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Ezaki T, Kishima K, Shibao S, Matsunaga T, Pareira ES, Kitamura Y, Nakayama Y, Tsuda N, Takahara K, Iwama T, Sampetrean O, Toda M, Ohnishi K, Shimono T, Sasaki H. Development of microsurgical forceps equipped with haptic technology for in situ differentiation of brain tumors during microsurgery. Sci Rep 2024; 14:21430. [PMID: 39271763 PMCID: PMC11399253 DOI: 10.1038/s41598-024-72326-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 09/05/2024] [Indexed: 09/15/2024] Open
Abstract
The stiffness of human cancers may be correlated with their pathology, and can be used as a biomarker for diagnosis, malignancy prediction, molecular expression, and postoperative complications. Neurosurgeons perform tumor resection based on tactile sensations. However, it takes years of surgical experience to appropriately distinguish brain tumors from surrounding parenchymal tissue. Haptics is a technology related to the touch sensation. Haptic technology can amplify, transmit, record, and reproduce real sensations, and the physical properties (e.g., stiffness) of an object can be quantified. In the present study, glioblastoma (SF126-firefly luciferase-mCherry [FmC], U87-FmC, U251-FmC) and malignant meningioma (IOMM-Lee-FmC, HKBMM-FmC) cell lines were transplanted into nude mice, and the stiffness of tumors and normal brain tissues were measured using our newly developed surgical forceps equipped with haptic technology. We found that all five brain tumor tissues were stiffer than normal brain tissue (p < 0.001), and that brain tumor pathology (three types of glioblastomas, two types of malignant meningioma) was significantly stiffer than normal brain tissue (p < 0.001 for all). Our findings suggest that tissue stiffness may be a useful marker to distinguish brain tumors from surrounding parenchymal tissue during microsurgery, and that haptic forceps may help neurosurgeons to sense minute changes in tissue stiffness.
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Affiliation(s)
- Taketo Ezaki
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kouki Kishima
- College of Engineering Science, Yokohama National University, 79-5 Tokiwadai, Hodogaya-ku, Yokohama City, Kanagawa, 240-8501, Japan
| | - Shunsuke Shibao
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
- Department of Neurosurgery, Dokkyo Medical University, 800 Ohji-Kita-kobayashi, Mibu Machi, Shimotsugagun, Tochigi, 321-0293, Japan
| | - Takuya Matsunaga
- Kanagawa Institute of Industrial Science and Technology, 3-25-10 Tonomachi, Kawasakiku, Kawasaki City, Kanagawa, 210-0821, Japan
| | - Eriel Sandika Pareira
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yohei Kitamura
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yuji Nakayama
- Department of Pathology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Noboru Tsuda
- Department of Pathology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kento Takahara
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Takashi Iwama
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Oltea Sampetrean
- Human Biology-Microbiome-Quantum Research Center (WPI-Bio2Q), Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kouhei Ohnishi
- Kanagawa Institute of Industrial Science and Technology, 3-25-10 Tonomachi, Kawasakiku, Kawasaki City, Kanagawa, 210-0821, Japan
- Haptics Research Center, Keio University, 7-1 Shinkawasaki, Saiwaiku, Kawasaki City, Kanagawa, 212-0032, Japan
| | - Tomoyuki Shimono
- Kanagawa Institute of Industrial Science and Technology, 3-25-10 Tonomachi, Kawasakiku, Kawasaki City, Kanagawa, 210-0821, Japan.
- Faculty of Engineering, Yokohama National University, 79-5 Tokiwadai, Hodogaya-ku, Yokohama City, Kanagawa, 240-8501, Japan.
| | - Hikaru Sasaki
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
- Department of Neurosurgery, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa-shi, Chiba, 272-8513, Japan.
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Fujiwara H, Furudate S, Takahara N, Nakai Y, Kodama Y, Arai J, Nakagawa H, Ikenoue T, Tateishi K, Kasuga M, Fujishiro M. Probe-guided endoscopic system for 5-aminolevulinic acid-based photodynamic diagnosis in cholangiocarcinoma. Photodiagnosis Photodyn Ther 2024; 48:104268. [PMID: 38971526 DOI: 10.1016/j.pdpdt.2024.104268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/23/2024] [Accepted: 07/03/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND AND AIM The diagnostic accuracy for cholangiocarcinoma (CCA) is inadequate, necessitating the exploration of novel diagnostic approaches. Protoporphyrin IX (Pp IX), a metabolic product of 5-aminolevulinic acid (5-ALA), emits red fluorescence upon blue light exposure. Because it accumulates selectively in cancer cells, photodynamic diagnosis using 5-ALA (5-ALA-PDD) has been integrated into clinical practice for diverse cancer types. Nevertheless, there is currently no device capable of capturing Pp IX-derived fluorescence for real-time 5-ALA-PDD within the biliary tract, largely due to challenges in device miniaturization. METHODS To investigate the feasibility of real-time 5ALA-PDD in CCA, we developed two essential components of the cholangioscopy system: a small-diameter flexible camera and a light guide for emitting blue light. We evaluated the detectability of Pp IX fluorescence using these devices in experimental gels and animal models. RESULTS Our camera and light guide were smoothly inserted into the lumen of existing cholangioscopes. Incorporating a long-pass filter at the camera tip enabled efficient detection of red fluorescence without significantly impacting white-light observation. The integration of these devices facilitated clear visualization of red fluorescence from gels containing Pp IX at concentrations of 5 μM or higher. Additionally, when observing subcutaneous human CCA tumor models in nude mice treated with 5-ALA, we successfully demonstrated distinct red fluorescence from Pp IX accumulation in tumors compared to peritumoral subcutaneous areas. CONCLUSION The integration of our device combination holds promise for real-time 5-ALA-PDD in human CCA, potentially enhancing the diagnostic accuracy for this complex condition.
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Affiliation(s)
- Hiroaki Fujiwara
- Division of Gastroenterology, The Institute of Medical Science, Asahi Life Foundation, 2-2-6 Bakurocho, Chuo-ku, Tokyo, 103-0002, Japan; Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Shiho Furudate
- Japan Lifeline Co., Ltd, 2-2-20 Higashishinagawa, Shinagawa-ku, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Yuki Kodama
- Japan Lifeline Co., Ltd, 2-2-20 Higashishinagawa, Shinagawa-ku, Tokyo, Japan
| | - Junya Arai
- Division of Gastroenterology, The Institute of Medical Science, Asahi Life Foundation, 2-2-6 Bakurocho, Chuo-ku, Tokyo, 103-0002, Japan; Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Hayato Nakagawa
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Tsuneo Ikenoue
- Division of Clinical Genome Research, The Institute of Medical Science, The University of Tokyo, Tokyo 108‑8639, Japan
| | - Keisuke Tateishi
- Department of Gastroenterology, St Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Masato Kasuga
- The Institute of Medical Science, Asahi Life Foundation, 2-2-6 Bakurocho, Chuo-ku, Tokyo, 103-0002, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Chang C, Chavarro VS, Gerstl JVE, Blitz SE, Spanehl L, Dubinski D, Valdes PA, Tran LN, Gupta S, Esposito L, Mazzetti D, Gessler FA, Arnaout O, Smith TR, Friedman GK, Peruzzi P, Bernstock JD. Recurrent Glioblastoma-Molecular Underpinnings and Evolving Treatment Paradigms. Int J Mol Sci 2024; 25:6733. [PMID: 38928445 PMCID: PMC11203521 DOI: 10.3390/ijms25126733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/13/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
Glioblastoma is the most common and lethal central nervous system malignancy with a median survival after progression of only 6-9 months. Major biochemical mechanisms implicated in glioblastoma recurrence include aberrant molecular pathways, a recurrence-inducing tumor microenvironment, and epigenetic modifications. Contemporary standard-of-care (surgery, radiation, chemotherapy, and tumor treating fields) helps to control the primary tumor but rarely prevents relapse. Cytoreductive treatment such as surgery has shown benefits in recurrent glioblastoma; however, its use remains controversial. Several innovative treatments are emerging for recurrent glioblastoma, including checkpoint inhibitors, chimeric antigen receptor T cell therapy, oncolytic virotherapy, nanoparticle delivery, laser interstitial thermal therapy, and photodynamic therapy. This review seeks to provide readers with an overview of (1) recent discoveries in the molecular basis of recurrence; (2) the role of surgery in treating recurrence; and (3) novel treatment paradigms emerging for recurrent glioblastoma.
