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Rauf SA, Ahmed R, Hussain T, Saad M, Shah HH, Jamalvi SA, Yogeeta F, Devi M, Subash A, Gul M, Ahmed S, Haque MA. Fluorescence in neurosurgery: its therapeutic and diagnostic significance - a comprehensive review. Ann Med Surg (Lond) 2024; 86:4255-4261. [PMID: 38989178 PMCID: PMC11230751 DOI: 10.1097/ms9.0000000000002218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/15/2024] [Indexed: 07/12/2024] Open
Abstract
This review provides a comprehensive overview of the therapeutic and diagnostic implications of fluorescence imaging in neurosurgery. Fluorescence imaging has become a valuable intraoperative visualization and guidance tool, facilitating precise surgical interventions. The therapeutic role of fluorescence is examined, including its application in photodynamic therapy and tumor-targeted therapy. It also explores its diagnostic capabilities in tumor detection, margin assessment, and blood-brain barrier evaluation. Drawing from clinical and preclinical studies, the review underscores the growing evidence supporting the efficacy of fluorescence imaging in neurosurgical practice. Furthermore, it discusses current limitations and future directions, emphasizing the potential for emerging technologies to enhance the utility and accessibility of fluorescence imaging, ultimately improving patient outcomes in neurosurgery.
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Affiliation(s)
| | | | - Tooba Hussain
- Dow University of Health Sciences, Karachi, Pakistan
| | | | | | | | | | | | - Arun Subash
- Dow University of Health Sciences, Karachi, Pakistan
| | - Maryam Gul
- Dow University of Health Sciences, Karachi, Pakistan
| | - Shaheer Ahmed
- Dow University of Health Sciences, Karachi, Pakistan
| | - Md Ariful Haque
- Department of Public Health, Atish Dipankar University of Science and Technology
- Voice of Doctors Research School, Dhaka, Bangladesh
- Department of Orthopaedic Surgery, Yan'an Hospital Affiliated to Kunming Medical University, Kunming, Yunnan, People's Republic of China
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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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Yang M, Wei Y, Reineck P, Ebendorff-Heidepriem H, Li J, McLaughlin RA. Development of a glass-based imaging phantom to model the optical properties of human tissue. BIOMEDICAL OPTICS EXPRESS 2024; 15:346-359. [PMID: 38223187 PMCID: PMC10783914 DOI: 10.1364/boe.504774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/30/2023] [Accepted: 12/03/2023] [Indexed: 01/16/2024]
Abstract
The fabrication of a stable, reproducible optical imaging phantom is critical to the assessment and optimization of optical imaging systems. We demonstrate the use of an alternative material, glass, for the development of tissue-mimicking phantoms. The glass matrix was doped with nickel ions to approximate the absorption of hemoglobin. Scattering levels representative of human tissue were induced in the glass matrix through controlled crystallization at elevated temperatures. We show that this type of glass is a viable material for creating tissue-mimicking optical phantoms by providing controlled levels of scattering and absorption with excellent optical homogeneity, long-term stability and reproducibility.
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Affiliation(s)
- Mingze Yang
- School of Biomedicine, The University of Adelaide, Adelaide, SA, Australia
- Institute for Photonics and Advanced Sensing, The University of Adelaide, Adelaide, SA, Australia
| | - Yunle Wei
- Institute for Photonics and Advanced Sensing, The University of Adelaide, Adelaide, SA, Australia
- School of Physics, Chemistry and Earth Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Philipp Reineck
- School of Science, RMIT University, Melbourne, VIC, Australia
| | - Heike Ebendorff-Heidepriem
- Institute for Photonics and Advanced Sensing, The University of Adelaide, Adelaide, SA, Australia
- School of Physics, Chemistry and Earth Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Jiawen Li
- Institute for Photonics and Advanced Sensing, The University of Adelaide, Adelaide, SA, Australia
- School of Electrical and Mechanical Engineering, The University of Adelaide, Adelaide, SA, Australia
| | - Robert A. McLaughlin
- School of Biomedicine, The University of Adelaide, Adelaide, SA, Australia
- Institute for Photonics and Advanced Sensing, The University of Adelaide, Adelaide, SA, Australia
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Ochoa MI, Ruiz A, LaRochelle E, Reed M, Berber E, Poultsides G, Pogue BW. Assessment of open-field fluorescence guided surgery systems: implementing a standardized method for characterization and comparison. JOURNAL OF BIOMEDICAL OPTICS 2023; 28:096007. [PMID: 37745774 PMCID: PMC10513724 DOI: 10.1117/1.jbo.28.9.096007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 09/26/2023]
Abstract
Significance Fluorescence guided surgery (FGS) has demonstrated improvements in decision making and patient outcomes for a wide range of surgical procedures. Not only can FGS systems provide a higher level of structural perfusion accuracy in tissue reconstruction cases but they can also serve for real-time functional characterization. Multiple FGS devices have been Food and Drug administration (FDA) cleared for use in open and laparoscopic surgery. Despite the rapid growth of the field, there has been a lack standardization methods. Aim This work overviews commonalities inherent to optical imaging methods that can be exploited to produce such a standardization procedure. Furthermore, a system evaluation pipeline is proposed and executed through the use of photo-stable indocyanine green fluorescence phantoms. Five different FDA-approved open-field FGS systems are used and evaluated with the proposed method. Approach The proposed pipeline encompasses the following characterization: (1) imaging spatial resolution and sharpness, (2) sensitivity and linearity, (3) imaging depth into tissue, (4) imaging system DOF, (5) uniformity of illumination, (6) spatial distortion, (7) signal to background ratio, (8) excitation bands, and (9) illumination wavelength and power. Results The results highlight how such a standardization approach can be successfully implemented for inter-system comparisons as well as how to better understand essential features within each FGS setup. Conclusions Despite clinical use being the end goal, a robust yet simple standardization pipeline before clinical trials, such as the one presented herein, should benefit regulatory agencies, manufacturers, and end-users to better assess basic performance and improvements to be made in next generation FGS systems.
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Affiliation(s)
- Marien I. Ochoa
- University of Wisconsin Madison, Department of Medical Physics, Madison, Wisconsin, United States
| | - Alberto Ruiz
- QUEL Imaging, White River Junction, Vermont, United States
| | | | - Matthew Reed
- University of Wisconsin Madison, Department of Medical Physics, Madison, Wisconsin, United States
| | - Eren Berber
- Cleveland Clinic - Marymount Hospital, Garfield Heights, Ohio, United States
| | - George Poultsides
- Stanford Medicine, Department of Surgery, Stanford, California, United States
| | - Brian W. Pogue
- University of Wisconsin Madison, Department of Medical Physics, Madison, Wisconsin, United States
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Marois M, Olson JD, Wirth DJ, Elliott JT, Fan X, Davis SC, Paulsen KD, Roberts DW. A birefringent spectral demultiplexer enables fast hyper-spectral imaging of protoporphyrin IX during neurosurgery. Commun Biol 2023; 6:341. [PMID: 36991092 PMCID: PMC10060426 DOI: 10.1038/s42003-023-04701-9] [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: 02/02/2022] [Accepted: 03/13/2023] [Indexed: 03/31/2023] Open
Abstract
Hyperspectral imaging and spectral analysis quantifies fluorophore concentration during fluorescence-guided surgery1-6. However, acquisition of the multiple wavelengths required to implement these methods can be time-consuming and hinder surgical workflow. To this end, a snapshot hyperspectral imaging system capable of acquiring 64 channels of spectral data simultaneously was developed for rapid hyperspectral imaging during neurosurgery. The system uses a birefringent spectral demultiplexer to split incoming light and redirect wavelengths to different sections of a large format microscope sensor. Its configuration achieves high optical throughput, accepts unpolarized input light and exceeds channel count of prior image-replicating imaging spectrometers by 4-fold. Tissue-simulating phantoms consisting of serial dilutions of the fluorescent agent characterize system linearity and sensitivity, and comparisons to performance of a liquid crystal tunable filter based hyperspectral imaging device are favorable. The new instrument showed comparable, if not improved, sensitivity at low fluorophore concentrations; yet, acquired wide-field images at more than 70-fold increase in frame rate. Image data acquired in the operating room during human brain tumor resection confirm these findings. The new device is an important advance in achieving real-time quantitative imaging of fluorophore concentration for guiding surgery.
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Affiliation(s)
- Mikael Marois
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | - Jonathan D Olson
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | - Dennis J Wirth
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
- Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Jonathan T Elliott
- Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
- Dartmouth-Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Xiaoyao Fan
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | - Scott C Davis
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | - Keith D Paulsen
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA.
- Geisel School of Medicine, Dartmouth College, Hanover, NH, USA.
| | - David W Roberts
- Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
- Dartmouth-Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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6
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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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Bernstock JD, Gary SE, Klinger N, Valdes PA, Ibn Essayed W, Olsen HE, Chagoya G, Elsayed G, Yamashita D, Schuss P, Gessler FA, Peruzzi PP, Bag A, Friedman GK. Standard clinical approaches and emerging modalities for glioblastoma imaging. Neurooncol Adv 2022; 4:vdac080. [PMID: 35821676 PMCID: PMC9268747 DOI: 10.1093/noajnl/vdac080] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Glioblastoma (GBM) is the most common primary adult intracranial malignancy and carries a dismal prognosis despite an aggressive multimodal treatment regimen that consists of surgical resection, radiation, and adjuvant chemotherapy. Radiographic evaluation, largely informed by magnetic resonance imaging (MRI), is a critical component of initial diagnosis, surgical planning, and post-treatment monitoring. However, conventional MRI does not provide information regarding tumor microvasculature, necrosis, or neoangiogenesis. In addition, traditional MRI imaging can be further confounded by treatment-related effects such as pseudoprogression, radiation necrosis, and/or pseudoresponse(s) that preclude clinicians from making fully informed decisions when structuring a therapeutic approach. A myriad of novel imaging modalities have been developed to address these deficits. Herein, we provide a clinically oriented review of standard techniques for imaging GBM and highlight emerging technologies utilized in disease characterization and therapeutic development.
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Affiliation(s)
- Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Sam E Gary
- Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham , AL, USA
| | - Neil Klinger
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Pablo A Valdes
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Walid Ibn Essayed
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Hannah E Olsen
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Gustavo Chagoya
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , AL, USA
| | - Galal Elsayed
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , AL, USA
| | - Daisuke Yamashita
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , AL, USA
| | - Patrick Schuss
- Department of Neurosurgery, Unfallkrankenhaus Berlin , Berlin, Germany
| | | | - Pier Paolo Peruzzi
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Asim Bag
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital , Memphis, TN USA
| | - Gregory K Friedman
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , AL, USA
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham , Birmingham, AL, USA
- Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham , AL, USA
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Tucker M, Lacayo M, Joseph S, Ross W, Chongsathidkiet P, Fecci P, Codd PJ. Creation of Non-Contact Device for Use in Metastatic Melanoma Margin Identification in ex vivo Mouse Brain. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2022; 11945:1194507. [PMID: 35619993 PMCID: PMC9131976 DOI: 10.1117/12.2608975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Because contemporary intraoperative tumor detection modalities, such as intraoperative MRI, are not ubiquitously available and can disrupt surgical workflow, there is an imperative for an accessible diagnostic device that can meet the surgeon's needs in identifying tissue types. The objective of this paper is to determine the efficacy of a novel non-contact tumor detection device for metastatic melanoma boundary identification in a tissue-mimicking phantom, evaluate the identification of metastatic melanoma boundaries in ex vivo mouse brain tissue, and find the error associated with identifying this boundary. To validate the spatial and fluorescence resolution of the device, tissue-mimicking phantoms were created with modifiable optical properties. Phantom tissue provided ground truth measurements for fluorophore concentration differences with respect to spatial dimensions. Modeling metastatic disease, ex vivo melanoma brain metastases were evaluated to detect differences in fluorescence between healthy and neoplastic tissue. This analysis includes determining required-to-observe fluorescence differences in tissue. H&E staining confirmed tumor presence in mouse tissue samples. The device detected a difference in normalized average fluorescence intensity in all three phantoms. There were differences in fluorescence with the presence and absence of melanin. The estimated tumor boundary of all tissue phantoms was within 0.30 mm of the ground truth tumor boundary for all boundaries. Likewise, when applied to the melanoma-bearing brains from ex vivo mice, a difference in normalized fluorescence intensity was successfully detected. The potential prediction window for the tumor boundary location is less than 1.5 mm for all ex vivo mouse brain tumors boundaries. We present a non-contact, laser-induced fluorescence device that can identify tumor boundaries based on changes in laser-induced fluorescence emission intensity. The device can identify phantom ground truth tumor boundaries within 0.30 mm using instantaneous rate of change of normalized fluorescence emission intensity and can detect endogenous fluorescence differences in melanoma brain metastases in ex vivo mouse tissue.
