1
|
Kwon MJ, House BJ, Barth CW, Solanki A, Jones JA, Davis SC, Gibbs SL. Dual probe difference specimen imaging for prostate cancer margin assessment. JOURNAL OF BIOMEDICAL OPTICS 2023; 28:082806. [PMID: 37082104 PMCID: PMC10111791 DOI: 10.1117/1.jbo.28.8.082806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 03/31/2023] [Indexed: 05/03/2023]
Abstract
Significance Positive margin status due to incomplete removal of tumor tissue during radical prostatectomy for high-risk localized prostate cancer requires reoperation or adjuvant therapy, which increases morbidity and mortality. Adverse effects of prostate cancer treatments commonly include erectile dysfunction, urinary incontinence, and bowel dysfunction, making successful initial curative prostatectomy imperative. Aim Current intraoperative tumor margin assessment is largely limited to frozen section analysis, which is a lengthy, labor-intensive process that is obtrusive to the clinical workflow within the operating room (OR). Therefore, a rapid method for prostate cancer margin assessment in the OR could improve outcomes for patients. Approach Dual probe difference specimen imaging (DDSI), which uses paired antibody-based probes that are labeled with spectrally distinct fluorophores, was shown herein for prostate cancer margin assessment. The paired antibody-based probes consisted of a targeted probe to prostate-specific membrane antigen (PSMA) and an untargeted probe, which were used as a cocktail to stain resected murine tissue specimens including prostate tumor, adipose, muscle, and normal prostate. Ratiometric images (i.e., DDSI) of the difference between targeted and untargeted probe uptake were calculated and evaluated for accuracy using receiver operator characteristic curve analysis with area under the curve values used to evaluate the utility of the DDSI method to detect PSMA positive prostate cancer. Results Targeted and untargeted probe uptake was similar between the high and low PSMA expressing tumor due to nonspecific probe uptake after topical administration. The ratiometric DDSI approach showed substantial contrast difference between the PSMA positive tumors and their respective normal tissues (prostate, adipose, muscle). Furthermore, DDSI showed substantial contrast difference between the high PSMA expressing tumors and the minimally PSMA expressing tumors due to the ratiometric correction for the nonspecific uptake patterns in resected tissues. Conclusions Previous work has shown that ratiometic imaging has strong predictive value for breast cancer margin status using topical administration. Translation of the ratiometric DDSI methodology herein from breast to prostate cancers demonstrates it as a robust, ratiometric technique that provides a molecularly specific imaging modality for intraoperative margin detection. Using the validated DDSI protocol on resected prostate cancers permitted rapid and accurate assessment of PSMA status as a surrogate for prostate cancer margin status. Future studies will further evaluate the utility of this technology to quantitatively characterize prostate margin status using PSMA as a biomarker.
Collapse
Affiliation(s)
- Marcus J. Kwon
- Oregon Health & Science University, Biomedical Engineering Department, Portland, Oregon, United States
| | - Broderick J. House
- Oregon Health & Science University, Biomedical Engineering Department, Portland, Oregon, United States
| | - Connor W. Barth
- Oregon Health & Science University, Biomedical Engineering Department, Portland, Oregon, United States
| | - Allison Solanki
- Oregon Health & Science University, Biomedical Engineering Department, Portland, Oregon, United States
| | - Jocelyn A. Jones
- Oregon Health & Science University, Biomedical Engineering Department, Portland, Oregon, United States
| | - Scott C. Davis
- Thayer School of Engineering at Dartmouth College, Hanover, New Hampshire, United States
| | - Summer L. Gibbs
- Oregon Health & Science University, Biomedical Engineering Department, Portland, Oregon, United States
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, United States
- Address all correspondence to Summer L. Gibbs,
| |
Collapse
|
2
|
Intraoperative Tumor Detection Using Pafolacianine. Int J Mol Sci 2022; 23:ijms232112842. [PMID: 36361630 PMCID: PMC9658182 DOI: 10.3390/ijms232112842] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/16/2022] [Accepted: 10/21/2022] [Indexed: 12/24/2022] Open
Abstract
Cancer is a leading cause of death worldwide, with increasing numbers of new cases each year. For the vast majority of cancer patients, surgery is the most effective procedure for the complete removal of the malignant tissue. However, relapse due to the incomplete resection of the tumor occurs very often, as the surgeon must rely primarily on visual and tactile feedback. Intraoperative near-infrared imaging with pafolacianine is a newly developed technology designed for cancer detection during surgery, which has been proven to show excellent results in terms of safety and efficacy. Therefore, pafolacianine was approved by the U.S. Food and Drug Administration (FDA) on 29 November 2021, as an additional approach that can be used to identify malignant lesions and to ensure the total resection of the tumors in ovarian cancer patients. Currently, various studies have demonstrated the positive effects of pafolacianine’s use in a wide variety of other malignancies, with promising results expected in further research. This review focuses on the applications of the FDA-approved pafolacianine for the accurate intraoperative detection of malignant tissues. The cancer-targeting fluorescent ligands can shift the paradigm of surgical oncology by enabling the visualization of cancer lesions that are difficult to detect by inspection or palpation. The enhanced detection and removal of hard-to-detect cancer tissues during surgery will lead to remarkable outcomes for cancer patients and society, specifically by decreasing the cancer relapse rate, increasing the life expectancy and quality of life, and decreasing future rates of hospitalization, interventions, and costs.
