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Sarkis HM, Zawy Alsofy S, Stroop R, Lewitz M, Schipmann S, Unnewehr M, Paulus W, Nakamura M, Ewelt C. Does 5-ALA Fluorescence Microscopy Improve Complete Resectability in Cerebral/Cerebellar Metastatic Surgery? A Retrospective Data Analysis from a Cranial Center. Cancers (Basel) 2024; 16:2242. [PMID: 38927947 PMCID: PMC11201798 DOI: 10.3390/cancers16122242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/18/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
(1) Background: In this study, the intraoperative fluorescence behavior of brain metastases after the administration of 5-aminolevulinic acid (5-ALA) was analyzed. The aim was to investigate whether the resection of brain metastases using 5-ALA fluorescence also leads to a more complete resections and thus to a prolongation of survival; (2) Methods: The following variables have been considered: age, sex, number of metastases, localization, involvement of eloquent area, correlation between fluorescence and primary tumor/subtype, resection, and survival time. The influence on the degree of resection was determined with a control MRI within the first three postoperative days; (3) Results: Brain metastases fluoresced in 57.5% of cases. The highest fluorescence rates of 73.3% were found in breast carcinoma metastases and the histologic subtype adenocarcinoma (68.1%). No correlation between fluorescence behavior and localization, primary tumor, or histological subtype was found. Complete resection was detected in 82.5%, of which 56.1% were fluorescence positive. There was a trend towards improved resectability (increase of 12.1%) and a significantly longer survival time (p = 0.009) in the fluorescence-positive group; (4) Conclusions: 5-ALA-assisted extirpation leads to a more complete resection and longer survival and can therefore represent a low-risk addition to modern surgery for brain metastases.
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Affiliation(s)
- Hraq Mourad Sarkis
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (H.M.S.); (R.S.); (M.L.); (M.U.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany;
- Department of Neurosurgery, St. Marien-Hospital, Academic Hospital of the Hannover Medical School, 49076 Osnabrueck, Germany
| | - Samer Zawy Alsofy
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (H.M.S.); (R.S.); (M.L.); (M.U.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany;
| | - Ralf Stroop
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (H.M.S.); (R.S.); (M.L.); (M.U.)
| | - Marc Lewitz
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (H.M.S.); (R.S.); (M.L.); (M.U.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany;
| | - Stephanie Schipmann
- Department of Neurosurgery, University Hospital Muenster, 48149 Muenster, Germany;
| | - Markus Unnewehr
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (H.M.S.); (R.S.); (M.L.); (M.U.)
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Muenster, 48149 Muenster, Germany;
| | - Makoto Nakamura
- Department of Neurosurgery, Academic Hospital Koeln-Merheim, Witten/Herdecke University, 51109 Koeln, Germany;
| | - Christian Ewelt
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany;
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2
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Oudin A, Moreno-Sanchez PM, Baus V, Niclou SP, Golebiewska A. Magnetic resonance imaging-guided intracranial resection of glioblastoma tumors in patient-derived orthotopic xenografts leads to clinically relevant tumor recurrence. BMC Cancer 2024; 24:3. [PMID: 38166949 PMCID: PMC10763155 DOI: 10.1186/s12885-023-11774-6] [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: 07/07/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Preclinical in vivo cancer models are essential tools for investigating tumor progression and response to treatment prior to clinical trials. Although treatment modalities are regularly assessed in mice upon tumor growth in vivo, surgical resection remains challenging, particularly in the orthotopic site. Here, we report a successful surgical resection of glioblastoma (GBM) in patient-derived orthotopic xenografts (PDOXs). METHODS We derived a cohort of 46 GBM PDOX models that faithfully recapitulate human disease in mice. We assessed the detection and quantification of intracranial tumors using magnetic resonance imaging (MRI).To evaluate feasibility of surgical resection in PDOXs, we selected two models representing histopathological features of GBM tumors, including diffuse growth into the mouse brain. Surgical resection in the mouse brains was performed based on MRI-guided coordinates. Survival study followed by MRI and immunohistochemistry-based evaluation of recurrent tumors allowed for assessment of clinically relevant parameters. RESULTS We demonstrate the utility of MRI for the noninvasive assessment of in vivo tumor growth, preoperative programming of resection coordinates and follow-up of tumor recurrence. We report tumor detection by MRI in 90% of GBM PDOX models (36/40), of which 55% (22/40) can be reliably quantified during tumor growth. We show that a surgical resection protocol in mice carrying diffuse primary GBM tumors in the brain leads to clinically relevant outcomes. Similar to neurosurgery in patients, we achieved a near total to complete extent of tumor resection, and mice with resected tumors presented significantly increased survival. The remaining unresected GBM cells that invaded the normal mouse brain prior to surgery regrew tumors with similar histopathological features and tumor microenvironments to the primary tumors. CONCLUSIONS Our data positions GBM PDOXs developed in mouse brains as a valuable preclinical model for conducting therapeutic studies that involve surgical tumor resection. The high detectability of tumors by MRI across a substantial number of PDOX models in mice will allow for scalability of our approach toward specific tumor types for efficacy studies in precision medicine-oriented approaches. Additionally, these models hold promise for the development of enhanced image-guided surgery protocols.
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Affiliation(s)
- Anais Oudin
- NORLUX Neuro-Oncology Laboratory, Department of Cancer Research, Luxembourg Institute of Health (LIH), 6A, Rue Nicolas-Ernest Barblé, Luxembourg, L-1210, Luxembourg
| | - Pilar M Moreno-Sanchez
- NORLUX Neuro-Oncology Laboratory, Department of Cancer Research, Luxembourg Institute of Health (LIH), 6A, Rue Nicolas-Ernest Barblé, Luxembourg, L-1210, Luxembourg
- Department of Life Sciences and Medicine, Faculty of Science, Technology and Medicine (FSTM), University of Luxembourg, Belvaux, L-4367, Luxembourg
| | - Virginie Baus
- NORLUX Neuro-Oncology Laboratory, Department of Cancer Research, Luxembourg Institute of Health (LIH), 6A, Rue Nicolas-Ernest Barblé, Luxembourg, L-1210, Luxembourg
| | - Simone P Niclou
- NORLUX Neuro-Oncology Laboratory, Department of Cancer Research, Luxembourg Institute of Health (LIH), 6A, Rue Nicolas-Ernest Barblé, Luxembourg, L-1210, Luxembourg
- Department of Life Sciences and Medicine, Faculty of Science, Technology and Medicine (FSTM), University of Luxembourg, Belvaux, L-4367, Luxembourg
| | - Anna Golebiewska
- NORLUX Neuro-Oncology Laboratory, Department of Cancer Research, Luxembourg Institute of Health (LIH), 6A, Rue Nicolas-Ernest Barblé, Luxembourg, L-1210, Luxembourg.
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3
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Cumba Garcia LM, Bouchal SM, Bauman MMJ, Parney IF. Advancements and Technical Considerations for Extracellular Vesicle Isolation and Biomarker Identification in Glioblastoma. Neurosurgery 2023; 93:33-42. [PMID: 36749103 DOI: 10.1227/neu.0000000000002393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/06/2022] [Indexed: 02/08/2023] Open
Abstract
Extracellular vesicles (EVs) are membrane-bound particles released by all cells. Previous research has found that these microscopic vesicles contribute to intercellular signaling and communication. EVs carry a variety of cargo, including nucleic acids, proteins, metabolites, and lipids. The composition of EVs varies based on cell of origin. Therefore, EVs can serve as an important biomarker in the diagnosis and treatment of various cancers. EVs derived from glioblastoma (GBM) cells carry biomarkers, which could serve as the basis for a potential diagnostic strategy known as liquid biopsy. Multiple EV isolation techniques exist, including ultrafiltration, size exclusion chromatography, flow field-flow fractionation, sequential filtration, differential ultracentrifugation, and density-gradient ultracentrifugation. Recent and ongoing work aims to identify cellular markers to distinguish GBM-derived EVs from those released by noncancerous cells. Strategies include proteomic analysis of GBM EVs, identification of GBM-specific metabolites, and use of Food and Drug Administration-approved 5-aminolevulinic acid-an oral agent that causes fluorescence of GBM cells-to recognize GBM EVs in a patient's blood. In addition, accurately and precisely monitoring changes in EV cargo concentrations could help differentiate between pseudoprogression and GBM recurrence, thus preventing unnecessary surgical interventions.
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Affiliation(s)
- Luz M Cumba Garcia
- Department of Immunology, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, USA
| | - Samantha M Bouchal
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Megan M J Bauman
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ian F Parney
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
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4
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Howley R, Chandratre S, Chen B. 5-Aminolevulinic Acid as a Theranostic Agent for Tumor Fluorescence Imaging and Photodynamic Therapy. Bioengineering (Basel) 2023; 10:bioengineering10040496. [PMID: 37106683 PMCID: PMC10136048 DOI: 10.3390/bioengineering10040496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023] Open
Abstract
5-Aminolevulinic acid (ALA) is a naturally occurring amino acid synthesized in all nucleated mammalian cells. As a porphyrin precursor, ALA is metabolized in the heme biosynthetic pathway to produce protoporphyrin IX (PpIX), a fluorophore and photosensitizing agent. ALA administered exogenously bypasses the rate-limit step in the pathway, resulting in PpIX accumulation in tumor tissues. Such tumor-selective PpIX disposition following ALA administration has been exploited for tumor fluorescence diagnosis and photodynamic therapy (PDT) with much success. Five ALA-based drugs have now received worldwide approval and are being used for managing very common human (pre)cancerous diseases such as actinic keratosis and basal cell carcinoma or guiding the surgery of bladder cancer and high-grade gliomas, making it the most successful drug discovery and development endeavor in PDT and photodiagnosis. The potential of ALA-induced PpIX as a fluorescent theranostic agent is, however, yet to be fully fulfilled. In this review, we would like to describe the heme biosynthesis pathway in which PpIX is produced from ALA and its derivatives, summarize current clinical applications of ALA-based drugs, and discuss strategies for enhancing ALA-induced PpIX fluorescence and PDT response. Our goal is two-fold: to highlight the successes of ALA-based drugs in clinical practice, and to stimulate the multidisciplinary collaboration that has brought the current success and will continue to usher in more landmark advances.
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Affiliation(s)
- Richard Howley
- Department of Pharmaceutical Sciences, Philadelphia College of Pharmacy, Saint Joseph's University, Philadelphia, PA 19104, USA
| | - Sharayu Chandratre
- Department of Pharmaceutical Sciences, Philadelphia College of Pharmacy, Saint Joseph's University, Philadelphia, PA 19104, USA
| | - Bin Chen
- Department of Pharmaceutical Sciences, Philadelphia College of Pharmacy, Saint Joseph's University, Philadelphia, PA 19104, USA
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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5
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Suero Molina E, Black D, Kaneko S, Müther M, Stummer W. Double dose of 5-aminolevulinic acid and its effect on protoporphyrin IX accumulation in low-grade glioma. J Neurosurg 2022; 137:943-952. [PMID: 35213830 DOI: 10.3171/2021.12.jns211724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 12/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Administration of 5-aminolevulinic acid (5-ALA) does not regularly elicit fluorescence in low-grade glioma (LGG) at currently established doses and timing of administration. One explanation may be differences in blood-brain barrier (BBB) integrity compared to high-grade glioma. The authors hypothesized that for a BBB semipermeable to 5-ALA there might be a relationship between plasma 5-ALA concentration and its movement into the brain. A higher dose would elicit more 5-ALA conversion into protoporphyrin IX (PPIX). The authors present a case series of patients harboring LGG who received higher doses of 5-ALA. METHODS Patients undergoing surgery for indeterminate glioma later diagnosed as LGG were included in this study. 5-ALA was administered at a standard dose of 20 mg/kg body weight (bw) 4 hours prior to induction of anesthesia. A subgroup of patients received a higher dose of 40 mg/kg bw. Fluorescence was evaluated visually and PPIX concentration (cPPIX) was determined ex vivo by hyperspectral measurements in freshly extracted tissue. All adverse events were recorded. RESULTS A total of 23 patients harboring diffuse low-grade astrocytomas (n = 19) and oligodendrogliomas (n = 4) were analyzed. Thirteen patients received 20 mg/kg bw, and 10 patients received 40 mg/kg bw of 5-ALA. In the 20 mg/kg group, 30.8% (4 of 13) of tumors harbored areas of visible fluorescence, compared to 60% of cases (n = 6 of 10) with 40 mg/kg bw. The threshold to visibility was 1 μg/ml in both groups. Measured over all biopsies, the mean cPPIX was significantly higher in the double-dose group (1.8 vs 0.45 μg/ml; p < 0.001). In non-visibly fluorescent tissue the mean cPPIX was 0.146 μg/ml in the 20 mg/kg and 0.347 μg/ml in the 40 mg/kg group, indicating an increase of 138% (p < 0.001). CONCLUSIONS These observations demonstrate different regions with different levels of PPIX accumulation in LGG. With higher 5-ALA doses cPPIX increases, leading to more regions surpassing the visibility threshold of 1 μg/ml. These observations can be explained by the fact that the BBB in LGG is semipermeable to 5-ALA. Higher 5-ALA doses result in more PPIX conversion, an observation with implications for future dosing in LGG.