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Affiliation(s)
- Matthew Tucker
- Duke University, Department of Mechanical Engineering and Materials Science, Durham, NC, USA
| | - Matthew Lacayo
- Duke University School of Medicine, Department of Neurosurgery, Durham, NC, USA
| | | | - Weston Ross
- Duke University, Department of Mechanical Engineering and Materials Science, Durham, NC, USA
- Duke University School of Medicine, Department of Neurosurgery, Durham, NC, USA
| | | | - Peter Fecci
- Duke University School of Medicine, Department of Neurosurgery, Durham, NC, USA
| | - Patrick J Codd
- Duke University, Department of Mechanical Engineering and Materials Science, Durham, NC, USA
- Duke University School of Medicine, Department of Neurosurgery, Durham, NC, USA
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Abramov I, Dru AB, Belykh E, Park MT, Bardonova L, Preul MC. Redosing of Fluorescein Sodium Improves Image Interpretation During Intraoperative Ex Vivo Confocal Laser Endomicroscopy of Brain Tumors. Front Oncol 2021; 11:668661. [PMID: 34660258 PMCID: PMC8514872 DOI: 10.3389/fonc.2021.668661] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 09/13/2021] [Indexed: 12/15/2022] Open
Abstract
Background Fluorescein sodium (FNa) is a fluorescence agent used with a wide-field operating microscope for intraoperative guidance and with confocal laser endomicroscopy (CLE) to evaluate brain tissue. Susceptibility of FNa to degradation over time may affect CLE image quality during prolonged surgeries. This study describes improved characteristics of CLE images after intraoperative redosing with FNa. Methods A retrospective analysis was performed using CLE images obtained ex vivo from samples obtained during tumor resections with FNa-based fluorescence guidance with a wide-field operating microscope. The comparison groups included CLE images acquired after FNa redosing (redose imaging group), images from the same patients acquired after the initial FNa dose (initial-dose imaging group), and images from patients in whom redosing was not used (single-dose imaging group). A detailed assessment of image quality and interpretation regarding different FNa dosage and timing of imaging after FNa administration was conducted for all comparison groups. Results The brightest and most contrasting images were observed in the redose group compared to the initial-dose and single-dose groups (P<0.001). The decay of FNa signal negatively correlated with brightness (rho = -0.52, P<0.001) and contrast (rho = -0.57, P<0.001). Different doses of FNa did not significantly affect the brightness (P=0.15) or contrast (P=0.09) in CLE images. As the mean timing of imaging increased, the percentage of accurately diagnosed images decreased (P=0.03). Conclusions The decay of the FNa signal is directly associated with image brightness and contrast. The qualitative interpretation scores of images were highest for the FNa redose imaging group. Redosing with FNa to improve the utility of CLE imaging should be considered a safe and beneficial strategy during prolonged surgeries.
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Affiliation(s)
- Irakliy Abramov
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Alexander B Dru
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Evgenii Belykh
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Marian T Park
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Liudmila Bardonova
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Mark C Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
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Use of Second Window ICG in spinal cord biopsy of a mildly contrast-enhancing lesion: Technical note and review of the literature. Neurochirurgie 2021; 68:239-242. [PMID: 34102223 DOI: 10.1016/j.neuchi.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Indocyanine green (ICG) is commonly used to visualize cerebral vasculature, particularly in the management of cerebral aneurysms. There have also been attempts to use ICG for visualization of tumors. Injection of ICG followed by immediate fluorescence microscopy is limited by the short time window for imaging and administration and restricted depth of imaging. Second Window Indocyanine Green (SWIG) addresses these issues by allowing for longer contrast times and the imaging of deeper regions of brain tissue. Biopsy of spinal cord lesions is often difficult for a variety of reasons, including the delicate nature of the tissue and differentiating normal from lesional tissue visually, especially in lesions with heterogeneous enhancement. METHODS In this case report, we describe the use of second window ICG to facilitate the visualization of a spinal cord lesion and subsequent biopsy of the lesion. RESULTS This patient is a 24-year-old female who had recurrence of a suprasellar germinoma. An MRI of the rest of the neuraxis was performed to assess for the presence of drop metastases. The spinal cord from C2-5 was expanded with areas of patchy enhancement; however, this lesion was asymptomatic. The patient's oncologist requested a biopsy of this lesion to help direct subsequent care of her recurrent germinoma. The day before surgery, the patient had an intravenous injection of ICG dye. She then underwent a C3-5 laminectomy for biopsy of her cervical intramedullary lesion. After opening of the dura, no visible abnormality of the spinal cord could be identified. A Stryker endoscope showed an area of ICG uptake in the cord at approximately the C3-4 level. A midline myelotomy was centered over the ICG demarcated area and several samples were taken for pathology. Final biopsy results determined the lesion to be spinal cord parenchyma with perivascular and intraparenchymal lymphocytes - not consistent with spinal cord tumor or germinoma. CONCLUSION Second Window ICG is effective in visualizing otherwise visually unremarkable spinal cord lesions. This technology can facilitate biopsy of these lesions and possibly their surgical resection.
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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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12
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Schucht P, Lee HR, Mezouar HM, Hewer E, Raabe A, Murek M, Zubak I, Goldberg J, Kovari E, Pierangelo A, Novikova T. Visualization of White Matter Fiber Tracts of Brain Tissue Sections With Wide-Field Imaging Mueller Polarimetry. IEEE TRANSACTIONS ON MEDICAL IMAGING 2020; 39:4376-4382. [PMID: 32822294 DOI: 10.1109/tmi.2020.3018439] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Identification of white matter fiber tracts of the brain is crucial for delineating the tumor border during neurosurgery. A custom-built Mueller polarimeter was used in reflection configuration for the wide-field imaging of thick sections of fixed human brain and fresh calf brain. The maps of the azimuth of the fast optical axis of linear birefringent medium reconstructed from the experimental Mueller matrix images of the specimen by applying a non-linear data compression algorithm showed a strong correlation with the silver-stained sample histology image, which is the gold standard for ex-vivo brain fiber tract visualization. The polarimetric maps of fresh calf brain tissue demonstrated the same trends in the depolarization, the scalar retardance and the azimuth of the fast optical axis as seen in fixed human brain tissue. Thus, label-free imaging Mueller polarimetry shows promise as an efficient intra-operative modality for the visualization of healthy brain white matter fiber tracts, which could improve the accuracy of tumor border detection and, ultimately, patient outcomes.
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13
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Suero Molina E, Ewelt C, Warneke N, Schwake M, Müther M, Schipmann S, Stummer W. Dual labeling with 5-aminolevulinic acid and fluorescein in high-grade glioma surgery with a prototype filter system built into a neurosurgical microscope: technical note. J Neurosurg 2020; 132:1724-1730. [DOI: 10.3171/2018.12.jns182422] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/13/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVERecent efforts to improve visualization of 5-aminolevulinic acid (5-ALA)–induced protoporphyrin IX (PPIX) fluorescence resulted in a dual-labeling technique, combining it with fluorescein sodium in a prototype setup. Fluorescein identifies regions with blood-brain barrier breakdown in gliomas. However, normally perfused and edematous brain fluoresces unselectively, with strong background enhancement. The aim of this study was to test the feasibility of a novel, integrated filter combination using porphyrins for selective tumor identification and fluorescein for background enhancement.METHODSA microscope with a novel built-in filter system (YB 475) for visualizing both fluorescein and 5-ALA–induced porphyrins was used. Resection limits were identified with the conventional BLUE 400 filter system. Six patients harboring contrast ring-enhancing lesions were analyzed.RESULTSThe complete surgical field could now be illuminated. Fluorescein was helpful for improving background visualization, and enhancing dura, edematous tissue, and cortex. Overlapping regions with both fluorophores harbored merged orange fluorescence. PPIX fluorescence was better visualized, even in areas beyond a normal working distance of approximately 25 cm, where the BLUE 400 filters recognized no or weak fluorescence.CONCLUSIONSThe novel filter system improved general tissue brightness and background visualization, enhancing fluorescence-guided tumor resection. Furthermore, it appears promising from a scientific perspective, enabling the simultaneous and direct observation of areas with blood-brain barrier breakdown and PPIX fluorescence.
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14
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Evaluation of multi-wavelengths LED-based photoacoustic imaging for maximum safe resection of glioma: a proof of concept study. Int J Comput Assist Radiol Surg 2020; 15:1053-1062. [PMID: 32451814 DOI: 10.1007/s11548-020-02191-2] [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: 01/14/2020] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE A real-time intra-operative imaging modality is required to update the navigation systems during neurosurgery, since precise localization and safe maximal resection of gliomas are of utmost clinical importance. Different intra-operative imaging modalities have been proposed to delineate the resection borders, each with advantages and disadvantages. This preliminary study was designed to simulate the photoacoustic imaging (PAI) to illustrate the brain tumor margin vessels for safe maximal resection of glioma. METHODS In this study, light emitting diode (LED)-based PAI was selected because of its lower cost, compact size and ease of use. We developed a simulation framework based on multi-wavelength LED-based PAI to further facilitate PAI during neurosurgery. This framework considers a multilayer model of the tumoral and normal brain tissue. The simulation of the optical fluence and absorption map in tissue at different depths was computed by Monte Carlo. Then, the propagation of initial photoacoustic pressure was simulated by using k-wave toolbox. RESULTS To evaluate the LED-based PAI, we used three evaluation criteria: signal-to-noise ratio (SNR), contrast ratio (CR) and full width of half maximum (FWHM). Results showed that by using proper wavelengths, the vessels were recovered with the same axial and lateral FWHM. Furthermore, by increasing the wavelength from 532 to 1064 nm, SNR and CR were increased in the deep region. The results showed that vessels with larger diameters at same wavelength have a higher CR with average improvement 28%. CONCLUSION Multi-wavelength LED-based PAI provides detailed images of the blood vessels which are crucial for detection of the residual glioma: The longer wavelengths like 1064 nm can be used for the deeper tumor margins, and the shorter wavelengths like 532 nm for tumor margins closer to the surface. LED-based PAI may be considered as a promising intra-operative imaging modality to delineate tumor margins.
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15
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Luo L, Yan L, Amirshaghaghi A, Wei Y, You T, Singhal S, Tsourkas A, Cheng Z. Indocyanine Green-Coated Polycaprolactone Micelles for Fluorescence Imaging of Tumors. ACS APPLIED BIO MATERIALS 2020; 3:2344-2349. [PMID: 32455339 DOI: 10.1021/acsabm.0c00091] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Recently, near-infrared (NIR) fluorescent dyes such as indocyanine green (ICG) have received tremendous interest as contrast agents for use in fluorescence-guided, intraoperative cancer resection surgery. However, despite showing great promise, ICG has many shortcomings such as rapid clearance and poor tumor accumulation. To improve the selective accumulation of ICG within tumors, numerous groups have formulated ICG into nanoparticles, but these approaches can suffer from rapid leakage of ICG, use of materials that exhibit poor or incomplete excretion, or complex chemistries that are not easily amenable to scale up for clinical use. Here, we developed a simple one-step method to prepare ICG-based fluorescent micelles that are composed solely of unmodified ICG and polycaprolactone (PCL), two clinically used materials with well-characterized safety profiles. The ICG-PCL micelles are prepared via oil-in-water emulsions, and the resulting micelles exhibit a uniform size, good reproducibility, and high loading efficiency. In vivo fluorescence imaging demonstrated that the ICG-PCL micelles led to a significant improvement in the accumulation and retention of ICG, in four different tumor models, compared with free dye, making them an attractive option for image-guided surgery.
