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Picart T, Gautheron A, Caredda C, Ray C, Mahieu-Williame L, Montcel B, Guyotat J. Fluorescence-Guided Surgical Techniques in Adult Diffuse Low-Grade Gliomas: State-of-the-Art and Emerging Techniques: A Systematic Review. Cancers (Basel) 2024; 16:2698. [PMID: 39123426 PMCID: PMC11311317 DOI: 10.3390/cancers16152698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 07/26/2024] [Accepted: 07/28/2024] [Indexed: 08/12/2024] Open
Abstract
Diffuse low-grade gliomas are infiltrative tumors whose margins are not distinguishable from the adjacent healthy brain parenchyma. The aim was to precisely examine the results provided by the intraoperative use of macroscopic fluorescence in diffuse low-grade gliomas and to describe the new fluorescence-based techniques capable of guiding the resection of low-grade gliomas. Only about 20% and 50% of low-grade gliomas are macroscopically fluorescent after 5-amino-levulinic acid (5-ALA) or fluorescein sodium intake, respectively. However, 5-ALA is helpful for detecting anaplastic foci, and thus choosing the best biopsy targets in diffuse gliomas. Spectroscopic detection of 5-ALA-induced fluorescence can detect very low and non-macroscopically visible concentrations of protoporphyrin IX, a 5-ALA metabolite, and, consequently, has excellent performances for the detection of low-grade gliomas. Moreover, these tumors have a specific spectroscopic signature with two fluorescence emission peaks, which is useful for distinguishing them not only from healthy brain but also from high-grade gliomas. Confocal laser endomicroscopy can generate intraoperative optic biopsies, but its sensitivity remains limited. In the future, the coupled measurement of autofluorescence and induced fluorescence, and the introduction of fluorescence detection technologies providing a wider field of view could result in the development of operator-friendly tools implementable in the operative routine.
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Affiliation(s)
- Thiebaud Picart
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Groupe Hospitalier Est, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500 Bron, France
- Faculty of Medicine Lyon Est, Université Claude Bernard Lyon 1, 8 Avenue Rockefeller, 69003 Lyon, France
- Cancer Research Centre of Lyon (CRCL) Inserm 1052, CNRS 5286, 28 Rue Laennec, 69008 Lyon, France
| | - Arthur Gautheron
- Laboratoire Hubert Curien UMR 5516, Institut d’Optique Graduate School, CNRS, Université Jean Monnet Saint-Etienne, 42023 Saint-Etienne, France;
- CREATIS CNRS, Inserm, UMR 5220, U1294, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, 69100 Lyon, France; (C.C.); (C.R.); (L.M.-W.); (B.M.)
| | - Charly Caredda
- CREATIS CNRS, Inserm, UMR 5220, U1294, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, 69100 Lyon, France; (C.C.); (C.R.); (L.M.-W.); (B.M.)
| | - Cédric Ray
- CREATIS CNRS, Inserm, UMR 5220, U1294, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, 69100 Lyon, France; (C.C.); (C.R.); (L.M.-W.); (B.M.)
| | - Laurent Mahieu-Williame
- CREATIS CNRS, Inserm, UMR 5220, U1294, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, 69100 Lyon, France; (C.C.); (C.R.); (L.M.-W.); (B.M.)
| | - Bruno Montcel
- CREATIS CNRS, Inserm, UMR 5220, U1294, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, 69100 Lyon, France; (C.C.); (C.R.); (L.M.-W.); (B.M.)
| | - Jacques Guyotat
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Groupe Hospitalier Est, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500 Bron, France
- Faculty of Medicine Lyon Est, Université Claude Bernard Lyon 1, 8 Avenue Rockefeller, 69003 Lyon, France
- CREATIS CNRS, Inserm, UMR 5220, U1294, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, 69100 Lyon, France; (C.C.); (C.R.); (L.M.-W.); (B.M.)
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2
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Gautheron A, Bernstock JD, Picart T, Guyotat J, Valdés PA, Montcel B. 5-ALA induced PpIX fluorescence spectroscopy in neurosurgery: a review. Front Neurosci 2024; 18:1310282. [PMID: 38348134 PMCID: PMC10859467 DOI: 10.3389/fnins.2024.1310282] [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: 10/09/2023] [Accepted: 01/02/2024] [Indexed: 02/15/2024] Open
Abstract
The review begins with an overview of the fundamental principles/physics underlying light, fluorescence, and other light-matter interactions in biological tissues. It then focuses on 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX) fluorescence spectroscopy methods used in neurosurgery (e.g., intensity, time-resolved) and in so doing, describe their specific features (e.g., hardware requirements, main processing methods) as well as their strengths and limitations. Finally, we review current clinical applications and future directions of 5-ALA-induced protoporphyrin IX (PpIX) fluorescence spectroscopy in neurosurgery.
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Affiliation(s)
- A. Gautheron
- Université Jean Monnet Saint-Etienne, CNRS, Institut d Optique Graduate School, Laboratoire Hubert Curien UMR 5516, Saint-Étienne, France
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1294, Lyon, France
| | - J. D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - T. Picart
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, INSERM 1052, CNRS 5286, Lyon, France
| | - J. Guyotat
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | - P. A. Valdés
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, United States
- Department of Neurobiology, University of Texas Medical Branch, Galveston, TX, United States
- Department of Electrical and Computer Engineering, Rice University, Houston, TX, United States
| | - B. Montcel
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1294, Lyon, France
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3
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Herta J, Cho A, Roetzer-Pejrimovsky T, Höftberger R, Marik W, Kronreif G, Peilnsteiner T, Rössler K, Wolfsberger S. Optimizing maximum resection of glioblastoma: Raman spectroscopy versus 5-aminolevulinic acid. J Neurosurg 2023; 139:334-343. [PMID: 36681953 DOI: 10.3171/2022.11.jns22693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 11/16/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The objective of this study was to assess and compare the potential of 5-aminolevulinic acid (5-ALA) and Raman spectroscopy (RS) in detecting tumor-infiltrated brain in patients with glioblastoma (GBM). METHODS Between July 2020 and October 2021, the authors conducted a prospective clinical trial with 15 patients who underwent neurosurgical treatment of newly diagnosed and histologically verified GBM. A solid contrast-enhancing tumor core and peritumoral tissue were investigated intraoperatively for cancer cells by using 5-ALA and RS to achieve pathology-tailored maximum resection. In each case, a minimum of 10 biopsies were sampled from navigation-guided areas. Two neuropathologists examined the biopsies for the presence of neoplastic cells. The detection performance of 5-ALA and RS alone and in combination was assessed. Pre- and postoperative MRI, Karnofsky Performance Status (KPS), and National Institutes of Health Stroke Scale (NIHSS) scores were compared, and median progression-free survival (PFS) was evaluated. RESULTS A total of 185 biopsy samples were harvested from the contrast-enhancing tumor core (n = 19) and peritumoral tissue (n = 166). In the tumor core, 5-ALA and RS each showed a sensitivity of 100%. In the peritumoral tissue, 5-ALA was less sensitive than RS in detecting cancer (46% vs 69%) but showed higher specificity (81% vs 57%). When the two methods were combined, the accuracy of tumor detection was increased by about 10%. Pathology-tailored resection led to a 52% increase in resection volume comparing the volume of preoperative contrast enhancement with the postoperative resection cavity on MRI (p = 0.0123). Eloquent brain involvement prevented gross-total resection in 4 patients. Four weeks after surgery, mean KPS (p = 0.7637) and NIHSS scores (p = 0.3146) were not significantly different from preoperative values. Of the 13 patients who had received postoperative chemoradiotherapy, 4 did not show any progression after a median follow-up of 14 months. The remaining 9 patients had a median PFS of 8 months. CONCLUSIONS According to the study data, RS is capable of detecting tumor-infiltrated brain with higher sensitivity but lower specificity than the current standard of 5-ALA. With further technological and workflow advancements, RS in combination with protoporphyrin IX fluorescence may contribute to pathology-tailored glioma resection in the future.
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Affiliation(s)
- Johannes Herta
- 1Department of Neurosurgery, Medical University of Vienna
| | - Anna Cho
- 1Department of Neurosurgery, Medical University of Vienna
| | | | - Romana Höftberger
- 2Department of Neurology, Division of Neuropathology and Neurochemistry, Medical University of Vienna
| | - Wolfgang Marik
- 3Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna; and
| | - Gernot Kronreif
- 4Austrian Center for Medical Innovation and Technology (ACMIT), Wiener Neustadt, Austria
| | | | - Karl Rössler
- 1Department of Neurosurgery, Medical University of Vienna
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4
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Walke A, Black D, Valdes PA, Stummer W, König S, Suero-Molina E. Challenges in, and recommendations for, hyperspectral imaging in ex vivo malignant glioma biopsy measurements. Sci Rep 2023; 13:3829. [PMID: 36882505 PMCID: PMC9992662 DOI: 10.1038/s41598-023-30680-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 02/28/2023] [Indexed: 03/09/2023] Open
Abstract
The visualization of protoporphyrin IX (PPIX) fluorescence with the help of surgical microscopes during 5-aminolevulinic acid-mediated fluorescence-guided resection (FGR) of gliomas is still limited at the tumor margins. Hyperspectral imaging (HI) detects PPIX more sensitively but is not yet ready for intraoperative use. We illustrate the current status with three experiments and summarize our own experience using HI: (1) assessment of HI analysis algorithm using pig brain tissue, (2) a partially retrospective evaluation of our experience from HI projects, and (3) device comparison of surgical microscopy and HI. In (1), we address the problem that current algorithms for evaluating HI data are based on calibration with liquid phantoms, which have limitations. Their pH is low compared to glioma tissue; they provide only one PPIX photo state and only PPIX as fluorophore. Testing the HI algorithm with brain homogenates, we found proper correction for optical properties but not pH. Considerably more PPIX was measured at pH 9 than at pH 5. In (2), we indicate pitfalls and guide HI application. In (3), we found HI superior to the microscope for biopsy diagnosis (AUC = 0.845 ± 0.024 (cut-off 0.75 µg PPIX/ml) vs. 0.710 ± 0.035). HI thus offers potential for improved FGR.