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Affiliation(s)
| | - David Black
- 2Carl Zeiss Meditec AG, Oberkochen, Germany
- 3Department of Physics and Astronomy, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - Sadahiro Kaneko
- 1Department of Neurosurgery, University Hospital of Münster
- 4Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Michael Müther
- 1Department of Neurosurgery, University Hospital of Münster
| | - Walter Stummer
- 1Department of Neurosurgery, University Hospital of Münster
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5 ALA Is a Potent Lactate Dehydrogenase Inhibitor But Not a Substrate: Implications for Cell Glycolysis and New Avenues in 5 ALA-Mediated Anticancer Action. Cancers (Basel) 2022; 14:cancers14164003. [PMID: 36010996 PMCID: PMC9406570 DOI: 10.3390/cancers14164003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/14/2022] [Accepted: 08/16/2022] [Indexed: 12/05/2022] Open
Abstract
Simple Summary In the present work, we found that 5-ALA, a natural precursor of heme, can hinder cell glycolysis, which is the main path of energy production for most cancer cells. More specifically, we found that 5-ALA can block an enzyme involved in glycolysis, called lactate dehydrogenase (LDH). We found that 5-ALA has a potency of LDH inhibition comparable to other established LDH inhibitors, such as oxamate or tartronic acid. Nevertheless, 5-ALA has a high accumulation rate in cancers and specifically in the incurable brain cancer glioblastoma multiforme (GBM), which is an important advantage. In fact, because of its high specificity to GBM, 5-ALA is used in the clinic to accurately guide the resection of the tumours, through the light emission of its photoactive product protoporphyrin IX (PpIX). PpIX is the penultimate step in the heme production. Importantly, we show here that continuous administration of 5-ALA killed GBM cells according to their dependence on glycolysis. We additionally found that 20% of externally administered 5-ALA is engaged in the inhibition of LDH, as when LDH was pre-loaded by another inhibitor, tartronic acid, then the cell production of PpIX from 5-ALA was increased by 20%. Since PpIX is an important drug for photodynamic therapy of cancer (excitation by light of PpIX produces oxygen by-products that can kill cancer cells), we additionally discovered that preloading LDH with its inhibitor tartronic acid before performing 5-ALA PDT increases the cancer cell death by 15%. Abstract In a course of metabolic experiments, we determined that the addition of δ-aminolevulinic acid (5-ALA) to a panel of glioblastoma multiforme (GBM) cells caused a steep reduction in their glycolytic activity. This reduction was accompanied by a decrease in adenosine triphosphate (ATP) production from glycolysis. These results suggested that 5-ALA is an inhibitor of glycolysis; due to the structural similarity of 5-ALA to the established lactate dehydrogenase (LDH) inhibitors oxamate (OXM) and tartronate (TART), we initially investigated LDH inhibition by 5-ALA in silico. The modelling revealed that 5-ALA could indeed be a competitive inhibitor of LDH but not a substrate. These theoretical findings were corroborated by enzymatic and cell lysate assays in which 5-ALA was found to confer a potent LDH inhibition comparable to that of OXM and TART. We subsequently evaluated the effect of 5-ALA-induced glycolysis inhibition on the viability of GBM cells with diverse metabolic phenotypes. In the Warburg-type cell lines Ln18 and U87, incubation with 5-ALA elicited profound and irreversible cell death (90–98%) at 10 mM after merely 24 h. In T98G, however, which exhibited both high respiratory and glycolytic rates, LD95 was achieved after 72 h of incubation with 20 mM 5-ALA. We additionally examined the production of the 5-ALA photosensitive metadrug protoporphyrin IX (PpIX), with and without prior LDH inhibition by TART. These studies revealed that ~20% of the 5-ALA taken up by the cells was engaged in LDH inhibition. We subsequently performed 5-ALA photodynamic therapy (PDT) on Ln18 GBM cells, again with and without prior LDH inhibition with TART, and found a PDT outcome enhancement of ~15% upon LDH pre-inhibition. We expect our findings to have a profound impact on contemporary oncology, particularly for the treatment of otherwise incurable brain cancers such as GBM, where the specific accumulation of 5-ALA is very high compared to the surrounding normal tissue.
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7
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5-Aminolevulinic acid fluorescence in brain non-neoplastic lesions: a systematic review and case series. Neurosurg Rev 2022; 45:3139-3148. [PMID: 35972631 DOI: 10.1007/s10143-022-01843-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
Fluorescence-guided surgery with 5-aminolevulinic acid (5-ALA) is used to assist brain tumor resection, especially for high-grade gliomas but also for low-grade gliomas, metastasis, and meningiomas. With the increasing use of this technique, even to assist biopsies, high-grade glioma-mimicking lesions had misled diagnosis by showing 5-ALA fluorescence in non-neoplastic lesions such as radiation necrosis and inflammatory or infectious disease. Since only isolated reports have been published, we systematically review papers reporting non-neoplastic lesion cases with 5-ALA according with the PRISMA guidelines, present our series, and discuss its pathophysiology. In total, 245 articles were identified and 12 were extracted according to our inclusion criteria. Analyzing 27 patients, high-grade glioma was postulated as preoperative diagnosis in 48% of the cases. Microsurgical resection was performed in 19 cases (70%), while 8 patients were submitted to biopsy (30%). We found 4 positive cases in demyelinating disease (50%), 4 in brain abscess (80%), 1 in neurocysticercosis (33%), 1 in neurotoxoplasmosis, infarction, and hematoma (100%), 4 in inflammatory disease (80%), and 3 in cortical dysplasia (100%). New indications are being considered especially in benign lesion biopsies with assistance of 5-ALA. Using fluorescence as an aid in biopsies may improve procedure time, number of samples, and necessity of intraoperative pathology. Further studies should include this technology to encourage more beneficial uses.
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8
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Solomou G, Gharooni AA, Patel W, Gillespie CS, Gough M, Venkatesh A, Poon MTC, Wykes V, Price SJ, Jenkinson MD, Watts C, Plaha P. Utility of 5-ALA for resection of CNS tumours other than high-grade gliomas: a protocol for a systematic review. BMJ Open 2022; 12:e056059. [PMID: 35868820 PMCID: PMC9315896 DOI: 10.1136/bmjopen-2021-056059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION 5-aminolevulinic acid (5-ALA) is a proagent developed for fluorescent-guided surgery for high-grade glioma patients associated with a significant increase in resection conferring survival. 5-ALA was shown to penetrate the blood-brain barrier accumulating in malignant glioma cells with high selectivity, sensitivity and positive predictive value. However, those have yet to be explored aiding diagnosis for tumours of the central nervous system (CNS) other than high-grade gliomas (HGG). No up-to-date systematic review exists reporting the major surgical outcomes and diagnostic accuracy. We sought to conduct a systematic review of the literature summarising surgical outcomes, evaluate the quality of diagnostic accuracy reported in the literature and qualitatively assess the evidence to inform future studies. METHODS AND ANALYSIS We will search electronic databases (Medline, Embase) with subsequent interrogation of references lists of articles reporting the use of 5-ALA for brain tumours other than high-grade glioma adult patients, which also report the extent of resection and/or survival. Prospective and retrospective cohort and case-control studies with more than five patients will be included. Two independent reviewers will screen the abstracts and full articles, with a third reviewer resolving any conflicts. The data will be extracted in a standardised template and outcomes will be reported using descriptive statists. The quality of non-randomised studies will be appraised. ETHICS AND DISSEMINATION The study will summarise the available evidence on the effect of the clinical utility of 5-ALA in achieving resection and improving survival and its diagnostic accuracy for tumours of the CNS other than HGG. The data will be presented nationally and internationally and the manuscript will be published in a peer-reviewed journal. No ethical approvals were needed. The aim is to inform prospective studies minimising reporting bias allowing for more reliable, reproducible and generalisable results. The study has been registered in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.PROSPERO registration numberCRD42021260542.
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Affiliation(s)
- Georgios Solomou
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Aref-Ali Gharooni
- Department of Clinical Neuroscience, Addenbrooke's Hospital, Cambridge, UK
| | - Waqqas Patel
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
| | - Conor S Gillespie
- Neurosurgery Division, Dept. Clinical Neurosciences, Cambridge University, Cambridge, UK
| | - Melissa Gough
- Department of Neurosurgery, Royal Victoria Infirmary Newcastle Hospitals NHS Trust, Newcastle, UK
| | - Ashwin Venkatesh
- Blizard Institute, Centre for Neuroscience Surgery and Trauma, Barts Health NHS Trust, London, UK
| | - Michael T C Poon
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neuroscience, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Victoria Wykes
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stephen John Price
- Neurosurgery Division, Dept. Clinical Neurosciences, Cambridge University, Cambridge, UK
| | - Michael D Jenkinson
- Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Clinical and Molecular Cancer, University of Liverpool, Liverpool, UK
| | - Colin Watts
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Puneet Plaha
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
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Lea-Banks H, Wu SK, Lee H, Hynynen K. Ultrasound-triggered oxygen-loaded nanodroplets enhance and monitor cerebral damage from sonodynamic therapy. Nanotheranostics 2022; 6:376-387. [PMID: 35795341 PMCID: PMC9254362 DOI: 10.7150/ntno.71946] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/03/2022] [Indexed: 11/05/2022] Open
Abstract
In sonodynamic therapy, cellular toxicity from sonosensitizer drugs, such as 5-aminolevulinic acid hydrochloride (5-ALA), may be triggered with focused ultrasound through the production of reactive oxygen species (ROS). Here we show that by increasing local oxygen during treatment, using oxygen-loaded perfluorocarbon nanodroplets (250 +/- 8 nm), we can increase the damage induced by 5-ALA, and monitor the severity by recording acoustic emissions in the brain. To achieve this, we sonicated the right striatum of 16 healthy rats after an intravenous dose of 5-ALA (200 mg/kg), followed by saline, nanodroplets, or oxygen-loaded nanodroplets. We assessed haemorrhage, edema and cell apoptosis immediately following, 24 hr, and 48 hr after focused ultrasound treatment. The localized volume of damaged tissue was significantly enhanced by the presence of oxygen-loaded nanodroplets, compared to ultrasound with unloaded nanodroplets (3-fold increase), and ultrasound alone (40-fold increase). Sonicating 1 hr following 5-ALA injection was found to be more potent than 2 hr following 5-ALA injection (2-fold increase), and the severity of tissue damage corresponded to the acoustic emissions from droplet vaporization. Enhancing the local damage from 5-ALA with monitored cavitation activity and additional oxygen could have significant implications in the treatment of atherosclerosis and non-invasive ablative surgeries.
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Affiliation(s)
- Harriet Lea-Banks
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Canada
| | - Sheng-Kai Wu
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Hannah Lee
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Canada
| | - Kullervo Hynynen
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada.,Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
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10
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5-Aminolevulinic Acid (5-ALA)-Induced Protoporphyrin IX Fluorescence by Glioma Cells-A Fluorescence Microscopy Clinical Study. Cancers (Basel) 2022; 14:cancers14122844. [PMID: 35740509 PMCID: PMC9221265 DOI: 10.3390/cancers14122844] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/25/2022] [Accepted: 06/06/2022] [Indexed: 02/05/2023] Open
Abstract
Simple Summary 5-aminolevulinic acid (5-ALA)-induced PpIX fluorescence is used in neurosurgery for intraoperative identification of high-grade glioma tissue. In this paper, using a fluorescence microscopy analysis on human tumor specimens, we assessed the actual number of fluorescence-positive tumor cells both in low-grade and high-grade glioma, and the ability of 5-ALA to cross the blood–brain barrier (BBB). We found that in high-grade gliomas, 32.7–75.5 percent of cells display 5-ALA induced PpIX fluorescence, whereas in low-grade gliomas the tumor cells did not fluoresce following 5-ALA. Immunofluorescence for BBB components suggested that 5-ALA does not cross the un-breached BBB. These findings are of crucial importance in planning neurosurgical resection of gliomas. Abstract 5-aminolevulinic acid (5-ALA)-induced PpIX fluorescence is used by neurosurgeons to identify the tumor cells of high-grade gliomas during operation. However, the issue of whether 5-ALA-induced PpIX fluorescence consistently stains all the tumor cells is still debated. Here, we assessed the cytoplasmatic signal of 5-ALA by fluorescence microscopy in a series of human gliomas. As tumor markers, we used antibodies against collapsin response-mediated protein 5 (CRMP5), alpha thalassemia/mental retardation syndrome X-linked (ATRX), and anti-isocitrate dehydrogenase 1 (IDH1). In grade III–IV gliomas, the signal induced by 5-ALA was detected in 32.7–75.5 percent of CRMP5-expressing tumor cells. In low-grade gliomas (WHO grade II), the CRMP5-expressing tumor cells did not fluoresce following 5-ALA. Immunofluorescence with antibodies that stain various components of the blood–brain barrier (BBB) suggested that 5-ALA does not cross the un-breached BBB, in spite of its small dimension. To conclude, 5-ALA-induced PpIX fluorescence has an established role in high-grade glioma surgery, but it has limited usefulness in surgery for low-grade glioma, especially when the BBB is preserved.
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11
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Zhang X, Jaman E, Habib A, Ozpinar A, Andrews E, Amankulor NM, Zinn PO. A Novel 5-Aminolevulinic Acid-Enabled Surgical Loupe System-A Consecutive Brain Tumor Series of 11 Cases. Oper Neurosurg (Hagerstown) 2022; 22:298-304. [PMID: 35315798 DOI: 10.1227/ons.0000000000000141] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 11/01/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The concept of maximally safe resection (MSR) has been shown to improve clinical outcomes in the treatment of high-grade gliomas (HGGs). To achieve MSR, surgical adjuncts such as functional imaging, neuronavigation, intraoperative mapping, ultrasound, and fluorescence-guided surgery are routinely used. 5-Aminolevulinic acid (5-ALA) is an oral agent that has been increasingly adopted in fluorescence-guided resection of HGG. In randomized clinical trials of 5-ALA, it has been shown to increase the extent of resection and progression-free survival in HGG. Current commercially available 5-ALA detection systems are all microscope-based and can sometimes be cumbersome to use. OBJECTIVE To present our experience using a novel 5-ALA-enabled surgical loupe system. METHODS 5-ALA-enabled loupes were used in 11 consecutive patients with either suspected HGG on magnetic resonance imaging or recurrence of known lesions. Lesion appearance was examined under white light, 5-ALA loupes, and a 5-ALA microscope. Tumor specimens were checked for fluorescence and sent for pathologic examination. RESULTS In our experience, a 5-ALA-enabled surgical loupe system offers excellent visualization of 5-ALA in patients with HGG. In 10 of 11 patients, fluorescent tissue was confirmed to be high-grade glioma by pathology. In 1 patient, tissue was not fluorescent, and final pathology was World Health Organization grade I meningioma. CONCLUSION A 5-ALA-enabled surgical loupe system offers excellent intraoperative visualization of 5-ALA fluorescence in HGG and can be a viable surgical adjunct for achieving MSR of HGG.