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Affiliation(s)
- Lijun Luo
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Lesan Yan
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Ahmad Amirshaghaghi
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Yulong Wei
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Tianyan You
- School of Agricultural Equipment Engineering, Jiangsu University, Zhenjiang, Jiangsu 212013, China
| | - Sunil Singhal
- Center for Precision Surgery, Perelman School of Medicine and Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Andrew Tsourkas
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Zhiliang Cheng
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
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16
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Alfonso-Garcia A, Bec J, Sridharan S, Hartl B, Unger J, Bobinski M, Lechpammer M, Girgis F, Boggan J, Marcu L. Real-time augmented reality for delineation of surgical margins during neurosurgery using autofluorescence lifetime contrast. JOURNAL OF BIOPHOTONICS 2020; 13:e201900108. [PMID: 31304655 PMCID: PMC7510838 DOI: 10.1002/jbio.201900108] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 07/11/2019] [Accepted: 07/11/2019] [Indexed: 05/05/2023]
Abstract
Current clinical brain imaging techniques used for surgical planning of tumor resection lack intraoperative and real-time feedback; hence surgeons ultimately rely on subjective evaluation to identify tumor areas and margins. We report a fluorescence lifetime imaging (FLIm) instrument (excitation: 355 nm; emission spectral bands: 390/40 nm, 470/28 nm, 542/50 nm and 629/53 nm) that integrates with surgical microscopes to provide real-time intraoperative augmentation of the surgical field of view with fluorescent derived parameters encoding diagnostic information. We show the functionality and safety features of this instrument during neurosurgical procedures in patients undergoing craniotomy for the resection of brain tumors and/or tissue with radiation damage. We demonstrate in three case studies the ability of this instrument to resolve distinct tissue types and pathology including cortex, white matter, tumor and radiation-induced necrosis. In particular, two patients with effects of radiation-induced necrosis exhibited longer fluorescence lifetimes and increased optical redox ratio on the necrotic tissue with respect to non-affected cortex, and an oligodendroglioma resected from a third patient reported shorter fluorescence lifetime and a decrease in optical redox ratio than the surrounding white matter. These results encourage the use of FLIm as a label-free and non-invasive intraoperative tool for neurosurgical guidance.
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Affiliation(s)
- Alba Alfonso-Garcia
- Dept. Biomedical Engineering, University of California, Davis, California, United States
| | - Julien Bec
- Dept. Biomedical Engineering, University of California, Davis, California, United States
| | - Shamira Sridharan
- Dept. Biomedical Engineering, University of California, Davis, California, United States
| | - Brad Hartl
- Dept. Biomedical Engineering, University of California, Davis, California, United States
| | - Jakob Unger
- Dept. Biomedical Engineering, University of California, Davis, California, United States
| | - Matthew Bobinski
- Dept. Radiology, University of California, Davis, California, United States
| | - Mirna Lechpammer
- Dept. Pathology and Laboratory Medicine, University of California, Davis, California, United States
| | - Fady Girgis
- Dept. Neurological Surgery, University of California, Davis, California, United States
| | - James Boggan
- Dept. Neurological Surgery, University of California, Davis, California, United States
| | - Laura Marcu
- Dept. Biomedical Engineering, University of California, Davis, California, United States
- Dept. Neurological Surgery, University of California, Davis, California, United States
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Foster CH, Morone PJ, Tomlinson SB, Cohen-Gadol AA. Application of Indocyanine Green During Arteriovenous Malformation Surgery: Evidence, Techniques, and Practical Pearls. Front Surg 2019; 6:70. [PMID: 31921884 PMCID: PMC6917574 DOI: 10.3389/fsurg.2019.00070] [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: 06/05/2019] [Accepted: 11/20/2019] [Indexed: 12/14/2022] Open
Abstract
Indocyanine green (ICG) is a fluorescent molecule that enables visualization of hemodynamic flow through blood vessels. The first description of its application to the resection of arteriovenous malformations (AVMs) did not occur until 2007. Since then, industry leaders have rapidly integrated this optical technology into the intraoperative microscope, and the use of ICG videoangiography (VA) has since become routine in AVM surgery among some academic centers. A number of case series have been published since the introduction of ICG VA to AVM neurosurgery. These early reports with small sample sizes were largely qualitative, assigning to the technology “usefulness” and “benefit” scores as perceived by the operators. This lack of objectivity prompted the development of FLOW 800 software, a proprietary technology of Carl Zeiss Meditec AG (Oberkochen, Germany) that can quantify relative fluorescence intensity under the microscope to generate color maps and intensity curves for ad hoc and post hoc analyses, respectively. However, subsequent case series have done little to quantify the effect of ICG VA on outcomes. The available literature predominately concludes that ICG VA, although intuitive to deploy and interpret, is limited by its dependence on direct illumination and visualization. The subcortical components of AVMs represent a natural challenge to ICG-based flow analysis, and the scope of ICG VA has therefore been limited to AVMs with a high proportion of superficial angioarchitecture. As a result, digital subtraction angiography has remained the gold standard for confirming AVM obliteration. In this review, we provide an overview of the existing literature on ICG VA in AVM resection surgery. In addition, we describe our own experiences with ICG VA and AVMs and offer the senior author's surgical pearls for optimizing the marriage of fluorescence flow technology and AVM resection surgery.
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Affiliation(s)
- Chase H Foster
- Department of Neurological Surgery, George Washington University Hospital, Washington, DC, United States
| | - Peter J Morone
- Department of Neurological Surgery, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, United States
| | - Samuel B Tomlinson
- School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY, United States
| | - Aaron A Cohen-Gadol
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University, Indianapolis, IN, United States
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18
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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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19
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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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20
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Johansen ML, Vincent J, Gittleman H, Craig SEL, Couce M, Sloan AE, Barnholtz-Sloan JS, Brady-Kalnay SM. A PTPmu Biomarker is Associated with Increased Survival in Gliomas. Int J Mol Sci 2019; 20:ijms20102372. [PMID: 31091655 PMCID: PMC6566278 DOI: 10.3390/ijms20102372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/06/2019] [Accepted: 05/09/2019] [Indexed: 12/24/2022] Open
Abstract
An integrated approach has been adopted by the World Health Organization (WHO) for diagnosing brain tumors. This approach relies on the molecular characterization of biopsied tissue in conjunction with standard histology. Diffuse gliomas (grade II to grade IV malignant brain tumors) have a wide range in overall survival, from months for the worst cases of glioblastoma (GBM) to years for lower grade astrocytic and oligodendroglial tumors. We previously identified a change in the cell adhesion molecule PTPmu in brain tumors that results in the generation of proteolytic fragments. We developed agents to detect this cell surface-associated biomarker of the tumor microenvironment. In the current study, we evaluated the PTPmu biomarker in tissue microarrays and individual tumor samples of adolescent and young adult (n = 25) and adult (n = 69) glioma populations using a fluorescent histochemical reagent, SBK4-TR, that recognizes the PTPmu biomarker. We correlated staining with clinical data and found that high levels of the PTPmu biomarker correlate with increased survival of glioma patients, including those with GBM. Patients with high PTPmu live for 48 months on average, whereas PTPmu low patients live only 22 months. PTPmu high staining indicates a doubling of patient survival. Use of the agent to detect the PTPmu biomarker would allow differentiation of glioma patients with distinct survival outcomes and would complement current molecular approaches used in glioma prognosis.
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Affiliation(s)
- Mette L Johansen
- Department of Molecular Biology and Microbiology, School of Medicine, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106-4960, USA.
| | - Jason Vincent
- Department of Molecular Biology and Microbiology, School of Medicine, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106-4960, USA.
| | - Haley Gittleman
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA.
| | - Sonya E L Craig
- Department of Molecular Biology and Microbiology, School of Medicine, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106-4960, USA.
| | - Marta Couce
- Department of Neurological Surgery, University Hospitals of Cleveland, Seidman Cancer Center and Case Comprehensive Cancer Center, School of Medicine, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA.
| | - Andrew E Sloan
- Department of Neurological Surgery, University Hospitals of Cleveland, Seidman Cancer Center and Case Comprehensive Cancer Center, School of Medicine, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA.
| | - Jill S Barnholtz-Sloan
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA.
| | - Susann M Brady-Kalnay
- Department of Molecular Biology and Microbiology, School of Medicine, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106-4960, USA.
- Department of Neurosciences, School of Medicine, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA.
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21
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5-aminolevulinic acid induced protoporphyrin IX (ALA-PpIX) fluorescence guidance in meningioma surgery. J Neurooncol 2019; 141:555-565. [PMID: 30604395 DOI: 10.1007/s11060-018-03079-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 12/12/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION 5-aminolevulinic acid induced protoporphyrin IX (5-ALA-PpIX) fluorescence guidance has emerged as a valuable surgical adjunct for resection of intracranial tumors. METHODS Here we present a focused review on 5-ALA-PpIX fluorescence guidance for meningiomas. RESULTS We discuss the clinical studies and specific applications to date as well as the two main intraoperative fluorescence technologies applied to meningiomas. CONCLUSIONS The use of 5-ALA-PpIX in meningiomas holds promising potential so neurosurgeons can improve surgical outcomes for patients with meningiomas as well as be pioneers in developing improved fluorescence imaging technologies.
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22
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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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Chang E, Patel CB, Pohling C, Young C, Song J, Flores TA, Zeng Y, Joubert LM, Arami H, Natarajan A, Sinclair R, Gambhir SS. Tumor treating fields increases membrane permeability in glioblastoma cells. Cell Death Discov 2018; 4:113. [PMID: 30534421 PMCID: PMC6281619 DOI: 10.1038/s41420-018-0130-x] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 01/04/2023] Open
Abstract
Glioblastoma is the most common yet most lethal of primary brain cancers with a one-year post-diagnosis survival rate of 65% and a five-year survival rate of barely 5%. Recently the U.S. Food and Drug Administration approved a novel fourth approach (in addition to surgery, radiation therapy, and chemotherapy) to treating glioblastoma; namely, tumor treating fields (TTFields). TTFields involves the delivery of alternating electric fields to the tumor but its mechanisms of action are not fully understood. Current theories involve TTFields disrupting mitosis due to interference with proper mitotic spindle assembly. We show that TTFields also alters cellular membrane structure thus rendering it more permeant to chemotherapeutics. Increased membrane permeability through the imposition of TTFields was shown by several approaches. For example, increased permeability was indicated through increased bioluminescence with TTFields exposure or with the increased binding and ingress of membrane-associating reagents such as Dextran-FITC or ethidium D or with the demonstration by scanning electron microscopy of augmented number and sizes of holes on the cellular membrane. Further investigations showed that increases in bioluminescence and membrane hole production with TTFields exposure disappeared by 24 h after cessation of alternating electric fields thus demonstrating that this phenomenom is reversible. Preliminary investigations showed that TTFields did not induce membrane holes in normal human fibroblasts thus suggesting that the phenomenom was specific to cancer cells. With TTFields, we present evidence showing augmented membrane accessibility by compounds such as 5-aminolevulinic acid, a reagent used intraoperatively to delineate tumor from normal tissue in glioblastoma patients. In addition, this mechanism helps to explain previous reports of additive and synergistic effects between TTFields and other chemotherapies. These findings have implications for the design of combination therapies in glioblastoma and other cancers and may significantly alter standard of care strategies for these diseases.
