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Vartholomatos G, Markopoulos GS, Vartholomatos E, Goussia AC, Dova L, Dimitriadis S, Mantziou S, Zoi V, Nasios A, Sioka C, Kyritsis AP, Voulgaris S, Alexiou GA. Assessment of Gliomas' Grade of Malignancy and Extent of Resection Using Intraoperative Flow Cytometry. Cancers (Basel) 2023; 15:2509. [PMID: 37173975 PMCID: PMC10177593 DOI: 10.3390/cancers15092509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/22/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Intraoperative Flow Cytometry (iFC) is a novel technique for the assessment of the grade of malignancy and the diagnosis of tumor type and resection margins during solid tumor surgery. Herein, we set out to analyze the role of iFC in the grading of gliomas and the evaluation of resection margins. MATERIAL AND METHODS iFC uses a fast cell cycle analysis protocol (Ioannina Protocol) that permits the analysis of tissue samples within 5-6 min. Cell cycle analysis evaluated the G0/G1 phase, S-phase, mitosis, and tumor index (S + mitosis phase fraction) and ploidy status. In the current study, we evaluated tumor samples and samples from the peripheral borders from patients with gliomas who underwent surgery over an 8-year period. RESULTS Eighty-one patients were included in the study. There were sixty-eight glioblastoma cases, five anaplastic astrocytomas, two anaplastic oligodendrogliomas, one pilocytic astrocytoma, three oligodendrogliomas and two diffuse astrocytomas. High-grade gliomas had a significantly higher tumor index than low grade gliomas (median value 22 vs. 7.5, respectively, p = 0.002). Using ROC curve analysis, a cut-off value of 17% in the tumor index could differentiate low- from high-grade gliomas with a 61.4% sensitivity and 100% specificity. All low-grade gliomas were diploid. From the high-grade gliomas, 22 tumors were aneuploid. In glioblastomas, aneuploid tumors had a significantly higher tumor index (p = 0.0018). Twenty-three samples from glioma margins were evaluated. iFC verified the presence of malignant tissue in every case, using histology as the gold standard. CONCLUSION iFC constitutes a promising intraoperative technique for glioma grading and resection margin assessment. Comparative studies with additional intraoperative adjuncts are necessary.
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Affiliation(s)
- George Vartholomatos
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Haematology Laboratory, Unit of Molecular Biology and Translational Flow Cytometry, 45110 Ioannina, Greece
| | - Georgios S. Markopoulos
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Haematology Laboratory, Unit of Molecular Biology and Translational Flow Cytometry, 45110 Ioannina, Greece
| | - Eyrysthenis Vartholomatos
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
| | - Anna C. Goussia
- Department of Pathology, Ioannina University Hospital, 45500 Ioannina, Greece;
- Department of Pathology, German Oncology Center, 4108 Limassol, Cyprus
| | - Lefkothea Dova
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Haematology Laboratory, Unit of Molecular Biology and Translational Flow Cytometry, 45110 Ioannina, Greece
| | - Savvas Dimitriadis
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
| | - Stefania Mantziou
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Haematology Laboratory, Unit of Molecular Biology and Translational Flow Cytometry, 45110 Ioannina, Greece
| | - Vaso Zoi
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
| | - Anastasios Nasios
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Haematology Laboratory, Unit of Molecular Biology and Translational Flow Cytometry, 45110 Ioannina, Greece
- Department of Neurosurgery, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Chrissa Sioka
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Department of Nuclear Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Athanasios P. Kyritsis
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
| | - Spyridon Voulgaris
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Department of Neurosurgery, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - George A. Alexiou
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Department of Neurosurgery, University Hospital of Ioannina, 45500 Ioannina, Greece
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Accurate Characterization of Bladder Cancer Cells with Intraoperative Flow Cytometry. Cancers (Basel) 2022; 14:cancers14215440. [PMID: 36358858 PMCID: PMC9656620 DOI: 10.3390/cancers14215440] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022] Open
Abstract
Simple Summary Bladder cancer is a malignancy that predominantly affects male patients. Surgical treatment is the first option for clinical management and cancer cell characterization is critical for tumor margin detection and complete tumor removal. We developed a specialized intraoperative flow cytometry (iFC) methodology for bladder cancer cell detection. Our study, including 52 individuals, reveals that iFC is highly specific, sensitive and accurate in detecting cancer cells, based on the quantification of cell proliferation and the presence of tumor aneuploidy. The results of this study advocate further research on the utility of iFC as a next-generation malignancy evaluation technique during transurethral resections. Abstract Bladder cancer represents a major health issue. Transurethral resection is the first line treatment and an accurate assessment of tumor margins might warrant complete tumor removal. Genomic instability and proliferative potential are common hallmarks of cancer cells. We have previously demonstrated the utility of intraoperative flow cytometry (iFC), a next-generation margin evaluation methodology for assessment of DNA content, in the detection of several types of malignancy. In the current study we investigated the possible value of iFC in the characterization of bladder cancer during surgery. Samples from a population of 52 people with urothelial cancer were included in the study. The total time for iFC evaluation is 3–5 min per sample and included a two-step analysis, including DNA-index and Tumor-index calculation. First, DNA-index calculation revealed 24 hyperploid and one hypoploid tumor. Second, cell cycle analysis and Tumor-index calculation revealed that tumor samples are distinguished from normal cells based on their significantly higher proliferative potential. The standard for iFC evaluation was pathology assessment and revealed that our protocol exhibits an accuracy of 98% in defining the presence of cancer cells in a given sample. Our results support the further assessment of iFC value towards its use as a novel malignancy evaluation tool in transurethral resections.
