Clinical Practice
An Interview with Johan Richter

Who is Johan? what do you do in your clinical practice ?

After basic neurosurgical training in Germany I moved to Sweden and can now look back on more than 30 years of neurosurgical practice, 25 of which as a specialist and nowadays as a senior consultant and researcher in the field of brain tumors and as such a member of the neurosurgical departments brain tumor group.

For many years I was also dedicated to functional neurosurgery and the experiences from DBS inspired and accelerated our development of the fluorescence guided diagnostics system originally invented by the group around professor Karin Wårdell.

What are the challenges you face today?  

Primary brain tumors are but too well known to neurosurgeons throughout the world. For more than a century the conditions for surgical treatment of those malignant tumors were basically unchanged, ie desolate. The advent of computed tomography and surgical microscopes did improve the results to some extent, but little did we know about the true nature of the tumor growth in the brain. The real game changer came with fluorescence guided surgery,

since more than a decade international standard in neurosurgical centers. Results have really improved, both in terms of preserving quality of life and regarding overall survival. Still, surgery alone does not cure the disease, in fact nothing does, but oncological methods of treatment (chemotherapy, radiotherapy) are improving too and the main task for neurosurgeons is to create the best conditions for that.

Can you explain how Fluolink's product is helping you to overcome those?

The bulk of the malignant primary brain tumors, mainly the glioblastomas, are usually removed without difficulties. But the problem lies in the growth zone, in the outer rim, where no membraneous limit can be found - these tumors infiltrate the brain and cellular remnants can be found beyond the radiologically visualized boundaries, ie beyond the contrast media enhancement areas (volumes).

The use of fluorescence guided surgery has unveiled this and thus confronted us neurosurgeons with new challenges. FluoLink provides a tool that can visualize malignant brain tumor tissue beyond the capabilities of the surgical microscopes. This can be of help during resection, of course, but more than that, it can be of immense value during stereotactic or navigated biopsies.

What are the main differences of Fluolink's product vs. common practice today?

During resection the FluoLink optical probe can detect tumor tissue with higher sensitivity than surgical microscopes and also, the fluorescence measured can be quantified, which can help differentiate between eg tumor growth zone and gliotic zone, otherwise not recognizable at all. In fact, the capabilities of tumor detection are so high, that fluorescing tissue can be seen through the optical probe far into potentially eloquent areas, where resection can only be carried out safely if there is a counterpart to control cerebral functions, like neurophysiological monitoring. We advocate resection always with the combination of such systems , or if possible, in wake patients.
The most obvious and noticeable use of the FluoLink optical equipment with spectroscopic identification of fluorescence and laser Doppler flowmetry is for stereotactic or navigated biopsy through burr hole trephination. The standard procedure is based solely on calculations of target points as measured on preoperative

magnetic resonance images (MRI) and the actual insertion of the biopsy needle therefore is carried out blinded, so to speak, while the FluoLink optical probe actually measures fluorescence and blood flow in real time along the path inside the brain, which means we can “see” both if blood vessels may be crossing the trajectory and when the target point is reached, ie where the tumor tissue is. The standard procedure requires sending tissue samples to pathological examination to confirm the nature of the specimens, a sometimes time consuming act. If the pathological exam cannot confirm tumor tissue, the procedure has to be repeated, ie the biopsy needle has to be inserted again, creating a new trajectory with new risks. With the FluoLink device the presence of pathological tissue, ie tumor, is proven before any tissue is taken, hence one specimen can be retrieved and the operation can be closed and the pathological examination can be done afterwards, which can save time.

What are the patient benefits? Other benefits?

Safety is the ultimate decree of all medical interventions, especially in neurosurgery. Positive confirmation that a sample will be taken in the right place and only once, will reduce the number of needle insertions into the brain  and save operation time, which are most relevant safety aspects that can prevent complications and release resources.

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