Collapse
|
3
|
Lam FC, Tsedev U, Kasper EM, Belcher AM. Forging the Frontiers of Image-Guided Neurosurgery—The Emerging Uses of Theranostics in Neurosurgical Oncology. Front Bioeng Biotechnol 2022; 10:857093. [PMID: 35903794 PMCID: PMC9315239 DOI: 10.3389/fbioe.2022.857093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Fred C. Lam
- The David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, United States
- Division of Neurosurgery, Saint Elizabeth’s Medical Center, Brighton, MA, United States
- *Correspondence: Fred C. Lam,
| | - Uyanga Tsedev
- The David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, United States
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Ekkehard M. Kasper
- Division of Neurosurgery, Saint Elizabeth’s Medical Center, Brighton, MA, United States
| | - Angela M. Belcher
- The David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, United States
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, United States
| |
Collapse
|
4
|
Vergeer RA, Theunissen REP, van Elk T, Schmidt I, Postma MR, Tamasi K, van Dijk JMC, Kuijlen JMA. Fluorescence-guided detection of pituitary neuroendocrine tumor (PitNET) tissue during endoscopic transsphenoidal surgery available agents, their potential, and technical aspects. Rev Endocr Metab Disord 2022; 23:647-657. [PMID: 35344185 PMCID: PMC9156450 DOI: 10.1007/s11154-022-09718-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 10/29/2022]
Abstract
Differentiation of pituitary neuroendocrine tumor (PitNET) tissue from surrounding normal tissue during surgery is challenging. A number of fluorescent agents is available for visualization of tissue discrepancy, with the potential of improving total tumor resection. This review evaluates the availability, clinical and technical applicability of the various fluorescent agents within the field of pituitary surgery. According to PRISMA guidelines, a systematic review was performed to identify reports describing results of in vivo application of fluorescent agents. In this review, 15 publications were included. Sodium Fluorescein (FNa) was considered in two studies. The first study reported noticeable fluorescence in adenoma tissue, the second demonstrated the strongest fluorescence in non-functioning pituitary adenomas. 5-Aminolevulinic acid (5-ALA) was investigated in three studies. One study compared laser-based optical biopsy system (OBS) with photo-diagnostic filter (PD) and found that the OBS was able to detect all microadenomas, even when MRI was negative. The second study retrospectively analyzed twelve pituitary adenomas and found only one positive for fluorescence. The third investigated fifteen pituitary adenomas of which one displayed vague fluorescence. Indocyanine green (ICG) was researched in four studies with variable results. Second-Window ICG yielded no significant difference between functioning and non-functioning adenomas in one study, while a second study displayed 4 times higher fluorescence in tumor tissue than in normal tissue. In three studies, OTL38 showed potential in non-functioning pituitary adenomas. At present, evidence for fluorescent agents to benefit total resection of PitNETs is lacking. OTL38 can potentially serve as a selective fluorescent agent in non-functioning pituitary adenomas in the near future.
Collapse
Affiliation(s)
- Rob A Vergeer
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Robin E P Theunissen
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Theodora van Elk
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Iris Schmidt
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mark R Postma
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Katalin Tamasi
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J Marc C van Dijk
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jos M A Kuijlen
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
5
|
Schouw HM, Huisman LA, Janssen YF, Slart RHJA, Borra RJH, Willemsen ATM, Brouwers AH, van Dijl JM, Dierckx RA, van Dam GM, Szymanski W, Boersma HH, Kruijff S. Targeted optical fluorescence imaging: a meta-narrative review and future perspectives. Eur J Nucl Med Mol Imaging 2021; 48:4272-4292. [PMID: 34633509 PMCID: PMC8566445 DOI: 10.1007/s00259-021-05504-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/23/2021] [Indexed: 12/27/2022]
Abstract
Purpose The aim of this review is to give an overview of the current status of targeted optical fluorescence imaging in the field of oncology, cardiovascular, infectious and inflammatory diseases to further promote clinical translation. Methods A meta-narrative approach was taken to systematically describe the relevant literature. Consecutively, each field was assigned a developmental stage regarding the clinical implementation of optical fluorescence imaging. Results Optical fluorescence imaging is leaning towards clinical implementation in gastrointestinal and head and neck cancers, closely followed by pulmonary, neuro, breast and gynaecological oncology. In cardiovascular and infectious disease, optical imaging is in a less advanced/proof of concept stage. Conclusion Targeted optical fluorescence imaging is rapidly evolving and expanding into the clinic, especially in the field of oncology. However, the imaging modality still has to overcome some major challenges before it can be part of the standard of care in the clinic, such as the provision of pivotal trial data. Intensive multidisciplinary (pre-)clinical joined forces are essential to overcome the delivery of such compelling phase III registration trial data and subsequent regulatory approval and reimbursement hurdles to advance clinical implementation of targeted optical fluorescence imaging as part of standard practice. Supplementary Information The online version contains supplementary material available at 10.1007/s00259-021-05504-y.
