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Bianconi A, Bonada M, Zeppa P, Colonna S, Tartara F, Melcarne A, Garbossa D, Cofano F. How Reliable Is Fluorescence-Guided Surgery in Low-Grade Gliomas? A Systematic Review Concerning Different Fluorophores. Cancers (Basel) 2023; 15:4130. [PMID: 37627158 PMCID: PMC10452554 DOI: 10.3390/cancers15164130] [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: 06/29/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Fluorescence-guided surgery has been increasingly used to support glioma surgery with the purpose of obtaining a maximal safe resection, in particular in high-grade gliomas, while its role is less definitely assessed in low-grade gliomas. METHODS A systematic review was conducted. 5-aminolevulinic acid, sodium fluorescein, indocyanine green and tozuleristide were taken into account. The main considered outcome was the fluorescence rate, defined as the number of patients in whom positive fluorescence was detected out of the total number of patients. Only low-grade gliomas were considered, and data were grouped according to single fluorophores. RESULTS 16 papers about 5-aminolevulinic acid, 4 about sodium fluorescein, 2 about indocyanine green and 1 about tozuleristide were included in the systematic review. Regarding 5-aminolevulinic acid, a total of 467 low-grade glioma patients were included, and fluorescence positivity was detected in 34 out of 451 Grade II tumors (7.3%); while in Grade I tumors, fluorescence positivity was detected in 9 out of 16 cases. In 16 sodium fluorescein patients, seven positive fluorescent cases were detected. As far as indocyanine is concerned, two studies accounting for six patients (three positive) were included, while for tozuleristide, a single clinical trial with eight patients (two positive) was retrieved. CONCLUSIONS The current evidence does not support the routine use of 5-aminolevulinic acid or sodium fluorescein with a standard operating microscope because of the low fluorescence rates. New molecules, including tozuleristide, and new techniques for fluorescence detection have shown promising results; however, their use still needs to be clinically validated on a large scale.
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Affiliation(s)
- Andrea Bianconi
- Neurosurgery, Department of Neurosciences, University of Turin, 10126 Turin, Italy; (M.B.); (P.Z.); (A.M.); (D.G.); (F.C.)
| | - Marta Bonada
- Neurosurgery, Department of Neurosciences, University of Turin, 10126 Turin, Italy; (M.B.); (P.Z.); (A.M.); (D.G.); (F.C.)
| | - Pietro Zeppa
- Neurosurgery, Department of Neurosciences, University of Turin, 10126 Turin, Italy; (M.B.); (P.Z.); (A.M.); (D.G.); (F.C.)
| | - Stefano Colonna
- Neurosurgery, Department of Neurosciences, University of Turin, 10126 Turin, Italy; (M.B.); (P.Z.); (A.M.); (D.G.); (F.C.)
| | - Fulvio Tartara
- Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
| | - Antonio Melcarne
- Neurosurgery, Department of Neurosciences, University of Turin, 10126 Turin, Italy; (M.B.); (P.Z.); (A.M.); (D.G.); (F.C.)
| | - Diego Garbossa
- Neurosurgery, Department of Neurosciences, University of Turin, 10126 Turin, Italy; (M.B.); (P.Z.); (A.M.); (D.G.); (F.C.)
| | - Fabio Cofano
- Neurosurgery, Department of Neurosciences, University of Turin, 10126 Turin, Italy; (M.B.); (P.Z.); (A.M.); (D.G.); (F.C.)
