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Fujiwara H, Furudate S, Takahara N, Nakai Y, Kodama Y, Arai J, Nakagawa H, Ikenoue T, Tateishi K, Kasuga M, Fujishiro M. Probe-guided endoscopic system for 5-aminolevulinic acid-based photodynamic diagnosis in cholangiocarcinoma. Photodiagnosis Photodyn Ther 2024; 48:104268. [PMID: 38971526 DOI: 10.1016/j.pdpdt.2024.104268] [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: 05/02/2024] [Revised: 06/23/2024] [Accepted: 07/03/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND AND AIM The diagnostic accuracy for cholangiocarcinoma (CCA) is inadequate, necessitating the exploration of novel diagnostic approaches. Protoporphyrin IX (Pp IX), a metabolic product of 5-aminolevulinic acid (5-ALA), emits red fluorescence upon blue light exposure. Because it accumulates selectively in cancer cells, photodynamic diagnosis using 5-ALA (5-ALA-PDD) has been integrated into clinical practice for diverse cancer types. Nevertheless, there is currently no device capable of capturing Pp IX-derived fluorescence for real-time 5-ALA-PDD within the biliary tract, largely due to challenges in device miniaturization. METHODS To investigate the feasibility of real-time 5ALA-PDD in CCA, we developed two essential components of the cholangioscopy system: a small-diameter flexible camera and a light guide for emitting blue light. We evaluated the detectability of Pp IX fluorescence using these devices in experimental gels and animal models. RESULTS Our camera and light guide were smoothly inserted into the lumen of existing cholangioscopes. Incorporating a long-pass filter at the camera tip enabled efficient detection of red fluorescence without significantly impacting white-light observation. The integration of these devices facilitated clear visualization of red fluorescence from gels containing Pp IX at concentrations of 5 μM or higher. Additionally, when observing subcutaneous human CCA tumor models in nude mice treated with 5-ALA, we successfully demonstrated distinct red fluorescence from Pp IX accumulation in tumors compared to peritumoral subcutaneous areas. CONCLUSION The integration of our device combination holds promise for real-time 5-ALA-PDD in human CCA, potentially enhancing the diagnostic accuracy for this complex condition.
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Affiliation(s)
- Hiroaki Fujiwara
- Division of Gastroenterology, The Institute of Medical Science, Asahi Life Foundation, 2-2-6 Bakurocho, Chuo-ku, Tokyo, 103-0002, Japan; Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Shiho Furudate
- Japan Lifeline Co., Ltd, 2-2-20 Higashishinagawa, Shinagawa-ku, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Yuki Kodama
- Japan Lifeline Co., Ltd, 2-2-20 Higashishinagawa, Shinagawa-ku, Tokyo, Japan
| | - Junya Arai
- Division of Gastroenterology, The Institute of Medical Science, Asahi Life Foundation, 2-2-6 Bakurocho, Chuo-ku, Tokyo, 103-0002, Japan; Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Hayato Nakagawa
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Tsuneo Ikenoue
- Division of Clinical Genome Research, The Institute of Medical Science, The University of Tokyo, Tokyo 108‑8639, Japan
| | - Keisuke Tateishi
- Department of Gastroenterology, St Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Masato Kasuga
- The Institute of Medical Science, Asahi Life Foundation, 2-2-6 Bakurocho, Chuo-ku, Tokyo, 103-0002, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Chang C, Chavarro VS, Gerstl JVE, Blitz SE, Spanehl L, Dubinski D, Valdes PA, Tran LN, Gupta S, Esposito L, Mazzetti D, Gessler FA, Arnaout O, Smith TR, Friedman GK, Peruzzi P, Bernstock JD. Recurrent Glioblastoma-Molecular Underpinnings and Evolving Treatment Paradigms. Int J Mol Sci 2024; 25:6733. [PMID: 38928445 PMCID: PMC11203521 DOI: 10.3390/ijms25126733] [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: 05/14/2024] [Revised: 06/13/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
Glioblastoma is the most common and lethal central nervous system malignancy with a median survival after progression of only 6-9 months. Major biochemical mechanisms implicated in glioblastoma recurrence include aberrant molecular pathways, a recurrence-inducing tumor microenvironment, and epigenetic modifications. Contemporary standard-of-care (surgery, radiation, chemotherapy, and tumor treating fields) helps to control the primary tumor but rarely prevents relapse. Cytoreductive treatment such as surgery has shown benefits in recurrent glioblastoma; however, its use remains controversial. Several innovative treatments are emerging for recurrent glioblastoma, including checkpoint inhibitors, chimeric antigen receptor T cell therapy, oncolytic virotherapy, nanoparticle delivery, laser interstitial thermal therapy, and photodynamic therapy. This review seeks to provide readers with an overview of (1) recent discoveries in the molecular basis of recurrence; (2) the role of surgery in treating recurrence; and (3) novel treatment paradigms emerging for recurrent glioblastoma.
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Affiliation(s)
- Christopher Chang
- Warren Alpert Medical School, Brown University, Providence, RI 02912, USA;
| | - Velina S. Chavarro
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
| | - Jakob V. E. Gerstl
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
| | - Sarah E. Blitz
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Lennard Spanehl
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
- Department of Neurosurgery, University of Rostock, 18055 Rostock, Germany; (D.D.); (F.A.G.)
| | - Daniel Dubinski
- Department of Neurosurgery, University of Rostock, 18055 Rostock, Germany; (D.D.); (F.A.G.)
| | - Pablo A. Valdes
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX 77555, USA;
| | - Lily N. Tran
- Division of Biology and Medicine, Brown University, Providence, RI 02912, USA;
| | - Saksham Gupta
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Luisa Esposito
- Department of Medicine and Surgery, Unicamillus University, 00131 Rome, Italy;
| | - Debora Mazzetti
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
| | - Florian A. Gessler
- Department of Neurosurgery, University of Rostock, 18055 Rostock, Germany; (D.D.); (F.A.G.)
| | - Omar Arnaout
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Timothy R. Smith
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Gregory K. Friedman
- Division of Pediatrics, Neuro-Oncology Section, MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Pierpaolo Peruzzi
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Joshua D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (V.S.C.); (J.V.E.G.); (S.E.B.); (L.S.); (S.G.); (D.M.); (O.A.); (T.R.S.); (J.D.B.)
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
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Sprenger F, da Silva Junior EB, Ramina R, Cavalcanti MS, Martins SB, Cerqueira MA, Falcão AX, Corrêa de Almeida Teixeira B. Ki67 Index Correlates with Tumoral Volumetry and 5-ALA Residual Fluorescence in Glioblastoma. World Neurosurg 2024:S1878-8750(24)00971-9. [PMID: 38857868 DOI: 10.1016/j.wneu.2024.06.023] [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: 05/12/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Malignant gliomas are the most prevalent primary malignant cerebral tumors. Preoperative imaging plays an important role, and the prognosis is closely related to surgical resection and histomolecular aspects. Our goal was to correlate Ki67 indexes with tumoral volumetry in semiautomatic segmentation on preoperative magnetic resonance images and residual fluorescence in a 5-ALA-assisted resection cohort. METHODS We included 86 IDH-wildtype glioblastoma patients with complete preoperative imaging submitted to 5-ALA assisted resections. Clinical, surgical, and histomolecular findings were also obtained. Preoperative magnetic resonance studies were preprocessed and segmented semiautomatically on Visualization and Analysis for whole tumor (WT) on 3D FLAIR, enhancing tumor (ET), and necrotic core on 3D postgadolinium T1. We performed a linear regression analysis for Ki67 and a multivariate analysis for surgical outcomes. RESULTS Higher Ki-67 indexes correlated positively with higher WT (P = 0.048) and ET (P = 0.002). Lower Ki67 correlated with 5-ALA free margins (P = 0.045). WT and ET volumes correlated with the extent of resection (EOR; P = 0.002 and 0.002, respectively). Eloquence did not impact EOR (P = 0.14). CONCLUSIONS There is a correlation between Ki67, the metabolically active tumoral volumes (WT and ET), and 5-ALA residual fluorescence. Methodological inconsistencies are probably responsible for contradictory literature findings, and further prospective studies are needed to validate and reproduce these findings.
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Affiliation(s)
- Flávia Sprenger
- Department of Radiology, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Paraná, Brazil.
| | | | - Ricardo Ramina
- Head of Neurosurgery, Instituto de Neurologia de Curitiba, Curitiba, Paraná, Brazil
| | | | | | | | | | - Bernardo Corrêa de Almeida Teixeira
- Department of Radiology, Hospital de Clínicas da Universidade Federal do Paraná, Instituto de Neurologia de Curitiba, Curitiba, Paraná, Brazil
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Gibson C, Wang SC, Phoon A, Thalanki Anantha N, Ottolino-Perry K, Petropoulos S, Qureshi Z, Subramanian V, Shahid A, O'Brien C, Carcone S, Chung S, Tsui T, Son V, Sukhram M, Meng F, Done SJ, Easson AM, Cil T, Reedijk M, Leong WL, DaCosta RS. A handheld device for intra-cavity and ex vivo fluorescence imaging of breast conserving surgery margins with 5-aminolevulinic acid. BMC Biomed Eng 2024; 6:5. [PMID: 38822389 PMCID: PMC11143723 DOI: 10.1186/s42490-024-00079-9] [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: 04/17/2024] [Accepted: 04/19/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Visualization of cancer during breast conserving surgery (BCS) remains challenging; the BCS reoperation rate is reported to be 20-70% of patients. An urgent clinical need exists for real-time intraoperative visualization of breast carcinomas during BCS. We previously demonstrated the ability of a prototype imaging device to identify breast carcinoma in excised surgical specimens following 5-aminolevulinic acid (5-ALA) administration. However, this prototype device was not designed to image the surgical cavity for remaining carcinoma after the excised lumpectomy specimen is removed. A new handheld fluorescence (FL) imaging prototype device, designed to image both excised specimens and within the surgical cavity, was assessed in a clinical trial to evaluate its clinical utility for first-in-human, real-time intraoperative imaging during index BCS. RESULTS The imaging device combines consumer-grade imaging sensory technology with miniature light-emitting diodes (LEDs) and multiband optical filtering to capture high-resolution white light (WL) and FL digital images and videos. The technology allows for visualization of protoporphyrin IX (PpIX), which fluoresces red when excited by violet-blue light. To date, n = 17 patients have received 20 mg kg bodyweight (BW) 5-ALA orally 2-4 h before imaging to facilitate the accumulation of PpIX within tumour cells. Tissue types were identified based on their colour appearance. Breast tumours in sectioned lumpectomies appeared red, which contrasted against the green connective tissues and orange-brown adipose tissues. In addition, ductal carcinoma in situ (DCIS) that was missed during intraoperative standard of care was identified at the surgical margin at <1 mm depth. In addition, artifacts due to the surgical drape, illumination, and blood within the surgical cavity were discovered. CONCLUSIONS This study has demonstrated the detection of a grossly occult positive margin intraoperatively. Artifacts from imaging within the surgical cavity have been identified, and potential mitigations have been proposed. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01837225 (Trial start date is September 2010. It was registered to ClinicalTrials.gov retrospectively on April 23, 2013, then later updated on April 9, 2020, to reflect the introduction of the new imaging device.).
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Affiliation(s)
- Christopher Gibson
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, 101 College Street, M5G 1L7, Toronto, Canada
| | - Shirley C Wang
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
| | - Arcturus Phoon
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
| | - Nayana Thalanki Anantha
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
| | - Kathryn Ottolino-Perry
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
| | - Stephen Petropoulos
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
| | - Zuha Qureshi
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
| | - Vasanth Subramanian
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
| | - Anam Shahid
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
| | - Cristiana O'Brien
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
| | - Steven Carcone
- The Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, 200 Elizabeth Street, 10th Floor Eaton Wing, M5G 2C4, Toronto, Canada
| | - Suzanne Chung
- The Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, 200 Elizabeth Street, 10th Floor Eaton Wing, M5G 2C4, Toronto, Canada
| | - Teresa Tsui
- The Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, 200 Elizabeth Street, 10th Floor Eaton Wing, M5G 2C4, Toronto, Canada
| | - Viktor Son
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
- Laboratory Medicine Program, University Health Network, 200 Elizabeth Street, 11th Floor Eaton Wing, M5G 2C4, Toronto, Canada
| | - Mayleen Sukhram
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
- Laboratory Medicine Program, University Health Network, 200 Elizabeth Street, 11th Floor Eaton Wing, M5G 2C4, Toronto, Canada
| | - Fannong Meng
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
- Laboratory Medicine Program, University Health Network, 200 Elizabeth Street, 11th Floor Eaton Wing, M5G 2C4, Toronto, Canada
| | - Susan J Done
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
- Laboratory Medicine Program, University Health Network, 200 Elizabeth Street, 11th Floor Eaton Wing, M5G 2C4, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, 1 King's College Circle, M5S 1A8, Toronto, Canada
| | - Alexandra M Easson
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
- Surgical Oncology Department, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, M5T 2M9, Toronto, Canada
| | - Tulin Cil
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
- Surgical Oncology Department, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, M5T 2M9, Toronto, Canada
| | - Michael Reedijk
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
- Surgical Oncology Department, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, M5T 2M9, Toronto, Canada
| | - Wey L Leong
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada
- Surgical Oncology Department, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, M5T 2M9, Toronto, Canada
| | - Ralph S DaCosta
- Princess Margaret Cancer Centre, University Health Network, 101 College Street, M5G 1L7, Toronto, Canada.
- Department of Medical Biophysics, University of Toronto, 101 College Street, M5G 1L7, Toronto, Canada.
- Techna Institute, University Health Network, 124-100 College Street, M5G 1P5, Toronto, Canada.