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Affiliation(s)
- Christopher Chang
- Warren Alpert Medical School, Brown University, Providence, RI 02912, USA;
| | - Velina S. Chavarro
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
| | - Jakob V. E. Gerstl
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
| | - Sarah E. Blitz
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Lennard Spanehl
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
- Department of Neurosurgery, University of Rostock, 18055 Rostock, Germany; (D.D.); (F.A.G.)
| | - Daniel Dubinski
- Department of Neurosurgery, University of Rostock, 18055 Rostock, Germany; (D.D.); (F.A.G.)
| | - Pablo A. Valdes
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX 77555, USA;
| | - Lily N. Tran
- Division of Biology and Medicine, Brown University, Providence, RI 02912, USA;
| | - Saksham Gupta
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Luisa Esposito
- Department of Medicine and Surgery, Unicamillus University, 00131 Rome, Italy;
| | - Debora Mazzetti
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
| | - Florian A. Gessler
- Department of Neurosurgery, University of Rostock, 18055 Rostock, Germany; (D.D.); (F.A.G.)
| | - Omar Arnaout
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Timothy R. Smith
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Gregory K. Friedman
- Division of Pediatrics, Neuro-Oncology Section, MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Pierpaolo Peruzzi
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Joshua D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
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4
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Ius T, Sabatino G, Panciani PP, Fontanella MM, Rudà R, Castellano A, Barbagallo GMV, Belotti F, Boccaletti R, Catapano G, Costantino G, Della Puppa A, Di Meco F, Gagliardi F, Garbossa D, Germanò AF, Iacoangeli M, Mortini P, Olivi A, Pessina F, Pignotti F, Pinna G, Raco A, Sala F, Signorelli F, Sarubbo S, Skrap M, Spena G, Somma T, Sturiale C, Angileri FF, Esposito V. Surgical management of Glioma Grade 4: technical update from the neuro-oncology section of the Italian Society of Neurosurgery (SINch®): a systematic review. J Neurooncol 2023; 162:267-293. [PMID: 36961622 PMCID: PMC10167129 DOI: 10.1007/s11060-023-04274-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/20/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE The extent of resection (EOR) is an independent prognostic factor for overall survival (OS) in adult patients with Glioma Grade 4 (GG4). The aim of the neuro-oncology section of the Italian Society of Neurosurgery (SINch®) was to provide a general overview of the current trends and technical tools to reach this goal. METHODS A systematic review was performed. The results were divided and ordered, by an expert team of surgeons, to assess the Class of Evidence (CE) and Strength of Recommendation (SR) of perioperative drugs management, imaging, surgery, intraoperative imaging, estimation of EOR, surgery at tumor progression and surgery in elderly patients. RESULTS A total of 352 studies were identified, including 299 retrospective studies and 53 reviews/meta-analysis. The use of Dexamethasone and the avoidance of prophylaxis with anti-seizure medications reached a CE I and SR A. A preoperative imaging standard protocol was defined with CE II and SR B and usefulness of an early postoperative MRI, with CE II and SR B. The EOR was defined the strongest independent risk factor for both OS and tumor recurrence with CE II and SR B. For intraoperative imaging only the use of 5-ALA reached a CE II and SR B. The estimation of EOR was established to be fundamental in planning postoperative adjuvant treatments with CE II and SR B and the stereotactic image-guided brain biopsy to be the procedure of choice when an extensive surgical resection is not feasible (CE II and SR B). CONCLUSIONS A growing number of evidences evidence support the role of maximal safe resection as primary OS predictor in GG4 patients. The ongoing development of intraoperative techniques for a precise real-time identification of peritumoral functional pathways enables surgeons to maximize EOR minimizing the post-operative morbidity.
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Affiliation(s)
- Tamara Ius
- Division of Neurosurgery, Head-Neck and NeuroScience Department, University Hospital of Udine, Udine, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Pier Paolo Panciani
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
| | - Marco Maria Fontanella
- Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, 10094, Torino, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, 10094, Torino, Italy
- Neurology Unit, Hospital of Castelfranco Veneto, 31033, Castelfranco Veneto, Italy
| | - Antonella Castellano
- Department of Neuroradiology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giuseppe Maria Vincenzo Barbagallo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico - San Marco" University Hospital, University of Catania, Catania, Italy
- Interdisciplinary Research Center On Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Francesco Belotti
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Giuseppe Catapano
- Division of Neurosurgery, Department of Neurological Sciences, Ospedale del Mare, Naples, Italy
| | | | - Alessandro Della Puppa
- Neurosurgical Clinical Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi Hospital, University of Florence, Florence, Italy
| | - Francesco Di Meco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Johns Hopkins Medical School, Baltimore, MD, USA
| | - Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini," Neurosurgery Unit, University of Turin, Torino, Italy
| | | | - Maurizio Iacoangeli
- Department of Neurosurgery, Università Politecnica Delle Marche, Azienda Ospedali Riuniti, Ancona, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | | | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Milan, Italy
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Milan, Italy
| | - Fabrizio Pignotti
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giampietro Pinna
- Unit of Neurosurgery, Department of Neurosciences, Hospital Trust of Verona, 37134, Verona, Italy
| | - Antonino Raco
- Division of Neurosurgery, Department of NESMOS, AOU Sant'Andrea, Sapienza University, Rome, Italy
| | - Francesco Sala
- Department of Neurosciences, Biomedicines and Movement Sciences, Institute of Neurosurgery, University of Verona, 37134, Verona, Italy
| | - Francesco Signorelli
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Neurosurgery Unit, University "Aldo Moro", 70124, Bari, Italy
| | - Silvio Sarubbo
- Department of Neurosurgery, Santa Chiara Hospital, Azienda Provinciale Per I Servizi Sanitari (APSS), Trento, Italy
| | - Miran Skrap
- Division of Neurosurgery, Head-Neck and NeuroScience Department, University Hospital of Udine, Udine, Italy
| | | | - Teresa Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | | | | | - Vincenzo Esposito
- Department of Neurosurgery "Giampaolo Cantore"-IRCSS Neuromed, Pozzilli, Italy
- Department of Human, Neurosciences-"Sapienza" University of Rome, Rome, Italy
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5
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McCracken DJ, Schupper AJ, Lakomkin N, Malcolm J, Painton Bray D, Hadjipanayis CG. Turning on the light for brain tumor surgery: A 5-aminolevulinic acid story. Neuro Oncol 2022; 24:S52-S61. [PMID: 36322101 PMCID: PMC9629477 DOI: 10.1093/neuonc/noac191] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
To aid surgeons in more complete and safe resection of brain tumors, adjuvant technologies have been developed to improve visualization of target tissue. Fluorescence-guided surgery relies on the use of fluorophores and specific light wavelengths to better delineate tumor tissue, inflammation, and areas of blood-brain barrier breakdown. 5-aminolevulinic acid (5-ALA), the first fluorophore developed specifically for brain tumors, accumulates within tumor cells, improving visualization of tumors both at the core, and infiltrative margin. Here, we describe the background of how 5-ALA integrated into the modern neurosurgery practice, clinical evidence for the current use of 5-ALA, and future directions for its role in neurosurgical oncology. Maximal safe resection remains the standard of care for most brain tumors. Gross total resection of high-grade gliomas (HGGs) is associated with greater overall survival and progression-free survival (PFS) in comparison to subtotal resection or adjuvant treatment therapies alone.1-3 A major challenge neurosurgeons encounter when resecting infiltrative gliomas is identification of the glioma tumor margin to perform a radical resection while avoiding and preserving eloquent regions of the brain. 5-aminolevulinic acid (5-ALA) remains the only optical-imaging agent approved by the FDA for use in glioma surgery and identification of tumor tissue.4 A multicenter randomized, controlled trial revealed that 5-ALA fluorescence-guided surgery (FGS) almost doubled the extent of tumor resection and also improved 6-month PFS.5 In this review, we will highlight the current evidence for use of 5-ALA FGS in brain tumor surgery, as well as discuss the future directions for its use.
