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Falco J, Broggi M, Rubiu E, Schiariti M, Restelli F, Mazzapicchi E, La Corte E, Ferroli P, Acerbi F. The Application of Sodium Fluorescein in Resection of Medulloblastoma Under YELLOW 560 Filter: Feasibility and Preliminary Results of a Monocentric Cohort and Systematic Review. World Neurosurg 2024; 183:e386-e394. [PMID: 38154682 DOI: 10.1016/j.wneu.2023.12.105] [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: 08/26/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Maximizing surgical resection of medulloblastoma (MB) affects overall survival; nevertheless, surgical resection remains a because of the infiltrative behavior of this tumor. Several dyes have been tested for improving tumor visualization; however, few reports with different protocols of fluorophores use are available and the results are inconsistent. Hence, we report our experience with sodium fluorescein in MB surgery, aiming to assess the role of this technique on the extent of resection. Furthermore, we performed a literature review of this topic. METHODS Fluorescence characteristics, extent of resection, and clinical outcome were analyzed in 9 consecutively operated patients with MB. A comprehensive literature search and review for English-language articles concerning fluorescein application in MB was conducted. RESULTS In our cohort, no side effect related to fluorescein occurred; all tumors presented with an intense or moderate yellow-green enhancement, and fluorescein was judged fundamental in distinguishing tumors from viable tissue in 7 of 9 cases. Gross total resection or near-total resection (i.e., a residual tumor volume <1.5 cm3) was achieved in 8 patients. The review explored the different techniques and surgical interpretations as well as surgical radicality; we did not find a homogenous protocol for fluorescein injection in the published articles. Fluorescence appeared moderate or intense in almost all cases, with a high percentage of usefulness and consensual achievement of a high rate of gross total resection. CONCLUSIONS Based on these results, we can infer that fluorescein-guided surgical resection is a safe and valuable method for patients with MB.
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Affiliation(s)
- Jacopo Falco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy.
| | - Emanuele Rubiu
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Francesco Restelli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Elio Mazzapicchi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Emanuele La Corte
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy; Department of Neurosurgery, Experimental Microsurgical Laboratory, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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Lee SM, Yoon K, Lee S, Ryu SY, Kim KG. Multi-Asymmetric Irradiation Method Using a Ring Array to Obtain an Emission-Capable LED Beam Power Effect to Observe Cancer Removal Status in a Surgical Microscope. Diagnostics (Basel) 2023; 13:3482. [PMID: 37998618 PMCID: PMC10670550 DOI: 10.3390/diagnostics13223482] [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] [Received: 08/21/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 11/25/2023] Open
Abstract
The light emitting diodes (LEDs) used in surgical fluorescence microscopes have weak power, to induce fluorescence emission. The LED induces fluorescence emission throughout a lesion due to its large beam width; however, the beam irradiation intensity is not uniform within the beam width, resulting in a fluorescence emission induction difference. To overcome this problem, this study proposes an asymmetric irradiation array for supplying power uniformly throughout the beam width of the LED and increasing the intensity of the LED. To increase the irradiation power of the LEDs, a multi-asymmetric irradiation method with a ring-type array structure was used. The LED consisted of eight rings, and the space between the LEDs, the placement position, and the placement angle were analyzed to devise an experimental method using 3D printing technology. To test the irradiation power of the LED, the working distance (WD) between the LED and target was 30 cm. The bias voltage of the LED for irradiating the light source was 5.0 V and the measured power was 4.63 mW. The brightness (lux) was 1153 lx. Consequently, the LED satisfied the fluorescence emission induction conditions. The diameter of the LED-irradiated area was 9.5 cm. Therefore, this LED could be used to observe fluorescent emission-guided lesions. This study maximized the advantages of LEDs with optimal conditions for fluorescence emission by increasing the beam width, irradiation area, and energy efficiency, using a small number of LEDs at the maximum WD. The proposed method, optimized for fluorescence expression-induced surgery, can be made available at clinical sites by mass producing them through semiconductor processes.
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Affiliation(s)
- Seon Min Lee
- Department of Nursing, College of Nursing, 191 Hambakmoero, Yeonsu-gu, Incheon 21936, Republic of Korea;
- Medical Devices R&D Center, Gachon University Gil Medical Center, 21, 774 Beon-gil, Namdong-daero Namdong-gu, Incheon 21565, Republic of Korea; (K.Y.); (S.L.); (S.Y.R.)
- Department of Biomedical Engineering, College of Health Science & Medicine, Gachon University, 1342 Seongnamdaero, Sujeong-gu, Seongnam-si 13120, Gyeonggi-do, Republic of Korea
| | - Kicheol Yoon
- Medical Devices R&D Center, Gachon University Gil Medical Center, 21, 774 Beon-gil, Namdong-daero Namdong-gu, Incheon 21565, Republic of Korea; (K.Y.); (S.L.); (S.Y.R.)
- Department of Biomedical Engineering, College of Health Science & Medicine, Gachon University, 1342 Seongnamdaero, Sujeong-gu, Seongnam-si 13120, Gyeonggi-do, Republic of Korea
| | - Sangyun Lee
- Medical Devices R&D Center, Gachon University Gil Medical Center, 21, 774 Beon-gil, Namdong-daero Namdong-gu, Incheon 21565, Republic of Korea; (K.Y.); (S.L.); (S.Y.R.)
- Department of Biomedical Engineering, College of Health Science & Medicine, Gachon University, 1342 Seongnamdaero, Sujeong-gu, Seongnam-si 13120, Gyeonggi-do, Republic of Korea
| | - Seung Yeob Ryu
- Medical Devices R&D Center, Gachon University Gil Medical Center, 21, 774 Beon-gil, Namdong-daero Namdong-gu, Incheon 21565, Republic of Korea; (K.Y.); (S.L.); (S.Y.R.)