- Humanitas Gradenigo, 10100 Turin, Italy
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Hosmann A, Jaber M, Roetzer-Pejrimovsky T, Timelthaler G, Borkovec M, Kiesel B, Wadiura LI, Millesi M, Mercea PA, Phillips J, Hervey-Jumper S, Berghoff AS, Hainfellner JA, Berger MS, Stummer W, Widhalm G. CD34 microvascularity in low-grade glioma: correlation with 5-aminolevulinic acid fluorescence and patient prognosis in a multicenter study at three specialized centers. J Neurosurg 2022; 138:1281-1290. [PMID: 36115057 DOI: 10.3171/2022.7.jns22921] [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: 04/26/2022] [Accepted: 07/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Early markers are urgently needed in low-grade glioma (LGG) evaluation to rapidly estimate the individual patient's prognosis and to determine the optimal postoperative management. Generally, visible 5-aminolevulinic acid (5-ALA) fluorescence is present in only a few LGGs. Recently, the authors identified visible 5-ALA fluorescence as a powerful intraoperative marker for unfavorable outcome in LGG treatment. However, its precise histopathological correlate is unclear. Neoangiogenesis represents a crucial event in tumor evolution, and CD34 is an established marker for vascular endothelial progenitors potentially indicating tumor progression. The aim of this study was thus to correlate 5-ALA fluorescence and CD34 microvascularity as well as to investigate the prognostic value of CD34 in a large series of LGGs. METHODS In this retrospective study including 3 specialized centers, patients with histopathologically confirmed isocitrate dehydrogenase-mutated LGGs (WHO grade II) receiving 5-ALA prior to resection were included. During surgery, the presence of visible fluorescence was analyzed and one representative tumor sample from the area with the maximum fluorescence effect (tumor with focal fluorescence or nonfluorescing tumor) was selected for each LGG. All fluorescing or nonfluorescing tumor samples were stained for CD34 and semiquantitatively analyzed for microvascular proliferation patterns (physiological vessels, branching capillaries, or microvessel clusters) as well as automatically quantified for CD34 microvessel density (MVD) by standardized histomorphometry software. These semiquantitative/quantitative CD34 data were correlated to the fluorescence status and patient outcome including progression-free survival (PFS), malignant transformation-free survival (MTFS), and overall survival (OS). RESULTS In a total of 86 LGGs, visible fluorescence was found during surgery in 13 (15%) cases. First, the semiquantitative CD34 score significantly correlated with intraoperative fluorescence (p = 0.049). Accordingly, the quantitative CD34 MVD was significantly higher in tumors showing fluorescence (p = 0.03). Altogether, the semiquantitative CD34 score showed a strong correlation with quantitative CD34 MVD (p < 0.001). At a mean follow-up of 5.4 ± 2.6 years, microvessel clusters in semiquantitative analysis were a prognostic marker for poor PFS (p = 0.01) and MTFS (p = 0.006), but not OS (p = 0.28). Finally, quantitative CD34 MVD > 10 vessels/mm2 was a prognostic marker for poor PFS (p = 0.01), MTFS (p = 0.008), and OS (p = 0.049). CONCLUSIONS The data indicate that CD34 microvascularity is associated with intraoperative 5-ALA fluorescence and outcomes in patients with LGG. Thus, visible fluorescence in LGGs might indicate increased CD34 microvascularity, serving as an early prognostic marker for unfavorable patient outcome that is already available during surgery.