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Affiliation(s)
- David J McCracken
- Department of Neurosurgery, Piedmont Healthcare, Atlanta, Georgia, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Nikita Lakomkin
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - James Malcolm
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | - Constantinos G Hadjipanayis
- Corresponding Author: Constantinos G. Hadjipanayis, MD, PhD, Mount Sinai Union Square, 10 Union Square East, Suite 5E, New York, NY 10003, USA ()
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6
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Li G, Rodrigues A, Kim L, Garcia C, Jain S, Zhang M, Hayden-Gephart M. 5-Aminolevulinic Acid Imaging of Malignant Glioma. Surg Oncol Clin N Am 2022; 31:581-593. [DOI: 10.1016/j.soc.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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7
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Mazurek M, Szczepanek D, Orzyłowska A, Rola R. Analysis of Factors Affecting 5-ALA Fluorescence Intensity in Visualizing Glial Tumor Cells-Literature Review. Int J Mol Sci 2022; 23:ijms23020926. [PMID: 35055109 PMCID: PMC8779265 DOI: 10.3390/ijms23020926] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 01/27/2023] Open
Abstract
Glial tumors are one of the most common lesions of the central nervous system. Despite the implementation of appropriate treatment, the prognosis is not successful. As shown in the literature, maximal tumor resection is a key element in improving therapeutic outcome. One of the methods to achieve it is the use of fluorescent intraoperative navigation with 5-aminolevulinic acid. Unfortunately, often the level of fluorescence emitted is not satisfactory, resulting in difficulties in the course of surgery. This article summarizes currently available knowledge regarding differences in the level of emitted fluorescence. It may depend on both the histological type and the genetic profile of the tumor, which is reflected in the activity and expression of enzymes involved in the intracellular metabolism of fluorescent dyes, such as PBGD, FECH, UROS, and ALAS. The transport of 5-aminolevulinic acid and its metabolites across the blood–brain barrier and cell membranes mediated by transporters, such as ABCB6 and ABCG2, is also important. Accompanying therapies, such as antiepileptic drugs or steroids, also have an impact on light emission by tumor cells. Accurate determination of the factors influencing the fluorescence of 5-aminolevulinic acid-treated cells may contribute to the improvement of fluorescence navigation in patients with highly malignant gliomas.
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8
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Intraoperative 5-ALA fluorescence-guided resection of high-grade glioma leads to greater extent of resection with better outcomes: a systematic review. J Neurooncol 2022; 156:233-256. [PMID: 34989964 DOI: 10.1007/s11060-021-03901-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/12/2021] [Indexed: 12/13/2022]
Abstract
IMPORTANCE High-grade gliomas (HGG) are the most aggressive and common malignant brain tumors in adults. They have a dismally fatal prognosis. Even if gross total resection of the enhancing tumor is achieved, inevitably, invading tumor cells that are indistinguishable to the un-aided eye are left behind, which eventually leads to tumor recurrence. 5-aminolevulinic acid (5-ALA) is an increasingly utilized intraoperative fluorescent imaging agent for patients with HGG. It enhances visualization of HGG tissue. Despite early promising randomized clinical trial data suggesting a survival benefit for 5-ALA-guided surgery, the growing body of literature must be analyzed to confirm efficacy on patient outcomes. OBJECTIVE To perform a systematic review of the literature to evaluate whether there is a beneficial effect upon survival and extent of resection due to the utilization of 5-ALA in HGG surgery. EVIDENCE REVIEW Literature regarding 5-ALA usage in HGG surgery was reviewed according to the PRISMA guidelines. Two databases, PubMed and SCOPUS, were searched for assorted combinations of the keywords "5-ALA," "high-grade glioma," "5-aminolevulinic acid," and "resection" in July 2020 for case reports and retrospective, prospective, and randomized clinical trials assessing and analyzing 5-ALA intraoperative use in patients with HGG. Entailed studies on PubMed and SCOPUS were found for screening using a snowball search technique upon the initially searched papers. Systematic reviews and meta-analyses were excluded from our PRISMA table. FINDINGS 3756 previously published studies were screened, 536 of which were further evaluated, and ultimately 45 were included in our systematic review. There were no date restrictions on the screened publications. Our literature search was finalized on July 16, 2020. We found an observed increase in the overall survival (OS) and progression-free survival (PFS) of the 5-ALA group compared to the white light group, as well as an observed increase in the OS and PFS of complete resections compared to incomplete resections. Of the studies that directly compared the use of 5-ALA to white light (13 of the total analyzed 45, or 28.9%), 5-ALA lead to a better PFS and OS in 88.4 and 67.5% of patients, respectively. When the studies that reported postoperative neurologic outcomes of surgeries using 5-ALA vs. white light were analyzed, 42.2% of subjects demonstrated 5-ALA use was associated with less post-op neurological deficits, whereas 34.5% demonstrated no difference between 5-ALA and without. 23.3% of studies showed that intraoperative 5-ALA guided surgeries lead to more post-op neurological deficits. CONCLUSIONS AND RELEVANCE Utilization of 5-ALA was found to be associated with a greater extent of resection in HGG surgeries, as well as longer OS and PFS. Postop neurologic deficit rates were mixed and inconclusive when comparing 5-ALA groups to white light groups. 5-ALA is a useful surgical adjunct for resection of HGG when patient safety is preserved.
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Palmieri G, Cofano F, Salvati LF, Monticelli M, Zeppa P, Perna GD, Melcarne A, Altieri R, La Rocca G, Sabatino G, Barbagallo GM, Tartara F, Zenga F, Garbossa D. Fluorescence-Guided Surgery for High-Grade Gliomas: State of the Art and New Perspectives. Technol Cancer Res Treat 2021; 20:15330338211021605. [PMID: 34212784 PMCID: PMC8255554 DOI: 10.1177/15330338211021605] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
High-grade gliomas are aggressive tumors that require multimodal management and gross total resection is considered to be the first crucial step of treatment. Because of their infiltrative nature, intraoperative differentiation of neoplastic tissue from normal parenchyma can be challenging. For these reasons, in the recent years, neurosurgeons have increasingly performed this surgery under the guidance of tissue fluorescence. Sodium fluoresceine and 5-aminolevulinic acid represent the 2 main compounds that allow real-time identification of residual malignant tissue and have been associated with improved gross total resection and radiological outcomes. Though presenting different profiles of sensitivity and specificity and further investigations concerning cost-effectiveness are need, Sodium fluoresceine, 5-aminolevulinic acid and new phluorophores, such as Indocyanine green, represent some of the most important tools in the neurosurgeon’s hands to achieve gross total resection.
