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Fang Q, Hou Q, Liu X, Ma L, Jiang G, He Z. Enhancing the Extent of Resection in Glioma Surgery Through the Integration of Intraoperative Contrast-Enhanced Ultrasound and Fluorescein Sodium. World Neurosurg 2024; 186:e662-e672. [PMID: 38608808 DOI: 10.1016/j.wneu.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Due to the infiltrative nature and high local recurrence of gliomas, particularly high-grade gliomas, gross total resection (GTR) of a tumor is the first critical step in treatment. This study aimed to determine whether the integration of intraoperative contrast-enhanced ultrasound (CEUS) and fluorescein sodium can improve the identification of tumor boundaries and residuals, and increasethe extent of resection (EOR) to better protect neurological function. METHODS We retrospectively analysed clinical data from 87 glioma surgeries and categorised the patients into 3 groups: CEUS plus fluorescein sodium, fluorescein sodium alone and microsurgery alone. RESULTS In terms of EOR, GTR was achieved in 22 (91.7%) patients in the CEUS plus fluorescein sodium group, which was significantly higher than that in other groups. In the subgroup analysis of tumors with lobulated or satellite lesions and WHO grade III or IV gliomas, CEUS plus fluorescein sodium group showed the highest GTR (86.7% and 88.9% respectively) among the groups. Logistic regression analysis of factors that may affect the GTR of tumors showed that the functional areas involvement and the presence of lobulated or satellite lesions were risk factors, whereas CEUS plus fluorescein sodium group was a protective factor. However, CEUS plus fluorescein sodium group had the longest surgery time. CONCLUSIONS Intraoperative CEUS with fluorescein sodium is a real-time, straightforward, safe, and effective approach to perform surgical resection of gliomas. This approach assists surgeons in identifying tumor boundaries, residual tumors, and normal brain parenchyma, which increases the EOR.
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Affiliation(s)
- Qinrui Fang
- Departments of Neurosurgery, The Tenth Affiliated Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan City, Guangdong Province, China
| | - Qingshi Hou
- Departments of Neurosurgery, The Tenth Affiliated Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan City, Guangdong Province, China
| | - Xiaohong Liu
- Departments of Neurosurgery, The Tenth Affiliated Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan City, Guangdong Province, China.
| | - Liya Ma
- Department of Ultrasonography, The Tenth Affiliated Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan City, Guangdong Province, China
| | - Gengsi Jiang
- Departments of Neurosurgery, The Tenth Affiliated Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan City, Guangdong Province, China
| | - Zhizhong He
- Department of Ultrasonography, The Tenth Affiliated Hospital, Southern Medical University (Dongguan People's Hospital), Dongguan City, Guangdong Province, China
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Nakayama N, Yamada T, Yano H, Takei H, Ohe N, Miwa K, Shinoda J, Iwama T. Prediction of nuclide accumulation spread based on the volume of enhancing magnetic resonance imaging lesion in glioblastoma patients. J Neurosurg Sci 2024; 68:164-173. [PMID: 34647709 DOI: 10.23736/s0390-5616.21.05353-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND 11C-methionine-PET (MET) and Thallium-201 chloride-SPECT (TL) are useful for predictive proliferation ability and tumor invasion range identification in glioma patients, however they are not always possible in any hospital or country. Our study aimed to assess whether the range of MET and Tl accumulation could be predicted from the contrast-enhanced lesions in Gadolinium (Gd)-T1 weighted magnetic resonance image in glioblastoma multiforme (GBM) patients. METHODS In 25 cases, the MET-area, TL-area, O-area where MET and TL overlap, and all accumulation area (AA-area) were measured in the same axial cross section as the Gd enhanced maximum area (Gd-area). This tracing operation was repeated with all axial fusion slices, and each volume was also measured (Gd-V, MET-V, TL-V, O-V, AA-V). RESULTS The maximum accumulation distance of MET and TL beyond the Gd-area was limited to within 30 mm, 35 mm, respectively. Significant positive correlations were showed in all combinations with Gd-area: MET-area (r=0.851, P<0.0001), TL-area (r=0.955, P<0.0001), O-area (r=0.935, P<0.0001) and AA-area (r=0.893, P<0.0001), respectively. All combinations with Gd-V showed significant positive correlation: MET-V (r=0.867, P<0.0001), TL-V (r=0.952, P<0.0001), O-V (r=0.935, P<0.0001) and AA-V (r=0.897, P<0.0001), respectively. CONCLUSIONS Approximate tumor volume Gd-V can be calculated using the formula A * B * C / 2, where A, B, and C represent the dimensions of Gd-enhanced lesion in 3 axes perpendicular to each other. The nuclide accumulation predictive table created using the obtained linear approximation functions can be used to predict the average tumor invasion range from the Gd-V without preoperative nuclear examinations.
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Affiliation(s)
- Noriyuki Nakayama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan -
| | - Tetsuya Yamada
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hirohito Yano
- Chubu Medical Center for Prolonged Traumatic Brain Dysfunction, Kizawa Memorial Hospital, Minokamo City, Gifu, Japan
| | - Hiroaki Takei
- Chubu Medical Center for Prolonged Traumatic Brain Dysfunction, Kizawa Memorial Hospital, Minokamo City, Gifu, Japan
| | - Naoyuki Ohe
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kazuhiro Miwa
- Chubu Medical Center for Prolonged Traumatic Brain Dysfunction, Kizawa Memorial Hospital, Minokamo City, Gifu, Japan
| | - Jun Shinoda
- Chubu Medical Center for Prolonged Traumatic Brain Dysfunction, Kizawa Memorial Hospital, Minokamo City, Gifu, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
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Zhang X, Habib A, Jaman E, Mallela AN, Amankulor NM, Zinn PO. Headlight and loupe-based fluorescein detection system in brain tumor surgery: a first-in-human experience. J Neurosurg Sci 2023; 67:374-379. [PMID: 34647714 PMCID: PMC11225590 DOI: 10.23736/s0390-5616.21.05469-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Fluorescein is an agent that accumulates in areas of blood-brain barrier breakdown and is commonly used in neurosurgical oncology to assist with lesion localization and visualizing the extent of resection. It is considered to be cost-effective and has a favorable safety profile. Studies on the utilization of fluorescein demonstrate an improved extent of tumor resection and increased overall survival. Currently, fluorescein detection systems are all microscope based, leading to limitations such as decreased maneuverability, limited visualization of the entire operative field, and significant cost associated with obtaining and maintaining a neurosurgical operating microscope. Three consecutive craniotomy patients for tumor resection were included, and surgery was carried out under loupe fluorescence guidance using the ReVeal 450 System, and also a surgical microscope for comparison. Loupe-mounted fluorescence system enabled excellent visualization of fluorescence in all three cases. In this manuscript, we describe our experience with a loupe-mounted fluorescein detection system in three patients with malignant gliomas. We found that the loupe-mounted system offered excellent ability to visualize fluorescein fluorescence. Although loupe-mounted systems are not an alternative to surgical microscopes, they could be a useful surgical adjunct for superficial lesions and in low-middle income counties.
