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Nasir-Moin M, Wadiura LI, Sacalean V, Juros D, Movahed-Ezazi M, Lock EK, Smith A, Lee M, Weiss H, Müther M, Alber D, Ratna S, Fang C, Suero-Molina E, Hellwig S, Stummer W, Rössler K, Hainfellner JA, Widhalm G, Kiesel B, Reichert D, Mischkulnig M, Jain R, Straehle J, Neidert N, Schnell O, Beck J, Trautman J, Pastore S, Pacione D, Placantonakis D, Oermann EK, Golfinos JG, Hollon TC, Snuderl M, Freudiger CW, Heiland DH, Orringer DA. Localization of protoporphyrin IX during glioma-resection surgery via paired stimulated Raman histology and fluorescence microscopy. Nat Biomed Eng 2024; 8:672-688. [PMID: 38987630 DOI: 10.1038/s41551-024-01217-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 04/20/2024] [Indexed: 07/12/2024]
Abstract
The most widely used fluorophore in glioma-resection surgery, 5-aminolevulinic acid (5-ALA), is thought to cause the selective accumulation of fluorescent protoporphyrin IX (PpIX) in tumour cells. Here we show that the clinical detection of PpIX can be improved via a microscope that performs paired stimulated Raman histology and two-photon excitation fluorescence microscopy (TPEF). We validated the technique in fresh tumour specimens from 115 patients with high-grade gliomas across four medical institutions. We found a weak negative correlation between tissue cellularity and the fluorescence intensity of PpIX across all imaged specimens. Semi-supervised clustering of the TPEF images revealed five distinct patterns of PpIX fluorescence, and spatial transcriptomic analyses of the imaged tissue showed that myeloid cells predominate in areas where PpIX accumulates in the intracellular space. Further analysis of external spatially resolved metabolomics, transcriptomics and RNA-sequencing datasets from glioblastoma specimens confirmed that myeloid cells preferentially accumulate and metabolize PpIX. Our findings question 5-ALA-induced fluorescence in glioma cells and show how 5-ALA and TPEF imaging can provide a window into the immune microenvironment of gliomas.
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Affiliation(s)
- Mustafa Nasir-Moin
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Vlad Sacalean
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Microenvironment and Immunology Research Laboratory, Medical Center - University of Freiburg, Freiburg, Germany
| | - Devin Juros
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Emily K Lock
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Andrew Smith
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Matthew Lee
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Hannah Weiss
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Michael Müther
- Department of Neurosurgery, Münster University Hospital, Münster, Germany
| | - Daniel Alber
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Camila Fang
- Department of Pathology, NYU Grossman School of Medicine, New York, NY, USA
| | - Eric Suero-Molina
- Department of Neurosurgery, Münster University Hospital, Münster, Germany
| | - Sönke Hellwig
- Department of Neurosurgery, Münster University Hospital, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, Münster University Hospital, Münster, Germany
| | - Karl Rössler
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Johannes A Hainfellner
- Division of Neuropathology and Neurochemistry (Obersteiner Institute), Department of Neurology, Medical University Vienna, Vienna, Austria
| | - Georg Widhalm
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Barbara Kiesel
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - David Reichert
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Mario Mischkulnig
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Rajan Jain
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Jakob Straehle
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Berta-Ottenstein Clinician Scientist Program, Faculty of Medicine, University Freiburg, Freiburg, Germany
| | - Nicolas Neidert
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Berta-Ottenstein Clinician Scientist Program, Faculty of Medicine, University Freiburg, Freiburg, Germany
| | - Oliver Schnell
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Translational NeuroOncology Research Group, Medical Center - University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for NeuroModulation (NeuroModul), University of Freiburg, Freiburg, Germany
| | | | | | - Donato Pacione
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Eric Karl Oermann
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
- Center for Data Science, New York University, New York, USA
| | - John G Golfinos
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Todd C Hollon
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Matija Snuderl
- Department of Pathology, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Dieter Henrik Heiland
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany.
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.
- Microenvironment and Immunology Research Laboratory, Medical Center - University of Freiburg, Freiburg, Germany.
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center - University of Freiburg, Freiburg, Germany.
- German Cancer Consortium (DKTK), partner site Freiburg, Freiburg, Germany.
| | - Daniel A Orringer
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA.
- Department of Pathology, NYU Grossman School of Medicine, New York, NY, USA.
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Czarnywojtek A, Borowska M, Dyrka K, Van Gool S, Sawicka-Gutaj N, Moskal J, Kościński J, Graczyk P, Hałas T, Lewandowska AM, Czepczyński R, Ruchała M. Glioblastoma Multiforme: The Latest Diagnostics and Treatment Techniques. Pharmacology 2023; 108:423-431. [PMID: 37459849 DOI: 10.1159/000531319] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 05/05/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Glioblastoma multiforme (GBM) is a WHO grade 4 glioma and the most common malignant primary brain tumour. Recently, there has been outstanding progress in the treatment of GBM. In addition to the newest form of GBM removal using fluorescence, three-dimensional (3D) imaging, tomoradiotherapy, moderate electro-hyperthermia, and adjuvant temozolomide (post-operative chemotherapy), new developments have been made in the fields of immunology, molecular biology, and virotherapy. An unusual and modern treatment has been created, especially for stage 4 GBM, using the latest therapeutic techniques, including immunotherapy and virotherapy. Modern oncological medicine is producing extraordinary and progressive therapeutic methods. Oncological therapy includes individual analysis of the properties of a tumour and targeted therapy using small-molecule inhibitors. Individualised medicine covers the entire patient (tumour and host) in the context of immunotherapy. An example is individualised multimodal immunotherapy (IMI), which relies on individual immunological tumour-host interactions. In addition, IMI is based on the concept of oncolytic virus-induced immunogenic tumour cell death. SUMMARY In this review, we outline current knowledge of the various available treatment options used in the therapy of GBM including both traditional therapeutic strategy and modern therapies, such as tomotherapy, electro-hyperthermia, and oncolytic virotherapy, which are promising treatment strategies with the potential to improve prognosis in patients with GBM. KEY MESSAGES This newest therapy, immunotherapy combined with virotherapy (oncolytic viruses and cancer vaccines), is displaying encouraging signs for combating GBM. Additionally, the latest 3D imaging is compared to conventional two-dimensional imaging.
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Affiliation(s)
- Agata Czarnywojtek
- Chair and Department of Pharmacology, Poznan University of Medical Sciences, Poznan, Poland
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Magdalena Borowska
- Chair and Department of Pharmacology, Poznan University of Medical Sciences, Poznan, Poland
| | - Kamil Dyrka
- Department of Pediatric Endocrinology and Rheumatology, Institute of Pediatrics, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Nadia Sawicka-Gutaj
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Jakub Moskal
- Department of Neurosurgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Jeremi Kościński
- Department of Neurosurgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Patryk Graczyk
- Chair and Department of Pharmacology, Poznan University of Medical Sciences, Poznan, Poland
| | - Tomasz Hałas
- Chair and Department of Pharmacology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Rafał Czepczyński
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Marek Ruchała
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
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Yang Z, Zhao C, Zong S, Piao J, Zhao Y, Chen X. A review on surgical treatment options in gliomas. Front Oncol 2023; 13:1088484. [PMID: 37007123 PMCID: PMC10061125 DOI: 10.3389/fonc.2023.1088484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/24/2023] [Indexed: 03/17/2023] Open
Abstract
Gliomas are one of the most common primary central nervous system tumors, and surgical treatment remains the principal role in the management of any grade of gliomas. In this study, based on the introduction of gliomas, we review the novel surgical techniques and technologies in support of the extent of resection to achieve long-term disease control and summarize the findings on how to keep the balance between cytoreduction and neurological morbidity from a list of literature searched. With modern neurosurgical techniques, gliomas resection can be safely performed with low morbidity and extraordinary long-term functional outcomes.
