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Vartholomatos G, Markopoulos GS, Vartholomatos E, Goussia AC, Dova L, Dimitriadis S, Mantziou S, Zoi V, Nasios A, Sioka C, Kyritsis AP, Voulgaris S, Alexiou GA. Assessment of Gliomas' Grade of Malignancy and Extent of Resection Using Intraoperative Flow Cytometry. Cancers (Basel) 2023; 15:2509. [PMID: 37173975 PMCID: PMC10177593 DOI: 10.3390/cancers15092509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/22/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Intraoperative Flow Cytometry (iFC) is a novel technique for the assessment of the grade of malignancy and the diagnosis of tumor type and resection margins during solid tumor surgery. Herein, we set out to analyze the role of iFC in the grading of gliomas and the evaluation of resection margins. MATERIAL AND METHODS iFC uses a fast cell cycle analysis protocol (Ioannina Protocol) that permits the analysis of tissue samples within 5-6 min. Cell cycle analysis evaluated the G0/G1 phase, S-phase, mitosis, and tumor index (S + mitosis phase fraction) and ploidy status. In the current study, we evaluated tumor samples and samples from the peripheral borders from patients with gliomas who underwent surgery over an 8-year period. RESULTS Eighty-one patients were included in the study. There were sixty-eight glioblastoma cases, five anaplastic astrocytomas, two anaplastic oligodendrogliomas, one pilocytic astrocytoma, three oligodendrogliomas and two diffuse astrocytomas. High-grade gliomas had a significantly higher tumor index than low grade gliomas (median value 22 vs. 7.5, respectively, p = 0.002). Using ROC curve analysis, a cut-off value of 17% in the tumor index could differentiate low- from high-grade gliomas with a 61.4% sensitivity and 100% specificity. All low-grade gliomas were diploid. From the high-grade gliomas, 22 tumors were aneuploid. In glioblastomas, aneuploid tumors had a significantly higher tumor index (p = 0.0018). Twenty-three samples from glioma margins were evaluated. iFC verified the presence of malignant tissue in every case, using histology as the gold standard. CONCLUSION iFC constitutes a promising intraoperative technique for glioma grading and resection margin assessment. Comparative studies with additional intraoperative adjuncts are necessary.
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Affiliation(s)
- George Vartholomatos
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Haematology Laboratory, Unit of Molecular Biology and Translational Flow Cytometry, 45110 Ioannina, Greece
| | - Georgios S. Markopoulos
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Haematology Laboratory, Unit of Molecular Biology and Translational Flow Cytometry, 45110 Ioannina, Greece
| | - Eyrysthenis Vartholomatos
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
| | - Anna C. Goussia
- Department of Pathology, Ioannina University Hospital, 45500 Ioannina, Greece;
- Department of Pathology, German Oncology Center, 4108 Limassol, Cyprus
| | - Lefkothea Dova
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Haematology Laboratory, Unit of Molecular Biology and Translational Flow Cytometry, 45110 Ioannina, Greece
| | - Savvas Dimitriadis
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
| | - Stefania Mantziou
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Haematology Laboratory, Unit of Molecular Biology and Translational Flow Cytometry, 45110 Ioannina, Greece
| | - Vaso Zoi
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
| | - Anastasios Nasios
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Haematology Laboratory, Unit of Molecular Biology and Translational Flow Cytometry, 45110 Ioannina, Greece
- Department of Neurosurgery, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Chrissa Sioka
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Department of Nuclear Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Athanasios P. Kyritsis
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
| | - Spyridon Voulgaris
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Department of Neurosurgery, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - George A. Alexiou
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece; (G.V.); (G.S.M.); (E.V.); (L.D.); (S.D.); (S.M.); (V.Z.); (A.N.); (C.S.); (A.P.K.); (S.V.)
