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Garufi G, Conti A, Chaurasia B, Cardali SM. Exoscopic versus Microscopic Surgery in 5-ALA-Guided Resection of High-Grade Gliomas. J Clin Med 2024; 13:3493. [PMID: 38930021 PMCID: PMC11205195 DOI: 10.3390/jcm13123493] [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: 05/01/2024] [Revised: 06/07/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Glioma surgery has been remarkably enhanced in the past 2 decades, with improved safety and limited but improved life expectations. The fluorescence-guided resection of high-grade gliomas (HGGs) plays a central role in this sense, allowing a greater extent of resection (EOR). The introduction of exoscopic-guided surgery may be considered in implementing fluorescence techniques over traditional microscopes. We present the application and the advantages of exoscopic-guided surgery compared to microscopic surgery in tumor resection guided by 5-ALA fluorescence in patients with HGGs. Methods: Ten consecutive patients underwent surgery for HGG resection. The surgery was performed via an exoscopic-guided procedure (Olympus ORBEYE) and after the oral administration of Gliolan 5 h before the procedure. During surgery, the procedure shifted to using a microscopic (Kinevo 900, Zeiss) view. The intensity of the fluorescence under the two different procedures was subjectively measured in different picture samples during the surgery on a 1 to 5 (from minimum to maximum) scale. The brightness of the surgical field and the detailing of the anatomy were also analyzed comparatively. Results: Among the ten patients, the histopathological diagnosis was an high-grade glioma in all cases. In nine cases, it was possible to achieve gross total resection. There was no perioperative mortality. The median fluorescence intensity, on a scale of 1-5, was 4.5 in the exoscope group and 3.5 in the microscope group (p < 0.01). Conclusions: The exoscopic-guided surgery adds advantages to traditional fluorescence-guided surgery with 5-aminolevulinic acid. Beyond the important advantage of low cost and the possibility to perform collaborative surgeries, it adds a plain and continuous visualization of the tumor and offers advantages in the surgical field of fluorescence-guided glioma surgery compared to the microscopic-guided one.
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Affiliation(s)
- Giada Garufi
- Department of Neurosurgery, Azienda Ospedaliera Papardo, University of Messina, 98158 Messina, Italy;
| | - Alfredo Conti
- Department of Neurosurgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy;
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Alma Mater Studiorum Università di Bologna, Via Altura 3, 40123 Bologna, Italy
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj 44300, Nepal;
| | - Salvatore Massimiliano Cardali
- Department of Neurosurgery, Azienda Ospedaliera Papardo, University of Messina, 98158 Messina, Italy;
- Department of Biomedical, Dental and Morphological and Functional Imaging, University of Messina, Via Consolare Valeria, 98125 Messina, Italy
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Herta J, Cho A, Roetzer-Pejrimovsky T, Höftberger R, Marik W, Kronreif G, Peilnsteiner T, Rössler K, Wolfsberger S. Optimizing maximum resection of glioblastoma: Raman spectroscopy versus 5-aminolevulinic acid. J Neurosurg 2023; 139:334-343. [PMID: 36681953 DOI: 10.3171/2022.11.jns22693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 11/16/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The objective of this study was to assess and compare the potential of 5-aminolevulinic acid (5-ALA) and Raman spectroscopy (RS) in detecting tumor-infiltrated brain in patients with glioblastoma (GBM). METHODS Between July 2020 and October 2021, the authors conducted a prospective clinical trial with 15 patients who underwent neurosurgical treatment of newly diagnosed and histologically verified GBM. A solid contrast-enhancing tumor core and peritumoral tissue were investigated intraoperatively for cancer cells by using 5-ALA and RS to achieve pathology-tailored maximum resection. In each case, a minimum of 10 biopsies were sampled from navigation-guided areas. Two neuropathologists examined the biopsies for the presence of neoplastic cells. The detection performance of 5-ALA and RS alone and in combination was assessed. Pre- and postoperative MRI, Karnofsky Performance Status (KPS), and National Institutes of Health Stroke Scale (NIHSS) scores were compared, and median progression-free survival (PFS) was evaluated. RESULTS A total of 185 biopsy samples were harvested from the contrast-enhancing tumor core (n = 19) and peritumoral tissue (n = 166). In the tumor core, 5-ALA and RS each showed a sensitivity of 100%. In the peritumoral tissue, 5-ALA was less sensitive than RS in detecting cancer (46% vs 69%) but showed higher specificity (81% vs 57%). When the two methods were combined, the accuracy of tumor detection was increased by about 10%. Pathology-tailored resection led to a 52% increase in resection volume comparing the volume of preoperative contrast enhancement with the postoperative resection cavity on MRI (p = 0.0123). Eloquent brain involvement prevented gross-total resection in 4 patients. Four weeks after surgery, mean KPS (p = 0.7637) and NIHSS scores (p = 0.3146) were not significantly different from preoperative values. Of the 13 patients who had received postoperative chemoradiotherapy, 4 did not show any progression after a median follow-up of 14 months. The remaining 9 patients had a median PFS of 8 months. CONCLUSIONS According to the study data, RS is capable of detecting tumor-infiltrated brain with higher sensitivity but lower specificity than the current standard of 5-ALA. With further technological and workflow advancements, RS in combination with protoporphyrin IX fluorescence may contribute to pathology-tailored glioma resection in the future.
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Affiliation(s)
- Johannes Herta
- 1Department of Neurosurgery, Medical University of Vienna
| | - Anna Cho
- 1Department of Neurosurgery, Medical University of Vienna
| | | | - Romana Höftberger
- 2Department of Neurology, Division of Neuropathology and Neurochemistry, Medical University of Vienna
| | - Wolfgang Marik
- 3Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; and
| | - Gernot Kronreif
- 4Austrian Center for Medical Innovation and Technology (ACMIT), Wiener Neustadt, Austria
| | | | - Karl Rössler
- 1Department of Neurosurgery, Medical University of Vienna
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Refining the Intraoperative Identification of Suspected High-Grade Glioma Using a Surgical Fluorescence Biomarker: GALA BIDD Study Report. J Pers Med 2023; 13:jpm13030514. [PMID: 36983696 PMCID: PMC10058333 DOI: 10.3390/jpm13030514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/09/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023] Open
Abstract
Background. Improving intraoperative accuracy with a validated surgical biomarker is important because identifying high-grade areas within a glioma will aid neurosurgical decision-making and sampling. Methods. We designed a multicentre, prospective surgical cohort study (GALA-BIDD) to validate the presence of visible fluorescence as a pragmatic intraoperative surgical biomarker of suspected high-grade disease within a tumour mass in patients undergoing 5-aminolevulinic acid (5-ALA) fluorescence-guided cytoreductive surgery. Results. A total of 106 patients with a suspected high-grade glioma or malignant transformation of a low-grade glioma were enrolled. Among the 99 patients who received 5-ALA, 89 patients were eligible to assess the correlation of fluorescence with diagnosis as per protocol. Of these 89, 81 patients had visible fluorescence at surgery, and 8 patients had no fluorescence. A total of 80 out of 81 fluorescent patients were diagnosed as high-grade gliomas on postoperative central review with 1 low-grade glioma case. Among the eight patients given 5-ALA who did not show any visible fluorescence, none were high-grade gliomas, and all were low-grade gliomas. Of the seven patients suspected radiologically of malignant transformation of low-grade gliomas and with visible fluorescence at surgery, six were diagnosed with high-grade gliomas, and one had no tissue collected. Conclusion. In patients where there is clinical suspicion, visible 5-ALA fluorescence has clinical utility as an intraoperative surgical biomarker of high-grade gliomas and can aid surgical decision-making and sampling. Further studies assessing the use of 5-ALA to assess malignant transformation in all diffuse gliomas may be valuable.
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Mui OOT, Murray DB, Walsh B, Crimmins DW, Caird JD. Spontaneous intracerebral haemorrhage secondary to 5-ALA-induced thrombocytopaenia in a paediatric patient: case report and literature review. Childs Nerv Syst 2023; 39:1051-1058. [PMID: 36662275 PMCID: PMC10160215 DOI: 10.1007/s00381-023-05846-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 01/10/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The primary objective of neurosurgical management of malignant gliomas is maximal safe resection of the tumour. One of the main obstacles in achieving this is the ability to accurately discriminate between tumour edges and the surrounding healthy brain tissue. The use of fluorescence-guided surgery utilising 5-aminolevulinic acid (5-ALA), first introduced more than 20 years ago, has become an invaluable adjunct in high-grade glioma surgery in adults. However, as 5-ALA is not licensed for use in paediatric patients, the safety profile for such use remains undetermined. CASE REPORT We describe the case of a 4-year-old boy who underwent 5-ALA-guided resection of a fourth ventricle anaplastic ependymoma. Although complete resection was achieved and the patient awoke from surgery well with no neurological deficits, the patient developed acute transaminitis, anaemia, thrombocytopaenia and coagulopathy postoperatively. The patient had a sudden neurological deterioration on postoperative day 2; imaging revealed that he had suffered a spontaneous right frontal intracerebral haemorrhage. The patient returned to theatre for surgical decompression and evacuation of the haematoma, and ultimately went on to make a full recovery. CONCLUSION The use of 5-ALA in paediatric patients can be helpful in maximising surgical resection, but the associated safety profile remains undefined. Further research is urgently warranted in order to characterise the efficacy and risk of the use of 5-ALA in the paediatric population.
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Affiliation(s)
- Olivia O T Mui
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland. .,Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Daniel B Murray
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland.,Temple Street Children's University Hospital, Dublin, Ireland
| | - Bill Walsh
- Temple Street Children's University Hospital, Dublin, Ireland
| | - Darach W Crimmins
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland.,Temple Street Children's University Hospital, Dublin, Ireland
| | - John D Caird
- Royal College of Surgeons in Ireland, Dublin, Ireland.,Temple Street Children's University Hospital, Dublin, Ireland
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Ikeda N, Furuse M, Futamura G, Kimura S, Nonoguchi N, Kawabata S, Kameda M, Yokoyama K, Takami T, Kawanishi M, Kajimoto Y, Kuroiwa T, Wanibuchi M. The Characteristic of Light Sources and Fluorescence in the 3-Dimensional Digital Exoscope "ORBEYE" for 5-Aminolevulinic Acid-Induced Fluorescence-Guided Surgery Compared with a Conventional Microscope. World Neurosurg 2022; 167:e1268-e1274. [PMID: 36087910 DOI: 10.1016/j.wneu.2022.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/04/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND The ORBEYE (ORB), an innovative 3-dimensional digital exoscope, is an equipped system for fluorescence-guided surgery with 5-aminolevulinic acid. Therefore, this study aimed to verify the characteristics of fluorescence-guided surgery with 5-aminolevulinic acid and excitation light source with ORB. METHODS The same operative field of glioblastoma was recorded under blue light (BL) excitation using a conventional microscope (MS) and ORB. For in vitro studies, the energy of 405-nm wavelength light in white light and BL modes of each scope was examined in various focal lengths. To examine the degree of photobleaching with BL for each scope, protoporphyrin IX-soaked filter papers were continuously exposed with BL of an MS and ORB, and the video-recorded red fluorescence intensity was analyzed. RESULTS The color tone of tumor-induced red fluorescence was remarkably different under each scope. Furthermore, nonfluorescent normal structures without red fluorescence were well recognized under ORB. The energy of 405-nm wavelength light in BL was significantly higher in ORB than that in an MS, especially in the short focal length. With continuous BL excitation to filter papers, the relative red fluorescence intensity of filter papers was significantly decreased over time in ORB than in an MS. In low protoporphyrin IX concentration, the difference was more significant. CONCLUSIONS With ORB, the good visibility due to BL energy as compared with an MS might improve the surgical manipulation even in BL mode. However, the weak fluorescent tissue and short focal length should be carefully considered because photobleaching might be critical for FGS.
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Affiliation(s)
- Naokado Ikeda
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan; Department of Neurosurgery, Ijinkai Takeda General Hospital, Fushimi, Kyoto, Japan.
| | - Motomasa Furuse
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Gen Futamura
- Department of Neurosurgery, Dai-ichi Towakai Hospital, Takatsuki, Osaka, Japan
| | - Seigo Kimura
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Naosuke Nonoguchi
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Shinji Kawabata
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masahiro Kameda
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Kunio Yokoyama
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Toshihiro Takami
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masahiro Kawanishi
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Yoshinaga Kajimoto
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Toshihiko Kuroiwa
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan; Department of Neurosurgery, Tesseikai Neurosurgical Hospital, Shijonawate, Osaka, Japan
| | - Masahiko Wanibuchi
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
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Haddad AF, Young JS, Morshed RA, Berger MS. FLAIRectomy: Resecting beyond the Contrast Margin for Glioblastoma. Brain Sci 2022; 12:brainsci12050544. [PMID: 35624931 PMCID: PMC9139350 DOI: 10.3390/brainsci12050544] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 12/11/2022] Open
Abstract
The standard of care for isocitrate dehydrogenase (IDH)-wildtype glioblastoma (GBM) is maximal resection followed by chemotherapy and radiation. Studies investigating the resection of GBM have primarily focused on the contrast enhancing portion of the tumor on magnetic resonance imaging. Histopathological studies, however, have demonstrated tumor infiltration within peri-tumoral fluid-attenuated inversion recovery (FLAIR) abnormalities, which is often not resected. The histopathology of FLAIR and local recurrence patterns of GBM have prompted interest in the resection of peri-tumoral FLAIR, or FLAIRectomy. To this point, recent studies have suggested a significant survival benefit associated with safe peri-tumoral FLAIR resection. In this review, we discuss the evidence surrounding the composition of peri-tumoral FLAIR, outcomes associated with FLAIRectomy, future directions of the field, and potential implications for patients.
