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Li Z, Song Y, Farrukh Hameed NU, Yuan S, Wu S, Gong X, Zhuang D, Lu J, Zhu F, Qiu T, Zhang J, Aibaidula A, Geng X, Yang Z, Tang W, Chen H, Zhou L, Mao Y, Wu J. Effect of high-field iMRI guided resection in cerebral glioma surgery: A randomized clinical trial. Eur J Cancer 2024; 199:113528. [PMID: 38218157 DOI: 10.1016/j.ejca.2024.113528] [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: 10/11/2023] [Revised: 12/18/2023] [Accepted: 12/26/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Extent of resection (EOR) in glioma contributes to longer survival. The purpose of NCT01479686 was to prove whether intraoperative magnetic resonance imaging (iMRI) increases EOR in glioma surgery and benefit survival. METHODS Patients were randomized (1:1) to receive the iMRI (n = 161) or the conventional neuronavigation (n = 160). The primary endpoint was gross total resection (GTR); secondary outcomes reported were progression-free survival (PFS), overall survival (OS), and safety. RESULTS 188 high-grade gliomas (HGGs) and 133 low-grade gliomas (LGGs) were enrolled. GTR was 83.85% in the iMRI group vs. 50.00% in the control group (P < 0.0001). In 321 patients, the median PFS (mPFS) was 65.12 months in the iMRI group and 61.01 months in the control group (P = 0.0202). For HGGs, mPFS was improved in the iMRI group (19.32 vs. 13.34 months, P = 0.0015), and a trend of superior OS compared with control was observed (29.73 vs. 25.33 months, P = 0.1233). In the predefined eloquent area HGG subgroup, mPFS, and mOS were 20.47 months and 33.58 months in the iMRI vs. 12.21 months and 21.16 months in the control group (P = 0.0098; P = 0.0375, respectively). From the exploratory analyses of HGGs, residual tumor volume (TV) < 1.0 cm3 decreased the risk of survival (mPFS: 18.99 vs. 9.43 months, P = 0.0055; mOS: 29.77 vs. 18.10 months, P = 0.0042). LGGs with preoperative (pre-OP) TV > 43.1 cm3 and postoperative (post-OP) TV > 4.6 cm3 showed worse OS (P= 0.0117) CONCLUSIONS: It showed that iMRI significantly increased EOR and indicated survival benefits for HGGs, particularly eloquent HGGs. Residual TV in either HGGs or LGGs is a prognostic factor for survival.
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Affiliation(s)
- Zeyang Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China
| | - Yanyan Song
- Department of Biostatistics, Clinical research institute, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - N U Farrukh Hameed
- University of Pittsburgh Medical Center and Hillman Cancer Center, Department of Neurosurgery, Pittsburgh, USA
| | - Shiwen Yuan
- Department of Psychiatry and Human Behavior, Brown University, Rhode Island Hospital, 146 West River Street, Providence, RI 02904, USA
| | - Shuai Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China
| | - Xiu Gong
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China
| | - Dongxiao Zhuang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; National Neurological Diseases Center, China
| | - Junfeng Lu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China; National Neurological Diseases Center, China
| | - Fengping Zhu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China; National Neurological Diseases Center, China
| | - Tianming Qiu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China; National Neurological Diseases Center, China
| | - Jie Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China; National Neurological Diseases Center, China
| | - Abudumijiti Aibaidula
- Department of Neurosurgery, University of Missouri in Columbia, One Hospital Drive, MO, 65212, Columbia
| | - Xu Geng
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China
| | - Zhong Yang
- Department of Radiotherapy, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China
| | - Weijun Tang
- Department of Radiotherapy, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China
| | - Hong Chen
- Department of Pathology, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China
| | - Liangfu Zhou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China; National Neurological Diseases Center, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China; National Neurological Diseases Center, China; Institute of Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jinsong Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Wulumuqi Zhong Road 12, Shanghai 200040, China; Neurosurgical Institute of Fudan University, China; National Neurological Diseases Center, China; Institute of Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China.
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2
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Abdelnabi D, Lastakchi S, Watts C, Atkins H, Hingtgen S, Valdivia A, McConville C. Local administration of irinotecan using an implantable drug delivery device stops high-grade glioma tumor recurrence in a glioblastoma tumor model. Drug Deliv Transl Res 2024:10.1007/s13346-024-01524-x. [PMID: 38319555 DOI: 10.1007/s13346-024-01524-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/07/2024]
Abstract
The treatment for Glioblastoma is limited due to the presence of the blood brain barrier, which restricts the entry of chemotherapeutic drugs into the brain. Local delivery into the tumor resection margin has the potential to improve efficacy of chemotherapy. We developed a safe and clinically translatable irinotecan implant for local delivery to increase its efficacy while minimizing systemic side effects. Irinotecan-loaded implants were manufactured using hot melt extrusion, gamma sterilized at 25 kGy, and characterized for their irinotecan content, release, and drug diffusion. Their therapeutic efficacy was evaluated in a patient-derived xenograft mouse resection model of glioblastoma. Their safety and translatability were evaluated using histological analysis of brain tissue and serum chemistry analysis. Implants containing 30% and 40% w/w irinotecan were manufactured without plasticizer. The 30% and 40% implants showed moderate local toxicity up to 2- and 6-day post-implantation. Histopathology of the implantation site showed signs of necrosis at days 45 and 14 for the 30% and 40% implants. Hematological analysis and clinical chemistry showed no signs of serious systemic toxicity for either implant. The 30% implants had an 80% survival at day 148, with no sign of tumor recurrence. Gamma sterilization and 12-month storage had no impact on the integrity of the 30% implants. This study demonstrates that the 30% implants are a promising novel treatment for glioblastoma that could be quickly translated into the clinic.
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Affiliation(s)
- Dina Abdelnabi
- School of Pharmacy, Robert Aitken Institute for Clinical Research, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, B15 2TT, UK
| | - Sarah Lastakchi
- School of Pharmacy, Robert Aitken Institute for Clinical Research, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, B15 2TT, UK
| | - Colin Watts
- Department of Neurosurgery, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Hannah Atkins
- Department of Pathology and Laboratory Medicine, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Shawn Hingtgen
- Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Alain Valdivia
- Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Christopher McConville
- School of Pharmacy, Robert Aitken Institute for Clinical Research, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, B15 2TT, UK.
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3
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Filip P, Lerner DK, Kominsky E, Schupper A, Liu K, Khan NM, Roof S, Hadjipanayis C, Genden E, Iloreta AMC. 5-Aminolevulinic Acid Fluorescence-Guided Surgery in Head and Neck Squamous Cell Carcinoma. Laryngoscope 2024; 134:741-748. [PMID: 37540051 DOI: 10.1002/lary.30910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVES To determine the utility of 5-aminolevulinic acid (5-ALA) fluorescence for resection of head and neck carcinoma. METHODS In this prospective pilot trial, 5-ALA was administered as an oral suspension 3-5 h prior to induction of anesthesia for resection of head and neck squamous cell carcinoma (HNSCC). Following resection, 405 nm blue light was applied, and fluorescence of the tumor as well as the surgical bed was recorded. Specimen fluorescence intensity was graded categorically as none (score = 0), mild (1), moderate (2), or robust (3) by the operating surgeon intraoperatively and corroborated with final pathologic diagnosis. RESULTS Seven patients underwent resection with 5-ALA. Five (83%) were male with an age range of 33-82 years (mean = 60). Sites included nasal cavity (n = 3), oral cavity (n = 3), and the larynx (n = 1). All specimens demonstrated robust fluorescence when 5-ALA was administered 3-5 h preoperatively. 5-ALA fluorescence predicted the presence of perineural invasion, a positive margin, and metastatic lymphadenopathy. Two patients had acute photosensitivity reactions, and one patient had a temporary elevation of hepatic enzymes. CONCLUSIONS 5-ALA induces robust intraoperative fluorescence of HNSCC, capable of demonstrating a positive margin, perineural invasion, and metastatic nodal disease. Although no conclusions are there about the safety of this drug in the head and neck cancer population, our study parallels the extensive safety data in the neurosurgical literature. Future applications may include intraoperative assessment of margin status, diagnostic accuracy, and impacts on survival. LEVEL OF EVIDENCE 4 Laryngoscope, 134:741-748, 2024.
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Affiliation(s)
- Peter Filip
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | - David K Lerner
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | - Evan Kominsky
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | - Alexander Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | - Katherine Liu
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | - Nazir Mohemmed Khan
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | - Scott Roof
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | | | - Eric Genden
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
| | - Alfred M C Iloreta
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, U.S.A
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Domena JB, Ferreira BCLB, Chen J, Bartoli M, Tagliaferro A, Vanni S, Graham RM, Leblanc RM. The art of simplicity: Water-soluble porphyrin-like carbon dots self-assemble into mesmerizing red glow. Colloids Surf B Biointerfaces 2024; 234:113719. [PMID: 38181692 DOI: 10.1016/j.colsurfb.2023.113719] [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: 09/27/2023] [Revised: 11/24/2023] [Accepted: 12/19/2023] [Indexed: 01/07/2024]
Abstract
In this new study, we present an intriguing development in the field of theranostics: the simplistic self-assembly of red-emissive amphiphilic porphyrin-like carbon dots (P-CDs). By harnessing their exceptional photophysical properties, we have revealed a strong candidate as the ideal photosensitizer (PS) for applications, particularly in the realm of imaging. Spanning a remarkable size average between 1-4 nm, these particles exhibit both highly stable and unparalleled emission characteristics between 650 and 715 nm in water in comparison to current carbon dots (CDs) available. Lastly, these CDs were fairly non-toxic when tested against normal human cell lines as well as were found to have favorable imaging capabilities in zebrafish embryo.
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Affiliation(s)
- Justin B Domena
- Department of Chemistry, University of Miami, Coral Gables, FL 33146, USA
| | | | - Jiuyan Chen
- Department of Chemistry, University of Miami, Coral Gables, FL 33146, USA
| | - M Bartoli
- Department of Applied Science and Technology, Politecnico di Torino, Italy
| | - A Tagliaferro
- Department of Applied Science and Technology, Politecnico di Torino, Italy
| | - Steven Vanni
- Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136, USA; HCA Florida University Hospital, 3476 S University Dr., Davie, FL 33328, USA; Department of Medicine, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, USA
| | - Regina M Graham
- Department of Medicine, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, USA
| | - Roger M Leblanc
- Department of Chemistry, University of Miami, Coral Gables, FL 33146, USA.
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5
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Albalkhi I, Shafqat A, Bin-Alamer O, Abou Al-Shaar AR, Mallela AN, Fernández-de Thomas RJ, Zinn PO, Gerszten PC, Hadjipanayis CG, Abou-Al-Shaar H. Fluorescence-guided resection of intradural spinal tumors: a systematic review and meta-analysis. Neurosurg Rev 2023; 47:10. [PMID: 38085385 DOI: 10.1007/s10143-023-02230-x] [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: 10/11/2023] [Revised: 11/13/2023] [Accepted: 11/25/2023] [Indexed: 12/18/2023]
Abstract
Intradural spinal tumors present significant challenges due to involvement of critical motor and sensory tracts. Achieving maximal resection while preserving functional tissue is therefore crucial. Fluorescence-guided surgery aims to improve resection accuracy and is well studied for brain tumors, but its efficacy has not been fully assessed for spinal tumors. This meta-analysis aims to delineate the efficacy of fluorescence guidance in intradural spinal tumor resection. The authors performed a systematic review in four databases. We included studies that have utilized fluorescence agents, 5-aminolevulinic acid (5-ALA) or sodium fluorescein, for the resection of intradural spinal tumors. A meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A total of 12 studies involving 552 patients undergoing fluorescence-guided intradural spinal tumor resection were included. Meningiomas demonstrated a 98% fluorescence rate and were associated with a homogenous florescence pattern; however, astrocytomas had variable fluorescence rate with pooled proportion of 70%. There was no significant difference in gross total resection (GTR) rates between fluorescein and 5-ALA (94% vs 84%, p = .22). Pre-operative contrast enhancement was significantly associated with intraoperative fluorescence with fluorescein. Intramedullary tumors with positive intraoperative fluorescence were significantly associated with higher GTR rates (96% vs 73%, p = .03). Utilizing fluorescence guidance during intradural spinal tumor resection holds promise of improving intraoperative visualization for specific intradural spinal tumors. Meningiomas and ependymomas have the highest fluorescence rates especially with sodium fluorescein; on the other hand, astrocytomas have variable fluorescence rates with no superiority of either agent. Positive fluorescence of intramedullary tumors is associated with a higher degree of resection.
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Affiliation(s)
- Ibrahem Albalkhi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Neuroradiology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Pascal O Zinn
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Peter C Gerszten
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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6
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Young JS, Morshed RA, Hervey-Jumper SL, Berger MS. The surgical management of diffuse gliomas: Current state of neurosurgical management and future directions. Neuro Oncol 2023; 25:2117-2133. [PMID: 37499054 PMCID: PMC10708937 DOI: 10.1093/neuonc/noad133] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Indexed: 07/29/2023] Open
Abstract
After recent updates to the World Health Organization pathological criteria for diagnosing and grading diffuse gliomas, all major North American and European neuro-oncology societies recommend a maximal safe resection as the initial management of a diffuse glioma. For neurosurgeons to achieve this goal, the surgical plan for both low- and high-grade gliomas should be to perform a supramaximal resection when feasible based on preoperative imaging and the patient's performance status, utilizing every intraoperative adjunct to minimize postoperative neurological deficits. While the surgical approach and technique can vary, every effort must be taken to identify and preserve functional cortical and subcortical regions. In this summary statement on the current state of the field, we describe the tools and technologies that facilitate the safe removal of diffuse gliomas and highlight intraoperative and postoperative management strategies to minimize complications for these patients. Moreover, we discuss how surgical resections can go beyond cytoreduction by facilitating biological discoveries and improving the local delivery of adjuvant chemo- and radiotherapies.
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Affiliation(s)
- Jacob S Young
- Department of Neurological Surgery, University of California, San Francisco, USA
| | - Ramin A Morshed
- Department of Neurological Surgery, University of California, San Francisco, USA
| | | | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, USA
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7
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Domena JB, Ferreira BCLB, Cilingir EK, Zhou Y, Chen J, Johnson QR, Chauhan BPS, Bartoli M, Tagliaferro A, Vanni S, Graham RM, Leblanc RM. Advancing glioblastoma imaging: Exploring the potential of organic fluorophore-based red emissive carbon dots. J Colloid Interface Sci 2023; 650:1619-1637. [PMID: 37494859 DOI: 10.1016/j.jcis.2023.07.107] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 07/28/2023]
Abstract
Over time, the interest in developing stable photosensitizers (PS) which both absorb and emit light in the red region (650 and 950 nm) has gained noticeable interest. Recently, carbon dots (CDs) have become the material of focus to act as a PS due to their high extinction coefficient, low cytotoxicity, and both high photo and thermal stability. In this work, a Federal and Drug Association (FDA) approved Near Infra-Red (NIR) organic fluorophore used for photo-imaging, indocyanine green (ICG), has been explored as a precursor to develop water-soluble red emissive CDs which possess red emission at 697 nm. Furthermore, our material was found to yield favorable red-imaging capabilities of glioblastoma stem-like cells (GSCs) meanwhile boasting low toxicity. Additionally with post modifications, our CDs have been found to have selectivity towards tumors over healthy tissue as well as crossing the blood-brain barrier (BBB) in zebrafish models.