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Affiliation(s)
- Xiaoran Zhang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Emade Jaman
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ahmed Habib
- Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alp Ozpinar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Edward Andrews
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nduka M Amankulor
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pascal O Zinn
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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12
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Correlation of Intraoperative 5-ALA-Induced Fluorescence Intensity and Preoperative 11C-Methionine PET Uptake in Glioma Surgery. Cancers (Basel) 2022; 14:cancers14061449. [PMID: 35326600 PMCID: PMC8946621 DOI: 10.3390/cancers14061449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/01/2022] [Accepted: 03/08/2022] [Indexed: 12/14/2022] Open
Abstract
Simple Summary In malignant brain tumor surgery, precise identification of the tumor is essential. 5-Aminolevulinic acid (5-ALA) labels tumor cells with red fluorescence to facilitate tumor resection. On the other hand, the nuclear medicine imaging technique, positron emission tomography with 11C-methionine (MET-PET), can delineate tumors precisely but is not widely available. This study aimed to determine the correlation between intraoperative 5-ALA-induced fluorescence and preoperative MET-PET signals of gliomas. We quantitatively measured the fluorescence intensity from tumor samples and calculated the MET-PET uptake by the tumor. Our study showed that strong tumor fluorescence correlated with high MET-PET uptake and cellular proliferation. Our findings might be valuable to rapidly provide information on tumor biology at the time of surgery in circumstances where MET-PET is inaccessible. Abstract Background: 5-Aminolevulinic acid (5-ALA) is widely employed to assist fluorescence-guided surgery for malignant brain tumors. Positron emission tomography with 11C-methionine (MET-PET) represents the activity of brain tumors with precise boundaries but is not readily available. We hypothesized that quantitative 5-ALA-induced fluorescence intensity might correlate with MET-PET uptake in gliomas. Methods: Adult patients with supratentorial astrocytic gliomas who underwent preoperative MET-PET and surgical tumor resection using 5-ALA were enrolled in this prospective study. The regional tumor uptake of MET-PET was expressed as the ratio of standardized uptake volume max to that of the normal contralateral frontal lobe. A spectrometric fluorescence detection system measured tumor specimens’ ex vivo fluorescence intensity at 635 nm. Ki-67 index and IDH mutation status were assessed by histopathological analysis. Use of an antiepileptic drug (AED) and contrast enhancement pattern on MRI were also investigated. Results: Thirty-two patients, mostly with Glioblastoma IDH wild type (46.9%) and anaplastic astrocytoma IDH mutant (21.9%), were analyzed. When the fluorescence intensity was ranked into four groups, the strongest fluorescence group exhibited the highest mean MET-PET uptake and Ki-67 index values. When rearranged into fluorescence Visible or Non-visible groups, the Visible group had significantly higher MET-PET uptake and Ki-67 index compared to the Non-visible group. Contrast enhancement on MRI and IDH wild type tumors were more frequent among the Visible group. AED use did not correlate with 5-ALA-induced fluorescence intensity. Conclusions: In astrocytic glioma surgery, visible 5-ALA-induced fluorescence correlated with high MET-PET uptake, along with a high Ki-67 index.
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13
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Mazurek M, Szczepanek D, Orzyłowska A, Rola R. Analysis of Factors Affecting 5-ALA Fluorescence Intensity in Visualizing Glial Tumor Cells-Literature Review. Int J Mol Sci 2022; 23:ijms23020926. [PMID: 35055109 PMCID: PMC8779265 DOI: 10.3390/ijms23020926] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 01/27/2023] Open
Abstract
Glial tumors are one of the most common lesions of the central nervous system. Despite the implementation of appropriate treatment, the prognosis is not successful. As shown in the literature, maximal tumor resection is a key element in improving therapeutic outcome. One of the methods to achieve it is the use of fluorescent intraoperative navigation with 5-aminolevulinic acid. Unfortunately, often the level of fluorescence emitted is not satisfactory, resulting in difficulties in the course of surgery. This article summarizes currently available knowledge regarding differences in the level of emitted fluorescence. It may depend on both the histological type and the genetic profile of the tumor, which is reflected in the activity and expression of enzymes involved in the intracellular metabolism of fluorescent dyes, such as PBGD, FECH, UROS, and ALAS. The transport of 5-aminolevulinic acid and its metabolites across the blood–brain barrier and cell membranes mediated by transporters, such as ABCB6 and ABCG2, is also important. Accompanying therapies, such as antiepileptic drugs or steroids, also have an impact on light emission by tumor cells. Accurate determination of the factors influencing the fluorescence of 5-aminolevulinic acid-treated cells may contribute to the improvement of fluorescence navigation in patients with highly malignant gliomas.
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14
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Ricci A, Di Pierro E, Marcacci M, Ventura P. Mechanisms of Neuronal Damage in Acute Hepatic Porphyrias. Diagnostics (Basel) 2021; 11:diagnostics11122205. [PMID: 34943446 PMCID: PMC8700611 DOI: 10.3390/diagnostics11122205] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 01/12/2023] Open
Abstract
Porphyrias are a group of congenital and acquired diseases caused by an enzymatic impairment in the biosynthesis of heme. Depending on the specific enzyme involved, different types of porphyrias (i.e., chronic vs. acute, cutaneous vs. neurovisceral, hepatic vs. erythropoietic) are described, with different clinical presentations. Acute hepatic porphyrias (AHPs) are characterized by life-threatening acute neuro-visceral crises (acute porphyric attacks, APAs), featuring a wide range of neuropathic (central, peripheral, autonomic) manifestations. APAs are usually unleashed by external "porphyrinogenic" triggers, which are thought to cause an increased metabolic demand for heme. During APAs, the heme precursors δ-aminolevulinic acid (ALA) and porphobilinogen (PBG) accumulate in the bloodstream and urine. Even though several hypotheses have been developed to explain the protean clinical picture of APAs, the exact mechanism of neuronal damage in AHPs is still a matter of debate. In recent decades, a role has been proposed for oxidative damage caused by ALA, mitochondrial and synaptic ALA toxicity, dysfunction induced by relative heme deficiency on cytochromes and other hemeproteins (i.e., nitric oxide synthases), pyridoxal phosphate functional deficiency, derangements in the metabolic pathways of tryptophan, and other factors. Since the pathway leading to the biosynthesis of heme is inscribed into a complex network of interactions, which also includes some fundamental processes of basal metabolism, a disruption in any of the steps of this pathway is likely to have multiple pathogenic effects. Here, we aim to provide a comprehensive review of the current evidence regarding the mechanisms of neuronal damage in AHPs.
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Affiliation(s)
- Andrea Ricci
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.)
| | - Elena Di Pierro
- Dipartimento di Medicina Interna, Fondazione IRCSS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Matteo Marcacci
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.)
| | - Paolo Ventura
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.)
- Correspondence: ; Tel.: +39-059-4225-542
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15
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Gerischer LM, Scheibe F, Nümann A, Köhnlein M, Stölzel U, Meisel A. Acute porphyrias - A neurological perspective. Brain Behav 2021; 11:e2389. [PMID: 34661997 PMCID: PMC8613433 DOI: 10.1002/brb3.2389] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/21/2021] [Accepted: 09/14/2021] [Indexed: 01/23/2023] Open
Abstract
Acute hepatic porphyrias (AHP) can cause severe neurological symptoms involving the central, autonomic, and peripheral nervous system. Due to their relative rarity and their chameleon-like presentation, delayed diagnosis and misdiagnosis are common. AHPs are genetically inherited disorders that result from heme biosynthesis enzyme deficiencies and comprise four forms: acute intermittent porphyria (AIP), variegate porphyria (VP), hereditary coproporphyria (HCP), and ALA-dehydratase porphyria (ALADP). Depending on the clinical presentation, the main differential diagnoses are Guillain-Barré syndrome and autoimmune encephalitis. Red flags that could raise the suspicion of acute porphyria are neurological symptoms starting after severe (abdominal) pain, in association with reddish urine, hyponatremia or photodermatitis, and the presence of encephalopathy and/or axonal neuropathy. We highlight the diagnostic difficulties by presenting three cases from our neurological intensive care unit and give a comprehensive overview about the diagnostic findings in imaging, electrophysiology, and neuropathology.
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Affiliation(s)
- Lea M. Gerischer
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, NeuroCure Clinical Research CenterBerlinGermany
| | - Franziska Scheibe
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, NeuroCure Clinical Research CenterBerlinGermany
| | - Astrid Nümann
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
| | - Martin Köhnlein
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
| | - Ulrich Stölzel
- Department of Internal Medicine II, Porphyria Center SaxoniaKlinikum Chemnitz gGmbHChemnitzGermany
| | - Andreas Meisel
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, NeuroCure Clinical Research CenterBerlinGermany
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16
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Beauchamp LH, Bercu MM, Avellino AM. 5-Aminolevulinic acid–assisted resection of pediatric dysembryoplastic neuroepithelial tumor: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE20153. [PMID: 35854680 PMCID: PMC9265167 DOI: 10.3171/case20153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/15/2021] [Indexed: 12/02/2022]
Abstract
BACKGROUND 5-Aminolevulinic acid (5-ALA) is approved as an adjunct for the resection of high-grade gliomas and is associated with improved outcomes. Dysembryoplastic neuroepithelial tumors (DNETs) are benign glioneural tumors occurring primarily in pediatric patients and often manifesting with seizure disorder. The goal of the surgical intervention is to obtain gross-total resection, which is associated, in the majority of cases, with seizure freedom. OBSERVATIONS The authors present the first case report of a pediatric patient who underwent gross-total resection of a 5-ALA–positive DNET with no evidence of recurrent seizures (Engel class I). LESSONS Fluorescence-guided surgery using 5-ALA facilitated gross-total resection of the mass.
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Affiliation(s)
- Luke H. Beauchamp
- College of Human Medicine, Michigan State University, East Lansing, Michigan; and
| | - Marian Michael Bercu
- Pediatric Neurosurgery, Helen DeVos Children’s Hospital, Spectrum Health, Grand Rapids, Michigan
| | - Anthony M. Avellino
- College of Human Medicine, Michigan State University, East Lansing, Michigan; and
- Pediatric Neurosurgery, Helen DeVos Children’s Hospital, Spectrum Health, Grand Rapids, Michigan
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17
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Palmieri G, Cofano F, Salvati LF, Monticelli M, Zeppa P, Perna GD, Melcarne A, Altieri R, La Rocca G, Sabatino G, Barbagallo GM, Tartara F, Zenga F, Garbossa D. Fluorescence-Guided Surgery for High-Grade Gliomas: State of the Art and New Perspectives. Technol Cancer Res Treat 2021; 20:15330338211021605. [PMID: 34212784 PMCID: PMC8255554 DOI: 10.1177/15330338211021605] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
High-grade gliomas are aggressive tumors that require multimodal management and gross total resection is considered to be the first crucial step of treatment. Because of their infiltrative nature, intraoperative differentiation of neoplastic tissue from normal parenchyma can be challenging. For these reasons, in the recent years, neurosurgeons have increasingly performed this surgery under the guidance of tissue fluorescence. Sodium fluoresceine and 5-aminolevulinic acid represent the 2 main compounds that allow real-time identification of residual malignant tissue and have been associated with improved gross total resection and radiological outcomes. Though presenting different profiles of sensitivity and specificity and further investigations concerning cost-effectiveness are need, Sodium fluoresceine, 5-aminolevulinic acid and new phluorophores, such as Indocyanine green, represent some of the most important tools in the neurosurgeon’s hands to achieve gross total resection.
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Affiliation(s)
- Giuseppe Palmieri
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Fabio Cofano
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy.,Neurosurgery/Spine Surgery, Humanitas Gradenigo Hospital, Turin, Italy
| | - Luca Francesco Salvati
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Matteo Monticelli
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Pietro Zeppa
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Giuseppe Di Perna
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Antonio Melcarne
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Roberto Altieri
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Italy
| | - Giuseppe La Rocca
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli Irccs, Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli Irccs, Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giuseppe Maria Barbagallo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Italy
| | - Fulvio Tartara
- Unit of Neurosurgery, Istituto Clinico Città Studi, Milan, Italy
| | - Francesco Zenga
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
| | - Diego Garbossa
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini," University of Turin, Turin, Italy
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18
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Kaneko S, Suero Molina E, Sporns P, Schipmann S, Black D, Stummer W. Fluorescence real-time kinetics of protoporphyrin IX after 5-ALA administration in low-grade glioma. J Neurosurg 2021; 136:9-15. [PMID: 34144512 DOI: 10.3171/2020.10.jns202881] [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: 07/25/2020] [Accepted: 10/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE 5-Aminolevulinic acid (5-ALA) induces fluorescence in high-grade glioma (HGG), which is used for resection. However, the value of 5-ALA-induced fluorescence in low-grade glioma (LGG) is unclear. Time dependency and time kinetics have not yet been investigated. The purpose of this study was to investigate real-time kinetics of protoporphyrin IX (PpIX) in LGG based on hyperspectral fluorescence-based measurements and identify factors that predict fluorescence. METHODS Patients with grade II gliomas and imaging from which HGGs could not be completely ruled out received 5-ALA at 20 mg/kg body weight 4 hours prior to surgery. Fluorescence intensity (FI) and PpIX concentration (CPpIX) were measured in tumor tissue utilizing a hyperspectral camera. Apparent diffusion coefficient (ADC)-based tumor cell density, Ki-67/MIB-1 index, chromosomal 1p/19q codeletion, and 18F-fluoroethyl-l-tyrosine (18F-FET) PET values and their role for predicting fluorescence were evaluated. RESULTS Eighty-one biopsies from 25 patients were included. Tissues with fluorescence demonstrated FI and CPpIX maxima between 7 and 8 hours after administration. When visible fluorescence was observed, peaks of FI and CPpIX were observed within this 7- to 8-hour time frame, regardless of any MRI gadolinium contrast enhancement. Gadolinium enhancement (p = 0.008), Ki-67/MIB-1 index (p < 0.001), 18F-FET PET uptake ratio (p = 0.004), and ADC-based tumor cellularity (p = 0.017) significantly differed between fluorescing and nonfluorescing tissue, but not 1p/19q codeletions. Logistic regression demonstrated that 18F-FET PET uptake and Ki-67/MIB-1 index were independently related to fluorescence. CONCLUSIONS This study reports a fluorescence-based assessment of CPpIX in human LGG tissues related to 18F-FET PET uptake and Ki-67/MIB-1. As in HGGs, fluorescence in LGGs peaked between 7 and 8 hours after 5-ALA application, which has consequences for the timing of administration.
