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Panesar SS, Abhinav K, Yeh FC, Jacquesson T, Collins M, Fernandez-Miranda J. Tractography for Surgical Neuro-Oncology Planning: Towards a Gold Standard. Neurotherapeutics 2019; 16:36-51. [PMID: 30542904 PMCID: PMC6361069 DOI: 10.1007/s13311-018-00697-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Magnetic resonance imaging tractography permits in vivo visualization of white matter structures. Aside from its academic value, tractography has been proven particularly useful to neurosurgeons for preoperative planning. Preoperative tractography permits both qualitative and quantitative analyses of tumor effects upon surrounding white matter, allowing the surgeon to specifically tailor their operative approach. Despite its benefits, there is controversy pertaining to methodology, implementation, and interpretation of results in this context. High-definition fiber tractography (HDFT) is one of several non-tensor tractography approaches permitting visualization of crossing white matter trajectories at high resolutions, dispensing with the well-known shortcomings of diffusion tensor imaging (DTI) tractography. In this article, we provide an overview of the advantages of HDFT in a neurosurgical context, derived from our considerable experience implementing the technique for academic and clinical purposes. We highlight nuances of qualitative and quantitative approaches to using HDFT for brain tumor surgery planning, and integration of tractography with complementary operative adjuncts, and consider areas requiring further research.
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Affiliation(s)
- Sandip S Panesar
- Department of Neurosurgery, Stanford University, 300 Pasteur Drive, Palo Alto, CA, 94304, USA
| | - Kumar Abhinav
- Department of Neurosurgery, Stanford University, 300 Pasteur Drive, Palo Alto, CA, 94304, USA
| | - Fang-Cheng Yeh
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Timothée Jacquesson
- CHU de Lyon - Hôpital Neurologique et Neurochirurgical Pierre Wertheimer, Lyon, France
| | - Malie Collins
- Department of Neurosurgery, Stanford University, 300 Pasteur Drive, Palo Alto, CA, 94304, USA
| | - Juan Fernandez-Miranda
- Department of Neurosurgery, Stanford University, 300 Pasteur Drive, Palo Alto, CA, 94304, USA.
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Celtikci P, Fernandes-Cabral DT, Yeh FC, Panesar SS, Fernandez-Miranda JC. Generalized q-sampling imaging fiber tractography reveals displacement and infiltration of fiber tracts in low-grade gliomas. Neuroradiology 2018; 60:267-280. [PMID: 29372286 DOI: 10.1007/s00234-018-1985-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 01/16/2018] [Indexed: 01/12/2023]
Abstract
PURPOSE Low-grade gliomas (LGGs) are slow growing brain tumors that often cause displacement and/or infiltration of the surrounding white matter pathways. Differentiation between infiltration and displacement of fiber tracts remains a challenge. Currently, there is no reliable noninvasive imaging method capable of revealing such white matter alteration patterns. We employed quantitative anisotropy (QA) derived from generalized q-sampling imaging (GQI) to identify patterns of fiber tract alterations by LGGs. METHODS Sixteen patients with a neuropathological diagnosis of LGG (WHO grade II) were enrolled. Peritumoral fiber tracts underwent qualitative and quantitative evaluation. Contralateral hemisphere counterparts were used for comparison. Tracts were qualitatively classified as unaffected, displaced, infiltrated or displaced, and infiltrated at once. The average QA of whole tract (W), peritumoral tract segment (S), and their ratio (S/W) were obtained and compared to the healthy side for quantitative evaluation. RESULTS Qualitative analysis revealed 9 (13.8%) unaffected, 24 (36.9%) displaced, 13 (20%) infiltrated, and 19 (29.2%) tracts with a combination of displacement and infiltration. There were no disrupted tracts. There was a significant increase in S/W ratio among displaced tracts in the pre-operative scans in comparison with the contralateral side. QA values of peritumoral tract segments (S) were significantly lower in infiltrated tracts. CONCLUSION WHO grade II LGGs might displace, infiltrate, or cause a combination of displacement and infiltration of WM tracts. QA derived from GQI provides valuable information that helps to differentiate infiltration from displacement. Anisotropy changes correlate with qualitative alterations, which may serve as a potential biomarker of fiber tract integrity.