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Skardelly M, Kaltenstadler M, Behling F, Mäurer I, Schittenhelm J, Bender B, Paulsen F, Hedderich J, Renovanz M, Gempt J, Barz M, Meyer B, Tabatabai G, Tatagiba MS. A Continuous Correlation Between Residual Tumor Volume and Survival Recommends Maximal Safe Resection in Glioblastoma Patients: A Nomogram for Clinical Decision Making and Reference for Non-Randomized Trials. Front Oncol 2021; 11:748691. [PMID: 34966669 PMCID: PMC8711700 DOI: 10.3389/fonc.2021.748691] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/12/2021] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe exact role of the extent of resection or residual tumor volume on overall survival in glioblastoma patients is still controversial. Our aim was to create a statistical model showing the association between resection extent/residual tumor volume and overall survival and to provide a nomogram that can assess the survival benefit of individual patients and serve as a reference for non-randomized studies.MethodsIn this retrospective multicenter cohort study, we used the non-parametric Cox regression and the parametric log-logistic accelerated failure time model in patients with glioblastoma. On 303 patients (training set), we developed a model to evaluate the effect of the extent of resection/residual tumor volume on overall survival and created a score to estimate individual overall survival. The stability of the model was validated by 20-fold cross-validation and predictive accuracy by an external cohort of 253 patients (validation set).ResultsWe found a continuous relationship between extent of resection or residual tumor volume and overall survival. Our final accelerated failure time model (pseudo R2 = 0.423; C-index = 0.749) included residual tumor volume, age, O6-methylguanine-DNA-methyltransferase methylation, therapy modality, resectability, and ventricular wall infiltration as independent predictors of overall survival. Based on these factors, we developed a nomogram for assessing the survival of individual patients that showed a median absolute predictive error of 2.78 (mean: 1.83) months, an improvement of about 40% compared with the most promising established models.ConclusionsA continuous relationship between residual tumor volume and overall survival supports the concept of maximum safe resection. Due to the low absolute predictive error and the consideration of uneven distributions of covariates, this model is suitable for clinical decision making and helps to evaluate the results of non-randomized studies.
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Affiliation(s)
- Marco Skardelly
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tuebingen Stuttgart, University Hospital Tuebingen, Eberhard Karls University of Tuebingen, Tuebingen, Germany
- *Correspondence: Marco Skardelly,
| | - Marlene Kaltenstadler
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Felix Behling
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Irina Mäurer
- Department of Neurology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
- Department Interdisciplinary Neuro-Oncology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Jens Schittenhelm
- Institute of Pathology and Neuropathology, Division of Neuropathology, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Benjamin Bender
- Department of Neuroradiology, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Frank Paulsen
- Center for Neuro-Oncology, Comprehensive Cancer Center Tuebingen Stuttgart, University Hospital Tuebingen, Eberhard Karls University of Tuebingen, Tuebingen, Germany
- University Department of Radiation Oncology, University Hospital Tuebingen, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | | | - Mirjam Renovanz
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tuebingen Stuttgart, University Hospital Tuebingen, Eberhard Karls University of Tuebingen, Tuebingen, Germany
- Department of Neurology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
- Department Interdisciplinary Neuro-Oncology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Melanie Barz
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Ghazaleh Tabatabai
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tuebingen Stuttgart, University Hospital Tuebingen, Eberhard Karls University of Tuebingen, Tuebingen, Germany
- Department of Neurology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
- Department Interdisciplinary Neuro-Oncology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Marcos Soares Tatagiba
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
- Center for Neuro-Oncology, Comprehensive Cancer Center Tuebingen Stuttgart, University Hospital Tuebingen, Eberhard Karls University of Tuebingen, Tuebingen, Germany
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A systematic review and meta-analysis of fluorescent-guided resection and therapy-based photodynamics on the survival of patients with glioma. Lasers Med Sci 2021; 37:789-797. [PMID: 34581904 DOI: 10.1007/s10103-021-03426-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
Glioma is the most common primary central nervous system tumor; many methods are currently being used to research and treat glioma. In recent years, fluorescent-guided resection (FGR) and photodynamic therapy (PDT) have become hot spots in the treatment of glioma. Based on the existing literatures regarding the FGR enhancing resection rate and regarding efficacy of PDT for the treatment of glioma, this paper made a systematic review of FGR for gross total resection of patients and the PDT for the survival of patients with glioma. Meta-analysis of eligible studies was performed to derive precise estimation of PDT on the prognosis of patients with glioma by searching all related literatures in PubMed, EMBASE, Cochrane, and Web of Science databases, and further to evaluate (GTR) under FGR and the efficacy of PDT therapy, including 1-year and 2-year survival rates, overall survival (OS), and progression-free survival (PFS). According to the inclusion and exclusion criteria, a total of 1294 patients with glioma were included in the final analysis of 31 articles, among which a 73.00% (95% CI, 68.00 ~ 79.00%, P < 0.01) rate of GTR in 27 groups included in 23 articles was reported for those receiving FGR. The OS was 17.78 months (95% CI, 8.89 ~ 26.67, P < 0.01) in 5 articles on PDT-treated patients with glioma, and the mean difference of OS was 6.18 (95% CI, 3.3 ~ 9.06, P < 0.01) between PDT treatment and conventional glioma surgery, showing a statistically significant difference (P < 0.01). The PFS was 10.82 months (95% CI, 7.04 ~ 14.61, P < 0.01) in 5 articles on PDT-treated patients with glioma. A 1-year survival rate of 59.00% (95% CI, 38.00 ~ 77.00%, P < 0.01) in 10 groups included in 8 articles and 2-year survival rate of 25.00% (95% CI, 15.00 ~ 36.00%, P < 0.01) in 7 groups included in 6 articles were reported for those with PDT. FGR and PDT are feasible for treatment of patients with glioma, because FGR can effectively increase the resection rate, at the same time, PDT can prolong the survival time. However, due to the limitation of small sample size in the existing studies, larger samples and randomized controlled clinical trials are needed to analyze the resection under FGR and efficacy of PDT in patients with glioma.
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Sun R, Cuthbert H, Watts C. Fluorescence-Guided Surgery in the Surgical Treatment of Gliomas: Past, Present and Future. Cancers (Basel) 2021; 13:cancers13143508. [PMID: 34298721 PMCID: PMC8304525 DOI: 10.3390/cancers13143508] [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: 05/18/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Gliomas are aggressive central nervous system tumours. The emergence and recent widespread adoption of 5-aminolevulinic acid and fluorescence guided surgery have improved the extent of resection, with implications for improved survival and progression-free survival. This review describes the history, rationale and mechanism behind the use of 5-aminolevulinic acid and fluorescence-guided surgery. We also discuss current limitations and future directions for this important adjunct to glioma surgery. This review aims to provide readers with an up-to-date overview and evidence base on this important topic. Abstract Gliomas are central nervous systems tumours which are diffusely infiltrative and difficult to treat. The extent of surgical resection is correlated with improved outcomes, including survival and disease-free progression. Cancerous tissue can be directly visualised intra-operatively under fluorescence by administration of 5-aminolevulinic acid to the patient. The adoption of this technique has allowed surgeons worldwide to achieve greater extents of resection, with implications for improved prognosis. However, there are practical limitations to use of 5-aminolevulinic acid. New adjuncts in the field of fluorescence-guided surgery aim to improve recognition of the interface between tumour and brain with the objective of improving resection and patient outcomes.
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Affiliation(s)
- Rosa Sun
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham B15 2GW, UK;
- Correspondence: (R.S.); (H.C.)
| | - Hadleigh Cuthbert
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham B15 2GW, UK;
- Correspondence: (R.S.); (H.C.)
| | - Colin Watts
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham B15 2GW, UK;
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2SY, UK
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Batalov AI, Goryaynov SA, Zakharova NE, Solozhentseva KD, Kosyrkova AV, Potapov AA, Pronin IN. Prediction of Intraoperative Fluorescence of Brain Gliomas: Correlation between Tumor Blood Flow and the Fluorescence. J Clin Med 2021; 10:jcm10112387. [PMID: 34071447 PMCID: PMC8198656 DOI: 10.3390/jcm10112387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION The prediction of the fluorescent effect of 5-aminolevulinic acid (5-ALA) in patients with diffuse gliomas can improve the selection of patients. The degree of enhancement of gliomas has been reported to predict 5-ALA fluorescence, while, at the same time, rarer cases of fluorescence have been described in non-enhancing gliomas. Perfusion studies, in particular arterial spin labeling perfusion, have demonstrated high efficiency in determining the degree of malignancy of brain gliomas and may be better for predicting fluorescence than contrast enhancement. The aim of the study was to investigate the relationship between tumor blood flow, measured by ASL, and intraoperative fluorescent glow of gliomas of different grades. MATERIALS AND METHODS Tumoral blood flow was assessed in 75 patients by pCASL (pseudo-continuous arterial spin labeling) within 1 week prior to surgery. In all cases of tumor removal, 5-ALA had been administered preoperatively. Maximum values of tumoral blood flow (TBF max) were measured, and normalized tumor blood flow (nTBF) was calculated. RESULTS A total of 76% of patients had significant contrast enhancement, while 24% were non-enhancing. The histopathology revealed 17 WHO grade II gliomas, 12 WHO grade III gliomas and 46 glioblastomas. Overall, there was a relationship between the degree of intraoperative tumor fluorescence and ASL-TBF (Rs = 0.28, p = 0.02 or the TBF; Rs = 0.34, p = 0.003 for nTBF). Non-enhancing gliomas were fluorescent in 9/18 patients, with nTBF in fluorescent gliomas being 54.58 ± 32.34 mL/100 mg/s and in non-fluorescent gliomas being 52.99 ± 53.61 mL/100 g/s (p > 0.05). Enhancing gliomas were fluorescent in 53/57 patients, with nTBF being 170.17 ± 107.65 mL/100 g/s in fluorescent and 165.52 ± 141.71 in non-fluorescent gliomas (p > 0.05). CONCLUSION Tumoral blood flow levels measured by non-contrast ASL perfusion method predict the fluorescence by 5-ALA; however, the additional value beyond contrast enhancement is not clear. ASL is, however, useful in cases with contraindication to contrast.
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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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12
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Traylor JI, Pernik MN, Sternisha AC, McBrayer SK, Abdullah KG. Molecular and Metabolic Mechanisms Underlying Selective 5-Aminolevulinic Acid-Induced Fluorescence in Gliomas. Cancers (Basel) 2021; 13:cancers13030580. [PMID: 33540759 PMCID: PMC7867275 DOI: 10.3390/cancers13030580] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/22/2021] [Accepted: 01/26/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary 5-aminolevulinic acid (5-ALA) is a medication that produces fluorescence in certain cancers, which enables surgeons to visualize tumor margins during surgery. Gliomas are brain tumors that can be difficult to fully resect due to their infiltrative nature. In this review we explored what is known about the mechanism of 5-ALA, recent discoveries that increase our understanding of that mechanism, and potential targets to increase fluorescence in lower grade gliomas. Abstract 5-aminolevulinic acid (5-ALA) is a porphyrin precursor in the heme synthesis pathway. When supplied exogenously, certain cancers consume 5-ALA and convert it to the fluorogenic metabolite protoporphyrin IX (PpIX), causing tumor-specific tissue fluorescence. Preoperative administration of 5-ALA is used to aid neurosurgical resection of high-grade gliomas such as glioblastoma, allowing for increased extent of resection and progression free survival for these patients. A subset of gliomas, especially low-grade tumors, do not accumulate PpIX intracellularly or readily fluoresce upon 5-ALA administration, making gross total resection difficult to achieve in diffuse lesions. We review existing literature on 5-ALA metabolism and PpIX accumulation to explore potential mechanisms of 5-ALA-induced glioma tissue fluorescence. Targeting the heme synthesis pathway and understanding its dysregulation in malignant tissues could aid the development of adjunct therapies to increase intraoperative fluorescence after 5-ALA treatment.
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Affiliation(s)
- Jeffrey I. Traylor
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA; (J.I.T.); (M.N.P.)
| | - Mark N. Pernik
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA; (J.I.T.); (M.N.P.)
| | - Alex C. Sternisha
- Children’s Medical Center Research Institute, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA;
| | - Samuel K. McBrayer
- Children’s Medical Center Research Institute, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA;
- Correspondence: (S.K.M.); (K.G.A.); Tel.: +1-(214)-648-3730 (S.K.M.); +1-(214)-645-2300 (K.G.A.)
| | - Kalil G. Abdullah
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA; (J.I.T.); (M.N.P.)
- Correspondence: (S.K.M.); (K.G.A.); Tel.: +1-(214)-648-3730 (S.K.M.); +1-(214)-645-2300 (K.G.A.)
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13
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Golub D, Hyde J, Dogra S, Nicholson J, Kirkwood KA, Gohel P, Loftus S, Schwartz TH. Intraoperative MRI versus 5-ALA in high-grade glioma resection: a network meta-analysis. J Neurosurg 2021; 134:484-498. [PMID: 32084631 DOI: 10.3171/2019.12.jns191203] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 12/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE High-grade gliomas (HGGs) continue to carry poor prognoses, and patient outcomes depend heavily on the extent of resection (EOR). The utility of conventional image-guided surgery is limited by intraoperative brain shift. More recent techniques to maximize EOR, including intraoperative imaging and the use of fluorescent dyes, combat these limitations. However, the relative efficacy of these two techniques has never been systematically compared. Thus, the authors performed an exhaustive systematic review in conjunction with quantitative network meta-analyses to evaluate the comparative effectiveness of 5-aminolevulinic acid (5-ALA) and intraoperative MRI (IMRI) in optimizing EOR in HGG. They secondarily analyzed associated progression-free and overall survival and performed subgroup analyses by level of evidence. METHODS PubMed, Embase, Cochrane Central, and Web of Science were searched for studies evaluating conventional neuronavigation, IMRI, and 5-ALA in HGG resection. The primary study endpoint was the proportion of patients attaining gross-total resection (GTR), defined as 100% elimination of contrast-enhancing lesion on postoperative MRI. Secondary endpoints included overall and progression-free survival and subgroup analyses for level of evidence. Comparative efficacy analysis of IMRI and 5-ALA was performed using Bayesian network meta-analysis models. RESULTS This analysis included 11 studies. In a classic meta-analysis, both IMRI (OR 4.99, 95% CI 2.65-9.39, p < 0.001) and 5-ALA (OR 2.866, 95% CI 2.127-3.863, p < 0.001) were superior to conventional navigation in achieving GTR. Bayesian network analysis was employed to indirectly compare IMRI to 5-ALA, and no significant difference in GTR was found between the two (OR 1.9 favoring IMRI, 95% CI 0.905-3.989, p = 0.090). A handful of studies additionally suggested that the use of either IMRI (2 and 4 studies, respectively) or 5-ALA (2 and 2 studies, respectively) improves progression-free and overall survival. CONCLUSIONS IMRI and 5-ALA are individually superior to conventional neuronavigation for achieving GTR of HGG. Between IMRI and 5-ALA, neither method is clearly more effective. Future studies evaluating the comparative cost and surgical time associated with IMRI and 5-ALA will better inform any cost-benefit analysis.