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Affiliation(s)
- Sadahiro Kaneko
- 1Department of Neurosurgery, University Hospital of Münster, Germany.,2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Eric Suero Molina
- 1Department of Neurosurgery, University Hospital of Münster, Germany
| | - Peter Sporns
- 3Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Switzerland.,4Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - David Black
- 5Carl Zeiss Meditec AG, Oberkochen, Germany; and.,6University of British Columbia, Vancouver, British Columbia, Canada
| | - Walter Stummer
- 1Department of Neurosurgery, University Hospital of Münster, Germany
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19
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Gull HH, Karadag C, Senger B, Sorg RV, Möller P, Mellert K, Steiger HJ, Hänggi D, Cornelius JF. Ciprofloxacin enhances phototoxicity of 5-aminolevulinic acid mediated photodynamic treatment for chordoma cell lines. Photodiagnosis Photodyn Ther 2021; 35:102346. [PMID: 34038764 DOI: 10.1016/j.pdpdt.2021.102346] [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: 12/08/2020] [Revised: 04/21/2021] [Accepted: 05/14/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chordoma are uncommon aggressive tumors of the skeleton. Surgical resection is often subtotal and adjuvant treatment possibilities are limited as chordomas are highly chemo- and radioresistant. In the present study we examined the impact of 5-ALA PDT on different human chordoma cell lines. Furthermore, we investigated the variation of two parameters: (1.) 5-ALA incubation time and (2.) supplemental use of ciprofloxacin as iron chelator. METHODS Experiments were realized in vitro with three different human chordoma cell lines: U-CH2, U-CH2B and U-CH14. After pre-incubation for 24 h with various concentrations of ciprofloxacin (1.5 - 5.0 μg/ml), different amounts of 5-ALA (15 - 50 μg/ml) were applied to the cells either for a brief (4 h) or a long (6 h) incubation time. Subsequently cells were exposed to photodynamic radiation. Cell viability was exploited by WST-1 assay. Thus, for each of the three cell lines, two drug combinations (ciprofloxacin plus 5-ALA and 5-ALA only) and two incubation times (short, 4 h and long, 6 h) were tested. Negative control groups were also examined. RESULTS Supplemental use of ciprofloxacin led to increased cell death in each of the cell lines. Different 5-ALA incubation times (4 h vs. 6 h) showed no significant differences in cell viability except for U-CH2. CONCLUSION Ciprofloxacin as an ordinary applied antibiotic, enhanced the effect of 5-ALA PDT on different human chordoma cell lines in vitro. The impact was dependent on the dose of ciprofloxacin-5-ALA. There were no notable differences for the tested 5-ALA incubation times. In human chordoma cell lines 5-ALA PDT may effectively be amended by ciprofloxacin.
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Affiliation(s)
- Hanah Hadice Gull
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Germany.
| | - Cihat Karadag
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Brigitte Senger
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Rüdiger V Sorg
- Institute for Transplantation Diagnostics and Cell Therapeutics, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Peter Möller
- Institute of Pathology, University Hospital, Ulm, Germany
| | - Kevin Mellert
- Institute of Pathology, University Hospital, Ulm, Germany
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Jan Frederick Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.
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20
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Zhou Q, van den Berg NS, Rosenthal EL, Iv M, Zhang M, Vega Leonel JCM, Walters S, Nishio N, Granucci M, Raymundo R, Yi G, Vogel H, Cayrol R, Lee YJ, Lu G, Hom M, Kang W, Hayden Gephart M, Recht L, Nagpal S, Thomas R, Patel C, Grant GA, Li G. EGFR-targeted intraoperative fluorescence imaging detects high-grade glioma with panitumumab-IRDye800 in a phase 1 clinical trial. Theranostics 2021; 11:7130-7143. [PMID: 34158840 PMCID: PMC8210618 DOI: 10.7150/thno.60582] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/24/2021] [Indexed: 12/12/2022] Open
Abstract
Rationale: First-line therapy for high-grade gliomas (HGGs) includes maximal safe surgical resection. The extent of resection predicts overall survival, but current neuroimaging approaches lack tumor specificity. The epidermal growth factor receptor (EGFR) is a highly expressed HGG biomarker. We evaluated the safety and feasibility of an anti-EGFR antibody, panitumuab-IRDye800, at subtherapeutic doses as an imaging agent for HGG. Methods: Eleven patients with contrast-enhancing HGGs were systemically infused with panitumumab-IRDye800 at a low (50 mg) or high (100 mg) dose 1-5 days before surgery. Near-infrared fluorescence imaging was performed intraoperatively and ex vivo, to identify the optimal tumor-to-background ratio by comparing mean fluorescence intensities of tumor and histologically uninvolved tissue. Fluorescence was correlated with preoperative T1 contrast, tumor size, EGFR expression and other biomarkers. Results: No adverse events were attributed to panitumumab-IRDye800. Tumor fragments as small as 5 mg could be detected ex vivo and detection threshold was dose dependent. In tissue sections, panitumumab-IRDye800 was highly sensitive (95%) and specific (96%) for pathology confirmed tumor containing tissue. Cellular delivery of panitumumab-IRDye800 was correlated to EGFR overexpression and compromised blood-brain barrier in HGG, while normal brain tissue showed minimal fluorescence. Intraoperative fluorescence improved optical contrast in tumor tissue within and beyond the T1 contrast-enhancing margin, with contrast-to-noise ratios of 9.5 ± 2.1 and 3.6 ± 1.1, respectively. Conclusions: Panitumumab-IRDye800 provided excellent tumor contrast and was safe at both doses. Smaller fragments of tumor could be detected at the 100 mg dose and thus more suitable for intraoperative imaging.
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Affiliation(s)
- Quan Zhou
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Nynke S. van den Berg
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Eben L. Rosenthal
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cancer Center, Stanford University, Stanford, CA, USA
| | - Michael Iv
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Shannon Walters
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Naoki Nishio
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Monica Granucci
- Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford, CA, USA
| | - Roan Raymundo
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford, CA, USA
| | - Grace Yi
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Cancer Clinical Trials Office, Stanford University School of Medicine, Stanford, CA, USA
| | - Hannes Vogel
- Department of Neuropathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Romain Cayrol
- Department of Neuropathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Yu-Jin Lee
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Guolan Lu
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Marisa Hom
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Wenying Kang
- Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Larry Recht
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Seema Nagpal
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Reena Thomas
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Chirag Patel
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gerald A. Grant
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
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Di L, Eichberg DG, Huang K, Shah AH, Jamshidi AM, Luther EM, Lu VM, Komotar RJ, Ivan ME, Gultekin SH. Stimulated Raman Histology for Rapid Intraoperative Diagnosis of Gliomas. World Neurosurg 2021; 150:e135-e143. [PMID: 33684587 DOI: 10.1016/j.wneu.2021.02.122] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/23/2021] [Accepted: 02/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intraoperative pathologic diagnosis traditionally involves frozen section histopathology, which may be labor and time intensive. Indeed, a technique that streamlines the acquisition and evaluation of intraoperative histologic data may expedite surgical decision-making and shorten operative time. Stimulated Raman histology (SRH) is an emerging technology that allows for more rapid acquisition and interpretation of intraoperative histopathologic data. METHODS A blinded, prospective cohort study was performed for 82 patients undergoing resection for a central nervous system tumor. Of these, 21 patients were diagnosed with glioma either intraoperatively or postoperatively on permanent section histology and included in this study. Time to diagnosis (TTD) and diagnostic accuracy relative to permanent section (the gold standard) were compared between SRH-based diagnosis and conventional frozen section histology. Diagnostic concordance with permanent section was also compared between frozen histopathology and SRH diagnosis. RESULTS Diagnostic accuracy was not significantly different between methods (P = 1.00). Diagnostic concordance was not significantly different between methods when comparing 95% confidence intervals for kappa values (κ = 0.215; κ = 0.297; κ = 0.369). Lastly, mean TTD was significantly shorter with SRH-based diagnosis compared with frozen section (43 vs. 9.7 minutes, P < 0.0001). SRH was able to identify key features associated with varying glioma types. CONCLUSIONS SRH allows for rapid intraoperative diagnosis without sacrificing diagnostic accuracy. SRH may serve as a promising adjuvant to conventional histopathology to expedite intraoperative pathology consultation and surgical decision-making.
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Affiliation(s)
- Long Di
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
| | - Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Kevin Huang
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Aria M Jamshidi
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Evan M Luther
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Victor M Lu
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA; Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA; Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - Sakir H Gultekin
- Department of Pathology, University of Miami Miller School of Medicine, Miami, Florida, USA
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22
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Takano T, Satoh K, Doki T. Possible Antiviral Activity of 5-Aminolevulinic Acid in Feline Infectious Peritonitis Virus (Feline Coronavirus) Infection. Front Vet Sci 2021; 8:647189. [PMID: 33644160 PMCID: PMC7903937 DOI: 10.3389/fvets.2021.647189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/20/2021] [Indexed: 11/13/2022] Open
Abstract
Feline infectious peritonitis (FIP) is a life-threatening infectious disease of cats caused by virulent feline coronavirus (FIP virus: FIPV). For the treatment of FIP, several effective antivirals were recently reported, but many of these are not available for practical use. 5-amino levulinic acid (5-ALA) is a low-molecular-weight amino acid synthesized in plant and animal cells. 5-ALA can be synthesized in a large amount, and it is widely applied in the medical and agricultural fields. We hypothesized that 5-ALA inhibits FIPV infection. Therefore, we evaluated its antiviral activity against FIPV in felis catus whole fetus-4 cells and feline primary macrophages. FIPV infection was significantly inhibited by 250 μM 5-ALA. Our study suggested that 5-ALA is applicable for the treatment and prevention of FIPV infection.
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Affiliation(s)
- Tomomi Takano
- Laboratory of Veterinary Infectious Disease, Department of Veterinary Medicine, Kitasato University, Towada, Japan
| | - Kumi Satoh
- Laboratory of Veterinary Infectious Disease, Department of Veterinary Medicine, Kitasato University, Towada, Japan
| | - Tomoyoshi Doki
- Laboratory of Veterinary Infectious Disease, Department of Veterinary Medicine, Kitasato University, Towada, Japan
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Traylor JI, Pernik MN, Sternisha AC, McBrayer SK, Abdullah KG. Molecular and Metabolic Mechanisms Underlying Selective 5-Aminolevulinic Acid-Induced Fluorescence in Gliomas. Cancers (Basel) 2021; 13:cancers13030580. [PMID: 33540759 PMCID: PMC7867275 DOI: 10.3390/cancers13030580] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/22/2021] [Accepted: 01/26/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary 5-aminolevulinic acid (5-ALA) is a medication that produces fluorescence in certain cancers, which enables surgeons to visualize tumor margins during surgery. Gliomas are brain tumors that can be difficult to fully resect due to their infiltrative nature. In this review we explored what is known about the mechanism of 5-ALA, recent discoveries that increase our understanding of that mechanism, and potential targets to increase fluorescence in lower grade gliomas. Abstract 5-aminolevulinic acid (5-ALA) is a porphyrin precursor in the heme synthesis pathway. When supplied exogenously, certain cancers consume 5-ALA and convert it to the fluorogenic metabolite protoporphyrin IX (PpIX), causing tumor-specific tissue fluorescence. Preoperative administration of 5-ALA is used to aid neurosurgical resection of high-grade gliomas such as glioblastoma, allowing for increased extent of resection and progression free survival for these patients. A subset of gliomas, especially low-grade tumors, do not accumulate PpIX intracellularly or readily fluoresce upon 5-ALA administration, making gross total resection difficult to achieve in diffuse lesions. We review existing literature on 5-ALA metabolism and PpIX accumulation to explore potential mechanisms of 5-ALA-induced glioma tissue fluorescence. Targeting the heme synthesis pathway and understanding its dysregulation in malignant tissues could aid the development of adjunct therapies to increase intraoperative fluorescence after 5-ALA treatment.
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Affiliation(s)
- Jeffrey I. Traylor
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA; (J.I.T.); (M.N.P.)
| | - Mark N. Pernik
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA; (J.I.T.); (M.N.P.)
| | - Alex C. Sternisha
- Children’s Medical Center Research Institute, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA;
| | - Samuel K. McBrayer
- Children’s Medical Center Research Institute, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA;
- Correspondence: (S.K.M.); (K.G.A.); Tel.: +1-(214)-648-3730 (S.K.M.); +1-(214)-645-2300 (K.G.A.)
| | - Kalil G. Abdullah
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA; (J.I.T.); (M.N.P.)