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Affiliation(s)
- Edwin Chang
- Molecular Imaging Program at Stanford, Department of Radiology, Stanford University School of Medicine, Room E150, 318 Campus Drive West, Stanford, CA 94305 USA
| | - Chirag B. Patel
- Molecular Imaging Program at Stanford, Department of Radiology, Stanford University School of Medicine, Room E150, 318 Campus Drive West, Stanford, CA 94305 USA
- Division of Neuro-Oncology, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA 94305 USA
| | - Christoph Pohling
- Molecular Imaging Program at Stanford, Department of Radiology, Stanford University School of Medicine, Room E150, 318 Campus Drive West, Stanford, CA 94305 USA
| | - Caroline Young
- Molecular Imaging Program at Stanford, Department of Radiology, Stanford University School of Medicine, Room E150, 318 Campus Drive West, Stanford, CA 94305 USA
| | - Jonathan Song
- Molecular Imaging Program at Stanford, Department of Radiology, Stanford University School of Medicine, Room E150, 318 Campus Drive West, Stanford, CA 94305 USA
| | - Thomas Anthony Flores
- Department of Applied Physics, Stanford University School of Medicine, Stanford, CA 94305 USA
| | - Yitian Zeng
- Department of Materials Science & Engineering, Stanford University School of Medicine, Stanford, CA 94305 USA
| | - Lydia-Marie Joubert
- Electron Microscopy Unit, Stellenbosch University, Stellenbosch, South Africa
| | - Hamed Arami
- Molecular Imaging Program at Stanford, Department of Radiology, Stanford University School of Medicine, Room E150, 318 Campus Drive West, Stanford, CA 94305 USA
| | - Arutselvan Natarajan
- Molecular Imaging Program at Stanford, Department of Radiology, Stanford University School of Medicine, Room E150, 318 Campus Drive West, Stanford, CA 94305 USA
| | - Robert Sinclair
- Department of Materials Science & Engineering, Stanford University School of Medicine, Stanford, CA 94305 USA
| | - Sanjiv S. Gambhir
- Molecular Imaging Program at Stanford, Department of Radiology, Stanford University School of Medicine, Room E150, 318 Campus Drive West, Stanford, CA 94305 USA
- Department of Materials Science & Engineering, Stanford University School of Medicine, Stanford, CA 94305 USA
- Department of Bioengineering, Stanford University School of Medicine, Stanford, CA 94305 USA
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Muller J, Muller J, Chen F, Tetzlaff R, Muller J, Bohl E, Kirsch M, Schnabel C. Registration and Fusion of Thermographic and Visual-Light Images in Neurosurgery. IEEE TRANSACTIONS ON BIOMEDICAL CIRCUITS AND SYSTEMS 2018; 12:1313-1321. [PMID: 30188838 DOI: 10.1109/tbcas.2018.2856407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
An intraoperative imaging system facilitating the localisation and characterisation of functional areas, pathological tissue, or perfusion disorders, could enormously support medical decisions during neurosurgical interventions and, thus, reduce the risk for the patients. To provide both structural and functional information of the brain tissue to the surgeon, a novel multimodal approach based on the measurement of long-wave infrared radiation and visual-light imaging is very promising. In this contribution, we discuss various methods for the registration and fusion of thermographic and visual-light images. The methods are evaluated quantitatively and qualitatively regarding their practicability during surgery. Furthermore, we introduce appropriate architectures for a digital hardware implementation of the registration and fusion algorithms. The designs are implemented on our reconfigurable intraoperative imaging system, revealing real-time processing performance.
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Pogue BW, Zhu TC, Ntziachristos V, Paulsen KD, Wilson BC, Pfefer J, Nordstrom RJ, Litorja M, Wabnitz H, Chen Y, Gioux S, Tromberg BJ, Yodh AG. Fluorescence-guided surgery and intervention - An AAPM emerging technology blue paper. Med Phys 2018; 45:2681-2688. [PMID: 29633297 PMCID: PMC9560243 DOI: 10.1002/mp.12909] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 03/18/2018] [Accepted: 03/28/2018] [Indexed: 12/10/2023] Open
Abstract
Fluorescence-guided surgery (FGS) and other interventions are rapidly evolving as a class of technologically driven interventional approaches in which many surgical specialties visualize fluorescent molecular tracers or biomarkers through associated cameras or oculars to guide clinical decisions on pathological lesion detection and excision/ablation. The technology has been commercialized for some specific applications, but also presents technical challenges unique to optical imaging that could confound the utility of some interventional procedures where real-time decisions must be made. Accordingly, the AAPM has initiated the publication of this Blue Paper of The Emerging Technology Working Group (TETAWG) and the creation of a Task Group from the Therapy Physics Committee within the Treatment Delivery Subcommittee. In describing the relevant issues, this document outlines the key parameters, stakeholders, impacts, and outcomes of clinical FGS technology and its applications. The presentation is not intended to be conclusive, but rather to inform the field of medical physics and stimulate the discussions needed in the field with respect to a seemingly low-risk imaging technology that has high potential for significant therapeutic impact. This AAPM Task Group is working toward consensus around guidelines and standards for advancing the field safely and effectively.
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Affiliation(s)
- Brian W. Pogue
- Thayer School of EngineeringDartmouth CollegeHanoverNHUSA
| | - Timothy C. Zhu
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | | | | | - Brian C. Wilson
- Department of Medical BiophysicsUniversity of TorontoTorontoONCanada
| | | | | | | | | | - Yu Chen
- Fischell Department of BioengineeringUniversity of MarylandCollege ParkMDUSA
| | - Sylvain Gioux
- Beth Israel Deaconess Medical Center Harvard Medical SchoolBostonMAUSA
| | | | - Arjun G. Yodh
- Department of PhysicsUniversity of PennsylvaniaPhiladelphiaPAUSA
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Bretonnier M, Henaux PL, Morandi X, Le Reste PJ. Fluorescein-guided resection of brain arteriovenous malformations: A short series. J Clin Neurosci 2018; 52:37-40. [DOI: 10.1016/j.jocn.2018.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 01/09/2018] [Accepted: 02/04/2018] [Indexed: 10/17/2022]
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Lee JYK, Thawani JP, Pierce J, Zeh R, Martinez-Lage M, Chanin M, Venegas O, Nims S, Learned K, Keating J, Singhal S. Intraoperative Near-Infrared Optical Imaging Can Localize Gadolinium-Enhancing Gliomas During Surgery. Neurosurgery 2017; 79:856-871. [PMID: 27741220 DOI: 10.1227/neu.0000000000001450] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Although real-time localization of gliomas has improved with intraoperative image guidance systems, these tools are limited by brain shift, surgical cavity deformation, and expense. OBJECTIVE To propose a novel method to perform near-infrared (NIR) imaging during glioma resections based on preclinical and clinical investigations, in order to localize tumors and to potentially identify residual disease. METHODS Fifteen patients were identified and administered a Food and Drug Administration-approved, NIR contrast agent (Second Window indocyanine green [ICG], 5 mg/kg) before surgical resection. An NIR camera was utilized to localize the tumor before resection and to visualize surgical margins following resection. Neuropathology and magnetic resonance imaging data were used to assess the accuracy and precision of NIR fluorescence in identifying tumor tissue. RESULTS NIR visualization of 15 gliomas (10 glioblastoma multiforme, 1 anaplastic astrocytoma, 2 low-grade astrocytoma, 1 juvenile pilocytic astrocytoma, and 1 ganglioglioma) was performed 22.7 hours (mean) after intravenous injection of ICG. During surgery, 12 of 15 tumors were visualized with the NIR camera. The mean signal-to-background ratio was 9.5 ± 0.8 and fluorescence was noted through the dura to a maximum parenchymal depth of 13 mm. The best predictor of positive fluorescence was enhancement on T1-weighted imaging; this correlated with signal-to-background ratio (P = .03). Nonenhancing tumors did not demonstrate NIR fluorescence. Using pathology as the gold standard, the technique demonstrated a sensitivity of 98% and specificity of 45% to identify tumor in gadolinium-enhancing specimens (n = 71). CONCLUSION With the use of Second Window ICG, gadolinium-enhancing tumors can be localized through brain parenchyma intraoperatively. Its utility for margin detection is promising but limited by lower specificity. ABBREVIATIONS 5-ALA, 5-aminolevulinic acidEPR, enhanced permeability and retentionFDA, Food and Drug AdministrationGBM, glioblastomaICG, indocyanine greenNIR, near-infraredNPV, negative predictive valuePPV, positive predictive valueROC, receiver operating characteristicROI, region of interestSBR, signal-to-background ratioWHO, World Health Organization.
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Affiliation(s)
- John Y K Lee
- *Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; ‡Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; §Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; ¶Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Xie Y, Thom M, Ebner M, Wykes V, Desjardins A, Miserocchi A, Ourselin S, McEvoy AW, Vercauteren T. Wide-field spectrally resolved quantitative fluorescence imaging system: toward neurosurgical guidance in glioma resection. JOURNAL OF BIOMEDICAL OPTICS 2017; 22:1-14. [PMID: 29139243 PMCID: PMC6742512 DOI: 10.1117/1.jbo.22.11.116006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 10/26/2017] [Indexed: 05/03/2023]
Abstract
In high-grade glioma surgery, tumor resection is often guided by intraoperative fluorescence imaging. 5-aminolevulinic acid-induced protoporphyrin IX (PpIX) provides fluorescent contrast between normal brain tissue and glioma tissue, thus achieving improved tumor delineation and prolonged patient survival compared with conventional white-light-guided resection. However, commercially available fluorescence imaging systems rely solely on visual assessment of fluorescence patterns by the surgeon, which makes the resection more subjective than necessary. We developed a wide-field spectrally resolved fluorescence imaging system utilizing a Generation II scientific CMOS camera and an improved computational model for the precise reconstruction of the PpIX concentration map. In our model, the tissue's optical properties and illumination geometry, which distort the fluorescent emission spectra, are considered. We demonstrate that the CMOS-based system can detect low PpIX concentration at short camera exposure times, while providing high-pixel resolution wide-field images. We show that total variation regularization improves the contrast-to-noise ratio of the reconstructed quantitative concentration map by approximately twofold. Quantitative comparison between the estimated PpIX concentration and tumor histopathology was also investigated to further evaluate the system.
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Affiliation(s)
- Yijing Xie
- University College London, Wellcome/EPSRC Centre for Interventional and Surgical Sciences, London, United Kingdom
- Address all correspondence to: Yijing Xie,
| | - Maria Thom
- University College London, Institute of Neurology, Department of Neuropathology, London, United Kingdom
| | - Michael Ebner
- University College London, Wellcome/EPSRC Centre for Interventional and Surgical Sciences, London, United Kingdom
| | - Victoria Wykes
- University College London, Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Adrien Desjardins
- University College London, Wellcome/EPSRC Centre for Interventional and Surgical Sciences, London, United Kingdom
| | - Anna Miserocchi
- University College London, Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Sebastien Ourselin
- University College London, Wellcome/EPSRC Centre for Interventional and Surgical Sciences, London, United Kingdom
| | - Andrew W. McEvoy
- University College London, Wellcome/EPSRC Centre for Interventional and Surgical Sciences, London, United Kingdom
- University College London, Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Tom Vercauteren
- University College London, Wellcome/EPSRC Centre for Interventional and Surgical Sciences, London, United Kingdom
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Flouty O, Reddy C, Holland M, Kovach C, Kawasaki H, Oya H, Greenlee J, Hitchon P, Howard M. Precision surgery of rolandic glioma and insights from extended functional mapping. Clin Neurol Neurosurg 2017; 163:60-66. [PMID: 29073500 DOI: 10.1016/j.clineuro.2017.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/06/2017] [Accepted: 10/09/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Electrical cortical stimulation mapping (ECSM) is the current gold standard functional mapping technique; however, it is burdened by several limitations. Our objective in this study is to show that extended functional mapping modalities can (1) allow neurosurgeons to map and preserve eloquent regions that are inaccessible by the traditional ECSM technique and (2) factor into the operative decision-making process and surgical trajectory during resection of Rolandic brain tumors. PATIENTS AND METHODS A 55year old patient having a right Rolandic glioblastoma underwent subdural grid implantation followed by surgical resection. Multimodal functional mapping including electrical stimulation, high gamma power mapping, functional magnetic resonance imaging, and diffusion tensor imaging were performed to define the location of the patient's eloquent cortex and white matter tracts in relation to the tumor and determine the optimal surgical trajectory prior to resection. RESULTS The patient tolerated a safe surgical resection without any new postoperative deficits. ECSM mapping successfully delineated safe areas for resection as well as eloquent areas related to motor control and speech production. High gamma power analysis successfully mapped areas involved in arm reach. Functional MRI showed the regions related to finger tapping. DTI demonstrated the corticospinal tract and its relation to the hand motor cortex and the tumor. CONCLUSION Adjunct mapping techniques used to supplement the data offered by ECSM can help advance the field of functional mapping and Rolandic surgery via broadening our accessibility to the human brain and providing a comprehensive map of eloquent grey and white matter structures and their relation to the tumor.
