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Chow CY, King GF. Shining a Light on Venom-Peptide Receptors: Venom Peptides as Targeted Agents for In Vivo Molecular Imaging. Toxins (Basel) 2024; 16:307. [PMID: 39057947 PMCID: PMC11281729 DOI: 10.3390/toxins16070307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/27/2024] [Accepted: 07/02/2024] [Indexed: 07/28/2024] Open
Abstract
Molecular imaging has revolutionised the field of biomedical research by providing a non-invasive means to visualise and understand biochemical processes within living organisms. Optical fluorescent imaging in particular allows researchers to gain valuable insights into the dynamic behaviour of a target of interest in real time. Ion channels play a fundamental role in cellular signalling, and they are implicated in diverse pathological conditions, making them an attractive target in the field of molecular imaging. Many venom peptides exhibit exquisite selectivity and potency towards ion channels, rendering them ideal agents for molecular imaging applications. In this review, we illustrate the use of fluorescently-labelled venom peptides for disease diagnostics and intraoperative imaging of brain tumours and peripheral nerves. Finally, we address challenges for the development and clinical translation of venom peptides as nerve-targeted imaging agents.
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Affiliation(s)
- Chun Yuen Chow
- Institute for Molecular Bioscience, The University of Queensland, St. Lucia, QLD 4072, Australia
- Australia Research Council Centre of Excellence for Innovations in Peptide and Protein Science, The University of Queensland, St. Lucia, QLD 4072, Australia
| | - Glenn F. King
- Institute for Molecular Bioscience, The University of Queensland, St. Lucia, QLD 4072, Australia
- Australia Research Council Centre of Excellence for Innovations in Peptide and Protein Science, The University of Queensland, St. Lucia, QLD 4072, Australia
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Tan Y, Fang Z, Tang Y, Liu K, Zhao H. Clinical advancement of precision theranostics in prostate cancer. Front Oncol 2023; 13:1072510. [PMID: 36816956 PMCID: PMC9932923 DOI: 10.3389/fonc.2023.1072510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/20/2023] [Indexed: 02/05/2023] Open
Abstract
Theranostic approaches with positron emission tomography/computed tomography (PET/CT) or PET/magnetic resonance imaging (PET/MRI) molecular imaging probes are being implemented clinically in prostate cancer (PCa) diagnosis and imaging-guided precision surgery. This review article provides a comprehensive summary of the rapidly expanding list of molecular imaging probes in this field, including their applications in early diagnosis of primary prostate lesions; detection of lymph node, skeletal and visceral metastases in biochemical relapsed patients; and intraoperative guidance for tumor margin detection and nerve preservation. Although each imaging probe shows preferred efficacy in some applications and limitations in others, the exploration and research efforts in this field will eventually lead to improved precision theranostics of PCa.
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Affiliation(s)
- Yue Tan
- Hengyang Medical College, University of South China, Hengyang, Hunan, China,Department of Nuclear Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhihui Fang
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China,Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yongxiang Tang
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Kai Liu
- Department of Systems Medicine and Bioengineering, Houston Methodist Neal Cancer Center, Weill Cornell Medicine, Houston TX, United States,Department of Gastrointestinal Surgery, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China,*Correspondence: Kai Liu, ; Hong Zhao,
| | - Hong Zhao
- Department of Systems Medicine and Bioengineering, Houston Methodist Neal Cancer Center, Weill Cornell Medicine, Houston TX, United States,*Correspondence: Kai Liu, ; Hong Zhao,
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Nazzi V, Innocenti N, Castelli N, Tramacere I, Eoli M, Cojazzi V, Gatti L, Acerbi F, Falco J, Vetrano IG. Assessing the role of sodium fluorescein in peripheral nerve sheath tumors and mimicking lesions surgery: An update after 142 cases. Front Oncol 2023; 12:1070878. [PMID: 36698394 PMCID: PMC9868923 DOI: 10.3389/fonc.2022.1070878] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/12/2022] [Indexed: 01/12/2023] Open
Abstract
