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Black D, Byrne D, Walke A, Liu S, Di Ieva A, Kaneko S, Stummer W, Salcudean T, Suero Molina E. Towards machine learning-based quantitative hyperspectral image guidance for brain tumor resection. COMMUNICATIONS MEDICINE 2024; 4:131. [PMID: 38965358 PMCID: PMC11224305 DOI: 10.1038/s43856-024-00562-3] [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: 07/19/2023] [Accepted: 06/25/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Complete resection of malignant gliomas is hampered by the difficulty in distinguishing tumor cells at the infiltration zone. Fluorescence guidance with 5-ALA assists in reaching this goal. Using hyperspectral imaging, previous work characterized five fluorophores' emission spectra in most human brain tumors. METHODS In this paper, the effectiveness of these five spectra was explored for different tumor and tissue classification tasks in 184 patients (891 hyperspectral measurements) harboring low- (n = 30) and high-grade gliomas (n = 115), non-glial primary brain tumors (n = 19), radiation necrosis (n = 2), miscellaneous (n = 10) and metastases (n = 8). Four machine-learning models were trained to classify tumor type, grade, glioma margins, and IDH mutation. RESULTS Using random forests and multilayer perceptrons, the classifiers achieve average test accuracies of 84-87%, 96.1%, 86%, and 91% respectively. All five fluorophore abundances vary between tumor margin types and tumor grades (p < 0.01). For tissue type, at least four of the five fluorophore abundances are significantly different (p < 0.01) between all classes. CONCLUSIONS These results demonstrate the fluorophores' differing abundances in different tissue classes and the value of the five fluorophores as potential optical biomarkers, opening new opportunities for intraoperative classification systems in fluorescence-guided neurosurgery.
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Affiliation(s)
- David Black
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Declan Byrne
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Anna Walke
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Sidong Liu
- Computational NeuroSurgery (CNS) Lab, Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Antonio Di Ieva
- Computational NeuroSurgery (CNS) Lab, Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Sadahiro Kaneko
- Department of Neurosurgery, Hokkaido Medical Center, National Hospital Organization, Sapporo, Japan
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Tim Salcudean
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Eric Suero Molina
- Department of Neurosurgery, University Hospital Münster, Münster, Germany.
- Computational NeuroSurgery (CNS) Lab, Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia.
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Sarkis HM, Zawy Alsofy S, Stroop R, Lewitz M, Schipmann S, Unnewehr M, Paulus W, Nakamura M, Ewelt C. Does 5-ALA Fluorescence Microscopy Improve Complete Resectability in Cerebral/Cerebellar Metastatic Surgery? A Retrospective Data Analysis from a Cranial Center. Cancers (Basel) 2024; 16:2242. [PMID: 38927947 PMCID: PMC11201798 DOI: 10.3390/cancers16122242] [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: 04/16/2024] [Revised: 05/18/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
(1) Background: In this study, the intraoperative fluorescence behavior of brain metastases after the administration of 5-aminolevulinic acid (5-ALA) was analyzed. The aim was to investigate whether the resection of brain metastases using 5-ALA fluorescence also leads to a more complete resections and thus to a prolongation of survival; (2) Methods: The following variables have been considered: age, sex, number of metastases, localization, involvement of eloquent area, correlation between fluorescence and primary tumor/subtype, resection, and survival time. The influence on the degree of resection was determined with a control MRI within the first three postoperative days; (3) Results: Brain metastases fluoresced in 57.5% of cases. The highest fluorescence rates of 73.3% were found in breast carcinoma metastases and the histologic subtype adenocarcinoma (68.1%). No correlation between fluorescence behavior and localization, primary tumor, or histological subtype was found. Complete resection was detected in 82.5%, of which 56.1% were fluorescence positive. There was a trend towards improved resectability (increase of 12.1%) and a significantly longer survival time (p = 0.009) in the fluorescence-positive group; (4) Conclusions: 5-ALA-assisted extirpation leads to a more complete resection and longer survival and can therefore represent a low-risk addition to modern surgery for brain metastases.
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Affiliation(s)
- Hraq Mourad Sarkis
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (H.M.S.); (R.S.); (M.L.); (M.U.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany;
- Department of Neurosurgery, St. Marien-Hospital, Academic Hospital of the Hannover Medical School, 49076 Osnabrueck, Germany
| | - Samer Zawy Alsofy
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (H.M.S.); (R.S.); (M.L.); (M.U.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany;
| | - Ralf Stroop
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (H.M.S.); (R.S.); (M.L.); (M.U.)
| | - Marc Lewitz
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (H.M.S.); (R.S.); (M.L.); (M.U.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany;
| | - Stephanie Schipmann
- Department of Neurosurgery, University Hospital Muenster, 48149 Muenster, Germany;
| | - Markus Unnewehr
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (H.M.S.); (R.S.); (M.L.); (M.U.)
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Muenster, 48149 Muenster, Germany;
| | - Makoto Nakamura
- Department of Neurosurgery, Academic Hospital Koeln-Merheim, Witten/Herdecke University, 51109 Koeln, Germany;
| | - Christian Ewelt
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany;
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Walke A, Krone C, Stummer W, König S, Suero Molina E. Protoporphyrin IX in serum of high-grade glioma patients: A novel target for disease monitoring via liquid biopsy. Sci Rep 2024; 14:4297. [PMID: 38383693 PMCID: PMC10881484 DOI: 10.1038/s41598-024-54478-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 02/12/2024] [Indexed: 02/23/2024] Open
Abstract
High-grade gliomas (HGG) carry a dismal prognosis. Diagnosis comprises MRI followed by histopathological evaluation of tissue; no blood biomarker is available. Patients are subjected to serial MRIs and, if unclear, surgery for monitoring of tumor recurrence, which is laborious. MRI provides only limited diagnostic information regarding the differentiation of true tumor progression from therapy-associated side effects. 5-aminolevulinic acid (5-ALA) is routinely used for induction of protoporphyrin IX (PpIX) accumulation in malignant glioma tissue, enabling improved tumor visualization during fluorescence-guided resection (FGR). We investigated whether PpIX can also serve as a serum HGG marker to monitor relapse. Patients (HGG: n = 23 primary, pHGG; n = 5 recurrent, rHGG) undergoing FGR received 5-ALA following standard clinical procedure. The control group of eight healthy volunteers (HCTR) also received 5-ALA. Serum was collected before and repeatedly up to 72 h after drug administration. Significant PpIX accumulation in HGG was observed after 5-ALA administration (ANOVA: p = 0.005, post-hoc: HCTR vs. pHGG p = 0.029, HCTR vs. rHGG p = 0.006). Separation of HCTR from pHGG was possible when maximum serum PpIX levels were reached (CI95% of tMax). ROC analysis of serum PpIX within CI95% of tMax showed successful classification of HCTR and pHGG (AUCROC 0.943, CI95% 0.884-1.000, p < 0.001); the optimal cut-off for diagnosis was 1275 pmol PpIX/ml serum, reaching 87.0% accuracy, 90.5% positive predictive and 84.0% negative predictive value. Baseline PpIX level was similar in patient and control groups. Thus, 5-ALA is required for PpIX induction, which is safe at the standard clinical dosage. PpIX is a new target for liquid biopsy in glioma. More extensive clinical studies are required to characterize its full potential.
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Affiliation(s)
- Anna Walke
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany.
- Core Unit Proteomics, Interdisciplinary Centre for Clinical Research, University of Münster, Münster, Germany.
| | - Christopher Krone
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
| | - Simone König
- Core Unit Proteomics, Interdisciplinary Centre for Clinical Research, University of Münster, Münster, Germany
| | - Eric Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany.
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Filip P, Lerner DK, Kominsky E, Schupper A, Liu K, Khan NM, Roof S, Hadjipanayis C, Genden E, Iloreta AMC. 5-Aminolevulinic Acid Fluorescence-Guided Surgery in Head and Neck Squamous Cell Carcinoma. Laryngoscope 2024; 134:741-748. [PMID: 37540051 DOI: 10.1002/lary.30910] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVES To determine the utility of 5-aminolevulinic acid (5-ALA) fluorescence for resection of head and neck carcinoma. METHODS In this prospective pilot trial, 5-ALA was administered as an oral suspension 3-5 h prior to induction of anesthesia for resection of head and neck squamous cell carcinoma (HNSCC). Following resection, 405 nm blue light was applied, and fluorescence of the tumor as well as the surgical bed was recorded. Specimen fluorescence intensity was graded categorically as none (score = 0), mild (1), moderate (2), or robust (3) by the operating surgeon intraoperatively and corroborated with final pathologic diagnosis. RESULTS Seven patients underwent resection with 5-ALA. Five (83%) were male with an age range of 33-82 years (mean = 60). Sites included nasal cavity (n = 3), oral cavity (n = 3), and the larynx (n = 1). All specimens demonstrated robust fluorescence when 5-ALA was administered 3-5 h preoperatively. 5-ALA fluorescence predicted the presence of perineural invasion, a positive margin, and metastatic lymphadenopathy. Two patients had acute photosensitivity reactions, and one patient had a temporary elevation of hepatic enzymes. CONCLUSIONS 5-ALA induces robust intraoperative fluorescence of HNSCC, capable of demonstrating a positive margin, perineural invasion, and metastatic nodal disease. Although no conclusions are there about the safety of this drug in the head and neck cancer population, our study parallels the extensive safety data in the neurosurgical literature. Future applications may include intraoperative assessment of margin status, diagnostic accuracy, and impacts on survival. LEVEL OF EVIDENCE 4 Laryngoscope, 134:741-748, 2024.