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Affiliation(s)
- Zhongxi Yang
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
| | - Chen Zhao
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
| | - Shan Zong
- Department of Gynecology Oncology, The First Hospital of Jilin University, Jilin, China
| | - Jianmin Piao
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
| | - Yuhao Zhao
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
| | - Xuan Chen
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
- *Correspondence: Xuan Chen,
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4
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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]
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5
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Solomou G, Gharooni AA, Patel W, Gillespie CS, Gough M, Venkatesh A, Poon MTC, Wykes V, Price SJ, Jenkinson MD, Watts C, Plaha P. Utility of 5-ALA for resection of CNS tumours other than high-grade gliomas: a protocol for a systematic review. BMJ Open 2022; 12:e056059. [PMID: 35868820 PMCID: PMC9315896 DOI: 10.1136/bmjopen-2021-056059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION 5-aminolevulinic acid (5-ALA) is a proagent developed for fluorescent-guided surgery for high-grade glioma patients associated with a significant increase in resection conferring survival. 5-ALA was shown to penetrate the blood-brain barrier accumulating in malignant glioma cells with high selectivity, sensitivity and positive predictive value. However, those have yet to be explored aiding diagnosis for tumours of the central nervous system (CNS) other than high-grade gliomas (HGG). No up-to-date systematic review exists reporting the major surgical outcomes and diagnostic accuracy. We sought to conduct a systematic review of the literature summarising surgical outcomes, evaluate the quality of diagnostic accuracy reported in the literature and qualitatively assess the evidence to inform future studies. METHODS AND ANALYSIS We will search electronic databases (Medline, Embase) with subsequent interrogation of references lists of articles reporting the use of 5-ALA for brain tumours other than high-grade glioma adult patients, which also report the extent of resection and/or survival. Prospective and retrospective cohort and case-control studies with more than five patients will be included. Two independent reviewers will screen the abstracts and full articles, with a third reviewer resolving any conflicts. The data will be extracted in a standardised template and outcomes will be reported using descriptive statists. The quality of non-randomised studies will be appraised. ETHICS AND DISSEMINATION The study will summarise the available evidence on the effect of the clinical utility of 5-ALA in achieving resection and improving survival and its diagnostic accuracy for tumours of the CNS other than HGG. The data will be presented nationally and internationally and the manuscript will be published in a peer-reviewed journal. No ethical approvals were needed. The aim is to inform prospective studies minimising reporting bias allowing for more reliable, reproducible and generalisable results. The study has been registered in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.PROSPERO registration numberCRD42021260542.
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Affiliation(s)
- Georgios Solomou
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Aref-Ali Gharooni
- Department of Clinical Neuroscience, Addenbrooke's Hospital, Cambridge, UK
| | - Waqqas Patel
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
| | - Conor S Gillespie
- Neurosurgery Division, Dept. Clinical Neurosciences, Cambridge University, Cambridge, UK
| | - Melissa Gough
- Department of Neurosurgery, Royal Victoria Infirmary Newcastle Hospitals NHS Trust, Newcastle, UK
| | - Ashwin Venkatesh
- Blizard Institute, Centre for Neuroscience Surgery and Trauma, Barts Health NHS Trust, London, UK
| | - Michael T C Poon
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neuroscience, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Victoria Wykes
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stephen John Price
- Neurosurgery Division, Dept. Clinical Neurosciences, Cambridge University, Cambridge, UK
| | - Michael D Jenkinson
- Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Clinical and Molecular Cancer, University of Liverpool, Liverpool, UK
| | - Colin Watts
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Puneet Plaha
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
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6
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Giantini Larsen AM, Parker WE, Cho SS, Goldberg JL, Carnevale JA, Michael AP, Teng CW, De Ravin E, Brennan CW, Lee JYK, Schwartz TH. The Evolution of 5-Aminolevulinic Acid Fluorescence Visualization: Time for a Headlamp/Loupe Combination. World Neurosurg 2021; 159:136-143. [PMID: 34971836 DOI: 10.1016/j.wneu.2021.12.089] [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: 10/27/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The use of 5-ALA for intraoperative protoporphyrin IX (PpIX) fluorescent imaging in the resection of malignant gliomas has been demonstrated to improve tumor visualization, increase extent of resection, and extend progression-free survival. The current technique for visualization of 5-ALA consists of excitation and emission filters built into the operating microscope. However, there are notable limitations to this process, including low quantum yield, expense, and masking of surrounding anatomy. METHODS We present three cases in which three separate methods were employed for visualizing fluorescence. The devices reported are 1) a low-cost blue light flashlight and 2) a low-cost headlamp, and 3) the first reported case of the new Design for Vision® REVEAL™ FGS (Fluorescence Guided Surgery) 5-ALA fluorescent headlight and loupes. The aim of the study is to provide confirmation that tumor fluorescence can be observed using commercially-available products other than the microscope. RESULTS We demonstrate through three intraoperative cases that a variety of devices can produce visible fluorescence of the high-grade tumor and allow for simultaneous real-time visualization of the adjacent brain parenchyma and vasculature. The REVEAL™ FGS system appears to offer increased fluorescence emission compared to all other methods, including the microscope. CONCLUSIONS Our study demonstrates the feasibility of using blue/ultraviolet light supplied by a commercially available, inexpensive flashlight or headlamp to visualize 5-ALA fluorescence in high-grade gliomas. We also provide the first documentation of intraoperative use of the new Design for Vision® REVEAL™ FGS 5-ALA fluorescent headlight and loupes and report on the experience. Lack of an operative microscope capable of fluorescent illumination should not be a limiting factor in performing fluorescent-guided glioma resection.
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Affiliation(s)
- Alexandra M Giantini Larsen
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA; Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Whitney E Parker
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA; Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Steve S Cho
- Department of Neurological Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jacob L Goldberg
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA; Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph A Carnevale
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA; Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alex P Michael
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Clare W Teng
- Department of Neurological Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Emma De Ravin
- Department of Neurological Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Cameron W Brennan
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - John Y K Lee
- Department of Neurological Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA.