- Department of Biomedical Engineering, College of Health Science & Medicine, Gachon University, 1342 Seongnamdaero, Sujeong-gu, Seongnam-si 13120, Gyeonggi-do, Republic of Korea
- Department of Biohealth & Medical Engineering Major, Gachon University, 1342 Seongnamdaero, Sujeong-gu, Seongnam-si 13120, Gyeonggi-do, Republic of Korea
| | - Kwang Gi Kim
- Medical Devices R&D Center, Gachon University Gil Medical Center, 21, 774 Beon-gil, Namdong-daero Namdong-gu, Incheon 21565, Republic of Korea; (K.Y.); (S.L.); (S.Y.R.)
- Department of Biomedical Engineering, College of Health Science & Medicine, Gachon University, 1342 Seongnamdaero, Sujeong-gu, Seongnam-si 13120, Gyeonggi-do, Republic of Korea
- Department of Health Sciences and Technology, Gachon Advanced Institute for Health Sciences and Technology (GAIHST), Gachon University, 155 Gaetbeol-ro, Yeonsu-gu, Incheon 21999, Republic of Korea
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Di Rocco F, de Laurentis C. Focus session on sodium fluorescein in pediatric oncological neurosurgery. Childs Nerv Syst 2023; 39:1449-1450. [PMID: 37160434 DOI: 10.1007/s00381-023-05957-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/07/2023] [Indexed: 05/11/2023]
Abstract
Many tools and techniques have been developed to obtain maximal safe tumoral resection in neurosurgery. Fluorescent dyes, including sodium fluorescein, have become also part of this armamentarium to localize the lesion and its boundaries peroperatively. Considering its alleged safety profile and its ability to diffuse in areas of altered blood-brain barrier, a typical characteristic of a number of both benign and malignant pediatric tumors, sodium fluorescein may appear an ideal candidate as intraoperative adjunct in pediatric neurosurgery. Nevertheless, a definitive role of this dye in children has not been established yet, and the reports on the pediatric population remain scarce. For this reason, we propose focusing on the use of sodium fluorescein in pediatric oncological neurosurgery by collecting articles reporting the result of the application of the technique in the management of intracranial pediatric tumors.
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Affiliation(s)
- Federico Di Rocco
- Pediatric Neurosurgery, Université Claude Bernard, Lyon 1 and Hôpital femme Mère Enfant, 59 bd Pinel, Lyon, France.
| | - Camilla de Laurentis
- Pediatric Neurosurgery, Université Claude Bernard, Lyon 1 and Hôpital femme Mère Enfant, 59 bd Pinel, Lyon, France
- Università degli Studi di Milano Bicocca, Milano, Italy
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Alcazar P, Avedillo A, Vazquez S, Lopez LB, Fustero D, Moles J, Gonzalez L, Orduna J. The usefulness of intraoperative sodium fluorescein in the surgical treatment of relapsed high-grade brain tumors in pediatric patients. Childs Nerv Syst 2023; 39:1501-1507. [PMID: 36961584 DOI: 10.1007/s00381-023-05930-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/17/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE We report the usefulness of intraoperative sodium fluorescein (SF) in the surgical treatment of relapsed high-grade brain tumors in pediatric neurosurgery. METHODS We describe our protocol for intraoperative SF and three cases of patients between 5 and 11 years diagnosed and surgically treated for relapsed high-grade brain tumors using SF. RESULTS The 560-nm microscope filter enables the use of low doses of this fluorochrome. A dose of 3 mg/kg of patient weight of 10% SF, administered intravenously, is safe and effective in children. The effect of SF was immediate, providing a clear margin between the tumor and healthy tissue, which enabled good tumor resection. We observed no adverse effects in the postoperative period, and the patients evolved satisfactorily. CONCLUSIONS To the best of our knowledge, we describe for the first time the use of fluorescein in reoperations of relapsed high-grade brain tumors in childhood with promising results. Using SF in children is a safe, affordable, and effective technique that offers an excellent intraoperative image, being a feasible option to improve oncological resection. This study is one of the few that uses SF in pediatric neurosurgery, where it could be very beneficial.
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Affiliation(s)
- Paula Alcazar
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain.
| | - Amanda Avedillo
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Silvia Vazquez
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Laura B Lopez
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - David Fustero
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Jesus Moles
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Luis Gonzalez
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Javier Orduna
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
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Intraoperative Fluorescein Sodium in Pediatric Neurosurgery: A Preliminary Case Series from a Singapore Children’s Hospital. NEUROSCI 2023. [DOI: 10.3390/neurosci4010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
(1) Background: Fluorescein sodium (Na-Fl) has been described as a safe and useful neurosurgical adjunct in adult neurooncology. However, its use has yet to be fully established in children. We designed a study to investigate the use of intraoperative Na-Fl in pediatric brain tumor surgery. (2) Methods: This is a single-institution study for pediatric brain tumor patients managed by the Neurosurgical Service, KK Women’s and Children’s Hospital. Inclusion criteria consists of patients undergoing surgery for suspected brain tumors from 3 to 19 years old. A predefined intravenous dose of 2 mg/kg of 10% Na-Fl is administered per patient. Following craniotomy, surgery is performed under alternating white light and YELLOW-560 nm filter illumination. (3) Results: A total of 21 patients with suspected brain tumours were included. Median age was 12.1 years old. For three patients (14.3%), there was no significant Na-Fl fluorescence detected and their final histologies reported a cavernoma and two radiation-induced high grade gliomas. The remaining patients (85.7%) had adequate intraoperative fluorescence for their lesions. No adverse side effects were encountered with the use of Na-Fl. (4) Conclusions: Preliminary findings demonstrate the safe and efficacious use of intraoperative Na-Fl for brain tumors as a neurosurgical adjunct in our pediatric patients.