- Correspondence: (S.K.M.); (K.G.A.); Tel.: +1-(214)-648-3730 (S.K.M.); +1-(214)-645-2300 (K.G.A.)
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24
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Ma L, Fei B. Comprehensive review of surgical microscopes: technology development and medical applications. JOURNAL OF BIOMEDICAL OPTICS 2021; 26:JBO-200292VRR. [PMID: 33398948 PMCID: PMC7780882 DOI: 10.1117/1.jbo.26.1.010901] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/04/2020] [Indexed: 05/06/2023]
Abstract
SIGNIFICANCE Surgical microscopes provide adjustable magnification, bright illumination, and clear visualization of the surgical field and have been increasingly used in operating rooms. State-of-the-art surgical microscopes are integrated with various imaging modalities, such as optical coherence tomography (OCT), fluorescence imaging, and augmented reality (AR) for image-guided surgery. AIM This comprehensive review is based on the literature of over 500 papers that cover the technology development and applications of surgical microscopy over the past century. The aim of this review is threefold: (i) providing a comprehensive technical overview of surgical microscopes, (ii) providing critical references for microscope selection and system development, and (iii) providing an overview of various medical applications. APPROACH More than 500 references were collected and reviewed. A timeline of important milestones during the evolution of surgical microscope is provided in this study. An in-depth technical overview of the optical system, mechanical system, illumination, visualization, and integration with advanced imaging modalities is provided. Various medical applications of surgical microscopes in neurosurgery and spine surgery, ophthalmic surgery, ear-nose-throat (ENT) surgery, endodontics, and plastic and reconstructive surgery are described. RESULTS Surgical microscopy has been significantly advanced in the technical aspects of high-end optics, bright and shadow-free illumination, stable and flexible mechanical design, and versatile visualization. New imaging modalities, such as hyperspectral imaging, OCT, fluorescence imaging, photoacoustic microscopy, and laser speckle contrast imaging, are being integrated with surgical microscopes. Advanced visualization and AR are being added to surgical microscopes as new features that are changing clinical practices in the operating room. CONCLUSIONS The combination of new imaging technologies and surgical microscopy will enable surgeons to perform challenging procedures and improve surgical outcomes. With advanced visualization and improved ergonomics, the surgical microscope has become a powerful tool in neurosurgery, spinal, ENT, ophthalmic, plastic and reconstructive surgeries.
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Affiliation(s)
- Ling Ma
- University of Texas at Dallas, Department of Bioengineering, Richardson, Texas, United States
| | - Baowei Fei
- University of Texas at Dallas, Department of Bioengineering, Richardson, Texas, United States
- University of Texas Southwestern Medical Center, Department of Radiology, Dallas, Texas, United States
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25
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Ma L, Tian Y, Peng C, Zhang Y, Zhang S. Recent advances in the epidemiology and genetics of acute intermittent porphyria. Intractable Rare Dis Res 2020; 9:196-204. [PMID: 33139978 PMCID: PMC7586877 DOI: 10.5582/irdr.2020.03082] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023] Open
Abstract
Acute intermittent porphyria (AIP) is a dominant inherited disorder with a low penetrance that is caused by mutations in the gene coding for hydroxymethylbilane synthase (HMBS). Information about the epidemiology and molecular genetic features of this rare disorder is crucial to clinical research, and particularly to the evaluation of new treatments. Variations in the prevalence and penetrance of AIP in various studies may due to the different inclusion criteria and methods of assessment. Here, the prevalence and penetrance of AIP are analyzed systematically, and the genetic traits of different populations and findings regarding the genotype-phenotype correlation are summarized. In addition, quite a few studies have indicated that AIP susceptibility was affected by other factors, such as modifying genes. Findings regarding possible modifying genes are documented here, helping to reveal the pathogenesis of and treatments for AIP. The status of research on AIP in China reveals the lack of epidemiological and genetic studies of the Chinese population, a situation that needs to be promptly remedied.
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Affiliation(s)
- Liyan Ma
- Department of Endocrinology, The second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yu Tian
- Department of Endocrinology, The second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Chenxing Peng
- Department of Endocrinology, The second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yiran Zhang
- School of First Clinical Medical College, Southern Medical University, Guangzhou, Guangdong, China
| | - Songyun Zhang
- Department of Endocrinology, The second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Lai HW, Nakayama T, Ogura SI. Key transporters leading to specific protoporphyrin IX accumulation in cancer cell following administration of aminolevulinic acid in photodynamic therapy/diagnosis. Int J Clin Oncol 2020; 26:26-33. [PMID: 32875514 DOI: 10.1007/s10147-020-01766-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/05/2020] [Indexed: 12/31/2022]
Abstract
The administration of aminolevulinic acid allow the formation and accumulation of protoporphyrin IX specifically in cancer cells, which then lead to photocytotoxicity following light irradiation. This compound, when accumulated at high levels, could also be used in cancer diagnosis as it would emit red fluorescence when being light irradiated. The concentration of protoporphyrin IX is pivotal in ensuring the effectiveness of the therapy. Studies have been carried out and showed the importance of various transporters in regulating the amount of these substrates by controlling the transport of various related metabolites in and out of the cell. There are many transporters involved and their expression levels are dependent on various factors, such as oxygen availability and iron ions. It is also important to note that these transporters may also have different expression levels depending on their organ. Understanding the mechanisms and the roles of these transporters are essential to ensure maximum accumulation of protoporphyrin IX, leading to higher efficiency in photodynamic therapy/diagnosis. In this review, we would like to discuss the roles of various transporters in protoporphyrin IX accumulation and how their involvement directly affect cancerous microenvironment.
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Affiliation(s)
- Hung Wei Lai
- School of Life Science and Technology, Tokyo Institute of Technology, 4259 B47, Nagatsuta-cho, Midori-ku, Yokohama, 226-8501, Japan
| | - Taku Nakayama
- School of Life Science and Technology, Tokyo Institute of Technology, 4259 B47, Nagatsuta-cho, Midori-ku, Yokohama, 226-8501, Japan.,Center for Photodynamic Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku-shi, Kochi, 783-8505, Japan
| | - Shun-Ichiro Ogura
- School of Life Science and Technology, Tokyo Institute of Technology, 4259 B47, Nagatsuta-cho, Midori-ku, Yokohama, 226-8501, Japan. .,Center for Photodynamic Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku-shi, Kochi, 783-8505, Japan.
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27
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5-Aminolevulinic acid for recurrent malignant gliomas: A systematic review. Clin Neurol Neurosurg 2020; 195:105913. [DOI: 10.1016/j.clineuro.2020.105913] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/28/2020] [Accepted: 05/10/2020] [Indexed: 11/24/2022]
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Müller P, Abdel Gaber SA, Zimmermann W, Wittig R, Stepp H. ABCG2 influence on the efficiency of photodynamic therapy in glioblastoma cells. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY B-BIOLOGY 2020; 210:111963. [PMID: 32795847 DOI: 10.1016/j.jphotobiol.2020.111963] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 07/12/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Photodynamic therapy with 5-aminolevulinic acid (5-ALA PDT) is a promising novel therapeutic approach in the therapy of malignant brain tumors. 5-ALA occurs as a natural precursor of protoporphyrin IX (PpIX), a tumor-selective photosensitizer. The ATP-binding cassette transporter ABCG2 plays a physiologically significant role in porphyrin efflux from living cells. ABCG2 is also associated with stemness properties. Here we investigate the role of ABCG2 on the susceptibility of glioblastoma cells to 5-ALA PDT. METHODS Accumulation of PpIX in doxycycline-inducible U251MG glioblastoma cells with or without induction of ABCG2 expression or ABCG2 inhibition by KO143 was analyzed using flow cytometry. In U251MG cells, ABCG2 was inducible by doxycycline after stable transfection with a tet-on expression plasmid. U251MG cells with high expression of ABCG2 were enriched and used for further experiments (sU251MG-V). PDT was performed on monolayer cell cultures by irradiation with laser light at 635 nm. RESULTS Elevated levels of ABCG2 in doxycycline induced sU251MG-V cells led to a diminished accumulation of PpIX and higher light doses were needed to reduce cell viability. By inhibiting the ABCG2 transporter with the efficient and non-toxic ABCG2 inhibitor KO143, PpIX accumulation and PDT efficiency could be strongly enhanced. CONCLUSION Glioblastoma cells with high ABCG2 expression accumulate less photosensitizer and require higher light doses to be eliminated. Inhibition of ABCG2 during photosensitizer accumulation and irradiation promises to restore full susceptibility of this crucial tumor cell population to photodynamic treatment.
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Affiliation(s)
- Patricia Müller
- Laser Forschungslabor, LIFE Center, University Hospital, LMU Munich, Fraunhoferstr. 20, 82152 Planegg, Germany; Labor für Tumorimmunologie, LIFE Center, University Hospital, LMU Munich, Fraunhoferstr. 20, 82152, Planegg, Germany.
| | - Sara A Abdel Gaber
- Laser Forschungslabor, LIFE Center, University Hospital, LMU Munich, Fraunhoferstr. 20, 82152 Planegg, Germany; Nanomedicine Department, Institute of Nanoscience and Nanotechnology, Kafrelsheikh University, Kafrelsheikh, 33516, Egypt.
| | - Wolfgang Zimmermann
- Labor für Tumorimmunologie, LIFE Center, University Hospital, LMU Munich, Fraunhoferstr. 20, 82152, Planegg, Germany; Department of Urology, University Hospital, LMU Munich, Fraunhoferstr. 20, 82152 Planegg, Germany
| | - Rainer Wittig
- Institut für Lasertechnologien in der Medizin und Messtechnik an der Universität Ulm, Helmholtzstr. 12, 89081 Ulm, Germany
| | - Herbert Stepp
- Laser Forschungslabor, LIFE Center, University Hospital, LMU Munich, Fraunhoferstr. 20, 82152 Planegg, Germany; Department of Urology, University Hospital, LMU Munich, Fraunhoferstr. 20, 82152 Planegg, Germany
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Jaber M, Ewelt C, Wölfer J, Brokinkel B, Thomas C, Hasselblatt M, Grauer O, Stummer W. Is Visible Aminolevulinic Acid-Induced Fluorescence an Independent Biomarker for Prognosis in Histologically Confirmed (World Health Organization 2016) Low-Grade Gliomas? Neurosurgery 2020; 84:1214-1224. [PMID: 30107580 PMCID: PMC6537633 DOI: 10.1093/neuros/nyy365] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 07/14/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Approximately 20% of low-grade gliomas (LGG) display visible protoporphyrin fluorescence during surgery after 5-aminolevulinic acid (5-ALA) administration. OBJECTIVE To determine if fluorescence represents a prognostic marker in LGG. METHODS Seventy-four consecutive patients with LGG (World Health Organization 2016) were operated on with 5-ALA. Fluorescent tissue was specifically biopsied. Tumor size, age, Karnofsky index, contrast-enhancement, fluorescence, and molecular factors (IDH1/IDH2-mutations, Ki67/MIB1 Index, 1p19q codeletions, ATRX, EGFR, p53 expression, and O6-methylguanine DNA methyltransferase promotor methylation), were related to progression-free survival (PFS), malignant transformation-free survival (MTFS) and overall survival (OS). RESULTS Sixteen of seventy-four LGGs (21.6%) fluoresced. Fluorescence was partially related to weak enhancement on magnetic resonance imaging and increased (positron emission tomography)PET-FET uptake, but not to Karnofsky Performance Score, tumor size, or age. Regarding molecular markers, only EGFR expression differed marginally (fluorescing vs nonfluorescing: 19% vs 5%; P = .057). Median follow-up was 46.4 mo (95% confidence interval [CI]: 41.8-51.1). PFS, MTFS, and OS were shorter in fluorescing tumors (PFS: median 9.8 mo, 95% CI: 1.00-27.7 vs 45.8, 31.9-59.7, MTFS: 43.0 [27.5-58.5] vs 64.6 [57.7-71.5], median not reached, P = .015; OS: 51.6, [34.8-68.3] vs [68.2, 62.7-73.8], P = .002). IDH mutations significantly predicted PFS, MTFS, and OS. In multivariate analysis IDH status and fluorescence both independently predicted MTFS and OS. PFS was not independently predicted by fluorescence. CONCLUSION This is the first report investigating the role of ALA-induced fluorescence in histologically confirmed LGG. Fluorescence appeared to be a marker for inherent malignant transformation and OS, independently of known prognostic markers. Fluorescence in LGG might be taken into account when deciding on adjuvant therapies.
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Affiliation(s)
- Mohammed Jaber
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Christian Ewelt
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Johannes Wölfer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Christian Thomas
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Martin Hasselblatt
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Oliver Grauer
- Department of Neurology, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
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30
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Wadiura LI, Mischkulnig M, Hosmann A, Borkovec M, Kiesel B, Rötzer T, Mercea PA, Furtner J, Hervey-Jumper S, Rössler K, Berger MS, Widhalm G. Influence of Corticosteroids and Antiepileptic Drugs on Visible 5-Aminolevulinic Acid Fluorescence in a Series of Initially Suspected Low-Grade Gliomas Including World Health Organization Grade II, III, and IV Gliomas. World Neurosurg 2020; 137:e437-e446. [DOI: 10.1016/j.wneu.2020.01.243] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 12/21/2022]
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Yamamoto J, Kitagawa T, Miyaoka R, Suzuki K, Takamatsu S, Saito T, Nakano Y. 5-Aminolevulinic Acid: Pitfalls of Fluorescence-guided Resection for Malignant Gliomas and Application for Malignant Glioma Therapy. J UOEH 2020; 42:27-34. [PMID: 32213740 DOI: 10.7888/juoeh.42.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
5-Aminolevulinic acid (ALA) has been widely used as an intravital fluorescence marker in the fluorescence-guided resection of malignant gliomas. Although not a photosensitizer itself, 5-ALA is a prodrug that accumulates protoporphyrin IX (PpIX) in the mitochondria of glioma cells; PpIX acts as a photosensitizer. Fluorescence-guided resection for malignant gliomas has some pitfalls. Moreover, 5-ALA is not merely a fluorescence marker but has potential as a mitochondria-targeting drug for malignant glioma therapy. In this article, we review the literature related to 5-ALA, discuss the pitfalls of fluorescence-guided resection using 5-ALA for malignant gliomas, and describe the application of 5-ALA for malignant glioma therapy with personal opinions.