Collapse
Affiliation(s)
- H M Schouw
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - L A Huisman
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Y F Janssen
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - R H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - R J H Borra
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Radiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - A T M Willemsen
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - A H Brouwers
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - J M van Dijl
- Department of Medical Microbiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - R A Dierckx
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Diagnostic Sciences, Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
| | - G M van Dam
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,AxelaRx/TRACER Europe BV, Groningen, The Netherlands
| | - W Szymanski
- Department of Radiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - H H Boersma
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre of Groningen, Groningen, The Netherlands
| | - S Kruijff
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands. .,Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
| |
Collapse
|
6
|
Hernandez Vargas S, Lin C, Tran Cao HS, Ikoma N, AghaAmiri S, Ghosh SC, Uselmann AJ, Azhdarinia A. Receptor-Targeted Fluorescence-Guided Surgery With Low Molecular Weight Agents. Front Oncol 2021; 11:674083. [PMID: 34277418 PMCID: PMC8279813 DOI: 10.3389/fonc.2021.674083] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/10/2021] [Indexed: 12/16/2022] Open
Abstract
Cancer surgery remains the primary treatment option for most solid tumors and can be curative if all malignant cells are removed. Surgeons have historically relied on visual and tactile cues to maximize tumor resection, but clinical data suggest that relapse occurs partially due to incomplete cancer removal. As a result, the introduction of technologies that enhance the ability to visualize tumors in the operating room represents a pressing need. Such technologies have the potential to revolutionize the surgical standard-of-care by enabling real-time detection of surgical margins, subclinical residual disease, lymph node metastases and synchronous/metachronous tumors. Fluorescence-guided surgery (FGS) in the near-infrared (NIRF) spectrum has shown tremendous promise as an intraoperative imaging modality. An increasing number of clinical studies have demonstrated that tumor-selective FGS agents can improve the predictive value of fluorescence over non-targeted dyes. Whereas NIRF-labeled macromolecules (i.e., antibodies) spearheaded the widespread clinical translation of tumor-selective FGS drugs, peptides and small-molecules are emerging as valuable alternatives. Here, we first review the state-of-the-art of promising low molecular weight agents that are in clinical development for FGS; we then discuss the significance, application and constraints of emerging tumor-selective FGS technologies.
Collapse
Affiliation(s)
- Servando Hernandez Vargas
- The Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States.,Therapeutics & Pharmacology Program, The University of Texas MD Anderson UTHealth Graduate School of Biomedical Sciences, Houston, TX, United States
| | | | - Hop S Tran Cao
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Naruhiko Ikoma
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Solmaz AghaAmiri
- The Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Sukhen C Ghosh
- The Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | | | - Ali Azhdarinia
- The Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States.,Therapeutics & Pharmacology Program, The University of Texas MD Anderson UTHealth Graduate School of Biomedical Sciences, Houston, TX, United States
| |
Collapse
|
7
|
Abstract
PURPOSE OF REVIEW Image guided navigation has had significant impact in head and neck surgery, and has been most prolific in endonasal surgeries. Although conventional image guidance involves static computed tomography (CT) images attained in the preoperative setting, the continual evolution of surgical navigation technologies is fast expanding to incorporate both real-time data and bioinformation that allows for improved precision in surgical guidance. With the rapid advances in technologies, this article allows for a timely review of the current and developing techniques in surgical navigation for head and neck surgery. RECENT FINDINGS Current advances for cross-sectional-based image-guided surgery include fusion of CT with other imaging modalities (e.g., magnetic resonance imaging and positron emission tomography) as well as the uptake in intraoperative real-time 'on the table' imaging (e.g., cone-beam CT). These advances, together with the integration of virtual/augmented reality, enable potential enhancements in surgical navigation. In addition to the advances in radiological imaging, the development of optical modalities such as fluorescence and spectroscopy techniques further allows the assimilation of biological data to improve navigation particularly for head and neck surgery. SUMMARY The steady development of radiological and optical imaging techniques shows great promise in changing the paradigm of head and neck surgery.
