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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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Li G, Rodrigues A, Kim L, Garcia C, Jain S, Zhang M, Hayden-Gephart M. 5-Aminolevulinic Acid Imaging of Malignant Glioma. Surg Oncol Clin N Am 2022; 31:581-593. [DOI: 10.1016/j.soc.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lehtonen SJR, Vrzakova H, Paterno JJ, Puustinen S, Bednarik R, Hauta-Kasari M, Haneishi H, Immonen A, Jääskeläinen JE, Kämäräinen OP, Elomaa AP. Detection improvement of gliomas in hyperspectral imaging of protoporphyrin IX fluorescence - in vitro comparison of visual identification and machine thresholds. Cancer Treat Res Commun 2022; 32:100615. [PMID: 35905671 DOI: 10.1016/j.ctarc.2022.100615] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 06/23/2022] [Accepted: 07/18/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND 5-aminolevulinic acid (5-ALA) - precursor of protoporphyrin IX (PpIX) - is utilized in fluorescence guided surgery (FGS) of high-grade gliomas. PpIX is used to identify traces of glioma during resection. Visual inspection of the fluorescence seems inaccurate in comparison to optic techniques such as hyperspectral imaging (HSI). AIM To characterize the limits of PpIX fluorescence detection of (i) visual evaluation and (ii) HSI analysis and to (iii) develop a classification system for visible and non-visible PpIX fluorescence. METHODS Samples with increasing concentrations (C) of PpIX and non-fluorescent controls were evaluated using a surgical microscope under blue light illumination. Similar samples were imaged with a HSI system tuned to PpIX fluorescence peak wavelength (635 nm) and control (RGB) channels. Samples' intensities were defined, leading to 96 analysed pixels after batching. RESULTS Three expert neurosurgeons assessed the PpIX samples (n = 16) and controls (n = 8) with unanimous decisions (ICC = 0.704), resulting in 63% recognition rate, 48% sensitivity, 92% specificity, 92% positive predictive value (PPV) and 47% negative predictive value (NPV). HSI image analysis, comparing mean relative values, resulted in 96%, 100%, 86%, 94%, 100%, respectively. Minimum PpIX concentration detection for experts was 0.6-1.8 μmol/l and HSI's 0.03-0.15 μmol/l. CONCLUSIONS PpIX concentrations of low-grade gliomas, and those reported on glioblastoma infiltration zones, are below experts' detection threshold. HSI analysis exceeds the performance of expert's visual inspection nearly by 20-fold. Hybrid FGS-HSI systems should be investigated in parallel to long-term outcomes. Described methods are applicable as a standard for calibration, testing and development of subvisual FGS techniques.
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Affiliation(s)
- Samu J R Lehtonen
- Neurosurgery Clinical Research Unit, Institute of Clinical Sciences, School of Medicine, Faculty of Health Sciences, UEF University of Eastern Finland, Yliopistonranta 1C, 70211, Kuopio, Finland; Microneurosurgery Photonics Research Group of The Microsurgery Center of Eastern Finland, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland.
