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Garufi G, Conti A, Chaurasia B, Cardali SM. Exoscopic versus Microscopic Surgery in 5-ALA-Guided Resection of High-Grade Gliomas. J Clin Med 2024; 13:3493. [PMID: 38930021 PMCID: PMC11205195 DOI: 10.3390/jcm13123493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/07/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Glioma surgery has been remarkably enhanced in the past 2 decades, with improved safety and limited but improved life expectations. The fluorescence-guided resection of high-grade gliomas (HGGs) plays a central role in this sense, allowing a greater extent of resection (EOR). The introduction of exoscopic-guided surgery may be considered in implementing fluorescence techniques over traditional microscopes. We present the application and the advantages of exoscopic-guided surgery compared to microscopic surgery in tumor resection guided by 5-ALA fluorescence in patients with HGGs. Methods: Ten consecutive patients underwent surgery for HGG resection. The surgery was performed via an exoscopic-guided procedure (Olympus ORBEYE) and after the oral administration of Gliolan 5 h before the procedure. During surgery, the procedure shifted to using a microscopic (Kinevo 900, Zeiss) view. The intensity of the fluorescence under the two different procedures was subjectively measured in different picture samples during the surgery on a 1 to 5 (from minimum to maximum) scale. The brightness of the surgical field and the detailing of the anatomy were also analyzed comparatively. Results: Among the ten patients, the histopathological diagnosis was an high-grade glioma in all cases. In nine cases, it was possible to achieve gross total resection. There was no perioperative mortality. The median fluorescence intensity, on a scale of 1-5, was 4.5 in the exoscope group and 3.5 in the microscope group (p < 0.01). Conclusions: The exoscopic-guided surgery adds advantages to traditional fluorescence-guided surgery with 5-aminolevulinic acid. Beyond the important advantage of low cost and the possibility to perform collaborative surgeries, it adds a plain and continuous visualization of the tumor and offers advantages in the surgical field of fluorescence-guided glioma surgery compared to the microscopic-guided one.
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Affiliation(s)
- Giada Garufi
- Department of Neurosurgery, Azienda Ospedaliera Papardo, University of Messina, 98158 Messina, Italy;
| | - Alfredo Conti
- Department of Neurosurgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy;
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Alma Mater Studiorum Università di Bologna, Via Altura 3, 40123 Bologna, Italy
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj 44300, Nepal;
| | - Salvatore Massimiliano Cardali
- Department of Neurosurgery, Azienda Ospedaliera Papardo, University of Messina, 98158 Messina, Italy;
- Department of Biomedical, Dental and Morphological and Functional Imaging, University of Messina, Via Consolare Valeria, 98125 Messina, Italy
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Di Cristofori A, Graziano F, Rui CB, Rebora P, Di Caro D, Chiarello G, Stefanoni G, Julita C, Florio S, Ferlito D, Basso G, Citerio G, Remida P, Carrabba G, Giussani C. Exoscopic Microsurgery: A Change of Paradigm in Brain Tumor Surgery? Comparison with Standard Operative Microscope. Brain Sci 2023; 13:1035. [PMID: 37508967 PMCID: PMC10377370 DOI: 10.3390/brainsci13071035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/01/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The exoscope is a high-definition telescope recently introduced in neurosurgery. In the past few years, several reports have described the advantages and disadvantages of such technology. No studies have compared results of surgery with standard microscope and exoscope in patients with glioblastoma multiforme (GBM). METHODS Our retrospective study encompassed 177 patients operated on for GBM (WHO 2021) between February 2017 and August 2022. A total of 144 patients were operated on with a microscope only and the others with a 3D4K exoscope only. All clinical and radiological data were collected. Progression-free survival (PFS) and overall survival (OS) have been estimated in the two groups and compared by the Cox model adjusting for potential confounders (e.g., sex, age, Karnofsky performance status, gross total resection, MGMT methylated promoter, and operator's experience). RESULTS IDH was mutated in 9 (5.2%) patients and MGMT was methylated in 76 (44.4%). Overall, 122 patients received a gross total resection, 14 patients received a subtotal resection, and 41 patients received a partial resection. During follow-up, 139 (73.5%) patients experienced tumor recurrence and 18.7% of them received a second surgery. After truncation to 12 months, the median PFS for patients operated on with the microscope was 8.82 months, while for patients operated on with the exoscope it was >12 months. Instead, the OS was comparable in the two groups. The multivariable Cox model showed that the use of microscope compared to the exoscope was associated with lower progression-free survival (hazard ratio = 3.55, 95%CI = 1.66-7.56, p = 0.001). CONCLUSIONS The exoscope has proven efficacy in terms of surgical resection, which was not different to that of the microscope. Furthermore, patients operated on with the exoscope had a longer PFS. A comparable OS was observed between microscope and exoscope, but further prospective studies with longer follow-up are needed.