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Affiliation(s)
- Pinar Celtikci
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St., Suite B-400, Pittsburgh, PA, 15213, USA
| | - David T Fernandes-Cabral
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St., Suite B-400, Pittsburgh, PA, 15213, USA
| | - Fang-Cheng Yeh
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St., Suite B-400, Pittsburgh, PA, 15213, USA
| | - Sandip S Panesar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St., Suite B-400, Pittsburgh, PA, 15213, USA
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St., Suite B-400, Pittsburgh, PA, 15213, USA.
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Duma CM, Kim BS, Chen PV, Plunkett ME, Mackintosh R, Mathews MS, Casserly RM, Mendez GA, Furman DJ, Smith G, Oh N, Caraway CA, Sanathara AR, Dillman RO, Riley AS, Weiland D, Stemler L, Cannell R, Abrams DA, Smith A, Owen CM, Eisenberg B, Brant-Zawadzki M. Upfront boost Gamma Knife “leading-edge” radiosurgery to FLAIR MRI–defined tumor migration pathways in 174 patients with glioblastoma multiforme: a 15-year assessment of a novel therapy. J Neurosurg 2016; 125:40-49. [DOI: 10.3171/2016.7.gks161460] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEGlioblastoma multiforme (GBM) is composed of cells that migrate through the brain along predictable white matter pathways. Targeting white matter pathways adjacent to, and leading away from, the original contrast-enhancing tumor site (termed leading-edge radiosurgery [LERS]) with single-fraction stereotactic radiosurgery as a boost to standard therapy could limit the spread of glioma cells and improve clinical outcomes.METHODSBetween December 2000 and May 2016, after an initial diagnosis of GBM and prior to or during standard radiation therapy and carmustine or temozolomide chemotherapy, 174 patients treated with radiosurgery to the leading edge (LE) of tumor cell migration were reviewed. The LE was defined as a region outside the contrast-enhancing tumor nidus, defined by FLAIR MRI. The median age of patients was 59 years (range 22–87 years). Patients underwent LERS a median of 18 days from original diagnosis. The median target volume of 48.5 cm3 (range 2.5–220.0 cm3) of LE tissue was targeted using a median dose of 8 Gy (range 6–14 Gy) at the 50% isodose line.RESULTSThe median overall survival was 23 months (mean 43 months) from diagnosis. The 2-, 3-, 5-, 7-, and 10-year actual overall survival rates after LERS were 39%, 26%, 16%, 10%, and 4%, respectively. Nine percent of patients developed treatment-related imaging-documented changes due to LERS. Nineteen percent of patients were hospitalized for management of edema, 22% for resection of a tumor cyst or new tumor bulk, and 2% for shunting to treat hydrocephalus throughout the course of their disease. Of the patients still alive, Karnofsky Performance Scale scores remained stable in 90% of patients and decreased by 1–3 grades in 10% due to symptomatic treatment-related imaging changes.CONCLUSIONSLERS is a safe and effective upfront adjunctive therapy for patients with newly diagnosed GBM. Limitations of this study include a single-center experience and single-institution determination of the LE tumor target. Use of a leading-edge calculation algorithm will be described to achieve a consistent approach to defining the LE target for general use. A multicenter trial will further elucidate its value in the treatment of GBM.