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Affiliation(s)
- Xiaoran Zhang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ahmed Habib
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Emade Jaman
- School of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nduka M Amankulor
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pascal O Zinn
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA -
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Belykh E, Bardonova L, Abramov I, Byvaltsev VA, Kerymbayev T, Yu K, Healey DR, Luna-Melendez E, Deneen B, Mehta S, Liu JK, Preul MC. 5-aminolevulinic acid, fluorescein sodium, and indocyanine green for glioma margin detection: analysis of operating wide-field and confocal microscopy in glioma models of various grades. Front Oncol 2023; 13:1156812. [PMID: 37287908 PMCID: PMC10242067 DOI: 10.3389/fonc.2023.1156812] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/28/2023] [Indexed: 06/09/2023] Open
Abstract
Introduction Surgical resection remains the first-line treatment for gliomas. Several fluorescent dyes are currently in use to augment intraoperative tumor visualization, but information on their comparative effectiveness is lacking. We performed systematic assessment of fluorescein sodium (FNa), 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX), and indocyanine green (ICG) fluorescence in various glioma models using advanced fluorescence imaging techniques. Methods Four glioma models were used: GL261 (high-grade model), GB3 (low-grade model), and an in utero electroporation model with and without red fluorescence protein (IUE +RFP and IUE -RFP, respectively) (intermediate-to-low-grade model). Animals underwent 5-ALA, FNa, and ICG injections and craniectomy. Brain tissue samples underwent fluorescent imaging using a wide-field operative microscope and a benchtop confocal microscope and were submitted for histologic analysis. Results Our systematic analysis showed that wide-field imaging of highly malignant gliomas is equally efficient with 5-ALA, FNa, and ICG, although FNa is associated with more false-positive staining of the normal brain. In low-grade gliomas, wide-field imaging cannot detect ICG staining, can detect FNa in only 50% of specimens, and is not sensitive enough for PpIX detection. With confocal imaging of low-intermediate grade glioma models, PpIX outperformed FNa. Discussion Overall, compared to wide-field imaging, confocal microscopy significantly improved diagnostic accuracy and was better at detecting low concentrations of PpIX and FNa, resulting in improved tumor delineation. Neither PpIX, FNa, nor ICG delineated all tumor boundaries in studied tumor models, which emphasizes the need for novel visualization technologies and molecular probes to guide glioma resection. Simultaneous administration of 5-ALA and FNa with use of cellular-resolution imaging modalities may provide additional information for margin detection and may facilitate maximal glioma resection.
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Affiliation(s)
- Evgenii Belykh
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
- Department of Neurosurgery, New Jersey Medical School, Rutgers University, Newark, NJ, United States
| | - Liudmila Bardonova
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Irakliy Abramov
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Vadim A. Byvaltsev
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Talgat Kerymbayev
- Department of Neurosurgery, JSC “National Scientific Center of Neurosurgery”, Nur-Sultan, Kazakhstan
| | - Kwanha Yu
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, United States
| | - Debbie R. Healey
- Department of Research Imaging, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | | | - Benjamin Deneen
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, United States
| | - Shwetal Mehta
- Ivy Brain Tumor Research Center, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - James K. Liu
- Department of Neurosurgery, New Jersey Medical School, Rutgers University, Newark, NJ, United States
| | - Mark C. Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
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Bonosi L, Marrone S, Benigno UE, Buscemi F, Musso S, Porzio M, Silven MP, Torregrossa F, Grasso G. Maximal Safe Resection in Glioblastoma Surgery: A Systematic Review of Advanced Intraoperative Image-Guided Techniques. Brain Sci 2023; 13:brainsci13020216. [PMID: 36831759 PMCID: PMC9954589 DOI: 10.3390/brainsci13020216] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/15/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
Glioblastoma multiforme (GBM) represents the most common and aggressive central nervous system tumor associated with a poor prognosis. The aim of this study was to depict the role of intraoperative imaging techniques in GBM surgery and how they can ensure the maximal extent of resection (EOR) while preserving the functional outcome. The authors conducted a systematic review following PRISMA guidelines on the PubMed/Medline and Scopus databases. A total of 1747 articles were identified for screening. Studies focusing on GBM-affected patients, and evaluations of EOR and functional outcomes with the aid of advanced image-guided techniques were included. The resulting studies were assessed for methodological quality using the Risk of Bias in Systematic Review tool. Open Science Framework registration DOI 10.17605/OSF.IO/3FDP9. Eighteen studies were eligible for this systematic review. Among the selected studies, eight analyzed Sodium Fluorescein, three analyzed 5-aminolevulinic acid, two evaluated IoMRI imaging, two evaluated IoUS, and three evaluated multiple intraoperative imaging techniques. A total of 1312 patients were assessed. Gross Total Resection was achieved in the 78.6% of the cases. Follow-up time ranged from 1 to 52 months. All studies assessed the functional outcome based on the Karnofsky Performance Status scale, while one used the Neurologic Assessment in Neuro-Oncology score. In 77.7% of the cases, the functional outcome improved or was stable over the pre-operative assessment. Combining multiple intraoperative imaging techniques could provide better results in GBM surgery than a single technique. However, despite good surgical outcomes, patients often present a neurocognitive decline leading to a marked deterioration of the quality of life. Advanced intraoperative image-guided techniques can allow a better understanding of the anatomo-functional relationships between the tumor and the surrounding brain, thus maximizing the EOR while preserving functional outcomes.
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Zeppa P, De Marco R, Monticelli M, Massara A, Bianconi A, Di Perna G, Greco Crasto S, Cofano F, Melcarne A, Lanotte MM, Garbossa D. Fluorescence-Guided Surgery in Glioblastoma: 5-ALA, SF or Both? Differences between Fluorescent Dyes in 99 Consecutive Cases. Brain Sci 2022; 12:brainsci12050555. [PMID: 35624942 PMCID: PMC9138621 DOI: 10.3390/brainsci12050555] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Glioblastoma (GBM) is the most common primary brain tumor. The extent of resection (EOR) has been claimed as one of the most important prognostic factors. Fluorescent dyes aid surgeons in detecting a tumor’s borders. 5-aminolevulinic acid (5-ALA) and sodium fluorescein (SF) are the most used. Only a few studies have directly compared these two fluorophores. Methods: A single center retrospective analysis of patients treated for GBM in the period between January 2018 and January 2021 was built to find any differences in terms of EOR, Karnofsky Performance Status (KPS), and overall survival (OS) on the use of 5-ALA, SF, or both. Results: Overall, 99 patients affected by isocitrate dehydrogenase (IDH) wild-type Glioblastoma were included. 5-ALA was administered to 40 patients, SF to 44, and both to 15. No statistically significant associations were identified between the fluorophore and EOR (p = 0.783) or postoperative KPS (p = 0.270). Survival analyses did not show a selective advantage for the use of a given fluorophore (p = 0.184), although there appears to be an advantageous trend associated with the concomitant use of both dyes, particularly after stratification by MGMT (p = 0.071). Conclusions: 5-Ala and SF are equally useful in achieving gross total resection of the enhancing tumor volume. The combination of both fluorophores could lead to an OS advantage.
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Affiliation(s)
- Pietro Zeppa
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Raffaele De Marco
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
- Correspondence:
| | - Matteo Monticelli
- Neurosurgery Unit, Department of Neuroscience and Rehabilitation, University of Ferrara, 44124 Ferrara, Italy;
| | - Armando Massara
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Andrea Bianconi
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Giuseppe Di Perna
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | | | - Fabio Cofano
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
- Humanitas Gradenigo Hospital, 10153 Turin, Italy
| | - Antonio Melcarne
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Michele Maria Lanotte
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Diego Garbossa
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
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Matsumae M, Nishiyama J, Kuroda K. Intraoperative MR Imaging during Glioma Resection. Magn Reson Med Sci 2022; 21:148-167. [PMID: 34880193 PMCID: PMC9199972 DOI: 10.2463/mrms.rev.2021-0116] [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] [Received: 08/24/2021] [Accepted: 10/11/2021] [Indexed: 11/09/2022] Open
Abstract
One of the major issues in the surgical treatment of gliomas is the concern about maximizing the extent of resection while minimizing neurological impairment. Thus, surgical planning by carefully observing the relationship between the glioma infiltration area and eloquent area of the connecting fibers is crucial. Neurosurgeons usually detect an eloquent area by functional MRI and identify a connecting fiber by diffusion tensor imaging. However, during surgery, the accuracy of neuronavigation can be decreased due to brain shift, but the positional information may be updated by intraoperative MRI and the next steps can be planned accordingly. In addition, various intraoperative modalities may be used to guide surgery, including neurophysiological monitoring that provides real-time information (e.g., awake surgery, motor-evoked potentials, and sensory evoked potential); photodynamic diagnosis, which can identify high-grade glioma cells; and other imaging techniques that provide anatomical information during the surgery. In this review, we present the historical and current context of the intraoperative MRI and some related approaches for an audience active in the technical, clinical, and research areas of radiology, as well as mention important aspects regarding safety and types of devices.