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Ott C, Proescholdt M, Friedrich M, Hoehne J, Rosengarth K, Schmidt NO, Schebesch KM. The use of the sodium fluorescein and YELLOW 560 nm filter for the resection of pediatric posterior fossa lesions. Childs Nerv Syst 2022; 39:1495-1500. [PMID: 36527464 DOI: 10.1007/s00381-022-05798-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE This study aimed to verify the feasibility, safety, and benefit of using fluorescein sodium (FL) and a YELLOW 560 nm filter in posterior fossa tumors in children. METHODS All cases of pediatric posterior fossa tumors that have undergone surgery using fluorescein (2018-2022) have been included and were examined retrospectively. In those cases where resection of the tumor was planned, a blinded neuroradiologist distinguished gross total resection and subtotal resection according to the postoperative MRI findings. The surgical report and medical files were reviewed regarding the intraoperative staining grade and adverse events. The grade of fluorescent staining of the targeted lesion was assessed as described in the surgical reports. The screening was conducted for any reference to the degree of fluorescent staining: "intense," "medium," "slight," and "no staining." RESULTS 19 cases have been included. In 14 cases, a complete resection was initially intended. In 11 of these cases, a gross total resection could be achieved (78.6%). Staining was described as intense in most cases (58.8%). Except for yellow-colored urine, no side effects obviously related to FL were found throughout the observation period. CONCLUSION In combination with a specific filter, FL is a reliable, safe, and feasible tool in posterior fossa surgery in children.
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Affiliation(s)
- Christian Ott
- Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany.
| | - Martin Proescholdt
- Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Monika Friedrich
- Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Julius Hoehne
- Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | | | - Nils-Ole Schmidt
- Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
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Falco J, Broggi M, Schiariti M, Vetrano IG, Esposito S, Ferroli P, Acerbi F. The role of sodium fluorescein in pediatric supratentorial intra-axial tumor resection: new insights from a monocentric series of 33 consecutive patients. Childs Nerv Syst 2022; 39:1463-1471. [PMID: 36520160 DOI: 10.1007/s00381-022-05764-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Surgical resection represents the mainstay of treatment, in pediatric central nervous system (CNS) tumors, and aggressive resection correlates with prognosis for several histotypes. Sodium fluorescein (SF), a green, water-soluble dye, is used as neurosurgical fluorescent tracer thanks to its property to accumulate in cerebral regions of blood-brain barrier disruption, acting as a valid tool to improve the extent of resection in tumors enhancing at preoperative MRI. Brain neoplasms represent a heterogeneous group of tumors in the pediatric age, constituting the most common solid cancers; they typically show a varying degree of contrast enhancement on MRI. MATERIALS AND METHODS In March 2016, the authors started a prospective, observational trial to evaluate intraoperative fluorescence's characteristics of CNS tumors, the percentage of extent of resection, thanks to fluorescein aid, and side effects related to fluorescein administration. This report is based on a retrospective analysis of a group of 33 consecutive pediatric patients harboring a supratentorial lesion. RESULTS In 17 of 33 (51.5%) procedures, fluorescence was reported as intense; in 14 of 33 (42.4%), moderate; and in 2 of 33 (6.1%), slight. Intraoperative fluorescence corresponds to preoperative-MRI-documented contrast enhancement. In 28 of 33 (84.8%) surgical procedures, SF was considered useful; in 2 of 33 (6.1%), partial useful; and in 3 of 33 (9.1%), not essential because the tumor was already recognizable. No adverse effect to SF administration was registered. CONCLUSION Fluorescein-guided surgery with a dedicated filter on the microscope is a safe and effective technique to improve visualization and resection of different pediatric brain tumors.
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Affiliation(s)
- Jacopo Falco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Ignazio Gaspare Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Silvia Esposito
- Developmental Neurology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy.
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de Laurentis C, Bteich F, Beuriat PA, Mottolese C, Giussani C, Szathmari A, Vinchon M, Di Rocco F. Sodium fluorescein in pediatric neurosurgery: a systematic review with technical considerations and future perspectives. Childs Nerv Syst 2022; 39:1451-1462. [PMID: 36459209 DOI: 10.1007/s00381-022-05772-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Sodium fluorescein (SF) is routinely used in several centers as a valid intraoperative adjunct in adult oncological neurosurgery. Its use in pediatric neurosurgery is increasing, although its role is not yet well-defined in children. We reviewed the current literature in order to evaluate the use of SF in children with CNS and PNS lesions. METHODS For this systematic review, we searched PubMed, Scopus, and Embase databases, and forward and backward citations for studies published between database inception and July 31st, 2022. We included any article type or congress abstract adding at least a new case, without restrictions of language or publication status, concerning the use of SF in neurosurgical procedures in patients under 18 years of age. We excluded studies concerning purely vascular cases and cerebrospinal fluid leaks. RESULTS Of 4094 records identified, 19 articles were eligible and included for further analysis. As per July 31st, 2022, at least 119 patients aged from 11 months to 17.9 years underwent surgery with SF. No serious adverse events were reported. A large variety of tumor types was operated, in most cases resected under the specific YELLOW 560 nm filter after a low-dose SF injection (2-5 mg/kg) at the end of anesthesia induction. SF was reported particularly useful in gangliogliomas and pilocytic astrocytomas. DISCUSSION/CONCLUSION Given its easy-to-use profile, low cost, and safety, SF seems to be a feasible and valid adjunct in the pediatric population when aiming at individuating a biopsy target or maximizing extent of resection, particularly in some tumor types. Further studies are required to strengthen the evidence on its impact on outcomes.