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Affiliation(s)
| | - Brian S. Kim
- 2Cancer Center, and
- 3Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Peter V. Chen
- 2Cancer Center, and
- 3Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Marianne E. Plunkett
- 2Cancer Center, and
- 3Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Ralph Mackintosh
- 2Cancer Center, and
- 3Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Marlon S. Mathews
- 4Department of Neurosurgery, University of California, Irvine, Orange; and
| | | | | | | | | | - Nathan Oh
- 1Neurosciences Institute,
- 5Department of Neurosurgery, Loma Linda University Health, Loma Linda, California
| | | | | | | | | | | | | | | | | | - Alexa Smith
- 4Department of Neurosurgery, University of California, Irvine, Orange; and
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The Disruption of Geniculocalcarine Tract in Occipital Neoplasm: A Diffusion Tensor Imaging Study. Radiol Res Pract 2016; 2016:8213076. [PMID: 27610244 PMCID: PMC5004003 DOI: 10.1155/2016/8213076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/18/2016] [Indexed: 11/18/2022] Open
Abstract
Aim. Investigate the disruption of geniculocalcarine tract (GCT) in different occipital neoplasm by diffusion tensor imaging (DTI). Methods. Thirty-two subjects (44.1 ± 3.6 years) who had single occipital neoplasm (9 gliomas, 6 meningiomas, and 17 metastatic tumors) with ipsilateral GCT involved and thirty healthy subjects (39.2 ± 3.3 years) underwent conventional sequences scanning and diffusion tensor imaging by a 1.5T MR scanner. The diffusion-sensitive gradient direction is 13. Compare the fractional anisotropy (FA) and mean diffusivity (MD) values of healthy GCT with the corresponding values of GCT in peritumoral edema area. Perform diffusion tensor tractography (DTT) on GCT by the line propagation technique in all subjects. Results. The FA values of GCT in peritumoral edema area decreased (P = 0.001) while the MD values increased (P = 0.002) when compared with healthy subjects. There was no difference in the FA values across tumor types (P = 0.114) while the MD values of GCT in the metastatic tumor group were higher than the other groups (P = 0.001). GCTs were infiltrated in all the 9 gliomas cases, with displacement in 2 cases and disruption in 7 cases. GCTs were displaced in 6 meningiomas cases. GCTs were displaced in all the 7 metastatic cases, with disruption in 7 cases. Conclusions. DTI represents valid markers for evaluating GCT's disruption in occipital neoplasm. The disruption of GCT varies according to the properties of neoplasm.
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Preoperative Quantitative MR Tractography Compared with Visual Tract Evaluation in Patients with Neuropathologically Confirmed Gliomas Grades II and III: A Prospective Cohort Study. Radiol Res Pract 2016; 2016:7671854. [PMID: 27190647 PMCID: PMC4852118 DOI: 10.1155/2016/7671854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/23/2016] [Indexed: 12/22/2022] Open
Abstract
Background and Purpose. Low-grade gliomas show infiltrative growth in white matter tracts. Diffusion tensor tractography can noninvasively assess white matter tracts. The aim was to preoperatively assess tumor growth in white matter tracts using quantitative MR tractography (3T). The hypothesis was that suspected infiltrated tracts would have altered diffusional properties in infiltrated tract segments compared to noninfiltrated tracts. Materials and Methods. Forty-eight patients with suspected low-grade glioma were included after written informed consent and underwent preoperative diffusion tensor imaging in this prospective review-board approved study. Major white matter tracts in both hemispheres were tracked, segmented, and visually assessed for tumor involvement in thirty-four patients with gliomas grade II or III (astrocytomas or oligodendrogliomas) on postoperative neuropathological evaluation. Relative fractional anisotropy (rFA) and mean diffusivity (rMD) in tract segments were calculated and compared with visual evaluation and neuropathological diagnosis. Results. Tract segment infiltration on visual evaluation was associated with a lower rFA and high rMD in a majority of evaluated tract segments (89% and 78%, resp.). Grade II and grade III gliomas had similar infiltrating behavior. Conclusion. Quantitative MR tractography corresponds to visual evaluation of suspected tract infiltration. It may be useful for an objective preoperative evaluation of tract segment involvement.
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Abstract
The advances in diffusion-weighted imaging (DWI), diffusion tensor imaging (DTI), and functional magnetic resonance imaging (fMRI) over the last 20 years have vastly contributed to improving the understanding of the brain structure and function in patients with many diseases of the central nervous system (CNS). DWI is commonly used, for instance, in the diagnostic workup of stroke, CNS neoplasia, and rapidly progressive dementia cases. The new DTI methods provide more specific information about the most destructive aspects of tumors, neurodegenerative dementia, and multiple sclerosis pathology and give a more complete picture of the complex pathologic mechanisms of these conditions. More recently, fMRI has provided insight to the mechanisms of brain adaptation and plasticity to damage related to many neurologic conditions and has further extended our ability to understand the functional significance of pathologic changes in these diseases. Although at present fMRI does not have a role in the diagnosis, routine assessment, and monitoring of neurologic diseases, significant efforts are under way in order to achieve harmonization of both acquisition and postprocessing procedures, which are likely to contribute to a significant change of the clinical scenario.