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Affiliation(s)
- Oliver Flouty
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - Chandan Reddy
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Marshall Holland
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Christopher Kovach
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Hiroto Kawasaki
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Hiroyuki Oya
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Jeremy Greenlee
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Patrick Hitchon
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Matthew Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Lee JYK, Pierce JT, Zeh R, Cho SS, Salinas R, Nie S, Singhal S. Intraoperative Near-Infrared Optical Contrast Can Localize Brain Metastases. World Neurosurg 2017; 106:120-130. [PMID: 28669877 PMCID: PMC11073792 DOI: 10.1016/j.wneu.2017.06.128] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/19/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Approximately 100,000 brain metastases are diagnosed annually in the United States. Our laboratory has pioneered a novel technique, second window indocyanine green (SWIG), which allows for real-time intraoperative visualization of brain metastasis through normal brain parenchyma and intact dura. METHODS Thirteen patients with intraparenchymal brain metastases were administered indocyanine green (ICG) at 5 mg/kg the day before surgery. A near-infrared (NIR)- capable camera was used intraoperatively to identify the tumor and to inspect surgical margins. Neuropathology was used to assess the accuracy and precision of the fluorescent dye for identifying tumor. RESULTS ICG was infused at 24.7 ± 3.45 hours before visualization. All 13 metastases fluoresced with an average signal-to-background ratio (SBR) of 6.62. The SBR with the dura intact was 67.2% of the mean SBR once the dura was opened. The NIR signal could be visualized through normal brain parenchyma up to 7 mm. For the 39 total specimens, the mean SBR for tumor specimens (n = 28) was 6.9, whereas the SBR for nontumor specimens (n = 11) was 3.7. The sensitivity, specificity, positive predictive value, and negative predictive value of NIR imaging for tumor was 96.4%, 27.3%, 77.1%, and 75.0%. DISCUSSION SWIG relies on the passive accumulation of dye in abnormal tumor tissue via the enhanced permeability and retention effect. It provides strong NIR optical contrast, which can be used to localize tumors before dural opening. The use of SWIG for margin assessment remains limited by its lack of specificity (high false-positive rate); however, ongoing improvements in imaging parameters show great potential to reduce false-positive results.
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Affiliation(s)
- John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - John T Pierce
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan Zeh
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steve S Cho
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan Salinas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shuming Nie
- Department of Biochemistry, Emory University, Atlanta, Georgia, USA
| | - Sunil Singhal
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Green O, Gnaim S, Blau R, Eldar-Boock A, Satchi-Fainaro R, Shabat D. Near-Infrared Dioxetane Luminophores with Direct Chemiluminescence Emission Mode. J Am Chem Soc 2017; 139:13243-13248. [PMID: 28853880 DOI: 10.1021/jacs.7b08446] [Citation(s) in RCA: 148] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chemiluminescent luminophores are considered as one of the most sensitive families of probes for detection and imaging applications. Due to their high signal-to-noise ratios, luminophores with near-infrared (NIR) emission are particularly important for in vivo use. In addition, light with such long wavelength has significantly greater capability for penetration through organic tissue. So far, only a few reports have described the use of chemiluminescence systems for in vivo imaging. Such systems are always based on an energy-transfer process from a chemiluminescent precursor to a nearby emissive fluorescent dye. Here, we describe the development of the first chemiluminescent luminophores with a direct mode of NIR light emission that are suitable for use under physiological conditions. Our strategy is based on incorporation of a substituent with an extended π-electron system on the excited species obtained during the chemiexcitation pathway of Schaap's adamantylidene-dioxetane probe. In this manner, we designed and synthesized two new luminophores with direct light emission wavelength in the NIR region. Masking of the luminophores with analyte-responsive groups has resulted in turn-ON probes for detection and imaging of β-galactosidase and hydrogen peroxide. The probes' ability to image their corresponding analyte/enzyme was effectively demonstrated in vitro for β-galactosidase activity and in vivo in a mouse model of inflammation. We anticipate that our strategy for obtaining NIR luminophores will open new doors for further exploration of complex biomolecular systems using non-invasive intravital chemiluminescence imaging techniques.
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Affiliation(s)
- Ori Green
- School of Chemistry, Raymond and Beverly Sackler Faculty of Exact Sciences, and ‡Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University , Tel Aviv 69978, Israel
| | - Samer Gnaim
- School of Chemistry, Raymond and Beverly Sackler Faculty of Exact Sciences, and ‡Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University , Tel Aviv 69978, Israel
| | - Rachel Blau
- School of Chemistry, Raymond and Beverly Sackler Faculty of Exact Sciences, and ‡Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University , Tel Aviv 69978, Israel
| | - Anat Eldar-Boock
- School of Chemistry, Raymond and Beverly Sackler Faculty of Exact Sciences, and ‡Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University , Tel Aviv 69978, Israel
| | - Ronit Satchi-Fainaro
- School of Chemistry, Raymond and Beverly Sackler Faculty of Exact Sciences, and ‡Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University , Tel Aviv 69978, Israel
| | - Doron Shabat
- School of Chemistry, Raymond and Beverly Sackler Faculty of Exact Sciences, and ‡Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University , Tel Aviv 69978, Israel
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Wang YW, Reder NP, Kang S, Glaser AK, Liu JTC. Multiplexed Optical Imaging of Tumor-Directed Nanoparticles: A Review of Imaging Systems and Approaches. Nanotheranostics 2017; 1:369-388. [PMID: 29071200 PMCID: PMC5647764 DOI: 10.7150/ntno.21136] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 07/08/2017] [Indexed: 12/18/2022] Open
Abstract
In recent decades, various classes of nanoparticles have been developed for optical imaging of cancers. Many of these nanoparticles are designed to specifically target tumor sites, and specific cancer biomarkers, to facilitate the visualization of tumors. However, one challenge for accurate detection of tumors is that the molecular profiles of most cancers vary greatly between patients as well as spatially and temporally within a single tumor mass. To overcome this challenge, certain nanoparticles and imaging systems have been developed to enable multiplexed imaging of large panels of cancer biomarkers. Multiplexed molecular imaging can potentially enable sensitive tumor detection, precise delineation of tumors during interventional procedures, and the prediction/monitoring of therapy response. In this review, we summarize recent advances in systems that have been developed for the imaging of optical nanoparticles that can be heavily multiplexed, which include surface-enhanced Raman-scattering nanoparticles (SERS NPs) and quantum dots (QDs). In addition to surveying the optical properties of these various types of nanoparticles, and the most-popular multiplexed imaging approaches that have been employed, representative preclinical and clinical imaging studies are also highlighted.
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Affiliation(s)
- Yu Winston Wang
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195, USA
| | - Nicholas P Reder
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195, USA.,Department of Pathology, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Soyoung Kang
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195, USA
| | - Adam K Glaser
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195, USA
| | - Jonathan T C Liu
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195, USA
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Bowden SG, Neira JA, Gill BJA, Ung TH, Englander ZK, Zanazzi G, Chang PD, Samanamud J, Grinband J, Sheth SA, McKhann GM, Sisti MB, Canoll P, D’Amico RS, Bruce JN. Sodium Fluorescein Facilitates Guided Sampling of Diagnostic Tumor Tissue in Nonenhancing Gliomas. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx271] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Accurate tissue sampling in nonenhancing (NE) gliomas is a unique surgical challenge due to their intratumoral histological heterogeneity and absence of contrast enhancement as a guide for intraoperative stereotactic guidance. Instead, T2/fluid-attenuated inversion-recovery (FLAIR) hyperintensity on MRI is commonly used as an imaging surrogate for pathological tissue, but sampling from this region can yield nondiagnostic or underdiagnostic brain tissue. Sodium fluorescein is an intraoperative fluorescent dye that has a high predictive value for tumor identification in areas of contrast enhancement and NE in glioblastomas. However, the underlying histopathological alterations in fluorescent regions of NE gliomas remain undefined.
OBJECTIVE
To evaluate whether fluorescein can identify diagnostic tissue and differentiate regions with higher malignant potential during surgery for NE gliomas, thus improving sampling accuracy.
METHODS
Thirteen patients who presented with NE, T2/FLAIR hyperintense lesions suspicious for glioma received fluorescein (10%, 3 mg/kg intravenously) during surgical resection.
RESULTS
Patchy fluorescence was identified within the T2/FLAIR hyperintense area in 10 of 13 (77%) patients. Samples taken from fluorescent regions were more likely to demonstrate diagnostic glioma tissue and cytologic atypia (P < .05). Fluorescein demonstrated a 95% positive predictive value for the presence of diagnostic tissue. Samples from areas of fluorescence also demonstrated greater total cell density and higher Ki-67 labeling than nonfluorescent biopsies (P < .05).
CONCLUSION
Fluorescence in NE gliomas is highly predictive of diagnostic tumor tissue and regions of higher cell density and proliferative activity.
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Affiliation(s)
- Stephen G Bowden
- Department of Neurological Surgery, College of Physicians and Surgeons at Columbia University, New York, New York
| | - Justin A Neira
- Department of Neurological Surgery, College of Physicians and Surgeons at Columbia University, New York, New York
| | - Brian J A Gill
- Department of Neurological Surgery, College of Physicians and Surgeons at Columbia University, New York, New York
| | - Timothy H Ung
- Department of Neurological Surgery, University of Colorado, Aurora, Colorado
| | - Zachary K Englander
- Department of Neurological Surgery, College of Physicians and Surgeons at Columbia University, New York, New York
| | - George Zanazzi
- Department of Pathology and Cell Biology, College of Physicians and Surgeons at Columbia University, New York, New York
| | - Peter D Chang
- Department of Radiology, College of Physicians and Surgeons at Columbia University, New York, New York
| | - Jorge Samanamud
- Department of Neurological Surgery, College of Physicians and Surgeons at Columbia University, New York, New York
| | - Jack Grinband
- Department of Radiology, College of Physicians and Surgeons at Columbia University, New York, New York
| | - Sameer A Sheth
- Department of Neurological Surgery, College of Physicians and Surgeons at Columbia University, New York, New York
| | - Guy M McKhann
- Department of Neurological Surgery, College of Physicians and Surgeons at Columbia University, New York, New York
| | - Michael B Sisti
- Department of Neurological Surgery, College of Physicians and Surgeons at Columbia University, New York, New York
| | - Peter Canoll
- Department of Pathology and Cell Biology, College of Physicians and Surgeons at Columbia University, New York, New York
| | - Randy S D’Amico
- Department of Neurological Surgery, College of Physicians and Surgeons at Columbia University, New York, New York
| | - Jeffrey N Bruce
- Department of Neurological Surgery, College of Physicians and Surgeons at Columbia University, New York, New York
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Le VH, Yoo SW, Yoon Y, Wang T, Kim B, Lee S, Lee KH, Kim KH, Chung E. Brain tumor delineation enhanced by moxifloxacin-based two-photon/CARS combined microscopy. BIOMEDICAL OPTICS EXPRESS 2017; 8:2148-2161. [PMID: 28736661 PMCID: PMC5516816 DOI: 10.1364/boe.8.002148] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/17/2017] [Accepted: 02/17/2017] [Indexed: 05/24/2023]
Abstract
Delineating brain tumor margin is critical for maximizing tumor removal while sparing adjacent normal tissue for better clinical outcome. We describe the use of moxifloxacin-based two-photon (TP)/coherent anti-Stokes Raman scattering (CARS) combined microscopy for differentiating normal mouse brain tissue from metastatic brain tumor tissue based on histoarchitectural and biochemical differences. Moxifloxacin, an FDA-approved compound, was used to label cells in the brain, and moxifloxacin-based two-photon microscopy (TPM) revealed tumor lesions with significantly high cellular density and invading edges in a metastatic brain tumor model. Besides, label-free CARS microscopy showed diminishing of lipid signal due to the destruction of myelin at the tumor site compared to a normal brain tissue site resulting in a complementary contrast for tumor detection. This study demonstrates that moxifloxacin-based TP/CARS combined microscopy might be advantageous for tumor margin identification in the brain that has been a long-standing challenge in the operating room.
