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A Systematic Review of Amino Acid PET Imaging in Adult-Type High-Grade Glioma Surgery: A Neurosurgeon's Perspective. Cancers (Basel) 2022; 15:cancers15010090. [PMID: 36612085 PMCID: PMC9817716 DOI: 10.3390/cancers15010090] [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: 09/30/2022] [Revised: 12/04/2022] [Accepted: 12/13/2022] [Indexed: 12/29/2022] Open
Abstract
Amino acid PET imaging has been used for a few years in the clinical and surgical management of gliomas with satisfactory results in diagnosis and grading for surgical and radiotherapy planning and to differentiate recurrences. Biological tumor volume (BTV) provides more meaningful information than standard MR imaging alone and often exceeds the boundary of the contrast-enhanced nodule seen in MRI. Since a gross total resection reflects the resection of the contrast-enhanced nodule and the majority of recurrences are at a tumor's margins, an integration of PET imaging during resection could increase PFS and OS. A systematic review of the literature searching for "PET" [All fields] AND "glioma" [All fields] AND "resection" [All fields] was performed in order to investigate the diffusion of integration of PET imaging in surgical practice. Integration in a neuronavigation system and intraoperative use of PET imaging in the primary diagnosis of adult high-grade gliomas were among the criteria for article selection. Only one study has satisfied the inclusion criteria, and a few more (13) have declared to use multimodal imaging techniques with the integration of PET imaging to intentionally perform a biopsy of the PET uptake area. Despite few pieces of evidence, targeting a biologically active area in addition to other tools, which can help intraoperatively the neurosurgeon to increase the amount of resected tumor, has the potential to provide incremental and complementary information in the management of brain gliomas. Since supramaximal resection based on the extent of MRI FLAIR hyperintensity resulted in an advantage in terms of PFS and OS, PET-based biological tumor volume, avoiding new neurological deficits, deserves further investigation.
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Surgical Treatment of Glioblastoma: State-of-the-Art and Future Trends. J Clin Med 2022; 11:jcm11185354. [PMID: 36143001 PMCID: PMC9505564 DOI: 10.3390/jcm11185354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/17/2022] [Accepted: 08/31/2022] [Indexed: 11/22/2022] Open
Abstract
Glioblastoma (GBM) is a highly aggressive disease and is associated with poor prognosis despite treatment advances in recent years. Surgical resection of tumor remains the main therapeutic option when approaching these patients, especially when combined with adjuvant radiochemotherapy. In the present study, we conducted a comprehensive literature review on the state-of-the-art and future trends of the surgical treatment of GBM, emphasizing topics that have been the object of recent study.
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Suero Molina E, Hellwig SJ, Walke A, Jeibmann A, Stepp H, Stummer W. Development and validation of a triple-LED surgical loupe device for fluorescence-guided resections with 5-ALA. J Neurosurg 2022; 137:582-590. [PMID: 34972076 DOI: 10.3171/2021.10.jns211911] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 10/14/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Fluorescence-guided resections performed using 5-aminolevulinic acid (5-ALA) have been studied extensively using the BLUE400 system. The authors introduce a triple-light-emitting diode (LED) headlight/loupe device for visualizing fluorescence, and compare this to the BLUE400 gold standard in order to assure similar and not more or less sensitive protoporphyrin-IX visualization. METHODS The authors defined the spectral requirements for a triple-LED headlight/loupe device for reproducing the xenon-based BLUE400 module. The system consisted of a white LED (normal surgery), a 409-nm LED for excitation, a 450-nm LED for background illumination, and appropriate observation filters. The prototype's excitation and emission spectra, illumination and detection intensities, and spot homogeneity were determined. The authors further performed a prospectively randomized and blinded study for fluorescence assessments of fresh, marginal, fluorescing and nonfluorescing tumor samples comparing the LED/loupe device with BLUE400 in patients with malignant glioma treated with 20 mg/kg body weight 5-ALA. Tumor samples were immediately assessed in turn, both with a Kinevo and with a novel triple-LED/loupe device by different surgeons. RESULTS Seven triple-LED/loupe devices were analyzed. Illumination intensities in the 409- and 450-nm range were comparable to BLUE400, with high spot homogeneity. Fluorescence intensities measured distally to microscope oculars/loupes were 9.9-fold higher with the loupe device. For validation 26 patients with malignant gliomas with 240 biopsies were analyzed. With BLUE400 results as the reference, sensitivity for reproducing fluorescence findings was 100%, specificity was 95%, positive predictive value was 98%, negative predictive value was 100%, and accuracy was 95%. This study reached its primary aim, with agreement in 226 of 240 (94.2%, 95% CI 0.904-0.968). CONCLUSIONS The authors observed only minor differences regarding spectra and illumination intensities during evaluation. Fluorescence intensities available to surgeons were 9.9-fold higher with the loupe device. Importantly, the independent perception of fluorescence achieved using the new system and BLUE400 was statistically equivalent. The authors believe the triple-LED/loupe device to be a useful and safe option for surgeons who prefer loupes to the microscope for resections in appropriate patients.
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Affiliation(s)
| | | | - Anna Walke
- 1Department of Neurosurgery, University Hospital of Münster
- 2Core Unit Proteomics, Interdisciplinary Center for Clinical Research, University of Münster
| | - Astrid Jeibmann
- 3Institute of Neuropathology, University Hospital of Münster; and
| | - Herbert Stepp
- 4Laser-Forschungslabor, LIFE Center, University Hospital, LMU Munich, Germany
| | - Walter Stummer
- 1Department of Neurosurgery, University Hospital of Münster
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Mazurek M, Szczepanek D, Orzyłowska A, Rola R. Analysis of Factors Affecting 5-ALA Fluorescence Intensity in Visualizing Glial Tumor Cells-Literature Review. Int J Mol Sci 2022; 23:ijms23020926. [PMID: 35055109 PMCID: PMC8779265 DOI: 10.3390/ijms23020926] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 01/27/2023] Open
Abstract
Glial tumors are one of the most common lesions of the central nervous system. Despite the implementation of appropriate treatment, the prognosis is not successful. As shown in the literature, maximal tumor resection is a key element in improving therapeutic outcome. One of the methods to achieve it is the use of fluorescent intraoperative navigation with 5-aminolevulinic acid. Unfortunately, often the level of fluorescence emitted is not satisfactory, resulting in difficulties in the course of surgery. This article summarizes currently available knowledge regarding differences in the level of emitted fluorescence. It may depend on both the histological type and the genetic profile of the tumor, which is reflected in the activity and expression of enzymes involved in the intracellular metabolism of fluorescent dyes, such as PBGD, FECH, UROS, and ALAS. The transport of 5-aminolevulinic acid and its metabolites across the blood–brain barrier and cell membranes mediated by transporters, such as ABCB6 and ABCG2, is also important. Accompanying therapies, such as antiepileptic drugs or steroids, also have an impact on light emission by tumor cells. Accurate determination of the factors influencing the fluorescence of 5-aminolevulinic acid-treated cells may contribute to the improvement of fluorescence navigation in patients with highly malignant gliomas.
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Chiaravalloti A, Cimini A, Ricci M, Quartuccio N, Arnone G, Filippi L, Calabria F, Leporace M, Bagnato A, Schillaci O. Positron emission tomography imaging in primary brain tumors. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Kiesel B, Freund J, Reichert D, Wadiura L, Erkkilae MT, Woehrer A, Hervey-Jumper S, Berger MS, Widhalm G. 5-ALA in Suspected Low-Grade Gliomas: Current Role, Limitations, and New Approaches. Front Oncol 2021; 11:699301. [PMID: 34395266 PMCID: PMC8362830 DOI: 10.3389/fonc.2021.699301] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/19/2021] [Indexed: 11/13/2022] Open
Abstract
Radiologically suspected low-grade gliomas (LGG) represent a special challenge for the neurosurgeon during surgery due to their histopathological heterogeneity and indefinite tumor margin. Therefore, new techniques are required to overcome these current surgical drawbacks. Intraoperative visualization of brain tumors with assistance of 5-aminolevulinic acid (5-ALA) induced protoporphyrin IX (PpIX) fluorescence is one of the major advancements in the neurosurgical field in the last decades. Initially, this technique was exclusively applied for fluorescence-guided surgery of high-grade glioma (HGG). In the last years, the use of 5-ALA was also extended to other indications such as radiologically suspected LGG. Here, we discuss the current role of 5-ALA for intraoperative visualization of focal malignant transformation within suspected LGG. Furthermore, we discuss the current limitations of the 5-ALA technology in pure LGG which usually cannot be visualized by visible fluorescence. Finally, we introduce new approaches based on fluorescence technology for improved detection of pure LGG tissue such as spectroscopic PpIX quantification fluorescence lifetime imaging of PpIX and confocal microscopy to optimize surgery.
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Affiliation(s)
- Barbara Kiesel
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Julia Freund
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - David Reichert
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory OPTRAMED, Medical University of Vienna, Vienna, Austria
| | - Lisa Wadiura
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Mikael T Erkkilae
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Adelheid Woehrer
- Department of Neurology, Institute for Neuropathology and Neurochemistry, Medical University of Vienna, Vienna, Austria
| | - Shawn Hervey-Jumper
- Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Georg Widhalm
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
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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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Batalov AI, Goryaynov SA, Zakharova NE, Solozhentseva KD, Kosyrkova AV, Potapov AA, Pronin IN. Prediction of Intraoperative Fluorescence of Brain Gliomas: Correlation between Tumor Blood Flow and the Fluorescence. J Clin Med 2021; 10:jcm10112387. [PMID: 34071447 PMCID: PMC8198656 DOI: 10.3390/jcm10112387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION The prediction of the fluorescent effect of 5-aminolevulinic acid (5-ALA) in patients with diffuse gliomas can improve the selection of patients. The degree of enhancement of gliomas has been reported to predict 5-ALA fluorescence, while, at the same time, rarer cases of fluorescence have been described in non-enhancing gliomas. Perfusion studies, in particular arterial spin labeling perfusion, have demonstrated high efficiency in determining the degree of malignancy of brain gliomas and may be better for predicting fluorescence than contrast enhancement. The aim of the study was to investigate the relationship between tumor blood flow, measured by ASL, and intraoperative fluorescent glow of gliomas of different grades. MATERIALS AND METHODS Tumoral blood flow was assessed in 75 patients by pCASL (pseudo-continuous arterial spin labeling) within 1 week prior to surgery. In all cases of tumor removal, 5-ALA had been administered preoperatively. Maximum values of tumoral blood flow (TBF max) were measured, and normalized tumor blood flow (nTBF) was calculated. RESULTS A total of 76% of patients had significant contrast enhancement, while 24% were non-enhancing. The histopathology revealed 17 WHO grade II gliomas, 12 WHO grade III gliomas and 46 glioblastomas. Overall, there was a relationship between the degree of intraoperative tumor fluorescence and ASL-TBF (Rs = 0.28, p = 0.02 or the TBF; Rs = 0.34, p = 0.003 for nTBF). Non-enhancing gliomas were fluorescent in 9/18 patients, with nTBF in fluorescent gliomas being 54.58 ± 32.34 mL/100 mg/s and in non-fluorescent gliomas being 52.99 ± 53.61 mL/100 g/s (p > 0.05). Enhancing gliomas were fluorescent in 53/57 patients, with nTBF being 170.17 ± 107.65 mL/100 g/s in fluorescent and 165.52 ± 141.71 in non-fluorescent gliomas (p > 0.05). CONCLUSION Tumoral blood flow levels measured by non-contrast ASL perfusion method predict the fluorescence by 5-ALA; however, the additional value beyond contrast enhancement is not clear. ASL is, however, useful in cases with contraindication to contrast.