- Department of Neurosurgery, University Hospital of Ioannina, 45500 Ioannina, Greece
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Alexiou GA, Markopoulos GS, Vartholomatos E, Goussia AC, Dova L, Dimitriadis S, Mantziou S, Zoi V, Nasios A, Sioka C, Kyritsis AP, Voulgaris S, Vartholomatos G. Intraoperative Flow Cytometry for the Evaluation of Meningioma Grade. Curr Oncol 2023; 30:832-838. [PMID: 36661712 PMCID: PMC9858265 DOI: 10.3390/curroncol30010063] [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: 12/06/2022] [Revised: 01/02/2023] [Accepted: 01/05/2023] [Indexed: 01/11/2023] Open
Abstract
Meningiomas are the most frequent central nervous system tumors in adults. The majority of these tumors are benign. Nevertheless, the intraoperative identification of meningioma grade is important for modifying surgical strategy in order to reduce postoperative complications. Here, we set out to investigate the role of intraoperative flow cytometry for the differentiation of low-grade (grade 1) from high-grade (grade 2-3) meningiomas. The study included 59 patients. Intraoperative flow cytometry analysis was performed using the 'Ioannina Protocol' which evaluates the G0/G1 phase, S-phase, mitosis and tumor index (S + mitosis phase fraction) of a tumor sample. The results are available within 5 min of sample receipt. There were 41 grade 1, 15 grade 2 and 3 grade 3 meningiomas. High-grade meningiomas had significantly higher S-phase fraction, mitosis fraction and tumor index compared to low-grade meningiomas. High-grade meningiomas had significantly lower G0/G1 phase fraction compared to low-grade meningiomas. Thirty-eight tumors were diploids and twenty-one were aneuploids. No significant difference was found between ploidy status and meningioma grade. ROC analysis indicated 11.4% of tumor index as the optimal cutoff value thresholding the discrimination between low- and high-grade meningiomas with 90.2% sensitivity and 72.2% specificity. In conclusion, intraoperative flow cytometry permits the detection of high-grade meningiomas within 5 min. Thus, surgeons may modify tumor removal strategy.
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Affiliation(s)
- George A. Alexiou
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece
- Department of Neurosurgery, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Georgios S. Markopoulos
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece
- Haematology Laboratory—Unit of Molecular Biology and Translational Flow Cytometry, University Hospital of Ioannina, 45500 Ioannina, Greece
| | | | - Anna C. Goussia
- Department of Pathology, University Hospital of Ioannina, 45500 Ioannina, Greece
- Department of Pathology, German Oncology Center, 4108 Limassol, Cyprus
| | - Lefkothea Dova
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece
- Haematology Laboratory—Unit of Molecular Biology and Translational Flow Cytometry, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Savvas Dimitriadis
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece
| | - Stefania Mantziou
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece
- Haematology Laboratory—Unit of Molecular Biology and Translational Flow Cytometry, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Vasiliki Zoi
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece
| | - Anastasios Nasios
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece
- Department of Neurosurgery, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Chrissa Sioka
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece
- Department of Nuclear Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Athanasios P. Kyritsis
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece
| | - Spyridon Voulgaris
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece
- Department of Neurosurgery, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - George Vartholomatos
- Neurosurgical Institute, University of Ioannina School of Medicine, 45110 Ioannina, Greece
- Haematology Laboratory—Unit of Molecular Biology and Translational Flow Cytometry, University Hospital of Ioannina, 45500 Ioannina, Greece
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D’Amato Figueiredo MV, Alexiou GA, Vartholomatos G, Rehder R. Advances in Intraoperative Flow Cytometry. Int J Mol Sci 2022; 23:ijms232113430. [PMID: 36362215 PMCID: PMC9655491 DOI: 10.3390/ijms232113430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/25/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
Flow cytometry is the gold-standard laser-based technique to measure and analyze fluorescence levels of immunostaining and DNA content in individual cells. It provides a valuable tool to assess cells in the G0/G1, S, and G2/M phases, and those with polyploidy, which holds prognostic significance. Frozen section analysis is the standard intraoperative assessment for tumor margin evaluation and tumor resection. Here, we present flow cytometry as a promising technique for intraoperative tumor analysis in different pathologies, including brain tumors, leptomeningeal dissemination, breast cancer, head and neck cancer, pancreatic tumor, and hepatic cancer. Flow cytometry is a valuable tool that can provide substantial information on tumor analysis and, consequently, maximize cancer treatment and expedite patients’ survival.