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Affiliation(s)
- Giuseppe Palmieri
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Fabio Cofano
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy.,Neurosurgery/Spine Surgery, Humanitas Gradenigo Hospital, Turin, Italy
| | - Luca Francesco Salvati
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Matteo Monticelli
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Pietro Zeppa
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Giuseppe Di Perna
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Antonio Melcarne
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Roberto Altieri
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Italy
| | - Giuseppe La Rocca
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli Irccs, Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli Irccs, Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giuseppe Maria Barbagallo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Italy
| | - Fulvio Tartara
- Unit of Neurosurgery, Istituto Clinico Città Studi, Milan, Italy
| | - Francesco Zenga
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Diego Garbossa
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
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10
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Dadario NB, Khatri D, Reichman N, Nwagwu CD, D'Amico RS. 5-Aminolevulinic Acid-Shedding Light on Where to Focus. World Neurosurg 2021; 150:9-16. [PMID: 33684574 DOI: 10.1016/j.wneu.2021.02.118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Surgical management of gliomas is predicated on "safe maximal resection" across all histopathologic grades because progression-free survival and overall survival are positively affected by the increasing extent of resection. Administration of the prodrug 5-aminolevulinic acid (5-ALA) induces tumor fluorescence with high specificity and sensitivity for malignant high-grade glioma (HGG). Fluorescence-guided surgery (FGS) using 5-ALA improves the extent of resection in the contrast-enhancing and nonenhancing tumor components in HGG. It has also shown preliminary usefulness in other central nervous system tumors, but with certain limitations. METHODS We review and discuss the state of 5-ALA FGS for central nervous system tumors and identify the limitations in its use as a guide for future clinical optimization. RESULTS 5-ALA FGS provides maximum clinical benefits in the treatment of newly diagnosed glioblastoma. 5-ALA fluorescence specificity is limited in low-grade glioma, recurrent HGG, and non-glial tumors. Several promising intraoperative adjuncts to 5-ALA FGS have been developed to expand its indications and improve the clinical efficacy and usefulness of 5-ALA FGS. CONCLUSIONS 5-ALA FGS improves the clinical outcomes in HGG. However, further optimization of the diagnostic performance and clinical use of 5-ALA FGS is necessary for low-grade glioma and recurrent HGG tumors. Neurosurgical oncology will benefit from the novel use of advanced technologies and intraoperative visualization techniques outlined in this review, such as machine learning, hand-held fibe-optic probes, augmented reality, and three-dimensional exoscope assistance, to optimize the clinical usefulness and operative outcomes of 5-ALA FGS.
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Affiliation(s)
- Nicholas B Dadario
- Department of Neurological Surgery, Lenox Hill Hospital/Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA; Rutgers Robert Wood Johnson School of Medicine, Rutgers University, New Brunswick, New Jersey, USA
| | - Deepak Khatri
- Department of Neurological Surgery, Lenox Hill Hospital/Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Noah Reichman
- Department of Neurological Surgery, Lenox Hill Hospital/Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Chibueze D Nwagwu
- Department of Neurological Surgery, Lenox Hill Hospital/Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital/Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA.
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11
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Kobets AJ, Nauen D, Lee A, Cohen AR. Unexpected Binding of Tozuleristide "Tumor Paint" to Cerebral Vascular Malformations: A Potentially Novel Application of Fluorescence-Guided Surgery. Neurosurgery 2021; 89:204-211. [PMID: 33826729 DOI: 10.1093/neuros/nyab106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 01/27/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Fluorescence-guided surgery (FGS) is under investigation as a means to improve the extent of resection for primary central nervous system (CNS) tumors. Tozuleristide, known also as "Tumor Paint," is an investigational tumor-targeting agent covalently conjugated to a derivative of the fluorescent dye indocyanine green. OBJECTIVE To report the finding of avid intraoperative fluorescence of tozuleristide on cerebral vascular malformations. METHODS Our institution is participating in a phase 2/3 study of intraoperative near-infrared fluorescence detection of pediatric primary CNS tumors in patients receiving intravenous tozuleristide and imaged with the Canvas system. Our site enrolled 2 patients with intracranial lesions, suspected preoperatively of possibly being gliomas that proved to be cavernous vascular malformations after resection. RESULTS Each lesion had a dark blue mulberry appearance and each fluoresced avidly with tozuleristide. Each was completely resected, and the patients recovered without deficit. Pathological assessment showed cavernous angioma for both cases. Tozuleristide fluorescence is postulated to result from binding to matrix metalloproteinase-2 and annexin A2, and literature review demonstrates expression of both these ligands on multiple cerebrovascular lesions, including cavernous malformations. CONCLUSION This finding deserves further investigation to determine if tozuleristide "Tumor Paint" may have a wider role in the identification of non-neoplastic intracranial pathologies.
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Affiliation(s)
- Andrew J Kobets
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, New York, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Nauen
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amy Lee
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Alan R Cohen
- Division of Pediatric Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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12
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Schipmann S, Müther M, Stögbauer L, Zimmer S, Brokinkel B, Holling M, Grauer O, Suero Molina E, Warneke N, Stummer W. Combination of ALA-induced fluorescence-guided resection and intraoperative open photodynamic therapy for recurrent glioblastoma: case series on a promising dual strategy for local tumor control. J Neurosurg 2021; 134:426-436. [PMID: 31978877 DOI: 10.3171/2019.11.jns192443] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/25/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE High-grade glioma (HGG) prognosis remains dismal, with inevitable, mostly local recurrence. Regimens for improving local tumor control are therefore needed. Photodynamic therapy (PDT) using porfimer sodium has been investigated but was abandoned due to side effects and lack of survival benefits. Intracellular porphyrins induced by 5-aminolevulinic acid (5-ALA) are approved for fluorescence-guided resections (FGRs), but are also photosensitizers. Activated by light, they generate reactive oxygen species with resultant cytotoxicity. The authors present a combined approach of 5-ALA FGR and PDT. METHODS After 5-ALA FGR in recurrent HGG, laser diffusors were strategically positioned inside the resection cavity. PDT was applied for 60 minutes (635 nm, 200 mW/cm diffusor, for 1 hour) under continuous irrigation for maintaining optical clarity and ventilation with 100% oxygen. MRI was performed at 24 hours, 14 days, and every 3 months after surgery, including diffusion tensor imaging and apparent diffusion coefficient maps. RESULTS Twenty patients were treated. One surgical site infection after treatment was noted at 6 months as the only adverse event. MRI revealed cytotoxic edema along resection margins in 16 (80%) of 20 cases, mostly annular around the cavity, corresponding to prior laser diffusor locations (mean volume 3.3 cm3). Edema appeared selective for infiltrated tissue or nonresected enhancing tumor. At the 14-day follow-up, enhancement developed in former regions of edema, in some cases vanishing after 4-5 months. Median progression-free survival (PFS) was 6 months (95% CI 4.8-7.2 months). CONCLUSIONS Combined 5-ALA FGR and PDT provides an innovative and safe method of local tumor control resulting in promising PFS. Further prospective studies are warranted to evaluate long-term therapeutic effects.
