1
|
Klint E, Richter J, Wårdell K. Combined Use of Frameless Neuronavigation and In Situ Optical Guidance in Brain Tumor Needle Biopsies. Brain Sci 2023; 13:brainsci13050809. [PMID: 37239281 DOI: 10.3390/brainsci13050809] [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: 04/17/2023] [Revised: 05/10/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
Brain tumor needle biopsies are performed to retrieve tissue samples for neuropathological analysis. Although preoperative images guide the procedure, there are risks of hemorrhage and sampling of non-tumor tissue. This study aimed to develop and evaluate a method for frameless one-insertion needle biopsies with in situ optical guidance and present a processing pipeline for combined postoperative analysis of optical, MRI, and neuropathological data. An optical system for quantified feedback on tissue microcirculation, gray-whiteness, and the presence of a tumor (protoporphyrin IX (PpIX) accumulation) with a one-insertion optical probe was integrated into a needle biopsy kit that was used for frameless neuronavigation. In Python, a pipeline for signal processing, image registration, and coordinate transformation was set up. The Euclidian distances between the pre- and postoperative coordinates were calculated. The proposed workflow was evaluated on static references, a phantom, and three patients with suspected high-grade gliomas. In total, six biopsy samples that overlapped with the region of the highest PpIX peak without increased microcirculation were taken. The samples were confirmed as being tumorous and postoperative imaging was used to define the biopsy locations. A 2.5 ± 1.2 mm difference between the pre- and postoperative coordinates was found. Optical guidance in frameless brain tumor biopsies could offer benefits such as quantified in situ indication of high-grade tumor tissue and indications of increased blood flow along the needle trajectory before the tissue is removed. Additionally, postoperative visualization enables the combined analysis of MRI, optical, and neuropathological data.
Collapse
Affiliation(s)
- Elisabeth Klint
- Department of Biomedical Engineering, Linköping University, 581 85 Linköping, Sweden
| | - Johan Richter
- Department of Biomedical Engineering, Linköping University, 581 85 Linköping, Sweden
- Department of Neurosurgery, Linköping University Hospital, 581 85 Linköping, Sweden
| | - Karin Wårdell
- Department of Biomedical Engineering, Linköping University, 581 85 Linköping, Sweden
| |
Collapse
|
2
|
Di Cristofori A, Carone G, Rocca A, Rui CB, Trezza A, Carrabba G, Giussani C. Fluorescence and Intraoperative Ultrasound as Surgical Adjuncts for Brain Metastases Resection: What Do We Know? A Systematic Review of the Literature. Cancers (Basel) 2023; 15:cancers15072047. [PMID: 37046709 PMCID: PMC10092992 DOI: 10.3390/cancers15072047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/25/2023] [Accepted: 03/27/2023] [Indexed: 04/14/2023] Open
Abstract
(1) Background: brain metastases (BMs) are the most common neoplasm of the central nervous system; despite the high incidence of this type of tumour, to date there is no universal consensus on the most effective treatment in patients with BMs, even if surgery still plays a primary role. Despite this, the adjunct systems that help to reach the GTR, which are well structured for other tumour forms such as ultrasound and fluorescence systems, are not yet well employed and standardised in surgical practice. The aim of this review is to provide a picture of the current state-of-art of the roles of iOUS and intraoperative fluorescence to better understand their potential roles as surgical tools. (2) Methods: to reach this goal, the PubMed database was searched using the following string as the keyword: (((Brain cerebral metastasis [MeSH Major Topic])OR (brain metastasis, [MeSH Major Topic])) AND ((5-ala, [MeSH Terms]) OR (Aminolevulinicacid [All fields]) OR (fluorescein, [MeSH Terms]) OR (contrast enhanced ultrasound [MeSH Terms])OR ((intraoperative ultrasound. [MeSH Terms]))) AND (english [Filter]) AND ((english [Filter]) AND (2010:2022 [pdat])) AND (english [Filter]). (3) Results: from our research, a total of 661 articles emerged; of these, 57 were selected. 21 of these included BMs generically as a secondary class for comparisons with gliomas, without going deeply into specific details. Therefore, for our purposes, 36 articles were considered. (4) Conclusions: with regard to BMs treatment and their surgical adjuncts, there is still much to be explored. This is mainly related to the heterogeneity of patients, the primary tumour histology and the extent of systemic disease; regardless, surgery plays a paramount role in obtaining a local disease control, and more standardised surgical protocols need to be made, with the aim of optimizing the use of the available surgical adjuncts and in order to increase the rate of GTR.