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Affiliation(s)
- Anna Walke
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany.,Core Unit Proteomics, Interdisciplinary Centre for Clinical Research, University of Münster, Münster, Germany
| | - David Black
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, Canada
| | - Pablo A Valdes
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
| | - Simone König
- Core Unit Proteomics, Interdisciplinary Centre for Clinical Research, University of Münster, Münster, Germany
| | - Eric Suero-Molina
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany.
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Correlation of Intraoperative 5-ALA-Induced Fluorescence Intensity and Preoperative 11C-Methionine PET Uptake in Glioma Surgery. Cancers (Basel) 2022; 14:cancers14061449. [PMID: 35326600 PMCID: PMC8946621 DOI: 10.3390/cancers14061449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/01/2022] [Accepted: 03/08/2022] [Indexed: 12/14/2022] Open
Abstract
Simple Summary In malignant brain tumor surgery, precise identification of the tumor is essential. 5-Aminolevulinic acid (5-ALA) labels tumor cells with red fluorescence to facilitate tumor resection. On the other hand, the nuclear medicine imaging technique, positron emission tomography with 11C-methionine (MET-PET), can delineate tumors precisely but is not widely available. This study aimed to determine the correlation between intraoperative 5-ALA-induced fluorescence and preoperative MET-PET signals of gliomas. We quantitatively measured the fluorescence intensity from tumor samples and calculated the MET-PET uptake by the tumor. Our study showed that strong tumor fluorescence correlated with high MET-PET uptake and cellular proliferation. Our findings might be valuable to rapidly provide information on tumor biology at the time of surgery in circumstances where MET-PET is inaccessible. Abstract Background: 5-Aminolevulinic acid (5-ALA) is widely employed to assist fluorescence-guided surgery for malignant brain tumors. Positron emission tomography with 11C-methionine (MET-PET) represents the activity of brain tumors with precise boundaries but is not readily available. We hypothesized that quantitative 5-ALA-induced fluorescence intensity might correlate with MET-PET uptake in gliomas. Methods: Adult patients with supratentorial astrocytic gliomas who underwent preoperative MET-PET and surgical tumor resection using 5-ALA were enrolled in this prospective study. The regional tumor uptake of MET-PET was expressed as the ratio of standardized uptake volume max to that of the normal contralateral frontal lobe. A spectrometric fluorescence detection system measured tumor specimens’ ex vivo fluorescence intensity at 635 nm. Ki-67 index and IDH mutation status were assessed by histopathological analysis. Use of an antiepileptic drug (AED) and contrast enhancement pattern on MRI were also investigated. Results: Thirty-two patients, mostly with Glioblastoma IDH wild type (46.9%) and anaplastic astrocytoma IDH mutant (21.9%), were analyzed. When the fluorescence intensity was ranked into four groups, the strongest fluorescence group exhibited the highest mean MET-PET uptake and Ki-67 index values. When rearranged into fluorescence Visible or Non-visible groups, the Visible group had significantly higher MET-PET uptake and Ki-67 index compared to the Non-visible group. Contrast enhancement on MRI and IDH wild type tumors were more frequent among the Visible group. AED use did not correlate with 5-ALA-induced fluorescence intensity. Conclusions: In astrocytic glioma surgery, visible 5-ALA-induced fluorescence correlated with high MET-PET uptake, along with a high Ki-67 index.
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6
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Characterization of autofluorescence and quantitative protoporphyrin IX biomarkers for optical spectroscopy-guided glioma surgery. Sci Rep 2021; 11:20009. [PMID: 34625597 PMCID: PMC8501114 DOI: 10.1038/s41598-021-99228-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/14/2021] [Indexed: 01/04/2023] Open
Abstract
5-Aminolevulinic acid (5-ALA)-mediated fluorescence does not effectively depict low grade gliomas (LGG) or the infiltrative tumor portion of high-grade gliomas (HGG). While spectroscopy improves sensitivity and precision, this is currently limited by autofluorescence and a second protoporphyrin IX (PpIX) fluorescence state at 620 nm. We investigated the autofluorescence to better characterize the present spectra and thus increase PpIX quantification precision and sensitivity. This study included 128 patients undergoing surgery for malignant glioma. 5-ALA (Gliolan) was administered before anesthesia, and fluorescence was measured using a hyperspectral device. It was found that all 2692 measured spectra consisted of contributions from 620 to 634 nm PpIX, NADH, lipofuscin, and flavins. The basis spectra were characterized and their use in spectral unmixing led to 82.4% lower fitting error for weakly fluorescing areas (p < 0.001), and 92.3% fewer false positive tumor identifications in control measurements (p = 0.0065) compared to previous works. They also decreased the PpIX620 contribution, thus halving the mean Ratio620/634 (p < 0.001). The ratio was approximately 0 for HGGs and increasing for LGGs, as demonstrated previously. Additionally, the Ratio620/634, the MIB-1/Ki-67 proliferation index, and the PpIX peak blue-shift were found to be significantly related to WHO grade, fluorescence visibility, and PpIX contribution (p < 0.001), and the value of these three as quantitative biomarkers is discussed.
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7
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Palmieri G, Cofano F, Salvati LF, Monticelli M, Zeppa P, Perna GD, Melcarne A, Altieri R, La Rocca G, Sabatino G, Barbagallo GM, Tartara F, Zenga F, Garbossa D. Fluorescence-Guided Surgery for High-Grade Gliomas: State of the Art and New Perspectives. Technol Cancer Res Treat 2021; 20:15330338211021605. [PMID: 34212784 PMCID: PMC8255554 DOI: 10.1177/15330338211021605] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
High-grade gliomas are aggressive tumors that require multimodal management and gross total resection is considered to be the first crucial step of treatment. Because of their infiltrative nature, intraoperative differentiation of neoplastic tissue from normal parenchyma can be challenging. For these reasons, in the recent years, neurosurgeons have increasingly performed this surgery under the guidance of tissue fluorescence. Sodium fluoresceine and 5-aminolevulinic acid represent the 2 main compounds that allow real-time identification of residual malignant tissue and have been associated with improved gross total resection and radiological outcomes. Though presenting different profiles of sensitivity and specificity and further investigations concerning cost-effectiveness are need, Sodium fluoresceine, 5-aminolevulinic acid and new phluorophores, such as Indocyanine green, represent some of the most important tools in the neurosurgeon’s hands to achieve gross total resection.
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Affiliation(s)
- Giuseppe Palmieri
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Fabio Cofano
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy.,Neurosurgery/Spine Surgery, Humanitas Gradenigo Hospital, Turin, Italy
| | - Luca Francesco Salvati
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Matteo Monticelli
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Pietro Zeppa
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Giuseppe Di Perna
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Antonio Melcarne
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Roberto Altieri
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Italy
| | - Giuseppe La Rocca
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli Irccs, Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli Irccs, Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giuseppe Maria Barbagallo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Italy
| | - Fulvio Tartara
- Unit of Neurosurgery, Istituto Clinico Città Studi, Milan, Italy
| | - Francesco Zenga
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Diego Garbossa
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
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8
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Alexiou GA, Vartholomatos G, Kobayashi T, Voulgaris S, Kyritsis AP. The emerging role of intraoperative flow cytometry in intracranial tumor surgery. Clin Neurol Neurosurg 2020; 192:105742. [PMID: 32087499 DOI: 10.1016/j.clineuro.2020.105742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/12/2020] [Accepted: 02/16/2020] [Indexed: 12/29/2022]
Abstract
Intraoperative flow cytometry has been recently emerged as a novel and promising tool for intracranial tumor surgery. Herewith, we discuss the role of intraoperative flow cytometry for the identification of gliomas boundaries, which may permit maximal resection and better prognosis. We also discuss its role in assessing tumor's grade of malignancy, both in adults and children and the prognostic information that may provide. Finally, intraoperative immunophenotypic analysis opens new horizons for flow cytometry. By evaluating tumor's specific cluster differentiation markers a diagnosis, within minutes, of certain tumor type can be achieved and additional information for therapeutic guidance can be provided.