Collapse
|
8
|
Lakomkin N, Van Gompel JJ, Post KD, Cho SS, Lee JYK, Hadjipanayis CG. Fluorescence guided surgery for pituitary adenomas. J Neurooncol 2021; 151:403-413. [PMID: 33611707 DOI: 10.1007/s11060-020-03420-z] [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: 11/05/2019] [Accepted: 01/31/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE Resection of pituitary adenomas presents a number of unique challenges in neuro-oncology. The proximity of these lesions to key vascular and endocrine structures as well as the need to interpret neuronavigation in the context of shifting tumor position increases the complexity of the operation. More recently, substantial advances in fluorescence-guided surgery have been demonstrated to facilitate the identification of numerous tumor types and result in increased rates of complete resection and overall survival. METHODS A review of the literature was performed, and data regarding the mechanism of the fluorescence agents, their administration, and intraoperative tumor visualization were extracted. Both in vitro and in vivo studies were assessed. The application of these agents to pituitary tumors, their advantages and limitations, as well as future directions are presented here. RESULTS Numerous laboratory and clinical studies have described the use of 5-ALA, fluorescein, indocyanine green, and OTL38 in pituitary lesions. All of these drugs have been demonstrated to accumulate in tumor cells. Several studies have reported the successful use of the majority of the agents in inducing intraoperative tumor fluorescence. However, their sensitivity and specificity varies across the literature and between functioning and non-functioning adenomas. CONCLUSIONS At present, numerous studies have shown the feasibility and safety of these agents for pituitary adenomas. However, further research is needed to assess the applicability of fluorescence-guided surgery across different tumor subtypes as well as explore the relationship between their use and postoperative clinical outcomes.
Collapse
Affiliation(s)
- Nikita Lakomkin
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Mount Sinai Downtown Union Square, 10 Union Square East, Suite 5E, New York, NY, 10003, USA.,Department of Neurosurgery, Icahn School of Medicine, Mount Sinai Beth Israel, Mount Sinai Health System, New York, USA
| | | | - Kalmon D Post
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Mount Sinai Downtown Union Square, 10 Union Square East, Suite 5E, New York, NY, 10003, USA
| | - Steve S Cho
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, USA
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, USA
| | - Constantinos G Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Mount Sinai Downtown Union Square, 10 Union Square East, Suite 5E, New York, NY, 10003, USA. .,Department of Neurosurgery, Icahn School of Medicine, Mount Sinai Beth Israel, Mount Sinai Health System, New York, USA.
| |
Collapse
|
9
|
De Ravin E, Phan HAT, Harmsen S, Cho SS, Teng CW, Petersson EJ, White C, Galban EM, Hess R, Lee JYK. Somatostatin Receptor as a Molecular Imaging Target in Human and Canine Cushing Disease. World Neurosurg 2021; 149:94-102. [PMID: 33601082 DOI: 10.1016/j.wneu.2021.02.034] [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: 11/19/2020] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Fluorescence-guided surgery may improve completeness of resection in transsphenoidal surgery for Cushing disease (CD) by enabling visualization of residual tumor tissue at the margins. In this review we discuss somatostatin receptors (SSTRs) as targets for fluorescence-guided surgery and overview existing SSTR-specific imaging agents. We also compare SSTR expression in normal pituitary and corticotrophinoma tissues from human and canine CD patients to assess canines as a translational model for CD. METHODS A PubMed literature search was conducted for publications containing the terms canine, somatostatin receptor, Cushing's disease, and corticotroph adenoma. SSTR expression data from each study was documented as the presence or absence of expression or, when possible, the number of tumors expressing a given SSTR subtype within a group of tumors being studied. Studies that used reverse transcription polymerase chain reaction to quantify SSTR expression were selected for additional comparative analysis. RESULTS SSTR5 is strongly expressed in human corticotroph adenomas and weakly expressed in surrounding pituitary parenchyma, a pattern not conclusively observed in canine patients. SSTR2 mRNA expression is similar in human normal pituitary and corticotrophinoma cells but may be significantly higher in canine normal pituitary tissue than in corticotroph tumoral tissue. Limited data were available on SSTR subtypes 1, 3, and 4. CONCLUSIONS Further studies must fill the knowledge gaps related to species-specific SSTR expression, so using canine CD as a translational model may be premature. We do conclude that the expression profile of SSTR5 (i.e., high local expression in pituitary adenomas relative to normal surrounding tissues) makes SSTR5 a promising molecular target for FGS.