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Affiliation(s)
- Camilla de Laurentis
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France. .,Department of Medicine and Surgery, Università degli Studi di Milano Bicocca, Milan, Italy.
| | - Fred Bteich
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France
| | | | - Carmine Mottolese
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France
| | - Carlo Giussani
- Department of Medicine and Surgery, Università degli Studi di Milano Bicocca, Milan, Italy.,Neurosurgery Unit, San Gerardo Hospital, Monza, Italy
| | | | - Matthieu Vinchon
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France
| | - Federico Di Rocco
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France.,Department of Medicine and Surgery, Université Claude Bernard Lyon I, Lyon, France
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Biopsy of paediatric brainstem intrinsic tumours: Experience from a Singapore Children’s Hospital. J Clin Neurosci 2022; 106:8-13. [DOI: 10.1016/j.jocn.2022.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/30/2022] [Indexed: 11/15/2022]
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Sodium fluorescein in pediatric oncological neurosurgery: a pilot study on 50 children. Childs Nerv Syst 2022; 39:1473-1484. [PMID: 36454309 DOI: 10.1007/s00381-022-05765-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/15/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Sodium fluorescein (SF) is currently considered a valid intraoperative adjunct in the resection of high-grade brain lesions in adults. Experiences in pediatric groups and in low-grade gliomas and other low-grade lesions are still limited in literature, and subjective evaluation of fluorescence is still a limitation. MATERIAL AND METHODS This study retrospectively reviewed all patients with brain or spine lesions operated on from September 2021 to July 2022 in the Pediatric Neurosurgery Unit of Hôpital Femme Mère Enfant, Lyon, who had received 5 mg/kg of 10%. Surgery was performed using a YELLOW560 filter at crucial times. At the end of surgery, the first operator completed a questionnaire, including his opinion on whether SF had been useful in tumor resection, recorded as a binary variable. Post hoc, surgical images were reviewed using ImageJ, an open-source Java image processing platform. In order to compare independent discrete variables, we applied the Student's t test, and we applied the Chi-square or Fisher exact test for binary variables. A threshold of p < 0.05 was set for statistical significance. RESULTS We included 50 pediatric patients (0.2-17.6 years old). Forty/50 lesions showed SF uptake (80%). The differentiation between healthy and affected tissue, thanks to SF, subjectively evaluated by the surgeon, had as objective counterpart the statistically significant higher brightness of green in lesions, registered by the software (p < 0.001). SF overall allowed a good differentiation in 33/50 lesions, and overall utility of SF has been noted in 67% of them. When specifically considering gliomas, overall utility reached 75%. CONCLUSION SF is a feasible, safe, and useful intraoperative adjunct in pediatric neurosurgery. In particular, it seems to have a promising role in some low-grade infiltrating glial tumors. The subjective evaluation of fluorescence seems to be reliable with respect to image analyses software.
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da Costa MDS, Vaz HHS, Silva NA, Dastoli PA, Nicácio JM, Malveira AS, Flores EIB, Cavalheiro S. Fluorescein-guided resection for pediatric low-grade gliomas: institutional experience on two cases and a narrative literature review. Childs Nerv Syst 2022; 39:1485-1493. [PMID: 36454311 DOI: 10.1007/s00381-022-05773-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/23/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE Low-grade gliomas compose 30% of pediatric central nervous system tumors and outcomes of disease-free progression, and survival is directly correlated to the extent of resection. The use of sodium fluorescein (Na-Fl) is an intraoperative method in the localization of tumor cells in adult patients to optimize resection. Our purpose is to describe the use of Na-Fl in pediatric low-grade gliomas and its outcomes. METHODS Patients under 18 years of age with low-grade gliomas at the author's institution underwent resection with the use of Na-Fl, with review of preoperative imaging findings, intraoperative results, and follow-up. Then, a comprehensive, narrative literature review of the use of Na-Fl in pediatric low-grade glioma was performed. RESULTS Our single-institution use of Na-Fl in pediatric patients with suspected low-grade glioma demonstrated excellent results of intraoperative enhancement of tumor cells as well as gross total resection. The literature demonstrated 84% Na-Fl staining and 59.2% of gross total resection in pediatric low-grade gliomas with few small case studies, a range of reported findings, and few side effects. CONCLUSION Na-Fl has a promising use in low-grade glioma resection in the pediatric patient population. Further research is warranted, such as randomized controlled studies, to assess Na-Fl as a potential tool in improving resection and long-term favorable outcomes.
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Affiliation(s)
- Marcos Devanir Silva da Costa
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
- Division of Neurosurgery, Instituto de Oncologia Pediatrica (IOP/GRAACC), Sao Paulo, SP, Brazil
| | | | - Nicole A Silva
- Department of Neurosurgery, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Patricia Alessandra Dastoli
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
- Division of Neurosurgery, Instituto de Oncologia Pediatrica (IOP/GRAACC), Sao Paulo, SP, Brazil
| | - Jardel Mendonça Nicácio
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
- Division of Neurosurgery, Instituto de Oncologia Pediatrica (IOP/GRAACC), Sao Paulo, SP, Brazil
| | - Adib Saraty Malveira
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
| | | | - Sergio Cavalheiro
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
- Division of Neurosurgery, Instituto de Oncologia Pediatrica (IOP/GRAACC), Sao Paulo, SP, Brazil
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12
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Pediatric Low-Grade Glioma Surgery with Sodium Fluorescein: Efficient Localization for Removal and Association with Intraoperative Pathological Sampling. Diagnostics (Basel) 2022; 12:diagnostics12122927. [PMID: 36552934 PMCID: PMC9777105 DOI: 10.3390/diagnostics12122927] [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: 11/02/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 11/25/2022] Open
Abstract
Low-grade gliomas are among the most common CNS lesions in pediatrics and surgery is often the first-line treatment. Intraoperative tools have been developed to maximize the results of surgery, and in particular dyes such as sodium fluorescein (SF) have been investigated in high-grade adult lesions. The use of SF in pediatric low-grade gliomas is still unclear. We retrospectively reviewed 22 pediatric CNS low-grade gliomas operated on with SF from September 2021 to October 2022. A total of 86% of lesions showed SF uptake, which was helpful intraoperatively (confirmation of initial localization of the tumor, or identification of tumor remnants) in 74% of them. The intraoperative fluorescence seems associated with gadolinium enhancement at the preoperative MRI. Interestingly, the extemporaneous pathological sampling (EPS) was informative in every case showing SF uptake, whereas in cases without SF uptake, the EPS was non-informative, although the tissue was later confirmed as pathological. These findings highlight the interest of SF for perioperative diagnosis of tumor tissue and may suggest in which cases the differentiation of tumor-healthy tissue could be especially blurred, posing difficulties for the pathologist.