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Affiliation(s)
- George A Alexiou
- Department of Neurosurgery, University Hospital of Ioannina, Greece; Neurosurgical Research Institute, University of Ioannina, Greece.
| | - George Vartholomatos
- Neurosurgical Research Institute, University of Ioannina, Greece; Department of Hematology-Unit of Molecular Biology, University Hospital of Ioannina, Greece
| | - Tatsuya Kobayashi
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan; Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering & Science, Graduate School of Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Spyridon Voulgaris
- Department of Neurosurgery, University Hospital of Ioannina, Greece; Neurosurgical Research Institute, University of Ioannina, Greece
| | - Athanasios P Kyritsis
- Neurosurgical Research Institute, University of Ioannina, Greece; Department of Neurology, University Hospital of Ioannina, Ioannina, Greece
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9
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La Rocca G, Sabatino G, Menna G, Altieri R, Ius T, Marchese E, Olivi A, Barresi V, Della Pepa GM. 5-Aminolevulinic Acid False Positives in Cerebral Neuro-Oncology: Not All That Is Fluorescent Is Tumor. A Case-Based Update and Literature Review. World Neurosurg 2020; 137:187-193. [PMID: 32058110 DOI: 10.1016/j.wneu.2020.01.238] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND One of the most valuable innovations in high-grade glioma surgery is 5-aminolevulinic acid (5-ALA). Fluorescence is a specific and sensitive indicator of metabolically active tumor tissue. In the published literature, the main focus has been placed on false-negative cases, with only a few articles addressing false positivity. The aim of the article was to highlight settings in which 5-ALA fluorescence does not necessarily mean tumor and to point out conditions in which intraoperative 5-ALA fluorescence has to be critically interpreted. METHODS Using PubMed, a review of pertinent literature was done to specifically investigate all conditions, including non-neoplastic and other metabolically active lesions, that can mimic high-grade gliomas and cause a misleading intraoperative diagnosis. In addition, an institutional case characterized by strong 5-ALA fluorescence in radionecrosis is presented. RESULTS Literature results were grouped in 2 main categories according to the field of application: oncologic setting (9 articles and 1 institutional case) and nononcologic settings (5 articles). CONCLUSIONS As reported, 5-ALA-induced fluorescence is not limited to glioma but is also evident in nonglioma and non-neoplastic conditions. Critical interpretation of intraoperative fluorescence is therefore mandatory in recurrences and in atypical cases that might hinder alternative diagnoses.
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Affiliation(s)
- Giuseppe La Rocca
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy; Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy; Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Grazia Menna
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Roberto Altieri
- Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico" University Hospital, Catania, Italy
| | - Tamara Ius
- Neurosurgery Unit, Department of Neuroscience, Santa Maria della Misericordia, University Hospital, Udine, Italy
| | - Enrico Marchese
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Valeria Barresi
- Department of Diagnostics and Public Health, Section of Anatomical Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Maria Della Pepa
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy.
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10
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Leclerc P, Ray C, Mahieu-Williame L, Alston L, Frindel C, Brevet PF, Meyronet D, Guyotat J, Montcel B, Rousseau D. Machine learning-based prediction of glioma margin from 5-ALA induced PpIX fluorescence spectroscopy. Sci Rep 2020; 10:1462. [PMID: 31996727 PMCID: PMC6989497 DOI: 10.1038/s41598-020-58299-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 01/06/2020] [Indexed: 12/22/2022] Open
Abstract
Gliomas are infiltrative brain tumors with a margin difficult to identify. 5-ALA induced PpIX fluorescence measurements are a clinical standard, but expert-based classification models still lack sensitivity and specificity. Here a fully automatic clustering method is proposed to discriminate glioma margin. This is obtained from spectroscopic fluorescent measurements acquired with a recently introduced intraoperative set up. We describe a data-driven selection of best spectral features and show how this improves results of margin prediction from healthy tissue by comparison with the standard biomarker-based prediction. This pilot study based on 10 patients and 50 samples shows promising results with a best performance of 77% of accuracy in healthy tissue prediction from margin tissue.
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Affiliation(s)
- Pierre Leclerc
- Univ Lyon, Université Claude Bernard Lyon 1, CNRS, Institut Lumière Matière, F-69622, Villeurbanne, France, 10 Rue Ada Byron, 69622, Villeurbanne, France.,CREATIS, Univ Lyon, CNRS UMR5220, INSERM U1044, Université Claude Bernard Lyon1, INSA Lyon, Villeurbanne, France
| | - Cedric Ray
- Univ Lyon, Université Claude Bernard Lyon 1, CNRS, Institut Lumière Matière, F-69622, Villeurbanne, France, 10 Rue Ada Byron, 69622, Villeurbanne, France
| | - Laurent Mahieu-Williame
- CREATIS, Univ Lyon, CNRS UMR5220, INSERM U1044, Université Claude Bernard Lyon1, INSA Lyon, Villeurbanne, France
| | - Laure Alston
- CREATIS, Univ Lyon, CNRS UMR5220, INSERM U1044, Université Claude Bernard Lyon1, INSA Lyon, Villeurbanne, France
| | - Carole Frindel
- CREATIS, Univ Lyon, CNRS UMR5220, INSERM U1044, Université Claude Bernard Lyon1, INSA Lyon, Villeurbanne, France
| | - Pierre-François Brevet
- Univ Lyon, Université Claude Bernard Lyon 1, CNRS, Institut Lumière Matière, F-69622, Villeurbanne, France, 10 Rue Ada Byron, 69622, Villeurbanne, France
| | - David Meyronet
- Hospices Civils de Lyon, Centre de Pathologie et de Neuropathologie Est, Lyon, F-69003, France.,Cancer Research Centre of Lyon, Univ Lyon, INSERM U1052, CNRS UMR5286, Lyon, France, Université Claude Bernard Lyon 1, Lyon, France
| | - Jacques Guyotat
- Hospices Civils de Lyon, Centre de Pathologie et de Neuropathologie Est, Lyon, F-69003, France
| | - Bruno Montcel
- CREATIS, Univ Lyon, CNRS UMR5220, INSERM U1044, Université Claude Bernard Lyon1, INSA Lyon, Villeurbanne, France.
| | - David Rousseau
- CREATIS, Univ Lyon, CNRS UMR5220, INSERM U1044, Université Claude Bernard Lyon1, INSA Lyon, Villeurbanne, France.,Laboratoire Angevin de Recherche en Ingénierie des Systèmes, UMR INRA IRHS, Université d'Angers, 62 avenue Notre Dame du Lac, 49000, Angers, France
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11
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Juarez-Chambi RM, Kut C, Rico-Jimenez JJ, Chaichana KL, Xi J, Campos-Delgado DU, Rodriguez FJ, Quinones-Hinojosa A, Li X, Jo JA. AI-Assisted In Situ Detection of Human Glioma Infiltration Using a Novel Computational Method for Optical Coherence Tomography. Clin Cancer Res 2019; 25:6329-6338. [PMID: 31315883 DOI: 10.1158/1078-0432.ccr-19-0854] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/24/2019] [Accepted: 07/12/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE In glioma surgery, it is critical to maximize tumor resection without compromising adjacent noncancerous brain tissue. Optical coherence tomography (OCT) is a noninvasive, label-free, real-time, high-resolution imaging modality that has been explored for glioma infiltration detection. Here, we report a novel artificial intelligence (AI)-assisted method for automated, real-time, in situ detection of glioma infiltration at high spatial resolution.Experimental Design: Volumetric OCT datasets were intraoperatively obtained from resected brain tissue specimens of 21 patients with glioma tumors of different stages and labeled as either noncancerous or glioma-infiltrated on the basis of histopathology evaluation of the tissue specimens (gold standard). Labeled OCT images from 12 patients were used as the training dataset to develop the AI-assisted OCT-based method for automated detection of glioma-infiltrated brain tissue. Unlabeled OCT images from the other 9 patients were used as the validation dataset to quantify the method detection performance. RESULTS Our method achieved excellent levels of sensitivity (∼100%) and specificity (∼85%) for detecting glioma-infiltrated tissue with high spatial resolution (16 μm laterally) and processing speed (∼100,020 OCT A-lines/second). CONCLUSIONS Previous methods for OCT-based detection of glioma-infiltrated brain tissue rely on estimating the tissue optical attenuation coefficient from the OCT signal, which requires sacrificing spatial resolution to increase signal quality, and performing systematic calibration procedures using tissue phantoms. By overcoming these major challenges, our AI-assisted method will enable implementing practical OCT-guided surgical tools for continuous, real-time, and accurate intraoperative detection of glioma-infiltrated brain tissue, facilitating maximal glioma resection and superior surgical outcomes for patients with glioma.
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Affiliation(s)
| | - Carmen Kut
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Jose J Rico-Jimenez
- Department of Biomedical Engineering, Texas A&M University, College Station, Texas
| | | | - Jiefeng Xi
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Daniel U Campos-Delgado
- Facultad de Ciencias, Universidad Autónoma de San Luis de Potosí, San Luis de Potosí, Mexico
| | - Fausto J Rodriguez
- Division of Neuropathology, Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | | | - Xingde Li
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Javier A Jo
- School of Electrical and Computer Engineering, University of Oklahoma, Norman, Oklahoma.