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Affiliation(s)
| | | | | | | | | | | | - Oliver Grauer
- 3Department of Neurology, University Hospital Münster, Germany
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13
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Ohba S, Murayama K, Kuwahara K, Pareira ES, Nakae S, Nishiyama Y, Adachi K, Yamada S, Sasaki H, Yamamoto N, Abe M, Mukherjee J, Hasegawa M, Pieper RO, Hirose Y. The Correlation of Fluorescence of Protoporphyrinogen IX and Status of Isocitrate Dehydrogenase in Gliomas. Neurosurgery 2021; 87:408-417. [PMID: 31833548 DOI: 10.1093/neuros/nyz524] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 10/01/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The extent of resection has been reported to be associated with overall survival in gliomas. The use of 5-aminolevulinic acid (5-ALA) has been recognized to increase the extent of tumor resection. OBJECTIVE To evaluate what factors affect the intraoperative fluorescence after administration of 5-ALA in gliomas. METHODS Correlation of intraoperative fluorescence and several clinical, radiographic, molecular biologic, and histopathologic characters was retrospectively evaluated in 104 patients (53 males and 51 females; mean age 54.2 yr) with gliomas at our institution. To clarify the mechanisms that mutant isocitrate dehydrogenase (IDH) affect the intraoperative fluorescence, in Vitro experiments using genetically engineered glioma cells harboring mutant IDH1 were performed. RESULTS Intraoperative fluorescence was observed in 82 patients (78.8%). In addition to age, magnetic resonance imaging enhancement, World Health Organization grades, and MIB-1 index, the status of IDH was revealed to be correlated with intraoperative fluorescence. In Vitro assay revealed that mutant IDH indirectly reduced the amount of exogenous 5-ALA-derived protoporphyrinogen IX in glioma cells by increasing activity of ferrochelatase and heme oxygenase 1. CONCLUSION Mutant IDH1/2-induced metabolite changes of exogenous 5-ALA were suggested to contribute to the lesser intraoperative fluorescence in gliomas with mutant IDH1/2 than in those without.
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Affiliation(s)
- Shigeo Ohba
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
| | | | - Kiyonori Kuwahara
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
| | | | - Shunsuke Nakae
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
| | - Yuya Nishiyama
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
| | - Kazuhide Adachi
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
| | - Seiji Yamada
- Department of Pathology, Fujita Health University, Toyoake, Japan
| | - Hikaru Sasaki
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Yamamoto
- Laboratory of Molecular Biology, Fujita Health University Institute of Joint Research, Toyoake, Japan
| | - Masato Abe
- Department of Pathology, School of Health Sciences, Fujita Health University, Toyoake, Japan
| | - Joydeep Mukherjee
- Department of Neurological Surgery, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
| | | | - Russell O Pieper
- Department of Neurological Surgery, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
| | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
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14
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Barbagallo GMV, Certo F, Di Gregorio S, Maione M, Garozzo M, Peschillo S, Altieri R. Recurrent high-grade glioma surgery: a multimodal intraoperative protocol to safely increase extent of tumor resection and analysis of its impact on patient outcome. Neurosurg Focus 2021; 50:E20. [PMID: 33386001 DOI: 10.3171/2020.10.focus20744] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE No consensus exists on the best treatment for recurrent high-grade glioma (HGG), particularly in terms of surgical indications, and scant data are available on the integrated use of multiple technologies to overcome intraoperative limits and pitfalls related to artifacts secondary to previous surgery and radiotherapy. Here, the authors report on their experience with the integration of multiple intraoperative tools in recurrent HGG surgery, analyzing their pros and cons as well as their effectiveness in increasing the extent of tumor resection. In addition, they present a review of the relevant literature on this topic. METHODS The authors reviewed all cases in which recurrent HGG had been histologically diagnosed after a first surgery and the patient had undergone a second surgery involving neuronavigation with MRI, intraoperative CT (iCT), 11C-methionine-positron emission tomography (11C-MET-PET), 5-aminolevulinic acid (5-ALA) fluorescence, intraoperative neurophysiological monitoring (IONM), and intraoperative navigated ultrasound (iUS). All cases were classified according to tumor functional grade (1, noneloquent area; 2, near an eloquent area; 3, eloquent area). RESULTS Twenty patients with recurrent HGG were operated on using a multimodal protocol. The recurrent tumor functional grade was 1 in 4 patients, 2 in 8 patients, and 3 in the remaining 8 patients. In all patients but 2, 100% EOTR was obtained. Intraoperative 5-ALA fluorescence and navigated iUS showed low specificity and sensitivity. iCT detected tumor remnants in 3 cases. Postoperatively, 6 patients (30%) had worsening neurological conditions: 4 recovered within 90 days, 1 partially recovered, and 1 experienced a permanent deficit. The median Karnofsky Performance Status remained substantially unchanged over the follow-up period. The mean progression-free survival after the second surgery was 7.7 months (range 2-11 months). The mean overall survival was 25.4 months (range 10-52 months), excluding 2 long survivors. Two patients died within 60 days after surgery, and 3 patients were still under follow-up at the end of this study. CONCLUSIONS This is the first study reporting the integration of neuronavigation, 5-ALA fluorescence, iUS, iCT, 11C-MET-PET, and IOM during microsurgical resection of recurrent glioma. The authors believe that the proposed multimodal protocol is useful to increase the safety, effectiveness, and EOTR in patients with recurrent HGG and brain alterations secondary to radio- and chemotherapy.
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Affiliation(s)
- Giuseppe Maria Vincenzo Barbagallo
- 1Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico-S. Marco," University Hospital, Catania.,2Multidisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania; and
| | - Francesco Certo
- 1Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico-S. Marco," University Hospital, Catania.,2Multidisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania; and
| | - Stefania Di Gregorio
- 1Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico-S. Marco," University Hospital, Catania
| | - Massimiliano Maione
- 1Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico-S. Marco," University Hospital, Catania
| | - Marco Garozzo
- 1Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico-S. Marco," University Hospital, Catania
| | - Simone Peschillo
- 1Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico-S. Marco," University Hospital, Catania
| | - Roberto Altieri
- 1Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico-S. Marco," University Hospital, Catania.,2Multidisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania; and.,3Department of Neuroscience, University of Turin, Italy
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Abstract
Fluorescence-guided surgery provides surgeons with improved visualization of tumor tissue in the operating room to allow for maximal safe resection of brain tumors. Multiple fluorescent agents have been studied for fluorescence-guided surgery. Both nontargeted and targeted fluorescent agents are currently being used for glioblastoma multiforme visualization and resection. Fluorescence detection in the visible light or near infrared spectrum is possible. Visualization device advancements have permitted greater detection of fluorescence down to the cellular level, which may provide even greater ability for the neurosurgeon to resect tumors.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | - Constantinos Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA; Department of Neurosurgery, Mount Sinai Beth Israel, New York, NY, USA.
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16
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Abstract
In neurosurgery, the extent of resection plays a critical role, especially in the management of malignant gliomas. These tumors are characterized through a diffuse infiltration into the surrounding brain parenchyma. Delineation between tumor and normal brain parenchyma can therefore often be challenging. During the recent years, several techniques, aiming at better intraoperative tumor visualization, have been developed and implemented in the field of brain tumor surgery. In this chapter, we discuss current strategies for intraoperative imaging in brain tumor surgery, comprising conventional techniques such as neuronavigation, techniques using fluorescence-guided surgery, and further highly precise developments such as targeted fluorescence spectroscopy or Raman spectroscopy.