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Affiliation(s)
- Arthur Hosmann
- 1Department of Neurosurgery, Medical University of Vienna, Austria
| | - Mohammed Jaber
- 2Department of Neurosurgery, University Hospital Münster, Germany
| | - Thomas Roetzer-Pejrimovsky
- 3Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Austria
| | | | - Martin Borkovec
- 1Department of Neurosurgery, Medical University of Vienna, Austria
| | - Barbara Kiesel
- 1Department of Neurosurgery, Medical University of Vienna, Austria
| | - Lisa I Wadiura
- 1Department of Neurosurgery, Medical University of Vienna, Austria
| | - Matthias Millesi
- 1Department of Neurosurgery, Medical University of Vienna, Austria
| | - Petra A Mercea
- 1Department of Neurosurgery, Medical University of Vienna, Austria
| | - Joanna Phillips
- 5Department of Pathology, University of California, San Francisco, California
| | - Shawn Hervey-Jumper
- 6Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Anna S Berghoff
- 7Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | - Johannes A Hainfellner
- 3Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Austria
| | - Mitchel S Berger
- 6Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Walter Stummer
- 2Department of Neurosurgery, University Hospital Münster, Germany
| | - Georg Widhalm
- 1Department of Neurosurgery, Medical University of Vienna, Austria
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3
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Kiesel B, Freund J, Reichert D, Wadiura L, Erkkilae MT, Woehrer A, Hervey-Jumper S, Berger MS, Widhalm G. 5-ALA in Suspected Low-Grade Gliomas: Current Role, Limitations, and New Approaches. Front Oncol 2021; 11:699301. [PMID: 34395266 PMCID: PMC8362830 DOI: 10.3389/fonc.2021.699301] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/19/2021] [Indexed: 11/13/2022] Open
Abstract
Radiologically suspected low-grade gliomas (LGG) represent a special challenge for the neurosurgeon during surgery due to their histopathological heterogeneity and indefinite tumor margin. Therefore, new techniques are required to overcome these current surgical drawbacks. Intraoperative visualization of brain tumors with assistance of 5-aminolevulinic acid (5-ALA) induced protoporphyrin IX (PpIX) fluorescence is one of the major advancements in the neurosurgical field in the last decades. Initially, this technique was exclusively applied for fluorescence-guided surgery of high-grade glioma (HGG). In the last years, the use of 5-ALA was also extended to other indications such as radiologically suspected LGG. Here, we discuss the current role of 5-ALA for intraoperative visualization of focal malignant transformation within suspected LGG. Furthermore, we discuss the current limitations of the 5-ALA technology in pure LGG which usually cannot be visualized by visible fluorescence. Finally, we introduce new approaches based on fluorescence technology for improved detection of pure LGG tissue such as spectroscopic PpIX quantification fluorescence lifetime imaging of PpIX and confocal microscopy to optimize surgery.
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Affiliation(s)
- Barbara Kiesel
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Julia Freund
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - David Reichert
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory OPTRAMED, Medical University of Vienna, Vienna, Austria
| | - Lisa Wadiura
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Mikael T Erkkilae
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Adelheid Woehrer
- Department of Neurology, Institute for Neuropathology and Neurochemistry, Medical University of Vienna, Vienna, Austria
| | - Shawn Hervey-Jumper
- Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Georg Widhalm
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
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Wu QL, Xu HL, Xiong C, Lan QH, Fang ML, Cai JH, Li H, Zhu ST, Xu JH, Tao FY, Lu CT, Zhao YZ, Chen B. c(RGDyk)-modified nanoparticles encapsulating quantum dots as a stable fluorescence probe for imaging-guided surgical resection of glioma under the auxiliary UTMD. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2021; 48:143-158. [PMID: 32207347 DOI: 10.1080/21691401.2019.1699821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Surgical resection remains the preferred approach for some patients with glioblastoma (GBM), and eradication of the residual tumour niche after surgical resection is very helpful for prolonging patient survival. However, complete surgical resection of invasive GBM is difficult because of its ambiguous boundary. Herein, a novel targeting material, c(RGDyk)-poloxamer-188, was synthesized by modifying carboxyl-terminated poloxamer-188 with a glioma-targeting cyclopeptide, c(RGDyk). Quantum dots (QDs) as fluorescent probe were encapsulated into the self-assembled c(RGDyk)-poloxamer-188 polymer nanoparticles (NPs) to construct glioma-targeted QDs-c(RGDyk)NP for imaging-guided surgical resection of GBM. QDs-c(RGDyk)NP exhibited a moderate hydrodynamic diameter of 212.4 nm, a negative zeta potential of -10.1 mV and good stability. QDs-c(RGDyk)NP exhibited significantly lower toxicity against PC12 and C6 cells and HUVECs than free QDs. Moreover, in vitro cellular uptake experiments demonstrated that QDs-c(RGDyk)NP specifically targeted C6 cells, making them display strong fluorescence. Combined with ultrasound-targeted microbubble destruction (UTMD), QDs-c(RGDyk)NP specifically accumulated in glioma tissue in orthotropic tumour rats after intravenous administration, evidenced by ex vivo NIR fluorescence imaging of bulk brain and glioma tissue sections. Furthermore, fluorescence imaging with QDs-c(RGDyk)NP guided accurate surgical resection of glioma. Finally, the safety of QDs-c(RGDyk)NP was verified using pathological HE staining. In conclusion, QDs-c(RGDyk)NP may be a potential imaging probe for imaging-guided surgery.