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Affiliation(s)
- Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
| | - Federica Agosta
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Shiban E, Krieg SM, Haller B, Buchmann N, Obermueller T, Boeckh-Behrens T, Wostrack M, Meyer B, Ringel F. Intraoperative subcortical motor evoked potential stimulation: how close is the corticospinal tract? J Neurosurg 2015; 123:711-20. [DOI: 10.3171/2014.10.jns141289] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Subcortical stimulation is a method used to evaluate the distance from the stimulation site to the corticospinal tract (CST) and to decide whether the resection of an adjacent lesion should be terminated to prevent damage to the CST. However, the correlation between stimulation intensity and distance to the CST has not yet been clearly assessed. The objective of this study was to investigate the appropriate correlation between the subcortical stimulation pattern and the distance to the CST.
METHODS
Monopolar subcortical motor evoked potential (MEP) mapping was performed in addition to continuous MEP monitoring in 37 consecutive patients with lesions located in motor-eloquent locations. The proximity of the resection cavity to the CST was identified by subcortical MEP mapping. At the end of resection, the point at which an MEP response was still measurable with minimal subcortical MEP intensity was marked with a titanium clip. At this location, different stimulation paradigms were executed with cathodal or anodal stimulation at 0.3-, 0.5-, and 0.7-msec pulse durations. Postoperatively, the distance between the CST as defined by postoperative diffusion tensor imaging fiber tracking and the titanium clip was measured. The correlation between this distance and the subcortical MEP electrical charge was calculated.
RESULTS
Subcortical MEP mapping was successful in all patients. There were no new permanent motor deficits. Transient new postoperative motor deficits were observed in 14% (5/36) of cases. Gross-total resection was achieved in 75% (27/36) and subtotal resection (> 80% of tumor mass) in 25% (9/36) of cases. Stimulation intensity with various pulse durations as well as current intensity was plotted against the measured distance between the CST and the titanium clip on postoperative MRI using diffusion-weighted imaging fiberitracking tractography. Correlational and regression analyses showed a nonlinear correlation between stimulation intensity and the distance to the CST. Cathodal stimulation appeared better suited for subcortical stimulation.
CONCLUSIONS
Subcortical MEP mapping is an excellent intraoperative method to determine the distance to the CST during resection of motor-eloquent lesions and is highly capable of further reducing the risk of a new neurological deficit.
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Affiliation(s)
| | | | - Bernhard Haller
- 3Institute for Medical Statistics and Epidemiology, Technische Universität München, Munich, Germany
| | | | | | - Tobias Boeckh-Behrens
- 2Section of Neuroradiology, Department of Radiology, Klinikum rechts der Isar, Technische Universität München; and
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Wang R, Ma J, Niu G, Zheng J, Liu Z, Du Y, Yu B, Yang J. Differentiation between Solitary Cerebral Metastasis and Astrocytoma on the Basis of Subventricular Zone Involvement on Magnetic Resonance Imaging. PLoS One 2015. [PMID: 26197398 PMCID: PMC4510882 DOI: 10.1371/journal.pone.0133480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Purpose To determine the relationship between the subventricular zone (SVZ) and astrocytoma based on magnetic resonance imaging (MRI) and whether SVZ involvement can be used to distinguish solitary cerebral metastases (SCMs) from astrocytomas. Methods This retrospective study involved 154 patients with solitary low-grade astrocytoma (LGA), high-grade astrocytoma (HGA), and SCM, who underwent T1-weighted imaging (T1WI), Gd-DTPA–enhanced T1WI, and T2-weighted imaging (T2WI) or fluid-attenuated inversion recovery (FLAIR) T2WI. The spatial relationship between the tumor and SVZ was classified as “involvement” or “segregation” on contrast-enhanced T1WI for enhanced tumors and T2WI/FLAIR T2WI for non-enhanced tumors. Patient-based SVZ-contact rates were compared between the LGA, HGA, and SCM groups. The frequencies of involvement of various lateral ventricle regions by astrocytoma were compared. The correlation between SVZ involvement and tumor necrosis was analyzed. Results Patient-based SVZ-contact rates in SCM, LGA, and HGA were 24.1%, 68.8%, and 85.4%, respectively. Univariate analysis showed that the SVZ-contact rate was significantly different between SCM and astrocytoma (24.1% vs. 75.2% P < 0.001), also between LGA and HGA (68.1% vs. 85.4% P=0.037). After the tumor volume was adjusted as a covariate, SVZ-contact rates still differed between SCMs and astrocytomas (Odds ratio [OR]: 4.58, 95% Confidence interval [CI]: 1.65 to 12.8, P=0.004). Tumor volume differed between LGA and HGA (P< 0.001), and influenced the association between SVZ involvement and astrocytoma grade (P = 0.05). Among the lateral ventricle regions, the frontal horn was the most frequently involved by astrocytomas. SVZ-contact rates were higher in necrosis group compared with non-necrosis groups (83.9% vs. 50.0%, P < 0.001) among astrocytoma patients. Necrosis positively correlated with SVZ involvement in astrocytomas (rs = 0.342, P < 0.001), but did not correlate with SVZ involvement in SCMs (P = 0.193). Conclusions Compared to SCMs, solitary cerebral astrocytomas exhibited spatial proximity to the SVZ, which might distinguish the supratentorial astrocytomas from SCMs.