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Affiliation(s)
- Mitsunori Matsumae
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Jun Nishiyama
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Kagayaki Kuroda
- Department of Human and Information Sciences, School of Information Science and Technology, Tokai University, Hiratsuka, Kanagawa, Japan
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Naik A, Smith EJ, Barreau A, Nyaeme M, Cramer SW, Najafali D, Krist DT, Arnold PM, Hassaneen W. Comparison of fluorescein sodium, 5-ALA, and intraoperative MRI for resection of high-grade gliomas: A systematic review and network meta-analysis. J Clin Neurosci 2022; 98:240-247. [PMID: 35219089 DOI: 10.1016/j.jocn.2022.02.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/08/2022] [Accepted: 02/17/2022] [Indexed: 12/31/2022]
Abstract
High grade gliomas (HGGs) are aggressive brain tumors associated with poor prognosis despite advances in surgical treatment and therapy. Navigated tumor resection has yielded improved outcomes for patients. We compare 5-ALA, fluorescein sodium (FS), and intraoperative MRI (IMRI) with no image guidance to determine the best intraoperative navigation method to maximize rates of gross total resection (GTR) and outcomes. A frequentist network meta-analysis was performed following standard PRISMA guidelines (PROSPERO registration CRD42021268659). Surface-under-the-cumulative ranking (SUCRA) analysis was executed to hierarchically rank modalities by the outcomes of interest. Heterogeneity was measured by the I2 statistic. Publication bias was assessed by funnel plots and the use of Egger's test. Statistical significance was determined by p < 0.05. Twenty-three studies were included for analysis with a total of 2,643 patients. Network meta-analysis comparing 5-ALA, IMRI, and FS was performed. The primary outcome assessed was the rate of GTR. Analysis revealed the superiority of all intraoperative navigation to control (no navigation). SUCRA analysis revealed the superiority of IMRI + 5-ALA, IMRI alone, followed by FS, and 5-ALA. Overall survival (OS) and progression free survival (PFS) were also examined. FS (vs. control) was associated with improved OS, while IMRI was associated with improved PFS (vs. control, FS, and 5-ALA). Intraoperative navigation using IMRI, FS, and 5-ALA lead to greater rates of GTR in HGGs. FS and 5-ALA also yielded improvement in OS and PFS. Further studies are needed to evaluate differences in survival benefit, operative duration, and cost.
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Affiliation(s)
- Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, IL 61820, United States
| | - Emily J Smith
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, IL 61820, United States
| | - Ariana Barreau
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, IL 61820, United States
| | - Mark Nyaeme
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, IL 61820, United States
| | - Samuel W Cramer
- Department of Neurosurgery, University of Minnesota Twin-Cities, Minneapolis MN, 55455, United States
| | - Daniel Najafali
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, IL 61820, United States
| | - David T Krist
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, IL 61820, United States
| | - Paul M Arnold
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, IL 61820, United States; Department of Neurosurgery, Carle Foundation Hospital, Urbana IL 61801, United States
| | - Wael Hassaneen
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, IL 61820, United States; Department of Neurosurgery, Carle Foundation Hospital, Urbana IL 61801, United States.
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9
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Kofoed MS, Pedersen CB, Schulz MK, Kristensen BW, Hansen RW, Markovic L, Halle B, Poulsen FR. Fluorescein-guided resection of cerebral metastases is associated with greater tumor resection. Acta Neurochir (Wien) 2022; 164:451-457. [PMID: 33721109 DOI: 10.1007/s00701-021-04796-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/25/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Sodium fluorescein (fluorescein) crosses a disrupted blood-brain barrier similarly to gadolinium contrast in contrast-enhancing cerebral tumors. When exposed to light with 560 nm wavelength during surgery, fluorescein emits a yellow-green fluorescent light that can be visualized through an operating microscope equipped with an appropriate emission filter. The distribution of the fluorescence correlates with the contrast on a gadolinium contrast-enhanced MRI. OBJECTIVE The objective of this single-center retrospective study was to investigate if the use of fluorescein would increase the extent of resection and to examine if fluorescein guided resection influences postoperative neurological status. METHODS During the study period from August 2014 to August 2018, 117 patients were operated for cerebral metastases. Of these, 56 operations were guided by fluorescein and 61 by traditional white light. All patients had an early postoperative MRI within 72 h after surgery. RESULTS The use of fluorescein increased the extent of resection in patients with cerebral metastases. The use of fluorescein was not associated with increased postoperative sequelae or neurological damage regardless of underlying primary cancer. CONCLUSION Fluorescein is a helpful supplement in the neurosurgical treatment of cerebral metastases.
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Affiliation(s)
- Mikkel S Kofoed
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- BRIDGE (Brain Research-Interdisciplinary Guided Excellence), Odense, Denmark.
| | - Christian B Pedersen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- BRIDGE (Brain Research-Interdisciplinary Guided Excellence), Odense, Denmark
| | - Mette K Schulz
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- BRIDGE (Brain Research-Interdisciplinary Guided Excellence), Odense, Denmark
| | - Bjarne W Kristensen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- BRIDGE (Brain Research-Interdisciplinary Guided Excellence), Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Rasmus W Hansen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ljubo Markovic
- Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Bo Halle
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- BRIDGE (Brain Research-Interdisciplinary Guided Excellence), Odense, Denmark
| | - Frantz R Poulsen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- BRIDGE (Brain Research-Interdisciplinary Guided Excellence), Odense, Denmark
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10
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van Leeuwen FW, van Willigen DM, Buckle T. Clinical application of fluorescent probes. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00104-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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11
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Nikova AS, Vlotinou P, Karelis L, Karanikas M, Birbilis TA. Gross total resection with fluorescence could lead to improved overall survival rates: a systematic review and meta-analysis. Br J Neurosurg 2021; 36:316-322. [PMID: 34313526 DOI: 10.1080/02688697.2021.1950637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Glioblastoma cases are often treated with aggressive resection. Recent studies have suggested that extended surgical resection could improve survival. Improved extent of resection could be afforded by the use of fluorescence during surgery. We aimed to examine the effect of fluorescence on the results of gross total resection (GTR) and its impact on the overall survival (OS) and progression-free survival (PFS) rates. METHODS We performed a literature search of studies published between 2000 and 2021. The study followed the PRISMA guidelines and focused on newly-diagnosed glioblastoma cases. The collected data were divided into two groups according to the fluorescence use: Group A (standard white-light use) and Group B (fluorescent-light use). RESULTS The results showed a superiority of the fluorescence use during surgery for newly diagnosed glioblastoma cases concerning the procurement of GTR. Additionally, we highlighted the importance of GTR on the OS but not on the PFS rate. We found that the use of 5-aminolevulinic acid resulted in better OS rates compared to fluorescein sodium. CONCLUSION GTR is a significant factor leading to improved OS; nevertheless, it was an apparently unrelated factor for estimating the PFS rate. Fluorescence use during surgery could lead to higher rates of complete resection and better OS rates.
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Affiliation(s)
- Alexandrina S Nikova
- Department of Neurosurgery, Democritus University of Thrace Medical School, Alexandroupolis, Greece.,Department of Neurosurgery, "Evangelismos" General Hospital, Athens, Greece
| | - Penelope Vlotinou
- Department of Neurology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Loukas Karelis
- Department of Pathology, "Metaxa" Cancer Hospital, Piraeus, Greece
| | - Michael Karanikas
- Department of Surgery, Democritus University of Thrace Medical School, Alexandroupolis, Greece
| | - Theodossios A Birbilis
- Department of Neurosurgery, Democritus University of Thrace Medical School, Alexandroupolis, Greece
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12
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Palmieri G, Cofano F, Salvati LF, Monticelli M, Zeppa P, Perna GD, Melcarne A, Altieri R, La Rocca G, Sabatino G, Barbagallo GM, Tartara F, Zenga F, Garbossa D. Fluorescence-Guided Surgery for High-Grade Gliomas: State of the Art and New Perspectives. Technol Cancer Res Treat 2021; 20:15330338211021605. [PMID: 34212784 PMCID: PMC8255554 DOI: 10.1177/15330338211021605] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
High-grade gliomas are aggressive tumors that require multimodal management and gross total resection is considered to be the first crucial step of treatment. Because of their infiltrative nature, intraoperative differentiation of neoplastic tissue from normal parenchyma can be challenging. For these reasons, in the recent years, neurosurgeons have increasingly performed this surgery under the guidance of tissue fluorescence. Sodium fluoresceine and 5-aminolevulinic acid represent the 2 main compounds that allow real-time identification of residual malignant tissue and have been associated with improved gross total resection and radiological outcomes. Though presenting different profiles of sensitivity and specificity and further investigations concerning cost-effectiveness are need, Sodium fluoresceine, 5-aminolevulinic acid and new phluorophores, such as Indocyanine green, represent some of the most important tools in the neurosurgeon’s hands to achieve gross total resection.