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5
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Ma R, Livermore LJ, Taylor L, Laycock J, Williams S, Ansorge O, Vallance C, Plaha P. Endoscopic 5-Aminolevulinic Acid-Induced Fluorescence-Guided Intraparenchymal Brain Tumor Resection-Can the Endoscope Detect More Fluorescence Than the Microscope? World Neurosurg 2024; 185:e1268-e1279. [PMID: 38514030 DOI: 10.1016/j.wneu.2024.03.067] [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: 01/29/2024] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVES Using a laboratory-based optical setup, we show that 5-aminolevulinic acid (5ALA) fluorescence is better detected using the endoscope than the microscope. Furthermore, we present our case series of fully endoscopic 5ALA-guided resection of intraparenchymal tumors. METHODS A Zeiss Pentero microscope was compared with the Karl Storz Hopkins endoscope. The spectra and intensity of each blue light source were measured. Quantitative fluorescence detection thresholds were measured using a spectrometer. Subjective fluorescence detection thresholds were measured by 6 blinded neuro-oncology surgeons. Clinical data were prospectively collected for all consecutive cases of fully endoscopic 5ALA-guided resection of intraparenchymal tumors between 2012 and 2023. RESULTS The intensity of blue light on the sample was greater for the endoscope than the microscope at working distances less than 20 mm. The quantitative fluorescence detection thresholds were lower for the endoscope than the microscope at both 30-/10-mm working distances. Fluorescence detection threshold was 0.65%-0.80% relative 4-dicyanomethylene-2-methyl-6-p-dimethylaminostyryl-4H-pyranthe concentration (3.20 × 10-7 to 3.94 × 10-7mol/dm-3) for the microscope, 0.40%-0.55% relative concentrations (1.97 × 10-7 to 2.71 × 10-7mol/dm-3) for the endoscope at 30 mm, and 0.15%-0.30% relative concentrations (7.40 × 10-8 to 1.48 × 10-7mol/dm-3) for the endoscope at 10 mm. In total, 49 5ALA endoscope-assisted brain tumor resections were carried out on 45 patients (mean age = 41 years, male = 28). Greater than 95% resection was achieved in 80% of cases and gross total resection in 42%. Gross total resection was achieved in 100% of tumors in noneloquent locations. There was 1 new neurologic deficit. CONCLUSIONS The endoscope provides enhanced visualization/detection of 5ALA-induced fluorescence compared with the microscope. 5ALA endoscopic-assisted resection of intraparenchymal tumors is safe and feasible.
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Affiliation(s)
- Ruichong Ma
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom.
| | - Laurent J Livermore
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Louis Taylor
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Jake Laycock
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Sarah Williams
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Olaf Ansorge
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Claire Vallance
- Deptment of Chemistry, University of Oxford, Oxford, United Kingdom
| | - Puneet Plaha
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
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6
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Ndabakuranye JP, Belcourt J, Sharma D, O'Connell CD, Mondal V, Srivastava SK, Stacey A, Long S, Fleiss B, Ahnood A. Miniature fluorescence sensor for quantitative detection of brain tumour. LAB ON A CHIP 2024; 24:946-954. [PMID: 38275166 DOI: 10.1039/d3lc00982c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Fluorescence-guided surgery has emerged as a vital tool for tumour resection procedures. As well as intraoperative tumour visualisation, 5-ALA-induced PpIX provides an avenue for quantitative tumour identification based on ratiometric fluorescence measurement. To this end, fluorescence imaging and fibre-based probes have enabled more precise demarcation between the cancerous and healthy tissues. These sensing approaches, which rely on collecting the fluorescence light from the tumour resection site and its "remote" spectral sensing, introduce challenges associated with optical losses. In this work, we demonstrate the viability of tumour detection at the resection site using a miniature fluorescence measurement system. Unlike the current bulky systems, which necessitate remote measurement, we have adopted a millimetre-sized spectral sensor chip for quantitative fluorescence measurements. A reliable measurement at the resection site requires a stable optical window between the tissue and the optoelectronic system. This is achieved using an antifouling diamond window, which provides stable optical transparency. The system achieved a sensitivity of 92.3% and specificity of 98.3% in detecting a surrogate tumour at a resolution of 1 × 1 mm2. As well as addressing losses associated with collecting and coupling fluorescence light in the current 'remote' sensing approaches, the small size of the system introduced in this work paves the way for its direct integration with the tumour resection tools with the aim of more accurate interoperative tumour identification.
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Affiliation(s)
| | | | - Deepak Sharma
- School of Engineering, RMIT University, VIC 3000, Australia.
- Photovoltaic Metrology Section, Advanced Materials and Device Metrology Division, CSIR-National Physical Laboratory, New Delhi, 110012, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad-201002, India
| | - Cathal D O'Connell
- School of Engineering, RMIT University, VIC 3000, Australia.
- Aikenhead Centre for Medical Discovery, St Vincent's Hospital Melbourne, VIC 3065, Australia
| | - Victor Mondal
- School of Health and Biomedical Sciences, RMIT University, VIC 3000, Australia
| | - Sanjay K Srivastava
- Photovoltaic Metrology Section, Advanced Materials and Device Metrology Division, CSIR-National Physical Laboratory, New Delhi, 110012, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad-201002, India
| | - Alastair Stacey
- School of Science, RMIT University, VIC 3000, Australia
- Princeton Plasma Physics Laboratory, Princeton University, Princeton, 08540 New Jersey, USA
| | - Sam Long
- Veterinary Referral Hospital, Victoria, Australia
| | - Bobbi Fleiss
- School of Health and Biomedical Sciences, RMIT University, VIC 3000, Australia
| | - Arman Ahnood
- School of Engineering, RMIT University, VIC 3000, Australia.
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7
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Gautheron A, Bernstock JD, Picart T, Guyotat J, Valdés PA, Montcel B. 5-ALA induced PpIX fluorescence spectroscopy in neurosurgery: a review. Front Neurosci 2024; 18:1310282. [PMID: 38348134 PMCID: PMC10859467 DOI: 10.3389/fnins.2024.1310282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/02/2024] [Indexed: 02/15/2024] Open
Abstract
The review begins with an overview of the fundamental principles/physics underlying light, fluorescence, and other light-matter interactions in biological tissues. It then focuses on 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX) fluorescence spectroscopy methods used in neurosurgery (e.g., intensity, time-resolved) and in so doing, describe their specific features (e.g., hardware requirements, main processing methods) as well as their strengths and limitations. Finally, we review current clinical applications and future directions of 5-ALA-induced protoporphyrin IX (PpIX) fluorescence spectroscopy in neurosurgery.
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Affiliation(s)
- A. Gautheron
- Université Jean Monnet Saint-Etienne, CNRS, Institut d Optique Graduate School, Laboratoire Hubert Curien UMR 5516, Saint-Étienne, France
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1294, Lyon, France
| | - J. D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - T. Picart
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, INSERM 1052, CNRS 5286, Lyon, France
| | - J. Guyotat
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | - P. A. Valdés
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, United States
- Department of Neurobiology, University of Texas Medical Branch, Galveston, TX, United States
- Department of Electrical and Computer Engineering, Rice University, Houston, TX, United States
| | - B. Montcel
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1294, Lyon, France
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8
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Chen L, Zhang J, Chi C, Che W, Dong G, Wang J, Du Y, Wang R, Zhu Z, Tian J, Ji N, Chen X, Li D. Lower-grade gliomas surgery guided by GRPR-targeting PET/NIR dual-modality image probe: a prospective and single-arm clinical trial. Theranostics 2024; 14:819-829. [PMID: 38169486 PMCID: PMC10758047 DOI: 10.7150/thno.91554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024] Open
Abstract
Purpose: Lower-grade gliomas (LGGs) are a group of infiltrative growing glial brain tumors characterized by intricate intratumoral heterogeneity and subtle visual appearance differences from non-tumor tissue, which can lead to errors in pathologic tissue sampling. Although 5-ALA fluorescence has been an essential method for visualizing gliomas during surgery, its effectiveness is limited in the case of LGGs due to low sensitivity. Therefore, we developed a novel PET/NIR dual-modality image probe targeting gastrin-releasing peptide receptor (GRPR) in glioma cells to enhance tumor visualization and improve the accuracy of sampling. Methods: A prospective, non-randomized, single-center feasibility clinical trial (NCT03407781) was conducted in the referral center from October 21, 2016, to August 17, 2018. Consecutive enrollment included patients suspected of having LGGs and considered suitable candidates for surgical removal. Group 1 comprised ten patients who underwent preoperative 68Ga-IRDye800CW-BBN PET/MRI assessment followed by intraoperative fluorescence-guided surgery. Group 2 included 42 patients who underwent IRDye800CW-BBN fluorescence-guided surgery. The primary endpoints were the predictive value of preoperative PET imaging for intraoperative fluorescence and the sensitivity and specificity of fluorescence-guided sampling. Results: Thirty-nine patients were included in the in-depth analysis of endpoints, with 25 (64.1%) exhibiting visible fluorescence, while 14 (35.9%) did not. The preoperative positive PET uptake exhibited a greater accuracy in predicting intraoperative fluorescence compared to MRI enhancement (100% [10/10] vs. 87.2% [34/39]). A total of 125 samples were harvested during surgery. Compared with pathology, subjective fluorescence intensity showed a sensitivity of 88.6% and a specificity of 88.2% in identifying WHO grade III samples. For WHO grade II samples, the sensitivity and specificity of fluorescence were 54.7% and 88.2%, respectively. Conclusion: This study has demonstrated the feasibility of the novel dual-modality imaging technique for integrated pre- and intraoperative targeted imaging via the same molecular receptor in surgeries for LGGs. The PET/NIR dual-modality probe exhibits promise for preoperative surgical planning in fluorescence-guided surgery and provides greater accuracy in guiding tumor sampling compared to 5-ALA in patients with LGGs.
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Affiliation(s)
- Liangpeng Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jingjing Zhang
- Departments of Diagnostic Radiology, Surgery, Chemical and Biomolecular Engineering, and Biomedical Engineering, Yong Loo Lin School of Medicine and Faculty of Engineering, National University of Singapore, Singapore
- Clinical Imaging Research Centre, Centre for Translational Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Nanomedicine Translational Research Program, NUS Center for Nanomedicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chongwei Chi
- Key Laboratory of Molecular Imaging, Chinese Academy of Science, Beijing, China
| | - Wenqiang Che
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gehong Dong
- Department of Neuropathology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Junmei Wang
- Department of Pathology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yanru Du
- Department of Neuropathology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Rongxi Wang
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Zhaohui Zhu
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Jie Tian
- Key Laboratory of Molecular Imaging, Chinese Academy of Science, Beijing, China
| | - Nan Ji
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Xiaoyuan Chen
- Departments of Diagnostic Radiology, Surgery, Chemical and Biomolecular Engineering, and Biomedical Engineering, Yong Loo Lin School of Medicine and Faculty of Engineering, National University of Singapore, Singapore
- Clinical Imaging Research Centre, Centre for Translational Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Nanomedicine Translational Research Program, NUS Center for Nanomedicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Deling Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
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9
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Walke A, Black D, Valdes PA, Stummer W, König S, Suero-Molina E. Challenges in, and recommendations for, hyperspectral imaging in ex vivo malignant glioma biopsy measurements. Sci Rep 2023; 13:3829. [PMID: 36882505 PMCID: PMC9992662 DOI: 10.1038/s41598-023-30680-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 02/28/2023] [Indexed: 03/09/2023] Open
Abstract
The visualization of protoporphyrin IX (PPIX) fluorescence with the help of surgical microscopes during 5-aminolevulinic acid-mediated fluorescence-guided resection (FGR) of gliomas is still limited at the tumor margins. Hyperspectral imaging (HI) detects PPIX more sensitively but is not yet ready for intraoperative use. We illustrate the current status with three experiments and summarize our own experience using HI: (1) assessment of HI analysis algorithm using pig brain tissue, (2) a partially retrospective evaluation of our experience from HI projects, and (3) device comparison of surgical microscopy and HI. In (1), we address the problem that current algorithms for evaluating HI data are based on calibration with liquid phantoms, which have limitations. Their pH is low compared to glioma tissue; they provide only one PPIX photo state and only PPIX as fluorophore. Testing the HI algorithm with brain homogenates, we found proper correction for optical properties but not pH. Considerably more PPIX was measured at pH 9 than at pH 5. In (2), we indicate pitfalls and guide HI application. In (3), we found HI superior to the microscope for biopsy diagnosis (AUC = 0.845 ± 0.024 (cut-off 0.75 µg PPIX/ml) vs. 0.710 ± 0.035). HI thus offers potential for improved FGR.
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Affiliation(s)
- Anna Walke
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany.,Core Unit Proteomics, Interdisciplinary Centre for Clinical Research, University of Münster, Münster, Germany
| | - David Black
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, Canada
| | - Pablo A Valdes
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
| | - Simone König
- Core Unit Proteomics, Interdisciplinary Centre for Clinical Research, University of Münster, Münster, Germany
| | - Eric Suero-Molina
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany.
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10
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Xu J, Meng Y, Qiu K, Topatana W, Li S, Wei C, Chen T, Chen M, Ding Z, Niu G. Applications of Artificial Intelligence Based on Medical Imaging in Glioma: Current State and Future Challenges. Front Oncol 2022; 12:892056. [PMID: 35965542 PMCID: PMC9363668 DOI: 10.3389/fonc.2022.892056] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/22/2022] [Indexed: 12/24/2022] Open
Abstract
Glioma is one of the most fatal primary brain tumors, and it is well-known for its difficulty in diagnosis and management. Medical imaging techniques such as magnetic resonance imaging (MRI), positron emission tomography (PET), and spectral imaging can efficiently aid physicians in diagnosing, treating, and evaluating patients with gliomas. With the increasing clinical records and digital images, the application of artificial intelligence (AI) based on medical imaging has reduced the burden on physicians treating gliomas even further. This review will classify AI technologies and procedures used in medical imaging analysis. Additionally, we will discuss the applications of AI in glioma, including tumor segmentation and classification, prediction of genetic markers, and prediction of treatment response and prognosis, using MRI, PET, and spectral imaging. Despite the benefits of AI in clinical applications, several issues such as data management, incomprehension, safety, clinical efficacy evaluation, and ethical or legal considerations, remain to be solved. In the future, doctors and researchers should collaborate to solve these issues, with a particular emphasis on interdisciplinary teamwork.