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Affiliation(s)
- Peter Filip
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | - David K Lerner
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | - Evan Kominsky
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | - Alexander Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | - Katherine Liu
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | - Nazir Mohemmed Khan
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | - Scott Roof
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | | | - Eric Genden
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | - Alfred M C Iloreta
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
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Gautheron A, Bernstock JD, Picart T, Guyotat J, Valdés PA, Montcel B. 5-ALA induced PpIX fluorescence spectroscopy in neurosurgery: a review. Front Neurosci 2024; 18:1310282. [PMID: 38348134 PMCID: PMC10859467 DOI: 10.3389/fnins.2024.1310282] [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: 10/09/2023] [Accepted: 01/02/2024] [Indexed: 02/15/2024] Open
Abstract
The review begins with an overview of the fundamental principles/physics underlying light, fluorescence, and other light-matter interactions in biological tissues. It then focuses on 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX) fluorescence spectroscopy methods used in neurosurgery (e.g., intensity, time-resolved) and in so doing, describe their specific features (e.g., hardware requirements, main processing methods) as well as their strengths and limitations. Finally, we review current clinical applications and future directions of 5-ALA-induced protoporphyrin IX (PpIX) fluorescence spectroscopy in neurosurgery.
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Affiliation(s)
- A. Gautheron
- Université Jean Monnet Saint-Etienne, CNRS, Institut d Optique Graduate School, Laboratoire Hubert Curien UMR 5516, Saint-Étienne, France
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1294, Lyon, France
| | - J. D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - T. Picart
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, INSERM 1052, CNRS 5286, Lyon, France
| | - J. Guyotat
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | - P. A. Valdés
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, United States
- Department of Neurobiology, University of Texas Medical Branch, Galveston, TX, United States
- Department of Electrical and Computer Engineering, Rice University, Houston, TX, United States
| | - B. Montcel
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1294, Lyon, France
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6
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Suero Molina E, Black D, Walke A, Azemi G, D’Alessandro F, König S, Stummer W. Unraveling the blue shift in porphyrin fluorescence in glioma: The 620 nm peak and its potential significance in tumor biology. Front Neurosci 2023; 17:1261679. [PMID: 38027504 PMCID: PMC10657867 DOI: 10.3389/fnins.2023.1261679] [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: 07/19/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
In glioma surgery, the low-density infiltration zone of tumors is difficult to detect by any means. While, for instance, 5-aminolevulinic acid (5-ALA)-induced fluorescence is a well-established surgical procedure for maximizing resection of malignant gliomas, a cell density in tumor tissue of 20-30% is needed to observe visual fluorescence. Hyperspectral imaging is a powerful technique for the optical characterization of brain tissue, which accommodates the complex spectral properties of gliomas. Thereby, knowledge about the signal source is essential to generate specific separation (unmixing) procedures for the different spectral characteristics of analytes and estimate compound abundances. It was stated that protoporphyrin IX (PpIX) fluorescence consists mainly of emission peaks at 634 nm (PpIX634) and 620 nm (PpIX620). However, other members of the substance group of porphyrins fluoresce similarly to PpIX due to their common tetrapyrrole core structure. While the PpIX634 signal has reliably been assigned to PpIX, it has not yet been analyzed if PpIX620 might result from a different porphyrin rather than being a second photo state of PpIX. We thus reviewed more than 200,000 spectra from various tumors measured in almost 600 biopsies of 130 patients. Insufficient consideration of autofluorescence led to artificial inflation of the PpIX620 peak in the past. Recently, five basis spectra (PpIX634, PpIX620, flavin, lipofuscin, and NADH) were described and incorporated into the analysis algorithm, which allowed more accurate unmixing of spectral abundances. We used the improved algorithm to investigate the PpIX620 signal more precisely and investigated coproporphyrin III (CpIII) fluorescence phantoms for spectral unmixing. Our findings show that the PpIX634 peak was the primary source of the 5-ALA-induced fluorescence. CpIII had a similar spectral characteristic to PpIX620. The supplementation of 5-ALA may trigger the increased production of porphyrins other than PpIX within the heme biosynthesis pathway, including that of CpIII. It is essential to correctly separate autofluorescence from the main PpIX634 peak to analyze the fluorescence signal. This article highlights the need for a comprehensive understanding of the spectral complexity in gliomas and suggests less significance of the 620 nm fluorescence peak for PpIX analysis and visualization.
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Affiliation(s)
- Eric Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
- Computational NeuroSurgery (CNS) Lab, Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - David Black
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Anna Walke
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
- Core Unit Proteomics, Interdisciplinary Centre for Clinical Research, University of Münster, Münster, Germany
| | - Ghasem Azemi
- Computational NeuroSurgery (CNS) Lab, Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Fabio D’Alessandro
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
- Core Unit Proteomics, Interdisciplinary Centre for Clinical Research, University of Münster, Münster, Germany
| | - Simone König
- Core Unit Proteomics, Interdisciplinary Centre for Clinical Research, University of Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
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Schaufler A, Sanin AY, Sandalcioglu IE, Hartmann K, Croner RS, Perrakis A, Wartmann T, Boese A, Kahlert UD, Fischer I. Concept of a fully-implantable system to monitor tumor recurrence. Sci Rep 2023; 13:16362. [PMID: 37773315 PMCID: PMC10541913 DOI: 10.1038/s41598-023-43226-3] [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: 04/12/2023] [Accepted: 09/21/2023] [Indexed: 10/01/2023] Open
Abstract
Current treatment for glioblastoma includes tumor resection followed by radiation, chemotherapy, and periodic post-operative examinations. Despite combination therapies, patients face a poor prognosis and eventual recurrence, which often occurs at the resection site. With standard MRI imaging surveillance, histologic changes may be overlooked or misinterpreted, leading to erroneous conclusions about the course of adjuvant therapy and subsequent interventions. To address these challenges, we propose an implantable system for accurate continuous recurrence monitoring that employs optical sensing of fluorescently labeled cancer cells and is implanted in the resection cavity during the final stage of tumor resection. We demonstrate the feasibility of the sensing principle using miniaturized system components, optical tissue phantoms, and porcine brain tissue in a series of experimental trials. Subsequently, the system electronics are extended to include circuitry for wireless energy transfer and power management and verified through electromagnetic field, circuit simulations and test of an evaluation board. Finally, a holistic conceptual system design is presented and visualized. This novel approach to monitor glioblastoma patients is intended to early detect recurrent cancerous tissue and enable personalization and optimization of therapy thus potentially improving overall prognosis.
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Affiliation(s)
- Anna Schaufler
- Molecular and Experimental Surgery, Clinic for General-, Visceral-, Vascular - and Transplant Surgery, Faculty of Medicine, Otto-von-Guericke University Magdeburg, 39120, Magdeburg, Germany
- Department of Neurosurgery, Otto-von-Guericke University Magdeburg, 39120, Magdeburg, Germany
- INKA Health Tech Innovation Lab., Medical Faculty, Otto-von-Guericke University Magdeburg, 39120, Magdeburg, Germany
| | - Ahmed Y Sanin
- Molecular and Experimental Surgery, Clinic for General-, Visceral-, Vascular - and Transplant Surgery, Faculty of Medicine, Otto-von-Guericke University Magdeburg, 39120, Magdeburg, Germany
- Research Campus STIMULATE, Otto-von-Guericke University Magdeburg, 39120, Magdeburg, Germany
| | - I Erol Sandalcioglu
- Department of Neurosurgery, Otto-von-Guericke University Magdeburg, 39120, Magdeburg, Germany
| | - Karl Hartmann
- Department of Neurosurgery, Otto-von-Guericke University Magdeburg, 39120, Magdeburg, Germany
| | - Roland S Croner
- Molecular and Experimental Surgery, Clinic for General-, Visceral-, Vascular - and Transplant Surgery, Faculty of Medicine, Otto-von-Guericke University Magdeburg, 39120, Magdeburg, Germany
| | - Aristotelis Perrakis
- Molecular and Experimental Surgery, Clinic for General-, Visceral-, Vascular - and Transplant Surgery, Faculty of Medicine, Otto-von-Guericke University Magdeburg, 39120, Magdeburg, Germany
| | - Thomas Wartmann
- Molecular and Experimental Surgery, Clinic for General-, Visceral-, Vascular - and Transplant Surgery, Faculty of Medicine, Otto-von-Guericke University Magdeburg, 39120, Magdeburg, Germany
| | - Axel Boese
- INKA Health Tech Innovation Lab., Medical Faculty, Otto-von-Guericke University Magdeburg, 39120, Magdeburg, Germany
| | - Ulf D Kahlert
- Molecular and Experimental Surgery, Clinic for General-, Visceral-, Vascular - and Transplant Surgery, Faculty of Medicine, Otto-von-Guericke University Magdeburg, 39120, Magdeburg, Germany
- Research Campus STIMULATE, Otto-von-Guericke University Magdeburg, 39120, Magdeburg, Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225, Düsseldorf, Germany.
