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Ohadi MAD, Dashtkoohi M, Babaei MR, Zamani R, Dashtkoohi M, Hadjipanayis CG. Sodium fluorescein-guided resection of brain metastases: A needed approach or an option? A systematic review and meta-analysis. Acta Neurochir (Wien) 2024; 166:334. [PMID: 39133319 DOI: 10.1007/s00701-024-06223-7] [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: 04/21/2024] [Accepted: 08/05/2024] [Indexed: 08/13/2024]
Abstract
PURPOSE Brain metastases (BM) often leave residual tumors despite having visible margins, which increases the risk of local tumor recurrence and can impact overall patient survival rates. Fluorescence-guided surgery (FGS) utilizing sodium fluorescein (FL) has been reported as an effective technique in recent studies. This study aimed to evaluate the efficacy of FL FGS in improving the extent of resection of brain metastases and its impact on overall survival. METHODS We conducted a systematic search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Our primary focus was on gross total resection (GTR). Additionally, we extracted survival data and evaluated the risk of bias using a modified version of the Joanna Briggs Institute critical appraisal tool. RESULTS The study comprised 970 patients with brain metastases through eight different studies. The study found that patients who underwent FL-guided resection had a significantly higher rate of GTR (OR: 2.02, 95% CI: 1.14-3.56, p = 0.0156, I2 = 41.5%). Additionally, the study concluded that FL-guided resection is associated with better overall survival rates (HR: 0.61, 95%CI: 0.47 0.80, p = 0.0003, I2 = 41.5%). CONCLUSION Our research suggests that the use of FL is associated with a higher rate of GTR and improved overall patient survival. None of the studies we reviewed reported significant complications associated with the use of FL in patients.
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Affiliation(s)
- Mohammad Amin Dabbagh Ohadi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Pediatric Neurological Surgery, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Dashtkoohi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Babaei
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Raha Zamani
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohadese Dashtkoohi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Picart T, Gautheron A, Caredda C, Ray C, Mahieu-Williame L, Montcel B, Guyotat J. Fluorescence-Guided Surgical Techniques in Adult Diffuse Low-Grade Gliomas: State-of-the-Art and Emerging Techniques: A Systematic Review. Cancers (Basel) 2024; 16:2698. [PMID: 39123426 PMCID: PMC11311317 DOI: 10.3390/cancers16152698] [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: 06/28/2024] [Revised: 07/26/2024] [Accepted: 07/28/2024] [Indexed: 08/12/2024] Open
Abstract
Diffuse low-grade gliomas are infiltrative tumors whose margins are not distinguishable from the adjacent healthy brain parenchyma. The aim was to precisely examine the results provided by the intraoperative use of macroscopic fluorescence in diffuse low-grade gliomas and to describe the new fluorescence-based techniques capable of guiding the resection of low-grade gliomas. Only about 20% and 50% of low-grade gliomas are macroscopically fluorescent after 5-amino-levulinic acid (5-ALA) or fluorescein sodium intake, respectively. However, 5-ALA is helpful for detecting anaplastic foci, and thus choosing the best biopsy targets in diffuse gliomas. Spectroscopic detection of 5-ALA-induced fluorescence can detect very low and non-macroscopically visible concentrations of protoporphyrin IX, a 5-ALA metabolite, and, consequently, has excellent performances for the detection of low-grade gliomas. Moreover, these tumors have a specific spectroscopic signature with two fluorescence emission peaks, which is useful for distinguishing them not only from healthy brain but also from high-grade gliomas. Confocal laser endomicroscopy can generate intraoperative optic biopsies, but its sensitivity remains limited. In the future, the coupled measurement of autofluorescence and induced fluorescence, and the introduction of fluorescence detection technologies providing a wider field of view could result in the development of operator-friendly tools implementable in the operative routine.
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Affiliation(s)
- Thiebaud Picart
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Groupe Hospitalier Est, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500 Bron, France
- Faculty of Medicine Lyon Est, Université Claude Bernard Lyon 1, 8 Avenue Rockefeller, 69003 Lyon, France
- Cancer Research Centre of Lyon (CRCL) Inserm 1052, CNRS 5286, 28 Rue Laennec, 69008 Lyon, France
| | - Arthur Gautheron
- Laboratoire Hubert Curien UMR 5516, Institut d’Optique Graduate School, CNRS, Université Jean Monnet Saint-Etienne, 42023 Saint-Etienne, France;
- CREATIS CNRS, Inserm, UMR 5220, U1294, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, 69100 Lyon, France; (C.C.); (C.R.); (L.M.-W.); (B.M.)
| | - Charly Caredda
- CREATIS CNRS, Inserm, UMR 5220, U1294, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, 69100 Lyon, France; (C.C.); (C.R.); (L.M.-W.); (B.M.)
| | - Cédric Ray
- CREATIS CNRS, Inserm, UMR 5220, U1294, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, 69100 Lyon, France; (C.C.); (C.R.); (L.M.-W.); (B.M.)
| | - Laurent Mahieu-Williame
- CREATIS CNRS, Inserm, UMR 5220, U1294, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, 69100 Lyon, France; (C.C.); (C.R.); (L.M.-W.); (B.M.)
| | - Bruno Montcel
- CREATIS CNRS, Inserm, UMR 5220, U1294, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, 69100 Lyon, France; (C.C.); (C.R.); (L.M.-W.); (B.M.)
| | - Jacques Guyotat
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Groupe Hospitalier Est, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500 Bron, France
- Faculty of Medicine Lyon Est, Université Claude Bernard Lyon 1, 8 Avenue Rockefeller, 69003 Lyon, France
- CREATIS CNRS, Inserm, UMR 5220, U1294, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, 69100 Lyon, France; (C.C.); (C.R.); (L.M.-W.); (B.M.)
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Ling G, Guo T, Guo F, Piao H. Effectiveness and Safety of Ultra-low-dose Fluorescein Sodium-Guided Resection of Malignant Glioma. World Neurosurg 2024; 185:e774-e785. [PMID: 38432505 DOI: 10.1016/j.wneu.2024.02.131] [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: 11/30/2023] [Revised: 02/23/2024] [Accepted: 02/24/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND This study analyzed the effectiveness and safety of ultra-low dose fluorescein sodium (FL)-guided malignant glioma resection and its potential to predict the pathological characteristics of glioma. METHODS Sixty patients who underwent FL-guided glioma resection were randomly divided into test (1 mg/kg) and control (5 mg/kg) groups. A retrospective analysis included 30 patients with gliomas who did not undergo FL-guided surgery; these patients were included as a blank control group. Surgical outcomes, Karnofsky performance scores (KPS), and progression-free survival (PFS) at 6 months postoperatively were compared between the 3 groups. The sensitivity and specificity of FL and the relationship between the intensity of FL and Glial fibrillary acidic protein (GFAP) or Ki-67 expression were compared. RESULTS The total tumor resection rates in the test, control, and blank control groups were 90% (27/30), 86.7% (26/30), and 60% (18/30), respectively. There were significant differences (P < 0.05) in the extent of resection, KPS, and PFS at 6 months after surgery between the test and control groups and the blank control group; however, no significant differences (P > 0.05) were observed between the test and control groups. The intensity of FL and the Ki67 positivity rate (P < 0.05) were directly proportional, but this relationship was not observed with GFAP. CONCLUSIONS Ultra-low-dose FL-guided resection of malignant gliomas is safe and effective. The Ki67 positivity rate was directly proportional to the intensity of FL, indicating its potential to predict gliomas during pathological examination.
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Affiliation(s)
- Guoyuan Ling
- Graduate School, Dalian Medical University, Liaoning Province, China; Department of Neurosurgery, Guangxi Medical University Cancer Hospital, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Tangjun Guo
- Department of Neurosurgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Fangzhou Guo
- Department of Neurosurgery, Guangxi Medical University Cancer Hospital, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Haozhe Piao
- Department of Neurosurgery, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning Province, China.
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Al-Adli NN, Young JS, Scotford K, Sibih YE, Payne J, Berger MS. Advances in Intraoperative Glioma Tissue Sampling and Infiltration Assessment. Brain Sci 2023; 13:1637. [PMID: 38137085 PMCID: PMC10741454 DOI: 10.3390/brainsci13121637] [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: 10/12/2023] [Revised: 11/06/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
Gliomas are infiltrative brain tumors that often involve functional tissue. While maximal safe resection is critical for maximizing survival, this is challenged by the difficult intraoperative discrimination between tumor-infiltrated and normal structures. Surgical expertise is essential for identifying safe margins, and while the intraoperative pathological review of frozen tissue is possible, this is a time-consuming task. Advances in intraoperative stimulation mapping have aided surgeons in identifying functional structures and, as such, has become the gold standard for this purpose. However, intraoperative margin assessment lacks a similar consensus. Nonetheless, recent advances in intraoperative imaging techniques and tissue examination methods have demonstrated promise for the accurate and efficient assessment of tumor infiltration and margin delineation within the operating room, respectively. In this review, we describe these innovative technologies that neurosurgeons should be aware of.
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Affiliation(s)
- Nadeem N. Al-Adli
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94131, USA; (N.N.A.-A.); (J.S.Y.); (K.S.); (J.P.)
- School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Jacob S. Young
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94131, USA; (N.N.A.-A.); (J.S.Y.); (K.S.); (J.P.)
| | - Katie Scotford
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94131, USA; (N.N.A.-A.); (J.S.Y.); (K.S.); (J.P.)
| | - Youssef E. Sibih
- School of Medicine, University of California San Francisco, San Francisco, CA 94131, USA;
| | - Jessica Payne
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94131, USA; (N.N.A.-A.); (J.S.Y.); (K.S.); (J.P.)
| | - Mitchel S. Berger
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA 94131, USA; (N.N.A.-A.); (J.S.Y.); (K.S.); (J.P.)
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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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Abstract
Glioblastoma is the most aggressive primary brain tumor with a poor prognosis. The 2021 WHO CNS5 classification has further stressed the importance of molecular signatures in diagnosis although therapeutic breakthroughs are still lacking. In this review article, updates on the current and novel therapies in IDH-wildtype GBM will be discussed.
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Affiliation(s)
- Jawad M Melhem
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Mary Jane Lim-Fat
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - James R Perry
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.
