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Wagner A, Brielmaier MC, Kampf C, Baumgart L, Aftahy AK, Meyer HS, Kehl V, Höhne J, Schebesch KM, Schmidt NO, Zoubaa S, Riemenschneider MJ, Ratliff M, Enders F, von Deimling A, Liesche-Starnecker F, Delbridge C, Schlegel J, Meyer B, Gempt J. Fluorescein-stained confocal laser endomicroscopy versus conventional frozen section for intraoperative histopathological assessment of intracranial tumors. Neuro Oncol 2024; 26:922-932. [PMID: 38243410 PMCID: PMC11066924 DOI: 10.1093/neuonc/noae006] [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: 10/10/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND The aim of this clinical trial was to compare Fluorescein-stained intraoperative confocal laser endomicroscopy (CLE) of intracranial lesions and evaluation by a neuropathologist with routine intraoperative frozen section (FS) assessment by neuropathology. METHODS In this phase II noninferiority, prospective, multicenter, nonrandomized, off-label clinical trial (EudraCT: 2019-004512-58), patients above the age of 18 years with any intracranial lesion scheduled for elective resection were included. The diagnostic accuracies of both CLE and FS referenced with the final histopathological diagnosis were statistically compared in a noninferiority analysis, representing the primary endpoint. Secondary endpoints included the safety of the technique and time expedited for CLE and FS. RESULTS A total of 210 patients were included by 3 participating sites between November 2020 and June 2022. Most common entities were high-grade gliomas (37.9%), metastases (24.1%), and meningiomas (22.7%). A total of 6 serious adverse events in 4 (2%) patients were recorded. For the primary endpoint, the diagnostic accuracy for CLE was inferior with 0.87 versus 0.91 for FS, resulting in a difference of 0.04 (95% confidence interval -0.10; 0.02; P = .367). The median time expedited until intraoperative diagnosis was 3 minutes for CLE and 27 minutes for FS, with a mean difference of 27.5 minutes (standard deviation 14.5; P < .001). CONCLUSIONS CLE allowed for a safe and time-effective intraoperative histological diagnosis with a diagnostic accuracy of 87% across all intracranial entities included. The technique achieved histological assessments in real time with a 10-fold reduction of processing time compared to FS, which may invariably impact surgical strategy on the fly.
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Affiliation(s)
- Arthur Wagner
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Maria Charlotte Brielmaier
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Charlotte Kampf
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Lea Baumgart
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Amir Kaywan Aftahy
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Hanno S Meyer
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Victoria Kehl
- Institute for AI and Informatics in Medicine & Muenchner Studienzentrum (MSZ), Technical University Munich School of Medicine, Munich, Germany
| | - Julius Höhne
- Department of Neurosurgery, Regensburg University Hospital, Regensburg, Germany
- Department of Neurosurgery, Paracelsus Medical University, Nürnberg, Germany
| | - Karl-Michael Schebesch
- Department of Neurosurgery, Regensburg University Hospital, Regensburg, Germany
- Department of Neurosurgery, Paracelsus Medical University, Nürnberg, Germany
| | - Nils O Schmidt
- Department of Neurosurgery, Regensburg University Hospital, Regensburg, Germany
| | - Saida Zoubaa
- Department of Neuropathology, Regensburg University Hospital, Regensburg, Germany
| | | | - Miriam Ratliff
- Department of Neurosurgery, University Hospital Mannheim, Mannheim, Germany
| | - Frederik Enders
- Department of Neurosurgery, University Hospital Mannheim, Mannheim, Germany
| | - Andreas von Deimling
- Department of Neuropathology, University Hospital Heidelberg and CCU Neuropathology, German Cancer Center (DKFZ), Heidelberg, Germany
| | | | - Claire Delbridge
- Department of Neuropathology, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Juergen Schlegel
- Department of Neuropathology, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Mohtasebi M, Huang C, Zhao M, Mazdeyasna S, Liu X, Haratbar SR, Fathi F, Sun J, Pittman T, Yu G. A Wearable Fluorescence Imaging Device for Intraoperative Identification of Human Brain Tumors. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE 2023; 12:225-232. [PMID: 38196823 PMCID: PMC10776094 DOI: 10.1109/jtehm.2023.3338564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/02/2023] [Accepted: 11/27/2023] [Indexed: 01/11/2024]
Abstract
Malignant glioma (MG) is the most common type of primary malignant brain tumors. Surgical resection of MG remains the cornerstone of therapy and the extent of resection correlates with patient survival. A limiting factor for resection, however, is the difficulty in differentiating the tumor from normal tissue during surgery. Fluorescence imaging is an emerging technique for real-time intraoperative visualization of MGs and their boundaries. However, most clinical grade neurosurgical operative microscopes with fluorescence imaging ability are hampered by low adoption rates due to high cost, limited portability, limited operation flexibility, and lack of skilled professionals with technical knowledge. To overcome the limitations, we innovatively integrated miniaturized light sources, flippable filters, and a recording camera to the surgical eye loupes to generate a wearable fluorescence eye loupe (FLoupe) device for intraoperative imaging of fluorescent MGs. Two FLoupe prototypes were constructed for imaging of Fluorescein and 5-aminolevulinic acid (5-ALA), respectively. The wearable FLoupe devices were tested on tumor-simulating phantoms and patients with MGs. Comparable results were observed against the standard neurosurgical operative microscope (PENTERO® 900) with fluorescence kits. The affordable and wearable FLoupe devices enable visualization of both color and fluorescence images with the same quality as the large and expensive stationary operative microscopes. The wearable FLoupe device allows for a greater range of movement, less obstruction, and faster/easier operation. Thus, it reduces surgery time and is more easily adapted to the surgical environment than unwieldy neurosurgical operative microscopes. Clinical and Translational Impact Statement-The affordable and wearable fluorescence imaging device developed in this study enables neurosurgeons to observe brain tumors with the same clarity and greater flexibility compared to bulky and costly operative microscopes.