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8
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García-Montaño LA, Licón-Muñoz Y, Martinez FJ, Keddari YR, Ziemke MK, Chohan MO, Piccirillo SG. Dissecting Intra-tumor Heterogeneity in the Glioblastoma Microenvironment Using Fluorescence-Guided Multiple Sampling. Mol Cancer Res 2023; 21:755-767. [PMID: 37255362 PMCID: PMC10390891 DOI: 10.1158/1541-7786.mcr-23-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/25/2023] [Accepted: 05/05/2023] [Indexed: 05/10/2023]
Abstract
The treatment of the most aggressive primary brain tumor in adults, glioblastoma (GBM), is challenging due to its heterogeneous nature, invasive potential, and poor response to chemo- and radiotherapy. As a result, GBM inevitably recurs and only a few patients survive 5 years post-diagnosis. GBM is characterized by extensive phenotypic and genetic heterogeneity, creating a diversified genetic landscape and a network of biological interactions between subclones, ultimately promoting tumor growth and therapeutic resistance. This includes spatial and temporal changes in the tumor microenvironment, which influence cellular and molecular programs in GBM and therapeutic responses. However, dissecting phenotypic and genetic heterogeneity at spatial and temporal levels is extremely challenging, and the dynamics of the GBM microenvironment cannot be captured by analysis of a single tumor sample. In this review, we discuss the current research on GBM heterogeneity, in particular, the utility and potential applications of fluorescence-guided multiple sampling to dissect phenotypic and genetic intra-tumor heterogeneity in the GBM microenvironment, identify tumor and non-tumor cell interactions and novel therapeutic targets in areas that are key for tumor growth and recurrence, and improve the molecular classification of GBM.
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Affiliation(s)
- Leopoldo A. García-Montaño
- The Brain Tumor Translational Laboratory, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico
| | - Yamhilette Licón-Muñoz
- The Brain Tumor Translational Laboratory, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico
| | - Frank J. Martinez
- The Brain Tumor Translational Laboratory, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico
| | - Yasine R. Keddari
- The Brain Tumor Translational Laboratory, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- University of California, Merced, California
| | - Michael K. Ziemke
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Muhammad O. Chohan
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Sara G.M. Piccirillo
- The Brain Tumor Translational Laboratory, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico
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Kim HM, Lee MH, Lee TK. Delayed Detection of a 5-Aminolevulinic Acid In Vivo: A Case of Metastatic Breast Cancer. Brain Tumor Res Treat 2023; 11:216-218. [PMID: 37550822 PMCID: PMC10409620 DOI: 10.14791/btrt.2023.0014] [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: 04/07/2023] [Revised: 05/31/2023] [Accepted: 06/26/2023] [Indexed: 08/09/2023] Open
Abstract
A 44-year-old female patient who had been diagnosed with breast cancer visited our oncology department. She had developed right-side weakness and mild dysarthria, and MRI revealed a 4-cm cystic-enhancing lesion in her left frontal lobe. Her surgery was postponed 48 hours after receiving 5-aminolevulinic acid (5-ALA), because a problem with thyroid function that had not been noticed before was discovered. The main lesion was enhanced on navigation and appeared to be a gross tumor; its 5-ALA uptake was very high. Specimens obtained from this location were histologically confirmed to contain tumor cells. The operation was completed, and removal of all enhancing lesions was confirmed by MRI within 24 hours postoperatively. The pathology report confirmed metastatic ductal carcinoma. The clinical efficacy of 5-ALA was confirmed even 48 hours after administration into a metastatic brain tumor from breast cancer.
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Affiliation(s)
- Hyung Min Kim
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Ho Lee
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Tae-Kyu Lee
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Korea
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10
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Howley R, Chandratre S, Chen B. 5-Aminolevulinic Acid as a Theranostic Agent for Tumor Fluorescence Imaging and Photodynamic Therapy. Bioengineering (Basel) 2023; 10:bioengineering10040496. [PMID: 37106683 PMCID: PMC10136048 DOI: 10.3390/bioengineering10040496] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023] Open
Abstract
5-Aminolevulinic acid (ALA) is a naturally occurring amino acid synthesized in all nucleated mammalian cells. As a porphyrin precursor, ALA is metabolized in the heme biosynthetic pathway to produce protoporphyrin IX (PpIX), a fluorophore and photosensitizing agent. ALA administered exogenously bypasses the rate-limit step in the pathway, resulting in PpIX accumulation in tumor tissues. Such tumor-selective PpIX disposition following ALA administration has been exploited for tumor fluorescence diagnosis and photodynamic therapy (PDT) with much success. Five ALA-based drugs have now received worldwide approval and are being used for managing very common human (pre)cancerous diseases such as actinic keratosis and basal cell carcinoma or guiding the surgery of bladder cancer and high-grade gliomas, making it the most successful drug discovery and development endeavor in PDT and photodiagnosis. The potential of ALA-induced PpIX as a fluorescent theranostic agent is, however, yet to be fully fulfilled. In this review, we would like to describe the heme biosynthesis pathway in which PpIX is produced from ALA and its derivatives, summarize current clinical applications of ALA-based drugs, and discuss strategies for enhancing ALA-induced PpIX fluorescence and PDT response. Our goal is two-fold: to highlight the successes of ALA-based drugs in clinical practice, and to stimulate the multidisciplinary collaboration that has brought the current success and will continue to usher in more landmark advances.
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Affiliation(s)
- Richard Howley
- Department of Pharmaceutical Sciences, Philadelphia College of Pharmacy, Saint Joseph's University, Philadelphia, PA 19104, USA
| | - Sharayu Chandratre
- Department of Pharmaceutical Sciences, Philadelphia College of Pharmacy, Saint Joseph's University, Philadelphia, PA 19104, USA
| | - Bin Chen
- Department of Pharmaceutical Sciences, Philadelphia College of Pharmacy, Saint Joseph's University, Philadelphia, PA 19104, USA
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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11
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Walke A, Black D, Valdes PA, Stummer W, König S, Suero-Molina E. Challenges in, and recommendations for, hyperspectral imaging in ex vivo malignant glioma biopsy measurements. Sci Rep 2023; 13:3829. [PMID: 36882505 PMCID: PMC9992662 DOI: 10.1038/s41598-023-30680-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 02/28/2023] [Indexed: 03/09/2023] Open
Abstract
The visualization of protoporphyrin IX (PPIX) fluorescence with the help of surgical microscopes during 5-aminolevulinic acid-mediated fluorescence-guided resection (FGR) of gliomas is still limited at the tumor margins. Hyperspectral imaging (HI) detects PPIX more sensitively but is not yet ready for intraoperative use. We illustrate the current status with three experiments and summarize our own experience using HI: (1) assessment of HI analysis algorithm using pig brain tissue, (2) a partially retrospective evaluation of our experience from HI projects, and (3) device comparison of surgical microscopy and HI. In (1), we address the problem that current algorithms for evaluating HI data are based on calibration with liquid phantoms, which have limitations. Their pH is low compared to glioma tissue; they provide only one PPIX photo state and only PPIX as fluorophore. Testing the HI algorithm with brain homogenates, we found proper correction for optical properties but not pH. Considerably more PPIX was measured at pH 9 than at pH 5. In (2), we indicate pitfalls and guide HI application. In (3), we found HI superior to the microscope for biopsy diagnosis (AUC = 0.845 ± 0.024 (cut-off 0.75 µg PPIX/ml) vs. 0.710 ± 0.035). HI thus offers potential for improved FGR.
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Affiliation(s)
- Anna Walke
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany.,Core Unit Proteomics, Interdisciplinary Centre for Clinical Research, University of Münster, Münster, Germany
| | - David Black
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, Canada
| | - Pablo A Valdes
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
| | - Simone König
- Core Unit Proteomics, Interdisciplinary Centre for Clinical Research, University of Münster, Münster, Germany
| | - Eric Suero-Molina
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany.