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Affiliation(s)
- Jiaona Xu
- Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuting Meng
- Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kefan Qiu
- Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Win Topatana
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shijie Li
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chao Wei
- Department of Neurology, Affiliated Ningbo First Hospital, Ningbo, China
| | - Tianwen Chen
- Department of Neurology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Mingyu Chen
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Mingyu Chen, ; Zhongxiang Ding, ; Guozhong Niu,
| | - Zhongxiang Ding
- Department of Radiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Mingyu Chen, ; Zhongxiang Ding, ; Guozhong Niu,
| | - Guozhong Niu
- Department of Neurology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Mingyu Chen, ; Zhongxiang Ding, ; Guozhong Niu,
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11
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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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12
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Matsumae M, Nishiyama J, Kuroda K. Intraoperative MR Imaging during Glioma Resection. Magn Reson Med Sci 2022; 21:148-167. [PMID: 34880193 PMCID: PMC9199972 DOI: 10.2463/mrms.rev.2021-0116] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/11/2021] [Indexed: 11/09/2022] Open
Abstract
One of the major issues in the surgical treatment of gliomas is the concern about maximizing the extent of resection while minimizing neurological impairment. Thus, surgical planning by carefully observing the relationship between the glioma infiltration area and eloquent area of the connecting fibers is crucial. Neurosurgeons usually detect an eloquent area by functional MRI and identify a connecting fiber by diffusion tensor imaging. However, during surgery, the accuracy of neuronavigation can be decreased due to brain shift, but the positional information may be updated by intraoperative MRI and the next steps can be planned accordingly. In addition, various intraoperative modalities may be used to guide surgery, including neurophysiological monitoring that provides real-time information (e.g., awake surgery, motor-evoked potentials, and sensory evoked potential); photodynamic diagnosis, which can identify high-grade glioma cells; and other imaging techniques that provide anatomical information during the surgery. In this review, we present the historical and current context of the intraoperative MRI and some related approaches for an audience active in the technical, clinical, and research areas of radiology, as well as mention important aspects regarding safety and types of devices.
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Affiliation(s)
- Mitsunori Matsumae
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Jun Nishiyama
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Kagayaki Kuroda
- Department of Human and Information Sciences, School of Information Science and Technology, Tokai University, Hiratsuka, Kanagawa, Japan
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13
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OCT-Guided Surgery for Gliomas: Current Concept and Future Perspectives. Diagnostics (Basel) 2022; 12:diagnostics12020335. [PMID: 35204427 PMCID: PMC8871129 DOI: 10.3390/diagnostics12020335] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/19/2022] [Accepted: 01/26/2022] [Indexed: 02/01/2023] Open
Abstract
Optical coherence tomography (OCT) has been recently suggested as a promising method to obtain in vivo and real-time high-resolution images of tissue structure in brain tumor surgery. This review focuses on the basics of OCT imaging, types of OCT images and currently suggested OCT scanner devices and the results of their application in neurosurgery. OCT can assist in achieving intraoperative precision identification of tumor infiltration within surrounding brain parenchyma by using qualitative or quantitative OCT image analysis of scanned tissue. OCT is able to identify tumorous tissue and blood vessels detection during stereotactic biopsy procedures. The combination of OCT with traditional imaging such as MRI, ultrasound and 5-ALA fluorescence has the potential to increase the safety and accuracy of the resection. OCT can improve the extent of resection by offering the direct visualization of tumor with cellular resolution when using microscopic OCT contact probes. The theranostic implementation of OCT as a part of intelligent optical diagnosis and automated lesion localization and ablation could achieve high precision, automation and intelligence in brain tumor surgery. We present this review for the increase of knowledge and formation of critical opinion in the field of OCT implementation in brain tumor surgery.
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14
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Dolganova IN, Varvina DA, Shikunova IA, Alekseeva AI, Karalkin PA, Kuznetsov MR, Nikitin PV, Zotov AK, Mukhina EE, Katyba GM, Zaytsev KI, Tuchin VV, Kurlov VN. Proof of concept for the sapphire scalpel combining tissue dissection and optical diagnosis. Lasers Surg Med 2021; 54:611-622. [PMID: 34918347 DOI: 10.1002/lsm.23509] [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] [Revised: 10/18/2021] [Accepted: 11/27/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The development of compact diagnostic probes and instruments with an ability to direct access to organs and tissues and integration of these instruments into surgical workflows is an important task of modern physics and medicine. The need for such tools is essential for surgical oncology, where intraoperative visualization and demarcation of tumor margins define further prognosis and survival of patients. In this paper, the possible solution for this intraoperative imaging problem is proposed and its feasibility to detect tumorous tissue is studied experimentally. METHODS For this aim, the sapphire scalpel was developed and fabricated using the edge-defined film-fed growth technique aided by mechanical grinding, polishing, and chemical sharpening of the cutting edge. It possesses optical transparency, mechanical strength, chemical inertness, and thermal resistance alongside the presence of the as-grown hollow capillary channels in its volume for accommodating optical fibers. The rounding of the cutting edge exceeds the same for metal scalpels and can be as small as 110 nm. Thanks to these features, sapphire scalpel combines tissue dissection with light delivering and optical diagnosis. The feasibility for the tumor margin detection was studied, including both gelatin-based tissue phantoms and ex vivo freshly excised specimens of the basal cell carcinoma from humans and the glioma model 101.8 from rats. These tumors are commonly diagnosed either non-invasively or intraoperatively using different modalities of fluorescence spectroscopy and imaging, which makes them ideal candidates for our feasibility test. For this purpose, fiber-based spectroscopic measurements of the backscattered laser radiation and the fluorescence signals were carried out in the visible range. RESULTS Experimental studies show the feasibility of the proposed sapphire scalpel to provide a 2-mm-resolution of the tumor margins' detection, along with an ability to distinguish the tumor invasion region, which results from analysis of the backscattered optical fields and the endogenous or exogenous fluorescence data. CONCLUSIONS Our findings justified a strong potential of the sapphire scalpel for surgical oncology. However, further research and engineering efforts are required to optimize the sapphire scalpel geometry and the optical diagnosis protocols to meet the requirements of oncosurgery, including diagnosis and resection of neoplasms with different localizations and nosologies.
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Affiliation(s)
- Irina N Dolganova
- Institute of Solid State Physics of the Russian Academy of Sciences, Chernogolovka, Russia.,Institute for Regenerative Medicine, Sechenov University, Moscow, Russia.,Bauman Moscow State Technical University, Moscow, Russia
| | - Daria A Varvina
- Institute for Regenerative Medicine, Sechenov University, Moscow, Russia.,International School "Medicine of the Future", Sechenov University, Moscow, Russia
| | - Irina A Shikunova
- Institute of Solid State Physics of the Russian Academy of Sciences, Chernogolovka, Russia
| | - Anna I Alekseeva
- Institute for Regenerative Medicine, Sechenov University, Moscow, Russia.,Research Institute of Human Morphology, Moscow, Russia
| | - Pavel A Karalkin
- Institute for Cluster Oncology, Sechenov University, Moscow, Russia.,Hertsen Moscow Oncology Research Institute, National Medical Research Radiological Centre, Moscow, Russia
| | | | - Pavel V Nikitin
- Institute for Regenerative Medicine, Sechenov University, Moscow, Russia
| | - Arsen K Zotov
- Institute of Solid State Physics of the Russian Academy of Sciences, Chernogolovka, Russia.,Bauman Moscow State Technical University, Moscow, Russia.,Prokhorov General Physics Institute of the Russian Academy of Sciences, Moscow, Russia
| | | | - Gleb M Katyba
- Institute of Solid State Physics of the Russian Academy of Sciences, Chernogolovka, Russia.,Bauman Moscow State Technical University, Moscow, Russia.,Prokhorov General Physics Institute of the Russian Academy of Sciences, Moscow, Russia
| | - Kirill I Zaytsev
- Institute for Regenerative Medicine, Sechenov University, Moscow, Russia.,Bauman Moscow State Technical University, Moscow, Russia.,Prokhorov General Physics Institute of the Russian Academy of Sciences, Moscow, Russia
| | - Valery V Tuchin
- Science Medical Center, Saratov State University, Saratov, Russia.,Institute of Precision Mechanics and Control of the Russian Academy of Sciences, Saratov, Russia.,National Research Tomsk University, Tomsk, Russia
| | - Vladimir N Kurlov
- Institute of Solid State Physics of the Russian Academy of Sciences, Chernogolovka, Russia.,Institute for Regenerative Medicine, Sechenov University, Moscow, Russia.,Bauman Moscow State Technical University, Moscow, Russia
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15
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Suero Molina E, Kaneko S, Black D, Stummer W. 5-Aminolevulinic Acid-Induced Porphyrin Contents in Various Brain Tumors: Implications Regarding Imaging Device Design and Their Validation. Neurosurgery 2021; 89:1132-1140. [PMID: 34670277 DOI: 10.1093/neuros/nyab361] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 08/04/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Fluorescence-guided resections using 5-aminolevulinic acid (5-ALA)-induced tumor porphyrins have been established as an adjunct for malignant glioma surgery based on a phase III study using specifically adapted microscopes for visualizing fluorescing protoporphyrin IX (PPIX). New hardware technologies are being introduced, which claim the same performance as the original technology for visualizing fluorescence. This assumes that qualitative fluorescence detection is equivalent to the established standard, an assumption that needs to be critically assessed. OBJECTIVE To determine PPIX concentrations (cPPIX) in tissue that can be detected visually using the established BLUE400 filter system (Carl Zeiss Meditec, Oberkochen, Germany) as a basis for defining the performance of this system. METHODS Utilizing a hyperspectral imaging system, tumor samples from patients harboring different tumor tissues, with or without visible fluorescence, were analyzed. Absolute values of cPPIX were calculated after calibrating the system with fluorescence phantoms with known cPPIX. RESULTS A total of 524 tumor samples from 162 patients were analyzed. Visual fluorescence under the BLUE400 filter was documented by experienced neurosurgeons. A 0.9 μg/ml threshold of cPPIX was defined as the minimal concentration required to detect and discriminate visual fluorescence. CONCLUSION This is the first report providing data on the threshold of cPPIX, which is visually detected using the current generation of microscopes, thus defining the specificity and sensitivity of this technology as initially tested in a randomized trial. Novel technologies should show similar characteristics in order to be used safely and effectively. If more sensitive, such technologies require further assessments of tumor selectivity.
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Affiliation(s)
- Eric Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - Sadahiro Kaneko
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany.,Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - David Black
- Carl Zeiss Meditec AG, Oberkochen, Germany.,University of British Columbia, Vancouver, Canada
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
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16
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Characterization of autofluorescence and quantitative protoporphyrin IX biomarkers for optical spectroscopy-guided glioma surgery. Sci Rep 2021; 11:20009. [PMID: 34625597 PMCID: PMC8501114 DOI: 10.1038/s41598-021-99228-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/14/2021] [Indexed: 01/04/2023] Open
Abstract
5-Aminolevulinic acid (5-ALA)-mediated fluorescence does not effectively depict low grade gliomas (LGG) or the infiltrative tumor portion of high-grade gliomas (HGG). While spectroscopy improves sensitivity and precision, this is currently limited by autofluorescence and a second protoporphyrin IX (PpIX) fluorescence state at 620 nm. We investigated the autofluorescence to better characterize the present spectra and thus increase PpIX quantification precision and sensitivity. This study included 128 patients undergoing surgery for malignant glioma. 5-ALA (Gliolan) was administered before anesthesia, and fluorescence was measured using a hyperspectral device. It was found that all 2692 measured spectra consisted of contributions from 620 to 634 nm PpIX, NADH, lipofuscin, and flavins. The basis spectra were characterized and their use in spectral unmixing led to 82.4% lower fitting error for weakly fluorescing areas (p < 0.001), and 92.3% fewer false positive tumor identifications in control measurements (p = 0.0065) compared to previous works. They also decreased the PpIX620 contribution, thus halving the mean Ratio620/634 (p < 0.001). The ratio was approximately 0 for HGGs and increasing for LGGs, as demonstrated previously. Additionally, the Ratio620/634, the MIB-1/Ki-67 proliferation index, and the PpIX peak blue-shift were found to be significantly related to WHO grade, fluorescence visibility, and PpIX contribution (p < 0.001), and the value of these three as quantitative biomarkers is discussed.
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17
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Kiesel B, Freund J, Reichert D, Wadiura L, Erkkilae MT, Woehrer A, Hervey-Jumper S, Berger MS, Widhalm G. 5-ALA in Suspected Low-Grade Gliomas: Current Role, Limitations, and New Approaches. Front Oncol 2021; 11:699301. [PMID: 34395266 PMCID: PMC8362830 DOI: 10.3389/fonc.2021.699301] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/19/2021] [Indexed: 11/13/2022] Open
Abstract
Radiologically suspected low-grade gliomas (LGG) represent a special challenge for the neurosurgeon during surgery due to their histopathological heterogeneity and indefinite tumor margin. Therefore, new techniques are required to overcome these current surgical drawbacks. Intraoperative visualization of brain tumors with assistance of 5-aminolevulinic acid (5-ALA) induced protoporphyrin IX (PpIX) fluorescence is one of the major advancements in the neurosurgical field in the last decades. Initially, this technique was exclusively applied for fluorescence-guided surgery of high-grade glioma (HGG). In the last years, the use of 5-ALA was also extended to other indications such as radiologically suspected LGG. Here, we discuss the current role of 5-ALA for intraoperative visualization of focal malignant transformation within suspected LGG. Furthermore, we discuss the current limitations of the 5-ALA technology in pure LGG which usually cannot be visualized by visible fluorescence. Finally, we introduce new approaches based on fluorescence technology for improved detection of pure LGG tissue such as spectroscopic PpIX quantification fluorescence lifetime imaging of PpIX and confocal microscopy to optimize surgery.