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12
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Alston L, Mahieu-Williame L, Hebert M, Kantapareddy P, Meyronet D, Rousseau D, Guyotat J, Montcel B. Spectral complexity of 5-ALA induced PpIX fluorescence in guided surgery: a clinical study towards the discrimination of healthy tissue and margin boundaries in high and low grade gliomas. BIOMEDICAL OPTICS EXPRESS 2019; 10:2478-2492. [PMID: 31149380 PMCID: PMC6524587 DOI: 10.1364/boe.10.002478] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/09/2019] [Accepted: 03/21/2019] [Indexed: 05/06/2023]
Abstract
Gliomas are diffuse and hard to cure brain tumors. A major reason for their aggressive behavior is their property to infiltrate the brain. The gross appearance of the infiltrative component is comparable to normal brain, constituting an obstacle to extended surgical resection. 5-ALA induced PpIX fluorescence measurements enable gains in sensitivity to detect infiltrated cells, but still lack sensitivity to get accurate discrimination between the tumor margin and healthy tissue. In this fluorescence spectroscopic study, we assume that two states of PpIX contribute to total fluorescence to get better discrimination of healthy tissues against tumor margins. We reveal that fluorescence in low-density margins of high-grade gliomas or in low-grade gliomas is mainly influenced by the second state of PpIX centered at 620 nm. We thus conclude that consideration of the contributions of both states to total fluorescence can help to improve fluorescence-guided resection of gliomas by discriminating healthy tissues from tumor margins.
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Affiliation(s)
- L. Alston
- Univ Lyon, INSA‐Lyon, Université Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR5220, U1206, F-69616, Lyon, France
| | - L. Mahieu-Williame
- Univ Lyon, INSA‐Lyon, Université Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR5220, U1206, F-69616, Lyon, France
| | - M. Hebert
- Univ Lyon, UJM-Saint-Etienne, CNRS, Institut d Optique Graduate School, Lab. Hubert Curien UMR5516, F-42023, St Etienne, France
| | - P. Kantapareddy
- Hospices Civils de Lyon, Groupe Hospitalier Est, Service d’anatomopathologie, 59 Bvd Pinel, 69394, Lyon, Cedex, France
| | - D. Meyronet
- Hospices Civils de Lyon, Groupe Hospitalier Est, Service d’anatomopathologie, 59 Bvd Pinel, 69394, Lyon, Cedex, France
- Department of Cancer Cell Plasticity, Cancer Research Centre of Lyon, INSERM U1052, CNRS UMR5286, Lyon, France, Université Claude Bernard Lyon 1, Lyon, France
| | - D. Rousseau
- Univ Lyon, INSA‐Lyon, Université Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR5220, U1206, F-69616, Lyon, France
| | - J. Guyotat
- Hospices Civils de Lyon, Groupe Hospitalier Est, Service d’anatomopathologie, 59 Bvd Pinel, 69394, Lyon, Cedex, France
| | - B. Montcel
- Univ Lyon, INSA‐Lyon, Université Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR5220, U1206, F-69616, Lyon, France
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13
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Zhu M, Chen F, Liu J, Wang G, Liao H. Ex vivo classification of spinal cord tumors using autofluorescence spectroscopy and immunohistochemical indexes. BIOMEDICAL OPTICS EXPRESS 2018; 9:4401-4412. [PMID: 30615743 PMCID: PMC6157786 DOI: 10.1364/boe.9.004401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/05/2018] [Accepted: 08/05/2018] [Indexed: 06/09/2023]
Abstract
Spinal cord tumors are complicated and infrequent, which poses a major challenge to surgeons during neurosurgery. Currently, the intraoperative identification of the tissues' pathological properties is usually difficult for surgeons. This issue influences the decision-making in treatment planning. Traditional pathological diagnoses can facilitate judging the tissues' properties, but the diagnosis process is complex and time-consuming. In this study, we evaluated the potential of autofluorescence spectroscopy for the fast pathological diagnosis of specific spinal cord tumors. The spectral properties of six types of spinal cord tumors were acquired ex vivo. Several peak intensity ratios were calculated for classification and then associated with the pathological immunohistochemical indexes. Our results revealed the spectral properties of three types of intramedullary tumors different from those of the other three types of extramedullary tumors. Furthermore, some peak intensity ratios revealed a high correlation with the immunohistochemical index of glial fibrillary acidic protein (GFAP). Thus, we believe that autofluorescence spectroscopy has the potential to provide real-time pathological information of spinal cord tumors and help surgeons validate tumor types and perform precise tumor resection.
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Affiliation(s)
- Mingyu Zhu
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing 100084, China
| | - Fang Chen
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing 100084, China
| | - Jia Liu
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing 100084, China
| | - Guihuai Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Beijing 102218, China
| | - Hongen Liao
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing 100084, China
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14
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Alston L, Rousseau D, Hebert M, Mahieu-Williame L, Montcel B. Nonlinear relation between concentration and fluorescence emission of protoporphyrin IX in calibrated phantoms. JOURNAL OF BIOMEDICAL OPTICS 2018; 23:1-7. [PMID: 30251489 DOI: 10.1117/1.jbo.23.9.097002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 09/05/2018] [Indexed: 05/22/2023]
Abstract
5-ALA-induced protoporphyrin IX (PpIX) has shown its relevance in medical assisting techniques, notably in the detection of glioma (brain tumors). Validation of instruments on phantoms is mandatory and a standardization procedure has recently been proposed. This procedure yields phantoms recipes to realize a linear relationship between PpIX concentration and fluorescence emission intensity. The present study puts forward phantoms where this linear relationship cannot be used. We propose a model that considers two states of PpIX, corresponding to two different aggregates of PpIX, with fluorescence spectra peaking at 634 and 620 nm, respectively. We characterize the influence of these two states on PpIX fluorescence emission spectra in phantoms with steady concentration of PpIX and various microenvironment parameters (surfactant, Intralipid or bovine blood concentration, and pH). We show that, with fixed PpIX concentration, a modification of the microenvironment induces a variation of the emitted spectrum, notably a shift in its central wavelength. We show that this modification reveals a variation of proportions of the two states. This establishes phantom microenvironment regimes where the usual single state model is biased while a linear combination of the two spectra enables accurate recovering of any measured spectra.
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Affiliation(s)
- Laure Alston
- University of Lyon, Universite Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, INSALyon, Inserm U120, France
| | - David Rousseau
- University of Lyon, Universite Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, INSALyon, Inserm U120, France
| | - Mathieu Hebert
- University of Lyon, UJM-Saint Etienne, CNRS, Institut dOptique Graduate School, Laboratoire Hubert C, France
| | - Laurent Mahieu-Williame
- University of Lyon, Universite Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, INSALyon, Inserm U120, France
| | - Bruno Montcel
- University of Lyon, Universite Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, INSALyon, Inserm U120, France
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15
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Munkvold BKR, Jakola AS, Reinertsen I, Sagberg LM, Unsgård G, Solheim O. The Diagnostic Properties of Intraoperative Ultrasound in Glioma Surgery and Factors Associated with Gross Total Tumor Resection. World Neurosurg 2018; 115:e129-e136. [PMID: 29631086 DOI: 10.1016/j.wneu.2018.03.208] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE In glioma operations, we sought to analyze sensitivity, specificity, and predictive values of intraoperative 3-dimensional ultrasound (US) for detecting residual tumor compared with early postoperative magnetic resonance imaging (MRI). Factors possibly associated with radiologic complete resection were also explored. METHODS One hundred forty-four operations for diffuse supratentorial gliomas were included prospectively in an unselected, population-based, single-institution series. Operating surgeons answered a questionnaire immediately after surgery, stating whether residual tumor was seen with US at the end of resection and rated US image quality (e.g., good, medium, poor). Extent of surgical resection was estimated from preoperative and postoperative MRI. RESULTS Overall specificity was 85% for "no tumor remnant" seen in US images at the end of resection compared with postoperative MRI findings. Sensitivity was 46%, but tumor remnants seen on MRI were usually small (median, 1.05 mL) in operations with false-negative US findings. Specificity was highest in low-grade glioma operations (94%) and lowest in patients who had undergone prior radiotherapy (50%). Smaller tumor volume and superficial location were factors significantly associated with gross total resection in a multivariable logistic regression analysis, whereas good ultrasound image quality did not reach statistical significance (P = 0.061). CONCLUSIONS The specificity of intraoperative US is good, but sensitivity for detecting the last milliliter is low compared with postoperative MRI. Tumor volume and tumor depth are the predictors of achieving gross total resection, although ultrasound image quality was not.