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Affiliation(s)
- Mehrana Mohtasebi
- Department of Biomedical EngineeringUniversity of KentuckyLexingtonKY40506USA
| | - Chong Huang
- Department of Biomedical EngineeringUniversity of KentuckyLexingtonKY40506USA
| | - Mingjun Zhao
- Department of Biomedical EngineeringUniversity of KentuckyLexingtonKY40506USA
| | - Siavash Mazdeyasna
- Department of Biomedical EngineeringUniversity of KentuckyLexingtonKY40506USA
| | - Xuhui Liu
- Department of Biomedical EngineeringUniversity of KentuckyLexingtonKY40506USA
| | | | - Faraneh Fathi
- Department of Biomedical EngineeringUniversity of KentuckyLexingtonKY40506USA
| | | | - Thomas Pittman
- Department of NeurosurgeryUniversity of KentuckyLexingtonKY40506USA
| | - Guoqiang Yu
- Department of Biomedical EngineeringUniversity of KentuckyLexingtonKY40506USA
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Kaynar G, Cakmakci D, Bund C, Todeschi J, Namer IJ, Cicek AE. PiDeeL: metabolic pathway-informed deep learning model for survival analysis and pathological classification of gliomas. Bioinformatics 2023; 39:btad684. [PMID: 37952175 PMCID: PMC10663986 DOI: 10.1093/bioinformatics/btad684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/19/2023] [Accepted: 11/10/2023] [Indexed: 11/14/2023] Open
Abstract
MOTIVATION Online assessment of tumor characteristics during surgery is important and has the potential to establish an intra-operative surgeon feedback mechanism. With the availability of such feedback, surgeons could decide to be more liberal or conservative regarding the resection of the tumor. While there are methods to perform metabolomics-based tumor pathology prediction, their model complexity predictive performance is limited by the small dataset sizes. Furthermore, the information conveyed by the feedback provided on the tumor tissue could be improved both in terms of content and accuracy. RESULTS In this study, we propose a metabolic pathway-informed deep learning model (PiDeeL) to perform survival analysis and pathology assessment based on metabolite concentrations. We show that incorporating pathway information into the model architecture substantially reduces parameter complexity and achieves better survival analysis and pathological classification performance. With these design decisions, we show that PiDeeL improves tumor pathology prediction performance of the state-of-the-art in terms of the Area Under the ROC Curve by 3.38% and the Area Under the Precision-Recall Curve by 4.06%. Similarly, with respect to the time-dependent concordance index (c-index), PiDeeL achieves better survival analysis performance (improvement of 4.3%) when compared to the state-of-the-art. Moreover, we show that importance analyses performed on input metabolite features as well as pathway-specific neurons of PiDeeL provide insights into tumor metabolism. We foresee that the use of this model in the surgery room will help surgeons adjust the surgery plan on the fly and will result in better prognosis estimates tailored to surgical procedures. AVAILABILITY AND IMPLEMENTATION The code is released at https://github.com/ciceklab/PiDeeL. The data used in this study are released at https://zenodo.org/record/7228791.
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Affiliation(s)
- Gun Kaynar
- Computer Engineering Department, Bilkent University, 06800 Ankara, Turkey
| | - Doruk Cakmakci
- School of Computer Science, McGill University, Montreal, QC, H3A 0E9, Canada
| | - Caroline Bund
- MNMS Platform, University Hospitals of Strasbourg, Strasbourg 67098, France
- ICube, University of Strasbourg, CNRS UMR, 7357, Strasbourg 67000, France
- Department of Nuclear Medicine and Molecular Imaging, ICANS, Strasbourg 67000, France
| | - Julien Todeschi
- Department of Neurosurgery, University Hospitals of Strasbourg, Strasbourg, 67091, France
| | - Izzie Jacques Namer
- MNMS Platform, University Hospitals of Strasbourg, Strasbourg 67098, France
- ICube, University of Strasbourg, CNRS UMR, 7357, Strasbourg 67000, France
- Department of Nuclear Medicine and Molecular Imaging, ICANS, Strasbourg 67000, France
| | - A Ercument Cicek
- Computer Engineering Department, Bilkent University, 06800 Ankara, Turkey
- Computational Biology Department, Carnegie Mellon University, Pittsburgh, PA 15213, United States
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Alcazar P, Avedillo A, Vazquez S, Lopez LB, Fustero D, Moles J, Gonzalez L, Orduna J. The usefulness of intraoperative sodium fluorescein in the surgical treatment of relapsed high-grade brain tumors in pediatric patients. Childs Nerv Syst 2023; 39:1501-1507. [PMID: 36961584 DOI: 10.1007/s00381-023-05930-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/17/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE We report the usefulness of intraoperative sodium fluorescein (SF) in the surgical treatment of relapsed high-grade brain tumors in pediatric neurosurgery. METHODS We describe our protocol for intraoperative SF and three cases of patients between 5 and 11 years diagnosed and surgically treated for relapsed high-grade brain tumors using SF. RESULTS The 560-nm microscope filter enables the use of low doses of this fluorochrome. A dose of 3 mg/kg of patient weight of 10% SF, administered intravenously, is safe and effective in children. The effect of SF was immediate, providing a clear margin between the tumor and healthy tissue, which enabled good tumor resection. We observed no adverse effects in the postoperative period, and the patients evolved satisfactorily. CONCLUSIONS To the best of our knowledge, we describe for the first time the use of fluorescein in reoperations of relapsed high-grade brain tumors in childhood with promising results. Using SF in children is a safe, affordable, and effective technique that offers an excellent intraoperative image, being a feasible option to improve oncological resection. This study is one of the few that uses SF in pediatric neurosurgery, where it could be very beneficial.