| | - Hana Vrzakova
- Microneurosurgery Photonics Research Group of The Microsurgery Center of Eastern Finland, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland; School of Computing, UEF University of Eastern Finland, Länsikatu 15, 80110 Joensuu, Finland; Institute of Photonics, UEF University of Eastern Finland, Länsikatu 15, 80110 Joensuu, Finland
| | - Jussi J Paterno
- Ophthalmology Clinical Research Unit, Institute of Clinical Sciences, School of Medicine, Faculty of Health Sciences, UEF University of Eastern Finland, Yliopistonranta 1C, 70211 Kuopio, Finland
| | - Sami Puustinen
- Neurosurgery Clinical Research Unit, Institute of Clinical Sciences, School of Medicine, Faculty of Health Sciences, UEF University of Eastern Finland, Yliopistonranta 1C, 70211, Kuopio, Finland; Microneurosurgery Photonics Research Group of The Microsurgery Center of Eastern Finland, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
| | - Roman Bednarik
- School of Computing, UEF University of Eastern Finland, Länsikatu 15, 80110 Joensuu, Finland; Institute of Photonics, UEF University of Eastern Finland, Länsikatu 15, 80110 Joensuu, Finland
| | - Markku Hauta-Kasari
- School of Computing, UEF University of Eastern Finland, Länsikatu 15, 80110 Joensuu, Finland; Institute of Photonics, UEF University of Eastern Finland, Länsikatu 15, 80110 Joensuu, Finland
| | - Hideaki Haneishi
- Center for Frontier Medical Engineering (CFME), Chiba University, 1-33 Yayoi-cho, Inage-ku, Chiba 263-8522, Japan
| | - Arto Immonen
- Neurosurgery Clinical Research Unit, Institute of Clinical Sciences, School of Medicine, Faculty of Health Sciences, UEF University of Eastern Finland, Yliopistonranta 1C, 70211, Kuopio, Finland; Microneurosurgery Photonics Research Group of The Microsurgery Center of Eastern Finland, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland; Eastern Finland Neuro-Oncology Group, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
| | - Juha E Jääskeläinen
- Neurosurgery Clinical Research Unit, Institute of Clinical Sciences, School of Medicine, Faculty of Health Sciences, UEF University of Eastern Finland, Yliopistonranta 1C, 70211, Kuopio, Finland; Microneurosurgery Photonics Research Group of The Microsurgery Center of Eastern Finland, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland; Eastern Finland Neuro-Oncology Group, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
| | - Olli-Pekka Kämäräinen
- Neurosurgery Clinical Research Unit, Institute of Clinical Sciences, School of Medicine, Faculty of Health Sciences, UEF University of Eastern Finland, Yliopistonranta 1C, 70211, Kuopio, Finland; Microneurosurgery Photonics Research Group of The Microsurgery Center of Eastern Finland, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland; Eastern Finland Neuro-Oncology Group, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
| | - Antti-Pekka Elomaa
- Neurosurgery Clinical Research Unit, Institute of Clinical Sciences, School of Medicine, Faculty of Health Sciences, UEF University of Eastern Finland, Yliopistonranta 1C, 70211, Kuopio, Finland; Microneurosurgery Photonics Research Group of The Microsurgery Center of Eastern Finland, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland; Eastern Finland Neuro-Oncology Group, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
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Intraoperative 5-ALA fluorescence-guided resection of high-grade glioma leads to greater extent of resection with better outcomes: a systematic review. J Neurooncol 2022; 156:233-256. [PMID: 34989964 DOI: 10.1007/s11060-021-03901-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/12/2021] [Indexed: 12/13/2022]
Abstract
IMPORTANCE High-grade gliomas (HGG) are the most aggressive and common malignant brain tumors in adults. They have a dismally fatal prognosis. Even if gross total resection of the enhancing tumor is achieved, inevitably, invading tumor cells that are indistinguishable to the un-aided eye are left behind, which eventually leads to tumor recurrence. 5-aminolevulinic acid (5-ALA) is an increasingly utilized intraoperative fluorescent imaging agent for patients with HGG. It enhances visualization of HGG tissue. Despite early promising randomized clinical trial data suggesting a survival benefit for 5-ALA-guided surgery, the growing body of literature must be analyzed to confirm efficacy on patient outcomes. OBJECTIVE To perform a systematic review of the literature to evaluate whether there is a beneficial effect upon survival and extent of resection due to the utilization of 5-ALA in HGG surgery. EVIDENCE REVIEW Literature regarding 5-ALA usage in HGG surgery was reviewed according to the PRISMA guidelines. Two databases, PubMed and SCOPUS, were searched for assorted combinations of the keywords "5-ALA," "high-grade glioma," "5-aminolevulinic acid," and "resection" in July 2020 for case reports and retrospective, prospective, and randomized clinical trials assessing and analyzing 5-ALA intraoperative use in patients with HGG. Entailed studies on PubMed and SCOPUS were found for screening using a snowball search technique upon the initially searched papers. Systematic reviews and meta-analyses were excluded from our PRISMA table. FINDINGS 3756 previously published studies were screened, 536 of which were further evaluated, and ultimately 45 were included in our systematic review. There were no date restrictions on the screened publications. Our literature search was finalized on July 16, 2020. We found an observed increase in the overall survival (OS) and progression-free survival (PFS) of the 5-ALA group compared to the white light group, as well as an observed increase in the OS and PFS of complete resections compared to incomplete resections. Of the studies that directly compared the use of 5-ALA to white light (13 of the total analyzed 45, or 28.9%), 5-ALA lead to a better PFS and OS in 88.4 and 67.5% of patients, respectively. When the studies that reported postoperative neurologic outcomes of surgeries using 5-ALA vs. white light were analyzed, 42.2% of subjects demonstrated 5-ALA use was associated with less post-op neurological deficits, whereas 34.5% demonstrated no difference between 5-ALA and without. 23.3% of studies showed that intraoperative 5-ALA guided surgeries lead to more post-op neurological deficits. CONCLUSIONS AND RELEVANCE Utilization of 5-ALA was found to be associated with a greater extent of resection in HGG surgeries, as well as longer OS and PFS. Postop neurologic deficit rates were mixed and inconclusive when comparing 5-ALA groups to white light groups. 5-ALA is a useful surgical adjunct for resection of HGG when patient safety is preserved.