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Netufo O, Connor K, Shiels LP, Sweeney KJ, Wu D, O’Shea DF, Byrne AT, Miller IS. Refining Glioblastoma Surgery through the Use of Intra-Operative Fluorescence Imaging Agents. Pharmaceuticals (Basel) 2022; 15:550. [PMID: 35631376 PMCID: PMC9143023 DOI: 10.3390/ph15050550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 02/01/2023] Open
Abstract
Glioblastoma (GBM) is the most aggressive adult brain tumour with a dismal 2-year survival rate of 26-33%. Maximal safe resection plays a crucial role in improving patient progression-free survival (PFS). Neurosurgeons have the significant challenge of delineating normal tissue from brain tumour to achieve the optimal extent of resection (EOR), with 5-Aminolevulinic Acid (5-ALA) the only clinically approved intra-operative fluorophore for GBM. This review aims to highlight the requirement for improved intra-operative imaging techniques, focusing on fluorescence-guided imaging (FGS) and the use of novel dyes with the potential to overcome the limitations of current FGS. The review was performed based on articles found in PubMed an.d Google Scholar, as well as articles identified in searched bibliographies between 2001 and 2022. Key words for searches included 'Glioblastoma' + 'Fluorophore'+ 'Novel' + 'Fluorescence Guided Surgery'. Current literature has favoured the approach of using targeted fluorophores to achieve specific accumulation in the tumour microenvironment, with biological conjugates leading the way. These conjugates target specific parts overexpressed in the tumour. The positive results in breast, ovarian and colorectal tissue are promising and may, therefore, be applied to intracranial neoplasms. Therefore, this design has the potential to produce favourable results in GBM by reducing the residual tumour, which translates to decreased tumour recurrence, morbidity and ultimately, mortality in GBM patients. Several preclinical studies have shown positive results with targeted dyes in distinguishing GBM cells from normal brain parenchyma, and targeted dyes in the Near-Infrared (NIR) emission range offer promising results, which may be valuable future alternatives.
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Affiliation(s)
- Oluwakanyinsolami Netufo
- Precision Cancer Medicine Group, Department of Physiology and Medical Physics, Royal College of Surgeons in Ireland, 2, D02 YN77 Dublin, Ireland; (O.N.); (K.C.); (L.P.S.); (K.J.S.); (A.T.B.)
| | - Kate Connor
- Precision Cancer Medicine Group, Department of Physiology and Medical Physics, Royal College of Surgeons in Ireland, 2, D02 YN77 Dublin, Ireland; (O.N.); (K.C.); (L.P.S.); (K.J.S.); (A.T.B.)
| | - Liam P. Shiels
- Precision Cancer Medicine Group, Department of Physiology and Medical Physics, Royal College of Surgeons in Ireland, 2, D02 YN77 Dublin, Ireland; (O.N.); (K.C.); (L.P.S.); (K.J.S.); (A.T.B.)
| | - Kieron J. Sweeney
- Precision Cancer Medicine Group, Department of Physiology and Medical Physics, Royal College of Surgeons in Ireland, 2, D02 YN77 Dublin, Ireland; (O.N.); (K.C.); (L.P.S.); (K.J.S.); (A.T.B.)
- National Centre for Neurosurgery, Beaumont Hospital, 9, D09 V2N0 Dublin, Ireland
| | - Dan Wu
- Department of Chemistry, Royal College of Surgeons in Ireland (RCSI), 2, D02 YN77 Dublin, Ireland; (D.W.); (D.F.O.)
| | - Donal F. O’Shea
- Department of Chemistry, Royal College of Surgeons in Ireland (RCSI), 2, D02 YN77 Dublin, Ireland; (D.W.); (D.F.O.)
| | - Annette T. Byrne
- Precision Cancer Medicine Group, Department of Physiology and Medical Physics, Royal College of Surgeons in Ireland, 2, D02 YN77 Dublin, Ireland; (O.N.); (K.C.); (L.P.S.); (K.J.S.); (A.T.B.)
- National Pre-Clinical Imaging Centre (NPIC), 2, D02 YN77 Dublin, Ireland
| | - Ian S. Miller
- Precision Cancer Medicine Group, Department of Physiology and Medical Physics, Royal College of Surgeons in Ireland, 2, D02 YN77 Dublin, Ireland; (O.N.); (K.C.); (L.P.S.); (K.J.S.); (A.T.B.)
- National Pre-Clinical Imaging Centre (NPIC), 2, D02 YN77 Dublin, Ireland
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Fluorescein-Guided Resection of High Grade Gliomas: A Meta-Analysis. World Neurosurg 2021; 155:181-188.e7. [PMID: 34492388 DOI: 10.1016/j.wneu.2021.08.126] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/27/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND High-grade gliomas (HGGs) have a poor prognosis despite current standard of care of surgery, chemotherapy, and radiation therapy. Achieving gross total resection (GTR) has been found to prolong survival in these patients. Intraoperative fluorescent agents are often used to aid in the resection of HGGs. One commonly used fluorescent agent is fluorescein sodium, which is U.S. Food and Drug Administration-approved for ocular surgeries and has a better side effect profile and is less costly than 5-aminolevulinic acid (5-ALA). In this meta-analysis, we provide statistical evidence of the efficacy in using fluorescein for HGG resection. METHODS Following the PRISMA framework, we assessed 119 reports from PubMed, Medline (Ovid), and BIOSIS Citation Index and found 21 eligible studies for meta-analysis, assessing the rates of GTR with fluorescein-guided resection of HGGs. RESULTS A pooled cohort of 336 patients underwent fluorescein-guided HGG resection with a GTR rate of 81% (95% confidence interval 73%-89%; P < 0.001). Ten case-controlled studies were analyzed, showing a 29.5% increase in GTR rate in the fluorescein group compared with non-fluorescein-guided surgeries. CONCLUSIONS This meta-analysis shows that fluorescein-guided surgery improves GTR rates of HGGs when compared with non-fluorescence guided surgery and has similar GTR rates when compared with reported 5-ALA-guided resection rates.
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Schupper AJ, Rao M, Mohammadi N, Baron R, Lee JYK, Acerbi F, Hadjipanayis CG. Fluorescence-Guided Surgery: A Review on Timing and Use in Brain Tumor Surgery. Front Neurol 2021; 12:682151. [PMID: 34220688 PMCID: PMC8245059 DOI: 10.3389/fneur.2021.682151] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/11/2021] [Indexed: 12/25/2022] Open
Abstract
Fluorescence-guided surgery (FGS) allows surgeons to have improved visualization of tumor tissue in the operating room, enabling maximal safe resection of malignant brain tumors. Over the past two decades, multiple fluorescent agents have been studied for FGS, including 5-aminolevulinic acid (5-ALA), fluorescein sodium, and indocyanine green (ICG). Both non-targeted and targeted fluorescent agents are currently being used in clinical practice, as well as under investigation, for glioma visualization and resection. While the efficacy of intraoperative fluorescence in studied fluorophores has been well established in the literature, the effect of timing on fluorophore administration in glioma surgery has not been as well depicted. In the past year, recent studies of 5-ALA use have shown that intraoperative fluorescence may persist beyond the previously studied window used in prior multicenter trials. Additionally, the use of fluorophores for different brain tumor types is discussed in detail, including a discussion of choosing the right fluorophore based on tumor etiology. In the following review, the authors will describe the temporal nature of the various fluorophores used in glioma surgery, what remains uncertain in FGS, and provide a guide for using fluorescence as a surgical adjunct in brain tumor surgery.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Manasa Rao
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Nicki Mohammadi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Rebecca Baron
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione Istituto Di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milan, Italy
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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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11
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Salinas HR, Miyasato DL, Eremina OE, Perez R, Gonzalez KL, Czaja AT, Burkitt S, Aron A, Fernando A, Ojeda LS, Larson KN, Mohamed AW, Campbell JL, Goins BA, Zavaleta C. A colorful approach towards developing new nano-based imaging contrast agents for improved cancer detection. Biomater Sci 2021; 9:482-495. [PMID: 32812951 PMCID: PMC7855687 DOI: 10.1039/d0bm01099e] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Providing physicians with new imaging agents to help detect cancer with better sensitivity and specificity has the potential to significantly improve patient outcomes. Development of new imaging agents could offer improved early cancer detection during routine screening or help surgeons identify tumor margins for surgical resection. In this study, we evaluate the optical properties of a colorful class of dyes and pigments that humans routinely encounter. The pigments are often used in tattoo inks and the dyes are FDA approved for the coloring of foods, drugs, and cosmetics. We characterized their absorption, fluorescence and Raman scattering properties in the hopes of identifying a new panel of dyes that offer exceptional imaging contrast. We found that some of these coloring agents, coined as "optical inks", exhibit a multitude of useful optical properties, outperforming some of the clinically approved imaging dyes on the market. The best performing optical inks (Green 8 and Orange 16) were further incorporated into liposomal nanoparticles to assess their tumor targeting and optical imaging potential. Mouse xenograft models of colorectal, cervical and lymphoma tumors were used to evaluate the newly developed nano-based imaging contrast agents. After intravenous injection, fluorescence imaging revealed significant localization of the new "optical ink" liposomal nanoparticles in all three tumor models as opposed to their neighboring healthy tissues (p < 0.05). If further developed, these coloring agents could play important roles in the clinical setting. A more sensitive imaging contrast agent could enable earlier cancer detection or help guide surgical resection of tumors, both of which have been shown to significantly improve patient survival.
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Affiliation(s)
- Helen R Salinas
- Department of Biomedical Engineering, University of Southern California, 1002 Childs Way, Los Angeles, CA 90089, USA.
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12
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Schupper AJ, Yong RL, Hadjipanayis CG. The Neurosurgeon's Armamentarium for Gliomas: An Update on Intraoperative Technologies to Improve Extent of Resection. J Clin Med 2021; 10:jcm10020236. [PMID: 33440712 PMCID: PMC7826675 DOI: 10.3390/jcm10020236] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 12/18/2022] Open
Abstract
Maximal safe resection is the standard of care in the neurosurgical treatment of high-grade gliomas. To aid surgeons in the operating room, adjuvant techniques and technologies centered around improving intraoperative visualization of tumor tissue have been developed. In this review, we will discuss the most advanced technologies, specifically fluorescence-guided surgery, intraoperative imaging, neuromonitoring modalities, and microscopic imaging techniques. The goal of these technologies is to improve detection of tumor tissue beyond what conventional microsurgery has permitted. We describe the various advances, the current state of the literature that have tested the utility of the different adjuvants in clinical practice, and future directions for improving intraoperative technologies.