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Affiliation(s)
- Stephanie Schipmann-Miletić
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
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Labuschagne JJ. 5-Aminolevulinic Acid-Guided Surgery for Recurrent Supratentorial Pediatric Neoplasms. World Neurosurg 2020; 141:e763-e769. [PMID: 32526366 DOI: 10.1016/j.wneu.2020.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/30/2020] [Accepted: 06/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The use of 5-aminolevulinic acid (5-ALA) in pediatric neuro-oncology is considered off-label, and little data are available on its use in tumor recurrence surgery. Here we present our experience with 5-ALA fluorescence-guided surgery for recurrent supratentorial tumors in the pediatric population. METHODS Eleven pediatric patients presenting with recurrence of a supratentorial high-grade malignancy (5 glioblastoma [GBM], 6 non-GBM) underwent 5-ALA-assisted surgery. Biopsy specimens were obtained from pathological and normal-appearing areas of the tumor margin. RESULTS From the margin of the tumor displaying solid fluorescence, a total of 36 samples were obtained. All of these histological samples were found to harbor tumor cells. From areas of vague enhancement, a total of 49 histological samples were taken, of which 38 samples (77%) harbored tumor cells. There was no significant difference in the percentage of biopsy-positive vague fluorescent areas between the GBM cases (80%) and non-GBM cases (75%). A total of 59 biopsy specimens were taken from the tumor margin that appeared completely negative for fluorescence. On analysis, 24 (40.7%) of these specimens demonstrated tumor cells. There was no significant difference in the number of false-negative biopsies between the GBM group (40%) and the non-GBM group (41%). CONCLUSIONS The positive predictive value of solid fluorescence is high in recurrent disease but is substantially lower in areas of vague fluorescence. The rate of false-negative fluorescence is high. 5-ALA should be considered as an adjuvant in revision surgery with the aforementioned caveats in mind.
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Affiliation(s)
- Jason John Labuschagne
- Department of Neurosurgery, University of the Witwatersrand, Johannesburg and Department of Paediatric Neurosurgery, Nelson Mandela Children's Hospital, Johannesburg, South Africa.
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18
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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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Fluorescent Guided Surgery in the Surgical Management of Glioma: The Dawn of a New Era. Brain Sci 2020; 10:brainsci10040237. [PMID: 32316309 PMCID: PMC7226232 DOI: 10.3390/brainsci10040237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/14/2020] [Indexed: 11/17/2022] Open
Abstract
A growing body of evidence supports the importance of marginal or even supramarginal resection in cases of high- but also of low-grade gliomas [...].
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20
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La Rocca G, Sabatino G, Menna G, Altieri R, Ius T, Marchese E, Olivi A, Barresi V, Della Pepa GM. 5-Aminolevulinic Acid False Positives in Cerebral Neuro-Oncology: Not All That Is Fluorescent Is Tumor. A Case-Based Update and Literature Review. World Neurosurg 2020; 137:187-193. [PMID: 32058110 DOI: 10.1016/j.wneu.2020.01.238] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND One of the most valuable innovations in high-grade glioma surgery is 5-aminolevulinic acid (5-ALA). Fluorescence is a specific and sensitive indicator of metabolically active tumor tissue. In the published literature, the main focus has been placed on false-negative cases, with only a few articles addressing false positivity. The aim of the article was to highlight settings in which 5-ALA fluorescence does not necessarily mean tumor and to point out conditions in which intraoperative 5-ALA fluorescence has to be critically interpreted. METHODS Using PubMed, a review of pertinent literature was done to specifically investigate all conditions, including non-neoplastic and other metabolically active lesions, that can mimic high-grade gliomas and cause a misleading intraoperative diagnosis. In addition, an institutional case characterized by strong 5-ALA fluorescence in radionecrosis is presented. RESULTS Literature results were grouped in 2 main categories according to the field of application: oncologic setting (9 articles and 1 institutional case) and nononcologic settings (5 articles). CONCLUSIONS As reported, 5-ALA-induced fluorescence is not limited to glioma but is also evident in nonglioma and non-neoplastic conditions. Critical interpretation of intraoperative fluorescence is therefore mandatory in recurrences and in atypical cases that might hinder alternative diagnoses.
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Affiliation(s)
- Giuseppe La Rocca
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy; Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy; Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Grazia Menna
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Roberto Altieri
- Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico" University Hospital, Catania, Italy
| | - Tamara Ius
- Neurosurgery Unit, Department of Neuroscience, Santa Maria della Misericordia, University Hospital, Udine, Italy
| | - Enrico Marchese
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Valeria Barresi
- Department of Diagnostics and Public Health, Section of Anatomical Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Maria Della Pepa
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy.
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21
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Stummer W, Koch R, Valle RD, Roberts DW, Sanai N, Kalkanis S, Hadjipanayis CG, Suero Molina E. Intraoperative fluorescence diagnosis in the brain: a systematic review and suggestions for future standards on reporting diagnostic accuracy and clinical utility. Acta Neurochir (Wien) 2019; 161:2083-2098. [PMID: 31363920 PMCID: PMC6739423 DOI: 10.1007/s00701-019-04007-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 07/05/2019] [Indexed: 12/24/2022]
Abstract
Background Surgery for gliomas is often confounded by difficulties in distinguishing tumor from surrounding normal brain. For better discrimination, intraoperative optical imaging methods using fluorescent dyes are currently being explored. Understandably, such methods require the demonstration of a high degree of diagnostic accuracy and clinical benefit. Currently, clinical utility is determined by tissue biopsies which are correlated to optical signals, and quantified using measures such as sensitivity, specificity, positive predictive values, and negative predictive values. In addition, surgical outcomes, such as extent of resection rates and/or survival (progression-free survival (PFS) and overall survival (OS)) have been measured. These assessments, however, potentially involve multiple biases and confounders, which have to be minimized to ensure reproducibility, generalizability and comparability of test results. Test should aim at having a high internal and external validity. The objective of this article is to analyze how diagnostic accuracy and outcomes are utilized in available studies describing intraoperative imaging and furthermore, to derive recommendations for reliable and reproducible evaluations. Methods A review of the literature was performed for assessing the use of measures of diagnostic accuracy and outcomes of intraoperative optical imaging methods. From these data, we derive recommendations for designing and reporting future studies. Results Available literature indicates that potential confounders and biases for reporting the diagnostic accuracy and usefulness of intraoperative optical imaging methods are seldom accounted for. Furthermore, methods for bias reduction are rarely used nor reported. Conclusions Detailed, transparent, and uniform reporting on diagnostic accuracy of intraoperative imaging methods is necessary. In the absence of such reporting, studies will not be comparable or reproducible. Future studies should consider some of the recommendations given here. Electronic supplementary material The online version of this article (10.1007/s00701-019-04007-y) contains supplementary material, which is available to authorized users.
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Zhang DY, Singhal S, Lee JYK. Optical Principles of Fluorescence-Guided Brain Tumor Surgery: A Practical Primer for the Neurosurgeon. Neurosurgery 2019; 85:312-324. [PMID: 30085129 DOI: 10.1093/neuros/nyy315] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 06/18/2018] [Indexed: 01/21/2023] Open
Abstract
Fluorescence-guided surgery is a rapidly growing field that has produced some of the most important innovations in surgical oncology in the past decade. These intraoperative imaging technologies provide information distinguishing tumor tissue from normal tissue in real time as the surgery proceeds and without disruption of the workflow. Many of these fluorescent tracers target unique molecular or cellular features of tumors, which offers the opportunity for identifying pathology with high precision to help surgeons achieve their primary objective of a maximal safe resection. As novel fluorophores and fluorescent probes emerge from preclinical development, a practical understanding of the principles of fluorescence remains critical for evaluating the clinical utility of these agents and identifying opportunities for further innovation. In this review, we provide an "in-text glossary" of the fundamental principles of fluorescence with examples of direct applications to fluorescence-guided brain surgery. We offer a detailed discussion of the various advantages and limitations of the most commonly used intraoperative imaging agents, including 5-aminolevulinic acid, indocyanine green, and fluorescein, with a particular focus on the photophysical properties of these specific agents as they provide a framework through which to understand the new agents that are entering clinical trials. To this end, we conclude with a survey of the fluorescent properties of novel agents that are currently undergoing or will soon enter clinical trials for the intraoperative imaging of brain tumors.
