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Xiao Y, Li M, Wang X, Tan J, Qin C, Liu Q. Fluorescein-guided surgery in high-grade gliomas: focusing on the eloquent and deep-seated areas. J Cancer Res Clin Oncol 2024; 150:274. [PMID: 38795238 PMCID: PMC11127876 DOI: 10.1007/s00432-024-05796-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 05/09/2024] [Indexed: 05/27/2024]
Abstract
PURPOSE The vital function of eloquent and deep brain areas necessitates precise treatment for tumors located in these regions. Fluorescein-guided surgery (FGS) has been widely used for high-grade gliomas (HGGs) resection. Nevertheless, the safety and efficacy of utilizing this technique for resecting brain tumors located in eloquent and deep-seated areas remain uncertain. This study aims to assess the safety and extent of resection of HGGs in these challenging tumors with fluorescein and explore its impact on patient survival. METHODS A retrospective analysis was conducted on the clinical and radiological data of 67 consecutive patients with eloquent or deep-seated HGGs who underwent surgery between January 2020 and June 2023. Lacroix functional location grade was used to determine the eloquence of the tumors. The comparison between the fluorescence-guided surgery group (FGS, n = 32) and the conventional white-light microscopic surgery group (non-FGS, n = 35) included assessments of extent of resection (EOR), rates of gross total resection (GTR, 100%) and near-total resection (NTR, 99 to 98%), postoperative Neurologic Assessment in Neuro-Oncology (NANO) scores, overall survival (OS), and progression-free survival (PFS), to evaluate the safety and efficacy of fluorescein-guided technology in tumor resection at these specific locations. RESULTS Baseline of demographics, lesion location, and pathology showed no significant difference between the two groups. GTR of the FGS group was higher than the non-FGS group (84.4% vs. 60.0%, OR 3.60, 95% CI 1.18-10.28, p < 0.05). The FGS group also showed higher GTR + NTR (EOR ≥ 98%) than the non-FGS group (93.8% vs. 65.7%, OR 7.83, 95% CI 1.86-36.85, p < 0.01). 87.0% of eloquent tumors (Lacroix grade III) in the FGS group achieved GTR + NTR, compared to 52.2% of control group (OR 6.11, 95% CI 1.50-22.78, p < 0.05). For deep-seated tumors, the rate of GTR + NTR in the two groups were 91.7% and 53.3%, respectively (OR 9.62, 95% CI 1.05-116.50, p < 0.05). No significant difference of the preoperative NANO score of the two groups was found. The postoperative NANO score of the FGS group was significantly lower than the non-FGS group (2.56 ± 1.29 vs. 3.43 ± 1.63, p < 0.05). Median OS of the FGS group was 4.2 months longer than the non-FGS group despite no statistical difference (18.2 months vs. 14.0 months, HR 0.63, 95% CI 0.36-1.11, p = 0.112), while PSF was found significantly longer in FGS patients than those of the non-FGS group (11.2 months vs. 7.7 months, HR 0.59, 95% CI 0.35-0.99, p < 0.05). CONCLUSION Sodium fluorescein-guided surgery for high-grade gliomas in eloquent and deep-seated brain regions enables more extensive resection while preserving neurologic function and improve patient survival.
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Affiliation(s)
- Yao Xiao
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Mingrui Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Xiangyu Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Jun Tan
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Chaoying Qin
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China.
| | - Qing Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China.
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Belykh E, Bardonova L, Abramov I, Byvaltsev VA, Kerymbayev T, Yu K, Healey DR, Luna-Melendez E, Deneen B, Mehta S, Liu JK, Preul MC. 5-aminolevulinic acid, fluorescein sodium, and indocyanine green for glioma margin detection: analysis of operating wide-field and confocal microscopy in glioma models of various grades. Front Oncol 2023; 13:1156812. [PMID: 37287908 PMCID: PMC10242067 DOI: 10.3389/fonc.2023.1156812] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/28/2023] [Indexed: 06/09/2023] Open
Abstract
Introduction Surgical resection remains the first-line treatment for gliomas. Several fluorescent dyes are currently in use to augment intraoperative tumor visualization, but information on their comparative effectiveness is lacking. We performed systematic assessment of fluorescein sodium (FNa), 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX), and indocyanine green (ICG) fluorescence in various glioma models using advanced fluorescence imaging techniques. Methods Four glioma models were used: GL261 (high-grade model), GB3 (low-grade model), and an in utero electroporation model with and without red fluorescence protein (IUE +RFP and IUE -RFP, respectively) (intermediate-to-low-grade model). Animals underwent 5-ALA, FNa, and ICG injections and craniectomy. Brain tissue samples underwent fluorescent imaging using a wide-field operative microscope and a benchtop confocal microscope and were submitted for histologic analysis. Results Our systematic analysis showed that wide-field imaging of highly malignant gliomas is equally efficient with 5-ALA, FNa, and ICG, although FNa is associated with more false-positive staining of the normal brain. In low-grade gliomas, wide-field imaging cannot detect ICG staining, can detect FNa in only 50% of specimens, and is not sensitive enough for PpIX detection. With confocal imaging of low-intermediate grade glioma models, PpIX outperformed FNa. Discussion Overall, compared to wide-field imaging, confocal microscopy significantly improved diagnostic accuracy and was better at detecting low concentrations of PpIX and FNa, resulting in improved tumor delineation. Neither PpIX, FNa, nor ICG delineated all tumor boundaries in studied tumor models, which emphasizes the need for novel visualization technologies and molecular probes to guide glioma resection. Simultaneous administration of 5-ALA and FNa with use of cellular-resolution imaging modalities may provide additional information for margin detection and may facilitate maximal glioma resection.