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Affiliation(s)
- Justin B Domena
- Department of Chemistry, University of Miami, Coral Gables, FL 33146, USA
| | | | - Emel K Cilingir
- Department of Chemistry, University of Miami, Coral Gables, FL 33146, USA
| | - Yiqun Zhou
- Department of Chemistry, University of Miami, Coral Gables, FL 33146, USA
| | - Jiuyan Chen
- Department of Chemistry, University of Miami, Coral Gables, FL 33146, USA
| | - Qiaxian R Johnson
- Department of Chemistry, William Paterson University of New Jersey, 300 Pompton Rd, Wayne, NJ 07470, USA
| | - Bhanu P S Chauhan
- Department of Chemistry, William Paterson University of New Jersey, 300 Pompton Rd, Wayne, NJ 07470, USA
| | - M Bartoli
- Department of Applied Science and Technology, Politecnico di Torino, Italy
| | - A Tagliaferro
- Department of Applied Science and Technology, Politecnico di Torino, Italy
| | - Steven Vanni
- Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136, USA; HCA Florida University Hospital, 3476 S University Dr, Davie, FL 33328, USA; Department of Medicine, Dr. Kiran C. Patel College of Allopathic Medicine, Davie, USA
| | - Regina M Graham
- Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136, USA; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136, USA; Dr. Kiran C. Patel College of Allopathic Medicine, Ft. Lauderdale, FL 33328, USA
| | - Roger M Leblanc
- Department of Chemistry, University of Miami, Coral Gables, FL 33146, USA.
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8
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Bin-Alamer O, Abou-Al-Shaar H, Gersey ZC, Huq S, Kallos JA, McCarthy DJ, Head JR, Andrews E, Zhang X, Hadjipanayis CG. Intraoperative Imaging and Optical Visualization Techniques for Brain Tumor Resection: A Narrative Review. Cancers (Basel) 2023; 15:4890. [PMID: 37835584 PMCID: PMC10571802 DOI: 10.3390/cancers15194890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/26/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
Advancements in intraoperative visualization and imaging techniques are increasingly central to the success and safety of brain tumor surgery, leading to transformative improvements in patient outcomes. This comprehensive review intricately describes the evolution of conventional and emerging technologies for intraoperative imaging, encompassing the surgical microscope, exoscope, Raman spectroscopy, confocal microscopy, fluorescence-guided surgery, intraoperative ultrasound, magnetic resonance imaging, and computed tomography. We detail how each of these imaging modalities contributes uniquely to the precision, safety, and efficacy of neurosurgical procedures. Despite their substantial benefits, these technologies share common challenges, including difficulties in image interpretation and steep learning curves. Looking forward, innovations in this field are poised to incorporate artificial intelligence, integrated multimodal imaging approaches, and augmented and virtual reality technologies. This rapidly evolving landscape represents fertile ground for future research and technological development, aiming to further elevate surgical precision, safety, and, most critically, patient outcomes in the management of brain tumors.
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Affiliation(s)
- Othman Bin-Alamer
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Hussam Abou-Al-Shaar
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Zachary C. Gersey
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Sakibul Huq
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Justiss A. Kallos
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - David J. McCarthy
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Jeffery R. Head
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Edward Andrews
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Xiaoran Zhang
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Constantinos G. Hadjipanayis
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Drexler R, Sauvigny T, Schüller U, Eckhardt A, Maire CL, Khatri R, Hausmann F, Hänzelmann S, Huber TB, Bonn S, Bode H, Lamszus K, Westphal M, Dührsen L, Ricklefs FL. Epigenetic profiling reveals a strong association between lack of 5-ALA fluorescence and EGFR amplification in IDH-wildtype glioblastoma. Neurooncol Pract 2023; 10:462-471. [PMID: 37720395 PMCID: PMC10502788 DOI: 10.1093/nop/npad025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Background 5-aminolevulinic acid (5-ALA) fluorescence-guided resection increases the percentage of complete CNS tumor resections and improves the progression-free survival of IDH-wildtype glioblastoma patients. A small subset of IDH-wildtype glioblastoma shows no 5-ALA fluorescence. An explanation for these cases is missing. In this study, we used DNA methylation profiling to further characterize non-fluorescent glioblastomas. Methods Patients with newly diagnosed and recurrent IDH-wildtype glioblastoma that underwent surgery were analyzed. The intensity of intraoperative 5-ALA fluorescence was categorized as non-visible or visible. DNA was extracted from tumors and genome-wide DNA methylation patterns were analyzed using Illumina EPIC (850k) arrays. Furthermore, 5-ALA intensity was measured by flow cytometry on human gliomasphere lines (BT112 and BT145). Results Of 74 included patients, 12 (16.2%) patients had a non-fluorescent glioblastoma, which were compared to 62 glioblastomas with 5-ALA fluorescence. Clinical characteristics were equally distributed between both groups. We did not find significant differences between DNA methylation subclasses and 5-ALA fluorescence (P = .24). The distribution of cells of the tumor microenvironment was not significantly different between the non-fluorescent and fluorescent tumors. Copy number variations in EGFR and simultaneous EGFRvIII expression were strongly associated with 5-ALA fluorescence since all non-fluorescent glioblastomas were EGFR-amplified (P < .01). This finding was also demonstrated in recurrent tumors. Similarly, EGFR-amplified glioblastoma cell lines showed no 5-ALA fluorescence after 24 h of incubation. Conclusions Our study demonstrates an association between non-fluorescent IDH-wildtype glioblastomas and EGFR gene amplification which should be taken into consideration for recurrent surgery and future studies investigating EGFR-amplified gliomas.
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Affiliation(s)
- Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrich Schüller
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Pediatric Hematology and Oncology, Research Institute Children’s Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Research Institute Children’s Cancer Center Hamburg, Hamburg, Germany
| | - Alicia Eckhardt
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Lab of Radiobiology & Experimental Radiation Oncology, University Cancer Center Hamburg, Hamburg, Germany
- Research Institute Children’s Cancer Center Hamburg, Hamburg, Germany
| | - Cecile L Maire
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Robin Khatri
- Institute of Medical Systems Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Center for Biomedical AI, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Hausmann
- Institute of Medical Systems Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Center for Biomedical AI, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sonja Hänzelmann
- Institute of Medical Systems Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Center for Biomedical AI, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias B Huber
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Hamburg Center for Translational Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Bonn
- Institute of Medical Systems Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Center for Biomedical AI, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Hamburg Center for Translational Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helena Bode
- Research Institute Children’s Cancer Center Hamburg, Hamburg, Germany
| | - Katrin Lamszus
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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10
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Mondal A, Kang J, Kim D. Recent Progress in Fluorescent Probes for Real-Time Monitoring of Glioblastoma. ACS APPLIED BIO MATERIALS 2023; 6:3484-3503. [PMID: 36917648 DOI: 10.1021/acsabm.3c00052] [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] [Indexed: 03/16/2023]
Abstract
Treating glioblastoma (GBM) by resecting to a large extent can prolong a patient's survival by controlling the tumor cells, but excessive resection may produce postoperative complications by perturbing the brain structures. Therefore, various imaging procedures have been employed to successfully diagnose and resect with utmost caution and to protect vital structural or functional features. Fluorescence tagging is generally used as an intraoperative imaging technique in glioma cells in collaboration with other surgical tools such as MRI and navigation methods. However, the existing fluorescent probes may have several limitations, including poor selectivity, less photostability, false signals, and intraoperative re-administration when used in clinical and preclinical studies for glioma surgery. The involvement of smart fluorogenic materials, specifically fluorescent dyes, and biomarker-amended cell-penetrable fluorescent probes have noteworthy advantages for precise glioma imaging. This review outlines the contemporary advancements of fluorescent probes for imaging glioma cells along with their challenges and visions, with the anticipation to develop next-generation smart glioblastoma detection modalities.
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Affiliation(s)
- Amita Mondal
- Department of Anatomy and Neurobiology, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea
| | - Jisoo Kang
- Department of Biomedical Science, Graduate School, Kyung Hee University, Seoul 02447, South Korea
| | - Dokyoung Kim
- Department of Anatomy and Neurobiology, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea
- Department of Biomedical Science, Graduate School, Kyung Hee University, Seoul 02447, South Korea
- Center for Converging Humanities, Kyung Hee University, Seoul 02447, Republic of Korea
- Center for Bioreaction to Reactive Oxygen Species and Biomedical Science Institute, Core Research Institute (CRI), Kyung Hee University, Seoul 02447, Republic of Korea
- Materials Research Science and Engineering Center, University of California at San Diego, 9500 Gilman Drive La Jolla, California 92093, United States
- Center for Brain Technology, Brain Science Institute, Korea Institute of Science and Technology, Seoul 02792, Republic of Korea
- KHU-KIST Department of Converging Science and Technology, Kyung Hee University, Seoul 02447, Republic of Korea
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11
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Bianconi A, Bonada M, Zeppa P, Colonna S, Tartara F, Melcarne A, Garbossa D, Cofano F. How Reliable Is Fluorescence-Guided Surgery in Low-Grade Gliomas? A Systematic Review Concerning Different Fluorophores. Cancers (Basel) 2023; 15:4130. [PMID: 37627158 PMCID: PMC10452554 DOI: 10.3390/cancers15164130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Fluorescence-guided surgery has been increasingly used to support glioma surgery with the purpose of obtaining a maximal safe resection, in particular in high-grade gliomas, while its role is less definitely assessed in low-grade gliomas. METHODS A systematic review was conducted. 5-aminolevulinic acid, sodium fluorescein, indocyanine green and tozuleristide were taken into account. The main considered outcome was the fluorescence rate, defined as the number of patients in whom positive fluorescence was detected out of the total number of patients. Only low-grade gliomas were considered, and data were grouped according to single fluorophores. RESULTS 16 papers about 5-aminolevulinic acid, 4 about sodium fluorescein, 2 about indocyanine green and 1 about tozuleristide were included in the systematic review. Regarding 5-aminolevulinic acid, a total of 467 low-grade glioma patients were included, and fluorescence positivity was detected in 34 out of 451 Grade II tumors (7.3%); while in Grade I tumors, fluorescence positivity was detected in 9 out of 16 cases. In 16 sodium fluorescein patients, seven positive fluorescent cases were detected. As far as indocyanine is concerned, two studies accounting for six patients (three positive) were included, while for tozuleristide, a single clinical trial with eight patients (two positive) was retrieved. CONCLUSIONS The current evidence does not support the routine use of 5-aminolevulinic acid or sodium fluorescein with a standard operating microscope because of the low fluorescence rates. New molecules, including tozuleristide, and new techniques for fluorescence detection have shown promising results; however, their use still needs to be clinically validated on a large scale.
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Affiliation(s)
- Andrea Bianconi
- Neurosurgery, Department of Neurosciences, University of Turin, 10126 Turin, Italy; (M.B.); (P.Z.); (A.M.); (D.G.); (F.C.)
| | - Marta Bonada
- Neurosurgery, Department of Neurosciences, University of Turin, 10126 Turin, Italy; (M.B.); (P.Z.); (A.M.); (D.G.); (F.C.)
| | - Pietro Zeppa
- Neurosurgery, Department of Neurosciences, University of Turin, 10126 Turin, Italy; (M.B.); (P.Z.); (A.M.); (D.G.); (F.C.)
| | - Stefano Colonna
- Neurosurgery, Department of Neurosciences, University of Turin, 10126 Turin, Italy; (M.B.); (P.Z.); (A.M.); (D.G.); (F.C.)
| | - Fulvio Tartara
- Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
| | - Antonio Melcarne
- Neurosurgery, Department of Neurosciences, University of Turin, 10126 Turin, Italy; (M.B.); (P.Z.); (A.M.); (D.G.); (F.C.)
| | - Diego Garbossa
- Neurosurgery, Department of Neurosciences, University of Turin, 10126 Turin, Italy; (M.B.); (P.Z.); (A.M.); (D.G.); (F.C.)
| | - Fabio Cofano
- Neurosurgery, Department of Neurosciences, University of Turin, 10126 Turin, Italy; (M.B.); (P.Z.); (A.M.); (D.G.); (F.C.)
- Humanitas Gradenigo, 10100 Turin, Italy
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12
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Lang A, Jeron RL, Lontzek B, Kiesel B, Mischkulnig M, Berghoff AS, Ricken G, Wöhrer A, Rössler K, Lötsch-Gojo D, Roetzer-Pejrimovsky T, Berger W, Hainfellner JA, Höftberger R, Widhalm G, Erhart F. Mapping high-grade glioma immune infiltration to 5-ALA fluorescence levels: TCGA data computation, classical histology, and digital image analysis. J Neurooncol 2023; 164:211-220. [PMID: 37543970 PMCID: PMC10462498 DOI: 10.1007/s11060-023-04406-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/22/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE Resection of high-grade gliomas has been considerably improved by 5-aminolevulinic acid (5-ALA). However, not all neurobiological properties of 5-ALA are fully understood. Specifically, potential differences in immune infiltration have not been conclusively examined, despite recent reports that immune cells might play a role. Thus, we here provide a systematic mapping of immune infiltration of different 5-ALA fluorescence levels. METHODS Tumor-associated macrophages (CD68, CD163), cytotoxic T cells (CD8), and regulatory T cells (FoxP3) were quantified via three methods. First, data from The Cancer Genome Atlas (TCGA) of 172 patients was examined for correlations between 5-ALA fluorescence-related mRNA expression signatures and immune markers. Second, as classical histology, 508 stained slides from 39 high-grade glioma patients were analysed semi-quantitatively by two independent reviewers, generating 1016 data points. Third, digital image analysis was performed with automated scanning and algorithm-based cell quantification. RESULTS TCGA mRNA data from 172 patients showed a direct, significant correlation between 5-ALA signatures and immune markers (p < 0.001). However, we were not able to confirm this finding in the here studied initial set of 39 patient histologies where we found a comparable immune infiltration in different fluorescence levels. Digital image analysis correlated excellently with standard histology. CONCLUSION With mapping the immune infiltration pattern of different 5-ALA categories, we are adding fundamental basic insights to the field of 5-ALA and glioma biology. The observation that a significant correlation in TCGA data did not fully translate to detectable differences in immune infiltration in first histology data warrants further investigation in larger cohorts.
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Affiliation(s)
- Alexandra Lang
- Department of Neurosurgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Central Nervous System Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Raphael L Jeron
- Department of Neurosurgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Bastian Lontzek
- Department of Neurosurgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Barbara Kiesel
- Department of Neurosurgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Central Nervous System Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Mario Mischkulnig
- Department of Neurosurgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Central Nervous System Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Anna S Berghoff
- Department of Medicine I/Division of Oncology, Medical University of Vienna, Vienna, Austria
- Central Nervous System Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Gerda Ricken
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Central Nervous System Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Adelheid Wöhrer
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Central Nervous System Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Karl Rössler
- Department of Neurosurgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Central Nervous System Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Daniela Lötsch-Gojo
- Department of Neurosurgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Central Nervous System Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Thomas Roetzer-Pejrimovsky
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Central Nervous System Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Walter Berger
- Center for Cancer Research, Medical University of Vienna, Vienna, Austria
| | - Johannes A Hainfellner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Central Nervous System Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Central Nervous System Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Georg Widhalm
- Department of Neurosurgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Central Nervous System Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
| | - Friedrich Erhart
- Department of Neurosurgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Central Nervous System Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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13
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García-Montaño LA, Licón-Muñoz Y, Martinez FJ, Keddari YR, Ziemke MK, Chohan MO, Piccirillo SG. Dissecting Intra-tumor Heterogeneity in the Glioblastoma Microenvironment Using Fluorescence-Guided Multiple Sampling. Mol Cancer Res 2023; 21:755-767. [PMID: 37255362 PMCID: PMC10390891 DOI: 10.1158/1541-7786.mcr-23-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/25/2023] [Accepted: 05/05/2023] [Indexed: 05/10/2023]
Abstract
The treatment of the most aggressive primary brain tumor in adults, glioblastoma (GBM), is challenging due to its heterogeneous nature, invasive potential, and poor response to chemo- and radiotherapy. As a result, GBM inevitably recurs and only a few patients survive 5 years post-diagnosis. GBM is characterized by extensive phenotypic and genetic heterogeneity, creating a diversified genetic landscape and a network of biological interactions between subclones, ultimately promoting tumor growth and therapeutic resistance. This includes spatial and temporal changes in the tumor microenvironment, which influence cellular and molecular programs in GBM and therapeutic responses. However, dissecting phenotypic and genetic heterogeneity at spatial and temporal levels is extremely challenging, and the dynamics of the GBM microenvironment cannot be captured by analysis of a single tumor sample. In this review, we discuss the current research on GBM heterogeneity, in particular, the utility and potential applications of fluorescence-guided multiple sampling to dissect phenotypic and genetic intra-tumor heterogeneity in the GBM microenvironment, identify tumor and non-tumor cell interactions and novel therapeutic targets in areas that are key for tumor growth and recurrence, and improve the molecular classification of GBM.