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Affiliation(s)
- Rong Wang
- Radiology Department of the First Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, People’s Republic of China
| | - Jiaqi Ma
- Radiology Department of the First Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, People’s Republic of China
| | - Gang Niu
- Radiology Department of the First Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, People’s Republic of China
| | - Jie Zheng
- Clinical research center of the First Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, People’s Republic of China
| | - Zhe Liu
- Radiology Department of the First Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, People’s Republic of China
| | - Yonghao Du
- Radiology Department of the First Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, People’s Republic of China
| | - Bolang Yu
- Radiology Department of the First Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, People’s Republic of China
| | - Jian Yang
- Radiology Department of the First Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, People’s Republic of China
- * E-mail:
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Chen L, Mao Y. Gross total resection plays a leading role in survival of patients with glioblastoma multiforme. World Neurosurg 2014; 82:e105-7. [PMID: 24802844 DOI: 10.1016/j.wneu.2014.04.074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 04/30/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Liang Chen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China.
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Shaaban MA, Alloush TK, Ibrahim MH, Abd el bar A, Morad SH. Volumetric Assessment of Corticospinal Tract Infiltration by Astrocytoma Using Diffusion Tensor Tractography. OPEN JOURNAL OF MEDICAL IMAGING 2014; 04:65-71. [DOI: 10.4236/ojmi.2014.42009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Abstract
In recent years, advances in the understanding of low-grade glioma (LGG) biology have driven new paradigms in molecular markers, diagnostic imaging, operative techniques and technologies, and adjuvant therapies. Taken together, these developments are collectively pushing the envelope toward improved quality of life and survival. In this article, the authors evaluate the recent literature to synthesize a comprehensive review of LGGs in the modern neurosurgical era.
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Affiliation(s)
- Nader Sanai
- Barrow Brain Tumor Research Center, Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Price SJ, Gillard JH. Imaging biomarkers of brain tumour margin and tumour invasion. Br J Radiol 2011; 84 Spec No 2:S159-67. [PMID: 22433826 PMCID: PMC3473903 DOI: 10.1259/bjr/26838774] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Invasion of tumour cells into the normal brain is one of the major reasons of treatment failure for gliomas. Although there is a good understanding of the molecular and cellular processes that occur during this invasion, it is not possible to detect the extent of the tumour with conventional imaging. However, there is an understanding that the degree of invasion differs with individual tumours, and yet they are all treated the same. Newer imaging techniques that probe the pathological changes within tumours may be suitable biomarkers for invasion. Imaging methods are now available that can detect subtle changes in white matter organisation (diffusion tensor imaging), tumour metabolism and cellular proliferation (using MR spectroscopy and positron emission tomography) occurring in regions of tumour that cannot be detected by conventional imaging. The role of such biomarkers of invasion should allow better delineation of tumour margins, which should improve treatment planning (especially surgery and radiotherapy) and provide information on the invasiveness of an individual tumour to help select the most appropriate therapy and help stratify patients for clinical trials.
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Affiliation(s)
- S J Price
- Academic Neurosurgery Division, Department of Clinical Neuroscience, Addenbrooke's Hospital, Cambridge, UK.