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Affiliation(s)
- Evgenii Belykh
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
- Department of Neurosurgery, New Jersey Medical School, Rutgers University, Newark, NJ, United States
| | - Liudmila Bardonova
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Irakliy Abramov
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Vadim A. Byvaltsev
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Talgat Kerymbayev
- Department of Neurosurgery, JSC “National Scientific Center of Neurosurgery”, Nur-Sultan, Kazakhstan
| | - Kwanha Yu
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, United States
| | - Debbie R. Healey
- Department of Research Imaging, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | | | - Benjamin Deneen
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, United States
| | - Shwetal Mehta
- Ivy Brain Tumor Research Center, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - James K. Liu
- Department of Neurosurgery, New Jersey Medical School, Rutgers University, Newark, NJ, United States
| | - Mark C. Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
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Bonosi L, Marrone S, Benigno UE, Buscemi F, Musso S, Porzio M, Silven MP, Torregrossa F, Grasso G. Maximal Safe Resection in Glioblastoma Surgery: A Systematic Review of Advanced Intraoperative Image-Guided Techniques. Brain Sci 2023; 13:brainsci13020216. [PMID: 36831759 PMCID: PMC9954589 DOI: 10.3390/brainsci13020216] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/15/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
Glioblastoma multiforme (GBM) represents the most common and aggressive central nervous system tumor associated with a poor prognosis. The aim of this study was to depict the role of intraoperative imaging techniques in GBM surgery and how they can ensure the maximal extent of resection (EOR) while preserving the functional outcome. The authors conducted a systematic review following PRISMA guidelines on the PubMed/Medline and Scopus databases. A total of 1747 articles were identified for screening. Studies focusing on GBM-affected patients, and evaluations of EOR and functional outcomes with the aid of advanced image-guided techniques were included. The resulting studies were assessed for methodological quality using the Risk of Bias in Systematic Review tool. Open Science Framework registration DOI 10.17605/OSF.IO/3FDP9. Eighteen studies were eligible for this systematic review. Among the selected studies, eight analyzed Sodium Fluorescein, three analyzed 5-aminolevulinic acid, two evaluated IoMRI imaging, two evaluated IoUS, and three evaluated multiple intraoperative imaging techniques. A total of 1312 patients were assessed. Gross Total Resection was achieved in the 78.6% of the cases. Follow-up time ranged from 1 to 52 months. All studies assessed the functional outcome based on the Karnofsky Performance Status scale, while one used the Neurologic Assessment in Neuro-Oncology score. In 77.7% of the cases, the functional outcome improved or was stable over the pre-operative assessment. Combining multiple intraoperative imaging techniques could provide better results in GBM surgery than a single technique. However, despite good surgical outcomes, patients often present a neurocognitive decline leading to a marked deterioration of the quality of life. Advanced intraoperative image-guided techniques can allow a better understanding of the anatomo-functional relationships between the tumor and the surrounding brain, thus maximizing the EOR while preserving functional outcomes.
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Liu D, Dai X, Ye L, Wang H, Qian H, Cheng H, Wang X. Nanotechnology meets glioblastoma multiforme: Emerging therapeutic strategies. WILEY INTERDISCIPLINARY REVIEWS. NANOMEDICINE AND NANOBIOTECHNOLOGY 2023; 15:e1838. [PMID: 35959642 DOI: 10.1002/wnan.1838] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 06/24/2022] [Accepted: 07/11/2022] [Indexed: 01/31/2023]
Abstract
Glioblastoma multiforme (GBM) represents the most common and fatal form of primary invasive brain tumors as it affects a great number of patients each year and has a median overall survival of approximately 14.6 months after diagnosis. Despite intensive treatment, almost all patients with GBM experience recurrence, and their 5-year survival rate is approximately 5%. At present, the main clinical treatment strategy includes surgical resection, radiotherapy, and chemotherapy. However, tumor heterogeneity, blood-brain barrier, glioma stem cells, and DNA damage repair mechanisms hinder efficient GBM treatment. The emergence of nanometer-scale diagnostic and therapeutic approaches in cancer medicine due to the establishment of nanotechnology provides novel and promising tools that will allow us to overcome these difficulties. This review summarizes the application and recent progress in nanotechnology-based monotherapies (e.g., chemotherapy) and combination cancer treatment strategies (chemotherapy-based combined cancer therapy) for GBM and describes the synergistic enhancement between these combination therapies as well as the current standard therapy for brain cancer and its deficiencies. These combination therapies that can reduce individual drug-related toxicities and significantly enhance therapeutic efficiency have recently undergone rapid development. The mechanisms underlying these different nanotechnology-based therapies as well as the application of nanotechnology in GBM (e.g., in photodynamic therapy and chemodynamic therapy) have been systematically summarized here in an attempt to review recent developments and to identify promising directions for future research. This review provides novel and clinically significant insights and directions for the treatment of GBM, which is of great clinical importance. This article is categorized under: Therapeutic Approaches and Drug Discovery > Nanomedicine for Oncologic Disease Diagnostic Tools > In Vivo Nanodiagnostics and Imaging.