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Affiliation(s)
| | | | - Siddhant Dogra
- 2Radiology, New York University School of Medicine, New York, New York
| | - Joseph Nicholson
- 3NYU Health Sciences Library, New York University School of Medicine, New York, New York
| | - Katherine A Kirkwood
- 4Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Stephen Loftus
- 5Department of Science, Technology, Engineering and Math, Sweet Briar College, Sweet Briar, Virginia
| | - Theodore H Schwartz
- 6Departments of Neurosurgery, Otolaryngology, and Neuroscience, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York; and
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Abstract
This review considers glioma molecular markers in brain tissues and body fluids, shows the pathways of their formation, and describes traditional methods of analysis. The most important optical properties of glioma markers in the terahertz (THz) frequency range are also presented. New metamaterial-based technologies for molecular marker detection at THz frequencies are discussed. A variety of machine learning methods, which allow the marker detection sensitivity and differentiation of healthy and tumor tissues to be improved with the aid of THz tools, are considered. The actual results on the application of THz techniques in the intraoperative diagnosis of brain gliomas are shown. THz technologies’ potential in molecular marker detection and defining the boundaries of the glioma’s tissue is discussed.
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15
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Mazurek M, Kulesza B, Stoma F, Osuchowski J, Mańdziuk S, Rola R. Characteristics of Fluorescent Intraoperative Dyes Helpful in Gross Total Resection of High-Grade Gliomas-A Systematic Review. Diagnostics (Basel) 2020; 10:E1100. [PMID: 33339439 PMCID: PMC7766001 DOI: 10.3390/diagnostics10121100] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 12/12/2022] Open
Abstract
Background: A very important aspect in the treatment of high-grade glioma is gross total resection to reduce the risk of tumor recurrence. One of the methods to facilitate this task is intraoperative fluorescence navigation. The aim of the study was to compare the dyes used in this technique fluorescent intraoperative navigation in terms of the mechanism of action and influence on the treatment of patients. Methods: The review was carried out on the basis of articles found in PubMed, Google Scholar, and BMC search engines, as well as those identified by searched bibliographies and suggested by experts during the preparation of the article. The database analysis was performed for the following phrases: "glioma", "glioblastoma", "ALA", "5ALA", "5-ALA", "aminolevulinic acid", "levulinic acid", "fluorescein", "ICG", "indocyanine green", and "fluorescence navigation". Results: After analyzing 913 citations identified on the basis of the search criteria, we included 36 studies in the review. On the basis of the analyzed articles, we found that 5-aminolevulinic acid and fluorescein are highly effective in improving the percentage of gross total resection achieved in high-grade glioma surgery. At the same time, the limitations resulting from the use of these methods are marked-higher costs of the procedure and the need to have neurosurgical microscope in combination with a special light filter in the case of 5-aminolevulinic acid (5-ALA), and low specificity for neoplastic cells and the dependence on the degree of damage to the blood-brain barrier in the intensity of fluorescence in the case of fluorescein. The use of indocyanine green in the visualization of glioma cells is relatively unknown, but some researchers have suggested its utility and the benefits of using it simultaneously with other dyes. Conclusion: The use of intraoperative fluorescence navigation with the use of 5-aminolevulinic acid and fluorescein allows the range of high-grade glioma resection to be increased.
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Affiliation(s)
- Marek Mazurek
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
| | - Bartłomiej Kulesza
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
| | - Filip Stoma
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
| | - Jacek Osuchowski
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
| | - Sławomir Mańdziuk
- Department of Clinical Oncology and Chemotherapy, Medical University of Lublin, 20-954 Lublin, Poland;
| | - Radosław Rola
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
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16
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Nørøxe DS, Yde CW, Østrup O, Michaelsen SR, Schmidt AY, Kinalis S, Torp MH, Skjøth‐Rasmussen J, Brennum J, Hamerlik P, Poulsen HS, Nielsen FC, Lassen U. Genomic profiling of newly diagnosed glioblastoma patients and its potential for clinical utility - a prospective, translational study. Mol Oncol 2020; 14:2727-2743. [PMID: 32885540 PMCID: PMC7607169 DOI: 10.1002/1878-0261.12790] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/29/2020] [Accepted: 08/27/2020] [Indexed: 12/27/2022] Open
Abstract
Glioblastoma (GBM) is an incurable brain tumor for which new treatment strategies are urgently needed. Next-generation sequencing of GBM has most often been performed retrospectively and on archival tissue from both diagnostic and relapse surgeries with limited knowledge of clinical information, including treatment given. We sought to investigate the genomic composition prospectively in treatment-naïve patients, searched for possible targetable aberrations, and investigated for prognostic and/or predictive factors. A total of 108 newly diagnosed GBM patients were included. Clinical information, progression-free survival, and overall survival (OS) were noted. Tissues were analyzed by whole-exome sequencing, single nucleotide polymorphism (SNP) and transcriptome arrays, and RNA sequencing; assessed for mutations, fusions, tumor mutational burden (TMB), and chromosomal instability (CI); and classified into GBM subgroups. Each genomic report was discussed at a multidisciplinary tumor board meeting to evaluate for matching trials. From 111 consecutive patients, 97.3% accepted inclusion in this study. Eighty-six (77%) were treated with radiation therapy/temozolomide (TMZ) and adjuvant TMZ. One NTRK2 and three FGFR3-TACC3 fusions were identified. Copy number alterations in GRB2 and SMYD4 were significantly correlated with worse median OS together with known clinical variables like age, performance status, steroid dose, and O6-methyl-guanine-DNA-methyl-transferase status. Patients with CI-median or TMB-high had significantly worse median OS compared to CI-low/high or TMB-low/median. In conclusion, performing genomic profiling at diagnosis enables evaluation of genomic-driven therapy at the first progression. Furthermore, TMB-high or CI-median patients had worse median OS, which can support the possibility of offering experimental treatment already at the first line for this group.
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Affiliation(s)
- Dorte S. Nørøxe
- Department of Radiation BiologyRigshospitaletCopenhagenDenmark
- Department of OncologyRigshospitaletCopenhagenDenmark
| | | | - Olga Østrup
- Center for Genomic MedicineRigshospitaletCopenhagenDenmark
| | - Signe R. Michaelsen
- Department of Radiation BiologyRigshospitaletCopenhagenDenmark
- Biotech, Research and Innovation Centre (BRIC)University of CopenhagenCopenhagenDenmark
| | - Ane Y. Schmidt
- Center for Genomic MedicineRigshospitaletCopenhagenDenmark
| | - Savvas Kinalis
- Center for Genomic MedicineRigshospitaletCopenhagenDenmark
| | | | | | | | | | - Hans S. Poulsen
- Department of Radiation BiologyRigshospitaletCopenhagenDenmark
- Department of OncologyRigshospitaletCopenhagenDenmark
| | | | - Ulrik Lassen
- Department of OncologyRigshospitaletCopenhagenDenmark
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17
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5-Aminolevulinic acid for recurrent malignant gliomas: A systematic review. Clin Neurol Neurosurg 2020; 195:105913. [DOI: 10.1016/j.clineuro.2020.105913] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/28/2020] [Accepted: 05/10/2020] [Indexed: 11/24/2022]
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18
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Verburg N, de Witt Hamer PC. State-of-the-art imaging for glioma surgery. Neurosurg Rev 2020; 44:1331-1343. [PMID: 32607869 PMCID: PMC8121714 DOI: 10.1007/s10143-020-01337-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/25/2020] [Accepted: 06/15/2020] [Indexed: 11/29/2022]
Abstract
Diffuse gliomas are infiltrative primary brain tumors with a poor prognosis despite multimodal treatment. Maximum safe resection is recommended whenever feasible. The extent of resection (EOR) is positively correlated with survival. Identification of glioma tissue during surgery is difficult due to its diffuse nature. Therefore, glioma resection is imaging-guided, making the choice for imaging technique an important aspect of glioma surgery. The current standard for resection guidance in non-enhancing gliomas is T2 weighted or T2w-fluid attenuation inversion recovery magnetic resonance imaging (MRI), and in enhancing gliomas T1-weighted MRI with a gadolinium-based contrast agent. Other MRI sequences, like magnetic resonance spectroscopy, imaging modalities, such as positron emission tomography, as well as intraoperative imaging techniques, including the use of fluorescence, are also available for the guidance of glioma resection. The neurosurgeon’s goal is to find the balance between maximizing the EOR and preserving brain functions since surgery-induced neurological deficits result in lower quality of life and shortened survival. This requires localization of important brain functions and white matter tracts to aid the pre-operative planning and surgical decision-making. Visualization of brain functions and white matter tracts is possible with functional MRI, diffusion tensor imaging, magnetoencephalography, and navigated transcranial magnetic stimulation. In this review, we discuss the current available imaging techniques for the guidance of glioma resection and the localization of brain functions and white matter tracts.
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Affiliation(s)
- Niels Verburg
- Department of Neurosurgery and Cancer Center Amsterdam, Amsterdam UMC location VU University Medical Center, Amsterdam, The Netherlands. .,Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Brain Tumor Imaging Laboratory, University of Cambridge, Addenbrooke's Hospital, Hill Rd, Cambridge, CB2 0QQ, UK.
| | - Philip C de Witt Hamer
- Department of Neurosurgery and Cancer Center Amsterdam, Amsterdam UMC location VU University Medical Center, Amsterdam, The Netherlands
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19
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Kitada M, Ohsaki Y, Yasuda S, Abe M, Yoshida N, Okazaki S, Ishibashi K. Photodynamic Diagnosis for Pleural Disseminated Lesions of Lung Cancer Using a Combination of 5-Aminolevulinic Acid and Autofluorescence Observation System. Ann Thorac Cardiovasc Surg 2020. [PMID: 32522900 DOI: 10.5761/atcs.oa.20-00014] [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: 11/16/2022] Open
Abstract
PURPOSE We developed a diagnostic method for pleural disseminated lesions of lung cancer using a combination of 5-aminolevulinic acid (5ALA) and autofluorescence observation system. We utilized a phenomenon in which externally ingested 5ALA is metabolized to protoporphyrin IX, a precursor of heme, which remains inside malignant cells and emits red fluorescence of approximately 630 nm. The diagnosis was made employing an observation system based on autofluorescence emitted from normal tissues that we have investigated. METHODS Between January 2017 and April 2019, we examined 82 lung cancer patients with suspected pleural invasion. We orally administered 5ALA (20 mg/m2) to the patients 4 hours before surgery, and malignant pleural lesions were thoracoscopically visualized using the autofluorescence observation system. RESULTS (1) Pleural disseminated lesions were observed in six patients. Of these lesions, two were not detected by usual white light inspection, and the use of this method enabled the diagnosis of disseminated lesions. (2) Regarding the diagnosis of lung cancer pleural invasion to estimate the risk of pleural dissemination, if limited to adenocarcinoma, the sensitivity was 93.9%; specificity, 74.3%; positive predictive value, 60.8%; and negative predictive value, 96.2%. CONCLUSION This method may facilitate the detection of minute disseminated lesions that are difficult to detect by usual inspection. In addition, the degree of pleural invasion may be diagnosed to evaluate the need for limited resection such as segmentectomy.
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Affiliation(s)
- Masahiro Kitada
- Department of Respiratory Center, Asahikawa Medical University, Asahikwa, Hokkaido, Japan
| | - Yoshinobu Ohsaki
- Department of Respiratory Center, Asahikawa Medical University, Asahikwa, Hokkaido, Japan
| | - Shunsuke Yasuda
- Department of Respiratory Center, Asahikawa Medical University, Asahikwa, Hokkaido, Japan
| | - Masahiro Abe
- Department of Respiratory Center, Asahikawa Medical University, Asahikwa, Hokkaido, Japan
| | - Nana Yoshida
- Department of Respiratory Center, Asahikawa Medical University, Asahikwa, Hokkaido, Japan
| | - Satoshi Okazaki
- Department of Respiratory Center, Asahikawa Medical University, Asahikwa, Hokkaido, Japan
| | - Kei Ishibashi
- Department of Respiratory Center, Asahikawa Medical University, Asahikwa, Hokkaido, Japan
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20
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van Oosterom MN, Meershoek P, Welling MM, Pinto F, Matthies P, Simon H, Wendler T, Navab N, van de Velde CJH, van der Poel HG, van Leeuwen FWB. Extending the Hybrid Surgical Guidance Concept With Freehand Fluorescence Tomography. IEEE TRANSACTIONS ON MEDICAL IMAGING 2020; 39:226-235. [PMID: 31247546 DOI: 10.1109/tmi.2019.2924254] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Within image-guided surgery, 'hybrid' guidance technologies have been used to integrate the complementary features of radioactive guidance and fluorescence guidance. Here, we explore how the generation of a novel freehand fluorescence (fhFluo) imaging approach complements freehand SPECT (fhSPECT) in a hybrid setup. Near-infrared optical tracking was used to register the position and the orientation of a hybrid opto-nuclear detection probe while recording its readings. Dedicated look-up table models were used for 3D reconstruction. In phantom and excised tissue settings (i.e., flat-surface human skin explants), fhSPECT and fhFluo were investigated for image resolution and in-tissue signal penetration. Finally, the combined potential of these freehand technologies was evaluated on prostate and lymph node specimens of prostate cancer patients receiving prostatectomy and sentinel lymph node dissection (tracers: indocyanine green (ICG) +99m Tc-nanocolloid or ICG-99mTc-nanocolloid). After hardware and software integration, the hybrid setup created 3D nuclear and fluorescence tomography scans. The imaging resolution of fhFluo (1 mm) was superior to that of fhSPECT (6 mm). Fluorescence modalities were confined to a maximum depth of 0.5 cm, while nuclear modalities were usable at all evaluated depths (<2 cm). Both fhSPECT and fhFluo enabled augmented- and virtual-reality navigation toward segmented image hotspots, including relative hotspot quantification with an accuracy of 3.9% and 4.1%. Imaging in surgical specimens confirmed these trends (fhSPECT: in-depth detectability, low resolution, and fhFluo: superior resolution, superficial detectability). Overall, when radioactive and fluorescent tracer signatures are used, fhFluo has complementary value to fhSPECT. Combined the freehand technologies render a unique hybrid imaging and navigation modality.