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Jaber M, Ewelt C, Wölfer J, Brokinkel B, Thomas C, Hasselblatt M, Grauer O, Stummer W. Is Visible Aminolevulinic Acid-Induced Fluorescence an Independent Biomarker for Prognosis in Histologically Confirmed (World Health Organization 2016) Low-Grade Gliomas? Neurosurgery 2020; 84:1214-1224. [PMID: 30107580 PMCID: PMC6537633 DOI: 10.1093/neuros/nyy365] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 07/14/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Approximately 20% of low-grade gliomas (LGG) display visible protoporphyrin fluorescence during surgery after 5-aminolevulinic acid (5-ALA) administration. OBJECTIVE To determine if fluorescence represents a prognostic marker in LGG. METHODS Seventy-four consecutive patients with LGG (World Health Organization 2016) were operated on with 5-ALA. Fluorescent tissue was specifically biopsied. Tumor size, age, Karnofsky index, contrast-enhancement, fluorescence, and molecular factors (IDH1/IDH2-mutations, Ki67/MIB1 Index, 1p19q codeletions, ATRX, EGFR, p53 expression, and O6-methylguanine DNA methyltransferase promotor methylation), were related to progression-free survival (PFS), malignant transformation-free survival (MTFS) and overall survival (OS). RESULTS Sixteen of seventy-four LGGs (21.6%) fluoresced. Fluorescence was partially related to weak enhancement on magnetic resonance imaging and increased (positron emission tomography)PET-FET uptake, but not to Karnofsky Performance Score, tumor size, or age. Regarding molecular markers, only EGFR expression differed marginally (fluorescing vs nonfluorescing: 19% vs 5%; P = .057). Median follow-up was 46.4 mo (95% confidence interval [CI]: 41.8-51.1). PFS, MTFS, and OS were shorter in fluorescing tumors (PFS: median 9.8 mo, 95% CI: 1.00-27.7 vs 45.8, 31.9-59.7, MTFS: 43.0 [27.5-58.5] vs 64.6 [57.7-71.5], median not reached, P = .015; OS: 51.6, [34.8-68.3] vs [68.2, 62.7-73.8], P = .002). IDH mutations significantly predicted PFS, MTFS, and OS. In multivariate analysis IDH status and fluorescence both independently predicted MTFS and OS. PFS was not independently predicted by fluorescence. CONCLUSION This is the first report investigating the role of ALA-induced fluorescence in histologically confirmed LGG. Fluorescence appeared to be a marker for inherent malignant transformation and OS, independently of known prognostic markers. Fluorescence in LGG might be taken into account when deciding on adjuvant therapies.
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Affiliation(s)
- Mohammed Jaber
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Christian Ewelt
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Johannes Wölfer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Christian Thomas
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Martin Hasselblatt
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Oliver Grauer
- Department of Neurology, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
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Müther M, Koch R, Weckesser M, Sporns P, Schwindt W, Stummer W. 5-Aminolevulinic Acid Fluorescence-Guided Resection of 18F-FET-PET Positive Tumor Beyond Gadolinium Enhancing Tumor Improves Survival in Glioblastoma. Neurosurgery 2020; 85:E1020-E1029. [PMID: 31215632 PMCID: PMC6855932 DOI: 10.1093/neuros/nyz199] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 02/24/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The value of early postoperative 18F-FET-PET in patients with glioblastoma (GBM) is unclear. Five-aminolevulinic acid (5-ALA) is used for fluorescence-guided resections in these patients and previous data suggest that fluorescence and 18F-FET-PET both demarcate larger tumor volumes than gadolinium enhanced magnet resonance imaging (MRI). OBJECTIVE To correlate fluorescence with enhancing volumes on postoperative MRI and 18F-FET-PET tumor volumes, and determine the value of postoperative 18F-FET-PET for predicting survival through observational study. METHODS GBM patients underwent fluorescence-guided resection after administration of 5-ALA followed by early postoperative MRI and 18F-FET-PET for determination of residual tissue volumes. All patients were treated with standard temozolomide radiochemotherapy and monitored for progression-free and overall survival (PFS, OS). RESULTS A total of 31 patients were included. For functional reasons, residual 5-ALA derived fluorescent tissue was left unresected in 18 patients with a median 18F-FET-PET volume of 17.82 cm3 (interquartile range 6.50-29.19). In patients without residual fluorescence, median 18F-FET-PET volume was 1.20 cm3 (interquartile range 0.87-5.50) and complete resection of gadolinium enhancing tumor was observed in 100% of patients. A 18F-FET-PET volume of above 4.3 cm3 was associated with worse OS (logrank P-value ≤ .05), also in patients with no residual contrast enhancing tumor on MRI. More patients in whom fluorescencing tissue had been removed completely had postoperative 18F-FET-PET tumor volumes below 4.3 cm3. CONCLUSION Postoperative 18F-FET-PET volumes predict OS and PFS. Resection of 5-ALA derived fluorescence beyond gadolinium enhancing tumor tissue leads to lower postoperative 18F-FET-PET tumor volumes and improved OS and PFS without additional deficits.
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Affiliation(s)
- Michael Müther
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Raphael Koch
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Matthias Weckesser
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
| | - Peter Sporns
- Institute of Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Wolfram Schwindt
- Institute of Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
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Fleischmann DF, Unterrainer M, Schön R, Corradini S, Maihöfer C, Bartenstein P, Belka C, Albert NL, Niyazi M. Margin reduction in radiotherapy for glioblastoma through 18F-fluoroethyltyrosine PET? - A recurrence pattern analysis. Radiother Oncol 2020; 145:49-55. [PMID: 31923709 DOI: 10.1016/j.radonc.2019.12.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE 18F-fluoroethyltyrosine (18F-FET) PET is increasingly used in radiation treatment planning for the primary treatment of glioblastoma (GBM) patients additionally to contrast-enhanced MRI. To answer the question, whether a margin reduction in the primary treatment setting could be achieved through 18F-FET PET imaging, a recurrence pattern analysis was performed. PATIENTS AND METHODS GBM patients undergoing 18F-FET PET examination before primary radiochemotherapy from 05/2009 to 11/2014 were included into the recurrence pattern analysis. Biological tumour volumes were semi-automatically created and fused with MR-based gross tumour volumes (MRGTVs). The pattern of recurrence was examined for MRGTVs and for PET-MRGTVs. The minimal margin including all recurrent tumour sites was assessed by gradual expansion of the PET-MRGTVs and MRGTVs until inclusion of all contrast-enhancing areas at recurrence. RESULTS 36 GBM patients were included to the analysis. The minimal margin including all contrast enhancing tumour at recurrence was significantly smaller for the PET-MRGTVs compared to the MRGTVs (median 12.5 mm vs. 16.5 mm; p < 0.001, Wilcoxon-Test). PET-MRGTVs with 15 mm CTV margins were significantly smaller than MRGTVs with 20 mm CTV margins (median volume 255.92 vs. 258.35 cm3; p = 0.020, Wilcoxon-Test; excluding 3 cases with large non-contrast enhancing tumours). The pattern of recurrence of PET-MRGTVs with 15 mm CTV margins was comparable to MRGTVs with 20 mm CTV margins (32 vs. 30 central, 2 vs. 4 in-field, 2 vs. 2 ex-field and no marginal recurrences). CONCLUSION Target volume delineation of GBM patients can be improved through 18F-FET PET imaging prior to primary radiation treatment, since vital tumour can be detected more accurately. Furthermore, the results suggest that CTV margins could be reduced through 18F-FET PET imaging prior to primary RT of GBM.
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Affiliation(s)
- Daniel F Fleischmann
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Marcus Unterrainer
- Department of Nuclear Medicine, University Hospital, LMU Munich, Germany.
| | - Rudolph Schön
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany.
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany.
| | - Cornelius Maihöfer
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany.
| | - Peter Bartenstein
- German Cancer Consortium (DKTK), Partner Site Munich, Germany; Department of Nuclear Medicine, University Hospital, LMU Munich, Germany.
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Germany.
| | - Nathalie L Albert
- Department of Nuclear Medicine, University Hospital, LMU Munich, Germany.
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Germany.
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Chiaravalloti A, Filippi L, Ricci M, Cimini A, Schillaci O. Molecular Imaging in Pediatric Brain Tumors. Cancers (Basel) 2019; 11:cancers11121853. [PMID: 31771237 PMCID: PMC6966547 DOI: 10.3390/cancers11121853] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/16/2019] [Accepted: 11/19/2019] [Indexed: 02/07/2023] Open
Abstract
In the last decade, several radiopharmaceuticals have been developed and investigated for imaging in vivo of pediatric brain tumors with the aim of exploring peculiar metabolic processes as glucose consumption, amino-acid metabolism, and protein synthesis with nuclear medicine techniques. Although the clinical shreds of evidence are limited, preliminary results are encouraging. In this review, we performed web-based and desktop research summarizing the most relevant findings of the literature published to date on this topic. Particular attention was given to the wide spectrum of nuclear medicine advances and trends in pediatric neurooncology and neurosurgery. Furthermore, the role of somatostatin receptor imaging through single-photon emission computed tomography (SPECT) and positron emission tomography (PET) probes, with reference to their potential therapeutic implications, was examined in the peculiar context. Preliminary results show that functional imaging in pediatric brain tumors might lead to significant improvements in terms of diagnostic accuracy and it could be of help in the management of the disease.
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Affiliation(s)
- Agostino Chiaravalloti
- Department of Biomedicine and Prevention, University Tor Vergata, 00133 Rome, Italy (O.S.)
- Nuclear Medicine Section, IRCCS Neuromed, 86077 Pozzilli, Italy
- Correspondence: or ; Tel.: +39-062-090-2457
| | - Luca Filippi
- Nuclear Medicine Section, “Santa Maria Goretti” Hospital, 04100 Latina, Italy;
| | - Maria Ricci
- Department of Radiological, Oncological and Pathological Sciences, Faculty of Medicine and Surgery, La Sapienza University, 00161 Rome, Italy;
| | - Andrea Cimini
- Department of Biomedicine and Prevention, University Tor Vergata, 00133 Rome, Italy (O.S.)
| | - Orazio Schillaci
- Department of Biomedicine and Prevention, University Tor Vergata, 00133 Rome, Italy (O.S.)
- Nuclear Medicine Section, IRCCS Neuromed, 86077 Pozzilli, Italy
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Molecular and Clinical Insights into the Invasive Capacity of Glioblastoma Cells. JOURNAL OF ONCOLOGY 2019; 2019:1740763. [PMID: 31467533 PMCID: PMC6699388 DOI: 10.1155/2019/1740763] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/01/2019] [Accepted: 07/07/2019] [Indexed: 12/22/2022]
Abstract
The invasive capacity of GBM is one of the key tumoral features associated with treatment resistance, recurrence, and poor overall survival. The molecular machinery underlying GBM invasiveness comprises an intricate network of signaling pathways and interactions with the extracellular matrix and host cells. Among them, PI3k/Akt, Wnt, Hedgehog, and NFkB play a crucial role in the cellular processes related to invasion. A better understanding of these pathways could potentially help in developing new therapeutic approaches with better outcomes. Nevertheless, despite significant advances made over the last decade on these molecular and cellular mechanisms, they have not been translated into the clinical practice. Moreover, targeting the infiltrative tumor and its significance regarding outcome is still a major clinical challenge. For instance, the pre- and intraoperative methods used to identify the infiltrative tumor are limited when trying to accurately define the tumor boundaries and the burden of tumor cells in the infiltrated parenchyma. Besides, the impact of treating the infiltrative tumor remains unclear. Here we aim to highlight the molecular and clinical hallmarks of invasion in GBM.