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Affiliation(s)
- Junkoh Yamamoto
- Department of Neurosurgery, University of Occupational and Environmental Health, Japan
| | - Takehiro Kitagawa
- Department of Neurosurgery, University of Occupational and Environmental Health, Japan
| | - Ryo Miyaoka
- Department of Neurosurgery, University of Occupational and Environmental Health, Japan
| | - Kohei Suzuki
- Department of Neurosurgery, University of Occupational and Environmental Health, Japan
| | - Seishiro Takamatsu
- Department of Neurosurgery, University of Occupational and Environmental Health, Japan
| | - Takeshi Saito
- Department of Neurosurgery, University of Occupational and Environmental Health, Japan
| | - Yoshiteru Nakano
- Department of Neurosurgery, University of Occupational and Environmental Health, Japan
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Almekkawi AK, El Ahmadieh TY, Wu EM, Abunimer AM, Abi-Aad KR, Aoun SG, Plitt AR, El Tecle NE, Patel T, Stummer W, Bendok BR. The Use of 5-Aminolevulinic Acid in Low-Grade Glioma Resection: A Systematic Review. Oper Neurosurg (Hagerstown) 2019; 19:1-8. [DOI: 10.1093/ons/opz336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 08/24/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
For optimizing high-grade glioma resection, 5-aminolevulinic acid is a reliable tool. However, its efficacy in low-grade glioma resection remains unclear.
OBJECTIVE
To study the role of 5-aminolevulinic acid in low-grade glioma resection and assess positive fluorescence rates and the effect on the extent of resection.
METHODS
A systematic review of PubMed, Google Scholar, and Cochrane was performed from the date of inception to February 1, 2019. Studies that correlated 5-aminolevulinic acid fluorescence with low-grade glioma in the setting of operative resection were selected. Studies with biopsy only were excluded. Positive fluorescence rates were calculated. The quality index of the selected papers was provided. No patient information was used, so Institutional Review Board approval and patient consent were not required.
RESULTS
A total of 12 articles met the selection criteria with 244 histologically confirmed low-grade glioma patients who underwent microsurgical resection. All patients received 20 mg/kg body weight of 5-aminolevulinic acid. Only 60 patients (n = 60/244; 24.5%) demonstrated visual intraoperative 5-aminolevulinic acid fluorescence. The extent of resection was reported in 4 studies; however, the data combined low- and high-grade tumors. Only 2 studies reported on tumor location. Only 3 studies reported on clinical outcomes. The Zeiss OPMI Pentero microscope was most commonly used across all studies. The average quality index was 14.58 (range: 10-17), which correlated with an overall good quality.
CONCLUSION
There is an overall low correlation between 5-aminolevulinic acid fluorescence and low-grade glioma. Advances in visualization technology and using standardized fluorescence quantification methods may further improve the visualization and reliability of 5-aminolevulinic acid fluorescence in low-grade glioma resection.
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Affiliation(s)
- Ahmad Kareem Almekkawi
- Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, University of Harvard, Boston, Massachusetts
| | - Tarek Y El Ahmadieh
- Department of Neurological Surgery, Zale Lipshy Hospital, The University of Texas Southwestern, Dallas, Texas
| | - Eva M Wu
- Department of Neurological Surgery, Zale Lipshy Hospital, The University of Texas Southwestern, Dallas, Texas
| | - Abdullah M Abunimer
- Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, University of Harvard, Boston, Massachusetts
| | - Karl R Abi-Aad
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona
| | - Salah G Aoun
- Department of Neurological Surgery, Zale Lipshy Hospital, The University of Texas Southwestern, Dallas, Texas
| | - Aaron R Plitt
- Department of Neurological Surgery, Zale Lipshy Hospital, The University of Texas Southwestern, Dallas, Texas
| | - Najib E El Tecle
- Department of Neurological Surgery, Saint Louis University Hospital, Saint Louis, Missouri
| | - Toral Patel
- Department of Neurological Surgery, Zale Lipshy Hospital, The University of Texas Southwestern, Dallas, Texas
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona
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Jaramillo-Calle DA, Solano JM, Rabinstein AA, Bonkovsky HL. Porphyria-induced posterior reversible encephalopathy syndrome and central nervous system dysfunction. Mol Genet Metab 2019; 128:242-253. [PMID: 31706631 DOI: 10.1016/j.ymgme.2019.10.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM An association between neuropsychiatric manifestations and neuroimaging suggestive of posterior reversible encephalopathy syndrome (PRES) during porphyric attacks has been described in numerous case reports. We aimed to systematically review clinical-radiological features and likely pathogenic mechanisms of PRES in patients with acute hepatic porphyrias (AHP) and porphyric attacks. METHODS PubMed, Scopus, Ovid MEDLINE, and Google Scholar were searched (July 30, 2019). We included articles describing patients with convincing evidence of an AHP, confirmed porphyric attacks, and PRES in neuroimaging. RESULTS Forty-three out of 269 articles were included, which reported on 46 patients. Thirty-nine (84.8%) patients were women. The median age was 24 ± 13.8 years. 52.2% had unspecified AHP, 41.3% acute intermittent porphyria, 4.3% hereditary coproporphyria, and 2.2% variegate porphyria. 70.2% had systemic arterial hypertension. Seizures, mental changes, arterial hypertension, and hyponatremia occurred more frequently than expected for porphyric attacks (p < .001). Seizures and hyponatremia were also more frequent than expected for PRES. The most common distributions of brain lesions were occipital (81.4%), parietal (65.1%), frontal (60.5%), subcortical (40%), and cortical (32.5%). Cerebral vasoconstriction was demonstrated in 41.7% of the patients who underwent angiography. 19.6% of the patients had ischemic lesions, and 4.3% developed long-term sequelae (cognitive decline and focal neurological deficits). CONCLUSIONS Brain edema, vasoconstriction, and ischemia in the context of PRES likely account for central nervous symptoms in some porphyric attacks.
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Affiliation(s)
- Daniel A Jaramillo-Calle
- IPS Universitaria, Universidad de Antioquia, Medellin, Colombia; Institute of Medical Research, Universidad de Antioquia, School of Medicine, Medellin, Colombia.
| | - Juan M Solano
- Department of Neurology, Universidad de Antioquia, School of Medicine, Medellin, Colombia
| | | | - Herbert L Bonkovsky
- Section on Gastroenterology & Hepatology, Wake Forest University School of Medicine/NC Baptist Hospital, Winston-Salem, United States of America..
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Jones PS, Yekula A, Lansbury E, Small JL, Ayinon C, Mordecai S, Hochberg FH, Tigges J, Delcuze B, Charest A, Ghiran I, Balaj L, Carter BS. Characterization of plasma-derived protoporphyrin-IX-positive extracellular vesicles following 5-ALA use in patients with malignant glioma. EBioMedicine 2019; 48:23-35. [PMID: 31628025 PMCID: PMC6838454 DOI: 10.1016/j.ebiom.2019.09.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 09/11/2019] [Accepted: 09/13/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Malignant gliomas are rapidly progressive brain tumors with high mortality. Fluorescence guided surgery (FGS) with 5-aminolevulinic acid (5-ALA) provides fluorescent delineation of malignant tissue, which helps achieve maximum safe resection. 5-ALA-based fluorescence is due to preferential accumulation of the fluorophore protoporphyrin-IX (PpIX) in malignant glioma tissue. Additionally, gliomas cells release extracellular vesicles (EVs) which carry biomarkers of disease. Herein, we performed animal and human studies to investigate whether 5-ALA dosed glioma cells, in vitro and in vivo, release PpIX positive EVs in circulation which can be captured and analyzed. METHODS We used imaging flow cytometry (IFC) to characterize PpIX-positive EVs released from 5-ALA-dosed glioma cells, glioma-bearing xenograft models, as well as patients with malignant glioma undergoing FGS. FINDINGS We first show that glioma cells dosed with 5-ALA release 247-fold higher PpIX positive EVs compared to mock dosed glioma cells. Second, we demonstrate that the plasma of glioma-bearing mice (n = 2) dosed with 5-ALA contain significantly higher levels of circulating PpIX-positive EVs than their pre-dosing background (p = 0.004). Lastly, we also show that the plasma of patients with avidly fluorescent tumors (n = 4) undergoing FGS contain circulating PpIX-positive EVs at levels significantly higher than their pre-dosing background (p = 0.00009) and this rise in signal correlates with enhancing tumor volumes (r 2 = 0.888). INTERPRETATION Our findings highlight the potential of plasma-derived PpIX-positive EV-based diagnostics for malignant gliomas, offering a novel liquid biopsy platform for confirming and monitoring tumor status.
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Affiliation(s)
- Pamela S Jones
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Anudeep Yekula
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Elizabeth Lansbury
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Julia L Small
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Caroline Ayinon
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Scott Mordecai
- Department of Pathology, Flow Cytometry Core, Massachusetts General Hospital, Boston, MA, United States
| | | | - John Tigges
- Flow Cytometry Core, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Bethany Delcuze
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Alain Charest
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Ionita Ghiran
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Leonora Balaj
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
| | - Bob S Carter
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
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Zhang DY, Singhal S, Lee JYK. Optical Principles of Fluorescence-Guided Brain Tumor Surgery: A Practical Primer for the Neurosurgeon. Neurosurgery 2019; 85:312-324. [PMID: 30085129 DOI: 10.1093/neuros/nyy315] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 06/18/2018] [Indexed: 01/21/2023] Open
Abstract
Fluorescence-guided surgery is a rapidly growing field that has produced some of the most important innovations in surgical oncology in the past decade. These intraoperative imaging technologies provide information distinguishing tumor tissue from normal tissue in real time as the surgery proceeds and without disruption of the workflow. Many of these fluorescent tracers target unique molecular or cellular features of tumors, which offers the opportunity for identifying pathology with high precision to help surgeons achieve their primary objective of a maximal safe resection. As novel fluorophores and fluorescent probes emerge from preclinical development, a practical understanding of the principles of fluorescence remains critical for evaluating the clinical utility of these agents and identifying opportunities for further innovation. In this review, we provide an "in-text glossary" of the fundamental principles of fluorescence with examples of direct applications to fluorescence-guided brain surgery. We offer a detailed discussion of the various advantages and limitations of the most commonly used intraoperative imaging agents, including 5-aminolevulinic acid, indocyanine green, and fluorescein, with a particular focus on the photophysical properties of these specific agents as they provide a framework through which to understand the new agents that are entering clinical trials. To this end, we conclude with a survey of the fluorescent properties of novel agents that are currently undergoing or will soon enter clinical trials for the intraoperative imaging of brain tumors.
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Affiliation(s)
- Daniel Y Zhang
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sunil Singhal
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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McNicholas K, MacGregor MN, Gleadle JM. In order for the light to shine so brightly, the darkness must be present-why do cancers fluoresce with 5-aminolaevulinic acid? Br J Cancer 2019; 121:631-639. [PMID: 31406300 PMCID: PMC6889380 DOI: 10.1038/s41416-019-0516-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 05/23/2019] [Accepted: 06/14/2019] [Indexed: 02/07/2023] Open
Abstract
Photodynamic diagnosis and therapy have emerged as a promising tool in oncology. Using the visible fluorescence from photosensitisers excited by light, clinicians can both identify and treat tumour cells in situ. Protoporphyrin IX, produced in the penultimate step of the haem synthesis pathway, is a naturally occurring photosensitiser that visibly fluoresces when exposed to light. This fluorescence is enhanced considerably by the exogenous administration of the substrate 5-aminolaevulinic acid (5-ALA). Significantly, 5-ALA-induced protoporphyrin IX accumulates preferentially in cancer cells, and this enhanced fluorescence has been harnessed for the detection and photodynamic treatment of brain, skin and bladder tumours. However, surprisingly little is known about the mechanistic basis for this phenomenon. This review focuses on alterations in the haem pathway in cancer and considers the unique features of the cancer environment, such as altered glucose metabolism, oncogenic mutations and hypoxia, and their potential effects on the protoporphyrin IX phenomenon. A better understanding of why cancer cells fluoresce with 5-ALA would improve its use in cancer diagnostics and therapies.