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Shi X, Zhang Z, Zhang Z, Cao C, Cheng Z, Hu Z, Tian J, Ji N. Near-infrared window II fluorescence image-guided surgery of high-grade gliomas prolongs the progression-free survival of patients. IEEE Trans Biomed Eng 2021; 69:1889-1900. [PMID: 34818184 DOI: 10.1109/tbme.2021.3130195] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE This translational study aims to investigate the clinical benefits of indocyanine green (ICG) based near-infrared window II (NIR-II) fluorescence image-guided surgery (FGS) on high-grade glioma (HGG) patients. METHODS Patients were randomly assigned to receive FGS or traditional white light image-guided surgery (WLS). The detection rate of NIR-II fluorescence was observed. Complete resection rate, progression-free survival (PFS), overall survival (OS), and neurological status were compared. Tissue samples were obtained from the FGS group, with the diagnosis based on the surgeons and the fluorescence recorded for comparison of diagnostic capability. Patients with WHO grade III gliomas or glioblastomas (GBM) were analyzed separately. RESULTS 15 GBM and 4 WHO grade III glioma patients in the FGS group and 18 GBM and 4 WHO grade III glioma patients in the WLS group were enrolled. The detection rate of NIR-II fluorescence was 100% for GBM. The complete resection rate was significantly increased by the FGS for GBM (FGS, 100% [95% CI 73.41-100] vs. WLS, 50% [95% CI 29.03-70.97], P = 0.0036). The PFS and OS of the FGS group were also significantly prolonged (Median PFS: FGS, 9.0 months vs. WLS, 7.0 months, P < 0.0001; Median OS: FGS, 19.0 months vs. WLS, 15.5 months, P = 0.0002). No recurrence was observed in WHO grade III glioma patients. CONCLUSIONS NIR-II FGS achieves much better complete resection rate of GBM than conventional WLS, leading to greatly improved survival of GBM patients. SIGNIFICANCE NIR-II FGS is a highly promising technique worthy of exploring more clinical applications.
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Brognaro E. The inverse paradigm and the ancestral cell of IDH-wildtype glioblastoma. Clin Transl Oncol 2021; 24:13-23. [PMID: 34152549 DOI: 10.1007/s12094-021-02663-0] [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: 03/30/2021] [Accepted: 06/04/2021] [Indexed: 11/30/2022]
Abstract
Rethinking IDH-wildtype glioblastoma through its unique features can help researchers find innovative and effective treatments. It is currently emerging that, after decades of therapeutic impasse, some traditional concepts regarding IDH-wildtype glioblastoma need to be supplemented and updated to overcome therapeutic resistance. Indeed, multiple clinical aspects and recent indirect and direct experimental data are providing evidence that the supratentorial brain parenchyma becomes entirely and quiescently micro-infiltrated long before primary tumor bulk growth. Furthermore, they are indicating that the known micro-infiltration that occurs during the IDH-wildtype glioblastoma growth and evolution is not at the origin of distant relapses. It follows that the ubiquitous supratentorial brain parenchyma micro-infiltration as a source for the development of widespread distant recurrences is actually due to the silent stage that precedes tumor growth rather than to the latter. All this implies that, in addition to the heterogeneity of the primary bulk, there is a second crucial cause of therapeutic resistance that has never hitherto been identified and challenged. In this regard, the ancestral founder cancer stem cell (CSC) appears as the key cell that can link the two causes of resistance.