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Affiliation(s)
- Leopoldo A. García-Montaño
- The Brain Tumor Translational Laboratory, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico
| | - Yamhilette Licón-Muñoz
- The Brain Tumor Translational Laboratory, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico
| | - Frank J. Martinez
- The Brain Tumor Translational Laboratory, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico
| | - Yasine R. Keddari
- The Brain Tumor Translational Laboratory, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- University of California, Merced, California
| | - Michael K. Ziemke
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Muhammad O. Chohan
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Sara G.M. Piccirillo
- The Brain Tumor Translational Laboratory, Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico
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14
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Andrieux G, Das T, Griffin M, Straehle J, Paine SML, Beck J, Boerries M, Heiland DH, Smith SJ, Rahman R, Chakraborty S. Spatially resolved transcriptomic profiles reveal unique defining molecular features of infiltrative 5ALA-metabolizing cells associated with glioblastoma recurrence. Genome Med 2023; 15:48. [PMID: 37434262 PMCID: PMC10337060 DOI: 10.1186/s13073-023-01207-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 06/26/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Spatiotemporal heterogeneity originating from genomic and transcriptional variation was found to contribute to subtype switching in isocitrate dehydrogenase-1 wild-type glioblastoma (GBM) prior to and upon recurrence. Fluorescence-guided neurosurgical resection utilizing 5-aminolevulinic acid (5ALA) enables intraoperative visualization of infiltrative tumors outside the magnetic resonance imaging contrast-enhanced regions. The cell population and functional status of tumor responsible for enhancing 5ALA-metabolism to fluorescence-active PpIX remain elusive. The close spatial proximity of 5ALA-metabolizing (5ALA +) cells to residual disease remaining post-surgery renders 5ALA + biology an early a priori proxy of GBM recurrence, which is poorly understood. METHODS We performed spatially resolved bulk RNA profiling (SPRP) analysis of unsorted Core, Rim, Invasive margin tissue, and FACS-isolated 5ALA + /5ALA - cells from the invasive margin across IDH-wt GBM patients (N = 10) coupled with histological, radiographic, and two-photon excitation fluorescence microscopic analyses. Deconvolution of SPRP followed by functional analyses was performed using CIBEROSRTx and UCell enrichment algorithms, respectively. We further investigated the spatial architecture of 5ALA + enriched regions by analyzing spatial transcriptomics from an independent IDH-wt GBM cohort (N = 16). Lastly, we performed survival analysis using Cox Proportinal-Hazards model on large GBM cohorts. RESULTS SPRP analysis integrated with single-cell and spatial transcriptomics uncovered that the GBM molecular subtype heterogeneity is likely to manifest regionally in a cell-type-specific manner. Infiltrative 5ALA + cell population(s) harboring transcriptionally concordant GBM and myeloid cells with mesenchymal subtype, -active wound response, and glycolytic metabolic signature, was shown to reside within the invasive margin spatially distinct from the tumor core. The spatial co-localization of the infiltrating MES GBM and myeloid cells within the 5ALA + region indicates PpIX fluorescence can effectively be utilized to resect the immune reactive zone beyond the tumor core. Finally, 5ALA + gene signatures were associated with poor survival and recurrence in GBM, signifying that the transition from primary to recurrent GBM is not discrete but rather a continuum whereby primary infiltrative 5ALA + remnant tumor cells more closely resemble the eventual recurrent GBM. CONCLUSIONS Elucidating the unique molecular and cellular features of the 5ALA + population within tumor invasive margin opens up unique possibilities to develop more effective treatments to delay or block GBM recurrence, and warrants commencement of such treatments as early as possible post-surgical resection of the primary neoplasm.
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Affiliation(s)
- Geoffroy Andrieux
- Institute of Medical Bioinformatics and Systems Medicine, Medical Center - University of Freiburg Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tonmoy Das
- Institute of Medical Bioinformatics and Systems Medicine, Medical Center - University of Freiburg Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Systems Cell-Signaling Laboratory, Department of Biochemistry and Molecular Biology, University of Dhaka, Dhaka, Bangladesh
| | - Michaela Griffin
- Children's Brain Tumour Research Centre, Biodiscovery Institute, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jakob Straehle
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
| | - Simon M L Paine
- Children's Brain Tumour Research Centre, Biodiscovery Institute, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
| | - Melanie Boerries
- Institute of Medical Bioinformatics and Systems Medicine, Medical Center - University of Freiburg Faculty of Medicine, University of Freiburg, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Dieter H Heiland
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Microenvironment and Immunology Research Laboratory, Medical Center - University of Freiburg, Freiburg, Germany
- Department of Neurological Surgery, Lou and Jean Malnati Brain Tumor Institute, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Stuart J Smith
- Children's Brain Tumour Research Centre, Biodiscovery Institute, School of Medicine, University of Nottingham, Nottingham, UK
| | - Ruman Rahman
- Children's Brain Tumour Research Centre, Biodiscovery Institute, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Sajib Chakraborty
- Institute of Medical Bioinformatics and Systems Medicine, Medical Center - University of Freiburg Faculty of Medicine, University of Freiburg, Freiburg, Germany.
- Systems Cell-Signaling Laboratory, Department of Biochemistry and Molecular Biology, University of Dhaka, Dhaka, Bangladesh.
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15
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García-Milán V, Franco A, Zvezdanova ME, Marcos S, Martin-Laez R, Moreno F, Velasquez C, Fernandez-Luna JL. Discriminating Glioblastoma from Peritumoral Tissue by a Nanohole Array-Based Optical and Label-Free Biosensor. BIOSENSORS 2023; 13:591. [PMID: 37366956 DOI: 10.3390/bios13060591] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/16/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023]
Abstract
In glioblastoma (GBM) patients, maximal safe resection remains a challenge today due to its invasiveness and diffuse parenchymal infiltration. In this context, plasmonic biosensors could potentially help to discriminate tumor tissue from peritumoral parenchyma based on differences in their optical properties. A nanostructured gold biosensor was used ex vivo to identify tumor tissue in a prospective series of 35 GBM patients who underwent surgical treatment. For each patient, two paired samples, tumor and peritumoral tissue, were extracted. Then, the imprint left by each sample on the surface of the biosensor was individually analyzed, obtaining the difference between their refractive indices. The tumor and non-tumor origins of each tissue were assessed by histopathological analysis. The refractive index (RI) values obtained by analyzing the imprint of the tissue were significantly lower (p = 0.0047) in the peritumoral samples (1.341, Interquartile Range (IQR) 1.339-1.349) compared with the tumor samples (1.350, IQR 1.344-1.363). The ROC (receiver operating characteristic) curve showed the capacity of the biosensor to discriminate between both tissues (area under the curve, 0.8779, p < 0.0001). The Youden index provided an optimal RI cut-off point of 0.003. The sensitivity and specificity of the biosensor were 81% and 80%, respectively. Overall, the plasmonic-based nanostructured biosensor is a label-free system with the potential to be used for real-time intraoperative discrimination between tumor and peritumoral tissue in patients with GBM.
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Affiliation(s)
- Víctor García-Milán
- Department of Neurological Surgery and Spine Unit, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain
| | - Alfredo Franco
- Department of Applied Physics, Faculty of Sciences, Universidad de Cantabria, 39005 Santander, Spain
- Instituto de Investigación Marqués de Valdecilla (IDIVAL), 39012 Santander, Spain
| | | | - Sara Marcos
- Servicio de Anatomía Patológica, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain
| | - Rubén Martin-Laez
- Department of Neurological Surgery and Spine Unit, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain
| | - Fernando Moreno
- Department of Applied Physics, Faculty of Sciences, Universidad de Cantabria, 39005 Santander, Spain
- Instituto de Investigación Marqués de Valdecilla (IDIVAL), 39012 Santander, Spain
| | - Carlos Velasquez
- Department of Neurological Surgery and Spine Unit, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain
- Instituto de Investigación Marqués de Valdecilla (IDIVAL), 39012 Santander, Spain
- Department of Anatomy and Cell Biology, Universidad de Cantabria, 39005 Santander, Spain
| | - José L Fernandez-Luna
- Instituto de Investigación Marqués de Valdecilla (IDIVAL), 39012 Santander, Spain
- Genetics Unit, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain
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16
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Belykh E, Bardonova L, Abramov I, Byvaltsev VA, Kerymbayev T, Yu K, Healey DR, Luna-Melendez E, Deneen B, Mehta S, Liu JK, Preul MC. 5-aminolevulinic acid, fluorescein sodium, and indocyanine green for glioma margin detection: analysis of operating wide-field and confocal microscopy in glioma models of various grades. Front Oncol 2023; 13:1156812. [PMID: 37287908 PMCID: PMC10242067 DOI: 10.3389/fonc.2023.1156812] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/28/2023] [Indexed: 06/09/2023] Open
Abstract
Introduction Surgical resection remains the first-line treatment for gliomas. Several fluorescent dyes are currently in use to augment intraoperative tumor visualization, but information on their comparative effectiveness is lacking. We performed systematic assessment of fluorescein sodium (FNa), 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX), and indocyanine green (ICG) fluorescence in various glioma models using advanced fluorescence imaging techniques. Methods Four glioma models were used: GL261 (high-grade model), GB3 (low-grade model), and an in utero electroporation model with and without red fluorescence protein (IUE +RFP and IUE -RFP, respectively) (intermediate-to-low-grade model). Animals underwent 5-ALA, FNa, and ICG injections and craniectomy. Brain tissue samples underwent fluorescent imaging using a wide-field operative microscope and a benchtop confocal microscope and were submitted for histologic analysis. Results Our systematic analysis showed that wide-field imaging of highly malignant gliomas is equally efficient with 5-ALA, FNa, and ICG, although FNa is associated with more false-positive staining of the normal brain. In low-grade gliomas, wide-field imaging cannot detect ICG staining, can detect FNa in only 50% of specimens, and is not sensitive enough for PpIX detection. With confocal imaging of low-intermediate grade glioma models, PpIX outperformed FNa. Discussion Overall, compared to wide-field imaging, confocal microscopy significantly improved diagnostic accuracy and was better at detecting low concentrations of PpIX and FNa, resulting in improved tumor delineation. Neither PpIX, FNa, nor ICG delineated all tumor boundaries in studied tumor models, which emphasizes the need for novel visualization technologies and molecular probes to guide glioma resection. Simultaneous administration of 5-ALA and FNa with use of cellular-resolution imaging modalities may provide additional information for margin detection and may facilitate maximal glioma resection.
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Affiliation(s)
- Evgenii Belykh
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
- Department of Neurosurgery, New Jersey Medical School, Rutgers University, Newark, NJ, United States
| | - Liudmila Bardonova
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Irakliy Abramov
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Vadim A. Byvaltsev
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Talgat Kerymbayev
- Department of Neurosurgery, JSC “National Scientific Center of Neurosurgery”, Nur-Sultan, Kazakhstan
| | - Kwanha Yu
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, United States
| | - Debbie R. Healey
- Department of Research Imaging, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | | | - Benjamin Deneen
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, United States
| | - Shwetal Mehta
- Ivy Brain Tumor Research Center, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - James K. Liu
- Department of Neurosurgery, New Jersey Medical School, Rutgers University, Newark, NJ, United States
| | - Mark C. Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
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Broggi G, Altieri R, Barresi V, Certo F, Barbagallo GMV, Zanelli M, Palicelli A, Magro G, Caltabiano R. Histologic Definition of Enhancing Core and FLAIR Hyperintensity Region of Glioblastoma, IDH-Wild Type: A Clinico-Pathologic Study on a Single-Institution Series. Brain Sci 2023; 13:brainsci13020248. [PMID: 36831791 PMCID: PMC9954517 DOI: 10.3390/brainsci13020248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
The extent of resection beyond the enhancing core (EC) in glioblastoma IDH-wild type (GBM, IDHwt) is one of the most debated topics in neuro-oncology. Indeed, it has been demonstrated that local disease recurrence often arises in peritumoral areas and that radiologically-defined FLAIR hyperintensity areas of GBM IDHwt are often visible beyond the conventional EC. Therefore, the need to extend the surgical resection also to the FLAIR hyperintensity areas is a matter of debate. Since little is known about the histological composition of FLAIR hyperintensity regions, in this study we aimed to provide a comprehensive description of the histological features of EC and FLAIR hyperintensity regions sampled intraoperatively using neuronavigation and 5-aminolevulinic acid (5-ALA) fluorescence, in 33 patients with GBM, IDHwt. Assessing a total 109 histological samples, we found that FLAIR areas consisted in: (i) fragments of white matter focally to diffusely infiltrated by tumor cells in 76% of cases; (ii) a mixture of white matter with reactive astrogliosis and grey matter with perineuronal satellitosis in 15% and (iii) tumor tissue in 9%. A deeper knowledge of the histology of FLAIR hyperintensity areas in GBM, IDH-wt may serve to better guide neurosurgeons on the choice of the most appropriate surgical approach in patients with this neoplasm.