Collapse
Affiliation(s)
- Andrea Di Cristofori
- Division of Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Via GB Pergolesi, 20900 Monza, Italy
- PhD Program in Neuroscience, University of Milano-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
| | - Giovanni Carone
- Department of Neurosurgery, School of Medicine, Surgery Università degli Studi di Milano-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
| | - Alessandra Rocca
- Department of Neurosurgery, School of Medicine, Surgery Università degli Studi di Milano-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
| | - Chiara Benedetta Rui
- Department of Neurosurgery, School of Medicine, Surgery Università degli Studi di Milano-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
| | - Andrea Trezza
- Division of Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Via GB Pergolesi, 20900 Monza, Italy
| | - Giorgio Carrabba
- Division of Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Via GB Pergolesi, 20900 Monza, Italy
- Department of Neurosurgery, School of Medicine, Surgery Università degli Studi di Milano-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
| | - Carlo Giussani
- Division of Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Via GB Pergolesi, 20900 Monza, Italy
- Department of Neurosurgery, School of Medicine, Surgery Università degli Studi di Milano-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
| |
Collapse
|
3
|
Bettag C, Hussein A, Schatlo B, Barrantes-Freer A, Abboud T, Rohde V, Mielke D. Endoscope-assisted visualization of 5-aminolevulinic acid fluorescence in surgery for brain metastases. J Neurosurg 2022; 137:1650-1655. [PMID: 35535845 DOI: 10.3171/2022.3.jns212301] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/08/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Fluorescence-guided resection of cerebral metastases has been proposed as an approach to visualize residual tumor tissue and maximize the extent of resection. Critics have argued that tumor cells at the resection margins might be overlooked under microscopic visualization because of technical limitations. Therefore, an endoscope, which is capable of inducing fluorescence, has been applied with the aim of improving exposure of fluorescent tumor tissue. In this retrospective analysis, authors assessed the utility of endoscope assistance in 5-aminolevulinic acid (5-ALA) fluorescence-guided resection of brain metastases. METHODS Between June 2013 and December 2016, a standard 20-mg/kg dose of 5-ALA was administered 4 hours prior to surgery in 26 patients with suspected single brain metastases. After standard neuronavigated microsurgical tumor resection, a microscope capable of inducing fluorescence was used to examine tumor margins. The authors classified the remaining fluorescence into 3 grades (0 = none, 1 = weak, and 2 = strong). Endoscopic assistance was employed if no or only weak fluorescence was visualized at the resection margins under the microscope. Endoscopically identified fluorescent tissue at the margins was resected and evaluated separately via histological examination to prove or disprove tumor infiltration. RESULTS Under the microscope, weakly fluorescent tissue was seen at the margins of the resection cavity in 15/26 (57.7%) patients. In contrast, endoscopic inspection revealed strongly fluorescent tissue in 22/26 (84.6%) metastases. In 11/26 (42.3%) metastases no fluorescence at the tumor margins was detected by the microscope; however, strong fluorescence was visualized under the endoscope in 7 (63.6%) of these 11 metastases. In the 15 metastases with microscopically weak fluorescence, strong fluorescence was seen when using the endoscope. Neither microscopic nor endoscopic fluorescence was found in 4/26 (15.4%) cases. In the 26 patients, 96 histological specimens were obtained from the margins of the resection cavity. Findings from these specimens were in conjunction with the histopathological findings, allowing identification of metastatic infiltration with a sensitivity of 95.5% and a specificity of 75% using endoscope assistance. CONCLUSIONS Fluorescence-guided endoscope assistance may overcome the technical limitations of the conventional microscopic exposure of 5-ALA-fluorescent metastases and thereby increase visualization of fluorescent tumor tissue at the margins of the resection cavity with high sensitivity and acceptable specificity.