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Affiliation(s)
- Viet-Hoan Le
- Division of Integrative Biosciences and Biotechnology, Pohang University of Science and Technology, 77 Cheongam-Ro, Nam-gu, Pohang, Gyeongbuk 37673, South Korea
- Co-first authors with equal contribution
| | - Su Woong Yoo
- Department of Biomedical Science and Engineering, Institute of Integrated Technology (IIT), Gwangju Institute of Science and Technology (GIST), 123 Cheomdangwagi-Ro, Buk-gu, Gwangju 61005, South Korea
- Co-first authors with equal contribution
| | - Yeoreum Yoon
- Department of Mechanical Engineering, Pohang University of Science and Technology, 77 Cheongam-Ro, Nam-gu, Pohang, Gyeongbuk 37673, South Korea
| | - Taejun Wang
- Division of Integrative Biosciences and Biotechnology, Pohang University of Science and Technology, 77 Cheongam-Ro, Nam-gu, Pohang, Gyeongbuk 37673, South Korea
| | - Bumju Kim
- Division of Integrative Biosciences and Biotechnology, Pohang University of Science and Technology, 77 Cheongam-Ro, Nam-gu, Pohang, Gyeongbuk 37673, South Korea
| | - Seunghun Lee
- Department of Mechanical Engineering, Pohang University of Science and Technology, 77 Cheongam-Ro, Nam-gu, Pohang, Gyeongbuk 37673, South Korea
| | - Kyung-Hwa Lee
- Department of Pathology, Chonnam National University Hwasun Hospital and Medical School, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do 58128, South Korea
| | - Ki Hean Kim
- Division of Integrative Biosciences and Biotechnology, Pohang University of Science and Technology, 77 Cheongam-Ro, Nam-gu, Pohang, Gyeongbuk 37673, South Korea
- Department of Mechanical Engineering, Pohang University of Science and Technology, 77 Cheongam-Ro, Nam-gu, Pohang, Gyeongbuk 37673, South Korea
- Co-corresponding author:
| | - Euiheon Chung
- Department of Biomedical Science and Engineering, Institute of Integrated Technology (IIT), Gwangju Institute of Science and Technology (GIST), 123 Cheomdangwagi-Ro, Buk-gu, Gwangju 61005, South Korea
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Wang W, Tabu K, Hagiya Y, Sugiyama Y, Kokubu Y, Murota Y, Ogura SI, Taga T. Enhancement of 5-aminolevulinic acid-based fluorescence detection of side population-defined glioma stem cells by iron chelation. Sci Rep 2017; 7:42070. [PMID: 28169355 PMCID: PMC5294410 DOI: 10.1038/srep42070] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 01/05/2017] [Indexed: 01/20/2023] Open
Abstract
Cancer stem cells (CSCs) are dominantly responsible for tumor progression and chemo/radio-resistance, resulting in tumor recurrence. 5-aminolevulinic acid (ALA) is metabolized to fluorescent protoporphyrin IX (PpIX) specifically in tumor cells, and therefore clinically used as a reagent for photodynamic diagnosis (PDD) and therapy (PDT) of cancers including gliomas. However, it remains to be clarified whether this method could be effective for CSC detection. Here, using flow cytometry-based analysis, we show that side population (SP)-defined C6 glioma CSCs (GSCs) displayed much less 5-ALA-derived PpIX fluorescence than non-GSCs. Among the C6 GSCs, cells with ultralow PpIX fluorescence exhibited dramatically higher tumorigenicity when transplanted into the immune-deficient mouse brain. We further demonstrated that the low PpIX accumulation in the C6 GSCs was enhanced by deferoxamine (DFO)-mediated iron chelation, not by reserpine-mediated inhibition of PpIX-effluxing ABCG2. Finally, we found that the expression level of the gene for heme oxygenase-1 (HO-1), a heme degradation enzyme, was high in C6 GSCs, which was further up-regulated when treated with 5-ALA. Our results provide important new insights into 5-ALA-based PDD of gliomas, particularly photodetection of SP-defined GSCs by iron chelation based on their ALA-PpIX-Heme metabolism.
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Affiliation(s)
- Wenqian Wang
- Department of Stem Cell Regulation, Medical Research Institute, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, 1138510, Japan
| | - Kouichi Tabu
- Department of Stem Cell Regulation, Medical Research Institute, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, 1138510, Japan
| | - Yuichiro Hagiya
- Graduate School of Bioscience and Biotechnology, Tokyo Institute of Technology, 4259-B102, Nagatsuta-cho, Midori-ku, Yokohama, 2268501, Japan
| | - Yuta Sugiyama
- Graduate School of Bioscience and Biotechnology, Tokyo Institute of Technology, 4259-B102, Nagatsuta-cho, Midori-ku, Yokohama, 2268501, Japan
| | - Yasuhiro Kokubu
- Department of Stem Cell Regulation, Medical Research Institute, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, 1138510, Japan
| | - Yoshitaka Murota
- Department of Stem Cell Regulation, Medical Research Institute, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, 1138510, Japan
| | - Shun-ichiro Ogura
- Graduate School of Bioscience and Biotechnology, Tokyo Institute of Technology, 4259-B102, Nagatsuta-cho, Midori-ku, Yokohama, 2268501, Japan
- School of Life Science and Technology, Tokyo Institute of Technology, 4259 B-47, Nagatsuta-cho, Midori-ku, Yokohama, 2268501, Japan
| | - Tetsuya Taga
- Department of Stem Cell Regulation, Medical Research Institute, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, 1138510, Japan
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Senders JT, Muskens IS, Schnoor R, Karhade AV, Cote DJ, Smith TR, Broekman MLD. Agents for fluorescence-guided glioma surgery: a systematic review of preclinical and clinical results. Acta Neurochir (Wien) 2017; 159:151-167. [PMID: 27878374 PMCID: PMC5177668 DOI: 10.1007/s00701-016-3028-5] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 11/09/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Fluorescence-guided surgery (FGS) is a technique used to enhance visualization of tumor margins in order to increase the extent of tumor resection in glioma surgery. In this paper, we systematically review all clinically tested fluorescent agents for application in FGS for glioma and all preclinically tested agents with the potential for FGS for glioma. METHODS We searched the PubMed and Embase databases for all potentially relevant studies through March 2016. We assessed fluorescent agents by the following outcomes: rate of gross total resection (GTR), overall and progression-free survival, sensitivity and specificity in discriminating tumor and healthy brain tissue, tumor-to-normal ratio of fluorescent signal, and incidence of adverse events. RESULTS The search strategy resulted in 2155 articles that were screened by titles and abstracts. After full-text screening, 105 articles fulfilled the inclusion criteria evaluating the following fluorescent agents: 5-aminolevulinic acid (5-ALA) (44 studies, including three randomized control trials), fluorescein (11), indocyanine green (five), hypericin (two), 5-aminofluorescein-human serum albumin (one), endogenous fluorophores (nine) and fluorescent agents in a pre-clinical testing phase (30). Three meta-analyses were also identified. CONCLUSIONS 5-ALA is the only fluorescent agent that has been tested in a randomized controlled trial and results in an improvement of GTR and progression-free survival in high-grade gliomas. Observational cohort studies and case series suggest similar outcomes for FGS using fluorescein. Molecular targeting agents (e.g., fluorophore/nanoparticle labeled with anti-EGFR antibodies) are still in the pre-clinical phase, but offer promising results and may be valuable future alternatives.
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Affiliation(s)
- Joeky T Senders
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ivo S Muskens
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rosalie Schnoor
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Aditya V Karhade
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA, 02115, USA
| | - David J Cote
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA, 02115, USA
| | - Timothy R Smith
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA, 02115, USA
| | - Marike L D Broekman
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Valdés PA, Roberts DW, Lu FK, Golby A. Optical technologies for intraoperative neurosurgical guidance. Neurosurg Focus 2016; 40:E8. [PMID: 26926066 DOI: 10.3171/2015.12.focus15550] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Biomedical optics is a broadly interdisciplinary field at the interface of optical engineering, biophysics, computer science, medicine, biology, and chemistry, helping us understand light-tissue interactions to create applications with diagnostic and therapeutic value in medicine. Implementation of biomedical optics tools and principles has had a notable scientific and clinical resurgence in recent years in the neurosurgical community. This is in great part due to work in fluorescence-guided surgery of brain tumors leading to reports of significant improvement in maximizing the rates of gross-total resection. Multiple additional optical technologies have been implemented clinically, including diffuse reflectance spectroscopy and imaging, optical coherence tomography, Raman spectroscopy and imaging, and advanced quantitative methods, including quantitative fluorescence and lifetime imaging. Here we present a clinically relevant and technologically informed overview and discussion of some of the major clinical implementations of optical technologies as intraoperative guidance tools in neurosurgery.
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Affiliation(s)
- Pablo A Valdés
- Departments of 1 Neurosurgery and.,Department of Neurosurgery, Harvard Medical School, Boston Children's Hospital, Boston
| | - David W Roberts
- Section of Neurosurgery, Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Alexandra Golby
- Departments of 1 Neurosurgery and.,Radiology, and.,Dana Farber Cancer Institute, Harvard Medical School, Brigham and Women's Hospital
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Belykh E, Martirosyan NL, Yagmurlu K, Miller EJ, Eschbacher JM, Izadyyazdanabadi M, Bardonova LA, Byvaltsev VA, Nakaji P, Preul MC. Intraoperative Fluorescence Imaging for Personalized Brain Tumor Resection: Current State and Future Directions. Front Surg 2016; 3:55. [PMID: 27800481 PMCID: PMC5066076 DOI: 10.3389/fsurg.2016.00055] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 09/12/2016] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Fluorescence-guided surgery is one of the rapidly emerging methods of surgical "theranostics." In this review, we summarize current fluorescence techniques used in neurosurgical practice for brain tumor patients as well as future applications of recent laboratory and translational studies. METHODS Review of the literature. RESULTS A wide spectrum of fluorophores that have been tested for brain surgery is reviewed. Beginning with a fluorescein sodium application in 1948 by Moore, fluorescence-guided brain tumor surgery is either routinely applied in some centers or is under active study in clinical trials. Besides the trinity of commonly used drugs (fluorescein sodium, 5-aminolevulinic acid, and indocyanine green), less studied fluorescent stains, such as tetracyclines, cancer-selective alkylphosphocholine analogs, cresyl violet, acridine orange, and acriflavine, can be used for rapid tumor detection and pathological tissue examination. Other emerging agents, such as activity-based probes and targeted molecular probes that can provide biomolecular specificity for surgical visualization and treatment, are reviewed. Furthermore, we review available engineering and optical solutions for fluorescent surgical visualization. Instruments for fluorescent-guided surgery are divided into wide-field imaging systems and hand-held probes. Recent advancements in quantitative fluorescence-guided surgery are discussed. CONCLUSION We are standing on the threshold of the era of marker-assisted tumor management. Innovations in the fields of surgical optics, computer image analysis, and molecular bioengineering are advancing fluorescence-guided tumor resection paradigms, leading to cell-level approaches to visualization and resection of brain tumors.
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Affiliation(s)
- Evgenii Belykh
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
- School of Life Sciences, Arizona State University, Tempe, AZ, USA
- Laboratory of Neurosurgery, Irkutsk Scientific Center of Surgery and Traumatology, Irkutsk, Russia
- Irkutsk State Medical University, Irkutsk, Russia
| | - Nikolay L. Martirosyan
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
- School of Life Sciences, Arizona State University, Tempe, AZ, USA
| | - Kaan Yagmurlu
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Eric J. Miller
- University of Arizona College of Medicine – Phoenix, Phoenix, AZ, USA
| | - Jennifer M. Eschbacher
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Mohammadhassan Izadyyazdanabadi
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
- School of Life Sciences, Arizona State University, Tempe, AZ, USA
| | - Liudmila A. Bardonova
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
- Laboratory of Neurosurgery, Irkutsk Scientific Center of Surgery and Traumatology, Irkutsk, Russia
- Irkutsk State Medical University, Irkutsk, Russia
| | - Vadim A. Byvaltsev
- Laboratory of Neurosurgery, Irkutsk Scientific Center of Surgery and Traumatology, Irkutsk, Russia
- Irkutsk State Medical University, Irkutsk, Russia
| | - Peter Nakaji
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Mark C. Preul
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
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Gerard IJ, Kersten-Oertel M, Petrecca K, Sirhan D, Hall JA, Collins DL. Brain shift in neuronavigation of brain tumors: A review. Med Image Anal 2016; 35:403-420. [PMID: 27585837 DOI: 10.1016/j.media.2016.08.007] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 08/22/2016] [Accepted: 08/23/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Neuronavigation based on preoperative imaging data is a ubiquitous tool for image guidance in neurosurgery. However, it is rendered unreliable when brain shift invalidates the patient-to-image registration. Many investigators have tried to explain, quantify, and compensate for this phenomenon to allow extended use of neuronavigation systems for the duration of surgery. The purpose of this paper is to present an overview of the work that has been done investigating brain shift. METHODS A review of the literature dealing with the explanation, quantification and compensation of brain shift is presented. The review is based on a systematic search using relevant keywords and phrases in PubMed. The review is organized based on a developed taxonomy that classifies brain shift as occurring due to physical, surgical or biological factors. RESULTS This paper gives an overview of the work investigating, quantifying, and compensating for brain shift in neuronavigation while describing the successes, setbacks, and additional needs in the field. An analysis of the literature demonstrates a high variability in the methods used to quantify brain shift as well as a wide range in the measured magnitude of the brain shift, depending on the specifics of the intervention. The analysis indicates the need for additional research to be done in quantifying independent effects of brain shift in order for some of the state of the art compensation methods to become useful. CONCLUSION This review allows for a thorough understanding of the work investigating brain shift and introduces the needs for future avenues of investigation of the phenomenon.