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Ahrens LC, Krabbenhøft MG, Hansen RW, Mikic N, Pedersen CB, Poulsen FR, Korshoej AR. Effect of 5-Aminolevulinic Acid and Sodium Fluorescein on the Extent of Resection in High-Grade Gliomas and Brain Metastasis. Cancers (Basel) 2022; 14:cancers14030617. [PMID: 35158885 PMCID: PMC8833379 DOI: 10.3390/cancers14030617] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Surgery is essential in the treatment of high-grade gliomas (HGG) and gross total resection (GTR) is known to increase the overall survival and progression-free survival. Several studies have shown that fluorescence-guided surgery with 5-aminolevulinic acid (5-ALA) increases GTR considerably compared to white light surgery (65% vs. 36%). In recent years, sodium fluorescein (SF) has become an increasingly popular agent for fluorescence-guided surgery due to numerous utility benefits compared to 5-ALA, including lower cost, non-toxicity, easy administration during surgery and a wide indication range covering all contrast-enhancing lesions with disruption of the blood-brain barrier in the CNS. However, currently, SF is an off-label agent and the level of evidence for use in HGG surgery is inferior compared to 5-ALA. Here, we give an update and review the latest literature on fluorescence-guided surgery with 5-ALA and SF for brain tumors with emphasis on fluorescence-guided surgery in HGG and brain metastases. Further, we assess the advantages and disadvantages of both fluorophores and discuss their future perspectives.
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Affiliation(s)
- Lasse Cramer Ahrens
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, J618, DK8200 Aarhus, Denmark; (M.G.K.); (N.M.)
- Correspondence: (L.C.A.); (A.R.K.); Tel.: +45-(20)-254418 (L.C.A.)
| | - Mathias Green Krabbenhøft
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, J618, DK8200 Aarhus, Denmark; (M.G.K.); (N.M.)
| | - Rasmus Würgler Hansen
- Department of Neurosurgery, Odense University Hospital, DK5000 Odense, Denmark; (R.W.H.); (C.B.P.); (F.R.P.)
| | - Nikola Mikic
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, J618, DK8200 Aarhus, Denmark; (M.G.K.); (N.M.)
- Department of Clinical Medicine, Aarhus University, Incuba Skejby, Building 2, Palle Juul-Jensens Boulevard 82, J618, DK8200 Aarhus, Denmark
| | - Christian Bonde Pedersen
- Department of Neurosurgery, Odense University Hospital, DK5000 Odense, Denmark; (R.W.H.); (C.B.P.); (F.R.P.)
| | - Frantz Rom Poulsen
- Department of Neurosurgery, Odense University Hospital, DK5000 Odense, Denmark; (R.W.H.); (C.B.P.); (F.R.P.)
| | - Anders Rosendal Korshoej
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, J618, DK8200 Aarhus, Denmark; (M.G.K.); (N.M.)
- Department of Clinical Medicine, Aarhus University, Incuba Skejby, Building 2, Palle Juul-Jensens Boulevard 82, J618, DK8200 Aarhus, Denmark
- Correspondence: (L.C.A.); (A.R.K.); Tel.: +45-(20)-254418 (L.C.A.)
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Fluorescein-Guided Resection of High Grade Gliomas: A Meta-Analysis. World Neurosurg 2021; 155:181-188.e7. [PMID: 34492388 DOI: 10.1016/j.wneu.2021.08.126] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/27/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND High-grade gliomas (HGGs) have a poor prognosis despite current standard of care of surgery, chemotherapy, and radiation therapy. Achieving gross total resection (GTR) has been found to prolong survival in these patients. Intraoperative fluorescent agents are often used to aid in the resection of HGGs. One commonly used fluorescent agent is fluorescein sodium, which is U.S. Food and Drug Administration-approved for ocular surgeries and has a better side effect profile and is less costly than 5-aminolevulinic acid (5-ALA). In this meta-analysis, we provide statistical evidence of the efficacy in using fluorescein for HGG resection. METHODS Following the PRISMA framework, we assessed 119 reports from PubMed, Medline (Ovid), and BIOSIS Citation Index and found 21 eligible studies for meta-analysis, assessing the rates of GTR with fluorescein-guided resection of HGGs. RESULTS A pooled cohort of 336 patients underwent fluorescein-guided HGG resection with a GTR rate of 81% (95% confidence interval 73%-89%; P < 0.001). Ten case-controlled studies were analyzed, showing a 29.5% increase in GTR rate in the fluorescein group compared with non-fluorescein-guided surgeries. CONCLUSIONS This meta-analysis shows that fluorescein-guided surgery improves GTR rates of HGGs when compared with non-fluorescence guided surgery and has similar GTR rates when compared with reported 5-ALA-guided resection rates.
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Markosian C, Mazzola CA, Tomycz LD. Sodium Fluorescein-Guided Gross Total Resection of Pediatric Exophytic Brainstem Glioma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E146-E147. [PMID: 33313758 DOI: 10.1093/ons/opaa357] [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: 05/22/2020] [Accepted: 08/12/2020] [Indexed: 11/13/2022] Open
Abstract
Brainstem gliomas comprise 10% to 20% of pediatric intracranial tumors.1 Gross total resection is associated with the greatest long-term survival.1 However, due to the eloquence of surrounding brain tissue, an aggressive resection is not always achievable and can be associated with significant risk.2 Sodium fluorescein can be used to help differentiate between tumor and normal tissue.3,4 In this operative video, we demonstrate the step-by-step technique to utilize fluorescence in surgically resecting an exophytic glioma arising from the midbrain in a 16-yr-old male. Technical nuances are highlighted in this operative video, including the use of the YELLOW 560 (Zeiss) filter to differentiate fluorescent tumor from normal tissue as well as strategic splitting of the tentorium to expose the supratentorial component of the tumor. A decrease in motor potentials of the right leg during the case did not translate into neurological worsening postoperatively; at 3-mo follow-up, the patient attests to better strength and coordination on his affected side. In summary, sodium fluorescein can be used as a critical adjunctive tool for successful surgery in the case of a brainstem tumor. Alternatives to this procedure included gross total resection with 5-aminolevulinic acid, subtotal resection with chemotherapy, and active monitoring, but were not chosen due to their limitations in this clinical case.5-7 Appropriate patient consent was obtained to perform this procedure and present this clinical case and surgical video for academic purposes.