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Gaw N, Hawkins-Daarud A, Hu LS, Yoon H, Wang L, Xu Y, Jackson PR, Singleton KW, Baxter LC, Eschbacher J, Gonzales A, Nespodzany A, Smith K, Nakaji P, Mitchell JR, Wu T, Swanson KR, Li J. Integration of machine learning and mechanistic models accurately predicts variation in cell density of glioblastoma using multiparametric MRI. Sci Rep 2019; 9:10063. [PMID: 31296889 PMCID: PMC6624304 DOI: 10.1038/s41598-019-46296-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 06/26/2019] [Indexed: 01/30/2023] Open
Abstract
Glioblastoma (GBM) is a heterogeneous and lethal brain cancer. These tumors are followed using magnetic resonance imaging (MRI), which is unable to precisely identify tumor cell invasion, impairing effective surgery and radiation planning. We present a novel hybrid model, based on multiparametric intensities, which combines machine learning (ML) with a mechanistic model of tumor growth to provide spatially resolved tumor cell density predictions. The ML component is an imaging data-driven graph-based semi-supervised learning model and we use the Proliferation-Invasion (PI) mechanistic tumor growth model. We thus refer to the hybrid model as the ML-PI model. The hybrid model was trained using 82 image-localized biopsies from 18 primary GBM patients with pre-operative MRI using a leave-one-patient-out cross validation framework. A Relief algorithm was developed to quantify relative contributions from the data sources. The ML-PI model statistically significantly outperformed (p < 0.001) both individual models, ML and PI, achieving a mean absolute predicted error (MAPE) of 0.106 ± 0.125 versus 0.199 ± 0.186 (ML) and 0.227 ± 0.215 (PI), respectively. Associated Pearson correlation coefficients for ML-PI, ML, and PI were 0.838, 0.518, and 0.437, respectively. The Relief algorithm showed the PI model had the greatest contribution to the result, emphasizing the importance of the hybrid model in achieving the high accuracy.
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Affiliation(s)
- Nathan Gaw
- School of Computing, Informatics, and Decision Systems Engineering, Arizona State University, 699 S Mill Ave, Tempe, AZ, 85281, USA
| | - Andrea Hawkins-Daarud
- Precision NeuroTherapeutics (PNT) Lab, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, Arizona, 85054, USA.
| | - Leland S Hu
- Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, Arizona, 85054, USA
| | - Hyunsoo Yoon
- School of Computing, Informatics, and Decision Systems Engineering, Arizona State University, 699 S Mill Ave, Tempe, AZ, 85281, USA
| | - Lujia Wang
- School of Computing, Informatics, and Decision Systems Engineering, Arizona State University, 699 S Mill Ave, Tempe, AZ, 85281, USA
| | - Yanzhe Xu
- School of Computing, Informatics, and Decision Systems Engineering, Arizona State University, 699 S Mill Ave, Tempe, AZ, 85281, USA
| | - Pamela R Jackson
- Precision NeuroTherapeutics (PNT) Lab, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, Arizona, 85054, USA
| | - Kyle W Singleton
- Precision NeuroTherapeutics (PNT) Lab, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, Arizona, 85054, USA
| | - Leslie C Baxter
- Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, Arizona, 85054, USA
| | - Jennifer Eschbacher
- Department of Pathology, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ashlyn Gonzales
- Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, Arizona, 85054, USA
| | - Ashley Nespodzany
- Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, Arizona, 85054, USA
| | - Kris Smith
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - J Ross Mitchell
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida, 33612, USA
| | - Teresa Wu
- School of Computing, Informatics, and Decision Systems Engineering, Arizona State University, 699 S Mill Ave, Tempe, AZ, 85281, USA
| | - Kristin R Swanson
- Precision NeuroTherapeutics (PNT) Lab, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, Arizona, 85054, USA
- Department of Neurosurgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, Arizona, 85054, USA
| | - Jing Li
- School of Computing, Informatics, and Decision Systems Engineering, Arizona State University, 699 S Mill Ave, Tempe, AZ, 85281, USA
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15
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Suero Molina E, Schipmann S, Stummer W. Maximizing safe resections: the roles of 5-aminolevulinic acid and intraoperative MR imaging in glioma surgery-review of the literature. Neurosurg Rev 2019; 42:197-208. [PMID: 28921173 PMCID: PMC6502775 DOI: 10.1007/s10143-017-0907-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/07/2017] [Accepted: 09/06/2017] [Indexed: 12/28/2022]
Abstract
Malignant glioma surgery involves the challenge of preserving the neurological status of patients harboring these lesions while pursuing a maximal tumor resection, which is correlated with overall and progression-free survival. Presently, several tools exist for assisting neurosurgeons in visualizing malignant tissue. Fluorescence-guided surgery (FGS) with 5-aminolevulinic acid (5-ALA) has increasingly been used during the last decade for identifying malignant glioma. Intraoperative magnetic resonance imaging (iMRI), first introduced in the mid-1990s, is being evaluated as a further tool to maximize the extent of resection. We aimed to evaluate the literature and discuss synergies and differences between FGS with 5-ALA and iMRI. We conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. After excluding non-relevant articles, 16 articles were evaluated and included in the qualitative analysis, comprising 2 (n = 2) reviews of the literatures, 1 (n = 1) book chapter, and 13 (n = 13) clinical articles. ALA-induced fluorescence goes beyond the borders of gadolinium contrast enhancement. Several studies stress the synergy between both tools, enabling increase in extent of resection. We point out advantages of combining both methods. iMRI, however, is not widely available, is expensive, and is not recommended as sole resection control tool in high-grade glioma. For these centers, FGS together with mapping and monitoring techniques, neuronavigation and, when needed, intraoperative ultrasound provides an excellent setting for achieving state-of-the-art gross total resection of high-grade gliomas.
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Affiliation(s)
- Eric Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany.
| | - S Schipmann
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
| | - W Stummer
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
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16
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Goryaynov SA, Widhalm G, Goldberg MF, Chelushkin D, Spallone A, Chernyshov KA, Ryzhova M, Pavlova G, Revischin A, Shishkina L, Jukov V, Savelieva T, Victor L, Potapov A. The Role of 5-ALA in Low-Grade Gliomas and the Influence of Antiepileptic Drugs on Intraoperative Fluorescence. Front Oncol 2019; 9:423. [PMID: 31192128 PMCID: PMC6540822 DOI: 10.3389/fonc.2019.00423] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 05/03/2019] [Indexed: 12/29/2022] Open
Abstract
Objectives: Intraoperative tumor visualization with 5-aminolevulinic acid (5-ALA) induced protoporphyrin IX (PpIX) fluorescence is widely applied for improved resection of high-grade gliomas. However, visible fluorescence is present only in a minority of low-grade gliomas (LGGs) according to current literature. Nowadays, antiepileptic drugs (AEDs) are frequently administered to LGG patients prior to surgery. A recent in-vitro study demonstrated that AEDs result in significant reduction of PpIX synthesis in glioma cells. The aim of this study was thus to investigate the role of 5-ALA fluorescence in LGG surgery and the influence of AEDs on visible fluorescence. Patients and Methods: Patients with resection of a newly diagnosed suspected LGG after 5-ALA (25 mg/kg) administration were initially included. During surgery, the presence of visible fluorescence (none, mild, moderate, or bright) within the tumor and intratumoral fluorescence homogeneity (diffuse or focal) were analyzed. Tissue samples from fluorescing and/or non-fluorescing areas within the tumor and/or the assumed tumor border were collected for histopathological analysis (WHO tumor diagnosis, cell density, and proliferation rate). Only patients with diagnosis of LGG after surgery remained in the final study cohort. In each patient, the potential preoperative intake of AEDs was investigated. Results: Altogether, 27 patients with a histopathologically confirmed LGG (14 diffuse astrocytomas, 6 oligodendrogliomas, 4 pilocytic astrocytomas, 2 gemistocytic astrocytomas, and one desmoplastic infantile ganglioglioma) were finally included. Visible fluorescence was detected in 14 (52%) of 27. In terms of fluorescence homogeneity (n = 14), 7 tumors showed diffuse fluorescence, while in 7 gliomas focal fluorescence was noted. Cell density (p = 0.03) and proliferation rate (p = 0.04) was significantly higher in fluorescence-positive than in fluorescence-negative samples. Furthermore, 15 (56%) of 27 patients were taking AEDs before surgery. Of these, 11 patients (73%) showed no visible fluorescence. In contrast, 10 (83%) of 12 patients without prior AEDs intake showed visible fluorescence. Thus, visible fluorescence was significantly more common in patients without AEDs compared to patients with preoperative AED intake (OR = 0,15 (CI 95% 0.012–1.07), p = 0.046). Conclusions: Our study shows a markedly higher rate of visible fluorescence in a series of LGGs compared to current literature. According to our preliminary data, preoperative intake of AEDs seems to reduce the presence of visible fluorescence in such tumors and should thus be taken into account in the clinical setting.
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Affiliation(s)
- Sergey A Goryaynov
- N. N. Burdenko Scientific Research Neurosurgery Institute, Moscow, Russia
| | - Georg Widhalm
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Maria F Goldberg
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Danil Chelushkin
- N. N. Burdenko Scientific Research Neurosurgery Institute, Moscow, Russia
| | - Aldo Spallone
- NCL-Institute of Neurological Sciences, Rome, Italy.,Department of Biomedicine, University of Rome Tor Vergata, Rome, Italy
| | | | - Marina Ryzhova
- N. N. Burdenko Scientific Research Neurosurgery Institute, Moscow, Russia
| | - Galina Pavlova
- Institute of Gene Biology, Russian Academy of Science, Moscow, Russia
| | | | - Ludmila Shishkina
- N. N. Burdenko Scientific Research Neurosurgery Institute, Moscow, Russia
| | - Vadim Jukov
- N. N. Burdenko Scientific Research Neurosurgery Institute, Moscow, Russia
| | - Tatyana Savelieva
- Prokhorov General Physics Institute, Russian Academy of Sciences, Moscow, Russia.,National Research Nuclear University, Moscow Engineering Physics Institute, Moscow, Russia
| | - Loschenov Victor
- Prokhorov General Physics Institute, Russian Academy of Sciences, Moscow, Russia
| | - Alexander Potapov
- Prokhorov General Physics Institute, Russian Academy of Sciences, Moscow, Russia
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17
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Picart T, Berhouma M, Dumot C, Pallud J, Metellus P, Armoiry X, Guyotat J. Optimization of high-grade glioma resection using 5-ALA fluorescence-guided surgery: A literature review and practical recommendations from the neuro-oncology club of the French society of neurosurgery. Neurochirurgie 2019; 65:164-177. [PMID: 31125558 DOI: 10.1016/j.neuchi.2019.04.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/17/2019] [Accepted: 04/28/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND When feasible, the surgical resection is the standard first step of the management of high-grade gliomas. 5-ALA fluorescence-guided-surgery (5-ALA-FGS) was developed to ease the intra-operative delineation of tumor borders in order to maximize the extent of resection. METHODS A Medline electronic database search was conducted. English language studies from January 1998 until July 2018 were included, following the PRISMA guidelines. RESULTS 5-ALA can be considered as a specific tool for the detection of tumor remnant but has a weaker sensibility (level 2). 5-ALA-FGS is associated with a significant increase in the rate of gross total resection reaching more than 90% in some series (level 1). Consistently, 5-ALAFGS improves progression-free survival (level 1). However, the gain in overall survival is more debated. The use of 5-ALA-FGS in eloquent areas is feasible but requires simultaneous intraoperative electrophysiologic functional brain monitoring to precisely locate and preserve eloquent areas (level 2). 5-ALA is usable during the first resection of a glioma but also at recurrence (level 2). From a practical standpoint, 5-ALA is orally administered 3 hours before the induction of anesthesia, the recommended dose being 20 mg/kg. Intra-operatively, the procedure is performed as usually with a central debulking and a peripheral dissection during which the surgeon switches from white to blue light. Provided that some precautions are observed, the technique does not expose the patient to particular complications. CONCLUSION Although 5-ALA-FGS contributes to improve gliomas management, there are still some limitations. Future methods will be developed to improve the sensibility of 5-ALA-FGS.