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Affiliation(s)
- Giuseppe Broggi
- Department of Medical and Surgical Sciences and Advanced Technologies “G. F. Ingrassia”, Anatomic Pathology, University of Catania, 95123 Catania, Italy
- Correspondence:
| | - Roberto Altieri
- Department of Neurological Surgery, Policlinico “G. Rodolico-S. Marco” University Hospital, 95123 Catania, Italy
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, 95123 Catania, Italy
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10124 Turin, Italy
| | - Valeria Barresi
- Department of Diagnostics and Public Health, Section of Anatomic Pathology, University of Verona, 37134 Verona, Italy
| | - Francesco Certo
- Department of Neurological Surgery, Policlinico “G. Rodolico-S. Marco” University Hospital, 95123 Catania, Italy
| | | | - Magda Zanelli
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Andrea Palicelli
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Gaetano Magro
- Department of Medical and Surgical Sciences and Advanced Technologies “G. F. Ingrassia”, Anatomic Pathology, University of Catania, 95123 Catania, Italy
| | - Rosario Caltabiano
- Department of Medical and Surgical Sciences and Advanced Technologies “G. F. Ingrassia”, Anatomic Pathology, University of Catania, 95123 Catania, Italy
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18
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Woo PYM, Law THP, Lee KKY, Chow JSW, Li LF, Lau SSN, Chan TKT, Ho JMK, Lee MWY, Chan DTM, Poon WS. Repeat resection for recurrent glioblastoma in the temozolomide era: a real-world multi-centre study. Br J Neurosurg 2023:1-9. [PMID: 36654527 DOI: 10.1080/02688697.2023.2167931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 12/28/2022] [Accepted: 01/08/2023] [Indexed: 01/20/2023]
Abstract
INTRODUCTION In contrast to standard-of-care treatment of newly diagnosed glioblastoma, there is limited consensus on therapy upon disease progression. The role of resection for recurrent glioblastoma remains unclear. This study aimed to identify factors for overall survival (OS) and post-progression survival (PPS) as well as to validate an existing prediction model. METHODS This was a multi-centre retrospective study that reviewed consecutive adult patients from 2006 to 2019 that received a repeat resection for recurrent glioblastoma. The primary endpoint was PPS defined as from the date of second surgery until death. RESULTS 1032 glioblastoma patients were identified and 190 (18%) underwent resection for recurrence. Patients that had second surgery were more likely to be younger (<70 years) (adjusted OR: 0.3; 95% CI: 0.1-0.6), to have non-eloquent region tumours (aOR: 1.7; 95% CI: 1.1-2.6) and received temozolomide chemoradiotherapy (aOR: 0.2; 95% CI: 0.1-0.4). Resection for recurrent tumour was an independent predictor for OS (aOR: 1.5; 95% CI: 1.3-1.7) (mOS: 16.9 months versus 9.8 months). For patients that previously received temozolomide chemoradiotherapy and subsequent repeat resection (137, 13%), the median PPS was 9.0 months (IQR: 5.0-17.5). Independent PPS predictors for this group were a recurrent tumour volume of >50cc (aOR: 0.6; 95% CI: 0.4-0.9), local recurrence (aOR: 1.7; 95% CI: 1.1-3.3) and 5-ALA fluorescence-guided resection during second surgery (aOR: 1.7; 95% CI: 1.1-2.8). A National Institutes of Health Recurrent Glioblastoma Multiforme Scale score of 0 conferred an mPPS of 10.0 months, a score of 1-2, 9.0 months and a score of 3, 4.0 months (log-rank test, p-value < 0.05). CONCLUSION Surgery for recurrent glioblastoma can be beneficial in selected patients and carries an acceptable morbidity rate. The pattern of recurrence influenced PPS and the NIH Recurrent GBM Scale was a reliable prognostication tool.
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Affiliation(s)
- Peter Y M Woo
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Tiffany H P Law
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Kelsey K Y Lee
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Joyce S W Chow
- Department of Neurosurgery, Queen Elizabeth Hospital, Hong Kong, China
| | - Lai-Fung Li
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - Sarah S N Lau
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - Tony K T Chan
- Department of Neurosurgery, Princess Margaret Hospital, Hong Kong, China
| | - Jason M K Ho
- Department of Neurosurgery, Tuen Mun Hospital, Hong Kong, China
| | - Michael W Y Lee
- Department of Neurosurgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Danny T M Chan
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, Hong Kong, China
| | - Wai-Sang Poon
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, Hong Kong, China
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Spille DC, Bunk EC, Thomas C, Özdemir Z, Wagner A, Akkurt BH, Mannil M, Paulus W, Grauer OM, Stummer W, Senner V, Brokinkel B. Protoporphyrin IX (PpIX) Fluorescence during Meningioma Surgery: Correlations with Histological Findings and Expression of Heme Pathway Molecules. Cancers (Basel) 2023; 15:cancers15010304. [PMID: 36612300 PMCID: PMC9818642 DOI: 10.3390/cancers15010304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 12/25/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023] Open
Abstract
Background: The usefulness of 5-ALA-mediated fluorescence-guided resection (FGR) in meningiomas is controversial, and information on the molecular background of fluorescence is sparse. Methods: Specimens obtained during 44 FGRs of intracranial meningiomas were analyzed for the presence of tumor tissue and fluorescence. Protein/mRNA expression of key transmembrane transporters/enzymes involved in PpIX metabolism (ABCB6, ABCG2, FECH, CPOX) were investigated using immunohistochemistry/qPCR. Results: Intraoperative fluorescence was observed in 70 of 111 specimens (63%). No correlation was found between fluorescence and the WHO grade (p = 0.403). FGR enabled the identification of neoplastic tissue (sensitivity 84%, specificity 67%, positive and negative predictive value of 86% and 63%, respectively, AUC: 0.75, p < 0.001), and was improved in subgroup analyses excluding dura specimens (86%, 88%, 96%, 63% and 0.87, respectively; p < 0.001). No correlation was found between cortical fluorescence and tumor invasion (p = 0.351). Protein expression of ABCB6, ABCG2, FECH and CPOX was found in meningioma tissue and was correlated with fluorescence (p < 0.05, each), whereas this was not confirmed for mRNA expression. Aberrant expression was observed in the CNS. Conclusion: FGR enables the intraoperative identification of meningioma tissue with limitations concerning dura invasion and due to ectopic expression in the CNS. ABCB6, ABCG2, FECH and CPOX are expressed in meningioma tissue and are related to fluorescence.
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Affiliation(s)
- Dorothee C. Spille
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
- Correspondence: ; Tel.: +49251-83-43959/-47472; Fax: +49251-83-45646
| | - Eva C. Bunk
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
| | - Christian Thomas
- Institute of Neuropathology, University Hospital Münster, 48149 Münster, Germany
| | - Zeynep Özdemir
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
| | - Andrea Wagner
- Institute of Neuropathology, University Hospital Münster, 48149 Münster, Germany
| | - Burak H. Akkurt
- Department of Radiology, University Hospital Münster, 48149 Münster, Germany
| | - Manoj Mannil
- Department of Radiology, University Hospital Münster, 48149 Münster, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, 48149 Münster, Germany
| | - Oliver M. Grauer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
| | - Volker Senner
- Institute of Neuropathology, University Hospital Münster, 48149 Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
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20
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Review of Intraoperative Adjuncts for Maximal Safe Resection of Gliomas and Its Impact on Outcomes. Cancers (Basel) 2022; 14:cancers14225705. [PMID: 36428797 PMCID: PMC9688206 DOI: 10.3390/cancers14225705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/12/2022] [Accepted: 11/18/2022] [Indexed: 11/22/2022] Open
Abstract
Maximal safe resection is the mainstay of treatment in the neurosurgical management of gliomas, and preserving functional integrity is linked to favorable outcomes. How these modalities differ in their effectiveness on the extent of resection (EOR), survival, and complications remains unknown. A systematic literature search was performed with the following inclusion criteria: published between 2005 and 2022, involving brain glioma surgery, and including one or a combination of intraoperative modalities: intraoperative magnetic resonance imaging (iMRI), awake/general anesthesia craniotomy mapping (AC/GA), fluorescence-guided imaging, or combined modalities. Of 525 articles, 464 were excluded and 61 articles were included, involving 5221 glioma patients, 7(11.4%) articles used iMRI, 21(36.8%) used cortical mapping, 15(24.5%) used 5-aminolevulinic acid (5-ALA) or fluorescein sodium, and 18(29.5%) used combined modalities. The heterogeneity in reporting the amount of surgical resection prevented further analysis. Progression-free survival/overall survival (PFS/OS) were reported in 18/61(29.5%) articles, while complications and permanent disability were reported in 38/61(62.2%) articles. The reviewed studies demonstrate that intraoperative adjuncts such as iMRI, AC/GA mapping, fluorescence-guided imaging, and a combination of these modalities improve EOR. However, PFS/OS were underreported. Combining multiple intraoperative modalities seems to have the highest effect compared to each adjunct alone.
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21
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Haddad AF, Aghi MK, Butowski N. Novel intraoperative strategies for enhancing tumor control: Future directions. Neuro Oncol 2022; 24:S25-S32. [PMID: 36322096 PMCID: PMC9629473 DOI: 10.1093/neuonc/noac090] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023] Open
Abstract
Maximal safe surgical resection plays a key role in the care of patients with gliomas. A range of technologies have been developed to aid surgeons in distinguishing tumor from normal tissue, with the goal of increasing tumor resection and limiting postoperative neurological deficits. Technologies that are currently being investigated to aid in improving tumor control include intraoperative imaging modalities, fluorescent tumor makers, intraoperative cell and molecular profiling of tumors, improved microscopic imaging, intraoperative mapping, augmented and virtual reality, intraoperative drug and radiation delivery, and ablative technologies. In this review, we summarize the aforementioned advancements in neurosurgical oncology and implications for improving patient outcomes.
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Affiliation(s)
- Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Manish K Aghi
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Nicholas Butowski
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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22
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Strickland BA, Wedemeyer M, Ruzevick J, Micko A, Shahrestani S, Daneshmand S, Shiroishi MS, Hwang DH, Attenello F, Chen T, Zada G. 5-Aminolevulinic acid-enhanced fluorescence-guided treatment of high-grade glioma using angled endoscopic blue light visualization: technical case series with preliminary follow-up. J Neurosurg 2022; 137:1378-1386. [PMID: 35303704 DOI: 10.3171/2022.1.jns212562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE 5-Aminolevulinic acid (5-ALA)-enhanced fluorescence-guided resection of high-grade glioma (HGG) using microscopic blue light visualization offers the ability to improve extent of resection (EOR); however, few descriptions of HGG resection performed using endoscopic blue light visualization are currently available. In this report, the authors sought to describe their surgical experience and patient outcomes of 5-ALA-enhanced fluorescence-guided resection of HGG using primary or adjunctive endoscopic blue light visualization. METHODS The authors performed a retrospective review of prospectively collected data from 30 consecutive patients who underwent 5-ALA-enhanced fluorescence-guided biopsy or resection of newly diagnosed HGG was performed. Patient demographic data, tumor characteristics, surgical technique, EOR, tumor fluorescence patterns, and progression-free survival were recorded. RESULTS In total, 30 newly diagnosed HGG patients were included for analysis. The endoscope was utilized for direct 5-ALA-guided port-based biopsy (n = 9), microscopic to endoscopic (M2E; n = 18) resection, or exoscopic to endoscopic (E2E; n = 3) resection. All endoscopic biopsies of fluorescent tissue were diagnostic. 5-ALA-enhanced tumor fluorescence was visible in all glioblastoma cases, but only in 50% of anaplastic astrocytoma cases and no anaplastic oligodendroglioma cases. Gross-total resection (GTR) was achieved in 10 patients in whom complete resection was considered safe, with 11 patients undergoing subtotal resection. In all cases, endoscopic fluorescence was more avid than microscopic fluorescence. The endoscope offered the ability to diagnose and resect additional tumor not visualized by the microscope in 83.3% (n = 10/12) of glioblastoma cases, driven by angled lenses and increased fluorescence facilitated by light source delivery within the cavity. Mean volumetric EOR was 90.7% in all resection patients and 98.8% in patients undergoing planned GTR. No complications were attributable to 5-ALA or blue light endoscopy. CONCLUSIONS The blue light endoscope is a viable primary or adjunctive visualization platform for optimization of 5-ALA-enhanced HGG fluorescence. Implementation of the blue light endoscope to guide resection of HGG glioma is feasible and ergonomically favorable, with a potential advantage of enabling increased detection of tumor fluorescence in deep surgical cavities compared to the microscope.
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Affiliation(s)
| | | | | | | | | | | | - Mark S Shiroishi
- 3Radiology, USC/Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Darryl H Hwang
- 3Radiology, USC/Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California
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23
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Li G, Rodrigues A, Kim L, Garcia C, Jain S, Zhang M, Hayden-Gephart M. 5-Aminolevulinic Acid Imaging of Malignant Glioma. Surg Oncol Clin N Am 2022; 31:581-593. [DOI: 10.1016/j.soc.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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24
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5-Aminolevulinic acid fluorescence in brain non-neoplastic lesions: a systematic review and case series. Neurosurg Rev 2022; 45:3139-3148. [PMID: 35972631 DOI: 10.1007/s10143-022-01843-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
Fluorescence-guided surgery with 5-aminolevulinic acid (5-ALA) is used to assist brain tumor resection, especially for high-grade gliomas but also for low-grade gliomas, metastasis, and meningiomas. With the increasing use of this technique, even to assist biopsies, high-grade glioma-mimicking lesions had misled diagnosis by showing 5-ALA fluorescence in non-neoplastic lesions such as radiation necrosis and inflammatory or infectious disease. Since only isolated reports have been published, we systematically review papers reporting non-neoplastic lesion cases with 5-ALA according with the PRISMA guidelines, present our series, and discuss its pathophysiology. In total, 245 articles were identified and 12 were extracted according to our inclusion criteria. Analyzing 27 patients, high-grade glioma was postulated as preoperative diagnosis in 48% of the cases. Microsurgical resection was performed in 19 cases (70%), while 8 patients were submitted to biopsy (30%). We found 4 positive cases in demyelinating disease (50%), 4 in brain abscess (80%), 1 in neurocysticercosis (33%), 1 in neurotoxoplasmosis, infarction, and hematoma (100%), 4 in inflammatory disease (80%), and 3 in cortical dysplasia (100%). New indications are being considered especially in benign lesion biopsies with assistance of 5-ALA. Using fluorescence as an aid in biopsies may improve procedure time, number of samples, and necessity of intraoperative pathology. Further studies should include this technology to encourage more beneficial uses.
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25
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The new era of bio-molecular imaging with O-(2-18F-fluoroethyl)-L-tyrosine (18F-FET) in neurosurgery of gliomas. Clin Transl Imaging 2022. [DOI: 10.1007/s40336-022-00509-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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26
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Workflow in the multidisciplinary management of glioma patients in everyday practice: how we do it. Clin Transl Imaging 2022. [DOI: 10.1007/s40336-022-00505-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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27
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Harada Y, Murayama Y, Takamatsu T, Otsuji E, Tanaka H. 5-Aminolevulinic Acid-Induced Protoporphyrin IX Fluorescence Imaging for Tumor Detection: Recent Advances and Challenges. Int J Mol Sci 2022; 23:ijms23126478. [PMID: 35742921 PMCID: PMC9223645 DOI: 10.3390/ijms23126478] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/02/2022] [Accepted: 06/07/2022] [Indexed: 12/18/2022] Open
Abstract
5-Aminolevulinic acid (5-ALA) is a natural amino acid and a precursor of heme and chlorophyll. Exogenously administered 5-ALA is metabolized into protoporphyrin IX (PpIX). PpIX accumulates in cancer cells because of the low activity of ferrochelatase, an enzyme that metabolizes PpIX to heme. High expression of 5-ALA influx transporters, such as peptide transporters 1/2, in cancer cells also enhances PpIX production. Because PpIX radiates red fluorescence when excited with blue/violet light, 5-ALA has been used for the visualization of various tumors. 5-ALA photodynamic diagnosis (PDD) has been shown to improve the tumor removal rate in high-grade gliomas and non-muscular invasive bladder cancers. However, 5-ALA PDD remains a challenge as a diagnostic method because tissue autofluorescence interferes with PpIX signals in cases where tumors emit only weak signals, and non-tumorous lesions, such as inflammatory sites, tend to emit PpIX fluorescence. Here, we review the current outline of 5-ALA PDD and strategies for improving its diagnostic applicability for tumor detection, focusing on optical techniques and 5-ALA metabolic pathways in both viable and necrotic tumor tissues.