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Affiliation(s)
- Dongdong Liu
- School of Biomedical Engineering, Research and Engineering Center of Biomedical Materials, Anhui Medical University, Hefei, China.,Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xingliang Dai
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Lei Ye
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hua Wang
- Department of Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Haisheng Qian
- School of Biomedical Engineering, Research and Engineering Center of Biomedical Materials, Anhui Medical University, Hefei, China
| | - Hongwei Cheng
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xianwen Wang
- School of Biomedical Engineering, Research and Engineering Center of Biomedical Materials, Anhui Medical University, Hefei, China
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A Systematic Review of Amino Acid PET Imaging in Adult-Type High-Grade Glioma Surgery: A Neurosurgeon's Perspective. Cancers (Basel) 2022; 15:cancers15010090. [PMID: 36612085 PMCID: PMC9817716 DOI: 10.3390/cancers15010090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/04/2022] [Accepted: 12/13/2022] [Indexed: 12/29/2022] Open
Abstract
Amino acid PET imaging has been used for a few years in the clinical and surgical management of gliomas with satisfactory results in diagnosis and grading for surgical and radiotherapy planning and to differentiate recurrences. Biological tumor volume (BTV) provides more meaningful information than standard MR imaging alone and often exceeds the boundary of the contrast-enhanced nodule seen in MRI. Since a gross total resection reflects the resection of the contrast-enhanced nodule and the majority of recurrences are at a tumor's margins, an integration of PET imaging during resection could increase PFS and OS. A systematic review of the literature searching for "PET" [All fields] AND "glioma" [All fields] AND "resection" [All fields] was performed in order to investigate the diffusion of integration of PET imaging in surgical practice. Integration in a neuronavigation system and intraoperative use of PET imaging in the primary diagnosis of adult high-grade gliomas were among the criteria for article selection. Only one study has satisfied the inclusion criteria, and a few more (13) have declared to use multimodal imaging techniques with the integration of PET imaging to intentionally perform a biopsy of the PET uptake area. Despite few pieces of evidence, targeting a biologically active area in addition to other tools, which can help intraoperatively the neurosurgeon to increase the amount of resected tumor, has the potential to provide incremental and complementary information in the management of brain gliomas. Since supramaximal resection based on the extent of MRI FLAIR hyperintensity resulted in an advantage in terms of PFS and OS, PET-based biological tumor volume, avoiding new neurological deficits, deserves further investigation.
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5-aminolevulinic acid and sodium fluorescein in IV ventricle ependymoma surgery: preliminary experience comparing the two techniques. Neurol Sci 2022; 43:5075-5082. [PMID: 35334013 PMCID: PMC9349074 DOI: 10.1007/s10072-022-06012-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/12/2022] [Indexed: 12/03/2022]
Abstract
Purpose The aim of this study is to compare the use of 5-aminolevulinic acid (5-ALA) and sodium fluorescein (SF) in IV ventricular ependymoma (IVEP) surgical resection. Methods In this retrospective study, six patients with IVEP were enrolled. Gender ratio 2:1 male to female, with mean age 38.9 years old. A 5-ALA oral dose of 20 mg/kg and a SF intravenous dose of 2 mg/kg were administered. Telo-velar approach, operative microscope, and intraoperative monitoring were used in all the operations. We retrospectively compared the two fluorescence techniques at four steps during the surgical procedure: step 1: exposure of the tumor; step 2: dissection of the lesion from the cerebellum; step 3: assessment of the tumor borders and differentiation from normal tissue at the base of implants; and step 4: evaluation of possible residual tissue in the surgical cavity. Results At the first step, the ependymomas resulted well delineated by both fluorescent agents. In this step, 5-ALA was particularly helpful in the case of recurrent ependymoma. At step 2, 5-ALA provided a better identification of the ependymoma boundaries and distinction from cerebellum hemispheres than SF. In steps 3 and 4, SF was really helpful to detect tumor tissue. Conclusion According to our experience, fluorescence-guided surgery of IVEP with 5-ALA and SF is useful to maximize surgical resection with less risk of brainstem injury. Both fluorescence techniques are helpful in different steps of IVEP resection. However, further studies are needed to confirm our preliminary data. Supplementary Information The online version contains supplementary material available at 10.1007/s10072-022-06012-z.
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Guo QL, Dai XL, Yin MY, Cheng HW, Qian HS, Wang H, Zhu DM, Wang XW. Nanosensitizers for sonodynamic therapy for glioblastoma multiforme: current progress and future perspectives. Mil Med Res 2022; 9:26. [PMID: 35676737 PMCID: PMC9178901 DOI: 10.1186/s40779-022-00386-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/22/2022] [Indexed: 02/07/2023] Open
Abstract
Glioblastoma multiforme (GBM) is the most common primary malignant brain tumor, and it is associated with poor prognosis. Its characteristics of being highly invasive and undergoing heterogeneous genetic mutation, as well as the presence of the blood-brain barrier (BBB), have reduced the efficacy of GBM treatment. The emergence of a novel therapeutic method, namely, sonodynamic therapy (SDT), provides a promising strategy for eradicating tumors via activated sonosensitizers coupled with low-intensity ultrasound. SDT can provide tumor killing effects for deep-seated tumors, such as brain tumors. However, conventional sonosensitizers cannot effectively reach the tumor region and kill additional tumor cells, especially brain tumor cells. Efforts should be made to develop a method to help therapeutic agents pass through the BBB and accumulate in brain tumors. With the development of novel multifunctional nanosensitizers and newly emerging combination strategies, the killing ability and selectivity of SDT have greatly improved and are accompanied with fewer side effects. In this review, we systematically summarize the findings of previous studies on SDT for GBM, with a focus on recent developments and promising directions for future research.