Collapse
Affiliation(s)
- Emma De Ravin
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hoang Anh T Phan
- Department of Chemistry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stefan Harmsen
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steve S Cho
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Clare W Teng
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - E James Petersson
- Department of Chemistry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Caitlin White
- Department of Endocrinology at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Evelyn M Galban
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecka Hess
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y K Lee
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
10
|
Micko A, Placzek F, Fonollà R, Winklehner M, Sentosa R, Krause A, Vila G, Höftberger R, Andreana M, Drexler W, Leitgeb RA, Unterhuber A, Wolfsberger S. Diagnosis of Pituitary Adenoma Biopsies by Ultrahigh Resolution Optical Coherence Tomography Using Neuronal Networks. Front Endocrinol (Lausanne) 2021; 12:730100. [PMID: 34733239 PMCID: PMC8560084 DOI: 10.3389/fendo.2021.730100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Despite advancements of intraoperative visualization, the difficulty to visually distinguish adenoma from adjacent pituitary gland due to textural similarities may lead to incomplete adenoma resection or impairment of pituitary function. The aim of this study was to investigate optical coherence tomography (OCT) imaging in combination with a convolutional neural network (CNN) for objectively identify pituitary adenoma tissue in an ex vivo setting. METHODS A prospective study was conducted to train and test a CNN algorithm to identify pituitary adenoma tissue in OCT images of adenoma and adjacent pituitary gland samples. From each sample, 500 slices of adjacent cross-sectional OCT images were used for CNN classification. RESULTS OCT data acquisition was feasible in 19/20 (95%) patients. The 16.000 OCT slices of 16/19 of cases were employed for creating a trained CNN algorithm (70% for training, 15% for validating the classifier). Thereafter, the classifier was tested on the paired samples of three patients (3.000 slices). The CNN correctly predicted adenoma in the 3 adenoma samples (98%, 100% and 84% respectively), and correctly predicted gland and transition zone in the 3 samples from the adjacent pituitary gland. CONCLUSION Trained convolutional neural network computing has the potential for fast and objective identification of pituitary adenoma tissue in OCT images with high sensitivity ex vivo. However, further investigation with larger number of samples is required.
Collapse
Affiliation(s)
- Alexander Micko
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Fabian Placzek
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Roger Fonollà
- Department of Electrical Engineering, Video Coding and Architectures, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Michael Winklehner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Ryan Sentosa
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Arno Krause
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Greisa Vila
- Division of Endocrinology and Metabolism of the Department of Internal Medicine III, Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Marco Andreana
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Wolfgang Drexler
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Rainer A. Leitgeb
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
- Christian Doppler Laboratory Innovative Optical Imaging and its Translation for “Innovative Optical Imaging and its Translation into Medicine” (OPTRAMED), Medical University of Vienna, Vienna, Austria
| | - Angelika Unterhuber
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
- *Correspondence: Stefan Wolfsberger,
| |
Collapse
|
11
|
Micko A, Rapoport BI, Youngerman BE, Fong RP, Kosty J, Brunswick A, Shahrestani S, Zada G, Schwartz TH. Limited utility of 5-ALA optical fluorescence in endoscopic endonasal skull base surgery: a multicenter retrospective study. J Neurosurg 2020; 135:535-541. [PMID: 33126212 DOI: 10.3171/2020.5.jns201171] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Incomplete resection of skull base pathology may result in local tumor recurrence. This study investigates the utility of 5-aminolevulinic acid (5-ALA) fluorescence during endoscopic endonasal approaches (EEAs) to increase visibility of pathologic tissue. METHODS This retrospective multicenter series comprises patients with planned resection of an anterior skull base lesion who received preoperative 5-ALA at two tertiary care centers. Diagnostic use of a blue light endoscope was performed during EEA for all cases. Demographic and tumor characteristics as well as fluorescence status, quality, and homogeneity were assessed for each skull base pathology. RESULTS Twenty-eight skull base pathologies underwent blue-light EEA with preoperative 5-ALA, including 15 pituitary adenomas (54%), 4 meningiomas (14%), 3 craniopharyngiomas (11%), 2 Rathke's cleft cysts (7%), as well as plasmacytoma, esthesioneuroblastoma, and sinonasal squamous cell carcinoma. Of these, 6 (21%) of 28 showed invasive growth into surrounding structures such as dura, bone, or compartments of the cavernous sinus. Tumor fluorescence was detected in 2 cases (7%), with strong fluorescence in 1 tuberculum sellae meningioma and vague fluorescence in 1 pituicytoma. In all other cases fluorescence was absent. Faint fluorescence of the normal pituitary gland was seen in 1 (7%) of 15 cases. A comparison between the particular tumor entities as well as a correlation between invasiveness, WHO grade, Ki-67, and positive fluorescence did not show any significant association. CONCLUSIONS With the possible exception of meningiomas, 5-ALA fluorescence has limited utility in the majority of endonasal skull base surgeries, although other pathology may be worth investigating.