Collapse
Affiliation(s)
| | | | | | - Alonso Barrantes-Freer
- 2Paul-Flechsig Institute of Neuropathology, University Medical Center Leipzig; and
- 3Institute of Neuropathology, University Medical Center Göttingen, Germany
| | - Tammam Abboud
- 1Department of Neurosurgery, University Hospital Göttingen
| | - Veit Rohde
- 1Department of Neurosurgery, University Hospital Göttingen
| | | |
Collapse
|
4
|
Shah HA, Leskinen S, Khilji H, Narayan V, Ben-Shalom N, D’Amico RS. Utility of 5-ALA for fluorescence-guided resection of brain metastases: a systematic review. J Neurooncol 2022; 160:669-675. [DOI: 10.1007/s11060-022-04188-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/01/2022] [Indexed: 11/14/2022]
|
5
|
Leavitt LA, Muñoz W, Jones PS. 5-ALA fluorescence-guided resection of a recurrent anaplastic pleomorphic xanthoastrocytoma: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22310. [PMID: 36193033 PMCID: PMC9552559 DOI: 10.3171/case22310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND 5-aminolevulinic acid (5-ALA)-induced fluorescence of neoplastic tissue is known to occur in a number of high-grade gliomas. This fluorescence helps surgeons maximize safe resection by distinguishing previously indiscernible neoplastic tissue from brain parenchyma. Still, the effectiveness of 5-ALA has not been fully explored for all central nervous system tumors. Consequently, the full spectrum of tumors that would benefit from fluorescence-guided surgery using 5-ALA is unknown. OBSERVATIONS This report describes successfully utilizing 5-ALA to achieve complete resection of a recurrent anaplastic pleomorphic xanthoastrocytoma (APXA). LESSONS APXA tumor cells accumulate sufficient amounts of 5-ALA and its fluorescent metabolite to produce visible intraoperative fluorescence. However, further investigation is needed to determine if 5-ALA fluorescent labeling routinely occurs in patients with APXAs.
Collapse
Affiliation(s)
- Lydia A. Leavitt
- University of Illinois College of Medicine, Rockford, Illinois; and
| | - William Muñoz
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Pamela S. Jones
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
6
|
Neijenhuis LKA, de Myunck LDAN, Bijlstra OD, Kuppen PJK, Hilling DE, Borm FJ, Cohen D, Mieog JSD, Steup WH, Braun J, Burggraaf J, Vahrmeijer AL, Hutteman M. Near-Infrared Fluorescence Tumor-Targeted Imaging in Lung Cancer: A Systematic Review. Life (Basel) 2022; 12:life12030446. [PMID: 35330197 PMCID: PMC8950608 DOI: 10.3390/life12030446] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 12/24/2022] Open
Abstract
Lung cancer is the most common cancer type worldwide, with non-small cell lung cancer (NSCLC) being the most common subtype. Non-disseminated NSCLC is mainly treated with surgical resection. The intraoperative detection of lung cancer can be challenging, since small and deeply located pulmonary nodules can be invisible under white light. Due to the increasing use of minimally invasive surgical techniques, tactile information is often reduced. Therefore, several intraoperative imaging techniques have been tested to localize pulmonary nodules, of which near-infrared (NIR) fluorescence is an emerging modality. In this systematic review, the available literature on fluorescence imaging of lung cancers is presented, which shows that NIR fluorescence-guided lung surgery has the potential to identify the tumor during surgery, detect additional lesions and prevent tumor-positive resection margins.
Collapse
Affiliation(s)
- Lisanne K. A. Neijenhuis
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
- Centre for Human Drug Research, 2333 CL Leiden, The Netherlands;
| | - Lysanne D. A. N. de Myunck
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
| | - Okker D. Bijlstra
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
| | - Peter J. K. Kuppen
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
| | - Denise E. Hilling
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
- Department of Surgery, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Frank J. Borm
- Department of Pulmonology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Danielle Cohen
- Department of Pathology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
| | - Willem H. Steup
- Department of Surgery, HAGA Hospital, 2545 AA The Hague, The Netherlands;
| | - Jerry Braun
- Department of Cardiothoracic Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | | | - Alexander L. Vahrmeijer
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
| | - Merlijn Hutteman
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.K.A.N.); (L.D.A.N.d.M.); (O.D.B.); (P.J.K.K.); (D.E.H.); (J.S.D.M.); (A.L.V.)
- Department of Cardiothoracic Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
- Correspondence: ; Tel.: +31-71-526-51-00
| |
Collapse
|
7
|
Schupper AJ, Yong RL, Hadjipanayis CG. The Neurosurgeon's Armamentarium for Gliomas: An Update on Intraoperative Technologies to Improve Extent of Resection. J Clin Med 2021; 10:jcm10020236. [PMID: 33440712 PMCID: PMC7826675 DOI: 10.3390/jcm10020236] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 12/18/2022] Open
Abstract
Maximal safe resection is the standard of care in the neurosurgical treatment of high-grade gliomas. To aid surgeons in the operating room, adjuvant techniques and technologies centered around improving intraoperative visualization of tumor tissue have been developed. In this review, we will discuss the most advanced technologies, specifically fluorescence-guided surgery, intraoperative imaging, neuromonitoring modalities, and microscopic imaging techniques. The goal of these technologies is to improve detection of tumor tissue beyond what conventional microsurgery has permitted. We describe the various advances, the current state of the literature that have tested the utility of the different adjuvants in clinical practice, and future directions for improving intraoperative technologies.
Collapse
|