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Affiliation(s)
| | - Asgeir Store Jakola
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway; Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Ingerid Reinertsen
- Norwegian National Advisory Unit for Ultrasound and Image Guided Therapy, St. Olav's University Hospital, Trondheim, Norway; SINTEF, Department of Medical Technology, Trondheim, Norway
| | - Lisa Millgård Sagberg
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway; Norwegian National Advisory Unit for Ultrasound and Image Guided Therapy, St. Olav's University Hospital, Trondheim, Norway; Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
| | - Geirmund Unsgård
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway; Norwegian National Advisory Unit for Ultrasound and Image Guided Therapy, St. Olav's University Hospital, Trondheim, Norway; Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ole Solheim
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway; Norwegian National Advisory Unit for Ultrasound and Image Guided Therapy, St. Olav's University Hospital, Trondheim, Norway; Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
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16
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Shimizu K, Nitta M, Komori T, Maruyama T, Yasuda T, Fujii Y, Masamune K, Kawamata T, Maehara T, Muragaki Y. Intraoperative Photodynamic Diagnosis Using Talaporfin Sodium Simultaneously Applied for Photodynamic Therapy against Malignant Glioma: A Prospective Clinical Study. Front Neurol 2018; 9:24. [PMID: 29441040 PMCID: PMC5797572 DOI: 10.3389/fneur.2018.00024] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 01/12/2018] [Indexed: 12/03/2022] Open
Abstract
Objective The goal of this study was to demonstrate the feasibility of intraoperative photodynamic diagnosis (PDD) of malignant glioma using the fluorescence from talaporfin sodium (TS), which is used simultaneously for photodynamic therapy (PDT). Methods Patients with suspected primary malignant glioma who were eligible for surgical removal of the tumor and PDT with TS were enrolled in this prospective study. Tissue samples were obtained from the contrast-enhanced (CE) region and from the surrounding non-contrast-enhanced (NCE) marginal tissue at the boundary between the tumor and normal tissue. The excised samples were set into a fluorescence measurement system, which consisted of a semiconductor laser with a 400-nm wavelength for excitation, and a compact spectrometer for detection, which were applied and received through a custom-made probe consisting of coaxial optical fibers. The fluorescence spectrum was obtained, and peak intensity was calculated. Tumor cellularity was histopathologically analyzed and semi-quantitatively classified into four (0–3) categories. Results 86 samples from 17 surgical cases were available for fluorescence measurement and analysis. The fluorescence from TS had a single peak at 664 nm that was easily distinguished from the 400-nm excitation light. Samples from the CE regions showed higher fluorescence intensity than those from the NCE regions (P < 0.001). DAPI staining and fluorescence microscopy confirmed that cells in the CE regions showed red fluorescence in their cytoplasm. The fluorescence was notably strong along vascular endothelium. CE samples from newly diagnosed versus recurrent cases showed no difference in fluorescence intensity (P = 0.26). Among all samples (CE and NCE combined), the fluorescence intensity was very high in those of histopathological class 3, and a trend of increased fluorescence according to histopathological class (P < 0.001) was shown. Differences between class 0 and 3 (P < 0.001), class 1 and 3 (P < 0.001), and class 2 and 3 (P = 0.018) were significant. Conclusion Intraoperative simultaneous PDD and PDT with TS can be performed for patients with malignant glioma. The blue excitation light that is used for 5-aminolevulinic acid PDD can be used for our technique (TS-PDD). The strong fluorescence from pathologically malignant tissues may be due at least in part to the involvement of microvascular structures.
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Affiliation(s)
- Kazuhide Shimizu
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan.,Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayuki Nitta
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Tokyo, Japan.,Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takashi Komori
- Department of Laboratory Medicine and Pathology (Neuropathology), Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Takashi Maruyama
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Tokyo, Japan.,Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takayuki Yasuda
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Yu Fujii
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Tokyo, Japan.,Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan.,Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Ken Masamune
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Taketoshi Maehara
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshihiro Muragaki
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Tokyo, Japan.,Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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17
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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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18
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TAMURA M, MURAGAKI Y, SAITO T, MARUYAMA T, NITTA M, TSUZUKI S, ISEKI H, OKADA Y. Strategy of Surgical Resection for Glioma Based on Intraoperative Functional Mapping and Monitoring. Neurol Med Chir (Tokyo) 2017; 55:383-98. [PMID: 26185825 PMCID: PMC4628166 DOI: 10.2176/nmc.ra.2014-0415] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A growing number of papers have pointed out the relationship between aggressive resection of gliomas and survival prognosis. For maximum resection, the current concept of surgical decision-making is in “information-guided surgery” using multimodal intraoperative information. With this, anatomical information from intraoperative magnetic resonance imaging (MRI) and navigation, functional information from brain mapping and monitoring, and histopathological information must all be taken into account in the new perspective for innovative minimally invasive surgical treatment of glioma. Intraoperative neurofunctional information such as neurophysiological functional monitoring takes the most important part in the process to acquire objective visual data during tumor removal and to integrate these findings as digitized data for intraoperative surgical decision-making. Moreover, the analysis of qualitative data and threshold-setting for quantitative data raise difficult issues in the interpretation and processing of each data type, such as determination of motor evoked potential (MEP) decline, underestimation in tractography, and judgments of patient response for neurofunctional mapping and monitoring during awake craniotomy. Neurofunctional diagnosis of false-positives in these situations may affect the extent of resection, while false-negatives influence intra- and postoperative complication rates. Additionally, even though the various intraoperative visualized data from multiple sources contribute significantly to the reliability of surgical decisions when the information is integrated and provided, it is not uncommon for individual pieces of information to convey opposing suggestions. Such conflicting pieces of information facilitate higher-order decision-making that is dependent on the policies of the facility and the priorities of the patient, as well as the availability of the histopathological characteristics from resected tissue.
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Affiliation(s)
- Manabu TAMURA
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, Tokyo
- Department of Neurosurgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, Tokyo
| | - Yoshihiro MURAGAKI
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, Tokyo
- Department of Neurosurgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, Tokyo
- Address reprint requests to: Yoshihiro Muragaki, MD, PhD, Department of Neurosurgery, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan. e-mail:
| | - Taiichi SAITO
- Department of Neurosurgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, Tokyo
| | - Takashi MARUYAMA
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, Tokyo
- Department of Neurosurgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, Tokyo
| | - Masayuki NITTA
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, Tokyo
- Department of Neurosurgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, Tokyo
| | - Shunsuke TSUZUKI
- Department of Neurosurgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, Tokyo
| | - Hiroshi ISEKI
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, Tokyo
| | - Yoshikazu OKADA
- Department of Neurosurgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, Tokyo
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19
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20
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Martirosyan NL, Georges J, Kalani MYS, Nakaji P, Spetzler RF, Feuerstein BG, Preul MC. Handheld confocal laser endomicroscopic imaging utilizing tumor-specific fluorescent labeling to identify experimental glioma cells in vivo. Surg Neurol Int 2016; 7:S995-S1003. [PMID: 28144472 PMCID: PMC5234279 DOI: 10.4103/2152-7806.195577] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 07/11/2016] [Indexed: 01/02/2023] Open
Abstract
Background: We have reported that handheld confocal laser endomicroscopy (CLE) can be used with various nonspecific fluorescent dyes to improve the microscopic identification of brain tumor and its boundaries. Here, we show that CLE can be used experimentally with tumor-specific fluorescent labeling to define glioma margins in vivo. Methods: Thirteen rats underwent craniectomy and in vivo imaging 21 days after implantation with green fluorescent protein (GFP)-labeled U251 (n = 7) cells or epidermal growth factor receptor (EGFR) overexpressing F98 cells (n = 6). Fluorescein isothiocyanate (FITC) conjugated EGFR fluorescent antibody (FITC-EGFR) was applied for contrast in F98 tumors. Confocal images of normal brain, obvious tumor, and peritumoral zones were collected using the CLE system. Bench-top confocal microscopy and hematoxylin and eosin-stained sections were correlated with CLE images. Results: GFP and FITC-EGFR fluorescence of glioma cells were detected by in vivo visible-wavelength fluorescence CLE. CLE of GFP-labeled tumors revealed bright individual satellite tumor cells within peritumoral tissue, a definitive tumor border, and subcellular structures. Imaging with FITC-EGFR labeling provided weaker contrast in F98-EGFR tumors but was able to delineate tumor cells. Imaging with both methods in various tumor regions correlated with standard confocal imaging and clinical histology. Conclusions: These data suggest that in vivo CLE of selectively tagged neoplasms could allow specific interactive identification of tumoral areas. Imaging of GFP and FITC-EGFR provides real-time histologic information precisely related to the site of microscopic imaging of tumor.
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Affiliation(s)
- Nikolay L Martirosyan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center Phoenix, Arizona, USA
| | - Joseph Georges
- School of Life Sciences, Arizona State University, Tempe, Arizona, USA
| | - M Yashar S Kalani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center Phoenix, Arizona, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center Phoenix, Arizona, USA
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center Phoenix, Arizona, USA
| | - Burt G Feuerstein
- School of Life Sciences, Arizona State University, Tempe, Arizona, USA; College of Medicine, University of Arizona, Phoenix, Arizona, USA
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center Phoenix, Arizona, USA
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21
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Markwardt NA, Haj-Hosseini N, Hollnburger B, Stepp H, Zelenkov P, Rühm A. 405 nm versus 633 nm for protoporphyrin IX excitation in fluorescence-guided stereotactic biopsy of brain tumors. JOURNAL OF BIOPHOTONICS 2016; 9:901-12. [PMID: 26564058 DOI: 10.1002/jbio.201500195] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 10/29/2015] [Accepted: 10/29/2015] [Indexed: 05/23/2023]
Abstract
Fluorescence diagnosis may be used to improve the safety and reliability of stereotactic brain tumor biopsies using biopsy needles with integrated fiber optics. Based on 5-aminolevulinic-acid-induced protoporphyrin IX (PpIX) fluorescence, vital tumor tissue can be localized in vivo during the excision procedure to reduce the number of necessary samples for a reliable diagnosis. In this study, the practical suitability of two different PpIX excitation wavelengths (405 nm, 633 nm) was investigated on optical phantoms. Violet excitation at 405 nm provides a 50-fold higher sensitivity for the bulk tumor; this factor increases up to 100 with decreasing fluorescent volume as shown by ray tracing simulations. Red excitation at 633 nm, however, is noticeably superior with regard to blood layers obscuring the fluorescence. Experimental results on the signal attenuation through blood layers of well-defined thicknesses could be confirmed by ray tracing simulations. Typical interstitial fiber probe measurements were mimicked on agarose-gel phantoms. Even in direct contact, blood layers of 20-40 µm between probe and tissue must be expected, obscuring 405-nm-excited PpIX fluorescence almost completely, but reducing the 633-nm-excited signal only by 25.5%. Thus, 633 nm seems to be the wavelength of choice for PpIX-assisted detection of high-grade gliomas in stereotactic biopsy. PpIX signal attenuation through clinically relevant blood layers for 405 nm (violet) and 633 nm (red) excitation.