Collapse
Affiliation(s)
- Alexander Micko
- 1Department of Neurosurgery, Medical University of Vienna, Austria
- 2Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Benjamin I Rapoport
- 3Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Brett E Youngerman
- 3Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Reginald P Fong
- 3Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Jennifer Kosty
- 3Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Andrew Brunswick
- 2Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Shane Shahrestani
- 2Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Gabriel Zada
- 2Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Theodore H Schwartz
- 3Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| |
Collapse
|
12
|
Salim L, Desaulniers JP. To Conjugate or to Package? A Look at Targeted siRNA Delivery Through Folate Receptors. Nucleic Acid Ther 2020; 31:21-38. [PMID: 33121373 DOI: 10.1089/nat.2020.0893] [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] [Indexed: 12/19/2022] Open
Abstract
RNA interference (RNAi) applications have evolved from experimental tools to study gene function to the development of a novel class of gene-silencing therapeutics. Despite decades of research, it was not until August 2018 that the US FDA approved the first-ever RNAi drug, marking a new era for RNAi therapeutics. Although there are many limitations associated with the inherent structure of RNA, delivery to target cells and tissues remains the most challenging. RNAs are unable to diffuse across cellular membranes due to their large size and polyanionic backbone and, therefore, require a delivery vector. RNAi molecules can be conjugated to a targeting ligand or packaged into a delivery vehicle. Alnylam has used both strategies in their FDA-approved formulations to achieve efficient delivery to the liver. To harness the full potential of RNAi therapeutics, however, we must be able to target additional cells and tissues. One promising target is the folate receptor α, which is overexpressed in a variety of tumors despite having limited expression and distribution in normal tissues. Folate can be conjugated directly to the RNAi molecule or used to functionalize delivery vehicles. In this review, we compare both delivery strategies and discuss the current state of research in the area of folate-mediated delivery of RNAi molecules.
Collapse
Affiliation(s)
- Lidya Salim
- Faculty of Science, University of Ontario Institute of Technology, Oshawa, Canada
| | | |
Collapse
|
13
|
Belykh E, Ngo B, Farhadi DS, Zhao X, Mooney MA, White WL, Daniels JK, Little AS, Eschbacher JM, Preul MC. Confocal Laser Endomicroscopy Assessment of Pituitary Tumor Microstructure: A Feasibility Study. J Clin Med 2020; 9:jcm9103146. [PMID: 33003336 PMCID: PMC7600847 DOI: 10.3390/jcm9103146] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/12/2020] [Accepted: 09/23/2020] [Indexed: 12/12/2022] Open
Abstract
This is the first study to assess confocal laser endomicroscopy (CLE) use within the transsphenoidal approach and show the feasibility of obtaining digital diagnostic biopsies of pituitary tumor tissue after intravenous fluorescein injection. We confirmed that the CLE probe reaches the tuberculum sellae through the transnasal transsphenoidal corridor in cadaveric heads. Next, we confirmed that CLE provides images with identifiable histological features of pituitary adenoma. Biopsies from nine patients who underwent pituitary adenoma surgery were imaged ex vivo at various times after fluorescein injection and were assessed by a blinded board-certified neuropathologist. With frozen sections used as the standard, pituitary adenoma was diagnosed as “definitively” for 13 and as “favoring” in 3 of 16 specimens. CLE digital biopsies were diagnostic for pituitary adenoma in 10 of 16 specimens. The reasons for nondiagnostic CLE images were biopsy acquisition <1 min or >10 min after fluorescein injection (n = 5) and blood artifacts (n = 1). In conclusion, fluorescein provided sufficient contrast for CLE at a dose of 2 mg/kg, optimally 1–10 min after injection. These results provide a basis for further in vivo studies using CLE in transsphenoidal surgery.
Collapse
Affiliation(s)
- Evgenii Belykh
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (E.B.); (B.N.); (D.S.F.); (X.Z.); (M.A.M.); (W.L.W.); (A.S.L.)
| | - Brandon Ngo
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (E.B.); (B.N.); (D.S.F.); (X.Z.); (M.A.M.); (W.L.W.); (A.S.L.)
| | - Dara S. Farhadi
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (E.B.); (B.N.); (D.S.F.); (X.Z.); (M.A.M.); (W.L.W.); (A.S.L.)
| | - Xiaochun Zhao
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (E.B.); (B.N.); (D.S.F.); (X.Z.); (M.A.M.); (W.L.W.); (A.S.L.)
| | - Michael A. Mooney
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (E.B.); (B.N.); (D.S.F.); (X.Z.); (M.A.M.); (W.L.W.); (A.S.L.)
| | - William L. White
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (E.B.); (B.N.); (D.S.F.); (X.Z.); (M.A.M.); (W.L.W.); (A.S.L.)
| | - Jessica K. Daniels
- Department of Neuropathology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (J.K.D.); (J.M.E.)
| | - Andrew S. Little
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (E.B.); (B.N.); (D.S.F.); (X.Z.); (M.A.M.); (W.L.W.); (A.S.L.)
| | - Jennifer M. Eschbacher
- Department of Neuropathology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (J.K.D.); (J.M.E.)
| | - Mark C. Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (E.B.); (B.N.); (D.S.F.); (X.Z.); (M.A.M.); (W.L.W.); (A.S.L.)