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Affiliation(s)
- T Picart
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; Inserm 1052, UMR 5286,Team ATIP/AVENIR Transcriptomic diversity of stem cells, centre de cancérologie de Lyon, centre Léon-Bérard, 69008 Lyon, France.
| | - M Berhouma
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; CREATIS Laboratory, Inserm U1206, UMR 5220, université de Lyon, 69100 Villeurbanne, France
| | - C Dumot
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; CREATIS Laboratory, Inserm U1206, UMR 5220, université de Lyon, 69100 Villeurbanne, France
| | - J Pallud
- Département de neurochirurgie, hôpital Sainte-Anne, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 75005 Paris, France; IMA-Brain, Inserm U894, institut de psychiatrie et neurosciences de Paris, 7013 Paris, France
| | - P Metellus
- Hôpital Privé Clairval, Ramsay général de santé, 13009 Marseille, France; UMR 7051, institut de neurophysiopathologie, université d'Aix-Marseille, 13344 Marseille, France
| | - X Armoiry
- MATEIS (Team I2B), University of Lyon, Lyon school of pharmacy, 69008 Lyon, France; Édouard-Herriot Hospital, Pharmacy Department, 69008 Lyon, France; University of Warwick, Warwick Medical School, Coventry, UK
| | - J Guyotat
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France
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18
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Ganau M, Ligarotti GK, Apostolopoulos V. Real-time intraoperative ultrasound in brain surgery: neuronavigation and use of contrast-enhanced image fusion. Quant Imaging Med Surg 2019; 9:350-358. [PMID: 31032183 DOI: 10.21037/qims.2019.03.06] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Mario Ganau
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gianfranco K Ligarotti
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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19
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Pala A, Reske SN, Eberhardt N, Scheuerle A, König R, Schmitz B, Beer AJ, Wirtz CR, Coburger J. Diagnostic accuracy of intraoperative perfusion-weighted MRI and 5-aminolevulinic acid in relation to contrast-enhanced intraoperative MRI and 11C-methionine positron emission tomography in resection of glioblastoma: a prospective study. Neurosurg Rev 2018; 42:471-479. [PMID: 29808321 DOI: 10.1007/s10143-018-0987-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 05/06/2018] [Accepted: 05/21/2018] [Indexed: 10/14/2022]
Abstract
The aim of our study was to compare depicted pre-, intra-, and postoperative tumor volume of met-PET, perfusion-weighed MRI (PWI), and Gd-DTPA MRI. Further, to assess their sensitivity and specificity in correlation with histopathological specimen. Inclusion criteria of the prospective study were histological confirmed glioblastoma (GB), age > 18, and eligible for gross total resection (GTR). Met-PET was performed before and after surgery. Gd-DTPA MRI and PWI were performed before, during, and after surgery. A combined 5-aminolevulinic acid (5-ALA) and iMRI-guided surgery was performed. Volumetric analysis was evaluated for all imaging modalities except for 5-ALA. A total of 59 navigated biopsies were taken. Sensitivity and specificity were calculated for Gd-DTPA MRI, PWI, met-PET, and 5-ALA according to the histology of specimen. Met-PET depicted significantly larger tumor volume before surgery (p = 0.01) compared to PWI and Gd-DTPI MRI. We found no significant difference in tumor volume between met-PET and PWI after surgery (p = 0.059). Both PWI and met-PET showed significantly larger tumor volume after surgery when compared to Gd-DTPA (p = 0.018 and p = 0.003, respectively). Intraoperative PWI reading was impaired in 33.3% due to artifacts. Met-PET showed the highest sensitivity for detection of GB with 95%. The lowest sensitivity was found with Gd-DTPA MRI (50%), while 5-ALA and intraoperative PWI showed similar results (69 and 67%). Met-Pet is the imaging modality with the highest sensitivity to detect a residual tumor in GB. Intraoperative PWI seems to have a synergistic effect to Gd-DTPA and 5-ALA. However, its value may be limited by artifacts. Both pre- and intraoperative PWI cannot substitute met-PET in tumor detection.
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Affiliation(s)
- Andrej Pala
- Department of Neurosurgery, University of Ulm, Ludwig-Heilmeyerstr. 2, 89312, Günzburg, Germany.
| | - Sven N Reske
- Department of Nuclear Medicine, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Nina Eberhardt
- Department of Nuclear Medicine, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Angelika Scheuerle
- Department of Neuropathology, University of Ulm, Ludwig-Heilmeyerstr. 2, 89312, Günzburg, Germany
| | - Ralph König
- Department of Neurosurgery, University of Ulm, Ludwig-Heilmeyerstr. 2, 89312, Günzburg, Germany
| | - Bernd Schmitz
- Department of Neuroradiology, University of Ulm, Ludwig-Heilmeyerstr. 2, 89312, Günzburg, Germany
| | - Ambros J Beer
- Department of Nuclear Medicine, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Christian R Wirtz
- Department of Neurosurgery, University of Ulm, Ludwig-Heilmeyerstr. 2, 89312, Günzburg, Germany
| | - Jan Coburger
- Department of Neurosurgery, University of Ulm, Ludwig-Heilmeyerstr. 2, 89312, Günzburg, Germany
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Kamp MA, Krause Molle Z, Munoz-Bendix C, Rapp M, Sabel M, Steiger HJ, Cornelius JF. Various shades of red-a systematic analysis of qualitative estimation of ALA-derived fluorescence in neurosurgery. Neurosurg Rev 2018; 41:3-18. [PMID: 27225452 DOI: 10.1007/s10143-016-0745-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 03/08/2016] [Accepted: 03/13/2016] [Indexed: 01/11/2023]
Abstract
5-Aminolevulinic acid (5-ALA)-fluorescence-guided resection is well established in many neuro-oncologic centers. Different classifications of 5-ALA-induced fluorescence have been reported. The aim of the systematic analysis was to evaluate the frequency of graduations, definitions, and designations of 5-ALA-induced fluorescence qualities. A systematic database search of PubMed was performed to identify studies reporting (1) on 5-ALA fluorescence-guided either spinal or cranial surgery, (2) on qualitative estimation and/or categorization of 5-ALA-induced fluorescence, (3) in English, and (4) were published as peer-reviewed original studies. Totally, 93 studies were identified. Different classification systems of 5-ALA-induced fluorescence were found. Over 60 % of the included studies used a dichotomized categorization of 5-ALA-induced fluorescence and 27.5 % of studies distinguished two different intensities of 5-ALA fluorescent tissue in addition to non-fluorescing tissue. More than 50 % of studies explicitly defined criteria for categorization of 5-ALA-induced fluorescence. The major limitation of the present analysis might be that it mainly comprises data from retrospective, uncontrolled, non-randomized trials. However, a precise definition of each 5-ALA-induced fluorescence quality is essential. Although dichotomized classification is the most common and simple graduation system, it may not be suitable for every clinical or scientific task. A three-level 5-ALA-induced fluorescence classification with precise definition of each fluorescence quality and their correlation with histological features would be more useful and reproducible in these cases.
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Affiliation(s)
- Marcel A Kamp
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Zarela Krause Molle
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Christopher Munoz-Bendix
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marion Rapp
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Michael Sabel
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
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Contemporary use of intraoperative imaging in glioma surgery: A survey among EANS members. Clin Neurol Neurosurg 2017; 163:133-141. [DOI: 10.1016/j.clineuro.2017.10.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/18/2017] [Accepted: 10/29/2017] [Indexed: 11/18/2022]
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Abstract
Intraoperative fluorescence imaging allows real-time identification of diseased tissue during surgery without being influenced by brain shift and surgery interruption. 5-Aminolevulinic acid, useful for malignant gliomas and other tumors, is the most broadly explored compound approved for fluorescence-guided resection. Intravenous fluorescein sodium has recently received attention, highlighting tumor tissue based on extravasation at the blood-brain barrier (defective in many brain tumors). Fluorescein in perfused brain, unselective extravasation in brain perturbed by surgery, and propagation with edema are concerns. Fluorescein is not approved but targeted fluorochromes with affinity to brain tumor cells, in development, may offer future advantages.
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Affiliation(s)
- Walter Stummer
- Department of Neurosurgery, Univerity Hospital Münster, Münster, Germany.
| | - Eric Suero Molina
- Department of Neurosurgery, Univerity Hospital Münster, Münster, Germany
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23
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Nuclear medicine for photodynamic therapy in cancer: Planning, monitoring and nuclear PDT. Photodiagnosis Photodyn Ther 2017; 18:236-243. [PMID: 28300723 DOI: 10.1016/j.pdpdt.2017.03.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 02/27/2017] [Accepted: 03/09/2017] [Indexed: 12/16/2022]
Abstract
Photodynamic therapy (PDT) is a modality with promising results for the treatment of various cancers. PDT is increasingly included in the standard of care for different pathologies. This therapy relies on the effects of light delivered to photosensitized cells. At different stages of delivery, PDT requires imaging to plan, evaluate and monitor treatment. The contribution of molecular imaging in this context is important and continues to increase. In this article, we review the contribution of nuclear medicine imaging in oncology to PDT for planning and therapeutic monitoring purposes. Several solutions have been proposed to plan PDT from nuclear medicine imaging. For instance, photosensitizer biodistribution has been evaluated with a radiolabeled photosensitizer or with conventional radiopharmaceuticals on positron emission tomography. The effects of PDT delivery have also been explored with specific SPECT or PET radiopharmaceuticals to evaluate the effects on cells (apoptosis, necrosis, proliferation, metabolism) or vascular damage. Finally, the synergy between photosensitizers and radiopharmaceuticals has been studied considering the Cerenkov effect to activate photosensitized cells.
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24
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Evers G, Kamp M, Warneke N, Berdel W, Sabel M, Stummer W, Ewelt C. 5-Aminolaevulinic Acid-Induced Fluorescence in Primary Central Nervous System Lymphoma. World Neurosurg 2016; 98:375-380. [PMID: 27838426 DOI: 10.1016/j.wneu.2016.11.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 11/01/2016] [Accepted: 11/01/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Diagnosis of primary central nervous system lymphoma (PCNSL) is usually confirmed by brain biopsy and subsequent neuropathologic workup. 5-Aminolevulinic acid (5-ALA)-induced fluorescence has been established for diagnostic and therapeutic purposes in glioma treatment during the last few years and is discussed for use in other cranial tumors. Its role in diagnosis and treatment of PCNSL is still elusive. METHODS This retrospective study includes clinical, magnetic resonance imaging, pathologic and surgical data of selected 11 patients with PCNSL at two university hospitals within the last 4 years undergoing surgical treatment for resection because of imminent mass effect or suspected cerebral glioma. Patients received 5-ALA for fluorescence-guided resection preoperatively. RESULTS The 11 subjects age ranged from 59 to 81 years. Postsurgical pathologic workup revealed malignant B cell lymphoma with morphologic features of diffuse large B cell lymphoma. Eight of these 11 patients with PCNSL showed a clear fluorescence induced by 5-ALA. After surgical resection, patients were treated with combination chemotherapy regimens. CONCLUSION In patients with glioma, the use of 5-ALA is known to be associated with increased extent of resection and survival benefit. Our data and retrospective analysis of a larger patient cohort suggest that the use of 5-ALA in PCNSL should be included in a surgical approach, if this is reconsidered for select patients within a clinical study. In addition, even photodynamic therapy in combination with 5-ALA might be studied.