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13
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Micko A, Placzek F, Fonollà R, Winklehner M, Sentosa R, Krause A, Vila G, Höftberger R, Andreana M, Drexler W, Leitgeb RA, Unterhuber A, Wolfsberger S. Diagnosis of Pituitary Adenoma Biopsies by Ultrahigh Resolution Optical Coherence Tomography Using Neuronal Networks. Front Endocrinol (Lausanne) 2021; 12:730100. [PMID: 34733239 PMCID: PMC8560084 DOI: 10.3389/fendo.2021.730100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Despite advancements of intraoperative visualization, the difficulty to visually distinguish adenoma from adjacent pituitary gland due to textural similarities may lead to incomplete adenoma resection or impairment of pituitary function. The aim of this study was to investigate optical coherence tomography (OCT) imaging in combination with a convolutional neural network (CNN) for objectively identify pituitary adenoma tissue in an ex vivo setting. METHODS A prospective study was conducted to train and test a CNN algorithm to identify pituitary adenoma tissue in OCT images of adenoma and adjacent pituitary gland samples. From each sample, 500 slices of adjacent cross-sectional OCT images were used for CNN classification. RESULTS OCT data acquisition was feasible in 19/20 (95%) patients. The 16.000 OCT slices of 16/19 of cases were employed for creating a trained CNN algorithm (70% for training, 15% for validating the classifier). Thereafter, the classifier was tested on the paired samples of three patients (3.000 slices). The CNN correctly predicted adenoma in the 3 adenoma samples (98%, 100% and 84% respectively), and correctly predicted gland and transition zone in the 3 samples from the adjacent pituitary gland. CONCLUSION Trained convolutional neural network computing has the potential for fast and objective identification of pituitary adenoma tissue in OCT images with high sensitivity ex vivo. However, further investigation with larger number of samples is required.
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Affiliation(s)
- Alexander Micko
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Fabian Placzek
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Roger Fonollà
- Department of Electrical Engineering, Video Coding and Architectures, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Michael Winklehner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Ryan Sentosa
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Arno Krause
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Greisa Vila
- Division of Endocrinology and Metabolism of the Department of Internal Medicine III, Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Marco Andreana
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Wolfgang Drexler
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Rainer A. Leitgeb
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
- Christian Doppler Laboratory Innovative Optical Imaging and its Translation for “Innovative Optical Imaging and its Translation into Medicine” (OPTRAMED), Medical University of Vienna, Vienna, Austria
| | - Angelika Unterhuber
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
- *Correspondence: Stefan Wolfsberger,
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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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15
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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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Abstract
Fluorescence-guided surgery provides surgeons with improved visualization of tumor tissue in the operating room to allow for maximal safe resection of brain tumors. Multiple fluorescent agents have been studied for fluorescence-guided surgery. Both nontargeted and targeted fluorescent agents are currently being used for glioblastoma multiforme visualization and resection. Fluorescence detection in the visible light or near infrared spectrum is possible. Visualization device advancements have permitted greater detection of fluorescence down to the cellular level, which may provide even greater ability for the neurosurgeon to resect tumors.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | - Constantinos Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA; Department of Neurosurgery, Mount Sinai Beth Israel, New York, NY, USA.
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Abstract
PURPOSE OF REVIEW Glioblastoma (GBM) patients have a poor prognosis despite the use of modern synergistic multimodal treatment strategies, with a progression-free survival estimated at 7-8 months, a median survival of 14-16 months and 5-year overall survival of 9.8%. RECENT FINDINGS Physical methods hold the promise to act synergistically with classical treatments to improve the outcome of GBM patients. Fluorescent guided surgery with 5-aminolevulinic acid and tumor-treating fields therapy have already shown positive results in randomized phase III trials and have been incorporated in the standard management. Other techniques such as photodynamic therapy (PDT) and focused ultrasound, often combined whit microbubbles, are reaching clinical development. SUMMARY Several clinical trials to evaluate the feasibility and efficacy of ultrasound devices to disrupt the blood-brain barrier are ongoing. PDT enables the creation of a safety margin or treatment of non-resecable tumors. However, randomized trials are urgently required to validate the efficacy of these promising approaches. We aim to critically review physical approaches to treat GBM, focusing on available clinical trial data.
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18
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Della Pepa GM, Ius T, La Rocca G, Gaudino S, Isola M, Pignotti F, Rapisarda A, Mazzucchi E, Giordano C, Dragonetti V, Chiesa S, Balducci M, Gessi M, Skrap M, Olivi A, Marchese E, Sabatino G. 5-Aminolevulinic Acid and Contrast-Enhanced Ultrasound: The Combination of the Two Techniques to Optimize the Extent of Resection in Glioblastoma Surgery. Neurosurgery 2020; 86:E529-E540. [PMID: 32186345 DOI: 10.1093/neuros/nyaa037] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 12/15/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The survival benefit in maximizing resection in glioblastomas (GBMs) has been demonstrated by numerous studies. The true limit of infiltration of GBMs has been an overwhelming obstacle, and several technological advances have been introduced to improve the identification of residual tumors. OBJECTIVE To evaluate whether the integration of 5-aminolevulinic acid (5-ALA) with microbubble contrast-enhanced ultrasound (CEUS) improves residual tumor identification and has an impact on the extent of resection (EOR), overall survival (OS), and progression-free survival (PFS). METHODS A total of 230 GBM procedures were retrospectively studied. Cases were stratified according to the surgical procedure into 4 groups: 5-ALA- and CEUS-guided surgeries, 5-ALA-guided surgeries, CEUS-guided surgeries, and conventional microsurgical procedures. RESULTS Patients undergoing conventional microsurgical procedures showed the worst EORs compared to the assisted techniques (5-ALA and CEUS procedures). Both 5-ALA and CEUS techniques improved the EOR compared to conventional microsurgical procedures. However, their combination gave the best results in terms of the EOR (P = .0003). The median EOR% and the number of supramarginal resections are hence superior in the 5-ALA + CEUS + group compared to the others; this observation had consequences on PFS and OS in our series. CONCLUSION In terms of the EOR, the best results can be achieved through a combination of both techniques, where the 5-ALA-guided procedure is followed by a final survey with CEUS. Compared with other intraoperative imaging techniques, CEUS is a real-time, readily repeatable, safe, and inexpensive technique that provides valuable information to the surgeon before, during, and after resection.
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Affiliation(s)
- Giuseppe Maria Della Pepa
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
| | - Tamara Ius
- Department of Neurosurgery, University Hospital, Udine, Italy
| | - Giuseppe La Rocca
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Simona Gaudino
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Catholic University of Rome, Rome, Italy
| | - Miriam Isola
- Department of Medicine, University of Udine, Udine, Italy
| | - Fabrizio Pignotti
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Alessandro Rapisarda
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
| | - Edoardo Mazzucchi
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
| | - Carolina Giordano
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Catholic University of Rome, Rome, Italy
| | - Valentino Dragonetti
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Catholic University of Rome, Rome, Italy
| | - Silvia Chiesa
- Department of Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCSSl, Catholic University of Rome, Rome, Italy
| | - Mario Balducci
- Department of Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCSSl, Catholic University of Rome, Rome, Italy
| | - Marco Gessi
- Department of Neuro-Pathology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Catholic University of Rome, Rome, Italy
| | - Miran Skrap
- Department of Neurosurgery, University Hospital, Udine, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
| | - Enrico Marchese
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
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19
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Katsevman GA, Turner RC, Urhie O, Voelker JL, Bhatia S. Utility of sodium fluorescein for achieving resection targets in glioblastoma: increased gross- or near-total resections and prolonged survival. J Neurosurg 2020; 132:914-920. [PMID: 30738388 DOI: 10.3171/2018.10.jns181174] [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: 05/08/2018] [Accepted: 10/04/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVE It is commonly reported that achieving gross-total resection of contrast-enhancing areas in patients with glioblastoma (GBM) improves overall survival. Efforts to achieve an improved resection have included the use of both imaging and pharmacological adjuvants. The authors sought to investigate the role of sodium fluorescein in improving the rates of gross-total resection of GBM and to assess whether patients undergoing resection with fluorescein have improved survival compared to patients undergoing resection without fluorescein. METHODS A retrospective chart review was performed on 57 consecutive patients undergoing 64 surgeries with sodium fluorescein to treat newly diagnosed or recurrent GBMs from May 2014 to June 2017 at a teaching institution. Outcomes were compared to those in patients with GBMs who underwent resection without fluorescein. RESULTS Complete or near-total (≥ 98%) resection was achieved in 73% (47/64) of fluorescein cases. Of 42 cases thought not to be amenable to complete resection, 10 procedures (24%) resulted in gross-total resection and 15 (36%) resulted in near-total resection following the use of sodium fluorescein. No patients developed any local or systemic side effects after fluorescein injection. Patients undergoing resection with sodium fluorescein, compared to the non-fluorescein-treated group, had increased rates of gross- or near-total resection (73% vs 53%, respectively; p < 0.05) as well as improved median survival (78 weeks vs 60 weeks, respectively; p < 0.360). CONCLUSIONS This study is the largest case series to date demonstrating the beneficial effect of utilizing sodium fluorescein as an adjunct in GBM resection. Sodium fluorescein facilitated resection in cases in which it was employed, including dominant-side resections particularly near speech and motor regions. The cohort of patients in which sodium fluorescein was utilized had statistically significantly increased rates of gross- or near-total resection. Additionally, the fluorescein group demonstrated prolonged median survival, although this was not statistically significant. This work demonstrates the promise of an affordable and easy-to-implement strategy for improving rates of total resection of contrast-enhancing areas in patients with GBM.
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Affiliation(s)
| | | | - Ogaga Urhie
- 2West Virginia University School of Medicine, Morgantown, West Virginia
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Navarro-Bonnet J, Suarez-Meade P, Brown DA, Chaichana KL, Quinones-Hinojosa A. Following the light in glioma surgery: a comparison of sodium fluorescein and 5-aminolevulinic acid as surgical adjuncts in glioma resection. J Neurosurg Sci 2020; 63:633-647. [PMID: 31961116 DOI: 10.23736/s0390-5616.19.04745-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Gliomas are molecularly complex neoplasms and require a multidisciplinary approach to treatment. Maximal safe resection is often the initial goal of treatment and extent of resection (EOR) is an important prognostic factor correlating with both progression-free-survival (PFS) and overall survival (OS). Postoperative patient outcome is also a critical and independent prognosticator and high EOR must not be achieved at the expense of good functional outcome. Several intraoperative adjuvant techniques have been developed to help the surgeon push the boundaries of EOR while maintaining safety. Fluorescence-guided surgery for brain tumors is a contemporary adjuvant technique that allows for intraoperative delineation of diseased and normal brain thus improving maximal safe resection. The most extensively used fluorophores are 5-aminolevulinic acid (5-ALA) and sodium fluorescein (SFL). These fluorophores have different spectrophotometric properties, mechanisms of action and considerations for use. Both have demonstrated utility in neurosurgical oncology. They are safe and both are FDA approved for use as surgical adjuncts during resection of primary CNS neoplasms although they have been used with varying success for other tumor types. When combined with other surgical adjuvant strategies such as neuronavigation, intraoperative ultrasound, intraoperative MRI, awake resection and/or electrophysiological mapping/monitoring, fluorescence-guided resection appears to further improve resection quality in regard to EOR and safety. In this article, we review the current knowledge related to both fluorophores for brain tumor resection, their benefits, and pitfalls, as well as the major advantages associated with their use. We also briefly review additional fluorophores in early clinical development. Fluorescence-guided surgery is a novel surgical adjuvant which allows for real-time delineation of neoplastic tissues. The most widely used fluorophores are 5-ALA and SFL. They are safe compounds and there is a large body of evidence suggesting improvement in EOR when these are employed. There are nuances to the use of each; the fluorescence intensity is dose-dependent in either case and the sensitivity and specificity for various tumors vary widely. Additional prospective studies will be necessary to parse the impact of this technique and these fluorophores on survival metrics.