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21
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Molecular and Clinical Insights into the Invasive Capacity of Glioblastoma Cells. JOURNAL OF ONCOLOGY 2019; 2019:1740763. [PMID: 31467533 PMCID: PMC6699388 DOI: 10.1155/2019/1740763] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/01/2019] [Accepted: 07/07/2019] [Indexed: 12/22/2022]
Abstract
The invasive capacity of GBM is one of the key tumoral features associated with treatment resistance, recurrence, and poor overall survival. The molecular machinery underlying GBM invasiveness comprises an intricate network of signaling pathways and interactions with the extracellular matrix and host cells. Among them, PI3k/Akt, Wnt, Hedgehog, and NFkB play a crucial role in the cellular processes related to invasion. A better understanding of these pathways could potentially help in developing new therapeutic approaches with better outcomes. Nevertheless, despite significant advances made over the last decade on these molecular and cellular mechanisms, they have not been translated into the clinical practice. Moreover, targeting the infiltrative tumor and its significance regarding outcome is still a major clinical challenge. For instance, the pre- and intraoperative methods used to identify the infiltrative tumor are limited when trying to accurately define the tumor boundaries and the burden of tumor cells in the infiltrated parenchyma. Besides, the impact of treating the infiltrative tumor remains unclear. Here we aim to highlight the molecular and clinical hallmarks of invasion in GBM.
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22
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Gandhi S, Tayebi Meybodi A, Belykh E, Cavallo C, Zhao X, Syed MP, Borba Moreira L, Lawton MT, Nakaji P, Preul MC. Survival Outcomes Among Patients With High-Grade Glioma Treated With 5-Aminolevulinic Acid-Guided Surgery: A Systematic Review and Meta-Analysis. Front Oncol 2019; 9:620. [PMID: 31380272 PMCID: PMC6652805 DOI: 10.3389/fonc.2019.00620] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/24/2019] [Indexed: 01/08/2023] Open
Abstract
Background: High-grade glioma (HGG) is associated with a dismal prognosis despite significant advances in adjuvant therapies, including chemotherapy, immunotherapy, and radiotherapy. Extent of resection continues to be the most important independent prognosticator of survival. This underlines the significance of increasing gross total resection (GTR) rates by using adjunctive intraoperative modalities to maximize resection with minimal neurological morbidity. 5-aminolevulinic acid (5-ALA) is the only US Food and Drug Administration–approved intraoperative optical agent used for fluorescence-guided surgical resection of gliomas. Despite several studies on the impact of intra-operative 5-ALA use on the extent of HGG resection, a clear picture of how such usage affects patient survival is still unavailable. Methods: A systematic review was conducted of all relevant studies assessing the GTR rate and survival outcomes [overall survival (OS) and progression-free survival (PFS)] in HGG. A meta-analysis of eligible studies was performed to assess the influence of 5-ALA-guided resection on improving GTR, OS, and PFS. GTR was defined as >95% resection. Results: Of 23 eligible studies, 19 reporting GTR rates were included in the meta-analysis. The pooled cohort had 998 patients with HGG, including 796 with newly diagnosed cases. The pooled GTR rate among patients with 5-ALA–guided resection was 76.8% (95% confidence interval, 69.1–82.9%). A comparative subgroup analysis of 5-ALA–guided vs. conventional surgery (controlling for within-study covariates) showed a 26% higher GTR rate in the 5-ALA subgroup (odds ratio, 3.8; P < 0.001). There were 11 studies eligible for survival outcome analysis, 4 of which reported PFS. The pooled mean difference in OS and PFS was 3 and 1 months, respectively, favoring 5-ALA vs. control (P < 0.001). Conclusions: This meta-analysis shows a significant increase in GTR rate with 5-ALA–guided surgical resection, with a higher weighted GTR rate (~76%) than the pivotal phase III study (~65%). Pooled analysis showed a small yet significant increase in survival measures associated with the use of 5-ALA. Despite the statistically significant results, the low level of evidence and heterogeneity across these studies make it difficult to conclusively report an independent association between 5-ALA use and survival outcomes in HGG. Additional randomized control studies are required to delineate the role of 5-ALA in survival outcomes in HGG.
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Affiliation(s)
- Sirin Gandhi
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Evgenii Belykh
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States.,Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Claudio Cavallo
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Xiaochun Zhao
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Masood Pasha Syed
- Department of Medicine, Saint Vincent Hospital, Worcester, MA, United States
| | - Leandro Borba Moreira
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Michael T Lawton
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Peter Nakaji
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Mark C Preul
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
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23
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Suero Molina E, Schipmann S, Stummer W. Maximizing safe resections: the roles of 5-aminolevulinic acid and intraoperative MR imaging in glioma surgery-review of the literature. Neurosurg Rev 2019; 42:197-208. [PMID: 28921173 PMCID: PMC6502775 DOI: 10.1007/s10143-017-0907-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/07/2017] [Accepted: 09/06/2017] [Indexed: 12/28/2022]
Abstract
Malignant glioma surgery involves the challenge of preserving the neurological status of patients harboring these lesions while pursuing a maximal tumor resection, which is correlated with overall and progression-free survival. Presently, several tools exist for assisting neurosurgeons in visualizing malignant tissue. Fluorescence-guided surgery (FGS) with 5-aminolevulinic acid (5-ALA) has increasingly been used during the last decade for identifying malignant glioma. Intraoperative magnetic resonance imaging (iMRI), first introduced in the mid-1990s, is being evaluated as a further tool to maximize the extent of resection. We aimed to evaluate the literature and discuss synergies and differences between FGS with 5-ALA and iMRI. We conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. After excluding non-relevant articles, 16 articles were evaluated and included in the qualitative analysis, comprising 2 (n = 2) reviews of the literatures, 1 (n = 1) book chapter, and 13 (n = 13) clinical articles. ALA-induced fluorescence goes beyond the borders of gadolinium contrast enhancement. Several studies stress the synergy between both tools, enabling increase in extent of resection. We point out advantages of combining both methods. iMRI, however, is not widely available, is expensive, and is not recommended as sole resection control tool in high-grade glioma. For these centers, FGS together with mapping and monitoring techniques, neuronavigation and, when needed, intraoperative ultrasound provides an excellent setting for achieving state-of-the-art gross total resection of high-grade gliomas.
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Affiliation(s)
- Eric Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany.
| | - S Schipmann
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
| | - W Stummer
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
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24
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Picart T, Berhouma M, Dumot C, Pallud J, Metellus P, Armoiry X, Guyotat J. Optimization of high-grade glioma resection using 5-ALA fluorescence-guided surgery: A literature review and practical recommendations from the neuro-oncology club of the French society of neurosurgery. Neurochirurgie 2019; 65:164-177. [PMID: 31125558 DOI: 10.1016/j.neuchi.2019.04.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/17/2019] [Accepted: 04/28/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND When feasible, the surgical resection is the standard first step of the management of high-grade gliomas. 5-ALA fluorescence-guided-surgery (5-ALA-FGS) was developed to ease the intra-operative delineation of tumor borders in order to maximize the extent of resection. METHODS A Medline electronic database search was conducted. English language studies from January 1998 until July 2018 were included, following the PRISMA guidelines. RESULTS 5-ALA can be considered as a specific tool for the detection of tumor remnant but has a weaker sensibility (level 2). 5-ALA-FGS is associated with a significant increase in the rate of gross total resection reaching more than 90% in some series (level 1). Consistently, 5-ALAFGS improves progression-free survival (level 1). However, the gain in overall survival is more debated. The use of 5-ALA-FGS in eloquent areas is feasible but requires simultaneous intraoperative electrophysiologic functional brain monitoring to precisely locate and preserve eloquent areas (level 2). 5-ALA is usable during the first resection of a glioma but also at recurrence (level 2). From a practical standpoint, 5-ALA is orally administered 3 hours before the induction of anesthesia, the recommended dose being 20 mg/kg. Intra-operatively, the procedure is performed as usually with a central debulking and a peripheral dissection during which the surgeon switches from white to blue light. Provided that some precautions are observed, the technique does not expose the patient to particular complications. CONCLUSION Although 5-ALA-FGS contributes to improve gliomas management, there are still some limitations. Future methods will be developed to improve the sensibility of 5-ALA-FGS.
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Affiliation(s)
- T Picart
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; Inserm 1052, UMR 5286,Team ATIP/AVENIR Transcriptomic diversity of stem cells, centre de cancérologie de Lyon, centre Léon-Bérard, 69008 Lyon, France.
| | - M Berhouma
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; CREATIS Laboratory, Inserm U1206, UMR 5220, université de Lyon, 69100 Villeurbanne, France
| | - C Dumot
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; CREATIS Laboratory, Inserm U1206, UMR 5220, université de Lyon, 69100 Villeurbanne, France
| | - J Pallud
- Département de neurochirurgie, hôpital Sainte-Anne, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 75005 Paris, France; IMA-Brain, Inserm U894, institut de psychiatrie et neurosciences de Paris, 7013 Paris, France
| | - P Metellus
- Hôpital Privé Clairval, Ramsay général de santé, 13009 Marseille, France; UMR 7051, institut de neurophysiopathologie, université d'Aix-Marseille, 13344 Marseille, France
| | - X Armoiry
- MATEIS (Team I2B), University of Lyon, Lyon school of pharmacy, 69008 Lyon, France; Édouard-Herriot Hospital, Pharmacy Department, 69008 Lyon, France; University of Warwick, Warwick Medical School, Coventry, UK
| | - J Guyotat
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France
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25
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Kaneko S, Suero Molina E, Ewelt C, Warneke N, Stummer W. Fluorescence-Based Measurement of Real-Time Kinetics of Protoporphyrin IX After 5-Aminolevulinic Acid Administration in Human In Situ Malignant Gliomas. Neurosurgery 2019; 85:E739-E746. [DOI: 10.1093/neuros/nyz129] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 03/31/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Five-aminolevulinic acid (5-ALA) is well established for fluorescence-guided resections of malignant gliomas by eliciting the accumulation of fluorescent protoporphyrin IX (PpIX) in tumors. Because of the assumed time point of peak fluorescence, 5-ALA is recommended to be administered 3 h before surgery. However, the actual time dependency of tumor fluorescence has not yet been evaluated in humans and may have important implications.
OBJECTIVE
To investigate the time dependency of PpIX by measuring fluorescence intensities in tumors at various time points during surgery.
METHODS
Patients received 5-ALA (20 mg/kg b.w.) 3 to 4 h before surgery. Fluorescence intensities (FI) and estimated tumor PpIX concentrations (CPPIX) were measured in the tumors over time with a hyperspectral camera. CPPIX was assessed using hyperspectral imaging and by evaluating fluorescence phantoms with known CPPIX.
RESULTS
A total of 201 samples from 68 patients were included in this study. On average, maximum values of calculated FI and CPPIX were observed between 7 and 8 h after 5-ALA administration. FI and CPPIX both reliably distinguished central strong and marginal weak fluorescence, and grade III compared to grade IV gliomas. Interestingly, marginal (weak) fluorescence was observed to peak later than strong fluorescence (8-9 vs 7-8 h).
CONCLUSION
In human in Situ brain tumor tissue, we determined fluorescence after 5-ALA administration to be maximal later than previously thought. In consequence, 5-ALA should be administered 4 to 5 h before surgery, with timing adjusted to internal logistical circumstances and factors related to approaching the tumor.
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Affiliation(s)
- Sadahiro Kaneko
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Eric Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - Christian Ewelt
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - Nils Warneke
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
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26
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Bright spot analysis for photodynamic diagnosis of brain tumors using confocal microscopy. Photodiagnosis Photodyn Ther 2019; 25:463-471. [PMID: 30738224 DOI: 10.1016/j.pdpdt.2019.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/11/2019] [Accepted: 02/04/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND In a previous study of photodynamic tumor diagnosis using 5-aminolevulinic acid (5-ALA), the authors proposed using fluorescence intensity and bright spot analyses under confocal microscopy for the precise discrimination of tumorous brain tissue (such as glioblastoma, GBM) from normal tissue. However, it remains unclear if bright spot analysis can discriminate infiltrating tumor in the boundary zone and whether this method is suitable for GBM with no 5-ALA fluorescence or for other tumor types. METHODS Brain tumor tissue resected from 5-ALA-treated patients was sectioned to evaluate bright spots under confocal microscopy with a 544.5 - 619.5 nm band-pass filter, which eliminated the fluorescence induced by 5-ALA. Border regions and adjacent normal tissues were observed for differences in bright spot distribution. Histopathology was also conducted by hematoxylin and eosin (H&E) staining of serial slices from the same samples to confirm the locations of tumorous, infiltrating, and normal regions. Bright spot areas were then calculated for the same regions evaluated by histopathology. This method was applied for GBM with and without 5-ALA-induced fluorescence as well as for lower-grade gliomas and other brain tumor types. RESULTS The bright spot area was substantially smaller in the GBM body than in normal brain tissues. Bright spot area was also smaller in infiltrating tumors than in normal tissue at the margin. The same bright spot pattern was observed in tumorous tissues with no 5-ALA-induced fluorescence and in non-GBM tumors. The bright spot fluorescence is suggested to arise from lipofuscin based on emission spectra (mainly within 544.5 - 619.5 nm) and optimum excitation wavelength (about 405 nm). CONCLUSIONS Bright spot analysis is useful for discriminating infiltrating tumor from bordering normal tissue as an alternative or complement to photodynamic diagnosis with 5-ALA. This method is also potentially useful for tumors with no 5-ALA-derived red fluorescence and other nervous system tumors.