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12
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Ochoa M, Smith JT, Gao S, Intes X. Computational macroscopic lifetime imaging and concentration unmixing of autofluorescence. JOURNAL OF BIOPHOTONICS 2022; 15:e202200133. [PMID: 36546622 PMCID: PMC10026351 DOI: 10.1002/jbio.202200133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/06/2022] [Accepted: 07/12/2022] [Indexed: 06/17/2023]
Abstract
Single-pixel computational imaging can leverage highly sensitive detectors that concurrently acquire data across spectral and temporal domains. For molecular imaging, such methodology enables to collect rich intensity and lifetime multiplexed fluorescence datasets. Herein we report on the application of a single-pixel structured light-based platform for macroscopic imaging of tissue autofluorescence. The super-continuum visible excitation and hyperspectral single-pixel detection allow for parallel characterization of autofluorescence intensity and lifetime. Furthermore, we exploit a deep learning based data processing pipeline, to perform autofluorescence unmixing while yielding the autofluorophores' concentrations. The full scheme (setup and processing) is validated in silico and in vitro with clinically relevant autofluorophores flavin adenine dinucleotide, riboflavin, and protoporphyrin. The presented results demonstrate the potential of the methodology for macroscopically quantifying the intensity and lifetime of autofluorophores, with higher specificity for cases of mixed emissions, which are ubiquitous in autofluorescence and multiplexed in vivo imaging.
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Affiliation(s)
- Marien Ochoa
- Center for Modeling, Simulation and Imaging in Medicine (CeMSIM), Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Jason T Smith
- Center for Modeling, Simulation and Imaging in Medicine (CeMSIM), Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Shan Gao
- Center for Modeling, Simulation and Imaging in Medicine (CeMSIM), Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Xavier Intes
- Center for Modeling, Simulation and Imaging in Medicine (CeMSIM), Rensselaer Polytechnic Institute, Troy, New York, USA
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13
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McCracken DJ, Schupper AJ, Lakomkin N, Malcolm J, Painton Bray D, Hadjipanayis CG. Turning on the light for brain tumor surgery: A 5-aminolevulinic acid story. Neuro Oncol 2022; 24:S52-S61. [PMID: 36322101 PMCID: PMC9629477 DOI: 10.1093/neuonc/noac191] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
To aid surgeons in more complete and safe resection of brain tumors, adjuvant technologies have been developed to improve visualization of target tissue. Fluorescence-guided surgery relies on the use of fluorophores and specific light wavelengths to better delineate tumor tissue, inflammation, and areas of blood-brain barrier breakdown. 5-aminolevulinic acid (5-ALA), the first fluorophore developed specifically for brain tumors, accumulates within tumor cells, improving visualization of tumors both at the core, and infiltrative margin. Here, we describe the background of how 5-ALA integrated into the modern neurosurgery practice, clinical evidence for the current use of 5-ALA, and future directions for its role in neurosurgical oncology. Maximal safe resection remains the standard of care for most brain tumors. Gross total resection of high-grade gliomas (HGGs) is associated with greater overall survival and progression-free survival (PFS) in comparison to subtotal resection or adjuvant treatment therapies alone.1-3 A major challenge neurosurgeons encounter when resecting infiltrative gliomas is identification of the glioma tumor margin to perform a radical resection while avoiding and preserving eloquent regions of the brain. 5-aminolevulinic acid (5-ALA) remains the only optical-imaging agent approved by the FDA for use in glioma surgery and identification of tumor tissue.4 A multicenter randomized, controlled trial revealed that 5-ALA fluorescence-guided surgery (FGS) almost doubled the extent of tumor resection and also improved 6-month PFS.5 In this review, we will highlight the current evidence for use of 5-ALA FGS in brain tumor surgery, as well as discuss the future directions for its use.
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Affiliation(s)
- David J McCracken
- Department of Neurosurgery, Piedmont Healthcare, Atlanta, Georgia, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Nikita Lakomkin
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - James Malcolm
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | - Constantinos G Hadjipanayis
- Corresponding Author: Constantinos G. Hadjipanayis, MD, PhD, Mount Sinai Union Square, 10 Union Square East, Suite 5E, New York, NY 10003, USA ()
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14
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Suero Molina E, Black D, Kaneko S, Müther M, Stummer W. Double dose of 5-aminolevulinic acid and its effect on protoporphyrin IX accumulation in low-grade glioma. J Neurosurg 2022; 137:943-952. [PMID: 35213830 DOI: 10.3171/2021.12.jns211724] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 12/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Administration of 5-aminolevulinic acid (5-ALA) does not regularly elicit fluorescence in low-grade glioma (LGG) at currently established doses and timing of administration. One explanation may be differences in blood-brain barrier (BBB) integrity compared to high-grade glioma. The authors hypothesized that for a BBB semipermeable to 5-ALA there might be a relationship between plasma 5-ALA concentration and its movement into the brain. A higher dose would elicit more 5-ALA conversion into protoporphyrin IX (PPIX). The authors present a case series of patients harboring LGG who received higher doses of 5-ALA. METHODS Patients undergoing surgery for indeterminate glioma later diagnosed as LGG were included in this study. 5-ALA was administered at a standard dose of 20 mg/kg body weight (bw) 4 hours prior to induction of anesthesia. A subgroup of patients received a higher dose of 40 mg/kg bw. Fluorescence was evaluated visually and PPIX concentration (cPPIX) was determined ex vivo by hyperspectral measurements in freshly extracted tissue. All adverse events were recorded. RESULTS A total of 23 patients harboring diffuse low-grade astrocytomas (n = 19) and oligodendrogliomas (n = 4) were analyzed. Thirteen patients received 20 mg/kg bw, and 10 patients received 40 mg/kg bw of 5-ALA. In the 20 mg/kg group, 30.8% (4 of 13) of tumors harbored areas of visible fluorescence, compared to 60% of cases (n = 6 of 10) with 40 mg/kg bw. The threshold to visibility was 1 μg/ml in both groups. Measured over all biopsies, the mean cPPIX was significantly higher in the double-dose group (1.8 vs 0.45 μg/ml; p < 0.001). In non-visibly fluorescent tissue the mean cPPIX was 0.146 μg/ml in the 20 mg/kg and 0.347 μg/ml in the 40 mg/kg group, indicating an increase of 138% (p < 0.001). CONCLUSIONS These observations demonstrate different regions with different levels of PPIX accumulation in LGG. With higher 5-ALA doses cPPIX increases, leading to more regions surpassing the visibility threshold of 1 μg/ml. These observations can be explained by the fact that the BBB in LGG is semipermeable to 5-ALA. Higher 5-ALA doses result in more PPIX conversion, an observation with implications for future dosing in LGG.
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Affiliation(s)
| | - David Black
- 2Carl Zeiss Meditec AG, Oberkochen, Germany
- 3Department of Physics and Astronomy, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - Sadahiro Kaneko
- 1Department of Neurosurgery, University Hospital of Münster
- 4Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Michael Müther
- 1Department of Neurosurgery, University Hospital of Münster
| | - Walter Stummer
- 1Department of Neurosurgery, University Hospital of Münster
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15
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Li G, Rodrigues A, Kim L, Garcia C, Jain S, Zhang M, Hayden-Gephart M. 5-Aminolevulinic Acid Imaging of Malignant Glioma. Surg Oncol Clin N Am 2022; 31:581-593. [DOI: 10.1016/j.soc.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Ahrens LC, Krabbenhøft MG, Hansen RW, Mikic N, Pedersen CB, Poulsen FR, Korshoej AR. Effect of 5-Aminolevulinic Acid and Sodium Fluorescein on the Extent of Resection in High-Grade Gliomas and Brain Metastasis. Cancers (Basel) 2022; 14:cancers14030617. [PMID: 35158885 PMCID: PMC8833379 DOI: 10.3390/cancers14030617] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Surgery is essential in the treatment of high-grade gliomas (HGG) and gross total resection (GTR) is known to increase the overall survival and progression-free survival. Several studies have shown that fluorescence-guided surgery with 5-aminolevulinic acid (5-ALA) increases GTR considerably compared to white light surgery (65% vs. 36%). In recent years, sodium fluorescein (SF) has become an increasingly popular agent for fluorescence-guided surgery due to numerous utility benefits compared to 5-ALA, including lower cost, non-toxicity, easy administration during surgery and a wide indication range covering all contrast-enhancing lesions with disruption of the blood-brain barrier in the CNS. However, currently, SF is an off-label agent and the level of evidence for use in HGG surgery is inferior compared to 5-ALA. Here, we give an update and review the latest literature on fluorescence-guided surgery with 5-ALA and SF for brain tumors with emphasis on fluorescence-guided surgery in HGG and brain metastases. Further, we assess the advantages and disadvantages of both fluorophores and discuss their future perspectives.
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Affiliation(s)
- Lasse Cramer Ahrens
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, J618, DK8200 Aarhus, Denmark; (M.G.K.); (N.M.)