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13
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Extent of resection influences outcomes for patients with gliomas. Rev Neurol (Paris) 2011; 167:648-54. [PMID: 21903234 DOI: 10.1016/j.neurol.2011.07.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 07/26/2011] [Indexed: 11/21/2022]
Abstract
In recent years, advances in our understanding of the biology of low-grade gliomas (LGG) and high-grade gliomas (HGG) have driven new paradigms in molecular markers, diagnostic imaging, operative techniques and technologies, and adjuvant therapies. Taken together, these developments are collectively pushing the envelope towards improved quality of life and survival. Here, we review the recent literature to synthesize a comprehensive review of the value of extent of resection for LGGs and HGGs in the modern neurosurgical era.
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Golby AJ, Kindlmann G, Norton I, Yarmarkovich A, Pieper S, Kikinis R. Interactive diffusion tensor tractography visualization for neurosurgical planning. Neurosurgery 2011; 68:496-505. [PMID: 21135713 DOI: 10.1227/neu.0b013e3182061ebb] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Diffusion tensor imaging (DTI) infers the trajectory and location of large white matter tracts by measuring the anisotropic diffusion of water. DTI data may then be analyzed and presented as tractography for visualization of the tracts in 3 dimensions. Despite the important information contained in tractography images, usefulness for neurosurgical planning has been limited by the inability to define which are critical structures within the mass of demonstrated fibers and to clarify their relationship to the tumor. OBJECTIVE To develop a method to allow the interactive querying of tractography data sets for surgical planning and to provide a working software package for the research community. METHODS The tool was implemented within an open source software project. Echo-planar DTI at 3 T was performed on 5 patients, followed by tensor calculation. Software was developed that allowed the placement of a dynamic seed point for local selection of fibers and for fiber display around a segmented structure, both with tunable parameters. A neurosurgeon was trained in the use of software in < 1 hour and used it to review cases. RESULTS Tracts near tumor and critical structures were interactively visualized in 3 dimensions to determine spatial relationships to lesion. Tracts were selected using 3 methods: anatomical and functional magnetic resonance imaging-defined regions of interest, distance from the segmented tumor volume, and dynamic seed-point spheres. CONCLUSION Interactive tractography successfully enabled inspection of white matter structures that were in proximity to lesions, critical structures, and functional cortical areas, allowing the surgeon to explore the relationships between them.
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Affiliation(s)
- Alexandra J Golby
- Brigham and Women's Hospital, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA.
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Abstract
In recent years, advances in the understanding of low-grade glioma (LGG) biology have driven new paradigms in molecular markers, diagnostic imaging, operative techniques and technologies, and adjuvant therapies. Taken together, these developments are collectively pushing the envelope toward improved quality of life and survival. In this article, the authors evaluate the recent literature to synthesize a comprehensive review of LGGs in the modern neurosurgical era.
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Affiliation(s)
- Nader Sanai
- 1Barrow Brain Tumor Research Center, Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Susan Chang
- 2Brain Tumor Research Center, Department of Neurological Surgery, University of California at San Francisco, California
| | - Mitchel S. Berger
- 2Brain Tumor Research Center, Department of Neurological Surgery, University of California at San Francisco, California
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Abstract
The advanced imaging techniques outlined in this article are only slowly establishing their place in surgical practice. Even a low risk of false information is unacceptable in neurosurgery, thus decision-making is necessarily conservative. As more validation studies and greater experience accrue, surgeons are becoming more comfortable weighing the quality of information from functional imaging studies. Advanced imaging information is highly complementary to established surgical "good practice" such as anatomic planning, awake craniotomy, and electrocortical stimulation; its greatest impact is perhaps on how neurosurgery is planned and discussed before the patient is ever brought to the operating room. Access to functional magnetic resonance (MR) imaging, diffusion tractography, and intraoperative MR imaging can influence neurosurgical decisions before, during, and after surgery. However, the widespread adoption of these techniques in neurosurgical practice remains limited by the lack of standardized methods, the need for validation across institutions, and the unclear cost-effectiveness particularly for intraoperative MR imaging. Before advanced imaging results can be used therapeutically, it is incumbent on the neurosurgeon and neuroradiologist to develop a working understanding of each technique's strengths and weaknesses, positive and negative predictive values, and modes of failure. This content presents several imaging methods that are increasingly used in neurosurgical planning. As these techniques are progressively applied to surgery, radiologists, medical physicists, neuroscientists, and engineers will be necessary partners with the treating neurosurgeon to bridge the gap between the experimental and the therapeutic.