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Anastasiadi Z, Mantziou S, Akrivis C, Paschopoulos M, Balasi E, Lianos GD, Alexiou GA, Mitsis M, Vartholomatos G, Markopoulos GS. Intraoperative Flow Cytometry for the Characterization of Gynecological Malignancies. BIOLOGY 2022; 11:biology11091339. [PMID: 36138818 PMCID: PMC9495699 DOI: 10.3390/biology11091339] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/06/2022] [Accepted: 09/08/2022] [Indexed: 12/23/2022]
Abstract
Simple Summary Aneuploidy and high proliferative potential are distinct features of neoplastic cells. Based on the established role of intraoperative flow cytometry in various types of cancer, the aim of the present study was to investigate its role in cancer cell identification during surgery for gynecological malignancies. The analysis time was 5–6 min per sample. A large percentage of tumors were characterized as aneuploid, while all tumor samples had a significantly high proliferation. Flow cytometry was performed in accordance with pathological evaluation, and the method had high sensitivity and specificity. Our results verify the value of intraoperative flow cytometry in gynecological malignancies, and warrant further investigation in multicenter studies. Abstract Cell-cycle analysis has shown the presence of aneuploidy to be associated with poor prognosis. We developed an innovative rapid cell-cycle analysis protocol (the Ioannina protocol) that permitted the intraoperative identification of neoplastic cells in a plethora of malignancies. Herein, we aimed to investigate the potential role of cell-cycle analysis in the intraoperative characterization of gynecological malignancies. Women who underwent surgery for gynecological malignancies in our institution over a three-year period were included in this study. Permanent section pathology evaluation was used as the gold standard for malignancy evaluation. Total accordance was observed between flow cytometry and pathology evaluation. In total, 21 aneuploid cancers were detected following DNA index calculation. Of these, 20 were hyperploid and 1 was hypoploid. In addition, tumor samples were characterized by a significantly lower percentage of cells in G0/G1, as well as an induced tumor index. The response time for flow cytometry to obtain results was 5–6 min per sample. It seems that flow cytometry analyses for intraoperative tumor evaluation can be safely expanded to gynecological malignancies. This is a novel practical approach that has been proven valuable in several tumor types to date, and also seems to be reliable for gynecological malignancies. Intraoperative flow cytometry is expected to be crucial in decisions of lymph node dissection in endometrial cancers, due to its rapid response regarding the tumor invasion of part or all of the myometrial thickness. In this way, the surgeon can quickly modify the plane of dissection. Our results warrant the further investigation of applying iFC in larger, multicenter studies.
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Affiliation(s)
- Zoi Anastasiadi
- Department of Obstetrics and Gynecology, ‘G. Chatzikosta’ General Hospital, 45001 Ioannina, Greece
| | - Stefania Mantziou
- Haematology Laboratory-Unit of Molecular Biology, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Christos Akrivis
- Department of Obstetrics and Gynecology, ‘G. Chatzikosta’ General Hospital, 45001 Ioannina, Greece
| | - Minas Paschopoulos
- Department of Obstetrics and Gynecology, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Eufemia Balasi
- Pathology Department, ‘G. Chatzikosta’ General Hospital, 45001 Ioannina, Greece
| | - Georgios D. Lianos
- Department of Surgery, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - George A. Alexiou
- Department of Neurosurgery, University Hospital of Ioannina, 45500 Ioannina, Greece
- Neurosurgical Institute, Faculty of Medicine, University of Ioannina, 45110 Ioannina, Greece
| | - Michail Mitsis
- Department of Surgery, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - George Vartholomatos
- Haematology Laboratory-Unit of Molecular Biology, University Hospital of Ioannina, 45500 Ioannina, Greece
- Neurosurgical Institute, Faculty of Medicine, University of Ioannina, 45110 Ioannina, Greece
- Correspondence: (G.V.); (G.S.M.)
| | - Georgios S. Markopoulos
- Haematology Laboratory-Unit of Molecular Biology, University Hospital of Ioannina, 45500 Ioannina, Greece
- Neurosurgical Institute, Faculty of Medicine, University of Ioannina, 45110 Ioannina, Greece
- Correspondence: (G.V.); (G.S.M.)
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