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Affiliation(s)
- Jorge Navarro-Bonnet
- Department of Neurosurgery, Medica Sur Clinical Foundation, Mexico City, Mexico - .,Faculty of Health Sciences, Anahuac University, Mexico City, Mexico -
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Stummer W, Koch R, Valle RD, Roberts DW, Sanai N, Kalkanis S, Hadjipanayis CG, Suero Molina E. Intraoperative fluorescence diagnosis in the brain: a systematic review and suggestions for future standards on reporting diagnostic accuracy and clinical utility. Acta Neurochir (Wien) 2019; 161:2083-2098. [PMID: 31363920 PMCID: PMC6739423 DOI: 10.1007/s00701-019-04007-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 07/05/2019] [Indexed: 12/24/2022]
Abstract
Background Surgery for gliomas is often confounded by difficulties in distinguishing tumor from surrounding normal brain. For better discrimination, intraoperative optical imaging methods using fluorescent dyes are currently being explored. Understandably, such methods require the demonstration of a high degree of diagnostic accuracy and clinical benefit. Currently, clinical utility is determined by tissue biopsies which are correlated to optical signals, and quantified using measures such as sensitivity, specificity, positive predictive values, and negative predictive values. In addition, surgical outcomes, such as extent of resection rates and/or survival (progression-free survival (PFS) and overall survival (OS)) have been measured. These assessments, however, potentially involve multiple biases and confounders, which have to be minimized to ensure reproducibility, generalizability and comparability of test results. Test should aim at having a high internal and external validity. The objective of this article is to analyze how diagnostic accuracy and outcomes are utilized in available studies describing intraoperative imaging and furthermore, to derive recommendations for reliable and reproducible evaluations. Methods A review of the literature was performed for assessing the use of measures of diagnostic accuracy and outcomes of intraoperative optical imaging methods. From these data, we derive recommendations for designing and reporting future studies. Results Available literature indicates that potential confounders and biases for reporting the diagnostic accuracy and usefulness of intraoperative optical imaging methods are seldom accounted for. Furthermore, methods for bias reduction are rarely used nor reported. Conclusions Detailed, transparent, and uniform reporting on diagnostic accuracy of intraoperative imaging methods is necessary. In the absence of such reporting, studies will not be comparable or reproducible. Future studies should consider some of the recommendations given here. Electronic supplementary material The online version of this article (10.1007/s00701-019-04007-y) contains supplementary material, which is available to authorized users.
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“Enhancing Vision” in High Grade Glioma Surgery: A Feasible Integrated 5-ALA + CEUS Protocol to Improve Radicality. World Neurosurg 2019; 129:401-403. [DOI: 10.1016/j.wneu.2019.06.127] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Cho SS, Salinas R, Lee JYK. Indocyanine-Green for Fluorescence-Guided Surgery of Brain Tumors: Evidence, Techniques, and Practical Experience. Front Surg 2019; 6:11. [PMID: 30915339 PMCID: PMC6422908 DOI: 10.3389/fsurg.2019.00011] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 02/19/2019] [Indexed: 01/10/2023] Open
Abstract
The primary treatment for brain tumors often involves surgical resection for diagnosis, relief of mass effect, and prolonged survival. In neurosurgery, it is of utmost importance to achieve maximal safe resection while minimizing iatrogenic neurologic deficit. Thus, neurosurgeons often rely on extra tools in the operating room, such as neuronavigation, intraoperative magnetic resonance imaging, and/or intraoperative rapid pathology. However, these tools can be expensive, not readily available, time-consuming, and/or inaccurate. Recently, fluorescence-guided surgery has emerged as a cost-effective method to accurately visualize neoplastic areas in real-time to guide resection. Currently, 5-aminolevulinic-acid (5-ALA) remains the only fluorophore that has been approved specifically for fluorescence-guided tumor resection. Its use has demonstrated improved resection rates and prolonged progression-free survival. However, protoporphyrin-IX, the metabolic product of 5-ALA that accumulates in neoplastic cells, fluoresces in the visible-light range, which suffers from limited tissue penetration and significant auto-fluorescence. Near-infrared fluorescence, on the other hand, overcomes these problems with ease. Since 2012, researchers at our institution have developed a novel technique using indocyanine-green, which is a well-known near-infrared fluorophore used traditionally for angiography. This Second-Window-ICG (SWIG) technique takes advantage of the increased endothelial permeability in peritumoral tissue, which allows indocyanine-green to accumulate in these areas for intraoperative visualization of the tumor. SWIG has demonstrated utility in gliomas, meningiomas, metastases, pituitary adenomas, chordomas, and craniopharyngiomas. The main benefits of SWIG stem from its highly sensitive detection of neoplastic tissue in a wide variety of intracranial pathologies in real-time, which can help neurosurgeons both during surgical resections and in stereotactic biopsies. In this review of this novel technique, we summarize the development and mechanism of action of SWIG, provide evidence for its benefits, and discuss its limitations. Finally, for those interested in near-infrared fluorescence-guided surgery, we provide suggestions for maximizing the benefits while minimizing the limitations of SWIG based on our own experience thus far.
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Affiliation(s)
- Steve S Cho
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.,Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Ryan Salinas
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - John Y K Lee
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, PA, United States
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Wang L, Liang B, Li YI, Liu X, Huang J, Li YM. What is the advance of extent of resection in glioblastoma surgical treatment-a systematic review. Chin Neurosurg J 2019; 5:2. [PMID: 32922902 PMCID: PMC7398311 DOI: 10.1186/s41016-018-0150-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/27/2018] [Indexed: 12/14/2022] Open
Abstract
Glioblastoma multiform (GBM) is the most common malignant brain tumor characterized by poor prognosis, increased invasiveness, and high relapse rates. The relative survival estimates are quite low in spite of the standard treatment for GBM in recent years. Now, it has been gradually accepted that the amount of tumor mass removed correlates with longer survival rates. Although new technique advances allowing intraoperative analysis of tumor and normal brain tissue and functional paradigms based on stimulation techniques to map eloquent areas have been used for GBM resection, visual identification of tumor margins still remains a challenge for neurosurgeons. This article attempts to review and summarize the evolution of surgical resection for glioblastomas.
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Affiliation(s)
- Lei Wang
- Department of Neurosurgery and Radiology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642 USA.,Department of Neurosurgery, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai West Road, Xuzhou, 221002 Jiangsu Province China
| | - Buqing Liang
- Department of Neurosurgery, Baylor Scott & White Health, Temple, TX 76508 USA
| | - Yan Icy Li
- Department of Neurosurgery and Radiology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642 USA.,Department of Bioinformatics, Nanjing Medical University, Nanjing, 211166 China
| | - Xiang Liu
- Department of Neurosurgery and Radiology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642 USA
| | - Jason Huang
- Department of Neurosurgery, Baylor Scott & White Health, Temple, TX 76508 USA
| | - Yan Michael Li
- Department of Neurosurgery and Radiology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642 USA
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Höhne J, Schebesch KM, de Laurentis C, Akçakaya MO, Pedersen CB, Brawanski A, Poulsen FR, Kiris T, Cavallo C, Broggi M, Ferroli P, Acerbi F. Fluorescein Sodium in the Surgical Treatment of Recurrent Glioblastoma Multiforme. World Neurosurg 2019; 125:e158-e164. [PMID: 30682505 DOI: 10.1016/j.wneu.2019.01.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 12/31/2018] [Accepted: 01/02/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Glioblastoma multiforme (GBM) is the most common primary brain tumor and has a high recurrence rate. Maximizing the extent of resection (EOR) in recurrent GBM has proved to be the cornerstone of neurosurgical retreatment. The development of surgical microscopes fitted with fluorescein-specific filters has facilitated fluorescein-guided microsurgery and the identification of tumor tissue. Use of fluorescein sodium (FL) in primary high-grade glioma resection has shown promising results. Here, we present our experience with FL and the dedicated surgical microscope filter YELLOW 560 nm in 106 patients with recurrent GBM. METHODS A total of 106 patients with recurrent GBM were included (53 women, 53 men; mean age, 53 years). A total of 5 mg/kg bodyweight of FL was intravenously injected approximately 45 minutes before craniotomy. A YELLOW 560 nm filter (PENTERO 900 [Carl Zeiss Meditec, Oberkochen Germany]) was used for microsurgical tumor resection and resection control. Surgical reports were reviewed regarding the degree of fluorescent staining. Postoperative magnetic resonance images were examined within 48 hours after surgery regarding the EOR and postoperative course regarding neurologic outcome, complications, and any adverse events. RESULTS Bright fluorescent staining was present in all patients, which markedly enhanced tumor visibility and was deemed helpful for tumor resection. Seventeen patients (16%) showed residual tumor tissue on postoperative magnetic resonance imaging (MRI). Therefore, gross total resection was achieved in 89 patients (84%). No adverse events were registered postoperatively. CONCLUSIONS FL and YELLOW 560 nm are readily available methods for fluorescence-guided tumor resection, similar to contrast enhancement in T1-weighted MRI. FL may improve resection in recurrent GBM with minimal risk, and tumor margins are clearly visualized. FL and the YELLOW 560 nm filter are safe and feasible tools for safe maximal resection of recurrent glioblastoma.