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Affiliation(s)
- Georg Evers
- Department of Medicine, Hematology and Oncology, University Hospital of Muenster, Muenster, Germany
| | - Marcel Kamp
- Department of Neurosurgery, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Nils Warneke
- Department of Neurosurgery, University Hospital of Muenster, Muenster, Germany
| | - Wolfgang Berdel
- Department of Medicine, Hematology and Oncology, University Hospital of Muenster, Muenster, Germany
| | - Michael Sabel
- Department of Neurosurgery, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Muenster, Muenster, Germany
| | - Christian Ewelt
- Department of Neurosurgery, University Hospital of Muenster, Muenster, Germany.
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25
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Jaber M, Wölfer J, Ewelt C, Holling M, Hasselblatt M, Niederstadt T, Zoubi T, Weckesser M, Stummer W. The Value of 5-Aminolevulinic Acid in Low-grade Gliomas and High-grade Gliomas Lacking Glioblastoma Imaging Features: An Analysis Based on Fluorescence, Magnetic Resonance Imaging, 18F-Fluoroethyl Tyrosine Positron Emission Tomography, and Tumor Molecular Factors. Neurosurgery 2016; 78:401-11; discussion 411. [PMID: 26366972 PMCID: PMC4747980 DOI: 10.1227/neu.0000000000001020] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND: Approximately 20% of grade II and most grade III gliomas fluoresce after 5-aminolevulinic acid (5-ALA) application. Conversely, approximately 30% of nonenhancing gliomas are actually high grade. OBJECTIVE: The aim of this study was to identify preoperative factors (ie, age, enhancement, 18F-fluoroethyl tyrosine positron emission tomography [18F-FET PET] uptake ratios) for predicting fluorescence in gliomas without typical glioblastomas imaging features and to determine whether fluorescence will allow prediction of tumor grade or molecular characteristics. METHODS: Patients harboring gliomas without typical glioblastoma imaging features were given 5-ALA. Fluorescence was recorded intraoperatively, and biopsy specimens collected from fluorescing tissue. World Health Organization (WHO) grade, Ki-67/MIB-1 index, IDH1 (R132H) mutation status, O6-methylguanine DNA methyltransferase (MGMT) promoter methylation status, and 1p/19q co-deletion status were assessed. Predictive factors for fluorescence were derived from preoperative magnetic resonance imaging and 18F-FET PET. Classification and regression tree analysis and receiver-operating-characteristic curves were generated for defining predictors. RESULTS: Of 166 tumors, 82 were diagnosed as WHO grade II, 76 as grade III, and 8 as glioblastomas grade IV. Contrast enhancement, tumor volume, and 18F-FET PET uptake ratio >1.85 predicted fluorescence. Fluorescence correlated with WHO grade (P < .001) and Ki-67/MIB-1 index (P < .001), but not with MGMT promoter methylation status, IDH1 mutation status, or 1p19q co-deletion status. The Ki-67/MIB-1 index in fluorescing grade III gliomas was higher than in nonfluorescing tumors, whereas in fluorescing and nonfluorescing grade II tumors, no differences were noted. CONCLUSION: Age, tumor volume, and 18F-FET PET uptake are factors predicting 5-ALA-induced fluorescence in gliomas without typical glioblastoma imaging features. Fluorescence was associated with an increased Ki-67/MIB-1 index and high-grade pathology. Whether fluorescence in grade II gliomas identifies a subtype with worse prognosis remains to be determined. ABBREVIATIONS: 5-ALA, 5-aminolevulinic acid CRT, classification and regression tree 18F-FET PET, 18F-fluoroethyl tyrosine positron emission tomography FLAIR, fluid-attenuated inversion recovery GBM, glioblastoma multiforme O6-MGMT, methylguanine DNA methyltransferase ROC, receiver-operating characteristic SUV, standardized uptake value WHO, World Health Organization
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Affiliation(s)
- Mohammed Jaber
- ‡Department of Neurosurgery, University Hospital Münster, Münster, Germany;§Institute of Neuropathology, University Hospital Münster, Münster, Germany;¶Institute for Clinical Radiology, University Hospital of Münster, Münster, Germany;‖Department of Nuclear Medicine, University Hospital of Münster, Münster, Germany
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26
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Stummer W. Commentary: Combining 5-Aminolevulinic Acid Fluorescence and Intraoperative Magnetic Resonance Imaging in Glioblastoma Surgery: A Histology-Based Evaluation. Neurosurgery 2016; 78:484-6. [PMID: 26552043 DOI: 10.1227/neu.0000000000001107] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Walter Stummer
- Department of Neurosurgery, University of Münster, Münster, Germany
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Holzgreve A, Brendel M, Gu S, Carlsen J, Mille E, Böning G, Mastrella G, Unterrainer M, Gildehaus FJ, Rominger A, Bartenstein P, Kälin RE, Glass R, Albert NL. Monitoring of Tumor Growth with [(18)F]-FET PET in a Mouse Model of Glioblastoma: SUV Measurements and Volumetric Approaches. Front Neurosci 2016; 10:260. [PMID: 27378835 PMCID: PMC4906232 DOI: 10.3389/fnins.2016.00260] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 05/23/2016] [Indexed: 11/15/2022] Open
Abstract
Noninvasive tumor growth monitoring is of particular interest for the evaluation of experimental glioma therapies. This study investigates the potential of positron emission tomography (PET) using O-(2-18F-fluoroethyl)-L-tyrosine ([18F]-FET) to determine tumor growth in a murine glioblastoma (GBM) model—including estimation of the biological tumor volume (BTV), which has hitherto not been investigated in the pre-clinical context. Fifteen GBM-bearing mice (GL261) and six control mice (shams) were investigated during 5 weeks by PET followed by autoradiographic and histological assessments. [18F]-FET PET was quantitated by calculation of maximum and mean standardized uptake values within a universal volume-of-interest (VOI) corrected for healthy background (SUVmax/BG, SUVmean/BG). A partial volume effect correction (PVEC) was applied in comparison to ex vivo autoradiography. BTVs obtained by predefined thresholds for VOI definition (SUV/BG: ≥1.4; ≥1.6; ≥1.8; ≥2.0) were compared to the histologically assessed tumor volume (n = 8). Finally, individual “optimal” thresholds for BTV definition best reflecting the histology were determined. In GBM mice SUVmax/BG and SUVmean/BG clearly increased with time, however at high inter-animal variability. No relevant [18F]-FET uptake was observed in shams. PVEC recovered signal loss of SUVmean/BG assessment in relation to autoradiography. BTV as estimated by predefined thresholds strongly differed from the histology volume. Strikingly, the individual “optimal” thresholds for BTV assessment correlated highly with SUVmax/BG (ρ = 0.97, p < 0.001), allowing SUVmax/BG-based calculation of individual thresholds. The method was verified by a subsequent validation study (n = 15, ρ = 0.88, p < 0.01) leading to extensively higher agreement of BTV estimations when compared to histology in contrast to predefined thresholds. [18F]-FET PET with standard SUV measurements is feasible for glioma imaging in the GBM mouse model. PVEC is beneficial to improve accuracy of [18F]-FET PET SUV quantification. Although SUVmax/BG and SUVmean/BG increase during the disease course, these parameters do not correlate with the respective tumor size. For the first time, we propose a histology-verified method allowing appropriate individual BTV estimation for volumetric in vivo monitoring of tumor growth with [18F]-FET PET and show that standardized thresholds from routine clinical practice seem to be inappropriate for BTV estimation in the GBM mouse model.
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Affiliation(s)
- Adrien Holzgreve
- Department of Nuclear Medicine, University Hospital of Munich, Ludwig Maximilians University of MunichMunich, Germany; Department of Neurosurgery, University Hospital of Munich, Ludwig Maximilians University of MunichMunich, Germany
| | - Matthias Brendel
- Department of Nuclear Medicine, University Hospital of Munich, Ludwig Maximilians University of Munich Munich, Germany
| | - Song Gu
- Department of Neurosurgery, University Hospital of Munich, Ludwig Maximilians University of Munich Munich, Germany
| | - Janette Carlsen
- Department of Nuclear Medicine, University Hospital of Munich, Ludwig Maximilians University of Munich Munich, Germany
| | - Erik Mille
- Department of Nuclear Medicine, University Hospital of Munich, Ludwig Maximilians University of Munich Munich, Germany
| | - Guido Böning
- Department of Nuclear Medicine, University Hospital of Munich, Ludwig Maximilians University of Munich Munich, Germany
| | - Giorgia Mastrella
- Department of Neurosurgery, University Hospital of Munich, Ludwig Maximilians University of Munich Munich, Germany
| | - Marcus Unterrainer
- Department of Nuclear Medicine, University Hospital of Munich, Ludwig Maximilians University of Munich Munich, Germany
| | - Franz J Gildehaus
- Department of Nuclear Medicine, University Hospital of Munich, Ludwig Maximilians University of Munich Munich, Germany
| | - Axel Rominger
- Department of Nuclear Medicine, University Hospital of Munich, Ludwig Maximilians University of Munich Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, University Hospital of Munich, Ludwig Maximilians University of Munich Munich, Germany
| | - Roland E Kälin
- Department of Neurosurgery, University Hospital of Munich, Ludwig Maximilians University of Munich Munich, Germany
| | - Rainer Glass
- Department of Neurosurgery, University Hospital of Munich, Ludwig Maximilians University of Munich Munich, Germany
| | - Nathalie L Albert
- Department of Nuclear Medicine, University Hospital of Munich, Ludwig Maximilians University of Munich Munich, Germany
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Potapov AA, Goryaynov SA, Okhlopkov VA, Pitskhelauri DI, Kobyakov GL, Zhukov VY, Gol'bin DA, Svistov DV, Martynov BV, Krivoshapkin AL, Gaytan AS, Anokhina YE, Varyukhina MD, Gol'dberg MF, Kondrashov AV, Chumakova AP. [Clinical guidelines for the use of intraoperative fluorescence diagnosis in brain tumor surgery]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2016; 79:91-101. [PMID: 26528619 DOI: 10.17116/neiro201579591-101] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In this paper, we present a review of current literature on the application of intraoperative fluorescence diagnosis and fluorescence spectroscopy using 5-aminolevulinic acid in surgery for various types of brain tumors, both alone and in combination with other neuroimaging methods. Authors' extensive experience with these methods allowed them to develop a set of clinical guidelines for the use of intraoperative fluorescence diagnosis and fluorescence spectroscopy in surgery of brain tumors.