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Affiliation(s)
- Daniel Y Zhang
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sunil Singhal
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Picart T, Berhouma M, Dumot C, Pallud J, Metellus P, Armoiry X, Guyotat J. Optimization of high-grade glioma resection using 5-ALA fluorescence-guided surgery: A literature review and practical recommendations from the neuro-oncology club of the French society of neurosurgery. Neurochirurgie 2019; 65:164-177. [PMID: 31125558 DOI: 10.1016/j.neuchi.2019.04.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/17/2019] [Accepted: 04/28/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND When feasible, the surgical resection is the standard first step of the management of high-grade gliomas. 5-ALA fluorescence-guided-surgery (5-ALA-FGS) was developed to ease the intra-operative delineation of tumor borders in order to maximize the extent of resection. METHODS A Medline electronic database search was conducted. English language studies from January 1998 until July 2018 were included, following the PRISMA guidelines. RESULTS 5-ALA can be considered as a specific tool for the detection of tumor remnant but has a weaker sensibility (level 2). 5-ALA-FGS is associated with a significant increase in the rate of gross total resection reaching more than 90% in some series (level 1). Consistently, 5-ALAFGS improves progression-free survival (level 1). However, the gain in overall survival is more debated. The use of 5-ALA-FGS in eloquent areas is feasible but requires simultaneous intraoperative electrophysiologic functional brain monitoring to precisely locate and preserve eloquent areas (level 2). 5-ALA is usable during the first resection of a glioma but also at recurrence (level 2). From a practical standpoint, 5-ALA is orally administered 3 hours before the induction of anesthesia, the recommended dose being 20 mg/kg. Intra-operatively, the procedure is performed as usually with a central debulking and a peripheral dissection during which the surgeon switches from white to blue light. Provided that some precautions are observed, the technique does not expose the patient to particular complications. CONCLUSION Although 5-ALA-FGS contributes to improve gliomas management, there are still some limitations. Future methods will be developed to improve the sensibility of 5-ALA-FGS.
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Affiliation(s)
- T Picart
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; Inserm 1052, UMR 5286,Team ATIP/AVENIR Transcriptomic diversity of stem cells, centre de cancérologie de Lyon, centre Léon-Bérard, 69008 Lyon, France.
| | - M Berhouma
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; CREATIS Laboratory, Inserm U1206, UMR 5220, université de Lyon, 69100 Villeurbanne, France
| | - C Dumot
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; CREATIS Laboratory, Inserm U1206, UMR 5220, université de Lyon, 69100 Villeurbanne, France
| | - J Pallud
- Département de neurochirurgie, hôpital Sainte-Anne, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 75005 Paris, France; IMA-Brain, Inserm U894, institut de psychiatrie et neurosciences de Paris, 7013 Paris, France
| | - P Metellus
- Hôpital Privé Clairval, Ramsay général de santé, 13009 Marseille, France; UMR 7051, institut de neurophysiopathologie, université d'Aix-Marseille, 13344 Marseille, France
| | - X Armoiry
- MATEIS (Team I2B), University of Lyon, Lyon school of pharmacy, 69008 Lyon, France; Édouard-Herriot Hospital, Pharmacy Department, 69008 Lyon, France; University of Warwick, Warwick Medical School, Coventry, UK
| | - J Guyotat
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France
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Díez Valle R, Hadjipanayis CG, Stummer W. Established and emerging uses of 5-ALA in the brain: an overview. J Neurooncol 2019; 141:487-494. [PMID: 30607705 DOI: 10.1007/s11060-018-03087-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 12/27/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION 5-aminolevulinic acid (5-ALA) was approved by the FDA in June 2017 as an intra-operative optical imaging agent for patients with gliomas (suspected World Health Organization Grades III or IV on preoperative imaging) as an adjunct for the visualization of malignant tissue during surgery. 5-ALA fluorescence-guided surgery (FGS) has been in widespread use in Europe and other continents since 2007. METHODS We reviewed the data available and summarize the most important known uses of 5-ALA FGS and its potential future applications. RESULTS/CONCLUSIONS The technique has been extensively studied, and more than 300 papers have been published on this topic. Visualization of high-grade glioma tissue is robust and reproducible, and can impact the extent of tumor resection and patient outcomes. 5-ALA FGS for other kind of tumors needs further development.
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Affiliation(s)
| | | | - Walter Stummer
- Department of Neurosurgery, Universitätsklinikum Münster, Münster, Germany
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Chohan MO, Berger MS. 5-Aminolevulinic acid fluorescence guided surgery for recurrent high-grade gliomas. J Neurooncol 2018; 141:517-522. [PMID: 30097823 DOI: 10.1007/s11060-018-2956-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 07/16/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Fluorescence guided surgery (FGS) with five-aminolevulinic acid (5-ALA) is expected to revolutionize neurosurgical care of patients with high-grade gliomas (HGG). After the recent landmark FDA approval, this optical agent is now available to neurosurgeons in the United States. METHODS This review is designed to highlight the evidence for the use of 5-ALA in recurrent HGG surgery for the neurosurgical community. The manuscript was prepared in accordance with the PRISMA guidelines. RESULTS Intra-operatively, a strong fluorescent signal is highly correlated with the presence of cellular tumor in recurrent HGG, giving it a high positive predictive value (PPV). Similar to what is observed in primary HGG surgery, false-negative results can occur if tumor cells do not emit fluorescence. In addition, false-positive fluorescence signals in tissues devoid of tumor cells can be observed more frequently in recurrent HGG compared to the primary setting. However, these areas overwhelmingly contain reactive/regressive tissue, resection of which is unlikely to cause functional deficits. The safety profile of 5-ALA is similarly favorable in primary and recurrent HGG. CONCLUSIONS 5-ALA FGS is a powerful adjunct in the resection of recurrent HGG with a high PPV and favorable safety profile. It is therefore the authors' opinion to routinely employ this fluorescent agent as a standard of care.
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Affiliation(s)
- Muhammad Omar Chohan
- Department of Neurological Surgery, University of New Mexico, 2211 Lomas Blvd. NE, Albuquerque, NM, 87111, USA.
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Ave. Rm. M779, San Francisco, CA, 94143-0112, USA
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THE ROLE OF PHOTODYNAMIC THERAPY IN THE TREATMENT OF PRIMARY, RECURRENT AND METASTATIC MALIGNANT BRAIN TUMORS. BIOMEDICAL PHOTONICS 2018. [DOI: 10.24931/2413-9432-2018-7-2-37-49] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Photodynamic therapy is a relevant and promising area for research in the field of clinical neuroonocology. Application of modern developments in the field of laser technologies and new photosensitizers allows us to refer to this field as to high-tech. According to various authors, the inclusion of photodynamic therapy in combined and complex treatments of patients with malignant brain tumors allows achieving overall survival median of patients from 11 to 26 months for primary form of glioblastoma, and from 7.5 to 15 months - for recurrent forms of glioblastoma. Certain results have been achieved in the treatment of patients with metastatic brain lesion. In this publication the authors analyzed and systematized the results of the main clinical studies in the field of fluorescent diagnostics and intraoperative photodynamic therapy of primary, recurrent and metastatic forms of malignant brain tumors.