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Affiliation(s)
- Barbara Kiesel
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Julia Freund
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - David Reichert
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory OPTRAMED, Medical University of Vienna, Vienna, Austria
| | - Lisa Wadiura
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Mikael T Erkkilae
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Adelheid Woehrer
- Department of Neurology, Institute for Neuropathology and Neurochemistry, Medical University of Vienna, Vienna, Austria
| | - Shawn Hervey-Jumper
- Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Georg Widhalm
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
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18
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Intraoperative fluorescence imaging with aminolevulinic acid detects grossly occult breast cancer: a phase II randomized controlled trial. Breast Cancer Res 2021; 23:72. [PMID: 34253233 PMCID: PMC8276412 DOI: 10.1186/s13058-021-01442-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/25/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Re-excision due to positive margins following breast-conserving surgery (BCS) negatively affects patient outcomes and healthcare costs. The inability to visualize margin involvement is a significant challenge in BCS. 5-Aminolevulinic acid hydrochloride (5-ALA HCl), a non-fluorescent oral prodrug, causes intracellular accumulation of fluorescent porphyrins in cancer cells. This single-center Phase II randomized controlled trial evaluated the safety, feasibility, and diagnostic accuracy of a prototype handheld fluorescence imaging device plus 5-ALA for intraoperative visualization of invasive breast carcinomas during BCS. METHODS Fifty-four patients were enrolled and randomized to receive no 5-ALA or oral 5-ALA HCl (15 or 30 mg/kg). Forty-five patients (n = 15/group) were included in the analysis. Fluorescence imaging of the excised surgical specimen was performed, and biopsies were collected from within and outside the clinically demarcated tumor border of the gross specimen for blinded histopathology. RESULTS In the absence of 5-ALA, tissue autofluorescence imaging lacked tumor-specific fluorescent contrast. Both 5-ALA doses caused bright red tumor fluorescence, with improved visualization of tumor contrasted against normal tissue autofluorescence. In the 15 mg/kg 5-ALA group, the positive predictive value (PPV) for detecting breast cancer inside and outside the grossly demarcated tumor border was 100.0% and 55.6%, respectively. In the 30 mg/kg 5-ALA group, the PPV was 100.0% and 50.0% inside and outside the demarcated tumor border, respectively. No adverse events were observed, and clinical feasibility of this imaging device-5-ALA combination approach was confirmed. CONCLUSIONS This is the first known clinical report of visualization of 5-ALA-induced fluorescence in invasive breast carcinoma using a real-time handheld intraoperative fluorescence imaging device. TRIAL REGISTRATION Clinicaltrials.gov identifier NCT01837225 . Registered 23 April 2013.
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Batalov AI, Goryaynov SA, Zakharova NE, Solozhentseva KD, Kosyrkova AV, Potapov AA, Pronin IN. Prediction of Intraoperative Fluorescence of Brain Gliomas: Correlation between Tumor Blood Flow and the Fluorescence. J Clin Med 2021; 10:jcm10112387. [PMID: 34071447 PMCID: PMC8198656 DOI: 10.3390/jcm10112387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION The prediction of the fluorescent effect of 5-aminolevulinic acid (5-ALA) in patients with diffuse gliomas can improve the selection of patients. The degree of enhancement of gliomas has been reported to predict 5-ALA fluorescence, while, at the same time, rarer cases of fluorescence have been described in non-enhancing gliomas. Perfusion studies, in particular arterial spin labeling perfusion, have demonstrated high efficiency in determining the degree of malignancy of brain gliomas and may be better for predicting fluorescence than contrast enhancement. The aim of the study was to investigate the relationship between tumor blood flow, measured by ASL, and intraoperative fluorescent glow of gliomas of different grades. MATERIALS AND METHODS Tumoral blood flow was assessed in 75 patients by pCASL (pseudo-continuous arterial spin labeling) within 1 week prior to surgery. In all cases of tumor removal, 5-ALA had been administered preoperatively. Maximum values of tumoral blood flow (TBF max) were measured, and normalized tumor blood flow (nTBF) was calculated. RESULTS A total of 76% of patients had significant contrast enhancement, while 24% were non-enhancing. The histopathology revealed 17 WHO grade II gliomas, 12 WHO grade III gliomas and 46 glioblastomas. Overall, there was a relationship between the degree of intraoperative tumor fluorescence and ASL-TBF (Rs = 0.28, p = 0.02 or the TBF; Rs = 0.34, p = 0.003 for nTBF). Non-enhancing gliomas were fluorescent in 9/18 patients, with nTBF in fluorescent gliomas being 54.58 ± 32.34 mL/100 mg/s and in non-fluorescent gliomas being 52.99 ± 53.61 mL/100 g/s (p > 0.05). Enhancing gliomas were fluorescent in 53/57 patients, with nTBF being 170.17 ± 107.65 mL/100 g/s in fluorescent and 165.52 ± 141.71 in non-fluorescent gliomas (p > 0.05). CONCLUSION Tumoral blood flow levels measured by non-contrast ASL perfusion method predict the fluorescence by 5-ALA; however, the additional value beyond contrast enhancement is not clear. ASL is, however, useful in cases with contraindication to contrast.
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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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21
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Erdman CM, Christie C, Iqbal MO, Mazzola CA, Tomycz L. The utilization of sodium fluorescein in pediatric brain stem gliomas: a case report and review of the literature. Childs Nerv Syst 2021; 37:1753-1758. [PMID: 32780271 DOI: 10.1007/s00381-020-04857-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/06/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION A major challenge in the surgical resection of brainstem tumors is distinguishing tumor from normal tissue. One approach for addressing this problem is the use of fluorescent tracers such as sodium fluorescein (NaFl). NaFl disseminates through a disruption in the blood-brain barrier (BBB) and accumulates in the extracellular space of brain tumors. Intraoperative fluorescence microscopy can be performed to identify tumor tissue and avoid damage to adjacent, normal tissue. Here, we present the case of a 16-year-old male who underwent a left retrosigmoid craniotomy with splitting of the tentorium to remove a large exophytic brainstem tumor involving the cerebellar peduncle and with superior extension into the midbrain and thalamus. OBJECTIVES The primary objective of this study was to investigate the effectiveness of sodium fluorescein as an intraoperative technique and evaluate its potential benefit for resection of tumors in eloquent regions in the pediatric population. To do so, we focused on a case study approach; however, we also performed a literature review and evaluated different intraoperative fluorescent techniques and their benefits for tumor resection. METHODS We performed a literature search using PubMed and Google Scholar by the key words "sodium fluorescein," "brain stem tumor," and "central nervous system neoplasms." Twenty-nine articles including both pediatric and adult populations were selected for analysis and qualitative review. RESULTS In this case study, sodium fluorescein helped the surgeons to identify and obtain a gross total resection of a large brainstem tumor. The marker was especially helpful for discerning the inferior pole of the tumor buried inconspicuously in cerebellar tissue. We evaluate different fluorescent tracers, 5-ALA and ICG, and discuss their application and benefits in tumor resection surgery. We present different cases that found sodium fluorescein to be helpful in achieving a gross total resection. CONCLUSION The application of sodium fluorescein proved to be a safe and effective technique for the resection of brain stem tumors as shown in this case study. It helped to expose concealed areas and illuminate the tumor capsule. Further studies should test the clinical use of sodium fluorescein on brain stem tumor resection.
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Affiliation(s)
- Cameron M Erdman
- Vassar College, 124 Raymond Avenue, Poughkeepsie, NY, 12603, USA
| | - Catherine Christie
- New Jersey Pediatric Neuroscience Institute, 131 Madison Avenue, Morristown, NJ, 07960, USA
| | - M Omar Iqbal
- Rutgers University, 90 Bergen Street, Newark, NJ, 07101, USA
| | - Catherine A Mazzola
- New Jersey Pediatric Neuroscience Institute, 131 Madison Avenue, Morristown, NJ, 07960, USA
| | - Luke Tomycz
- New Jersey Pediatric Neuroscience Institute, 131 Madison Avenue, Morristown, NJ, 07960, USA.
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22
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Vermandel M, Dupont C, Lecomte F, Leroy HA, Tuleasca C, Mordon S, Hadjipanayis CG, Reyns N. Standardized intraoperative 5-ALA photodynamic therapy for newly diagnosed glioblastoma patients: a preliminary analysis of the INDYGO clinical trial. J Neurooncol 2021; 152:501-514. [PMID: 33743128 DOI: 10.1007/s11060-021-03718-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/13/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE Glioblastoma (GBM) is the most aggressive malignant primary brain tumor. The unfavorable prognosis despite maximal therapy relates to high propensity for recurrence. Thus, overall survival (OS) is quite limited and local failure remains the fundamental problem. Here, we present a safety and feasibility trial after treating GBM intraoperatively by photodynamic therapy (PDT) after 5-aminolevulinic acid (5-ALA) administration and maximal resection. METHODS Ten patients with newly diagnosed GBM were enrolled and treated between May 2017 and June 2018. The standardized therapeutic approach included maximal resection (near total or gross total tumor resection (GTR)) guided by 5-ALA fluorescence-guided surgery (FGS), followed by intraoperative PDT. Postoperatively, patients underwent adjuvant therapy (Stupp protocol). Follow-up included clinical examinations and brain MR imaging was performed every 3 months until tumor progression and/or death. RESULTS There were no unacceptable or unexpected toxicities or serious adverse effects. At the time of the interim analysis, the actuarial 12-months progression-free survival (PFS) rate was 60% (median 17.1 months), and the actuarial 12-months OS rate was 80% (median 23.1 months). CONCLUSIONS This trial assessed the feasibility and the safety of intraoperative 5-ALA PDT as a novel approach for treating GBM after maximal tumor resection. The current standard of care remains microsurgical resection whenever feasible, followed by adjuvant therapy (Stupp protocol). We postulate that PDT delivered immediately after resection as an add-on therapy of this primary brain cancer is safe and may help to decrease the recurrence risk by targeting residual tumor cells in the resection cavity. Trial registration NCT number: NCT03048240. EudraCT number: 2016-002706-39.
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Affiliation(s)
- Maximilien Vermandel
- Univ. Lille, Inserm, CHU Lille, U1189 - ONCO-THAI -Laser Assisted Therapies and Immunotherapies for Oncology, 59000, Lille, France
- Neurosurgery Department, CHU Lille, 59000, Lille, France
| | - Clément Dupont
- Univ. Lille, Inserm, CHU Lille, U1189 - ONCO-THAI -Laser Assisted Therapies and Immunotherapies for Oncology, 59000, Lille, France
| | - Fabienne Lecomte
- Univ. Lille, Inserm, CHU Lille, U1189 - ONCO-THAI -Laser Assisted Therapies and Immunotherapies for Oncology, 59000, Lille, France
| | - Henri-Arthur Leroy
- Univ. Lille, Inserm, CHU Lille, U1189 - ONCO-THAI -Laser Assisted Therapies and Immunotherapies for Oncology, 59000, Lille, France
- Neurosurgery Department, CHU Lille, 59000, Lille, France
| | - Constantin Tuleasca
- Faculty of Biology and Medicine (FBM) and Centre Hospitalier Universitaire Vaudois (CHUV), Clinical Neurosciences Department, Neurosurgery Service and Gamma Knife Center, University of Lausanne (Unil), Lausanne, Switzerland
- Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Serge Mordon
- Univ. Lille, Inserm, CHU Lille, U1189 - ONCO-THAI -Laser Assisted Therapies and Immunotherapies for Oncology, 59000, Lille, France
| | - Constantinos G Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine At Mount Sinai, Mount Sinai Health System, New York, NY, USA
- Department of Neurosurgery, Mount Sinai Beth Israel, New York, NY, USA
| | - Nicolas Reyns
- Univ. Lille, Inserm, CHU Lille, U1189 - ONCO-THAI -Laser Assisted Therapies and Immunotherapies for Oncology, 59000, Lille, France.
- Neurosurgery Department, CHU Lille, 59000, Lille, France.
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23
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Molecular imaging of a fluorescent antibody against epidermal growth factor receptor detects high-grade glioma. Sci Rep 2021; 11:5710. [PMID: 33707521 PMCID: PMC7952570 DOI: 10.1038/s41598-021-84831-4] [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: 12/08/2020] [Accepted: 02/16/2021] [Indexed: 01/31/2023] Open
Abstract
The prognosis for high-grade glioma (HGG) remains dismal and the extent of resection correlates with overall survival and progression free disease. Epidermal growth factor receptor (EGFR) is a biomarker heterogeneously expressed in HGG. We assessed the feasibility of detecting HGG using near-infrared fluorescent antibody targeting EGFR. Mice bearing orthotopic HGG xenografts with modest EGFR expression were imaged in vivo after systemic panitumumab-IRDye800 injection to assess its tumor-specific uptake macroscopically over 14 days, and microscopically ex vivo. EGFR immunohistochemical staining of 59 tumor specimens from 35 HGG patients was scored by pathologists and expression levels were compared to that of mouse xenografts. Intratumoral distribution of panitumumab-IRDye800 correlated with near-infrared fluorescence and EGFR expression. Fluorescence distinguished tumor cells with 90% specificity and 82.5% sensitivity. Target-to-background ratios peaked at 14 h post panitumumab-IRDye800 infusion, reaching 19.5 in vivo and 7.6 ex vivo, respectively. Equivalent or higher EGFR protein expression compared to the mouse xenografts was present in 77.1% HGG patients. Age, combined with IDH-wildtype cerebral tumor, was predictive of greater EGFR protein expression in human tumors. Tumor specific uptake of panitumumab-IRDye800 provided remarkable contrast and a flexible imaging window for fluorescence-guided identification of HGGs despite modest EGFR expression.