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Affiliation(s)
- Julius Höhne
- Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany.
| | | | - Camilla de Laurentis
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | | | | | - Alexander Brawanski
- Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
| | | | - Talat Kiris
- Department of Neurosurgery, Liv Hospital, Istanbul, Turkey
| | - Claudio Cavallo
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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Lea D, Annie-Kim GL, Eve-Lyne L, Madeleine L, Marianne B, Sarah ML, Lucie D, Philippe Y L. Sodium Fluorescein for Ureteral Jet Detection: A Prospective Observational Study. JSLS 2018; 22:JSLS.2018.00019. [PMID: 30356883 PMCID: PMC6191068 DOI: 10.4293/jsls.2018.00019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives: Laparoscopic hysterectomy poses the risk of lower urinary tract injury, and intraoperative recognition of urinary tract injury is often difficult. We sought to evaluate sodium fluorescein coloration of ureteral jets during cystoscopy after laparoscopic hysterectomy and to evaluate surgeons' satisfaction with this method of injury detection. Methods: This was an observational study, in which data were collected prospectively. A total of 30 women who underwent laparoscopic hysterectomy from August 2016 to February 2017 at the Centre Hospitalier de l'Université Laval (CHUL) de Québec. Twenty-five milligrams of 10% intravenous sodium fluorescein was administered after vaginal cuff closure. Cystoscopy was then systematically performed, and the time to visualization (time from injection to coloration of ureteral jet), the quality of coloration, and the duration of cystoscopy were recorded. Side effects were systematically recorded and rigorously analyzed. Results: Most frequent indications for hysterectomy were fibroids and endometriosis with uterine weight from 76 to 885 g. Ninety-three percent of patients (n = 28) had bilateral ureteral jet coloration, whereas 1 patient had no coloration bilaterally, and another patient had a complete unilateral obstruction immediately diagnosed and resolved intraoperatively after removal of the vaginal sutures. In 90% of cases (n = 27), surgeons were highly satisfied with the use of sodium fluorescein. The average time between visualization of both left and right ureteral jets was 1 minute. Side effects included hypotension (n = 3) and yellow coloration of urine (n = 15). Conclusion: Our study suggests that sodium fluorescein is an effective dye for documenting ureteral patency and improving visualization of ureteral jets during cystoscopy upon completion of laparoscopic hysterectomy.
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Affiliation(s)
- Delbos Lea
- Département de gynécologie du CHU de Québec - Université Laval, Québec, QC, Canada
| | | | - Langlais Eve-Lyne
- Département de gynécologie du CHU de Québec - Université Laval, Québec, QC, Canada
| | - Lemyre Madeleine
- Département de gynécologie du CHU de Québec - Université Laval, Québec, QC, Canada
| | - Boutet Marianne
- Département de gynécologie du CHU de Québec - Université Laval, Québec, QC, Canada
| | - Maheux-Lacroix Sarah
- Département de gynécologie du CHU de Québec - Université Laval, Québec, QC, Canada
| | - Dallaire Lucie
- Département de pharmacie du CHU de Québec - Université Laval, Québec, QC, Canada
| | - Laberge Philippe Y
- Département de gynécologie du CHU de Québec - Université Laval, Québec, QC, Canada
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Abstract
The 'standard of care' method for sentinel node mapping is the combination technique using radioisotope and blue dye although some centres use radioisotope or blue dye alone. Radioisotope usage requires licensing, has regulatory issues around handling and disposal of waste, and logistically may be unavailable or difficult to implement in some centres or less developed country. This has led to the development of alternative methods such as superparamagnetic iron oxide (SPIO), fluorescence techniques using indocyanine green (ICG) or fluorescein, computed tomography lymphography, and contrast-enhanced ultrasound scan (CEUS) using microbubbles. The newer techniques will potentially enable a more widespread adoption of this procedure; however, a common barrier for these techniques is the lack of standardisation and no randomised trials to evaluate their effectiveness against the current standard of care. Furthermore, many of these techniques are more costly and may become redundant in node-negative patients with small tumours if ongoing trials show that sentinel node biopsy offers no additional benefit to grey-scale axillary ultrasound. This review discusses the new techniques for sentinel node mapping that have emerged including their pros and cons.
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Affiliation(s)
- Amit Goyal
- Department of Surgery, Royal Derby Hospital, Derby, UK
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Hong J, Chen B, Yao X, Yang Y. Outcome comparisons of high-grade glioma resection with or without fluorescein sodium-guidance. Curr Probl Cancer 2018; 43:236-244. [PMID: 30119909 DOI: 10.1016/j.currproblcancer.2018.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 07/16/2018] [Indexed: 01/16/2023]
Abstract
PURPOSE To compare surgical outcomes and adverse events between patients received microsurgical resection of high-grade gliomas with or without fluorescein sodium-guidance. PATIENTS A retrospective study was conducted in our hospital between June 2016 and January 2017. Patients were divided into 2 groups: Fluorescein Group (42 patients) and Nonfluorescein Group (40 patients). MEASUREMENTS Intraoperative (hemorrhage value and operation time) and postoperative (consistency between fluorescence-stained tissue and histopathological results, rate of resection) measurements were documented. Postoperative adverse events were recorded. Patients were followed up for 6 months to evaluate postsurgery glioma recurrence. MAIN RESULTS Intraoperatively, hemorrhage value, and operation time were significantly less in Fluorescencein than in Nonfluorescencein group. The rate of glioma complete resection was significantly higher in Fluorescencein than in Nonfluorescencein group (85.7%vs 62.5%, P = 0.02). The rate of glioma recurrence was significantly lower in Fluorescencein than in Nonfluorescencein group (11.9%vs 25.0%, P = 0.01), and no significant differences on adverse events were observed. CONCLUSIONS Intraoperative fluorescein sodium-guidance could facilitate the complete resection and significantly decrease the postoperative recurrence in patients with high-grade gliomas.
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Affiliation(s)
- Jian Hong
- Department of Neurosurgery, Tianjin HuanHu Hospital, Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Jinnan District, Tianjin, China.
| | - Budong Chen
- Department of Neurosurgery, Tianjin HuanHu Hospital, Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Jinnan District, Tianjin, China
| | - Xin Yao
- Department of Neurosurgery, Tianjin HuanHu Hospital, Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Jinnan District, Tianjin, China
| | - Yushan Yang
- Department of Neurosurgery, Tianjin HuanHu Hospital, Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Jinnan District, Tianjin, China
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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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With a Little Help from My Friends: The Role of Intraoperative Fluorescent Dyes in the Surgical Management of High-Grade Gliomas. Brain Sci 2018; 8:brainsci8020031. [PMID: 29414911 PMCID: PMC5836050 DOI: 10.3390/brainsci8020031] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 01/09/2018] [Accepted: 01/31/2018] [Indexed: 12/12/2022] Open
Abstract
High-grade gliomas (HGGs) are the most frequent primary malignant brain tumors in adults, which lead to death within two years of diagnosis. Maximal safe resection of malignant gliomas as the first step of multimodal therapy is an accepted goal in malignant glioma surgery. Gross total resection has an important role in improving overall survival (OS) and progression-free survival (PFS), but identification of tumor borders is particularly difficult in HGGS. For this reason, imaging adjuncts, such as 5-aminolevulinic acid (5-ALA) or fluorescein sodium (FS) have been proposed as superior strategies for better defining the limits of surgical resection for HGG. 5-aminolevulinic acid (5-ALA) is implicated as precursor in the synthetic pathway of heme group. Protoporphyrin IX (PpIX) is an intermediate compound of heme metabolism, which produces fluorescence when excited by appropriate light wavelength. Malignant glioma cells have the capacity to selectively synthesize or accumulate 5-ALA-derived porphyrins after exogenous administration of 5-ALA. Fluorescein sodium (FS), on the other hand, is a fluorescent substance that is not specific to tumor cells but actually it is a marker for compromised blood-brain barrier (BBB) areas. Its effectiveness is confirmed by multicenter phase-II trial (FLUOGLIO) but lack of randomized phase III trial data. We conducted an analytic review of the literature with the objective of identifying the usefulness of 5-ALA and FS in HGG surgery in adult patients.
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Xiang Y, Zhu XP, Zhao JN, Huang GH, Tang JH, Chen HR, Du L, Zhang D, Tang XF, Yang H, Lv SQ. Blood-Brain Barrier Disruption, Sodium Fluorescein, And Fluorescence-Guided Surgery Of Gliomas. Br J Neurosurg 2018; 32:141-148. [PMID: 29357709 DOI: 10.1080/02688697.2018.1428731] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Sodium fluorescein (SF) is an ideal dye for intraoperative guided-resection of high-grade gliomas (HGGs). However, it is not well understood whether the SF-guided technique is suitable for different grades of gliomas, and the correlation between fluorescence and pathology is also not yet clear. MATERIALS AND METHODS In this study, we investigated 28 patients, including 23 patients with HGG and 5 patients with low-grade glioma (LGG). All patients were treated using the SF-guided technique on a Pentero 900 microscope (Carl Zeiss, Oberkochen, Germany). Claudin-5 immunohistochemical (IHC) staining for the tumours and peritumour tissues was analyzed. RESULTS Intraoperative yellow fluorescence was noted in all the HGGs but not in the LGGs. Claudin-5 expression in the blood brain barrier endothelial cells was downregulated and disconnected in the HGGs (p < 0.05), but had no difference or slightly decreased in the LGGs (p > 0.05). CONCLUSIONS The SF-guided technique is suitable for HGG surgery but not for LGG surgery. Downregulation of claudin-5 expression may contribute to the presence of yellow fluorescence in the glioma in SF-guided surgery.
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Affiliation(s)
- Yan Xiang
- a Department of Neurosurgery , Xinqiao Hospital, Third Military Medical University , Chongqing , P.R. China
| | - Xiao-Peng Zhu
- a Department of Neurosurgery , Xinqiao Hospital, Third Military Medical University , Chongqing , P.R. China
| | - Jian-Nong Zhao
- b Department of Neurosurgery , Hainan General Hospital , Haikou , P.R. China
| | - Guo-Hao Huang
- a Department of Neurosurgery , Xinqiao Hospital, Third Military Medical University , Chongqing , P.R. China
| | - Jun-Hai Tang
- a Department of Neurosurgery , Xinqiao Hospital, Third Military Medical University , Chongqing , P.R. China
| | - Huan-Ran Chen
- a Department of Neurosurgery , Xinqiao Hospital, Third Military Medical University , Chongqing , P.R. China
| | - Lei Du
- a Department of Neurosurgery , Xinqiao Hospital, Third Military Medical University , Chongqing , P.R. China
| | - Dong Zhang
- c Department of Radiology , Xinqiao Hospital, Third Military Medical University , Chongqing , P.R. China
| | - Xue-Feng Tang
- d Department of Pathology , Xinqiao Hospital, Third Military Medical University , Chongqing , P.R. China
| | - Hui Yang
- a Department of Neurosurgery , Xinqiao Hospital, Third Military Medical University , Chongqing , P.R. China
| | - Sheng-Qing Lv
- a Department of Neurosurgery , Xinqiao Hospital, Third Military Medical University , Chongqing , P.R. China
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Nagaya T, Nakamura YA, Choyke PL, Kobayashi H. Fluorescence-Guided Surgery. Front Oncol 2017; 7:314. [PMID: 29312886 PMCID: PMC5743791 DOI: 10.3389/fonc.2017.00314] [Citation(s) in RCA: 225] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 12/05/2017] [Indexed: 01/02/2023] Open
Abstract
Surgical resection of cancer remains an important treatment modality. Despite advances in preoperative imaging, surgery itself is primarily guided by the surgeon’s ability to locate pathology with conventional white light imaging. Fluorescence-guided surgery (FGS) can be used to define tumor location and margins during the procedure. Intraoperative visualization of tumors may not only allow more complete resections but also improve safety by avoiding unnecessary damage to normal tissue which can also reduce operative time and decrease the need for second-look surgeries. A number of new FGS imaging probes have recently been developed, complementing a small but useful number of existing probes. In this review, we describe current and new fluorescent probes that may assist FGS.