Objective Peripheral nerve sheath tumors (PNST) include mainly schwannomas and neurofibromas. Surgical resection represents the mainstay of treatment but due to their pathogenesis, distinguishing between intact functional nerve and the fibers from whence the PNST arose may not always be easy to perform, constituting the most relevant risk factor in determining a worsening in neurological condition. The introduction of intraoperative tools to better visualize these tumors could help achieve a gross-total resection. In this study, we analyzed the effect of sodium fluorescein (SF) on the visualization and resection of a large cohort of PNST. Methods Between September 2018 and December 2021, 142 consecutive patients harboring a suspected PNST underwent fluorescein-guided surgery at the Department of Neurosurgery of the Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy. All patients presented with a different degree of contrast enhancement at preoperative MRI. SF was intravenously injected after intubation at 1 mg/kg. Intraoperative fluorescein characteristics and postoperative neurological and radiological outcomes were collected, analyzed, and retrospectively compared with a historical series. Results 142 patients were included (42 syndromic and 100 sporadic); schwannoma was the predominant histology, followed by neurofibroma (17 neurofibroma e 12 plexiform neurofibroma) and MPNST. Bright fluorescence was present in all cases of schwannomas and neurofibromas, although with a less homogeneous pattern, whereas it was significantly less evident for malignant PNST; perineurioma and hybrid nerve sheath tumors were characterized by a faint fluorescence enhancement. The surgical resection rate in the general population and even among the subgroups was about 66.7%; from the comparative analysis, we found a consistently higher rate of complete tumor removal in plexiform neurofibromas, 66% in the "fluorescent" group vs 44% in the "historical" group (p-value < 0.05). The rate of complications and mean surgical time were superimposable among the two populations. Conclusions SF is a valuable method for safe fluorescence-guided PNST and mimicking lesions resection. Our data showed a positive effect of fluorescein-guided surgery in increasing the rate of surgical resection of plexiform neurofibromas, suggesting a possible role in improving the functional and oncological outcome of these lesions.
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Affiliation(s)
- Vittoria Nazzi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Niccolò Innocenti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Nicolò Castelli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marica Eoli
- Molecular Neuro-Oncology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Vittoria Cojazzi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Laura Gatti
- Neurobiology Laboratory, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Jacopo Falco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Ignazio G. Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy,Neurobiology Laboratory, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy,Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy,*Correspondence: Ignazio G. Vetrano,
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Lenartowicz KA, Wolf AS, Desy NM, Strakowski JA, Amrami KK, Spinner RJ. Preoperative Imaging of Intraneural Ganglion Cysts: A Critical Systematic Analysis of the World Literature. World Neurosurg 2022; 166:e968-e979. [PMID: 35953037 DOI: 10.1016/j.wneu.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/30/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Advancements in imaging and an understanding of the pathomechanism for intraneural ganglion cyst formation have led to increased awareness and recognition of this lesion. However, the precise role of imaging has been advocated for but not formally evaluated. METHODS We performed a systematic review of the world literature to study the frequency of imaging used to diagnose intraneural ganglion cysts at different sites and compared trends in identifying joint connections. RESULTS We identified 941 cases of intraneural ganglion cysts, of which 673 had published imaging. Magnetic resonance imaging (MRI, n = 527) and ultrasonography (US, n = 123) were the most commonly reported. They occurred most frequently in the common peroneal nerve (n = 570), followed by the ulnar nerve at the elbow (n = 88), and the tibial nerve at the ankle (n = 58). A joint connection was identified in 375 cases (48%), with 62% of MRIs showing a joint connection, followed by 16% on US, and 6% on computed tomography (CT). MRI was statistically more likely to identify a joint connection than was US (P < 0.01). In the last decade, joint connections have been identified with increasing frequency using preoperative imaging, with up to 75% of cases reporting joint connections. CONCLUSIONS Preoperative imaging plays an important role in establishing the diagnosis of intraneural ganglion cyst as well as treatment planning. Imaging has proved superior to the sole reliance of operative exposure to identify a joint connection, which is necessary to treat the underlying disease. Failure to identify cyst connections on imaging can result in an inability to truly address the underlying pathoanatomy at the time of definitive surgery, leading to a risk for clinical recurrence. Therefore, management should be guided by an intersection between new knowledge presented in the literature, clinical expertise, and surgeon experience.