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Affiliation(s)
- Qing-Long Guo
- School of Biomedical Engineering, Research and Engineering Center of Biomedical Materials, Anhui Medical University, Hefei, 230032, China.,Department of Neurosurgery, the First Affiliated Hospital of Anhui Medical University, Hefei, 230032, China
| | - Xing-Liang Dai
- Department of Neurosurgery, the First Affiliated Hospital of Anhui Medical University, Hefei, 230032, China
| | - Meng-Yuan Yin
- School of Biomedical Engineering, Research and Engineering Center of Biomedical Materials, Anhui Medical University, Hefei, 230032, China.,Department of Neurosurgery, the First Affiliated Hospital of Anhui Medical University, Hefei, 230032, China
| | - Hong-Wei Cheng
- Department of Neurosurgery, the First Affiliated Hospital of Anhui Medical University, Hefei, 230032, China.
| | - Hai-Sheng Qian
- School of Biomedical Engineering, Research and Engineering Center of Biomedical Materials, Anhui Medical University, Hefei, 230032, China
| | - Hua Wang
- Department of Oncology, the First Affiliated Hospital of Anhui Medical University, Hefei, 230032, China
| | - Dao-Ming Zhu
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, the First School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China.
| | - Xian-Wen Wang
- School of Biomedical Engineering, Research and Engineering Center of Biomedical Materials, Anhui Medical University, Hefei, 230032, China.
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Zeppa P, De Marco R, Monticelli M, Massara A, Bianconi A, Di Perna G, Greco Crasto S, Cofano F, Melcarne A, Lanotte MM, Garbossa D. Fluorescence-Guided Surgery in Glioblastoma: 5-ALA, SF or Both? Differences between Fluorescent Dyes in 99 Consecutive Cases. Brain Sci 2022; 12:brainsci12050555. [PMID: 35624942 PMCID: PMC9138621 DOI: 10.3390/brainsci12050555] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Glioblastoma (GBM) is the most common primary brain tumor. The extent of resection (EOR) has been claimed as one of the most important prognostic factors. Fluorescent dyes aid surgeons in detecting a tumor’s borders. 5-aminolevulinic acid (5-ALA) and sodium fluorescein (SF) are the most used. Only a few studies have directly compared these two fluorophores. Methods: A single center retrospective analysis of patients treated for GBM in the period between January 2018 and January 2021 was built to find any differences in terms of EOR, Karnofsky Performance Status (KPS), and overall survival (OS) on the use of 5-ALA, SF, or both. Results: Overall, 99 patients affected by isocitrate dehydrogenase (IDH) wild-type Glioblastoma were included. 5-ALA was administered to 40 patients, SF to 44, and both to 15. No statistically significant associations were identified between the fluorophore and EOR (p = 0.783) or postoperative KPS (p = 0.270). Survival analyses did not show a selective advantage for the use of a given fluorophore (p = 0.184), although there appears to be an advantageous trend associated with the concomitant use of both dyes, particularly after stratification by MGMT (p = 0.071). Conclusions: 5-Ala and SF are equally useful in achieving gross total resection of the enhancing tumor volume. The combination of both fluorophores could lead to an OS advantage.
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Affiliation(s)
- Pietro Zeppa
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Raffaele De Marco
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
- Correspondence:
| | - Matteo Monticelli
- Neurosurgery Unit, Department of Neuroscience and Rehabilitation, University of Ferrara, 44124 Ferrara, Italy;
| | - Armando Massara
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Andrea Bianconi
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Giuseppe Di Perna
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | | | - Fabio Cofano
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
- Humanitas Gradenigo Hospital, 10153 Turin, Italy
| | - Antonio Melcarne
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Michele Maria Lanotte
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
| | - Diego Garbossa
- Neurosurgery Unit, Department of Neuroscience Rita Levi Montalcini, Città della Salute e della Scienza University Hospital, University of Turin, 10126 Turin, Italy; (P.Z.); (A.M.); (A.B.); (G.D.P.); (F.C.).; (A.M.); (M.M.L.); (D.G.)
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Matsumae M, Nishiyama J, Kuroda K. Intraoperative MR Imaging during Glioma Resection. Magn Reson Med Sci 2022; 21:148-167. [PMID: 34880193 PMCID: PMC9199972 DOI: 10.2463/mrms.rev.2021-0116] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/11/2021] [Indexed: 11/09/2022] Open
Abstract
One of the major issues in the surgical treatment of gliomas is the concern about maximizing the extent of resection while minimizing neurological impairment. Thus, surgical planning by carefully observing the relationship between the glioma infiltration area and eloquent area of the connecting fibers is crucial. Neurosurgeons usually detect an eloquent area by functional MRI and identify a connecting fiber by diffusion tensor imaging. However, during surgery, the accuracy of neuronavigation can be decreased due to brain shift, but the positional information may be updated by intraoperative MRI and the next steps can be planned accordingly. In addition, various intraoperative modalities may be used to guide surgery, including neurophysiological monitoring that provides real-time information (e.g., awake surgery, motor-evoked potentials, and sensory evoked potential); photodynamic diagnosis, which can identify high-grade glioma cells; and other imaging techniques that provide anatomical information during the surgery. In this review, we present the historical and current context of the intraoperative MRI and some related approaches for an audience active in the technical, clinical, and research areas of radiology, as well as mention important aspects regarding safety and types of devices.