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Affiliation(s)
- Giuseppe Palmieri
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Fabio Cofano
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy.,Neurosurgery/Spine Surgery, Humanitas Gradenigo Hospital, Turin, Italy
| | - Luca Francesco Salvati
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Matteo Monticelli
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Pietro Zeppa
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Giuseppe Di Perna
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Antonio Melcarne
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Roberto Altieri
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Italy
| | - Giuseppe La Rocca
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli Irccs, Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli Irccs, Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giuseppe Maria Barbagallo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Italy
| | - Fulvio Tartara
- Unit of Neurosurgery, Istituto Clinico Città Studi, Milan, Italy
| | - Francesco Zenga
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Diego Garbossa
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
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13
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Kitagawa Y, Tanaka S, Kamiya M, Kuriki Y, Yamamoto K, Shimizu T, Nejo T, Hana T, Matsuura R, Koike T, Yamazawa E, Kushihara Y, Takahashi S, Nomura M, Takami H, Takayanagi S, Mukasa A, Urano Y, Saito N. A Novel Topical Fluorescent Probe for Detection of Glioblastoma. Clin Cancer Res 2021; 27:3936-3947. [PMID: 34031057 DOI: 10.1158/1078-0432.ccr-20-4518] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/12/2021] [Accepted: 05/17/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Five-aminolevulinic acid (5-ALA) is widely used as an intraoperative fluorescent probe for radical resection of high-grade glioma, and thus aids in extending progression-free survival of patients. However, there exist some cases where 5-ALA fails to fluoresce. In some other cases, it may undergo fluorescence quenching but cannot be orally readministered during surgery. This study aimed to develop a novel hydroxymethyl rhodamine green (HMRG)-based fluorescence labeling system that can be repeatedly administered as a topical spray during surgery for the detection of glioblastoma. EXPERIMENTAL DESIGN We performed a three-stage probe screening using tumor lysates and fresh tumor tissues with our probe library consisting of a variety of HMRG probes with different dipeptides. We then performed proteome and transcript expression analyses to detect candidate enzymes responsible for cleaving the probe. Moreover, in vitro and ex vivo studies using U87 glioblastoma cell line were conducted to validate the findings. RESULTS The probe screening identified proline-arginine-HMRG (PR-HMRG) as the optimal probe that distinguished tumors from peritumoral tissues. Proteome analysis identified calpain-1 (CAPN1) to be responsible for cleaving the probe. CAPN1 was highly expressed in tumor tissues which reacted to the PR-HMRG probe. Knockdown of this enzyme suppressed fluorescence intensity in U87 glioblastoma cells. In situ assay using a mouse U87 xenograft model demonstrated marked contrast of fluorescence with the probe between the tumor and peritumoral tissues. CONCLUSIONS The novel fluorescent probe PR-HMRG is effective in detecting glioblastoma when applied topically. Further investigations are warranted to assess the efficacy and safety of its clinical use.
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Affiliation(s)
- Yosuke Kitagawa
- Department of Neurosurgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shota Tanaka
- Department of Neurosurgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Mako Kamiya
- Laboratory of Chemical Biology and Molecular Imaging, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yugo Kuriki
- Laboratory of Chemistry and Biology, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Kyoko Yamamoto
- Laboratory of Chemical Biology and Molecular Imaging, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takenori Shimizu
- Department of Neurosurgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takahide Nejo
- Department of Neurosurgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Taijun Hana
- Department of Neurosurgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Reiko Matsuura
- Department of Neurosurgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsukasa Koike
- Department of Neurosurgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Erika Yamazawa
- Department of Neurosurgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihiro Kushihara
- Department of Neurosurgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoshi Takahashi
- Department of Neurosurgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masashi Nomura
- Department of Neurosurgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirokazu Takami
- Department of Neurosurgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shunsaku Takayanagi
- Department of Neurosurgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akitake Mukasa
- Department of Neurosurgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasuteru Urano
- Laboratory of Chemical Biology and Molecular Imaging, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan. .,Laboratory of Chemistry and Biology, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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14
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Erdman CM, Christie C, Iqbal MO, Mazzola CA, Tomycz L. The utilization of sodium fluorescein in pediatric brain stem gliomas: a case report and review of the literature. Childs Nerv Syst 2021; 37:1753-1758. [PMID: 32780271 DOI: 10.1007/s00381-020-04857-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/06/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION A major challenge in the surgical resection of brainstem tumors is distinguishing tumor from normal tissue. One approach for addressing this problem is the use of fluorescent tracers such as sodium fluorescein (NaFl). NaFl disseminates through a disruption in the blood-brain barrier (BBB) and accumulates in the extracellular space of brain tumors. Intraoperative fluorescence microscopy can be performed to identify tumor tissue and avoid damage to adjacent, normal tissue. Here, we present the case of a 16-year-old male who underwent a left retrosigmoid craniotomy with splitting of the tentorium to remove a large exophytic brainstem tumor involving the cerebellar peduncle and with superior extension into the midbrain and thalamus. OBJECTIVES The primary objective of this study was to investigate the effectiveness of sodium fluorescein as an intraoperative technique and evaluate its potential benefit for resection of tumors in eloquent regions in the pediatric population. To do so, we focused on a case study approach; however, we also performed a literature review and evaluated different intraoperative fluorescent techniques and their benefits for tumor resection. METHODS We performed a literature search using PubMed and Google Scholar by the key words "sodium fluorescein," "brain stem tumor," and "central nervous system neoplasms." Twenty-nine articles including both pediatric and adult populations were selected for analysis and qualitative review. RESULTS In this case study, sodium fluorescein helped the surgeons to identify and obtain a gross total resection of a large brainstem tumor. The marker was especially helpful for discerning the inferior pole of the tumor buried inconspicuously in cerebellar tissue. We evaluate different fluorescent tracers, 5-ALA and ICG, and discuss their application and benefits in tumor resection surgery. We present different cases that found sodium fluorescein to be helpful in achieving a gross total resection. CONCLUSION The application of sodium fluorescein proved to be a safe and effective technique for the resection of brain stem tumors as shown in this case study. It helped to expose concealed areas and illuminate the tumor capsule. Further studies should test the clinical use of sodium fluorescein on brain stem tumor resection.
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Affiliation(s)
- Cameron M Erdman
- Vassar College, 124 Raymond Avenue, Poughkeepsie, NY, 12603, USA
| | - Catherine Christie
- New Jersey Pediatric Neuroscience Institute, 131 Madison Avenue, Morristown, NJ, 07960, USA
| | - M Omar Iqbal
- Rutgers University, 90 Bergen Street, Newark, NJ, 07101, USA
| | - Catherine A Mazzola
- New Jersey Pediatric Neuroscience Institute, 131 Madison Avenue, Morristown, NJ, 07960, USA
| | - Luke Tomycz
- New Jersey Pediatric Neuroscience Institute, 131 Madison Avenue, Morristown, NJ, 07960, USA.