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Affiliation(s)
| | - Alexandre S Wolf
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas M Desy
- Department of Orthopedics, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey A Strakowski
- Department of Physical Medicine and Rehabilitation, Ohio Health, Columbus, Ohio, USA
| | | | - Robert J Spinner
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Klifto KM, Azoury SC, Gurno CF, Card EB, Levin LS, Kovach SJ. Treatment approach to isolated common peroneal nerve palsy by mechanism of injury: Systematic review and meta-analysis of individual participants' data. J Plast Reconstr Aesthet Surg 2021; 75:683-702. [PMID: 34801427 DOI: 10.1016/j.bjps.2021.09.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/27/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND We reviewed the individual participant data of patients who sustained isolated common peroneal nerve (CPN) injuries resulting in foot drop. Functional results were compared between eight interventions for CPN palsies to determine step-wise treatment approaches for the underlying mechanisms of nerve injury. METHODS PubMed, Embase, Cochrane Library, Web of Science, Scopus, and CINAHL databases were searched. PRISMA-IPD and Cochrane guidelines were followed in the data search. Eligible patients sustained isolated CPN injuries resulting in their foot drop. Patients were stratified by mechanisms of nerve injury, ages, duration of motor symptoms, and nerve defect/zone of injury sizes, and were compared by functional results (poor = 0, fair = 1, good = 2, excellent = 3), using meta-regression between interventions. Interventions evaluated were primary neurorrhaphy, neurolysis, nerve grafts, partial nerve transfer, neuromusculotendinous transfer, tendon transfer, ankle-foot orthosis (AFO), and arthrodesis. RESULTS One hundred and forty-four studies included 1284 patients published from 1985 through 2020. Transection/Cut: Excellent functional results following tendon transfer (OR: 126, 95%CI: 6.9, 2279.7, p=0.001), compared to AFO. Rupture/Avulsion: Excellent functional results following tendon transfer (OR: 73985359, 95%CI: 73985359, 73985359, p<0.001), nerve graft (OR: 4465917, 95%CI: 1288542, 15478276, p<0.001), and neuromusculotendinous transfer (OR: 42277348, 95%CI: 3001397, 595514030, p<0.001), compared to AFO. Traction/Stretch: Good functional results following tendon transfer (OR: 4.1, 95%CI: 1.17, 14.38, p=0.028), compared to AFO. Entrapment: Excellent functional results following neurolysis (OR: 4.6, 95%CI: 1.3, 16.6, p=0.019), compared to AFO. CONCLUSIONS Functional results may be optimized for treatments by the mechanism of nerve injury. Transection/Cut and Traction/Stretch had the best functional results following tendon transfer. Rupture/Avulsion had the best functional results following tendon transfer, nerve graft, or neuromusculotendinous transfer. Entrapment had the best functional results following neurolysis.
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Affiliation(s)
- Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, University of Missouri School of Medicine, Columbia, MO, USA; Division of Plastic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Said C Azoury
- Division of Plastic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Caresse F Gurno
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Elizabeth B Card
- Division of Plastic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - L Scott Levin
- Division of Plastic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Pedro MT, Grübel N, Durner G, Pala A, Wirtz CR, Koenig RW. Intraoperative Sodium-Fluorescence Imaging in Peripheral Nerve Sheath Tumors (PNST)-A New Additional Promising Diagnostic Tool. Front Oncol 2021; 11:655392. [PMID: 33768010 PMCID: PMC7985443 DOI: 10.3389/fonc.2021.655392] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/12/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Through the development and implementation of specific fluorophore filters to microscopes in 2012, sodium fluorescein (SF) is currently experiencing a remarkable renaissance in neurosurgery. The present study examines its intraoperative application during surgical removal of peripheral nerve sheath tumors (PNST) and metastases. Methods: This single-center study includes 10 cases of benign and malignant tumors as well as metastases of peripheral nerves (in total 11 PNST). Their surgical resections were all performed under microscope-based fluorescence with SF, which was administered intravenously (0.5-1.0 mg/kg