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27
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Marner L, Nysom K, Sehested A, Borgwardt L, Mathiasen R, Henriksen OM, Lundemann M, Munck Af Rosenschöld P, Thomsen C, Bøgeskov L, Skjøth-Rasmussen J, Juhler M, Kruse A, Broholm H, Scheie D, Lauritsen T, Forman JL, Wehner PS, Højgaard L, Law I. Early Postoperative 18F-FET PET/MRI for Pediatric Brain and Spinal Cord Tumors. J Nucl Med 2019; 60:1053-1058. [PMID: 30683767 DOI: 10.2967/jnumed.118.220293] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 12/11/2018] [Indexed: 11/16/2022] Open
Abstract
Complete resection is the treatment of choice for most pediatric brain tumors, but early postoperative MRI for detection of residual tumor may be misleading because of MRI signal changes caused by the operation. PET imaging with amino acid tracers in adults increases the diagnostic accuracy for brain tumors, but the literature in pediatric neurooncology is limited. A hybrid PET/MRI system is highly beneficial in children, reducing the number of scanning procedures, and this is to our knowledge the first larger study using PET/MRI in pediatric neurooncology. We evaluated if additional postoperative 18F-fluoro-ethyl-tyrosine (18F-FET) PET in children and adolescents would improve diagnostic accuracy for the detection of residual tumor as compared with MRI alone and would assist clinical management. Methods: Twenty-two patients (7 male; mean age, 9.5 y; range, 0-19 y) were included prospectively and consecutively in the study and had 27 early postoperative 18F-FET PET exams performed preferentially in a hybrid PET/MRI system (NCT03402425). Results: Using follow-up (93%) or reoperation (7%) as the reference standard, PET combined with MRI discriminated tumor from treatment effects with a lesion-based sensitivity/specificity/accuracy (95% confidence intervals) of 0.73 (0.50-1.00)/1.00 (0.74-1.00)/0.87 (0.73-1.00) compared with MRI alone: 0.80 (0.57-1.00)/0.75 (0.53-0.94)/0.77 (0.65-0.90); that is, the specificity for PET/MRI was 1.00 as compared with 0.75 for MRI alone (P = 0.13). In 11 of 27 cases (41%), results from the 18F-FET PET scans added relevant clinical information, including one scan that directly influenced clinical management because an additional residual tumor site was identified. 18F-FET uptake in reactive changes was frequent (52%), but correct interpretation was possible in all cases. Conclusion: The high specificity for detecting residual tumor suggests that supplementary 18F-FET PET is relevant in cases where reoperation for residual tumor is considered.
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Affiliation(s)
- Lisbeth Marner
- Department of Clinical Physiology, Nuclear Medicine, and PET, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Karsten Nysom
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Astrid Sehested
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Lise Borgwardt
- Department of Clinical Physiology, Nuclear Medicine, and PET, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - René Mathiasen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Otto Mølby Henriksen
- Department of Clinical Physiology, Nuclear Medicine, and PET, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Michael Lundemann
- Department of Clinical Physiology, Nuclear Medicine, and PET, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | - Carsten Thomsen
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, Denmark.,Department of Radiology, Zealand University Hospital, Køge, Denmark
| | - Lars Bøgeskov
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Anders Kruse
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Helle Broholm
- Department of Pathology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - David Scheie
- Department of Pathology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Torsten Lauritsen
- Department of Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Julie Lyng Forman
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; and
| | - Peder Skov Wehner
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Liselotte Højgaard
- Department of Clinical Physiology, Nuclear Medicine, and PET, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Ian Law
- Department of Clinical Physiology, Nuclear Medicine, and PET, Copenhagen University Hospital, Rigshospitalet, Denmark
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28
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Michael AP, Watson VL, Ryan D, Delfino KR, Bekker SV, Cozzens JW. Effects of 5-ALA dose on resection of glioblastoma. J Neurooncol 2019; 141:523-531. [PMID: 30644009 DOI: 10.1007/s11060-019-03100-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/10/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE Fluorescence-guided surgery (FGS) with the use of 5-aminolevulinic acid (5-ALA) leads to more extensive resection of high-grade glioma (HGG) and longer overall survival (OS) of patients compared to conventional resection. The purpose of this study is to investigate the effect of 5-ALA dosages on residual tumor volume (RTV) and OS in patients with glioblastoma. METHODS A retrospective cohort study for patients who participated in a phase I and II dose-escalation clinical trial on 5-ALA for resection of HGG. A total of 25 patients were found to have newly diagnosed glioblastoma on histology and enrolled in our study. Patients receiving low doses of 5-ALA (10-30 mg/kg) (n = 6) were compared to those receiving high doses (40-50 mg/kg) (n = 19). Pre- and post-operative contrast enhanced T1W MRI were evaluated with volumetric analysis. RESULTS Median RTV was 0.69 cm3 and 0.00 cm3 in the low and high dose groups respectively (p = 0.975). A gross total resection (GTR) was more likely in the high dose group, though this was not statistically significant. No significant difference was found in median OS between the high and low dose groups (p = 0.6787). CONCLUSIONS High doses of 5-ALA FGS are associated with less RTV and greater probability of GTR. 5-ALA dose was not associated with OS. Further studies with a larger patient cohort are warranted.
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Affiliation(s)
- Alex P Michael
- Division of Neurosurgery, Southern Illinois University School of Medicine, 421 N. 9th Street, Springfield, IL, 62702, USA.
| | - Victoria L Watson
- Division of Neurosurgery, Southern Illinois University School of Medicine, 421 N. 9th Street, Springfield, IL, 62702, USA
| | - Daniel Ryan
- Department of Radiology, Southern Illinois University School of Medicine, 421 N. 9th Street, Springfield, IL, 62702, USA
| | - Kristin R Delfino
- Center for Clinical Research, SIU School of Medicine, 201 E. Madison, P.O. Box 19664, Springfield, IL, 62794-9664, USA
| | - Simon V Bekker
- Department of Radiology, Southern Illinois University School of Medicine, 111 Oakwood Road, East Peoria, IL, 61611, USA
| | - Jeffrey W Cozzens
- Division of Neurosurgery, Southern Illinois University School of Medicine, 421 N. 9th Street, Springfield, IL, 62702, USA
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29
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Ji SY, Kim JW, Park CK. Experience Profiling of Fluorescence-Guided Surgery I: Gliomas. Brain Tumor Res Treat 2019; 7:98-104. [PMID: 31686440 PMCID: PMC6829086 DOI: 10.14791/btrt.2019.7.e38] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 07/23/2019] [Accepted: 08/06/2019] [Indexed: 12/21/2022] Open
Abstract
Background Numerous studies reported a usefulness of 5-aminolevulinic acid (5-ALA) fluorescence-guided surgery (FGS) in high grade gliomas. However, fluorescence patterns and intensities are variable among gliomas. In this study, we report our extensive experience with FGS in various gliomas, focusing on epidemiological data of fluorescence patterns. Methods A total of 827 histologically proven glioma patients out of 900 brain tumor patients who had undergone FGS using 5-ALA during the period of 8.5 years between July 2010 and January 2019 were analyzed. Indications of FGS in glioma surgery are evidence for possible high-grade foci in putative gliomas in preoperative MRI. Results Among the 827 gliomas, the number of cases corresponding to 2016 World Health Organization (WHO) grade IV, III, II, and I are 528 (58.7%), 193 (21.4%), 87 (9.7%) and 19 (2.1%), respectively. In terms of fluorescence rate, grade IV gliomas showed positive fluorescence in 95.4% of cases including strong intensity in 85.6%. Grade III gliomas showed fluorescence in about half of cases (55.0%), but 45.0% of the cases showed no fluorescence at all. Anaplastic oligodendroglioma had a higher positive rate (63.9%) than anaplastic astrocytoma (46.2%). Both grade II and I gliomas still showed positive fluorescence in about one-fourth of cases (24.1% and 26.3% respectively). Among them ependymoma and pilocytic astrocytoma were fluorescence-prone tumors. Conclusion This epidemiological data of 5-ALA fluorescence in various grades of glioma provides a basic reference to the clinical application of FGS with 5-ALA in glioma surgery.
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Affiliation(s)
- So Young Ji
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Jin Wook Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chul Kee Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.
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30
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The Impact of Compressed Femtosecond Laser Pulse Durations on Neuronal Tissue Used for Two-Photon Excitation Through an Endoscope. Sci Rep 2018; 8:11124. [PMID: 30042504 PMCID: PMC6057889 DOI: 10.1038/s41598-018-29404-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 07/11/2018] [Indexed: 11/09/2022] Open
Abstract
Accurate intraoperative tumour margin assessment is a major challenge in neurooncology, where sparse tumours beyond the bulk tumour are left undetected under conventional resection. Non-linear optical imaging can diagnose tissue at the sub-micron level and provide functional label-free histopathology in vivo. For this reason, a non-linear endomicroscope is being developed to characterize brain tissue intraoperatively based on multiple endogenous optical contrasts such as spectrally- and temporally-resolved fluorescence. To produce highly sensitive optical signatures that are specific to a given tissue type, short femtosecond pulsed lasers are required for efficient two-photon excitation. Yet, the potential of causing bio-damage has not been studied on neuronal tissue. Therefore, as a prerequisite to clinically testing the non-linear endomicroscope in vivo, the effect of short laser pulse durations (40-340 fs) on ex vivo brain tissue was investigated by monitoring the intensity, the spectral, and the lifetime properties of endogenous fluorophores under 800 and 890 nm two-photon excitation using a bi-modal non-linear endoscope. These properties were also validated by imaging samples on a benchtop multiphoton microscope. Our results show that under a constant mean laser power, excitation pulses as short as 40 fs do not negatively alter the biochemical/ biophysical properties of tissue even for prolonged irradiation.
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31
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Roberts DW, Olson JD, Evans LT, Kolste KK, Kanick SC, Fan X, Bravo JJ, Wilson BC, Leblond F, Marois M, Paulsen KD. Red-light excitation of protoporphyrin IX fluorescence for subsurface tumor detection. J Neurosurg 2018; 128:1690-1697. [PMID: 28777025 PMCID: PMC5797501 DOI: 10.3171/2017.1.jns162061] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The objective of this study was to detect 5-aminolevulinic acid (ALA)-induced tumor fluorescence from glioma below the surface of the surgical field by using red-light illumination. METHODS To overcome the shallow tissue penetration of blue light, which maximally excites the ALA-induced fluorophore protoporphyrin IX (PpIX) but is also strongly absorbed by hemoglobin and oxyhemoglobin, a system was developed to illuminate the surgical field with red light (620-640 nm) matching a secondary, smaller absorption peak of PpIX and detecting the fluorescence emission through a 650-nm longpass filter. This wide-field spectroscopic imaging system was used in conjunction with conventional blue-light fluorescence for comparison in 29 patients undergoing craniotomy for resection of high-grade glioma, low-grade glioma, meningioma, or metastasis. RESULTS Although, as expected, red-light excitation is less sensitive to PpIX in exposed tumor, it did reveal tumor at a depth up to 5 mm below the resection bed in 22 of 24 patients who also exhibited PpIX fluorescence under blue-light excitation during the course of surgery. CONCLUSIONS Red-light excitation of tumor-associated PpIX fluorescence below the surface of the surgical field can be achieved intraoperatively and enables detection of subsurface tumor that is not visualized under conventional blue-light excitation. Clinical trial registration no.: NCT02191488 (clinicaltrials.gov).
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Affiliation(s)
- David W. Roberts
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Jonathan D. Olson
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Linton T. Evans
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon
| | - Kolbein K. Kolste
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Stephen C. Kanick
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Xiaoyao Fan
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Jaime J. Bravo
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Brian C. Wilson
- Princess Margaret Cancer Centre/University Health Network and Department of Medical Biophysics, University of Toronto, Ontario
| | - Frederic Leblond
- Department of Engineering Physics, Polytechnique Montreal, Quebec
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Quebec, Canada
| | - Mikael Marois
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Keith D. Paulsen
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
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32
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Coburger J, Scheuerle A, Pala A, Thal D, Wirtz CR, König R. Histopathological Insights on Imaging Results of Intraoperative Magnetic Resonance Imaging, 5-Aminolevulinic Acid, and Intraoperative Ultrasound in Glioblastoma Surgery. Neurosurgery 2018; 81:165-174. [PMID: 28204539 DOI: 10.1093/neuros/nyw143] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 12/13/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND For appropriate use of available intraoperative imaging techniques in glioblastoma (GB) surgery, it is crucial to know the potential of the respective techniques in tumor detection. OBJECTIVE To assess histopathological basis of imaging results of intraoperative magnetic resonance imaging (iMRI), 5-aminolevulinic acid (5-ALA), and linear array intraoperative ultrasound (lioUS). METHODS We prospectively compared the imaging findings of iMRI, 5-ALA, and lioUS at 99 intraoperative biopsy sites in 33 GB patients during resection control. Histological classification of specimens, tumor load, presence of necrosis, presence of vascular malformations, and O6-methylguanin-DNA methyltransferase (MGMT) promoter state was correlated with imaging findings. RESULTS Solid tumor was found in 57%, infiltration zone in 42%, and no tumor in 1% of specimens. However, imaging was negative in iMRI in 49%, using 5-ALA in 17%, and in lioUS in 21%. In positive imaging results, share of solid tumor was highest in 5-ALA (65%) followed by lioUS (60%) and lowest in iMRI (55%). In comparison to 5-ALA, iMRI had a high share of solid tumor in specimens when showing intermediate results. Sensitivity for invasive tumor was higher in 5-ALA (84%) and lioUS (80%) than in iMRI (50%). We found a significant correlation of 5-ALA with classification of specimen, presence of necrosis, and microproliferations. Methylated MGMT promoter correlated with positive findings in 5-ALA. lioUS and iMRI showed no correlations with histopathological findings. CONCLUSION All of the assessed established imaging techniques detect infiltrating tumor only to a certain extent. Only 5-ALA showed a significant correlation with histopathological findings. Interestingly, tumor remnants in an MGMT-methylated tumor are more likely to be visible using 5-ALA as in unmethylated tumors.