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Affiliation(s)
- Niklas A Markwardt
- Laser-Forschungslabor, LIFE-Zentrum, Klinikum der Universität München, Munich, Germany.
| | - Neda Haj-Hosseini
- Department of Biomedical Engineering, Linköping University, Linköping, Sweden
| | - Bastian Hollnburger
- Laser-Forschungslabor, LIFE-Zentrum, Klinikum der Universität München, Munich, Germany
| | - Herbert Stepp
- Laser-Forschungslabor, LIFE-Zentrum, Klinikum der Universität München, Munich, Germany
| | | | - Adrian Rühm
- Laser-Forschungslabor, LIFE-Zentrum, Klinikum der Universität München, Munich, Germany
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Hadjipanayis CG, Widhalm G, Stummer W. What is the Surgical Benefit of Utilizing 5-Aminolevulinic Acid for Fluorescence-Guided Surgery of Malignant Gliomas? Neurosurgery 2016; 77:663-73. [PMID: 26308630 DOI: 10.1227/neu.0000000000000929] [Citation(s) in RCA: 230] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The current neurosurgical goal for patients with malignant gliomas is maximal safe resection of the contrast-enhancing tumor. However, a complete resection of the contrast-enhancing tumor is achieved only in a minority of patients. One reason for this limitation is the difficulty in distinguishing viable tumor from normal adjacent brain during surgery at the tumor margin using conventional white-light microscopy. To overcome this limitation, fluorescence-guided surgery (FGS) using 5-aminolevulinic acid (5-ALA) has been introduced in the treatment of malignant gliomas. FGS permits the intraoperative visualization of malignant glioma tissue and supports the neurosurgeon with real-time guidance for differentiating tumor from normal brain that is independent of neuronavigation and brain shift. Tissue fluorescence after oral administration of 5-ALA is associated with unprecedented high sensitivity, specificity, and positive predictive values for identifying malignant glioma tumor tissue. 5-ALA-induced tumor fluorescence in diffusely infiltrating gliomas with non-significant magnetic resonance imaging contrast-enhancement permits intraoperative identification of anaplastic foci and establishment of an accurate histopathological diagnosis for proper adjuvant treatment. 5-ALA FGS has enabled surgeons to achieve a significantly higher rate of complete resections of malignant gliomas in comparison with conventional white-light resections. Consequently, 5-ALA FGS has become an indispensable surgical technique and standard of care at many neurosurgical departments around the world. We conducted an extensive literature review concerning the surgical benefit of using 5-ALA for FGS of malignant gliomas. According to the literature, there are a number of reasons for the neurosurgeon to perform 5-ALA FGS, which will be discussed in detail in the current review.
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Affiliation(s)
- Costas G Hadjipanayis
- *Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY; ‡Department of Neurosurgery, Medical University Vienna, Vienna, Austria; §Department of Neurosurgery, University of Munster, Munster, Germany
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Neumann LM, Beseoglu K, Slotty PJ, Senger B, Kamp MA, Hänggi D, Steiger HJ, Cornelius JF. Efficacy of 5-aminolevulinic acid based photodynamic therapy in pituitary adenomas-experimental study on rat and human cell cultures. Photodiagnosis Photodyn Ther 2016; 14:77-83. [PMID: 26906188 DOI: 10.1016/j.pdpdt.2016.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 02/13/2016] [Accepted: 02/17/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Incomplete resection of pituitary adenomas may result in recurrence. As adjuvant irradiation is not riskless, alternative treatment options should be investigated. 5-aminolevulinic acid based photodynamic therapy (5-ALA based PDT) showed promising results for malignant gliomas. The present study examined the efficacy of 5-ALA PDT in vitro on benign pituitary adenoma cell cultures. METHODS In group I experiments were performed on immortalized rat pituitary adenoma cells (GH3). The cultured cells were treated with different 5-ALA concentrations ranging from 7.5-16.5μg/ml. In Group II human pituitary adenoma cell cultures were obtained from surgically resected adenoma tissue (n=15). These were incubated with 5-ALA concentrations from 12.5-100μg/ml. The concentration ranges had been determined in preliminary dose-finding tests. For both groups incubation time was four hours and PDT was performed by exposition to laser light (635nm, 625s, 18.75J/cm(2)). Cell viability was examined by WST-1 assay. RESULTS In both groups PDT showed a 5-ALA concentration-dependent effect on cell death. In group I lower 5-ALA concentrations were necessary to destroy all cells as compared to group II. Moreover, in group II, the different subtypes of human adenomas showed different sensitivities to 5-ALA-based PDT (secreting vs. non-secreting). Especially corticotroph adenomas were highly sensitive to 5-ALA PDT. CONCLUSIONS The GH3 cell line was an useful in vitro model to optimize different PDT parameters. Human pituitary adenoma cells could also be killed by 5-ALA PDT, however this required higher 5-ALA concentrations. Furthermore, the results suggested different 5-ALA sensitivities between different human adenoma cell types. More experiments are necessary to confirm these preliminary results.
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Affiliation(s)
- Lisa Margarete Neumann
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Philipp Joerg Slotty
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Brigitte Senger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Marcel Alexander Kamp
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, 40225 Düsseldorf, Germany; Department of Neurosurgery, Medical Faculty, Ruprecht-Karls-University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Hans Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Jan Frederick Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, 40225 Düsseldorf, 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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Abstract
5-aminolevulinic acid-induced protoporphyrin IX fluorescence was authorized in the EU for visualization of tumor tissue during surgery for WHO grade III and IV gliomas in 2007. It facilitates tumor identification and doubles the number of gross total resections that can be achieved in these tumors. The growing acceptance of fluorescence-guided surgery in malignant gliomas brings forward a substantial yield of data on many types of intracranial lesions. The following review summarizes the main findings of these publications and illustrates the limitations, caveats and future perspectives of 5-aminolevulinic acid-induced fluorescence in malignant glioma as well as in other brain neoplasms.
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Affiliation(s)
- Martin Hefti
- Department of Neurosurgery, Hirslanden Private Hospital Group, Brauerstrasse 95, 9016 St Gallen, Switzerland.
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Yamada S, Muragaki Y, Maruyama T, Komori T, Okada Y. Role of neurochemical navigation with 5-aminolevulinic acid during intraoperative MRI-guided resection of intracranial malignant gliomas. Clin Neurol Neurosurg 2015; 130:134-9. [PMID: 25615582 DOI: 10.1016/j.clineuro.2015.01.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 12/29/2014] [Accepted: 01/03/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the role of the neurochemical navigation with 5-aminolevulinic acid (5-ALA) during intraoperative MRI (iMRI)-guided resection of the intracranial malignant gliomas. METHODS The analysis included 99 consecutive surgical cases. Resection of the bulk of the neoplasm was mainly guided by the updated neuronavigation based on the low-field-strength (0.3T) iMRI, whereas at the periphery of the lesion neurochemical navigation with 5-ALA was additionally used. RESULTS In total, 286 tissue specimens were obtained during surgeries for histopathological examination. According to iMRI 98 samples with strong (91 cases), weak (6 cases), or absent (1 case) fluorescence corresponded to the bulk of the lesion and all of those ones contained tumor. Out of 188 tissue specimens obtained from the "peritumoral brain," the neoplastic elements were identified in 89%, 81% and 29% of samples with, respectively, strong (107 cases), weak (47 cases) and absent (34 cases) fluorescence. Positive predictive values of the tissue fluorescence for presence of neoplasm within and outside of its boundaries on iMRI were 100% and 86%, respectively. CONCLUSION Neurochemical navigation with 5-ALA is useful adjunct during iMRI-guided resection of intracranial malignant gliomas, which allows identification of the tumor extension beyond its radiological borders.
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Affiliation(s)
- Shinobu Yamada
- Faculty of Advanced Techno-Surgery, Tokyo Women's Medical University, Tokyo, Japan; Departments of Business Development and Research and Development, Nobelpharma Co., Ltd., Tokyo, Japan
| | - Yoshihiro Muragaki
- Faculty of Advanced Techno-Surgery, Tokyo Women's Medical University, Tokyo, Japan; Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan.