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Affiliation(s)
- Ian J Gerard
- McConnell Brain Imaging Center, MNI, McGill University, Montreal, Canada.
| | | | - Kevin Petrecca
- Department of Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Denis Sirhan
- Department of Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Jeffery A Hall
- Department of Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - D Louis Collins
- McConnell Brain Imaging Center, MNI, McGill University, Montreal, Canada; Department of Neurosurgery, McGill University, Montreal, Quebec, Canada
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Bravo JJ, Davis SC, Roberts DW, Paulsen KD, Kanick SC. Mathematical model to interpret localized reflectance spectra measured in the presence of a strong fluorescence marker. JOURNAL OF BIOMEDICAL OPTICS 2016; 21:61004. [PMID: 26836297 PMCID: PMC4734982 DOI: 10.1117/1.jbo.21.6.061004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 12/31/2015] [Indexed: 06/05/2023]
Abstract
Quantification of multiple fluorescence markers during neurosurgery has the potential to provide complementary contrast mechanisms between normal and malignant tissues, and one potential combination involves fluorescein sodium (FS) and aminolevulinic acid-induced protoporphyrin IX (PpIX). We focus on the interpretation of reflectance spectra containing contributions from elastically scattered (reflected) photons as well as fluorescence emissions from a strong fluorophore (i.e., FS). A model-based approach to extract μa and μ′s in the presence of FS emission is validated in optical phantoms constructed with Intralipid (1% to 2% lipid) and whole blood (1% to 3% volume fraction), over a wide range of FS concentrations (0 to 1000 μg/ml 1000 μg/ml ). The results show that modeling reflectance as a combination of elastically scattered light and attenuation-corrected FS-based emission yielded more accurate tissue parameter estimates when compared with a nonmodified reflectance model, with reduced maximum errors for blood volume (22% versus 90%), microvascular saturation (21% versus 100%), and μs′ (13% versus 207%). Additionally, quantitative PpIX fluorescence sampled in the same phantom as FS showed significant differences depending on the reflectance model used to estimate optical properties (i.e., maximum error 29% versus 86%). These data represent a first step toward using quantitative optical spectroscopy to guide surgeries through simultaneous assessment of FS and PpIX.
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Affiliation(s)
- Jaime J. Bravo
- Dartmouth College, Thayer School of Engineering, 14 Engineering Drive, Hanover, New Hampshire 03755, United States
| | - Scott C. Davis
- Dartmouth College, Thayer School of Engineering, 14 Engineering Drive, Hanover, New Hampshire 03755, United States
- Dartmouth-Hitchcock Medical Center, Norris Cotton Cancer Center, 1 Medical Center Drive, Lebanon, New Hampshire 03756, United States
| | - David W. Roberts
- Dartmouth-Hitchcock Medical Center, Norris Cotton Cancer Center, 1 Medical Center Drive, Lebanon, New Hampshire 03756, United States
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, New Hampshire 03755, United States
- Dartmouth-Hitchcock Medical Center, Section of Neurosurgery, 1 Medical Center Drive, Lebanon, New Hampshire 03756, United States
| | - Keith D. Paulsen
- Dartmouth College, Thayer School of Engineering, 14 Engineering Drive, Hanover, New Hampshire 03755, United States
- Dartmouth-Hitchcock Medical Center, Norris Cotton Cancer Center, 1 Medical Center Drive, Lebanon, New Hampshire 03756, United States
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, New Hampshire 03755, United States
| | - Stephen C. Kanick
- Dartmouth College, Thayer School of Engineering, 14 Engineering Drive, Hanover, New Hampshire 03755, United States
- Dartmouth-Hitchcock Medical Center, Norris Cotton Cancer Center, 1 Medical Center Drive, Lebanon, New Hampshire 03756, United States
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Craig SEL, Wright J, Sloan AE, Brady-Kalnay SM. Fluorescent-Guided Surgical Resection of Glioma with Targeted Molecular Imaging Agents: A Literature Review. World Neurosurg 2016; 90:154-163. [PMID: 26915698 PMCID: PMC4915969 DOI: 10.1016/j.wneu.2016.02.060] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 02/11/2016] [Accepted: 02/12/2016] [Indexed: 12/11/2022]
Abstract
The median life expectancy after a diagnosis of glioblastoma is 15 months. Although chemotherapeutics may someday cure glioblastoma by killing the highly dispersive malignant cells, the most important contribution that clinicians can currently offer to improve survival is by maximizing the extent of resection and providing concurrent chemo-radiation, which has become standard. Strides have been made in this area with the advent and implementation of methods of improved intraoperative tumor visualization. One of these techniques, optical fluorescent imaging with targeted molecular imaging agents, allows the surgeon to view fluorescently labeled tumor tissue during surgery with the use of special microscopy, thereby highlighting where to resect and indicating when tumor-free margins have been obtained. This advantage is especially important at the difficult-to-observe margins where tumor cells infiltrate normal tissue. Targeted fluorescent agents also may be valuable for identifying tumor versus nontumor tissue. In this review, we briefly summarize nontargeted fluorescent tumor imaging agents before discussing several novel targeted fluorescent agents being developed for glioma imaging in the context of fluorescent-guided surgery or live molecular navigation. Many of these agents are currently undergoing preclinical testing. As the agents become available, however, it is necessary to understand the strengths and weaknesses of each.
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Affiliation(s)
- Sonya E L Craig
- Department of Molecular Biology and Microbiology, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - James Wright
- Department of Neurosurgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Andrew E Sloan
- Case Comprehensive Cancer Center, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Department of Neurosurgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Brain Tumor and Neuro-Oncology Center, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Susann M Brady-Kalnay
- Department of Molecular Biology and Microbiology, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Case Comprehensive Cancer Center, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Department of Neurosciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
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Marois M, Bravo J, Davis SC, Kanick SC. Characterization and standardization of tissue-simulating protoporphyrin IX optical phantoms. JOURNAL OF BIOMEDICAL OPTICS 2016; 21:35003. [PMID: 26968385 PMCID: PMC5994807 DOI: 10.1117/1.jbo.21.3.035003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 02/19/2016] [Indexed: 05/04/2023]
Abstract
Optical devices for measuring protoporphryin IX (PpIX) fluorescence in tissue are routinely validated by measurements in optical phantoms. Yet there exists limited data to form a consensus on the recipe for phantoms that both mimic the optical properties found in tissue and yield a reliable and stable relationship between PpIX concentration and the fluorescence remission intensity. This study characterizes the influence of multiple phantom components on PpIX fluorescence emission intensity, using Intralipid as the scattering source, bovine whole blood as the background absorber, and Tween as a surfactant to prevent PpIX aggregation. Optical measurements showed a linear proportionality (r > 0.99) between fluorescence intensity and PpIX concentration (0.1 to 10 μg/mL) over a range of Intralipid (1 to 2%) and whole blood (0.5 to 3%) for phantoms containing low surfactant (≤ 0.1%), with fluorescence intensities and scattering and absorption properties stable for 5 h after mixing. The role of surfactant in PpIX phantoms was found to be complex, as aggregation was evident in aqueous nonturbid phantoms with no surfactant (0% Tween), and avoided in phantoms containing Intralipid as the scattering source with no additional or low amounts of added surfactant (≤ 0.1% Tween). Conversely, phantoms containing higher surfactant content (>0.1% Tween) and whole blood showed interactions that distorted the fluorescence emissions.
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Affiliation(s)
- Mikael Marois
- Polytechnique Montreal, 2500 Chemin de Polytechnique, Montreal, Quebec H3T 1J4, Canada
- Dartmouth College, 14 Engineering Drive, Hanover, New Hampshire 03755, United States
| | - Jaime Bravo
- Polytechnique Montreal, 2500 Chemin de Polytechnique, Montreal, Quebec H3T 1J4, Canada
| | - Scott C. Davis
- Dartmouth College, 14 Engineering Drive, Hanover, New Hampshire 03755, United States
- Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire 03766, United States
| | - Stephen Chad Kanick
- Dartmouth College, 14 Engineering Drive, Hanover, New Hampshire 03755, United States
- Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire 03766, United States
- Address all correspondence to: Stephen Chad Kanick,
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Cheng H, Qiu X, Zhao X, Meng W, Huo D, Wei H. Functional Nucleic Acid Probe for Parallel Monitoring K+ and Protoporphyrin IX in Living Organisms. Anal Chem 2016; 88:2937-43. [DOI: 10.1021/acs.analchem.5b04936] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Hanjun Cheng
- Department
of Biomedical Engineering, College of Engineering and Applied Sciences,
Collaborative Innovation Center of Chemistry for Life Sciences, Nanjing National Laboratory of Microstructures, Nanjing, Jiangsu 210093, China
- State
Key Laboratory of Analytical Chemistry for Life Science, Nanjing University, Nanjing 210093, China
| | - Xuefeng Qiu
- Department
of Urology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Xiaozhi Zhao
- Department
of Urology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Wei Meng
- School
of Physics, Collaborative Innovation Center of Advanced Microstructures,
Nanjing National Laboratory of Microstructures, Nanjing University, Nanjing, Jiangsu 210093, China
| | - Da Huo
- Department
of Biomedical Engineering, College of Engineering and Applied Sciences,
Collaborative Innovation Center of Chemistry for Life Sciences, Nanjing National Laboratory of Microstructures, Nanjing, Jiangsu 210093, China
| | - Hui Wei
- Department
of Biomedical Engineering, College of Engineering and Applied Sciences,
Collaborative Innovation Center of Chemistry for Life Sciences, Nanjing National Laboratory of Microstructures, Nanjing, Jiangsu 210093, China
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Juhl K, Christensen A, Persson M, Ploug M, Kjaer A. Peptide-Based Optical uPAR Imaging for Surgery: In Vivo Testing of ICG-Glu-Glu-AE105. PLoS One 2016; 11:e0147428. [PMID: 26828431 PMCID: PMC4734687 DOI: 10.1371/journal.pone.0147428] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 01/03/2016] [Indexed: 12/22/2022] Open
Abstract
Near infrared intra-operative optical imaging is an emerging technique with clear implications for improved cancer surgery by enabling a more distinct delineation of the tumor margins during resection. This modality has the potential to increase the number of patients having a curative radical tumor resection. In the present study, a new uPAR-targeted fluorescent probe was developed and the in vivo applicability was evaluated in a human xenograft mouse model. Most human carcinomas express high level of uPAR in the tumor-stromal interface of invasive lesions and uPAR is therefore considered an ideal target for intra-operative imaging. Conjugation of the flourophor indocyanine green (ICG) to the uPAR agonist (AE105) provides an optical imaging ligand with sufficiently high receptor affinity to allow for a specific receptor targeting in vivo. For in vivo testing, human glioblastoma xenograft mice were subjected to optical imaging after i.v. injection of ICG-AE105, which provided an optimal contrast in the time window 6–24 h post injection. Specificity of the uPAR-targeting probe ICG-AE105 was demonstrated in vivo by 1) no uptake of unconjugated ICG after 15 hours, 2) inhibition of ICG-AE105 tumor uptake by a bolus injection of the natural uPAR ligand pro-uPA, and finally 3) the histological colocalization of ICG-AE105 fluorescence and immunohistochemical detected human uPAR on resected tumor slides. Taken together, our data supports the potential use of this probe for intra-operative optical guidance in cancer surgery to ensure complete removal of tumors while preserving adjacent, healthy tissue.