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Affiliation(s)
- Paula Alcazar
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain.
| | - Amanda Avedillo
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Silvia Vazquez
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Laura B Lopez
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - David Fustero
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Jesus Moles
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Luis Gonzalez
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
| | - Javier Orduna
- Department of Neurosurgery, Miguel Servet University Hospital, Saragossa, Aragon, Spain
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5
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Intraoperative Fluorescein Sodium in Pediatric Neurosurgery: A Preliminary Case Series from a Singapore Children’s Hospital. NEUROSCI 2023. [DOI: 10.3390/neurosci4010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
(1) Background: Fluorescein sodium (Na-Fl) has been described as a safe and useful neurosurgical adjunct in adult neurooncology. However, its use has yet to be fully established in children. We designed a study to investigate the use of intraoperative Na-Fl in pediatric brain tumor surgery. (2) Methods: This is a single-institution study for pediatric brain tumor patients managed by the Neurosurgical Service, KK Women’s and Children’s Hospital. Inclusion criteria consists of patients undergoing surgery for suspected brain tumors from 3 to 19 years old. A predefined intravenous dose of 2 mg/kg of 10% Na-Fl is administered per patient. Following craniotomy, surgery is performed under alternating white light and YELLOW-560 nm filter illumination. (3) Results: A total of 21 patients with suspected brain tumours were included. Median age was 12.1 years old. For three patients (14.3%), there was no significant Na-Fl fluorescence detected and their final histologies reported a cavernoma and two radiation-induced high grade gliomas. The remaining patients (85.7%) had adequate intraoperative fluorescence for their lesions. No adverse side effects were encountered with the use of Na-Fl. (4) Conclusions: Preliminary findings demonstrate the safe and efficacious use of intraoperative Na-Fl for brain tumors as a neurosurgical adjunct in our pediatric patients.
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Zhang M, Xiao X, Gu G, Zhang P, Wu W, Wang Y, Pan C, Wang L, Li H, Wu Z, Zhang J, Zhang L. Role of neuronavigation in the surgical management of brainstem gliomas. Front Oncol 2023; 13:1159230. [PMID: 37205194 PMCID: PMC10185888 DOI: 10.3389/fonc.2023.1159230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 03/20/2023] [Indexed: 05/21/2023] Open
Abstract
Objective NeuroNavigation (NN) is a widely used intraoperative imaging guidance technique in neurosurgical operations; however, its value in brainstem glioma (BSG) surgery is inadequately reported and lacks objective proof. This study aims to investigate the applicational value of NN in BSG surgery. Method A retrospective analysis was performed on 155 patients with brainstem gliomas who received craniotomy from May 2019 to January 2022 at Beijing Tiantan Hospital. Eighty-four (54.2%) patients received surgery with NN. Preoperative and postoperative cranial nerve dysfunctions, muscle strength, and Karnofsky (KPS) were evaluated. Patients' radiological features, tumor volume, and extent of resection (EOR) were obtained from conventional MRI data. Patients' follow-up data were also collected. Comparative analyses on these variables were made between the NN group and the non-NN group. Result The usage of NN is independently related to a higher EOR in diffuse intrinsic pontine glioma (DIPG) (p=0.005) and non-DIPG group (p<0.001). It was observed that fewer patients in the NN group suffered from deterioration of KPS (p=0.032) and cranial nerve function (p=0.017) in non-DIPG group, and deterioration of muscle strength (p=0.040) and cranial nerve function (p=0.038) in DIPG group. Moreover, the usage of NN is an independent protective factor for the deterioration of KPS (p=0.04) and cranial nerve function (p=0.026) in non-DIPG patients and the deterioration of muscle strength (p=0.009) in DIPG patients. Furthermore, higher EOR subgroups were found to be independently related to better prognoses in DIPG patients (p=0.008). Conclusion NN has significant value in BSG surgery. With the assistance of NN, BSG surgery achieved higher EOR without deteriorating patients' functions. In addition, DIPG patients may benefit from the appropriate increase of EOR.