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15
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Cui Y, Zeng W, Jiang H, Ren X, Lin S, Fan Y, Liu Y, Zhao J. Higher Cho/NAA Ratio in Postoperative Peritumoral Edema Zone Is Associated With Earlier Recurrence of Glioblastoma. Front Neurol 2020; 11:592155. [PMID: 33343496 PMCID: PMC7747764 DOI: 10.3389/fneur.2020.592155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/17/2020] [Indexed: 12/13/2022] Open
Abstract
Objective: To explore the prognostic significance of metabolic parameters in postoperative peritumoral edema zone (PEZ) of patients with glioblastoma (GBM) based on proton magnetic resonance spectroscopy (MRS). Methods: The postoperative MRS data of 67 patients with GBM from Beijing Tiantan Hospital were retrospectively reviewed. Metabolite ratios including Cho/NAA, Cho/Cr, and NAA/Cr in both postoperative PEZ and contralateral normal brain region were recorded. Log-rank analysis and Cox regression model were used to identify parameters correlated with progression-free survival (PFS) and overall survival (OS). Results: Compared with the contralateral normal brain region, postoperative PEZ showed a lower ratio of NAA/Cr (1.20 ± 0.42 vs. 1.81 ± 0.48, P < 0.001), and higher ratios of Cho/Cr and Cho/NAA (1.36 ± 0.44 vs. 1.02 ± 0.27, P < 0.001 and 1.32 ± 0.59 vs. 0.57 ± 0.14, P < 0.001). Both the ratios of Cho/NAA and NAA/Cr were identified as prognostic factors in univariate analysis (P < 0.05), while only Cho/NAA ≥ 1.31 was further confirmed as an independent risk factor for early recurrence in the Cox regression model (P < 0.01). According to the factors of MGMT promoter unmethylation, without radiotherapy and Cho/NAA ≥ 1.31, a prognostic scoring scale for GBM was established, which could divide patients into low-risk, moderate-risk, and high-risk groups. There was a significant difference of survival rate between the three groups (P < 0.001). Conclusions: Higher Cho/NAA ratio in the postoperative PEZ of GBM predicts earlier recurrence and is associated with poor prognosis. The prognostic scoring scale based on clinical, molecular and metabolic parameters of patients with GBM can help doctors to make more precise prediction of survival time and to adjust therapeutic regimens.
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Affiliation(s)
- Yong Cui
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Wei Zeng
- Department of Neurosurgery, Beijing Electric Power Hospital, Beijing, China
| | - Haihui Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Xiaohui Ren
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Song Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Yanzhu Fan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Yapeng Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
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16
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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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17
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Domino JS, Ormond DR, Germano IM, Sami M, Ryken TC, Olson JJ. Cytoreductive surgery in the management of newly diagnosed glioblastoma in adults: a systematic review and evidence-based clinical practice guideline update. J Neurooncol 2020; 150:121-142. [PMID: 33215341 DOI: 10.1007/s11060-020-03606-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/23/2020] [Indexed: 11/29/2022]
Abstract
TARGET POPULATION These recommendations apply to adults with newly diagnosed or suspected glioblastoma. QUESTION What is the effect of extent of surgical resection on patient outcome in the initial management of adult patients with suspected newly diagnosed glioblastoma? RECOMMENDATION Level II: Maximal cytoreductive surgery is recommended in adult patients with suspected newly diagnosed supratentorial glioblastoma with gross total resection defined as removal of contrast enhancing tumor. Level III: Biopsy, subtotal resection, or gross total resection is suggested depending on medical comorbidities, functional status, and location of tumor if maximal resection may cause significant neurologic deficit. QUESTION What is the role of cytoreductive surgery in adults with newly diagnosed bi-frontal "butterfly" glioblastoma? RECOMMENDATION Level III: Resection of newly diagnosed bi-frontal "butterfly" glioblastoma is suggested to improve overall survival over biopsy alone. QUESTION What is the goal of cytoreductive surgery in elderly adult patients with newly diagnosed glioblastoma? RECOMMENDATION Level III: Elderly patients (> 65 years) show survival benefit with gross total resection and it is suggested they undergo cytoreductive surgery. QUESTION What is the role of advanced intraoperative guidance techniques in cytoreductive surgery in adults with newly diagnosed glioblastoma? RECOMMENDATION Level III: The use of intraoperative guidance adjuncts such as intraoperative MRI (iMRI) or 5-aminolevulinic acid (5-ALA) are suggested to maximize extent of resection in newly diagnosed glioblastoma. There is insufficient evidence to make a suggestion on the use of fluorescein, indocyanine green, or intraoperative ultrasound.
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Affiliation(s)
- Joseph S Domino
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, KS, USA. .,Department of Neurosurgery, University of Kansas Medical Center, 3901 Rainbow Blvd, MS 3021, Kansas City, KS, 66160, USA.
| | - D Ryan Ormond
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Isabelle M Germano
- Department of Neurosurgery, The Mount Sinai Medical Center, New York, NY, USA
| | - Mairaj Sami
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Timothy C Ryken
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
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18
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Meershoek P, KleinJan GH, van Willigen DM, Bauwens KP, Spa SJ, van Beurden F, van Gennep EJ, Mottrie AM, van der Poel HG, Buckle T, van Leeuwen FWB, van Oosterom MN. Multi-wavelength fluorescence imaging with a da Vinci Firefly-a technical look behind the scenes. J Robot Surg 2020; 15:751-760. [PMID: 33179201 PMCID: PMC8423683 DOI: 10.1007/s11701-020-01170-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/29/2020] [Indexed: 12/19/2022]
Abstract
The field of fluorescence-guided surgery builds on colored fluorescent tracers that have become available for different clinical applications. Combined use of complementary fluorescent emissions can allow visualization of different anatomical structures (e.g. tumor, lymphatics and nerves) in the same patient. With the aim to assess the requirements for multi-color fluorescence guidance under in vivo conditions, we thoroughly characterized two FDA-approved laparoscopic Firefly camera systems available on the da Vinci Si or da Vinci Xi surgical robot. In this process, we studied the cameras’ performance with respect to the photophysical properties of the FDA-approved dyes Fluorescein and ICG. Our findings indicate that multi-wavelength fluorescence imaging of Fluorescein and ICG is possible using clinical-grade fluorescence laparoscopes, but critical factors for success include the photophysical dye properties, imaging system performance and the amount of accumulated dye. When comparing the camera performance, the Xi system provided more effective excitation (adaptions in the light source) and higher detection sensitivity (chip-on-a-tip and/or enhanced image processing) for both Fluorescein and ICG. Both systems can readily be used for multi-wavelength fluorescence imaging of Fluorescein and ICG under clinically relevant conditions. With that, another step has been made towards the routine implementation of multi-wavelength image-guided surgery concepts.
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Affiliation(s)
- Philippa Meershoek
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Gijs H KleinJan
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, Leiden University Medical Center, Leiden, The Netherlands
| | - Danny M van Willigen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Silvia J Spa
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Florian van Beurden
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Erik J van Gennep
- Department of Urology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexandre M Mottrie
- Orsi Academy, Melle, Belgium.,Department of Urology, Onze-Lieve-Vrouw Hospital, Aalst, Belgium
| | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - T Buckle
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.,Orsi Academy, Melle, Belgium
| | - Matthias N van Oosterom
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands. .,Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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19
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Hansen RW, Pedersen CB, Halle B, Korshoej AR, Schulz MK, Kristensen BW, Poulsen FR. Comparison of 5-aminolevulinic acid and sodium fluorescein for intraoperative tumor visualization in patients with high-grade gliomas: a single-center retrospective study. J Neurosurg 2020; 133:1324-1331. [PMID: 31585425 DOI: 10.3171/2019.6.jns191531] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 06/25/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Maximal safe resection is an important surgical goal in the treatment for high-grade gliomas. Fluorescent dyes help the surgeon to distinguish malignant tissue from healthy. The aims of this study were 1) to compare the 2 fluorescent dyes 5-aminolevulinic acid (5-ALA) and sodium fluorescein (fluorescein) regarding extent of resection, progression-free survival, and overall survival; and 2) to assess the influence of other risk factors on clinical outcome and screen for potential disadvantages of the dyes. METHODS A total of 209 patients with high-grade gliomas were included in this retrospective study. Resections were performed in the period from 2012 to 2017 using 5-ALA or fluorescein. Extent of resection was assessed as the difference in tumor volume between early postoperative and preoperative MRI studies. Tumor progression-free survival and overall survival were analyzed using an adjusted Cox proportional hazards model. RESULTS One hundred fifty-eight patients were operated on with 5-ALA and 51 with fluorescein. The median duration of follow-up was 46.7 and 21.2 months, respectively. Covariables were evenly distributed. There was no statistically significant difference in volumetrically assessed median extent of resection (96.9% for 5-ALA vs 97.4% for fluorescein, p = 0.46) or the percentage of patients with residual tumor volume less than 0.175 cm3 (29.5% for 5-ALA vs 36.2% for fluorescein, p = 0.39). The median overall survival was 14.8 months for the 5-ALA group and 19.7 months for the fluorescein group (p = 0.06). The median adjusted progression-free survival was 8.7 months for the 5-ALA group and 9.2 months for the fluorescein group (p = 0.03). CONCLUSIONS Fluorescein can be used as a viable alternative to 5-ALA for intraoperative fluorescent guidance in brain tumor surgery. Comparative, prospective, and randomized studies are much needed.