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Affiliation(s)
- Yoshinori Harada
- Department of Pathology and Cell Regulation, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kamigyo-ku, Kyoto 602-8566, Japan;
- Correspondence: ; Tel.: +81-75-251-5322
| | - Yasutoshi Murayama
- Division of Digestive Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kamigyo-ku, Kyoto 602-8566, Japan; (Y.M.); (E.O.)
| | - Tetsuro Takamatsu
- Department of Medical Photonics, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kamigyo-ku, Kyoto 602-8566, Japan;
| | - Eigo Otsuji
- Division of Digestive Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kamigyo-ku, Kyoto 602-8566, Japan; (Y.M.); (E.O.)
| | - Hideo Tanaka
- Department of Pathology and Cell Regulation, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kamigyo-ku, Kyoto 602-8566, Japan;
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5-Aminolevulinic Acid (5-ALA)-Induced Protoporphyrin IX Fluorescence by Glioma Cells-A Fluorescence Microscopy Clinical Study. Cancers (Basel) 2022; 14:cancers14122844. [PMID: 35740509 PMCID: PMC9221265 DOI: 10.3390/cancers14122844] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/25/2022] [Accepted: 06/06/2022] [Indexed: 02/05/2023] Open
Abstract
Simple Summary 5-aminolevulinic acid (5-ALA)-induced PpIX fluorescence is used in neurosurgery for intraoperative identification of high-grade glioma tissue. In this paper, using a fluorescence microscopy analysis on human tumor specimens, we assessed the actual number of fluorescence-positive tumor cells both in low-grade and high-grade glioma, and the ability of 5-ALA to cross the blood–brain barrier (BBB). We found that in high-grade gliomas, 32.7–75.5 percent of cells display 5-ALA induced PpIX fluorescence, whereas in low-grade gliomas the tumor cells did not fluoresce following 5-ALA. Immunofluorescence for BBB components suggested that 5-ALA does not cross the un-breached BBB. These findings are of crucial importance in planning neurosurgical resection of gliomas. Abstract 5-aminolevulinic acid (5-ALA)-induced PpIX fluorescence is used by neurosurgeons to identify the tumor cells of high-grade gliomas during operation. However, the issue of whether 5-ALA-induced PpIX fluorescence consistently stains all the tumor cells is still debated. Here, we assessed the cytoplasmatic signal of 5-ALA by fluorescence microscopy in a series of human gliomas. As tumor markers, we used antibodies against collapsin response-mediated protein 5 (CRMP5), alpha thalassemia/mental retardation syndrome X-linked (ATRX), and anti-isocitrate dehydrogenase 1 (IDH1). In grade III–IV gliomas, the signal induced by 5-ALA was detected in 32.7–75.5 percent of CRMP5-expressing tumor cells. In low-grade gliomas (WHO grade II), the CRMP5-expressing tumor cells did not fluoresce following 5-ALA. Immunofluorescence with antibodies that stain various components of the blood–brain barrier (BBB) suggested that 5-ALA does not cross the un-breached BBB, in spite of its small dimension. To conclude, 5-ALA-induced PpIX fluorescence has an established role in high-grade glioma surgery, but it has limited usefulness in surgery for low-grade glioma, especially when the BBB is preserved.
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Zeppa P, De Marco R, Monticelli M, Massara A, Bianconi A, Di Perna G, Greco Crasto S, Cofano F, Melcarne A, Lanotte MM, Garbossa D. Fluorescence-Guided Surgery in Glioblastoma: 5-ALA, SF or Both? Differences between Fluorescent Dyes in 99 Consecutive Cases. Brain Sci 2022; 12:brainsci12050555. [PMID: 35624942 PMCID: PMC9138621 DOI: 10.3390/brainsci12050555] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Glioblastoma (GBM) is the most common primary brain tumor. The extent of resection (EOR) has been claimed as one of the most important prognostic factors. Fluorescent dyes aid surgeons in detecting a tumor’s borders. 5-aminolevulinic acid (5-ALA) and sodium fluorescein (SF) are the most used. Only a few studies have directly compared these two fluorophores. Methods: A single center retrospective analysis of patients treated for GBM in the period between January 2018 and January 2021 was built to find any differences in terms of EOR, Karnofsky Performance Status (KPS), and overall survival (OS) on the use of 5-ALA, SF, or both. Results: Overall, 99 patients affected by isocitrate dehydrogenase (IDH) wild-type Glioblastoma were included. 5-ALA was administered to 40 patients, SF to 44, and both to 15. No statistically significant associations were identified between the fluorophore and EOR (p = 0.783) or postoperative KPS (p = 0.270). Survival analyses did not show a selective advantage for the use of a given fluorophore (p = 0.184), although there appears to be an advantageous trend associated with the concomitant use of both dyes, particularly after stratification by MGMT (p = 0.071). Conclusions: 5-Ala and SF are equally useful in achieving gross total resection of the enhancing tumor volume. The combination of both fluorophores could lead to an OS advantage.
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Affiliation(s)
- Pietro Zeppa
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Raffaele De Marco
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
- Correspondence:
| | - Matteo Monticelli
- Neurosurgery Unit, Department of Neuroscience and Rehabilitation, University of Ferrara, 44124 Ferrara, Italy;
| | - Armando Massara
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Andrea Bianconi
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Giuseppe Di Perna
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | | | - Fabio Cofano
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
- Humanitas Gradenigo Hospital, 10153 Turin, Italy
| | - Antonio Melcarne
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Michele Maria Lanotte
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Diego Garbossa
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
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Wach J, Güresir Á, Hamed M, Vatter H, Herrlinger U, Güresir E. Impact of Levetiracetam Treatment on 5-Aminolevulinic Acid Fluorescence Expression in IDH1 Wild-Type Glioblastoma. Cancers (Basel) 2022; 14:cancers14092134. [PMID: 35565263 PMCID: PMC9099986 DOI: 10.3390/cancers14092134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/21/2022] [Accepted: 04/24/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary The amino acid 5-aminolevulinic acid (5-ALA) is the benchmark regarding intraoperative imaging tools for glioblastoma (GB) surgery, and is known to facilitate the extent of resection, which results in an enhanced 6 month progression-free survival rate. Recent in vitro studies suggest that antiepileptic drugs (AEDs) result in a reduction in the fluorescence quality in gliomas. To date, there is no large clinical series investigating this issue in a homogeneous cohort. Approximately 25% of all GB patients have a symptomatic epilepsy as the initial symptom at presentation. Hence, this potential dilemma is of paramount importance. We found that the preoperative intake of levetiracetam is a significant risk factor for reduced intraoperative fluorescence in IDH1 wild-type GBs. We believe that this issue must be considered in future external validations, and physicians must carefully evaluate the indication of levetiracetam and avoid a prophylactic levetiracetam treatment in terms of the suspected diagnosis of glioblastoma. Abstract The amino acid 5-aminolevulinic acid (5-ALA) is the most established neurosurgical fluorescent dye and facilitates the achievement of gross total resection. In vitro studies raised concerns that antiepileptic drugs (AED) reduce the quality of fluorescence. Between 2013 and 2018, 175 IDH1 wild-type glioblastoma (GB) patients underwent 5-ALA guided surgery. Patients’ data were retrospectively reviewed regarding demographics, comorbidities, medications, tumor morphology, neuropathological characteristics, and their association with intraoperative 5-ALA fluorescence. The fluorescence of 5-ALA was graded in a three point scaling system (grade 0 = no; grade 1 = weak; grade 2 = strong). Univariable analysis shows that the intake of dexamethasone or levetiracetam, and larger preoperative tumor area significantly reduce the intraoperative fluorescence activity (fluorescence grade: 0 + 1). Multivariable binary logistic regression analysis demonstrates the preoperative intake of levetiracetam (adjusted odds ratio: 12.05, 95% confidence interval: 3.91–37.16, p = 0.001) as the only independent and significant risk factor for reduced fluorescence quality. Preoperative levetiracetam intake significantly reduced intraoperative fluorescence. The indication for levetiracetam in suspected GB should be carefully reviewed and prophylactic treatment avoided for this tumor entity. Future comparative trials of neurosurgical fluorescent dyes need a special focus on the influence of levetiracetam on fluorescence intensity. Further trials must validate our findings.
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Affiliation(s)
- Johannes Wach
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (Á.G.); (M.H.); (H.V.); (E.G.)
- Correspondence: ; Tel.: +49-228-287-16521
| | - Ági Güresir
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (Á.G.); (M.H.); (H.V.); (E.G.)
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (Á.G.); (M.H.); (H.V.); (E.G.)
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (Á.G.); (M.H.); (H.V.); (E.G.)
| | - Ulrich Herrlinger
- Division of Clinical Neurooncology, Department of Neurology and Centre of Integrated Oncology, University Hospital Bonn, 53127 Bonn, Germany;
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (Á.G.); (M.H.); (H.V.); (E.G.)
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Correlation of Intraoperative 5-ALA-Induced Fluorescence Intensity and Preoperative 11C-Methionine PET Uptake in Glioma Surgery. Cancers (Basel) 2022; 14:cancers14061449. [PMID: 35326600 PMCID: PMC8946621 DOI: 10.3390/cancers14061449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/01/2022] [Accepted: 03/08/2022] [Indexed: 12/14/2022] Open
Abstract
Simple Summary In malignant brain tumor surgery, precise identification of the tumor is essential. 5-Aminolevulinic acid (5-ALA) labels tumor cells with red fluorescence to facilitate tumor resection. On the other hand, the nuclear medicine imaging technique, positron emission tomography with 11C-methionine (MET-PET), can delineate tumors precisely but is not widely available. This study aimed to determine the correlation between intraoperative 5-ALA-induced fluorescence and preoperative MET-PET signals of gliomas. We quantitatively measured the fluorescence intensity from tumor samples and calculated the MET-PET uptake by the tumor. Our study showed that strong tumor fluorescence correlated with high MET-PET uptake and cellular proliferation. Our findings might be valuable to rapidly provide information on tumor biology at the time of surgery in circumstances where MET-PET is inaccessible. Abstract Background: 5-Aminolevulinic acid (5-ALA) is widely employed to assist fluorescence-guided surgery for malignant brain tumors. Positron emission tomography with 11C-methionine (MET-PET) represents the activity of brain tumors with precise boundaries but is not readily available. We hypothesized that quantitative 5-ALA-induced fluorescence intensity might correlate with MET-PET uptake in gliomas. Methods: Adult patients with supratentorial astrocytic gliomas who underwent preoperative MET-PET and surgical tumor resection using 5-ALA were enrolled in this prospective study. The regional tumor uptake of MET-PET was expressed as the ratio of standardized uptake volume max to that of the normal contralateral frontal lobe. A spectrometric fluorescence detection system measured tumor specimens’ ex vivo fluorescence intensity at 635 nm. Ki-67 index and IDH mutation status were assessed by histopathological analysis. Use of an antiepileptic drug (AED) and contrast enhancement pattern on MRI were also investigated. Results: Thirty-two patients, mostly with Glioblastoma IDH wild type (46.9%) and anaplastic astrocytoma IDH mutant (21.9%), were analyzed. When the fluorescence intensity was ranked into four groups, the strongest fluorescence group exhibited the highest mean MET-PET uptake and Ki-67 index values. When rearranged into fluorescence Visible or Non-visible groups, the Visible group had significantly higher MET-PET uptake and Ki-67 index compared to the Non-visible group. Contrast enhancement on MRI and IDH wild type tumors were more frequent among the Visible group. AED use did not correlate with 5-ALA-induced fluorescence intensity. Conclusions: In astrocytic glioma surgery, visible 5-ALA-induced fluorescence correlated with high MET-PET uptake, along with a high Ki-67 index.
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Ricciardi L, Sturiale CL, Scerrati A, Stifano V, Somma T, Ius T, Trungu S, Acqui M, Raco A, Miscusi M, Della Pepa GM. 5-Aminolevulinic Acid False-Positive Rates in Newly Diagnosed and Recurrent Glioblastoma: Do Pseudoprogression and Radionecrosis Play a Role? A Meta-Analysis. Front Oncol 2022; 12:848036. [PMID: 35252015 PMCID: PMC8891510 DOI: 10.3389/fonc.2022.848036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/24/2022] [Indexed: 01/15/2023] Open
Abstract
Background Several studies have confirmed the impact of 5-aminolevulinic acid (5-ALA) on the extent of resection in newly diagnosed glioblastoma (GBM). However, there are controversies on the 5-ALA fluorescence status in recurrent GBM surgery, with specific reference to pseudoprogression or radionecrosis; therefore, the safety and accuracy of surgical planning in 5-ALA-assisted procedures in the recurrent context are still unclear. Materials and Methods This is a systematic review and meta-analysis of comparative studies on the use of 5-ALA in newly diagnosed and recurrent GBM, consistently conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Data on fluorescence status and correlation between fluorescence and histological findings were collected. We performed a meta-analysis of proportions to estimate the pooled rates of each outcome. Results Three online medical databases (PubMed, Scopus, Cochrane Library) were screened, 448 articles were evaluated, and 3 papers were finally included for data analysis. Fluorescence rate was not different between newly diagnosed and recurrent GBM [p = 0.45; odds ratio (OR): 1.23; 95% CI: 0.72–2.09; I2 = 0%], while the rate of 5-ALA fluorescence-positive areas not associated with histological findings of GBM cells was higher in recurrent GBM (p = 0.04; OR: 0.24; 95% CI: 0.06–0.91; I2 = 19%). Furthermore, there were no cases of radionecrosis in false-positive samples, while inflammation and signs of pseudoprogression were found in 81.4% of the cases. Discussion and Conclusions Therefore, a robust awareness of 5-ALA potentialities and pitfalls in recurrent GBM surgery should be considered for a cognizant surgical strategy. Further clinical trials could confirm the results of the present meta-analysis.