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Morisawa S, Jobu K, Ishida T, Kawada K, Fukuda H, Kawanishi Y, Nakayama T, Yamamoto S, Tamura N, Takemura M, Kagimoto N, Ohta T, Masahira N, Fukuhara H, Ogura SI, Ueba T, Inoue K, Miyamura M. Association of 5-aminolevulinic acid with intraoperative hypotension in malignant glioma surgery. Photodiagnosis Photodyn Ther 2021; 37:102657. [PMID: 34848378 DOI: 10.1016/j.pdpdt.2021.102657] [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: 10/09/2021] [Revised: 11/17/2021] [Accepted: 11/24/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Use of 5-aminolevulinic acid for photodynamic malignant tumor diagnosis reportedly causes intraoperative hypotension (systolic blood pressure < 70 mmHg) during urologic surgery. However, its association with intraoperative hypotension in malignant glioma surgery and underlying mechanisms has not yet been elucidated.. This study aimed to investigate whether 5-aminolevulinic acid administration is associated with intraoperative hypotension in malignant glioma surgery and explore the mechanisms of 5-aminolevulinic acid-induced hypotension in vitro. METHODS In this retrospective multicenter cohort study, we investigated intracellular nitric oxide as a candidate mediator of hypotension in response to 5-aminolevulinic acid in vitro in human umbilical vein endothelial cell cultures. RESULTS Of 142 patients, 94 underwent 5-aminolevulinic acid-guided surgery. Systolic blood pressure was significantly lower throughout surgery with 5-aminolevulinic acid administration. 5-Aminolevulinic acid administration was an independent risk factor for intraoperative hypotension according to multivariable logistic regression analysis (89% vs. 56%; odds ratio = 6.72, 95% confidence interval [2.05-22.1], P = 002). In subgroup analysis of the 5-aminolevulinic acid group, increasing age and use of renin-angiotensin system inhibitors had a synergistic effect with 5-aminolevulinic acid on decreased blood pressure. In the vascular endothelial cell culture study, 5-aminolevulinic acid induced a significant increase in intracellular nitric oxide generation. CONCLUSIONS 5-Aminolevulinic acid administration was associated with intraoperative hypotension in malignant glioma surgery, with increasing age and use of renin-angiotensin system inhibitors boosting the blood pressure-lowering effect of 5-aminolevulinic acid. According to in vitro results, the low blood pressure induced by 5-aminolevulinic acid may be mediated by a nitric oxide increase in vascular endothelial cells.
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Affiliation(s)
- Shumpei Morisawa
- Department of Pharmacy, Kochi Medical School Hospital, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan; Graduate School of Integrated Arts and Sciences Kochi University, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan.
| | - Kohei Jobu
- Department of Pharmacy, Kochi Medical School Hospital, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan
| | - Tomoaki Ishida
- Department of Pharmacy, Kochi Medical School Hospital, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan
| | - Kei Kawada
- Department of Pharmacy, Kochi Medical School Hospital, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan; Graduate School of Integrated Arts and Sciences Kochi University, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kochi Medical School, Kochi University, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan
| | - Yu Kawanishi
- Department of Neurosurgery, Kochi Medical School, Kochi University, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan
| | - Taku Nakayama
- Center for Photodynamic Medicine, Kochi Medical School, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan
| | - Shinkuro Yamamoto
- Department of Urology, Kochi Medical School, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan
| | - Naohisa Tamura
- Department of Pharmacy, Kochi Medical School Hospital, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan; Graduate School of Integrated Arts and Sciences Kochi University, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan
| | - Mitsuhiro Takemura
- Department of Neurosurgery, Kochi Medical School, Kochi University, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan
| | - Nao Kagimoto
- Department of Neurosurgery, Kochi Medical School, Kochi University, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, National Cerebral and Cardiovascular Center Hospital, 6-1 Kishibe Shimmachi, Suita Osaka, Japan
| | - Noritaka Masahira
- Department of Neurosurgery, Kochi Health Sciences Center, 2125-1, Ike, Kochi, Kochi, Japan
| | - Hideo Fukuhara
- Center for Photodynamic Medicine, Kochi Medical School, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan; Department of Urology, Kochi Medical School, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan
| | - Shun-Ichiro Ogura
- Center for Photodynamic Medicine, Kochi Medical School, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan; School of Life Science and Technology, Tokyo Institute of Technology, 4259 B47, Nagatsuta-cho, Midori-ku, Yokohama, Kanagawa, Japan
| | - Tetsuya Ueba
- Department of Neurosurgery, Kochi Medical School, Kochi University, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan
| | - Keiji Inoue
- Center for Photodynamic Medicine, Kochi Medical School, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan; Department of Urology, Kochi Medical School, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan
| | - Mitsuhiko Miyamura
- Department of Pharmacy, Kochi Medical School Hospital, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan; Graduate School of Integrated Arts and Sciences Kochi University, 185-1, Kohasu, Oko town, Nankoku, Kochi, Japan
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8
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Mazurek M, Kulesza B, Stoma F, Osuchowski J, Mańdziuk S, Rola R. Characteristics of Fluorescent Intraoperative Dyes Helpful in Gross Total Resection of High-Grade Gliomas-A Systematic Review. Diagnostics (Basel) 2020; 10:E1100. [PMID: 33339439 PMCID: PMC7766001 DOI: 10.3390/diagnostics10121100] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 12/12/2022] Open
Abstract
Background: A very important aspect in the treatment of high-grade glioma is gross total resection to reduce the risk of tumor recurrence. One of the methods to facilitate this task is intraoperative fluorescence navigation. The aim of the study was to compare the dyes used in this technique fluorescent intraoperative navigation in terms of the mechanism of action and influence on the treatment of patients. Methods: The review was carried out on the basis of articles found in PubMed, Google Scholar, and BMC search engines, as well as those identified by searched bibliographies and suggested by experts during the preparation of the article. The database analysis was performed for the following phrases: "glioma", "glioblastoma", "ALA", "5ALA", "5-ALA", "aminolevulinic acid", "levulinic acid", "fluorescein", "ICG", "indocyanine green", and "fluorescence navigation". Results: After analyzing 913 citations identified on the basis of the search criteria, we included 36 studies in the review. On the basis of the analyzed articles, we found that 5-aminolevulinic acid and fluorescein are highly effective in improving the percentage of gross total resection achieved in high-grade glioma surgery. At the same time, the limitations resulting from the use of these methods are marked-higher costs of the procedure and the need to have neurosurgical microscope in combination with a special light filter in the case of 5-aminolevulinic acid (5-ALA), and low specificity for neoplastic cells and the dependence on the degree of damage to the blood-brain barrier in the intensity of fluorescence in the case of fluorescein. The use of indocyanine green in the visualization of glioma cells is relatively unknown, but some researchers have suggested its utility and the benefits of using it simultaneously with other dyes. Conclusion: The use of intraoperative fluorescence navigation with the use of 5-aminolevulinic acid and fluorescein allows the range of high-grade glioma resection to be increased.