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Affiliation(s)
- Kym McNicholas
- Department of Renal Medicine, Flinders Medical Centre, Flinders University, Bedford Park, SA, 5042, Australia. .,College of Medicine and Public Health, Flinders University, Bedford Park, SA, 5042, Australia.
| | - Melanie N MacGregor
- Future Industries Institute, School of Engineering, University of South Australia, Adelaide, SA, 5095, Australia
| | - Jonathan M Gleadle
- Department of Renal Medicine, Flinders Medical Centre, Flinders University, Bedford Park, SA, 5042, Australia.,College of Medicine and Public Health, Flinders University, Bedford Park, SA, 5042, Australia
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37
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Speckle modulation enables high-resolution wide-field human brain tumor margin detection and in vivo murine neuroimaging. Sci Rep 2019; 9:10388. [PMID: 31316099 PMCID: PMC6637128 DOI: 10.1038/s41598-019-45902-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 06/05/2019] [Indexed: 11/18/2022] Open
Abstract
Current in vivo neuroimaging techniques provide limited field of view or spatial resolution and often require exogenous contrast. These limitations prohibit detailed structural imaging across wide fields of view and hinder intraoperative tumor margin detection. Here we present a novel neuroimaging technique, speckle-modulating optical coherence tomography (SM-OCT), which allows us to image the brains of live mice and ex vivo human samples with unprecedented resolution and wide field of view using only endogenous contrast. The increased visibility provided by speckle elimination reveals white matter fascicles and cortical layer architecture in brains of live mice. To our knowledge, the data reported herein represents the highest resolution imaging of murine white matter structure achieved in vivo across a wide field of view of several millimeters. When applied to an orthotopic murine glioblastoma xenograft model, SM-OCT readily identifies brain tumor margins with resolution of approximately 10 μm. SM-OCT of ex vivo human temporal lobe tissue reveals fine structures including cortical layers and myelinated axons. Finally, when applied to an ex vivo sample of a low-grade glioma resection margin, SM-OCT is able to resolve the brain tumor margin. Based on these findings, SM-OCT represents a novel approach for intraoperative tumor margin detection and in vivo neuroimaging.
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38
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Picart T, Berhouma M, Dumot C, Pallud J, Metellus P, Armoiry X, Guyotat J. Optimization of high-grade glioma resection using 5-ALA fluorescence-guided surgery: A literature review and practical recommendations from the neuro-oncology club of the French society of neurosurgery. Neurochirurgie 2019; 65:164-177. [PMID: 31125558 DOI: 10.1016/j.neuchi.2019.04.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/17/2019] [Accepted: 04/28/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND When feasible, the surgical resection is the standard first step of the management of high-grade gliomas. 5-ALA fluorescence-guided-surgery (5-ALA-FGS) was developed to ease the intra-operative delineation of tumor borders in order to maximize the extent of resection. METHODS A Medline electronic database search was conducted. English language studies from January 1998 until July 2018 were included, following the PRISMA guidelines. RESULTS 5-ALA can be considered as a specific tool for the detection of tumor remnant but has a weaker sensibility (level 2). 5-ALA-FGS is associated with a significant increase in the rate of gross total resection reaching more than 90% in some series (level 1). Consistently, 5-ALAFGS improves progression-free survival (level 1). However, the gain in overall survival is more debated. The use of 5-ALA-FGS in eloquent areas is feasible but requires simultaneous intraoperative electrophysiologic functional brain monitoring to precisely locate and preserve eloquent areas (level 2). 5-ALA is usable during the first resection of a glioma but also at recurrence (level 2). From a practical standpoint, 5-ALA is orally administered 3 hours before the induction of anesthesia, the recommended dose being 20 mg/kg. Intra-operatively, the procedure is performed as usually with a central debulking and a peripheral dissection during which the surgeon switches from white to blue light. Provided that some precautions are observed, the technique does not expose the patient to particular complications. CONCLUSION Although 5-ALA-FGS contributes to improve gliomas management, there are still some limitations. Future methods will be developed to improve the sensibility of 5-ALA-FGS.
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Affiliation(s)
- T Picart
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; Inserm 1052, UMR 5286,Team ATIP/AVENIR Transcriptomic diversity of stem cells, centre de cancérologie de Lyon, centre Léon-Bérard, 69008 Lyon, France.
| | - M Berhouma
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; CREATIS Laboratory, Inserm U1206, UMR 5220, université de Lyon, 69100 Villeurbanne, France
| | - C Dumot
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; CREATIS Laboratory, Inserm U1206, UMR 5220, université de Lyon, 69100 Villeurbanne, France
| | - J Pallud
- Département de neurochirurgie, hôpital Sainte-Anne, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 75005 Paris, France; IMA-Brain, Inserm U894, institut de psychiatrie et neurosciences de Paris, 7013 Paris, France
| | - P Metellus
- Hôpital Privé Clairval, Ramsay général de santé, 13009 Marseille, France; UMR 7051, institut de neurophysiopathologie, université d'Aix-Marseille, 13344 Marseille, France
| | - X Armoiry
- MATEIS (Team I2B), University of Lyon, Lyon school of pharmacy, 69008 Lyon, France; Édouard-Herriot Hospital, Pharmacy Department, 69008 Lyon, France; University of Warwick, Warwick Medical School, Coventry, UK
| | - J Guyotat
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France
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El Ahmadieh TY, Aoun SG, Lega BC. Autofluorescence Technology in Glioblastoma Resection: Evolution of New Tool and Approach. World Neurosurg 2019; 126:139-141. [PMID: 30862573 DOI: 10.1016/j.wneu.2019.02.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 02/15/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Tarek Y El Ahmadieh
- Department of Neurological Surgery, The University of Texas Southwestern, Zale Lipshy Hospital, Dallas, Texas, USA
| | - Salah G Aoun
- Department of Neurological Surgery, The University of Texas Southwestern, Zale Lipshy Hospital, Dallas, Texas, USA.
| | - Bradley C Lega
- Department of Neurological Surgery, The University of Texas Southwestern, Zale Lipshy Hospital, Dallas, Texas, USA
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Yoshida M, Kobayashi H, Terasaka S, Endo S, Yamaguchi S, Motegi H, Itay R, Suzuki S, Brokman O, Shapira Y, Moriyama K, Kawase Y, Akahane T, Kato Y, Kamada H, Houkin K. Sonodynamic Therapy for Malignant Glioma Using 220-kHz Transcranial Magnetic Resonance Imaging-Guided Focused Ultrasound and 5-Aminolevulinic acid. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:526-538. [PMID: 30522817 DOI: 10.1016/j.ultrasmedbio.2018.10.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 09/07/2018] [Accepted: 10/11/2018] [Indexed: 06/09/2023]
Abstract
Sonodynamic therapy (SDT) is used to treat various malignancies and can be applied to brain tumors using a transcranial magnetic resonance imaging-guided focused ultrasound (TcMRgFUS) device. This study investigated the efficacy of 220-kHz TcMRgFUS combined with 5-aminolevulinic acid (5-ALA) on malignant glioma in vitro and in vivo. F98 cells were irradiated with focused ultrasound (FUS) (4000 J, 20 W, 240 s, 100% duty cycle, target medium temperature <40°C) after treatment with 200 µg/mL 5-ALA, and cell viability and apoptosis were evaluated with the water-soluble tetrazolium-1 assay, triple fluorescent staining and Western blot analysis 20 h later. The anti-tumor effects of 5-ALA combined with FUS (500 J, 18 W, 30 s, 100% duty cycle, 10 repeats, target tissue temperature ≤42°C) were assessed on the basis of changes in tumor volume determined by MRI and histopathological analysis before and after treatment. The FUS/5-ALA combination reduced cell viability by inducing apoptosis and suppressed tumor proliferation and invasion as well as angiogenesis in vivo, while causing minimal damage to normal brain tissue. SDT with 220-kHz TcMRgFUS and 5-ALA can be safely used for the treatment of malignant glioma.
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Affiliation(s)
- Michiharu Yoshida
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan; Department of Neurosurgery, Hokuto Hospital, Obihiro, Hokkaido, Japan
| | - Hiroyuki Kobayashi
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Shunsuke Terasaka
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Shogo Endo
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Shigeru Yamaguchi
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroaki Motegi
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | | | | | | | | | - Kenji Moriyama
- Department of Radiology, Hokuto Hospital, Obihiro, Japan
| | - Yumiko Kawase
- Department of Biology and Genetics, Laboratory of Cancer Medical Science, Hokuto Hospital, Obihiro, Japan
| | - Toshiaki Akahane
- Department of Biology and Genetics, Laboratory of Cancer Medical Science, Hokuto Hospital, Obihiro, Japan
| | - Yasutaka Kato
- Department of Biology and Genetics, Laboratory of Cancer Medical Science, Hokuto Hospital, Obihiro, Japan
| | - Hajime Kamada
- Department of Neurosurgery, Hokuto Hospital, Obihiro, Hokkaido, Japan
| | - Kiyohiro Houkin
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Kröger S, Niehoff AC, Jeibmann A, Sperling M, Paulus W, Stummer W, Karst U. Complementary Molecular and Elemental Mass-Spectrometric Imaging of Human Brain Tumors Resected by Fluorescence-Guided Surgery. Anal Chem 2018; 90:12253-12260. [PMID: 30215510 DOI: 10.1021/acs.analchem.8b03516] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Fluorescence-guided surgery (FGS) has been established as a powerful technique for glioblastoma resection. After oral application of the prodrug 5-aminolevulinic acid (5-ALA), protoporphyrin IX (PpIX) is formed as an intermediate of the heme-biosynthesis cascade and accumulates within the tumor. By intraoperative fluorescence microscopy, the specific PpIX fluorescence can be used to differentiate the tumor from healthy brain tissue. To investigate possible limitations of fluorescence diagnosis, the complementary use of molecular and elemental mass-spectrometry imaging (MSI) is presented. Matrix-assisted laser-desorption-ionization mass spectrometry (MALDI-MS) is used to examine the distribution of PpIX and heme b in human brain tumors. MALDI-MS/MS imaging is performed to validate MS data and improve the signal-to-noise ratio (S/N). Comparing the imaging results with histological evaluation, increased PpIX accumulation in areas of high tumor-cell density is observed. Heme b accumulation are only found in areas of blood vessels and hemorrhage, confirming the hampered transformation from PpIX to heme b in glioblastoma tissue. Investigation of non-neoplastic brain tissue and glioblastoma resected without external 5-ALA administration as control samples with true-negative fluorescence verified the absence of PpIX accumulation. Analysis of necrotic tumor tissue and gliosarcoma, one rare type of glioma appearing nonfluorescent during FGS, as case examples with false-negative-fluorescence diagnosis, revealed the absence of significant amounts of PpIX, indicating an impairment of PpIX formation. Molecular analysis is complemented by quantitative laser ablation-inductively coupled plasma (LA-ICP) MSI correlating heme b and Fe distribution. Mathematical pixel-by-pixel correlation of molecular and elemental data revealed a positive correlation with heteroscedasticity for the spatially resolved heme b signal intensities and Fe concentrations.
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Affiliation(s)
- Sabrina Kröger
- Institute of Inorganic and Analytical Chemistry , University of Münster , Corrensstraße 30 , 48149 Münster , Germany
| | - Ann-Christin Niehoff
- Institute of Inorganic and Analytical Chemistry , University of Münster , Corrensstraße 30 , 48149 Münster , Germany
| | - Astrid Jeibmann
- Institute of Neuropathology , University Hospital Münster , Pottkamp 2 , 48149 Münster , Germany
| | - Michael Sperling
- Institute of Inorganic and Analytical Chemistry , University of Münster , Corrensstraße 30 , 48149 Münster , Germany.,European Virtual Institute for Speciation Analysis (EVISA) , Mendelstraße 11 , 48149 Münster , Germany
| | - Werner Paulus
- Institute of Neuropathology , University Hospital Münster , Pottkamp 2 , 48149 Münster , Germany
| | - Walter Stummer
- Department of Neurosurgery , University Hospital Münster , Albert-Schweitzer-Campus 1 , 48149 Münster , Germany
| | - Uwe Karst
- Institute of Inorganic and Analytical Chemistry , University of Münster , Corrensstraße 30 , 48149 Münster , Germany
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Stepp H, Stummer W. 5‐ALA in the management of malignant glioma. Lasers Surg Med 2018; 50:399-419. [DOI: 10.1002/lsm.22933] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Herbert Stepp
- LIFE Center and Department of UrologyUniversity Hospital of MunichFeodor‐Lynen‐Str. 1981377MunichGermany
| | - Walter Stummer
- Department of NeurosurgeryUniversity Clinic MünsterAlbert‐Schweitzer‐Campus 1, Gebäude A148149MünsterGermany
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Coburger J, Scheuerle A, Pala A, Thal D, Wirtz CR, König R. Histopathological Insights on Imaging Results of Intraoperative Magnetic Resonance Imaging, 5-Aminolevulinic Acid, and Intraoperative Ultrasound in Glioblastoma Surgery. Neurosurgery 2018; 81:165-174. [PMID: 28204539 DOI: 10.1093/neuros/nyw143] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 12/13/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND For appropriate use of available intraoperative imaging techniques in glioblastoma (GB) surgery, it is crucial to know the potential of the respective techniques in tumor detection. OBJECTIVE To assess histopathological basis of imaging results of intraoperative magnetic resonance imaging (iMRI), 5-aminolevulinic acid (5-ALA), and linear array intraoperative ultrasound (lioUS). METHODS We prospectively compared the imaging findings of iMRI, 5-ALA, and lioUS at 99 intraoperative biopsy sites in 33 GB patients during resection control. Histological classification of specimens, tumor load, presence of necrosis, presence of vascular malformations, and O6-methylguanin-DNA methyltransferase (MGMT) promoter state was correlated with imaging findings. RESULTS Solid tumor was found in 57%, infiltration zone in 42%, and no tumor in 1% of specimens. However, imaging was negative in iMRI in 49%, using 5-ALA in 17%, and in lioUS in 21%. In positive imaging results, share of solid tumor was highest in 5-ALA (65%) followed by lioUS (60%) and lowest in iMRI (55%). In comparison to 5-ALA, iMRI had a high share of solid tumor in specimens when showing intermediate results. Sensitivity for invasive tumor was higher in 5-ALA (84%) and lioUS (80%) than in iMRI (50%). We found a significant correlation of 5-ALA with classification of specimen, presence of necrosis, and microproliferations. Methylated MGMT promoter correlated with positive findings in 5-ALA. lioUS and iMRI showed no correlations with histopathological findings. CONCLUSION All of the assessed established imaging techniques detect infiltrating tumor only to a certain extent. Only 5-ALA showed a significant correlation with histopathological findings. Interestingly, tumor remnants in an MGMT-methylated tumor are more likely to be visible using 5-ALA as in unmethylated tumors.