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Affiliation(s)
- Mitsunori Matsumae
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Jun Nishiyama
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Kagayaki Kuroda
- Department of Human and Information Sciences, School of Information Science and Technology, Tokai University, Hiratsuka, Kanagawa, Japan
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Wu W, Klockow JL, Zhang M, Lafortune F, Chang E, Jin L, Wu Y, Daldrup-Link HE. Glioblastoma multiforme (GBM): An overview of current therapies and mechanisms of resistance. Pharmacol Res 2021; 171:105780. [PMID: 34302977 PMCID: PMC8384724 DOI: 10.1016/j.phrs.2021.105780] [Citation(s) in RCA: 190] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 12/21/2022]
Abstract
Glioblastoma multiforme (GBM) is a WHO grade IV glioma and the most common malignant, primary brain tumor with a 5-year survival of 7.2%. Its highly infiltrative nature, genetic heterogeneity, and protection by the blood brain barrier (BBB) have posed great treatment challenges. The standard treatment for GBMs is surgical resection followed by chemoradiotherapy. The robust DNA repair and self-renewing capabilities of glioblastoma cells and glioma initiating cells (GICs), respectively, promote resistance against all current treatment modalities. Thus, durable GBM management will require the invention of innovative treatment strategies. In this review, we will describe biological and molecular targets for GBM therapy, the current status of pharmacologic therapy, prominent mechanisms of resistance, and new treatment approaches. To date, medical imaging is primarily used to determine the location, size and macroscopic morphology of GBM before, during, and after therapy. In the future, molecular and cellular imaging approaches will more dynamically monitor the expression of molecular targets and/or immune responses in the tumor, thereby enabling more immediate adaptation of tumor-tailored, targeted therapies.
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Affiliation(s)
- Wei Wu
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA
| | - Jessica L Klockow
- Department of Radiation Oncology, Stanford University, Stanford, CA 94305, USA
| | - Michael Zhang
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA; Department of Neurosurgery, Stanford University, Stanford, CA 94305, USA
| | - Famyrah Lafortune
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA
| | - Edwin Chang
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA
| | - Linchun Jin
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
| | - Yang Wu
- Department of Neuropathology, Institute of Pathology, Technical University of Munich, Munich, Bayern 81675, Germany
| | - Heike E Daldrup-Link
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, Stanford, CA 94305, USA.
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11
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Wang LM, Banu MA, Canoll P, Bruce JN. Rationale and Clinical Implications of Fluorescein-Guided Supramarginal Resection in Newly Diagnosed High-Grade Glioma. Front Oncol 2021; 11:666734. [PMID: 34123831 PMCID: PMC8187787 DOI: 10.3389/fonc.2021.666734] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
Current standard of care for glioblastoma is surgical resection followed by temozolomide chemotherapy and radiation. Recent studies have demonstrated that >95% extent of resection is associated with better outcomes, including prolonged progression-free and overall survival. The diffusely infiltrative pattern of growth in gliomas results in microscopic extension of tumor cells into surrounding brain parenchyma that makes complete resection unattainable. The historical goal of surgical management has therefore been maximal safe resection, traditionally guided by MRI and defined as removal of all contrast-enhancing tumor. Optimization of surgical resection has led to the concept of supramarginal resection, or removal beyond the contrast-enhancing region on MRI. This strategy of extending the cytoreductive goal targets a tumor region thought to be important in the recurrence or progression of disease as well as resistance to systemic and local treatment. This approach must be balanced against the risk of impacting eloquent regions of brain and causing permanent neurologic deficit, an important factor affecting overall survival. Over the years, fluorescent agents such as fluorescein sodium have been explored as a means of more reliably delineating the boundary between tumor core, tumor-infiltrated brain, and surrounding cortex. Here we examine the rationale behind extending resection into the infiltrative tumor margins, review the current literature surrounding the use of fluorescein in supramarginal resection of gliomas, discuss the experience of our own institution in utilizing fluorescein to maximize glioma extent of resection, and assess the clinical implications of this treatment strategy.
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Affiliation(s)
- Linda M Wang
- Gabriele Bartoli Brain Tumor Laboratory, Department of Neurological Surgery and Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, United States
| | - Matei A Banu
- Gabriele Bartoli Brain Tumor Laboratory, Department of Neurological Surgery and Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, United States
| | - Peter Canoll
- Gabriele Bartoli Brain Tumor Laboratory, Department of Neurological Surgery and Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, United States
| | - Jeffrey N Bruce
- Gabriele Bartoli Brain Tumor Laboratory, Department of Neurological Surgery and Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, United States
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12
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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:diagnostics10121100. [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.)