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Affiliation(s)
- Tadanobu Nagaya
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Yu A Nakamura
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Peter L Choyke
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Hisataka Kobayashi
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
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Acerbi F, Broggi M, Schebesch KM, Höhne J, Cavallo C, De Laurentis C, Eoli M, Anghileri E, Servida M, Boffano C, Pollo B, Schiariti M, Visintini S, Montomoli C, Bosio L, La Corte E, Broggi G, Brawanski A, Ferroli P. Fluorescein-Guided Surgery for Resection of High-Grade Gliomas: A Multicentric Prospective Phase II Study (FLUOGLIO). Clin Cancer Res 2017; 24:52-61. [PMID: 29018053 DOI: 10.1158/1078-0432.ccr-17-1184] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 08/05/2017] [Accepted: 10/05/2017] [Indexed: 11/16/2022]
Abstract
Purpose: Sodium fluorescein is a dye that, intravenously injected, selectively accumulates in high-grade glioma (HGG) tissue through a damaged blood-brain barrier. In this article, the final results of a multicentric prospective phase II trial (FLUOGLIO) on fluorescein-guided HGG resection through a dedicated filter on the surgical microscope were reported.Methods: Patients with suspected HGGs considered suitable for removal were eligible to participate in this trial. Fluorescein was intravenously injected at a dose of 5 to 10 mg/kg. The primary endpoint was the percentage of patients with histologically confirmed HGGs, without contrast-enhancing tumor at the immediate postoperative MRI. Secondary endpoints were PFS, residual tumor on postoperative MRI, overall survival, neurologic deficits, and fluorescein-related toxicity. The sensitivity and specificity of fluorescein in identifying tumor tissue were estimated by fluorescent and nonfluorescent biopsies at the tumor margin. The study was registered on the European Regulatory Authorities website (EudraCT 2011-002527-18).Results: Fifty-seven patients aged 45 to 75 years were screened for participation, and 46 were considered for primary and secondary endpoints. Mean preoperative tumor volume was 28.75 cm3 (range, 1.3-87.8 cm3). Thirty-eight patients (82.6%) underwent a complete tumor removal. Median follow-up was 11 months. PFS-6 and PFS-12 were 56.6% and 15.2%. Median survival was 12 months. No adverse reaction related to SF administration was recorded. The sensitivity and specificity of fluorescein in identifying tumor tissue were respectively 80.8% and 79.1%.Conclusions: Fluorescein-guided technique with a dedicated filter on the surgical microscope is safe and enables a high percentage of contrast-enhancing tumor in patients with HGGs. Clin Cancer Res; 24(1); 52-61. ©2017 AACR.
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Affiliation(s)
- Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy.
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Karl-Michael Schebesch
- Department of Neuropathology and Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Julius Höhne
- Department of Neuropathology and Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Claudio Cavallo
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Camilla De Laurentis
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Marica Eoli
- Department of Molecular Neuro-Oncology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Elena Anghileri
- Department of Molecular Neuro-Oncology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Maura Servida
- Department of Molecular Neuro-Oncology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Carlo Boffano
- Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Bianca Pollo
- Department of Neuropathology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Sergio Visintini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Cristina Montomoli
- Department of Public Health, Forensic and Experimental Medicine, Unit of Biostatistic and Clinic Epidemiology, University of Pavia, Pavia, Italy
| | - Lorenzo Bosio
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Emanuele La Corte
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Giovanni Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Alexander Brawanski
- Department of Neuropathology and Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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Acerbi F, Cavallo C, Schebesch KM, Akçakaya MO, de Laurentis C, Hamamcioglu MK, Broggi M, Brawanski A, Falco J, Cordella R, Ferroli P, Kiris T, Höhne J. Fluorescein-Guided Resection of Intramedullary Spinal Cord Tumors: Results from a Preliminary, Multicentric, Retrospective Study. World Neurosurg 2017; 108:603-609. [PMID: 28935546 DOI: 10.1016/j.wneu.2017.09.061] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 09/07/2017] [Accepted: 09/09/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Intramedullary spinal cord tumors (IMSCTs) are rare, heterogenous lesions that are usually enhanced on preoperative magnetic resonance imaging (MRI) because of a damaged blood-brain barrier. Sodium fluorescein is a dye that accumulates in areas of the central nervous system with a damaged BBB. Given the pattern of MRI contrast enhancement of the majority of IMSCTs, the use of this fluorescent tracer could improve tumor visualization and quality of resection. In this article, we present the first experience with the application of fluorescein-guided technique for surgical removal of IMSCTs. METHODS Eleven patients (6 men, 5 women; mean age, 50.1 years), harboring 5 ependymomas, 3 hemangioblastomas, 1 astrocytoma, 1 pilocytic astrocytoma, and 1 glioneuronal tumor forming rosettes were included. Sodium fluorescein (5 mg/kg) was injected immediately after patient intubation. Tumors were removed with microsurgical technique and standard neurophysiological monitoring, under YELLOW 560 filter (Pentero 900) visualization. Surgical reports were reviewed regarding usefulness and grade of fluorescein staining. Postoperative MRI was performed within 72 hours after surgery, and postoperative clinical outcome was registered. RESULTS No adverse events were registered. Fluorescent staining was reported in 9 of 11 cases (82%), all of them enhancing on preoperative MRI (100% of ependymomas, 100% of pilocytic astrocytomas, 100% of hemangioblastomas). No fluorescence was reported in 1 astrocytoma and 1 glioneuronal tumor-forming rosette. Intraoperative fluorescence was considered helpful for tumor resection in 9 of 11 cases (82%). Gross total resection was obtained in 8 of 11 cases (72.7%). CONCLUSIONS Our results suggest that fluorescein-guided surgery is a safe and effective technique that can be used during the surgical resection of IMSCTs presenting with contrast-enhancement on preoperative MRI.
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Affiliation(s)
- Francesco Acerbi
- Neurosurgical Unit 2, Department of Neurosurgery, Foundation IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Claudio Cavallo
- Neurosurgical Unit 2, Department of Neurosurgery, Foundation IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Mehmet Osman Akçakaya
- Department of Neurosurgery, Liv Hospital Ulus affiliated to Istinye University Medical Faculty, Istanbul, Turkey
| | - Camilla de Laurentis
- Neurosurgical Unit 2, Department of Neurosurgery, Foundation IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Mustafa Kemal Hamamcioglu
- Department of Neurosurgery, Liv Hospital Ulus affiliated to Istinye University Medical Faculty, Istanbul, Turkey
| | - Morgan Broggi
- Neurosurgical Unit 2, Department of Neurosurgery, Foundation IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Jacopo Falco
- Neurosurgical Unit 2, Department of Neurosurgery, Foundation IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Roberto Cordella
- Neurosurgical Unit 2, Department of Neurosurgery, Foundation IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paolo Ferroli
- Neurosurgical Unit 2, Department of Neurosurgery, Foundation IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Talat Kiris
- Department of Neurosurgery, Liv Hospital Ulus affiliated to Istinye University Medical Faculty, Istanbul, Turkey
| | - Julius Höhne
- Department of Neurosurgery, University Medical Center, Regensburg, Germany
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Abstract
Intraoperative fluorescence imaging allows real-time identification of diseased tissue during surgery without being influenced by brain shift and surgery interruption. 5-Aminolevulinic acid, useful for malignant gliomas and other tumors, is the most broadly explored compound approved for fluorescence-guided resection. Intravenous fluorescein sodium has recently received attention, highlighting tumor tissue based on extravasation at the blood-brain barrier (defective in many brain tumors). Fluorescein in perfused brain, unselective extravasation in brain perturbed by surgery, and propagation with edema are concerns. Fluorescein is not approved but targeted fluorochromes with affinity to brain tumor cells, in development, may offer future advantages.
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Affiliation(s)
- Walter Stummer
- Department of Neurosurgery, Univerity Hospital Münster, Münster, Germany.
| | - Eric Suero Molina
- Department of Neurosurgery, Univerity Hospital Münster, Münster, Germany
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Fluorescein-Guided Surgery for High-Grade Glioma Resection: An Intraoperative “Contrast-Enhancer”. World Neurosurg 2017; 104:239-247. [DOI: 10.1016/j.wneu.2017.05.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/01/2017] [Accepted: 05/04/2017] [Indexed: 11/22/2022]
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Lovato RM, Vitorino Araujo JL, Esteves Veiga JC. Low-Cost Device for Fluorescein-Guided Surgery in Malignant Brain Tumor. World Neurosurg 2017; 104:61-67. [DOI: 10.1016/j.wneu.2017.04.169] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/26/2017] [Accepted: 04/27/2017] [Indexed: 11/29/2022]
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Francaviglia N, Iacopino DG, Costantino G, Villa A, Impallaria P, Meli F, Maugeri R. Fluorescein for resection of high-grade gliomas: A safety study control in a single center and review of the literature. Surg Neurol Int 2017; 8:145. [PMID: 28781922 PMCID: PMC5523479 DOI: 10.4103/sni.sni_89_17] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 05/18/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The importance of a complete resection of high-grade gliomas (HGGs) has been highlighted in scientific literature, in order to limit tumor recurrence and above all to improve disease-free survival rates. Several fluorescent biomarkers have been tested to improve intraoperative identification of residual tumor; 5-aminolevulinic acid (5-ALA) and fluorescein sodium (FS) are now starting to play a central role in glioma surgery. We performed a retrospective analysis on 47 patients operated for HGGs. Here we report our preliminary data. METHODS Data of 47 consecutive patients with HGG have been collected in our study (25 males, 22 females; mean age: 60.3 years, range: 27-86 years). Fluorescein (5 mg/kg of body weight) was injected intravenously right after the induction of general anesthesia. A YELLOW 560 filter was used on an OPMI Pentero 900 microscope (Carl Zeiss Meditec, Oberkochen, Germany) to complete a microsurgical tumor removal. Glioma resection and quality of life were evaluated preoperative and postoperatively. RESULTS Gross total resection (GTR) was achieved in 53.2% (n = 25) of patients. A subtotal resection (STR) (>95%) was achieved in 29.8% (n = 14), while a partial resection (PR) (<95%) was obtained in 17% (n = 8) of patients. Overall, in 83% (n = 39) of patients who underwent fluorescence-guided surgery the resection rate achieved was >95%. No adverse effects correlated to fluorescein have been recorded. CONCLUSION Fluorescein seems to be safe and effective in the resection of HGGs, allowing a high rate of gross total removal of contrast enhanced areas.