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Sanai N, Berger MS. Intraoperative stimulation techniques for functional pathway preservation and glioma resection. Neurosurg Focus 2010; 28:E1. [PMID: 20121436 DOI: 10.3171/2009.12.focus09266] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Although a primary tenet of neurosurgical oncology is that survival can improve with greater tumor resection, this principle must be tempered by the potential for functional loss following a radical removal. Preoperative planning with functional and physiological imaging paradigms, combined with intraoperative strategies such as cortical and subcortical stimulation mapping, can effectively reduce the risks associated with operating in eloquent territory. In addition to identifying critical motor pathways, these techniques can be adapted to identify language function reliably. The authors review the technical nuances of intraoperative mapping for low- and high-grade gliomas, demonstrating their efficacy in optimizing resection even in patients with negative mapping data. Collectively, these surgical strategies represent the cornerstone for operating on gliomas in and around functional pathways.
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Affiliation(s)
- Nader Sanai
- Brain Tumor Research Center, Department of Neurological Surgery, University of California, San Francisco, California 94143, USA.
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Yen PS, Teo BT, Chiu CH, Chen SC, Chiu TL, Su CF. White matter tract involvement in brain tumors: a diffusion tensor imaging analysis. ACTA ACUST UNITED AC 2009; 72:464-9; discussion 469. [DOI: 10.1016/j.surneu.2009.05.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 05/04/2009] [Indexed: 11/16/2022]
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Abstract
Magnetic resonance technology is continually improving. Functional imaging techniques such as magnetic resonance spectroscopy, perfusion imaging, diffusion imaging, and diffusion tensor imaging are increasingly used in the diagnosis and treatment of brain tumors in children. However, estimate of tumor size remains the primary imaging endpoint in the evaluation of response to treatment, and validation across institutions and vendor platforms of magnetic resonance imaging functional parameters is necessary given the relatively uncommon occurrence of brain tumors in children. Pediatric neuroimaging can be challenging, and the optimal way to image children with tumors of the central nervous system is not uniformly applied across all centers. Application of proper scanning techniques and validation of functional imaging techniques should lead to improved care of children with central nervous system tumors.
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Affiliation(s)
- Louis-Gilbert Vézina
- Program in Neuroradiology, Children's National Medical Center, Radiology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC 20010-2970, USA.
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Rosenberger G, Kubicki M, Nestor PG, Connor E, Bushell GB, Markant D, Niznikiewicz M, Westin CF, Kikinis R, Saykin AJ, McCarley RW, Shenton ME. Age-related deficits in fronto-temporal connections in schizophrenia: a diffusion tensor imaging study. Schizophr Res 2008; 102:181-8. [PMID: 18504117 PMCID: PMC2684860 DOI: 10.1016/j.schres.2008.04.019] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Revised: 04/01/2008] [Accepted: 04/04/2008] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Impairment of white matter connecting frontal and temporal cortices has been reported in schizophrenia. Yet, not much is known about the effects of age on fibers connecting these brain regions. Using diffusion tensor imaging tractography, we investigated the relationship between age and fiber integrity in patients with schizophrenia vs. healthy adults. METHODS DTI tractography was used to create 3D reconstructions of the cingulum, uncinate and inferior occipito-frontal fasciculi in 27 patients with schizophrenia and 34 healthy volunteers (23-56 years of age, group-matched on age). Fractional anisotropy (FA), describing fiber integrity, was then calculated along the entire length of these tracts, and correlated with subjects' age. RESULTS Patients revealed a significant decline in FA with age in both the cingulum and uncinate, but not in the inferior occipito-frontal fasciculi. No statistically significant correlations were found in these fiber bundles in controls. CONCLUSIONS These results suggest an age-associated reduction of frontal-temporal connectivity in schizophrenia, but not in healthy controls.