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Affiliation(s)
- Luca Ricciardi
- Division of Neurosurgery, Sant’Andrea Hospital, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Carmelo Lucio Sturiale
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
- Division of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Alba Scerrati
- Neurosurgery Department, S. Anna University Hospital, Ferrara, Italy
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Vito Stifano
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
- Division of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Teresa Somma
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Tamara Ius
- Division of Neurosurgery, Neuroscience Department, University Hospital of Udine, Udine, Italy
| | - Sokol Trungu
- Division of Neurosurgery, Sant’Andrea Hospital, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Sapienza University of Rome, Rome, Italy
- Neurosurgery Unit, Cardinal G. Panico Hospital, Tricase, Italy
- *Correspondence: Sokol Trungu,
| | - Michele Acqui
- Division of Neurosurgery, Sant’Andrea Hospital, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Antonino Raco
- Division of Neurosurgery, Sant’Andrea Hospital, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Massimo Miscusi
- Division of Neurosurgery, Sant’Andrea Hospital, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Giuseppe Maria Della Pepa
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
- Division of Neurosurgery, Catholic University of Rome, Rome, Italy
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Kiesel B, Wadiura LI, Mischkulnig M, Makolli J, Sperl V, Borkovec M, Freund J, Lang A, Millesi M, Berghoff AS, Furtner J, Woehrer A, Widhalm G. Efficacy, Outcome, and Safety of Elderly Patients with Glioblastoma in the 5-ALA Era: Single Center Experience of More Than 10 Years. Cancers (Basel) 2021; 13:cancers13236119. [PMID: 34885227 PMCID: PMC8657316 DOI: 10.3390/cancers13236119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/25/2021] [Accepted: 11/30/2021] [Indexed: 11/25/2022] Open
Abstract
Simple Summary In the next decades, the incidence of patients with glioblastoma (GBM) will markedly increase due to the growth of the elderly population. Despite the increasing incidence of GBM, elderly patients are frequently excluded from clinical studies and thus, only few data are available specifically focusing on the elderly population. In the current study, we aimed to investigate the efficacy, outcome, and safety of surgically-treated GBM including resections and biopsies in the 5-ALA era in a large elderly cohort of altogether 272 patients. Our data of this large elderly cohort demonstrate for the first time the clinical utility and safety of 5-ALA fluorescence in GBM for improved tumor visualization in both resections as well as biopsies. Therefore, we recommend the use of 5-ALA not only in resections, but also in open/stereotactic biopsies to optimize the neurosurgical management of elderly GBM patients. Abstract Background: In the next decades, the incidence of patients with glioblastoma (GBM) will increase due to the growth of the elderly population. Fluorescence-guided resection using 5-aminolevulinic acid (5-ALA) is widely applied to achieve maximal safe resection of GBM and is identified as a novel intraoperative marker for diagnostic tissue during biopsies. However, detailed analyses of the use of 5-ALA in resections as well as biopsies in a large elderly cohort are still missing. The aim of this study was thus to investigate the efficacy, outcome, and safety of surgically- treated GBM in the 5-ALA era in a large elderly cohort. Methods: All GBM patients aged 65 years or older who underwent neurosurgical intervention between 2007 and 2019 were included. Data on 5-ALA application, intraoperative fluorescence status, and 5-ALA-related side effects were derived from our databank. In the case of resection, the tumor resectability and the extent of resection were determined. Potential prognostic parameters relevant for overall survival were analyzed. Results: 272 GBM patients with a median age of 71 years were included. Intraoperative 5-ALA fluorescence was applied in most neurosurgical procedures (n = 255/272, 88%) and visible fluorescence was detected in most cases (n = 252/255, 99%). In biopsies, 5-ALA was capable of visualizing tumor tissue by visible fluorescence in all but one case (n = 91/92, 99%). 5-ALA administration did not result in any severe side effects. Regarding patient outcome, smaller preoperative tumor volume (<22.75 cm3), gross total resection, single lesions, improved postoperative neurological status, and concomitant radio-chemotherapy showed a significantly longer overall survival. Conclusions: Our data of this large elderly cohort demonstrate the clinical utility and safety of 5-ALA fluorescence in GBM for improved tumor visualization in both resections as well as biopsies. Therefore, we recommend the use of 5-ALA not only in resections, but also in open/stereotactic biopsies to optimize the neurosurgical management of elderly GBM patients.
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Affiliation(s)
- Barbara Kiesel
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (B.K.); (L.I.W.); (M.M.); (J.M.); (V.S.); (M.B.); (J.F.); (A.L.); (M.M.)
| | - Lisa I. Wadiura
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (B.K.); (L.I.W.); (M.M.); (J.M.); (V.S.); (M.B.); (J.F.); (A.L.); (M.M.)
| | - Mario Mischkulnig
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (B.K.); (L.I.W.); (M.M.); (J.M.); (V.S.); (M.B.); (J.F.); (A.L.); (M.M.)
| | - Jessica Makolli
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (B.K.); (L.I.W.); (M.M.); (J.M.); (V.S.); (M.B.); (J.F.); (A.L.); (M.M.)
| | - Veronika Sperl
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (B.K.); (L.I.W.); (M.M.); (J.M.); (V.S.); (M.B.); (J.F.); (A.L.); (M.M.)
| | - Martin Borkovec
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (B.K.); (L.I.W.); (M.M.); (J.M.); (V.S.); (M.B.); (J.F.); (A.L.); (M.M.)
| | - Julia Freund
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (B.K.); (L.I.W.); (M.M.); (J.M.); (V.S.); (M.B.); (J.F.); (A.L.); (M.M.)
| | - Alexandra Lang
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (B.K.); (L.I.W.); (M.M.); (J.M.); (V.S.); (M.B.); (J.F.); (A.L.); (M.M.)
| | - Matthias Millesi
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (B.K.); (L.I.W.); (M.M.); (J.M.); (V.S.); (M.B.); (J.F.); (A.L.); (M.M.)
| | - Anna S. Berghoff
- Department of Medicine I, Clinical Division of Oncology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Julia Furtner
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, 1090 Vienna, Austria;
| | - Adelheid Woehrer
- Department of Neurology, Institute of Neuropathology and Neurochemistry, Medical University Vienna, 1090 Vienna, Austria;
| | - Georg Widhalm
- Department of Neurosurgery, Medical University Vienna, 1090 Vienna, Austria; (B.K.); (L.I.W.); (M.M.); (J.M.); (V.S.); (M.B.); (J.F.); (A.L.); (M.M.)
- Correspondence:
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Akimoto J, Fukami S, Ichikawa M, Nagai K, Kohno M. Preliminary Report: Rapid Intraoperative Detection of Residual Glioma Cell in Resection Cavity Walls Using a Compact Fluorescence Microscope. J Clin Med 2021; 10:jcm10225375. [PMID: 34830662 PMCID: PMC8620805 DOI: 10.3390/jcm10225375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: The surgical eradication of malignant glioma cells is theoretically impossible. Therefore, reducing the number of remaining tumor cells around the brain–tumor interface (BTI) is crucial for achieving satisfactory clinical results. The usefulness of fluorescence–guided resection for the treatment of malignant glioma was recently reported, but the detection of infiltrating tumor cells in the BTI using a surgical microscope is not realistic. Therefore, we have developed an intraoperative rapid fluorescence cytology system, and exploratorily evaluated its clinical feasibility for the management of malignant glioma. Materials and methods: A total of 25 selected patients with malignant glioma (newly diagnosed: 17; recurrent: 8) underwent surgical resection under photodiagnosis using photosensitizer Talaporfin sodium and a semiconductor laser. Intraoperatively, a crush smear preparation was made from a tiny amount of tumor tissue, and the fluorescence emitted upon 620/660 nm excitation was evaluated rapidly using a compact fluorescence microscope in the operating theater. Results: Fluorescence intensities of tumor tissues measured using a surgical microscope correlated with the tumor cell densities of tissues evaluated by measuring the red fluorescence emitted from the cytoplasm of tumor cells using a fluorescence microscope. A “weak fluorescence” indicated a reduction in the tumor cell density, whereas “no fluorescence” did not indicate the complete eradication of the tumor cells, but indicated that few tumor cells were emitting fluorescence. Conclusion: The rapid intraoperative detection of fluorescence from glioma cells using a compact fluorescence microscope was probably useful to evaluate the presence of tumor cells in the resection cavity walls, and could provide surgical implications for the more complete resection of malignant gliomas.
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Affiliation(s)
- Jiro Akimoto
- Department of Neurosurgery, Kohsei Chuo General Hospital, Tokyo 153-0062, Japan
- Department of Neurosurgery, Tokyo Medical University, Tokyo 160-8402, Japan; (S.F.); (M.I.); (K.N.); (M.K.)
- Correspondence:
| | - Shinjiro Fukami
- Department of Neurosurgery, Tokyo Medical University, Tokyo 160-8402, Japan; (S.F.); (M.I.); (K.N.); (M.K.)
| | - Megumi Ichikawa
- Department of Neurosurgery, Tokyo Medical University, Tokyo 160-8402, Japan; (S.F.); (M.I.); (K.N.); (M.K.)
| | - Kenta Nagai
- Department of Neurosurgery, Tokyo Medical University, Tokyo 160-8402, Japan; (S.F.); (M.I.); (K.N.); (M.K.)
| | - Michihiro Kohno
- Department of Neurosurgery, Tokyo Medical University, Tokyo 160-8402, Japan; (S.F.); (M.I.); (K.N.); (M.K.)
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Shiratori T, Hotta K, Satoh M, Sato A, Kamigaito T, Kiuchi C, Tanaka R. Differences in 5-Aminolevulinic Acid-Induced Hemodynamic Changes between Patients Undergoing Neurosurgery and Urological Surgery. JMA J 2021; 4:374-386. [PMID: 34796292 PMCID: PMC8580708 DOI: 10.31662/jmaj.2021-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/29/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction: Oral 5-aminolevulinic acid (5-ALA) is often used for photodynamic diagnosis-assisted glioma or bladder tumor surgery. 5-ALA affects blood pressure (BP). In fact, hypotension is a well-known adverse effect of 5-ALA in urology. However, information regarding 5-ALA-induced hemodynamic changes in neurosurgery remains limited. Furthermore, the duration of hypotension and how 5-ALA affects the heart rate (HR) are yet to be determined. Thus, in this study, we aimed to elucidate 5-ALA-induced perioperative hemodynamic changes in neurosurgery and urological surgery by examining real-world data. Methods: Consecutive patients who underwent neurosurgery (neurosurgery patients; 5-ALA-pretreated vs. non-pretreated [17 vs. 16], from January 2014 to March 2021) and urological surgery (urological surgery patients; 5-ALA-pretreated vs. non-pretreated [26 vs. 101], from August 2018 to September 2020) were enrolled. Differences in hemodynamics were evaluated using the linear mixed model. BP and HR in 5-ALA-pretreated patients were compared with those in non-pretreated patients. Differences in 5-ALA-induced preoperative BP changes were compared between the neurosurgery patients and urological surgery patients. Results: 5-ALA scarcely affected the hemodynamics in neurosurgery patients, whereas 5-ALA-induced hemodynamic changes were clearly observed in urological surgery patients. Hemodynamic parameters were found to be not significantly different between 5-ALA-pretreated and non-pretreated neurosurgery patients. The preoperative, intraoperative, and postoperative BP in 5-ALA-pretreated urological surgery patients were significantly lower than those in the non-pretreated patients. Preoperatively, two 5-ALA-pretreated urological surgery patients had severe postural hypotension (systolic BP <50 mmHg), and one of them did not continue with the surgery because of prolonged severe hypotension. The BP in 5-ALA-pretreated urological surgery patients tended to be persistently lower for 9 h after 5-ALA pretreatment. The preoperative and postoperative HR values were higher in 5-ALA-pretreated urological surgery patients. Cumulative incidences of BP reduction and HR elevation were significantly higher in 5-ALA-pretreated urological surgery patients. The preoperative BP reduction in 5-ALA-pretreated urological surgery patients was significantly larger than that in neurosurgery patients. Conclusions: 5-ALA-induced hemodynamics may differ between neurosurgery patients and urological surgery patients. 5-ALA may affect BP for at least 9 h.
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Affiliation(s)
- Tohru Shiratori
- Department of Anesthesiology, Ina Central Hospital, Nagano, Japan
| | - Kunihisa Hotta
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Tochigi, Japan
| | - Masaaki Satoh
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Tochigi, Japan
| | - Atsushi Sato
- Department of Neurosurgery, Ina Central Hospital, Nagano, Japan
| | | | - Chiaki Kiuchi
- Department of Anesthesiology, Ina Central Hospital, Nagano, Japan
| | - Ryusuke Tanaka
- Department of Anesthesiology, Ina Central Hospital, Nagano, Japan
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36
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Schupper AJ, Baron RB, Cheung W, Rodriguez J, Kalkanis SN, Chohan MO, Andersen BJ, Chamoun R, Nahed BV, Zacharia BE, Kennedy J, Moulding HD, Zucker L, Chicoine MR, Olson JJ, Jensen RL, Sherman JH, Zhang X, Price G, Fowkes M, Germano IM, Carter BS, Hadjipanayis CG, Yong RL. 5-Aminolevulinic acid for enhanced surgical visualization of high-grade gliomas: a prospective, multicenter study. J Neurosurg 2021:1-10. [PMID: 34624862 DOI: 10.3171/2021.5.jns21310] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/05/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Greater extent of resection (EOR) is associated with longer overall survival in patients with high-grade gliomas (HGGs). 5-Aminolevulinic acid (5-ALA) can increase EOR by improving intraoperative visualization of contrast-enhancing tumor during fluorescence-guided surgery (FGS). When administered orally, 5-ALA is converted by glioma cells into protoporphyrin IX (PPIX), which fluoresces under blue 400-nm light. 5-ALA has been available for use in Europe since 2010, but only recently gained FDA approval as an intraoperative imaging agent for HGG tissue. In this first-ever, to the authors' knowledge, multicenter 5-ALA FGS study conducted in the United States, the primary objectives were the following: 1) assess the diagnostic accuracy of 5-ALA-induced PPIX fluorescence for HGG histopathology across diverse centers and surgeons; and 2) assess the safety profile of 5-ALA FGS, with particular attention to neurological morbidity. METHODS This single-arm, multicenter, prospective study included adults aged 18-80 years with Karnofsky Performance Status (KPS) score > 60 and an MRI diagnosis of suspected new or recurrent resectable HGG. Intraoperatively, 3-5 samples per tumor were taken and their fluorescence status was recorded by the surgeon. Specimens were submitted for histopathological analysis. Patients were followed for 6 weeks postoperatively for adverse events, changes in the neurological exam, and KPS score. Multivariate analyses were performed of the outcomes of KPS decline, EOR, and residual enhancing tumor volume to identify predictive patient and intraoperative variables. RESULTS Sixty-nine patients underwent 5-ALA FGS, providing 275 tumor samples for analysis. PPIX fluorescence had a sensitivity of 96.5%, specificity of 29.4%, positive predictive value (PPV) for HGG histopathology of 95.4%, and diagnostic accuracy of 92.4%. Drug-related adverse events occurred at a rate of 22%. Serious adverse events due to intraoperative neurological injury, which may have resulted from FGS, occurred at a rate of 4.3%. There were 2 deaths unrelated to FGS. Compared to preoperative KPS scores, postoperative KPS scores were significantly lower at 48 hours and 2 weeks but were not different at 6 weeks postoperatively. Complete resection of enhancing tumor occurred in 51.9% of patients. Smaller preoperative tumor volume and use of intraoperative MRI predicted lower residual tumor volume. CONCLUSIONS PPIX fluorescence, as judged by the surgeon, has a high sensitivity and PPV for HGG. 5-ALA was well tolerated in terms of drug-related adverse events, and its application by trained surgeons in FGS for HGGs was not associated with any excess neurological morbidity.
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Affiliation(s)
- Alexander J Schupper
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - Rebecca B Baron
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - William Cheung
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - Jessica Rodriguez
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - Steven N Kalkanis
- 2Department of Neurological Surgery, Henry Ford Medical Center, Detroit, Michigan
| | - Muhammad O Chohan
- 3Department of Neurological Surgery, University of New Mexico Hospital, Albuquerque, New Mexico
| | - Bruce J Andersen
- 4Department of Neurological Surgery, St. Alphonsus Regional Medical Center, Boise, Idaho
| | - Roukoz Chamoun
- 5Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Brian V Nahed
- 6Department of Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Brad E Zacharia
- 7Department of Neurological Surgery, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | - Hugh D Moulding
- 9Department of Neurological Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Lloyd Zucker
- 10Department of Neurological Surgery, Delray Medical Center, Delray Beach, Florida
| | - Michael R Chicoine
- 11Department of Neurological Surgery, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Jeffrey J Olson
- 12Department of Neurological Surgery, Emory University Hospital, Atlanta, Georgia
| | - Randy L Jensen
- 13Department of Neurological Surgery, Huntsman Cancer Institute, Salt Lake City, Utah; and
| | - Jonathan H Sherman
- 14Department of Neurological Surgery, George Washington University Hospital, Washington, DC
| | - Xiangnan Zhang
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - Gabrielle Price
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - Mary Fowkes
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - Isabelle M Germano
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
| | - Bob S Carter
- 6Department of Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Raymund L Yong
- 1Department of Neurological Surgery, Mount Sinai Health System, New York, New York
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Palmieri G, Cofano F, Salvati LF, Monticelli M, Zeppa P, Perna GD, Melcarne A, Altieri R, La Rocca G, Sabatino G, Barbagallo GM, Tartara F, Zenga F, Garbossa D. Fluorescence-Guided Surgery for High-Grade Gliomas: State of the Art and New Perspectives. Technol Cancer Res Treat 2021; 20:15330338211021605. [PMID: 34212784 PMCID: PMC8255554 DOI: 10.1177/15330338211021605] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
High-grade gliomas are aggressive tumors that require multimodal management and gross total resection is considered to be the first crucial step of treatment. Because of their infiltrative nature, intraoperative differentiation of neoplastic tissue from normal parenchyma can be challenging. For these reasons, in the recent years, neurosurgeons have increasingly performed this surgery under the guidance of tissue fluorescence. Sodium fluoresceine and 5-aminolevulinic acid represent the 2 main compounds that allow real-time identification of residual malignant tissue and have been associated with improved gross total resection and radiological outcomes. Though presenting different profiles of sensitivity and specificity and further investigations concerning cost-effectiveness are need, Sodium fluoresceine, 5-aminolevulinic acid and new phluorophores, such as Indocyanine green, represent some of the most important tools in the neurosurgeon’s hands to achieve gross total resection.
