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Suero Molina E, Schipmann S, Stummer W. Maximizing safe resections: the roles of 5-aminolevulinic acid and intraoperative MR imaging in glioma surgery-review of the literature. Neurosurg Rev 2019; 42:197-208. [PMID: 28921173 PMCID: PMC6502775 DOI: 10.1007/s10143-017-0907-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/07/2017] [Accepted: 09/06/2017] [Indexed: 12/28/2022]
Abstract
Malignant glioma surgery involves the challenge of preserving the neurological status of patients harboring these lesions while pursuing a maximal tumor resection, which is correlated with overall and progression-free survival. Presently, several tools exist for assisting neurosurgeons in visualizing malignant tissue. Fluorescence-guided surgery (FGS) with 5-aminolevulinic acid (5-ALA) has increasingly been used during the last decade for identifying malignant glioma. Intraoperative magnetic resonance imaging (iMRI), first introduced in the mid-1990s, is being evaluated as a further tool to maximize the extent of resection. We aimed to evaluate the literature and discuss synergies and differences between FGS with 5-ALA and iMRI. We conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. After excluding non-relevant articles, 16 articles were evaluated and included in the qualitative analysis, comprising 2 (n = 2) reviews of the literatures, 1 (n = 1) book chapter, and 13 (n = 13) clinical articles. ALA-induced fluorescence goes beyond the borders of gadolinium contrast enhancement. Several studies stress the synergy between both tools, enabling increase in extent of resection. We point out advantages of combining both methods. iMRI, however, is not widely available, is expensive, and is not recommended as sole resection control tool in high-grade glioma. For these centers, FGS together with mapping and monitoring techniques, neuronavigation and, when needed, intraoperative ultrasound provides an excellent setting for achieving state-of-the-art gross total resection of high-grade gliomas.
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Affiliation(s)
- Eric Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany.
| | - S Schipmann
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
| | - W Stummer
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
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Della Puppa A, Rustemi O, Rampazzo E, Persano L. Letter: Combining 5-Aminolevulinic Acid Fluorescence and Intraoperative Magnetic Resonance Imaging in Glioblastoma Surgery: A Histology-Based Evaluation. Neurosurgery 2018; 80:E188-E190. [PMID: 28173486 DOI: 10.1093/neuros/nyw033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Oriela Rustemi
- Department of Neurosurgery, Padova University Hospital, Padua, Italy
| | - Elena Rampazzo
- Oncohematology Laboratory, IRP - Istituto di Ricerca Pediatrica, Città della Speranza, Department of Woman and Child Health, University of Padova, Padua, Italy
| | - Luca Persano
- Oncohematology Laboratory, IRP - Istituto di Ricerca Pediatrica, Città della Speranza, Department of Woman and Child Health, University of Padova, Padua, Italy
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Hu S, Kang H, Baek Y, El Fakhri G, Kuang A, Choi HS. Real-Time Imaging of Brain Tumor for Image-Guided Surgery. Adv Healthc Mater 2018; 7:e1800066. [PMID: 29719137 PMCID: PMC6105507 DOI: 10.1002/adhm.201800066] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/22/2018] [Indexed: 02/05/2023]
Abstract
The completion of surgical resection is a key prognostic factor in brain tumor treatment. This requires surgeons to identify residual tumors in theater as well as to margin the proximity of the tumor to adjacent normal tissue. Subjective assessments, such as texture palpation or visual tissue differences, are commonly used by oncology surgeons during resection to differentiate cancer lesions from normal tissue, which can potentially result in either an incomplete tumor resection, or accidental removal of normal tissue. Moreover, malignant brain tumors are even more difficult to distinguish from normal brain tissue, and resecting noncancerous tissue may create neurological defects after surgery. To optimize the resection margin in brain tumors, a variety of intraoperative guidance techniques are developed, such as neuronavigation, magnetic resonance imaging, ultrasound, Raman spectroscopy, and optical fluorescence imaging. When combined with appropriate contrast agents, optical fluorescence imaging can provide the neurosurgeon real-time image guidance to improve resection completeness and to decrease surgical complications.
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Affiliation(s)
- Shuang Hu
- Department of Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Homan Kang
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Yoonji Baek
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Georges El Fakhri
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Anren Kuang
- Department of Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hak Soo Choi
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
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Kim S, Kim JE, Kim YH, Hwang T, Kim SK, Xu WJ, Shin JY, Kim JI, Choi H, Kim HC, Cho HR, Choi A, Chowdhury T, Seo Y, Dho YS, Kim JW, Kim DG, Park SH, Kim H, Choi SH, Park S, Lee SH, Park CK. Glutaminase 2 expression is associated with regional heterogeneity of 5-aminolevulinic acid fluorescence in glioblastoma. Sci Rep 2017; 7:12221. [PMID: 28939850 PMCID: PMC5610329 DOI: 10.1038/s41598-017-12557-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/12/2017] [Indexed: 01/11/2023] Open
Abstract
Fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA) is now a widely-used modality for glioblastoma (GBM) treatment. However, intratumoral heterogeneity of fluorescence intensity may reflect different onco-metabolic programs. Here, we investigated the metabolic mechanism underlying the heterogeneity of 5-ALA fluorescence in GBM. Using an in-house developed fluorescence quantification system for tumor tissues, we collected 3 types of GBM tissues on the basis of their fluorescence intensity, which was characterized as strong, weak, and none. Expression profiling by RNA-sequencing revealed 77 genes with a proportional relationship and 509 genes with an inverse relationship between gene expression and fluorescence intensity. Functional analysis and in vitro experiments confirmed glutaminase 2 (GLS2) as a key gene associated with the fluorescence heterogeneity. Subsequent metabolite profiling discovered that insufficient NADPH due to GLS2 underexpression was responsible for the delayed metabolism of 5-ALA and accumulation of protoporphyrin IX (PpIX) in the high fluorescence area. The expression level of GLS2 and related NADPH production capacity is associated with the regional heterogeneity of 5-ALA fluorescence in GBM.
