diagnosis and therapy of advanced PCa disease.

Breakthroughs in modern cancer therapy and elusive cardiotoxicity: Critical research-practice gaps, challenges, and insights

To date, five cancer treatment modalities have been defined. The three traditional modalities of cancer treatment are surgery, radiotherapy, and conventional chemotherapy, and the two modern modalities include molecularly targeted therapy (the fourth modality) and immunotherapy (the fifth modality). The cardiotoxicity associated with conventional chemotherapy and radiotherapy is well known. Similar adverse cardiac events are resurging with the fourth modality. Aside from the conventional and newer targeted agents, even the most newly developed, immune‐based therapeutic modalities of anticancer treatment (the fifth modality), e.g., immune checkpoint inhibitors and chimeric antigen receptor (CAR) T‐cell therapy, have unfortunately led to potentially lethal cardiotoxicity in patients. Cardiac complications represent unresolved and potentially life‐threatening conditions in cancer survivors, while effective clinical management remains quite challenging. As a consequence, morbidity and mortality related to cardiac complications now threaten to offset some favorable benefits of modern cancer treatments in cancer‐related survival, regardless of the oncologic prognosis. This review focuses on identifying critical research‐practice gaps, addressing real‐world challenges and pinpointing real‐time insights in general terms under the context of clinical cardiotoxicity induced by the fourth and fifth modalities of cancer treatment. The information ranges from basic science to clinical management in the field of cardio‐oncology and crosses the interface between oncology and onco‐pharmacology. The complexity of the ongoing clinical problem is addressed at different levels. A better understanding of these research‐practice gaps may advance research initiatives on the development of mechanism‐based diagnoses and treatments for the effective clinical management of cardiotoxicity.

Design of high energy laser pulse delivery in a multimode fiber for photoacoustic tomography

In photoacoustic tomography (PAT), delivering high energy pulses through optical fiber is critical for achieving high quality imaging. A fiber coupling scheme with a beam homogenizer is demonstrated for coupling high energy pulses in a single multimode fiber. This scheme can benefit PAT applications that require miniaturized illumination or internal illumination with a small fiber. The beam homogenizer is achieved by using a cross cylindrical lens array, which provides a periodic spatial modulation on the phase of the input light. Thus the lens array acts as a phase grating which diffracts the beam into a 2D diffraction pattern. Both theoretical analysis and experiments demonstrate that the focused beam can be split into a 2D spot array that can reduce the peak power on the fiber tip surface and thus enhance the coupling performance. The theoretical analysis of the intensity distribution of the focused beam is carried out by Fourier optics. In experiments, coupled energy at 48 mJ/pulse and 60 mJ/pulse have been achieved and the corresponding coupling efficiency is 70% and 90% in a 1000-μm and a 1500-μm-core-diameter fiber, respectively. The high energy pulses delivered by the multimode fiber are further tested for PAT imaging in phantoms. PAT imaging of a printed dot array shows a large illumination area of 7 cm² under 5 mm thick chicken breast tissue. In vivo imaging is also demonstrated on the human forearm. The large improvement in coupling energy can potentially benefit PAT with single fiber delivery to achieve large area imaging and deep penetration detection.