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24
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Maragkos GA, Schüpper AJ, Lakomkin N, Sideras P, Price G, Baron R, Hamilton T, Haider S, Lee IY, Hadjipanayis CG, Robin AM. Fluorescence-Guided High-Grade Glioma Surgery More Than Four Hours After 5-Aminolevulinic Acid Administration. Front Neurol 2021; 12:644804. [PMID: 33767664 PMCID: PMC7985355 DOI: 10.3389/fneur.2021.644804] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Fluorescence-guided surgery (FGS) using 5-aminolevulic acid (5-ALA) is a widely used strategy for delineating tumor tissue from surrounding brain intraoperatively during high-grade glioma (HGG) resection. 5-ALA reaches peak plasma levels ~4 h after oral administration and is currently approved by the FDA for use 2–4 h prior to induction to anesthesia. Objective: To demonstrate that there is adequate intraoperative fluorescence in cases undergoing surgery more than 4 h after 5-ALA administration and compare survival and radiological recurrence to previous data. Methods: Retrospective analysis of HGG patients undergoing FGS more than 4 h after 5-ALA administration was performed at two institutions. Clinical, operative, and radiographic pre- and post-operative characteristics are presented. Results: Sixteen patients were identified, 6 of them female (37.5%), with mean (SD) age of 59.3 ± 11.5 years. Preoperative mean modified Rankin score (mRS) was 2 ± 1. All patients were dosed with 20 mg/kg 5-ALA the morning of surgery. Mean time to anesthesia induction was 425 ± 334 min. All cases had adequate intraoperative fluorescence. Eloquent cortex was involved in 12 cases (75%), and 13 cases (81.3%) had residual contrast enhancement on postoperative MRI. Mean progression-free survival was 5 ± 3 months. In the study period, 6 patients died (37.5%), mean mRS was 2.3 ± 1.3, Karnofsky score 71.9 ± 22.1, and NIHSS 3.9 ± 2.4. Conclusion: Here we demonstrate that 5-ALA-guided HGG resection can be performed safely more than 4 h after administration, with clinical results largely similar to previous reports. Relaxation of timing restrictions could improve procedure workflow in busy neurosurgical centers, without additional risk to patients.
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Affiliation(s)
- Georgios A Maragkos
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Alexander J Schüpper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Nikita Lakomkin
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Panagiotis Sideras
- Department of Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Gabrielle Price
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Rebecca Baron
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Travis Hamilton
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
| | - Sameah Haider
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
| | - Ian Y Lee
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
| | - Constantinos G Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States.,Department of Neurosurgery, Icahn School of Medicine, Mount Sinai Beth Israel, Mount Sinai Health System, New York, NY, United States
| | - Adam M Robin
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
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25
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Costa PC, Guang Z, Ledwig P, Zhang Z, Neill S, Olson JJ, Robles FE. Towards in-vivo label-free detection of brain tumor margins with epi-illumination tomographic quantitative phase imaging. BIOMEDICAL OPTICS EXPRESS 2021; 12:1621-1634. [PMID: 33796377 PMCID: PMC7984798 DOI: 10.1364/boe.416731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/11/2021] [Accepted: 02/20/2021] [Indexed: 05/03/2023]
Abstract
Brain tumor surgery involves a delicate balance between maximizing the extent of tumor resection while minimizing damage to healthy brain tissue that is vital for neurological function. However, differentiating between tumor, particularly infiltrative disease, and healthy brain in-vivo remains a significant clinical challenge. Here we demonstrate that quantitative oblique back illumination microscopy (qOBM)-a novel label-free optical imaging technique that achieves tomographic quantitative phase imaging in thick scattering samples-clearly differentiates between healthy brain tissue and tumor, including infiltrative disease. Data from a bulk and infiltrative brain tumor animal model show that qOBM enables quantitative phase imaging of thick fresh brain tissues with remarkable cellular and subcellular detail that closely resembles histopathology using hematoxylin and eosin (H&E) stained fixed tissue sections, the gold standard for cancer detection. Quantitative biophysical features are also extracted from qOBM which yield robust surrogate biomarkers of disease that enable (1) automated tumor and margin detection with high sensitivity and specificity and (2) facile visualization of tumor regions. Finally, we develop a low-cost, flexible, fiber-based handheld qOBM device which brings this technology one step closer to in-vivo clinical use. This work has significant implications for guiding neurosurgery by paving the way for a tool that delivers real-time, label-free, in-vivo brain tumor margin detection.
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Affiliation(s)
- Paloma Casteleiro Costa
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Zhe Guang
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
| | - Patrick Ledwig
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
| | - Zhaobin Zhang
- Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Stewart Neill
- Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Jeffrey J. Olson
- Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Francisco E. Robles
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
- Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
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26
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Rafaelyan AA, Alekseev DE, Martynov BV, Kholyavin AI, Papayan GV, Lytkin MV, Svistov DV, Zheleznyak IS, Imyanitov EN. [Stereotactic photodynamic therapy for recurrent glioblastoma. Case report and literature review]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:81-88. [PMID: 33095536 DOI: 10.17116/neiro20208405181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report a patient with recurrent glioblastoma in eloquent brain area. Stereotactic fluorescence biospectroscopy and stereotactic photodynamic therapy of tumor in opercular area of the left frontal lobe under neurophysiological monitoring were carried out. Literature data on this issue were analyzed.
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Affiliation(s)
- A A Rafaelyan
- Kirov Military Medical Academy, St. Petersburg, Russia
| | - D E Alekseev
- Kirov Military Medical Academy, St. Petersburg, Russia
| | - B V Martynov
- Kirov Military Medical Academy, St. Petersburg, Russia
| | - A I Kholyavin
- Kirov Military Medical Academy, St. Petersburg, Russia.,Bekhtereva Institute of Human Brain, St. Petersburg, Russia
| | - G V Papayan
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia.,Almazov National Medical Research Center, St. Petersburg, Russia
| | - M V Lytkin
- Kirov Military Medical Academy, St. Petersburg, Russia
| | - D V Svistov
- Kirov Military Medical Academy, St. Petersburg, Russia
| | | | - E N Imyanitov
- Petrov National Medical Research Oncology Center, St. Petersburg, Russia
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27
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Livermore LJ, Isabelle M, Bell IM, Edgar O, Voets NL, Stacey R, Ansorge O, Vallance C, Plaha P. Raman spectroscopy to differentiate between fresh tissue samples of glioma and normal brain: a comparison with 5-ALA-induced fluorescence-guided surgery. J Neurosurg 2020; 135:469-479. [PMID: 33007757 DOI: 10.3171/2020.5.jns20376] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 05/22/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Raman spectroscopy is a biophotonic tool that can be used to differentiate between different tissue types. It is nondestructive and no sample preparation is required. The aim of this study was to evaluate the ability of Raman spectroscopy to differentiate between glioma and normal brain when using fresh biopsy samples and, in the case of glioblastomas, to compare the performance of Raman spectroscopy to predict the presence or absence of tumor with that of 5-aminolevulinic acid (5-ALA)-induced fluorescence. METHODS A principal component analysis (PCA)-fed linear discriminant analysis (LDA) machine learning predictive model was built using Raman spectra, acquired ex vivo, from fresh tissue samples of 62 patients with glioma and 11 glioma-free brain samples from individuals undergoing temporal lobectomy for epilepsy. This model was then used to classify Raman spectra from fresh biopsies from resection cavities after functional guided, supramaximal glioma resection. In cases of glioblastoma, 5-ALA-induced fluorescence at the resection cavity biopsy site was recorded, and this was compared with the Raman spectral model prediction for the presence of tumor. RESULTS The PCA-LDA predictive model demonstrated 0.96 sensitivity, 0.99 specificity, and 0.99 accuracy for differentiating tumor from normal brain. Twenty-three resection cavity biopsies were taken from 8 patients after supramaximal resection (6 glioblastomas, 2 oligodendrogliomas). Raman spectroscopy showed 1.00 sensitivity, 1.00 specificity, and 1.00 accuracy for predicting tumor versus normal brain in these samples. In the glioblastoma cases, where 5-ALA-induced fluorescence was used, the performance of Raman spectroscopy was significantly better than the predictive value of 5-ALA-induced fluorescence, which showed 0.07 sensitivity, 1.00 specificity, and 0.24 accuracy (p = 0.0009). CONCLUSIONS Raman spectroscopy can accurately classify fresh tissue samples into tumor versus normal brain and is superior to 5-ALA-induced fluorescence. Raman spectroscopy could become an important intraoperative tool used in conjunction with 5-ALA-induced fluorescence to guide extent of resection in glioma surgery.
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Affiliation(s)
- Laurent J Livermore
- 1Nuffield Department of Clinical Neurosciences, and
- 3Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Martin Isabelle
- 4Renishaw plc, Spectroscopy Products Division, Gloucestershire
| | - Ian M Bell
- 4Renishaw plc, Spectroscopy Products Division, Gloucestershire
| | - Oliver Edgar
- 1Nuffield Department of Clinical Neurosciences, and
| | - Natalie L Voets
- 2Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, Oxford
- 6FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Richard Stacey
- 3Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Olaf Ansorge
- 1Nuffield Department of Clinical Neurosciences, and
| | | | - Puneet Plaha
- 2Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, Oxford
- 3Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford
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28
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Roberts DW, Bravo JJ, Olson JD, Hickey WF, Harris BT, Nguyen LN, Hong J, Evans LT, Fan X, Wirth D, Wilson BC, Paulsen KD. 5-Aminolevulinic Acid-Induced Fluorescence in Focal Cortical Dysplasia: Report of 3 Cases. Oper Neurosurg (Hagerstown) 2020; 16:403-414. [PMID: 29920583 DOI: 10.1093/ons/opy116] [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: 07/10/2017] [Accepted: 04/20/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Three patients enrolled in a clinical trial of 5-aminolevulinic-acid (5-ALA)-induced fluorescence-guidance, which has been demonstrated to facilitate intracranial tumor resection, were found on neuropathological examination to have focal cortical dysplasia (FCD). OBJECTIVE To evaluate in this case series visible fluorescence and quantitative levels of protoporphyrin IX (PpIX) during surgery and correlate these findings with preoperative magnetic resonance imaging (MRI) and histopathology. METHODS Patients were administered 5-ALA (20 mg/kg) approximately 3 h prior to surgery and underwent image-guided, microsurgical resection of their MRI- and electrophysiologically identified lesions. Intraoperative visible fluorescence was evaluated using an operating microscope adapted with a commercially available blue light module. Quantitative PpIX levels were assessed using a handheld fiber-optic probe and a wide-field imaging spectrometer. Sites of fluorescence measurements were co-registered with both preoperative MRI and histopathological analysis. RESULTS Three patients with a pathologically confirmed diagnosis of FCD (Types 1b, 2a, and 2b) underwent surgery. All patients demonstrated some degree of visible fluorescence (faint or moderate), and all patients had quantitatively elevated concentrations of PpIX. No evidence of neoplasia was identified on histopathology, and in 1 patient, the highest concentrations of PpIX were found at a tissue site with marked gliosis but no typical histological features of FCD. CONCLUSION FCD has been found to be associated with intraoperative 5-ALA-induced visible fluorescence and quantitatively confirmed elevated concentrations of the fluorophore PpIX in 3 patients. This finding suggests that there may be a role for fluorescence-guidance during surgical intervention for epilepsy-associated FCD.
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Affiliation(s)
- David W Roberts
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Geisel School Medicine, Dartmouth College, Hanover, New Hampshire.,Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Jaime J Bravo
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Jonathan D Olson
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - William F Hickey
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Brent T Harris
- Departments of Pathology and Neurology, Georgetown University Medical Center, Washington, District of Columbia
| | - Lananh N Nguyen
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jennifer Hong
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Linton T Evans
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Xiaoyao Fan
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Dennis Wirth
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Brian C Wilson
- Princess Margaret Cancer Centre, University Health Network, Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Keith D Paulsen
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
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29
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Gesperger J, Lichtenegger A, Roetzer T, Salas M, Eugui P, Harper DJ, Merkle CW, Augustin M, Kiesel B, Mercea PA, Widhalm G, Baumann B, Woehrer A. Improved Diagnostic Imaging of Brain Tumors by Multimodal Microscopy and Deep Learning. Cancers (Basel) 2020; 12:E1806. [PMID: 32640583 PMCID: PMC7408054 DOI: 10.3390/cancers12071806] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/26/2020] [Accepted: 07/01/2020] [Indexed: 11/16/2022] Open
Abstract
Fluorescence-guided surgery is a state-of-the-art approach for intraoperative imaging during neurosurgical removal of tumor tissue. While the visualization of high-grade gliomas is reliable, lower grade glioma often lack visible fluorescence signals. Here, we present a hybrid prototype combining visible light optical coherence microscopy (OCM) and high-resolution fluorescence imaging for assessment of brain tumor samples acquired by 5-aminolevulinic acid (5-ALA) fluorescence-guided surgery. OCM provides high-resolution information of the inherent tissue scattering and absorption properties of tissue. We here explore quantitative attenuation coefficients derived from volumetric OCM intensity data and quantitative high-resolution 5-ALA fluorescence as potential biomarkers for tissue malignancy including otherwise difficult-to-assess low-grade glioma. We validate our findings against the gold standard histology and use attenuation and fluorescence intensity measures to differentiate between tumor core, infiltrative zone and adjacent brain tissue. Using large field-of-view scans acquired by a near-infrared swept-source optical coherence tomography setup, we provide initial assessments of tumor heterogeneity. Finally, we use cross-sectional OCM images to train a convolutional neural network that discriminates tumor from non-tumor tissue with an accuracy of 97%. Collectively, the present hybrid approach offers potential to translate into an in vivo imaging setup for substantially improved intraoperative guidance of brain tumor surgeries.
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Affiliation(s)
- Johanna Gesperger
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria; (J.G.); (A.L.); (M.S.); (P.E.); (D.J.H.); (C.W.M.); (M.A.)