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Affiliation(s)
- Karina Juhl
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Anders Christensen
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
- Department of Otolaryngology, Head & Neck Surgery and Audiology, Rigshospitalet, Copenhagen, Denmark
| | - Morten Persson
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Michael Ploug
- Finsen Laboratory, Rigshospitalet, Copenhagen, Denmark
- Biotech Research and Innovation Centre (BRIC), Copenhagen University, Copenhagen, Denmark
| | - Andreas Kjaer
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
- * E-mail:
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Lipid and metabolite profiles of human brain tumors by desorption electrospray ionization-MS. Proc Natl Acad Sci U S A 2016; 113:1486-91. [PMID: 26787885 DOI: 10.1073/pnas.1523306113] [Citation(s) in RCA: 154] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Examination of tissue sections using desorption electrospray ionization (DESI)-MS revealed phospholipid-derived signals that differ between gray matter, white matter, gliomas, meningiomas, and pituitary tumors, allowing their ready discrimination by multivariate statistics. A set of lower mass signals, some corresponding to oncometabolites, including 2-hydroxyglutaric acid and N-acetyl-aspartic acid, was also observed in the DESI mass spectra, and these data further assisted in discrimination between brain parenchyma and gliomas. The combined information from the lipid and metabolite MS profiles recorded by DESI-MS and explored using multivariate statistics allowed successful differentiation of gray matter (n = 223), white matter (n = 66), gliomas (n = 158), meningiomas (n = 111), and pituitary tumors (n = 154) from 58 patients. A linear discriminant model used to distinguish brain parenchyma and gliomas yielded an overall sensitivity of 97.4% and a specificity of 98.5%. Furthermore, a discriminant model was created for tumor types (i.e., glioma, meningioma, and pituitary), which were discriminated with an overall sensitivity of 99.4% and a specificity of 99.7%. Unsupervised multivariate statistics were used to explore the chemical differences between anatomical regions of brain parenchyma and secondary infiltration. Infiltration of gliomas into normal tissue can be detected by DESI-MS. One hurdle to implementation of DESI-MS intraoperatively is the need for tissue freezing and sectioning, which we address by analyzing smeared biopsy tissue. Tissue smears are shown to give the same chemical information as tissue sections, eliminating the need for sectioning before MS analysis. These results lay the foundation for implementation of intraoperative DESI-MS evaluation of tissue smears for rapid diagnosis.
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Guyotat J, Pallud J, Armoiry X, Pavlov V, Metellus P. 5-Aminolevulinic Acid-Protoporphyrin IX Fluorescence-Guided Surgery of High-Grade Gliomas: A Systematic Review. Adv Tech Stand Neurosurg 2016:61-90. [PMID: 26508406 DOI: 10.1007/978-3-319-21359-0_3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The current first-line treatment of malignant gliomas consists in surgical resection (if possible) as large as possible. The existing tools don't permit to identify the limits of tumor infiltration, which goes beyond the zone of contrast enhancement on MRI. The fluorescence-guided malignant gliomas surgery was started 15 years ago and had become a standard of care in many countries. The technique is based on fluorescent molecule revelation using the filters, positioned within the surgical microscope. The fluorophore, protoporphyrin IX (PpIX), is converted in tumoral cells from 5-aminolevulinic acid (5-ALA), given orally before surgery. Many studies have shown that the ratio of gross total resections was higher if the fluorescence technique was used. The fluorescence signal intensity is correlated to the cell density and the PpIX concentration. The current method has a very high specificity but still lower sensibility, particularly regarding the zones with poor tumoral infiltration. This book reviews the principles of the technique and the results (extent of resection and survival).
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Affiliation(s)
- Jacques Guyotat
- Department of Neurosurgery, Neurological Hospital, Lyon, France.
| | - Johan Pallud
- Department of Neurosurgery, Sainte Anne Hospital, Paris, France.
- Paris Descartes University, Paris, France.
| | - Xavier Armoiry
- Délégation à la recherche clinique et à l'innovation, cellule innovation Hospices Civils de, Lyon, France.
| | - Vladislav Pavlov
- Department of Neurosurgery, Neurological Hospital, Lyon, France.
| | - Philippe Metellus
- Department of Neurosurgery, Timone Hospital, Marseille, France.
- University Aix Marseille, Marseille, France.
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Elliott JT, Dsouza AV, Davis SC, Olson JD, Paulsen KD, Roberts DW, Pogue BW. Review of fluorescence guided surgery visualization and overlay techniques. BIOMEDICAL OPTICS EXPRESS 2015; 6:3765-82. [PMID: 26504628 PMCID: PMC4605037 DOI: 10.1364/boe.6.003765] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/26/2015] [Accepted: 09/01/2015] [Indexed: 05/03/2023]
Abstract
In fluorescence guided surgery, data visualization represents a critical step between signal capture and display needed for clinical decisions informed by that signal. The diversity of methods for displaying surgical images are reviewed, and a particular focus is placed on electronically detected and visualized signals, as required for near-infrared or low concentration tracers. Factors driving the choices such as human perception, the need for rapid decision making in a surgical environment, and biases induced by display choices are outlined. Five practical suggestions are outlined for optimal display orientation, color map, transparency/alpha function, dynamic range compression, and color perception check.
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Affiliation(s)
- Jonathan T. Elliott
- Thayer School of Engineering, Dartmouth College, 14 Engineering Drive, Hanover, NH 03755, USA
| | - Alisha V. Dsouza
- Thayer School of Engineering, Dartmouth College, 14 Engineering Drive, Hanover, NH 03755, USA
| | - Scott C. Davis
- Thayer School of Engineering, Dartmouth College, 14 Engineering Drive, Hanover, NH 03755, USA
| | - Jonathan D. Olson
- Neurosurgery Section, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03766, USA
| | - Keith D. Paulsen
- Thayer School of Engineering, Dartmouth College, 14 Engineering Drive, Hanover, NH 03755, USA
| | - David W. Roberts
- Neurosurgery Section, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03766, USA
- Department of Surgery, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH 03755, USA
| | - Brian W. Pogue
- Thayer School of Engineering, Dartmouth College, 14 Engineering Drive, Hanover, NH 03755, USA
- Department of Surgery, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH 03755, USA
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Alotaibi FE, AlZhrani GA, Mullah MAS, Sabbagh AJ, Azarnoush H, Winkler-Schwartz A, Del Maestro RF. Assessing bimanual performance in brain tumor resection with NeuroTouch, a virtual reality simulator. Neurosurgery 2015; 11 Suppl 2:89-98; discussion 98. [PMID: 25599201 DOI: 10.1227/neu.0000000000000631] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Validated procedures to objectively measure neurosurgical bimanual psychomotor skills are unavailable. The NeuroTouch simulator provides metrics to determine bimanual performance, but validation is essential before implementation of this platform into neurosurgical training, assessment, and curriculum development. OBJECTIVE To develop, evaluate, and validate neurosurgical bimanual performance metrics for resection of simulated brain tumors with NeuroTouch. METHODS Bimanual resection of 8 simulated brain tumors with differing color, stiffness, and border complexity was evaluated. Metrics assessed included blood loss, tumor percentage resected, total simulated normal brain volume removed, total tip path lengths, maximum and sum of forces used by instruments, efficiency index, ultrasonic aspirator path length index, coordination index, and ultrasonic aspirator bimanual forces ratio. Six neurosurgeons and 12 residents (6 senior and 6 junior) were evaluated. RESULTS Increasing tumor complexity impaired resident bimanual performance significantly more than neurosurgeons. Operating on black vs glioma-colored tumors resulted in significantly higher blood loss and lower tumor percentage, whereas altering tactile cues from hard to soft decreased resident tumor resection. Regardless of tumor complexity, significant differences were found between neurosurgeons, senior residents, and junior residents in efficiency index and ultrasonic aspirator path length index. Ultrasonic aspirator bimanual force ratio outlined significant differences between senior and junior residents, whereas coordination index demonstrated significant differences between junior residents and neurosurgeons. CONCLUSION The NeuroTouch platform incorporating the simulated scenarios and metrics used differentiates novice from expert neurosurgical performance, demonstrating NeuroTouch face, content, and construct validity and the possibility of developing brain tumor resection proficiency performance benchmarks.
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Affiliation(s)
- Fahad E Alotaibi
- *Neurosurgical Simulation Research Center, Department of Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada; ‡Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia; §Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada; ¶Faculty of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh Saudi Arabia; ‖Department of Biomedical Engineering, Tehran Polytechnic, Tehran, Iran
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Valdés PA, Jacobs V, Harris BT, Wilson BC, Leblond F, Paulsen KD, Roberts DW. Quantitative fluorescence using 5-aminolevulinic acid-induced protoporphyrin IX biomarker as a surgical adjunct in low-grade glioma surgery. J Neurosurg 2015; 123:771-80. [PMID: 26140489 DOI: 10.3171/2014.12.jns14391] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECT Previous studies in high-grade gliomas (HGGs) have indicated that protoporphyrin IX (PpIX) accumulates in higher concentrations in tumor tissue, and, when used to guide surgery, it has enabled improved resection leading to increased progression-free survival. Despite the benefits of complete resection and the advances in fluorescence-guided surgery, few studies have investigated the use of PpIX in low-grade gliomas (LGGs). Here, the authors describe their initial experience with 5-aminolevulinic acid (ALA)-induced PpIX fluorescence in a series of patients with LGG. METHODS Twelve patients with presumed LGGs underwent resection of their tumors after receiving 20 mg/kg of ALA approximately 3 hours prior to surgery under an institutional review board-approved protocol. Intraoperative assessments of the resulting PpIX emissions using both qualitative, visible fluorescence and quantitative measurements of PpIX concentration were obtained from tissue locations that were subsequently biopsied and evaluated histopathologically. Mixed models for random effects and receiver operating characteristic curve analysis for diagnostic performance were performed on the fluorescence data relative to the gold-standard histopathology. RESULTS Five of the 12 LGGs (1 ganglioglioma, 1 oligoastrocytoma, 1 pleomorphic xanthoastrocytoma, 1 oligodendroglioma, and 1 ependymoma) demonstrated at least 1 instance of visible fluorescence during surgery. Visible fluorescence evaluated on a specimen-by-specimen basis yielded a diagnostic accuracy of 38.0% (cutoff threshold: visible fluorescence score ≥ 1, area under the curve = 0.514). Quantitative fluorescence yielded a diagnostic accuracy of 67% (for a cutoff threshold of the concentration of PpIX [CPpIX] > 0.0056 μg/ml, area under the curve = 0.66). The authors found that 45% (9/20) of nonvisibly fluorescent tumor specimens, which would have otherwise gone undetected, accumulated diagnostically significant levels of CPpIX that were detected quantitatively. CONCLUSIONS The authors' initial experience with ALA-induced PpIX fluorescence in LGGs concurs with other literature reports that the resulting visual fluorescence has poor diagnostic accuracy. However, the authors also found that diagnostically significant levels of CPpIX do accumulate in LGGs, and the resulting fluorescence emissions are very often below the detection threshold of current visual fluorescence imaging methods. Indeed, at least in the authors' initial experience reported here, if quantitative detection methods are deployed, the diagnostic performance of ALA-induced PpIX fluorescence in LGGs approaches the accuracy associated with visual fluorescence in HGGs.
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Affiliation(s)
- Pablo A Valdés
- Department of Neurosurgery, Brigham and Women's/Boston Children's Hospitals, Harvard Medical School;,Geisel School of Medicine at Dartmouth, Hanover;,Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon;,Thayer School of Engineering, Hanover, New Hampshire
| | - Valerie Jacobs
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts;,Geisel School of Medicine at Dartmouth, Hanover
| | | | - Brian C Wilson
- Ontario Cancer Institute, University of Toronto, Ontario; and
| | - Frederic Leblond
- Department of Engineering Physics, Polytechnique Montreal, Quebec, Canada
| | | | - David W Roberts
- Geisel School of Medicine at Dartmouth, Hanover;,Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon
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