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Affiliation(s)
- Rasmus W Hansen
- 1Department of Neurosurgery, Odense University Hospital, Clinical Institute, University of Southern Denmark and BRIDGE (Brain Research-Interdisciplinary Guided Excellence), Odense
- 4Odense Patient Data Explorative Network, Odense, Denmark
| | - Christian B Pedersen
- 1Department of Neurosurgery, Odense University Hospital, Clinical Institute, University of Southern Denmark and BRIDGE (Brain Research-Interdisciplinary Guided Excellence), Odense
| | - Bo Halle
- 1Department of Neurosurgery, Odense University Hospital, Clinical Institute, University of Southern Denmark and BRIDGE (Brain Research-Interdisciplinary Guided Excellence), Odense
| | - Anders R Korshoej
- 1Department of Neurosurgery, Odense University Hospital, Clinical Institute, University of Southern Denmark and BRIDGE (Brain Research-Interdisciplinary Guided Excellence), Odense
- 2Department of Neurosurgery, Aarhus University Hospital, Aarhus
| | - Mette K Schulz
- 1Department of Neurosurgery, Odense University Hospital, Clinical Institute, University of Southern Denmark and BRIDGE (Brain Research-Interdisciplinary Guided Excellence), Odense
| | | | - Frantz R Poulsen
- 1Department of Neurosurgery, Odense University Hospital, Clinical Institute, University of Southern Denmark and BRIDGE (Brain Research-Interdisciplinary Guided Excellence), Odense
- 4Odense Patient Data Explorative Network, Odense, Denmark
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Save AV, Gill BJ, D'amico RS, Canoll P, Bruce JN. Fluorescein-guided resection of gliomas. J Neurosurg Sci 2020; 63:648-655. [PMID: 31961117 DOI: 10.23736/s0390-5616.19.04738-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Standard of care in the management of high-grade gliomas includes gross total resection (GTR) followed by treatment with radiation and temozolomide. GTR remains one of the few independent prognostic factors for improved survival in this disease. Sodium fluorescein is an organic fluorophore that has been studied as a surgical adjunct to improve the likelihood of achieving GTR in gliomas. Though sodium fluorescein does not selectively accumulate in glioma cells, it allows for real-time identification of regions of blood brain barrier breakdown, corresponding to the contrast-enhancing cores of high-grade gliomas. In addition to its high predictive value for identifying pathologic tissue, use of fluorescein has been shown to improve rates of GTR. In stereotactic needle biopsies, it helps reduce procedure time by rapidly confirming the presence of diagnostic tissue. Furthermore, in non-enhancing, low-grade gliomas, it labels focal regions of vascular dysregulation that have been correlated with high-grade features. Fluorescein has also been shown to be significantly less expensive than other contemporary surgical adjuncts such as intraoperative ultrasound, intraoperative MRI, and the recently FDA approved fluorophore, 5-aminolevulinic acid (5-ALA). Here, we review the current literature on the effectiveness of fluorescein as a surgical tool in the resection of gliomas.
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Affiliation(s)
- Akshay V Save
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA -
| | - Brian J Gill
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Randy S D'amico
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Peter Canoll
- Department of Neuropathology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jeffrey N Bruce
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
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21
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Verburg N, de Witt Hamer PC. State-of-the-art imaging for glioma surgery. Neurosurg Rev 2020; 44:1331-1343. [PMID: 32607869 PMCID: PMC8121714 DOI: 10.1007/s10143-020-01337-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/25/2020] [Accepted: 06/15/2020] [Indexed: 11/29/2022]
Abstract
Diffuse gliomas are infiltrative primary brain tumors with a poor prognosis despite multimodal treatment. Maximum safe resection is recommended whenever feasible. The extent of resection (EOR) is positively correlated with survival. Identification of glioma tissue during surgery is difficult due to its diffuse nature. Therefore, glioma resection is imaging-guided, making the choice for imaging technique an important aspect of glioma surgery. The current standard for resection guidance in non-enhancing gliomas is T2 weighted or T2w-fluid attenuation inversion recovery magnetic resonance imaging (MRI), and in enhancing gliomas T1-weighted MRI with a gadolinium-based contrast agent. Other MRI sequences, like magnetic resonance spectroscopy, imaging modalities, such as positron emission tomography, as well as intraoperative imaging techniques, including the use of fluorescence, are also available for the guidance of glioma resection. The neurosurgeon’s goal is to find the balance between maximizing the EOR and preserving brain functions since surgery-induced neurological deficits result in lower quality of life and shortened survival. This requires localization of important brain functions and white matter tracts to aid the pre-operative planning and surgical decision-making. Visualization of brain functions and white matter tracts is possible with functional MRI, diffusion tensor imaging, magnetoencephalography, and navigated transcranial magnetic stimulation. In this review, we discuss the current available imaging techniques for the guidance of glioma resection and the localization of brain functions and white matter tracts.
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Affiliation(s)
- Niels Verburg
- Department of Neurosurgery and Cancer Center Amsterdam, Amsterdam UMC location VU University Medical Center, Amsterdam, The Netherlands. .,Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Brain Tumor Imaging Laboratory, University of Cambridge, Addenbrooke's Hospital, Hill Rd, Cambridge, CB2 0QQ, UK.
| | - Philip C de Witt Hamer
- Department of Neurosurgery and Cancer Center Amsterdam, Amsterdam UMC location VU University Medical Center, Amsterdam, The Netherlands
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22
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Maytin EV, Hasan T. Vitamin D and Other Differentiation-promoting Agents as Neoadjuvants for Photodynamic Therapy of Cancer. Photochem Photobiol 2020; 96:529-538. [PMID: 32077114 PMCID: PMC7384449 DOI: 10.1111/php.13230] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 12/12/2019] [Indexed: 12/30/2022]
Abstract
The efficacy of photodynamic therapy (PDT) using aminolevulinic acid (ALA), which is preferentially taken up by cancerous cells and converted to protoporphyrin IX (PpIX), can be substantially improved by pretreating the tumor cells with vitamin D (Vit D). Vit D is one of several "differentiation-promoting agents" that can promote the preferential accumulation of PpIX within the mitochondria of neoplastic cells, making them better targets for PDT. This article provides a historical overview of how the concept of using combination agents ("neoadjuvants") for PDT evolved, from initial discoveries about neoadjuvant effects of methotrexate and fluorouracil to later studies to determine how vitamin D and other agents actually work to augment PDT efficacy. While this review focuses mainly on skin cancer, it includes a discussion about how these concepts may be applied more broadly toward improving PDT outcomes in other types of cancer.
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Affiliation(s)
- Edward V Maytin
- Departments of Dermatology and Biomedical Engineering, Cleveland Clinic, Cleveland, OH
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA
| | - Tayyaba Hasan
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA
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23
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Yu Y, Du Z, Yuan C, Li J, Ardlee B. Application of Computed Tomography Angiography Data Monitoring in Cerebral Glioma (Preprint). JMIR Med Inform 2020. [DOI: 10.2196/19078] [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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24
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van Beurden F, van Willigen DM, Vojnovic B, van Oosterom MN, Brouwer OR, van der Poel HG, Kobayashi H, van Leeuwen FW, Buckle T. Multi-Wavelength Fluorescence in Image-Guided Surgery, Clinical Feasibility and Future Perspectives. Mol Imaging 2020; 19:1536012120962333. [PMID: 33125289 PMCID: PMC7607779 DOI: 10.1177/1536012120962333] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/22/2020] [Accepted: 09/01/2020] [Indexed: 12/15/2022] Open
Abstract
With the rise of fluorescence-guided surgery, it has become evident that different types of fluorescence signals can provide value in the surgical setting. Hereby a different range of targets have been pursued in a great variety of surgical indications. One of the future challenges lies in combining complementary fluorescent readouts during one and the same surgical procedure, so-called multi-wavelength fluorescence guidance. In this review we summarize the current clinical state-of-the-art in multi-wavelength fluorescence guidance, basic technical concepts, possible future extensions of existing clinical indications and impact that the technology can bring to clinical care.