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Affiliation(s)
- Jan Coburger
- Department of Neurosurgery, University of Ulm, Günzburg, Germany
| | | | - Andrej Pala
- Department of Neurosurgery, University of Ulm, Günzburg, Germany
| | - Dietmar Thal
- Research Group Experimental Neurology, Leuven, Belgium
| | | | - Ralph König
- Department of Neurosurgery, University of Ulm, Günzburg, Germany
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Kamp MA, Krause Molle Z, Munoz-Bendix C, Rapp M, Sabel M, Steiger HJ, Cornelius JF. Various shades of red-a systematic analysis of qualitative estimation of ALA-derived fluorescence in neurosurgery. Neurosurg Rev 2018; 41:3-18. [PMID: 27225452 DOI: 10.1007/s10143-016-0745-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 03/08/2016] [Accepted: 03/13/2016] [Indexed: 01/11/2023]
Abstract
5-Aminolevulinic acid (5-ALA)-fluorescence-guided resection is well established in many neuro-oncologic centers. Different classifications of 5-ALA-induced fluorescence have been reported. The aim of the systematic analysis was to evaluate the frequency of graduations, definitions, and designations of 5-ALA-induced fluorescence qualities. A systematic database search of PubMed was performed to identify studies reporting (1) on 5-ALA fluorescence-guided either spinal or cranial surgery, (2) on qualitative estimation and/or categorization of 5-ALA-induced fluorescence, (3) in English, and (4) were published as peer-reviewed original studies. Totally, 93 studies were identified. Different classification systems of 5-ALA-induced fluorescence were found. Over 60 % of the included studies used a dichotomized categorization of 5-ALA-induced fluorescence and 27.5 % of studies distinguished two different intensities of 5-ALA fluorescent tissue in addition to non-fluorescing tissue. More than 50 % of studies explicitly defined criteria for categorization of 5-ALA-induced fluorescence. The major limitation of the present analysis might be that it mainly comprises data from retrospective, uncontrolled, non-randomized trials. However, a precise definition of each 5-ALA-induced fluorescence quality is essential. Although dichotomized classification is the most common and simple graduation system, it may not be suitable for every clinical or scientific task. A three-level 5-ALA-induced fluorescence classification with precise definition of each fluorescence quality and their correlation with histological features would be more useful and reproducible in these cases.
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Affiliation(s)
- Marcel A Kamp
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Zarela Krause Molle
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Christopher Munoz-Bendix
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marion Rapp
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Michael Sabel
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
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Matsuda F, Ikeda N, Kajimoto Y, Nonoguchi N, Takeuchi K, Fukumura M, Kawabata S, Furuse M, Sugano T, Sato T, Saito K, Kuroiwa T. Neurosurgical microscopic solid laser-based light inhibits photobleaching during fluorescence-guided brain tumor removal with 5-aminolevulinic acid. Photodiagnosis Photodyn Ther 2017; 20:120-124. [PMID: 28935534 DOI: 10.1016/j.pdpdt.2017.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 09/07/2017] [Accepted: 09/17/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Fluorescence image guided surgery (FIGS) with 5-aminolevulinic acid for malignant gliomas improves surgical outcome. One of the problems during FIGS is photobleaching under surgical microscopic white light. A solid laser-based white light source for neurosurgery that we developed does not include light with a wavelength of around 405nm, which is strongly absorbed by protoporphyrin IX. In the present study, we examined the efficacy of this light source to prevent the photobleaching of protoporphyrin IX-induced fluorescence. METHODS Filter papers transfused with protoporphyrin IX solution and a coronally sectioned F98 glioma rat model pretreated with 50mg/kg 5-aminolevulinic acid were continuously exposed to white light. One group was exposed to conventional xenon-based white light and another group was exposed to laser-based white light. Fluorescence at a wavelength of 635nm was measured with a radiospectrometer (in vitro study) and the relative fluorescence brightness was also measured in digital images (in vivo study) under excitation from violet blue light emitted from diodes every 5min. RESULTS AND CONCLUSION Estimated time for 50% photobleaching was prolonged about two times in the laser-based white light exposure group compared with that in the xenon-based white light exposure group (9.1/18.7min). In the brain tumor rat model, it was also prolonged about 2.7 times (15.1/40.7min). A laser-based white light source may inhibit photobleaching during FIGS for malignant gliomas. This light source for neurosurgical microscopy has the potential to prolong the prognosis of malignant glioma patients.
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Affiliation(s)
- Fumitaka Matsuda
- Department of Neurosurgery and Endovascular Neurosurgery, Osaka Medical College, 2-7 Daigaku-Machi, Takatsuki, Osaka 569-8686, Japan
| | - Naokado Ikeda
- Department of Neurosurgery and Endovascular Neurosurgery, Osaka Medical College, 2-7 Daigaku-Machi, Takatsuki, Osaka 569-8686, Japan.
| | - Yoshinaga Kajimoto
- Department of Neurosurgery and Endovascular Neurosurgery, Osaka Medical College, 2-7 Daigaku-Machi, Takatsuki, Osaka 569-8686, Japan
| | - Naosuke Nonoguchi
- Department of Neurosurgery and Endovascular Neurosurgery, Osaka Medical College, 2-7 Daigaku-Machi, Takatsuki, Osaka 569-8686, Japan
| | - Koji Takeuchi
- Department of Neurosurgery and Endovascular Neurosurgery, Osaka Medical College, 2-7 Daigaku-Machi, Takatsuki, Osaka 569-8686, Japan
| | - Masao Fukumura
- Department of Neurosurgery and Endovascular Neurosurgery, Osaka Medical College, 2-7 Daigaku-Machi, Takatsuki, Osaka 569-8686, Japan
| | - Shinji Kawabata
- Department of Neurosurgery and Endovascular Neurosurgery, Osaka Medical College, 2-7 Daigaku-Machi, Takatsuki, Osaka 569-8686, Japan
| | - Motomasa Furuse
- Department of Neurosurgery and Endovascular Neurosurgery, Osaka Medical College, 2-7 Daigaku-Machi, Takatsuki, Osaka 569-8686, Japan
| | - Tetsuo Sugano
- Mitsubishi Electric Engineering Co., Ltd., 1 Baba-Zusho, Nagaokakyo, Kyoto 617-8550, Japan
| | - Taku Sato
- Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima 960-1295, Japan
| | - Kiyoshi Saito
- Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima 960-1295, Japan
| | - Toshihiko Kuroiwa
- Department of Neurosurgery and Endovascular Neurosurgery, Osaka Medical College, 2-7 Daigaku-Machi, Takatsuki, Osaka 569-8686, Japan
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Kitada M, Ohsaki Y, Yasuda S, Abe M, Takahashi N, Okazaki S, Ishibashi K, Hayashi S. Photodynamic diagnosis of visceral pleural invasion of lung cancer with a combination of 5-aminolevulinic acid and autofluorescence observation systems. Photodiagnosis Photodyn Ther 2017; 20:10-15. [PMID: 28842241 DOI: 10.1016/j.pdpdt.2017.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/13/2017] [Accepted: 08/17/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Visceral pleural invasion (PL) is a prognostic factor in lung cancer. In the lung, lymph flows along the pleura, in addition to the flow toward the pulmonary hilum just as the pulmonary arteries and veins run toward it. Even with the same tumor diameter, a PL1 or higher level of pleural invasion is indicative of a more advanced disease stage. Final diagnosis based on the PL level is made by pathological examination of excised specimens. However, if an intraoperative diagnosis can be established, proper selection of the surgical procedure can be made, and unnecessary surgeries for disseminated lesions can be avoided. We investigated optical diagnostic techniques for identifying the presence or absence of visceral pleural invasion in lung cancer by capitalizing on the phenomenon of 5-amino-levulinic acid (5-ALA) being metabolized to a photosensitizing substance or protoporphyrin IX within malignant tumors, generating red luminescence in response to excitation light. METHOD This study included 38 patients with primary lung cancer who underwent surgery. They received 5-ALA (20mg/kg) orally 4h before surgery and then we assessed the presence or absence of pleural invasion using an autofluorescence observation system. At visceral pleural invasion sites, we were able to confirm tumor sites visualized in red with a clear border in contrast to the green autofluorescence generated in normal tissues. RESULT Red luminescence could be confirmed in 100% of PL1-PL3 patients (14/14) and 41.6% of PL0 patients (10/24) with primary lung cancer. PL0 patients in whom visualization was possible were preoperatively diagnosed as having PL1 and many of them showed vascular channel invasion. The sensitivity, specificity, positive predictive value, and negative predictive value of this diagnostic technique were 100%, 58.0%, 63.1%, and 100%, respectively. Red fluorescence emission was observed significantly more often in pleural invasion cases. CONCLUSION Accurate intraoperative diagnosis for visceral pleural invasion in lung cancer may contribute to determining the indications for limited operations such as segmental resection. In addition, accurate local diagnosis has the possibility of being applicable to photodynamic therapy.
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Affiliation(s)
| | | | | | - Masahiro Abe
- Respiratory Center, Asahikawa medical University, Japan.
| | - Nana Takahashi
- Respiratory Center, Asahikawa medical University, Japan.
| | | | - Kei Ishibashi
- Respiratory Center, Asahikawa medical University, Japan.
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Stummer W, Stepp H, Wiestler OD, Pichlmeier U. Randomized, Prospective Double-Blinded Study Comparing 3 Different Doses of 5-Aminolevulinic Acid for Fluorescence-Guided Resections of Malignant Gliomas. Neurosurgery 2017; 81:230-239. [PMID: 28379547 PMCID: PMC5808499 DOI: 10.1093/neuros/nyx074] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 03/24/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Five-aminolevulinic acid (5-ALA) is used for fluorescence-guided resections of malignant glioma at a dose of 20 mg/kg; yet, it is unknown whether lower doses may also provide efficacy. OBJECTIVE To perform a double-blinded randomized study comparing 3 different doses of 5-ALA. METHODS Twenty-one patients with suspected malignant glioma were randomly assigned to 0.2, 2, or 20 mg/kg 5-ALA. Investigators were unaware of dose. Intraoperatively, regions of interest were first defined in tumor core, margin, and adjacent white matter under white light. Under violet-blue illumination, the surgeon's impression of fluorescence was recorded per region, followed by spectrometry and biopsy. Plasma was collected after administration and analyzed for 5-ALA and protoporphyrin IX (PPIX) content. RESULTS The positive predictive value of fluorescence was 100%. Visual and spectrometric fluorescence assessment showed 20 mg/kg to elicit the strongest fluorescence in tumor core and margins, which correlated with cell density. Spectrometric and visual fluorescence correlated significantly. A 10-fold increase in 5-ALA dose (2-20 mg/kg) resulted in a 4-fold increase of fluorescence contrast between marginal tumor and adjacent brain. t max for 5-ALA was 0.94 h for 20 mg/kg (0.2 kg: 0.50 h, 2 mg/kg: 0.61 h). Integrated PPIX plasma levels were 255.8 and 779.9 mcg*h/l (2 vs 20 mg/kg). Peak plasma concentrations were observed at 1.89 ± 0.71 and 7.83 ± 0.68 h (2 vs 20 mg/kg; average ± Standard Error of Mean [SEM]). CONCLUSION The highest visible and measurable fluorescence was yielded by 20 mg/kg. No fluorescence was elicited at 0.2 mg/kg. Increasing 5-ALA doses did not result in proportional increases in tissue fluorescence or PPIX accumulation in plasma, indicating that doses higher than 20 mg/kg will not elicit useful increases in fluorescence.
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Affiliation(s)
- Walter Stummer
- Department of Neurosurgery, University of Münster, Münster, Germany
| | - Herbert Stepp
- Laser-Research Laboratory, LIFE-Center at University Hospital of Munich, Munich, Germany
| | | | - Uwe Pichlmeier
- Medac GmbH, Gesellschaft für klinische Spezialpräparate mbH, Wedel, Germany
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D’Amico RS, Englander ZK, Canoll P, Bruce JN. Extent of Resection in Glioma–A Review of the Cutting Edge. World Neurosurg 2017; 103:538-549. [DOI: 10.1016/j.wneu.2017.04.041] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/03/2017] [Accepted: 04/06/2017] [Indexed: 11/29/2022]
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Reyns N, Leroy HA, Delmaire C, Derre B, Le-Rhun E, Lejeune JP. Intraoperative MRI for the management of brain lesions adjacent to eloquent areas. Neurochirurgie 2017; 63:181-188. [PMID: 28571707 DOI: 10.1016/j.neuchi.2016.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 09/17/2016] [Accepted: 12/04/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of our study was to report the usefulness of intraoperative MRI guidance in the resection of brain lesions adjacent to eloquent areas. PATIENTS AND METHODS A single center prospective series of gliomas amenable to optimized resection with intraoperative MRI between September 2014 and December 2015. RESULTS The study included 56 patients. The median duration of the first intraoperative MRI was 38min, interquartile range (IQR 30-46). Fourteen patients (40%) underwent a second intraoperative MRI, which had a median duration of 26min (IQR, 18-30). The median total operative time was 265min (IQR, 242-337). After the first intraoperative MRI, the median residual glioma volume of the 35 gliomas adjacent to eloquent areas was 7.04cm3 (IQR, 2.22-13.8), which did not significantly differ from the other gliomas (P=0.07). After the second intraoperative MRI, the median residual glioma volume was 3.86cm3 (IQR, 0.82-6.99), which did not significantly differ from the other patients (P=0.700). On the postoperative MRI, the median extent of the glioma resections adjacent to eloquent areas was 99.78% (IQR, 88.9-100), which was not significantly different from the rest of the population (P=0.290). At 6 months after surgery, the median Karnofsky Performance Score was 90, and 2.8% of the patients presented a permanent new neurological deficit. CONCLUSION Our results suggest that intraoperative MRI is an effective and safe technique to improve the extent of brain lesion resections close to eloquent areas.
