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Alcazar P, Avedillo A, Vazquez S, Lopez LB, Fustero D, Moles J, Gonzalez L, Orduna J. The usefulness of intraoperative sodium fluorescein in the surgical treatment of relapsed high-grade brain tumors in pediatric patients. Childs Nerv Syst 2023; 39:1501-1507. [PMID: 36961584 DOI: 10.1007/s00381-023-05930-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/17/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE We report the usefulness of intraoperative sodium fluorescein (SF) in the surgical treatment of relapsed high-grade brain tumors in pediatric neurosurgery. METHODS We describe our protocol for intraoperative SF and three cases of patients between 5 and 11 years diagnosed and surgically treated for relapsed high-grade brain tumors using SF. RESULTS The 560-nm microscope filter enables the use of low doses of this fluorochrome. A dose of 3 mg/kg of patient weight of 10% SF, administered intravenously, is safe and effective in children. The effect of SF was immediate, providing a clear margin between the tumor and healthy tissue, which enabled good tumor resection. We observed no adverse effects in the postoperative period, and the patients evolved satisfactorily. CONCLUSIONS To the best of our knowledge, we describe for the first time the use of fluorescein in reoperations of relapsed high-grade brain tumors in childhood with promising results. Using SF in children is a safe, affordable, and effective technique that offers an excellent intraoperative image, being a feasible option to improve oncological resection. This study is one of the few that uses SF in pediatric neurosurgery, where it could be very beneficial.
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Affiliation(s)
- Paula Alcazar
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain.
| | - Amanda Avedillo
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Silvia Vazquez
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Laura B Lopez
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - David Fustero
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Jesus Moles
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Luis Gonzalez
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Javier Orduna
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
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Sánchez Fernández C, Choque Cuba B, Rivero-Garvía M, de Borja Arteaga Romero F, Márquez Rivas J. Combined microsurgical fluorescence for optimizing resection in refractory empyema and cerebritis. Childs Nerv Syst 2020; 36:1835-1841. [PMID: 32601901 DOI: 10.1007/s00381-020-04762-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/22/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Due to the generalization of new microsurgical equipment, intraoperative fluorescence techniques have extended in neurosurgical practice, mainly in neurovascular and neuro-oncology patients. The aim of identifying pathological tissue and also differentiating from the normal brain helps neurosurgeons to approach other kinds of intracranial entities such as infections. METHODS It is described in the case of an 11-year-old patient who underwent a subdural empyema by performing a craniotomy and evacuation of the purulent collection. After a non-optimal evolution, a frontobasal meningoencephalitis was assessed with cerebral involvement and associated intracranial hypertension. Indocyanine green (ICG) was used in reintervention for demonstrating a great damage of cortical vascularization around the infected area as well as fluorescein (FL), which identified a large area of avascularized tissue. RESULTS Both techniques allowed a selective excision of the affected brain parenchyma while preserving viable parenchymal areas. Radiological evolution and clinical outcome were good. CONCLUSIONS The identification of vascular patterns in brain lesions and the recognition of viable or necrotized tissues are suitable for a selective resection of the parenchyma, minimizing morbidity. Clinical outcome is related to a safe and effective management of inflammatory and infectious processes.
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Affiliation(s)
- Carlos Sánchez Fernández
- Department of Neurosurgery, University Clinical Hospital of Valladolid, Ramón y Cajal 3, St., 47005, Valladolid, Valladolid, Spain.