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Affiliation(s)
- Christopher Markosian
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | | | - Luke D Tomycz
- New Jersey Pediatric Neuroscience Institute, Morristown, New Jersey
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16
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Erdman CM, Christie C, Iqbal MO, Mazzola CA, Tomycz L. The utilization of sodium fluorescein in pediatric brain stem gliomas: a case report and review of the literature. Childs Nerv Syst 2021; 37:1753-1758. [PMID: 32780271 DOI: 10.1007/s00381-020-04857-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/06/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION A major challenge in the surgical resection of brainstem tumors is distinguishing tumor from normal tissue. One approach for addressing this problem is the use of fluorescent tracers such as sodium fluorescein (NaFl). NaFl disseminates through a disruption in the blood-brain barrier (BBB) and accumulates in the extracellular space of brain tumors. Intraoperative fluorescence microscopy can be performed to identify tumor tissue and avoid damage to adjacent, normal tissue. Here, we present the case of a 16-year-old male who underwent a left retrosigmoid craniotomy with splitting of the tentorium to remove a large exophytic brainstem tumor involving the cerebellar peduncle and with superior extension into the midbrain and thalamus. OBJECTIVES The primary objective of this study was to investigate the effectiveness of sodium fluorescein as an intraoperative technique and evaluate its potential benefit for resection of tumors in eloquent regions in the pediatric population. To do so, we focused on a case study approach; however, we also performed a literature review and evaluated different intraoperative fluorescent techniques and their benefits for tumor resection. METHODS We performed a literature search using PubMed and Google Scholar by the key words "sodium fluorescein," "brain stem tumor," and "central nervous system neoplasms." Twenty-nine articles including both pediatric and adult populations were selected for analysis and qualitative review. RESULTS In this case study, sodium fluorescein helped the surgeons to identify and obtain a gross total resection of a large brainstem tumor. The marker was especially helpful for discerning the inferior pole of the tumor buried inconspicuously in cerebellar tissue. We evaluate different fluorescent tracers, 5-ALA and ICG, and discuss their application and benefits in tumor resection surgery. We present different cases that found sodium fluorescein to be helpful in achieving a gross total resection. CONCLUSION The application of sodium fluorescein proved to be a safe and effective technique for the resection of brain stem tumors as shown in this case study. It helped to expose concealed areas and illuminate the tumor capsule. Further studies should test the clinical use of sodium fluorescein on brain stem tumor resection.
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Affiliation(s)
- Cameron M Erdman
- Vassar College, 124 Raymond Avenue, Poughkeepsie, NY, 12603, USA
| | - Catherine Christie
- New Jersey Pediatric Neuroscience Institute, 131 Madison Avenue, Morristown, NJ, 07960, USA
| | - M Omar Iqbal
- Rutgers University, 90 Bergen Street, Newark, NJ, 07101, USA
| | - Catherine A Mazzola
- New Jersey Pediatric Neuroscience Institute, 131 Madison Avenue, Morristown, NJ, 07960, USA
| | - Luke Tomycz
- New Jersey Pediatric Neuroscience Institute, 131 Madison Avenue, Morristown, NJ, 07960, USA.
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Pedro MT, Grübel N, Durner G, Pala A, Wirtz CR, Koenig RW. Intraoperative Sodium-Fluorescence Imaging in Peripheral Nerve Sheath Tumors (PNST)-A New Additional Promising Diagnostic Tool. Front Oncol 2021; 11:655392. [PMID: 33768010 PMCID: PMC7985443 DOI: 10.3389/fonc.2021.655392] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/12/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Through the development and implementation of specific fluorophore filters to microscopes in 2012, sodium fluorescein (SF) is currently experiencing a remarkable renaissance in neurosurgery. The present study examines its intraoperative application during surgical removal of peripheral nerve sheath tumors (PNST) and metastases. Methods: This single-center study includes 10 cases of benign and malignant tumors as well as metastases of peripheral nerves (in total 11 PNST). Their surgical resections were all performed under microscope-based fluorescence with SF, which was administered intravenously (0.5-1.0 mg/kg body weight) during anesthesia induction. Microsurgical tumor removals were filmed and the collected data were retrospectively analyzed via ImageJ. Results: Microsurgical tumor preparation was possible under the usage of fluorophore filter. In seven histological confirmed schwannoma (n = 6 patients) tissue differentiation between tumor mass and not involved fascicles was statistically significant for the colors green and red. Schwannoma maximum mean for green reached 254.7 pixel and 179.4 pixel for red, whereas passing healthy fascicles revealed a maximum mean for green 94.91 and for red 120.76 pixel. One case of neurofibroma achieved lower amount of pixel. Similar to schwannoma, the two MPNST cases showed a strong homogeneous fluorescence (max. mean green 215 pixel and red 124.51) involving the whole nerve segment. Subcutaneous tumor remnants were visualized and therefore resected. Via fascicular nerve biopsy a B-cell lymphoma of the tibial nerve could be detected. SF led to variable stain intensities in single fascicles. The resected fascicle revealed a max mean green of 100.54 pixel, whereas surrounding fascicles came up with max. mean green of 63.0 pixel. Conclusions: Intraoperative SF visualization for PNST is feasible and of low risk. During resection of benign PNST, enhanced tissue differentiation between affected and not affected nerve segments is very useful. Tumor remnants can be detected safely and effectively. Its application during resection of malignant PNST is limited. Due to the infiltrative nature of those tumors, intraneural tissue differentiation is not possible. "Fluorescence-guided" biopsy can be regarded as an additional advantage in PNST surgery. Due to the encouraging experience in our institution SF was established as standard visualization tool in PNST surgery.