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Affiliation(s)
- Mingxin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiong Xiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guocan Gu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenhao Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Changcun Pan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Junting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liwei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Liwei Zhang,
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Falco J, Broggi M, Schiariti M, Vetrano IG, Esposito S, Ferroli P, Acerbi F. The role of sodium fluorescein in pediatric supratentorial intra-axial tumor resection: new insights from a monocentric series of 33 consecutive patients. Childs Nerv Syst 2022; 39:1463-1471. [PMID: 36520160 DOI: 10.1007/s00381-022-05764-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Surgical resection represents the mainstay of treatment, in pediatric central nervous system (CNS) tumors, and aggressive resection correlates with prognosis for several histotypes. Sodium fluorescein (SF), a green, water-soluble dye, is used as neurosurgical fluorescent tracer thanks to its property to accumulate in cerebral regions of blood-brain barrier disruption, acting as a valid tool to improve the extent of resection in tumors enhancing at preoperative MRI. Brain neoplasms represent a heterogeneous group of tumors in the pediatric age, constituting the most common solid cancers; they typically show a varying degree of contrast enhancement on MRI. MATERIALS AND METHODS In March 2016, the authors started a prospective, observational trial to evaluate intraoperative fluorescence's characteristics of CNS tumors, the percentage of extent of resection, thanks to fluorescein aid, and side effects related to fluorescein administration. This report is based on a retrospective analysis of a group of 33 consecutive pediatric patients harboring a supratentorial lesion. RESULTS In 17 of 33 (51.5%) procedures, fluorescence was reported as intense; in 14 of 33 (42.4%), moderate; and in 2 of 33 (6.1%), slight. Intraoperative fluorescence corresponds to preoperative-MRI-documented contrast enhancement. In 28 of 33 (84.8%) surgical procedures, SF was considered useful; in 2 of 33 (6.1%), partial useful; and in 3 of 33 (9.1%), not essential because the tumor was already recognizable. No adverse effect to SF administration was registered. CONCLUSION Fluorescein-guided surgery with a dedicated filter on the microscope is a safe and effective technique to improve visualization and resection of different pediatric brain tumors.
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Affiliation(s)
- Jacopo Falco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Ignazio Gaspare Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Silvia Esposito
- Developmental Neurology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy.
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de Laurentis C, Bteich F, Beuriat PA, Mottolese C, Giussani C, Szathmari A, Vinchon M, Di Rocco F. Sodium fluorescein in pediatric neurosurgery: a systematic review with technical considerations and future perspectives. Childs Nerv Syst 2022; 39:1451-1462. [PMID: 36459209 DOI: 10.1007/s00381-022-05772-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Sodium fluorescein (SF) is routinely used in several centers as a valid intraoperative adjunct in adult oncological neurosurgery. Its use in pediatric neurosurgery is increasing, although its role is not yet well-defined in children. We reviewed the current literature in order to evaluate the use of SF in children with CNS and PNS lesions. METHODS For this systematic review, we searched PubMed, Scopus, and Embase databases, and forward and backward citations for studies published between database inception and July 31st, 2022. We included any article type or congress abstract adding at least a new case, without restrictions of language or publication status, concerning the use of SF in neurosurgical procedures in patients under 18 years of age. We excluded studies concerning purely vascular cases and cerebrospinal fluid leaks. RESULTS Of 4094 records identified, 19 articles were eligible and included for further analysis. As per July 31st, 2022, at least 119 patients aged from 11 months to 17.9 years underwent surgery with SF. No serious adverse events were reported. A large variety of tumor types was operated, in most cases resected under the specific YELLOW 560 nm filter after a low-dose SF injection (2-5 mg/kg) at the end of anesthesia induction. SF was reported particularly useful in gangliogliomas and pilocytic astrocytomas. DISCUSSION/CONCLUSION Given its easy-to-use profile, low cost, and safety, SF seems to be a feasible and valid adjunct in the pediatric population when aiming at individuating a biopsy target or maximizing extent of resection, particularly in some tumor types. Further studies are required to strengthen the evidence on its impact on outcomes.
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Affiliation(s)
- Camilla de Laurentis
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France. .,Department of Medicine and Surgery, Università degli Studi di Milano Bicocca, Milan, Italy.