body weight) during anesthesia induction. Microsurgical tumor removals were filmed and the collected data were retrospectively analyzed via ImageJ. Results: Microsurgical tumor preparation was possible under the usage of fluorophore filter. In seven histological confirmed schwannoma (n = 6 patients) tissue differentiation between tumor mass and not involved fascicles was statistically significant for the colors green and red. Schwannoma maximum mean for green reached 254.7 pixel and 179.4 pixel for red, whereas passing healthy fascicles revealed a maximum mean for green 94.91 and for red 120.76 pixel. One case of neurofibroma achieved lower amount of pixel. Similar to schwannoma, the two MPNST cases showed a strong homogeneous fluorescence (max. mean green 215 pixel and red 124.51) involving the whole nerve segment. Subcutaneous tumor remnants were visualized and therefore resected. Via fascicular nerve biopsy a B-cell lymphoma of the tibial nerve could be detected. SF led to variable stain intensities in single fascicles. The resected fascicle revealed a max mean green of 100.54 pixel, whereas surrounding fascicles came up with max. mean green of 63.0 pixel. Conclusions: Intraoperative SF visualization for PNST is feasible and of low risk. During resection of benign PNST, enhanced tissue differentiation between affected and not affected nerve segments is very useful. Tumor remnants can be detected safely and effectively. Its application during resection of malignant PNST is limited. Due to the infiltrative nature of those tumors, intraneural tissue differentiation is not possible. "Fluorescence-guided" biopsy can be regarded as an additional advantage in PNST surgery. Due to the encouraging experience in our institution SF was established as standard visualization tool in PNST surgery.
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Affiliation(s)
- Maria Teresa Pedro
- Klinik für Neurochirurgie, Medizinische Fakultät, Universität Ulm, Ulm, Germany
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Vetrano IG, Acerbi F, Falco J, Devigili G, Rinaldo S, Messina G, Prada F, D'Ammando A, Nazzi V. Fluorescein-guided removal of peripheral nerve sheath tumors: a preliminary analysis of 20 cases. J Neurosurg 2021; 134:260-269. [PMID: 31812148 DOI: 10.3171/2019.9.jns19970] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 09/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Benign peripheral nerve sheath tumors (PNSTs) include mainly schwannomas-the most common tumors arising from peripheral nerves-and neurofibromas. Due to their origin, distinguishing between functional intact nerve and the fibers from whence the PNST arose may not always be easy to perform. The introduction of intraoperative tools to better visualize these tumors could be helpful in achieving a gross-total resection. In this study, the authors present a series of patients harboring PNST in which the surgery was performed under fluorescein guidance. METHODS Between September 2018 and February 2019, 20 consecutive patients with a total of 25 suspected PNSTs underwent fluorescein-guided surgery performed under microscopic view with a dedicated filter integrated into the surgical microscope (YELLOW 560) and with intraoperative monitoring. All patients presented with a different degree of contrast enhancement at preoperative MRI. Fluorescein was intravenously injected after intubation at a dose of 1 mg/kg. Preoperative clinical and radiological data, intraoperative fluorescein characteristics, and postoperative neurological and radiological outcomes were collected and analyzed. RESULTS Six patients were affected by neurofibromatosis or schwannomatosis. There were 14 schwannomas, 8 neurofibromas, 1 myxoma, 1 reactive follicular hyperplasia, and 1 giant cell tumor of tendon sheath. No patient experienced worsening of neurological status after surgery. No side effects related to fluorescein injection were found in this series. Fluorescein allowed an optimal intraoperative distinction between tumor and surrounding nerves in 13 of 14 schwannomas and in all neurofibromas. In 6 neurofibromas and in 1 schwannoma, the final YELLOW 560 visualization showed the presence of small tumor remnants that were not visible under white-light illumination and that could be removed, obtaining a gross-total resection. CONCLUSIONS Fluorescein was demonstrated to be a feasible, safe, and helpful intraoperative adjunct to better identify and distinguish PNSTs from intact functional nerves, with a possible impact on tumor resection, particularly in diffuse neurofibromas.