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Affiliation(s)
- Giuseppe Palmieri
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Fabio Cofano
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy.,Neurosurgery/Spine Surgery, Humanitas Gradenigo Hospital, Turin, Italy
| | - Luca Francesco Salvati
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Matteo Monticelli
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Pietro Zeppa
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Giuseppe Di Perna
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Antonio Melcarne
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Roberto Altieri
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Italy
| | - Giuseppe La Rocca
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli Irccs, Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli Irccs, Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giuseppe Maria Barbagallo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Italy
| | - Fulvio Tartara
- Unit of Neurosurgery, Istituto Clinico Città Studi, Milan, Italy
| | - Francesco Zenga
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Diego Garbossa
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
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38
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Certo F, Altieri R, Maione M, Schonauer C, Sortino G, Fiumanò G, Tirrò E, Massimino M, Broggi G, Vigneri P, Magro G, Visocchi M, Barbagallo GMV. FLAIRectomy in Supramarginal Resection of Glioblastoma Correlates With Clinical Outcome and Survival Analysis: A Prospective, Single Institution, Case Series. Oper Neurosurg (Hagerstown) 2021; 20:151-163. [PMID: 33035343 DOI: 10.1093/ons/opaa293] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 07/02/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Extent of tumor resection (EOTR) in glioblastoma surgery plays an important role in improving survival. OBJECTIVE To analyze the efficacy, safety and reliability of fluid-attenuated inversion-recovery (FLAIR) magnetic resonance (MR) images used to guide glioblastoma resection (FLAIRectomy) and to volumetrically measure postoperative EOTR, which was correlated with clinical outcome and survival. METHODS A total of 68 glioblastoma patients (29 males, mean age 65.8) were prospectively enrolled. Hyperintense areas on FLAIR images, surrounding gadolinium-enhancing tissue on T1-weighted MR images, were screened for signal changes suggesting tumor infiltration and evaluated for supramaximal resection. The surgical protocol included 5-aminolevulinic acid (5-ALA) fluorescence, neuromonitoring, and intraoperative imaging tools. 5-ALA fluorescence intensity was analyzed and matched with the different sites on navigated MR, both on postcontrast T1-weighted and FLAIR images. Volumetric evaluation of EOTR on T1-weighted and FLAIR sequences was compared. RESULTS FLAIR MR volumetric evaluation documented larger tumor volume than that assessed on contrast-enhancing T1 MR (72.6 vs 54.9 cc); residual tumor was seen in 43 patients; postcontrast T1 MR volumetric analysis showed complete resection in 64 cases. O6-methylguanine-DNA methyltransferase promoter was methylated in 8/68 (11.7%) cases; wild type Isocytrate Dehydrogenase-1 (IDH-1) was found in 66/68 patients. Progression free survival and overall survival (PFS and OS) were 17.43 and 25.11 mo, respectively. Multiple regression analysis showed a significant correlation between EOTR based on FLAIR, PFS (R2 = 0.46), and OS (R2 = 0.68). CONCLUSION EOTR based on FLAIR and 5-ALA fluorescence is feasible. Safety of resection relies on the use of neuromonitoring and intraoperative multimodal imaging tools. FLAIR-based EOTR appears to be a stronger survival predictor compared to gadolinium-enhancing, T1-based resection.
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Affiliation(s)
- Francesco Certo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico ``G. Rodolico - San Marco'' University Hospital, University of Catania, Italy.,Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Via S. Sofia, Catania, Italy
| | - Roberto Altieri
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico ``G. Rodolico - San Marco'' University Hospital, University of Catania, Italy
| | - Massimiliano Maione
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico ``G. Rodolico - San Marco'' University Hospital, University of Catania, Italy
| | - Claudio Schonauer
- Department of Neurological Surgery, Santa Maria delle Grazie Hospital ASLNa2Nord, Via Domitiana, Naples, Italy
| | - Giuseppe Sortino
- Department of Radiodiagnostic and Oncological Radiotherapy, University Hospital Policlinico-Vittorio Emanuele, Via S. Sofia, Catania, Italy
| | - Giuseppa Fiumanò
- Department of Neurological Surgery, Santa Maria delle Grazie Hospital ASLNa2Nord, Via Domitiana, Naples, Italy
| | - Elena Tirrò
- Department of Clinical and Experimental Medicine, Center of Experimental Oncology and Hematology, University Hospital Policlinico-Vittorio Emanuele, Via S. Sofia, Catania, Italy
| | - Michele Massimino
- Department of Clinical and Experimental Medicine, Center of Experimental Oncology and Hematology, University Hospital Policlinico-Vittorio Emanuele, Via S. Sofia, Catania, Italy
| | - Giuseppe Broggi
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Anatomic Pathology, Policlinico ``G. Rodolico - San Marco'' University Hospital, University of Catania, Italy
| | - Paolo Vigneri
- Department of Clinical and Experimental Medicine, Center of Experimental Oncology and Hematology, University Hospital Policlinico-Vittorio Emanuele, Via S. Sofia, Catania, Italy
| | - Gaetano Magro
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Anatomic Pathology, Policlinico ``G. Rodolico - San Marco'' University Hospital, University of Catania, Italy
| | - Massimiliano Visocchi
- Institute of Neurosurgery, Catholic University, Via della Pineta Sacchetti, Rome, Italy
| | - Giuseppe M V Barbagallo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico ``G. Rodolico - San Marco'' University Hospital, University of Catania, Italy.,Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Via S. Sofia, Catania, Italy
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39
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Kaneko S, Suero Molina E, Sporns P, Schipmann S, Black D, Stummer W. Fluorescence real-time kinetics of protoporphyrin IX after 5-ALA administration in low-grade glioma. J Neurosurg 2021; 136:9-15. [PMID: 34144512 DOI: 10.3171/2020.10.jns202881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE 5-Aminolevulinic acid (5-ALA) induces fluorescence in high-grade glioma (HGG), which is used for resection. However, the value of 5-ALA-induced fluorescence in low-grade glioma (LGG) is unclear. Time dependency and time kinetics have not yet been investigated. The purpose of this study was to investigate real-time kinetics of protoporphyrin IX (PpIX) in LGG based on hyperspectral fluorescence-based measurements and identify factors that predict fluorescence. METHODS Patients with grade II gliomas and imaging from which HGGs could not be completely ruled out received 5-ALA at 20 mg/kg body weight 4 hours prior to surgery. Fluorescence intensity (FI) and PpIX concentration (CPpIX) were measured in tumor tissue utilizing a hyperspectral camera. Apparent diffusion coefficient (ADC)-based tumor cell density, Ki-67/MIB-1 index, chromosomal 1p/19q codeletion, and 18F-fluoroethyl-l-tyrosine (18F-FET) PET values and their role for predicting fluorescence were evaluated. RESULTS Eighty-one biopsies from 25 patients were included. Tissues with fluorescence demonstrated FI and CPpIX maxima between 7 and 8 hours after administration. When visible fluorescence was observed, peaks of FI and CPpIX were observed within this 7- to 8-hour time frame, regardless of any MRI gadolinium contrast enhancement. Gadolinium enhancement (p = 0.008), Ki-67/MIB-1 index (p < 0.001), 18F-FET PET uptake ratio (p = 0.004), and ADC-based tumor cellularity (p = 0.017) significantly differed between fluorescing and nonfluorescing tissue, but not 1p/19q codeletions. Logistic regression demonstrated that 18F-FET PET uptake and Ki-67/MIB-1 index were independently related to fluorescence. CONCLUSIONS This study reports a fluorescence-based assessment of CPpIX in human LGG tissues related to 18F-FET PET uptake and Ki-67/MIB-1. As in HGGs, fluorescence in LGGs peaked between 7 and 8 hours after 5-ALA application, which has consequences for the timing of administration.
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Affiliation(s)
- Sadahiro Kaneko
- 1Department of Neurosurgery, University Hospital of Münster, Germany.,2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Eric Suero Molina
- 1Department of Neurosurgery, University Hospital of Münster, Germany
| | - Peter Sporns
- 3Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Switzerland.,4Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - David Black
- 5Carl Zeiss Meditec AG, Oberkochen, Germany; and.,6University of British Columbia, Vancouver, British Columbia, Canada
| | - Walter Stummer
- 1Department of Neurosurgery, University Hospital of Münster, Germany
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40
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Schupper AJ, Rao M, Mohammadi N, Baron R, Lee JYK, Acerbi F, Hadjipanayis CG. Fluorescence-Guided Surgery: A Review on Timing and Use in Brain Tumor Surgery. Front Neurol 2021; 12:682151. [PMID: 34220688 PMCID: PMC8245059 DOI: 10.3389/fneur.2021.682151] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/11/2021] [Indexed: 12/25/2022] Open
Abstract
Fluorescence-guided surgery (FGS) allows surgeons to have improved visualization of tumor tissue in the operating room, enabling maximal safe resection of malignant brain tumors. Over the past two decades, multiple fluorescent agents have been studied for FGS, including 5-aminolevulinic acid (5-ALA), fluorescein sodium, and indocyanine green (ICG). Both non-targeted and targeted fluorescent agents are currently being used in clinical practice, as well as under investigation, for glioma visualization and resection. While the efficacy of intraoperative fluorescence in studied fluorophores has been well established in the literature, the effect of timing on fluorophore administration in glioma surgery has not been as well depicted. In the past year, recent studies of 5-ALA use have shown that intraoperative fluorescence may persist beyond the previously studied window used in prior multicenter trials. Additionally, the use of fluorophores for different brain tumor types is discussed in detail, including a discussion of choosing the right fluorophore based on tumor etiology. In the following review, the authors will describe the temporal nature of the various fluorophores used in glioma surgery, what remains uncertain in FGS, and provide a guide for using fluorescence as a surgical adjunct in brain tumor surgery.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Manasa Rao
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Nicki Mohammadi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Rebecca Baron
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione Istituto Di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milan, Italy
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41
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Let Me See: Correlation between 5-ALA Fluorescence and Molecular Pathways in Glioblastoma: A Single Center Experience. Brain Sci 2021; 11:brainsci11060795. [PMID: 34208653 PMCID: PMC8235669 DOI: 10.3390/brainsci11060795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 06/04/2021] [Accepted: 06/10/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Despite the aggressiveness of multimodal treatment, glioblastoma (GBM) is still a challenge for neurosurgeons, neurooncologists, and radiotherapists. A surgical approach is still a cornerstone in GBM therapeutic management, as the extent of resection is strongly related both to overall survival and progression-free survival. From this perspective, the use of photodynamic molecules could represent an interesting tool to achieve maximal and safe resection. Being able to trace the lesion’s edges, indeed, could allow to improve the extent of resection and to minimize residual tumor while sparing normal tissue. The use of 5-aminolevulinic acid (5-ALA) as a photodynamic tracer is well established due to its strict correlation both with cellularity and metabolic activity of the GBM cell clones. Objective: Our study aims to define whether a different molecular asset of GBM (especially investigating IDH 1/2 mutation, proliferation index, and MGMT promoter methylation) results in different fluorescence expression, possibly because of differences in metabolic pathways due to different genotypes. Methods: Patients undergoing surgery for GBM removal at our Institute (Dep. Of Neurosurgery, Ospedale Città della Salute e della Scienza, University of Turin, Italy) were retrospectively reviewed. Patients with histological diagnosis confirmation and to whom 5-ALA was given before surgery were included. The whole surgical procedure was recorded and then analyzed by three different people (a medical student, a resident, and a senior surgeon with an interest in neurooncology and experience in using 5-ALA) and a score was assigned to the different degrees of intraoperative fluorescence. The degree of fluorescence was then matched with the genotype. Results: A trend of grade 2 fluorescence (i.e., ”strong”) was observed in the IDH 1/2 wild-type (WT) genotype, suggesting a more intense metabolic activity in this particular subgroup, while, no or weak fluorescence was observed more often in the IDH 1/2 mutated tumors, suggesting a lower metabolic activity. No relations were found between fluorescence grade and MGMT promoter methylation or, interestingly, cellularity. As a secondary analysis, more epileptogenicity of the IDH 1/2 mutated GBM was noticed, similarly to other recent literature. Conclusion: Our results do not support the use of 5-ALA as a diagnostic tool, or a way to substitute the molecular profiling, but confirm 5-ALA as a powerful metabolic tracer, able to easily detect the pathological cells, especially in the IDH WT genotype, and in this perspective, further studies will be necessary to better describe the metabolic activity of GBM cells.
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Pekmezci M, Morshed RA, Chunduru P, Pandian B, Young J, Villanueva-Meyer JE, Tihan T, Sloan EA, Aghi MK, Molinaro AM, Berger MS, Hervey-Jumper SL. Detection of glioma infiltration at the tumor margin using quantitative stimulated Raman scattering histology. Sci Rep 2021; 11:12162. [PMID: 34108566 PMCID: PMC8190264 DOI: 10.1038/s41598-021-91648-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 05/10/2021] [Indexed: 11/23/2022] Open
Abstract
In the management of diffuse gliomas, the identification and removal of tumor at the infiltrative margin remains a central challenge. Prior work has demonstrated that fluorescence labeling tools and radiographic imaging are useful surgical adjuvants with macroscopic resolution. However, they lose sensitivity at the tumor margin and have limited clinical utility for lower grade histologies. Fiber-laser based stimulated Raman histology (SRH) is an optical imaging technique that provides microscopic tissue characterization of unprocessed tissues. It remains unknown whether SRH of tissues taken from the infiltrative glioma margin will identify microscopic residual disease. Here we acquired glioma margin specimens for SRH, histology, and tumor specific tissue characterization. Generalized linear mixed models were used to evaluate agreement. We find that SRH identified residual tumor in 82 of 167 margin specimens (49%), compared to IHC confirming residual tumor in 72 of 128 samples (56%), and H&E confirming residual tumor in 82 of 169 samples (49%). Intraobserver agreements between all 3 modalities were confirmed. These data demonstrate that SRH detects residual microscopic tumor at the infiltrative glioma margin and may be a promising tool to enhance extent of resection.