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Affiliation(s)
- Andrea Di Cristofori
- Department of Medicine and Surgery, University of Milano-Bicocca, Ospedale San Gerardo, Piazza Ateneo Nuovo, 120126 Milan, Italy
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori Via G.B. Pergolesi 33, 20900 Monza, Italy
| | - Francesca Graziano
- Bicocca Bioinformatics, Biostatistics and Bioimaging Centre-B4, School of Medicine and Surgery, University of Milano-Bicocca, Piazza Ateneo Nuovo, 120126 Milan, Italy
| | - Chiara Benedetta Rui
- Department of Medicine and Surgery, University of Milano-Bicocca, Ospedale San Gerardo, Piazza Ateneo Nuovo, 120126 Milan, Italy
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori Via G.B. Pergolesi 33, 20900 Monza, Italy
| | - Paola Rebora
- Bicocca Bioinformatics, Biostatistics and Bioimaging Centre-B4, School of Medicine and Surgery, University of Milano-Bicocca, Piazza Ateneo Nuovo, 120126 Milan, Italy
| | - Diego Di Caro
- Department of Medicine and Surgery, University of Milano-Bicocca, Ospedale San Gerardo, Piazza Ateneo Nuovo, 120126 Milan, Italy
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori Via G.B. Pergolesi 33, 20900 Monza, Italy
| | - Gaia Chiarello
- Pathology, Fondazione IRCCS San Gerardo dei Tintori, Via G.B. Pergolesi 33, 20900 Monza, Italy
| | - Giovanni Stefanoni
- Neurology, Fondazione IRCCS San Gerardo dei Tintori, Via G.B. Pergolesi 33, 20900 Monza, Italy
| | - Chiara Julita
- Radiotherapy, Fondazione IRCCS San Gerardo dei Tintori, Via G.B. Pergolesi 33, 20900 Monza, Italy
| | - Santa Florio
- Neuroradiology, Fondazione IRCCS San Gerardo dei Tintori, Via G.B. Pergolesi 33, 20900 Monza, Italy
| | - Davide Ferlito
- Department of Medicine and Surgery, University of Milano-Bicocca, Ospedale San Gerardo, Piazza Ateneo Nuovo, 120126 Milan, Italy
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori Via G.B. Pergolesi 33, 20900 Monza, Italy
| | - Gianpaolo Basso
- Department of Medicine and Surgery, University of Milano-Bicocca, Ospedale San Gerardo, Piazza Ateneo Nuovo, 120126 Milan, Italy
- Neuroradiology, Fondazione IRCCS San Gerardo dei Tintori, Via G.B. Pergolesi 33, 20900 Monza, Italy
| | - Giuseppe Citerio
- Department of Medicine and Surgery, University of Milano-Bicocca, Ospedale San Gerardo, Piazza Ateneo Nuovo, 120126 Milan, Italy
- Neurointensive Care Unit, Department of Neuroscience, Fondazione IRCCS San Gerardo deiTintori, Via G.B. Pergolesi 33, 20900 Monza, Italy
| | - Paolo Remida
- Neuroradiology, Fondazione IRCCS San Gerardo dei Tintori, Via G.B. Pergolesi 33, 20900 Monza, Italy
| | - Giorgio Carrabba
- Department of Medicine and Surgery, University of Milano-Bicocca, Ospedale San Gerardo, Piazza Ateneo Nuovo, 120126 Milan, Italy
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori Via G.B. Pergolesi 33, 20900 Monza, Italy
| | - Carlo Giussani
- Department of Medicine and Surgery, University of Milano-Bicocca, Ospedale San Gerardo, Piazza Ateneo Nuovo, 120126 Milan, Italy
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori Via G.B. Pergolesi 33, 20900 Monza, Italy
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Optimization of novel exoscopic blue light filter during fluorescence-guided resection of Glioblastoma. J Neurooncol 2023; 161:617-623. [PMID: 36745272 DOI: 10.1007/s11060-022-04231-0] [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: 11/30/2022] [Accepted: 12/29/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Operative guidelines and use optimization for new surgical exoscopes are not well described in the literature. In this study, we evaluated use of the ORBEYE (Olympus) surgical exoscope system during 5-ALA fluorescence-guided resection of GBMs to optimize workflow and exoscope settings. METHODS The ORBEYE exoscope system was fitted with a blue light filter for 5-ALA mediated fluorescence-guided surgery (FGS). Intraoperative images were obtained during 5-ALA FGS in 9 patients with primary or recurrent GBM. The exoscope was set up at constant, increasing focal distances from the target tissue, and light source intensity varied. High-resolution 4 K images were captured and analyzed. Comparisons of fluorescence to background were then generated for use optimization. RESULTS Light intensity did not significantly influence tumor fluorescence (P = 0.878). However, focal distance significantly impacted relative fluorescent intensity (P = 0.007). Maximum average fluorescence was seen consistently at a focal length of 220 mm and a light intensity of approximately 75% maximum. Decreasing focal distance from 400 mm to 220 mm significantly increased visualized fluorescence (P = 0.0038). CONCLUSIONS The ORBEYE surgical exoscope system with blue light filter is a powerful imaging tool for 5-ALA FGS in GBM. The ORBEYE blue filter performs optimally at shorter focal distance with moderate light intensity. Similar to microscope systems, decreasing focal distance significantly influences visualized fluorescence.
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