- Correspondence: ; Tel.: +1-602-406-3593
| |
Collapse
|
14
|
Surface-Registration Frameless Stereotactic Navigation Is Less Accurate During Prone Surgeries: Intraoperative Near-Infrared Visualization Using Second Window Indocyanine Green Offers an Adjunct. Mol Imaging Biol 2020; 22:1572-1580. [PMID: 32232627 DOI: 10.1007/s11307-020-01495-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Frameless neuronavigation allows neurosurgeons to visualize and relate the position of surgical instruments to intracranial pathologies based on preoperative tomographic imaging. However, neuronavigation can often be inaccurate. Multiple factors have been proposed as potential causes, and new technologies are needed to overcome these challenges. OBJECTIVE To evaluate the accuracy of neuronavigation systems compared to near-infrared (NIR) fluorescence imaging using Second Window Indocyanine Green, a novel technique, and to determine factors that lead to neuronavigation errors. METHODS A retrospective analysis was conducted on 56 patients who underwent primary resections of intracranial tumors. Patients received 5 mg/kg ICG approximately 24 h preoperatively. Intraoperatively, neuronavigation was used to plan craniotomies to place the tumors in the center. After craniotomy, NIR imaging visualized tumor-specific NIR signals. The accuracy of neuronavigation and NIR fluorescence imaging for delineating the tumor boundary prior to durotomy was compared. RESULTS The neuronavigation centers and NIR centers were 23.0 ± 7.7 % and 2.6 ± 1.1 % deviated from the tumor centers, respectively, relative to the craniotomy sizes. In 12 cases, significant changes were made to the planned durotomy based on NIR imaging. Patient position was a significant predictor of neuronavigation inaccuracy on both univariate and multivariate analysis, with the prone position having significantly higher inaccuracy (29.2 ± 8.1 %) compared to the supine (16.2 ± 8.1 %, p value < 0.001) or the lateral (17.9 ± 5.1 %, p value = 0.003) positions. CONCLUSION Patient position significantly affects neuronavigation accuracy. Intraoperative NIR fluorescence imaging before durotomy offers an opportunity to readjust the neuronavigation image space to better align with the patient space.
Collapse
|
15
|
Jeon JW, Cho SS, Nag S, Buch L, Pierce J, Su YS, Adappa ND, Palmer JN, Newman JG, Singhal S, Lee JYK. Near-Infrared Optical Contrast of Skull Base Tumors During Endoscopic Endonasal Surgery. Oper Neurosurg (Hagerstown) 2019; 17:32-42. [PMID: 30124919 PMCID: PMC7311828 DOI: 10.1093/ons/opy213] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 08/07/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Near-infrared (NIR) tumor contrast is achieved through the "second-window ICG" technique, which relies on passive accumulation of high doses of indocyanine green (ICG) in neoplasms via the enhanced permeability and retention effect. OBJECTIVE To report early results and potential challenges associated with the application of second-window ICG technique in endonasal endoscopic, ventral skull-base surgery, and to determine potential predictors of NIR signal-to-background ratio (SBR) using endoscopic techniques. METHODS Pituitary adenoma (n = 8), craniopharyngioma (n = 3), and chordoma (n = 4) patients received systemic infusions of ICG (5 mg/kg) approximately 24 h before surgery. Dual-channel endoscopy with visible light and NIR overlay were photodocumented and analyzed post hoc. RESULTS All tumors (adenoma, craniopharyngioma, chordoma) demonstrated NIR positivity and fluoresced with an average SBR of 3.9 ± 0.8, 4.1 ± 1.7, and 2.1 ± 0.6, respectively. Contrast-enhanced T1 signal intensity proved to be the single best predictor of observed SBR (P = .0003). For pituitary adenomas, the sensitivity, specificity, positive predictive value, and negative predictive value of NIR-guided identification of tumor was 100%, 20%, 71%, and 100%, respectively. CONCLUSION In this preliminary study of a small set of patients, we demonstrate that second-window ICG can provide NIR optical tumor contrast in 3 types of ventral skull-base tumors. Chordomas demonstrated the weakest NIR signal, suggesting limited utility in those patients. Both nonfunctional and functional pituitary adenomas appear to accumulate ICG, but utility for margin detection for the adenomas is limited by low specificity. Craniopharyngiomas with third ventricular extension appear to be a particularly promising target given the clean brain parenchyma background and strong SBR.
Collapse
Affiliation(s)
- Jun W Jeon
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steve S Cho
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shayoni Nag
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Love Buch
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Pierce
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - YouRong S Su
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nithin D Adappa
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James N Palmer
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason G Newman
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sunil Singhal
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
16
|
Technological and Ideological Innovations in Endoscopic Skull Base Surgery. World Neurosurg 2019; 124:513-521. [PMID: 30708082 DOI: 10.1016/j.wneu.2019.01.120] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/25/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Endoscopic skull base surgery has evolved over the last several decades due to technological advances and operative techniques. Several innovations that are not yet mainstream may have significant impact on the future of endoscopic skull base surgery. METHODS Current literature pertaining to innovations in endoscopic skull base surgery was retrieved using PubMed, Embase, Web of Science, and Google Scholar. RESULTS Several recent innovations may play an influential role in the advancement of endoscopic skull base surgery, including fluorescent dyes such as indocyanine green fluorescence, fluorescein, and 5-aminolevulinic acid, 3-dimensional endoscopes, robotic surgery, and intraoperative magnetic resonance imaging. CONCLUSIONS Several technologies are under current investigation with the hope to improve future outcomes in endoscopic skull base surgery. Additional research and evolution are necessary and will require intense scrutiny before becoming standard of care.