- Correspondence: (L.C.A.); (A.R.K.); Tel.: +45-(20)-254418 (L.C.A.)
| | - Mathias Green Krabbenhøft
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, J618, DK8200 Aarhus, Denmark; (M.G.K.); (N.M.)
| | - Rasmus Würgler Hansen
- Department of Neurosurgery, Odense University Hospital, DK5000 Odense, Denmark; (R.W.H.); (C.B.P.); (F.R.P.)
| | - Nikola Mikic
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, J618, DK8200 Aarhus, Denmark; (M.G.K.); (N.M.)
- Department of Clinical Medicine, Aarhus University, Incuba Skejby, Building 2, Palle Juul-Jensens Boulevard 82, J618, DK8200 Aarhus, Denmark
| | - Christian Bonde Pedersen
- Department of Neurosurgery, Odense University Hospital, DK5000 Odense, Denmark; (R.W.H.); (C.B.P.); (F.R.P.)
| | - Frantz Rom Poulsen
- Department of Neurosurgery, Odense University Hospital, DK5000 Odense, Denmark; (R.W.H.); (C.B.P.); (F.R.P.)
| | - Anders Rosendal Korshoej
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, J618, DK8200 Aarhus, Denmark; (M.G.K.); (N.M.)
- Department of Clinical Medicine, Aarhus University, Incuba Skejby, Building 2, Palle Juul-Jensens Boulevard 82, J618, DK8200 Aarhus, Denmark
- Correspondence: (L.C.A.); (A.R.K.); Tel.: +45-(20)-254418 (L.C.A.)
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17
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Suero Molina E, Kaneko S, Black D, Stummer W. 5-Aminolevulinic Acid-Induced Porphyrin Contents in Various Brain Tumors: Implications Regarding Imaging Device Design and Their Validation. Neurosurgery 2021; 89:1132-1140. [PMID: 34670277 DOI: 10.1093/neuros/nyab361] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 08/04/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Fluorescence-guided resections using 5-aminolevulinic acid (5-ALA)-induced tumor porphyrins have been established as an adjunct for malignant glioma surgery based on a phase III study using specifically adapted microscopes for visualizing fluorescing protoporphyrin IX (PPIX). New hardware technologies are being introduced, which claim the same performance as the original technology for visualizing fluorescence. This assumes that qualitative fluorescence detection is equivalent to the established standard, an assumption that needs to be critically assessed. OBJECTIVE To determine PPIX concentrations (cPPIX) in tissue that can be detected visually using the established BLUE400 filter system (Carl Zeiss Meditec, Oberkochen, Germany) as a basis for defining the performance of this system. METHODS Utilizing a hyperspectral imaging system, tumor samples from patients harboring different tumor tissues, with or without visible fluorescence, were analyzed. Absolute values of cPPIX were calculated after calibrating the system with fluorescence phantoms with known cPPIX. RESULTS A total of 524 tumor samples from 162 patients were analyzed. Visual fluorescence under the BLUE400 filter was documented by experienced neurosurgeons. A 0.9 μg/ml threshold of cPPIX was defined as the minimal concentration required to detect and discriminate visual fluorescence. CONCLUSION This is the first report providing data on the threshold of cPPIX, which is visually detected using the current generation of microscopes, thus defining the specificity and sensitivity of this technology as initially tested in a randomized trial. Novel technologies should show similar characteristics in order to be used safely and effectively. If more sensitive, such technologies require further assessments of tumor selectivity.
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Affiliation(s)
- Eric Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - Sadahiro Kaneko
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany.,Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - David Black
- Carl Zeiss Meditec AG, Oberkochen, Germany.,University of British Columbia, Vancouver, Canada
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
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18
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Schupper AJ, Baron RB, Cheung W, Rodriguez J, Kalkanis SN, Chohan MO, Andersen BJ, Chamoun R, Nahed BV, Zacharia BE, Kennedy J, Moulding HD, Zucker L, Chicoine MR, Olson JJ, Jensen RL, Sherman JH, Zhang X, Price G, Fowkes M, Germano IM, Carter BS, Hadjipanayis CG, Yong RL. 5-Aminolevulinic acid for enhanced surgical visualization of high-grade gliomas: a prospective, multicenter study. J Neurosurg 2021:1-10. [PMID: 34624862 DOI: 10.3171/2021.5.jns21310] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/05/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Greater extent of resection (EOR) is associated with longer overall survival in patients with high-grade gliomas (HGGs). 5-Aminolevulinic acid (5-ALA) can increase EOR by improving intraoperative visualization of contrast-enhancing tumor during fluorescence-guided surgery (FGS). When administered orally, 5-ALA is converted by glioma cells into protoporphyrin IX (PPIX), which fluoresces under blue 400-nm light. 5-ALA has been available for use in Europe since 2010, but only recently gained FDA approval as an intraoperative imaging agent for HGG tissue. In this first-ever, to the authors' knowledge, multicenter 5-ALA FGS study conducted in the United States, the primary objectives were the following: 1) assess the diagnostic accuracy of 5-ALA-induced PPIX fluorescence for HGG histopathology across diverse centers and surgeons; and 2) assess the safety profile of 5-ALA FGS, with particular attention to neurological morbidity. METHODS This single-arm, multicenter, prospective study included adults aged 18-80 years with Karnofsky Performance Status (KPS) score > 60 and an MRI diagnosis of suspected new or recurrent resectable HGG. Intraoperatively, 3-5 samples per tumor were taken and their fluorescence status was recorded by the surgeon. Specimens were submitted for histopathological analysis. Patients were followed for 6 weeks postoperatively for adverse events, changes in the neurological exam, and KPS score. Multivariate analyses were performed of the outcomes of KPS decline, EOR, and residual enhancing tumor volume to identify predictive patient and intraoperative variables. RESULTS Sixty-nine patients underwent 5-ALA FGS, providing 275 tumor samples for analysis. PPIX fluorescence had a sensitivity of 96.5%, specificity of 29.4%, positive predictive value (PPV) for HGG histopathology of 95.4%, and diagnostic accuracy of 92.4%. Drug-related adverse events occurred at a rate of 22%. Serious adverse events due to intraoperative neurological injury, which may have resulted from FGS, occurred at a rate of 4.3%. There were 2 deaths unrelated to FGS. Compared to preoperative KPS scores, postoperative KPS scores were significantly lower at 48 hours and 2 weeks but were not different at 6 weeks postoperatively. Complete resection of enhancing tumor occurred in 51.9% of patients. Smaller preoperative tumor volume and use of intraoperative MRI predicted lower residual tumor volume. CONCLUSIONS PPIX fluorescence, as judged by the surgeon, has a high sensitivity and PPV for HGG. 5-ALA was well tolerated in terms of drug-related adverse events, and its application by trained surgeons in FGS for HGGs was not associated with any excess neurological morbidity.
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Affiliation(s)
- Alexander J Schupper
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - Rebecca B Baron
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - William Cheung
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - Jessica Rodriguez
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - Steven N Kalkanis
- 2Department of Neurological Surgery, Henry Ford Medical Center, Detroit, Michigan
| | - Muhammad O Chohan
- 3Department of Neurological Surgery, University of New Mexico Hospital, Albuquerque, New Mexico
| | - Bruce J Andersen
- 4Department of Neurological Surgery, St. Alphonsus Regional Medical Center, Boise, Idaho
| | - Roukoz Chamoun
- 5Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Brian V Nahed
- 6Department of Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Brad E Zacharia
- 7Department of Neurological Surgery, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | - Hugh D Moulding
- 9Department of Neurological Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Lloyd Zucker
- 10Department of Neurological Surgery, Delray Medical Center, Delray Beach, Florida
| | - Michael R Chicoine
- 11Department of Neurological Surgery, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Jeffrey J Olson
- 12Department of Neurological Surgery, Emory University Hospital, Atlanta, Georgia
| | - Randy L Jensen
- 13Department of Neurological Surgery, Huntsman Cancer Institute, Salt Lake City, Utah; and
| | - Jonathan H Sherman
- 14Department of Neurological Surgery, George Washington University Hospital, Washington, DC
| | - Xiangnan Zhang
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - Gabrielle Price
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - Mary Fowkes
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - Isabelle M Germano
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - Bob S Carter
- 6Department of Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Raymund L Yong
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
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19
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Characterization of autofluorescence and quantitative protoporphyrin IX biomarkers for optical spectroscopy-guided glioma surgery. Sci Rep 2021; 11:20009. [PMID: 34625597 PMCID: PMC8501114 DOI: 10.1038/s41598-021-99228-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/14/2021] [Indexed: 01/04/2023] Open
Abstract
5-Aminolevulinic acid (5-ALA)-mediated fluorescence does not effectively depict low grade gliomas (LGG) or the infiltrative tumor portion of high-grade gliomas (HGG). While spectroscopy improves sensitivity and precision, this is currently limited by autofluorescence and a second protoporphyrin IX (PpIX) fluorescence state at 620 nm. We investigated the autofluorescence to better characterize the present spectra and thus increase PpIX quantification precision and sensitivity. This study included 128 patients undergoing surgery for malignant glioma. 5-ALA (Gliolan) was administered before anesthesia, and fluorescence was measured using a hyperspectral device. It was found that all 2692 measured spectra consisted of contributions from 620 to 634 nm PpIX, NADH, lipofuscin, and flavins. The basis spectra were characterized and their use in spectral unmixing led to 82.4% lower fitting error for weakly fluorescing areas (p < 0.001), and 92.3% fewer false positive tumor identifications in control measurements (p = 0.0065) compared to previous works. They also decreased the PpIX620 contribution, thus halving the mean Ratio620/634 (p < 0.001). The ratio was approximately 0 for HGGs and increasing for LGGs, as demonstrated previously. Additionally, the Ratio620/634, the MIB-1/Ki-67 proliferation index, and the PpIX peak blue-shift were found to be significantly related to WHO grade, fluorescence visibility, and PpIX contribution (p < 0.001), and the value of these three as quantitative biomarkers is discussed.