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (T.R.); (A.W.)
| | - Antonia Lichtenegger
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria; (J.G.); (A.L.); (M.S.); (P.E.); (D.J.H.); (C.W.M.); (M.A.)
| | - Thomas Roetzer
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (T.R.); (A.W.)
| | - Matthias Salas
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria; (J.G.); (A.L.); (M.S.); (P.E.); (D.J.H.); (C.W.M.); (M.A.)
| | - Pablo Eugui
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria; (J.G.); (A.L.); (M.S.); (P.E.); (D.J.H.); (C.W.M.); (M.A.)
| | - Danielle J. Harper
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria; (J.G.); (A.L.); (M.S.); (P.E.); (D.J.H.); (C.W.M.); (M.A.)
| | - Conrad W. Merkle
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria; (J.G.); (A.L.); (M.S.); (P.E.); (D.J.H.); (C.W.M.); (M.A.)
| | - Marco Augustin
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria; (J.G.); (A.L.); (M.S.); (P.E.); (D.J.H.); (C.W.M.); (M.A.)
| | - Barbara Kiesel
- Department of Neurosurgery, Medical University of Vienna, 1090 Vienna, Austria; (B.K.); (P.A.M.)
| | - Petra A. Mercea
- Department of Neurosurgery, Medical University of Vienna, 1090 Vienna, Austria; (B.K.); (P.A.M.)
| | - Georg Widhalm
- Department of Neurosurgery, Medical University of Vienna, 1090 Vienna, Austria; (B.K.); (P.A.M.)
| | - Bernhard Baumann
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria; (J.G.); (A.L.); (M.S.); (P.E.); (D.J.H.); (C.W.M.); (M.A.)
| | - Adelheid Woehrer
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (T.R.); (A.W.)
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30
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Dupont C, Vermandel M, Leroy HA, Quidet M, Lecomte F, Delhem N, Mordon S, Reyns N. INtraoperative photoDYnamic Therapy for GliOblastomas (INDYGO): Study Protocol for a Phase I Clinical Trial. Neurosurgery 2020; 84:E414-E419. [PMID: 30053213 DOI: 10.1093/neuros/nyy324] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/17/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Glioblastoma (GBM) is characterized by marked proliferation, major infiltration, and poor prognosis. Despite current treatments, including surgery, radiation oncology, and chemotherapy, the overall median survival is 15 mo and the progression-free survival is 7 to 8 mo. Because of systematic relapse of the tumor, the improvement of local control remains an issue. In this context, photodynamic therapy (PDT) may offer a new treatment modality for GBM. OBJECTIVE To assess the feasibility of intraoperative PDT early after surgical resection of GBM without unacceptable and unexpected toxicities. METHODS The INDYGO clinical trial (INtraoperative photoDYnamic Therapy for GliOblastomas) treatment will be carried out in addition to the current standard of care (SOC) of glioblastoma: maximum resection surgery followed by concomitant radio-chemotherapy and adjuvant chemotherapy. PDT treatment will be delivered during surgery early, after the fluorescence-guided resection. Immunological responses and biomarkers will also be investigated during the follow-up. A total of 10 patients will be recruited during this study. EXPECTED OUTCOMES Clinical follow-up after the SOC with PDT is expected to be similar (no significant difference) to the SOC alone. DISCUSSION This INDYGO trial assesses the feasibility of intraoperative 5-aminolevulinic acid PDT, a novel seamless approach to treat GBM. The technology is easily embeddable within the reference treatment at a low-incremental cost. The safety of this new treatment modality is a preliminary requirement before a multicenter randomized clinical trial can be further conducted to assess local control improvement by treating infiltrating and nonresected GBM cells.
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Affiliation(s)
- Clément Dupont
- University of Lille, Inserm, CHU Lille, ONCO-THAI - Image Assisted Laser Therapy for Oncology, Lille, France
| | - Maximilien Vermandel
- University of Lille, Inserm, CHU Lille, ONCO-THAI - Image Assisted Laser Therapy for Oncology, Lille, France.,Department of Neurosurgery, University of Lille, CHU Lille, Lille, France
| | - Henri-Arthur Leroy
- University of Lille, Inserm, CHU Lille, ONCO-THAI - Image Assisted Laser Therapy for Oncology, Lille, France.,Department of Neurosurgery, University of Lille, CHU Lille, Lille, France
| | - Mathilde Quidet
- University of Lille, Inserm, CHU Lille, ONCO-THAI - Image Assisted Laser Therapy for Oncology, Lille, France.,Department of Neurosurgery, University of Lille, CHU Lille, Lille, France
| | - Fabienne Lecomte
- University of Lille, Inserm, CHU Lille, ONCO-THAI - Image Assisted Laser Therapy for Oncology, Lille, France
| | - Nadira Delhem
- Institut de biologie de Lille, Institut Pasteur de Lille, University of Lille, CNRS, Lille, France
| | - Serge Mordon
- University of Lille, Inserm, CHU Lille, ONCO-THAI - Image Assisted Laser Therapy for Oncology, Lille, France
| | - Nicolas Reyns
- University of Lille, Inserm, CHU Lille, ONCO-THAI - Image Assisted Laser Therapy for Oncology, Lille, France.,Department of Neurosurgery, University of Lille, CHU Lille, Lille, France
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31
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Mischkulnig M, Kiesel B, Borkovec M, Wadiura LI, Benner D, Hosmann A, Hervey‐Jumper S, Knosp E, Roessler K, Berger MS, Widhalm G. High Interobserver Agreement in the Subjective Classification of 5-Aminolevulinic Acid Fluorescence Levels in Newly Diagnosed Glioblastomas. Lasers Surg Med 2020; 52:814-821. [PMID: 32147864 PMCID: PMC7586784 DOI: 10.1002/lsm.23228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES Fluorescence-guided resection of glioblastomas (GBM) using 5-aminolevulinic acid (5-ALA) improves intraoperative tumor visualization and is thus widely used nowadays. During resection, different fluorescence levels can usually be distinguished within the same tumor. Recently, we demonstrated that strong, vague, and no fluorescence correspond to distinct histopathological characteristics in newly diagnosed GBM. However, the qualitative fluorescence classification by the neurosurgeon is subjective and currently no comprehensive data on interobserver variability is available. The aim of this study was thus to investigate the interobserver variability in the classification of 5-ALA fluorescence levels in newly diagnosed GBM. STUDY DESIGN/MATERIALS AND METHODS A questionnaire investigating the interobserver variability in 5-ALA fluorescence quantification was performed at a nation-wide neurosurgical oncology meeting. The participants involved in the neurosurgical/neurooncological field were asked to categorize 30 cases of 5-ALA fluorescence images derived from GBM resection on a lecture hall screen according to the widely used three-tier fluorescence classification scheme (negative, vague, or strong fluorescence). Additionally, participants were asked for information on their medical background such as specialty, level of training, and experience with 5-ALA fluorescence-guided procedures. Interobserver agreement was defined as the calculated mean κ values for each observer. RESULTS A total of 36 questionnaires were included in the final analysis. The mean average κ value in fluorescence classification within the entire cohort was 0.71 ± 0.12 and 29 (81%) participants had a substantial or almost perfect interobserver agreement (κ values 0.6-1.0). Interobserver agreement was significantly higher in neurosurgeons (mean κ: 0.83) as compared with non-neurosurgeons involved in the neurooncological field (mean κ: 0.52; P < 0.001). Furthermore, interobserver agreement was significantly higher in participants who had experience with at least 25 5-ALA fluorescence-guided surgeries (mean κ: 0.87) compared with less experienced colleagues (mean κ: 0.82; P = 0.039). CONCLUSION Our study found a high interobserver agreement in the qualitative classification of different 5-ALA fluorescence levels in newly diagnosed GBM. Interobserver agreement increases significantly in more experienced participants and therefore a high level of experience is crucial for reliable intraoperative fluorescence classification. Lasers Surg. Med. © 2020 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals, Inc.
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Affiliation(s)
- Mario Mischkulnig
- Department of NeurosurgeryMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
- Central Nervous System Tumours Unit, Comprehensive Cancer CenterMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
| | - Barbara Kiesel
- Department of NeurosurgeryMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
- Central Nervous System Tumours Unit, Comprehensive Cancer CenterMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
| | - Martin Borkovec
- Department of NeurosurgeryMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
- Department of StatisticsLudwig‐Maximilians‐UniversityLudwigstraße 33Munich80539Germany
| | - Lisa I. Wadiura
- Department of NeurosurgeryMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
- Central Nervous System Tumours Unit, Comprehensive Cancer CenterMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
| | - Dimitri Benner
- Department of NeurosurgeryMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
| | - Arthur Hosmann
- Department of NeurosurgeryMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
- Central Nervous System Tumours Unit, Comprehensive Cancer CenterMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
| | - Shawn Hervey‐Jumper
- Department of Neurological SurgeryUniversity of California, San Francisco505 Parnassus AvenueSan FranciscoCalifornia94143
| | - Engelbert Knosp
- Department of NeurosurgeryMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
- Central Nervous System Tumours Unit, Comprehensive Cancer CenterMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
| | - Karl Roessler
- Department of NeurosurgeryMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
- Central Nervous System Tumours Unit, Comprehensive Cancer CenterMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
| | - Mitchel S. Berger
- Department of Neurological SurgeryUniversity of California, San Francisco505 Parnassus AvenueSan FranciscoCalifornia94143
| | - Georg Widhalm
- Department of NeurosurgeryMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
- Central Nervous System Tumours Unit, Comprehensive Cancer CenterMedical University ViennaWaehringer Guertel 18‐20Vienna1090Austria
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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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Spectroscopic measurement of 5-ALA-induced intracellular protoporphyrin IX in pediatric brain tumors. Acta Neurochir (Wien) 2019; 161:2099-2105. [PMID: 31435824 DOI: 10.1007/s00701-019-04039-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/09/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE 5-Aminolevulinic acid (5-ALA)-guided resection of gliomas in adults enables better delineation between tumor and normal brain, allowing improved resection and improved patients' outcome. Recently, several reports were published regarding 5-ALA for resection of pediatric brain tumors. The aim of the study was to determine the intracellular fluorescence of protoporphyrin IX (PPIX) in pediatric brain tumors by hyperspectral imaging and to compare it with visually observed intraoperative fluorescence. METHODS 5-ALA was administered orally 4 h prior to surgery. During tumor resection, the surgeon assessed the fluorescence signal to be strong, weak, or absent. Subsequently, fluorescence intensity of tumor samples was measured via spectroscopy. In addition, clinical data, imaging, and laboratory data were analyzed. RESULTS Eleven children (1-16 years) were operated. Tumor entities included three (n = 3) medulloblastomas, two (n = 2) pilocytic astrocytomas (PA), two (n = 2) anaplastic ependymomas and one (n = 1) diffuse astrocytoma, anaplastic astrocytoma (n = 1), pilomyxoid astrocytoma (n = 1) and anaplastic pleomorphic xanthoastrocytoma (n = 1). Strong fluorescence was visible in all anaplastic tumors and one PA; one PA demonstrated weak fluorescence. Visible fluorescence was strongly associated with intracellular fluorescence intensity and PPIX concentration (P < 0.05). Within all tumors with visible fluorescence, the intracellular PPIX concentration was greater than 4 μg/ml. Except for moderate and transient elevation of liver enzymes, no 5-ALA related adverse events were reported. CONCLUSION We demonstrate a strong association between intraoperative observations and spectrometric measurements of PPIX fluorescence in tumor tissue. As in former studies, fluorescence signal was more commonly observed in malignant glial tumors. Further prospective controlled trials should be conducted to investigate the feasibility of 5-ALA-guided resection of pediatric brain tumors.
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Stummer W, Koch R, Valle RD, Roberts DW, Sanai N, Kalkanis S, Hadjipanayis CG, Suero Molina E. Intraoperative fluorescence diagnosis in the brain: a systematic review and suggestions for future standards on reporting diagnostic accuracy and clinical utility. Acta Neurochir (Wien) 2019; 161:2083-2098. [PMID: 31363920 PMCID: PMC6739423 DOI: 10.1007/s00701-019-04007-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 07/05/2019] [Indexed: 12/24/2022]
Abstract
Background Surgery for gliomas is often confounded by difficulties in distinguishing tumor from surrounding normal brain. For better discrimination, intraoperative optical imaging methods using fluorescent dyes are currently being explored. Understandably, such methods require the demonstration of a high degree of diagnostic accuracy and clinical benefit. Currently, clinical utility is determined by tissue biopsies which are correlated to optical signals, and quantified using measures such as sensitivity, specificity, positive predictive values, and negative predictive values. In addition, surgical outcomes, such as extent of resection rates and/or survival (progression-free survival (PFS) and overall survival (OS)) have been measured. These assessments, however, potentially involve multiple biases and confounders, which have to be minimized to ensure reproducibility, generalizability and comparability of test results. Test should aim at having a high internal and external validity. The objective of this article is to analyze how diagnostic accuracy and outcomes are utilized in available studies describing intraoperative imaging and furthermore, to derive recommendations for reliable and reproducible evaluations. Methods A review of the literature was performed for assessing the use of measures of diagnostic accuracy and outcomes of intraoperative optical imaging methods. From these data, we derive recommendations for designing and reporting future studies. Results Available literature indicates that potential confounders and biases for reporting the diagnostic accuracy and usefulness of intraoperative optical imaging methods are seldom accounted for. Furthermore, methods for bias reduction are rarely used nor reported. Conclusions Detailed, transparent, and uniform reporting on diagnostic accuracy of intraoperative imaging methods is necessary. In the absence of such reporting, studies will not be comparable or reproducible. Future studies should consider some of the recommendations given here. Electronic supplementary material The online version of this article (10.1007/s00701-019-04007-y) contains supplementary material, which is available to authorized users.
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35
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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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Comparison of commercial 5-aminolevulinic acid (Gliolan®) and the pharmacy-compounded solution fluorescence in glioblastoma. Acta Neurochir (Wien) 2019; 161:1733-1741. [PMID: 31187267 DOI: 10.1007/s00701-019-03930-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND 5-Aminolevulinic acid (5-ALA) has become an important assistant in glioblastoma (GB) surgery. Unfortunately, its price affects its widespread use. OBJECTIVE The aim of this study was to compare commercial 5-ALA with the pharmacy-compounded solution. METHODS Using first an in vitro experimental approach, different concentrations of the pharmacy-compounded solution and commercial 5-ALA were tested in U87MG, LN229, U373, and T98G commercial glioblastoma cell lines. Fluorescence intensity was compared for each concentration by flow cytometry. Mean fluorescence of culture supernatant and lysate samples were analyzed. In a second phase, both preparations were used for surgical glioblastoma resection and tumor samples were analyzed by confocal microscopy. Mean fluorescence intensity was analyzed for each preparation and compared. RESULTS There was a high variability of fluorescence intensity between cell lines, but each cell line showed similar fluorescence for both preparations (compounded preparation and commercial 5-ALA). In the same way, both preparations had similar fluorescence intensity in glioblastoma samples. CONCLUSION Both, compounded and commercial 5-ALA preparations produce equivalent fluorescent responses in human glioblastoma cells. Fluorescence intensity is cell line specific, but fluorescent properties of both preparations are undistinguishable.