| | - Fred Bteich
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France
| | | | - Carmine Mottolese
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France
| | - Carlo Giussani
- Department of Medicine and Surgery, Università degli Studi di Milano Bicocca, Milan, Italy.,Neurosurgery Unit, San Gerardo Hospital, Monza, Italy
| | | | - Matthieu Vinchon
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France
| | - Federico Di Rocco
- Pediatric Neurosurgery Unit, Hôpital Femme Mère Enfant, Lyon, France.,Department of Medicine and Surgery, Université Claude Bernard Lyon I, Lyon, France
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Cakmakci D, Kaynar G, Bund C, Piotto M, Proust F, Namer IJ, Cicek AE. Targeted metabolomics analyses for brain tumor margin assessment during surgery. BIOINFORMATICS (OXFORD, ENGLAND) 2022; 38:3238-3244. [PMID: 35512389 DOI: 10.1093/bioinformatics/btac309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/13/2022] [Accepted: 05/02/2022] [Indexed: 01/17/2023]
Abstract
MOTIVATION Identification and removal of micro-scale residual tumor tissue during brain tumor surgery are key for survival in glioma patients. For this goal, High-Resolution Magic Angle Spinning Nuclear Magnetic Resonance (HRMAS NMR) spectroscopy-based assessment of tumor margins during surgery has been an effective method. However, the time required for metabolite quantification and the need for human experts such as a pathologist to be present during surgery are major bottlenecks of this technique. While machine learning techniques that analyze the NMR spectrum in an untargeted manner (i.e. using the full raw signal) have been shown to effectively automate this feedback mechanism, high dimensional and noisy structure of the NMR signal limits the attained performance. RESULTS In this study, we show that identifying informative regions in the HRMAS NMR spectrum and using them for tumor margin assessment improves the prediction power. We use the spectra normalized with the ERETIC (electronic reference to access in vivo concentrations) method which uses an external reference signal to calibrate the HRMAS NMR spectrum. We train models to predict quantities of metabolites from annotated regions of this spectrum. Using these predictions for tumor margin assessment provides performance improvements up to 4.6% the Area Under the ROC Curve (AUC-ROC) and 2.8% the Area Under the Precision-Recall Curve (AUC-PR). We validate the importance of various tumor biomarkers and identify a novel region between 7.97 ppm and 8.09 ppm as a new candidate for a glioma biomarker. AVAILABILITY AND IMPLEMENTATION The code is released at https://github.com/ciceklab/targeted_brain_tumor_margin_assessment. The data underlying this article are available in Zenodo, at https://doi.org/10.5281/zenodo.5781769. SUPPLEMENTARY INFORMATION Supplementary data are available at Bioinformatics online.
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Affiliation(s)
- Doruk Cakmakci
- School of Computer Science, McGill University, Montreal, QC H3A 0E9, Canada
| | - Gun Kaynar
- School of Computer Science, McGill University, Montreal, QC H3A 0E9, Canada
| | - Caroline Bund
- MNMS Platform, University Hospitals of Strasbourg, Strasbourg 67098, France.,ICube, University of Strasbourg/CNRS UMR 7357, Strasbourg 67000, France.,Department of Nuclear Medicine and Molecular Imaging, ICANS, Strasbourg 67000, France
| | | | - Francois Proust
- Department of Neurosurgery, University Hospitals of Strasbourg, Strasbourg 67091, France
| | - Izzie Jacques Namer
- MNMS Platform, University Hospitals of Strasbourg, Strasbourg 67098, France.,ICube, University of Strasbourg/CNRS UMR 7357, Strasbourg 67000, France.,Department of Nuclear Medicine and Molecular Imaging, ICANS, Strasbourg 67000, France
| | - A Ercument Cicek
- Computer Engineering Department, Bilkent University, Ankara 06800, Turkey.,Computational Biology Department, Carnegie Mellon University, Pittsburgh, PA 15213, USA
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10
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Zhang Z, He K, Chi C, Hu Z, Tian J. Intraoperative fluorescence molecular imaging accelerates the coming of precision surgery in China. Eur J Nucl Med Mol Imaging 2022; 49:2531-2543. [PMID: 35230491 PMCID: PMC9206608 DOI: 10.1007/s00259-022-05730-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/13/2022] [Indexed: 02/06/2023]
Abstract
Purpose China has the largest cancer population globally. Surgery is the main choice for most solid cancer patients. Intraoperative fluorescence molecular imaging (FMI) has shown its great potential in assisting surgeons in achieving precise resection. We summarized the typical applications of intraoperative FMI and several new trends to promote the development of precision surgery. Methods The academic database and NIH clinical trial platform were systematically evaluated. We focused on the clinical application of intraoperative FMI in China. Special emphasis was placed on a series of typical studies with new technologies or high-level evidence. The emerging strategy of combining FMI with other modalities was also discussed. Results The clinical applications of clinically approved indocyanine green (ICG), methylene blue (MB), or fluorescein are on the rise in different surgical departments. Intraoperative FMI has achieved precise lesion detection, sentinel lymph node mapping, and lymphangiography for many cancers. Nerve imaging is also exploring to reduce iatrogenic injuries. Through different administration routes, these fluorescent imaging agents provided encouraging results in surgical navigation. Meanwhile, designing new cancer-specific fluorescent tracers is expected to be a promising trend to further improve the surgical outcome. Conclusions Intraoperative FMI is in a rapid development in China. In-depth understanding of cancer-related molecular mechanisms is necessary to achieve precision surgery. Molecular-targeted fluorescent agents and multi-modal imaging techniques might play crucial roles in the era of precision surgery.
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Affiliation(s)
- Zeyu Zhang
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Engineering Medicine, Beihang University, Beijing, China.,CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, The State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | - Kunshan He
- CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, The State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China.,State Key Laboratory of Computer Science and Beijing Key Lab of Human-Computer Interaction, Institute of Software, Chinese Academy of Sciences, Beijing, China
| | - Chongwei Chi
- CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, The State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China. .,University of Chinese Academy of Sciences, Beijing, China.
| | - Zhenhua Hu
- CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, The State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China. .,University of Chinese Academy of Sciences, Beijing, China.
| | - Jie Tian
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Engineering Medicine, Beihang University, Beijing, China. .,CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, The State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China.