| | - Takashi Maruyama
- Faculty of Advanced Techno-Surgery, Tokyo Women's Medical University, Tokyo, Japan; Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takashi Komori
- Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Tokyo, Japan; Department of Pathology, Tokyo Women's Medical University, Tokyo, Japan; Laboratory of Brain Tumor Pathology, Department of Brain Development and Regeneration, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Yoshikazu Okada
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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Stummer W, Tonn JC, Goetz C, Ullrich W, Stepp H, Bink A, Pietsch T, Pichlmeier U. 5-Aminolevulinic acid-derived tumor fluorescence: the diagnostic accuracy of visible fluorescence qualities as corroborated by spectrometry and histology and postoperative imaging. Neurosurgery 2014; 74:310-9; discussion 319-20. [PMID: 24335821 PMCID: PMC4206350 DOI: 10.1227/neu.0000000000000267] [Citation(s) in RCA: 206] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND 5-Aminolevulinic acid is used for fluorescence-guided resections. During resection, different macroscopic fluorescence qualities ("strong," "weak") can be distinguished that help guide resections. OBJECTIVE This prospective study was designed to assess the reliability of visible fluorescence qualities by spectrometry, pathology, and imaging. METHODS Thirty-three patients with malignant gliomas received 5-aminolevulinic acid (20 mg/kg). After debulking surgery, standardized biopsies were obtained from tissues with "weak" and "strong" fluorescence and from nonfluorescing near and distant brain for blinded assessment of cell density and tissue type (necrosis, solid or infiltrating tumor, normal tissue). The positive predictive value was calculated. Unresected fluorescing tissue was navigated for blinded correlation to postoperative magnetic resonance imaging (MRI). Receiver operating characteristic curves were generated for assessing the classification efficiency of spectrometry. RESULTS "Strong" fluorescence corresponded to greater spectrometric fluorescence, solidly proliferating tumor, and high cell densities, whereas "weak" fluorescence corresponded to lower spectrometric fluorescence, infiltrating tumor, and medium cell densities. The positive predictive value was 100% in strongly fluorescing tissue and 95% in weakly fluorescing tissue. Spectrometric fluorescence was detected in marginal tissue without macroscopic fluorescence. Depending on the threshold, spectrometry displayed greater sensitivity but lower specificity (accuracy 88.4%). Residual MRI enhancement in the tumor bed was detected in 15 of 23 (65%) patients with residual fluorescence, but in none of the patients without residual fluorescence. CONCLUSION Macroscopic fluorescence qualities predict solid and infiltrating tumor, providing useful information during resection. Fluorescence appears superior to contrast enhancement on MRI for indicating residual tumor. Spectrometry, on the other hand, is more sensitive but less specific, depending on threshold definition. ABBREVIATIONS 5-ALA, 5-aminolevulinic acidCI, confidence intervalgamma-GT, gamma-glutamyl transpeptidaseGBM, glioblastoma multiformeNPV, negative predictive valuePPIX, protoporphyrin IXPPV, positive predictive valueSD, standard deviationWHO, World Health Organization.
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Affiliation(s)
- Walter Stummer
- *Department of Neurosurgery, University of Münster, Münster, Germany; ‡Department of Neurosurgery, Ludwig-Maximilians-University Munich, Klinikum Grosshadern, Munich, Germany; §Asklepios Klinik Nord Heidberg, Hamburg, Germany; ¶Department of Neurosurgery, University Regensburg Medical Center, Regensburg, Germany; ‖Laser-Research Laboratory, LIFE-Center at University Hospital of Munich, Munich, Germany; #Department of Clinical Radiology, Universitätsklinikum Münster, Münster, Germany; **Department of Neuropathology, Universtitätsklinikum Bonn, University of Bonn Medical Center, Bonn, Germany; ‡‡Medac, Gesellschaft für klinische Spezialpräparate mbH, Wedel, Germany
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De la Garza-Ramos R, Bydon M, Macki M, Huang J, Tamargo RJ, Bydon A. Fluorescent techniques in spine surgery. Neurol Res 2014; 36:928-38. [DOI: 10.1179/1743132814y.0000000340] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Martirosyan NL, Georges J, Eschbacher JM, Cavalcanti DD, Elhadi AM, Abdelwahab MG, Scheck AC, Nakaji P, Spetzler RF, Preul MC. Potential application of a handheld confocal endomicroscope imaging system using a variety of fluorophores in experimental gliomas and normal brain. Neurosurg Focus 2014; 36:E16. [DOI: 10.3171/2013.11.focus13486] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors sought to assess the feasibility of a handheld visible-wavelength confocal endomicroscope imaging system (Optiscan 5.1, Optiscan Pty., Ltd.) using a variety of rapid-acting fluorophores to provide histological information on gliomas, tumor margins, and normal brain in animal models.
Methods
Mice (n = 25) implanted with GL261 cells were used to image fluorescein sodium (FNa), 5-aminolevulinic acid (5-ALA), acridine orange (AO), acriflavine (AF), and cresyl violet (CV). A U251 glioma xenograft model in rats (n = 5) was used to image sulforhodamine 101 (SR101). A swine (n = 3) model with AO was used to identify confocal features of normal brain. Images of normal brain, obvious tumor, and peritumoral zones were collected using the handheld confocal endomicroscope. Histological samples were acquired through biopsies from matched imaging areas. Samples were visualized with a benchtop confocal microscope. Histopathological features in corresponding confocal images and photomicrographs of H & E–stained tissues were reviewed.
Results
Fluorescence induced by FNa, 5-ALA, AO, AF, CV, and SR101 and detected with the confocal endomicroscope allowed interpretation of histological features. Confocal endomicroscopy revealed satellite tumor cells within peritumoral tissue, a definitive tumor border, and striking fluorescent cellular and subcellular structures. Fluorescence in various tumor regions correlated with standard histology and known tissue architecture. Characteristic features of different areas of normal brain were identified as well.
Conclusions
Confocal endomicroscopy provided rapid histological information precisely related to the site of microscopic imaging with imaging characteristics of cells related to the unique labeling features of the fluorophores. Although experimental with further clinical trial validation required, these data suggest that intraoperative confocal imaging can help to distinguish normal brain from tumor and tumor margin and may have application in improving intraoperative decisions during resection of brain tumors.
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Affiliation(s)
| | - Joseph Georges
- 4School of Life Sciences, Arizona State University, Tempe, Arizona
| | | | | | | | - Mohammed G. Abdelwahab
- 3Neuro-Oncology Research, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix; and
| | - Adrienne C. Scheck
- 3Neuro-Oncology Research, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix; and
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Loshchenov M, Zelenkov P, Potapov A, Goryajnov S, Borodkin A. Endoscopic fluorescence visualization of 5-ALA photosensitized central nervous system tumors in the neural tissue transparency spectral range. ACTA ACUST UNITED AC 2014. [DOI: 10.1515/plm-2013-0017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractBackground:Fluorescence endoscopy systems for photosensitizer visualization have proved to be powerful tools for highlighting malignant tumor boundaries as well as detecting small, visually non-detectable, residual parts during photodynamic therapy. Most of these devices use excitation wavelengths in the blue visual spectrum range (405 nm) which limits the penetration depth in the tissue.Objective:In the study being presented in this article an apparatus and a method were developed for performing endoscopic fluorescence diagnostics of photosensitizer accumulation using excitation light in the red part of visual spectrum, i.e., 635 nm, which allows not only a deeper penetration of light into the tissue but also better scanning abilities and a higher diagnostic quality. Additionally, 635-nm radiation can penetrate thin layers of blood which appear during surgery.Material and methods:In order to use 635-nm excitation, a specially designed video endoscopy system was developed. The key feature of the video system is a dual camera video receiver where one sensitive B/W camera receives the fluorescence signal and a color camera receives the real-time image in natural colors during navigation. The software developed for the apparatus allows overlaying of the video output of fluorescence image on top of the conventional color image in real-time. The experimental setup and method were tested on Intralipid-based phantoms with protoporphyrin IX (PpIX) concentrations of 0.5–5 mg/kg, and then on two patients during surgery. The patients were administered 20 mg/kg 5-ALA photosensitizer 3 h before surgery according to standard practice of 5-ALA in neurosurgery.Results:The experiments demonstrate that the designed setup is sensitive enough for clear visualization of biological concentrations of PpIX in both phantoms with 0.5 mg/kg PpIX and previously photosensitized tissues of patients.Conclusion:Further prospective validation is needed to translate the results to clinical practice.
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Shioyama T, Suzuki A, Nomura K, Shigaki N, Kubo H, Takeda S, Yamamori S, Maruyama T, Iseki H, Komori T, Nitta M, Sakayori T, Muragaki Y. Fully automatic rapid DNA Ploidy Analyzer for intraoperative rapid diagnosis support. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2013:906-9. [PMID: 24109835 DOI: 10.1109/embc.2013.6609648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Frozen section studies are a useful method to rapidly define tumor malignancy and identify the extent of surgical resection. However, diagnosis with a frozen section is qualitative and sometimes difficult. Therefore a quantitative method for grading tumors is desired. We have already reported a technique of intraoperative flow cytometry (iFC) that supports intraoperative histopathological examination of frozen sections. In this study, we report an advanced system named "Fully Automatic Rapid DNA Ploidy Analyzer" with a tissue pretreatment function and a freeze-dried reagent kit for cell staining. To evaluate our system, we analyzed samples from glioma patients who underwent open surgery for brain tumors. We observed obvious difference of the Malignancy Index (MI) between neoplastic and perilesional brain tissue (26.0 ±22.1% and 4.1 ±2.5%, respectively, P<0.001). Cut-off level for identification of the tumor in the biopsy specimen was 6.8% which provided 86% sensitivity and 81% specificity. We also obtained a good correlation between the MI and histological grade (WHO grading). Our new system also enabled finishing the process from sample preparation to the end of analysis in ten minutes or less. These results demonstrate that our fully automatic rapid DNA ploidy analyzer is feasible for rapid determination of glioma presence in a surgical biopsy sample.