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Affiliation(s)
- A A Potapov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | | | - G L Kobyakov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - V Yu Zhukov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - D A Gol'bin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - D V Svistov
- Kirov Military Medical Academy, St. Petersburg, Russia
| | - B V Martynov
- Kirov Military Medical Academy, St. Petersburg, Russia
| | | | - A S Gaytan
- Meshalkin Research Institute of Pathology of Circulation, Novosibirsk, Russia
| | - Yu E Anokhina
- Kirov Military Medical Academy, St. Petersburg, Russia
| | - M D Varyukhina
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M F Gol'dberg
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A V Kondrashov
- Sechenov First Moscow State Medical University, Moscow, Russia
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Guyotat J, Pallud J, Armoiry X, Pavlov V, Metellus P. 5-Aminolevulinic Acid-Protoporphyrin IX Fluorescence-Guided Surgery of High-Grade Gliomas: A Systematic Review. Adv Tech Stand Neurosurg 2016:61-90. [PMID: 26508406 DOI: 10.1007/978-3-319-21359-0_3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The current first-line treatment of malignant gliomas consists in surgical resection (if possible) as large as possible. The existing tools don't permit to identify the limits of tumor infiltration, which goes beyond the zone of contrast enhancement on MRI. The fluorescence-guided malignant gliomas surgery was started 15 years ago and had become a standard of care in many countries. The technique is based on fluorescent molecule revelation using the filters, positioned within the surgical microscope. The fluorophore, protoporphyrin IX (PpIX), is converted in tumoral cells from 5-aminolevulinic acid (5-ALA), given orally before surgery. Many studies have shown that the ratio of gross total resections was higher if the fluorescence technique was used. The fluorescence signal intensity is correlated to the cell density and the PpIX concentration. The current method has a very high specificity but still lower sensibility, particularly regarding the zones with poor tumoral infiltration. This book reviews the principles of the technique and the results (extent of resection and survival).
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Affiliation(s)
- Jacques Guyotat
- Department of Neurosurgery, Neurological Hospital, Lyon, France.
| | - Johan Pallud
- Department of Neurosurgery, Sainte Anne Hospital, Paris, France.
- Paris Descartes University, Paris, France.
| | - Xavier Armoiry
- Délégation à la recherche clinique et à l'innovation, cellule innovation Hospices Civils de, Lyon, France.
| | - Vladislav Pavlov
- Department of Neurosurgery, Neurological Hospital, Lyon, France.
| | - Philippe Metellus
- Department of Neurosurgery, Timone Hospital, Marseille, France.
- University Aix Marseille, Marseille, France.
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Abstract
Mounting evidence suggests that a more extensive surgical resection is associated with an improved life expectancy for both low-grade and high-grade glioma patients. However, radiographically complete resections are not often achieved in many cases because of the lack of sensitivity and specificity of current neurosurgical guidance techniques at the margins of diffuse infiltrative gliomas. Intraoperative fluorescence imaging offers the potential to improve the extent of resection and to investigate the possible benefits of resecting beyond the radiographic margins. Here, we provide a review of wide-field and high-resolution fluorescence-imaging strategies that are being developed for neurosurgical guidance, with a focus on emerging imaging technologies and clinically viable contrast agents. The strengths and weaknesses of these approaches will be discussed, as well as issues that are being addressed to translate these technologies into the standard of care.
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Affiliation(s)
- Jonathan T C Liu
- *Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York; ‡Barrow Brain Tumor Research Center, Division of Neurosurgical Oncology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Feng X, Chen A, Zhang Y, Wang J, Shao L, Wei L. Central nervous system toxicity of metallic nanoparticles. Int J Nanomedicine 2015; 10:4321-40. [PMID: 26170667 PMCID: PMC4498719 DOI: 10.2147/ijn.s78308] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Nanomaterials (NMs) are increasingly used for the therapy, diagnosis, and monitoring of disease- or drug-induced mechanisms in the human biological system. In view of their small size, after certain modifications, NMs have the capacity to bypass or cross the blood–brain barrier. Nanotechnology is particularly advantageous in the field of neurology. Examples may include the utilization of nanoparticle (NP)-based drug carriers to readily cross the blood–brain barrier to treat central nervous system (CNS) diseases, nanoscaffolds for axonal regeneration, nanoelectromechanical systems in neurological operations, and NPs in molecular imaging and CNS imaging. However, NPs can also be potentially hazardous to the CNS in terms of nano-neurotoxicity via several possible mechanisms, such as oxidative stress, autophagy, and lysosome dysfunction, and the activation of certain signaling pathways. In this review, we discuss the dual effect of NMs on the CNS and the mechanisms involved. The limitations of the current research are also discussed.
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Affiliation(s)
- Xiaoli Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Aijie Chen
- Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Yanli Zhang
- Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Jianfeng Wang
- School and Hospital of Stomatology, Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Longquan Shao
- Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Limin Wei
- School and Hospital of Stomatology, Wenzhou Medical University, Wenzhou, People's Republic of China
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32
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Valdés PA, Jacobs V, Harris BT, Wilson BC, Leblond F, Paulsen KD, Roberts DW. Quantitative fluorescence using 5-aminolevulinic acid-induced protoporphyrin IX biomarker as a surgical adjunct in low-grade glioma surgery. J Neurosurg 2015; 123:771-80. [PMID: 26140489 DOI: 10.3171/2014.12.jns14391] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECT Previous studies in high-grade gliomas (HGGs) have indicated that protoporphyrin IX (PpIX) accumulates in higher concentrations in tumor tissue, and, when used to guide surgery, it has enabled improved resection leading to increased progression-free survival. Despite the benefits of complete resection and the advances in fluorescence-guided surgery, few studies have investigated the use of PpIX in low-grade gliomas (LGGs). Here, the authors describe their initial experience with 5-aminolevulinic acid (ALA)-induced PpIX fluorescence in a series of patients with LGG. METHODS Twelve patients with presumed LGGs underwent resection of their tumors after receiving 20 mg/kg of ALA approximately 3 hours prior to surgery under an institutional review board-approved protocol. Intraoperative assessments of the resulting PpIX emissions using both qualitative, visible fluorescence and quantitative measurements of PpIX concentration were obtained from tissue locations that were subsequently biopsied and evaluated histopathologically. Mixed models for random effects and receiver operating characteristic curve analysis for diagnostic performance were performed on the fluorescence data relative to the gold-standard histopathology. RESULTS Five of the 12 LGGs (1 ganglioglioma, 1 oligoastrocytoma, 1 pleomorphic xanthoastrocytoma, 1 oligodendroglioma, and 1 ependymoma) demonstrated at least 1 instance of visible fluorescence during surgery. Visible fluorescence evaluated on a specimen-by-specimen basis yielded a diagnostic accuracy of 38.0% (cutoff threshold: visible fluorescence score ≥ 1, area under the curve = 0.514). Quantitative fluorescence yielded a diagnostic accuracy of 67% (for a cutoff threshold of the concentration of PpIX [CPpIX] > 0.0056 μg/ml, area under the curve = 0.66). The authors found that 45% (9/20) of nonvisibly fluorescent tumor specimens, which would have otherwise gone undetected, accumulated diagnostically significant levels of CPpIX that were detected quantitatively. CONCLUSIONS The authors' initial experience with ALA-induced PpIX fluorescence in LGGs concurs with other literature reports that the resulting visual fluorescence has poor diagnostic accuracy. However, the authors also found that diagnostically significant levels of CPpIX do accumulate in LGGs, and the resulting fluorescence emissions are very often below the detection threshold of current visual fluorescence imaging methods. Indeed, at least in the authors' initial experience reported here, if quantitative detection methods are deployed, the diagnostic performance of ALA-induced PpIX fluorescence in LGGs approaches the accuracy associated with visual fluorescence in HGGs.
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Affiliation(s)
- Pablo A Valdés
- Department of Neurosurgery, Brigham and Women's/Boston Children's Hospitals, Harvard Medical School;,Geisel School of Medicine at Dartmouth, Hanover;,Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon;,Thayer School of Engineering, Hanover, New Hampshire
| | - Valerie Jacobs
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts;,Geisel School of Medicine at Dartmouth, Hanover
| | | | - Brian C Wilson
- Ontario Cancer Institute, University of Toronto, Ontario; and
| | - Frederic Leblond
- Department of Engineering Physics, Polytechnique Montreal, Quebec, Canada
| | | | - David W Roberts
- Geisel School of Medicine at Dartmouth, Hanover;,Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon
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Surgery for Glioblastoma: Impact of the Combined Use of 5-Aminolevulinic Acid and Intraoperative MRI on Extent of Resection and Survival. PLoS One 2015; 10:e0131872. [PMID: 26115409 PMCID: PMC4482740 DOI: 10.1371/journal.pone.0131872] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 06/08/2015] [Indexed: 01/01/2023] Open
Abstract
Background There is rising evidence that in glioblastoma(GBM) surgery an increase of extent of resection(EoR) leads to an increase of patient’s survival. Based on histopathological assessments tumor depiction of Gd-DTPA enhancement and 5-aminolevulinic-acid-fluorescence(5-ALA) might be synergistic for intraoperative resection control. Objective To assess impact of additional use of 5-ALA in intraoperative MRI(iMRI) assisted surgery of GBMs on extent of resection(EoR), progression free survival(PFS) and overall survival(OS). Methods We prospectively enrolled 33 patients with GBMs eligible for gross-total-resection(GTR) and performed a combined approach using 5-ALA and iMRI. As a control group, we performed a retrospective matched pair assessment, based on 144 patients with iMRI-assisted surgery. Matching criteria were, MGMT promotor methylation, recurrent surgery, eloquent location, tumor size and age. Only patients with an intended GTR and primary GBMs were included. We calculated Kaplan Mayer estimates to compare OS and PFS using the Log-Rank-Test. We used the T-test to compare volumetric results of EoR and the Chi-Square-Test to compare new permanent neurological deficits(nPND) and general complications between the two groups. Results Median follow up was 31 months. No significant differences between both groups were found concerning the matching criteria. GTR was achieved significantly more often (p <0.010) using 5-ALA&iMRI (100%) compared to iMRI alone(82%). Mean EoR was significantly(p<0.004) higher in 5-ALA&iMRI-group(99.7%) than in iMRI-alone-group(97.4%) Rate of complications did not differ significantly between groups(21% iMRI-group,27%5-ALA&iMRI-group,p<0.518). nPND were found in 6% in both groups. Median PFS (6mo resp.;p<0.309) and median OS(iMRI:17mo;5-ALA&iMRI-group:18mo;p<0.708)) were not significantly different between both groups. Conclusion We found a significant increase of EoR when combining 5-ALA&iMRI compared to use of iMRI alone. Maximizing EoR did not lead to an increase of complications or neurological deficits if used with neurophysiological monitoring in eloquent lesions. No final conclusion can be drawn whether a further increase of EoR benefits patient’s progression free survival and overall survival.
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Ewelt C, Nemes A, Senner V, Wölfer J, Brokinkel B, Stummer W, Holling M. Fluorescence in neurosurgery: Its diagnostic and therapeutic use. Review of the literature. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY B-BIOLOGY 2015; 148:302-309. [PMID: 26000742 DOI: 10.1016/j.jphotobiol.2015.05.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 05/05/2015] [Accepted: 05/07/2015] [Indexed: 12/27/2022]
Abstract
Fluorescent agents, e.g. 5-aminolevulinic acid (5-ALA), fluorescein and indocyanine green (ICG) are in common use in neurosurgery for tumor resection and neurovascular surgery. Protoporphyrine IX (PPIX) as major metabolite of 5-ALA is a strong fluorescent substance accumulated within malignant glioma tissue and a very sensitive and specific tool for visualizing high grade glioma tissue during surgery. Furthermore, 5-ALA or rather PPIX also offers an intratumoral therapeutic option stimulated by laser light in specific wavelength. Fluorescein was demonstrated to show similar fluorescent reactions in neurosurgery, but is controversial in its use, especially in high grade tumor surgery. Intraoperative angiography during resection of arterio-venous malformations, extracranial-intracranial-bypass or aneurysm surgery is supported by ICG fluorescence. Generally ICG will provide beneficial information for both, exposure of the pathology and illustration of healthy structures. This manuscript shows an overview of the literature focussing fluorescence in neurosurgery.