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Affiliation(s)
- N Reyns
- Inserm U1189, Onco-Thai - Image Assisted Laser Therapy for Oncology, University of Lille, 59000 Lille, France; Department of Neurosurgery, CHU de Lille, 59000 Lille, France.
| | - H-A Leroy
- Department of Neurosurgery, CHU de Lille, 59000 Lille, France
| | - C Delmaire
- Department of Radiology, CHU de Lille, 59000 Lille, France
| | - B Derre
- Department of Neurosurgery, CHU de Lille, 59000 Lille, France; Department of Radiology, CHU de Lille, 59000 Lille, France
| | - E Le-Rhun
- Department of Neuro-oncology, CHU de Lille, 59000 Lille, France
| | - J-P Lejeune
- Inserm U1189, Onco-Thai - Image Assisted Laser Therapy for Oncology, University of Lille, 59000 Lille, France; Department of Neurosurgery, CHU de Lille, 59000 Lille, France
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Nuclear medicine for photodynamic therapy in cancer: Planning, monitoring and nuclear PDT. Photodiagnosis Photodyn Ther 2017; 18:236-243. [PMID: 28300723 DOI: 10.1016/j.pdpdt.2017.03.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 02/27/2017] [Accepted: 03/09/2017] [Indexed: 12/16/2022]
Abstract
Photodynamic therapy (PDT) is a modality with promising results for the treatment of various cancers. PDT is increasingly included in the standard of care for different pathologies. This therapy relies on the effects of light delivered to photosensitized cells. At different stages of delivery, PDT requires imaging to plan, evaluate and monitor treatment. The contribution of molecular imaging in this context is important and continues to increase. In this article, we review the contribution of nuclear medicine imaging in oncology to PDT for planning and therapeutic monitoring purposes. Several solutions have been proposed to plan PDT from nuclear medicine imaging. For instance, photosensitizer biodistribution has been evaluated with a radiolabeled photosensitizer or with conventional radiopharmaceuticals on positron emission tomography. The effects of PDT delivery have also been explored with specific SPECT or PET radiopharmaceuticals to evaluate the effects on cells (apoptosis, necrosis, proliferation, metabolism) or vascular damage. Finally, the synergy between photosensitizers and radiopharmaceuticals has been studied considering the Cerenkov effect to activate photosensitized cells.
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Yoneyama T, Watanabe T, Kagawa H, Hayashi Y, Nakada M. Fluorescence intensity and bright spot analyses using a confocal microscope for photodynamic diagnosis of brain tumors. Photodiagnosis Photodyn Ther 2016; 17:13-21. [PMID: 27840177 DOI: 10.1016/j.pdpdt.2016.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/20/2016] [Accepted: 11/09/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND In photodynamic diagnosis using 5-aminolevulinic acid (5-ALA), discrimination between the tumor and normal tissue is very important for a precise resection. However, it is difficult to distinguish between infiltrating tumor and normal regions in the boundary area. In this study, fluorescent intensity and bright spot analyses using a confocal microscope is proposed for the precise discrimination between infiltrating tumor and normal regions. METHODS From the 5-ALA-resected brain tumor tissue, the red fluorescent and marginal regions were sliced for observation under a confocal microscope. Hematoxylin and eosin (H&E) staining were performed on serial slices of the same tissue. According to the pathological inspection of the H&E slides, the tumor and infiltrating and normal regions on confocal microscopy images were investigated. From the fluorescent intensity of the image pixels, a histogram of pixel number with the same fluorescent intensity was obtained. The fluorescent bright spot sizes and total number were compared between the marginal and normal regions. RESULTS The fluorescence intensity distribution and average intensity in the tumor were different from those in the normal region. The probability of a difference from the dark enhanced the difference between the tumor and the normal region. The bright spot size and number in the infiltrating tumor were different from those in the normal region. CONCLUSIONS Fluorescence intensity analysis is useful to distinguish a tumor region, and a bright spot analysis is useful to distinguish between infiltrating tumor and normal regions. These methods will be important for the precise resection or photodynamic therapy of brain tumors.
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Affiliation(s)
- Takeshi Yoneyama
- School of Mechanical Engineering, Kanazawa University, Kakuma-machi, Kanazawa 920-1192, Japan.
| | - Tetsuyo Watanabe
- School of Mechanical Engineering, Kanazawa University, Kakuma-machi, Kanazawa 920-1192, Japan
| | - Hiroyuki Kagawa
- School of Mechanical Engineering, Kanazawa University, Kakuma-machi, Kanazawa 920-1192, Japan
| | - Yutaka Hayashi
- Department of Neurosurgery Graduate School of Medical Science, Kanazawa University Takara-machi, Kanazawa 920-8641, Japan
| | - Mitsutoshi Nakada
- Department of Neurosurgery Graduate School of Medical Science, Kanazawa University Takara-machi, Kanazawa 920-8641, Japan
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Jaber M, Wölfer J, Ewelt C, Holling M, Hasselblatt M, Niederstadt T, Zoubi T, Weckesser M, Stummer W. The Value of 5-Aminolevulinic Acid in Low-grade Gliomas and High-grade Gliomas Lacking Glioblastoma Imaging Features: An Analysis Based on Fluorescence, Magnetic Resonance Imaging, 18F-Fluoroethyl Tyrosine Positron Emission Tomography, and Tumor Molecular Factors. Neurosurgery 2016; 78:401-11; discussion 411. [PMID: 26366972 PMCID: PMC4747980 DOI: 10.1227/neu.0000000000001020] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND: Approximately 20% of grade II and most grade III gliomas fluoresce after 5-aminolevulinic acid (5-ALA) application. Conversely, approximately 30% of nonenhancing gliomas are actually high grade. OBJECTIVE: The aim of this study was to identify preoperative factors (ie, age, enhancement, 18F-fluoroethyl tyrosine positron emission tomography [18F-FET PET] uptake ratios) for predicting fluorescence in gliomas without typical glioblastomas imaging features and to determine whether fluorescence will allow prediction of tumor grade or molecular characteristics. METHODS: Patients harboring gliomas without typical glioblastoma imaging features were given 5-ALA. Fluorescence was recorded intraoperatively, and biopsy specimens collected from fluorescing tissue. World Health Organization (WHO) grade, Ki-67/MIB-1 index, IDH1 (R132H) mutation status, O6-methylguanine DNA methyltransferase (MGMT) promoter methylation status, and 1p/19q co-deletion status were assessed. Predictive factors for fluorescence were derived from preoperative magnetic resonance imaging and 18F-FET PET. Classification and regression tree analysis and receiver-operating-characteristic curves were generated for defining predictors. RESULTS: Of 166 tumors, 82 were diagnosed as WHO grade II, 76 as grade III, and 8 as glioblastomas grade IV. Contrast enhancement, tumor volume, and 18F-FET PET uptake ratio >1.85 predicted fluorescence. Fluorescence correlated with WHO grade (P < .001) and Ki-67/MIB-1 index (P < .001), but not with MGMT promoter methylation status, IDH1 mutation status, or 1p19q co-deletion status. The Ki-67/MIB-1 index in fluorescing grade III gliomas was higher than in nonfluorescing tumors, whereas in fluorescing and nonfluorescing grade II tumors, no differences were noted. CONCLUSION: Age, tumor volume, and 18F-FET PET uptake are factors predicting 5-ALA-induced fluorescence in gliomas without typical glioblastoma imaging features. Fluorescence was associated with an increased Ki-67/MIB-1 index and high-grade pathology. Whether fluorescence in grade II gliomas identifies a subtype with worse prognosis remains to be determined. ABBREVIATIONS: 5-ALA, 5-aminolevulinic acid CRT, classification and regression tree 18F-FET PET, 18F-fluoroethyl tyrosine positron emission tomography FLAIR, fluid-attenuated inversion recovery GBM, glioblastoma multiforme O6-MGMT, methylguanine DNA methyltransferase ROC, receiver-operating characteristic SUV, standardized uptake value WHO, World Health Organization
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Affiliation(s)
- Mohammed Jaber
- ‡Department of Neurosurgery, University Hospital Münster, Münster, Germany;§Institute of Neuropathology, University Hospital Münster, Münster, Germany;¶Institute for Clinical Radiology, University Hospital of Münster, Münster, Germany;‖Department of Nuclear Medicine, University Hospital of Münster, Münster, Germany
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Ji YB, Oh SJ, Kang SG, Heo J, Kim SH, Choi Y, Song S, Son HY, Kim SH, Lee JH, Haam SJ, Huh YM, Chang JH, Joo C, Suh JS. Terahertz reflectometry imaging for low and high grade gliomas. Sci Rep 2016; 6:36040. [PMID: 27782153 PMCID: PMC5080552 DOI: 10.1038/srep36040] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 10/10/2016] [Indexed: 01/02/2023] Open
Abstract
Gross total resection (GTR) of glioma is critical for improving the survival rate of glioma patients. One of the greatest challenges for achieving GTR is the difficulty in discriminating low grade tumor or peritumor regions that have an intact blood brain barrier (BBB) from normal brain tissues and delineating glioma margins during surgery. Here we present a highly sensitive, label-free terahertz reflectometry imaging (TRI) that overcomes current key limitations for intraoperative detection of World Health Organization (WHO) grade II (low grade), and grade III and IV (high grade) gliomas. We demonstrate that TRI provides tumor discrimination and delineation of tumor margins in brain tissues with high sensitivity on the basis of Hematoxylin and eosin (H&E) stained image. TRI may help neurosurgeons to remove gliomas completely by providing visualization of tumor margins in WHO grade II, III, and IV gliomas without contrast agents, and hence, improve patient outcomes.
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Affiliation(s)
- Young Bin Ji
- YUHS-KRIBB Medical Convergence Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Jae Oh
- YUHS-KRIBB Medical Convergence Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seok-Gu Kang
- Department of Neurosurgery, Brain Tumor Center, Brain Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Heo
- Department of Mechanical Engineering, Yonsei University, Seoul, Republic of Korea
| | - Sang-Hoon Kim
- YUHS-KRIBB Medical Convergence Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
- Applied Electromagnetic Wave Research Center, Korea Electrotechnology Research Institute, Ansan, Republic of Korea
| | - Yuna Choi
- YUHS-KRIBB Medical Convergence Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seungri Song
- Department of Mechanical Engineering, Yonsei University, Seoul, Republic of Korea
| | - Hye Young Son
- Severance Biomedical Science Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Se Hoon Kim
- Department of Pathology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Hyun Lee
- Department of Neurosurgery, Brain Tumor Center, Brain Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Joo Haam
- Department of Chemical and Biomolecular Engineering, Yonsei University, Seoul, Republic of Korea
| | - Yong Min Huh
- YUHS-KRIBB Medical Convergence Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Brain Tumor Center, Brain Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chulmin Joo
- Department of Mechanical Engineering, Yonsei University, Seoul, Republic of Korea
| | - Jin-Suck Suh
- YUHS-KRIBB Medical Convergence Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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43
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Monge F, Shakir DI, Lejeune F, Morandi X, Navab N, Jannin P. Acquisition models in intraoperative positron surface imaging. Int J Comput Assist Radiol Surg 2016; 12:691-703. [PMID: 27714566 DOI: 10.1007/s11548-016-1487-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 09/07/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Intraoperative imaging aims at identifying residual tumor during surgery. Positron Surface Imaging (PSI) is one of the solutions to help surgeons in a better detection of resection margins of brain tumor, leading to an improved patient outcome. This system relies on a tracked freehand beta probe, using [Formula: see text]F-based radiotracer. Some acquisition models have been proposed in the literature in order to enhance image quality, but no comparative validation study has been performed for PSI. METHODS In this study, we investigated the performance of different acquisition models by considering validation criteria and normalized metrics. We proposed a reference-based validation framework to perform the comparative study between acquisition models and a basic method. We estimated the performance of several acquisition models in light of four validation criteria: efficiency, computational speed, spatial accuracy and tumor contrast. RESULTS Selected acquisition models outperformed the basic method, albeit with the real-time aspect compromised. One acquisition model yielded the best performance among all according to the validation criteria: efficiency (1-Spe: 0.1, Se: 0.94), spatial accuracy (max Dice: 0.77) and tumor contrast (max T/B: 5.2). We also found out that above a minimum threshold value of the sampling rate, the reconstruction quality does not vary significantly. CONCLUSION Our method allowed the comparison of different acquisition models and highlighted one of them according to our validation criteria. This novel approach can be extended to 3D datasets, for validation of future acquisition models dedicated to intraoperative guidance of brain surgery.