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Affiliation(s)
| | - Domenico Gerardo Iacopino
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Neurosurgical Clinic, AOUP “Paolo Giaccone”, Palermo, Italy
| | | | | | | | - Francesco Meli
- Division of Neurosurgery, ARNAS Civico Hospital, Palermo, Italy
| | - Rosario Maugeri
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Neurosurgical Clinic, AOUP “Paolo Giaccone”, Palermo, Italy
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Pogue BW, Paulsen KD, Samkoe KS, Elliott JT, Hasan T, Strong TV, Draney DR, Feldwisch J. Vision 20/20: Molecular-guided surgical oncology based upon tumor metabolism or immunologic phenotype: Technological pathways for point of care imaging and intervention. Med Phys 2017; 43:3143-3156. [PMID: 27277060 DOI: 10.1118/1.4951732] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Surgical guidance with fluorescence has been demonstrated in individual clinical trials for decades, but the scientific and commercial conditions exist today for a dramatic increase in clinical value. In the past decade, increased use of indocyanine green based visualization of vascular flow, biliary function, and tissue perfusion has spawned a robust growth in commercial systems that have near-infrared emission imaging and video display capabilities. This recent history combined with major preclinical innovations in fluorescent-labeled molecular probes, has the potential for a shift in surgical practice toward resection guidance based upon molecular information in addition to conventional visual and palpable cues. Most surgical subspecialties already have treatment management decisions partially based upon the immunohistochemical phenotype of the cancer, as assessed from molecular pathology of the biopsy tissue. This phenotyping can inform the surgical resection process by spatial mapping of these features. Further integration of the diagnostic and therapeutic value of tumor metabolism sensing molecules or immune binding agents directly into the surgical process can help this field mature. Maximal value to the patient would come from identifying the spatial patterns of molecular expression in vivo that are well known to exist. However, as each molecular agent is advanced into trials, the performance of the imaging system can have a critical impact on the success. For example, use of pre-existing commercial imaging systems are not well suited to image receptor targeted fluorophores because of the lower concentrations expected, requiring orders of magnitude more sensitivity. Additionally the imaging system needs the appropriate dynamic range and image processing features to view molecular probes or therapeutics that may have nonspecific uptake or pharmacokinetic issues which lead to limitations in contrast. Imaging systems need to be chosen based upon objective performance criteria, and issues around calibration, validation, and interpretation need to be established before a clinical trial starts. Finally, as early phase trials become more established, the costs associated with failures can be crippling to the field, and so judicious use of phase 0 trials with microdose levels of agents is one viable paradigm to help the field advance, but this places high sensitivity requirements on the imaging systems used. Molecular-guided surgery has truly transformative potential, and several key challenges are outlined here with the goal of seeing efficient advancement with ideal choices. The focus of this vision 20/20 paper is on the technological aspects that are needed to be paired with these agents.
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Affiliation(s)
- Brian W Pogue
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire 03755 and Department of Surgery, Dartmouth College, Hanover, New Hampshire 03755
| | - Keith D Paulsen
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire 03755; Department of Surgery, Dartmouth College, Hanover, New Hampshire 03755; and Department of Diagnostic Radiology, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire 03755
| | - Kimberley S Samkoe
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire 03755 and Department of Surgery, Dartmouth College, Hanover, New Hampshire 03755
| | - Jonathan T Elliott
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire 03755
| | - Tayyaba Hasan
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114 and Division of Health Sciences and Technology, Harvard University and Massachusetts Institute of Technology, Cambridge, Massachusetts 02139
| | - Theresa V Strong
- Vector Production Facility, Division of Hematology Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35294
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Senders JT, Muskens IS, Schnoor R, Karhade AV, Cote DJ, Smith TR, Broekman MLD. Agents for fluorescence-guided glioma surgery: a systematic review of preclinical and clinical results. Acta Neurochir (Wien) 2017; 159:151-167. [PMID: 27878374 PMCID: PMC5177668 DOI: 10.1007/s00701-016-3028-5] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 11/09/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Fluorescence-guided surgery (FGS) is a technique used to enhance visualization of tumor margins in order to increase the extent of tumor resection in glioma surgery. In this paper, we systematically review all clinically tested fluorescent agents for application in FGS for glioma and all preclinically tested agents with the potential for FGS for glioma. METHODS We searched the PubMed and Embase databases for all potentially relevant studies through March 2016. We assessed fluorescent agents by the following outcomes: rate of gross total resection (GTR), overall and progression-free survival, sensitivity and specificity in discriminating tumor and healthy brain tissue, tumor-to-normal ratio of fluorescent signal, and incidence of adverse events. RESULTS The search strategy resulted in 2155 articles that were screened by titles and abstracts. After full-text screening, 105 articles fulfilled the inclusion criteria evaluating the following fluorescent agents: 5-aminolevulinic acid (5-ALA) (44 studies, including three randomized control trials), fluorescein (11), indocyanine green (five), hypericin (two), 5-aminofluorescein-human serum albumin (one), endogenous fluorophores (nine) and fluorescent agents in a pre-clinical testing phase (30). Three meta-analyses were also identified. CONCLUSIONS 5-ALA is the only fluorescent agent that has been tested in a randomized controlled trial and results in an improvement of GTR and progression-free survival in high-grade gliomas. Observational cohort studies and case series suggest similar outcomes for FGS using fluorescein. Molecular targeting agents (e.g., fluorophore/nanoparticle labeled with anti-EGFR antibodies) are still in the pre-clinical phase, but offer promising results and may be valuable future alternatives.
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Affiliation(s)
- Joeky T Senders
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ivo S Muskens
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rosalie Schnoor
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Aditya V Karhade
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA, 02115, USA
| | - David J Cote
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA, 02115, USA
| | - Timothy R Smith
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA, 02115, USA
| | - Marike L D Broekman
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Bravo JJ, Davis SC, Roberts DW, Paulsen KD, Kanick SC. Mathematical model to interpret localized reflectance spectra measured in the presence of a strong fluorescence marker. JOURNAL OF BIOMEDICAL OPTICS 2016; 21:61004. [PMID: 26836297 PMCID: PMC4734982 DOI: 10.1117/1.jbo.21.6.061004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 12/31/2015] [Indexed: 06/05/2023]
Abstract
Quantification of multiple fluorescence markers during neurosurgery has the potential to provide complementary contrast mechanisms between normal and malignant tissues, and one potential combination involves fluorescein sodium (FS) and aminolevulinic acid-induced protoporphyrin IX (PpIX). We focus on the interpretation of reflectance spectra containing contributions from elastically scattered (reflected) photons as well as fluorescence emissions from a strong fluorophore (i.e., FS). A model-based approach to extract μa and μ′s in the presence of FS emission is validated in optical phantoms constructed with Intralipid (1% to 2% lipid) and whole blood (1% to 3% volume fraction), over a wide range of FS concentrations (0 to 1000 μg/ml 1000 μg/ml ). The results show that modeling reflectance as a combination of elastically scattered light and attenuation-corrected FS-based emission yielded more accurate tissue parameter estimates when compared with a nonmodified reflectance model, with reduced maximum errors for blood volume (22% versus 90%), microvascular saturation (21% versus 100%), and μs′ (13% versus 207%). Additionally, quantitative PpIX fluorescence sampled in the same phantom as FS showed significant differences depending on the reflectance model used to estimate optical properties (i.e., maximum error 29% versus 86%). These data represent a first step toward using quantitative optical spectroscopy to guide surgeries through simultaneous assessment of FS and PpIX.
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Affiliation(s)
- Jaime J. Bravo
- Dartmouth College, Thayer School of Engineering, 14 Engineering Drive, Hanover, New Hampshire 03755, United States
| | - Scott C. Davis
- Dartmouth College, Thayer School of Engineering, 14 Engineering Drive, Hanover, New Hampshire 03755, United States
- Dartmouth-Hitchcock Medical Center, Norris Cotton Cancer Center, 1 Medical Center Drive, Lebanon, New Hampshire 03756, United States
| | - David W. Roberts
- Dartmouth-Hitchcock Medical Center, Norris Cotton Cancer Center, 1 Medical Center Drive, Lebanon, New Hampshire 03756, United States
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, New Hampshire 03755, United States
- Dartmouth-Hitchcock Medical Center, Section of Neurosurgery, 1 Medical Center Drive, Lebanon, New Hampshire 03756, United States
| | - Keith D. Paulsen
- Dartmouth College, Thayer School of Engineering, 14 Engineering Drive, Hanover, New Hampshire 03755, United States
- Dartmouth-Hitchcock Medical Center, Norris Cotton Cancer Center, 1 Medical Center Drive, Lebanon, New Hampshire 03756, United States
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, New Hampshire 03755, United States
| | - Stephen C. Kanick
- Dartmouth College, Thayer School of Engineering, 14 Engineering Drive, Hanover, New Hampshire 03755, United States
- Dartmouth-Hitchcock Medical Center, Norris Cotton Cancer Center, 1 Medical Center Drive, Lebanon, New Hampshire 03756, United States
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Fluorescein assistance in neuro-oncological surgery: A trend of the moment or a real technical adjunt? Clin Neurol Neurosurg 2016; 144:119-20. [PMID: 27038874 DOI: 10.1016/j.clineuro.2016.03.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 03/13/2016] [Accepted: 03/14/2016] [Indexed: 12/14/2022]
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Stummer W. Factors confounding fluorescein-guided malignant glioma resections: edema bulk flow, dose, timing, and now: imaging hardware? Acta Neurochir (Wien) 2016; 158:327-8. [PMID: 26643371 PMCID: PMC4715125 DOI: 10.1007/s00701-015-2655-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 11/24/2015] [Indexed: 11/29/2022]
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Guyotat J, Pallud J, Armoiry X, Pavlov V, Metellus P. 5-Aminolevulinic Acid-Protoporphyrin IX Fluorescence-Guided Surgery of High-Grade Gliomas: A Systematic Review. Adv Tech Stand Neurosurg 2016:61-90. [PMID: 26508406 DOI: 10.1007/978-3-319-21359-0_3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The current first-line treatment of malignant gliomas consists in surgical resection (if possible) as large as possible. The existing tools don't permit to identify the limits of tumor infiltration, which goes beyond the zone of contrast enhancement on MRI. The fluorescence-guided malignant gliomas surgery was started 15 years ago and had become a standard of care in many countries. The technique is based on fluorescent molecule revelation using the filters, positioned within the surgical microscope. The fluorophore, protoporphyrin IX (PpIX), is converted in tumoral cells from 5-aminolevulinic acid (5-ALA), given orally before surgery. Many studies have shown that the ratio of gross total resections was higher if the fluorescence technique was used. The fluorescence signal intensity is correlated to the cell density and the PpIX concentration. The current method has a very high specificity but still lower sensibility, particularly regarding the zones with poor tumoral infiltration. This book reviews the principles of the technique and the results (extent of resection and survival).