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Affiliation(s)
- Ignazio G Vetrano
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta
| | - Francesco Acerbi
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta
| | - Jacopo Falco
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta
| | - Grazia Devigili
- 2Neurological Unit 1, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; and
| | - Sara Rinaldo
- 2Neurological Unit 1, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; and
| | - Giuseppe Messina
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta
| | - Francesco Prada
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta
- 3Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Antonio D'Ammando
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta
| | - Vittoria Nazzi
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta
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Wilson TJ, Stone JJ, Howe BM, Rock MG, Spinner RJ. Joint Outcomes Following Surgery for Superior Tibiofibular Joint-Associated Peroneal Intraneural Ganglion Cysts. Neurosurgery 2020; 86:383-390. [PMID: 31215635 DOI: 10.1093/neuros/nyz205] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 12/20/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Intraneural ganglion cysts are joint-connected, with the primary pathology residing in the associated joint. For peroneal intraneural ganglion cysts, the surgical strategy can include resection of the synovial surface of the superior tibiofibular joint (STFJ). However, the rate of instability postoperatively is unclear. OBJECTIVE To evaluate the rate of STFJ instability, following surgery for peroneal intraneural ganglion cysts. The second goal of the study was to assess the relationship between volume of resection of the STFJ and risk of extraneural recurrence. METHODS We performed a retrospective analysis of a cohort of patients with peroneal intraneural ganglion cysts. We analyzed clinical factors, including recurrence, and assessed the rate of postoperative STFJ instability. We created 3-dimensional models of the STFJ pre- and postoperatively to compare the volume of resection in recurrent cases and nonrecurrent cases using a case-control design. RESULTS The total cohort consisted of 65 subjects. No patient had evidence of radiological or clinical instability of the STFJ postoperatively. Extraneural radiological recurrence occurred in 6 (9%) patients. No intraneural recurrences were observed. The average volume of resection for patients with recurrence was 1349 mm3 (SD = 1027 mm3) vs 3018 mm3 (SD = 1433 mm3) in controls that did not have a recurrence (P = .018). CONCLUSION This study supports performing an aggressive STFJ resection to minimize the risk of extraneural recurrence. Superior tibiofibular joint resection is not associated with postoperative joint instability. A smaller volume resection is correlated with recurrence risk.
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Affiliation(s)
- Thomas J Wilson
- Department of Neurosurgery, Stanford University, Stanford, California
| | | | - B Matthew Howe
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Michael G Rock
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Abstract
OBJECTIVE This review details the agents for fluorescence-guided nerve imaging in both preclinical and clinical use to identify factors important in selecting nerve-specific fluorescent agents for surgical procedures. BACKGROUND Iatrogenic nerve injury remains a significant cause of morbidity in patients undergoing surgical procedures. Current real-time identification of nerves during surgery involves neurophysiologic nerve stimulation, which has practical limitations. Intraoperative fluorescence-guided imaging provides a complimentary means of differentiating tissue types and pathology. Recent advances in fluorescence-guided nerve imaging have shown promise, but the ideal agent remains elusive. METHODS In February 2018, PubMed was searched for articles investigating peripheral nerve fluorescence. Key terms used in this search include: "intraoperative, nerve, fluorescence, peripheral nerve, visualization, near infrared, and myelin." Limits were set to exclude articles exclusively dealing with central nervous system targets or written in languages other than English. References were cross-checked for articles not otherwise identified. RESULTS Of the nonspecific agents, tracers that rely on axonal transport showed the greatest tissue specificity; however, neurovascular dyes already enjoy wide clinical use. Fluorophores specific to nerve moieties result in excellent nerve to background ratios. Although noteworthy findings on tissue specificity, toxicity, and route of administration specific to each fluorescent agent were reported, significant data objectively quantifying nerve-specific fluorescence and toxicity are lacking. CONCLUSIONS Fluorescence-based nerve enhancement has advanced rapidly over the past 10 years with potential for continued utilization and progression in translational research. An ideal agent would be easily administered perioperatively, would not cross the blood-brain barrier, and would fluoresce in the near-infrared spectrum. Agents administered systemically that target nerve-specific moieties have shown the greatest promise. Based on the heterogeneity of published studies and methods for reporting outcomes, it appears that the development of an optimal nerve imaging agent remains challenging.
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