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Affiliation(s)
- Florian van Beurden
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Danny M. van Willigen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Borivoj Vojnovic
- Department of Oncology, Cancer Research UK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - Matthias N. van Oosterom
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Oscar R. Brouwer
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Henk G. van der Poel
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Hisataka Kobayashi
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Fijs W.B. van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Orsi Academy, Melle, Belgium
| | - Tessa Buckle
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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25
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Dimou J, Beland B, Kelly J. Supramaximal resection: A systematic review of its safety, efficacy and feasibility in glioblastoma. J Clin Neurosci 2019; 72:328-334. [PMID: 31864830 DOI: 10.1016/j.jocn.2019.12.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/01/2019] [Indexed: 02/03/2023]
Abstract
The philosophy of 'supramaximal resection' (SMR) beyond the T1-enhanced margin holds some potential in glioblastoma surgery, but the quality of available literature has not been elucidated. A systematic review of published studies of SMR in glioblastoma surgery was performed. Articles were sought in MEDLINE, EMBASE, Scopus and Cochrane Central Register for Clinical Trials. The search items were grouped into three themes; supramaximal resection, glioblastoma and outcomes. Cases were included wherein the initial extent of resection was described as exceeding gross total resection, that is to say, beyond the area of T1-enhancement on MRI. Only newly diagnosed glioblastoma was considered. Articles containing primary patient data, including outcome data, were included; reviews, editorials, descriptive articles and systematic reviews were excluded. Subsequently, 1123 unique articles were initially retrieved. After screening article titles and abstracts for relevance to SMR in glioblastoma, seven articles remained, and were all included post-full text review. No randomized controlled trials were discovered. Almost all studies were of Level 4 quality, according to Oxford Center for Evidence-Based Medicine guidelines. The included articles yielded a total of 2019 surgically treated glioblastoma patients, 13.5% of whom underwent SMR. Preliminary results suggest SMR of glioblastoma positively impacts overall and progression free survival. However, the contemporaneous literature supporting glioblastoma SMR is of low quality, with neither anatomical nor radiographic definitional consensus for what constitutes SMR. Prospective studies of larger pooled populations with standardized technical, radiological and outcome measures in designated centers would help minimize bias and validate SMR in appropriately selected glioblastoma patients.
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Affiliation(s)
- James Dimou
- Division of Neurosurgery, University of Calgary, Alberta, Canada.
| | - Benjamin Beland
- Division of Neurosurgery, University of Calgary, Alberta, Canada
| | - John Kelly
- Division of Neurosurgery, University of Calgary, Alberta, Canada
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26
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Falco J, Cavallo C, Vetrano IG, de Laurentis C, Siozos L, Schiariti M, Broggi M, Ferroli P, Acerbi F. Fluorescein Application in Cranial and Spinal Tumors Enhancing at Preoperative MRI and Operated With a Dedicated Filter on the Surgical Microscope: Preliminary Results in 279 Patients Enrolled in the FLUOCERTUM Prospective Study. Front Surg 2019; 6:49. [PMID: 31475153 PMCID: PMC6705221 DOI: 10.3389/fsurg.2019.00049] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 07/29/2019] [Indexed: 12/28/2022] Open
Abstract
Objective: Sodium fluorescein, a green, water soluble dye, is used as neurosurgical fluorescent tracer thanks to its property to accumulate in cerebral regions of blood-brain barrier (BBB) disruption. The authors report the preliminary results of a prospective observational study regarding the use of fluorescein-guided technique for the resection of suspected malignant neoplasms of the central nervous system (CNS), contrast enhancing at preoperative magnetic resonance imaging (MRI), using a dedicated filter on the surgical microscope. Methods: In March 2016 the authors started a prospective, observational trial to evaluate intraoperative fluorescence's characteristics of CNS tumors, the percentage of extent of resection thanks to fluorescein aid and side effects related to fluorescein administration. This report is based on a preliminary analysis of the results of first 279 enrolled patients. Fluorescein was intravenously injected after intubation or immediately at the entrance in the operating room for awake procedures; the tumor was removed using a dedicated filter on the surgical microscope in an inside-out fashion until all fluorescent tissue was removed, as considered feasible by the surgeon. Results: The 279 patients finally enrolled in the trial, both firstly diagnosed and recurrent, were categorized according to WHO pathological classification and there were 212 neuroepithelial tumors, 25 brain metastases, 10 cerebral lymphomas, 7 hemangioblastomas, or hemangioendotheliomas and 25 other tumors and conditions. No adverse reaction related to the administration of fluorescein or to the combined use of fluorescein with other fluorophores was registered. Fluorescein accumulated in cerebral regions where the BBB was damaged, representing a significant surgical aid in most of the CNS tumors with contrast enhancement. In cases of complete removal of all fluorescent tissue, as intraoperatively judged by the surgeon, postoperative MRI revealed a gross total resection in 181/198 patients (91.4%). Conclusions: Based on these preliminary results, fluorescein-guided surgery with a dedicated filter on the microscope is a safe and effective technique to improve visualization and resection of different CNS tumors and conditions, based on BBB alteration.
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Affiliation(s)
- Jacopo Falco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Claudio Cavallo
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.,Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Ignazio G Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Camilla de Laurentis
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Lampros Siozos
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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27
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Molecular and Clinical Insights into the Invasive Capacity of Glioblastoma Cells. JOURNAL OF ONCOLOGY 2019; 2019:1740763. [PMID: 31467533 PMCID: PMC6699388 DOI: 10.1155/2019/1740763] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/01/2019] [Accepted: 07/07/2019] [Indexed: 12/22/2022]
Abstract
The invasive capacity of GBM is one of the key tumoral features associated with treatment resistance, recurrence, and poor overall survival. The molecular machinery underlying GBM invasiveness comprises an intricate network of signaling pathways and interactions with the extracellular matrix and host cells. Among them, PI3k/Akt, Wnt, Hedgehog, and NFkB play a crucial role in the cellular processes related to invasion. A better understanding of these pathways could potentially help in developing new therapeutic approaches with better outcomes. Nevertheless, despite significant advances made over the last decade on these molecular and cellular mechanisms, they have not been translated into the clinical practice. Moreover, targeting the infiltrative tumor and its significance regarding outcome is still a major clinical challenge. For instance, the pre- and intraoperative methods used to identify the infiltrative tumor are limited when trying to accurately define the tumor boundaries and the burden of tumor cells in the infiltrated parenchyma. Besides, the impact of treating the infiltrative tumor remains unclear. Here we aim to highlight the molecular and clinical hallmarks of invasion in GBM.
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28
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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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Abstract
Adolf Baeyer announced the discovery of fluorescein in 1871 and named it after its most striking property, i.e., fluorescence. I describe here the synthesis of fluorescein. There are seven molecular species in both the solid state or in solution. I also summarize some of the diverse applications of the dye, both medical and nonmedical, which depend mostly on the facile detection of fluorescein at low concentration. Both animal and human toxicity are examined.
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Affiliation(s)
- C J Cooksey
- a Independent scholar , Watford , United Kingdom
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30
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Augmentation of 5-Aminolevulinic Acid Treatment of Glioblastoma by Adding Ciprofloxacin, Deferiprone, 5-Fluorouracil and Febuxostat: The CAALA Regimen. Brain Sci 2018; 8:brainsci8120203. [PMID: 30469467 PMCID: PMC6315943 DOI: 10.3390/brainsci8120203] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 11/15/2018] [Accepted: 11/20/2018] [Indexed: 02/08/2023] Open
Abstract
The CAALA (Complex Augmentation of ALA) regimen was developed with the goal of redressing some of the weaknesses of 5-aminolevulinic acid (5-ALA) use in glioblastoma treatment as it now stands. 5-ALA is approved for use prior to glioblastoma surgery to better demarcate tumor from brain tissue. 5-ALA is also used in intraoperative photodynamic treatment of glioblastoma by virtue of uptake of 5-ALA and its preferential conversion to protoporphyrin IX in glioblastoma cells. Protoporphyrin IX becomes cytotoxic after exposure to 410 nm or 635 nm light. CAALA uses four currently-marketed drugs—the antibiotic ciprofloxacin, the iron chelator deferiprone, the antimetabolite 5-FU, and the xanthine oxidase inhibitor febuxostat—that all have evidence of ability to both increase 5-ALA mediated intraoperative glioblastoma demarcation and photodynamic cytotoxicity of in situ glioblastoma cells. Data from testing the full CAALA on living minipigs xenotransplanted with human glioblastoma cells will determine safety and potential for benefit in advancing CAALA to a clinical trial.