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Affiliation(s)
- Marek Mazurek
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
| | - Bartłomiej Kulesza
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
| | - Filip Stoma
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
| | - Jacek Osuchowski
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
| | - Sławomir Mańdziuk
- Department of Clinical Oncology and Chemotherapy, Medical University of Lublin, 20-954 Lublin, Poland;
| | - Radosław Rola
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
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9
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5-Aminolevulinic acid for recurrent malignant gliomas: A systematic review. Clin Neurol Neurosurg 2020; 195:105913. [DOI: 10.1016/j.clineuro.2020.105913] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/28/2020] [Accepted: 05/10/2020] [Indexed: 11/24/2022]
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10
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Ramonaite R, Petrolis R, Unay S, Kiudelis G, Skieceviciene J, Kupcinskas L, Bilgin MD, Krisciukaitis A. Mathematical morphology-based imaging of gastrointestinal cancer cell motility and 5-aminolevulinic acid-induced fluorescence. BIOMED ENG-BIOMED TE 2019; 64:711-720. [PMID: 31326958 DOI: 10.1515/bmt-2018-0197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 02/26/2019] [Indexed: 11/15/2022]
Abstract
The aim of this study was the quantitative evaluation of gastrointestinal cancer cell motility and 5-aminolevulinic acid (5-ALA)-induced fluorescence in vitro using mathematical morphology and structural analysis methods. The results of our study showed that MKN28 cells derived from the lymph node have the highest motility compared with AGS or HCT116 cells derived from primary tumors. Regions of single cells were characterized as most moving, and "tightly packed" cell colonies as nearly immobile. We determined the reduction of cell motility in late passage compared to early passage. Application of 5-ALA caused fluorescence in all investigated cells, and the fluorescence was different with regard to the cell type and application time. We observed higher fluorescence in MKN28 cells. Comprehensive image analysis did not reveal any statistically significant difference in fluorescence intensity between "tightly packed" cell regions, where nearly no motility was registered and loosely distributed cells, where the highest cell motility was registered. In conclusions, our study revealed that MKN28 cells derived from the lymph node have higher motility and 5-ALA-induced fluorescence than AGS or HCT116 derived from primary tumors. Moreover, image analysis based on a large amount of processed data is an important tool to study these tumor cell properties.
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Affiliation(s)
- Rima Ramonaite
- Institute for Digestive Research, Lithuanian University of Health Sciences, Mickeviciaus St. 9, Kaunas, LT-44307, Lithuania, E-mail:
| | - Robertas Petrolis
- Neuroscience Institute, Lithuanian University of Health Sciences, Kaunas, LT-44307, Lithuania
| | - Simge Unay
- Department of Biophysics, Healthy Science Institute, Adnan Menderes University, Aydin, TR-09000, Turkey
| | - Gediminas Kiudelis
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, LT-44307, Lithuania
| | - Jurgita Skieceviciene
- Institute for Digestive Research, Lithuanian University of Health Sciences, Mickeviciaus St. 9, Kaunas, LT-44307, Lithuania
| | - Limas Kupcinskas
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, LT-44307, Lithuania
- Institute for Digestive Research, Lithuanian University of Health Sciences, Mickeviciaus St. 9, Kaunas, LT-44307, Lithuania
| | - Mehmet Dincer Bilgin
- Department of Biophysics, Healthy Science Institute, Adnan Menderes University, Aydin, TR-09000, Turkey
- Department of Biophysics, Medical Faculty, Adnan Menderes University, Aydin, TR-09000, Turkey
| | - Algimantas Krisciukaitis
- Neuroscience Institute, Lithuanian University of Health Sciences, Kaunas, LT-44307, Lithuania
- Department of Physics, Mathematics and Biophysics, Lithuanian University of Health Sciences, Kaunas, LT-44307, Lithuania
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11
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Initial biopsy and early re-resection practices in the treatment of glioblastoma among AANS/CNS tumor section surgeons. J Neurooncol 2019; 144:529-534. [DOI: 10.1007/s11060-019-03253-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 07/29/2019] [Indexed: 12/14/2022]
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12
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Wei L, Fujita Y, Sanai N, Liu JTC. Toward Quantitative Neurosurgical Guidance With High-Resolution Microscopy of 5-Aminolevulinic Acid-Induced Protoporphyrin IX. Front Oncol 2019; 9:592. [PMID: 31334117 PMCID: PMC6616084 DOI: 10.3389/fonc.2019.00592] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 06/17/2019] [Indexed: 12/13/2022] Open
Abstract
Low-power fluorescence microscopy of 5-ALA-induced PpIX has emerged as a valuable intraoperative imaging technology for improving the resection of malignant gliomas. However, current fluorescence imaging tools are not highly sensitive nor quantitative, which limits their effectiveness for optimizing operative decisions near the surgical margins of gliomas, in particular non-enhancing low-grade gliomas. Intraoperative high-resolution optical-sectioning microscopy can potentially serve as a valuable complement to low-power fluorescence microscopy by providing reproducible quantification of tumor parameters at the infiltrative margins of diffuse gliomas. In this forward-looking perspective article, we provide a brief discussion of recent technical advancements, pilot clinical studies, and our vision of the future adoption of handheld optical-sectioning microscopy at the final stages of glioma surgeries to enhance the extent of resection. We list a number of challenges for clinical acceptance, as well as potential strategies to overcome such obstacles for the surgical implementation of these in vivo microscopy techniques.
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Affiliation(s)
- Linpeng Wei
- Department of Mechanical Engineering, University of Washington, Seattle, WA, United States
| | - Yoko Fujita
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Nader Sanai
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Jonathan T C Liu
- Department of Mechanical Engineering, University of Washington, Seattle, WA, United States.,Department of Pathology, University of Washington School of Medicine, Seattle, WA, United States
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13
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Abstract
For the neurosurgical oncologist, a specialty practice in gliomas represents an intersection of tailored surgical approaches, emerging intraoperative technologies, expanding surgical trial portfolios, and new paradigms in glioma biology. Assembling these disparate pieces into a cohesive career trajectory is a difficult task but ultimately enables the subspecialist to navigate all domains relevant to improving glioma patient outcomes. Within the larger clinical and basic science community, thoughtful integration and intensive collaborations are essential mechanisms when building a multidisciplinary glioma program.
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Affiliation(s)
- Nader Sanai
- Division of Neurosurgical Oncology, Ivy Brain Tumor Center, Barrow Neurological Institute, 2910 North Third Avenue, Phoenix, AZ 85013, USA.
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14
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15
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Wei L, Chen Y, Yin C, Borwege S, Sanai N, Liu JTC. Optical-sectioning microscopy of protoporphyrin IX fluorescence in human gliomas: standardization and quantitative comparison with histology. JOURNAL OF BIOMEDICAL OPTICS 2017; 22:46005. [PMID: 28418534 PMCID: PMC5390779 DOI: 10.1117/1.jbo.22.4.046005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/27/2017] [Indexed: 05/02/2023]
Abstract
Systemic delivery of 5-aminolevulinic acid leads to enhanced fluorescence image contrast in many tumors due to the increased accumulation of protoporphyrin IX (PpIX), a fluorescent porphyrin that is associated with tumor burden and proliferation. The value of PpIX-guided resection of malignant gliomas has been demonstrated in prospective randomized clinical studies in which a twofold greater extent of resection and improved progression-free survival have been observed. In low-grade gliomas and at the diffuse infiltrative margins of all gliomas, PpIX fluorescence is often too weak to be detected with current low-resolution surgical microscopes that are used in operating rooms. However, it has been demonstrated that high-resolution optical-sectioning microscopes are capable of detecting the sparse and punctate accumulations of PpIX that are undetectable via conventional low-power surgical fluorescence microscopes. To standardize the performance of high-resolution optical-sectioning devices for future clinical use, we have developed an imaging phantom and methods to ensure that the imaging of PpIX-expressing brain tissues can be performed reproducibly. Ex vivo imaging studies with a dual-axis confocal microscope demonstrate that these methods enable the acquisition of images from unsectioned human brain tissues that quantitatively and consistently correlate with images of histologically processed tissue sections.