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Affiliation(s)
- Gudrun Rosenberger
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States,Department of General Psychiatry, Innsbruck Medical University, Innsbruck, Austria
| | - Marek Kubicki
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States,Clinical Neuroscience Division, Laboratory of Neuroscience, Boston VA Healthcare System-Brockton Division, Department of Psychiatry, Harvard Medical School, Brockton, MA, United States
| | - Paul G. Nestor
- Clinical Neuroscience Division, Laboratory of Neuroscience, Boston VA Healthcare System-Brockton Division, Department of Psychiatry, Harvard Medical School, Brockton, MA, United States
| | - Erin Connor
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Georgia B. Bushell
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Douglas Markant
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Margaret Niznikiewicz
- Clinical Neuroscience Division, Laboratory of Neuroscience, Boston VA Healthcare System-Brockton Division, Department of Psychiatry, Harvard Medical School, Brockton, MA, United States
| | - Carl-Fredrik Westin
- Laboratory of Mathematic Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Ron Kikinis
- Surgical Planning Laboratory, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Andrew J. Saykin
- Center for Neuroimaging, Department of Radiology, Indiana University School of Medicine, Indianapolis IN, United States
| | - Robert W. McCarley
- Clinical Neuroscience Division, Laboratory of Neuroscience, Boston VA Healthcare System-Brockton Division, Department of Psychiatry, Harvard Medical School, Brockton, MA, United States
| | - Martha E. Shenton
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States,Clinical Neuroscience Division, Laboratory of Neuroscience, Boston VA Healthcare System-Brockton Division, Department of Psychiatry, Harvard Medical School, Brockton, MA, United States,Surgical Planning Laboratory, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States,Corresponding author. Psychiatry Neuroimaging Laboratory; 1249, Boylston Street, Boston, MA 02215, United States. Tel.: +1 617 525 6105; fax: +1 617 525 6150. E-mail address: (M.E. Shenton)
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Deisboeck TS, Guiot C. Surgical impact on brain tumor invasion: a physical perspective. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2008; 2:1. [PMID: 18384681 PMCID: PMC2359755 DOI: 10.1186/1750-1164-2-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Accepted: 04/02/2008] [Indexed: 01/01/2023]
Abstract
It is conventional strategy to treat highly malignant brain tumors initially with cytoreductive surgery followed by adjuvant radio- and chemotherapy. However, in spite of all such efforts, the patients' prognosis remains dismal since residual glioma cells continue to infiltrate adjacent parenchyma and the tumors almost always recur. On the basis of a simple biomechanical conjecture that we have introduced previously, we argue here that by affecting the 'volume-pressure' relationship and minimizing surface tension of the remaining tumor cells, gross total resection may have an inductive effect on the invasiveness of the tumor cells left behind. Potential implications for treatment strategies are discussed.
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Affiliation(s)
- Thomas S Deisboeck
- Complex Biosystems Modeling Laboratory, Harvard-MIT (HST) Athinoula A, Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA 02129, USA.
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Khwaja FW. Prognostic markers of astrocytoma: how to predict the unpredictable? ACTA ACUST UNITED AC 2007; 1:463-79. [PMID: 23496354 DOI: 10.1517/17530059.1.4.463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Astrocytomas are the most frequent tumors originating in the human nervous system. They carry a dismal prognosis as high-grade astroctyoma patients (World Health Organization [WHO] grade III and IV) rarely live beyond 5 years. At present, these tumors are mainly diagnosed through the difficult task of histologic examination of tissue obtained through stereotactic biopsy or tumor resection. In addition to determining the malignancy grade through histologic studies, the only other prognostic factors used in clinical setting are patient age and performance status. To overcome current limitations, research is underway to develop molecular approaches for glioma classification. These include identification, characterization and expansion of clinical (patient characteristics and imaging variables), histologic (WHO classification criteria) and molecular (genetic and proteomic) factors with prognostic potential. In this review the established classification characteristics, along with recent advances that may lead to the addition of new parameters and thus improve patient management and survival, are discussed.
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Affiliation(s)
- Fatima W Khwaja
- Shaukat Khanum Memorial Cancer Hospital and Research Center, Basic Science Lab, Abdul Hafeez Research Wing, 77A, Block R/8, Lahore, 54000, Pakistan +92 042 5180727 ext. 2523 ; +92 042 5945207 ;
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