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Affiliation(s)
- Marcos V. D’Amato Figueiredo
- Department of Neurosurgery, Hospital Estadual Mario Covas, Santo Andre 09190-615, Brazil
- Department of Neurosurgery, Hospital do Coracao, Sao Paulo 04004-030, Brazil
| | - George A. Alexiou
- Department of Neurosurgery, School of Medicine, University of Ioannina, 45500 Ioannina, Greece
- Neurosurgical Institute, University of Ioannina, 45500 Ioannina, Greece
- Correspondence: ; Tel.: +30-6948-525134
| | - George Vartholomatos
- Neurosurgical Institute, University of Ioannina, 45500 Ioannina, Greece
- Hematology Laboratory, Unit of Molecular Biology and Translational Flow Cytometry, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Roberta Rehder
- Department of Neurosurgery, Hospital do Coracao, Sao Paulo 04004-030, Brazil
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Hospital Santa Marcelina, Sao Paulo 08270-070, Brazil
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Vartholomatos G, Ηarissis Η, Andreou M, Tatsi V, Pappa L, Kamina S, Βatistatou A, Markopoulos GS, Alexiou GA. Rapid Assessment of Resection Margins During Breast Conserving Surgery Using Intraoperative Flow Cytometry. Clin Breast Cancer 2021; 21:e602-e610. [PMID: 33820744 DOI: 10.1016/j.clbc.2021.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/28/2021] [Accepted: 03/03/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Positive margins are the most important factor for recurrence of the disease after breast-conserving surgery. Several methods have been developed throughout the years to evaluate the margin status during surgery in an attempt to assist the surgeon in excising the whole tumor at once, a goal that has not yet been accomplished. PATIENTS AND METHODS In our study, we compared intraoperative flow cytometry (iFC) with cytology and pathology in order to evaluate 606 samples of margins and tumors corresponding to 99 patients with invasive ductal carcinoma of no special type and invasive lobular carcinoma obtained from breast-conserving surgeries. RESULTS Using the pathology as the gold standard, flow cytometry had 93.3% sensitivity, 92.4% specificity, and 92.5% accuracy. Cytology had 82.3% sensitivity, 94.6% specificity, and 94.2% accuracy. CONCLUSIONS Our data support the suggestion that iFC is a novel, reliable technique that allows rapid evaluation of the excision margins of lumpectomies, thus improving the precision of breast-conserving surgery. Among the advantages of iFC are that it does not rely on the expertise of a pathologist or cytologist, it is low cost, and it has no additional psychological effect on patients, because no re-operation is needed.
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Affiliation(s)
- George Vartholomatos
- Haematology Laboratory-Unit of Molecular Biology, University Hospital of Ioannina, Ioannina, Greece; Neurosurgical Institute, University of Ioannina School of Medicine, Ioannina, Greece
| | | | - Maria Andreou
- Haematology Laboratory-Unit of Molecular Biology, University Hospital of Ioannina, Ioannina, Greece
| | | | - Lamprini Pappa
- Department of Cytology, University Hospital of Ioannina, Ioannina, Greece
| | - Sevasti Kamina
- Department of Pathology, University Hospital of Ioannina, Ioannina, Greece
| | - Anna Βatistatou
- Department of Pathology, University Hospital of Ioannina, Ioannina, Greece
| | | | - George A Alexiou
- Neurosurgical Institute, University of Ioannina School of Medicine, Ioannina, Greece; Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece.
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Millesi M, Widhalm G. In Reply: Is Intraoperative Pathology Needed if 5-Aminolevulinic-Acid-Induced Tissue Fluorescence Is Found in Stereotactic Brain Tumor Biopsy? Neurosurgery 2020; 87:E427. [PMID: 32503032 DOI: 10.1093/neuros/nyaa237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Matthias Millesi
- Department of Neurosurgery Medical University of Vienna Vienna, Austria.,Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS) Medical University of Vienna Vienna, Austria
| | - Georg Widhalm
- Department of Neurosurgery Medical University of Vienna Vienna, Austria.,Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS) Medical University of Vienna Vienna, Austria
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