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Juarez-Chambi RM, Kut C, Rico-Jimenez JJ, Chaichana KL, Xi J, Campos-Delgado DU, Rodriguez FJ, Quinones-Hinojosa A, Li X, Jo JA. AI-Assisted In Situ Detection of Human Glioma Infiltration Using a Novel Computational Method for Optical Coherence Tomography. Clin Cancer Res 2019; 25:6329-6338. [PMID: 31315883 DOI: 10.1158/1078-0432.ccr-19-0854] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/24/2019] [Accepted: 07/12/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE In glioma surgery, it is critical to maximize tumor resection without compromising adjacent noncancerous brain tissue. Optical coherence tomography (OCT) is a noninvasive, label-free, real-time, high-resolution imaging modality that has been explored for glioma infiltration detection. Here, we report a novel artificial intelligence (AI)-assisted method for automated, real-time, in situ detection of glioma infiltration at high spatial resolution.Experimental Design: Volumetric OCT datasets were intraoperatively obtained from resected brain tissue specimens of 21 patients with glioma tumors of different stages and labeled as either noncancerous or glioma-infiltrated on the basis of histopathology evaluation of the tissue specimens (gold standard). Labeled OCT images from 12 patients were used as the training dataset to develop the AI-assisted OCT-based method for automated detection of glioma-infiltrated brain tissue. Unlabeled OCT images from the other 9 patients were used as the validation dataset to quantify the method detection performance. RESULTS Our method achieved excellent levels of sensitivity (∼100%) and specificity (∼85%) for detecting glioma-infiltrated tissue with high spatial resolution (16 μm laterally) and processing speed (∼100,020 OCT A-lines/second). CONCLUSIONS Previous methods for OCT-based detection of glioma-infiltrated brain tissue rely on estimating the tissue optical attenuation coefficient from the OCT signal, which requires sacrificing spatial resolution to increase signal quality, and performing systematic calibration procedures using tissue phantoms. By overcoming these major challenges, our AI-assisted method will enable implementing practical OCT-guided surgical tools for continuous, real-time, and accurate intraoperative detection of glioma-infiltrated brain tissue, facilitating maximal glioma resection and superior surgical outcomes for patients with glioma.
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Affiliation(s)
| | - Carmen Kut
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Jose J Rico-Jimenez
- Department of Biomedical Engineering, Texas A&M University, College Station, Texas
| | | | - Jiefeng Xi
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Daniel U Campos-Delgado
- Facultad de Ciencias, Universidad Autónoma de San Luis de Potosí, San Luis de Potosí, Mexico
| | - Fausto J Rodriguez
- Division of Neuropathology, Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | | | - Xingde Li
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Javier A Jo
- School of Electrical and Computer Engineering, University of Oklahoma, Norman, Oklahoma.
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Wei L, Fujita Y, Sanai N, Liu JTC. Toward Quantitative Neurosurgical Guidance With High-Resolution Microscopy of 5-Aminolevulinic Acid-Induced Protoporphyrin IX. Front Oncol 2019; 9:592. [PMID: 31334117 PMCID: PMC6616084 DOI: 10.3389/fonc.2019.00592] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 06/17/2019] [Indexed: 12/13/2022] Open
Abstract
Low-power fluorescence microscopy of 5-ALA-induced PpIX has emerged as a valuable intraoperative imaging technology for improving the resection of malignant gliomas. However, current fluorescence imaging tools are not highly sensitive nor quantitative, which limits their effectiveness for optimizing operative decisions near the surgical margins of gliomas, in particular non-enhancing low-grade gliomas. Intraoperative high-resolution optical-sectioning microscopy can potentially serve as a valuable complement to low-power fluorescence microscopy by providing reproducible quantification of tumor parameters at the infiltrative margins of diffuse gliomas. In this forward-looking perspective article, we provide a brief discussion of recent technical advancements, pilot clinical studies, and our vision of the future adoption of handheld optical-sectioning microscopy at the final stages of glioma surgeries to enhance the extent of resection. We list a number of challenges for clinical acceptance, as well as potential strategies to overcome such obstacles for the surgical implementation of these in vivo microscopy techniques.
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Affiliation(s)
- Linpeng Wei
- Department of Mechanical Engineering, University of Washington, Seattle, WA, United States
| | - Yoko Fujita
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Nader Sanai
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Jonathan T C Liu
- Department of Mechanical Engineering, University of Washington, Seattle, WA, United States.,Department of Pathology, University of Washington School of Medicine, Seattle, WA, United States
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Valdes PA, Juvekar P, Agar NYR, Gioux S, Golby AJ. Quantitative Wide-Field Imaging Techniques for Fluorescence Guided Neurosurgery. Front Surg 2019; 6:31. [PMID: 31245380 PMCID: PMC6563771 DOI: 10.3389/fsurg.2019.00031] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/15/2019] [Indexed: 11/26/2022] Open
Abstract
Fluorescence guided surgery (FGS) has fueled the development of novel technologies aimed at maximizing the utility of fluorescence imaging to help clinicians diagnose and in certain cases treat diseases across a breadth of disciplines such as dermatology, gynecology, oncology, ophthalmology, and neurosurgery. In neurosurgery, the goal of FGS technologies is to provide the neurosurgeon with additional information which can serve as a visual aid to better identify tumor tissue and associated margins. Yet, current clinical FGS technologies are qualitative in nature, limiting the ability to make accurate, reliable, and repeatable measurements. To this end, developments in fluorescence quantification are needed to overcome current limitations of FGS. Here we present an overview of the recent developments in quantitative fluorescence guidance technologies and conclude with the most recent developments aimed at wide-field quantitative fluorescence imaging approaches in neurosurgery.
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Affiliation(s)
- Pablo A Valdes
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Parikshit Juvekar
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Nathalie Y R Agar
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Sylvain Gioux
- ICube Laboratory, University of Strasbourg, Télécom Physique Strasbourg, Alsace, France
| | - Alexandra J Golby
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
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Schwake M, Schipmann S, Müther M, Köchling M, Brentrup A, Stummer W. 5-ALA fluorescence-guided surgery in pediatric brain tumors-a systematic review. Acta Neurochir (Wien) 2019; 161:1099-1108. [PMID: 30989383 DOI: 10.1007/s00701-019-03898-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/28/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND 5-Aminolevulinic acid (5-ALA)-guided resection of gliomas in adults enables better differentiation between tumor and normal brain tissue, allowing a higher degree of resection, and improves patient outcomes. In recent years, several reports have emerged regarding the use of 5-ALA in other brain tumor entities, including pediatric brains tumors. Since gross total resection (GTR) of many brain tumors in children is crucial and the role of 5-ALA-guided resection of these tumors is not clear, we sought to perform a comprehensive literature review on this topic. METHODS A systematic literature review of EMBASE and MEDLINE/PubMed databases revealed 19 eligible publications encompassing 175 5-ALA-guided operations on pediatric brain tumors. To prevent bias, publications were revised independently by two authors. RESULTS We found that 5-ALA-guided resection enabled the surgeons to identify the tumor more easily and was considered helpful mainly in cases of glioblastoma (GBM, 21/27, 78%), anaplastic ependymoma WHO grade III (10/14, 71%), and anaplastic astrocytoma (4/6, 67%). In contrast, cases of pilocytic astrocytomas (PAs) and medulloblastomas 5-ALA-guided surgery did not show consistent fluorescent signals and 5-ALA was considered helpful only in 12% and 22% of cases, respectively. Accumulation of fluorescent porphyrins seems to depend on WHO tumor grading. One important finding is that when 5-ALA-guided resections were considered helpful, the degree of resection was higher than is cases where it was not helpful. The rate of adverse events related to 5-ALA was negligible, especially new postoperative sequelae. CONCLUSION 5-ALA could play a role in resection of pediatric brain tumors. However, further prospective clinical trials are needed.
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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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Widhalm G, Olson J, Weller J, Bravo J, Han SJ, Phillips J, Hervey-Jumper SL, Chang SM, Roberts DW, Berger MS. The value of visible 5-ALA fluorescence and quantitative protoporphyrin IX analysis for improved surgery of suspected low-grade gliomas. J Neurosurg 2019; 133:79-88. [PMID: 31075771 PMCID: PMC7184556 DOI: 10.3171/2019.1.jns182614] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 01/28/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE In patients with suspected diffusely infiltrating low-grade gliomas (LGG), the prognosis is dependent especially on extent of resection and precision of tissue sampling. Unfortunately, visible 5-aminolevulinic acid (5-ALA) fluorescence is usually only present in high-grade gliomas (HGGs), and most LGGs cannot be visualized. Recently, spectroscopic probes were introduced allowing in vivo quantitative analysis of intratumoral 5-ALA-induced protoporphyrin IX (PpIX) accumulation. The aim of this study was to intraoperatively investigate the value of visible 5-ALA fluorescence and quantitative PpIX analysis in suspected diffusely infiltrating LGG. METHODS Patients with radiologically suspected diffusely infiltrating LGG were prospectively recruited, and 5-ALA was preoperatively administered. During resection, visual fluorescence and absolute tissue PpIX concentration (CPpIX) measured by a spectroscopic handheld probe were determined in different intratumoral areas. Subsequently, corresponding tissue samples were safely collected for histopathological analysis. Tumor diagnosis was established according to the World Health Organization 2016 criteria. Additionally, the tumor grade and percentage of tumor cells were investigated in each sample. RESULTS All together, 69 samples were collected from 22 patients with histopathologically confirmed diffusely infiltrating glioma. Visible fluorescence was detected in focal areas in most HGGs (79%), but in none of the 8 LGGs. The mean CPpIX was significantly higher in fluorescing samples than in nonfluorescing samples (0.693 μg/ml and 0.008 μg/ml, respectively; p < 0.001). A significantly higher mean percentage of tumor cells was found in samples with visible fluorescence compared to samples with no fluorescence (62% and 34%, respectively; p = 0.005), and significant correlation of CPpIX and percentage of tumor cells was found (r = 0.362, p = 0.002). Moreover, high-grade histology was significantly more common in fluorescing samples than in nonfluorescing samples (p = 0.001), whereas no statistically significant difference in mean CPpIX was noted between HGG and LGG samples. Correlation between maximum CPpIX and overall tumor grade was highly significant (p = 0.005). Finally, 14 (40%) of 35 tumor samples with no visible fluorescence and 16 (50%) of 32 LGG samples showed significantly increased CPpIX (cutoff value: 0.005 μg/ml). CONCLUSIONS Visible 5-ALA fluorescence is able to detect focal intratumoral areas of malignant transformation, and additional quantitative PpIX analysis is especially useful to visualize mainly LGG tissue that usually remains undetected by conventional fluorescence. Thus, both techniques will support the neurosurgeon in achieving maximal safe resection and increased precision of tissue sampling during surgery for suspected LGG.Clinical trial registration no.: NCT01116661 (clinicaltrials.gov).
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Affiliation(s)
- Georg Widhalm
- Department of Neurological Surgery, University of California, San Francisco, California
- Department of Neurosurgery, Medical University of Vienna, Austria
| | - Jonathan Olson
- Thayer School of Engineering, Dartmouth College, Hanover
| | - Jonathan Weller
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Jaime Bravo
- Thayer School of Engineering, Dartmouth College, Hanover
| | - Seunggu J. Han
- Department of Neurological Surgery, University of California, San Francisco, California
- Department of Neurological Surgery, Oregon Health and Sciences University, Portland, Oregon
| | - Joanna Phillips
- Department of Pathology, University of California, San Francisco, California
| | | | - Susan M. Chang
- Department of Neurological Surgery, University of California, San Francisco, California
| | - David W. Roberts
- Thayer School of Engineering, Dartmouth College, Hanover
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Mitchel S. Berger
- Department of Neurological Surgery, University of California, San Francisco, California
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Kaneko S, Suero Molina E, Ewelt C, Warneke N, Stummer W. Fluorescence-Based Measurement of Real-Time Kinetics of Protoporphyrin IX After 5-Aminolevulinic Acid Administration in Human In Situ Malignant Gliomas. Neurosurgery 2019; 85:E739-E746. [DOI: 10.1093/neuros/nyz129] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 03/31/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Five-aminolevulinic acid (5-ALA) is well established for fluorescence-guided resections of malignant gliomas by eliciting the accumulation of fluorescent protoporphyrin IX (PpIX) in tumors. Because of the assumed time point of peak fluorescence, 5-ALA is recommended to be administered 3 h before surgery. However, the actual time dependency of tumor fluorescence has not yet been evaluated in humans and may have important implications.
OBJECTIVE
To investigate the time dependency of PpIX by measuring fluorescence intensities in tumors at various time points during surgery.
METHODS
Patients received 5-ALA (20 mg/kg b.w.) 3 to 4 h before surgery. Fluorescence intensities (FI) and estimated tumor PpIX concentrations (CPPIX) were measured in the tumors over time with a hyperspectral camera. CPPIX was assessed using hyperspectral imaging and by evaluating fluorescence phantoms with known CPPIX.
RESULTS
A total of 201 samples from 68 patients were included in this study. On average, maximum values of calculated FI and CPPIX were observed between 7 and 8 h after 5-ALA administration. FI and CPPIX both reliably distinguished central strong and marginal weak fluorescence, and grade III compared to grade IV gliomas. Interestingly, marginal (weak) fluorescence was observed to peak later than strong fluorescence (8-9 vs 7-8 h).
CONCLUSION
In human in Situ brain tumor tissue, we determined fluorescence after 5-ALA administration to be maximal later than previously thought. In consequence, 5-ALA should be administered 4 to 5 h before surgery, with timing adjusted to internal logistical circumstances and factors related to approaching the tumor.