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Affiliation(s)
- Jacques Guyotat
- Department of Neurosurgery, Neurological Hospital, Lyon, France.
| | - Johan Pallud
- Department of Neurosurgery, Sainte Anne Hospital, Paris, France.
- Paris Descartes University, Paris, France.
| | - Xavier Armoiry
- Délégation à la recherche clinique et à l'innovation, cellule innovation Hospices Civils de, Lyon, France.
| | - Vladislav Pavlov
- Department of Neurosurgery, Neurological Hospital, Lyon, France.
| | - Philippe Metellus
- Department of Neurosurgery, Timone Hospital, Marseille, France.
- University Aix Marseille, Marseille, France.
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Affiliation(s)
- Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany,
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46
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Abstract
Mounting evidence suggests that a more extensive surgical resection is associated with an improved life expectancy for both low-grade and high-grade glioma patients. However, radiographically complete resections are not often achieved in many cases because of the lack of sensitivity and specificity of current neurosurgical guidance techniques at the margins of diffuse infiltrative gliomas. Intraoperative fluorescence imaging offers the potential to improve the extent of resection and to investigate the possible benefits of resecting beyond the radiographic margins. Here, we provide a review of wide-field and high-resolution fluorescence-imaging strategies that are being developed for neurosurgical guidance, with a focus on emerging imaging technologies and clinically viable contrast agents. The strengths and weaknesses of these approaches will be discussed, as well as issues that are being addressed to translate these technologies into the standard of care.
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Affiliation(s)
- Jonathan T C Liu
- *Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York; ‡Barrow Brain Tumor Research Center, Division of Neurosurgical Oncology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Maawy AA, Hiroshima Y, Zhang Y, Luiken GA, Hoffman RM, Bouvet M. Polyethylene glycol (PEG) linked to near infrared (NIR) dyes conjugated to chimeric anti-carcinoembryonic antigen (CEA) antibody enhances imaging of liver metastases in a nude-mouse model of human colon cancer. PLoS One 2014; 9:e97965. [PMID: 24859320 PMCID: PMC4032229 DOI: 10.1371/journal.pone.0097965] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 04/26/2014] [Indexed: 11/18/2022] Open
Abstract
We report here that polyethylene glycol (PEG) linked to near infrared dyes conjugated to chimeric mouse-human anti-carcinoembryonic antigen (CEA) antibody greatly improves imaging of liver metastases in a nude mouse model of colon-cancer experimental metastases. PEGylated and non-PEGylated DyLight 650 and 750 dyes were conjugated to the chimeric anti-CEA antibody. The dyes were initially injected intravenously into nude mice without tumors. Tissue biodistribution was determined by tissue sonication and analyzing tissue dye concentration profiles over time. PEGylated dyes had significantly lower accumulation in the liver (p = 0.03 for the 650 dyes; p = 0.002 for the 750 dyes) compared to non-PEGylated dyes. In an experimental liver metastasis model of HT-29 colon cancer, PEGylated dyes conjugated to the anti-CEA antibody showed good labeling of metastatic tumors with high contrast between normal and malignant tissue which was not possible with the non-PEGylated dyes since there was so much non-specific accumulation in the liver. PEGylation of the DyLight 650 and 750 NIR dyes significantly altered tissue biodistribution, allowing brighter tissue labeling, decreased accumulation in normal organs, particularly the liver. This enabled high fidelity and high contrast imaging of liver metastases.
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Affiliation(s)
- Ali A. Maawy
- Department of Surgery, University of California San Diego, San Diego, California, United States of America
| | - Yukihiko Hiroshima
- AntiCancer, Inc., San Diego, California, United States of America
- Yokohama City University, Yokohama City, Japan
| | - Yong Zhang
- AntiCancer, Inc., San Diego, California, United States of America
| | - George A. Luiken
- OncoFluor, Inc., San Diego, California, United States of America
| | - Robert M. Hoffman
- Department of Surgery, University of California San Diego, San Diego, California, United States of America
- AntiCancer, Inc., San Diego, California, United States of America
| | - Michael Bouvet
- Department of Surgery, University of California San Diego, San Diego, California, United States of America
- VA San Diego Healthcare System, San Diego, California, United States of America
- * E-mail:
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Muthuraj B, Deshmukh R, Trivedi V, Iyer PK. Highly selective probe detects Cu2+ and endogenous NO gas in living cell. ACS APPLIED MATERIALS & INTERFACES 2014; 6:6562-9. [PMID: 24703409 DOI: 10.1021/am501476w] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The rapid and highly sensitive detection of extremely short-lived nitric oxide (NO) gas generated in vivo by a water-soluble fluorescein derivative is developed. This assay system comprises of indole-3-carboxaldehyde functionalized fluorescein hydrazone (FI) assay which displays a typically high absorption at 492 and 620 nm in the presence of Cu2+ and also shows FRET induced fluorescence turn-on exclusively with Cu2+. FI selectively detects Cu2+ in vivo and in vitro by the "turn-on" mechanism followed by fluorescence "turn-off" with NO gas generated by the lipopolysaccharide (LPS) action. The in vivo experiment performed in the cellular system indicates that FI loaded RAW264.7 cells showed bright fluorescence in the presence of Cu2+, while other metals did not influence the FI fluorescence. In addition, the fluorescence of FI-Cu2+ was efficiently quenched by NO generated in macrophages through LPS stimulation. FI demonstrates characteristic "turn-on" behavior in the presence of Cu2+ via spirolactom ring-opening, while other metals such as Na+, K+, Ca2+, Cr3+, Mn2+, Fe3+, Fe2+, Co2+, Ni2+, Zn2+, Cd2+, Hg2+, and Ag+ did not influence FI fluorescence even at very high concentration. Further, the FI-Cu2+ complex fluorescence was not quenched with any anions or amino acids but totally quenched by NO and the paramagnetic nature of Cu2+ ion converted into the diamagnetic nature when reduced to Cu1+. FI and the FI-Cu2+ complex are nontoxic to the cellular system and have high potential for biomedical applications.
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Affiliation(s)
- Balakrishnan Muthuraj
- Department of Chemistry, Indian Institute of Technology , Guwahati-781039, Assam, India
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Fluorescein-guided surgery for malignant gliomas: a review. Neurosurg Rev 2014; 37:547-57. [DOI: 10.1007/s10143-014-0546-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 01/08/2014] [Accepted: 01/26/2014] [Indexed: 01/11/2023]
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50
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Maawy AA, Hiroshima Y, Kaushal S, Luiken GA, Hoffman RM, Bouvet M. Comparison of a chimeric anti-carcinoembryonic antigen antibody conjugated with visible or near-infrared fluorescent dyes for imaging pancreatic cancer in orthotopic nude mouse models. JOURNAL OF BIOMEDICAL OPTICS 2013; 18:126016. [PMID: 24356647 PMCID: PMC3868446 DOI: 10.1117/1.jbo.18.12.126016] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/23/2013] [Accepted: 10/24/2013] [Indexed: 06/01/2023]
Abstract
The aim of this study was to evaluate a set of visible and near-infrared dyes conjugated to a tumor-specific chimeric antibody for high-resolution tumor imaging in orthotopic models of pancreatic cancer. BxPC-3 human pancreatic cancer was orthotopically implanted into pancreata of nude mice. Mice received a single intravenous injection of a chimeric anti-carcinoembryonic antigen antibody conjugated to one of the following fluorophores: 488-nm group (Alexa Fluor 488 or DyLight 488); 550-nm group (Alexa Fluor 555 or DyLight 550); 650-nm group (Alexa Fluor 660 or DyLight 650), or the 750-nm group (Alexa Fluor 750 or DyLight 755). After 24 h, the Olympus OV100 small-animal imaging system was used for noninvasive and intravital fluorescence imaging of mice. Dyes were compared with respect to depth of imaging, resolution, tumor-to-background ratio (TBR), photobleaching, and hemoglobin quenching. The longer wavelength dyes had increased depth of penetration and ability to detect the smallest tumor deposits and provided the highest TBRs, resistance to hemoglobin quenching, and specificity. The shorter wavelength dyes were more photostable. This study showed unique advantages of each dye for specific cancer imaging in a clinically relevant orthotopic model.
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Affiliation(s)
- Ali A. Maawy
- University of California San Diego, UCSD Moores Cancer Center, 3855 Health Sciences Drive #0987, La Jolla, California 92093
| | - Yukihiko Hiroshima
- University of California San Diego, UCSD Moores Cancer Center, 3855 Health Sciences Drive #0987, La Jolla, California 92093
- Yokohama City University Graduate School of Medicine, 3-9 Fukuura Kanazawa-ku,Yokohama city, Kanagawa 2360004, Japan
- AntiCancer, Inc., 7917 Ostrow Street, San Diego, California 92111
| | - Sharmeela Kaushal
- University of California San Diego, UCSD Moores Cancer Center, 3855 Health Sciences Drive #0987, La Jolla, California 92093
| | | | - Robert M. Hoffman
- University of California San Diego, UCSD Moores Cancer Center, 3855 Health Sciences Drive #0987, La Jolla, California 92093
- AntiCancer, Inc., 7917 Ostrow Street, San Diego, California 92111
| | - Michael Bouvet
- University of California San Diego, UCSD Moores Cancer Center, 3855 Health Sciences Drive #0987, La Jolla, California 92093
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, California 92161
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