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Affiliation(s)
- Linpeng Wei
- University of Washington, Department of Mechanical Engineering, Seattle, Washington, United States
| | - Ye Chen
- University of Washington, Department of Mechanical Engineering, Seattle, Washington, United States
| | - Chengbo Yin
- University of Washington, Department of Mechanical Engineering, Seattle, Washington, United States
| | - Sabine Borwege
- Barrow Neurological Institute, St. Joseph’s Hospital, Phoenix, Arizona, United States
| | - Nader Sanai
- Barrow Neurological Institute, St. Joseph’s Hospital, Phoenix, Arizona, United States
| | - Jonathan T. C. Liu
- University of Washington, Department of Mechanical Engineering, Seattle, Washington, United States
- Address all correspondence to: Jonathan T. C. Liu, E-mail:
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16
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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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17
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Mansouri A, Mansouri S, Hachem LD, Klironomos G, Vogelbaum MA, Bernstein M, Zadeh G. The role of 5-aminolevulinic acid in enhancing surgery for high-grade glioma, its current boundaries, and future perspectives: A systematic review. Cancer 2016; 122:2469-78. [PMID: 27183272 DOI: 10.1002/cncr.30088] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/07/2016] [Accepted: 03/17/2016] [Indexed: 01/26/2023]
Abstract
5-Aminolevulinic acid (5-ALA) has been approved as an intraoperative adjunct in glioma surgery in Europe, but not North America. A systematic review was conducted to assess the evidence regarding 5-ALA as a surgical adjunct. The MEDLINE, EMBASE, and CENTRAL databases were searched, using terms relevant to "5-ALA" and "high-grade gliomas." Included studies were based on adults aged ≥18 years who underwent surgical resection/biopsy. No language or date limitations were used. Forty-three studies (1830 patients) were identified. Thirty-six were coordinated by European countries, 2 were in the United States, and none were in Canada. One was randomized, 28 were prospective, and 14 were retrospective. Twenty-six studies assessed the utility of 5-ALA as a diagnostic tool, 24 assessed its influence on the extent of resection (EOR), 9 assessed survival, and 22 reported adverse events. 5-ALA had high sensitivity and positive predictive value, whereas its specificity increased with additional adjuncts. The EOR increased with 5-ALA, but only progression-free survival was significantly influenced. Reporting of adverse events was not systematic. The use of 5-ALA improved tumor visualization and thus enabled a greater EOR and perhaps increased survival. However, additional adjuncts may be necessary for maximizing the specificity of resection and patient safety. Additional parameters, such as patient quality of life and health economic analyses, would be informative. Thus, additional systematic collection of prospective evidence may be necessary for the global incorporation of this potentially valuable surgical adjunct into routine practice. Cancer 2016;122:2469-78. © 2016 American Cancer Society.
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Affiliation(s)
- Alireza Mansouri
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Sheila Mansouri
- MacFeeters Adult Brain Tumor Research Program, Toronto, Ontario, Canada
| | - Laureen D Hachem
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - George Klironomos
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael A Vogelbaum
- Department of Neurological Surgery, Center for Translational Therapeutics, Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Mark Bernstein
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,MacFeeters Adult Brain Tumor Research Program, Toronto, Ontario, Canada
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18
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Kairdolf BA, Bouras A, Kaluzova M, Sharma AK, Wang MD, Hadjipanayis CG, Nie S. Intraoperative Spectroscopy with Ultrahigh Sensitivity for Image-Guided Surgery of Malignant Brain Tumors. Anal Chem 2016; 88:858-67. [PMID: 26587976 PMCID: PMC8559335 DOI: 10.1021/acs.analchem.5b03453] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Intraoperative cancer imaging and fluorescence-guided surgery have attracted considerable interest because fluorescence signals can provide real-time guidance to assist a surgeon in differentiating cancerous and normal tissues. Recent advances have led to the clinical use of a natural fluorophore called protoporphyrin IX (PpIX) for image-guided surgical resection of high-grade brain tumors (glioblastomas). However, traditional fluorescence imaging methods have only limited detection sensitivity and identification accuracy and are unable to detect low-grade or diffuse infiltrating gliomas (DIGs). Here we report a low-cost hand-held spectroscopic device that is capable of ultrasensitive detection of protoporphyrin IX fluorescence in vivo, together with intraoperative spectroscopic data obtained from both animal xenografts and human brain tumor specimens. The results indicate that intraoperative spectroscopy is at least 3 orders of magnitude more sensitive than the current surgical microscopes, allowing ultrasensitive detection of as few as 1000 tumor cells. For detection specificity, intraoperative spectroscopy allows the differentiation of brain tumor cells from normal brain cells with a contrast signal ratio over 100. In vivo animal studies reveal that protoporphyrin IX fluorescence is strongly correlated with both MRI and histological staining, confirming that the fluorescence signals are highly specific to tumor cells. Furthermore, ex vivo spectroscopic studies of excised brain tissues demonstrate that the hand-held spectroscopic device is capable of detecting diffuse tumor margins with low fluorescence contrast that are not detectable with current systems in the operating room. These results open new opportunities for intraoperative detection and fluorescence-guided resection of microscopic and low-grade glioma brain tumors with invasive or diffusive margins.
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Affiliation(s)
- Brad A. Kairdolf
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, 1760 Haygood Drive, Suite E116, Atlanta, Georgia 30322, USA
| | - Alexandros Bouras
- Department of Neurosurgery, Emory University School of Medicine, Winship Cancer Institute of Emory University, Atlanta, Georgia, 30322, USA
| | - Milota Kaluzova
- Department of Neurosurgery, Emory University School of Medicine, Winship Cancer Institute of Emory University, Atlanta, Georgia, 30322, USA
| | - Abhinav K. Sharma
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, 1760 Haygood Drive, Suite E116, Atlanta, Georgia 30322, USA
| | - May D. Wang
- Department of Biomedical Engineering, Georgia Institute of Technology, 313 Ferst Drive, UA Whitaker Building 4106, Atlanta, Georgia 30332, USA
| | - Constantinos G. Hadjipanayis
- Department of Neurosurgery, Emory University School of Medicine, Winship Cancer Institute of Emory University, Atlanta, Georgia, 30322, USA
- Department of Neurosurgery, Icahn School of Medicine, Tisch Cancer Institute at Mount Sinai, New York, NY 10029
| | - Shuming Nie
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, 1760 Haygood Drive, Suite E116, Atlanta, Georgia 30322, USA
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19
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Sanai N, Berger MS. Techniques in the Resection of Gliomas. Neurooncol Pract 2015. [DOI: 10.1093/nop/npv048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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20
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Abstract
Mounting evidence suggests that a more extensive surgical resection is associated with an improved life expectancy for both low-grade and high-grade glioma patients. However, radiographically complete resections are not often achieved in many cases because of the lack of sensitivity and specificity of current neurosurgical guidance techniques at the margins of diffuse infiltrative gliomas. Intraoperative fluorescence imaging offers the potential to improve the extent of resection and to investigate the possible benefits of resecting beyond the radiographic margins. Here, we provide a review of wide-field and high-resolution fluorescence-imaging strategies that are being developed for neurosurgical guidance, with a focus on emerging imaging technologies and clinically viable contrast agents. The strengths and weaknesses of these approaches will be discussed, as well as issues that are being addressed to translate these technologies into the standard of care.