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Affiliation(s)
- Qi-Long Wu
- Department of Ultrasonography, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou City, Zhejiang Province, China
| | - He-Lin Xu
- Department of Pharmaceutics, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou City, Zhejiang Province, China
| | - Cui Xiong
- Department of Ultrasonography, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou City, Zhejiang Province, China
| | - Qing-Hua Lan
- Department of Pharmaceutics, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou City, Zhejiang Province, China
| | - Ming-Ling Fang
- Department of Ultrasonography, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou City, Zhejiang Province, China
| | - Jin-Hua Cai
- Department of Ultrasonography, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou City, Zhejiang Province, China
| | - Hui Li
- Department of Ultrasonography, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou City, Zhejiang Province, China
| | - Shu-Ting Zhu
- Department of Ultrasonography, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou City, Zhejiang Province, China
| | - Jing-Hong Xu
- Department of Ultrasonography, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou City, Zhejiang Province, China
| | - Fang-Yi Tao
- Department of Ultrasonography, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou City, Zhejiang Province, China
| | - Cui-Tao Lu
- Department of Pharmaceutics, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou City, Zhejiang Province, China
| | - Ying-Zheng Zhao
- Department of Pharmaceutics, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou City, Zhejiang Province, China
| | - Bin Chen
- Department of Ultrasonography, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou City, Zhejiang Province, China
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5
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Spectral analysis of basal cell cancer in vivo. Photodiagnosis Photodyn Ther 2020; 31:101938. [PMID: 32755636 DOI: 10.1016/j.pdpdt.2020.101938] [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: 03/14/2020] [Revised: 07/20/2020] [Accepted: 07/24/2020] [Indexed: 11/22/2022]
Abstract
One of the most important features of optical biopsy methods is its non-invasive nature, high sensitivity and resolution in comparison to traditional diagnostic methods. Optical diagnostic methods, contrary to histopathological tests and biochemical analysis, do not require the collection of tissue samples for analysis, and the amount of analyzed material is practically unlimited. The aim of this study was to evaluate the usefulness of spectral studies in the diagnostics of skin basal cell cancer using a protoptive device in clinical conditions. Each of the subjects was measured 4 times. The measurements were performed on the skin of a patient without a photosensitizer and on the healthy skin on the opposite side of the change in relation to the middle line, also without a photosensitizer. Patients were then given photosensitizer in form of ointment from ALA (Sigma Aldrich, USA) and lubricated with this ointment with occlusal dressing. The patient was examined again 3 h after the application. In each case the measurement time was 1.2 s. Significant differences were observed for the measurements of the sick patient's skin with photosensitizer. Significant differences in spectral curve between 570 and 780 nm were observed.