Collapse
|
17
|
Cho SS, Salinas R, Lee JYK. Indocyanine-Green for Fluorescence-Guided Surgery of Brain Tumors: Evidence, Techniques, and Practical Experience. Front Surg 2019; 6:11. [PMID: 30915339 PMCID: PMC6422908 DOI: 10.3389/fsurg.2019.00011] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 02/19/2019] [Indexed: 01/10/2023] Open
Abstract
The primary treatment for brain tumors often involves surgical resection for diagnosis, relief of mass effect, and prolonged survival. In neurosurgery, it is of utmost importance to achieve maximal safe resection while minimizing iatrogenic neurologic deficit. Thus, neurosurgeons often rely on extra tools in the operating room, such as neuronavigation, intraoperative magnetic resonance imaging, and/or intraoperative rapid pathology. However, these tools can be expensive, not readily available, time-consuming, and/or inaccurate. Recently, fluorescence-guided surgery has emerged as a cost-effective method to accurately visualize neoplastic areas in real-time to guide resection. Currently, 5-aminolevulinic-acid (5-ALA) remains the only fluorophore that has been approved specifically for fluorescence-guided tumor resection. Its use has demonstrated improved resection rates and prolonged progression-free survival. However, protoporphyrin-IX, the metabolic product of 5-ALA that accumulates in neoplastic cells, fluoresces in the visible-light range, which suffers from limited tissue penetration and significant auto-fluorescence. Near-infrared fluorescence, on the other hand, overcomes these problems with ease. Since 2012, researchers at our institution have developed a novel technique using indocyanine-green, which is a well-known near-infrared fluorophore used traditionally for angiography. This Second-Window-ICG (SWIG) technique takes advantage of the increased endothelial permeability in peritumoral tissue, which allows indocyanine-green to accumulate in these areas for intraoperative visualization of the tumor. SWIG has demonstrated utility in gliomas, meningiomas, metastases, pituitary adenomas, chordomas, and craniopharyngiomas. The main benefits of SWIG stem from its highly sensitive detection of neoplastic tissue in a wide variety of intracranial pathologies in real-time, which can help neurosurgeons both during surgical resections and in stereotactic biopsies. In this review of this novel technique, we summarize the development and mechanism of action of SWIG, provide evidence for its benefits, and discuss its limitations. Finally, for those interested in near-infrared fluorescence-guided surgery, we provide suggestions for maximizing the benefits while minimizing the limitations of SWIG based on our own experience thus far.
Collapse
Affiliation(s)
- Steve S Cho
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.,Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Ryan Salinas
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - John Y K Lee
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
18
|
Chang SW, Donoho DA, Zada G. Use of optical fluorescence agents during surgery for pituitary adenomas: current state of the field. J Neurooncol 2018; 141:585-593. [PMID: 30523607 DOI: 10.1007/s11060-018-03062-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/24/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Differentiation of normal pituitary from abnormal tumor tissue remains a surgical challenge despite improvements in optical visualization technology for pituitary adenoma (PA) surgery. During neurosurgical procedures for other tumor types, 5-aminolevulinic acid (5-ALA) has become a focus of investigation based on its high specificity in differentiating tumor tissue. However, the role of 5-ALA and other optical fluorescent agents in PA surgery remains less clear. OBJECTIVE To perform a systematic review on the use of various optical fluorescent agents in PA surgery. METHOD Using PRISMA guidelines, a systematic literature review to identify reports describing 5-ALA and other optical agents for fluorescence-guided surgery for PA was performed. Eleven research studies met inclusion criteria and were reviewed. RESULTS In two studies, 5-ALA was not shown to be effective in aiding PA resection using standard neurosurgical endoscopic/microscopic approaches. 5-ALA photodynamic therapy was evaluated in two in-vitro models with inconsistent results. Intraoperative use of indocyanine green (ICG) concluded with varying results, but showed a tendency towards improved differentiation of functional PA. OTL38 showed potential for intraoperative identification of nonfunctioning PA, particularly in tumors with high folate receptor expression. One study reported clinically useful fluorescence following sodium fluorescein administration. CONCLUSION We conclude that selected optical fluorescent agents, including ICG and folate receptors, are most likely to hold promise for clinical use in differentiating PA from normal tissue.
Collapse
Affiliation(s)
- Stephanie W Chang
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Daniel A Donoho
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| |
Collapse
|