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Affiliation(s)
- Jonathan T C Liu
- *Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York; ‡Barrow Brain Tumor Research Center, Division of Neurosurgical Oncology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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21
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Meza D, Wang D, Wang Y, Borwege S, Sanai N, Liu JTC. Comparing high-resolution microscopy techniques for potential intraoperative use in guiding low-grade glioma resections. Lasers Surg Med 2015; 47:289-95. [PMID: 25872487 DOI: 10.1002/lsm.22347] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Fluorescence image-guided surgery (FIGS), with contrast provided by 5-ALA-induced PpIX, has been shown to enable a higher extent of resection of high-grade gliomas. However, conventional FIGS with low-power microscopy lacks the sensitivity to aid in low-grade glioma (LGG) resection because PpIX signal is weak and sparse in such tissues. Intraoperative high-resolution microscopy of PpIX fluorescence has been proposed as a method to guide LGG resection, where sub-cellular resolution allows for the visualization of sparse and punctate mitochondrial PpIX production in tumor cells. Here, we assess the performance of three potentially portable high-resolution microscopy techniques that may be used for the intraoperative imaging of human LGG tissue samples with PpIX contrast: high-resolution fiber-optic microscopy (HRFM), high-resolution wide-field microscopy (WFM), and dual-axis confocal (DAC) microscopy. MATERIALS AND METHODS Thick unsectioned human LGG tissue samples (n = 7) with 5-ALA-induced PpIX contrast were imaged using three imaging techniques (HRFM, WFM, DAC). The average signal-to-background ratio (SBR) was then calculated for each imaging modality (5 images per tissue, per modality). RESULTS HRFM provides the ease of use and portability of a flexible fiber bundle, and is simple and inexpensive to build. However, in most cases (6/7), HRFM is not capable of detecting PpIX signal from LGGs due to high autofluorescence, generated by the fiber bundle under laser illumination at 405 nm, which overwhelms the PpIX signal and impedes its visualization. WFM is a camera-based method possessing high lateral resolution but poor axial resolution, resulting in sub-optimal image contrast. CONCLUSIONS Consistent successful detection of PpIX signal throughout our human LGG tissue samples (n = 7), with an acceptable image contrast (SBR >2), was only achieved using DAC microscopy, which offers superior image resolution and contrast that is comparable to histology, but requires a laser-scanning mechanism to achieve optical sectioning.
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Affiliation(s)
- Daphne Meza
- Department of Biomedical Engineering, Stony Brook University (SUNY), Stony Brook, New York, 11794
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22
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Hickmann AK, Nadji-Ohl M, Hopf NJ. Feasibility of fluorescence-guided resection of recurrent gliomas using five-aminolevulinic acid: retrospective analysis of surgical and neurological outcome in 58 patients. J Neurooncol 2015; 122:151-60. [DOI: 10.1007/s11060-014-1694-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 12/21/2014] [Indexed: 10/24/2022]
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23
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The Value of Extent of Resection of Glioblastomas: Clinical Evidence and Current Approach. Curr Neurol Neurosci Rep 2014; 15:517. [DOI: 10.1007/s11910-014-0517-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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24
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Grossman R, Nossek E, Shimony N, Raz M, Ram Z. Intraoperative 5-aminolevulinic acid-induced fluorescence in primary central nervous system lymphoma. J Neurosurg 2013; 120:67-9. [PMID: 24138204 DOI: 10.3171/2013.9.jns131076] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report a case of primary CNS lymphoma located in the floor of the fourth ventricle that showed intense fluorescence after preoperative administration of 5-aminolevulinic acid. The authors believe that this is the first demonstration of a 5-aminolevulinic acid-induced fluorescence pattern in primary CNS lymphoma.
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Affiliation(s)
- Rachel Grossman
- Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv University Sackler Faculty of Medicine, Tel-Aviv, Israel
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25
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Zhao S, Wu J, Wang C, Liu H, Dong X, Shi C, Shi C, Liu Y, Teng L, Han D, Chen X, Yang G, Wang L, Shen C, Li H. Intraoperative fluorescence-guided resection of high-grade malignant gliomas using 5-aminolevulinic acid-induced porphyrins: a systematic review and meta-analysis of prospective studies. PLoS One 2013; 8:e63682. [PMID: 23723993 PMCID: PMC3665818 DOI: 10.1371/journal.pone.0063682] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 04/06/2013] [Indexed: 12/18/2022] Open
Abstract
Background We performed a systematic review and meta-analysis to address the (added) value of intraoperative 5-aminolevulinic acid (5-ALA)-guided resection of high-grade malignant gliomas compared with conventional neuronavigation-guided resection, with respect to diagnostic accuracy, extent of tumor resection, safety, and survival. Methods and Findings An electronic database search of Medline, Embase, and the Cochrane Library was undertaken. The review process followed the guidelines of the Cochrane Collaboration. 10 studies matched all selection criteria, and were thus used for qualitative synthesis. 5-ALA-guided resection demonstrated an overall sensitivity of 0.87 (95% confidence interval [CI], 0.81–0.92), specificity of 0.89 (95% CI, 0.79–0.94), positive likelihood ratio (LR) of 7.62 (95% CI, 3.87–15.01), negative LR of 0.14 (95% CI, 0.09–0.23), and diagnostic odds ratio (OR) of 53.06 (95% CI, 18.70–150.51). Summary receiver operating characteristic curves (SROC) showed an area under curve (AUC) of 94%. Contrast-enhancing tumor was completely resected in patients assigned 5-ALA as compared with patients assigned white light. Patients in the 5-ALA group had higher 6-month progression free survival and overall survival than those in the white light group. Conclusion Based on available literature, there is level 2 evidence that 5-ALA-guided surgery is more effective than conventional neuronavigation-guided surgery in increasing diagnostic accuracy and extent of tumor resection, enhancing quality of life, or prolonging survival in patients with high-grade malignant gliomas.
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Affiliation(s)
- Shiguang Zhao
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.
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26
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Abstract
PURPOSE OF REVIEW In recent years, the safety and efficacy of neurosurgical intervention has rapidly improved for brain tumor patients. Technological advances, combined with refined intraoperative techniques, now enable well tolerated surgical access to any region of the human brain. For patients with gliomas, these improvements have redefined the clinical possibilities, and here we review several emerging operative strategies that are essential for next-generation neurosurgical oncologists and major brain tumor centers. RECENT FINDINGS The value of glioma extent of resection remains controversial, but review of the modern literature reveals important opportunities for early neurosurgical intervention. Although microsurgical resection must be balanced by the risk of neurological compromise, improvements in intraoperative stimulation techniques now enable resection of highly eloquent tumors with minimal morbidity. Additionally, the emergence of fluorescence-guided surgery as a new operative paradigm provides a unique opportunity to resect tumors to the margins of microscopic infiltration. SUMMARY Neurosurgical intervention remains the first step in effective glioma management. With intraoperative mapping techniques, aggressive microsurgical resection can be safely pursued even when tumors occupy essential functional pathways. With the development of tumor-specific fluorophores, such as 5-aminolevulinic acid, real-time microscopic visualization of tumor infiltration can be surgically targeted prior to adjuvant therapy.