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Stepp H, Stummer W. 5‐ALA in the management of malignant glioma. Lasers Surg Med 2018; 50:399-419. [DOI: 10.1002/lsm.22933] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Herbert Stepp
- LIFE Center and Department of UrologyUniversity Hospital of MunichFeodor‐Lynen‐Str. 1981377MunichGermany
| | - Walter Stummer
- Department of NeurosurgeryUniversity Clinic MünsterAlbert‐Schweitzer‐Campus 1, Gebäude A148149MünsterGermany
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Kim AV, Khachatryan VA. [Intraoperative fluorescence diagnosis using 5-aminolevulinic acid in surgical treatment of children with recurrent neuroepithelial tumors]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2017; 81:51-57. [PMID: 28291213 DOI: 10.17116/neiro201780751-57] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To analyze the efficacy and safety of 5-aminolevulinic acid for intraoperative fluorescence diagnosis (FD) during repeated surgery for recurrent neuroepithelial tumors (NETs) in children. MATERIAL AND METHODS We performed a retrospective analysis of the results of recurrent NET resection in 13 children aged from 3 to 17 years in the period between December 2013 and May 2015. The source of 5-ALA was a drug "Alasens" that was administered at a dose of 20 mg/kg of body weight 4 h before the beginning of tumor resection. A visual scale was used to evaluate the fluorescence intensity. The drug was used with the informed consent of the child's parents and approval of the Polenov Neurosurgical Institute ethics committee. All patients underwent complex clinical and introscopic examination in the pre- and postoperative periods and a repeated histological tumor examination. RESULTS There was no fluorescence in 4 cases (Gr I in 2 cases; Gr II in 2 cases). Grade 1 fluorescence (Gr II) was observed in one case, and grade 2-3 fluorescence was observed in the remaining 8 patients. Total and subtotal tumor resection was achieved in 11 (84.6%) of 13 patients. There were no clinically significant adverse effects. A transient increase in transaminases was observed in 2 patients. Two girls had an elevated photosensitivity to light for two days. CONCLUSION FD is a safe technique in childhood and can improve intraoperative detection of NET during its repeated growth as well as differentiate the tumor from pathological tissues of non-tumorous nature, which increases completeness of blastomatous tissue removal. However, the character and intensity of fluorescence may change in recurrent NETs. Further research is required to investigate the FD effectiveness in various age patients with tumors of a different histological structure and malignancy in the case of both primary and recurrent lesions.
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Affiliation(s)
- A V Kim
- Polenov Neurosurgical Institute, Branch of the Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russia
| | - V A Khachatryan
- Polenov Neurosurgical Institute, Branch of the Almazov Federal North-West Medical Research Centre, Saint-Petersburg, Russia
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Senders JT, Muskens IS, Schnoor R, Karhade AV, Cote DJ, Smith TR, Broekman MLD. Agents for fluorescence-guided glioma surgery: a systematic review of preclinical and clinical results. Acta Neurochir (Wien) 2017; 159:151-167. [PMID: 27878374 PMCID: PMC5177668 DOI: 10.1007/s00701-016-3028-5] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 11/09/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Fluorescence-guided surgery (FGS) is a technique used to enhance visualization of tumor margins in order to increase the extent of tumor resection in glioma surgery. In this paper, we systematically review all clinically tested fluorescent agents for application in FGS for glioma and all preclinically tested agents with the potential for FGS for glioma. METHODS We searched the PubMed and Embase databases for all potentially relevant studies through March 2016. We assessed fluorescent agents by the following outcomes: rate of gross total resection (GTR), overall and progression-free survival, sensitivity and specificity in discriminating tumor and healthy brain tissue, tumor-to-normal ratio of fluorescent signal, and incidence of adverse events. RESULTS The search strategy resulted in 2155 articles that were screened by titles and abstracts. After full-text screening, 105 articles fulfilled the inclusion criteria evaluating the following fluorescent agents: 5-aminolevulinic acid (5-ALA) (44 studies, including three randomized control trials), fluorescein (11), indocyanine green (five), hypericin (two), 5-aminofluorescein-human serum albumin (one), endogenous fluorophores (nine) and fluorescent agents in a pre-clinical testing phase (30). Three meta-analyses were also identified. CONCLUSIONS 5-ALA is the only fluorescent agent that has been tested in a randomized controlled trial and results in an improvement of GTR and progression-free survival in high-grade gliomas. Observational cohort studies and case series suggest similar outcomes for FGS using fluorescein. Molecular targeting agents (e.g., fluorophore/nanoparticle labeled with anti-EGFR antibodies) are still in the pre-clinical phase, but offer promising results and may be valuable future alternatives.
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Affiliation(s)
- Joeky T Senders
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ivo S Muskens
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rosalie Schnoor
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Aditya V Karhade
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA, 02115, USA
| | - David J Cote
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA, 02115, USA
| | - Timothy R Smith
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA, 02115, USA
| | - Marike L D Broekman
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Rahman M, Abbatematteo J, De Leo EK, Kubilis PS, Vaziri S, Bova F, Sayour E, Mitchell D, Quinones-Hinojosa A. The effects of new or worsened postoperative neurological deficits on survival of patients with glioblastoma. J Neurosurg 2016; 127:123-131. [PMID: 27689459 DOI: 10.3171/2016.7.jns16396] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE An increased extent of resection (EOR) has been shown to improve overall survival of patients with glioblastoma (GBM) but has the potential for causing a new postoperative neurological deficit. To investigate the impact of surgical neurological morbidity on survival, the authors performed a retrospective analysis of the clinical data from patients with GBM to quantify the impact of a new neurological deficit on the survival benefit achieved with an increased EOR. METHODS The data from all GBM patients who underwent resection at the University of Florida from 2010 to 2015 with postoperative imaging within 72 hours of surgery were included in the study. Retrospective analysis was performed on clinical outcomes and tumor volumes determined on postoperative and follow-up imaging examinations. RESULTS Overall, 115 patients met the inclusion criteria for the study. Tumor volume at the time of presentation was a median of 59 cm3 (enhanced on T1-weighted MRI scans). The mean EOR (± SD) was 94.2% ± 8.7% (range 59.9%-100%). Almost 30% of patients had a new postoperative neurological deficit, including motor weakness, sensory deficits, language difficulty, visual deficits, confusion, and ataxia. The neurological deficits had resolved in 41% of these patients on subsequent follow-up examinations. The median overall survival was 13.1 months (95% CI 10.9-15.2 months). Using a multipredictor Cox model, the authors observed that increased EOR was associated with improved survival except for patients with smaller tumor volumes (≤ 15 cm3). A residual volume of 2.5 cm3 or less predicted a favorable overall survival. Developing a postoperative neurological deficit significantly affected survival (9.2 months compared with 14.7 months, p = 0.02), even if the neurological deficit had resolved by the first follow-up. However, there was a trend of improved survival among patients with resolution of a neurological deficit by the first follow-up compared with patients with a permanent neurological deficit. Any survival benefit from achieving a 95% EOR was abrogated by the development of a new neurological deficit postoperatively. CONCLUSIONS Developing a new neurological deficit after resection of GBM is associated with a decrease in overall survival. A careful balance between EOR and neurological compromise needs to be taken into account to reduce the likelihood of neurological morbidity from surgery.
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Affiliation(s)
- Maryam Rahman
- Department of Neurosurgery, University of Florida, Gainesville, Florida; and
| | - Joseph Abbatematteo
- Department of Neurosurgery, University of Florida, Gainesville, Florida; and
| | - Edward K De Leo
- Department of Neurosurgery, University of Florida, Gainesville, Florida; and
| | - Paul S Kubilis
- Department of Neurosurgery, University of Florida, Gainesville, Florida; and
| | - Sasha Vaziri
- Department of Neurosurgery, University of Florida, Gainesville, Florida; and
| | - Frank Bova
- Department of Neurosurgery, University of Florida, Gainesville, Florida; and
| | - Elias Sayour
- Department of Neurosurgery, University of Florida, Gainesville, Florida; and
| | - Duane Mitchell
- Department of Neurosurgery, University of Florida, Gainesville, Florida; and
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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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