| | | | - Mónica Rivero-Garvía
- Department of Neurosurgery, University Hospital Vírgen del Rocío, Sevilla, Sevilla, Spain
| | | | - Javier Márquez Rivas
- Department of Neurosurgery, University Hospital Vírgen del Rocío, Sevilla, Sevilla, Spain
- Center for Advanced Neurology, Sevilla, Spain
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Cavallo C, De Laurentis C, Vetrano IG, Falco J, Broggi M, Schiariti M, Ferroli P, Acerbi F. The utilization of fluorescein in brain tumor surgery: a systematic review. J Neurosurg Sci 2018; 62:690-703. [PMID: 29790725 DOI: 10.23736/s0390-5616.18.04480-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Sodium fluorescein (SF) is a green, water-soluble dye with the capacity to accumulate in cerebral areas as a result of damaged blood-brain barrier (BBB); this property allows SF to concentrate specifically at the tumor site of various types of brain neoplasms, making the tumor tissue more clearly visible. EVIDENCE ACQUISITION A literature search (1947-2018) was conducted with the keywords "fluorescein neurosurgery," "YELLOW neurosurgery," "fluorescein brain tumor," "YELLOW brain tumor." We included clinical studies, clinical trials, observational studies, only conducted on humans and concerning surgery; in addition, we have included 3 articles derived from the analysis of the references of other papers. Ultimately, 57 articles were included for further analysis. EVIDENCE SYNTHESIS Fluorescein as a fluorescent tracer in neuro-oncology is gaining a wider acceptance in the neurosurgical literature: until February 1st, 2018, at least 1099 neuro-oncological patients have been operated through fluorescein-assistance, mostly only after 2012. The most important application remains the aim to improve tumor visualization and extent of resection for high-grade gliomas (HGG), but the nonspecific mechanism of action is the theoretical base for its use also for tumors different from HGG. Nevertheless, no homogenous protocol of fluorescein utilization in neurosurgical oncology can be found in literature. CONCLUSIONS Fluorescein-guided surgery is a safe and effective technique to improve visualization and resection of different CNS tumors and conditions, based on BBB alteration, with a growing evidence-based background.
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Affiliation(s)
- Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph Hospital and Medical Center, Phoenix, AZ, USA
| | - Camilla De Laurentis
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Ignazio G Vetrano
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Jacopo Falco
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Morgan Broggi
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Marco Schiariti
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Paolo Ferroli
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Francesco Acerbi
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy -
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Belykh E, Miller EJ, Patel AA, Yazdanabadi MI, Martirosyan NL, Yağmurlu K, Bozkurt B, Byvaltsev VA, Eschbacher JM, Nakaji P, Preul MC. Diagnostic Accuracy of a Confocal Laser Endomicroscope for In Vivo Differentiation Between Normal Injured And Tumor Tissue During Fluorescein-Guided Glioma Resection: Laboratory Investigation. World Neurosurg 2018; 115:e337-e348. [PMID: 29673821 DOI: 10.1016/j.wneu.2018.04.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/06/2018] [Accepted: 04/07/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Glioma resection with fluorescein sodium (FNa) guidance has a potential drawback of nonspecific leakage of FNa from nontumor areas with a compromised blood-brain barrier. We investigated the diagnostic accuracy of in vivo confocal laser endomicroscopy (CLE) after FNa administration to differentiate normal brain, injured normal brain, and tumor tissue in an animal glioma model. METHODS GL261-Luc2 gliomas in C57BL/6 mice were used as a brain tumor model. CLE images of normal, injured normal, and tumor brain tissues were collected after intravenous FNa administration. Correlative sections stained with hematoxylin and eosin were taken at the same sites. A set of 40 CLE images was given to 1 neuropathologist and 3 neurosurgeons to assess diagnostic accuracy and rate image quality (1-10 scale). Additionally, we developed a deep convolution neural network (DCNN) model for automatic image classification. RESULTS The mean observer accuracy for correct diagnosis of glioma compared with either injured or uninjured brain using CLE images was 85%, and the DCNN model accuracy was 80%. For differentiation of tumor from nontumor tissue, the experts' mean accuracy, specificity, and sensitivity were 90%, 86%, and 96%, respectively, with high interobserver agreement overall (Cohen κ = 0.74). The percentage of correctly identified images was significantly higher for images with a quality rating >5 (104/116, 90%) than for images with a quality rating ≤5 (32/44, 73%) (P = 0.007). CONCLUSIONS With sufficient FNa present in tissues, CLE was an effective tool for intraoperative differentiation among normal, injured normal, and tumor brain tissue. Clinical studies are warranted to confirm these findings.
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Affiliation(s)
- Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Irkutsk State Medical University, Irkutsk, Russia
| | - Eric J Miller
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Arpan A Patel
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | | | - Nikolay L Martirosyan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kaan Yağmurlu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Baran Bozkurt
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | | | - Jennifer M Eschbacher
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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