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27
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Arita H, Kinoshita M, Kagawa N, Fujimoto Y, Kishima H, Hashimoto N, Yoshimine T. ¹¹C-methionine uptake and intraoperative 5-aminolevulinic acid-induced fluorescence as separate index markers of cell density in glioma: a stereotactic image-histological analysis. Cancer 2011; 118:1619-27. [PMID: 21837671 DOI: 10.1002/cncr.26445] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 05/13/2011] [Accepted: 06/27/2011] [Indexed: 11/06/2022]
Abstract
BACKGROUND The extent of tumor resection is acknowledged as 1 of the prognostic factors for glioma. 5-Aminolevulinic acid (5-ALA)-induced fluorescence guidance and neuronavigation integrated with (11) C-methionine positron emission tomography (PET) are widely utilized under the expectation of improving the extent of resection. These 2 novel approaches are beneficial for glioma resections, and the combination of these approaches appears rational. However, biological characteristics reflecting 5-ALA-induced fluorescence and (11) C-methionine uptake have not been clearly elucidated, and studies about the relationship between 5-ALA-induced fluorescence and (11) C-methionine uptake have been limited. The present study aimed to clarify this issue. METHODS Data from 11 consecutive patients harboring astrocytic tumors were analyzed: 2 grade II and 2 grade III, and 7 grade IV tumors were included. Thirty samples from these patients were obtained from the relative periphery of each tumor. Relationships among histology, 5-ALA-induced fluorescence and (11) C-methionine uptake were analyzed by stereotactic sampling and image analysis. RESULTS Uptake of (11) C-methionine correlated with cell density (R(2) = 0.322, P = .0059). Cell density was higher in fluorescence-positive areas than in negative areas (2760 ± 1080 vs 1450 ± 1380/mm(2) , P = .0132). Although both (11) C-methionine uptake and fluorescence seemed to correlate with cell density, no significant difference in (11) C-methionine uptake was seen between fluorescence-positive and -negative areas (P = .367). Multiple linear regression analysis revealed (11) C-methionine uptake and 5-ALA-induced fluorescence as independent indices for tumor cell density. CONCLUSIONS These results indicate that 5-ALA fluorescence and (11) C-methionine PET image are separate index markers for cytoreduction surgery of gliomas.
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Affiliation(s)
- Hideyuki Arita
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Sanai N, Snyder LA, Honea NJ, Coons SW, Eschbacher JM, Smith KA, Spetzler RF. Intraoperative confocal microscopy in the visualization of 5-aminolevulinic acid fluorescence in low-grade gliomas. J Neurosurg 2011; 115:740-8. [PMID: 21761971 DOI: 10.3171/2011.6.jns11252] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Greater extent of resection (EOR) for patients with low-grade glioma (LGG) corresponds with improved clinical outcome, yet remains a central challenge to the neurosurgical oncologist. Although 5-aminolevulinic acid (5-ALA)-induced tumor fluorescence is a strategy that can improve EOR in gliomas, only glioblastomas routinely fluoresce following 5-ALA administration. Intraoperative confocal microscopy adapts conventional confocal technology to a handheld probe that provides real-time fluorescent imaging at up to 1000× magnification. The authors report a combined approach in which intraoperative confocal microscopy is used to visualize 5-ALA tumor fluorescence in LGGs during the course of microsurgical resection. METHODS Following 5-ALA administration, patients with newly diagnosed LGG underwent microsurgical resection. Intraoperative confocal microscopy was conducted at the following points: 1) initial encounter with the tumor; 2) the midpoint of tumor resection; and 3) the presumed brain-tumor interface. Histopathological analysis of these sites correlated tumor infiltration with intraoperative cellular tumor fluorescence. RESULTS Ten consecutive patients with WHO Grades I and II gliomas underwent microsurgical resection with 5-ALA and intraoperative confocal microscopy. Macroscopic tumor fluorescence was not evident in any patient. However, in each case, intraoperative confocal microscopy identified tumor fluorescence at a cellular level, a finding that corresponded to tumor infiltration on matched histological analyses. CONCLUSIONS Intraoperative confocal microscopy can visualize cellular 5-ALA-induced tumor fluorescence within LGGs and at the brain-tumor interface. To assess the clinical value of 5-ALA for high-grade gliomas in conjunction with neuronavigation, and for LGGs in combination with intraoperative confocal microscopy and neuronavigation, a Phase IIIa randomized placebo-controlled trial (BALANCE) is underway at the authors' institution.
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Affiliation(s)
- Nader Sanai
- Barrow Brain Tumor Research Center, Barrow Neurological Institute, Phoenix, Arizona 85013, USA.
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Intraoperative 5-aminolevulinic-acid-induced fluorescence in meningiomas. Acta Neurochir (Wien) 2010; 152:1711-9. [PMID: 20535506 DOI: 10.1007/s00701-010-0708-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 05/28/2010] [Indexed: 10/19/2022]
Abstract
OBJECT 5-aminolevulinic acid (5-ALA) has gained importance as an intraoperative photodynamic diagnostic agent for the extirpation of malignant gliomas. The application of this technique for resection of meningiomas has barely been explored. The aim of this study was to evaluate the utility of 5-ALA-induced fluorescence as a visual tool in meningioma resection and its correlation with histological findings. METHODS A total of 33 consecutive patients undergoing resection of intracranial meningiomas from December 2007 to August 2009 were included in this study. After confirmation of normal liver function, 5-ALA was administered orally (20 mg/kg) within 3-5 h prior to skin incision. All cases were operated on using standard microsurgical and neuronavigation-guided techniques. Intraoperative 440 nm fluorescence was applied periodically during and at the end of resection in order to detect tumor-infiltrated sites. The fluorescence of the tumor was evaluated intraoperatively by the surgeon and confirmed by subsequent video analysis. RESULTS A total of 32 (97%) patients presented with benign meningiomas (WHO I-II). In 1 (3%) patient, histological anaplastic signs (WHO III) could be demonstrated. 5-ALA-induced fluorescence of the tumor was confirmed in a total of 31 (94%) patients. The fluorescence did not correlate with the histological findings (n = 30 WHO I-II, n = 1 WHO grade III) or with preoperative brain edema and administration of steroids. A total resection could be postoperatively demonstrated in 25 (76%) patients. No adverse effects attributable to 5-ALA occurred. CONCLUSIONS 5-ALA-induced fluorescence is a useful and promising intraoperative tool for the visualization of meningioma tissue. The novel findings demonstrated in this study in terms of high fluorescence and poor correlation with histological findings highlight the usefulness of this technique as a routine visual tool to achieve optimal resection of meningiomas.