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11
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Ahrens LC, Krabbenhøft MG, Hansen RW, Mikic N, Pedersen CB, Poulsen FR, Korshoej AR. Effect of 5-Aminolevulinic Acid and Sodium Fluorescein on the Extent of Resection in High-Grade Gliomas and Brain Metastasis. Cancers (Basel) 2022; 14:cancers14030617. [PMID: 35158885 PMCID: PMC8833379 DOI: 10.3390/cancers14030617] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Surgery is essential in the treatment of high-grade gliomas (HGG) and gross total resection (GTR) is known to increase the overall survival and progression-free survival. Several studies have shown that fluorescence-guided surgery with 5-aminolevulinic acid (5-ALA) increases GTR considerably compared to white light surgery (65% vs. 36%). In recent years, sodium fluorescein (SF) has become an increasingly popular agent for fluorescence-guided surgery due to numerous utility benefits compared to 5-ALA, including lower cost, non-toxicity, easy administration during surgery and a wide indication range covering all contrast-enhancing lesions with disruption of the blood-brain barrier in the CNS. However, currently, SF is an off-label agent and the level of evidence for use in HGG surgery is inferior compared to 5-ALA. Here, we give an update and review the latest literature on fluorescence-guided surgery with 5-ALA and SF for brain tumors with emphasis on fluorescence-guided surgery in HGG and brain metastases. Further, we assess the advantages and disadvantages of both fluorophores and discuss their future perspectives.
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Affiliation(s)
- Lasse Cramer Ahrens
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, J618, DK8200 Aarhus, Denmark; (M.G.K.); (N.M.)
- Correspondence: (L.C.A.); (A.R.K.); Tel.: +45-(20)-254418 (L.C.A.)
| | - Mathias Green Krabbenhøft
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, J618, DK8200 Aarhus, Denmark; (M.G.K.); (N.M.)
| | - Rasmus Würgler Hansen
- Department of Neurosurgery, Odense University Hospital, DK5000 Odense, Denmark; (R.W.H.); (C.B.P.); (F.R.P.)
| | - Nikola Mikic
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, J618, DK8200 Aarhus, Denmark; (M.G.K.); (N.M.)
- Department of Clinical Medicine, Aarhus University, Incuba Skejby, Building 2, Palle Juul-Jensens Boulevard 82, J618, DK8200 Aarhus, Denmark
| | - Christian Bonde Pedersen
- Department of Neurosurgery, Odense University Hospital, DK5000 Odense, Denmark; (R.W.H.); (C.B.P.); (F.R.P.)
| | - Frantz Rom Poulsen
- Department of Neurosurgery, Odense University Hospital, DK5000 Odense, Denmark; (R.W.H.); (C.B.P.); (F.R.P.)
| | - Anders Rosendal Korshoej
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, J618, DK8200 Aarhus, Denmark; (M.G.K.); (N.M.)
- Department of Clinical Medicine, Aarhus University, Incuba Skejby, Building 2, Palle Juul-Jensens Boulevard 82, J618, DK8200 Aarhus, Denmark
- Correspondence: (L.C.A.); (A.R.K.); Tel.: +45-(20)-254418 (L.C.A.)
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12
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Xue Z, Kong L, Hao S, Wang Y, Jia G, Wu Z, Jia W, Zhang J, Zhang L. Combined Application of Sodium Fluorescein and Neuronavigation Techniques in the Resection of Brain Gliomas. Front Neurol 2021; 12:747072. [PMID: 34938258 PMCID: PMC8685407 DOI: 10.3389/fneur.2021.747072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 11/01/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives: To explore the effectiveness and safety of the combined application of sodium fluorescein and neuronavigation techniques in the resection of brain gliomas in different locations and patients of different ages. Methods: Fifty clinical cases of brain gliomas treated at the Department of Neurosurgery of Beijing Tiantan Hospital were collected from March 2014 to March 2019. These cases were divided into a supratentorial group (24 cases) and a brainstem group (26 cases) based on location and an adult group (28 cases) and a pediatric group (22 cases) based on age. Fluorescein-guided surgery was performed: the adult group received 5 mg/kg sodium fluorescein before opening the dura, while the pediatric group received 2.5 mg/kg during resection. Tumor visualization was evaluated by the enhancement of yellow fluorescein and considered “satisfactory” if the illumination demarcated the tumor boundary. Additionally, the consistency between fluorescein and neuronavigation was analyzed. The Karnofsky performance score (KPS) of all patients was recorded and assessed at admission, discharge, and the 6-month follow-up. Results: In the 28 adult cases, 4 were unsatisfactory, while in the 22 pediatric cases, 2 were unsatisfactory; in 7 cases, there was an inconsistency between yellow fluorescein enhancement and neuronavigation, 6 were in the supratentorial group, and 1 was in the brainstem group. Statistical analysis showed no significant differences in the satisfactory rate between the adult and pediatric groups (P = 0.575), whereas there were significant differences inconsistency between the supratentorial group and brainstem group (P = 0.031). The mean KPS at admission was between 70 and 100, which was not significantly different from that at discharge (P = 0.839), but the KPS at the 6-month follow-up was significantly higher than that at admission (P = 0.041). Conclusions: The consistency between sodium fluorescein and the neuronavigation system was higher in the brainstem group than in the supratentorial group; a half dose of sodium fluorescein (2.5 mg/kg) was sufficient for pediatric patients. The combined utilization of sodium fluorescein and neuronavigation techniques may confer glioma patients the opportunity to obtain better clinical outcomes after surgery.