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Affiliation(s)
- Melike Pekmezci
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Ramin A Morshed
- Department of Neurological Surgery, University of California, 505 Parnassus Ave., Rm. M-779, San Francisco, CA, 94143-0112, USA
| | - Pranathi Chunduru
- Department of Neurological Surgery, University of California, 505 Parnassus Ave., Rm. M-779, San Francisco, CA, 94143-0112, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Balaji Pandian
- Department of Neurological Surgery, University of California, 505 Parnassus Ave., Rm. M-779, San Francisco, CA, 94143-0112, USA.,Invenio Imaging, Inc, Santa Clara, CA, USA
| | - Jacob Young
- Department of Neurological Surgery, University of California, 505 Parnassus Ave., Rm. M-779, San Francisco, CA, 94143-0112, USA
| | | | - Tarik Tihan
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Emily A Sloan
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Manish K Aghi
- Department of Neurological Surgery, University of California, 505 Parnassus Ave., Rm. M-779, San Francisco, CA, 94143-0112, USA
| | - Annette M Molinaro
- Department of Neurological Surgery, University of California, 505 Parnassus Ave., Rm. M-779, San Francisco, CA, 94143-0112, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, 505 Parnassus Ave., Rm. M-779, San Francisco, CA, 94143-0112, USA
| | - Shawn L Hervey-Jumper
- Department of Neurological Surgery, University of California, 505 Parnassus Ave., Rm. M-779, San Francisco, CA, 94143-0112, USA.
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Zhou Q, van den Berg NS, Rosenthal EL, Iv M, Zhang M, Vega Leonel JCM, Walters S, Nishio N, Granucci M, Raymundo R, Yi G, Vogel H, Cayrol R, Lee YJ, Lu G, Hom M, Kang W, Hayden Gephart M, Recht L, Nagpal S, Thomas R, Patel C, Grant GA, Li G. EGFR-targeted intraoperative fluorescence imaging detects high-grade glioma with panitumumab-IRDye800 in a phase 1 clinical trial. Theranostics 2021; 11:7130-7143. [PMID: 34158840 PMCID: PMC8210618 DOI: 10.7150/thno.60582] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/24/2021] [Indexed: 12/12/2022] Open
Abstract
Rationale: First-line therapy for high-grade gliomas (HGGs) includes maximal safe surgical resection. The extent of resection predicts overall survival, but current neuroimaging approaches lack tumor specificity. The epidermal growth factor receptor (EGFR) is a highly expressed HGG biomarker. We evaluated the safety and feasibility of an anti-EGFR antibody, panitumuab-IRDye800, at subtherapeutic doses as an imaging agent for HGG. Methods: Eleven patients with contrast-enhancing HGGs were systemically infused with panitumumab-IRDye800 at a low (50 mg) or high (100 mg) dose 1-5 days before surgery. Near-infrared fluorescence imaging was performed intraoperatively and ex vivo, to identify the optimal tumor-to-background ratio by comparing mean fluorescence intensities of tumor and histologically uninvolved tissue. Fluorescence was correlated with preoperative T1 contrast, tumor size, EGFR expression and other biomarkers. Results: No adverse events were attributed to panitumumab-IRDye800. Tumor fragments as small as 5 mg could be detected ex vivo and detection threshold was dose dependent. In tissue sections, panitumumab-IRDye800 was highly sensitive (95%) and specific (96%) for pathology confirmed tumor containing tissue. Cellular delivery of panitumumab-IRDye800 was correlated to EGFR overexpression and compromised blood-brain barrier in HGG, while normal brain tissue showed minimal fluorescence. Intraoperative fluorescence improved optical contrast in tumor tissue within and beyond the T1 contrast-enhancing margin, with contrast-to-noise ratios of 9.5 ± 2.1 and 3.6 ± 1.1, respectively. Conclusions: Panitumumab-IRDye800 provided excellent tumor contrast and was safe at both doses. Smaller fragments of tumor could be detected at the 100 mg dose and thus more suitable for intraoperative imaging.
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Affiliation(s)
- Quan Zhou
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Nynke S. van den Berg
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Eben L. Rosenthal
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cancer Center, Stanford University, Stanford, CA, USA
| | - Michael Iv
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Shannon Walters
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Naoki Nishio
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Monica Granucci
- Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford, CA, USA
| | - Roan Raymundo
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford, CA, USA
| | - Grace Yi
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford, CA, USA
| | - Hannes Vogel
- Department of Neuropathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Romain Cayrol
- Department of Neuropathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Yu-Jin Lee
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Guolan Lu
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Marisa Hom
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Wenying Kang
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Larry Recht
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Seema Nagpal
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Reena Thomas
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Chirag Patel
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gerald A. Grant
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
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Yadav V, Mai Y, McCoubrey LE, Wada Y, Tomioka M, Kawata S, Charde S, Basit AW. 5-Aminolevulinic Acid as a Novel Therapeutic for Inflammatory Bowel Disease. Biomedicines 2021; 9:biomedicines9050578. [PMID: 34065300 PMCID: PMC8160866 DOI: 10.3390/biomedicines9050578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/13/2021] [Accepted: 05/15/2021] [Indexed: 12/22/2022] Open
Abstract
5-Aminolevulinic acid (5-ALA) is a naturally occurring nonprotein amino acid licensed as an optical imaging agent for the treatment of gliomas. In recent years, 5-ALA has been shown to possess anti-inflammatory and immunoregulatory properties through upregulation of heme oxygenase-1 via enhancement of porphyrin, indicating that it may be beneficial for the treatment of inflammatory conditions. This study systematically examines 5-ALA for use in inflammatory bowel disease (IBD). Firstly, the ex vivo colonic stability and permeability of 5-ALA was assessed using human and mouse fluid and tissue. Secondly, the in vivo efficacy of 5-ALA, in the presence of sodium ferrous citrate, was investigated via the oral and intracolonic route in an acute DSS colitis mouse model of IBD. Results showed that 5-ALA was stable in mouse and human colon fluid, as well as in colon tissue. 5-ALA showed more tissue restricted pharmacokinetics when exposed to human colonic tissue. In vivo dosing demonstrated significantly improved colonic inflammation, increased local heme oxygenase-1 levels, and decreased concentrations of proinflammatory cytokines TNF-α, IL-6, and IL-1β in both plasma and colonic tissue. These effects were superior to that measured concurrently with established anti-inflammatory treatments, ciclosporin and 5-aminosalicylic acid (mesalazine). As such, 5-ALA represents a promising addition to the IBD armamentarium, with potential for targeted colonic delivery.
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Affiliation(s)
- Vipul Yadav
- Intract Pharma Limited, London Bioscience Innovation Centre, London NW1 0NH, UK
- Correspondence: (V.Y.); (A.W.B.)
| | - Yang Mai
- School of Pharmaceutical Sciences (Shenzen), Sun Yat-sen University, Guangzhou 510275, China;
| | - Laura E. McCoubrey
- Department of Pharmaceutics, UCL School of Pharmacy, University College, London WC1N 1AX, UK;
| | - Yasufumi Wada
- Neopharma Japan, Iidabashi Grand Bloom 4th Floor, 2-10-2 Fujimi, Chiyoda-ku, Tokyo 102-0071, Japan; (Y.W.); (M.T.); (S.K.); (S.C.)
| | - Motoyasu Tomioka
- Neopharma Japan, Iidabashi Grand Bloom 4th Floor, 2-10-2 Fujimi, Chiyoda-ku, Tokyo 102-0071, Japan; (Y.W.); (M.T.); (S.K.); (S.C.)
| | - Satofumi Kawata
- Neopharma Japan, Iidabashi Grand Bloom 4th Floor, 2-10-2 Fujimi, Chiyoda-ku, Tokyo 102-0071, Japan; (Y.W.); (M.T.); (S.K.); (S.C.)
| | - Shrikant Charde
- Neopharma Japan, Iidabashi Grand Bloom 4th Floor, 2-10-2 Fujimi, Chiyoda-ku, Tokyo 102-0071, Japan; (Y.W.); (M.T.); (S.K.); (S.C.)
| | - Abdul W. Basit
- Intract Pharma Limited, London Bioscience Innovation Centre, London NW1 0NH, UK
- Department of Pharmaceutics, UCL School of Pharmacy, University College, London WC1N 1AX, UK;
- Correspondence: (V.Y.); (A.W.B.)
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45
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Menna G, Olivi A, Della Pepa GM. Letter to the Editor. A new approach for local tumor control. J Neurosurg 2021; 135:984-985. [PMID: 33962380 DOI: 10.3171/2021.2.jns21409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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46
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Darrigues E, Elberson BW, De Loose A, Lee MP, Green E, Benton AM, Sink LG, Scott H, Gokden M, Day JD, Rodriguez A. Brain Tumor Biobank Development for Precision Medicine: Role of the Neurosurgeon. Front Oncol 2021; 11:662260. [PMID: 33981610 PMCID: PMC8108694 DOI: 10.3389/fonc.2021.662260] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/29/2021] [Indexed: 12/18/2022] Open
Abstract
Neuro-oncology biobanks are critical for the implementation of a precision medicine program. In this perspective, we review our first year experience of a brain tumor biobank with integrated next generation sequencing. From our experience, we describe the critical role of the neurosurgeon in diagnosis, research, and precision medicine efforts. In the first year of implementation of the biobank, 117 patients (Female: 62; Male: 55) had 125 brain tumor surgeries. 75% of patients had tumors biobanked, and 16% were of minority race/ethnicity. Tumors biobanked were as follows: diffuse gliomas (45%), brain metastases (29%), meningioma (21%), and other (5%). Among biobanked patients, 100% also had next generation sequencing. Eleven patients qualified for targeted therapy based on identification of actionable gene mutations. One patient with a hereditary cancer predisposition syndrome was also identified. An iterative quality improvement process was implemented to streamline the workflow between the operating room, pathology, and the research laboratory. Dedicated tumor bank personnel in the department of neurosurgery greatly improved standard operating procedure. Intraoperative selection and processing of tumor tissue by the neurosurgeon was integral to increasing success with cell culture assays. Currently, our institutional protocol integrates standard histopathological diagnosis, next generation sequencing, and functional assays on surgical specimens to develop precision medicine protocols for our patients. This perspective reviews the critical role of neurosurgeons in brain tumor biobank implementation and success as well as future directions for enhancing precision medicine efforts.
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Affiliation(s)
- Emilie Darrigues
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Benjamin W Elberson
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Annick De Loose
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Madison P Lee
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Ebonye Green
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Ashley M Benton
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Ladye G Sink
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Hayden Scott
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Murat Gokden
- Division of Neuropathology, Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - John D Day
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Analiz Rodriguez
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States
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Kobets AJ, Nauen D, Lee A, Cohen AR. Unexpected Binding of Tozuleristide "Tumor Paint" to Cerebral Vascular Malformations: A Potentially Novel Application of Fluorescence-Guided Surgery. Neurosurgery 2021; 89:204-211. [PMID: 33826729 DOI: 10.1093/neuros/nyab106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 01/27/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Fluorescence-guided surgery (FGS) is under investigation as a means to improve the extent of resection for primary central nervous system (CNS) tumors. Tozuleristide, known also as "Tumor Paint," is an investigational tumor-targeting agent covalently conjugated to a derivative of the fluorescent dye indocyanine green. OBJECTIVE To report the finding of avid intraoperative fluorescence of tozuleristide on cerebral vascular malformations. METHODS Our institution is participating in a phase 2/3 study of intraoperative near-infrared fluorescence detection of pediatric primary CNS tumors in patients receiving intravenous tozuleristide and imaged with the Canvas system. Our site enrolled 2 patients with intracranial lesions, suspected preoperatively of possibly being gliomas that proved to be cavernous vascular malformations after resection. RESULTS Each lesion had a dark blue mulberry appearance and each fluoresced avidly with tozuleristide. Each was completely resected, and the patients recovered without deficit. Pathological assessment showed cavernous angioma for both cases. Tozuleristide fluorescence is postulated to result from binding to matrix metalloproteinase-2 and annexin A2, and literature review demonstrates expression of both these ligands on multiple cerebrovascular lesions, including cavernous malformations. CONCLUSION This finding deserves further investigation to determine if tozuleristide "Tumor Paint" may have a wider role in the identification of non-neoplastic intracranial pathologies.
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Affiliation(s)
- Andrew J Kobets
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, New York, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Nauen
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amy Lee
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Alan R Cohen
- Division of Pediatric Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Molecular imaging of a fluorescent antibody against epidermal growth factor receptor detects high-grade glioma. Sci Rep 2021; 11:5710. [PMID: 33707521 PMCID: PMC7952570 DOI: 10.1038/s41598-021-84831-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/16/2021] [Indexed: 01/31/2023] Open
Abstract
The prognosis for high-grade glioma (HGG) remains dismal and the extent of resection correlates with overall survival and progression free disease. Epidermal growth factor receptor (EGFR) is a biomarker heterogeneously expressed in HGG. We assessed the feasibility of detecting HGG using near-infrared fluorescent antibody targeting EGFR. Mice bearing orthotopic HGG xenografts with modest EGFR expression were imaged in vivo after systemic panitumumab-IRDye800 injection to assess its tumor-specific uptake macroscopically over 14 days, and microscopically ex vivo. EGFR immunohistochemical staining of 59 tumor specimens from 35 HGG patients was scored by pathologists and expression levels were compared to that of mouse xenografts. Intratumoral distribution of panitumumab-IRDye800 correlated with near-infrared fluorescence and EGFR expression. Fluorescence distinguished tumor cells with 90% specificity and 82.5% sensitivity. Target-to-background ratios peaked at 14 h post panitumumab-IRDye800 infusion, reaching 19.5 in vivo and 7.6 ex vivo, respectively. Equivalent or higher EGFR protein expression compared to the mouse xenografts was present in 77.1% HGG patients. Age, combined with IDH-wildtype cerebral tumor, was predictive of greater EGFR protein expression in human tumors. Tumor specific uptake of panitumumab-IRDye800 provided remarkable contrast and a flexible imaging window for fluorescence-guided identification of HGGs despite modest EGFR expression.
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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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50
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Hollon T, Orringer DA. Label-free brain tumor imaging using Raman-based methods. J Neurooncol 2021; 151:393-402. [PMID: 33611706 DOI: 10.1007/s11060-019-03380-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/20/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Label-free Raman-based imaging techniques create the possibility of bringing chemical and histologic data into the operation room. Relying on the intrinsic biochemical properties of tissues to generate image contrast and optical tissue sectioning, Raman-based imaging methods can be used to detect microscopic tumor infiltration and diagnose brain tumor subtypes. METHODS Here, we review the application of three Raman-based imaging methods to neurosurgical oncology: Raman spectroscopy, coherent anti-Stokes Raman scattering (CARS) microscopy, and stimulated Raman histology (SRH). RESULTS Raman spectroscopy allows for chemical characterization of tissue and can differentiate normal and tumor-infiltrated tissue based on variations in macromolecule content, both ex vivo and in vivo. To improve signal-to-noise ratio compared to conventional Raman spectroscopy, a second pulsed excitation laser can be used to coherently drive the vibrational frequency of specific Raman active chemical bonds (i.e. symmetric stretching of -CH2 bonds). Coherent Raman imaging, including CARS and stimulated Raman scattering microscopy, has been shown to detect microscopic brain tumor infiltration in fresh brain tumor specimens with submicron image resolution. Advances in fiber-laser technology have allowed for the development of intraoperative SRH as well as artificial intelligence algorithms to facilitate interpretation of SRH images. With molecular diagnostics becoming an essential part of brain tumor classification, preliminary studies have demonstrated that Raman-based methods can be used to diagnose glioma molecular classes intraoperatively. CONCLUSIONS These results demonstrate how label-free Raman-based imaging methods can be used to improve the management of brain tumor patients by detecting tumor infiltration, guiding tumor biopsy/resection, and providing images for histopathologic and molecular diagnosis.
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