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20
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Yan F, Zhuang J, Yu Q, Dou Z, Jiang X, Tan S, Han Y, Wu X, Zang Y, Li C, Li J, Chen H, Hu L, Li X, Chen G. Strategy of De Novo Design toward First-In-Class Imaging Agents for Simultaneously Differentiating Glioma Boundary and Grades. ACS Sens 2021; 6:3330-3339. [PMID: 34448576 DOI: 10.1021/acssensors.1c01168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The extent of resection and tumor grade are two predominant prognostic factors for glioma. Fluorescent imaging is promising to facilitate accurate resection and simultaneous tumor grading. However, no probe fulfilling this task has been reported. Herein, we proposed a strategy of de novo design toward first-in-class fluorescent probes for simultaneously differentiating glioma boundary and grades. By bioinformatics analysis in combination with experimental validation, platelet-derived growth factor receptor β (PDGFRβ) was revealed as a promising biomarker for glioma imaging and grading. Then, fluorogenic probe PDGFP 1 was designed, guided by the structure-activity relationship study. Finally, the probe was demonstrated to stain glioma cells and tissues in the mice orthotopic glioma model with high selectivity over normal brain cells or tissues. Meanwhile, ex vivo experiments using patient-derived samples indicated that the fluorescence was significantly positively correlated with the tumor grades. This result highlighted the feasibility of the three-step de novo probe design strategy and suggested PDGFP 1 as a promising probe for simultaneously differentiating glioma boundary and grades, showing prospects of clinical translation.
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Affiliation(s)
- Feng Yan
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Jianfeng Zhuang
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Qian Yu
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Zhangqi Dou
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Xuefeng Jiang
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Shuyu Tan
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Yifeng Han
- Department of Chemistry, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Xinyan Wu
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Yi Zang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Cong Li
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Jia Li
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Huaijun Chen
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Libin Hu
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Xin Li
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Gao Chen
- College of Pharmaceutical Sciences, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
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21
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Kaneko S, Suero Molina E, Sporns P, Schipmann S, Black D, Stummer W. Fluorescence real-time kinetics of protoporphyrin IX after 5-ALA administration in low-grade glioma. J Neurosurg 2021; 136:9-15. [PMID: 34144512 DOI: 10.3171/2020.10.jns202881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE 5-Aminolevulinic acid (5-ALA) induces fluorescence in high-grade glioma (HGG), which is used for resection. However, the value of 5-ALA-induced fluorescence in low-grade glioma (LGG) is unclear. Time dependency and time kinetics have not yet been investigated. The purpose of this study was to investigate real-time kinetics of protoporphyrin IX (PpIX) in LGG based on hyperspectral fluorescence-based measurements and identify factors that predict fluorescence. METHODS Patients with grade II gliomas and imaging from which HGGs could not be completely ruled out received 5-ALA at 20 mg/kg body weight 4 hours prior to surgery. Fluorescence intensity (FI) and PpIX concentration (CPpIX) were measured in tumor tissue utilizing a hyperspectral camera. Apparent diffusion coefficient (ADC)-based tumor cell density, Ki-67/MIB-1 index, chromosomal 1p/19q codeletion, and 18F-fluoroethyl-l-tyrosine (18F-FET) PET values and their role for predicting fluorescence were evaluated. RESULTS Eighty-one biopsies from 25 patients were included. Tissues with fluorescence demonstrated FI and CPpIX maxima between 7 and 8 hours after administration. When visible fluorescence was observed, peaks of FI and CPpIX were observed within this 7- to 8-hour time frame, regardless of any MRI gadolinium contrast enhancement. Gadolinium enhancement (p = 0.008), Ki-67/MIB-1 index (p < 0.001), 18F-FET PET uptake ratio (p = 0.004), and ADC-based tumor cellularity (p = 0.017) significantly differed between fluorescing and nonfluorescing tissue, but not 1p/19q codeletions. Logistic regression demonstrated that 18F-FET PET uptake and Ki-67/MIB-1 index were independently related to fluorescence. CONCLUSIONS This study reports a fluorescence-based assessment of CPpIX in human LGG tissues related to 18F-FET PET uptake and Ki-67/MIB-1. As in HGGs, fluorescence in LGGs peaked between 7 and 8 hours after 5-ALA application, which has consequences for the timing of administration.
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Affiliation(s)
- Sadahiro Kaneko
- 1Department of Neurosurgery, University Hospital of Münster, Germany.,2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Eric Suero Molina
- 1Department of Neurosurgery, University Hospital of Münster, Germany
| | - Peter Sporns
- 3Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Switzerland.,4Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - David Black
- 5Carl Zeiss Meditec AG, Oberkochen, Germany; and.,6University of British Columbia, Vancouver, British Columbia, Canada
| | - Walter Stummer
- 1Department of Neurosurgery, University Hospital of Münster, Germany
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22
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Schupper AJ, Rao M, Mohammadi N, Baron R, Lee JYK, Acerbi F, Hadjipanayis CG. Fluorescence-Guided Surgery: A Review on Timing and Use in Brain Tumor Surgery. Front Neurol 2021; 12:682151. [PMID: 34220688 PMCID: PMC8245059 DOI: 10.3389/fneur.2021.682151] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/11/2021] [Indexed: 12/25/2022] Open
Abstract
Fluorescence-guided surgery (FGS) allows surgeons to have improved visualization of tumor tissue in the operating room, enabling maximal safe resection of malignant brain tumors. Over the past two decades, multiple fluorescent agents have been studied for FGS, including 5-aminolevulinic acid (5-ALA), fluorescein sodium, and indocyanine green (ICG). Both non-targeted and targeted fluorescent agents are currently being used in clinical practice, as well as under investigation, for glioma visualization and resection. While the efficacy of intraoperative fluorescence in studied fluorophores has been well established in the literature, the effect of timing on fluorophore administration in glioma surgery has not been as well depicted. In the past year, recent studies of 5-ALA use have shown that intraoperative fluorescence may persist beyond the previously studied window used in prior multicenter trials. Additionally, the use of fluorophores for different brain tumor types is discussed in detail, including a discussion of choosing the right fluorophore based on tumor etiology. In the following review, the authors will describe the temporal nature of the various fluorophores used in glioma surgery, what remains uncertain in FGS, and provide a guide for using fluorescence as a surgical adjunct in brain tumor surgery.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Manasa Rao
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Nicki Mohammadi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Rebecca Baron
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione Istituto Di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milan, Italy
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23
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Owari T, Iwamoto T, Anai S, Miyake M, Nakai Y, Hori S, Hara T, Ishii T, Ota U, Torimoto K, Kuniyasu H, Fujii T, Tanaka N, Fujimoto K. The sustaining of fluorescence in photodynamic diagnosis after the administration of 5-aminolevulinic acid in carcinogen-induced bladder cancer orthotopic rat model and urothelial cancer cell lines. Photodiagnosis Photodyn Ther 2021; 34:102309. [PMID: 33901687 DOI: 10.1016/j.pdpdt.2021.102309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/12/2021] [Accepted: 04/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The administration of 5-aminolevulic acid hydrochloride (5-ALA·HCl) 3 h (range: 2-4 h) before photodynamic diagnosis (PDD) is recommended for detecting bladder tumors. However, there is insufficient evidence on the time duration for the fluorescence of PDD after oral administration of 5-ALA. We investigated the sustainability of the photodynamic effect and protoporphyrinⅨ (PpⅨ) after 5-ALA administration in a carcinogen-induced bladder tumor rat model and bladder cancer cell lines. METHODS The carcinogen-induced bladder tumor orthotopic rat model was established by the administration of N-butyl-N-(4-hydroxybutyl) nitrosamine. RESULTS Red fluorescence was visible 2-8 h after the oral administration of 5-ALA in the carcinogen-induced bladder tumor rat model. Plasma and intratissue PpⅨ (nM) progressed to a higher level at 2 h and remained almost constant 2-8 h after oral administration of 5-ALA. The peak fluorescence intensity of PpⅨ was observed 3-4 h after the administration of 5-ALA in bladder cancer cell lines. The accumulated PpⅨ remained for 4 h after the removal of 5-ALA in UMUC3 cells. It was not clearly visible 3 h after the removal of 5-ALA in MGHU3 and T24 cells. The expression level of ferrochelatase was significantly lower in UMUC3 cells than in other cells. Our findings suggest that 5-ALA-assisted PDD (ALA-PDD) can aid in detecting non-muscle-invasive bladder cancer 2-8 h after 5-ALA administration. CONCLUSION Urologists might not be required to make excess effort to start ALA-PDD-assisted transurethral resection of bladder tumor after the administration of 5-ALA.