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Tissue discrimination by uncorrected autofluorescence spectra: a proof-of-principle study for tissue-specific laser surgery. SENSORS 2013; 13:13717-31. [PMID: 24152930 PMCID: PMC3859088 DOI: 10.3390/s131013717] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 09/27/2013] [Indexed: 11/21/2022]
Abstract
Laser surgery provides a number of advantages over conventional surgery. However, it implies large risks for sensitive tissue structures due to its characteristic non-tissue-specific ablation. The present study investigates the discrimination of nine different ex vivo tissue types by using uncorrected (raw) autofluorescence spectra for the development of a remote feedback control system for tissue-selective laser surgery. Autofluorescence spectra (excitation wavelength 377 ± 50 nm) were measured from nine different ex vivo tissue types, obtained from 15 domestic pig cadavers. For data analysis, a wavelength range between 450 nm and 650 nm was investigated. Principal Component Analysis (PCA) and Quadratic Discriminant Analysis (QDA) were used to discriminate the tissue types. ROC analysis showed that PCA, followed by QDA, could differentiate all investigated tissue types with AUC results between 1.00 and 0.97. Sensitivity reached values between 93% and 100% and specificity values between 94% and 100%. This ex vivo study shows a high differentiation potential for physiological tissue types when performing autofluorescence spectroscopy followed by PCA and QDA. The uncorrected autofluorescence spectra are suitable for reliable tissue discrimination and have a high potential to meet the challenges necessary for an optical feedback system for tissue-specific laser surgery.
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Shioyama T, Muragaki Y, Maruyama T, Komori T, Iseki H. Intraoperative flow cytometry analysis of glioma tissue for rapid determination of tumor presence and its histopathological grade. J Neurosurg 2013; 118:1232-8. [DOI: 10.3171/2013.1.jns12681] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Intraoperative histopathological investigation plays an important role during surgery for gliomas. To facilitate the rapid characterization of resected tissue, an original technique of intraoperative flow cytometry (iFC) was established. The objective in this study was evaluation of this technique's efficacy for rapidly determining tumor presence in the surgical biopsy sample and WHO histopathological grade of the neoplasm.
Methods
In total, 328 separate biopsy specimens obtained during the resection of 81 intracranial gliomas were analyzed with iFC. The evaluated malignancy index (MI) was defined as the ratio of the number of cells with greater than normal DNA content to the total number of cells. The duration of iFC in all cases was approximately 10 minutes. Each sample was additionally investigated histopathologically on frozen and permanent formalin-fixed paraffin-embedded tissue sections. The latter process was used as a “gold standard” control for evaluation of the diagnostic efficacy of iFC analysis.
Results
The MI differed significantly between neoplastic and perilesional brain tissue (25.3% ± 22.0% vs 4.6% ± 2.6%, p < 0.01). Receiver operating characteristic curve analysis revealed a corresponding area under the curve value of 0.941. The optimal cutoff level of the MI for identification of tumor in the biopsy specimen was 6.8%, which provided 0.88 sensitivity, 0.88 specificity, 0.97 positive predictive value, 0.60 negative predictive value, and 0.88 diagnostic accuracy. Additionally, the MI showed a significant association with WHO histopathological grades of glioma (p < 0.01), but its values in Grade II, III, and IV tumors overlapped prominently and were on average 13.3% ± 11.0%, 35.0% ± 21.8%, and 46.6% ± 23.1%, respectively.
Conclusions
Results of this study demonstrate that iFC with the determination of the MI may be feasible for rapidly determining glioma presence in a surgical biopsy sample.
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Affiliation(s)
- Takahiro Shioyama
- 1Institute of Advanced Biomedical Engineering and Science
- 6Nihon Kohden Corporation, Tokyo, Japan
| | - Yoshihiro Muragaki
- 2Faculty of Advanced Techno-Surgery, Graduate School of Medicine
- 3Departments of Neurosurgery and
| | - Takashi Maruyama
- 2Faculty of Advanced Techno-Surgery, Graduate School of Medicine
- 3Departments of Neurosurgery and
| | - Takashi Komori
- 1Institute of Advanced Biomedical Engineering and Science
- 4Pathology, Tokyo Women's Medical University
- 5Laboratory of Brain Tumor Pathology, Department of Brain Development and Regeneration, Tokyo Metropolitan Institute of Medical Science; and
| | - Hiroshi Iseki
- 2Faculty of Advanced Techno-Surgery, Graduate School of Medicine
- 3Departments of Neurosurgery and
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Montcel B, Mahieu-Williame L, Armoiry X, Meyronet D, Guyotat J. Two-peaked 5-ALA-induced PpIX fluorescence emission spectrum distinguishes glioblastomas from low grade gliomas and infiltrative component of glioblastomas. BIOMEDICAL OPTICS EXPRESS 2013; 4:548-58. [PMID: 23577290 PMCID: PMC3617717 DOI: 10.1364/boe.4.000548] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 02/28/2013] [Accepted: 03/08/2013] [Indexed: 05/22/2023]
Abstract
5-ALA-induced protoporphyrin IX (PpIX) fluorescence enables to guiding in intra-operative surgical glioma resection. However at present, it has yet to be shown that this method is able to identify infiltrative component of glioma. In extracted tumor tissues we measured a two-peaked emission in low grade gliomas and in the infiltrative component of glioblastomas due to multiple photochemical states of PpIX. The second emission peak appearing at 620 nm (shifted by 14 nm from the main peak at 634 nm) limits the sensibility of current methods to measured PpIX concentration. We propose new measured parameters, by taking into consideration the two-peaked emission, to overcome these limitations in sensitivity. These parameters clearly distinguish the solid component of glioblastomas from low grade gliomas and infiltrative component of glioblastomas.
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Affiliation(s)
- Bruno Montcel
- CREATIS; Université de Lyon; Université Lyon1; CNRS UMR5220; INSERM U1044; INSA Lyon, Villeurbanne, France
| | - Laurent Mahieu-Williame
- CREATIS; Université de Lyon; Université Lyon1; CNRS UMR5220; INSERM U1044; INSA Lyon, Villeurbanne, France
| | - Xavier Armoiry
- Pharmacy Department/Cellule Innovation; Groupement Hospitalier Est; Hospices Civils de Lyon, Bron, France
| | - David Meyronet
- ONCOFLAM, Inserm U1028; CNRS UMR5292; Neuroscience Center, Université Lyon1, Lyon, F-69000, France
- Hospices Civils de Lyon, Centre de Pathologie et de Neuropathologie Est, Lyon, F-69003, France
| | - Jacques Guyotat
- Service de Neurochirurgie D; Hospices Civils de Lyon, Bron, France
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Intraoperative fluorescent imaging of intracranial tumors: a review. Clin Neurol Neurosurg 2013; 115:517-28. [PMID: 23523009 DOI: 10.1016/j.clineuro.2013.02.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 02/15/2013] [Accepted: 02/18/2013] [Indexed: 11/24/2022]
Abstract
A review of fluorescent imaging for intracranial neoplasms is presented. Complete resection of brain cancer is seldom possible because of the goal to preserve brain tissue and the inability to visualize individual infiltrative tumor cells. Verification of histology and identification of tumor invasion in macroscopically normal-appearing brain tissue determine prognosis after resection of malignant gliomas. Therefore, imaging modalities aim to facilitate intraoperative decision-making. Intraoperative fluorescent imaging techniques have the potential to enable precise histopathologic diagnosis and to detect tumor remnants in the operative field. Macroscopic fluorescence imaging is effective for gross tumor detection. Microscopic imaging techniques enhance the sensitivity of the macroscopic observations and provide real-time histological information. Further development of clinical grade fluorescent agents specifically targeting tumor cells could improve the diagnostic and prognostic yield of intraoperative imaging.
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Muragaki Y, Chernov M, Yoshimitsu K, Suzuki T, Iseki H, Maruyama T, Tamura M, Ikuta S, Nitta M, Watanabe A, Saito T, Okamoto J, Niki C, Hayashi M, Takakura K. Information-Guided Surgery of Intracranial Gliomas: Overview of an Advanced Intraoperative Technology. JOURNAL OF HEALTHCARE ENGINEERING 2012. [DOI: 10.1260/2040-2295.3.4.551] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Liao H, Fujiwara K, Ando T, Maruyama T, Kobayashi E, Muragaki Y, Iseki H, Sakuma I. Automatic laser scanning ablation system for high-precision treatment of brain tumors. Lasers Med Sci 2012; 28:891-900. [PMID: 22865089 DOI: 10.1007/s10103-012-1164-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 07/12/2012] [Indexed: 11/27/2022]
Abstract
Complete removal of malignant gliomas is important for the prognosis in neurosurgery treatment. Currently, the challenge is how to detect any remaining tumors and resect them during the operation. We have developed a laser ablation system with accurate tumor analysis and fluorescence guidance for high-precision brain tumor resection during neurosurgery. A 5-aminolevulinic acid-induced fluorescent protoporphyrins IX (PpIX)-based intra-operative fluorescence measurement and corresponding spectra analysis technique is used to identify the position of tumors. A galvano mirror scanning mechanism is integrated into the fluorescence measurement and the laser ablation devices for automatic tumor area scanning and corresponding laser ablation. A set of phantom experiments was performed to evaluate the proposed system. Results showed that the galvano scanning mechanism enabled both PpIX fluorescence detection and laser ablation in the same optical axis. In vitro experiments using porcine brain were performed to evaluate the effectiveness of the automatic laser scanning, fluorescence detection, and laser ablation system. The proposed fluorescence-guided laser ablation system can provide accurate analysis and high-precision treatment for tumor resection in neurosurgery. With further improvement, the system can be used in neurosurgical implementation to provide accurate, safe, and simple surgical diagnosis and therapy.
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Affiliation(s)
- Hongen Liao
- Graduate School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan.
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