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Kiesslich T, Neureiter D, Alinger B, Jansky GL, Berlanda J, Mkrtchyan V, Ocker M, Plaetzer K, Berr F. Uptake and phototoxicity of meso-tetrahydroxyphenyl chlorine are highly variable in human biliary tract cancer cell lines and correlate with markers of differentiation and proliferation. Photochem Photobiol Sci 2010; 9:734-43. [PMID: 20358123 DOI: 10.1039/b9pp00201d] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Photodynamic therapy (PDT) using Photofrin and, recently, Foscan has gained broad acceptance for palliative treatment of non-resectable cholangiocarcinoma (CC). No information, however, is available whether the phenotype of CC tumour cells has an effect on the efficiency of the treatment. Using a well-characterised set of n = 9 biliary tract cancer cell lines this study investigated the uptake, phototoxicity, and release of meso-tetrahydroxyphenyl chlorine (mTHPC, Foscan) after incubation with 200 or 400 ng ml(-1) mTHPC. For uptake of mTHPC we found great variations between the individual cell lines (up to a factor 2), resulting in even more pronounced differences in phototoxicity. Based on statistical classification by hierarchical cluster analysis, two groups of cell lines can be distinguished which are characterised by either high or low susceptibility towards mTHPC-based photodynamic treatment. Correlation analysis with previously established immunochemical parameters showed that cells with a low cytokeratin-19 (ductal differentiation), high vimentin (mesenchymal marker), and high proliferative phenotype preferentially show higher uptake of mTHPC and subsequent phototoxicity. These results demonstrate high variability of biliary tract cancer cells when subjected to mTHPC-based photodynamic treatment and identify possible markers that could be used in the clinical setting in order to predict the efficiency of PDT and adjust the dose for complete tumour elimination.
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Affiliation(s)
- Tobias Kiesslich
- Department of Internal Medicine I, Paracelsus Medical University/Salzburger Landeskliniken (SALK), Muellner Hauptstrasse 48, 5020, Salzburg, Austria
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Gibbs-Strauss SL, O’Hara JA, Hoopes PJ, Hasan T, Pogue BW. Noninvasive measurement of aminolevulinic acid-induced protoporphyrin IX fluorescence allowing detection of murine glioma in vivo. JOURNAL OF BIOMEDICAL OPTICS 2009; 14:014007. [PMID: 19256695 PMCID: PMC2799166 DOI: 10.1117/1.3065543] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) fluorescence is studied as a contrast agent for noninvasive detection of murine glioma, using the fluorescence-to-transmission ratio measured through the cranium. Signals measured prior to administration of ALA are very similar between control animals, 9L-GFP, and U251 tumor-bearing animals. However, 2 h after ALA administration, the PpIX signal from both tumor-bearing groups is significantly higher than the control group (9L-GFP group p-value=0.016, and U251 group p-value=0.004, relative to the control group). The variance in signal from the 9L-GFP group is much larger than either the control group or the U251 group, which is consistent with higher intrinsic PpIX fluorescence heterogeneity as seen in situ at ex vivo analysis. Decreasing the skin PpIX fluorescence via intentional photobleaching using red light (635 nm) is examined as a tool for increasing PpIX contrast between the tumor-bearing and control groups. The red light bleaching is found to increase the ability to accurately quantify PpIX fluorescence in vivo, but decreases the specificity of detection between tumor-bearing and nontumor-bearing groups.
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Affiliation(s)
| | - Julia A. O’Hara
- Thayer School of Engineering, Dartmouth College, Hanover New Hampshire 03755
| | - P. Jack Hoopes
- Thayer School of Engineering, Dartmouth College, Hanover New Hampshire 03755
- Department of Surgery, Dartmouth College, Hanover New Hampshire 03755
| | - Tayyaba Hasan
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
| | - Brian W. Pogue
- Thayer School of Engineering, Dartmouth College, Hanover New Hampshire 03755
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
- Thayer School of Engineering, Dartmouth College, Hanover NH 03755
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Abstract
A 3-chip CCD imaging system has been developed for quantitative in vivo fluorescence imaging. This incorporates a ratiometric algorithm to correct for the effects of tissue optical absorption and scattering, imaging “geometry” and tissue autofluorescence background. The performance was characterized, and the algorithm was validated in tissue-simulating optical phantoms for quantitative measurement of the fluorescent molecule protoporphyrin IX (PpIX). The technical feasibility to use this system for fluorescence-guided surgical resection of malignant brain tumor tissue was assessed in an animal model in which PpIX was induced exogenously in the tumor cells by systemic administration of aminolevulinic acid (ALA).
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Ritz R, Müller M, Dietz K, Duffner F, Bornemann A, Roser F, Tatagiba M. Hypericin uptake: A prognostic marker for survival in high-grade glioma. J Clin Neurosci 2008; 15:778-83. [DOI: 10.1016/j.jocn.2007.03.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2006] [Revised: 02/12/2007] [Accepted: 03/20/2007] [Indexed: 11/25/2022]
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Sailer R, Strauss WSL, Wagner M, Emmert H, Schneckenburger H. Relation between intracellular location and photodynamic efficacy of 5-aminolevulinic acid-induced protoporphyrin IX in vitro. Comparison between human glioblastoma cells and other cancer cell lines. Photochem Photobiol Sci 2006; 6:145-51. [PMID: 17277837 DOI: 10.1039/b611715e] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A promising clinical application of 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PP IX) is fluorescence detection and photodynamic treatment of residual tumour tissue during surgical resection of high grade malignant glioma. U373 MG human glioblastoma cells were used as a model system to study the relation between intracellular location and photodynamic efficacy of 5-ALA-induced PP IX in more detail. Therefore, ultra-sensitive fluorescence microscopy, using either optical excitation of whole cells or selective excitation of the plasma membrane by an evanescent electromagnetic field, was combined with quantitative measurements of intracellular porphyrin amount and phototoxicity. Glioblastoma cells accumulated PP IX to a moderate extent as compared to T47D breast cancer cells (high accumulation) or OV2774 ovarian cancer cells (low accumulation). Although photodynamic inactivation of the different cell lines (decreasing in the order T47D > U373 MG > OV2774) seemed to be directly related to PP IX accumulation, examination of the data in more detail revealed that photodynamic efficacy per photosensitizer molecule (PE) was about two times higher in glioblastoma and ovarian cancer cells as compared to breast cancer cells. The different photodynamic efficacy of PP IX was related to the different intracellular location. In contrast to breast cancer cells where PP IX fluorescence was localized in small granules, PP IX fluorescence in glioblastoma cells and ovarian cancer cells originated mainly from cellular membranes. Thus, the intracellular location of PP IX in a predominantly lipophilic environment, characterized by a comparably high photostability (probed by photobleaching and photoproduct formation) and a lower degree of porphyrin aggregation (probed previously by fluorescence decay kinetics), seems to be the key factor for high photodynamic efficacy of 5-ALA-induced PP IX. In the case of OV2774 ovarian cancer cells, however, a low PP IX accumulation limited cell inactivation upon irradiation, whereas the results obtained for glioblastoma cells are encouraging to develop PDT to an additional therapeutic option for the treatment of tumour margins in patients who underwent fluorescence-guided resection of high grade malignant glioma after 5-ALA administration.
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Affiliation(s)
- Reinhard Sailer
- Institut für Lasertechnologien in der Medizin und Messtechnik an der Universität Ulm, Helmholtzstr. 12, 89081, Ulm, Germany
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