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Affiliation(s)
- Takuya Owari
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Takashi Iwamoto
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Satoshi Anai
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Makito Miyake
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Yasushi Nakai
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Shunta Hori
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Takeshi Hara
- SBI Pharmaceuticals Co., Ltd., Minato-ku, Tokyo, Japan
| | - Takuya Ishii
- SBI Pharmaceuticals Co., Ltd., Minato-ku, Tokyo, Japan
| | - Urara Ota
- SBI Pharmaceuticals Co., Ltd., Minato-ku, Tokyo, Japan
| | - Kazumasa Torimoto
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Hiroki Kuniyasu
- Department of Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Tomomi Fujii
- Department of Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Nobumichi Tanaka
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Kiyohide Fujimoto
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan.
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24
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Maragkos GA, Schüpper AJ, Lakomkin N, Sideras P, Price G, Baron R, Hamilton T, Haider S, Lee IY, Hadjipanayis CG, Robin AM. Fluorescence-Guided High-Grade Glioma Surgery More Than Four Hours After 5-Aminolevulinic Acid Administration. Front Neurol 2021; 12:644804. [PMID: 33767664 PMCID: PMC7985355 DOI: 10.3389/fneur.2021.644804] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Fluorescence-guided surgery (FGS) using 5-aminolevulic acid (5-ALA) is a widely used strategy for delineating tumor tissue from surrounding brain intraoperatively during high-grade glioma (HGG) resection. 5-ALA reaches peak plasma levels ~4 h after oral administration and is currently approved by the FDA for use 2–4 h prior to induction to anesthesia. Objective: To demonstrate that there is adequate intraoperative fluorescence in cases undergoing surgery more than 4 h after 5-ALA administration and compare survival and radiological recurrence to previous data. Methods: Retrospective analysis of HGG patients undergoing FGS more than 4 h after 5-ALA administration was performed at two institutions. Clinical, operative, and radiographic pre- and post-operative characteristics are presented. Results: Sixteen patients were identified, 6 of them female (37.5%), with mean (SD) age of 59.3 ± 11.5 years. Preoperative mean modified Rankin score (mRS) was 2 ± 1. All patients were dosed with 20 mg/kg 5-ALA the morning of surgery. Mean time to anesthesia induction was 425 ± 334 min. All cases had adequate intraoperative fluorescence. Eloquent cortex was involved in 12 cases (75%), and 13 cases (81.3%) had residual contrast enhancement on postoperative MRI. Mean progression-free survival was 5 ± 3 months. In the study period, 6 patients died (37.5%), mean mRS was 2.3 ± 1.3, Karnofsky score 71.9 ± 22.1, and NIHSS 3.9 ± 2.4. Conclusion: Here we demonstrate that 5-ALA-guided HGG resection can be performed safely more than 4 h after administration, with clinical results largely similar to previous reports. Relaxation of timing restrictions could improve procedure workflow in busy neurosurgical centers, without additional risk to patients.
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Affiliation(s)
- Georgios A Maragkos
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Alexander J Schüpper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Nikita Lakomkin
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Panagiotis Sideras
- Department of Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Gabrielle Price
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Rebecca Baron
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Travis Hamilton
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
| | - Sameah Haider
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
| | - Ian Y Lee
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
| | - Constantinos G Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States.,Department of Neurosurgery, Icahn School of Medicine, Mount Sinai Beth Israel, Mount Sinai Health System, New York, NY, United States
| | - Adam M Robin
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
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25
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Schupper AJ, Yong RL, Hadjipanayis CG. The Neurosurgeon's Armamentarium for Gliomas: An Update on Intraoperative Technologies to Improve Extent of Resection. J Clin Med 2021; 10:jcm10020236. [PMID: 33440712 PMCID: PMC7826675 DOI: 10.3390/jcm10020236] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 12/18/2022] Open
Abstract
Maximal safe resection is the standard of care in the neurosurgical treatment of high-grade gliomas. To aid surgeons in the operating room, adjuvant techniques and technologies centered around improving intraoperative visualization of tumor tissue have been developed. In this review, we will discuss the most advanced technologies, specifically fluorescence-guided surgery, intraoperative imaging, neuromonitoring modalities, and microscopic imaging techniques. The goal of these technologies is to improve detection of tumor tissue beyond what conventional microsurgery has permitted. We describe the various advances, the current state of the literature that have tested the utility of the different adjuvants in clinical practice, and future directions for improving intraoperative technologies.
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26
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Reuter G, Moïse M, Roll W, Martin D, Lombard A, Scholtes F, Stummer W, Suero Molina E. Conventional and advanced imaging throughout the cycle of care of gliomas. Neurosurg Rev 2021; 44:2493-2509. [PMID: 33411093 DOI: 10.1007/s10143-020-01448-3] [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: 08/03/2020] [Revised: 11/18/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
Although imaging of gliomas has evolved tremendously over the last decades, published techniques and protocols are not always implemented into clinical practice. Furthermore, most of the published literature focuses on specific timepoints in glioma management. This article reviews the current literature on conventional and advanced imaging techniques and chronologically outlines their practical relevance for the clinical management of gliomas throughout the cycle of care. Relevant articles were located through the Pubmed/Medline database and included in this review. Interpretation of conventional and advanced imaging techniques is crucial along the entire process of glioma care, from diagnosis to follow-up. In addition to the described currently existing techniques, we expect deep learning or machine learning approaches to assist each step of glioma management through tumor segmentation, radiogenomics, prognostication, and characterization of pseudoprogression. Thorough knowledge of the specific performance, possibilities, and limitations of each imaging modality is key for their adequate use in glioma management.
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Affiliation(s)
- Gilles Reuter
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium. .,GIGA-CRC In-vivo Imaging Center, ULiege, Liège, Belgium.
| | - Martin Moïse
- Department of Radiology, University Hospital of Liège, Liège, Belgium
| | - Wolfgang Roll
- Department of Nuclear Medicine, University Hospital of Münster, Münster, Germany
| | - Didier Martin
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium
| | - Arnaud Lombard
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium
| | - Félix Scholtes
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium.,Department of Neuroanatomy, University of Liège, Liège, Belgium
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - Eric Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
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27
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Yamamoto S, Fukuhara H, Karashima T, Inoue K. Real-world experience with 5-aminolevulinic acid for the photodynamic diagnosis of bladder cancer: Diagnostic accuracy and safety. Photodiagnosis Photodyn Ther 2020; 32:101999. [DOI: 10.1016/j.pdpdt.2020.101999] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/31/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022]
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28
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Abstract
Fluorescence-guided surgery provides surgeons with improved visualization of tumor tissue in the operating room to allow for maximal safe resection of brain tumors. Multiple fluorescent agents have been studied for fluorescence-guided surgery. Both nontargeted and targeted fluorescent agents are currently being used for glioblastoma multiforme visualization and resection. Fluorescence detection in the visible light or near infrared spectrum is possible. Visualization device advancements have permitted greater detection of fluorescence down to the cellular level, which may provide even greater ability for the neurosurgeon to resect tumors.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | - Constantinos Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA; Department of Neurosurgery, Mount Sinai Beth Israel, New York, NY, USA.
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29
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De Silva P, Saad MA, Thomsen HC, Bano S, Ashraf S, Hasan T. Photodynamic therapy, priming and optical imaging: Potential co-conspirators in treatment design and optimization - a Thomas Dougherty Award for Excellence in PDT paper. J PORPHYR PHTHALOCYA 2020; 24:1320-1360. [PMID: 37425217 PMCID: PMC10327884 DOI: 10.1142/s1088424620300098] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Photodynamic therapy is a photochemistry-based approach, approved for the treatment of several malignant and non-malignant pathologies. It relies on the use of a non-toxic, light activatable chemical, photosensitizer, which preferentially accumulates in tissues/cells and, upon irradiation with the appropriate wavelength of light, confers cytotoxicity by generation of reactive molecular species. The preferential accumulation however is not universal and, depending on the anatomical site, the ratio of tumor to normal tissue may be reversed in favor of normal tissue. Under such circumstances, control of the volume of light illumination provides a second handle of selectivity. Singlet oxygen is the putative favorite reactive molecular species although other entities such as nitric oxide have been credibly implicated. Typically, most photosensitizers in current clinical use have a finite quantum yield of fluorescence which is exploited for surgery guidance and can also be incorporated for monitoring and treatment design. In addition, the photodynamic process alters the cellular, stromal, and/or vascular microenvironment transiently in a process termed photodynamic priming, making it more receptive to subsequent additional therapies including chemo- and immunotherapy. Thus, photodynamic priming may be considered as an enabling technology for the more commonly used frontline treatments. Recently, there has been an increase in the exploitation of the theranostic potential of photodynamic therapy in different preclinical and clinical settings with the use of new photosensitizer formulations and combinatorial therapeutic options. The emergence of nanomedicine has further added to the repertoire of photodynamic therapy's potential and the convergence and co-evolution of these two exciting tools is expected to push the barriers of smart therapies, where such optical approaches might have a special niche. This review provides a perspective on current status of photodynamic therapy in anti-cancer and anti-microbial therapies and it suggests how evolving technologies combined with photochemically-initiated molecular processes may be exploited to become co-conspirators in optimization of treatment outcomes. We also project, at least for the short term, the direction that this modality may be taking in the near future.