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Affiliation(s)
- Zhan Xue
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lu Kong
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Shuyu Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guijun Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wang Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Junting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liwei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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13
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Kutlay M, Durmaz O, Ozer İ, Kırık A, Yasar S, Kural C, Temiz Ç, Tehli Ö, Ezgu MC, Daneyemez M, Izci Y. Fluorescein Sodium-Guided Neuroendoscopic Resection of Deep-Seated Malignant Brain Tumors: Preliminary Results of 18 Patients. Oper Neurosurg (Hagerstown) 2021; 20:206-218. [PMID: 33047137 DOI: 10.1093/ons/opaa313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/02/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Deep-seated intracranial lesions are challenging to resect completely and safely. Fluorescence-guided surgery (FGS) promotes the resection of malignant brain tumors (MBTs). Classically, FGS is performed using microscope equipped with a special filter. Fluorescence-guided neuroendoscopic resection of deep-seated brain tumors has not been reported yet. OBJECTIVE To evaluate the feasibility, safety, and effectiveness of the fluorescence-guided neuroendoscopic surgery in deep-seated MBTs. METHODS A total of 18 patients with high-grade glioma (HGG) and metastatic tumor (MT) underwent fluorescein sodium (FS)-guided neuroendoscopic surgery. Tumor removal was carried out using bimanual microsurgical techniques under endoscopic view. The degree of fluorescence staining was classified as "helpful" and "unhelpful" based on surgical observation. Extent of resection was determined using magnetic resonance imaging (MRI). Karnofsky Performance Status (KPS) score was used for evaluation of general physical performances of patients. RESULTS A total of 11 patients had HGG, and 7 had MT. No technical difficulty was encountered regarding the use of endoscopic technique. "Helpful" fluorescence staining was observed in 16 patients and fluorescent tissue was completely removed. Postoperative MRI confirmed gross total resection (88.9%). In 2 patients, FS enhancement was not helpful enough for tumor demarcation and postoperative MRI revealed near total resection (11.1%). No complication, adverse events, or side effects were encountered regarding the use of FS. KPS score of patients was improved at 3-mo follow-up. CONCLUSION FS-guided endoscopic resection is a feasible technique for deep-seated MBTs. It is safe, effective, and allows for a high rate of resection. Future prospective randomized studies are needed to confirm these preliminary data.
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Affiliation(s)
- Murat Kutlay
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Ozan Durmaz
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - İlker Ozer
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Alpaslan Kırık
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Soner Yasar
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Cahit Kural
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Çağlar Temiz
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Özkan Tehli
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Mehmet Can Ezgu
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Mehmet Daneyemez
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Yusuf Izci
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
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14
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Höhne J, Schebesch KM, Zoubaa S, Proescholdt M, Riemenschneider MJ, Schmidt NO. Intraoperative imaging of brain tumors with fluorescein: confocal laser endomicroscopy in neurosurgery. Clinical and user experience. Neurosurg Focus 2021; 50:E19. [PMID: 33386020 DOI: 10.3171/2020.11.focus20783] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Confocal laser endomicroscopy (CLE) is an established tool in basic research for tissue imaging at the level of microstructures. Miniaturization and refinement of the technology have made this modality available for operative imaging with a handheld device. Sufficient image contrast is provided by the preoperative application of fluorescein sodium. The authors report their first experiences in a clinical case series using the new confocal laser endomicroscope. METHODS Handling, operative workflow, and visualization of the CLE were critically evaluated in 12 cases of different CNS tumors. Three different imaging positions in relation to the tumor were chosen: the tumor border (I), tumor center (II), and perilesional zone (III). Respective diagnostic sampling with H & E staining and matching intraoperative neuronavigation and microscope images are provided. RESULTS CLE was found to be beneficial in terms of high-quality visualization of fine structures and for displaying hidden anatomical details. The handling of the device was good, and the workflow was easy. CONCLUSIONS Handling ergonomics and image acquisition are intuitive. The endomicroscope allows excellent additional visualization of microstructures in the surgical field with a minimally invasive technique and could improve safety and clinical outcomes. The new confocal laser endomicroscope is an advanced tool with the potential to change intracranial tumor surgery. Imaging of these microstructures is novel, and research with comparative validation with traditional neuropathological assessments is needed.