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Mischkulnig M, Kiesel B, Lötsch D, Roetzer T, Borkovec M, Wadiura LI, Mercea PA, Jaklin FJ, Hervey-Jumper S, Roessler K, Berger MS, Widhalm G, Erhart F. TCGA mRNA Expression Analysis of the Heme Biosynthesis Pathway in Diffusely Infiltrating Gliomas: A Comparison of Typically 5-ALA Fluorescent and Non-Fluorescent Gliomas. Cancers (Basel) 2020; 12:cancers12082043. [PMID: 32722247 PMCID: PMC7466145 DOI: 10.3390/cancers12082043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 12/13/2022] Open
Abstract
5-Aminolevulinic acid (5-ALA) is a fluorescent dye that after metabolization to Protoporphyrin IX (PpIX) by the heme biosynthesis pathway typically leads to visible fluorescence in WHO grade IV but not grade II gliomas. The exact mechanism for high PpIX levels in WHO grade IV gliomas and low PpIX levels in WHO grade II gliomas is not fully clarified. To detect relevant changes in mRNA expression, we performed an in-silico analysis of WHO grade II and IV glioma sequencing datasets provided by The Cancer Genome Atlas (TCGA) to investigate mRNA expression levels of relevant heme biosynthesis genes: Solute Carrier Family 15 Member 1 and 2 (SLC15A1 and SLC15A2), Aminolevulinate-Dehydratase (ALAD), Hydroxymethylbilane-Synthase (HMBS), Uroporphyrinogen-III-Synthase (UROS), Uroporphyrinogen-Decarboxylase (UROD), Coproporphyrinogen-Oxidase (CPOX), Protoporphyrinogen-Oxidase (PPOX), ATP-binding Cassette Subfamily B Member 6 (ABCB6)/G Member 2 (ABCG2) and Ferrochelatase (FECH). Altogether, 258 WHO grade II and 166 WHO grade IV samples were investigated. The mRNA expression levels showed significant differences in 8 of 11 examined genes between WHO grade II and IV gliomas. Significant differences in mRNA expression included increases of HMBS, UROD, FECH and PPOX as well as decreases of SLC15A2, ALAD, UROS and ABCB6 in WHO IV gliomas. Since the majority of changes was found in directions that might actually impair PpIX accumulation in WHO grade IV gliomas, additional studies are needed to analyze the corresponding factors of the heme biosynthesis also on protein level.
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Affiliation(s)
- Mario Mischkulnig
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (M.M.); (B.K.); (D.L.); (M.B.); (L.I.W.); (P.A.M.); (F.J.J.); (K.R.); (F.E.)
- Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University Vienna, 1090 Vienna, Austria;
| | - Barbara Kiesel
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (M.M.); (B.K.); (D.L.); (M.B.); (L.I.W.); (P.A.M.); (F.J.J.); (K.R.); (F.E.)
- Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University Vienna, 1090 Vienna, Austria;
| | - Daniela Lötsch
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (M.M.); (B.K.); (D.L.); (M.B.); (L.I.W.); (P.A.M.); (F.J.J.); (K.R.); (F.E.)
- Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University Vienna, 1090 Vienna, Austria;
| | - Thomas Roetzer
- Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University Vienna, 1090 Vienna, Austria;
- Department of Neurology, Division of Neuropathology and Neurochemistry, Medical University Vienna, 1090 Vienna, Austria
| | - Martin Borkovec
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (M.M.); (B.K.); (D.L.); (M.B.); (L.I.W.); (P.A.M.); (F.J.J.); (K.R.); (F.E.)
- Department of Statistics, Ludwig-Maximilians-University, 80539 Munich, Germany
| | - Lisa I. Wadiura
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (M.M.); (B.K.); (D.L.); (M.B.); (L.I.W.); (P.A.M.); (F.J.J.); (K.R.); (F.E.)
- Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University Vienna, 1090 Vienna, Austria;
| | - Petra A. Mercea
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (M.M.); (B.K.); (D.L.); (M.B.); (L.I.W.); (P.A.M.); (F.J.J.); (K.R.); (F.E.)
- Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University Vienna, 1090 Vienna, Austria;
| | - Florian J. Jaklin
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (M.M.); (B.K.); (D.L.); (M.B.); (L.I.W.); (P.A.M.); (F.J.J.); (K.R.); (F.E.)
| | - Shawn Hervey-Jumper
- Department of Neurological Surgery, University of California, San Francisco, CA 94143, USA; (S.H.-J.); (M.S.B.)
| | - Karl Roessler
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (M.M.); (B.K.); (D.L.); (M.B.); (L.I.W.); (P.A.M.); (F.J.J.); (K.R.); (F.E.)
- Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University Vienna, 1090 Vienna, Austria;
| | - Mitchel S. Berger
- Department of Neurological Surgery, University of California, San Francisco, CA 94143, USA; (S.H.-J.); (M.S.B.)
| | - Georg Widhalm
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (M.M.); (B.K.); (D.L.); (M.B.); (L.I.W.); (P.A.M.); (F.J.J.); (K.R.); (F.E.)
- Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University Vienna, 1090 Vienna, Austria;
- Correspondence: ; Tel.: +43-1-40400-45650
| | - Friedrich Erhart
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (M.M.); (B.K.); (D.L.); (M.B.); (L.I.W.); (P.A.M.); (F.J.J.); (K.R.); (F.E.)
- Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University Vienna, 1090 Vienna, Austria;
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Valli D, Belykh E, Zhao X, Gandhi S, Cavallo C, Martirosyan NL, Nakaji P, Lawton MT, Preul MC. Development of a Simulation Model for Fluorescence-Guided Brain Tumor Surgery. Front Oncol 2019; 9:748. [PMID: 31475107 PMCID: PMC6706957 DOI: 10.3389/fonc.2019.00748] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/25/2019] [Indexed: 12/11/2022] Open
Abstract
Objective: Fluorescence dyes are increasingly used in brain tumor surgeries, and thus the development of simulation models is important for teaching neurosurgery trainees how to perform fluorescence-guided operations. We aimed to create a tumor model for fluorescence-guided surgery in high-grade glioma (HGG). Methods: The tumor model was generated by the following steps: creating a tumor gel with a similar consistency to HGG, selecting fluorophores at optimal concentrations with realistic color, mixing the fluorophores with tumor gel, injecting the gel into fresh pig/sheep brain, and testing resection of the tumor model under a fluorescence microscope. The optimal tumor gel was selected among different combinations of agar and gelatin. The fluorophores included fluorescein, indocyanine green (ICG), europium, chlorin e6 (Ce6), and protoporphyrin IX (PpIX). The tumor model was tested by neurosurgeons and neurosurgery trainees, and a survey was used to assess the validity of the model. In addition, the photobleaching phenomenon was studied to evaluate its influence on fluorescence detection. Results: The best tumor gel formula in terms of consistency and tactile response was created using 100 mL water at 100°C, 0.5 g of agar, and 3 g of gelatin mixed thoroughly for 3 min. An additional 1 g of agar was added when the tumor gel cooled to 50°C. The optimal fluorophore concentration ranges were fluorescein 1.9 × 10−4 to 3.8 × 10−4 mg/mL, ICG 4.9 × 10−3 to 9.8 × 10−3 mg/mL, europium 7.0 × 10−2 to 1.4 × 10−1 mg/mL, Ce6 2.2 × 10−3 to 4.4 × 10−3 mg/mL, and PpIX 1.8 × 10−2 to 3.5 × 10−2 mg/mL. No statistical differences among fluorophores were found for face validity, content validity, and fluorophore preference. Europium, ICG, and fluorescein were shown to be relatively stable during photobleaching experiments, while chlorin e6 and PpIX had lower stability. Conclusions: The model can efficiently highlight the “tumor” with 3 different colors—green, yellow, or infrared green with color overlay. These models showed high face and content validity, although there was no significant difference among the models regarding the degree of simulation and training effectiveness. They are useful educational tools for teaching the key concepts of intra-axial tumor resection techniques, such as subpial dissection and nuances of fluorescence-guided surgery.
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Affiliation(s)
- Daniel Valli
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Xiaochun Zhao
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Sirin Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | | | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
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