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Affiliation(s)
- Maria Teresa Pedro
- Klinik für Neurochirurgie, Medizinische Fakultät, Universität Ulm, Ulm, Germany
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Olguner SK, Arslan A, Açık V, İstemen İ, Can M, Gezercan Y, Ökten Aİ. Sodium Fluorescein for Spinal Intradural Tumors. Front Oncol 2021; 10:618579. [PMID: 33585245 PMCID: PMC7877540 DOI: 10.3389/fonc.2020.618579] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/11/2020] [Indexed: 01/11/2023] Open
Abstract
Technological innovations in spinal intradural tumor surgery simplify treatment. Surgical treatment of cranial benign and malignant pathologies under microscope with sodium (Na)-fluorescein guidance has often been reported, but few studies have focused on spinal intradural tumors. We aimed to investigate the usefulness of Na-fluorescein under yellow filter in intradural spinal tumor surgery by retrospectively reviewing cases involving intramedullary and extramedullary tumors operated under the guidance of Na-fluorescein. Forty-nine adult patients with a diagnosis of spinal intradural tumor operated under a yellow filter (560 nm) microscope using Na-fluorescein dye were included in the study. Demographic data, such as age and sex, neurological status, extent of tumor resection, histopathological diagnosis, Na-fluorescein staining pattern, and its usefulness during surgery were noted and statistically analyzed. Of all recruited patients, 26 women (53.1%) and 23 men (46.9%), were included for analysis. The age range of the patients was 18–64 years, with a mean age of 41.6 ± 13.9. An intradural intramedullary mass was found in 30.6% (n = 15) of the patients, and an intradural extramedullary mass in 69.4% (n: 34). While Na-fluorescein staining was homogeneous in all intradural extramedullary tumors, 73.3% (n: 11) of intradural intramedullary tumors were homogeneous, and 13.3% (n: 2) moderately heterogeneous. In the whole study group, the Na-fluorescein staining pattern was helpful in surgical resection in 47 cases (95.9%). While 34/34 (100%) found it helpful for extramedullary tumors, 13/15 (86.7%) did in intramedullary tumors, and for 2/15 (13.3%) it was not. In conclusion, Na-fluorescein helps in distinguishing tumor from healthy tissue in intradural extramedullary and intramedullary tumor surgery under a yellow filter microscope in most cases, thus providing convenient assistance to surgeons.
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Affiliation(s)
- Semih Kivanc Olguner
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
| | - Ali Arslan
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
| | - Vedat Açık
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
| | - İsmail İstemen
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
| | - Mehmet Can
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
| | - Yurdal Gezercan
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
| | - Ali İhsan Ökten
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
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Kutlay M, Durmaz O, Ozer İ, Kırık A, Yasar S, Kural C, Temiz Ç, Tehli Ö, Ezgu MC, Daneyemez M, Izci Y. Fluorescein Sodium-Guided Neuroendoscopic Resection of Deep-Seated Malignant Brain Tumors: Preliminary Results of 18 Patients. Oper Neurosurg (Hagerstown) 2021; 20:206-218. [PMID: 33047137 DOI: 10.1093/ons/opaa313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/02/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Deep-seated intracranial lesions are challenging to resect completely and safely. Fluorescence-guided surgery (FGS) promotes the resection of malignant brain tumors (MBTs). Classically, FGS is performed using microscope equipped with a special filter. Fluorescence-guided neuroendoscopic resection of deep-seated brain tumors has not been reported yet. OBJECTIVE To evaluate the feasibility, safety, and effectiveness of the fluorescence-guided neuroendoscopic surgery in deep-seated MBTs. METHODS A total of 18 patients with high-grade glioma (HGG) and metastatic tumor (MT) underwent fluorescein sodium (FS)-guided neuroendoscopic surgery. Tumor removal was carried out using bimanual microsurgical techniques under endoscopic view. The degree of fluorescence staining was classified as "helpful" and "unhelpful" based on surgical observation. Extent of resection was determined using magnetic resonance imaging (MRI). Karnofsky Performance Status (KPS) score was used for evaluation of general physical performances of patients. RESULTS A total of 11 patients had HGG, and 7 had MT. No technical difficulty was encountered regarding the use of endoscopic technique. "Helpful" fluorescence staining was observed in 16 patients and fluorescent tissue was completely removed. Postoperative MRI confirmed gross total resection (88.9%). In 2 patients, FS enhancement was not helpful enough for tumor demarcation and postoperative MRI revealed near total resection (11.1%). No complication, adverse events, or side effects were encountered regarding the use of FS. KPS score of patients was improved at 3-mo follow-up. CONCLUSION FS-guided endoscopic resection is a feasible technique for deep-seated MBTs. It is safe, effective, and allows for a high rate of resection. Future prospective randomized studies are needed to confirm these preliminary data.