- Correspondence: (M.M.); (B.K.); Tel.: +48-81-724-48-51 (M.M.)
| | - Bartłomiej Kulesza
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
- Correspondence: (M.M.); (B.K.); Tel.: +48-81-724-48-51 (M.M.)
| | - 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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13
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Meershoek P, KleinJan GH, van Willigen DM, Bauwens KP, Spa SJ, van Beurden F, van Gennep EJ, Mottrie AM, van der Poel HG, Buckle T, van Leeuwen FWB, van Oosterom MN. Multi-wavelength fluorescence imaging with a da Vinci Firefly-a technical look behind the scenes. J Robot Surg 2020; 15:751-760. [PMID: 33179201 PMCID: PMC8423683 DOI: 10.1007/s11701-020-01170-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/29/2020] [Indexed: 12/19/2022]
Abstract
The field of fluorescence-guided surgery builds on colored fluorescent tracers that have become available for different clinical applications. Combined use of complementary fluorescent emissions can allow visualization of different anatomical structures (e.g. tumor, lymphatics and nerves) in the same patient. With the aim to assess the requirements for multi-color fluorescence guidance under in vivo conditions, we thoroughly characterized two FDA-approved laparoscopic Firefly camera systems available on the da Vinci Si or da Vinci Xi surgical robot. In this process, we studied the cameras’ performance with respect to the photophysical properties of the FDA-approved dyes Fluorescein and ICG. Our findings indicate that multi-wavelength fluorescence imaging of Fluorescein and ICG is possible using clinical-grade fluorescence laparoscopes, but critical factors for success include the photophysical dye properties, imaging system performance and the amount of accumulated dye. When comparing the camera performance, the Xi system provided more effective excitation (adaptions in the light source) and higher detection sensitivity (chip-on-a-tip and/or enhanced image processing) for both Fluorescein and ICG. Both systems can readily be used for multi-wavelength fluorescence imaging of Fluorescein and ICG under clinically relevant conditions. With that, another step has been made towards the routine implementation of multi-wavelength image-guided surgery concepts.
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Affiliation(s)
- Philippa Meershoek
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Gijs H KleinJan
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, Leiden University Medical Center, Leiden, The Netherlands
| | - Danny M van Willigen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Silvia J Spa
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Florian van Beurden
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Erik J van Gennep
- Department of Urology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexandre M Mottrie
- Orsi Academy, Melle, Belgium.,Department of Urology, Onze-Lieve-Vrouw Hospital, Aalst, Belgium
| | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - T Buckle
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.,Orsi Academy, Melle, Belgium
| | - Matthias N van Oosterom
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands. .,Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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14
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van Beurden F, van Willigen DM, Vojnovic B, van Oosterom MN, Brouwer OR, der Poel HGV, Kobayashi H, van Leeuwen FWB, Buckle T. Multi-Wavelength Fluorescence in Image-Guided Surgery, Clinical Feasibility and Future Perspectives. Mol Imaging 2020; 19:1536012120962333. [PMID: 33125289 PMCID: PMC7607779 DOI: 10.1177/1536012120962333] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
With the rise of fluorescence-guided surgery, it has become evident that different types of fluorescence signals can provide value in the surgical setting. Hereby a different range of targets have been pursued in a great variety of surgical indications. One of the future challenges lies in combining complementary fluorescent readouts during one and the same surgical procedure, so-called multi-wavelength fluorescence guidance. In this review we summarize the current clinical state-of-the-art in multi-wavelength fluorescence guidance, basic technical concepts, possible future extensions of existing clinical indications and impact that the technology can bring to clinical care.
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Affiliation(s)
- Florian van Beurden
- Interventional Molecular Imaging Laboratory, Department of Radiology, 4501Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, 1228The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Danny M van Willigen
- Interventional Molecular Imaging Laboratory, Department of Radiology, 4501Leiden University Medical Center, Leiden, The Netherlands
| | - Borivoj Vojnovic
- Department of Oncology, Cancer Research UK/MRC Oxford Institute for Radiation Oncology, 6396University of Oxford, Oxford, United Kingdom
| | - Matthias N van Oosterom
- Interventional Molecular Imaging Laboratory, Department of Radiology, 4501Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, 1228The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Oscar R Brouwer
- Interventional Molecular Imaging Laboratory, Department of Radiology, 4501Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, 1228The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Henk G van der Poel
- Department of Urology, 1228The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Hisataka Kobayashi
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, 2511National Institutes of Health, Bethesda, MD, USA
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, 4501Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, 1228The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.,Orsi Academy, Melle, Belgium
| | - Tessa Buckle
- Interventional Molecular Imaging Laboratory, Department of Radiology, 4501Leiden University Medical Center, Leiden, The Netherlands.,Department of Urology, 1228The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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15
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Save AV, Gill BJ, D'amico RS, Canoll P, Bruce JN. Fluorescein-guided resection of gliomas. J Neurosurg Sci 2020; 63:648-655. [PMID: 31961117 DOI: 10.23736/s0390-5616.19.04738-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Standard of care in the management of high-grade gliomas includes gross total resection (GTR) followed by treatment with radiation and temozolomide. GTR remains one of the few independent prognostic factors for improved survival in this disease. Sodium fluorescein is an organic fluorophore that has been studied as a surgical adjunct to improve the likelihood of achieving GTR in gliomas. Though sodium fluorescein does not selectively accumulate in glioma cells, it allows for real-time identification of regions of blood brain barrier breakdown, corresponding to the contrast-enhancing cores of high-grade gliomas. In addition to its high predictive value for identifying pathologic tissue, use of fluorescein has been shown to improve rates of GTR. In stereotactic needle biopsies, it helps reduce procedure time by rapidly confirming the presence of diagnostic tissue. Furthermore, in non-enhancing, low-grade gliomas, it labels focal regions of vascular dysregulation that have been correlated with high-grade features. Fluorescein has also been shown to be significantly less expensive than other contemporary surgical adjuncts such as intraoperative ultrasound, intraoperative MRI, and the recently FDA approved fluorophore, 5-aminolevulinic acid (5-ALA). Here, we review the current literature on the effectiveness of fluorescein as a surgical tool in the resection of gliomas.