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Affiliation(s)
- Enrico Brognaro
- Department of Neurosurgery, S. Maria della Misericordia Hospital, Viale Tre Martiri, 45100, Rovigo, Italy.
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Baig Mirza A, Christodoulides I, Lavrador JP, Giamouriadis A, Vastani A, Boardman T, Ahmed R, Norman I, Murphy C, Devi S, Vergani F, Gullan R, Bhangoo R, Ashkan K. 5-Aminolevulinic acid-guided resection improves the overall survival of patients with glioblastoma-a comparative cohort study of 343 patients. Neurooncol Adv 2021; 3:vdab047. [PMID: 34131646 PMCID: PMC8193902 DOI: 10.1093/noajnl/vdab047] [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] [Indexed: 12/24/2022] Open
Abstract
Background 5-Aminolevulic acid-guided surgery (5-ALA-GS) improves the extent of resection (EoR) and progression-free survival in patients with glioblastoma multiforme (GBM). Methods A single-center retrospective cohort study of adult patients with GBM who had surgical resection between 2013 and 2019, 5-ALA guided versus a non-5-ALA cohort. The primary outcome was the overall survival (OS). Secondary outcomes were EoR, performance status (PS), and new focal neurological deficit. Results Three hundred and forty-three patients were included: 253 patients in 5-ALA-GS group and 90 patients in the non-5-ALA-GS group. The OS (17.47 vs 10.63 months, P < .0001), postoperative PS (P < .0001), PS at 6 months (P = .002), new focal neurological deficit (23.3% vs 44.9%, P < .0001), and radiological EoR (gross total resection [GTR]-47.4% vs 22.9%, P < .0001) were significantly better in the 5-ALA-GS group compared to non-5-ALA-GS group. In multivariate analysis, use of 5-ALA (P = .003) and MGMT promoter methylation (P = .001) were significantly related with a better OS. In patients with radiological GTR, OS was also significantly better (P < .0001) in the 5-ALA-GS group compared to the non-5-ALA-GS group. Conclusions 5-ALA-GS is associated with a significant improvement in the OS, PS after surgery and at 6 months, larger EoR, and fewer new motor deficits in patients with GBM.
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Affiliation(s)
- Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Jose Pedro Lavrador
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Amisha Vastani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Timothy Boardman
- GKT School of Medical Education, King's College London, London, UK
| | - Razna Ahmed
- GKT School of Medical Education, King's College London, London, UK
| | - Irena Norman
- GKT School of Medical Education, King's College London, London, UK
| | - Christopher Murphy
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Sharmila Devi
- GKT School of Medical Education, King's College London, London, UK
| | - Francesco Vergani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Richard Gullan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Ranjeev Bhangoo
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
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Nagaraja TN, Lee IY. Cerebral microcirculation in glioblastoma: A major determinant of diagnosis, resection, and drug delivery. Microcirculation 2021; 28:e12679. [PMID: 33474805 DOI: 10.1111/micc.12679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/12/2021] [Indexed: 12/25/2022]
Abstract
Glioblastoma (GBM) is the most common primary brain tumor with a dismal prognosis. Current standard of treatment is safe maximal tumor resection followed by chemotherapy and radiation. Altered cerebral microcirculation and elevated blood-tumor barrier (BTB) permeability in tumor periphery due to glioma-induced vascular dysregulation allow T1 contrast-enhanced visualization of resectable tumor boundaries. Newer tracers that label the tumor and its vasculature are being increasingly used for intraoperative delineation of glioma boundaries for even more precise resection. Fluorescent 5-aminolevulinic acid (5-ALA) and indocyanine green (ICG) are examples of such intraoperative tracers. Recently, magnetic resonance imaging (MRI)-based MR thermometry is being employed for laser interstitial thermal therapy (LITT) for glioma debulking. However, aggressive, fatal recurrence always occurs. Postsurgical chemotherapy is hampered by the inability of most drugs to cross the blood-brain barrier (BBB). Understanding postsurgical changes in brain microcirculation and permeability is crucial to improve chemotherapy delivery. It is important to understand whether any microcirculatory indices can differentiate between true recurrence and radiation necrosis. LITT leads to peri-ablation BBB opening that persists for several weeks. Whether it can be a conduit for chemotherapy delivery is yet to be explored. This review will address the role of cerebral microcirculation in such emerging ideas in GBM diagnosis and therapy.