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Affiliation(s)
- Christian Ewelt
- Department of Neurosurgery, University Hospital, Münster, Germany.
| | - Andrei Nemes
- Institute of Neuropathology, University Hospital, Münster, Germany
| | - Volker Senner
- Institute of Neuropathology, University Hospital, Münster, Germany
| | - Johannes Wölfer
- Department of Neurosurgery, University Hospital, Münster, Germany
| | | | - Walter Stummer
- Department of Neurosurgery, University Hospital, Münster, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital, Münster, Germany
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Misch M, Guggemos A, Driever PH, Koch A, Grosse F, Steffen IG, Plotkin M, Thomale UW. (18)F-FET-PET guided surgical biopsy and resection in children and adolescence with brain tumors. Childs Nerv Syst 2015; 31:261-7. [PMID: 25231277 DOI: 10.1007/s00381-014-2552-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 09/03/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE MRI alone has its limitations for target selection in biopsy or resection in newly diagnosed and pretreated pediatric brain tumor patients. (18)F-FET-PET imaging is considered to identify metabolically active tumor tissue and to differentiate it from therapy-associated changes. We retrospectively analyzed our experience with (18)F-FET-PET in targeted surgical interventions for pediatric brain tumors. METHODS In 26 cases with lesions suspicious of a growing brain tumor on MRI, either newly diagnosed or after antitumoral treatment led to (18)F-FET-PET imaging for target selection prior to stereotactic biopsy, navigated open biopsy or navigated microsurgical tumor resection. Indications for (18)F-FET-PET imaging were visualization of metabolic active tumor tissue within diffuse tumors or pretreated lesions as well as depicting their extent. RESULTS (18)F-FET-PET integration in surgery was feasible in all patients using stereotaxy or neuronavigation. Sensitivity for tumor detection was 20/24. (18)F-FET-PET was false positive in two pretreated patients. CONCLUSION (18)F-FET-PET imaging is helpful for target selection and can be integrated in surgical guidance. (18)F-FET-PET image-guided surgical targeting yielded histological diagnosis with decent specificity and high sensitivity in our cohort of pediatric brain tumor patients. Our results warrant further evaluation of (18)F-FET-PET imaging for surgical guidance.
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Affiliation(s)
- Martin Misch
- Department of Neurosurgery, Charité Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Oh SJ, Kim SH, Ji YB, Jeong K, Park Y, Yang J, Park DW, Noh SK, Kang SG, Huh YM, Son JH, Suh JS. Study of freshly excised brain tissues using terahertz imaging. BIOMEDICAL OPTICS EXPRESS 2014; 5:2837-42. [PMID: 25136506 PMCID: PMC4133010 DOI: 10.1364/boe.5.002837] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 07/03/2014] [Accepted: 07/23/2014] [Indexed: 05/19/2023]
Abstract
We demonstrated that tumors in freshly excised whole brain tissue could be differentiated clearly from normal brain tissue using a reflection-type terahertz (THz) imaging system. THz binary images of brain tissues with tumors indicated that the tumor boundaries in the THz images corresponded well to those in visible images. Grey and white-matter regions were distinguishable owing to the different distribution of myelin in the brain tissue. THz images corresponded closely with magnetic resonance imaging (MRI) results. The MRI and hematoxylin and eosin-stained microscopic images were investigated to account for the intensity differences in the THz images for fresh and paraffin-embedded brain tissue. Our results indicated that the THz signals corresponded to the cell density when water was removed. Thus, THz imaging could be used as a tool for label-free and real-time imaging of brain tumors, which would be helpful for physicians to determine tumor margins during brain surgery.
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Affiliation(s)
- Seung Jae Oh
- YUMS-KRIBB Medical Convergence Research Institute, College of Medicine, Yonsei University, Seoul 120-752, South Korea
| | - Sang-Hoon Kim
- YUMS-KRIBB Medical Convergence Research Institute, College of Medicine, Yonsei University, Seoul 120-752, South Korea
| | - Young Bin Ji
- Yonsei Institute of Convergence Technology, Yonsei University, Seoul 120-752, South Korea
| | - Kiyoung Jeong
- Nanomedical National Core Research Center, Yonsei University, Seoul 120-749, South Korea
| | - Yeonji Park
- YUMS-KRIBB Medical Convergence Research Institute, College of Medicine, Yonsei University, Seoul 120-752, South Korea
| | - Jaemoon Yang
- Department of Radiology, College of Medicine, Yonsei University, Seoul 120-752, South Korea
| | - Dong Woo Park
- Nano Materials Evaluation Center, Korea Research Institute of Standards and Science, Daejeon 305-340, South Korea
| | - Sam Kyu Noh
- Nano Materials Evaluation Center, Korea Research Institute of Standards and Science, Daejeon 305-340, South Korea
| | - Seok-Gu Kang
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, South Korea
| | - Yong-Min Huh
- YUMS-KRIBB Medical Convergence Research Institute, College of Medicine, Yonsei University, Seoul 120-752, South Korea
- Department of Radiology, College of Medicine, Yonsei University, Seoul 120-752, South Korea
| | - Joo-Hiuk Son
- Department of Physics, University of Seoul, Seoul 130-743, South Korea
| | - Jin-Suck Suh
- YUMS-KRIBB Medical Convergence Research Institute, College of Medicine, Yonsei University, Seoul 120-752, South Korea
- Department of Radiology, College of Medicine, Yonsei University, Seoul 120-752, South Korea
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Abstract
Although glioblastoma occurs mostly in elderly patients, there is a paucity of trials addressing patients older than 70 years of age. Age, by itself, constitutes an unfavorable prognostic factor, which is probably due to unpropitious genetic features, but also due to iatrogenic defeatism. However, many retrospective studies report a survival benefit achieved by aggressive surgical resection seeking gross total removal of contrast-enhancing tumor according to preoperative MRI. Combined radiochemotherapy with concomitant and adjuvant temozolomide has not been investigated in prospective trials. Numerous retrospective studies and a meta-analysis suggest benefit from combined treatment. Prospective randomized trials only evaluated either temozolomide or radiotherapy. Single-treatment hypofractionated radiotherapy performed superior to conventional fractionation. In patients with methylated MGMT promoter, first-line dose-dense temozolomide facilitates prolonged survival. However, there is no comparison with combined radiochemotherapy as the standard-of-care in adult patients. Comorbidity is more frequent in elderly patients, but does not correlate with preterm termination of temozolomide treatment. This review article compiles data proposing a straightforward glioblastoma treatment, irrespective of age.
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Affiliation(s)
- Florian Stockhammer
- Department of Neurosurgery, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37075 Göttingen, Germany
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Jaaskelainen JE. Role of intraoperative neurophysiological monitoring during fluorescence-guided resection surgery : Aiming at seemingly complete resection of diffuse gliomas under 5-ALA guidance-Is it safe? Acta Neurochir (Wien) 2013; 155:2215-6. [PMID: 24018982 DOI: 10.1007/s00701-013-1865-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Accepted: 08/25/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Juha E Jaaskelainen
- Neurosurgery, Kuopio University Hospital, P.O. Box 1777, Kuopio, 70211, Finland,
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Stockhammer F. What does fluorescence depict in glioma surgery? Acta Neurochir (Wien) 2013; 155:1479-80. [PMID: 23797731 DOI: 10.1007/s00701-013-1798-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 06/07/2013] [Indexed: 10/26/2022]
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Langen KJ, Floeth FW, Galldiks N. Sensitivity of intraoperative 5-aminolevulinic acid fluorescence compared with PET using O-(2-¹⁸F-fluoroethyl)-L-tyrosine to detect cerebral gliomas. Neurol Res 2013; 35:329-30. [PMID: 23485058 DOI: 10.1179/1743132812y.0000000140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Colditz MJ, Jeffree RL. Aminolevulinic acid (ALA)-protoporphyrin IX fluorescence guided tumour resection. Part 1: Clinical, radiological and pathological studies. J Clin Neurosci 2012; 19:1471-4. [PMID: 22959448 DOI: 10.1016/j.jocn.2012.03.009] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 03/10/2012] [Indexed: 11/19/2022]
Abstract
The intraoperative identification and resection of glioma is a significant and important challenge in neurosurgery. Complete resection of the enhancing tumour increases the median survival time in glioblastoma compared to partial glioma resection; however, it is achieved in fewer than half of eligible patients when conventional tumour identification methods are used. Increasing the incidence of complete resection, without causing excess morbidity, requires new methods to accurately identify neoplastic tissue intraoperatively, such as use of the drug 5-amino-levulinic acid (ALA). After ALA ingestion, the fluorescent molecule protoporphyrin IX (PpIX) accumulates in high grade glioma, allowing the neurosurgeon to more easily detect and accurately resect tumour. The utility of ALA has been demonstrated in a large, multicentre phase III randomised control trial of 243 patients with high grade glioma. ALA use led to a significant increase in the incidence of complete resection (65% compared to 36%), improved progression-free survival at 6 months (41% compared to 21%), fewer reinterventions, and delayed onset of neurological deterioration. This review provides a broad assessment of ALA-PpIX fluorescence-guided resection, with Part 1 focusing on its clinical efficacy, and correlations with imaging and histology. The theoretical, biochemical and practical aspects of ALA use are reviewed in Part 2.
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Affiliation(s)
- Michael J Colditz
- Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane & Women's Hospital, Herston, Queensland 4029, Australia
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MRI-suspected low-grade glioma: is there a need to perform dynamic FET PET? Eur J Nucl Med Mol Imaging 2012; 39:1021-9. [PMID: 22491781 DOI: 10.1007/s00259-012-2109-9] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Accepted: 03/02/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Since differentiation between low-grade glioma (LGG) and high-grade glioma (HGG) remains challenging according to MRI criteria alone, we investigated the discriminative value of additional dynamic FET PET in patients with MRI-suspected LGG. METHODS Included in this retrospective study were 127 patients with newly diagnosed MRI-suspected LGG and dynamic FET PET prior to histopathological assessment. FET PET lesions were visually classified as having reduced, normal, or increased tracer uptake. Maximal tumour uptake scaled to the mean background uptake (SUV(max)/BG), mean tumour uptake (SUV(mean)/BG), biological tumour volume and kinetics were evaluated and correlated with individual histopathological findings. RESULTS Histopathological analysis revealed 71 patients with LGG, 47 patients with HGG (including 5 glioblastoma multiforme), 2 patients with low-grade ganglioglioma and 7 patients with non-neoplastic lesions. Of the 127 patients, 97 had lesions with increased FET uptake, of which 93 were neoplastic. Increased uptake was found in 49/71 LGG (69 %) and 42/47 HGG (89 %). None of the conventional uptake parameters differed significantly between the HGG and LGG groups. Kinetic analysis reliably identified HGG (sensitivity 95 %, specificity 72 %, PPV 74 %, NPV 95 %). Normal tracer uptake was observed in 19 patients (15 with LGG, 1 with HGG and 3 with non-neoplastic lesions) and reduced uptake in 11 patients (7 with LGG and 4 with HGG). CONCLUSION Among the MRI-suspected LGG, kinetic but not conventional analysis of FET uptake enabled remarkably high sensitivity for detection of HGG. This held true even for lesions with low or diffuse tracer uptake. Lesions with reduced tracer uptake must be interpreted with caution, as they can also harbour HGG tissue.