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Affiliation(s)
- Akshay V Save
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA -
| | - Brian J Gill
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Randy S D'amico
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Peter Canoll
- Department of Neuropathology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jeffrey N Bruce
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
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16
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Kim JK, Jung TY, Jung S, Kim IY, Jang WY, Moon KS, Kim SK, Kim JH, Lee KH. Relationship between tumor cell infiltration and 5-aminolevulinic acid fluorescence signals after resection of MR-enhancing lesions and its prognostic significance in glioblastoma. Clin Transl Oncol 2020; 23:459-467. [PMID: 32617871 DOI: 10.1007/s12094-020-02438-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/19/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE This study investigated the degree of tumor cell infiltration in the tumor cavity and ventricle wall based on fluorescent signals of 5-aminolevulinic acid (5-ALA) after removal of the magnetic resonance (MR)-enhancing area and analyzed its prognostic significance in glioblastoma. METHODS Twenty-five newly developed isocitrate dehydrogenase (IDH)-wildtype glioblastomas with complete resection both of MR-enhancing lesions and strong purple fluorescence on resection cavity were retrospectively analyzed. The fluorescent signals of 5-ALA were divided into strong purple, vague pink, and blue colors. The pathologic findings were classified into massively infiltrating tumor cells, infiltrating tumor cells, suspicious single-cell infiltration, and normal-appearing cells. The pathological findings were analyzed according to the fluorescent signals in the resection cavity and ventricle wall. RESULTS There was no correlation between fluorescent signals and infiltrating tumor cells in the resection cavity (p = 0.199) and ventricle wall (p = 0.704) after resection of the MR-enhancing lesion. The median progression-free survival (PFS) and median overall survival (OS) were 12.5 (± 2.1) and 21.1 (± 3.5) months, respectively. In univariate analysis, the presence of definitive infiltrating tumor cells in the resection cavity and ventricle wall was significantly related to the PFS (p = 0.002) and OS (p = 0.027). In multivariate analysis, the absence of definitive infiltrating tumor cells improved PFS (hazard ratio: 0.184; 95% CI: 0.049-0.690, p = 0.012) and OS (hazard ratio: 0.124; 95% CI: 0.015-0.998, p = 0.050). CONCLUSIONS After resection both of the MR-enhancing lesions and strong purple fluorescence on resection cavity, there was no correlation between remnant fluorescent signals and infiltrating tumor cells. The remnant definitive infiltrating tumor cells in the resection cavity and ventricle wall significantly influenced the prognosis of patients with glioblastoma. Aggressive surgical removal of infiltrating tumor cells may improve their prognosis.
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Affiliation(s)
- J -K Kim
- Department of Neurosurgery, Chonnam National University Medical School and Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, South Korea
| | - T -Y Jung
- Department of Neurosurgery, Chonnam National University Medical School and Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, South Korea.
| | - S Jung
- Department of Neurosurgery, Chonnam National University Medical School and Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, South Korea
| | - I -Y Kim
- Department of Neurosurgery, Chonnam National University Medical School and Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, South Korea
| | - W -Y Jang
- Department of Neurosurgery, Chonnam National University Medical School and Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, South Korea
| | - K -S Moon
- Department of Neurosurgery, Chonnam National University Medical School and Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 58128, South Korea
| | - S -K Kim
- Department of Radiology, Chonnam National University Medical School and Hwasun Hospital, Gwangju, South Korea
| | - J -H Kim
- Department of Pathology, Chonnam National University Medical School and Hwasun Hospital, Gwangju, South Korea
| | - K -H Lee
- Department of Pathology, Chonnam National University Medical School and Hwasun Hospital, Gwangju, South Korea
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17
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Verburg N, de Witt Hamer PC. State-of-the-art imaging for glioma surgery. Neurosurg Rev 2020; 44:1331-1343. [PMID: 32607869 PMCID: PMC8121714 DOI: 10.1007/s10143-020-01337-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/25/2020] [Accepted: 06/15/2020] [Indexed: 11/29/2022]
Abstract
Diffuse gliomas are infiltrative primary brain tumors with a poor prognosis despite multimodal treatment. Maximum safe resection is recommended whenever feasible. The extent of resection (EOR) is positively correlated with survival. Identification of glioma tissue during surgery is difficult due to its diffuse nature. Therefore, glioma resection is imaging-guided, making the choice for imaging technique an important aspect of glioma surgery. The current standard for resection guidance in non-enhancing gliomas is T2 weighted or T2w-fluid attenuation inversion recovery magnetic resonance imaging (MRI), and in enhancing gliomas T1-weighted MRI with a gadolinium-based contrast agent. Other MRI sequences, like magnetic resonance spectroscopy, imaging modalities, such as positron emission tomography, as well as intraoperative imaging techniques, including the use of fluorescence, are also available for the guidance of glioma resection. The neurosurgeon’s goal is to find the balance between maximizing the EOR and preserving brain functions since surgery-induced neurological deficits result in lower quality of life and shortened survival. This requires localization of important brain functions and white matter tracts to aid the pre-operative planning and surgical decision-making. Visualization of brain functions and white matter tracts is possible with functional MRI, diffusion tensor imaging, magnetoencephalography, and navigated transcranial magnetic stimulation. In this review, we discuss the current available imaging techniques for the guidance of glioma resection and the localization of brain functions and white matter tracts.