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Affiliation(s)
| | - Ian Y Lee
- Department of Neurosurgery, Henry Ford Hospital, Detroit, MI, USA
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Manini I, Caponnetto F, Dalla E, Ius T, Pepa GMD, Pegolo E, Bartolini A, Rocca GL, Menna G, Loreto CD, Olivi A, Skrap M, Sabatino G, Cesselli D. Heterogeneity Matters: Different Regions of Glioblastoma Are Characterized by Distinctive Tumor-Supporting Pathways. Cancers (Basel) 2020; 12:cancers12102960. [PMID: 33066172 PMCID: PMC7601979 DOI: 10.3390/cancers12102960] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/09/2020] [Accepted: 10/09/2020] [Indexed: 12/22/2022] Open
Abstract
Simple Summary 5-ALA Fluorescence Guided Surgery aims at extending the boundaries of glioblastoma (GBM) resection. It is based on the use of a fluorescent dye, 5-aminolevulinic acid (5-ALA). Depending on the fluorescence levels, it is possible to distinguish the core of the tumor, the infiltrating borders and the healthy tissue. Since GBM progression is supported by tumor cells and their interaction with the surrounding microenvironment, we hypothesized that 5-ALA intensity could identify microenvironments with different tumor supporting properties. Taking advantage of glioma-associated stem cells; a human in vitro model of the glioma microenvironment, we demonstrate that all regions of the tumor support the tumor growth, but through different pathways. This study highlights the importance of understanding the TME to obtain key information on GBM biology and develop new therapeutic approaches. Abstract The glioblastoma microenvironment plays a substantial role in glioma biology. However, few studies have investigated its spatial heterogeneity. Exploiting 5-ALA Fluorescence Guided Surgery (FGS), we were able to distinguish between the tumor core (ALA+), infiltrating area (ALA-PALE) and healthy tissue (ALA−) of the glioblastoma, based on the level of accumulated fluorescence. The aim of this study was to investigate the properties of the microenvironments associated with these regions. For this purpose, we isolated glioma-associated stem cells (GASC), resident in the glioma microenvironment, from ALA+, ALA-PALE and ALA− samples and compared them in terms of growth kinetic, phenotype and for the expression of 84 genes associated with cancer inflammation and immunity. Differentially expressed genes were correlated with transcriptomic datasets from TCGA/GTEX. Our results show that GASC derived from the three distinct regions, despite a similar phenotype, were characterized by different transcriptomic profiles. Moreover, we identified a GASC-based genetic signature predictive of overall survival and disease-free survival. This signature, highly expressed in ALA+ GASC, was also well represented in ALA PALE GASC. 5-ALA FGS allowed to underline the heterogeneity of the glioma microenvironments. Deepening knowledge of these differences can contribute to develop new adjuvant therapies targeting the crosstalk between tumor and its supporting microenvironment.
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Affiliation(s)
- Ivana Manini
- Institute of Pathology, University Hospital of Udine, 33100 Udine, Italy; (E.P.); (A.B.); (C.D.L.); (D.C.)
- Correspondence:
| | - Federica Caponnetto
- Department of Medicine, University of Udine, 33100 Udine, Italy; (F.C.); (E.D.)
| | - Emiliano Dalla
- Department of Medicine, University of Udine, 33100 Udine, Italy; (F.C.); (E.D.)
| | - Tamara Ius
- Neurosurgery Unit, Department of Neurosciences, University Hospital of Udine, 33100 Udine, Italy; (T.I.); (M.S.)
| | - Giuseppe Maria Della Pepa
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, 00168 Rome, Italy; (G.M.D.P.); (G.L.R.); (G.M.); (A.O.); (G.S.)
| | - Enrico Pegolo
- Institute of Pathology, University Hospital of Udine, 33100 Udine, Italy; (E.P.); (A.B.); (C.D.L.); (D.C.)
| | - Anna Bartolini
- Institute of Pathology, University Hospital of Udine, 33100 Udine, Italy; (E.P.); (A.B.); (C.D.L.); (D.C.)
| | - Giuseppe La Rocca
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, 00168 Rome, Italy; (G.M.D.P.); (G.L.R.); (G.M.); (A.O.); (G.S.)