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Affiliation(s)
- Sojin Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ja Eun Kim
- Cell and Gene Therapy Products Division, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Cheongju, Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Taeyoung Hwang
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sung Kwon Kim
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Wen Jun Xu
- College of Pharmacy, Natural Product Research Institute, Seoul National University, Seoul, Korea
| | - Jong-Yeon Shin
- Genomic Medicine Institute, Medical Research Center, Seoul National University, Seoul, Korea
| | - Jong-Il Kim
- Department of Biochemical and Molecular Biology, Seoul National University College of Medicine, Seoul, Korea
| | | | - Hee Chan Kim
- Department of Biomedical Engineering, College of Medicine and Institute of Medical and Biological Engineering, Medical Research Center, Seoul National University, Seoul, Korea
| | - Hye Rim Cho
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Anna Choi
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Tamrin Chowdhury
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Youngbeom Seo
- Department of Neurosurgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Yun-Sik Dho
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin Wook Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dong Gyu Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sung-Hye Park
- Department of Pathology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyeonjin Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seung Hong Choi
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sunghyouk Park
- College of Pharmacy, Natural Product Research Institute, Seoul National University, Seoul, Korea
| | - Se-Hoon Lee
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chul-Kee Park
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea.
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Reyns N, Leroy HA, Delmaire C, Derre B, Le-Rhun E, Lejeune JP. Intraoperative MRI for the management of brain lesions adjacent to eloquent areas. Neurochirurgie 2017; 63:181-188. [PMID: 28571707 DOI: 10.1016/j.neuchi.2016.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 09/17/2016] [Accepted: 12/04/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of our study was to report the usefulness of intraoperative MRI guidance in the resection of brain lesions adjacent to eloquent areas. PATIENTS AND METHODS A single center prospective series of gliomas amenable to optimized resection with intraoperative MRI between September 2014 and December 2015. RESULTS The study included 56 patients. The median duration of the first intraoperative MRI was 38min, interquartile range (IQR 30-46). Fourteen patients (40%) underwent a second intraoperative MRI, which had a median duration of 26min (IQR, 18-30). The median total operative time was 265min (IQR, 242-337). After the first intraoperative MRI, the median residual glioma volume of the 35 gliomas adjacent to eloquent areas was 7.04cm3 (IQR, 2.22-13.8), which did not significantly differ from the other gliomas (P=0.07). After the second intraoperative MRI, the median residual glioma volume was 3.86cm3 (IQR, 0.82-6.99), which did not significantly differ from the other patients (P=0.700). On the postoperative MRI, the median extent of the glioma resections adjacent to eloquent areas was 99.78% (IQR, 88.9-100), which was not significantly different from the rest of the population (P=0.290). At 6 months after surgery, the median Karnofsky Performance Score was 90, and 2.8% of the patients presented a permanent new neurological deficit. CONCLUSION Our results suggest that intraoperative MRI is an effective and safe technique to improve the extent of brain lesion resections close to eloquent areas.
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Affiliation(s)
- N Reyns
- Inserm U1189, Onco-Thai - Image Assisted Laser Therapy for Oncology, University of Lille, 59000 Lille, France; Department of Neurosurgery, CHU de Lille, 59000 Lille, France.
| | - H-A Leroy
- Department of Neurosurgery, CHU de Lille, 59000 Lille, France
| | - C Delmaire
- Department of Radiology, CHU de Lille, 59000 Lille, France
| | - B Derre
- Department of Neurosurgery, CHU de Lille, 59000 Lille, France; Department of Radiology, CHU de Lille, 59000 Lille, France
| | - E Le-Rhun
- Department of Neuro-oncology, CHU de Lille, 59000 Lille, France
| | - J-P Lejeune
- Inserm U1189, Onco-Thai - Image Assisted Laser Therapy for Oncology, University of Lille, 59000 Lille, France; Department of Neurosurgery, CHU de Lille, 59000 Lille, France
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Halani SH, Adamson DC. Clinical utility of 5-aminolevulinic acid HCl to better visualize and more completely remove gliomas. Onco Targets Ther 2016; 9:5629-42. [PMID: 27672334 PMCID: PMC5026178 DOI: 10.2147/ott.s97030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Surgical resection is typically the first line of treatment for gliomas. However, the neurosurgeon faces a major challenge in achieving maximal resection in high-grade gliomas as these infiltrative tumors make it difficult to discern tumor margins from normal brain with conventional white-light microscopy alone. To aid in resection of these infiltrative tumors, fluorescence-guided surgery has gained much popularity in intraoperative visualization of malignant gliomas, with 5-aminolevulinic acid (5-ALA) leading the way. First introduced in an article in Neurosurgery, 5-ALA has since become a safe, effective, and inexpensive method to visualize and improve resection of gliomas. This has undoubtedly led to improvements in the clinical course of patients as demonstrated by the increased overall and progression-free survival in patients with such devastating disease. This literature review aims to discuss the major studies and trials demonstrating the clinical utility of 5-ALA and its ability to aid in complete resection of malignant gliomas.
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Affiliation(s)
- Sameer H Halani
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - D Cory Adamson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA; Neurosurgery Section, Atlanta VA Medical Center, Decatur, GA, USA
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