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Affiliation(s)
- Frédéric Monge
- LTSI INSERM, UMR 1099, Campus de Villejean, Université de Rennes 1, 2, Avenue du Pr. Léon Bernard, 35043, Rennes Cedex, France.
| | | | | | - Xavier Morandi
- LTSI INSERM, UMR 1099, Campus de Villejean, Université de Rennes 1, 2, Avenue du Pr. Léon Bernard, 35043, Rennes Cedex, France.,CHU Rennes, Service de Neurochirurgie, Rennes, 35000, France
| | - Nassir Navab
- CAMP, Technische Universität München, Munich, Germany
| | - Pierre Jannin
- LTSI INSERM, UMR 1099, Campus de Villejean, Université de Rennes 1, 2, Avenue du Pr. Léon Bernard, 35043, Rennes Cedex, France
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Abstract
A previous review published in 2012 demonstrated the role of clinical PET for diagnosis and management of brain tumors using mainly FDG, amino acid tracers, and 18F-fluorothymidine. This review provides an update on clinical PET studies, most of which are motivated by prediction of prognosis and planning and monitoring of therapy in gliomas. For FDG, there has been additional evidence supporting late scanning, and combination with 13N ammonia has yielded some promising results. Large neutral amino acid tracers have found widespread applications mostly based on 18F-labeled compounds fluoroethyltyrosine and fluorodopa for targeting biopsies, therapy planning and monitoring, and as outcome markers in clinical trials. 11C-alpha-methyltryptophan (AMT) has been proposed as an alternative to 11C-methionine, and there may also be a role for cyclic amino acid tracers. 18F-fluorothymidine has shown strengths for tumor grading and as an outcome marker. Studies using 18F-fluorocholine (FCH) and 68Ga-labeled compounds are promising but have not yet clearly defined their role. Studies on radiotherapy planning have explored the use of large neutral amino acid tracers to improve the delineation of tumor volume for irradiation and the use of hypoxia markers, in particular 18F-fluoromisonidazole. Many studies employed the combination of PET with advanced multimodal MR imaging methods, mostly demonstrating complementarity and some potential benefits of hybrid PET/MR.
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Affiliation(s)
- Karl Herholz
- The University of Manchester, Division of Neuroscience and Experimental Psychology Wolfson Molecular Imaging Centre, Manchester, England, United Kingdom.
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45
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Stummer W. Commentary: Combining 5-Aminolevulinic Acid Fluorescence and Intraoperative Magnetic Resonance Imaging in Glioblastoma Surgery: A Histology-Based Evaluation. Neurosurgery 2016; 78:484-6. [PMID: 26552043 DOI: 10.1227/neu.0000000000001107] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Walter Stummer
- Department of Neurosurgery, University of Münster, Münster, Germany
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46
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Hadjipanayis CG, Widhalm G, Stummer W. What is the Surgical Benefit of Utilizing 5-Aminolevulinic Acid for Fluorescence-Guided Surgery of Malignant Gliomas? Neurosurgery 2016; 77:663-73. [PMID: 26308630 DOI: 10.1227/neu.0000000000000929] [Citation(s) in RCA: 230] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The current neurosurgical goal for patients with malignant gliomas is maximal safe resection of the contrast-enhancing tumor. However, a complete resection of the contrast-enhancing tumor is achieved only in a minority of patients. One reason for this limitation is the difficulty in distinguishing viable tumor from normal adjacent brain during surgery at the tumor margin using conventional white-light microscopy. To overcome this limitation, fluorescence-guided surgery (FGS) using 5-aminolevulinic acid (5-ALA) has been introduced in the treatment of malignant gliomas. FGS permits the intraoperative visualization of malignant glioma tissue and supports the neurosurgeon with real-time guidance for differentiating tumor from normal brain that is independent of neuronavigation and brain shift. Tissue fluorescence after oral administration of 5-ALA is associated with unprecedented high sensitivity, specificity, and positive predictive values for identifying malignant glioma tumor tissue. 5-ALA-induced tumor fluorescence in diffusely infiltrating gliomas with non-significant magnetic resonance imaging contrast-enhancement permits intraoperative identification of anaplastic foci and establishment of an accurate histopathological diagnosis for proper adjuvant treatment. 5-ALA FGS has enabled surgeons to achieve a significantly higher rate of complete resections of malignant gliomas in comparison with conventional white-light resections. Consequently, 5-ALA FGS has become an indispensable surgical technique and standard of care at many neurosurgical departments around the world. We conducted an extensive literature review concerning the surgical benefit of using 5-ALA for FGS of malignant gliomas. According to the literature, there are a number of reasons for the neurosurgeon to perform 5-ALA FGS, which will be discussed in detail in the current review.
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Affiliation(s)
- Costas G Hadjipanayis
- *Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY; ‡Department of Neurosurgery, Medical University Vienna, Vienna, Austria; §Department of Neurosurgery, University of Munster, Munster, Germany
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47
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Mansouri A, Mansouri S, Hachem LD, Klironomos G, Vogelbaum MA, Bernstein M, Zadeh G. The role of 5-aminolevulinic acid in enhancing surgery for high-grade glioma, its current boundaries, and future perspectives: A systematic review. Cancer 2016; 122:2469-78. [PMID: 27183272 DOI: 10.1002/cncr.30088] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/07/2016] [Accepted: 03/17/2016] [Indexed: 01/26/2023]
Abstract
5-Aminolevulinic acid (5-ALA) has been approved as an intraoperative adjunct in glioma surgery in Europe, but not North America. A systematic review was conducted to assess the evidence regarding 5-ALA as a surgical adjunct. The MEDLINE, EMBASE, and CENTRAL databases were searched, using terms relevant to "5-ALA" and "high-grade gliomas." Included studies were based on adults aged ≥18 years who underwent surgical resection/biopsy. No language or date limitations were used. Forty-three studies (1830 patients) were identified. Thirty-six were coordinated by European countries, 2 were in the United States, and none were in Canada. One was randomized, 28 were prospective, and 14 were retrospective. Twenty-six studies assessed the utility of 5-ALA as a diagnostic tool, 24 assessed its influence on the extent of resection (EOR), 9 assessed survival, and 22 reported adverse events. 5-ALA had high sensitivity and positive predictive value, whereas its specificity increased with additional adjuncts. The EOR increased with 5-ALA, but only progression-free survival was significantly influenced. Reporting of adverse events was not systematic. The use of 5-ALA improved tumor visualization and thus enabled a greater EOR and perhaps increased survival. However, additional adjuncts may be necessary for maximizing the specificity of resection and patient safety. Additional parameters, such as patient quality of life and health economic analyses, would be informative. Thus, additional systematic collection of prospective evidence may be necessary for the global incorporation of this potentially valuable surgical adjunct into routine practice. Cancer 2016;122:2469-78. © 2016 American Cancer Society.
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Affiliation(s)
- Alireza Mansouri
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Sheila Mansouri
- MacFeeters Adult Brain Tumor Research Program, Toronto, Ontario, Canada
| | - Laureen D Hachem
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - George Klironomos
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael A Vogelbaum
- Department of Neurological Surgery, Center for Translational Therapeutics, Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Mark Bernstein
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,MacFeeters Adult Brain Tumor Research Program, Toronto, Ontario, Canada
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48
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Jermyn M, Mok K, Mercier J, Desroches J, Pichette J, Saint-Arnaud K, Bernstein L, Guiot MC, Petrecca K, Leblond F. Intraoperative brain cancer detection with Raman spectroscopy in humans. Sci Transl Med 2016; 7:274ra19. [PMID: 25673764 DOI: 10.1126/scitranslmed.aaa2384] [Citation(s) in RCA: 367] [Impact Index Per Article: 45.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cancers are often impossible to visually distinguish from normal tissue. This is critical for brain cancer where residual invasive cancer cells frequently remain after surgery, leading to disease recurrence and a negative impact on overall survival. No preoperative or intraoperative technology exists to identify all cancer cells that have invaded normal brain. To address this problem, we developed a handheld contact Raman spectroscopy probe technique for live, local detection of cancer cells in the human brain. Using this probe intraoperatively, we were able to accurately differentiate normal brain from dense cancer and normal brain invaded by cancer cells, with a sensitivity of 93% and a specificity of 91%. This Raman-based probe enabled detection of the previously undetectable diffusely invasive brain cancer cells at cellular resolution in patients with grade 2 to 4 gliomas. This intraoperative technology may therefore be able to classify cell populations in real time, making it an ideal guide for surgical resection and decision-making.
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Affiliation(s)
- Michael Jermyn
- Brain Tumour Research Centre, Montreal Neurological Institute and Hospital, Department of Neurology and Neurosurgery, McGill University, 3801 University Street, Montreal, Quebec H3A 2B4, Canada. Department of Engineering Physics, Polytechnique Montréal, CP 6079, Succursale Centre-Ville, Montreal, Quebec H3C 3A7, Canada
| | - Kelvin Mok
- Neuronavigation Unit, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec H3A 2B4, Canada
| | - Jeanne Mercier
- Department of Engineering Physics, Polytechnique Montréal, CP 6079, Succursale Centre-Ville, Montreal, Quebec H3C 3A7, Canada
| | - Joannie Desroches
- Medical Physics Unit, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
| | - Julien Pichette
- Department of Engineering Physics, Polytechnique Montréal, CP 6079, Succursale Centre-Ville, Montreal, Quebec H3C 3A7, Canada
| | - Karl Saint-Arnaud
- Department of Engineering Physics, Polytechnique Montréal, CP 6079, Succursale Centre-Ville, Montreal, Quebec H3C 3A7, Canada
| | - Liane Bernstein
- Department of Engineering Physics, Polytechnique Montréal, CP 6079, Succursale Centre-Ville, Montreal, Quebec H3C 3A7, Canada
| | - Marie-Christine Guiot
- Brain Tumour Research Centre, Montreal Neurological Institute and Hospital, Department of Neurology and Neurosurgery, McGill University, 3801 University Street, Montreal, Quebec H3A 2B4, Canada. Division of Neuropathology, Department of Pathology, McGill University, Montreal, Quebec H3A 2B4, Canada
| | - Kevin Petrecca
- Brain Tumour Research Centre, Montreal Neurological Institute and Hospital, Department of Neurology and Neurosurgery, McGill University, 3801 University Street, Montreal, Quebec H3A 2B4, Canada.
| | - Frederic Leblond
- Department of Engineering Physics, Polytechnique Montréal, CP 6079, Succursale Centre-Ville, Montreal, Quebec H3C 3A7, Canada.
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49
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Guyotat J, Pallud J, Armoiry X, Pavlov V, Metellus P. 5-Aminolevulinic Acid-Protoporphyrin IX Fluorescence-Guided Surgery of High-Grade Gliomas: A Systematic Review. Adv Tech Stand Neurosurg 2016:61-90. [PMID: 26508406 DOI: 10.1007/978-3-319-21359-0_3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The current first-line treatment of malignant gliomas consists in surgical resection (if possible) as large as possible. The existing tools don't permit to identify the limits of tumor infiltration, which goes beyond the zone of contrast enhancement on MRI. The fluorescence-guided malignant gliomas surgery was started 15 years ago and had become a standard of care in many countries. The technique is based on fluorescent molecule revelation using the filters, positioned within the surgical microscope. The fluorophore, protoporphyrin IX (PpIX), is converted in tumoral cells from 5-aminolevulinic acid (5-ALA), given orally before surgery. Many studies have shown that the ratio of gross total resections was higher if the fluorescence technique was used. The fluorescence signal intensity is correlated to the cell density and the PpIX concentration. The current method has a very high specificity but still lower sensibility, particularly regarding the zones with poor tumoral infiltration. This book reviews the principles of the technique and the results (extent of resection and survival).
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Affiliation(s)
- Jacques Guyotat
- Department of Neurosurgery, Neurological Hospital, Lyon, France.
| | - Johan Pallud
- Department of Neurosurgery, Sainte Anne Hospital, Paris, France.
- Paris Descartes University, Paris, France.
| | - Xavier Armoiry
- Délégation à la recherche clinique et à l'innovation, cellule innovation Hospices Civils de, Lyon, France.
| | - Vladislav Pavlov
- Department of Neurosurgery, Neurological Hospital, Lyon, France.
| | - Philippe Metellus
- Department of Neurosurgery, Timone Hospital, Marseille, France.
- University Aix Marseille, Marseille, France.
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50
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Kurimoto M, Suzuki H, Aoki K, Ohka F, Kondo G, Motomura K, Iijima K, Yamamichi A, Ranjit M, Wakabayashi T, Kimura S, Natsume A. Rapid sensitive analysis of IDH1 mutation in lower-grade gliomas by automated genetic typing involving a quenching probe. Cancer Invest 2015; 34:12-5. [PMID: 26695622 DOI: 10.3109/07357907.2015.1084001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The authors recently found that 80% of lower-grade gliomas (LGGs) harbored a mutation in IDH1. Intraoperative detection of the mutated IDH1 helps not only differentiate LGGs from other type of brain tumors, but determine the resection border. In the current study, the authors have applied an automated genetic typing involving a quenching probe to detect the mutated IDH1. If tumor cells with the mutated IDH1 contained 10% or more in the mixture of normal and tumor cells, the device could detect it sensitively. The intraoperative assessment of IDH1 mutation is useful in brain tumor surgeries.
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Affiliation(s)
| | - Hiromichi Suzuki
- a Department of Neurosurgery , Nagoya University , Nagoya , Japan.,b Department of Pathology and Tumor Biology , Kyoto University , Kyoto , Japan
| | - Kosuke Aoki
- a Department of Neurosurgery , Nagoya University , Nagoya , Japan.,b Department of Pathology and Tumor Biology , Kyoto University , Kyoto , Japan
| | - Fumiharu Ohka
- a Department of Neurosurgery , Nagoya University , Nagoya , Japan
| | - Goro Kondo
- a Department of Neurosurgery , Nagoya University , Nagoya , Japan
| | - Kazuya Motomura
- a Department of Neurosurgery , Nagoya University , Nagoya , Japan
| | - Kentaro Iijima
- a Department of Neurosurgery , Nagoya University , Nagoya , Japan
| | - Akane Yamamichi
- a Department of Neurosurgery , Nagoya University , Nagoya , Japan.,c Department of Neurosurgery , Mie University , Tsu , Mie , Japan
| | - Melissa Ranjit
- a Department of Neurosurgery , Nagoya University , Nagoya , Japan
| | | | - Shinya Kimura
- d Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine , Saga University , Saga , Japan
| | - Atsushi Natsume
- a Department of Neurosurgery , Nagoya University , Nagoya , Japan
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