- Department of Neurosurgery, Mater Olbia Hospital, 07026 Olbia, Italy
| | - Grazia Menna
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, 00168 Rome, Italy; (G.M.D.P.); (G.L.R.); (G.M.); (A.O.); (G.S.)
| | - Carla Di Loreto
- Institute of Pathology, University Hospital of Udine, 33100 Udine, Italy; (E.P.); (A.B.); (C.D.L.); (D.C.)
- Department of Medicine, University of Udine, 33100 Udine, Italy; (F.C.); (E.D.)
| | - Alessandro Olivi
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, 00168 Rome, Italy; (G.M.D.P.); (G.L.R.); (G.M.); (A.O.); (G.S.)
| | - Miran Skrap
- Neurosurgery Unit, Department of Neurosciences, University Hospital of Udine, 33100 Udine, Italy; (T.I.); (M.S.)
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, 00168 Rome, Italy; (G.M.D.P.); (G.L.R.); (G.M.); (A.O.); (G.S.)
- Department of Neurosurgery, Mater Olbia Hospital, 07026 Olbia, Italy
| | - Daniela Cesselli
- Institute of Pathology, University Hospital of Udine, 33100 Udine, Italy; (E.P.); (A.B.); (C.D.L.); (D.C.)
- Department of Medicine, University of Udine, 33100 Udine, Italy; (F.C.); (E.D.)
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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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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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Ji SY, Kim JW, Park CK. Experience Profiling of Fluorescence-Guided Surgery I: Gliomas. Brain Tumor Res Treat 2019; 7:98-104. [PMID: 31686440 PMCID: PMC6829086 DOI: 10.14791/btrt.2019.7.e38] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 07/23/2019] [Accepted: 08/06/2019] [Indexed: 12/21/2022] Open
Abstract
Background Numerous studies reported a usefulness of 5-aminolevulinic acid (5-ALA) fluorescence-guided surgery (FGS) in high grade gliomas. However, fluorescence patterns and intensities are variable among gliomas. In this study, we report our extensive experience with FGS in various gliomas, focusing on epidemiological data of fluorescence patterns. Methods A total of 827 histologically proven glioma patients out of 900 brain tumor patients who had undergone FGS using 5-ALA during the period of 8.5 years between July 2010 and January 2019 were analyzed. Indications of FGS in glioma surgery are evidence for possible high-grade foci in putative gliomas in preoperative MRI. Results Among the 827 gliomas, the number of cases corresponding to 2016 World Health Organization (WHO) grade IV, III, II, and I are 528 (58.7%), 193 (21.4%), 87 (9.7%) and 19 (2.1%), respectively. In terms of fluorescence rate, grade IV gliomas showed positive fluorescence in 95.4% of cases including strong intensity in 85.6%. Grade III gliomas showed fluorescence in about half of cases (55.0%), but 45.0% of the cases showed no fluorescence at all. Anaplastic oligodendroglioma had a higher positive rate (63.9%) than anaplastic astrocytoma (46.2%). Both grade II and I gliomas still showed positive fluorescence in about one-fourth of cases (24.1% and 26.3% respectively). Among them ependymoma and pilocytic astrocytoma were fluorescence-prone tumors. Conclusion This epidemiological data of 5-ALA fluorescence in various grades of glioma provides a basic reference to the clinical application of FGS with 5-ALA in glioma surgery.
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Affiliation(s)
- So Young Ji
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Jin Wook Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chul Kee Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.
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The impact of 5-aminolevulinic acid on extent of resection in newly diagnosed high grade gliomas: a systematic review and single institutional experience. J Neurooncol 2018; 141:507-515. [DOI: 10.1007/s11060-018-03061-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 11/24/2018] [Indexed: 12/12/2022]
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