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Roessler K, Becherer A, Donat M, Cejna M, Zachenhofer I. Intraoperative tissue fluorescence using 5-aminolevolinic acid (5-ALA) is more sensitive than contrast MRI or amino acid positron emission tomography ((18)F-FET PET) in glioblastoma surgery. Neurol Res 2012; 34:314-7. [PMID: 22449387 DOI: 10.1179/1743132811y.0000000078] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The sensitivity of 5-aminolevolinic acid (5-ALA) in detecting intraoperative glioblastoma (GBM) tissue compared to postoperative (18)F-fluoroethyl-L-tyrosine and T1 contrast uptake of tumor cells in positron emission tomography (PET) and magnetic resonance imaging (MRI) scans was investigated in a retrospective image correlative study. METHODS Ten patients with histological verified GBM in eloquent brain regions underwent 11 surgeries with neuronavigation and 5-ALA assisted tumor resection. Residual 5-ALA fluorescence was labeled intraoperatively on the navigation MRI scans and images were fused with postoperative (18)F-FET PET and T1 contrast MRI. RESULTS Intraoperatively, at the end of save resection, in all patients 2-5 faint 5-ALA positive resection planes were detected (mean 3·6), compared to 0-4 (18)F-FET positive resection planes (mean 1·4) and 0-2 positive T1 contrast MRI resection planes in postoperative scans. The difference between the number of 5-ALA and (18)F-FET positive resection planes was statistically significant (P = 0·0002). The histological investigation of 5-ALA positive resection margins demonstrated infiltrative tumor in every case. Residual 5-ALA fluorescence on resection margins and postoperative (18)F-FET uptake areas or residual contrast T1 areas were colocalized in all cases, documented by pre-/postoperative image fusion. CONCLUSION Residual faint 5ALA uptake is documented in large areas at the end of GBM resection and corresponds to tumor infiltration. These 5-ALA positive resection plans exceeded the (18)F-FET uptake areas in postoperative PET scans. Thus, intraoperative 5-ALA residual fluorescence seems to be a more sensitive marker than (18)F-FET PET for residual tumor in malignant gliomas.
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Affiliation(s)
- Karl Roessler
- Department of Neurosurgery, Academic Teaching Hospital, Feldkirch, Austria
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Cellular-based immunotherapies for patients with glioblastoma multiforme. Clin Dev Immunol 2012; 2012:764213. [PMID: 22474481 PMCID: PMC3299309 DOI: 10.1155/2012/764213] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 12/08/2011] [Indexed: 12/30/2022]
Abstract
Treatment of patients with glioblastoma multiforme (GBM) remains to be a challenge with a median survival of 14.6 months following diagnosis. Standard treatment options include surgery, radiation therapy, and systemic chemotherapy with temozolomide. Despite the fact that the brain constitutes an immunoprivileged site, recent observations after immunotherapies with lysate from autologous tumor cells pulsed on dendritic cells (DCs), peptides, protein, messenger RNA, and cytokines suggest an immunological and even clinical response from immunotherapies. Given this plethora of immunomodulatory therapies, this paper gives a structure overview of the state-of-the art in the field. Particular emphasis was also put on immunogenic antigens as potential targets for a more specific stimulation of the immune system against GBM.
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Sarantopoulos A, Beziere N, Ntziachristos V. Optical and Opto-Acoustic Interventional Imaging. Ann Biomed Eng 2012; 40:346-66. [DOI: 10.1007/s10439-011-0501-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 12/23/2011] [Indexed: 12/20/2022]
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Cornelius JF, Langen KJ, Stoffels G, Hänggi D, Sabel M, Steiger HJ. Positron Emission Tomography Imaging of Meningioma in Clinical Practice. Neurosurgery 2011; 70:1033-41; discussion 1042. [DOI: 10.1227/neu.0b013e31823bcd87] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Meningiomas represent about 20% of intracranial tumors and are the most frequent nonglial primary brain tumors. Diagnosis is based on computed tomography (CT) and magnetic resonance imaging (MRI). Mainstays of therapy are surgery and radiotherapy. Adjuvant chemotherapy is tested in clinical trials of phase II. Patients are followed clinically by imaging. However, classical imaging modalities such as CT and MRI have limitations. Hence, we need supplementary imaging tools. Molecular imaging modalities, especially positron emission tomography (PET), represent promising new instruments that are able to characterize specific metabolic features. So far, these modalities have only been part of limited study protocols, and their impact on clinical routine management is still under investigation. It may be expected that their extended use will provide new aspects about meningioma imaging and biology.
In the present article, we summarize PET imaging for meningiomas based on a thorough review of the literature. We discuss and illustrate the potential role of PET imaging in the clinical management of meningiomas. Finally, we indicate current limitations and outline directions for future research.
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Affiliation(s)
- Jan Frederick Cornelius
- Neurochirurgische Klinik, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Karl Josef Langen
- Institut für Medizin, Forschungszentrum Jülich, Heinrich-Heine-Universität, Jülich, Germany
| | - Gabriele Stoffels
- Institut für Medizin, Forschungszentrum Jülich, Heinrich-Heine-Universität, Jülich, Germany
| | - Daniel Hänggi
- Neurochirurgische Klinik, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Michael Sabel
- Neurochirurgische Klinik, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Hans Jakob Steiger
- Neurochirurgische Klinik, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Germany
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Ewelt C, Floeth FW, Felsberg J, Steiger HJ, Sabel M, Langen KJ, Stoffels G, Stummer W. Finding the anaplastic focus in diffuse gliomas: The value of Gd-DTPA enhanced MRI, FET-PET, and intraoperative, ALA-derived tissue fluorescence. Clin Neurol Neurosurg 2011; 113:541-7. [DOI: 10.1016/j.clineuro.2011.03.008] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Revised: 02/13/2011] [Accepted: 03/19/2011] [Indexed: 10/18/2022]
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Arita H, Kinoshita M, Kagawa N, Fujimoto Y, Kishima H, Hashimoto N, Yoshimine T. ¹¹C-methionine uptake and intraoperative 5-aminolevulinic acid-induced fluorescence as separate index markers of cell density in glioma: a stereotactic image-histological analysis. Cancer 2011; 118:1619-27. [PMID: 21837671 DOI: 10.1002/cncr.26445] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 05/13/2011] [Accepted: 06/27/2011] [Indexed: 11/06/2022]
Abstract
BACKGROUND The extent of tumor resection is acknowledged as 1 of the prognostic factors for glioma. 5-Aminolevulinic acid (5-ALA)-induced fluorescence guidance and neuronavigation integrated with (11) C-methionine positron emission tomography (PET) are widely utilized under the expectation of improving the extent of resection. These 2 novel approaches are beneficial for glioma resections, and the combination of these approaches appears rational. However, biological characteristics reflecting 5-ALA-induced fluorescence and (11) C-methionine uptake have not been clearly elucidated, and studies about the relationship between 5-ALA-induced fluorescence and (11) C-methionine uptake have been limited. The present study aimed to clarify this issue. METHODS Data from 11 consecutive patients harboring astrocytic tumors were analyzed: 2 grade II and 2 grade III, and 7 grade IV tumors were included. Thirty samples from these patients were obtained from the relative periphery of each tumor. Relationships among histology, 5-ALA-induced fluorescence and (11) C-methionine uptake were analyzed by stereotactic sampling and image analysis. RESULTS Uptake of (11) C-methionine correlated with cell density (R(2) = 0.322, P = .0059). Cell density was higher in fluorescence-positive areas than in negative areas (2760 ± 1080 vs 1450 ± 1380/mm(2) , P = .0132). Although both (11) C-methionine uptake and fluorescence seemed to correlate with cell density, no significant difference in (11) C-methionine uptake was seen between fluorescence-positive and -negative areas (P = .367). Multiple linear regression analysis revealed (11) C-methionine uptake and 5-ALA-induced fluorescence as independent indices for tumor cell density. CONCLUSIONS These results indicate that 5-ALA fluorescence and (11) C-methionine PET image are separate index markers for cytoreduction surgery of gliomas.
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Affiliation(s)
- Hideyuki Arita
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Sanai N, Snyder LA, Honea NJ, Coons SW, Eschbacher JM, Smith KA, Spetzler RF. Intraoperative confocal microscopy in the visualization of 5-aminolevulinic acid fluorescence in low-grade gliomas. J Neurosurg 2011; 115:740-8. [PMID: 21761971 DOI: 10.3171/2011.6.jns11252] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Greater extent of resection (EOR) for patients with low-grade glioma (LGG) corresponds with improved clinical outcome, yet remains a central challenge to the neurosurgical oncologist. Although 5-aminolevulinic acid (5-ALA)-induced tumor fluorescence is a strategy that can improve EOR in gliomas, only glioblastomas routinely fluoresce following 5-ALA administration. Intraoperative confocal microscopy adapts conventional confocal technology to a handheld probe that provides real-time fluorescent imaging at up to 1000× magnification. The authors report a combined approach in which intraoperative confocal microscopy is used to visualize 5-ALA tumor fluorescence in LGGs during the course of microsurgical resection. METHODS Following 5-ALA administration, patients with newly diagnosed LGG underwent microsurgical resection. Intraoperative confocal microscopy was conducted at the following points: 1) initial encounter with the tumor; 2) the midpoint of tumor resection; and 3) the presumed brain-tumor interface. Histopathological analysis of these sites correlated tumor infiltration with intraoperative cellular tumor fluorescence. RESULTS Ten consecutive patients with WHO Grades I and II gliomas underwent microsurgical resection with 5-ALA and intraoperative confocal microscopy. Macroscopic tumor fluorescence was not evident in any patient. However, in each case, intraoperative confocal microscopy identified tumor fluorescence at a cellular level, a finding that corresponded to tumor infiltration on matched histological analyses. CONCLUSIONS Intraoperative confocal microscopy can visualize cellular 5-ALA-induced tumor fluorescence within LGGs and at the brain-tumor interface. To assess the clinical value of 5-ALA for high-grade gliomas in conjunction with neuronavigation, and for LGGs in combination with intraoperative confocal microscopy and neuronavigation, a Phase IIIa randomized placebo-controlled trial (BALANCE) is underway at the authors' institution.
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Affiliation(s)
- Nader Sanai
- Barrow Brain Tumor Research Center, Barrow Neurological Institute, Phoenix, Arizona 85013, USA.
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la Fougère C, Suchorska B, Bartenstein P, Kreth FW, Tonn JC. Molecular imaging of gliomas with PET: opportunities and limitations. Neuro Oncol 2011; 13:806-19. [PMID: 21757446 DOI: 10.1093/neuonc/nor054] [Citation(s) in RCA: 190] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Neuroimaging enables the noninvasive evaluation of glioma and is considered to be one of the key factors for individualized therapy and patient management, since accurate diagnosis and demarcation of viable tumor tissue is required for treatment planning as well as assessment of treatment response. Conventional imaging techniques like MRI and CT reveal morphological information but are of limited value for the assessment of more specific and reproducible information about biology and activity of the tumor. Molecular imaging with PET is increasingly implemented in neuro-oncology, since it provides additional metabolic information of the tumor, both for patient management as well as for evaluation of newly developed therapeutics. Different molecular processes have been proposed to be useful, like glucose consumption, expression of amino acid transporters, proliferation rate, membrane biosynthesis, and hypoxia. Thus, PET might help neuro-oncologists gain further insights into tumor biology by "true molecular imaging" as well as understand treatment-related phenomena. This review describes the method of PET acquisition as well as the tracers used to image biological processes in gliomas. Furthermore, it considers the clinical impact of PET on the use of currently available radiotracers, which were shown to be potentially valuable for discrimination between neoplastic and nonneoplastic tissue, as well as on tumor grading, determinination of treatment response, and providing an outlook toward further developments.
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Affiliation(s)
- Christian la Fougère
- Department of Nuclear Medicine, University of Munich – Campus Grosshadern, Marchioninistr 15, 81377 Munich, Germany
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