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Affiliation(s)
- Sadahiro Kaneko
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Eric Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - Christian Ewelt
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - Nils Warneke
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
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Sibai M, Wirth DJ, Leblond F, Roberts DW, Paulsen KD, Wilson BC. Quantitative subsurface spatial frequency-domain fluorescence imaging for enhanced glioma resection. JOURNAL OF BIOPHOTONICS 2019. [PMID: 30358162 DOI: 10.1002/jbio.2019.12.issue-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
The rate of complete resection of glioma has improved with the introduction of 5-aminolevulinic acid-induced protoporphyrin IX (PpIX) fluorescence image guidance. Surgical outcomes are further enhanced when the fluorescence signal is decoupled from the intrinsic tissue optical absorption and scattering obtained from diffuse reflectance measurements, yielding the absolute PpIX concentration, [PpIX]. Spatial frequency domain imaging was used previously to measure [PpIX] in near-surface tumors under blue fluorescence excitation. Here, we extend this to subsurface [PpIX] fluorescence under red-light excitation. The decay rate of the modulation amplitude of the fluorescence signal was used to calculate the PpIX depth, which was then applied in a forward diffusion model to estimate [PpIX] at depth. For brain-like optical properties in phantoms with PpIX fluorescent inclusions, the depth can be recovered up to depths of 9.5 mm ± 0.4 mm, with [PpIX] ranging from 5 to 15 μg/mL within an average deviation of 15% from the true [PpIX] value.
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Affiliation(s)
- Mira Sibai
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
| | - Dennis J Wirth
- Dartmouth-Hitchcock Medical Center, Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire
| | - Frederic Leblond
- Department of Engineering Physics, École Polytechnique De Montreal, Montreal, Quebec, Canada
| | - David W Roberts
- Department of Neurosurgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Keith D Paulsen
- Dartmouth-Hitchcock Medical Center, Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire
| | - Brian C Wilson
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
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45
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Sibai M, Wirth DJ, Leblond F, Roberts DW, Paulsen KD, Wilson BC. Quantitative subsurface spatial frequency-domain fluorescence imaging for enhanced glioma resection. JOURNAL OF BIOPHOTONICS 2019; 12:e201800271. [PMID: 30358162 PMCID: PMC6470016 DOI: 10.1002/jbio.201800271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/20/2018] [Accepted: 10/23/2018] [Indexed: 05/03/2023]
Abstract
The rate of complete resection of glioma has improved with the introduction of 5-aminolevulinic acid-induced protoporphyrin IX (PpIX) fluorescence image guidance. Surgical outcomes are further enhanced when the fluorescence signal is decoupled from the intrinsic tissue optical absorption and scattering obtained from diffuse reflectance measurements, yielding the absolute PpIX concentration, [PpIX]. Spatial frequency domain imaging was used previously to measure [PpIX] in near-surface tumors under blue fluorescence excitation. Here, we extend this to subsurface [PpIX] fluorescence under red-light excitation. The decay rate of the modulation amplitude of the fluorescence signal was used to calculate the PpIX depth, which was then applied in a forward diffusion model to estimate [PpIX] at depth. For brain-like optical properties in phantoms with PpIX fluorescent inclusions, the depth can be recovered up to depths of 9.5 mm ± 0.4 mm, with [PpIX] ranging from 5 to 15 μg/mL within an average deviation of 15% from the true [PpIX] value.
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Affiliation(s)
- Mira Sibai
- Princess Margaret Cancer Center/University Health Network, 101 College Street, Toronto, ON M5G 1L7 Canada, Canada
- Dept. of Medical Biophysics, University of Toronto, Faculty of Medicine, 101 College Street, Toronto, ON M5G 1L7 Canada
| | - Dennis J. Wirth
- Dartmouth College, Thayer School of Engineering, 14 Engineering Drive Hanover, NH USA 03755 USA
| | - Frederic Leblond
- Dept. of Engineering Physics, École Polytechnique De Montreal, 2900, boul. Édouard-Montpetit Montréal, Québec H3T 1J4 Canada
| | - David W. Roberts
- Dept. of Neurosurgery, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Keith D. Paulsen
- Dartmouth College, Thayer School of Engineering, 14 Engineering Drive Hanover, NH USA 03755 USA
| | - Brian C. Wilson
- Princess Margaret Cancer Center/University Health Network, 101 College Street, Toronto, ON M5G 1L7 Canada, Canada
- Dept. of Medical Biophysics, University of Toronto, Faculty of Medicine, 101 College Street, Toronto, ON M5G 1L7 Canada
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Alston L, Mahieu-Williame L, Hebert M, Kantapareddy P, Meyronet D, Rousseau D, Guyotat J, Montcel B. Spectral complexity of 5-ALA induced PpIX fluorescence in guided surgery: a clinical study towards the discrimination of healthy tissue and margin boundaries in high and low grade gliomas. BIOMEDICAL OPTICS EXPRESS 2019; 10:2478-2492. [PMID: 31149380 PMCID: PMC6524587 DOI: 10.1364/boe.10.002478] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/09/2019] [Accepted: 03/21/2019] [Indexed: 05/06/2023]
Abstract
Gliomas are diffuse and hard to cure brain tumors. A major reason for their aggressive behavior is their property to infiltrate the brain. The gross appearance of the infiltrative component is comparable to normal brain, constituting an obstacle to extended surgical resection. 5-ALA induced PpIX fluorescence measurements enable gains in sensitivity to detect infiltrated cells, but still lack sensitivity to get accurate discrimination between the tumor margin and healthy tissue. In this fluorescence spectroscopic study, we assume that two states of PpIX contribute to total fluorescence to get better discrimination of healthy tissues against tumor margins. We reveal that fluorescence in low-density margins of high-grade gliomas or in low-grade gliomas is mainly influenced by the second state of PpIX centered at 620 nm. We thus conclude that consideration of the contributions of both states to total fluorescence can help to improve fluorescence-guided resection of gliomas by discriminating healthy tissues from tumor margins.
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Affiliation(s)
- L. Alston
- Univ Lyon, INSA‐Lyon, Université Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR5220, U1206, F-69616, Lyon, France
| | - L. Mahieu-Williame
- Univ Lyon, INSA‐Lyon, Université Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR5220, U1206, F-69616, Lyon, France
| | - M. Hebert
- Univ Lyon, UJM-Saint-Etienne, CNRS, Institut d Optique Graduate School, Lab. Hubert Curien UMR5516, F-42023, St Etienne, France
| | - P. Kantapareddy
- Hospices Civils de Lyon, Groupe Hospitalier Est, Service d’anatomopathologie, 59 Bvd Pinel, 69394, Lyon, Cedex, France
| | - D. Meyronet
- Hospices Civils de Lyon, Groupe Hospitalier Est, Service d’anatomopathologie, 59 Bvd Pinel, 69394, Lyon, Cedex, France
- Department of Cancer Cell Plasticity, Cancer Research Centre of Lyon, INSERM U1052, CNRS UMR5286, Lyon, France, Université Claude Bernard Lyon 1, Lyon, France
| | - D. Rousseau
- Univ Lyon, INSA‐Lyon, Université Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR5220, U1206, F-69616, Lyon, France
| | - J. Guyotat
- Hospices Civils de Lyon, Groupe Hospitalier Est, Service d’anatomopathologie, 59 Bvd Pinel, 69394, Lyon, Cedex, France
| | - B. Montcel
- Univ Lyon, INSA‐Lyon, Université Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR5220, U1206, F-69616, Lyon, France
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Brognaro E. Glioblastoma Unique Features Drive the Ways for Innovative Therapies in the Trunk-branch Era. Folia Med (Plovdiv) 2019. [DOI: 10.3897/folmed.61.e34900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Glioblastoma multiforme is a solid tumor with particular aspects due to its organ of origin and its development modalities. The brain is very sensitive to oxygen and glucose deprivation and it is the only organ that cannot be either transplanted or entirely removed. Furthermore, many clues and recent indirect experimental evidence indicate that the micro-infiltration of the whole brain parenchyma occurs in very early stages of tumor bulk growth or likely even before. As a consequence, the primary glioblastoma (IDH-wildtype, WHO 2016) is the only tumor where the malignant (i.e. distantly infiltrating the organ of origin) and deadly (i.e. leading cause to patient’s death) phases coincide and overlap in one single phase of its natural history. To date, the prognosis of optimally treated glioblastoma patients remains dismal despite recent fundamental progress in neurosurgical techniques which are enabling better maximal safe resection and survival outcome. Intratumor variegated heterogeneity of glioblastoma bulk due to trunk-branch evolution and very early micro-infiltration and settlement of neoplastic cells in the entire brain parenchyma are the reasons for resistance to current therapeutic treatments. With the aim of future innovative and effective therapies, this paper deals with the unique glioblastoma features, the appropriate research methods as well as the strategies to follow to overcome current causes of resistance.
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Wei L, Roberts DW, Sanai N, Liu JTC. Visualization technologies for 5-ALA-based fluorescence-guided surgeries. J Neurooncol 2018; 141:495-505. [PMID: 30554344 DOI: 10.1007/s11060-018-03077-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/10/2018] [Indexed: 01/27/2023]
Abstract
INTRODUCTION 5-ALA-based fluorescence-guided surgery has been shown to be a safe and effective method to improve intraoperative visualization and resection of malignant gliomas. However, it remains ineffective in guiding the resection of lower-grade, non-enhancing, and deep-seated tumors, mainly because these tumors do not produce detectable fluorescence with conventional visualization technologies, namely, wide-field (WF) surgical microscopy. METHODS We describe some of the main factors that limit the sensitivity and accuracy of conventional WF surgical microscopy, and then provide a survey of commercial and research prototypes being developed to address these challenges, along with their principles, advantages and disadvantages, as well as the current status of clinical translation for each technology. We also provide a neurosurgical perspective on how these visualization technologies might best be implemented for guiding glioma surgeries in the future. RESULTS Detection of PpIX expression in low-grade gliomas and at the infiltrative margins of all gliomas has been achieved with high-sensitivity probe-based visualization techniques. Deep-tissue PpIX imaging of up to 5 mm has also been achieved using red-light illumination techniques. Spectroscopic approaches have enabled more accurate quantification of PpIX expression. CONCLUSION Advancements in visualization technologies have extended the sensitivity and accuracy of conventional WF surgical microscopy. These technologies will continue to be refined to further improve the extent of resection in glioma patients using 5-ALA-induced fluorescence.
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Affiliation(s)
- Linpeng Wei
- Department of Mechanical Engineering, University of Washington, Seattle, WA, 98195, USA.
| | - David W Roberts
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, 03756, USA
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, 03756, USA
- Thayer School of Engineering, Dartmouth College, Hanover, NH, 03755, USA
- Geisel School of Medicine, Dartmouth College, Hanover, NH, 03755, USA
| | - Nader Sanai
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, 85013, USA
| | - Jonathan T C Liu
- Department of Mechanical Engineering, University of Washington, Seattle, WA, 98195, USA
- Department of Pathology, University of Washington, Seattle, WA, 98195, USA
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Augmentation of 5-Aminolevulinic Acid Treatment of Glioblastoma by Adding Ciprofloxacin, Deferiprone, 5-Fluorouracil and Febuxostat: The CAALA Regimen. Brain Sci 2018; 8:brainsci8120203. [PMID: 30469467 PMCID: PMC6315943 DOI: 10.3390/brainsci8120203] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 11/15/2018] [Accepted: 11/20/2018] [Indexed: 02/08/2023] Open
Abstract
The CAALA (Complex Augmentation of ALA) regimen was developed with the goal of redressing some of the weaknesses of 5-aminolevulinic acid (5-ALA) use in glioblastoma treatment as it now stands. 5-ALA is approved for use prior to glioblastoma surgery to better demarcate tumor from brain tissue. 5-ALA is also used in intraoperative photodynamic treatment of glioblastoma by virtue of uptake of 5-ALA and its preferential conversion to protoporphyrin IX in glioblastoma cells. Protoporphyrin IX becomes cytotoxic after exposure to 410 nm or 635 nm light. CAALA uses four currently-marketed drugs—the antibiotic ciprofloxacin, the iron chelator deferiprone, the antimetabolite 5-FU, and the xanthine oxidase inhibitor febuxostat—that all have evidence of ability to both increase 5-ALA mediated intraoperative glioblastoma demarcation and photodynamic cytotoxicity of in situ glioblastoma cells. Data from testing the full CAALA on living minipigs xenotransplanted with human glioblastoma cells will determine safety and potential for benefit in advancing CAALA to a clinical trial.
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Optical Characterization of Neurosurgical Operating Microscopes: Quantitative Fluorescence and Assessment of PpIX Photobleaching. Sci Rep 2018; 8:12543. [PMID: 30135440 PMCID: PMC6105612 DOI: 10.1038/s41598-018-30247-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 07/25/2018] [Indexed: 01/01/2023] Open
Abstract
Protoporphyrin IX (PpIX) induced by 5-aminolevulinic acid (5-ALA) is increasingly used as a fluorescent marker for fluorescence-guided resection of malignant gliomas. Understanding how the properties of the excitation light source and PpIX fluorescence interact with the surgical microscope is critical for effective use of the fluorescence-guided tumor resection technique. In this study, we performed a detailed assessment of the intensity of the emitted blue light and white light and the light beam profile of clinical grade operating microscopes used for PpIX visualization. These measurements revealed both recognized fluorescence photobleaching limitations and unrecognized limitations that may alter quantitative observations of PpIX fluorescence obtained with the operating microscope with potential impact on research and clinical uses. We also evaluated the optical properties of a photostable fluorescent standard with an excitation-emission profile similar to PpIX. In addition, we measured the time-dependent dynamics of 5-ALA-induced PpIX fluorescence in an animal glioma model. Finally, we developed a ratiometric method for quantification of the PpIX fluorescence that uses the photostable fluorescent standard to normalize PpIX fluorescence intensity. This method increases accuracy and allows reproducible and direct comparability of the measurements from multiple samples.
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