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Affiliation(s)
- Murat Kutlay
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Ozan Durmaz
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - İlker Ozer
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Alpaslan Kırık
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Soner Yasar
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Cahit Kural
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Çağlar Temiz
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Özkan Tehli
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Mehmet Can Ezgu
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Mehmet Daneyemez
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Yusuf Izci
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
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Vetrano IG, Acerbi F, Falco J, Devigili G, Rinaldo S, Messina G, Prada F, D'Ammando A, Nazzi V. Fluorescein-guided removal of peripheral nerve sheath tumors: a preliminary analysis of 20 cases. J Neurosurg 2021; 134:260-269. [PMID: 31812148 DOI: 10.3171/2019.9.jns19970] [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: 04/05/2019] [Accepted: 09/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Benign peripheral nerve sheath tumors (PNSTs) include mainly schwannomas-the most common tumors arising from peripheral nerves-and neurofibromas. Due to their origin, distinguishing between functional intact nerve and the fibers from whence the PNST arose may not always be easy to perform. The introduction of intraoperative tools to better visualize these tumors could be helpful in achieving a gross-total resection. In this study, the authors present a series of patients harboring PNST in which the surgery was performed under fluorescein guidance. METHODS Between September 2018 and February 2019, 20 consecutive patients with a total of 25 suspected PNSTs underwent fluorescein-guided surgery performed under microscopic view with a dedicated filter integrated into the surgical microscope (YELLOW 560) and with intraoperative monitoring. All patients presented with a different degree of contrast enhancement at preoperative MRI. Fluorescein was intravenously injected after intubation at a dose of 1 mg/kg. Preoperative clinical and radiological data, intraoperative fluorescein characteristics, and postoperative neurological and radiological outcomes were collected and analyzed. RESULTS Six patients were affected by neurofibromatosis or schwannomatosis. There were 14 schwannomas, 8 neurofibromas, 1 myxoma, 1 reactive follicular hyperplasia, and 1 giant cell tumor of tendon sheath. No patient experienced worsening of neurological status after surgery. No side effects related to fluorescein injection were found in this series. Fluorescein allowed an optimal intraoperative distinction between tumor and surrounding nerves in 13 of 14 schwannomas and in all neurofibromas. In 6 neurofibromas and in 1 schwannoma, the final YELLOW 560 visualization showed the presence of small tumor remnants that were not visible under white-light illumination and that could be removed, obtaining a gross-total resection. CONCLUSIONS Fluorescein was demonstrated to be a feasible, safe, and helpful intraoperative adjunct to better identify and distinguish PNSTs from intact functional nerves, with a possible impact on tumor resection, particularly in diffuse neurofibromas.
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Affiliation(s)
- Ignazio G Vetrano
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta
| | - Francesco Acerbi
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta
| | - Jacopo Falco
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta
| | - Grazia Devigili
- 2Neurological Unit 1, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; and
| | - Sara Rinaldo
- 2Neurological Unit 1, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; and
| | - Giuseppe Messina
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta
| | - Francesco Prada
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta
- 3Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Antonio D'Ammando
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta
| | - Vittoria Nazzi
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta
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Ma L, Fei B. Comprehensive review of surgical microscopes: technology development and medical applications. JOURNAL OF BIOMEDICAL OPTICS 2021; 26:JBO-200292VRR. [PMID: 33398948 PMCID: PMC7780882 DOI: 10.1117/1.jbo.26.1.010901] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/04/2020] [Indexed: 05/06/2023]
Abstract
SIGNIFICANCE Surgical microscopes provide adjustable magnification, bright illumination, and clear visualization of the surgical field and have been increasingly used in operating rooms. State-of-the-art surgical microscopes are integrated with various imaging modalities, such as optical coherence tomography (OCT), fluorescence imaging, and augmented reality (AR) for image-guided surgery. AIM This comprehensive review is based on the literature of over 500 papers that cover the technology development and applications of surgical microscopy over the past century. The aim of this review is threefold: (i) providing a comprehensive technical overview of surgical microscopes, (ii) providing critical references for microscope selection and system development, and (iii) providing an overview of various medical applications. APPROACH More than 500 references were collected and reviewed. A timeline of important milestones during the evolution of surgical microscope is provided in this study. An in-depth technical overview of the optical system, mechanical system, illumination, visualization, and integration with advanced imaging modalities is provided. Various medical applications of surgical microscopes in neurosurgery and spine surgery, ophthalmic surgery, ear-nose-throat (ENT) surgery, endodontics, and plastic and reconstructive surgery are described. RESULTS Surgical microscopy has been significantly advanced in the technical aspects of high-end optics, bright and shadow-free illumination, stable and flexible mechanical design, and versatile visualization. New imaging modalities, such as hyperspectral imaging, OCT, fluorescence imaging, photoacoustic microscopy, and laser speckle contrast imaging, are being integrated with surgical microscopes. Advanced visualization and AR are being added to surgical microscopes as new features that are changing clinical practices in the operating room. CONCLUSIONS The combination of new imaging technologies and surgical microscopy will enable surgeons to perform challenging procedures and improve surgical outcomes. With advanced visualization and improved ergonomics, the surgical microscope has become a powerful tool in neurosurgery, spinal, ENT, ophthalmic, plastic and reconstructive surgeries.
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Affiliation(s)
- Ling Ma
- University of Texas at Dallas, Department of Bioengineering, Richardson, Texas, United States
| | - Baowei Fei
- University of Texas at Dallas, Department of Bioengineering, Richardson, Texas, United States
- University of Texas Southwestern Medical Center, Department of Radiology, Dallas, Texas, United States
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Save AV, Gill BJ, D'amico RS, Canoll P, Bruce JN. Fluorescein-guided resection of gliomas. J Neurosurg Sci 2020; 63:648-655. [PMID: 31961117 DOI: 10.23736/s0390-5616.19.04738-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Standard of care in the management of high-grade gliomas includes gross total resection (GTR) followed by treatment with radiation and temozolomide. GTR remains one of the few independent prognostic factors for improved survival in this disease. Sodium fluorescein is an organic fluorophore that has been studied as a surgical adjunct to improve the likelihood of achieving GTR in gliomas. Though sodium fluorescein does not selectively accumulate in glioma cells, it allows for real-time identification of regions of blood brain barrier breakdown, corresponding to the contrast-enhancing cores of high-grade gliomas. In addition to its high predictive value for identifying pathologic tissue, use of fluorescein has been shown to improve rates of GTR. In stereotactic needle biopsies, it helps reduce procedure time by rapidly confirming the presence of diagnostic tissue. Furthermore, in non-enhancing, low-grade gliomas, it labels focal regions of vascular dysregulation that have been correlated with high-grade features. Fluorescein has also been shown to be significantly less expensive than other contemporary surgical adjuncts such as intraoperative ultrasound, intraoperative MRI, and the recently FDA approved fluorophore, 5-aminolevulinic acid (5-ALA). Here, we review the current literature on the effectiveness of fluorescein as a surgical tool in the resection of gliomas.
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Affiliation(s)
- Akshay V Save
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA -
| | - Brian J Gill
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Randy S D'amico
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Peter Canoll
- Department of Neuropathology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jeffrey N Bruce
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
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