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Affiliation(s)
- Pushpamali De Silva
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Mohammad A. Saad
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Hanna C. Thomsen
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Shazia Bano
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Shoaib Ashraf
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Tayyaba Hasan
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Division of Health Sciences and Technology, Harvard University and Massachusetts Institute of Technology, Cambridge, MA 02139, USA
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30
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Abstract
In neurosurgery, the extent of resection plays a critical role, especially in the management of malignant gliomas. These tumors are characterized through a diffuse infiltration into the surrounding brain parenchyma. Delineation between tumor and normal brain parenchyma can therefore often be challenging. During the recent years, several techniques, aiming at better intraoperative tumor visualization, have been developed and implemented in the field of brain tumor surgery. In this chapter, we discuss current strategies for intraoperative imaging in brain tumor surgery, comprising conventional techniques such as neuronavigation, techniques using fluorescence-guided surgery, and further highly precise developments such as targeted fluorescence spectroscopy or Raman spectroscopy.
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Affiliation(s)
- Stephanie Schipmann-Miletić
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
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31
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Kaneko S, Brokinkel B, Suero Molina E, Warneke N, Holling M, Bunk EC, Hess K, Senner V, Paulus W, Stummer W. Real-time in vivo kinetics of protoporphyrin IX after administration of 5-aminolevulinic acid in meningiomas and comparative analyses with glioblastomas. Acta Neurochir (Wien) 2020; 162:2197-2202. [PMID: 32361907 DOI: 10.1007/s00701-020-04353-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/14/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The usefulness of 5-aminolevulinic acid (5-ALA)-mediated fluorescence-guided surgery (FGS) in meningiomas is intensely discussed. However, data about kinetics of 5-ALA and protoporphyrin (Pp) IX in meningiomas are lacking. METHODS As the first study so far, we performed longitudinal intraoperative real-time ex situ measurements of fluorescence intensity and PpIX concentrations during FGS of ten benign and two atypical meningiomas. Kinetics were subsequently compared with data from 229 glioblastomas. RESULTS Spectroscopy revealed fluorescence (median 2945.65 a.u.) and PpIX accumulation (median 18.31 μg/ml) in all 43 analyzed samples. Fluorescence intensity (2961.50 a.u. vs 118.41 a.u.; p < .001) and PpIX concentrations (18.72 μg/ml vs .98 μg/ml; p < .001) were higher in samples with (N = 30) than without (N = 2) visible intraoperative tumor fluorescence. ROC curve analyses revealed a PpIX cut-off concentration of 3.85 μg/ml (AUC = .992, p = .005) and a quantitative fluorescence cut-off intensity of 286.73 a.u. (AUC = .983, p = .006) for intraoperative visible tumor fluorescence. Neither fluorescence intensity (p = .356) nor PpIX (p = .631) differed between atypical and benign meningiomas. Fluorescence and PpIX peaked 7-8 h following administration of 5-ALA. Meningiomas displayed a higher fluorescence intensity (p = .012) and PpIX concentration (p = .005) than glioblastomas 5-6 h after administration of 5-ALA. Although fluorescence was basically maintained, PpIX appeared to be cleared faster in meningiomas than in glioblastomas. CONCLUSIONS Kinetics of PpIX and fluorescence intensity differ between meningiomas and glioblastomas in the early phase after 5-ALA administration. Modification of the timing of drug administration might impact visibility of intraoperative fluorescence and helpfulness of FGS and should be investigated in future analyses.
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Affiliation(s)
- Sadahiro Kaneko
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany.
| | - Eric Suero Molina
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Nils Warneke
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Eva Christina Bunk
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Katharina Hess
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Volker Senner
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
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32
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Belykh E, Shaffer KV, Lin C, Byvaltsev VA, Preul MC, Chen L. Blood-Brain Barrier, Blood-Brain Tumor Barrier, and Fluorescence-Guided Neurosurgical Oncology: Delivering Optical Labels to Brain Tumors. Front Oncol 2020; 10:739. [PMID: 32582530 PMCID: PMC7290051 DOI: 10.3389/fonc.2020.00739] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 04/17/2020] [Indexed: 12/17/2022] Open
Abstract
Recent advances in maximum safe glioma resection have included the introduction of a host of visualization techniques to complement intraoperative white-light imaging of tumors. However, barriers to the effective use of these techniques within the central nervous system remain. In the healthy brain, the blood-brain barrier ensures the stability of the sensitive internal environment of the brain by protecting the active functions of the central nervous system and preventing the invasion of microorganisms and toxins. Brain tumors, however, often cause degradation and dysfunction of this barrier, resulting in a heterogeneous increase in vascular permeability throughout the tumor mass and outside it. Thus, the characteristics of both the blood-brain and blood-brain tumor barriers hinder the vascular delivery of a variety of therapeutic substances to brain tumors. Recent developments in fluorescent visualization of brain tumors offer improvements in the extent of maximal safe resection, but many of these fluorescent agents must reach the tumor via the vasculature. As a result, these fluorescence-guided resection techniques are often limited by the extent of vascular permeability in tumor regions and by the failure to stain the full volume of tumor tissue. In this review, we describe the structure and function of both the blood-brain and blood-brain tumor barriers in the context of the current state of fluorescence-guided imaging of brain tumors. We discuss features of currently used techniques for fluorescence-guided brain tumor resection, with an emphasis on their interactions with the blood-brain and blood-tumor barriers. Finally, we discuss a selection of novel preclinical techniques that have the potential to enhance the delivery of therapeutics to brain tumors in spite of the barrier properties of the brain.
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Affiliation(s)
- Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Kurt V. Shaffer
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Chaoqun Lin
- Department of Neurosurgery, School of Medicine, Southeast University, Nanjing, China
| | - Vadim A. Byvaltsev
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Mark C. Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Lukui Chen
- Department of Neurosurgery, Neuroscience Center, Cancer Center, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
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Spectroscopic measurement of 5-ALA-induced intracellular protoporphyrin IX in pediatric brain tumors. Acta Neurochir (Wien) 2019; 161:2099-2105. [PMID: 31435824 DOI: 10.1007/s00701-019-04039-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/09/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE 5-Aminolevulinic acid (5-ALA)-guided resection of gliomas in adults enables better delineation between tumor and normal brain, allowing improved resection and improved patients' outcome. Recently, several reports were published regarding 5-ALA for resection of pediatric brain tumors. The aim of the study was to determine the intracellular fluorescence of protoporphyrin IX (PPIX) in pediatric brain tumors by hyperspectral imaging and to compare it with visually observed intraoperative fluorescence. METHODS 5-ALA was administered orally 4 h prior to surgery. During tumor resection, the surgeon assessed the fluorescence signal to be strong, weak, or absent. Subsequently, fluorescence intensity of tumor samples was measured via spectroscopy. In addition, clinical data, imaging, and laboratory data were analyzed. RESULTS Eleven children (1-16 years) were operated. Tumor entities included three (n = 3) medulloblastomas, two (n = 2) pilocytic astrocytomas (PA), two (n = 2) anaplastic ependymomas and one (n = 1) diffuse astrocytoma, anaplastic astrocytoma (n = 1), pilomyxoid astrocytoma (n = 1) and anaplastic pleomorphic xanthoastrocytoma (n = 1). Strong fluorescence was visible in all anaplastic tumors and one PA; one PA demonstrated weak fluorescence. Visible fluorescence was strongly associated with intracellular fluorescence intensity and PPIX concentration (P < 0.05). Within all tumors with visible fluorescence, the intracellular PPIX concentration was greater than 4 μg/ml. Except for moderate and transient elevation of liver enzymes, no 5-ALA related adverse events were reported. CONCLUSION We demonstrate a strong association between intraoperative observations and spectrometric measurements of PPIX fluorescence in tumor tissue. As in former studies, fluorescence signal was more commonly observed in malignant glial tumors. Further prospective controlled trials should be conducted to investigate the feasibility of 5-ALA-guided resection of pediatric brain tumors.
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