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31
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Della Puppa A, Munari M, Gardiman MP, Volpin F. Combined Fluorescence Using 5-Aminolevulinic Acid and Fluorescein Sodium at Glioblastoma Border: Intraoperative Findings and Histopathologic Data About 3 Newly Diagnosed Consecutive Cases. World Neurosurg 2018; 122:e856-e863. [PMID: 30391771 DOI: 10.1016/j.wneu.2018.10.163] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/21/2018] [Accepted: 10/23/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Fluorescence-guided glioblastoma surgery is an intraoperative technique developed in recent years. Two main compounds have been used so far: 5-amilovelulinic acid (5-ALA) and fluorescein sodium (Fl-Na). Despite a large amount of literature on both techniques, few data are available on the use of both compounds in the same patient. METHODS Three consecutive patients affected by a newly diagnosed glioblastoma underwent surgical resection using both 5-ALA and Fl-Na. 5-ALA was orally administered 3 hours before induction of anesthesia at a dosage of 20 mg/kg, whereas fluorescein was intravenously administered at induction of anesthesia at a dosage of 4 mg/kg. Tumor resection was carried out combining these fluorophores. At tumor borders, multiple samples were collected, and fluorescent pattern of each sample was registered. Samples were then analyzed by a neuropathologist blinded for intraoperative fluorescence findings. RESULTS Eighteen samples were analyzed. At tumor margin, bright pink fluorescence was highly indicative of residual tumor (positive predictive value [PPV], 94%), and it was superior to faint pink and fluorescein (PPVs, 89% and 87%, respectively). The gradual reduction of pink fluorescence warned of the risk of gradually entering healthy tissue (specificity of 67% compared with 33% with fluorescein). Using 5-ALA, detecting no fluorescence was highly suggestive of healthy tissue (negative predictive value of 100% compared with 50% with fluorescence). CONCLUSIONS In our experience with 3 patients, the 2 techniques presented different advantages and limitations in specific steps of tumor resection, showing complementary properties. Larger studies are mandatory to investigate the synergistic use of both techniques.
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Affiliation(s)
| | - Marina Munari
- Department of Intensive Care Unit, Padua University Hospital, Padova, Italy
| | | | - Francesco Volpin
- Department of Neurosurgery, Padua University Hospital, Padova, Italy.
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32
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Cavallo C, De Laurentis C, Vetrano IG, Falco J, Broggi M, Schiariti M, Ferroli P, Acerbi F. The utilization of fluorescein in brain tumor surgery: a systematic review. J Neurosurg Sci 2018; 62:690-703. [PMID: 29790725 DOI: 10.23736/s0390-5616.18.04480-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Sodium fluorescein (SF) is a green, water-soluble dye with the capacity to accumulate in cerebral areas as a result of damaged blood-brain barrier (BBB); this property allows SF to concentrate specifically at the tumor site of various types of brain neoplasms, making the tumor tissue more clearly visible. EVIDENCE ACQUISITION A literature search (1947-2018) was conducted with the keywords "fluorescein neurosurgery," "YELLOW neurosurgery," "fluorescein brain tumor," "YELLOW brain tumor." We included clinical studies, clinical trials, observational studies, only conducted on humans and concerning surgery; in addition, we have included 3 articles derived from the analysis of the references of other papers. Ultimately, 57 articles were included for further analysis. EVIDENCE SYNTHESIS Fluorescein as a fluorescent tracer in neuro-oncology is gaining a wider acceptance in the neurosurgical literature: until February 1st, 2018, at least 1099 neuro-oncological patients have been operated through fluorescein-assistance, mostly only after 2012. The most important application remains the aim to improve tumor visualization and extent of resection for high-grade gliomas (HGG), but the nonspecific mechanism of action is the theoretical base for its use also for tumors different from HGG. Nevertheless, no homogenous protocol of fluorescein utilization in neurosurgical oncology can be found in literature. CONCLUSIONS Fluorescein-guided surgery is a safe and effective technique to improve visualization and resection of different CNS tumors and conditions, based on BBB alteration, with a growing evidence-based background.
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Affiliation(s)
- Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph Hospital and Medical Center, Phoenix, AZ, USA
| | - Camilla De Laurentis
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Ignazio G Vetrano
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Jacopo Falco
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Morgan Broggi
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Marco Schiariti
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Paolo Ferroli
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Francesco Acerbi
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy -
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Belykh E, Miller EJ, Patel AA, Yazdanabadi MI, Martirosyan NL, Yağmurlu K, Bozkurt B, Byvaltsev VA, Eschbacher JM, Nakaji P, Preul MC. Diagnostic Accuracy of a Confocal Laser Endomicroscope for In Vivo Differentiation Between Normal Injured And Tumor Tissue During Fluorescein-Guided Glioma Resection: Laboratory Investigation. World Neurosurg 2018; 115:e337-e348. [PMID: 29673821 DOI: 10.1016/j.wneu.2018.04.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/06/2018] [Accepted: 04/07/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Glioma resection with fluorescein sodium (FNa) guidance has a potential drawback of nonspecific leakage of FNa from nontumor areas with a compromised blood-brain barrier. We investigated the diagnostic accuracy of in vivo confocal laser endomicroscopy (CLE) after FNa administration to differentiate normal brain, injured normal brain, and tumor tissue in an animal glioma model. METHODS GL261-Luc2 gliomas in C57BL/6 mice were used as a brain tumor model. CLE images of normal, injured normal, and tumor brain tissues were collected after intravenous FNa administration. Correlative sections stained with hematoxylin and eosin were taken at the same sites. A set of 40 CLE images was given to 1 neuropathologist and 3 neurosurgeons to assess diagnostic accuracy and rate image quality (1-10 scale). Additionally, we developed a deep convolution neural network (DCNN) model for automatic image classification. RESULTS The mean observer accuracy for correct diagnosis of glioma compared with either injured or uninjured brain using CLE images was 85%, and the DCNN model accuracy was 80%. For differentiation of tumor from nontumor tissue, the experts' mean accuracy, specificity, and sensitivity were 90%, 86%, and 96%, respectively, with high interobserver agreement overall (Cohen κ = 0.74). The percentage of correctly identified images was significantly higher for images with a quality rating >5 (104/116, 90%) than for images with a quality rating ≤5 (32/44, 73%) (P = 0.007). CONCLUSIONS With sufficient FNa present in tissues, CLE was an effective tool for intraoperative differentiation among normal, injured normal, and tumor brain tissue. Clinical studies are warranted to confirm these findings.
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Affiliation(s)
- Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Irkutsk State Medical University, Irkutsk, Russia
| | - Eric J Miller
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Arpan A Patel
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | | | - Nikolay L Martirosyan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kaan Yağmurlu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Baran Bozkurt
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | | | - Jennifer M Eschbacher
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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34
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Schebesch KM, Brawanski A, Höhne J. Fluorescein Sodium in Intracranial Meningioma Surgery. World Neurosurg 2017; 108:967. [PMID: 29179415 DOI: 10.1016/j.wneu.2017.08.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 08/08/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Karl-Michael Schebesch
- Department of Neurosurgery and Wilhelm Sander-Neuro-Oncology Unit, University Med, Regensburg, Germany.
| | - Alexander Brawanski
- Department of Neurosurgery and Wilhelm Sander-Neuro-Oncology Unit, University Med, Regensburg, Germany
| | - Julius Höhne
- Department of Neurosurgery and Wilhelm Sander-Neuro-Oncology Unit, University Med, Regensburg, Germany
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