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Affiliation(s)
- Jan Coburger
- Department of Neurosurgery, University of Ulm, Günzburg, Germany
| | | | - Andrej Pala
- Department of Neurosurgery, University of Ulm, Günzburg, Germany
| | - Dietmar Thal
- Research Group Experimental Neurology, Leuven, Belgium
| | | | - Ralph König
- Department of Neurosurgery, University of Ulm, Günzburg, Germany
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Pippin AB, Voll RJ, Li Y, Wu H, Mao H, Goodman MM. Radiochemical Synthesis and Evaluation of 13N-Labeled 5-Aminolevulinic Acid for PET Imaging of Gliomas. ACS Med Chem Lett 2017; 8:1236-1240. [PMID: 29259740 DOI: 10.1021/acsmedchemlett.7b00311] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 11/15/2017] [Indexed: 01/05/2023] Open
Abstract
The endogenous amino acid, 5-aminolevulinic acid (5-ALA), has received significant attention as an imaging agent, including ongoing clinical trials for image-guided tumor resection due to its selective uptake and subsequent accumulation of the fluorescent protoporphyrin IX in tumor cells. Based on the widely reported selectivity of 5-ALA, a new positron emission tomography imaging probe was developed by reacting methyl 5-bromolevulinate with [13N] ammonia. The radiotracer, [13N] 5-ALA, was produced in high radiochemical yield (65%) in 10 min and could be purified using only solid phase cartridges. In vivo testing in rats bearing intracranial 9L glioblastoma showed peak tumor uptake occurred within 10 min of radiotracer administration. Immunohistochemical staining and fluorescent imaging was used to confirm the tumor location and accumulation of the tracer seen from the PET images. The quick synthesis and rapid tumor specific uptake of [13N] 5-ALA makes it a potential novel clinical applicable radiotracer for detecting and monitoring tumors noninvasively.
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Affiliation(s)
- Adam B. Pippin
- Department of Radiology
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Imaging Sciences, Emory University Center for Systems Imaging, Wesley Woods Health Center, 1841 Clifton Road, NE, Atlanta, Georgia 30329, United States
| | - Ronald J. Voll
- Department of Radiology
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Imaging Sciences, Emory University Center for Systems Imaging, Wesley Woods Health Center, 1841 Clifton Road, NE, Atlanta, Georgia 30329, United States
| | - Yuancheng Li
- Department of Radiology
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Imaging Sciences, Emory University Center for Systems Imaging, Wesley Woods Health Center, 1841 Clifton Road, NE, Atlanta, Georgia 30329, United States
| | - Hui Wu
- Department of Radiology
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Imaging Sciences, Emory University Center for Systems Imaging, Wesley Woods Health Center, 1841 Clifton Road, NE, Atlanta, Georgia 30329, United States
| | - Hui Mao
- Department of Radiology
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Imaging Sciences, Emory University Center for Systems Imaging, Wesley Woods Health Center, 1841 Clifton Road, NE, Atlanta, Georgia 30329, United States
| | - Mark M. Goodman
- Department of Radiology
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Imaging Sciences, Emory University Center for Systems Imaging, Wesley Woods Health Center, 1841 Clifton Road, NE, Atlanta, Georgia 30329, United States
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Jamali Z, Hejazi SM, Ebrahimi SM, Moradi-Sardareh H, Paknejad M. Effects of LED-Based photodynamic therapy using red and blue lights, with natural hydrophobic photosensitizers on human glioma cell line. Photodiagnosis Photodyn Ther 2017; 21:50-54. [PMID: 29126958 DOI: 10.1016/j.pdpdt.2017.11.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 10/03/2017] [Accepted: 11/06/2017] [Indexed: 10/18/2022]
Abstract
Photodynamic therapy (PDT) has received high attention in cancer treatment due to its minimal side effects, specific cancer-targeting, non-invasion and low cost. It utilizes a specific group of anti-cancer drugs called photosensitizers (PS), which can be only activated under a certain wavelength light illumination and kills cancer cells. To screen the potential of PS and setup of PDT treatment protocol, it is essential to assess the PDT efficacy in vitro. In this study, a light-emitting diode- (LED-) based illumination system at two wavelengths (red & blue) with homogeneous and stable irradiation, and constant temperature conditions in 96-well plates was provided. The photodynamic effect of curcumin (CUR) and methyl ester of 5-aminolevulinic acid (MAL) using LED light on human glioma cell line was investigated. The obtained results indicate that this homemade LED-based illumination system is a favorable light source for in vitro PDT in 96-well plates. The PDT using CUR and MAL was efficient at final concentrations of 25μM and 2mM, and light doses of 60J/cm2 and 40J/cm2 respectively. The blue PDT efficiency was dependent on the light and PS doses. MAL-PDT and CUR-PDT using blue LED significantly decreased cell viability in the treatment groups compared with control groups. Furthermore, MAL-PDT using blue LEDs was more effective in comparison with conventional red LEDs on the human glioma cell line.
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Affiliation(s)
- Zahra Jamali
- Department of Medical Biochemistry, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Sedigheh Marjaneh Hejazi
- Department of Medical Physics and Biomedical Engineering, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Bio Optical Imaging Group, Research Center for Molecular and Cellular Imaging, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohsen Ebrahimi
- Bio Optical Imaging Group, Research Center for Molecular and Cellular Imaging, Tehran University of Medical Sciences, Tehran, Iran
| | - Hemen Moradi-Sardareh
- Department of Medical Biochemistry, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Maliheh Paknejad
- Department of Medical Biochemistry, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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Cordova JS, Gurbani SS, Holder CA, Olson JJ, Schreibmann E, Shi R, Guo Y, Shu HKG, Shim H, Hadjipanayis CG. Semi-Automated Volumetric and Morphological Assessment of Glioblastoma Resection with Fluorescence-Guided Surgery. Mol Imaging Biol 2017; 18:454-62. [PMID: 26463215 DOI: 10.1007/s11307-015-0900-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Glioblastoma (GBM) neurosurgical resection relies on contrast-enhanced MRI-based neuronavigation. However, it is well-known that infiltrating tumor extends beyond contrast enhancement. Fluorescence-guided surgery (FGS) using 5-aminolevulinic acid (5-ALA) was evaluated to improve extent of resection (EOR) of GBMs. Preoperative morphological tumor metrics were also assessed. PROCEDURES Thirty patients from a phase II trial evaluating 5-ALA FGS in newly diagnosed GBM were assessed. Tumors were segmented preoperatively to assess morphological features as well as postoperatively to evaluate EOR and residual tumor volume (RTV). RESULTS Median EOR and RTV were 94.3 % and 0.821 cm(3), respectively. Preoperative surface area to volume ratio and RTV were significantly associated with overall survival, even when controlling for the known survival confounders. CONCLUSIONS This study supports claims that 5-ALA FGS is helpful at decreasing tumor burden and prolonging survival in GBM. Moreover, morphological indices are shown to impact both resection and patient survival.
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Affiliation(s)
- J Scott Cordova
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1701 Uppergate Drive, C5018, Atlanta, GA, 30322, USA
| | - Saumya S Gurbani
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1701 Uppergate Drive, C5018, Atlanta, GA, 30322, USA
| | - Chad A Holder
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1701 Uppergate Drive, C5018, Atlanta, GA, 30322, USA
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, 1701 Uppergate Drive, C5018, Atlanta, GA, 30322, USA.,Winship Cancer Institute of Emory University, Atlanta, GA, 30322, USA
| | - Eduard Schreibmann
- Department of Radiation Oncology, Emory University School of Medicine, 1701 Uppergate Drive, C5018, Atlanta, GA, 30322, USA
| | - Ran Shi
- Department of Biostatistics, Emory University School of Public Health, 1701 Uppergate Drive, C5018, Atlanta, GA, 30322, USA
| | - Ying Guo
- Department of Biostatistics, Emory University School of Public Health, 1701 Uppergate Drive, C5018, Atlanta, GA, 30322, USA
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Emory University School of Medicine, 1701 Uppergate Drive, C5018, Atlanta, GA, 30322, USA.,Winship Cancer Institute of Emory University, Atlanta, GA, 30322, USA
| | - Hyunsuk Shim
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1701 Uppergate Drive, C5018, Atlanta, GA, 30322, USA. .,Winship Cancer Institute of Emory University, Atlanta, GA, 30322, USA.
| | - Costas G Hadjipanayis
- Department of Neurosurgery, Emory University School of Medicine, 1701 Uppergate Drive, C5018, Atlanta, GA, 30322, USA. .,Winship Cancer Institute of Emory University, Atlanta, GA, 30322, USA. .,Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, 10 Union Square, 5th Floor, Suite 5E, New York, NY, 10003, USA.
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ALA-PpIX mediated photodynamic therapy of malignant gliomas augmented by hypothermia. PLoS One 2017; 12:e0181654. [PMID: 28759636 PMCID: PMC5536352 DOI: 10.1371/journal.pone.0181654] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/05/2017] [Indexed: 12/03/2022] Open
Abstract
Background Malignant gliomas are highly invasive, difficult to treat, and account for 2% of cancer deaths worldwide. Glioblastoma Multiforme (GBM) comprises the most common and aggressive intracranial tumor. The study hypothesis is to investigate the modification of Photodynamic Therapy (PDT) efficacy by mild hypothermia leads to increased glioma cell kill while protecting normal neuronal structures. Methods Photosensitizer accumulation and PDT efficacy in vitro were quantified in various glioma cell lines, primary rat neurons, and astrocytes. In vivo studies were carried out in healthy brain and RG2 glioma of naïve Fischer rats. Hypothermia was induced at 1 hour pre- to 2 hours post-PDT, with ALA-PpIX accumulation and PDT treatments effects on tumor and normal brain PDT quantified using optical spectroscopy, histology, immunohistochemistry, MRI, and survival studies, respectively. Findings In vitro studies demonstrated significantly improved post-PDT survival in primary rat neuronal cells. Rat in vivo studies confirmed a neuroprotective effect to hypothermia following PpIX mediated PDT by T2 mapping at day 10, reflecting edema/inflammation volume reduction. Mild hypothermia increased PpIX fluorescence in tumors five-fold, and the median post-PDT rat survival time (8.5 days normothermia; 14 days hypothermia). Histology and immunohistochemistry show close to complete cellular protection in normal brain structures under hypothermia. Conclusions The benefits of hypothermia on both normal neuronal tissue as well as increased PpIX fluorescence and RG2 induced rat survival strongly suggest a role for hypothermia in photonics-based surgical techniques, and that a hypothermic intervention could lead to considerable patient outcome improvements.
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Picart T, Armoiry X, Berthiller J, Dumot C, Pelissou-Guyotat I, Signorelli F, Guyotat J. Is fluorescence-guided surgery with 5-ala in eloquent areas for malignant gliomas a reasonable and useful technique? Neurochirurgie 2017; 63:189-196. [DOI: 10.1016/j.neuchi.2016.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/29/2016] [Accepted: 12/04/2016] [Indexed: 11/30/2022]
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Epithelial growth factor receptor expression influences 5-ALA induced glioblastoma fluorescence. J Neurooncol 2017; 133:497-507. [PMID: 28500562 PMCID: PMC5537329 DOI: 10.1007/s11060-017-2474-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 05/04/2017] [Indexed: 11/05/2022]
Abstract
The extent of 5-aminolevulinic acid (5-ALA) guided tumor resection has a determining impact in high-grade glioma and glioblastoma surgery. Yet the intensity of the 5-ALA induced fluorescence may vary within the tumor. We aimed to correlate 5-ALA induced fluorescence with the expression of epithelial growth factor receptor (EGFR) and its constitutively active version EGFRvIII in different glioblastoma (GBM) cell lines. To elucidate the role of EGFR in the metabolism of 5-ALA in GBM cell lines with variable EGFR expression status, we analyzed the activation of EGFR by its primary ligand EGF, and its downstream effect on Heme oxygenase-1 (HO-1), a key enzyme regulating the metabolism of Protoporphyrin IX (PpIX), the fluorescent metabolite of 5-ALA. Effects of direct pharmacological inhibition by Tin(IV)-Protoporphyrin (SnPP) or gene knockdown by small interfering RNA (siRNA) on HO-1 enzyme were analyzed in respect to 5-ALA induced fluorescence. Furthermore, inhibition of EGFR by Gefitinib was tested. A significant difference in 5-ALA induced fluorescence was obtained in U87MG (low EGFR expression) and LN229EGFR cells (EGFR overexpression) compared to BS153 (EGFR overexpression/EGFRvIII+). Treatment of U87MG and LN229EGFR cells with EGF significantly reduced cellular fluorescence, by promoting HO-1 transcription and expression in a concentration-dependent manner. This effect could be reversed by EGFR-specific siRNA treatment, which reduced protein expression of about 80% in U87MG. Remarkably, inhibition of HO-1 activity by SnPP or reduction of HO-1 protein levels by siHO-1 treatment restored fluorescence in all cell lines, independently of EGFR quantitative and qualitative expression. Gefitinib treatment was able to restore fluorescence after EGF stimulation in U87MG cells but not in BS153 cells, overexpressing EGFR/EGFRvIII. In GBM cell lines, 5-ALA induced fluorescence is variable and influenced by EGF-induced downstream activation of HO-1. HO-1 protein expression was identified as a negative regulator of 5-ALA induced fluorescence in GBM cells. We further propose that co-expression of EGFRvIII but not quantitative EGFR expression influence HO-1 activity and therefore cellular fluorescence.
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