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Affiliation(s)
- Niels Verburg
- Department of Neurosurgery and Cancer Center Amsterdam, Amsterdam UMC location VU University Medical Center, Amsterdam, The Netherlands. .,Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Brain Tumor Imaging Laboratory, University of Cambridge, Addenbrooke's Hospital, Hill Rd, Cambridge, CB2 0QQ, UK.
| | - Philip C de Witt Hamer
- Department of Neurosurgery and Cancer Center Amsterdam, Amsterdam UMC location VU University Medical Center, Amsterdam, The Netherlands
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18
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Boschi A, Della Puppa A. 5-ALA fluorescence on tumors different from malignant gliomas. Review of the literature and our experience. J Neurosurg Sci 2019; 63:661-669. [PMID: 31355622 DOI: 10.23736/s0390-5616.19.04766-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Fluorescence guided surgery with 5-aminolevulinic acid (5-ALA) is a well-established technique for improving resection of malignant cerebral glioma. In recent years, this technique is being increasingly applied off label to other brain tumor entities such as Low-grade glioma, meningioma, metastases, lymphoma and other central nervous system tumors. In this paper We collected all the data of 5-ALA guided surgery in "not malignant glioma" in literature compared to our experience. EVIDENCE ACQUISITION We searched the PubMed/Medline database all clinical series reporting 5-ALA guided-surgery in not malignant glioma. We reviewed all data also showing our experience. EVIDENCE SYNTHESIS Fluorescence guided surgery with 5-ALA might be helpful not only in high-grade glioma but also in other brain tumor especially in Low grade glioma with a suspect of anaplastic spot, meningioma with bone invasion or parenchymal infiltration, ependymoma, lymphoma and pediatric tumors. CONCLUSIONS Due to the relatively few number or clinical studies, prospective clinical trials are needed to increase the overall level of evidence concerning the usage of 5-ALA in CNS tumors different from high-grade glioma. Furthermore, a greater us of new tools such as, spectroscopy or confocal microscope or the use of combination of other fluorescence could make more effective this technique.
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Affiliation(s)
- Andrea Boschi
- Department of Neurosurgery, Careggi Hospital, University of Florence, Florence, Italy
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19
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Gandhi S, Tayebi Meybodi A, Belykh E, Cavallo C, Zhao X, Syed MP, Borba Moreira L, Lawton MT, Nakaji P, Preul MC. Survival Outcomes Among Patients With High-Grade Glioma Treated With 5-Aminolevulinic Acid-Guided Surgery: A Systematic Review and Meta-Analysis. Front Oncol 2019; 9:620. [PMID: 31380272 PMCID: PMC6652805 DOI: 10.3389/fonc.2019.00620] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/24/2019] [Indexed: 01/08/2023] Open
Abstract
Background: High-grade glioma (HGG) is associated with a dismal prognosis despite significant advances in adjuvant therapies, including chemotherapy, immunotherapy, and radiotherapy. Extent of resection continues to be the most important independent prognosticator of survival. This underlines the significance of increasing gross total resection (GTR) rates by using adjunctive intraoperative modalities to maximize resection with minimal neurological morbidity. 5-aminolevulinic acid (5-ALA) is the only US Food and Drug Administration–approved intraoperative optical agent used for fluorescence-guided surgical resection of gliomas. Despite several studies on the impact of intra-operative 5-ALA use on the extent of HGG resection, a clear picture of how such usage affects patient survival is still unavailable. Methods: A systematic review was conducted of all relevant studies assessing the GTR rate and survival outcomes [overall survival (OS) and progression-free survival (PFS)] in HGG. A meta-analysis of eligible studies was performed to assess the influence of 5-ALA-guided resection on improving GTR, OS, and PFS. GTR was defined as >95% resection. Results: Of 23 eligible studies, 19 reporting GTR rates were included in the meta-analysis. The pooled cohort had 998 patients with HGG, including 796 with newly diagnosed cases. The pooled GTR rate among patients with 5-ALA–guided resection was 76.8% (95% confidence interval, 69.1–82.9%). A comparative subgroup analysis of 5-ALA–guided vs. conventional surgery (controlling for within-study covariates) showed a 26% higher GTR rate in the 5-ALA subgroup (odds ratio, 3.8; P < 0.001). There were 11 studies eligible for survival outcome analysis, 4 of which reported PFS. The pooled mean difference in OS and PFS was 3 and 1 months, respectively, favoring 5-ALA vs. control (P < 0.001). Conclusions: This meta-analysis shows a significant increase in GTR rate with 5-ALA–guided surgical resection, with a higher weighted GTR rate (~76%) than the pivotal phase III study (~65%). Pooled analysis showed a small yet significant increase in survival measures associated with the use of 5-ALA. Despite the statistically significant results, the low level of evidence and heterogeneity across these studies make it difficult to conclusively report an independent association between 5-ALA use and survival outcomes in HGG. Additional randomized control studies are required to delineate the role of 5-ALA in survival outcomes in HGG.
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Affiliation(s)
- Sirin Gandhi
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Evgenii Belykh
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States.,Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Claudio Cavallo
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Xiaochun Zhao
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Masood Pasha Syed
- Department of Medicine, Saint Vincent Hospital, Worcester, MA, United States
| | - Leandro Borba Moreira
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Michael T Lawton
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Peter Nakaji
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Mark C Preul
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
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