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Affiliation(s)
- Julius Höhne
- 1Department of Neurosurgery.,3Wilhelm Sander-Neuro-Oncology Unit, University Medical Center Regensburg, Germany
| | - Karl-Michael Schebesch
- 1Department of Neurosurgery.,3Wilhelm Sander-Neuro-Oncology Unit, University Medical Center Regensburg, Germany
| | - Saida Zoubaa
- 2Institute of Neuropathology, and.,3Wilhelm Sander-Neuro-Oncology Unit, University Medical Center Regensburg, Germany
| | - Martin Proescholdt
- 1Department of Neurosurgery.,3Wilhelm Sander-Neuro-Oncology Unit, University Medical Center Regensburg, Germany
| | - Markus J Riemenschneider
- 2Institute of Neuropathology, and.,3Wilhelm Sander-Neuro-Oncology Unit, University Medical Center Regensburg, Germany
| | - Nils Ole Schmidt
- 1Department of Neurosurgery.,3Wilhelm Sander-Neuro-Oncology Unit, University Medical Center Regensburg, Germany
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15
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Labuschagne J. 5-aminolevulinic acid-guided surgery for focal pediatric brainstem gliomas: A preliminary study. Surg Neurol Int 2020; 11:334. [PMID: 33194268 PMCID: PMC7656004 DOI: 10.25259/sni_246_2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/28/2020] [Indexed: 12/22/2022] Open
Abstract
Background: There is a growing body of literature supporting the use of 5-aminolevulinic acid (5-ALA) in the pediatric population, however, its use is still considered “off label” in this setting. In this retrospective study, we report our experience using 5-ALA in pediatric patients with focal brainstem gliomas (BSGs). Methods: Patients younger than 16 years presenting with a newly diagnosed BSG that was focal in nature were considered suitable for treatment with 5-ALA-assisted surgery. Exclusion criteria included MRI features suggestive of a diffuse intrinsic pontine glioma. A single dose of 5-ALA was administered preoperatively. Intraoperative fluorescence was recorded as “solid,” “vague,” or “none.” The effectiveness of the fluorescence was graded as “helpful” or “unhelpful.” Results: Eight patients underwent 5-ALA-assisted surgery. There were four tumors located in the pons, two midbrain tumors, and two cervicomedullary tumors. Histological analysis demonstrated three diffuse astrocytomas, three pilocytic astrocytomas, and two anaplastic astrocytomas. Solid fluorescence was found in three of the eight cases, vague fluorescence was found in two cases, and no fluorescence was found in three cases. Fluorescence was useful in 3 (37%) cases. No patients experienced any complications attributable to the administration of the 5-ALA. Conclusion: With a total fluorescence rate of 62.5% but a subjectively assessed “usefulness” rate of only 37.5%, the role of 5-ALA in BSG surgery is limited. Given the toxicological safety, however, of the agent, caution is perhaps needed before dismissing the use of 5-ALA entirely.
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Affiliation(s)
- Jason Labuschagne
- Department of Paediatric Neurosurgery, Nelson Mandela Childrens Hospital, Parktown, Johanessburg, South Africa
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16
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Cakmakci D, Karakaslar EO, Ruhland E, Chenard MP, Proust F, Piotto M, Namer IJ, Cicek AE. Machine learning assisted intraoperative assessment of brain tumor margins using HRMAS NMR spectroscopy. PLoS Comput Biol 2020; 16:e1008184. [PMID: 33175838 PMCID: PMC7682900 DOI: 10.1371/journal.pcbi.1008184] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 11/23/2020] [Accepted: 07/22/2020] [Indexed: 11/19/2022] Open
Abstract
Complete resection of the tumor is important for survival in glioma patients. Even if the gross total resection was achieved, left-over micro-scale tissue in the excision cavity risks recurrence. High Resolution Magic Angle Spinning Nuclear Magnetic Resonance (HRMAS NMR) technique can distinguish healthy and malign tissue efficiently using peak intensities of biomarker metabolites. The method is fast, sensitive and can work with small and unprocessed samples, which makes it a good fit for real-time analysis during surgery. However, only a targeted analysis for the existence of known tumor biomarkers can be made and this requires a technician with chemistry background, and a pathologist with knowledge on tumor metabolism to be present during surgery. Here, we show that we can accurately perform this analysis in real-time and can analyze the full spectrum in an untargeted fashion using machine learning. We work on a new and large HRMAS NMR dataset of glioma and control samples (n = 565), which are also labeled with a quantitative pathology analysis. Our results show that a random forest based approach can distinguish samples with tumor cells and controls accurately and effectively with a median AUC of 85.6% and AUPR of 93.4%. We also show that we can further distinguish benign and malignant samples with a median AUC of 87.1% and AUPR of 96.1%. We analyze the feature (peak) importance for classification to interpret the results of the classifier. We validate that known malignancy biomarkers such as creatine and 2-hydroxyglutarate play an important role in distinguishing tumor and normal cells and suggest new biomarker regions. The code is released at http://github.com/ciceklab/HRMAS_NC.
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Affiliation(s)
- Doruk Cakmakci
- Computer Engineering Department, Bilkent University, Ankara, Turkey
| | | | - Elisa Ruhland
- MNMS Platform, University Hospitals of Strasbourg, Strasbourg, France
| | | | - Francois Proust
- Department of Neurosurgery, University Hospitals of Strasbourg, Strasbourg, France
| | | | - Izzie Jacques Namer
- MNMS Platform, University Hospitals of Strasbourg, Strasbourg, France
- ICube, University of Strasbourg / CNRS UMR 7357, Strasbourg, France
- Department of Nuclear Medicine and Molecular Imaging, ICANS, Strasbourg, France
| | - A. Ercument Cicek
- Computer Engineering Department, Bilkent University, Ankara, Turkey
- Computational Biology Department, Carnegie Mellon University, Pittsburgh, Pennsylvania
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